Proximate context of gender-unequal norms and women's HIV risk in sub-Saharan Africa

OBJECTIVE: To determine whether the proximate context of gender-unequal norms about violence against women undermines women's ability to negotiate condom use in sexual relationships. DESIGN: Secondary analysis of cross-sectional data pooled from 22 Demographic and Health Surveys conducted in sub-Saharan Africa. METHODS: Each of the 22 surveys employed a multistage stratified design with probabilistic sampling and was designed to be nationally representative of reproductive-age women. The outcome was self-reported condom use at last sexual intercourse. The primary explanatory variable of interest was a scale consisting of five questions about whether the respondent agreed with the appropriateness of wife beating under five different scenarios. To measure the proximate context of norms about violence against women, this scale was aggregated to the level of the primary sampling unit. We fit logistic regression models with cluster-correlated robust standard errors and adjustment for country-level fixed effects and sociodemographic characteristics. RESULTS: Our analysis sample included data from 198,806 sexually active women living in 22 sub-Saharan African countries. The wife-beating scale was internally consistent (Cronbach's α = 0.84), and factor analysis confirmed the presence of a single factor. Condom use was associated with gender-unequal contextual norms about violence against women (adjusted odds ratio = 0.88; 95% confidence interval, 0.85-0.92; P < 0.001). The estimated association was robust to adjustment for sociodemographic characteristics and several sensitivity analyses. CONCLUSIONS: The proximate context of gender-unequal norms about violence against women is associated with lack of condom use among women in sub-Saharan Africa.