AIDS Education and Prevention, 26(1), 1–12, 2014 © 2014 The Guilford Press WOMEN’S AUTONOMY IN NEGOTIATING SAFER SEX ATTERAYA ET AL.

WOMEN’S AUTONOMY IN NEGOTIATING SAFER SEX TO PREVENT HIV: FINDINGS FROM THE 2011 NEPAL DEMOGRAPHIC AND HEALTH SURVEY Madhu Sudhan Atteraya, Heejin Kimm, and In Han Song

Women with greater autonomy have higher HIV-related knowledge and condom use. Inability to negotiate safer sex in high-risk situations might increase HIV infection. This study examined the relationship between women’s autonomy and ability to negotiate safer sex practices among married women. The 2011 Nepal Demographic and Health Survey data were used. The data were collected by two-stage stratified cluster sampling and faceto-face interviews. Autonomy was measured in Decision-Making Participation and Assets Ownership, while ability to negotiate safer sex consists of Refusal of Sex and Ask for Condom Use. Among 12,674 women of 15–49 years, married women were analyzed (n = 8,896). Women with greater autonomy in decision-making participation were more likely to negotiate safer sex. After controlling for socio-demographic factors, odds ratios (OR) for refusal of sex was 2.70 (95% CI [2.14, 3.40]) in women with the highest decision-making participation. These women showed higher OR for ‘ask for condom use’ in high risk situations (2.10, 95% CI [1.81, 2.44]). Assets ownership also demonstrated a positive statistical relationship with asking for a condom use (OR 1.31, 95% CI [1.10, 1.56]). The results point to the importance of women’s autonomy on sexual health. It emphasizes women’s empowerment-based approach to curbing HIV/AIDS in developing countries.

Women’s ability to negotiate for their rights on safer sex is desirable for sexual health and HIV prevention when intimate partners are engaging in risky behavior (Mantell, Stein, & Susser, 2008). Women’s inability to negotiate safer sex is more likely to result in the risk of HIV infection (Wingood & DiClemente, 2000). Conversely, empowering women to negotiate safer sex is an effective HIV prevention strategy (Amaro, 1995; Exner, Seal, & Ehrhardt, 1997; Wingood & DiClemente, 1996). Heejin Kimm is affiliated with the Institute for Health Promotion & Department of Epidemiology and Health Promotion, Graduate School of Public Health, Yonsei University, Seoul, Republic of Korea. Madhu Sudhan Atteraya and In Han Song are affiliated with Yonsei University Graduate School of Social Welfare, Seoul, Republic of Korea. This research was supported by Basic Science Research Program Through the National Research Foundation of Korea (NRF) funded by the Ministry of Education, Science and Technology (14245). Address correspondence to Heejin Kimm, M.D., M.P.H., Ph.D., Department of Epidemiology and Health Promotion, Graduate School of Public Health, Yonsei University, Seoul, Republic of Korea. E-mail: [email protected]

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WOMEN’S AUTONOMY IN NEGOTIATING SAFER SEX

Evidence from populations with high instances of HIV infection suggests that refusing sexual intercourse in wedlock is almost impossible and coercive sex for married couples is common (Santhya, Haberland, Ram, Sinha, & Mohanty, 2007; Tenkorang, 2012). When women lack the power to refuse sex or insist on condom use, they are susceptible to HIV. HIV infection has been found to be steadily increasing in this vulnerable group (Gupta, 2002; Quinn & Overbaugh, 2005). Most of these new infections occur through unprotected heterosexual practices in cases where women lacked power to negotiate their own sexual health safety (Do & Fu, 2011; Gupta, 2002). However, self-efficacy in negotiating safer sex is difficult to achieve where gender-based inequality in power relations exists in all local communities (Poudel & Carryer, 2000). The construct of women’s autonomy was first developed by Dyson and Moore (1983), defining autonomy as women’s decision-making power or freedom over their personal affairs and their ability to inherit property, especially within a family or household. Following Dyson and Moore (1983), Mason (1986) and Anderson and Eswaran (2009) defined women’s autonomy as the ability of women to make choices/decisions within the household relative to their husbands within culturally specific practices. Previous studies empirically measured women’s autonomy in power relations through examination of decision-making abilities, access to productive resources, and control over their earnings, freedom of movement, permissiveness, and freedom from threat (Allendorf, 2007a, 2007b; Anderson & Eswaran, 2009; Bloom & Griffiths, 2007; Bloom, Wypij, & Das Gupta, 2001; Jejeebhoy & Sathar, 2001; Mistry, Galal, & Lu, 2009). Further, women’s autonomy has been empirically examined as a main predictor variable on health-related outcomes, such as health care utilization (Allendorf, 2007a; Bloom et al., 2001), pregnancy care (Haque, Rahman, Mostofa, & Zahan, 2012; Mistry et al., 2009), birth weight of children (Chakraborty & Anderson, 2011), family planning utilization (Al Riyami, Afifi, & Mabry, 2004; Govindasamy & Malhotra, 1996), child health and nutrition (Doan & Bisharat, 1990), and HIV/AIDS knowledge and behavior (Bloom & Griffiths, 2007; Chacham, Maia, Greco, Silva, & Greco, 2007; Snelling et al., 2007). These studies found that autonomous women were healthier and had higher levels of wellbeing. However, a literature review has produced no evidence of empirical investigation into the relationship between women’s autonomy in decision-making participation and assets ownership to women’s ability to negotiate safer sex practices (refusal of sex in high risk situations, and the ability to ask for condom use) so as to prevent HIV. Nepal is one of the riskiest countries in the South Asian region after India due to its widespread poverty, seasonal labor migration, and issues with sex-trafficking involving brothels in India (Rodrigo & Rajapakse, 2009; Singh, Mills, Honeyman, Suvedi, & Pant, 2005). Married women are not exceptional for these risks. Increasing HIV prevalence has been observed among migrant families who reside in the remotest and poorest areas of Nepal where HIV testing, counseling, and antiretroviral drugs are virtually unavailable (Smith-Estelle & Gruskin, 2003). A survey conducted among 137 migrant workers in the Far-Western Region of Nepal found 8% of the migrant workers to be HIV-positive (Poudel et al., 2003). Despite having knowledge of condom use and being aware of HIV/AIDS, overall sexual practices are generally unsafe in Nepal (Furber, Newell, & Lubben, 2002). A study on sexual practice among HIV-positive men revealed that of 167 participants, 47% had multiple partners, and 46% of participants did not always use condoms (Poudel, Nakahara, Poudel-Tandukar, Yasuoka, & Jimba, 2009).

ATTERAYA ET AL. 3

Women have less access to education, employment, and involvement in general decision-making participation, as well as the ownership of productive resources such as land and/or house. This socio-cultural context relegates women to a powerless and submissive role relative to their husbands (Connell, 1987). In this context, women’s refusing sex or asking for the use of condoms is uncommon in Nepalese marriages, too. It is argued that a woman’s choices/decisions, and their power or control over productive resources advances women’s ability to negotiate safer sexual health. In this study, we aimed to analyze the association between women’s autonomy and their ability to negotiate sex in order to mitigate the risks of new HIV infection.

METHODS DATA This study used the 2011 Nepal Demographic and Health Survey (NDHS; Ministry of Health and Population (MOHP) [Nepal], New ERA, and ICF International Inc., 2012). The NDHS (2011) is a nationally representative cross-sectional study designed to provide reliable information about fertility behavior, maternal and child health issues, domestic violence, and adult HIV/AIDS-related knowledge and behavior. The survey has been conducted every five years with funding from the United States Agency for International Development (USAID) through its mission in Nepal. The data were collected in both urban and rural areas using two-stage stratified cluster sampling which stratified 13 domains obtained by cross-classifying three geographical regions (Mountain, Hill, and Terai) and five developmental regions (East, Central, West, Midwest, and Far west). The participants were selected with probability proportional to size from a total of 11,085 households. In these selected households, males and females aged 15–49 were randomly selected for face-to-face interviews on health issues, including adult HIV/AIDS-related knowledge and behavior, yielding a 95% response rate (Ministry of Health and Population (MOHP) [Nepal], New ERA, and ICF International Inc., 2012). Among them, this study utilized the data set of the currently married female population of 8,896 in the 15–49 age range, excluding 564 missing cases from decision-making participation (424), assets ownership (119), and 21 cases from caste and ethnicity (Figure 1).

MEASURES DEPENDENT VARIABLES We analyzed two dependent variables that show women’s ability to negotiate safer sex. The first question asked each married woman whether she was justified in refusing sex when she knew her husband had had sex with other women. The second asked whether she was justified in asking for the use of a condom if she knew her husband had STI (Sexually Transmitted Infections). We recorded those who Refuse Sex and ask for Condom Use as Safer Sex, and No or Don’t Know answers were recorded for Unsafe Sex. Don’t Know responses were counted as unsafe sexual behavior.

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FIGURE 1. Participant Flow Diagram: Characteristics of the Sample.

INDEPENDENT VARIABLES The independent variables included in the analysis were structured into two main blocks: women’s autonomy factors and socio-demographic factors. We measured two dimensions of women’s autonomy based on their choices, decisions, and access with resources: decision-making participation and assets ownership (Agarwal, 1994; Anderson & Eswaran, 2009; Bloom & Griffiths, 2007; Bloom et al., 2001; Dixon-Mueller, 1998; Jejeebhoy & Sathar, 2001; Malhotra, Schuler, & Boender, 2002; Mistry et al., 2009). One is Decision Making Participation that has been measured in women’s participation in her Personal Health Care, Major Household Purchases, Visit to Family or Relatives, and their Participation in Husband’s Income. A value of 1 is assigned if the respondents participated in decision-making (respondents alone, and jointly with husbands and other family members), and value 0 is assigned for women who did not participate in the process of decision-making at all. The sum of the values resulted in a scores from 0 to 4. Low participation was recorded for those who did not participate at all, score 1 to 3 were recorded as a medium level of participation, high participation was recorded for those who participated in the whole decision-making process (Anderson & Eswaran, 2009; DixonMueller, 1998). Another is that married women who owned assets (land and/or any house) themselves or jointly as a dimension of women’s autonomy (Agarwal, 1994; Allendorf, 2007b; Anderson & Eswaran, 2009; Dyson & Moore, 1983). Aggregated values were recorded as 1 for those who owned one or both land and house, and 0 for those women who stated they did not own a house or any land.

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Socio-demographic factors were control variables that included education, wealth index, age, work status, place of residence, caste and ethnicity, and religion. The education level was defined according to the Nepalese education system as illiterate, primary, and completed secondary and higher education. The wealth index in the 2011 NDHS is based on household income, consumption, and expenditures. The DHS computed national-level wealth-quintiles (from lowest to highest) and divided the rankings into five equal categories, each of which comprise 20 percent of the population, grouped as poorest, poor, middle, rich, and richest. We grouped the wealth index into three categories: poor, middle, and rich. The NDHS data provide information about 15–49 year age group with 5-year intervals. Ages are regrouped into 15–19 (adolescents), 20–29, 30–39, and 40–49 years old. The NDHS asked questions related to women’s current work status. Value 1 was coded for women who were currently working, and 0 was coded for not working. Places of residence were defined as the following: neighborhoods in large cities, small cities, towns, and villages. Large cities, small cities and towns were grouped together as urban area. Villages were rural areas. Castes and ethnicities were restructured into four categories based on the Nepalese social hierarchy (Lawati, 2005), as the high Hindu caste (Brahmin-Chhetry), indigenous people (Newars and Janajati), untouchable caste (Dalits), and Terai caste (Madeshi and Muslim). Self-reported religious status was coded into Hindu, Buddhist, Muslim, Kirat, and Christian.

STATISTICAL ANALYSIS Descriptive analyses were undertaken to explore the relationship between autonomy factors and the safer sex practices (refusal of sex and ask for the condom use). Odds ratios of safer sex were computed from logistic regression models controlling for socio-demographic factors (education, wealth, age, work status, place of residence, caste and ethnicity, and religion). The statistical analyses were performed using the SPSS for windows (version 18; SPSS Inc., Chicago, IL) statistical software program.

RESULTS Table 1 presents the descriptive statistics of selected independent variables and their relations with dependent variables. A majority of married women in Nepal were Hindu and lived in rural areas. In terms of education, 46.8% of women were illiterate, 19.2% had completed primary schooling, and 34% of women had secondary and higher education. The poor group of women accounted for 38.6% and 18.8% women were middle class. The majority (40.2%) were high Hindu caste, followed by indigenous, untouchables, and Terai caste. A large number (40.4%) of women participated in all dimensions of the decision-making process, while 18.4% of women did not participate at all. Few (14.5%) women owned either land or a house; 85.5% of women did not own any assets. A great majority (92.5%) of women reported they can refuse sex if they know their husband had sex with other women, and 74.5% of women ask their husband to use a condom if they are aware their husbands have an STI. Decision making-participation, assets ownership, educational level, wealth status, place of residence, and caste/ethnicity were strongly associated with safer sex (Table 1). Determinants of safer sexual practices (refusal of sex and asking for condom use) from logistic regression models are shown in Table 2 and Table 3, respectively. Model 1 in both tables demonstrated that autonomy factors were strong predictors

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WOMEN’S AUTONOMY IN NEGOTIATING SAFER SEX

TABLE 1. Descriptive Statistics of Autonomy Factors and Socio-demographic Factors of All Women, Compared with Safer Sex Negotiation (Refusal of Sex and Ask for Condom Use) and Associations of Autonomy Factors and Socio-demographic Factors With Safer Sex Negotiation, the 2011 NDHS (n = 8,896) All Women Variables Autonomy factors Decision-making participation Low Medium High Assets ownership No ownership Ownership Socio-demographic factors Education Illiterate Primary Secondary plus Wealth Poor Middle Rich Age 15–19 20–29 30–39 40–49 Work status Currently working Not working Place of resident Urban Rural Caste/Ethnicityb High caste Indigenous Untouchable Terai caste Religion Hindu Buddhist Muslim Kiratc Christian All

Refusal of Sex

n

%

yes (n)

%

1637 3662 3597

18.4 41.2 40.4

1435 3368 3435

87.7 92.0 95.5

7602 1294

85.5 14.5

6995 1243

92.0 96.1

4159 1712 3025

46.8 19.2 34.0

3706 1592 2940

89.1 93.0 97.2

3435 1672 3789

38.6 18.8 42.6

3057 1549 3632

89.0 92.6 95.9

676 3462 2926 1832

7.6 38.9 32.9 20.6

625 3232 2700 1681

92.5 93.4 92.3 91.8

5835 3061

65.6 34.5

5401 2837

92.6 92.7

2412 6484

27.1 72.9

2266 5972

93.6 92.1

3573 3208 1296 819

40.2 36.1 14.6 9.2

3361 2983 1170 724

94.1 93.0 90.3 88.4

7630 726 248 137 155 8896

85.8 8.2 2.8 1.5 1.7 100

7067 670 224 129 147 8236

92.6 92.3 90.3 94.2 94.8 92.6

Ask for Condom Use Pa

yes (n)

%

1007 2793 2834

61.5 76.3 78.8

5553 1081

73.0 83.5

2514 1350 2770

60.4 78.9 91.6

2208 1199 3227

64.3 71.7 85.2

503 2736 2230 1165

74.4 79.0 76.2 63.6

4349 2285

74.5 74.6

1982 4652

82.2 71.7

2914 2473 833 414

81.6 77.1 64.3 50.5

5751 534 113 105 130 6634

75.4 73.6 45.6 76.6 83.9 74.6

< .001

Pa < .001

< .001

< .001

< .001

< .001

< .001

< .001

.154

< .001

.837

.905

.003

< .001

< .001

< .001

.461

< .001

Note. 2011 NDHS = Nepal Demographic and Health Survey, 2011. aP values were determined using the X2 test for association, which identifies differences across all levels; this test does not identify between which cells the differences are meaningful; all expected cell values were adequate for testing. bCaste/ethnicity are constructed according to Nepalese social hierarchy. High castes refer to Brahmin and Chhetry, who belong to the highest social ranking in the Hindu religion. Untouchables are the lowest castes according the Hindu religion. Indigenous refers to distinct communities who have their own mother tongue, traditional culture, and their own distinct history. Terai castes refer to Muslim communities and other non-Hindu minorities who reside in the inner Terai region. cKirat are natives of Himalayas (mid-hills) of mongoloid ethnic groups who practice Shamanism.

of safer sex. In model 2, socio-demographic factors were included. After controlling for socio-demographic characteristics, the highest level of decision-making participation, and assets ownership were associated with safer sex. In Table 2, after controlling for socio-demographic factors, odds of women with the highest decision-making participation were 2.70 times (95% Confidence

ATTERAYA ET AL. 7 TABLE 2. Determinants of Refusal of Sex From Logistic Regression Analyses, the 2011 NDHS (n = 8,896) Model 1 Variables Autonomy factors Decision making Low (ref) Medium High Asset ownership No ownership (ref) Ownership Socio-demographic factors Education Illiterate (ref) Primary Secondary plus Wealth Poor (ref) Middle Rich Work status Not working (ref) Working Place of resident Urban(ref) Rural Caste/Ethnicityc High caste Indigenous Untouchable Terai caste

Model 2a

OR

95% CI

Pb

OR

95% CI

Pb

1.00 1.55 2.75

[1.28, 1.87] [2.21, 3.42]

< .001 < .001

1.00 1.45 2.70

[1.19, 1.78] [2.14, 3.40]

< .001 < .001

1.00 1.69

[1.25, 2.27]

.001

1.00 1.32

[0.97, 1.79]

0.078

1.00 1.42 2.88

[1.13, 1.78] [2.18, 3.79]

.002 < .001

1.00 1.44 2.12

[1.15, 1.80] [1.66, 2.72]

.001 < .001

1.00 1.16

[0.95, 1.40]

.125

1.00 1.33

[1.06, 1.66]

.012

1.00 .946 .862 .572

[0.73, 1.17] [0.67, 1.10] [0.41, 0.78]

.633 .232 < .001

Note. 2011 NDHS = Nepal Demographic and Health Survey, 2011; OR = odds ratio; CI = confidence interval. aAge and religion were also adjusted in Model 2. bP values are based on a significance level of .05 and were calculated using logistic regression. cCaste/ethnicity are constructed according to Nepalese social hierarchy. High castes refer to Brahmin and Chhetry, who belong to the highest social ranking in the Hindu religion. Untouchables are the lowest castes according the Hindu religion. Indigenous refers to distinct communities who have their own mother tongue, traditional culture, and their own distinct history. Terai castes refer to Muslim communities and other non-Hindu minorities who reside in the inner Terai region.

Interval, CI [2.14, 3.40]) the odds of their counterparts with the lowest levels of decision-making participation in refusal of sex (p < .001). In Table 3, after controlling for socio-demographic characteristics, the odds ratio of women with the highest decision making participation were 2.10 times (95% CI [1.81, 2.44]) than that of their counterpart in asking for condom use. Assets ownership was also found to have a strong relationship with condom use (OR 1.31, 95% CI [1.10, 1.56]). Among the socio-demographic factors, both education and the wealth index showed statistically significant relationship with safer sex. The magnitude of the relationship between formal educational attainment and safer sex outcome was larger than any of the other factors. Women who completed secondary and higher education were 2.88 times more likely to refuse sex (p < .001) in the cases where husband had had extramarital sex and had an STI. Similarly, women with higher educational attainment were 4.03 times more likely to ask for a condom use (p < .001). Women with the highest wealth index were also more likely to practice safer sex. The results show that rural people were more likely to refuse sex than urban people, but do not show any statistical significance regarding condom use. Terai castes women were less likely to refuse sex and condoms use (OR 0.57, p < .001; OR 0.28, p < .001).

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WOMEN’S AUTONOMY IN NEGOTIATING SAFER SEX

TABLE 3. Determinants of Ask for a Condom Use From Logistic Regression Analyses, the 2011 NDHS (n = 8,896) Model 1 Variables Autonomy factors Decision making participation Low (ref) Medium High Asset ownership No ownership (ref) Ownership Socio-demographic factors Education Illiterate (ref) Primary Secondary plus Wealth Poor (ref) Middle Rich Work status Not working (ref) Working Place of resident Urban(ref) Rural Caste/Ethnicityc High caste Indigenous Untouchable Terai caste

Model 2a

OR

95% CI

Pb

OR

95% CI

Pb

1.00 1.93 2.14

[1.70, 2.19] [1.88, 2.44]

< .001 < .001

1.00 1.76 2.10

[1.53, 2.03] [1.81, 2.44]

< .001 < .001

1.00 1.62

[1.38, 1.90]

< .001

1.00 1.31

[1.10, 1.56]

.003

1.00 1.93 4.03

[1.67, 2.23] [3.41, 4.77]

< .001 < .001

1.00 1.29 1.95

[1.12, 1.48] [1.67, 2.27]

< .001 < .001

1.00 1.11

[0.77, 1.02]

.089

1.00 .906

[0.78, 1.04]

.182

1.00 .890 .587 .276

[0.77, 1.02] [0.50, 0.68] [0.22, 0.34]

.101 < .001 < .001

Note. 2011 NDHS = Nepal Demographic and Health Survey, 2011; OR = odds ratio; CI= confidence interval. aAge and religion were also adjusted in Model 2. bP values are based on a significance level of .05 and were calculated using logistic regression. cCaste/ethnicity are constructed according to Nepalese social hierarchy. High castes refer to Brahmin and Chhetry, who belong to the highest social ranking in the Hindu religion. Untouchables are the lowest castes according the Hindu religion. Indigenous refers to distinct communities who have their own mother tongue, traditional culture, and their own distinct history. Terai castes refer to Muslim communities and other non-Hindu minorities who reside in the inner Terai region.

Also, untouchable castes were less likely to use condoms (OR 0.58, p < .001). There was found to be a weak relationship between women’s work status and condom use (OR 1.11, p = .089), and had no significant relationship with refusal of sex. Age and religion were not statistically significant for safer sex.

DISCUSSION This study examined the association of married Nepalese women’s decisionmaking participation and assets ownership in negotiating safer sex by refusing sex and asking for condom use in a situation where her husband has an STI and has had extramarital sexual relations. We presume that the ability to refuse sex and insist on condom use leads to the actual acts of condom use and refusal of sex with an infected partner. Women’s autonomy as measured with their decision-making participation and assets ownership were shown to be associated with negotiating for safer sex. For this, our results demonstrate that women with greater decision-making participation are more likely to have safer sex in both refusal of sex and ask for condom use, even after controlling for socio-demographic factors. This finding adds in the

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literatures of women’s empowerment and women’s health that women’s decisionmaking participation makes positive impact on their health and wellbeing, including sexual negotiation at risky situations which may prevent new HIV/AIDS transmission. Though asset ownership has only a weak relationship with refusing sex, it is strongly associated with condom use. Women are at great risk of infection and are less likely to negotiate safer sex in South Asian countries such as Nepal. Studies have argued that greater gender equality and equal socio-economic status empowers women to decide their sexual and reproductive preferences, which greatly reduces their risk of becoming infected with HIV (Connell, 1987). Empowerment to choose safer behavior also has to be made the core of HIV prevention programs (Poindexter, Lane, & Boyer, 2002). An additional note worth taking of in this study is of educational attainment on safer sex negotiation. Our findings also revealed a strong relation with educational attainment and safer sex, which is consistent with previous studies that found that completion of formal education to have a positive impact on health related outcomes including HIV knowledge and condom use (Bloom & Griffiths, 2007; Snelling et al., 2007). Along with higher levels of education, women from richer households were better able to act for safer sex. The findings of this study suggest that more educated and affluent women have more power to negotiate safer sex, whereas uneducated and poor women are more susceptible to HIV infection. Caste and gender-based inequality are apparent in the Nepalese social structure. The socio-economic status of untouchables is lower than that of those belonging to high Hindu castes. Further, the socio-economic conditions of untouchable women are worse compared to their male counterparts. Additionally, the conditions of those in the Terai castes are even worse than the untouchables (Bhattachan, Sunar, & Bhattachan, 2009). Within this social structure, we found that women who belong to indigenous, untouchables, and Terai castes are less able to negotiate safer sex, mainly condom use. Terai caste women are even less efficacious in refusing sex even in cases where their husbands have STIs. Some unexpected results were found. Congruent with Do & Fu (2011), women’s working status was not correlated with refusing sex, and perceived efficacy to negotiate condom use is weaker (p = .089). This is in contrast to the normative argument that working women have more power and greater financial influence they can exert to negotiate safer sex. In developing countries context, women who work outside of their home may be doing manual labor that does not provide them with financial freedom. The majority of women working outside may represent their supplementary labors for others along with childbearing and childrearing of their own (Levine, 1988). In this context, women’s working status may neither influence their financial autonomy nor impact their level of power in negotiating condom use or refusal of sex. Another unexpected result was the effects of place of residence on safer sex. Even though bivariate analysis results predicted urban women would be more able to practice safer sex, in logistic regression analysis rural women were found to be more able to refuse sex, but were not efficacious in condom use negotiation. This result is unlikely and inconsistent with the findings of Indian sub-state context (Bloom & Griffiths, 2007). Our results were also inconsistent in terms of the proportion of actual condom use with the Bloom’s article, which reported a condom use of just 2–14%. These differences may be due to the questionnaire; in the previous report, they included respondents who reported “ever using one or currently using condoms,” but in our study, the question was not on actual use. Additionally, the report was based on the

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WOMEN’S AUTONOMY IN NEGOTIATING SAFER SEX

1998–1999 National Family Health Survey-2 of India, so we cannot exclude the influence from social change during the 13-year gap.

Limitations and strengths The findings of this study may be tempered by some limitations such as crosssectional design, which hinder us from identifying a casual connection between independent and dependent variables. Questions on safer sexual practices were asked only once to the respondents whether they refuse sex and ask to use condoms. Women may report safer sex (refusal of sex and ask to use a condom), however they may not actually carry out these professed acts. In reality, condom use and refusal of sex seems to be very low among married women in the male dominated cultural context. Therefore, further research is needed to explore the validity of the women’s positive answers in this survey in comparison with their actual practice. Despite these limitations, this study has several strengths. We analyzed the most recent nationally representative survey data of the geographic, demographic, socioeconomic, and cultural characteristics of the population. Thus the findings are helpful in devising national policy to curb HIV where the existing legal and policy efforts have been ineffective in addressing risky behavior. As the policies to prevent HIV in the general population are still in the initial states in Nepal, the findings of this study have important implications for public policy regarding women’s empowerment to negotiate safer behavior in curbing HIV/AIDS.

CONCLUSIONS The current study points to the importance of women’s autonomy in decision making participation and asset ownership on safer sex in high-risk situations. It emphasizes a gender-based approach while formulating policies and programs in curbing HIV/AIDS in Nepal and other resource-poor developing countries.

REFERENCES Agarwal, B. (1994). A field of one’s own: Gender and land rights in South Asia. Cambridge: Cambridge University Press. Al Riyami, A., Afifi, M., & Mabry, R. M. (2004). Women’s autonomy, education and employment in Oman and their influence on contraceptive use. Reproductive Health Matters, 12, 144–154. Allendorf, K. (2007a). Couples’ reports of women’s autonomy and health‐care use in Nepal. Studies in Family Planning, 38, 35–46. Allendorf, K. (2007b). Do women’s land rights promote empowerment and child health in Nepal? World Development, 35, 1975– 1988. Amaro, H. (1995). Love, sex, and power: Considering women’s realities in HIV prevention. American Psychologist, 50, 437–447. Anderson, S., & Eswaran, M. (2009). What determines female autonomy? Evidence from Bangladesh. Journal of Development Economics, 90, 179–191.

Bhattachan, K. B., Sunar, T. B., & Bhattachan, Y. K. (2009). Caste-based discrimination in Nepal. New Delhi, India: Indian Institute of Dalit Studies. Bloom, S. S., & Griffiths, P. L. (2007). Female autonomy as a contributing factor to women’s HIV-related knowledge and behaviour in three culturally contrasting states in India. Journal of Biosocical Science, 39, 557–573. Bloom, S. S., Wypij, D., & Das Gupta, M. (2001). Dimensions of women’s autonomy and the influence on maternal health care utilization in a north Indian city. Demography, 38, 67–78. Chacham, A. S., Maia, M. B., Greco, M., Silva, A. P., & Greco, D. B. (2007). Autonomy and susceptibility to HIV/AIDS among young women living in a slum in Belo Horizonte, Brazil. AIDS Care, 19, 12–22. Chakraborty, P., & Anderson, A. K. (2011). Maternal autonomy and low birth weight in

ATTERAYA ET AL. 11 India. Journal of Women’s Health, 20, 1373–1382. Connell, R. W. (1987). Gender and power: Society, the person and sexual politics. Redwood City, CA: Stanford University Press. Dixon-Mueller, R. (1998). Female empowerment and demographic processes: Moving beyond Cairo. Paris, France: International Union for the Scientific Study of Population. Do, M., & Fu, H. (2011). Is Women’s self‐efficacy in negotiating sexual decision making associated with condom use in marital relationships in Vietnam? Studies in Family Planning, 42, 273–282. Doan, R. M., & Bisharat, L. (1990). Female autonomy and child nutritional status: The extended-family residential unit in Amman, Jordan. Social Science & Medicine, 31, 783–789. Dyson, T., & Moore, M. (1983). On kinship structure, female autonomy, and demographic behavior in India. Population and Development Review, 9, 35­–60. Exner, T. M., Seal, D. W., & Ehrhardt, A. A. (1997). A review of HIV interventions for at-risk women. AIDS and Behavior, 1, 93–124. Furber, A. S., Newell, J. N., & Lubben, M. M. (2002). A systematic review of current knowledge of HIV epidemiology and of sexual behaviour in Nepal. Tropical Medicine & International Health, 7, 140–148. Govindasamy, P., & Malhotra, A. (1996). Women’s position and family planning in Egypt. Studies in Family Planning, 27, 328–340. Gupta, G. R. (2002). How men’s power over women fuels the HIV epidemic: It limits women’s ability to control sexual interactions. British Medical Journal, 324, 183–184. Haque, S. E., Rahman, M., Mostofa, M. G., & Zahan, M. S. (2012). Reproductive health care utilization among young mothers in Bangladesh: Does autonomy matter? Women’s Health Issues, 22, e171–e180. Jejeebhoy, S. J., & Sathar, Z. A. (2001). Women’s autonomy in India and Pakistan: The influence of religion and region. Population and Development Review, 27, 687–712. Lawati, M. (2005). Towards a democratic Nepal: Inclusive political institutions for a multicultural society. Thousand Oaks, CA: Sage Publications. Levine, N. E. (1988). Women’s work and infant feeding: A case from rural Nepal. Ethnology, 27, 231–251. Malhotra, A., Schuler, S. S., & Boender, C. (2002). Measuring women’s empowerment as a variable in international development. Commissioned paper of the Gender and Development Group of the World Bank. Washington, DC: World Bank.

Mantell, J. E., Stein, Z. A., & Susser, I. (2008). Women in the time of AIDS: Barriers, bargains, and benefits. AIDS Education and Prevention, 20, 91–106. Mason, K. O. (1986). The status of women: Conceptual and methodological issues in demographic studies. Sociological Forum, 1, 284–300. Ministry of Health and Population (MOHP) [Nepal], New ERA, and ICF International Inc. (2012). Nepal Demographic and Health Survey 2011. Kathmandu, Nepal: Ministry of Health and Population, New ERA, and Calverton, MD: ICF International. Mistry, R., Galal, O., & Lu, M. (2009). Women’s autonomy and pregnancy care in rural India: A contextual analysis. Social Science & Medicine, 69, 926–933. Poindexter, C. C., Lane, T. S., & Boyer, N. C. (2002). Teaching and learning by example: Empowerment principles applied to development, delivery, and evaluation of community-based training for HIV service providers and supervisors. AIDS Education and Prevention, 14, 391–400. Poudel, K. C, Nakahara, S., Poudel-Tandukar, K., Yasuoka, J., & Jimba, M. (2009). Unsafe sexual behaviors among HIV-positive men in Kathmandu Valley, Nepal. AIDS and Behavior, 13, 1143–1150. Poudel, K. C., Okumura, J., Sherchand, J. B., Jimba, M., Murakami, I., & Wakai, S. (2003). Mumbai disease in far western Nepal: HIV infection and syphilis among male migrant‐ returnees and non‐migrants. Tropical Medicine & International Health, 8, 933–939. Poudel, P., & Carryer, J. (2000). Girl-trafficking, HIV/AIDS, and the position of women in Nepal. Gender and Development, 8, 74–79. Quinn, T. C., & Overbaugh, J. (2005). HIV/AIDS in women: An expanding epidemic. Science, 308, 1582–1583. Rodrigo, C., & Rajapakse, S. (2009). Current status of HIV/AIDS in South Asia. Journal of Global Infectious Disease, 1, 93–101. Santhya, K. G., Haberland, N., Ram, F., Sinha, R. K., & Mohanty, S. K. (2007). Consent and coercion: Examining unwanted sex among married young women in India. International Family Planning Perspectives, 33, 124–132. Singh, S., Mills, E., Honeyman, S., Suvedi, B. K., & Pant, N. P. (2005). HIV in Nepal: Is the violent conflict fuelling the epidemic? PLOS Medicine, 2, e216. Smith-Estelle, A., & Gruskin, S. (2003).Vulnerability to HIV/STIs among rural women from migrant communities in Nepal: A health and human rights framework. Reproductive Health Matters, 11, 142–151. Snelling, D., Omariba, D. W. R., Hong, S., Georgiades, K., Racine. Y., & Boyle, M. H.

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(2007). HIV/AIDS knowledge, women’s education, epidemic severity and protective sexual behaviour in low-and middle-income countries. Journal of Biosocial Science, 39, 421–442. Tenkorang, E. Y. (2012). Negotiating safer sex among married women in Ghana. Archives of Sexual Behavior, 41, 1353–1362. Wingood, G. M., & DiClemente, R. J. (1996). HIV sexual risk reduction interventions for

women: A review. American Journal of Preventive Medicine, 12, 209–217. Wingood, G. M., & DiClemente, R. J. (2000). Application of the theory of gender and power to examine HIV-related exposures, risk factors, and effective interventions for women. Health Education & Behavior, 27, 539–565.

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