Examining the influence of contextual factors on risky sexual behavior among young women in Zomba district, Malawi: A multilevel analysis

The objective of this study was to examine the association between risky sexual behavior and contextual factors related to economic resources, woman’s empowerment, and health facility characteristics among young women in Zomba district, Malawi. Secondary analyses of the Schooling, Income, and Health Risk (SIHR) study were undertaken. Four outcomes related to risky sexual behavior were examined: if participants had ever had sex, consistent condom use, and two scores measuring risk related to partner history and age during sexual activity. Regression models with cluster-robust standard errors and multilevel regression models were used to estimate associations; analyses were stratified by school enrolment status at baseline of the SIHR study and utilized weights to account for SIHR sampling design. For participants in school at baseline, the percent of girls enrolled in school at the community level was associated with ever having sex and consistent condom use. Belief in the right to refuse sex was protective against ever having sex, lower household education was associated with higher odds of ever having sex, and near rural and far rural residence was associated with decreased odds of condom. For participants not in school at baseline, lower individual education was associated with riskier scores related to age and partner history and lower household education was associated with lower age during sexual activity. Private or non-governmental health facilities were associated with decreased odds of condom use and higher age during sexual activity. In both strata, increasing age and near rural residence (within 16 kilometers of urban center) increased odds of ever having sex; lower educational achievement was associated with lower age during sexual activity. A history of pregnancy was associated with lower odds of condom use and riskier partner history. Risky sexual behavior is multifaceted and complex. While various factors related to women’s empowerment played a role, the most consistent variables associated with risky sexual behavior were those related to education. Interventions and programs seeking to reduce risky sexual behavior among young women, thereby reducing their risk of HIV infection, should continue to focus on improving access to education at multiple levels