Women's Autonomy and Condom Use Negotiations: A Multi-Country Analysis

Background and Purpose: Women’s autonomy and the ability to negotiate safer sex practices are critical in HIV prevention efforts. Autonomy gives women the ability to negotiate safer sex, make individual decision on whether or not to use condom and test for HIV. Several knowledge gaps exist however, on women’s decision making in diverse cultures (Mashinini & Pelton-Cooper, 2012). Significant gaps include the process of condom negotiations, susceptibility to HIV due to unequal power relations, and evidence around testing for ones HIV status (Quinlivan et al., 2013). Thus, our study examines women’s autonomy in four culturally diverse societies: Nigeria, Kenya, Malawi, and Nepal and how autonomy impacts women’s risk for HIV by always using a condom. The dynamics in women’s autonomy to reduce risk for HIV and condom negotiations is still understudied. We chose these four countries for their geographical diversity, HIV prevalence, and HIV regional significance.

Methods: We used the most recent nationally representative Demographic and Health Surveys (DHS) data from the four countries, Nigeria (2013), Kenya (2008-09), Malawi (2010) and Nepal (2011). The sample included women aged 15-54 from Nigeria (9017), Kenya (1463) Malawi (3764) and Nepal (2296) couples. Factor analysis was used to create  latent construct of women autonomy.   Bivariate analysis were conducted to assess statistical differences between women’s autonomy and always using a condom to reduce the risk for HIV/AIDs. Logistic regression was used to assess the association between indicator variables of autonomy and a dichotomous dependent variable of always using a condom by country.

Result: Findings indicate that a majority of women in these countries live in rural areas (77%). Resources, including health infrastructure and qualified doctors, are often scarce or nonexistent in rural populations, which often put women at a disadvantage for effective treatment. Logistic regression shows that labor participation, individual autonomy and decision making in Nigeria significantly increased the odds of reducing the risk for HIV/AIDs by always using a condom during sex by 1.18,1.39 and .79 times, respectively. Similarly, the women autonomy factors of labor participation and individual autonomy in Kenya significantly increased the odds of reducing the risk for HIV/AIDs by always using a condom during sex by .77 and 1.32 times, respectively. Women autonomy factors were not significant determinants in reducing risk for HIV/AIDs for Malawi and Nepal.

Implication for policy and practice: The findings indicate that women’s autonomy is a significant variable in condom use to prevent HIV. Interventions that have promoted condom use since the 1990s have focused on building the women’s “negotiating power” within sexual relationships (Snow, Winter & Harlow, 2013), however, more still need to be done in this area. For example, significant cultural norms that exist in Malawi and Nepal need more exploration. Policies that promote women’s autonomy in decision-making, labor force participation are needed to address HIV infections. Health workers and government programs are needed to educate women on the importance of HIV testing and condom use using culturally sensitive communications.