PROJECT SUMMARY High numbers of women experience sexual violence (SV) in Uganda, and this includes violence from intimate and non-intimate partners. Studies of past year violence have revealed that three out of four females were exposed to at least one type of SV: one out of four are victims of sexual coercion, and one out of four have experienced forced sex. Experiencing SV has harmful effects on physical and mental health including: unwanted pregnancy, physical injury, risky behaviors, sexual risk-taking behaviors exposing women to sexually-transmitted infections, chronic stress, depression, low self-esteem and lack of control over reproductive choices. The negative impacts of SV can be mitigated by health services providing timely and effective interventions that target injury management and psychological support. However, health services for victims of SV in Uganda, and much of sub-Saharan Africa (SSA), are vastly underutilized to the extent that nine out of 10 females who experience SV never seek care. Many factors contribute to limited uptake of health services in Uganda and elsewhere in SSA for SV survivors, including psychological, cultural, economic, and other factors, such as fear and stigma. Further, health services for victims often lack sufficiently qualified staff and medical supplies, and confidentiality cannot be ensured. In the absence of timely and effective treatment, high rates of SV result in serious psychological and physical consequences at a population level and compromise future social and economic development. Thus, there is a strong need for research that will generate knowledge that may be used to improve health service utilization for survivors of SV. The proposed Obuvumu (meaning “courage” in Luganda – a local Ugandan language) study in Uganda innovates and addresses this need through the following specific aims: Aim 1: Conduct formative qualitative research to inform a discrete choice experiment (DCE) that will generate systematic information on health service utilization for female survivors of SV in Uganda; Aim 2: Using a DCE approach, assess the factors that influence women’s decisions to seek services after experiencing SV among; and Aim 3: Based on findings from the DCE, apply user-centered design principles to co-design an intervention that addresses barriers and preferences identified in Aims 1 and 2. If warranted, findings from this R34 will be used to inform an R01 application to test the intervention. Ultimately, study findings may help inform efforts to increase rates of reporting SV, and improve reproductive health, mental health and related health outcomes for women in Uganda, and more broadly in low-resource countries in SSA and other regions where rates of SV are high. Relatedly, the long-term goal of the proposed research is to inform the future development of culturally appropriate, feasible, acceptable and effective interventions to increase health service utilization among female survivors of SV.

PROJECT NARRATIVE The proposed study will be the first to quantitatively investigate the demand for, barriers to, and preferences for health services among sexual violence (SV) survivors. Study findings can inform interventions that facilitate health service utilization among victims of SV in low-income countries (LICs) like Uganda, ultimately improving the overall reproductive health, mental health, and related health outcomes for women in communities where rates of SV are high. Lessons learned from public health efforts in LICs, such as Uganda, may be relevant to improving overall care for vulnerable populations, such as women experiencing sexual violence, in high- income countries, including the United States where utilization of sexual violence health services remains low.