Use of sexual health services at hospitals by cleaning workers in Bogotá D.C. 2016

Abstract


Use of sexual health services at hospitals by cleaning workers in Bogotá D.C. 2016
Uso de los servicios de salud sexual por parte de trabajadoras de servicios generales en hospitales en Bogotá D.C. 2016

Introduction
In recent history, women have legitimized sexual rights as human rights, promoting gender equity as a determining factor for sexual and reproductive health research and public policy planning.(1,2) The Colombian health care model is strongly influenced by the competition within the supply and demand of health services; moreover, market laws compromise the equality and universality of these services.(3) According to a systematic review of studies on access to health services in Colombia, access has not increased as there are barriers associated with insurance, economic income, educational attainment and geographical, organizational and quality-service accessibility.(4) In this regard, the efforts of national and international health organizations to fight the occurence of sexually transmitted diseases (STDs) specifically have not prevented persistent reproductive and sexual health risks.(5) UNAIDS estimates show that although the incidence of HIV has decreased in recent decades, it is still a public health problem.(6,7) Both women and men living with HIV and receiving treatment have increased significantly (8); it is also a matter of concern that around 1.4 million maternal infections and 520 000 congenital infections caused by syphilis have been reported worldwide, including 304 000 perinatal deaths from 2009 to 2012 among working populations and disadvantaged social classes of Latin America.(9,10) Furthermore, the people most prone to contract these diseases are the most disadvantaged human groups.(10,11) It should be noted that barriers to accessing sexual health services are determined by internal factors that depend on each person's perception and decision while looking for a health service, as well as external factors that can derive from administrative, legal and structural difficulties, lack of awareness about the health system, socio-economic situation, culture, communication and education.(12)(13)(14) Identifying the barriers to accessing health services largely contributes to monitor inequalities and generate proposals to mitigate impacts on their health condition.(15) The utilization of health services comes from the interaction of three main factors: 1) predisposing factors: they are inherent to the patient, do not depend on the pathology and evaluate the perception of health and disease related to socioeconomic and demographic variables (age, sex, occupation, ethnicity, etc.) (16); 2) mediating or capacity factors: they can facilitate or limit access to services and are subject to changes in health policies, and 3) need factors: they include aspects related to the health-disease process and address the need in two ways, namely, the patient's perspective and the evaluation by the health staff.(17)(18)(19) Therefore, the objective of this study was to analyze the barriers to accessing sexual and reproductive health services by female cleaning workers at a hospital center in Bogotá D.C. in 2016; these women are one of the most marginalized human groups given their low educational attainment, low income and lack of knowledge about their health rights.

Materials and methods
The study was developed under an observational, descriptive crosssectional design.A survey was conducted based on the behavioral model of health services proposed by Aday & Andersen and adapted for sexual health.(17) Need factor variables were: knowledge of sexual health services, sexual and reproductive rights, STDs, contraception and quality of health care received.The predisposing factor variables were: age, marital status, ethnicity, educational attainment, socio-economic level and social support.Finally, capacity factor variables were: family income, commuting time and location of the Healthcare Service Provider (IPS by its acronym in Spanish), out-of-pocket expenses, among others.The query "sexual health services over the past 12 months" was established for the exposure variable.
Similarly, a pilot study (10 surveys) was conducted to check whether the questionnaire was understood, as well as the coherence and relevance of questions concerning the topic under evaluation.
The inclusion criteria used were: women who were not pregnant, female hospital cleaning workers hired by the JDR company (contracting party) at Fundación Hospital San Carlos, an institution where 37 women work in cleaning services.It was relevant to conduct the study in this vulnerable population because there was no prior record.
Frequency measurements were performed to determine the sample distribution based on age, marital status, ethnicity, employment status, educational attainment and socio-economic level.Predisposing, capacity and need factors concerning the use of sexual and reproductive health services were identified through bivariate and multivariate analyses; the goal was to develop an explanatory model based on the individual determining factors of the Aday & Andersen model.
The chi square test was performed in the bivariate analysis, where the significant statistical evidence were values of p<0.10.Effect confusion and modification were assessed through a multivariate analysis by selecting the variables with values p<0.25 in the bivariate analysis; this analysis was performed using the logistic regression model.The Wald test was used to establish statistical significance and measure the strength of association with the odds ratio (OR) values.The process was executed in the SPSS® software version 14.
The study was approved by the Research Committee of the Master's Degree in Public Health and Social Development of Fundación Universitaria del Área Andina and all the participants signed and informed consent.On the one hand, the research followed the guidelines of the Declaration of Helsinki (20) on the participation of the subjects and the researcher's confidentiality duties both at the beginning of and during the study; on the other, the research followed the guidelines established in the Resolution 8430 of the Colombian Ministry of Health (21), which sets forth the scientific, technical and administrative standards for health research.

Results
Regarding predisposing factors, 18.9% of the sample had not completed secondary studies, and only 2.7% had completed higher education studies, thus confirming that most of them have a low educational attainment; no participant was identified within an ethnic group (Table 1).35.1% of the respondent women were 21 to 40 years old and the bivariate analysis showed that age influenced the utilization of sexual health services before the 12 months; for example, 21 to 30-year old women used the service the most (66.7%), while 41 to 50-year old women used it less (12.5%).The marital status variable showed that 100% of married women attended the appointments, while only 14.3% of unmarried women attended the appointments (based on the p-value of the chi square test); 40.5% of the interviewed population lived in cohabitation.Finally, the multivariate analysis did not find any variables of predisposing factors that were closely related to the utilization of health services.With respect to capacity factors, 54.1% of the respondents belonged to the socio-economic level 2, 100% had an income of one current legal minimum wage, 59% had 1 to 2 children, 83% did not have any additional financial support and 89.2% considered that their income was insufficient to cover their monthly expenses.Moreover, 48.6% mentioned that the IPS was close to their workplace.It is worth mentioning that 67.6% stated that they have economic difficulties to use health services and nobody mentioned any difficulties related to work for such access (Table 1).The bivariate analysis showed that family income is related to lack of attendance to health services in 75.7% of the sample and that no variables in the multivariate analysis were strongly associated with the use of services.
Need factors showed that 43.2% is not aware of their sexual and reproductive rights and 64.9% is not aware of the sexual health services offered by their health promotion organization.Concerning knowledge about STDs, it was observed that 91% know what STDs are, since most of them have received information directly from health professionals at their workplace.It was evident that the respondents associate infidelity and having multiple sexual partners to a risk behavior leading to HIV infection (45.9%), as well as not using condoms (67%).
Concerning quality of health care, 100% of the participants gave a low rating to the opportunity they have to get appointments and the explanations given by health care professionals, 10.8% felt discriminated and 13.5% felt judged during the appointment; in short, the quality of health care in general had a low rating from 37.8% of the respondents.
Moreover, only 27% use condoms on a regular basis during their sexual relations, 24.3% did not consider it necessary and 21.6% did not like it.54% had taken an HIV test, the majority (27%) had been tested more than 3 years before the execution of the study and did not deemed it necessary to repeat it.89% had undergone a cytology test; however, 78.4% had not taken this test in the last year.Taking into account the time of the last appointment for sexual health services, it was found that 37.8% had never accessed these services and that 37.8% had not used them in the last 12 months (Table 1).
Multivariate analysis showed that the need factors related to knowledge about STDs, purchase of condoms and problems related to access to sexual health services have a statistically significant correlation with the utilization of sexual and reproductive health services by women.That is to say, those who do not have proper knowledge about HIV/AIDS risk behaviors use sexual health services 5.9 times less than women with such knowledge.Furthermore, purchasing condoms in places such as pharmacies and supermarkets has an impact on access to the services, since those buyers access the services 0.8 times less than those who get condoms at their IPS.Finally, when there are issues to make sexual health appointments, women access 2.1 times less than those who do not have any difficulty in doing so (Table 2).

Discussion
The state of the art of research on access to health services in Colombia shows that Colombians experience mainly administrative, economic and cultural barriers, where the perception of health condition and the need for care together with a low educational attainment and the lack of information on matters related to the right to health play a key role in the utilization of health services.(22,23) This study demonstrated that the perception of risk in health care is related to the utilization of services and is influenced by the social and economic context of the individual, as well as by variables such as age, marital status, educational attainment and ethnicity.The above has been shown in research on access to health services, mostly among women who suffer a high-cost disease such as cervical cancer or breast cancer.(24)(25)(26)(27)(28)(29)(30)(31) It is also essential to recognize the role of social support in the utilization of health care, since it was demonstrated that married women accessed services more frequently than unmarried women or women in cohabitation.In contrast to these results, a research on taking Pap test stated that one of the main factors that limits access to said test is the pressure that women are subjected to by their partner.(32) Geographic and travelling access barriers have also been identified, particularly in rural areas (24); this demonstrates that the use of health services in cities is not linked to the travelling time, since the servicing IPS are located close to the participants' residence or workplace.(12,33,34) Out-of-pocket expenditure represents an economic burden that the most vulnerable populations are not able to afford.(35) In the case of Colombia, this translates into not guaranteeing full access to services due to factors such as copayment, travelling and treatments that are not covered by the Mandatory Health Plan (POS for its acronym in Spanish).The bivariate analysis of this research showed that capacity factors are related to and represent barriers to accessing sexual health services; however, they are not the most representative factors.
STDs have been studied in depth worldwide, demonstrating that they are preventable diseases transmitted primarily by sexual contact (36); nevertheless, STDs and their negative impacts on health, which may include chronicity, infertility, cancer or even death, have not been controlled.(37,38) Consequently, STDs continue to be a priority for public health and a change that focuses on preventing contagion and providing timely treatment (39-41) that encompasses the perception of risk is required, since there is a higher probability of non-access to health services when risk behaviors related to STD transmission are not known, condoms are purchased in commercial places and issues arise while making an appointment.
Furthermore, some research studies have found a correlation between the social stigma generated by HIV in communities and the access to and effective use of health services for the diagnosis and treatment of the disease.(42) Also, gender status is considered to be one of the factors that lead to health inequalities, since it has been defined as a social construction that takes the female and male concepts beyond biological characteristics, relates to all economic, social and private aspects of life of individuals, and determines features and roles depending on sex or on how society sees the subject.(1,(43)(44)(45)(46) Access to health services has been studied throughout the world; however, the lack of a specific characterization of populations is evident; although population groups with similarities are addressed, it is not possible to extrapolate their special features.(47) This study allows advancing in knowledge about access barriers and determining factors that influence access to sexual health services by a group of women that has not been extensively studied nor intervened in a timely manner by the health system, even less when they are immigrants, considering essential variables such as predisposing factors, capacity factors and need factors to evaluate the utilization of health services, which are modified over time.Thus, it is imperative to generate continuous monitoring to determine the actual needs of the population.
Identifying access barriers contributes largely to monitor inequalities and generate proposals to mitigate impacts on health condition.(48) Therefore, one of the limitations of this study lies on the fact that the results obtained show a correlation between the perceived need to attend health services, the knowledge about sexual health rights and the risk behaviors of STD transmission; these are, however, not enough to demonstrate the cultural, social, political and economic reasons influencing the use of health services.Therefore, it is advisable to perform a qualitative study to identify and go in depth regarding other determining factors related to women's sexual health.

Conclusion
The determining factor identified for the utilization of sexual health services by female cleaning workers at a hospital in Bogotá D.C. is health care need; associated variables such as perception of risk behaviors and appropriateness of health care significantly influence the use of the service.

Table 1 .
Determining factors for the utilization of sexual and reproductive health services by cleaning workers at a hospital in Bogotá D.C.. 2015.

Table 2 .
Logistic regression analysis.Explanatory model of self-perception of sexual health and its correlation with quality of life among female cleaning workers.