Women’s autonomy in household decision-making and safer sex negotiation in sub-Saharan Africa: An analysis of data from 27 Demographic and Health Surveys

SSM - Population Health, Volume 14, Year 2021

Ukuhunyushwa

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.

I-AI Digest

Study Justification:

This study aimed to investigate the association between women’s autonomy in household decision-making and safer sex negotiation (SSN) in sub-Saharan Africa (SSA). The study is justified by the importance of women’s ability to negotiate the conditions and timing of sex for reproductive health outcomes, such as family planning and prevention of sexually transmitted infections. Understanding the factors that influence women’s autonomy and SSN can inform programs and interventions to promote sexual and reproductive health and gender equality.

Highlights:

– The study analyzed data from 27 countries in SSA using the Demographic and Health Survey (DHS), which is a nationally representative survey conducted in low-and-middle-income countries.
– The prevalence of SSN in the 27 countries was found to be 77.1%.
– Women with medium and high levels of autonomy in household decision-making were more likely to have greater SSN compared to those with low autonomy.
– Women with primary and secondary/higher education levels had higher odds of SSN compared to those with no formal education.
– Working women had higher odds of SSN compared to those who were not working.
– Women in the middle and richer 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.

Recommendations:

– Intensify programs and interventions that promote women’s autonomy in household decision-making to achieve Sustainable Development Goals 3.7 and 5, which aim to achieve universal access to sexual and reproductive health services and ensure gender equality and empowerment of all women and girls by 2030.

Key Role Players:

– Policy makers and government agencies responsible for implementing and funding sexual and reproductive health programs.
– Non-governmental organizations (NGOs) and community-based organizations (CBOs) working on women’s empowerment and gender equality.
– Health professionals and educators involved in providing sexual and reproductive health services and education.
– Researchers and academics studying gender issues and reproductive health.

Cost Items for Planning Recommendations:

– Funding for the development and implementation of programs and interventions that promote women’s autonomy in household decision-making.
– Resources for training and capacity building of health professionals and educators.
– Budget for research and evaluation of the effectiveness of interventions.
– Costs associated with awareness campaigns and community mobilization efforts.
– Monitoring and evaluation expenses to track progress and outcomes of the interventions.

Amandla Obufakazi

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is strong because it is based on a cross-sectional analysis of data from 27 countries in sub-Saharan Africa. The study used a large sample size of 133,678 married/cohabiting women aged 15-49. The statistical analysis included descriptive statistics, chi-square test, and logistic regression models. The study found a significant association between women’s autonomy in household decision-making and safer sex negotiation. To improve the evidence, future studies could consider using a longitudinal design to establish causality and explore potential confounding factors.

Abstract

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.

Izinto zokwakha

N/A

Emisha

Based on the information provided, the study “Women’s autonomy in household decision-making and safer sex negotiation in sub-Saharan Africa: An analysis of data from 27 Demographic and Health Surveys” highlights the association between women’s autonomy in household decision-making and safer sex negotiation (SSN) in sub-Saharan Africa. The study found that women with medium and high levels of autonomy in household decision-making were more likely to have greater SSN compared to those with low autonomy. Additionally, women with primary and secondary/higher education levels, as well as those who were working, had higher odds of SSN. On the other hand, women in the middle and richer wealth status had lower odds of SSN compared to those in the poorest wealth status.

Based on these findings, potential innovations to improve access to maternal health could include:

1. Women’s empowerment programs: Implementing programs that focus on enhancing women’s autonomy in household decision-making can help empower women to negotiate safer sex practices and make informed decisions about their reproductive health.

2. Education and awareness campaigns: Promoting education and awareness about reproductive health, including safer sex practices, can help increase knowledge and empower women to negotiate for safer sex within their relationships.

3. Skill-building programs: Providing women with skills and resources to improve their economic independence can contribute to their autonomy in decision-making, including decisions related to reproductive health.

4. Access to contraceptives: Ensuring easy access to a range of contraceptive methods can empower women to make choices about their reproductive health and negotiate safer sex practices with their partners.

5. Gender-sensitive healthcare services: Healthcare providers can play a crucial role in promoting women’s autonomy and safer sex negotiation by providing gender-sensitive and comprehensive reproductive health services, including counseling on safer sex practices.

6. Engaging men and boys: Involving men and boys in discussions and interventions related to reproductive health can help challenge traditional gender norms and promote equitable decision-making within relationships.

It is important to note that these recommendations are based on the findings of the specific study mentioned and may need to be adapted to the specific context and needs of each community or country.

AI Innovations Description

The recommendation that can be developed into an innovation to improve access to maternal health based on the study is to implement programs and interventions that focus on enhancing women’s autonomy in household decision-making. This can be achieved by empowering women to have a greater say in decisions related to their own health care, household purchases, and visits to family or relatives.

By promoting women’s autonomy in these areas, it is expected that they will have a stronger ability to negotiate safer sex practices with their partners. This, in turn, can lead to improved reproductive health outcomes, including increased access to family planning methods and reduced risk of sexually transmitted infections.

To implement this recommendation, various strategies can be employed. These may include:

1. Education and awareness campaigns: Conducting campaigns to raise awareness about the importance of women’s autonomy in household decision-making and its impact on reproductive health. These campaigns can target both women and men, emphasizing the benefits of shared decision-making and mutual respect within relationships.

2. Skill-building programs: Providing women with the necessary skills and knowledge to effectively negotiate safer sex practices. This can include communication skills training, assertiveness training, and education on sexual and reproductive health.

3. Supportive policies and legislation: Advocating for policies and legislation that promote gender equality and women’s rights, including their right to make decisions about their own bodies and health. This can involve working with governments and other stakeholders to develop and implement supportive policies and laws.

4. Strengthening healthcare systems: Ensuring that healthcare systems are equipped to provide comprehensive sexual and reproductive health services, including access to family planning methods, HIV testing, and counseling. This can involve training healthcare providers, improving infrastructure, and ensuring the availability of necessary resources.

5. Community engagement: Engaging communities in discussions and activities that promote gender equality and women’s empowerment. This can include community dialogues, support groups, and community-led initiatives to address gender norms and promote positive attitudes towards women’s autonomy.

By implementing these recommendations, it is expected that access to maternal health services will be improved, leading to better health outcomes for women and their families.

AI Innovations Methodology

The study you provided focuses on the association between women’s autonomy in household decision-making and safer sex negotiation in sub-Saharan Africa. To improve access to maternal health, it is important to consider innovations that address the barriers faced by women in this region. Here are a few potential recommendations:

1. Women’s empowerment programs: Implement programs that aim to empower women and enhance their decision-making power within households. These programs can include education and skills training, financial literacy, and leadership development.

2. Gender-sensitive healthcare services: Ensure that healthcare services are designed to be gender-sensitive, taking into account the unique needs and preferences of women. This can involve training healthcare providers on gender issues and providing services in a respectful and non-discriminatory manner.

3. Community-based interventions: Develop community-based interventions that promote women’s autonomy and encourage safer sex negotiation. These interventions can involve community education, peer support groups, and the involvement of community leaders and influencers.

4. Access to contraceptives and family planning services: Improve access to contraceptives and family planning services, as these play a crucial role in enabling women to make informed decisions about their reproductive health. This can include increasing the availability and affordability of contraceptives, as well as providing comprehensive family planning counseling.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could involve the following steps:

1. Baseline data collection: Collect data on the current status of women’s autonomy in household decision-making, safer sex negotiation, and access to maternal health services in the target population.

2. Intervention implementation: Implement the recommended interventions in a selected sample of the population. This can involve implementing women’s empowerment programs, training healthcare providers, conducting community-based interventions, and improving access to contraceptives and family planning services.

3. Post-intervention data collection: Collect data after the interventions have been implemented to assess changes in women’s autonomy, safer sex negotiation, and access to maternal health services. This can involve surveys, interviews, and other data collection methods.

4. Data analysis: Analyze the collected data using appropriate statistical methods to determine the impact of the interventions on improving access to maternal health. This can include comparing pre- and post-intervention data, conducting regression analyses, and assessing statistical significance.

5. Evaluation and recommendations: Evaluate the findings of the data analysis and make recommendations based on the results. This can involve identifying successful interventions, areas for improvement, and strategies for scaling up effective interventions.

By following this methodology, it would be possible to simulate the impact of the recommended innovations on improving access to maternal health and inform future interventions and policies in this area.

Ababhali & Co-Ababhali

Statistics:

Citations: 15

Authors: 9

Identifiers:

DOI: 10.1016/j.ssmph.2021.100773

Research Areas:

Community Interventions, Health System and Policy, Infectious Diseases, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants

Study Design:

Case-Control Study, Cross Sectional Study

Study Approach:

Quantitative

Participants Gender:

Male & Female

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