Women’s ability to negotiate the conditions and timing of sex is key to several reproductive health outcomes including family planning and prevention of sexually transmitted infections. We investigated the association between women’s autonomy in household decision-making and safer sex negotiation (SSN) in sub-Saharan Africa (SSA). This was a cross-sectional analysis of data from the Demographic and Health Survey (DHS) of 27 countries in SSA. Data were analyzed using Stata version 16.0 using descriptive statistics, chi square test, and logistic regression models. Statistical significance was set at p < 0.05 at 95% confidence interval. The pooled prevalence of SSN in the 27 countries was 77.1%. Compared to women with low autonomy in household decision-making, those with medium (aOR = 1.30; CI = 1.23–1.37) and high levels of autonomy in household decision-making (aOR = 1.28; CI = 1.17–1.40) were more likely to have greater SSN. Those with primary (aOR = 1.35; CI = 1.28–1.41) and secondary/higher education level of education (aOR = 1.68; CI = 1.58–1.79) had higher odds of SSN, compared to those with no formal education. Women who were working had higher odds of SSN (aOR = 1.44; CI = 1.37–1.51) than those who were not working. Women in the middle (aOR = 0.93; CI = 0.87–0.99) and richer (aOR = 0.92; CI = 0.85–0.98) wealth status had lower odds of SSN, compared to those in the poorest wealth status. Women's autonomy in household decision-making is a significant predictor of SSN. Women autonomy in household decision-making programs and interventions should be intensified to achieve Sustainable Development Goals 3.7 and 5 which seek to achieve universal access to sexual and reproductive health services and ensure gender equality and empower all women and girls by 2030.
This study involved a cross-sectional analysis of data from the Demographic and Health Survey (DHS) of twenty-seven (27) countries in sub-Saharan Africa. Specifically, the data used was extracted from the women's recode (IR) file which contains data on women from 15 to 49 years. The DHS is a nationally representative survey that is carried out globally in over eighty-five (85) low-and-middle-income countries. The survey collects data on men, maternal, and child health issues (Corsi, Neuman, Finlay, & Subramanian, 2012). A two-stage stratified sampling technique was employed to collect the nationally representative data from the respondents. A detailed explanation of the sampling procedure has been highlighted in a study by Aliaga and Ruilin (2006). In the present study, a total of 133,678 married/cohabiting women aged 15–49 with complete data on the variables of interest were included in the final analysis. A detailed description of the sample extracted for the study can be found in Table 1. The dataset is freely available for download at https://dhsprogram.com/data/available-datasets.cfm. We relied on the “Strengthening the Reporting of Observational Studies in Epidemiology” (STROBE) guideline in writing the manuscript (Knottnerus & Tugwell, 2008). Distribution of study sample *SSN=Safer Sex Negotiation. The main outcome variable was SSN. This variable was assessed as an index from two questions which consisted of “whether married/cohabiting women can refuse sex with their partners” and “whether married/cohabiting women can ask their partners to use condom during sex”. The response options in both questions were 1 = No; 2 = Yes; and 3 = don't know/not sure/depends. For this study, the respondents who responded “Don't know/not sure/depends” were dropped. Therefore, the final response options used in the analysis were 1 = No; and 2 = Yes. A third variable called the SSN was created using the responses from the two questions (can refuse sex and can ask their partner to use condoms). The SSN variable was coded as “1” if the woman could either “refuse sex” or “ask her partner to use condoms” or both and “0” if the woman cannot do any of them. The selection of the variables and their recoding were informed by literature (Putra, Dendup, & Januraga, 2020; Sano et al., 2018; Tenkorang, 2012) and their availability in the datasets. Women's autonomy in household decision-making was the main explanatory variable. This was created from three variables measuring women's participation in deciding (1) their health care; (2) household purchases; and (3) visit to family or relatives. All three variables had the same response format. The response options were 1 = respondent alone; 2 = respondent and husband/partner; 3 = husband/partner alone; 4 = someone else; and 5 = other. The responses were further recoded into “yes” for women whose response option was “1” and “no” to those whose response options were “2, 3, 4, and 5”. An index variable was created and we termed it as “women's autonomy in household decision-making”. A composite score was then generated ranging from “0” to “3”. An index score of “0” = no autonomy in household decision-making; “1–2” = medium autonomy in household decision-making; and “3” = high autonomy in household decision-making. The variables used to determine women's autonomy in household decision-making, as well as its scoring, were selected based on previous studies (Atteraya, Kimm, & Song, 2014; Putra et al., 2020). A total of 14 covariates were selected and included in the study. These variables were selected based on their availability in the dataset and their significant association with SSN from previous studies (Atteraya et al., 2014; Feyisetan & Oyediran, 2019; Putra et al., 2020; Sano et al., 2018; Tenkorang, 2012; Ung et al., 2014). The variables studied consisted of maternal age, husband/partner's age, marital status, maternal educational level, husband/partner's educational level, wealth status, employment status, religion, place of residence, mass media exposure (reading newspaper/magazine, listening to radio, watching television), HIV testing, and comprehensive HIV/AIDS knowledge. This study utilized the already pre-coded responses in the DHS for maternal age, wealth status, employment status, place of residence, wealth status, and HIV testing. The level of education was coded as no education, primary, secondary and higher in the DHS. However, in the present study, maternal and husband/partner's educational level were recoded as no education, primary and secondary/higher. The husband/partner's age was recoded as 15–19; 20–24; 25–29; 30–34; 35–39; 40–44; and 45 years and above. Marital status was coded as married and cohabiting. Religious affiliation was coded as "Christianity, Islam, Traditional, No religion, and other. Each of mass media exposure variables (frequency of reading newspaper/magazine, frequency of listening to radio, and frequency of watching television) was categorized into “not at all, less than once a week and at least once a week”, which were re-categorized into "No" (not at all) and “Yes” (less than once a week and at least once a week). Lastly, comprehensive HIV/AIDS knowledge was coded as “Yes” and “No”. Data analyses were performed using Stata version 16.0 (Stata Corporation, College Station, TX, USA). The analyses were carried out in four steps. In the first analysis, percentages were used to present the result of SSN and women autonomy in household decision-making as shown in Table 1. Secondly, a bivariate analysis using chi-square test of independence was performed to determine the proportions of SSN practices across women autonomy in household decision-making and covariates (Table 2). In the third phase of the analysis, bivariate and multivariable logistic regression were carried out to determine the association between SSN and women autonomy in household decision-making, adjusted for all the covariates. Similarly, the last analysis was performed to determine the effect of women autonomy in household decision-making on SSN in all the 27 countries through bivariate and multivariable logistic regression analysis (Table 3). The results of the regression analyses were presented using crude odds ratios (cOR) and adjusted odds ratios (aOR) and their respective 95% confidence intervals (CIs). Statistical significance was set at p < 0.05. A multicollinearity test was conducted using the variance inflation factor (VIF). A mean VIF of 2.40 was found, showing no evidence of multicollinearity among the variables studied. The women's sample weights (v005/1,000,000) were applied to obtain unbiased estimates according to the DHS guidelines and the survey command (svy) in Stata was used to adjust for the complex sampling structure of the data in both the chi-square and regression analyses. Background characteristics, autonomy in household decision-making, and safer sex negotiation among women in SSA Note. Autonomy in household decision-making and safer sex negotiation among women in SSA *p < 0.05, **p < 0.01, ***p < 0.001, cOR = Crude Odds Ratio; aOR = Adjusted Odds Ratio; CI=Confidence Interval; [1.00,1.00] = reference category. From the DHS reports, ethical clearances were obtained from the Ethics Committee of ORC Macro Inc. as well as Ethics Boards of partner organizations of the various countries such as the Ministries of Health. The survey was conducted with adherence to the standards for ensuring the protection of respondents' privacy. Inner City Fund International ensures that the survey complies with the U.S. Department of Health and Human Services’ regulations for the respect of human subjects. This was a secondary analysis of data and therefore no further approval was required since the data is available in the public domain. Further information about the DHS data usage and ethical standards are available at http://goo.gl/ny8T6X.
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