Condom Use at Last Sex and Sexual Negotiation Among Young African American Women in North Carolina: Context or Personal Agency.

African American women are 10.8 times more likely to be diagnosed with HIV compared with White women. This descriptive study fills a gap by examining associations among social and contextual factors and sexual communication, condom use, and safer sex negotiation among African American women. Study participants between 18 and 25 years of age and who reported recent substance use were recruited from three North Carolina counties. A risk behavior survey was administered via audio computer-assisted self-interview, and logistic regression analyses were conducted to assess associations between social and contextual variables and condom use at last sex with a main partner. Education (AOR: 2.078; 95% CI: 1.214, 3.556), sexual communication with a main partner (AOR: 1.079; 95% CI: 1.050, 1.109), and condom use relationship scale (AOR: 1.059; 95% CI: 1.023, 1.098) were positively associated with condom use at last sex, whereas living with a main partner (AOR: 0.447; 95% CI: 0.210, 0.950) and the alcohol and drug problem scale (AOR: 0.971; 95% CI: 0.944, 0.998) were negatively associated with condom use (p < 0.05). The study findings show that among young African American women at risk for HIV, contextual and personal factors may influence condom use. A socio-ecological approach combining personal empowerment, interpersonal, structural, and biobehavioral strategies is necessary in implementing holistic gender-focused HIV prevention programs.

Women's ability to negotiate safer sex with partners by contraceptive status among a nationally representative sample of married women in Nigeria.

BACKGROUND: Existing studies established that safer sex negotiation influences contraceptive use, and women who are able to negotiate safer sex were expected to be contraceptive users. However, it is not certain that all contraceptive users have the ability to negotiate safer sex. Likewise, there is no evidence that all non-users are not able to negotiate safer sex with partners. The study assesses the prevalence of women's ability to negotiate safer sex and examines the determinants of women's ability to negotiate safer sex among contraceptive users and non-users. METHODS: The comparative cross-sectional research design was adopted. Data were extracted from the 2018 Nigeria Demographic and Health Survey. The study analyzed a sample of 2,765 contraceptive users and 20,304 non-users. The outcome variable was women's ability to negotiate safer sex with partners. The explanatory variables examined are eight socio-demographic characteristics (age, child marriage, education, parity, media exposure, religion, work status, and experience of female genital mutilation), six relational characteristics (healthcare autonomy, financial autonomy, household wealth quintile, partners' education, ownership of assets, and type of marriage). Attitude to wife-beating, male controlling behavior, place of residence, and geo-political zone of residence were included as control variables. Multivariable regression models were estimated. RESULTS: Findings showed that 6.2% of women who were not able to negotiate safer sex were contraceptive users, while 15.9% of women who were able to negotiate safer sex were contraceptive users. Among non-users, the significant determinants were child marriage, education, parity, mass media exposure, religion, work status, healthcare autonomy, financial autonomy, household wealth, partner education, type of marriage, geo-political zone, attitude to wife-beating, and male controlling behavior. Regarding contraceptive users, the significant determinants were parity, religion, the experience of female genital mutilation, financial autonomy, partner education, type of marriage, and the geo-political zone of residence. CONCLUSION: The ability to negotiate safer sex differs among contraceptive users and non-users. Also, the determinants of the ability to negotiate safer sex differ among contraceptive users and non-users. While existing strategies may continue to focus on women not using contraceptives, new strategies promoting reproductive autonomy are required among contraceptive users.

Existing studies established that safer sex negotiation influences contraceptive use, and women who are able to negotiate safer sex were expected to be contraceptive users. However, it is not certain that all contraceptive users have the ability to negotiate safer sex. Likewise, there is no evidence that all non-users are not able to negotiate safer sex with partners. The objectives of the study were to assess the prevalence of women's ability to negotiate safer sex and to examine the determinants of women's ability to negotiate safer sex among contraceptive users and non-users. The comparative cross-sectional research design was adopted. Data were extracted from the most recent Nigeria Demographic and Health Survey. Samples of contraceptive users and non-users were analyzed in the study. The outcome variable was women's ability to negotiate safer sex with partners. The explanatory variables examined are eight socio-demographic characteristics (age, child marriage, education, parity, media exposure, religion, work status, and experience of female genital mutilation), six relational characteristics (healthcare autonomy, financial autonomy, household wealth quintile, partners' education, ownership of assets, and type of marriage). Attitude to wife-beating, male controlling behavior, place of residence, and geo-political zone of residence were included as control variables. Findings showed a higher ability to negotiate safer sex among contraceptive users. There were differences in the determinants of safer sex negotiation among contraceptive users and non-users. The study concluded that the ability to negotiate safer sex and its determinants differs among contraceptive users and non-users. It was suggested that while existing strategies may continue to focus on women not using contraceptives, new strategies promoting reproductive autonomy are required among contraceptive users.

Safer Sex Negotiation Among Ghanaian Women in Sexual Unions: Does Women's Household Decision-Making Capacity Matter?

Women's ability to negotiate for safer sex has been found to be dependent on their household decision making power. However, there is paucity of studies investigating the association between women's household decision making power and safer sex negotiation in Ghana. Thus, we examined the association between women's household decision making autonomy and safer sex negotiation among Ghanaian women in sexual unions using the 2014 Ghana's Demographic and Health Survey. Descriptive statistics, Chi-square test, and multivariable logistic regression models were performed. Statistical significance was set at p < .05 at 95% confidence interval. The results showed high prevalence of safer sex negotiation among women with high household decision-making capacity (91.6%). Compared to women with low household decision making autonomy, those with high autonomy in household decision making were more likely to negotiate for safer sex (aOR = 2.06; CI = 1.32-3.21). Women aged 25-34 were more likely to negotiate for safer sex compared to those aged 15-24 (aOR = 1.50; CI = 1.07-2.11). Higher odds of safer sex negotiation were found among women with comprehensive HIV and AIDS knowledge (aOR = 1.49; CI = 1.09-2.05), women who had tested for HIV (aOR = 1.57; CI = 1.27-1.95) and those exposed to newspaper (aOR = 1.80; CI = 1.17-2.78) compared to those who had no comprehensive knowledge on HIV and AIDS, those who had never tested for HIV and those who were not exposed to newspaper, respectively. However, women who belonged to other ethnic groups and the Islamic religion had lower odds of safer sex negotiation compared to Akans (aOR = 0.68; CI = 0.48-0.96) and Christian women (aOR = 0.63; CI = 0.46-0.85). Women empowerment programmes need to be intensified to enable Ghanaian women with low household decision making autonomy to negotiate for safer sex with their partners. Ghana could achieve the Sustainable Development Goals (SDGs), particularly, SDG 3.7 (universal access to sexual and reproductive health services), and SDG 5 (achieve gender equality and empower all women and girls) when household decision-making capacity among women is further strengthened.

Attitude towards negotiating safer sexual relations: Exploring power dynamics among married couples in India.

The study primarily focuses on analyzing married women's attitudes towards negotiating safer sex in two contexts. The first context is when a woman refuses to have sex with husband if she knows her husband has a sexually transmitted disease (STD) and the second is when she does so if she knows he has sex with other women. The study examined predictors of Indian women's attitude towards negotiating safer-sex using data on 92,306 ever married women from the state module of the 2015-16, National Family Health Survey 4. Descriptive and multilevel logistic regression was used to understand the interplay between the attitude towards negotiation of safer sexual relationships with husband and the selected background characteristics with a primary focus on controlling behaviour and power relations. About 17% of women did not believe in negotiating safer sexual relations with the husband. An approximately equal proportion of ever-married women (79% each) believed in doing so under the two specific conditions, that is, if they knew the husband had an STD and they knew he had sex with other women. Multilevel regression analysis showed that women who had household decision-making power [AOR=0.71; p<0.01] and those whose husbands displayed low control towards them [AOR=0.91; p<0.05] were more likely to believe in negotiating safer-sex. Our findings suggest that women who have controlling partners or those who live under the umbrella of the husband's authority lack the power to negotiate for safer sex. Interventions promoting sexual well-being must deal with negative male perceptions and expectations that perpetuate unhealthy sexual habits and marriage ties.

Safer sex negotiation and parity among women in sub-Saharan Africa.

Women's ability to negotiate for safer sex has effects on their sexual and reproductive health. This study investigated the association between safer sex negotiation and parity among women in sub-Saharan Africa. The data were sourced from the Demographic and Health Surveys of 28 sub-Saharan African countries conducted from 2010 to 2019. A total of 215,397 women aged 15-49 were included in the study. Multilevel logistic analysis was conducted to examine the association between safer sex negotiation and parity among women in sub-Saharan Africa. The results were presented as adjusted odds ratios (aOR) and the significance level set at p<0.05. The overall prevalences of safer sex negotiation and high parity among women in sub-Saharan Africa were 82.7% and 52.1%, respectively. The prevalence of high parity ranged from 32.3% in Chad to 72.1% in Lesotho. The lowest prevalence of safer sex negotiation was in Chad (16.8%) while the highest prevalence was recorded in Rwanda (99.7%). Women who had the capacity to negotiate for safer sex were less likely to have high parity compared with those who had no capacity to negotiate for safer sex (aOR = 0.78, CI: 0.75-0.81). Other factors that were associated with high parity were age, educational level, marital status, exposure to media, contraceptive use, religion, wealth quintile, sex of household head, and place of residence. The study identified significant association between safer sex negotiation and high parity among women of reproductive age in sub-Saharan Africa. It is worth noting that women's ability to negotiate for safer sex could reduce high parity among women in sub-Saharan Africa. Therefore, policies and programmes aimed at birth control or reducing high parity among women could be targeted at improving their capacity to negotiate for safer sex through education.

Exploring the perception and socio-cultural barriers to safer sex negotiation among married women in Northwest Nigeria.

BACKGROUND: Safer sex negotiation refers to the means through which partners in sexual relationships agree to have intercourse that protects both partners from adverse sexual health outcomes. Evidence is sparse on the socio-cultural barriers to safer sex negotiation, especially in Northwest Nigeria where almost every aspect of women's lives is influenced by religious and cultural norms. Understanding the socio-cultural barriers requires having knowledge of the perspectives of community stakeholders such as religious leaders, and community leaders. Thus, from the perspectives of community stakeholders, this study explored the perception and socio-cultural barriers to safer sex negotiation of married women in Northwest Nigeria. METHOD: A qualitative research design was adopted. Participants were purposively selected across six states, namely, Kano, Katsina, Jigawa, Kebbi, Kaduna, and Zamfara. Data were collected through Key Informant Interview (KII). A total of 24 KIIs were conducted using the in-depth interview guide developed for the study. The selection of the participants was stratified between rural and urban areas. The interviews were tape-recorded, transcribed, and translated from the Hausa language into the English language. Verbal and written informed consent were obtained from participants prior to the interviews. Data were analyzed using inductive thematic content analysis. RESULTS: Safer sex negotiation was well-understood by community stakeholders. Men dominate women in sexual relationships through the suppression of women's agency to negotiate safer sex. Married women endured domination by males in sexual relationships to sustain conjugal harmony. The practice of complying with traditional, cultural, and religious norms in marital relationships deters women from negotiating safer sex. Other socio-cultural causes of the inability to negotiate safer sex are child marriage, poverty, poor education, and polygyny. CONCLUSION: Community stakeholders have a clear understanding of safer sex negotiation in Northwest Nigeria but this has not translated into a widespread practice of safer sex negotiation by married women due to diverse socio-cultural barriers. Strategies that will empower women not only to gain more access to relevant sexual and reproductive health information and services but also to encourage women's assertiveness in family reproductive health decisions are imperative in Northwest Nigeria.

Comprehensive HIV/AIDS knowledge and safer sex negotiation among adolescent girls and young women in sub-Saharan Africa.

Globally, HIV/AIDS remains a public health issue, especially in sub-Saharan Africa (SSA). Despite the increased advocacy and dissemination of comprehensive HIV/AIDS information in SSA, it appears that little progress has been made to reduce the incidence of HIV/AIDS in the sub-region. This study, therefore, examined the association between comprehensive HIV/AIDS knowledge and safer sex negotiation among adolescent girls and young women in SSA. Data were taken from the Demographic and Health Surveys conducted between 2010 and 2019 in 30 countries in SSA. The study sample comprised 37,364 adolescent girls and young women aged 15-24. A multivariable binary logistic regression analysis was done to test the hypothesis that there is a positive association between comprehensive HIV/AIDS knowledge and safer sex negotiation. Adolescent girls and young women who had comprehensive knowledge on HIV/AIDS were more likely to negotiate for safer sex compared with those who had no comprehensive knowledge on HIV/AIDS (AOR=1.31, 95% CI: 1.22-1.41). At the country level, the positive association between comprehensive knowledge on HIV/AIDS and safer sex negotiation was significant in Chad, Congo DR, Gambia, Guinea, Liberia, Ethiopia and Malawi. On the other hand, in Togo, adolescent girls and young women who had comprehensive HIV/AIDS knowledge were less likely to negotiate for safer sex. These findings can inform policies and programmes on the crucial role of comprehensive HIV/AIDS education and knowledge in increasing safer sex negotiation among adolescent girls and young women in SSA. The study recommends that Togo needs to address certain practices such as intimate partner violence against adolescent girls and young women, which prevent them from negotiating for safer sex, despite their higher knowledge on comprehensive HIV/AIDS. Lessons can be learnt from Chad, Congo DR, Gambia, Guinea, Liberia, Ethiopia and Malawi about the scale-up of programmes and interventions targeted at young women.

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.

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.

Women's household decision-making autonomy and safer sex negotiation in Nigeria: An analysis of the Nigeria Demographic and Health Survey.

Although married women's safer sex negotiation with their husbands is critical in reducing new HIV infections in Nigeria, its linkage to women's household decision-making autonomy is less explored in Nigeria. Drawing data from the 2013 Nigeria Demographic and Health Survey and using the logistic regression technique, we examined the associations between women's household decision-making autonomy and two indicators of the ability to engage in safer sex including whether married women 1) can refuse sex and 2) ask for condom use during sexual intercourse with husbands. Findings indicate that 64% and 41% of married women can refuse sex and ask for condom use, respectively. While the impact of women's household decision-making autonomy on the ability to refuse sex remained statistically significant after controlling for theoretically relevant variables (OR = 1.15; p < 0.001), its impact on the ability to ask for condom use became weakly significant once socioeconomic variables were controlled (OR = 1.03; p < 0.1). Based on these results, we have two suggestions. First, it may be important that marital-based policies and counselling promote environments in which married women can establish equal power relations with their husbands. Second, it is also important to eliminate structural barriers that hinder married women's economic opportunities in Nigeria.

Community Influences on Married Women's Safer Sex Negotiation Attitudes in Bangladesh: A Multilevel Analysis.

The influence of disadvantaged or deprived community on individuals' health risk-behaviors is increasingly being documented in a growing body of literature. However, little is known about the effects of community characteristics on women's sexual attitudes and behaviors. To examine community effects on married women's safer sex negotiation attitudes, we analyzed cross-sectional data from the 2011 Bangladesh Demographic and Health Surveys on a sample of 15,134 married women in 600 communities. We estimated two multilevel logistic regression models. Model 1, which included only individual-level variables, showed that women's autonomy/empowerment, age, and HIV knowledge had significant associations with their safer sex negotiation attitudes. We did not find any socioeconomic status gradient in safer sex negotiation attitudes at the individual level. Adding community-level variables in Model 2 significantly improved the fit of the model. Strikingly, we found that higher community-level poverty was associated with greater positive safer sex negotiation attitudes. Prevailing gender norms and overall women's empowerment in the community also had significant effects. While research on community influences calls for focusing on disadvantaged communities, our research highlights the importance of not underestimating the challenges that married women in economically privileged communities may face in negotiating safer sex. To have sufficient and equitable impact on married women's sexual and reproductive health, sexual and reproductive health promotion policies and programs need to be directed to women in wealthier communities as well.

Can a woman refuse sex if her husband has a sexually transmitted infection? Attitudes toward safer-sex negotiation among married women in Bangladesh.

In developing countries, HIV, sexually transmitted infections (STIs) and unintended pregnancy take an enormous toll on women's reproductive health, yet preventive programmes are lacking as married women's risks are frequently underestimated. We examined predictors of married Bangladeshi women's attitudes towards safer-sex negotiation using data on 15,178 currently married women aged 15-49 from the 2011 Bangladesh Demographic Health Survey. Approximately 92% of women believed that a wife's refusal to have sex with her husband is justified if he has an STI. Multilevel logistic regression analysis revealed that the likelihood of a woman holding this belief increased with her autonomy, as measured by the ability to go to a health centre/hospital without another adult, participation in household decision making and rejection of wife beating (p < 0.001). Other significant predictors were knowledge/awareness of STIs (p < 0.05), living in Dhaka division (p < 0.001) and younger age (p < 0.01). Our findings suggest that sexual health education programmes may be more effective if they include strategies to address social norms and cultural practices that limit women's autonomy in society.