Factors Inuencing Uptake of Sexually Transmitted Infections Screening Among Adolescent Female Sex Workers in Mukono District

Worldwide, more than 1 million Sexually Transmitted Infections (STIs) are acquired every day and female adolescents aged 10 to 19 years are almost twice more susceptible to STIs than boys of the same age. The highest STI prevalence has been reported among key populations such as Female Sex Workers (FSWs) and sher folk. This study investigated the factors inuencing uptake of sexually transmitted infections screening among Adolescent Female sex Workers (AFSWs) in Mukono district, Uganda. Data was collected using Analysis was at three for Bivariate to test for possible association between each independent and the outcome variable, and Multivariate logistic to possible effects independent variables. Chi square (χ2) test was done and p value 0.05 used to determine the association.

followed by prompt treatment among high risk vulnerable groups such as Adolescent Female Sex Workers (AFSWs).
Adolescence is a transitional phase of growth and development between childhood and adulthood and an adolescent is any person between ages 10 and 19. Sex work is the exchange of money, goods or services for sex and he who practices sex work is a sex worker. Quite a number of reasons such as age, peer pressure and others may explain why adolescents engage in immoral behaviors including sex work.
In this STI screening uptake study, pre-tested semi-structured questionnaires were used to collect data from respondents on what was in uencing their uptake of STI screening. Of the 355 respondents, majority 241 had never screened for STIs and 114 had screened.
The research priorities identi ed were individual factors (attitude) and health facility factors as real in uencers of uptake of STI screening among AFSWs in Mukono district.
In conclusion, AFSWs require information related to STIs and its screening. Information dissemination can be intensi ed at clinical and non-clinical sites to increase awareness and improve accessibility to STI screening experience among high risk vulnerable groups in Mukono district, hence reduce the prevalence among AFSWs, avert the risk of complications and eliminate sustained transmission in the community.

Background
Sexually transmitted infections other than HIV are an important global health issue. Sexually transmitted infections (STIs) in general, and among adolescents in particular, are of paramount concern to all people who work on improving the health status of populations (WHO 2019). The majority of STIs have no symptoms or only mild symptoms that may not be recognized as an STI in some cases. STIs can have serious reproductive health consequences beyond the immediate impact of the infection itself such as infertility in women and STIs consequences are a major reason for health seeking behavior among women.
According to WHO (2016), more than 1 million STIs are acquired every day worldwide. Each year, there are an estimated 357 million new infections with 1 of 4 STIs: chlamydia (131 million), gonorrhea (78 million), syphilis (5.6 million) and trichomoniasis (143 million). Worldwide the highest reported rates of STIs are found among young people between 15 and 24 years; up to 60% of the new infections and half of all people living with HIV globally are in this age group. Females adolescents in the age range of 10 to 19 years are almost twice as susceptible to STIs than boys of the same age and one in 20 adolescents acquires a new STI each year (UNAIDS 2014).
The goal of STI screening is to identify and treat individuals with curable infections, reduce transmission to others, avoid or minimize long term consequences, identify other exposed and potentially infected individuals and decrease overall incidence and prevalence of infection.
Since the International Conference on Population and Development in Cairo in 1994, attempts to date to promote the sexual health of young people have tended to focus on prevention, education and counseling for those who are not yet sexually active, while the provision of health services like STI screening to those who have already engaged in unprotected sexual activity and faced the consequences, including pregnancy, STIs or sexual violence, has lagged behind.
According to mukono district population data 2017, Mukono has a population of 807,923 people of which 403,117 are females and 141,990 are males. There are a high number of female adolescents aged 10-24 years at 25% (213,638 people). It has a large population of shing communities on the Islands and shores of Lake Victoria and has a high number of bars, lodges, hotels and brothels. These combined make sex work highly prevalent especially among adolescent girls and young women hence are at high risk of STI acquisition and transmission. In Mukono district, STI prevalence stands at 6.2% among females and 3.8% for males (MOH status report 2018).

Methods
In this cross sectional descriptive and analytical study, snow ball sampling was used to recruit 355 adolescent female sex workers based on the streets, bars, lodges, hotels, brothels, landing sites and other entertainment places in Mukono. Mukono district lies in the central region of Uganda and it lies approximately 20 km East of Kampala along the highway which links Uganda to Kenya.

Data collection methods
Quantitative data was collected through face to face interviews using pretested semi-structured and selfadministered questionnaires with the help of trained research assistants. All potential participants who met the eligibility criteria were briefed about the study. Eligibility was assessed for respondents who expressed willingness to participate and consent to participate were sought from eligible participants.

Quantitative data management and analysis
Quantitative data collected was entered into EPI-DATA, cleaned, and then exported to SPSS for analysis at univariate, bivariate and multivariate level. Cross tabulations were used to show the proportions of AFSWs and uptake of STI screening per variable. Bivariate analysis was done using chi-square to test and show the factors that were associated with uptake of STI screening. Factors with a P-value ≤ 0.1 at bivariate level were further analyzed at multivariate level using binary logistic regression analysis to determine the factors that were signi cantly and independently associated with uptake of STI screening.
Using the binary logistic regression analysis model, the summary model generated R 2 = 40.7%. This means that the factors generated as in uencing factors can only explain 40.7% of the observed situation.

Results
The results show that the proportion of AFSWs who had screened was 32.1% (114) while 67.9% (241) hadn't screened as shown in the Fig. 1.
Majority, 83 (72.8%) of those who had screened were in the age group of 15-19 years and 158 (65.6%) of those who had not screened were in the same age group (χ 2 :1.864, P = 0.172), this therefore means that AFSWs age was not found to in uence STI screening uptake.
None of the socio-demographic factors of the AFSWs including:-age, religion, marital status, occupation alongside sex work, base as AFSW, years of practice as sex worker, as well as location of residence of the AFSW had any signi cant relationship with the uptake of STI screening among AFSWs as presented in Table 1. Our results revealed attitudes that were associated with uptake of STI screening among AFSWs, risk of contracting STI (χ 2 : 23.538, p = 0.001); embarrassing to screen for STI (χ 2 : 45.146, p = 0.001); STI screening painful (χ 2 : 57.019, p = 0.001); Screening for STI makes one worry (χ 2 : 16.584, p = 0.001) and advising another AFSW to screen for STI (χ 2 : 15.823, p = 0.001), see Table 2. Among the health facility factors that the study assessed, our ndings revealed that distance (χ 2 : 10.335, p = 0.035); sensitization on STIs and their screening (χ 2 : 15.307, p = 0.001); Waiting time (χ 2 : 9.731, p = 0.021); presence of follow-up system (χ 2 : 11.488, p = 0.001); adolescent friendly clinic at your nearest health facility (χ 2 : 12.985, p = 0.001) and provision of STI screening services at nearest facility (χ 2 : 18.714, p = 0.001) were signi cantly associated with uptake of STI screening among AFSWs as shown in Table 3. Our results indicate that AFSWs who reported STI screening wasn't embarrassing were more than 3 times likely to take-up STI screening than those who said uptake of STI screening was embarrassing (PR = 3.45, 95%CI = 1.96-6.09, P = 0.001). AFSWs who said STI screening wasn't painful were more than 5 times likely to take-up STI screening than those who said uptake of STI screening was painful (PR = 5.45, 95%CI = 2.78-10.66, P = 0.001). AFSWs who said screening for STI will not make one worry were almost 4 times likely to take-up STI screening than those who said screening for STI will make one worry (PR = 3.74, 95%CI = 1.37-10.17, P = 0.010). Those who said they can't advise another AFSW to take up STI screening were 0.2 times less likely to go for STI screening than those who said they can advise another AFSW (PR = 0.25, 95%CI = 0.09-0.70, P = 0.009). Those who said they don't have STI screening at the nearest facility to where they live were 0.2 times less likely to go for STI screening than those who said they have STI screening at the nearest facility to where they live (PR = 0.20, 95%CI = 0.07-0.54, P = 0.002).
Those who said they don't have an adolescent friendly clinic in the nearest facility were 2 times more likely to take up STI screening than those who said the adolescent clinic was available (PR = 2.42, 95%CI = 1.22-4.82, P = 0.012). Using the binary logistic regression analysis model with L/R forward, the summary model generated R 2 = 40.7%. This means that the factors generated as in uencing factors can only explain 40.7% of the observed situation, see Table 4 Table  This study found that the uptake of STI screening rate was at 32.1%. This is probably due to AFSWs attitudes including STI screening being embarrassing, painful, makes one worry and advising another AFSW to go for STI screening as well as health facility factors including provision of STI screening in the nearest health facility and availability of adolescent friendly clinic as these proved to be statistically signi cant variables which in uenced uptake of sexually transmitted infection screening at different levels of analysis.
In a USA study among AFSWs, Roth et al. 2013, found out that 90% of AFSWs had not screened for STIs yet 88% of other women reported willingness to screen only if they were allowed to collect their own sample. This is in agreement with the 2010 US Federal and prostitution law report on FSWs in which it was stated that the prevalence of STIs was higher among FSWs than other women such as migrants, adding that it was due to neglect of screening uptake amidst high risk sexual behavior that results in worse sexual health outcomes.

Socio-demographic Factors And Uptake Of Sti Screening
Our study ndings show that 241 (67.9%) of the respondents were in the age group of in 15-19years, older than other respondents in the age group of 10-14 years 114 (32.1%), possibly because currently AFSW 15-19 years are more exposed to independent life without any parenteral or guardian restrictions to movement, social networking and peer in uence.
Majority of those who had screened were in the age group of 15-19 years, an indicator that older AFSWs were more likely to takeup STI screening than their counterparts in the age group of 10-14 years, and this may be possibly due to the fact thet they can easily access information that enables them undestand, that they are at risk of acquiring STIs by nature of their job than those aged 10-14 years. Our study also revealed that an AFSWs age (χ 2 :1.864, P = 0.172) was not found to in uence STI screening uptake. This is supported by a Nigerian study carried out by Erin et al., (2013), in which female adolescents in transactional sex reported that they wanted to get information from parents and providers about STIs and its screening but parents did not provide it adding that given their discreet sexual behavior, frequent asking of their parents on this topic would lead to unexpected eventualities including dismissal from home. Contrary to this, Chakuvinga et al., (2017) found out that the AFSWs perceived themselves as young, not susceptible and therefore, not bothered about STI screening issues and the older sex workers found it di cult to discuss this with the young ones for them to clearly understand and change their perception hence this poor relationship affected STI screening uptake.
In this study, none of the socio-demographic factors had a signi cant relationship with the uptake of STI screening among AFSWs unlike in another Ugandan study carried out by Mbonye et al., 2013, whichrevealed that some socio-demographic factors including the age group, years of sex work practice and residence of an AFSW in uenced their uptake of STI screening.

Attitudes Towards Sti Screening
In our study, majority 59.6% of the respondents reported that it was not too embarrassing to screen for sexually transmitted infections. This can be attributed to their past experience with uptake of STI screening. AFSWs who said STI screening wasn't embarrassing were 3 times more likely to take-up STI screening than those who said uptake of STI screening was embarrassing. This is contrary with a USA study among AFSWs, in which Malla and Goyal, (2012) reported that participants (87%) indicated willingness to recommend self-sampling to a friend because they felt having a clinician collect a sample was awkward and embarrassing.
From this study ndings, 81.6% of the respondents said screening for STIs will make one worry. This is true because of the uncertainty of the test result amidst the already known high risk job circumstances and exposure of these AFSWs. There was a signi cant relationship between being worried and uptake of STIs screening (χ 2 : 16.584, p = < 0.001) at 0.05 level of signi cance. AFSWs who said screening for STI will not make one worry were 4times more likely to take-up STI screening than those who said screening for STI will make one worry. This could be because they knew they were at risk of acquiring STI and were highly suspecting to have an STI, they were possibly therefore willing to take up STI screening for early diagnosis to be started on treatment just in case they had positive test result or to be advised on how to prevent themselves from acquiring STIs if given a negative test result.

Health Facility Factors And Uptake Of Sti Screening
In this study, 96.5% said STI screening services were available in Mukono district and majority 78.1% said that they had an adolescent friendly clinic at the nearest facility to where they lived. However, in this study, ndings are that those who said they don't have an adolescent friendly clinic in the nearest facility were 2 times more likely to take up STI screening than those who said the adolescent clinic was available. This is possibly due to the fact that the services are widely provided by the MOH through health facilities in outreaches or camps which are not consistently organized at speci c facilities/adolescent friendly clinics near to where they live. In another high-prevalence cohort in India, Das, et al. (2011) reported that participants indicated that being screened for STIs outside of a clinic setting would provide a more feasible option for taking up STI screening. Similar to this was in Ethiopia, Adisababa where Cherie and Berhane (2012) reported that clinic systems were not usually oriented to providing youth with reproductive health screening especially for STIs. This frequently led to the perception that SRH services and the systems themselves were 'not for youths' which overlapped with barriers related to acceptability of services In Uganda, non-government organizations have single handedly or have partnered with MOH to stage organized screening outreaches and camps not necessarily at health facilities that have targeted high risk groups. This is supported by this study ndings in which most 55.2% of those that screened accessed screening services at non-clinical sites such as outreaches than at health facilities. In this current study, there was an association between availability of adolescent friendly clinic in the nearest health facility and uptake of STI screening (χ 2 : 12.985, p = < 0.001) Failure to screen at adolescent clinic can also be attributed to the long distance that had to be travelled to reach the nearest health facilities with an adolescent clinic in relation to the providers who bring screening services nearer to targeted users.
The study revealed that 88.6% of the respondents said STI screening was provided at the nearest facility to where they lived. This can be true because the government of Uganda through the MOH has established and integrated reproductive health services including screening within existing health facilities to ease access and facilitate acceptability among even high risk and vulnerable groups such as

Conclusions
In this study where sexually transmitted infection screening rates among AFSWs in Mukono district was still low at 32.1% which is still far below the national average of 80% for eligible women, individual factors (attitude) and health facility factors were found to be the real in uencers of uptake of STI screening among AFSWs in Mukono district. It's important for government to scale-up/intensify provision of information related to STIs and its screening at clinical and non-clinical sites such as the possibility of STI community-based self-sampling among adolescents to increase awareness and improve accessibility to STI screening experience among high risk vulnerable groups in Mukono district so as to reduce the prevalence among AFSWs.  Figure 1 Level of uptake of STI screening among adolescent sex workers in Mukono district