Community and socioeconomic risks of premarital sex among young women in Albania, Moldova, and Ukraine: evidence from Demographic and Health Surveys Chi Chiao, Bianca Marella Institute of Health and Welfare Policy, National Yang-Ming University INTRODUCTION The reasons behind the global spread of HIV infection are complex. However, it is clear that premarital sex behavior among young women acts as a major obstacle to implementing HIV prevention programs, particularly as it engenders complacency in groups socioeconomically disadvantaged, yet at risk for HIV infection (Cheluget et al., 2006; Hargreaves et al., 2015). In East Europe, there is a growing concern about heterosexual transmission in HIV infection. Epidemiological evidence shows an increase in STI and HIV prevalence for female populations in their teens and early 20s (ECDPC/WHO Regional Office for Europe, 2013). Similarly, there is concern about the role of the socioeconomic epidemic of AIDS acting as a major obstacle in dealing effectively with HIV infection and AIDS for individuals and communities (Nyblade et al., 2003; Rankin et al., 2005). Given that premarital sex among young women contributes an important venue to the socioeconomic disparities of AIDS, a better understanding of communities and women s socioeconomic characteristics that act as risks or protective factors to premarital sex is relevant to informing the design of interventions that could be implemented to reduce the general epidemic of HIV in young women. Prior research has found that socioeconomic status (SES) such as employment and household wealth predict women s premarital sex through their inherent social qualities (Hargreaves et al., 2015). Young women from low household wealth may be more likely to have higher risks of premarital sex due to economic dependence (Luke, 2005). There is ample evidence that employment status and job characteristics are associated with women s risks to involve premarital sex (Liang et al., 2013). As high rates of economic expansion and rapid urbanization, premarital sex of young women in the East European region is thus considered as one of the most risk behaviors in contracting STI and HIV. Another body of research has been interested in how communities SES with more health-enabling resources promote individual superior health outcomes (Agampodi et al., 2015; Campbell, 2003). Several studies have concluded that communities with health-enhancing capabilities have an impact on premarital sex behavior (Chiao, 2011; Cubbin et al., 2005; Djamba, 2003). These studies have focused on North America, African, and Asian contexts; yet, little is known in this regard with respect to East European female populations. 1
In order to fill the empirical gaps in the current literature about female youth sex in context, the focus of this study is to explore whether context influences premarital sex of young women in East Europe, and the socioeconomic mechanisms by which premarital sex is shaped. In this regard, such lessdeveloped countries as Albania, Moldova, and Ukraine provide interesting contexts for exploring this question. Although these three countries are geographically closed to each other but they have very different social structures and cultural backgrounds with respect to social expectation for youth sexual behaviors. METHODS Sample and Data Collection The present study used recent Demographic and Health Surveys (DHS) data to examine the linkage between community SES characteristics, women s SES, and premarital sex in various contexts of Eastern Europe. DHS data were nationally representative surveys of women that used a two-stage sampling strategy. These standard surveys were designed to examine population health and included detailed information on women s reproductive health and behaviors. Further information on the DHS can be found at www.measuredhs.com. Given that the present research aims are to gain a better understanding of the relationship between the risk of premarital sex and community context, my analyses focused on never-married young women aged 15-24 with completed information on premarital sex, women s SES and the indicators of community context. This selection yielded a total of 2,014 women from 434 communities in Albania, 1,708 women from 387 communities in Moldova, and 1,217 women from 432 communities in Ukraine. The study protocol was approved by the Ethical Committee of National Yang- Ming University, Taiwan. Measures Outcome Measure. Involvement among the never-married young women of premarital sex was assessed based on the DHS women s reports, whether or not they ever had sex. Responses are categorized into two categories, where young women ever had sex, this is coded as Y=1 or yes and young women not having sex, this is coded Y=0 or no. Community-Level Variables. The present study hypothesizes that community context affects the young women in terms of premarital sex involvement. Although the measures of community SES context in the DHS are limited due to data collection, I included community religious affiliation of women, community stability, and community female labor force participation (FLFP) to assess community SES context. 2
Three indicators of community SES context were integral community variables that were created by averaging all individual responses within each tract. The study sample within each tract was assigned to have a computed mean score. The first variable of community female religion featured population homogeneity; it was constructed from the DHS women s reports by more than 90 percent of the dominant religious group among women in the community as homogeneous community. The second variable of residential stability was constructed from the DHS household surveys and measured more than 80 percent of households staying in the same community for 10 years or longer as stable communities. The third variable of FLFP was computed from the DHS women s reports, which gave the rate of FLFP among women aged 15-49 within the communities (less than 0.50, 0.50-0.75, and over 0.75). Women s SES was assessed by two measures: household wealth and employment status. Household wealth was based on the assets-based wealth index quintiles for each country. 15 This measure was categorized into quintiles, those who were the poorest, the second quintile (poor), the middle quintile, the fourth quintile (richer) and the richest quintile of households. Employment status is often a point of transition for young adults, and this study utilized information provided on their current employment status and coded categorically as unemployment, professional or managerial occupation, and others. Covariates. Several measures in terms of HIV related prevention knowledge and attitude as well as media exposure were used due to their potential effects on the relationships between the main explanatory variables and premarital sex. These HIV related variables consisted of HIV knowledge, accepting attitudes toward People living with HIV (PLHIV), and acceptance of wife-beating. In the surveys, women were asked if they had knowledge that condom use and multiple sexual partners can prevent HIV infection (correct or incorrect). We also included three binary measures related to accepting attitudes toward PLHIV (e.g., willingness to care for an infected household member, willingness to purchase vegetables from an infected vendor, and willingness to allow an infected female teacher to continue teaching) and a measure related to accepting attitude toward wife-beating in the analyses. Finally, media exposure was assessed by three separate binary variables on whether young women listened to radio, watched television, and read newspapers daily (yes or no). Analytical Strategy The present study conducted a two-level multilevel model to examine whether or not the community characteristics independently influenced the likelihood of premarital sex risk after taking the characteristics of women s SES and HIV prevention related variables into consideration. The results obtained from all models are presented as odds ratios with 95% confidence intervals. Model 1 estimates the odds of premarital sex in terms of measures of community characteristics. In Model 1 our primary 3
interest is in the community influence. Model 2 adds women s SES and HIV related variables when adjusting for household backgrounds and age. These models reflect the relative effects of community context, women s SES, and HIV related variables that may be varied across country. All analyses were carried out separately for Albania, Moldova, and Ukraine and using Stata version 14.0. RESULTS Table 1 presents the adjusted ORs and 95 percent confidence intervals of the predictor variables for premarital sex risk and the results for models of premarital sex risk estimated separately for Albania, Moldova, and Ukraine. The results from Model 1 include only the community variables. The primary interest here is in the influence of communities. Community characteristics (community religious affiliation of women, community stability, and community FLFP) showed a significant association with premarital sex involvement among young women in the three selected countries. In all three countries, young women living in tracts with higher levels of community stability were less likely to have premarital sex, compared to women living in communities with lower levels of community stability (Albania: OR=0.38, p<0.001; Moldova: OR=0.76, p<0.1; Ukraine: OR=0.56, p<0.01). And, young women living in tracts with more than 75% of FLFP rate were more likely to have premarital sex, compared to women living in communities in less than 50% of FLFP rate (Albania: OR=3.19, p<0.1; Moldova: OR=2.05, p<0.05; Ukraine: OR=1.95, p<0.05). The statistically significant relationship was also found in the relationship between community religious affiliation of women and premarital sex. In Albania and Ukraine, young women living in a tract where more than 90 percent of women had dominant religious affiliation were less likely to report premarital sex, compared to young women living in lower proportion of dominant religious communities (Albania: OR=0.59, p<0.05; Ukraine: OR=0.70, p<0.1). Model 2 adds indicators of women s SES, HIV related variables, and household covariates. The overall community influences in Albania and Ukraine are still significant after inclusion of these SES and HIV related covariates. However, this inclusion produces an appreciable change in the significance of the premarital sex odds in Moldova. The significance of the community influence was reduced, suggesting that women s SES, HIV related variables, and household covariates have contributed to the reduction. Turning to women s SES, household wealth is significant at predicting the risk of premarital sex. The odds for premarital sex risk among young women who were in the richest quartile were significantly higher than for those who were in the lowest quartile in Albania (OR=7.42, p<0.001) and in Moldova (OR=2.23, p<0.05), although this significant relationship acted in a contradictory direction in Ukraine. In addition, compared to unemployed women, never-married young women who were employed as non-professional or non-managerial occupations had significantly higher odds of premarital sex in Albania (OR=2.19, p<0.01) and Ukraine (OR=2.27, p<0.05); this relationship was absent in Moldova. 4
Several measures related to HIV prevention are significant; however, some indicators act in contradictory directions in different countries. In terms of HIV knowledge, young women with correct knowledge about multiple sexual partners had a 2.36 times higher odds of premarital sex risks in Albania, but this association was non-significant in Moldova and Ukraine. In Moldova, young women with accepting attitude toward wife-beating had higher odds of premarital sex risks (OR=1.83, p<0.01). However, this statistically significant relationship was not found in Albania and Ukraine. Furthermore, young women with daily exposure to newspaper or magazine had significantly lower odds of premarital sex risks in Albania (OR=0.42, p<0.01) and Moldova (OR=0.63, p<0.05); this significant relationship was absent in Ukraine. These findings from multilevel logit models suggest the importance of independent contextual influences on young women s premarital sex in Eastern Europe. CONCLUSION In conclusion, this study extends prior research by using multilevel analyses and contribute important knowledge to the current literature where there is only limited evidence on community context, women s SES, and premarital sex among members of East European societies. Further research should examine how the vertical aspect of the community context impacts on premarital sexual activity, such as whether the bonding and interaction between community members and interaction with the government affect the women s premarital sexual behavior. 5
REFERENCES Agampodi, T.C., Agampodi, S.B., Glozier, N., et al. (2015). Measurement of social capital in relation to health in low and middle income countries (LMIC): a systematic review. Social Science & Medicine 2015; 128:95-104. Campbell, C. (2003). Letting Them Die: Why HIV/Aids Prevention Programmes Fail Indiana University Press Cheluget, B., Baltazar, G., Orege, P., Ibrahim, M., Marum, L. H., & Stover, J. (2006). Evidence for population level declines in adult HIV prevalence in Kenya. Sexually Transmitted Infections, 82 Suppl 1, i21-26. Cubbin, C., Santelli, J., Brindis, C. D., & Braveman, P. (2005). Neighborhood context and sexual behaviors among adolescents: findings from the national longitudinal study of adolescent health. Perspective Sexual and Reproductive Health, 37(3), 125-134. Djamba, Y. K. (2003). Social capital and premarital sexual activity in Africa: the case of Kinshasa, Democratic Republic of Congo. Archives of Sexual Behaviors, 32(4), 327-337. European Center for Disease Prevention and Control (ECDPC)/WHO Regional Office for Europe. (2013). HIV/AIDS surveillance in Europe 2012. Stockholm: European Centre for Disease Prevention and Control. Hargreaves, J.R., Davey, C., Fearon, E., Hensen, B., & Krishnaratne, S. (2015). Trends in socioeconomic inequalities in HIV prevalence among young people in seven countries in eastern and southern Africa. PLOS ONE http://dx.doi.org/10.1371/journal.pone.0121775 Lang, D.L., Salazar, L.F., DiClemente, R.J., Markosyan, K. (2013). Gender based violence as a risk factor for HIV-associated risk. AIDS & Behavior, 17:551-558. Luke, N. (2005). Confronting the 'sugar daddy' stereotype: age and economic asymmetries and risky sexual behavior in urban Kenya. International Family Planning Perspective, 31(1), 6-14. Nyblade, L., J. Mbwambo, A. Schneider, V. Bond, A. Kidanu, H. Banteyerga, and I. Kayawe. 2002. Addressing HIV-related stigma and resulting discrimination in Africa: A three-country study of Ethiopia, Tanzania and Zambia. Washington, D.C.: International Center for Research on Women. Rankin, W.W., S. Brennan, E. Schell, J. Laviwa, and S.H. Rankin. 2005. The stigma of being HIVpositive in Africa. PLoS Med 2(8): e247. 6
Table 1. Multilevel regression models of community influences on the likelihood of premarital sex involvement among young women in Albania, Moldova, and Ukraine, DHS 2005-2009 Albania Moldova Ukraine Model 1 Model 2 Model 1 Model 2 Model 1 Model 2 OR 95% CI OR 95% CI OR 95% CI OR 95% CI OR 95% CI OR 95% CI Community characteristics Community religious affiliation of 0.59 ** (0.40, 0.88) 0.81 (0.52, 1.27) 0.88 (0.49, 1.59) 1.04 (0.55, 1.96) 0.70 (0.48, 1.01) 0.48 ** (0.28, 0.82) women Community stability 0.38 *** (0.25, 0.56) 0.48 ** (0.31, 0.74) 0.76 (0.55, 1.05) 0.94 (0.65, 1.36) 0.56 ** (0.38, 0.81) 0.44 ** (0.26, 0.76) Community female labor force participation (ref= Low, less 0.50) Medium, 0.50-0.75 2.51 *** (1.67, 3.77) 1.79 * (1.12, 2.86) 1.38 (0.96, 1.99) 0.99 (0.65, 1.51) 1.13 (0.61, 2.08) 0.76 (0.32, 1.81) High, over 0.75 3.19 (0.98,10.37) 1.86 (0.50, 6.96) 2.05 * (1.04, 4.03) 1.15 (0.54, 2.46) 1.95 * (1.03, 3.68) 0.69 (0.27, 1.80) Women s SES Household wealth (ref=poorest) Poor 1.93 (0.94, 3.98) 1.35 (0.71, 2.57) 0.40 * (0.20, 0.82) Middle 2.77 * (1.22, 6.31) 1.23 (0.67, 2.26) 0.78 (0.36, 1.73) Richer 4.31 ** (1.65,11.21) 1.41 (0.73, 2.71) 0.77 (0.32, 1.87) Richest 7.42 *** (2.68,20.53) 2.23 * (1.07, 4.60) 0.78 (0.31, 1.93) Employment status (ref= Unemployed) Professional or managerial 1.38 (0.73, 2.59) 1.41 (0.90, 2.15) 1.58 (0.93, 2.69) occupation Others 2.19 ** (1.25, 3.84) 1.25 (0.79, 1.97) 2.27 * (1.11, 4.67) HIV related variables HIV knowledge (ref=no) Condom use 1.45 (0.75, 2.80) 1.35 (0.88, 2.08) 0.88 (0.40, 1.95) Multiple sexual partners 2.36 * (1.10, 5.06) 0.72 (0.48, 1.08) 1.18 (0.61, 2.31) Accepting attitudes toward PLHIV (ref=no acceptance) An infected household member 0.63 (0.38, 1.05) 1.24 (0.91, 1.68) 0.66 (0.42, 1.05) An infected female teacher 1.70 * (1.04, 2.76) 0.94 (0.68, 1.30) 1.42 (0.90, 2.24) An infected vendor 1.04 (0.68, 1.60) 1.19 (0.78, 1.80) 1.29 (0.75, 2.21) Acceptance of wife-beating 1.34 (0.81, 2.23) 1.83 ** (1.24, 2.70) 1.88 (0.57, 6.22) Daily mass media exposure Newspaper or magazine 0.42 ** (0.24, 0.72) 0.63 * (0.44, 0.90) 0.74 (0.47, 1.15) Radio 0.98 (0.64, 1.50) 1.25 (0.89, 1.78) 1.46 (0.95, 2.26) Television 0.67 (0.19, 2.31) 0.98 (0.62, 1.56) 0.54 (0.26, 1.14) Note: p<0.1; * p<0.05; ** p<0.01; *** p<0.001. Model 2 adjusted for women s age and household characteristics (i.e., sex of household head, household size, number of children under five, and residence of place). 7