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A literature review: efficacy of online learning courses for higher education institution using meta-analysis

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  • Volume 26 , pages 1367–1385, ( 2021 )

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literature review about online education

  • Mayleen Dorcas B. Castro   ORCID: orcid.org/0000-0002-6618-6958 1 , 2 &
  • Gilbert M. Tumibay 3  

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The Internet has made online learning possible, and many educators and researchers are interested in online learning courses to enhance and improve the student learning outcomes while battling the shortage in resources, facilities and equipment particularly in higher education institution. Online learning has become popular because of its potential for providing more flexible access to content and instruction at any time, from any place. It is imperative that the researchers consider, and examine the efficacy of online learning in educating students. For this study, the researchers reviewed literature through meta-analysis as the method of research concerning the use of ADDIE (Analysis, Design, Development, Implementation and Evaluation) framework for designing and developing instructional materials that can provide wider access to quality higher education. This framework can be used to list generic processes that instructional designers and training developers use (Morrison et al., 2010 ). It represents a descriptive guideline for building effective training and performance support tools in five phases, as follows: 1.) Analysis, 2.) Design, 3.) Development, 4.) Implementation, and 5.) Evaluation. The researchers collected papers relating to online learning courses efficacy studies to provide a synthesis of scientifically rigorous knowledge in online learning courses, the researchers searched on ERIC (Education Resources Information Center), ProQuest databases, PubMed, Crossref, Scribd EBSCO, and Scopus. The researchers also conducted a manual search using Google Scholar. Based on the analysis, three main themes developed: 1.) comparison of online learning and traditional face-to-face setting, 2.) identification of important factors of online learning delivery, and 3.) factors of institutional adoption of online learning. Based on the results obtained 50 articles. The researchers examine each paper and found 30 articles that met the efficacy of online learning courses through having well-planned, well-designed courses and programs for higher education institution. Also, it highlights the importance of instructional design and the active role of institutions play in providing support structures for educators and students. Identification of different processes and activities in designing and developing an Online Learning Courses for Higher Education Institution will be the second phase of this study for which the researchers will consider using the theoretical aspect of the ADDIE framework.

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Castro, M.D.B., Tumibay, G.M. A literature review: efficacy of online learning courses for higher education institution using meta-analysis. Educ Inf Technol 26 , 1367–1385 (2021). https://doi.org/10.1007/s10639-019-10027-z

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Online Distance Learning: A Literature Review

29 Sep 2020

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This week’s blogpost is a guest post by Dr John L. Taylor , Director of Learning, Teaching and Innovation at Cranleigh School .

Dr Taylor is leading a free CIRL professional development webinar on project-based learning, on 17 November from 4-5pm GMT. The link will be available on CIRL’s Eventbrite page soon and the webinar recording will be added to CIRL’s Resources and Professional Development page .

What does the secondary research literature tell us about distance learning?

This blogpost offers a literature review on online distance learning, which is thematically divided into four sections. I first consider what the literature tells us about the efficacy of online distance learning (section 1) and the importance of building a learning community (section 2). I then discuss what the literature says in response to two questions: ‘Does online distance learning work better for some students?’ (section 3) and ‘Can online distance learning support the development of self-regulated learning?’ (section 4).

In this review, the following key terms are defined as follows:

  • Distance learning: a ‘form of education in which the main elements include physical separation of teachers and students during instruction and the use of various technologies to facilitate student-teacher and student-student communication.’ [1]
  • Online learning: ‘education that takes place over the internet’. [2] This can be subdivided into asynchronous online courses that do not take place in real-time and synchronous online courses in which teacher and student interact online simultaneously. [3]
  • Blended learning: a hybrid mode of interaction which combines face-to-face in-person meetings with online interaction. [4] As blended learning is a hybrid model, either the face-to-face or the online elements may be dominant. So, for example, blended learning can occur when online instructional tools are used to support face-to-face learning in a classroom, or when some face-to-face instruction is interspersed with online learning as part of a longer course.
  • A virtual school: ‘an entity approved by a state or governing body that offers courses through distance delivery – most commonly using the internet’. [5]
  • Self-regulated learning: ‘the modulation of affective, cognitive and behavioural processes throughout a learning experience in order to reach a desired level of achievement’. [6] Self-regulating learning skills have been described as abilities such as planning, managing and controlling the learning process. [7] Processes that occur during self-regulated learning include goal setting, metacognition and self-assessment. [8]

1. The Efficacy of Online Distance Learning

That said, there is also evidence of equivalence across a number of outcome measures. A 2004 meta-analysis by Cathy Cavanaugh et al of 116 effect sizes measured across 14 K-12 web-delivered distance learning programmes between 1999 and 2004 found that there was no significant difference in outcomes between virtual and face-to-face schools. [10]

A 2015 study by Heather Kauffmann explored factors predictive of student success and satisfaction with online learning. [11] Kauffmann notes that several studies have found that online learning programmes lead to outcomes that are comparable to those of face-to-face programmes.

VanPortfliet and Anderson note that research into hybrid instruction indicates that students achieve outcomes that match, if not exceed, outcomes from other instructional modalities. In particular, academic achievement by students in hybrid programmes is consistently higher than that of students engaged in purely online programmes. [12]

The ongoing discussion in the literature suggests that it is difficult to draw general conclusions about the efficacy of online learning as such, not least because it constitutes in significant ways a distinctive mode of learning when compared with real-world instruction. It is perhaps better, then, to look more specifically at questions such as the comparative strengths and challenges of moving to virtual schooling, the conditions which need to be in place for it to function well and the manner in which this transition is experienced by learners with different capabilities.

2. The Importance of Building a Learning Community

A helpful summary of research about online learning by Jonathan Beale at CIRL contains an outline of principles concerning successful online distance learning programmes.The summary explores research-based recommendations for effective teaching and learning practices in online and blended environments made by Judith V. Boettcher and Rita-Marie Conrad in their 2016 work, The Online Teaching Survival Guide: Simple and Practical Pedagogical Tips . [13] A central emphasis of these recommendations is that successful online learning depends upon the formation of an online learning community, and this is only possible if there is regular online interaction between teachers and students:

Why is presence so important in the online environment? When faculty actively interact and engage students in a face-to-face classroom, the class evolves as a group and develops intellectual and personal bonds. The same type of community bonding happens in an online setting if the faculty presence is felt consistently. [14]

The significance of relationship building is noted in the Michigan Virtual Learning Research Institute’s Teacher Guide to Online Learning :

Creating a human-to-human bond with your online students, as well as with their parents/guardians and the student’s local online mentor, is critical in determining student success in your online course. This can be accomplished through effective individual and group communication, encouraging engagement in the course, productive and growth-focused feedback, and multiple opportunities for students to ask questions and learn in a way that is meaningful to them. [15]

Research into virtual learning emphasises the importance of the connection between students and their teachers. This can be lost if there is no ‘live’ contact element at all. As Beale notes, this does not necessarily mean that every lesson needs to include a video meeting, though there is a beneficial psychological impact of knowing that the teacher is still in contact and regular face-to-face online discussions can enable this. There are other forms – a discussion thread which begins during a lesson and is open throughout can perform the same role, though in cases where meeting functions are available, students may be directed to use these rather than email.

As well as the teacher-student relationship, student-student links are important. There is evidence of improved learning when students are asked to share their learning experiences with each other. [16]

Beale’s research summary also emphasizes the importance of a supportive and encouraging online environment. Distance learning is challenging for students and the experience can be frustrating and de-motivating if technology fails (e.g., if work gets lost or a live session cannot be joined due to a connection failure or time-zone difference). More than ever, teachers need to work at providing positive encouragement to their students, praising and rewarding success and acknowledging challenges when they exist. It is also valuable if teachers can identify new skills that students are acquiring – not least skills in problem-solving, using information technology and resilience – and encourage their classes when they see evidence of these.

3. Does online distance learning work better for some students?

Given that, more or less by definition, students participating in an online distance learning programme will be operating with a greater degree of autonomy, it may be expected that those who will be best suited to online learning will be those with the greatest propensity for self-regulated learning. This view is advanced in a review of the literature on virtual schools up until 2009, by Michael Barbour and Thomas Reeves:

The benefits associated with virtual schooling are expanding educational access, providing high-quality learning opportunities, improving student outcomes and skills, allowing for educational choice, and achieving administrative efficiency. However, the research to support these conjectures is limited at best. The challenges associated with virtual schooling include the conclusion that the only students typically successful in online learning environments are those who have independent orientations towards learning, highly motivated by intrinsic sources, and have strong time management, literacy, and technology skills. These characteristics are typically associated with adult learners. This stems from the fact that research into and practice of distance education has typically been targeted to adult learners. [17]

Given the lack of evidence noted by Barbour and Reeves, a more cautious conclusion would be that we may expect to find a relationship between outcomes from online distance learning programmes and the propensity of students for self-regulated learning, rather than the conclusion that this capacity is a precondition of success.

Kauffmann notes that students with the capacity for self-regulated learning tend to achieve better outcomes from online courses. This result is not surprising, given that in online learning more responsibility is placed on the learner. [18]

A 2019 review of 35 studies into online learning by Jacqueline Wong et al explores the connection between online learning and self-regulated learning. The study highlights the significance of supports for self-regulated learning such as the use of prompts or feedback in promoting the development and deployment of strategies for self-regulated learning, leading to better achievement in online learning:

In online learning environments where the instructor presence is low, learners have to make the decisions regarding when to study or how to approach the study materials. Therefore, learners’ ability to self-regulate their own learning becomes a crucial factor in their learning success … [S]upporting self-regulated learning strategies can help learners become better at regulating their learning, which in turn could enhance their learning performance. [19]

In a 2005 study of ‘Virtual High School’ (VHS), the oldest provider of distance learning courses to high school students in the United States, Susan Lowes notes that the VHS’s pedagogical approach ‘emphasizes student-centered teaching; collaborative, problem-based learning; small-group work; and authentic performance-based assessment’. [20] This approach, Lowes comments, is aligned with a growing body of literature on the characteristics of successful online courses.

Taking a more student-centred approach during online instruction fits with features of the online environment. It is natural to make more use of asynchronous assignments and to expect students to take more responsibility for their study, given that they are not subject to direct supervision in a classroom setting and may be accessing course materials outside of a conventional timetable.

4. Can online distance learning support the development of self-regulated learning?

It may be the case that, even if Barbour and Reeves are correct in claiming that only those students with an ‘independent orientation towards learning’typically achieve successful outcomes from online distance learning programmes, a countervailing relationship obtains insofar as participation in an online distance learning programme may foster the development of the propensity for self-regulated learning.

A controlled study in 2018 by Ruchan Uz and Adem Uzun of 167 undergraduate students on a programming language course compared blended learning with a traditional learning environment.  The study found that, for the purpose of developing self-regulated learning skills, blended instruction was more effective than traditional instruction. [21]

In a 2011 review of 55 empirical studies, Matthew Bernacki, Anita Aguilar and James Byrnes noted that research suggests that:

[T]echnologically enhanced learning environments … represent an opportunity for students to build their ability to self-regulate, and for some, leverage their ability to apply self-regulated learning … to acquire knowledge. [22]

Their review suggests that the use of technologically enhanced learning environments can promote self-regulated learning and that such environments are best used by learners who can self-regulate their learning. [23]

However, an investigation by Peter Serdyukov and Robyn Hill into whether online students do learn independently argues that independent learning requires active promotion as well as a desire to promote autonomy on the part of the instructor and the necessary skills and motivation on the part of students. Where these conditions are not met, the aspiration to autonomy is frustrated, which can lead to negative outcomes from the online learning experience. [24]

Bernacki, Aguilar and Brynes employed an Opportunity-Propensity (O-P) framework. The O-P framework was introduced by Brynes and Miller in a 2007 paper exploring the relative importance of predictors of math and science achievement, where it was described as follows:

This framework assumes that high achievement is a function of three categories of factors: (a) opportunity factors (e.g., coursework), (b) propensity factors (e.g., prerequisite skills, motivation), and (c) distal factors (e.g., SES). [25]

It is plausible to suggest that the two-way relationship between self-regulated learning skills and successful participation in an online distance learning programme can be explained in terms of the opportunities online distance learning offers in three areas: first, to develop self-regulated learning skills afforded by the online distance learning environment; second, the prior propensity of learners to self-regulate their learning; and third, changes in distal factors (such as exclusive mediation of learning through online platforms to IT and parental involvement in learning).

Summary of Secondary Research Literature

The following points can be made about online distance learning based on the foregoing review:

  • Successful online learning depends upon the formation of an online learning community. Regular online interaction between teachers and students is important in the development of an online community. Teacher-student and student-student links are part of this.
  • Students with the capacity for self-regulated learning tend to achieve better outcomes from online courses.
  • There is some evidence that online distance learning programmes can be used to help develop self-regulated learning skills. This is provided that both teacher and student are motivated by the goal of building autonomy .
  • There is support in the research literature for using collaborative, problem-based learning and authentic performance-based assessment within online learning programmes.

Coda: review and revise

It is fair to say that the move to an entirely distance learning programme is the single biggest and most rapid change that many educators will ever have had to make. As with any large-scale rapid and fundamental innovation, it is hard to get everything right. We need to be willing to revise and refine. This may mean adapting to use a new software platform across the whole school if problems are found with existing provision, or it may be an adjustment to expectations about lesson length or frequency of feedback. Keeping distance learning programmes under review is also essential as we look towards a possible future in which it will co-exist with face-to-face teaching.

This literature review is an edited version of the literature review in my report, ‘An Investigation of Online Distance Learning at Cranleigh’ , September 2020, which can be downloaded here . In that report, the literature review is used to establish several conclusions about the implementation of online learning programmes. Those findings are compared to trends discernible in the responses to a questionnaire survey of three year groups at Cranleigh School (years 9, 10 and 12). The programme of study for these year groups was designed to provide continuity of delivery of the curriculum, in contrast to the programmes developed for years 11 and 13, where a customised programme of study was developed to bridge the gap created by the withdrawal of national public examinations during the summer term of 2020.

[1] ‘Distance learning | education | Britannica’ .

[2] Joshua Stern, ‘Introduction to Online Teaching and Learning’ .

[3] Fordham University, ‘Types of Online Learning’ .

[5] Michael K. Barbour and Thomas C. Reeves, ‘The reality of virtual schools: A review of the literature’, Computers & Education 52.2 (2009), pp. 402-416.

[6] Maaike A. van Houten‐Schat et al , ‘Self‐regulated learning in the clinical context: a systematic review’, Medical Education 52.10 (2018), pp. 1008-1015.

[7] René F. Kizilcec, Mar Pérez-Sanagustín & Jorge J. Maldonado, ‘Self-regulated learning strategies predict learner behavior and goal attainment in Massive Open Online Courses’, Computers & education 104 (2017), pp. 18-33.

[8] Sofie M. M. Loyens, Joshua Magda and Remy M. J. P. Rikers, ‘Self-directed learning in problem-based learning and its relationships with self-regulated learning’, Educational Psychology Review 20.4 (2008), pp. 411-427.

[9] Paul VanPortfliet and Michael Anderson, ‘Moving from online to hybrid course delivery: Increasing positive student outcomes’, Journal of Research in Innovative Teaching 6.1 (2013), pp. 80-87.

[10] Cathy Cavanaugh et al , ‘The effects of distance education on K-12 student outcomes: A meta-analysis’, Learning Point Associates/North Central Regional Educational Laboratory (NCREL), 2004.

[11] Heather Kauffman, ‘A review of predictive factors of student success in and satisfaction with online learning’, Research in Learning Technology 23 (2015).

[12] VanPortfliet & Anderson, op. cit., pp 82 – 83 .

[13] Judith V. Boettcher & Rita-Marie Conrad, The Online Teaching Survival Guide: Simple and Practical Pedagogical Tips (Second Edition; San Francisco, CA: Jossey-Bass, 2016).

[14] Ibid. Boettcher & Conrad’s chapter is reprinted with permission in this article , from which the quotation is taken.

[15] Michigan Virtual’s ‘Teacher Guide to Online Learning’ .

[16] Joan Van Tassel & Joseph Schmitz, ‘Enhancing learning in the virtual classroom’, Journal of Research in Innovative Teaching 6.1 (2013), pp. 37-53.

[17] Michael K. Barbour & Thomas C. Reeves, ‘The reality of virtual schools: A review of the literature’, Computers & Education 52.2 (2009), pp. 402-416.

[18] Heather Kauffman, ‘A review of predictive factors of student success in and satisfaction with online learning’, Research in Learning Technology 23 (2015).

[19] Jacqueline Wong et al , ‘Supporting self-regulated learning in online learning environments and MOOCs: A systematic review’, International Journal of Human–Computer Interaction 35.4-5 (2019), pp. 356-373.

[20] ‘Online Teaching and Classroom Change – CiteSeerX’ .

[21] Ruchan Uz & Adem Uzun, ‘The Influence of Blended Learning Environment on Self-Regulated and Self-Directed Learning Skills of Learners’, European Journal of Educational Research 7.4 (2018), pp. 877-886.

[22] Matthew L. Bernacki, Anita C. Aguilar & James P. Byrnes, ‘Self-regulated learning and technology-enhanced learning environments: An opportunity-propensity analysis’, Fostering self-regulated learning through ICT , IGI Global (2011), pp. 1-26.

[24] Peter Serdyukov & R. Hill, ‘Flying with clipped wings: Are students independent in online college classes’, Journal of Research in Innovative Teaching 6.1 (2013), pp. 52-65.

[25] James P. Byrnes & David C. Miller, ‘The relative importance of predictors of math and science achievement: An opportunity–propensity analysis’, Contemporary Educational Psychology 32.4 (2007), pp. 599-629.

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Caring: The heart of online nursing education- An integrative review

Affiliations.

  • 1 Johns Hopkins University School of Nursing, Baltimore, MD, United States of America. Electronic address: [email protected].
  • 2 Thomas Jefferson University, College of Nursing, United States of America.
  • 3 Johns Hopkins University School of Nursing, Baltimore, MD, United States of America. Electronic address: [email protected].
  • PMID: 38777524
  • DOI: 10.1016/j.profnurs.2024.03.008

With the widespread adoption of online education, nursing educators have observed significant challenges related to learner engagement and participation. Over the past decade, the implementation of Caring has consistently displayed a beneficial influence on creating and maintaining a sustainable online learning environment. However, existing online nursing curricula often lack a Caring and learner-centered approach. The aim of this integrative review is to analyze existing research and gain a comprehensive understanding of the factors that promote a sense of Caring in online nursing education programs. A systematic search for published peer reviewed, English language literature identifying the factors that contribute to Caring in online nursing education was conducted utilizing five databases. Findings from 18 included articles suggest that a combination of Caring strategies implemented by faculty and students, and the utilization of institutional resources contribute to enhanced student outcomes. Faculty driven strategies that promote an online Caring environment are Caring communication, role modeling, building personal connections, demonstrating teaching passion, and embodying emotional intelligence. Student behaviors that promote a Caring online environment include deliberate commitment to learning, genuine presence, active listening, and meaningful interactions with peers. Furthermore, incorporating instructional design to develop a Caring learning platform provides synergy to the student and faculty strategies to produce a Caring environment.

Keywords: Caring; Nursing education; Online; Resources; Strategies.

Copyright © 2024 Elsevier Inc. All rights reserved.

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Declaration of competing interest The authors declare there are no conflicts of interest.

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In the last decade, there has been an increase in online or digital technology-based training. Online training offers promising, accessible learning opportunities for everyone. However, few studies have specifically evaluated the scope of this training for adults with disabilities. The primary aim of this study is to conduct a systematic review of this topic. This involves evaluating the literature, including the methodology used, the variables analyzed, and the characteristics of the training program, as well as identifying gaps in the research. Our findings show that the number of publications is low, although there has been an increase in recent years. Furthermore, it is critical to highlight the importance of an intervention methodology grounded in scientific research and the evaluation of implementation fidelity. In general, online programs improve a variety of trained skills. Expanding interventions within this population, mainly targeting adult women with disabilities, is essential to promote equity and inclusivity in lifelong learning.

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Introduction.

The advancement of Information and Communication Technologies (ICT) has greatly impacted society, transforming the way we live, work, and learn. In this last aspect, ICT has become a fundamental support, opening new possibilities and opportunities. Thus, in recent decades, online education has experienced significant growth (Karademir Coşkun & Alper, 2019 ; Wallace-Spurgin, 2020 ). Educational platforms, online training courses, and digital resources are presented as globally accessible learning opportunities. However, is online education truly accessible to everyone, including adults with disabilities? And is the provision of this training sufficient for this group? Although ICTs offer significant opportunities, access to online training is not always equitable, presenting challenges particularly for adults with disabilities.

According to the World Health Organization ( 2023 ), it is estimated that approximately 1.3 billion people worldwide have some form of disability, accounting for 16% of the global population. In Europe, the Council of the European Union ( 2022 ) reports that 101 million adults are living with disabilities, representing 27% of the adult population. They further note that the age groups most affected are those between 45 and 64 years old, as well as those over 65. Additionally, within the European Union, the prevalence of disabilities is higher among women, at 29.5%, compared to 24.4% among men (Council of the European Union, 2022 ).

We must keep in mind that people with disabilities encounter a multitude of challenges. Compared to those without disabilities, they experience higher rates of unemployment, increased risk of poverty or social exclusion, greater susceptibility to violence and abuse, poorer academic performance, and a higher school dropout rate (Council of the European Union, 2022 ). In this context, online education could help mitigate some of these issues, potentially improving the quality of life for people with disabilities and fostering their social integration. Furthermore, Article 24.5 of the Convention on the Rights of Persons with Disabilities (Instrument of Ratification of the CRPC, December 13, 2006, April 21, 2008) explicitly recognizes the right to education for persons with disabilities:

States Parties shall ensure that persons with disabilities have general access to higher education, vocational training, adult education, and lifelong learning without discrimination and on an equal basis with others. To this end, States Parties will ensure that reasonable adjustments are made for persons with disabilities (Article 24.5, p. 96)

In this regard, online training could offer several advantages over face-to-face training for people with disabilities. For instance, its adaptability allows for training to be personalized based on the individual’s profile, learning style, and specific needs (Aeiadand & Meziane, 2019 ). Online training also provides flexibility in terms of when the training is accessed, enabling learners to set their own pace, and thereby fostering greater autonomy in learning. Another key feature of online education is its accessibility, both in terms of time and location, which allows learners to access training from any place (Herrera et al., 2015 ). Additionally, some studies (e.g., Biggs & Tang, 2011 ) have noted that for individuals with autism spectrum disorder (ASD), asynchronous participation in discussions can reduce stress by allowing them to respond at their own pace.

Considering these advantages, there has recently been a considerable increase in online or virtual learning environments developed specifically for individuals with special educational needs (Ozdemir et al., 2019 ). These environments include a range of tools such as online learning platforms, collaborative learning environments, virtual classrooms, 3D simulators, and virtual environments, as well as virtual reality (VR) and augmented reality (AR). These emerging technologies are being explored for their potential to enhance the educational experience by offering immersive simulations and more engaging learning environments. For instance, Contreras-Ortiz et al. ( 2023 ) note that the technologies like VR, AR, and mobile applications are particularly implemented with individuals with autism, alongside other utilized environments.

These educational environments are versatile, enabling the development of a broad range of skills, including academic, social, emotional, communication, personal autonomy, and cognitive skills, among others. For example, Howard and Gutworth ( 2020 ) emphasize the potential of virtual reality (VR) to enhance social and emotional skills in individuals with autism.

However, key questions remain: What components or elements should a learning environment include to ensure meaningful learning for people with disabilities? Additionally, what skills must individuals possess to effectively interact with online environments?

Research by Meyers and Bagnall ( 2015 ) and Downing ( 2014 ), which reflects the perceptions of students with autism, underscores the necessity for clear instructions and presentation of material. They recommend minimizing the number of resources and links available. In line with these findings, it is crucial to design simpler environments that feature clear, specific, simple, literal, and easy-to-follow instructions (Contreras-Ortiz et al., 2023 ).

Adams et al. ( 2019 ) identified several barriers and facilitators in the learning experience of university students with autism. Among the barriers, notable issues include the overwhelming amount of information on a page, the need for immediate answers to their questions, difficulty planning the schedule, excessive workloads, and pressing deadlines. Conversely, facilitators include the ability to pause and replay videos, flexible scheduling, prompt responses to inquiries, availability of evaluation rubrics, and a detailed timetable. The authors emphasize the importance of interaction and creating collaborative learning communities. However, they caution that the nature and frequency of these interactions can either hinder or help students with autism, thus underscoring the need to establish a functional virtual community (Garrison, 2017 ). Additional studies (Contreras-Ortiz et al., 2023 ) highlight essential characteristics of an effective online environment. These environments should be dynamic, incorporating a variety of resources and a robust learning support system, and must adapt to meet individual needs and preferences (Brown, 2000 ). For individuals with ASD, it is crucial to include visual elements such as videos and images, utilize authentic images, provide specific instructions, and employ a natural voice in presentations. In addition, instructional strategies should incorporate positive reinforcements, gradually increase the difficulty of activities, and ensure thorough supervision and monitoring throughout the teaching-learning process (Contreras-Ortiz et al., 2023 ). Acosta et al. ( 2020 ) also provide recommendations for creating accessible and inclusive online content. These guidelines align with the Authoring Tools Accessibility Guidelines (ATAG) 2.0 of the World Wide Web Consortium. They design online training programs for people of any age with disabilities. Ultimately, any intervention or training must be tailored to the specific needs of its target population.

Key skills necessary for successful online learning include self-regulation, self-discipline, time management, organization, and self-evaluation. These skills, crucial for engagement with learning content, are highlighted in a review by Kauffman ( 2015 ) and further supported by research from Serdyukov and Hill ( 2013 ). Additionally, digital competence is essential for effective interaction with online platforms and resources, particularly for adults with disabilities.

Despite a significant increase over the last decade in the number of publications on interventions and training through online environments, VR/AR, etc., across various population groups (e.g., Dechsling et al., 2020 ; Mesa-Gresa et al., 2018 ; Lorenzo et al., 2018 ), and the positive outcomes from the implementation of ICT in training processes (Contreras-Ortiz et al., 2023 ), a critical question remains: What do we really know about the online training of adults with disabilities?

Several review studies have investigated virtual and augmented reality (VR/AR) in educational interventions for individuals with autism. For example, studies conducted by Mesa-Gresa et al. ( 2018 ) and Lorenzo et al. ( 2018 ) have primarily focused on children with autism. Expanding this demographic scope, the research by Dechsling et al. ( 2022 ) reviewed the literature on autism interventions using VR/AR across different age groups. Their analysis of 49 articles found that only one study (Amaral et al., 2018 ) included participants over 31, with no studies involving individuals over 40. Similarly, Contreras-Ortiz et al. ( 2023 ) reviewed e-learning ecosystems for people with ASD, observing a notable gap in research focused on adults. An e-learning ecosystem integrates all essential components needed to implement an online learning system, as discussed in studies by Ezzahraa et al. ( 2020 ) and Luna-Encalada et al. ( 2021 ).

To our knowledge, no studies from previous reviews have specifically aimed to analyze online training for adults with disabilities. Given the rapid development of online learning and the notable lack of information about this demographic, there is a clear justification for conducting a review to systematically map and evaluate the existing research in this field.

The aim of this review is to provide a comprehensive summary of studies that have utilized online training formats for adults with disabilities. This involves evaluating the literature, including the methodologies used, the variables analyzed, and the characteristics of the training program. Additionally, this review seeks to identify any research gaps in the existing literature.

Material and methods

A systematic review was conducted following the protocol “Preferred Reporting Items for Systematic Reviews and Meta-Analyses” PRISMA protocol version 2020 (Page et al., 2021 ). This protocol includes four phases: identification, selection, eligibility, and inclusion (Urrútia & Bonfill, 2010 ).

Search strategy

We searched for relevant documents related to our object of study in two electronic databases: SCOPUS and WoS. The search was carried out by topic in the last ten years (January 2014 to January 2024). We conducted the search using a combination of keywords with different Boolean operators. Quotation marks (“”) were used to find documents that contained the specific concept related to our study. Likewise, the operator “OR” expanded the search with synonyms for the keywords. We also used the asterisk (*) after the root of a word to search for all documents containing that word and its possible endings. Finally, to find only the documents containing the key concepts (or set of concepts simultaneously), the logical operator joined these “AND.” The first topic involved words related to online education. We use (“e-learning” OR “online education” OR “distance learning” OR “virtual learning” OR “distance education” OR “online learning” OR “online course” OR “remote education” OR “remote learning” OR “virtual education” OR “virtual course” OR “web-based learning” OR “web-based training” OR “web-based education” OR “online training program”). The second topic was related to the age or population that is the object of our study. The words used were (“adults” OR “adulthood” OR “Elderly” OR “Age group: 18 and older”). The last topic referred to the disabled group. This dernier topic was as follows: (“disabilities” OR “disabled” OR “impairments” OR “special needs” OR “neurodevelopmental disorders” OR “intellectual disorders” OR “intellectual disabilities” OR “communication disorders” OR “autism spectrum disorder” OR “attention-deficit/hyperactivity disorder” OR “specific learning disorders” OR “motor disorders” OR “physically challenged” OR “physical disabilities” OR “sensory impairments” OR “chronic health conditions” OR “autis*“ OR “sensory disabilities” OR “syndrome down”).

Inclusion and exclusion criteria

For an article to be included, it had to: (1) address directly online training aimed at adults with disabilities; (2) the sample study had to be people with disabilities; (3) were published in the last ten years (from January 2014 to October 2023); (4) were studied from any country (published in English or Spanish). Exclusion criteria were: (1) Gray literature (dissertations, posters, etc.); and (2) studies not reporting results about the online program.

Selection process

The search identified 535 articles (105 from WoS and 430 from SCOPUS). All documents were exported to the Rayyan tool for subsequent classification and selection. Of the 535 papers found, we removed 54 duplicate documents. The titles and abstracts of the 481 papers found were then examined. To ensure fairness and improve the reliability of our selection process, we employed a method known as blind selection, as described by Ouzzani et al. ( 2016 ). This method allowed multiple judges to rank documents independently without being influenced by the ratings of others. Our selection process followed a structured approach inspired by Belur et al. ( 2021 ), which involves dividing screening into multiple stages. In line, each author screened the documents found in three different stages: in the first stage, each author reviewed 161 papers, and in the second and third stages, reviewed 160 articles, respectively. During this phase, disagreements arose that were discussed by the authors, reaching a justified agreement on selecting the article for the next phase. This iterative method allows judges to refine their understanding of the inclusion criteria and improve consensus at each stage, ultimately improving the reliability of the IRR index. After completing the blind selection, we collected the rankings of all judges and transferred them to a database. Subsequently, we calculated inter-rater reliability indices (IRR) to assess the consistency of the judgments. IRR indices were calculated using Coen’s Kappa, achieving 0.74 in the first stage, 0.80 in the second stage, and a perfect score of 1 in the last stage (see Table 1 ).

After screening, 408 records were eliminated for not meeting the inclusion criteria. The remaining 73 documents were assessed for the eligibility phase. For this purpose, the full texts were obtained. The process was carried out through a collaborative effort between the two authors, so the articles were distributed equally. Next, each author reviewed the work done by her colleague to check and verify that the articles met the criteria. If there was any disagreement, it was analyzed and discussed. Finally, 16 articles are selected for review once the inclusion and exclusion criteria have been examined and applied. Fifty-nine articles were excluded during this phase for the following reasons: (1) The purpose of the training in these studies was solely rehabilitative rather than educational. These interventions focused on recovering or improving skills and functions physically lost or impaired by illness or injury rather than educational interventions aimed at enhancing knowledge and skills in a health context or other contexts. For example, studies involving the use of a robot connected to an arm, intended to improve mobility after an injury, were excluded. (2) Some studies included both minors and adults in their sample, but presented the results without distinguishing between different age groups. (3) Despite targeting people with disabilities, certain training programs were tested on healthy individuals. (4) Some studies included diseases that could potentially lead to disabilities in the future, but did not necessarily involve individuals with current disabilities. (5) Studies lacking comprehensive explanations of their research design (including sampling methods, description of the sample, instruments, procedures, and data analysis) were excluded from consideration. This decision was made with the recognition that a thorough explanation of these aspects is crucial for maintaining rigor.

Figure 1 offers a visual representation of the process conducted in accordance with the PRISMA protocol.

figure 1

Data extraction procedure in four phases: identification, selection, eligibility and inclusion.

Document coding

The 16 scientific articles underwent analysis and coding based on the following criteria: (1) Participant information, including age, number of participants, gender, and type of disabilities. (2) Study details, encompassing authors, year of publication, objectives, methodology, measurements, instruments, analysis, and principal findings. (3) Program specifics, covering objectives, methodology, and duration.

Following the PRISMA protocol, 16 scientific articles were included and analyzed based on criteria encompassing the study participants’ characteristics, characteristics of the studies, and program attributes, as previously mentioned.

About the characteristics of the study participants (see Table 2 ), most studies provide specific details on age, sex, and type of disability. The studies encompass a range of age groups, with some focusing on specific development stages (Arachchi et al., 2021 ; Bruce et al., 2017 ; Garcia et al., 2023 ; Mead et al., 2023 ). Participant numbers vary significantly, from a single participant in the study by Silva de Souza et al. ( 2018 ) to 5586 participants in Mead et al. ( 2023 ), bringing the total number of participants across all studies to 6129. Generally, the sample sizes are small, with most studies involving no more than 128 participants, except for Mead et al. ( 2023 ), which analyzed institutional accommodations for students with disabilities using existing registered data. The gender distribution across the studies appears relatively balanced, although some studies show slight variations toward one gender. Now, if we narrow our focus to the subset of individuals with disabilities within the sample under consideration, excluding the study by Mead et al. ( 2023 ), where the large sample skews the overall statistics, we find that 55.83% of participants are male, while 44.15% are female among those with disabilities. The studies also cover various types of disabilities: two concentrate on intellectual disabilities (Arachchi et al., 2021 ; St. John et al., 2022 ), two on autism spectrum disorder (De Felice et al., 2023 ; Garcia et al., 2023 ), two on Attention Deficit/Hyperactivity Disorder (Bruce et al., 2017 ; Moëll et al., 2015 ) and two on visually impairments (Güdül Öz & Yangın, 2021 ; Silva de Souza et al., 2018 ), with others addressing additional disabilities.

Regarding the characteristics of the studies (see Table 3 ), it is observed that while the aims of the studies are diverse, some common themes emerge. For instance, St. John et al. ( 2022 ) and Rimmer et al. ( 2022 ) focus on evaluating programs aimed at improving well-being, while Curtiss et al. ( 2023 ) and Güdül Öz and Yangın ( 2021 ) evaluate educational programs centered on sexuality education. Additionally, Fjellström et al. ( 2022 ) and Rimmer et al. ( 2022 ) both involve programs related to physical activity. All these articles commonly evaluate training programs designed for adults with disabilities. The methodologies employed across these studies vary, with 50% utilizing quantitative methods (e.g., Bruce et al., 2017 ; De Felice et al., 2023 ; Mead et al., 2023 ; Moëll et al., 2015 ; Worobey et al., 2018 ), 37.5% using mixed methods, and 12.5% adopting qualitative approaches. These studies assess the effectiveness of ICT-based training by analyzing improvements in various domains, including cognitive (e.g., Chiu et al., 2023 ; Moëll et al., 2015 and Worobey et al., 2018 ), physiological and physical activity (e.g., Busse et al., 2022 ; Fjellström et al., 2022 ; Rimmer et al., 2022 ; Silva de Souza et al., 2018 ), educational and behavioral (v.gr., Ayuso & Santiago, 2022 ; Bruce et al., 2017 ; Curtiss et al., 2023 ; García et al., 2023 ; Güdül Öz & Yangın, 2021 ; Moëll et al., 2015 ) and performance variables (Arachchi et al., 2021 ; De Felice et al., 2023 ; Mead et al., 2023 ). Additionally, several studies assess the feasibility, usability, satisfaction, and participants’ perception of their experiences (e.g., Busse et al., 2022 ; Fjellström et al., 2022 ; Garcia et al., 2023 ; Güdül Öz & Yangın, 2021 ; Rimmer et al., 2022 ; St. John et al., 2022 ), while a few analyze implementation fidelity (e.g., Busse et al., 2022 ; Chiu et al., 2023 ; Garcia et al., 2023 ). A variety of tools, including scales, questionnaires, observations, and interviews, are employed, and analyses such as ANOVA and regression are commonly used (e.g., De Felice et al., 2023 ; Fjellström et al., 2022 ; Mead et al., 2023 ; Rimmer et al., 2022 , Worobey et al., 2018 ). In qualitative studies, thematic and content analyses are prevalent (e.g., Curtiss et al., 2023 ; García et al., 2023 ; Silva de Souza et al., 2018 ; St. John et al., 2022 ).

Concerning the characteristics of the programs (see Table 4 ) and the main objectives pursued in the interventions, various focuses are evident. Some programs aim to improve specific skills such as danger perception and driving ability (Bruce et al., 2017 ) or cognitive skills (Chiu et al., 2023 ). Others provide knowledge on diverse topics, like effective web search techniques (Arachchi et al., 2021 ) or a broad range of content (De Felice et al., 2023 ). Regarding the intervention methodologies, many studies report that the programs often include support from professionals, researchers, or teachers who help reinforce learning, address questions, or resolve technical issues (Arachchi et al., 2021 ; Ayuso & Santiago, 2022 ; Busse et al., 2022 ; Chiu et al., 2023 ; De Felice et al., 2023 ; Fjellström et al., 2022 ; Moëll et al., 2015 ; Rimmer et al., 2022 ; Silva de Sousa et al., 2018 ; St. John et al., 2022 ; Worobey et al., 2018 ). Some studies highlight a structured sequence of instruction grounded in empirical evidence (Busse et al., 2022 ; Garcia et al., 2023 ). Additionally, the modalities of delivery vary, with some programs featuring real-time video calls and interactive sessions between teachers and students (De Felice et al., 2023 ), while others utilize platforms that offer pre-recorded content alongside messaging systems for communication (Garcia et al., 2023 ). The duration of these programs also varies considerably. Some are conducted in a single session lasting 40–60 min (De Felice et al., 2023 ; Silva de Souza et al., 2018 ) whereas others consist of multiple weekly sessions, each lasting 45–60 min, over several weeks (Ayuso & Santiago, 2022 ; Fjellström et al., 2022 ).

In general, the findings from multiple studies underscore the benefits of web tools and online learning for people with disabilities, presenting overall positive results. However, when comparing in-person to online learning, the results are mixed. For example, Ayuso and Santiago ( 2022 ) observed better outcomes with online formats, whereas Mead et al. ( 2023 ) noted that face-to-face settings offer more adaptations beneficial to students with disabilities. Worobey et al. ( 2018 ) found that both in-person and web-based training groups showed improvement, with web-based training proving as effective as in-person training. Furthermore, several authors (Curtiss et al., 2023 ; St. John et al., 2022 ) emphasize the importance of co-creating learning environments with people with disabilities. They advocate for involving these individuals in the planning and design processes to ensure the environments meet their specific needs and preferences.

This review aimed to identify studies focused on training adults with disabilities through electronic means. We adopted the staged selection procedure outlined by Belur et al. ( 2021 ) to enhance the accuracy and precision in document selection and minimize observer bias. From this rigorous selection process, we identified 16 studies with diverse characteristics.

In analyzing the gender distribution within these studies, we found no consistent pattern indicating a higher proportion of male or female participants across the entire sample. However, when focusing specifically on the disabled adults within these studies, a higher rate of male participation emerged. This finding aligns with Dechsling et al. ( 2022 ), where only 7.4% of participants were women. In our analysis, the gender difference was 11 percentage points, which is somewhat less pronounced than in the Dechsling study. It is important to note that this analysis excluded three of the 16 selected studies due to their lack of gender-specific data (Curtiss et al., 2023 ; Rimmer et al., 2022 ) or because they were not focused on a direct intervention program at the time but rather on analyzing accommodations for students with disabilities in online programs over an extended period (Mead et al., 2023 ). Given the observed gender discrepancies and considering that some reports indicate a higher incidence rate of disabilities among women (Council of the European Union, 2022 ), future online training initiatives should strive for greater representation of women to ensure equity and inclusiveness.

As noted earlier, with the exception of the study by Mead et al. ( 2023 ), most studies we reviewed have small sample sizes, ranging from 1 to 128 participants. This underscores the need for research involving larger sample sizes to enhance the validity and transferability of the findings.

Despite having identified only 16 studies that analyze online training for people with disabilities, our review indicates a rapid growth in research within this field, as 81.3% of the included studies were published after 2021. This surge in research activity is promising and reflects a growing interest in this area of study.

Furthermore, it is noteworthy that half of the studies employed quantitative methodologies, including four controlled trials. Interestingly, 37.5% of the studies utilized mixed methods, an approach that can offer a more comprehensive understanding of the nuances of online training for adults with disabilities. The methodological diversity observed in these studies represents a significant strength, enhancing our understanding of the field’s complexities.

Studies have employed various metrics to assess the effectiveness and viability of online training. Aligning with the evaluation model proposed by Kirkpatrick ( 2006 ), the analyzed variables correspond to the first level (reaction), focusing on participants’ satisfaction with the training, and the second level (learning), which examines changes in the skills taught. Notably, several studies have delved into participants’ perceptions of their learning experiences, which is an essential aspect of the reaction level. For instance, in the study by Güdül Öz and Yangın ( 2021 ), participants suggested enhancements to the learning environment, such as the inclusion of more images and videos. This feedback aligns with findings from Contreras-Ortiz et al. ( 2023 ), who emphasized the significance of incorporating visual elements like videos and images in the design of educational environments.

Additionally, several of the reviewed studies have focused on implementation fidelity within training programs, an aspect critical to their success. Implementation fidelity refers to the extent to which training is executed as originally designed (Jiménez & Crespo, 2019 ). This ensures that any shortcomings in the training outcomes are not due to deviations from the planned instruction. Davis Bianco ( 2010 ) notes that deviations can significantly diminish the effectiveness of a program. Evaluating implementation fidelity, therefore, not only supports the validity of the training’s theoretical and methodological foundations but also substantiates the observed intervention effects. This aspect was notably addressed in the studies by Busse et al. ( 2022 ), Chiu et al. ( 2023 ), and Garcia et al. ( 2023 ) included in our review.

The limited number of studies that employ an evidence-based learning methodology supported by a robust pedagogical framework is noteworthy. According to Murray et al. ( 2012 ), practices and interventions for people with disabilities should provide ample learning opportunities, clearly define intended outcomes, offer models, and include guided practices and feedback. Several studies in our review, including those by Busse et al. ( 2022 ), Chiu et al. ( 2023 ), Garcia et al. ( 2023 ), and Worobey et al. ( 2018 ), have incorporated these critical elements. Additionally, it is essential for educational platforms and resources to embrace inclusive design principles from the outset, ensuring that accessibility needs are considered during content creation and technology implementation. Contreras-Orticz et al. ( 2023 ) emphasize that learning environments should be dynamic and feature a variety of resources along with a robust learning support system. This approach is mirrored in studies like Moël et al. (2023) and Rimmer et al. ( 2022 ), which provide structured guidance and support, aligning with best practices for creating effective online learning environments.

Finally, another crucial consideration in creating online learning environments is addressing the specific needs of the intended participants. Studies included in our review, such as those by Arachchi et al. ( 2021 ), Curtiss et al. ( 2023 ), and St. John et al. ( 2022 ), highlight the benefits of this approach.

In general, online programs have been shown to enhance many of the skills being trained, corroborating findings from other research, such as that of Odom et al. ( 2015 ). Moreover, some studies, such as Ayuso and Santiago ( 2022 ), report improvements using online formats over in-person methods, although other studies present conflicting results. Thus, there is a clear need for further research comparing in-person and online formats to derive more definitive conclusions.

Despite the recent surge in publications related to our research objectives, significant improvements are still needed to enhance access to online training. Digital accessibility remains a paramount challenge, particularly for people with disabilities and older adults who may encounter barriers when engaging with online platforms and digital content not tailored to their specific needs. Compliance with accessibility standards, such as the Web Content Accessibility Guidelines (WCAG), is essential to ensure that online platforms are universally accessible. Additionally, when designing online training programs for adults with disabilities, it is crucial to adopt an interdisciplinary approach. This should involve collaboration among technology experts, pedagogy specialists, and the program recipients themselves. Such collaboration ensures that the programs are responsive to the needs and interests of the users, as highlighted by Curtiss et al. ( 2023 ) and St. John et al. ( 2022 ). This comprehensive approach not only enhances the effectiveness of the training but also ensures inclusivity and accessibility in the learning process.

As previously discussed, the design of the virtual environment is crucial, yet equally important is the attention to the specific needs of people with disabilities. Supporting these individuals in how to use ICT can significantly enhance their online learning opportunities and success in interaction (Ellis & Goodyear, 2019 ). This was a key goal of the study by Arachchi et al. ( 2021 ), which focused on training individuals in information skills and information literacy to boost their digital competence (Jin et al. 2019 ).

Moreover, it is essential to recognize that older adults also require targeted support when engaging with ICT. Studies such as those by Briones and Meijering ( 2021 ) have highlighted the critical role of social support provided by “technology experts” and the educational resources available through community centers. These supports are vital to ensuring that older individuals can successfully navigate and benefit from technology. Such inclusive approaches are fundamental to making digital education accessible and effective for all learners, regardless of age or disability.

Limitations

While this systematic review provides valuable insights, the scope of information gathered could be broadened through a scoping review. Such a review would allow for the inclusion of additional research and findings from the gray literature, which might offer more comprehensive perspectives on the subject.

Furthermore, future searches should extend beyond the databases currently used, to include specific psychology and education databases such as PsycINFO and ERIC. Expanding the search to these databases could uncover more nuanced and detailed studies relevant to the intersection of online learning, disabilities, and educational outcomes.

Implications for practice

The favorable outcomes observed across all studies in our review, concerning skills such as academic prowess, instrumental abilities, social interaction, personal autonomy, and physical activity, underscore the effectiveness of online and electronic device-based training for adults with disabilities. Nonetheless, there is a clear need to ensure greater representation of women in studies and to expand sample sizes to enhance the robustness and generalizability of the findings.

Furthermore, as suggested by Gorski ( 2009 ), there is a critical need to design collaborative digital learning spaces that involve a range of professionals. Such collaboration ensures that the learning environments are not only technologically advanced but also pedagogically sound.

Additionally, assessing implementation fidelity must be prioritized in training programs. This practice is essential to ensure that the training adheres to its intended design, thereby improving the validity and reliability of the results.

Despite the limited number of studies initially identified, the notable increase in research post-2021 reflects a growing interest in online training for adults with disabilities. This trend suggests a burgeoning concern in this field, though significant gaps remain that require further exploration.

The methodological diversity observed in the studies is viewed as a strength, underscoring the value of mixed-method approaches. These methodologies provide deeper insights into the complexities of online training, enabling a more nuanced understanding.

While the studies generally report positive outcomes in skill enhancement, the variability in results between in-person and online formats underscores the necessity for more targeted and detailed research. This will help to fully comprehend the impacts and effectiveness of different training modalities.

A recurring issue in the analyzed studies is the lack of a clear theoretical foundation and a supportive pedagogical framework. It is crucial for future research and practice to incorporate evidence-based theories and pedagogical strategies. This would ensure that training programs are not only technologically sound but also educationally effective.

Moreover, the studies highlight the importance of training and raising awareness among educators and content developers. Future training initiatives should prioritize interdisciplinary collaboration, involving technology developers, researchers in special educational needs and educational technology, and, importantly, people with disabilities themselves.

The objectives of the programs analyzed are diverse, covering a wide array of skills and knowledge areas. The methodologies employed are specifically tailored to meet these varied objectives and include participatory approaches, learning transfer models, and the use of online platforms. Although basic technology underpins these interventions, the duration of the programs varies significantly, reflecting the complexity and specific goals of each rather than a uniform approach.

Despite the surge in related publications, there remains a pressing need to broaden the scope of online interventions and training for adults with disabilities. This expansion is crucial to fully ascertain the potential and limits of such training. As we advance, it is imperative to maintain a steadfast commitment to ensuring that online education is accessible and advantageous to all, irrespective of individual capabilities or limitations. Such inclusivity is essential for achieving equity in training, thereby enhancing the quality of life and fostering social integration for all individuals.

Data availability

Data sharing does not apply to this article as no datasets were generated or analyzed during the current study. However, the files with the selected articles from the WoS and SCOPUS databases and the link to the RYYAN platform are available from the corresponding author upon reasonable request.

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Understanding the contexts in which female sex workers sell sex in Kampala, Uganda: a qualitative study

  • Kenneth Roger Katumba 1 , 2 ,
  • Mercy Haumba 1 ,
  • Yunia Mayanja 1 , 2 ,
  • Yvonne Wangui Machira 3 ,
  • Mitzy Gafos 2 ,
  • Matthew Quaife 2 ,
  • Janet Seeley 2 &
  • Giulia Greco 2  

BMC Women's Health volume  24 , Article number:  371 ( 2024 ) Cite this article

Metrics details

Structural, interpersonal and individual level factors can present barriers for HIV prevention behaviour among people at high risk of HIV acquisition, including women who sell sex. In this paper we document the contexts in which women selling sex in Kampala meet and provide services to their clients.

We collected qualitative data using semi-structured interviews. Women were eligible to participate if they were 18 years or older, self-identified as sex workers or offered sex for money and spoke Luganda or English. Ten women who met clients in venues and outdoor locations were selected randomly from a clinic for women at high risk of HIV acquisition. Ten other women who met clients online were recruited using snowball sampling. Interviews included demographic data, and themes included reasons for joining and leaving sex work, work locations, nature of relationships with clients and peers, interaction with authorities, regulations on sex work, and reported stigma. We conducted interviews over three months. Data were analysed thematically using a framework analysis approach. The coding framework was based on structural factors identified from literature, but also modified inductively with themes arising from the interviews.

Women met clients in physical and virtual spaces. Physical spaces included venues and outdoor locations, and virtual spaces were online platforms like social media applications and websites. Of the 20 women included, 12 used online platforms to meet clients. Generally, women from the clinic sample were less educated and predominantly unmarried, while those from the snowball sample had more education, had professional jobs, or were university students. Women from both samples reported experiences of stigma, violence from clients and authorities, and challenges accessing health care services due to the illegality of sex work. Even though all participants worked in settings where sex work was illegal and consequently endured harsh treatment, those from the snowball sample faced additional threats of cybersecurity attacks, extortion from clients, and high levels of violence from clients.

Conclusions

To reduce risk of HIV acquisition among women who sell sex, researchers and implementers should consider these differences in contexts, challenges, and risks to design innovative interventions and programs that reach and include all women.

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Introduction

Globally women who sell sex face a disproportionately large risk of HIV acquisition compared to the general population [ 1 , 2 , 3 ]. Among those at greatest risk are female sex workers (FSWs) in low- and middle-income countries (LMICs) who are 13.5 times more likely to acquire HIV relative to the general population [ 3 , 4 ]. Research indicates that structural, interpersonal, and individual factors influence HIV prevention behaviour [ 4 , 5 , 6 , 7 , 8 , 9 ]. Structural factors are defined as the economic, social, political, organizational or other aspects of the environment in which women sell sex, and which might act as barriers to or facilitators of women’s HIV prevention behaviour [ 7 , 10 , 11 , 12 , 13 , 14 ]. Interpersonal factors are those which relate to risks or protective factors between women and their clients, or intimate partners [ 2 , 15 ]. Individual factors are those which relate to a woman’s individual attributes such as age of initiation into sex work, alcohol and other substance use, knowledge of HIV prevention, physical, and psychological attributes [ 6 , 15 ]. Together, the structural and interpersonal factors influence the contexts in which women who sell sex work. Several structural and interpersonal factors that influence condom use among sex workers have been identified, including zoning restrictions and regulation of sex work, how women join sex work, the location where sex workers meet and provide services to clients, experiences of violent relationships with clients, and harassment by authorities and police [ 7 ]. Stigma has also been identified as an important influence on the way sex workers work and as a contributor to their risk environment. Stigma increases the risk of HIV acquisition to sex workers, yet it is experienced in several forms at the individual, interpersonal and structural levels [ 14 , 16 , 17 , 18 , 19 ].

In Uganda, sex work is illegal and criminalised. Research that investigated the contexts in which women in Kampala sell sex has however shown that women join commercial sex work because of their disadvantaged backgrounds and restricted access to economic resources [ 11 , 20 , 21 , 22 ]. Mbonye et al. [ 11 ] showed that women providing services in outdoor locations like streets, alleys and parking lots faced more challenges than women providing services in indoor locations like nightclubs, bars, and lodges. These challenges included exposure to violence, stigma from the public, and visibility to police [ 11 , 23 ]. Kawuma et al. [ 20 ]reported in a more recent study that the places in which women sell sex in Kampala are fluid in that they move from one type of venue to another. All these studies also showed that women selling sex in Kampala faced violent relationships with both the police/authorities and with their clients [ 11 , 20 , 21 ].

It is however noteworthy that women included in these studies were participants from large epidemiological cohorts that recruited participants from low socio-economic settings, with little or no education, and who typically recruited their clients in physical locations, indoor or outdoor [ 11 , 23 ]. Women outside of these cohort settings, who have higher education, belong to higher socioeconomic status, and meet clients in spaces other than those identified in these studies have not been included in important HIV research, programming, and prevention efforts in Uganda to date. Research in the United Kingdom, USA, Australia, Japan, and India has reported the experiences of women who sell sex using internet websites and social media platforms [ 24 , 25 , 26 ]. These women also face risks, violence, and crime just like their peers who meet clients in physical locations like venues and streets [ 24 , 27 ]. Understanding the contexts in which women sell sex and the strategies that they use to advertise, meet, and provide services to their clients will help us to understand HIV risk among women by highlighting how structural, interpersonal, and individual factors interact to influence HIV transmission. In Kampala, earlier studies have reported on the contexts in which women recruiting and providing services in physical locations work, but there is still a gap in knowledge about the prevalence of client recruitment using online platforms, how women who recruit this way are organised, and how this strategy affects their risk of HIV acquisition. Understanding these gaps will improve our understanding of the structural determinants framework for HIV prevention among women selling sex in Kampala. This paper presents a more comprehensive understanding of the contexts in which women sell sex in Kampala by including women who have not been included in prior research studies and emphasizes the need to reach them and target intervention efforts to them. This aligns with the UNAIDS strategy of leaving no one behind and reaching the populations at the greatest need of care [ 28 ].

Study design, participants, and process

Twenty women from Kampala and surrounding suburbs were included in the study, using two sampling strategies. The first sample – the clinic sample – included 10 women sampled from a cohort of 4500 women who had been attending a clinic dedicated to women at risk of HIV acquisition including FSWs run by the Medical Research Council/ Uganda Virus Research Institute and London School of Hygiene & Tropical Medicine (MRC/UVRI & LSHTM) Uganda Research Unit in Kampala [ 23 ]. Women who met clients in physical spaces like venues and outdoor locations had prior been recruited into the clinic through peers. The second sample – the snowball sample – included 10 women who met clients using online platforms including social media and websites such as Instagram. We identified one key informant who started the snowball recruitment as described by Heckathorn [ 29 ] and Rao et al. [ 30 ]. Women were eligible to participate if they were 18 years or older, self-identified as sex workers or offered sex for money and spoke Luganda or English. In our study, “women who meet clients” includes women actively recruiting clients, women searched out by clients, and women who are introduced to clients by peers, but meet using online spaces.

Data collection and management

An experienced female graduate social scientist (MH) made first contact with all women, planned interview appointments, administered the study information and consent process, and carried out in-depth interviews with them. For the clinic sample, we selected women from the cohort using a random number generator in Microsoft Excel to generate 10 random numbers within the range of 1 and 4,500 inclusive, which matched the women’s unique cohort identifiers. We invited women with the corresponding numbers to participate. To identify the seed for the snowball sample, the female social scientist (MH) used the Instagram search function to search through posts of women who offered mobile (in-house) massage services or sex for money. She used the keyword “massage” and the location filter set to “Kampala”. The results included both personal accounts and accounts for massage parlors. We considered the first personal account that appeared on the search results as the potential seed for our sample. The female social scientist (MH) contacted the first personal account via the Instagram chat function, providing information about the opportunity to participate in a research study. The owner of the personal account agreed to take part in the study. After her interview, the seed identified through Instagram identified other women and provided their contacts. The female social scientist (MH) then invited the potential participants to the study, and the snowball continued until 10 interviews were completed. We allocated participant numbers from A01 to A10 for those in the snowball sample, and B01 to B10 for those in the clinic sample. Interviews were carried out between September and October 2022.

We developed the interview guide from a literature review of the structural factors that influence HIV prevention for women who sell sex, and a review by Shannon et al. [ 6 ], which presented a framework for the structural drivers of HIV and the pathways through which they interact with interpersonal and individual behavioural factors. This framework expanded structural factors to include macro-structural factors such as legal, socio-political, cultural, economic, and geographic contexts in which women sell sex, sex work organisation which includes the organisational structure, community empowerment and collectivisation of sex work, and the work environment which includes the physical, social, economic and political features of the environments in which sex workers operate, such as violence, access to condoms and anti-retroviral therapy (ART), and venue policies [ 6 ]. Using this framework, we developed this guide specifically for this study, and included questions on how women joined and why they would leave sex work, how their work was organised including recruitment and where they provided services to clients, their relationships with clients and authorities, the illegality of sex work, and the stigma they experienced. A copy of this interview guide is included as an additional file (see Additional file 1). We collected basic demographics at the beginning of the interview, asking women about their age, number of children, level of education, if sex work was the main occupation, and if they used social media to meet men for sex work. These were summarised in MS Excel, and the corresponding frequencies presented as descriptive statistics. Recruitment logs with personal information were stored in a secure access-controlled cabinet separate from where interview notes, recorders and computers were kept. After obtaining informed consent from the participants, we audio-recorded interviews, then transcribed and translated them into English. The social scientist (MH) took notes to back up the recordings. We imported the transcripts, translations, and interviewer notes into NVivo 12 for data organisation and management.

Data analysis

We used framework analysis as outlined by Gale et al. [ 31 ] to analyse the qualitative data. This analytical approach involves developing a thematic structure for interpretation, under which individual codes can be grouped and compared [ 31 ].

A study team member checked five random transcripts in English for transcription accuracy, and all the 10 Luganda transcripts for translation accuracy. In the first step of the coding, both the first author and the social scientist (MH) coded four interviews independently using initial frameworks constructed both deductively using the review by Shannon et al. (2015) and inductively using themes arising from the interviews [ 3 ]. The two coders then met and consolidated their coding frameworks into a revised version, which the first author used to finalise coding of all the interviews. From the consolidated coding framework, we developed a framework matrix with the themes and subthemes as the columns, and the participants as the rows. We populated the cells of the matrix with both summaries and representative quotes from the data. We then analysed the data from each of the columns to generate analytical memos on prominent themes arising from the data. All the steps of the analysis were reviewed by two other co-authors.

Ethical considerations

This study was approved by the Uganda Virus Research Institute Research and Ethics Committee (GC/127/912), the Uganda National Council for Science and Technology (HS2386ES), and the ethics committee of the London School of Hygiene and Tropical Medicine (28,175). We obtained written informed consent from all the respondents before data collection. We compensated the participants 20,000 Uganda shillings (UGX), (USD 5.5) for their time, and 20,000 UGX (USD 5.5) for their transport. We did not offer current participants any incentive to refer seeds and informed them that they would not face any penalties whatsoever if they did not refer any seeds. To contact new participants for the snowball sample, the qualitative researcher was provided with a partial name and a contact number, or with the new participant’s Instagram handle. The identity of the referring participant was not disclosed to new participants. The referring participant was not told which of the potential participants suggested by her eventually participated in the study. A copy of the script we used is included as an additional file (see Additional file 2).

Women in our study

Twenty women participated in the study, 10 in each of the clinic and snowball samples. Of the 20 included women, 12 met clients using online platforms. Of these 12, nine were from the snowball sample and three were from the clinic sample. We reached out to 26 women for inclusion in the snowball sample, eight of whom opted not to participate, six did not come for their appointments, and two did not respond. In the clinic sample, only one of the 10 women was not reachable and was replaced. While women from the clinic sample generally had less schooling and were predominantly unmarried, women from the snowball sample generally had high levels of education, had professional jobs or were students in training for professional jobs, were able to negotiate better prices for sex, and were able to avoid outdoor confrontation with police, authorities, and the public. Table  1 below gives details of women’s individual characteristics.

The contexts in which women sold sex

The prominent themes we identified in our study included: how the women organised their work, why and how they joined or would leave sex work, the relationships that they had with clients, authorities, family, and their peers, and the stigma they experienced. We present them in Table  2 below and explain them in detail in the sections that follow.

Reasons women joined sex work, and why they would leave

Women mentioned economic need as the main reason for joining sex work, and this was driven by the loss of parents, abandonment by partners, economic hardships due to the COVID-19 pandemic, inability to continue school due to lack of school fees, and costs like rent and food.

I joined sex work because of the hardship I was going through after my husband abandoned me and the children, he was not paying their school dues, and they had nothing to eat. So, I decided to devise means of survival. (Clinic sample, 23–25 years, B04).

Women remained in sex work because of economic responsibilities and no alternative sources of comparable income. For women who met clients in public spaces, these responsibilities included costs such as rent, school fees and food for themselves and their families. For women who met clients using online spaces, responsibilities included special costs such as maintaining their lifestyle and good aesthetics both on online platforms and the social scene. They included rent for expensive apartments, hairstyles, makeup, expensive clothing and phones, trips outside Kampala and Uganda, and keeping up appearances on the Kampala party scene.

At this point as much as the money you get from sex work is little if I decide to leave, I won’t be able to sustain myself or even be able to start another business since I will not have money. The situation is bad these days, so if I leave sex work, which other job am I going to do? (Clinic sample, 23–25 years, B04). The money that it comes with is not little money. This is like salaries that people get for months, and I am doing it for just one day. So, it becomes addictive, and you must keep up with the lifestyle that you have started so you must keep going back until you are somewhere that you want to be. (Snowball sample, 25–30 years, A04).

While all participants mentioned economic need as reason for joining or staying in sex work, some women joined sex work because of trauma from being abused as children. The pain that they harboured from this trauma kept them in sex work, even if they were not proud of their work. Regardless of how they joined sex work or where they met their clients, most women would leave sex work if they had major changes in their social or financial status, for example if they got married, achieved financial stability through stable alternative and comparable sources of income, or having a home that they own.

Oh well yeah one day I want to have a family settle down and have a husband and have kids so definitely there is no way I can be married to someone when I am still doing this kind of work. (Snowball sample, 25–30 years, A04).

How female sex work in Kampala was organised

Where women met clients and provided services.

Women discussed recruiting clients in public physical spaces, in private virtual online spaces, and through go-betweens. The public spaces were both outdoor and indoor. Outdoor public spaces included streets, alleys, and markets, while indoor public spaces included venues such as bars, pubs, cafés, offices, churches, malls, casinos, hotels, restaurants, massage parlours and lodges. Women also discussed the lack of privacy and the higher risks of police prosecution and arrests, attacks by thugs, robbery, and exposure to judgement by the society, in addition to meteorological challenges like cold, windy, and rainy weather.

The person who took me on the streets [a female friend], one time we were on the street and her [the friend’s] uncle was the one haggling with her. (Laughs). Those are the things that make us leave the streets. At least you go to [the clients’] places or at our [the woman’s] place it has no problem. (Clinic sample, > 30 years, B02).

Women discussed benefiting from security offered by the management of indoor public spaces, even if in some cases they were charged a fee to be allowed to work at these places.

The street is not good but at the bar they first check clients before entering, they do not allow them to enter with keys, knives and other things which is not done on streets. That is why you see that many people who work from streets die a lot, that is why the street near [a pub nearby] many people die from there…For the places, I told you like [a specific pub], it is safe, even if a client becomes chaotic, we are protected by the guards at the bars. (Clinic sample, > 30 years, B03.

The private virtual spaces mentioned by women were online platforms that can be accessed from their homes, or other private and protected places. They included social media applications (apps) and sites such as Snapchat, Instagram, Badoo, and dating websites. Women who met clients using these spaces were able to reach many clients, had more time between the first contact with a client and accepting to offer services to the client. This time allowed them to make decisions both about their perceived safety with clients and avoid potential violent clients, but also about HIV prevention. They earned more than their peers who met clients in public spaces, and they provided services mostly in hotels, in the clients’ homes, and sometimes in their homes.

The advantage of hotels is that you can easily get help in case of any problems, which you can’t get when you are in someone’s home because its already night and some people’s homes are fenced even if you shout no one can help. (Snowball sample, 25–30 years, A07). Well, the truth is there is a lot going on, on social media. When you get offers, it is up to you to take them or not. Social media things are so easy now. You can meet people; you can easily associate with people from different parts of the world. (Snowball sample, 25–30 years, A02).

Women who met clients in virtual spaces faced some challenges particular to their strategy of recruiting clients, for example cyber threats and their online accounts being hacked into, new clients who did not want to pay being extorting money from them, and old clients who traded women’s confidentiality for money.

Because I had so many people writing to me. They wanted to meet me. So, I felt like Instagram wasn’t a safe place for me. And by then people used to hack into accounts. (Snowball sample, 25–30 years, A01).

Some women relied on pimps or peers who acted as go-betweens procuring clients for them. These women were assured of a reliable flow of clients from middle and high socio-economic status; and of more security since the go-between knew which woman was with which client, and at what location. However, they were prone to exploitation since the go-between usually took a commission off the women’s pay, while some protected violent clients.

Well, first there are what they call pimps who usually have contacts of men. Some are like delegates who come to Uganda, or who want to take girls outside for meetings outside of Uganda. These pimps are always looking for sex workers you don’t even have to look for them. (Snowball sample, 25–30 years, A04).

As much as some women used only private online spaces, others had a primary space where they usually met clients, and one ‘filler’ space they would resort to in case they didn’t have enough clients from their primary space. For example, women from the clinic sample mostly relied on online spaces during day, but used go-between or went out to clubs and bars in the night. On the other hand, women from the clinic sample relied heavily on physical spaces to recruit their clients.

During the day you can be on your phone, but you must go to clubs at night. If you are in another country, you can’t just stay in the house and chat on phone, you must go outside and look for clients if you need money. (Snowball sample, 25–30 years, A07).

Women who met clients using online platforms provided services in indoor spaces like their own and clients’ homes, and in hotels, but never mentioned offering services in public outdoor spaces. On the other hand, women who met clients in public outdoor spaces like streets provided services in indoor spaces, but also in the outdoor spaces where they met the clients.

How women competed for clients

Women who met their clients in public spaces viewed their counterparts who met clients using online platforms to be in a higher income and of a higher socio-economic status. The latter women discussed that the former operated a more versatile, more mobile, and less exposing form of sex work which was able to attract a clientele of higher socio-economic status and higher paying. Among women who met clients in physical spaces, women who met clients using online platforms were referred to as bikapu (plural for kikapu ) sex workers. A kikapu is a large travel or shopping basket that can be carried anywhere at any time, and whose contents are known only to the owner.

There are sex workers whom you will never see seated in corridors waiting for clients or even see clients entering her house. But she is also at her home doing sex work. If a client calls her, she goes, services the client, and returns to her house. They are always called ‘bikapu’ sex workers. (Clinic sample, 25–30 years, B05).

The prices women charged, and how they negotiated with clients

It was clear from the interviews that women who met clients using online spaces charged more than women who met clients in public spaces. Among women who met clients in public spaces, the highest amount received for a sexual act was 100,000 UGX (USD 27), compared to 40,000,000 UGX (USD 10,767) for those who met clients using online spaces. The latter had a minimum reserve price of 250,000 UGX (USD 67), compared to no payment or providing sex on credit among the former. Moreover, those recruiting online had more time to negotiate prices and compare offers from clients before meeting clients physically, compared to the former, who usually negotiated with one client at a time and when they had already met physically.

I can even get 8 million shillings. The lowest I get in a month is 5,000,000 shillings [USD 1,356] but it’s usually between 8 and 15 million shillings [USD 2,170–4,069]. When people who live abroad are around in large numbers, I can get up to 15,000,000 UGX [USD 4,069]. (Snowball sample, 25–30 years, A06). There are those sex workers who cannot come to my place where I work, but they meet their clients using the internet and somehow charge more expensively than me. I cannot compete with them; I am cheaper because I charge from 5,000 UGX [USD 1.40] but those sex workers charge from 100,000 [USD 28] or 200,000 UGX [USD 54]. (clinic sample, > 30 years, B03). You can get a customer who runs away after getting the service as agreed. That is what they call ‘bidding farewell with a zip’ (okusibuza zip). It depends, there is when we work tirelessly and you get 30,000–50,000 shillings [USD 8.20–13.60] monthly, and between two to three thousand (54–81 cents) daily. (Clinic sample, 25–30 years, B01).

Moreover, women who met clients using online spaces discussed being offered substantial non-financial incentives in addition to cash payment. In most cases, these incentives, which included gifts and trips within and outside Uganda, supplemented the cash payment clients offered and influenced women’s decision to reconsider some clients that had been rejected because the initial payment offer was deemed unattractive.

The relationships women had with authorities, clients, and peers

Women faced violence from clients in form of physical, verbal, and sexual abuse such as rape, clients removing or tearing condoms intentionally, and even death threats.

For me a man almost killed me. We went into a room, and I told him the amount of money I wanted. He said he did not have it. I told him to let me get out, but he started strangling me. Then I accepted that he had robbed me. (Clinic sample, > 30 years, B02). Ah God (covers her face with her palms and shakes her head) it was so hard for me. He slapped me, did everything you can think of. My dear, I gave up and had to act soft because some clients need you to be submissive. So, you must act like you are enjoying whatever he wanted. (Snowball sample, 25–30 years, A06).

However, some women met friendly and supportive clients who treated them well, got them business connections and supported them financially in their personal lives.

I will not lie to you; he was taking care of me just like any other man takes care of what he loves. (Snowball sample, 25–30 years, A01). Women’s relationships with peers were usually characterised by jealousy, mistrust, hatred, and threats. They fought with each other verbally, physically, and spiritually with witchcraft. That said, there was evidence of friendships among women who met clients in physical spaces. For example, they could demand their peers’ release if they witnessed their arrest. First, a massage parlour has a lot of girls. So, there is that hatred that comes along. Then there is a risk of being bewitched by those girls at the parlour. (Snowball sample, 23–25 years, A08). Yes, there are sex workers who compete against each other. I don’t know how to explain this but sometimes your fellow sex workers might notice that you are getting a lot of customers then they go and bewitch you. (Clinic sample, 23–25 years, B04).

Women who met using online spaces worked in isolation and were in many cases not able to get help in cases where clients turned violent. And because sex work is illegal in Uganda, women had no legal support or protection from authorities. Instead, they were exploited sexually and financially by the authorities, abused, and violated. All our participants faced some form of violence, abuse and exploitation from police and authorities.

We are treated badly. Police officers also come and arrest you and sometimes even rape you. Sometimes when they arrest you and you don’t have money to give, they force you to have sex. (Clinic sample, 23–25 years, B04. They all want sex (laughs). The truth is I don’t want to say everybody is bad among authorities but it’s like they all want to get something [sex]. Of course, I don’t give them, but I am sure there are people who do. (Snowball sample, 25–30 years, A02).

Authorities only offered protection when they got sexual favours from women, and when women paid regular fees to them. Women working in private indoor spaces like pubs discussed being protected from clients that turned violent, by private guards stationed at these indoor spaces.

Women who met clients in physical spaces were more affected by the illegality of sex work compared to their peers who met clients using online platforms. The former discussed restrictions on the areas or times when they could work, being exposed to arrest by authorities, and public shame and ridicule. The latter women discussed not knowing any laws against sex work, and their work not being hindered in by any regulations. However, majority of the women discussed not being able to report to authorities or disclose to friends and family in cases where they had been raped, for fear of prosecution, ridicule, and stigmatisation.

Women’s experiences of stigma

Our participants experienced internalised stigma where they felt like disappointments to their families, and unworthy of some things or levels of achievement in life, such as good loving relationships respect, and leadership positions in society. Some women thought they would only be able to fit in society if they left sex work. Otherwise, they had to live with persistent guilt, shame, and embarrassment from doing sex work, and consequently keeping their work secret from friends, family, and society.

Then there is also that persistent guilt of letting down your family and them expecting better. I don’t know but it’s embarrassing, how do you even start telling someone that you are getting money from having sex with multiple people not even one. (Snowball sample, 25–30 years, A07).

Women experienced stigma when they were shunned by their family and friends, health workers, local leaders, and the communities in which they live and work. They were pushed to operate in secrecy because they feared the stigma they would face if exposed. Women who met clients in public outdoor spaces like streets were most affected because they were more exposed to the public while working, and to arrests by authorities.

Banvuma [They insulted me]. I remember my mum told me I decided to go out and embarrass the family, yet they have degrees and masters. It was really bad. I never got invited to any family function. Ever since then I became a reject, and you know you can tell when you are rejected by how people look at and talk to you. (Snowball sample, 25–30 years, A01). Yes, from the neighbours one of them can see you or in a way find out that you do sex work. Then she comes and tells another person that you are a sex worker. Then they spend the whole day gossiping about you. (Clinic sample, 25–30 years, B05).

Women discussed not being able to get licences since their work is illegal, and not being able to report in cases where clients violated them. They were exposed to discrimination because they had no legal or structural backing for them to work or to be protected against violence, attacks, and exploitation.

We present the contexts in which women selling sex in Kampala met and provided services to their clients. Our participants met clients in physical spaces including venues and outdoor locations and using online spaces that included social media applications and websites. Earlier studies also found that women who sell sex in Kampala recruit clients in venues and outdoor locations like those we presented [ 11 , 17 ]. Our study goes a step further and highlights that some women met clients using virtual online spaces like social media platforms and websites. While this finding is new to literature on Uganda, it is consistent with studies carried out in other settings, where sex workers recruiting clients using online platforms like social media and websites were identified [ 24 , 25 , 27 ]. similarly to their peers who recruit clients from physical spaces, women who recruit clients using online platforms are also high-risk population, yet they have not been targeted in HIV prevention efforts. There is need for inclusion of women who recruit clients using online platforms in HIV prevention interventions.

We assert that women selling sex in Kampala work in settings where sex work is illegal and criminalised, and because of this they are forced to endure harsh treatment; they face violent and abusive clients; they are arrested, abused, and exploited by authorities; and they experience jealousy and violence from their peers, and stigma from society. It is known that sex work is illegal in Uganda, that women who sell sex have violent relationships with both clients and authorities, and that women selling sex get no legal protection [ 17 , 21 ]. Our findings are consistent with other studies in this respect. We go further and highlight the larger extent to which the illegality of sex work was felt by women who met clients in physical spaces compared to those who met clients using online platforms. This stresses the continued need for support to women who face violent relationships, and to create safe spaces for women selling sex.

We also show that women who met clients using online platforms had more time to engage and negotiate with the clients before meeting them physically, were able to generate a pool of potential clients and consequently had less pressure to find clients. These women also seemed to have better education and income compared to their peers who met clients in physical spaces. Despite these apparent individual level advantages, we show that in many ways women selling sex faced similar pressures at the structural and interpersonal levels and faced similar risks with regards to HIV acquisition.

All our participants faced challenges that are similar and consistent with those identified in earlier studies [ 11 , 17 , 20 , 21 , 23 ]. These challenges were sustained by gaps in structural, social, and interpersonal support with regards to HIV prevention. For example, all study participants were either unable or unwilling to obtain support from authorities in situations where they were abused, exploited, or violated by clients or authorities. Women who met clients using online platforms faced some challenges specific to them because of their client recruitment strategy. First, they had to deal with cybersecurity threats like their social media accounts being hacked into and being exposed on the online platforms where they met clients. The damage caused by such negative exposure would be amplified by information on these platforms being easily and affordably accessible to very many people simultaneously. Secondly, they were threatened with exposure and reputational harm by clients who did not want to pay for services. This further increased their already high costs of operation. In terms of risk, most women who met clients using online platforms were unable to get immediate help in case a client turned violent because they mostly provided services to clients in their homes (both the clients’ and women’s) and in hotels. These women were exposed to high levels of violence that was potentially fatal from clients, and yet they did not readily access the needed services because they were pushed to operate in secrecy due to fear of stigma, judgement, and prosecution. This was exacerbated by the fact that they were mostly university graduates with professional jobs and were therefore very secretive and protective of their involvement in selling sex. Women’s experiences of stigma were consistent with what has been found in the literature (Beattie et al., 2023; Cruz, 2015; Fitzgerald-Husek et al., 2017; Ruegsegger et al., 2021; Seeley et al., 2012). It is still interesting to note that our participants across the samples faced stigma in similar ways and that most were ashamed of their work. Even women who met clients using online platforms were unable to report clients because they feared the prosecution by authorities or judgement by society that would come with being exposed. Provision of safe structural and social environments that support and protect women who sell sex as they carry out their work is necessary. Additionally, interventions to reduce stigma for women who sell sex are still very important but should target the more secretive and protective women who recruit clients using online platforms.

While access to health care for women who sell sex has improved over the years, these improvements in access have been identified among women who sell sex and have been included in research studies. This includes women in the clinic sample of our study, who mostly meet clients in physical spaces. Access to health care and HIV prevention services for women who meet clients using online platforms has not been systematically recorded. Yet, our results show that women who meet clients using online platforms face similar and even more challenges than their peers who meet clients in physical spaces. While the common challenges that all women face, including stigma and violence are barriers to health care access [ 32 , 33 , 34 ], the additional challenges that women who meet clients using online platforms face could be additional barriers for access to health care. This calls for continued efforts to address the common challenges but also highlights the need for specific interventions to improve access to health care among women who meet clients using online platforms. Our findings on how women joined sex work or would leave are consistent with published literature. Earlier research showed that women joined due to economic need, or because of earlier traumatic experiences of sexual abuse, and they would leave if they achieved economic stability [ 16 , 21 , 35 ]. This further highlights the importance of continued efforts to empower all women, and protect them from sexual violence, regardless of their level of education, status of work, and where they recruit or provide services to their clients.

Women who met clients using online platforms were hard to reach for us as a research team, and we assume that it will be hard for other researchers, health service providers and policy to reach them effectively. In fact, most women who we contacted to be part of the snowball sample (16 of 26) did not participate in the study, and those who accepted did so with caution. The spaces in which our participants provided services were identical to those reported in the literature, i.e., in indoor venues and outdoor locations [ 11 , 17 , 20 ]. We however highlight the fact that women who met clients using online spaces always provided services in indoor spaces and never in public outdoor spaces. Intervention efforts that target women recruiting clients in venues and in outdoor spaces will therefore miss women who recruit using online platforms. To increase their access to health care, to support services, and to the HIV prevention services they need, research and policy makers need to generate innovative strategies that will reach and engage women recruiting clients using online platforms.

Strengths and limitations

We used the framework analysis method. This method can neither handle highly heterogeneous data nor pay attention to the language of the respondents and how it is used [ 31 ]. We could therefore have missed some heterogeneity in women’s individual, interpersonal, or structural factors because of our choice of data analysis method. Moreover, we based our initial interview guide and coding framework on structural factors identified in the literature. Even though we used some inductive coding to complement the initial deductive framework, results from a similar study using a fully inductive approach would make an interesting comparison. We neither used complex theories nor sought to develop theory derived from the data but used robust framework analysis techniques to generate the major themes related to the structural factors that affect the sexual and reproductive health of women selling sex in Uganda. Despite these limitations, we present important results that could be applicable to women selling sex in Uganda, and other similar settings.

Over half of women in our study met their clients using online platforms and faced additional specific challenges and risks by recruiting their clients using online platforms. Regardless of where they met their clients, our participants worked in environments that exposed them to high risk of acquiring HIV. To reduce risk of HIV acquisition among women who sell sex, researchers and implementers should consider these differences in contexts, challenges, and risks, and design innovative interventions and programs that reach and include all women selling sex in Kampala.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

Female Sex Worker

Low and Middle Income Country

Human Immunodeficiency Virus

Anti-Retroviral Therapy

Uganda Shillings

United States Dollars

COrona VIrus Disease of 2019

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Acknowledgements

We are grateful to all the participants for their time and information, the entire UPTAKE consortium from which this work drew, Rachel Kawuma and Andrew Ssemata for the support on qualitative data analysis, and the MUL study site team for the invaluable support, thank you.

This work was supported by the European and Developing Countries Clinical Trials Partnership (EDCTP) [grant number CSA2018HS-2525]. This work was conducted at the MRC/UVRI and LSHTM Uganda Research Unit which is jointly funded by the UK Medical Research Council (MRC) part of UK Research and Innovation (UKRI) and the UK Foreign, Commonwealth and Development Office (FCDO) under the MRC/FCDO Concordat agreement and is also part of the EDCTP2 programme supported by the European Union.

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Kenneth Roger Katumba, Mercy Haumba & Yunia Mayanja

London School of Hygiene and Tropical Medicine, London, UK

Kenneth Roger Katumba, Yunia Mayanja, Mitzy Gafos, Matthew Quaife, Janet Seeley & Giulia Greco

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Contributions

KRK: Conceptualization, formal analysis, investigation, methodology, project administration, writing - original draft, writing - review & editing. MH: Investigation, writing - review & editing. YM: Funding acquisition, project administration, writing - review & editing. MG: Funding acquisition, supervision, validation, writing - review & editing. YWM: Funding acquisition, writing - review & editing. MQ: Conceptualization, funding acquisition, methodology, supervision, validation, writing - review & editing. JS: Methodology, supervision, validation, writing - review & editing. GG: Conceptualization, methodology, supervision, validation, writing - review & editing. All authors read and approved the final version.

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Correspondence to Kenneth Roger Katumba .

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The study received ethical approvals from the Uganda Virus Research Institute Research Ethics Committee (Ref: GC/127/912), the Uganda National Council for Science and Technology (Ref: HS2386ES), and from the London School of Hygiene and Tropical Medicine Research and Ethics Committee (28175). All women provided written informed consent to participate in this qualitative methods study.

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Katumba, K.R., Haumba, M., Mayanja, Y. et al. Understanding the contexts in which female sex workers sell sex in Kampala, Uganda: a qualitative study. BMC Women's Health 24 , 371 (2024). https://doi.org/10.1186/s12905-024-03216-7

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Received : 26 March 2024

Accepted : 19 June 2024

Published : 26 June 2024

DOI : https://doi.org/10.1186/s12905-024-03216-7

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    Background Structural, interpersonal and individual level factors can present barriers for HIV prevention behaviour among people at high risk of HIV acquisition, including women who sell sex. In this paper we document the contexts in which women selling sex in Kampala meet and provide services to their clients. Methods We collected qualitative data using semi-structured interviews. Women were ...