MZUZU UNIVERSITY
FACULTY OF ENVIRONMENTAL SCIENCES
DEPARTMENT OF WATER AND SANITATION
RESEARCH TOPIC: INVESTIGATION OF BARRIERS AND ENABLING FACTORS TO WATER,
SANITATION AND HYGIENE ACCESS AMONG FEMALE SEX WORKERS IN LILONGWE
DISTRICT - MALAWI
STUDENT NAME: ANGELLAH CHIKOKO LUHANGA
REGISTRATION NUMBER: MSAN 0721
FIRST SUPERVISOR: DR E. PHUMA
SECOND SUPERVISOR: MR WILLY CHIPETA
DATE:
11TH MAY 2023
i
ABSTRACT
Introduction: Advancing access to water, basic sanitation, and hygiene (WASH) is the first step of
achieving each of the world’s crucial human rights issues, and it mostly affects the marginalized
populations such as Females sex workers (FSWs). Females sex workers are part of the vulnerable
segments in WASH, whose needs are not regarded fully and they face extra vulnerabilities due to
nature of the lifestyle and places they operate, resulting into negative health outcomes. The global
progress in achieving the Sustainable Development Goals (SDGs) in relation to water and sanitation
disguises the very limited progress in the vulnerable population with the emphasis of enhancing
the principle of Living no one behind (LNOB) in the programming of WASH interventions.
Achieving equitable access to WASH services requires paying special attention to the most
disadvantaged segments of the population such as the female sex worker. Therefore, this study has
been designed to explore the unmet WASH needs of FSWs in Lilongwe district.
Aim of the study: The Main aim of this study is to investigate the barriers and enabling factors to
water, sanitation and hygiene access among female sex workers in Lilongwe district.
Methods and materials: A mixed method approach will be used. All Female Sex Workers accessing
services in Drop-in Centres will be requested to participate in the study using a snowball rolling
sampling technique. An interviewer administered questionnaire will be used to collect relevant
information. Quantitative Data will be analysed using SPSS version 2.0 and qualitative data will be
analysed using thematic analysis.
Significance of the study: The results of this study will unlock issues surrounding Water Sanitation
and Hygiene (WASH) among Female sex workers. The information from the research will further
assist policy makers to device Water Sanitation and Hygiene-based interventions for Female Sex
Workers.
Limitation of the study: Self-reported data always comes with limitation there is a high possibility
that the respondents may provide responses that are socially acceptable rather than being truthful
(social desirability). However, this will be mitigated by ab triangulating the collected data with
records and
the knowledge of key people that know the plight of sex workers including
observational check lists.
ii
explaining properly to the participants the importance of providing honest answers, furthermore
no identification will be utilised on questionnaire to ensure that participants are free to provide
information.
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iv
TABLE OF CONTENTS
ABSTRACT .................................................................................................................................................................. ii
Operational definitions .............................................................................. Ошибка! Закладка не определена.
TABLE OF CONTENTS............................................................................................................................................. v
CHAPTER 1 .0 INTRODUCTION ............................................................................................................................ 7
1.1 Problem statement ............................................................................................................................................... 8
1.2 Justification of the study ................................................................................................................................. 9
1.3 Aim of the study............................................................................................................................................... 9
1.3.1 Main objective ............................................................................................................................................... 9
1.3.2 Specific objective.........................................................................................................................................10
1.3.4 Research Questions.....................................................................................................................................10
CHAPTER 2.0: LITERATURE REVIEW ..................................................................................................................11
2.1 Access to water sanitation hygiene globally ..............................................................................................11
2.2 Access to water sanitation hygiene in Malawi..........................................................................................12
2.3 Access to wash for vulnerable populations. ...............................................................................................13
2.5 Stigma and discrimination and its links to water, sanitation, and hygiene ............................................16
2.6 The principle of leave no one behind in wash ( LNOB) ..........................................................................17
2.7 Legal framework of sex work ......................................................................................................................18
2.8 Research gap ..................................................................................................................................................19
CHAPTER 3.0 METHODOLOGY AND MATERIALS...........................................................................................20
3.1 Research design .................................................................................................................................................21
3.2 Study setting .......................................................................................................................................................21
3.3. Study population ..............................................................................................................................................21
3.4 Sampling and Sample size ..............................................................................................................................22
3.5 Inclusion and exclusion criteria ........................................................................................................................22
3.6. Data collection and management ..................................................................................................................22
3.7. Data analysis .....................................................................................................................................................23
Table 1: Methodology Matrix ................................................................................................................................23
3.8 Ethical considerations........................................................................................................................................25
3.9. Study Limitation ...............................................................................................................................................25
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3.10 Dissemination of the results ............................................................................................................................25
REFERENCE ..............................................................................................................................................................26
ANNEXES ..................................................................................................................................................................31
Annex 1 : Ghart chart .........................................................................................................................................31
Annex 2: Budgets and Justification ....................................................................................................................32
Annex 3: Informed consent ................................................................................................................................34
Annex 4: Questionnaire in English .....................................................................................................................38
Annex 5: Observation checklist ..........................................................................................................................44
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CHAPTER 1 .0 INTRODUCTION
Advancing access to water, basic sanitation, and hygiene (WASH) is the first step of
achieving each of the world’s crucial human rights issues, and it mostly affects the
marginalized populations such as Females sex workers. The global progress in achieving
the SDGs in relation to water and sanitation disguises the very limited progress in the
vulnerable population with the emphasis of enhancing the principle of Living no one
behind (LNOB) in the programming of WASH interventions, (SNV,2019).
Reducing Inequalities in Water Supply, Sanitation, and Hygiene in the Era of the Sustainable
Development Goals’ reveals a drastic change is required in the way countries manage
resources and provide key services by targeting and reaching the vulnerable populations
(World Bank, 2020). Achieving equitable access to water, sanitation and hygiene (WASH)
services requires paying special attention to the most disadvantaged segments of the
population such as the female sex workers (FSWs) (Shawmy, 2019).
Due to the nature of their work, FSWs often experience high levels of stigma and
discrimination resulting in negative health outcomes, (OSISA, 2018). Stigma and
discrimination often result in lack of access to water and sanitation and poor hygiene
standards. FSWs problems have been documented at household, community and by service
provider with regards to water and sanitation access, (ASWA,2019). Yet, despite all the
progress made to evaluate the access of vulnerable groups, important knowledge gaps still
remain with respect to identifying their specific barriers and need regarding wash, (OSISA,
2018). Sub-Saharan Africa remains on the bottom of the world listing regarding increased
access to safe drinking water and sanitation. Hence Malawi context in sub Saharan Africa
is not exempted,
In Malawi, sex work is highly stigmatized and sex workers face severe isolation from their
family and friends(NAC, 2020).A sex worker is defined as a person who voluntarily does
a commercial exchange of sex for money or goods (NAC, 2020).According to
PLACE
study (2018) there are more than 36700 Female sex workers in Malawi, and they live in
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rest houses, lodges and houses with constricted space and extremely unhygienic conditions
which makes them vulnerable to ill health.
Furthermore, the Female sex workers have also been identified as being more vulnerable
to HIV and AIDS and stigma and discrimination than the general population and this puts
them at risk of contracting some opportunistic infections such as diarrhea, (NAC,2020).
Therefore, it is more important to specifically explore the WASH needs of this population.
While nascent research in Sub-Saharan Africa and Malawi has demonstrated the importance
of assessing the WASH services among girls and women of reproductive age group, (Taulo
et, al 2018, Saleem, et al, 2019, Cassiv, et al, 2018, Adams 2018, Adam, et al, 2018,
Wayland,2018). Research has paid limited attention to exploring factors associated with
unmet WASH needs among FSWs. This research is therefore aimed at investigating the
barriers and enabling factors to water, sanitation and hygiene access among female sex
workers in Lilongwe district exploring the unmet needs to access of water, sanitation and
hygiene among the female sex workers in Lilongwe district. The findings of this study will
be expected to guide policy makers responsible in designing programs to address challenges
faced by the FSWs in WASH services in Malawi.
1.1 Problem statement
Clean water and sanitation are basic human rights that shouldn’t be determined by a
person’s economic situation. To ensure health for all by 2030, we must tell world leaders
to invest in access to sanitation and hygiene for the most marginalized communities such
as FSWs. Unfortunately, due to the stigma associated with this profession, sex workers do
not receive any respect and are often deprived of basic human rights, including access to
WASH facilities which puts them at risk of contracting WASH related diseases such as
diarrhea, (Shawmy, 2019). Most sex workers live together in windowless rooms, as many
as 30 people share one public bathroom and toilet. Additionally, more than 40% of sex
workers are homeless and hence, live on the streets and rest houses (ASWA, 2019). This
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tells us that they are dependent on public bathrooms for water and privacy. The water,
sanitation, and hygiene (WASH) needs of Female Sex Workers (FSWs) is a new area of
research which was often neglected (SNV, 2019). Most of the FSWs are HIV positive with
prevalence of 46.9% and this puts them at risk of contracting other diseases such as
diarrhea, more especially when their viral load is unsuppressed (NAC, 2020). This calls for
a robust approach to empowering the FSWs to identify the major triggers of ill health and
take preventive measures and empower them on good WASH practices. Several studies,
(Taulo et, al 2018, Saleem, et al, 2019, Cassiv, et al, 2018, Adams 2018) have highlighted
on WASH needs of women but there is limited research on minority groups such as female
sex workers. Additionally, UN, 2017 emphases the importance of paying attention to the
needs of People who are at risk of being left behind to be actively and meaningfully
identified, included, engaged, and considered in all aspects of sanitation and hygiene
programming. Strategies are needed to address existing inequalities and avoid creating new
inequalities as side effects of programming. Without this, communities and areas will not
achieve SDG 6 By 2030 (UN,2019). The principle of living no one behind seeks to reach
the vulnerable populations, and combat stigma and discrimination and rising inequalities
(OSISA, 2019). Therefore, this research is aimed at investigating and addressing the
challenges faced by the female sex workers in accessing WASH services.
1.2 Justification of the study
The results of this study will establish information on WASH challenges among the FSWs,
that can be used in future in Water sanitation and hygiene-based interventions among this
population. Furthermore, the findings of this study will also inform the policy makers and
Non-Governmental Organizations (NGO’s), to critically assess the issues surrounding
WASH among FSWs and to device appropriate policies and interventions to prevent
diseases in this population.
1.3 Aim of the study
1.3.1 Main objective
The broad objective of this study is to investigate the barriers and enabling factors to water,
sanitation and hygiene access among female sex workers in Lilongwe, district.
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1.3.2 Specific objective
1. To assess level of access to WASH services among female sex works in the study
area
2. To analyze barriers impeding access to WASH services among female sex workers
in the study area
3. To assess enabling factors promoting access to WASH services among female sex
workers in the study area
1.3.4 Research Questions
1. What is the level of access to WASH services among female sex works in the study
area
2. What are barriers impeding access to WASH services among female sex workers in
the study area
3. What are enabling factors promoting access to WASH services among female sex
workers in the study area
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CHAPTER 2.0: LITERATURE REVIEW
This chapter presents the literature review and opens the door to the originality of the
research. The purpose of the literature review is to show the current state of knowledge
and therefore, to identify any gaps in the knowledge around the WASH needs of Female
Sex workers. It also aims to ensure that this research does not duplicate any previous
research and avoids the mistakes of previous work done.
2.1 Access to water sanitation hygiene globally
Globally 1,2 billion people lack access to safely managed drinking water at home. Out of
those, 1.2 billion people have basic drinking water service (WHO/UNICEF, 2021). Between
2015 and 2020, 107 million people gained access to safely managed drinking water at
home, and 115 million people gained access to safe toilets at home (WHO/UNICEF, 2021).
However, 8 out 10 people continue to lack basic drinking water services live in rural areas
(WHO, UNICEF,2021).
Regarding sanitation about3.6 billion people, nearly half the world’s population, do not
have access to safely managed sanitation in their home. Of those, 1.9 billion people live
with basic
sanitation
services,
and
494
million
people
practice
open
defecation,(WHO/UNICEF, 2021).Furthermore, 2.3 billion people lack basic hygiene
services, including soap and water at home. This includes 670 million people with no
handwashing facilities at all. In rural settings, only 1 in 3 people have access to basic hygiene
services such as soap and water at home, additionally 8 out 10 people continue to lack
basic drinking water services live in rural areas, (WHO/UNICEF, 2021).
Worldwide, hundreds of millions of people are affected by diseases such diarrhea,
trachoma and schistosomiasis due to inadequate access to WASH, (Charles et al,2020).
Universal access to safe drinking water, adequate sanitation, and hygiene has the potential
to reduce the global disease burden by 10%. Furthermore, increasing access to safe drinking
water and sanitation services can prevent many diarrheal deaths, (Pruss,2019).
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2.2Trends of Water Sanitation Hygiene (WASH) access in Malawi
Malawi is one of Sub-Saharan Africa’s most densely populated countries with about 18
million people spread over land area of 94,276 km2, giving a population density of 139
persons/km (NSO, 2018).Furthermore, is among the world’s poorest countries and most
of its population still live below the international poverty line of $1.25 per day,(NSO,
2018).While impressive progress has been made to achieve the Millennium Development
Goal target on water, 1.7million Malawians remain without access to a safe water facility.
Although 67 per cent of Malawi’s households have access to drinking water, distribution
among
districts,
and
between
urban
and
rural
areas,
is
uneven,
(WHO/UNICEF,2020). Improved drinking water sources are more common in urban areas
at 87 per cent compared to 63 per cent in rural area, (NSHS,2018 - 2023). In rural areas,
37 per cent of households spend 30 minutes or more to fetch drinking water in comparison
to 13 per cent in urban areas (WHO/UNICEF, 2020). Further analyses within districts also
reveals the distribution of water services in some areas is poor and uneven. Only 77 per
cent of water points nationwide are functional. The rest no longer work because of old
age, catchment deterioration, neglect, lack of spare parts and inadequate community-based
water management structures (Cassivi, et al,2018). Women and children shoulder the
burden of poor access to water services as they often walk long distances to collect water
for their families (Adams, 2018). Evidence shows that improving access to water
significantly decreases the burden of water related diseases (WHO/UNICEF,2020).
Poor sanitation and hygiene are major contributors to the burden of disease and child
survival, costing Malawi US$57 million each year, or 1.1 per cent of national GDP, due to
health costs and productivity losses (WHO/UNICEF, 2021). Although significant progress
has been to decrease open defecation (OD), six per cent of the population still practice
OD and only 26 per cent have access to basic sanitation services. Sanitation services are
also unequally spread across the country such that 7 per cent of households practicing OD
are in rural areas compared to one per cent in urban areas (WHO/ UNICEF, 2021).
Changing behaviour around the use of latrines has been challenging as has
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handwashing. Only 10 per cent of households in Malawi have handwashing facilities with
soap (a proxy indicator for handwashing practice, (WHO/UNICEF,2021)
The WASH sector is guided by the Government of Malawi’s (GoM) Development and
Growth Strategy (MDGS-III) and the Health Sector Strategic Plan (HSSP II) in addition to
other sector strategies. GOM also developed the National Sanitation and Hygiene Strategy
of 2018-2023 which has been aligned with the Sustainable Development Goals (SDG),
specifically SDG 6.1 and 6.2, which aims for improved universal and sustainable access to
safe drinking water, sanitation and hygiene, and the elimination of open defecation by
2030.
2.3 Access to wash for vulnerable populations.
According to Dickin (2018), vulnerability in WASH means denial or failure to ensure that
people access water, sanitation and hygiene services. This could be in terms of non-existent
or limited representation in decision making processes and therefore lacking a platform to
voice concerns, lack of physical access to the services limited by technology and location,
lack of access and control over resources to put up facilities and failure to access justice in
instances of unfair denial, (Adams, 2018).There are several groups of marginalized
populations such as female sex workers, women, the disabled and children to mention a
few, (Somalia, et al, 2019).Somaila et al. (2019) further, highlights that vulnerable
populations are at risk of facing stigma and discrimination which makes them to be unable
to accesses basic health care including WASH services. This, therefore, increases the
likeliness of the vulnerable populations contracting water-related health problems.
In Malawi several studies have demonstrated that female sex workers like other highly
stigmatized groups in society, avoid making themselves visible to authorities or refrain from
accessing health services for fear of being identified, targeted and rejected, (Wanyenza
2021,scorgie, et al, 2019,NAC,2020).This makes it difficult for them to access health care
services and information including WASH services which may expose them to water borne
diseases .Additionally, NAC (2020),revealed that most Female sex workers leave in
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informal settlements such as brothels, streets, and rest houses which lack proper water
supply, hygiene and sanitation facilities which predisposes them to infection as a result of
inadequate water and basic sanitation access. Lack of access to WASH facilities is linked to
many other pressing problems therefore access to WASH facilities lead to better health,
greater productivity, and more success according to the World Health Organization
(2021).
A study done by Sinharoy et, al, (2019) highlight the importance of addressing the water
and sanitation needs of vulnerable populations such as female sex worker as essential to
acknowledge and support the vision that United Nations has under their sustainable
development goals. The United Nations declared access to water and sanitation to be a
human right, simply because lack of water and sanitation in vulnerable populations is
related to social and health implications throughout the world (UN,2021). A substantial
number of studies worldwide demonstrates that vulnerable populations are unable to
afford well-located formal housing due to high rates of poverty and unemployment
(Fleifel. et al, 2019, Sinharoy, et al, 2019, Bisung, et al,2019, Dickson, et al, 2019). As a
matter of fact, lack of adequate water and basic sanitation is perpetuated by poverty.
Poverty drives people to settle for poor conditions. The informal settlements suffer the
most with services pertaining to water and sanitation, (World Bank, 2020). It is important
therefore to understand the extent in which vulnerable populations experience inadequate
water and basic sanitation access to discover solution to this problem.
There is a broad consensus in the international development community that equity in the
water and sanitation sector needs to be the focus of all efforts, (UNOCHA, 2018). For this
to happen there is need to prioritize reaching to disadvantaged populations and ensuring
equitable and inclusive water sanitation and hygiene outcomes. But most countries are
not making the right choices in prioritizing equity to get there, (UNICEF, 2019). A number
of UN and other international studies indicate that even with the spending that is occurring
in the WASH sector those in local rural communities, and other members of marginalized
populations like female sex workers are the ones that still significantly lack access to the
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essential services of water, sanitation and hygiene,(SNV, 2019,UN, 2021, World
bank,2018,WHO/UNICEF, 2019).Additionally WHO/ UNICEF, (2021), revealed that lack
of data about marginalized groups access to WASH is one of the first challenge
governments need to address. This research study is therefore essential since it will unlock
the WASH needs of FSWs and also add information on the vulnerable populations
regarding WASH.
2.4 The link between wash and ill health
The exclusion of any segment of the population from essential healthcare and water,
sanitation and hygiene services not only puts these individuals at risk but creates an
unnecessary and unacceptable risk to the entire population by allowing highly
communicable diseases like diarrhea to spread more easily,(WHO/UNICEF, 2020).
Improved Water, sanitation, and hygiene (WASH) practices are critical contributors to
illness prevention and response globallay, (World bank,2018). However, one-third of the
world's population, mainly marginalized and vulnerable individuals living in many
developing nations still lack access to WASH, (Dickin et al 2021). Most individuals in
vulnerable areas suffer from water-borne diseases such as diarrhoea, acute respiratory
infections, and skin infections because of contaminated water, inadequate sanitation, and
poor hygiene, (Podder et al,2019). Additionally, due to poverty, limited access to basic
WASH services, and inadequate housing, vulnerable populations are particularly exposed
to illness, (Equal international, 2021). In addition, vulnerable populations have a low level
of awareness and information about illness and WASH practices, which can lead to poor
health and dangerous protective behaviours (Hsan et al. 2019).Therefore Understanding
venerable populations WASH conditions, their vulnerability, knowledge and practices can
aid in identifying elements that influence their protective behaviours when it comes to
adopting response practices (Podder et al. 2019).
In dealing with pandemics, knowledge enhancement and education initiatives are likely
methods for improving the self-protection of marginalized people (Al-Hanawi et al. 2020).
The water borne infectious agent spreads fast within the society and communities
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therefore, protecting marginalized groups helps reduce the risk faced by individuals and
society. Several studies conducted in developing countries such as,Ethiopia (Berhe et al.
2020) and Bangladesh (Islam et al. 2021) showed low knowledge on WASH issues among
the vulnerable populations. Knowing, learning, and practising WASH can help people
reduce their risks of contracting communicable diseases (Berhe et al. 2020). Some
researchers have confirmed the link between knowledge and practice, as well as attitudes
and behaviours (Nguyen et al. 2019). Previous research in the field has shown that people
with high WASH and health-protection knowledge and attitudes are more likely to adopt
safe hygiene and self-protection practices (Ozdemir et al. 2020).Therefore, it is critical that
policymakers implement alternative and innovative measures to prevent further illnesses
in the vulnerable populations such as the Female sex workers.
2.5 Stigma and discrimination and its links to water, sanitation, and hygiene
Venerable groups often face discrimination and stigma from WASH in many ways. The
human right to water entitles everyone without stigma and discrimination to sufficient,
safe, acceptable, physically accessible and affordable water for personal and domestic
us,(UNOCHA,2018). Additionally, the human right to sanitation entitles everyone without
discrimination and discrimination to physical and affordable access to sanitation, in all
spheres of life, which is safe, hygienic, secure, socially and culturally acceptable, which
provides for privacy and ensures dignity, (Dery, et al, 2021). Stigma and discrimination
often results in lack of access to water and sanitation and poor hygiene standards,
(UNOCHA,2018).The lack of access to essential services is a symptom, while the root
causes lie in stigma and discrimination,(MHRC,2018).Only through an understanding of
these causes will it be possible to implement effective measures to improve access to WASH
services for the vulnerable populations such as the female sex workers. Individuals who
find themselves stigmatized are socially ostracized and denied access to water, sanitation
and hygiene services, hence reinforcing the stereotype of uncleanliness and prolonging a
vicious circle(WHO,UNICEF, 2018).
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Several studies globally observed that vulnerable communities are disproportionately
excluded from access to water and sanitation due to stigma and discrimination(Dery et al,
2021,Bisung et al, 2021, Mclean,2018). Another study done by, Dickin et al (2021), reveled
that stigma and discrimination contributed to decreased ability to meet WASH needs and
perform WASH behaviors among the vulnerable populations.Additionally several studies
highlighted that stigma associated with the profession of sex work contributes to depriving
sex workers of their basic human rights, including access to health services,(Shawmy, 2020,
ASWA, 2021,NAC, 2020, Scorgie, et al, 2019).Furthermore, Sex workers in southern Africa
are marginalized, face human rights violations, discrimination, harassment, and numerous
other barriers to accessing healthcare which directly impact on their health,(ASWA,2021).
It is essential therefore, that programming must help to reveal and address underlying and
systemic causes of discrimination and stigma in WASH sector and work to change negative
attitudes and harmful social norms. This requires direct attention and inclusion of those
suffering stigma, marginalisation and those experiencing multiple forms of discrimination.
Therefore, this research is essential to unlock issues pertaining to WASH needs among the
female sex workers and find the solutions to this problem.
2.6 The principle of leave no one behind in wash ( LNOB)
Access to water and sanitation are recognized by the United Nations as human rights
fundamental to everyone’s health, dignity, and prosperity (UN, 2021). However, billions
of people are still living without safely managed water and sanitation. Marginalized groups
are often overlooked, and sometimes face discrimination, as they try to access the water
and sanitation services they need (SNV, 2019). Marginalized groups such Female sex
workers, children, refugees, disabled people, and many others also face active
discrimination from, those planning and governing water and sanitation improvements
and services, and other service users (WHO, UNICEF, 2020). To address this issue the
Governments, need to take a human rights-based approach (HRBA) to water and
sanitation improvements, so that no one gets left behind because all people are entitled to
water and sanitation without discrimination.Leaving no one behind is the central promise
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of the 2030 Agenda for Sustainable Development to ensure that all people are accesses
WASH services without hindrances, (UNOCHA,2018).
In Malawi, the government aligned the National Sanitation and Hygiene Strategy of 20182023 with the Sustainable Development Goals (SDG) specifically, SDG 6.1 and 6.2, which
aims for improved universal and sustainable access to safe drinking water, sanitation and
hygiene, and the elimination of open defecation by 2030. The strategy emphasizes the
need of ensuring that all inequalities regarding WASH are addressed and all the Malawians
have access to WASH regardless of their social status, (NSHS,2018- 2023).A society can
only achieve high rates of public health, gender equity, educational attainment, and
economic productivity when all of its members enjoy their rights to water and sanitation
(WHO/UNICEF,2020). Respect for human rights must be integrated into development
plans for all sectors, at all levels,(UN, 2021).
SDGs, Goal 6 on clean water and sanitation, follows the guiding principle of leave no one
behind,
(McDemant,2018).
However,
barriers
to
accessing
WASH
services
disproportionately affect the vulnerable populations. Previous joint WSSCC/OHCHR
roundtables on Interdependencies and mutual impacts between the human rights to water
and sanitation and other human rights, particularly for left behind groups
and on
Interdependencies between water and sanitation and other human rights highlighted that
marginalized groups such as Female Sex Workers, migrants, refugees and others are often
overlooked and sometimes face active discrimination from those planning and governing
water and sanitation improvements and service.The participants to these meetings
recommended that there is need to urgently give the floor directly to those in vulnerable
situations, to influence policies (UN,2019,WHO/UNICEF, 2018).To make this happen we
have to strategically aim to address the challenge of the inequalities that prevent the
marginalized people from realizing their rights to safe water, sanitation and hygiene hence
the importance of conducting this research among the female sex workers in Malawi.
2.7 Legal framework of sex work
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The legal frameworks around sex work between countries vary considerably, (OSISA,
2020). Enforcement practices play a key part in determining outcomes, regardless of the
law. In some cases, very harsh laws may not be strictly enforced, but in other cases more
benign laws may be enforced in unfair or abusive ways,(ASWA, 2020).In Malawi sex work
is legal but it is a highly stigmatized practice where police use laws against loitering and
public disorder to prosecute FSWs and healthcare workers deny care on the basis of
profession thereby preventing access to health care service,(FPAM, 2018).Furthermore, no
provision in the Malawi Penal Code criminalises the selling of sexual services by a sex
worker. Yet, some police officers in Malawi appear to be operating under the assumption
that sex work is illegal. This assumption is based on an interpretation of section 146 of the
Penal Code which prohibits a woman from living on the earnings of prostitution. Such an
interpretation is then used to justify an arrest under section 184(c) of the Penal Code, which
provides that a person found in a place in circumstances which lead to the conclusion that
such person is there for an illegal purpose, is deemed a rogue and vagabond. Additionally,
an approach of interpreting “where a woman knowingly lives wholly or in part on the
earnings of prostitution” to apply to and criminalise the earnings of a sex worker violates
the principle of legality because it broadens the offence beyond the plain meaning of its
words and beyond the legislative intent of the section,(FPAM, 2020). Such an approach
also violates the provisions of the Constitution requiring that a person not be convicted of
an offence which clearly does not exist (MHRC,2018).
2.8 Research gap
The gap to be addressed is to provide recommendations to meet the WASH needs of FSWs.
The literature sparsely addresses any WASH needs for the female sex workers women
during the perimenopause, with only fleeting, indirect references to needs for sanitation in
Egypt (Shawmy e, 2020) and South Africa (ASWA, 2018) despite a projected rise in the
number Female sex workers globally a. Nor does it explore practical aspects of WASH
provision for FSWs. Whilst these needs are hidden from the literature, they warrant
attention if the SDGs are to be met to ensure that no one is left behind.
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2.9 Theoretical Framework
Enabling
factors
+
Access to
WASH
Well - being
Addressing
Barriers
Figure 1. Conceptual framework of this study (Source: Shooya, 2017).
As indicated in Figure 2, enabling factors and barriers affect access to WASH which then
affects the well-being of communities. Enabling factors in this study include sources of
accessing and the means of accessing water sanitation and hygiene. The means further
consist of modes of accessing WASH and user participation. The barriers consist of social,
environmental and technical constraints to accessing WASH. These have been expanded in
the methodological matrix in Chapter 3 below.
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CHAPTER 3.0 METHODOLOGY AND MATERIALS
This section will discuss the research design, the study population, sampling technique, data
collection, presentation of findings, data analysis, dissemination of findings, ethical
considerations as well as the study variables.
3.1 Research design
A cross – sectional descriptive mixed method approach will be utilised in this this research
study. A mixed approach is a methodology for conducting research that involves collecting,
analysing and integrating quantitative and qualitative research (Foodrisc ,2016). With the
integration of the data, this approach highlights and provides greater understanding and
in-depth knowledge. Furthermore, a quantitative approach will be used to gain
information about the study area through generalized observations and surveys. Once the
data is collected, it will be converted into numbers and displayed in graphs, models and
tables. The practice of WASH and its related activities will be observed and documented
as well as the alternatives used for the lack of accessible toilets and sanitation devices.
3.2 Study setting
The study will be conducted in the four Drop-in Center (DICs) of the Pakachere Institute
of Health and Development Communication (PIHDC) and observation will be conducted
in the selected hotspots where FSWs reside. Drop-in-centers are stigma-free spaces where
female sex workers (FSWs) access basic health care services such as HIV counseling and
testing; STI screening and treatment; family planning information; and some contraceptive
methods, including condoms and lubricants. PIHDC have four drop-in centers in Lilongwe
namely Area 23 DIC, Area 36 DIC, Likuni DIC and area 25 DIC. Hotspots are places such
as rest houses, bars or lodges where female sex workers reside. The study will be conducted
from 1st January 2023 to 31st December 2023.
3.3. Study population
The study population will include female sex workers patronizing the DICs in the Lilongwe
district. Pakachere IHDC is currently reaching to 1180 female sex workers (PIHDC data
21
base- 2022). In Malawi it is estimated that there are more than 36,700 sex workers
(NAC,2020), most of whom remain hidden and marginalized because of social stigma
associated with sex work.
3.4 Sampling and Sample size
Purposive sampling will be utilized to select the four DICs, 32 participants to be part of the
focus group discussion, 8 from each DIC and 20 hotspots where observation will be
conducted in Lilongwe District. Snowball rolling approach will be utilized to select the
participants in this study. The observations will be conducted during outreach clinics which
are conducted in the hotspots where female sex workers reside. The study sample size will
be 298 study participants determined using the formula for systematic random sampling
using single proportions (Yamane, 1967).
N
The employed sample size formula will be:n = 1+N(e2 )
Where n = Sample size
N= expected proportion of Female Sex Workers accessing DICs = 1180 (PIHDC
data base, 2022) and
e= absolute precision (5%) = 0.005.
Therefore, from the above sample size is:
n=
1180
= 298
1 + 1180 ∗ 0.05 ∗ 0.05
3.5 Inclusion and exclusion criteria
The inclusion criteria will be Female Sex Workers 18 years old and above who will give
consent to participate in the study. The exclusion criteria will include Female Sex Workers
who will not be willing to sign the informed consent form and Female sex workers less
than 18 years of age.
3.6. Data collection and management
The data collection will start with the review of secondary data including the DIC records.
An interviewer-administered questionnaire will be utilized to obtain data relevant to the
22
study in a face-to-face interview. Additionally, focus group discussions from the selected
female sex workers will be conducted. A structured observation check list will also be
utilized to collect data on the WASH practices at hotspot level. The questionnaire and the
checklist will be adopted from the published studies and modified to suit the responding
population. Four research assistants who are the outreach workers working in the DICs
will be employed to conduct the interviews since they have good skills in handling FSWs.
3.7. Data analysis
Qualitative data will be analysed using content analysis based on key themes generated
from the objectives of the study. Some of the data will be analysed in verbatim (data
presented in the form in which the respondent offered it). Additionally, quantitative data
will be analyzed using a statistical software package for social sciences version 23 (SPSS
V.23). A regression model will be used to show the significance of predictor’s variables.
Statistical tests will be computed to show an association between the predictor’s variables
and the outcome variables. Frequency tables, pie charts and bar graphs will be generated
in presenting the research results. Differences between the parameters of estimate will be
deemed statistically significant at p < 0. 005.The detailed data analysis methods are
detailed in Table 1 below.
Table 1: Methodology Matrix
Specific objectives
Variables
Data
collection Methods
tool
SPSS V 23
WASH
Content
among FSWs with access to Observation
female sex works in the improved
study area
and checklist
Unimproved
water
source
and
un
improved
sanitation
23
analysis
Descriptive analysis
Linear regression – P
Value of 0.005
Access to Improved
data
analysis
To assess level of access to The proportion of Questionnaire
services
of
Availability
of
handwashing
facilities with water
and soap
To
analyze
barriers Stigmatized
and Questionnaire
impeding access to WASH discriminated
services among female sex Attitudes
workers in the study area
Observation
towards check list
SPSS V 23
content analysis
Chi-square,
logistic
WASH
regression – P Value of
Economic challenges
0.005
Distance
to
water
collection points
Administration
of
WASH
Infrastructure
Time allocation on
communal taps
To assess enabling factors Knowledge
and Questionnaire
promoting access to WASH practice on WASH
services among female sex Health
workers in the study area
Observation
seeking checklist
SPSS V 23
Content analysis
logistic regression -
behaviors
P Value of 0.005
ownership of water,
Chi- square
hygiene
and
sanitation
Access to health care
services
and
information
24
3.8 Ethical considerations
Respondent’s rights to make independent decisions on whether to participate in the study
or not will be respected. The participants will sign an informed consent form, which will
be an agreement by a prospective subject to voluntarily participate in a study after learning
all of the pertinent details about it. Additionally, no unauthorized person will get hold of
raw data and the completed questionnaires will be in safe keeping and not available for
any other purpose than in this research. Furthermore, the research proposal will be
reviewed by the Mzuzu University Research and Ethics Committee and permission will be
obtained from Pakachere IHDC to conduct the study in the Drop-in Centers in Lilongwe
district.
3.9. Study Limitation
Since this study will use questionnaires,self-reported data always comes with limitation
since there is a high possibility that the respondents may provide responses that are socially
acceptable rather than being truthful (social desirability).However this will mitigate by
explaining properly to the participants the importance of providing honest answers,
furthermore no any identification will be utilised on questionnaire to ensure that
participants are free to provide the required information.
3.10 Dissemination of the results
The final report of the research findings will be submitted to the Mzuzu University
Research and Ethics Committee, Mzuzu University Library, the National Health Sciences
Research Committee (through MZUNI), The University Research and Publication
Committee (URPC) (through the MZUNI Secretariat) and Pakachere IHDC secretariate.
The findings of the research study will also be disseminated through conference journal
articles.
25
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30
ANNEXES
Annex 1 : Ghart chart
ACTIVITY
MONTH
Jan
Feb
Mar-
June
July
Aug
2023
2023
May
2023
2023
2023 2023
2023
Identify
research
topic
Literature
review and
proposal
writing
Submission
of proposal
and
clearance
Data
collection
Data
analysis
Report
writing
Submission
of
dissertation
31
Sep
Oct
Nov
Dec
2023
2023
2023
Disseminati
on
of
findings
Annex 2: Budgets and Justification
ITEMS
Pens
QUANTITY
1box
PRICE
/
TOTAL
UNIT
AMOUNT
K1000
K 1,000.00
Justification
To be used during
data collection
Rim of papers
1
K12,000
K 12,000.00
(A4)
To
be
used
during
for
data
collection
Handbooks
1Pack
K10,000
K 10,000
To be used by data
collectors
Printing
360
K50.00
K 18,000.00
questionnaires
Payment
for
printing services at
the bureau
Printing
3
K5000
K 15,000.00
report
Payment
for
printing services at
the bureau
32
Binding
3
K5,000
K 15,000.00
Payment
for
binding services at
the bureau
Lunch
4for 5days
Allowance for
K6,000/
K
To
day
120,000.00
during
data
buy
lunch
data
collection
collectors
MZUNIREC
1
K 150 usd
K 150,000
1
1
K 350,000 .
Administration fee
Fee
Total
00
MZUNIREC
10% of the
K49,900
K 35,000. 00
budget
Grand total
1
Proposal processing
fee
1
K
385,000.00
33
Annex 3: Informed consent
Mzuzu University Research Ethics Committee (MZUNIREC)
Informed Consent Form for Research in
Master of science in Sanitation
Introduction
I am Angellah Chikoko Luhanga from Mzuzu University. We are doing research on
Water, sanitation and hygiene practices as predictors of diarrhea occurrence among
Female Sex Workers in Lilongwe district in Malawi. This consent form may contain
words that you do not understand. Please ask me to stop as we go through the
information, and I will take time to explain. If you have questions later, you can ask
them of me or of another researcher.
Purpose of the research
This research aims to explore the unmet needs of access to Water Sanitation and hygiene
among the Female Sex Workers in Lilongwe district - Malawi.
Type of Research Intervention
This research will involve your participation in an individual interview.
Participant Selection
34
You are being invited to take part in this research because you are one of the Female Sex
worker in Lilongwe district and your responses will us to address the challenges that
affects FSWs regarding WASH and diarrhea issues.
Voluntary Participation
Your participation in this research is entirely voluntary. It is your choice whether to
participate or not. If you choose not to participate nothing will change. You may skip
any question and move on to the next question.
Duration
The research takes place for a period of 1 year.
Risks
You do not have to answer any question or take part in the discussion/interview/survey
if you feel the question(s) are too personal or if talking about them makes you
uncomfortable.)
Reimbursements
You will not be provided any incentive to take part in the research.
Sharing the Results
The knowledge that we get from this research will be shared with you and your
community before it is made widely available to the public. Following, we will publish
the results so other interested people may learn from the research.
Who to Contact
If you have any questions, you can ask them now or later. If you wish to ask questions
later, you may contact: Mrs. Angellah Chikoko Luhanga on 0888554991/0993113240
35
This proposal has been reviewed and approved by Mzuzu University Research Ethics
Committee (MZUNIREC) which is a committee whose task it is to make sure that
research participants are protected from harm. If you wish to find about more about the
Committee, contact Mr. Gift Mbwele, Mzuzu University Research Ethics (MZUNIREC)
Administrator, Mzuzu University, P/Bag 201, Luwinga, Mzuzu 2, Phone:
0999404008/0888641486
Do you have any questions?
Part II: Certificate of Consent
I have been invited to participate in research about Water, sanitation and hygiene
practices as predictors of diarrhea occurrence among Female Sex Workers in Lilongwe
district in Malawi
I have read the foregoing information, or it has been read to me. I have had the
opportunity to ask questions about it and any questions I have been asked have been
answered to my satisfaction. I consent voluntarily to be a participant in this study
Print Name of Participant__________________
Signature of Participant ___________________
Date ___________________________
Day/month/year
If illiterate 1
I have witnessed the accurate reading of the consent form to the potential participant,
and the individual has had the opportunity to ask questions. I confirm that the individual
has given consent freely.
1
A literate witness must sign (if possible, this person should be selected by the participant and should have no connection to the
research team). Participants who are illiterate should include their thumb print as well.
36
Print name of witness____________
Signature of witness
Thumb print of participant
_____________
Date ________________________
Day/month/year
Statement by the researcher/person taking consent
I have accurately read out the information sheet to the potential participant, and to
the best of my ability made sure that the participant understands the research project. I
confirm the participant was given an opportunity to ask questions about the study, and
all the questions asked by the participant have been answered correctly and to the best
of my ability. I confirm that the individual has not been coerced into giving consent, and
the consent has been given freely and voluntarily.
Signature of Researcher /person taking the consent__________________________
Date ___________________________
Day/month/year
37
Annex 4: Questionnaire in English
This study is aimed at assessing the WASH needs for the FSWs to guide public health action.
The information obtained from the interviews will be confidential and your consent is
requested. Hence as the respondent you are requested to give correct and honest
information.
SECTION A: DEMOGRAPHIC INFORMATION
Q1. How old are you?
a. 18 -24
b. 24- 35
c. 36 -45
d. 45- 60
Q2. How far did you go with Education?
a. Primary school
b. Secondary school
c. Tertiary
Q3.Place of residence?
a. Bar based.
b. Home based.
c. Street based.
SECTION B:KNOWLEDGE ON WASH
Q4. Can unsafe water cause diarrheal diseases?
a. Yes
b. No
Q5. Can water get contaminated if not properly stored?
a. Yes
b. No
Q6. What are the consequences of improper waste disposal?
a .Expose to diseases
b. Does not expose diseases.
38
Q7. Have you got information on WASH in the last 3 month?
a. yes
b. no
Q8. Where did you get information?
a. Friends
b. Health facility
c. News paper
d. Radio/ TV
SECTION C: HYGIENE PRACTICES
Q9. When do you wash your hands?
a. Before having food
b. After having food
c. After going to toilet
d. Before taking medication
e. Before feeding baby
f. After changing baby nappies
Q10. What do you use when washing hands?
a. Soap
b. Water only
c. Ash
Q11. How often do you take bath?
a. Everyday
b. Every alternate day
c. Twice a week
d. Once a week or less frequent
Q12. Why don’t you take bath frequently?
a. Don’t like to
b. Don’t think necessary.
c. Due to lack of Water
39
d. Can’t afford soap.
Q13.How many times do you brush your teeth in a day?
a. Once every day
b. Twice or more every day
c. Less than once everyday
SECTION D: ACCESS TO WATER
Q14.What is the Main source of drinking water at your household?
a. Piped water.
b. Borehole
c. Well
d. kiosk
Q16.How do you treat water before drinking?(multiple answers)
a. Boil
b. Filter
c. Chlorination
d. don’t treat.
Q12.Does your household have to pay for water?
a.
Yes
b. No
Q17. Do you manage to pay your water bills without problems?
a. Yes
b. No
Q18. Is the water you are receiving enough to satisfy your needs?
a. Yes
b. No
Q19.Have you ever received any information or training about hygiene?
a. Yes
40
b. No
Q20. If yes, where did you receive the information from?
a. Family members
b. Support Group
c. Health Facility
d. Radio/TV
e. Newspaper/Magazine
Q 21.Do FSWs have increased need for better hygiene?
a. Yes
b. No
Q22. Why do you think FSWs have increased need? (Multiple response)
a. They are vulnerable for illnesses.
b. To prevent
c. Don’t know.
Q23. How do you think FSWs can prevent diarrhoea?
a. Drinking safe water
b. Eating clean food
c. Maintaining good hygiene
d. Keeping surrounding clean
e. Faeces management
SECTION E: ACCESS TO SANITATION
Q24.What type of latrine do you use?
a. VIP improved latrine
b. Traditional pit latrines
c. Flush toilet with a septic tank
Q25. Do you share the latrine?
a. Yes
b. No
Q26. How many people use one latrine at your hotspot.
41
a. Yes
b. No
Q27. Do you have a hand washing facility near your toilet?
a. Yes
b. No
Q28.IS soap always available for you hand washing?
a. Yes
b. No
Q.29. Where you dispose of your refuse in the right place?
a. Bin ( collected by city council)
b. Rubbish pit
c. Anywhere
SECTION F: Health in relation to WASH
Q30.Have you ever been sick for the past 3months.
a. Yes
b. No
Q31. Did you suffer from any of the diseases the past 3 months?(Multiple answers)
a. Diarrhoea
b. Dysentery
c. Skin infections
d. Typhoid
e. Conjunctivitis
Q 32. Do you take medication when sick?
a. Yes
b. No
Q33. Where do get the treatment when sick?
a. At home only 7
b. Government hospital
c. Private health facility
d. Private phamarcy
42
e. Faith-healers
Q 34.Did service providers give you WASH information?
a. Yes
b. No
SECTION G: FSTIGMA AND DESCRIMINATION
Q35. Have you ever disclosed to anyone that you are an FSW?
a . Yes
b . No
Q36. If no, why did you not disclose?
a. Fear
b. stigma
c. discrimination
d. didn’t know.
Q37. Have you ever been discriminated or stigmatized by a family member?
a. Yes
b. No
Q38. Have you ever been discriminated or stigmatized when accessing community?
people.
a. Yes
b. no
Q39. Have you ever been discriminated or stigmatized by a health care worker?
a. Yes
b. No
Q40. Have you ever been discriminated or stigmatized by a family member when
accessing the toilet?
c. Yes
d. No
Q41. Have you ever been discriminated or stigmatized by community people when
accessing the toilet?
c. Yes
43
d. no
Q48. Have you ever been discriminated or stigmatized by a family member when
accessing water?
a. Yes
b. No
Q49. Have you ever been discriminated or stigmatized by community people when
accessing water?
a. Yes
b. No
Thank you for your time.
Annex 5: Observation checklist
Serial #
Statement / Question
Answer
Are all the latrines functioning properly?
Yes
1.
No
Are there separate latrines for women and men ?
2
Yes
No
Is there easy access to the women’s latrines?
3.
Yes
No
Number of people per latrine ?
1-5
4
6- 10
11-20
21-30
31 and more
Condition of latrines
Good
44
5
Fair (needs repair)
Bad (needs replacement
6
Are there hand washing facilities.
Yes
near the latrine?
No
What type of water is available ?
Tap water.
7
share a common
container.
8
Do the hotspot always have enough water and
Yes
soap
No
Sometimes
Is there soap by the hand washing facility?
9
Yes
No
Do FSWs use the hand washing facilities?
10
Often
Quite often
Not often
11
What kind of source of water is there
Well
Tap water.
Borehole
none
12
Is the area around the water point clean, free
Yes
from visible garbage and puddles?
No
45