Reduction in prevalence of food insecurity, a key factor in reaching the United Nations Sustainable Development Goal 2.2, was challenged by COVID-19 lockdowns in low- and middle-income countries, which impacted the affordability and accessibility of food. Prevalence and determinants of food insecurity among female sex workers who are mothers (FSWM) and heads of households (FSWM-HH) in the African region have not been previously assessed. This study validated the food insecurity experience scale (FIES) using data collected from 852 FSWM-HH living in the Democratic Republic of the Congo (DRC), Kenya, or Nigeria. Results were calibrated on the global metric to compare with the country-level prevalence of household severe food insecurity (HSFI). Associated individual and household determinants and their intersections were examined to identify vulnerable sub-groups. The FIES reliably assessed (fit index=0.75) household food insecurity among FSWM-HH using a 7-item scale, omitting the item of being worried about not having enough food to eat. The prevalence of HSFI was 59.6% in the DRC, 77.8% in Kenya, and 89.0% in Nigeria and compared to FAO 2016-2018 country levels, 1.5, 3.0, and 4.5 times higher, respectively, than previous estimates. Determinants of HSFI among FSWM-HH were similar to the African region, except FSWM-HH composition of children, but the magnitudes of odds were higher. Multiple logistic regression revealed important ecological relationships. FSWM-HH with 0-3 children living with them (AOR=1.63,95% CI:1.13-2.37, reference >4 children) and mothers having no schooling or primary education (AOR=1.92,95% CI:1.33-2.78, reference with higher education) significantly determined HSFI. Prevalence of HSFI was highest among two subgroups of FSWM-HH: those > 30 years of age, without partners (93.7%, p=0.002) and those with low levels of education with 0-3 children living with them (85%, p=0.03). Food programs and welfare policies may be effective strategies to reduce HSFI among this high-risk group of mothers with children.

The authors have declared no competing interest.

This study was supported by New Venture Fund NVF-NGDF-Global Health Promise-Subgrant-016357-2022-03-01. Funders played no role in study design, data collection, analysis or reporting.

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The details of the IRB/oversight body that provided approval or exemption for the research described are given below:

The study protocol was approved by the Institutional Review Board of Oregon Health & Sciences University (IRB ID: STUDY0002296) and the Ethics Review Committees in each of the three countries, Kenyata University Centre for Research Ethics and Safety in Kenya, Ecole De Sante Public, University de Kenshasha, DRC and Nigerian Institute of Medical Research, Institutional Review Board, Nigeria.

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The senior author, BW, affirms that the manuscript is an honest, accurate, and transparent account of the data collected, stored, and analyzed. Due to ethical considerations (i.e., consent was not obtained or given for open data access or additional data usage), controlled and secure data access and usage is necessary for subject protections. De-identified aggregate data used for this analysis can be requested from Brian Willis at bwillis@globalhealthpromise.org. Access permission will be considered based on the following usage criteria: (a) for the purpose of partnering on research on female sex workers (b) for inclusion in curriculum for educational purposes or (c) for the provision of services to female sex workers and their children by governmental and non-governmental organizations.