title: Universal Coverage without Universal Access: Institutional Barriers to Health Care among Women Sex Workers in Vancouver, Canada.
abstract: Access to health care is a crucial determinant of health. Yet, even within settings that purport to provide universal health coverage (UHC), sex workers' experiences reveal systematic, institutionally ingrained barriers to appropriate quality health care. The aim of this study was to assess prevalence and correlates of institutional barriers to care among sex workers in a setting with UHC.
  
  
  
  Data was drawn from an ongoing community-based, prospective cohort of women sex workers in Vancouver, Canada (An Evaluation of Sex Workers' Health Access). Multivariable logistic regression analyses, using generalized estimating equations (GEE), were employed to longitudinally investigate correlates of institutional barriers to care over a 44-month follow-up period (January 2010-August 2013).
  
  
  
  In total, 723 sex workers were included, contributing to 2506 observations. Over the study period, 509 (70.4%) women reported one or more institutional barriers to care. The most commonly reported institutional barriers to care were long wait times (54.6%), limited hours of operation (36.5%), and perceived disrespect by health care providers (26.1%). In multivariable GEE analyses, recent partner- (adjusted odds ratio [AOR] = 1.46, % 95% Confidence Interval [CI] 1.10-1.94), workplace- (AOR = 1.31, 95% CI 1.05-1.63), and community-level violence (AOR = 1.41, 95% CI 1.04-1.92), as well as other markers of vulnerability, such as self-identification as a gender/sexual minority (AOR = 1.32, 95% CI 1.03-1.69), a mental illness diagnosis (AOR = 1.66, 95% CI 1.34-2.06), and lack of provincial health insurance card (AOR = 3.47, 95% CI 1.59-7.57) emerged as independent correlates of institutional barriers to health services.
  
  
  
  Despite Canada's UHC, women sex workers in Vancouver face high prevalence of institutional barriers to care, with highest burden among most marginalized women. These findings underscore the need to explore new models of care, alongside broader policy changes to fulfill sex workers' health and human rights.
authors.affiliation: British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, Vancouver, BC, Canada.|Department of Medicine, University of British Columbia, St. Paul's Hospital, Vancouver, BC, Canada.
authors.forename: M Eugenia
authors.initials: ME
authors.lastname: Socías
authors.affiliation: School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada.
authors.forename: Jean
authors.initials: J
authors.lastname: Shoveller
authors.affiliation: Sex Workers United Against Violence Society, Vancouver, BC, Canada.
authors.forename: Chili
authors.initials: C
authors.lastname: Bean
authors.affiliation: British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, Vancouver, BC, Canada.
authors.forename: Paul
authors.initials: P
authors.lastname: Nguyen
authors.affiliation: British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, Vancouver, BC, Canada.|Department of Medicine, University of British Columbia, St. Paul's Hospital, Vancouver, BC, Canada.
authors.forename: Julio
authors.initials: J
authors.lastname: Montaner
authors.affiliation: British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, Vancouver, BC, Canada.|Department of Medicine, University of British Columbia, St. Paul's Hospital, Vancouver, BC, Canada.
authors.forename: Kate
authors.initials: K
authors.lastname: Shannon
mesh_terms: D000328:Adult; D002170:Canada; D003695:Delivery of Health Care / Q000592:standards* / Q000706:statistics & numerical data*; D005260:Female; D005500:Follow-Up Studies; D019538:Health Care Surveys; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D006801:Humans; D011446:Prospective Studies; D062486:Public Health Surveillance; D057566:Self Report; D060386:Sex Workers / Q000706:statistics & numerical data*; D019472:Universal Health Insurance / Q000592:standards* / Q000706:statistics & numerical data*