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Examining the Intrapersonal, Interpersonal and Community Level Correlates of Access to Medical Care Among Women Employed by Sex Work in Southern Uganda: A cross-sectional Analysis of the Kyaterekera Study

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Abstract

Women employed by sex work (WESW) experience significant gaps in accessing necessary healthcare services, leading to unmet health needs. Yet, there is a dearth of literature on the barriers to medical care access among WESW in Uganda. We used data from the Kyaterekera baseline to examine the correlates of access to medical care among WESW, defined as the ability of individuals to obtain the necessary healthcare services they require in a timely, affordable, and equitable manner. The Kyaterekera study recruited 542 WESW aged 18–58 years from Southern Uganda. We conducted a multilevel linear regression model to determine the intrapersonal (age, education level, marital status, HIV knowledge, and asset ownership), interpersonal (family cohesion and domestic violence attitudes), and community (community satisfaction, sex work stigma and distance to health facility) level correlates of access to medical care among WESW. Intrapersonal and interpersonal factors were associated with access to medical care among WESW. There was no significant association between community level factors and access to medical care. WESW with secondary education (β = 0.928, 95% CI = 0.007, 1.849) were associated with increased access to medical care. WESW with high asset ownership (β = -1.154, 95% CI= -1.903, -0.405), high family cohesion (β = -0.069, 95% CI= -0.106, -0.031), and high domestic violence attitudes (β = -0.253, 95% CI= -0.438, -0.068) were associated with decreased access to medical care. The findings emphasize the critical need for targeted family strengthening interventions to enhance family support for WESW and address domestic violence.

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Data Availability

Due to the sensitivity around the data, the data will not be deposited in a data repository. However, data used in this analysis is available upon reasonable request. The team is open to data sharing provided the points outlined below, which were part of the study protocol, data sharing plan, and consenting process, are met; (1) A formal research question is specified a priori; (2) Names, affiliations, and roles of any other individuals who will access the shared data; (3) The deliverable(s)—e.g., manuscript, conference presentation—are specified a priori; 4)Proper credit and attribution—e.g., authorship, co-authorship, and order—for each deliverable are specified a priori; 5) A statement indicating an understanding that the data cannot be further shared with any additional individual(s) or parties without the PI’s permission; 6) IRB approval for the use of the data (or documentation that IRB has determined the research is exempt).

Code Availability

Statistical analysis code is available at the request of the first author.

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Acknowledgements

We would like to express our sincere appreciation to the women employed by sex work (WESW) who participated in this research study. We would also like to acknowledge the dedicated research team at the International Centre for Child Health and Development (ICHAD), Masaka Field Office, Washington University in St. Louis, Columbia University in New York, New York University, and the University of North Carolina at Chapel Hill for their meticulous implementation of the study. Furthermore, we extend our gratitude to the study partners, including the Rakai Health Sciences Program, Reach the Youth Uganda, the Community Collaborative Board; and the Data and Safety Monitoring Board whose collaboration and support were instrumental in the implementation of the study.

Funding

Kyaterekera study is funded by the National Institute of Mental Health (NIMH) under award number R01MH116768 (MPIs: Fred Ssewamala, PhD & Susan Witte, PhD). The trial is registered at https://clinicaltrials.gov. NIMH was not involved in the study design, data collection, analysis, findings interpretation and manuscript preparation. The content in this article does not reflect the views of NIMH or the National Institutes of Health.

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Authors and Affiliations

  1. International Center for Child Health and Development (ICHAD), Washington University in St. Louis Brown School, 1 Brookings Drive, St. Louis, MO, 63130, USA

    Joshua Kiyingi, Proscovia Nabunya, Samuel Kizito, Josephine Nabayinda, Jennifer Nattabi, Edward Nsubuga, Ozge Sensoy Bahar, Flavia Namuwonge & Fred M. Ssewamala

  2. Department of Heath Behavior, Department of Maternal and Child Health, University of North Carolina, 316 Rosenau Hall, CB #7400, 135 Dauer Drive, Chapel Hill, NC, 27599, USA

    Larissa Jennings Mayo-Wilson

  3. International Center for Child Health and Development (ICHAD), Masaka, Uganda

    Fatuma Nakabuye, Flavia Nanteza & Dinah Mukasa

  4. Silver School of Social Work, New York University, 1 Washington Square North, New York, NY, 10003, USA

    Prema L. Filippone

  5. Columbia University School of Social, Work1255 Amsterdam Avenue, New York, NY, 10027, USA

    Susan S. Witte

  6. Brown School, Washington University in St. Louis International Center for Child Health and Development (ICHAD), Goldfarb, Room 346 Campus Box 1196, One Brookings Drive, St. Louis, MO, 63130, USA

    Fred M. Ssewamala

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  1. Joshua Kiyingi
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Contributions

FMS and SSW conceptualized the study, secured funding, and oversaw all aspects of its implementation. JK, PN, LJMW and FMS contributed to the study’s conceptualization. JK drafted the initial manuscript and conducted data analysis. LJMW, PN, SK, JN, JN, OSB, FN, PLF, DM, SSW, and FMS provided critical feedback and contributed to manuscript revisions. EN, FN, and FN supervised field data collection. All authors reviewed and commented on earlier versions of the manuscript and approved the final version.

Corresponding author

Correspondence to Fred M. Ssewamala.

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Ethical Consideration

Institutional review boards in Uganda and the United States of America approved the study protocol, in Uganda it was approved by the Uganda Virus Research Institute (UVRI) (Ref: GC/127/18/10/690) and the Uganda National Council for Science and Technology (Ref: UNCST –SS4828) in Uganda. In the USA it was approved by Columbia University Institutional Review Board (Ref: AAAR9804) and Washington University in St. Louis Institutional Review Board (Ref: #201,811,106). All study participants provided voluntary written consent before study participation and were made aware of their rights to withdraw from the study anytime they want without the study team approval.

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Kiyingi, J., Mayo-Wilson, L.J., Nabunya, P. et al. Examining the Intrapersonal, Interpersonal and Community Level Correlates of Access to Medical Care Among Women Employed by Sex Work in Southern Uganda: A cross-sectional Analysis of the Kyaterekera Study. AIDS Behav (2024). https://doi.org/10.1007/s10461-024-04333-y

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