A Multi-Country Analysis of Women's Autonomy and High-Risk Sexual Behavior Using Demographic and Health Surveys Data

Background and Purpose: HIV/AIDS tragedy has caused one of the greatest humanitarian public health problems (Uchudi, Magadi & Mostazir, 2012), with 35 million people with the disease and 25 million more dead (The Joint United Nations Program on HIV/AIDS, 2013). High-risk sexual behavior, multiple and concurrent partnerships, reckless sexual relationships, premarital sex, and extramarital sex have been implicated for the HIV incidents in developing countries (Halperin & Epstein, 2004; Leclerc-Madlala, 2003, 2008). Although available data show socio-cultural attributes for HIV incidents (Leclerc-Madlala, 2009), very few studies attempt to identify the determinants of sexual risk behavior using gender related socio-cultural theory of women’s autonomy. The socio-cultural context impacts a woman’s decision-making, labor force participation and general wellbeing. The present study uses a multi-country analysis in understanding women’s autonomy in negotiating safer sex practices to avoid HIV/AIDS in Kenya, Malawi, Nepal and Nigeria based on their high HIV burden in their respective region (UNAIDS, 2013).

Method: The Demographic Health Survey (DHS) data for Nigeria (2013), Malawi (2010), Kenya (2008-09), and Nepal (2011) were used for their geographical variability and risk for HIV. The sample included women aged 15-54 years from each country who self-identified as ever married, Malawi (3764), Nigeria (9017) Kenya (1463) and Nepal (2296). Factor analysis for women’s autonomy was conducted based on socio-cultural theory. Logistic regression was conducted and the odds of women’s autonomy on HIV risk was examined.

Results: Results from Kaiser-Meyer-Olkin measure of sampling adequacy was .7 and above for Nigeria, Malawi, Kenya and Nepal indicating appropriate factor loading. The Bartlett's test of sphericity was significant for Nigeria χ² (6)=537.55, p<.001, Kenya χ² (15)=1034.22, p <.001, Malawi χ² (6)=1646.34, p<.001 and Nepal χ² ( 6)=2953.87, p<.001. Communalities were all above.3 and all factor loading met criteria of .4 or above generating three latent variables of labor force participation, decision making and individual autonomy for all countries. Results indicated decision-making, labor force participation and individual autonomy as significant predictors for reducing risk for HIV infection by having one sex partner. For example, results show that, individual autonomy and decision making participation among autonomous women in Nigeria, significantly increased the odds of reducing risk for HIV/AIDs by having one sex partner by 1.12 and .82 times, respectively.  Ominibus model and Hosmer and Lemeshow insignificant tests predicted final fit model for the four countries. Other social-demographic characteristics of education, place of residence, marital status and religion were also significantly associated with women autonomy factors and risk for HIV.

Implications for policy and practice: Our study indicates that effective management of HIV transmission requires addressing women autonomy factors and affirms similar findings by other researchers (Dunkle et al., 2004; Wojcicki & Malala, 2001). Future studies should examine the impact of traditional gender roles on women’s ability to negotiate safer sex. Focusing on evidence based intervention with socio-culture diversity in the context in relation to sexual behavior and women’s autonomy.