The Trend of Women’s Autonomy in Refusing Risky Sex and Associated Factors in Ethiopia: Evidence From 2011 & 2016 EDHS Data

Background: Risky sexual behavior is a major public health concern of Ethiopians. Although studying the autonomy of women in refusing risky sex is signicant to take proper actions, the issue is not yet studied. Accordingly, this population-based nationwide study was aimed at assessing the trends of women’s autonomy in refusing risky sex and its associated factors in Ethiopia. Method: The sample was limited to married women of 2011 (n=8369) and 2016 (n=8403) Ethiopian Demographic and Health Survey (EDHS) data. Women's autonomy in refusing risky sex was measured based on wives' response to 'not having sex because of husbands have other women. To examine associated factors, sociodemographic variables were computed using binary logistic regression. Result: The nding revealed that the trend of women’s autonomy in refusing risky sex had declined from 78.9% in 2011 to 69.5% in 2016. Women aged from 25-34 were less likely autonomous in refusing sex (AOR=.764;95%CI=.605,.965), in comparison with women aged less than 24 years old. The autonomy of women with primary, secondary, and higher educational status were AOR=1.607;95%CI:1.379,1.874, AOR=2.208;95%CI:1.639,2.975, and AOR=3.221;95%CI:1.647,6.300 respectively. The autonomy of women from rich households was more likely higher (AOR=1.523;95%CI:1.28,1.813) in comparison to women from poor households. The autonomy of women in Tigray, (AOR=2.938;95%CI:2.025,4.263), Afar (AOR=1.497;95%CI:1.111,2.017), Amhara (AOR=4.870;95%CI:3.388,7.000), Benishangul Gumuz (AOR=.568;95%CI:.406,.796), SNNP (AOR=1.900;95%CI:1.355,2.664), Harari (AOR=.516;95%CI:.372,.716), and Addis Ababa (AOR=3.809;95%CI:2.227,6.516) when compared with autonomy of women who resides Dire Dawa. to from of risky sexual


Introduction
Risky sexual behavior is de ned as an individual's practice in one or more of the following acts such as unprotected sexual intercourse, starting sexual activity at a young age, having multiple sexual partners, having sex under the in uence of stimulant substances, or having sex immediately after watching pornographic (1)(2)(3)(4). Risky sexual behavior is a major public health concern across the world but the issue is more serious in developing countries including Ethiopia. It increases the likelihood of individuals' vulnerability in sexually transmitted infections (STIs), HIV/AIDS, unwanted pregnancy, and psychological distress (5).
Having multiple sexual partners refers that an individual's sexual interaction with two or more sexual partners that overlapped in time (6). Since having multiple sexual partners is risky sexual behavior and a key driver of HIV/AIDS transmission, those who have concurrent sexual partners increase their risk of contracting HIV/AIDS. Moreover, actors of multiple sexual partners are more likely exposed to sexually Page 3/13 transmitted infections (STIs). Thus, since having multiple sexual partners is risky sex, measures not to have sexual intercourse with those who have multiple sexual partners can be understood as a refusal of risky sex.
Autonomy can be de ned as a technical, social-psychological ability of an individual for making decisions about his/her private concerns (7). An individual is autonomous when she/he can act under her/his direction, i.e. make her/his actions (8). Autonomous women can refuse risky sex if husbands have risky sexual behavior like having sexual contact with an additional woman. This is to protect themselves from adverse effects of risky sexual behavior like sexually transmitted infections (STIs) and HIV/AIDS. Concerning women's autonomy, research and policy discourse indicated the presence of limited autonomy of women in developing countries and also the challenge of their lower autonomy to improve their reproductive health (9,10).
In Ethiopia, the magnitude of risky sexual behavior particularly in having multiple sexual partners estimated up to 53.7% (11). Understanding the trend of women's autonomy and associated factors in refusing risky sex is necessary to take possible interventions like empowering women and minimize the risk of sexually transmitted diseases due to multiple sexual partners. However, the trend of women's autonomy and its associated factors in refusing risky sex is overlooked by researchers in Ethiopia. Thus, this study was focused on examining the trends of women's autonomy in refusing risky sex and its associated factors in Ethiopia. Since the study was completed using the 2011 and 2016 Ethiopian DHS data, the nding will help to understand the trends of women's autonomy from time to time in one hand, and since associated factors were identi ed, it is also important to take proper intervention for women health on the other hand.

Objectives Of The Study
The study's objectives were: To examine the trends of women's autonomy in refusing risky sex in Ethiopia using 2011 & 2016 EDHS data and to identify determinants factors of women's autonomy in refusing risky sex in Ethiopia.

Study Design and Data Collection
It is a population-based cross-sectional study design based on the 2011 and 2016 EDHS data. The study used data from the 2011 and 2016 EDHS that were collected by the Central Statistical Authority (CSA) of Ethiopia and Opinion Research Corporation Company (ORC) Macro International. It was conducted in all Regional States of Ethiopia namely Tigray, Afar, Amhara, Oromia, Somali, Benishangul Gumuz, Southern Nations Nationalities and Peoples (SNNP), Gambella, and Harari and Addis Ababa, and Dire Dawa city Administrations (CSA and ICF, 2016) (12). It is a nationally representative sample survey, aged 15-49 years' women.
The survey collected a detailed woman's background characteristics. The survey also collected information from unmarried, married, living with a partner, divorced, and widowed women. However, for this study, the researcher has used only married women's data. Based on the valid number of responses for identi ed variables, the sample size of the study from 2011 and 2016 DHS data was limited to 8369 and 8403 respectively.

Variables and Measurement Dependent Variable
The study's dependent variable was women's autonomy in refusing risky sex. This was measured based on women's response on 'Reason for not having sex because of husbands have other women'. Wives who can refuse sex if husbands have other women were considered as 'autonomous in refusing risky sex' and wives who cannot refuse sex if husbands have other women were considered as 'not autonomous in refusing risky sex'. Finally, the dependent variable that dichotomized as ''autonomous in refusing risky sex', and 'not autonomous in refusing risky sex' was coded as "0" and "1" respectively

Independent Variables
The study identi ed the following independent variables including women's age, education status, working status, place of residence, household wealth index, religion, and region. The researcher adopted the measurements of the DHS survey for the following four independent variables. However, the measurements of the DHS survey on the following variables including age, education level, and household wealth index were adapted as follows.
The adapted measurements include (1) age of respondents that was open to writing their exact age, but the study that focused on modern contraceptive use measured age of label age of respondents by labeling from aged 15-24, 25-34, and 35-49 (13). Since there are few women in marriage since the age of 11, this study used 11-24, 25-34, and 35-49 age categories of women. (2) For educational attainment, the DHS used six responses such as no education, incomplete primary, primary, incomplete secondary, secondary, and higher. As studies were done using DHS data on "the effect of maternal health service utilization in early initiation of breastfeeding among Nepalese mothers" (14). as well as "women empowerment and their reproductive behavior among currently married women in Ethiopia" (4) have used 'illiterate', 'primary', 'secondary' and 'higher' to measure this variable, for this study, incomplete primary and primary, and incomplete secondary and secondary merged into 'primary' and 'secondary' respectively.
(3) Concerning the wealth index, the middle was taken as it is but the categories poorest and poor, and rich and richest were merged into poor and rich respectively. Other studies (15)(16)(17)(18) have also used these variables to measure the wealth index.

Data Analysis
The data obtained from 2011 and 2016 EDHS were analyzed through SPSS version 22 in three levels. First, the univariate/descriptive statistics were used to summarize the socio-demographic variables of the study participants using frequency and percentages. Second, the bivariate analysis was done using the chi-square test (p<0.05) to identify the socio-demographic variables that were signi cantly associated with women's autonomy in refusing risky sex. Finally, analysis of the determinants of women's autonomy in refusing risky sex was carried out using logistic regression. This is because logistic regression is used to examine the relationships between a categorical outcome variable and one or more categorical or continuous predictor variables (19). Principally, binary logistic regression is applied in cases where the dependent variable is dichotomous (20). This is because the dependent variable (women autonomy in refusing risky sex) was dichotomized as "not autonomous in refusing risky sex" and "autonomous in refusing risky sex".
For binary logistic regression analyses, statistical inferences were made based on estimates of the odds ratio (OR) with a 95% con dence level and 5% margin of error or p-value less than 0.05. The study used an unadjusted odds ratio to estimate the gross effect of each independent variable on the outcome variable. The independent variables that had an association of a p-value less than 0.05 with the outcome variable were taken for the multiple or adjusted analysis.
Before reporting the result of the adjusted odds ratio, the overall goodness of t was assessed via the Hosmer-Lemeshow test. The result of this analysis's P-value (0.606) was greater than the level of signi cance α=0.05, hence data t the model well. Because in the Hosmer-Lemeshow test, an insigni cant chi-square indicates a good t to the data (Hosmer & Lemeshow, 2000).

Results
As we have seen in gure 1, the autonomy of women in refusing risky sex has declined from 78.9% in 2011 to 69.5% in 2016.
As it has shown in Table 1 Less performed women in refusing risky sex were women from other religions (61.3%) and women from the traditional religion (64.6%) in 2011 and 2016 respectively. In the case of geographic areas or regions, the top three autonomous women in refusing risky sex were found in Addis Ababa (95.3%), Tigray (89.2%), and Amhara (88.3%) in 2011. In 2016, the top three autonomous women refusing risky sex were found in Addis Ababa (93.6%), Amhara (89.1%), and Tigray (85.6%). Fewer performance women autonomy in refusing risky sex was recorded from Gambela (61.9%) and Harari (53.7%) regional states' women in 2011 and 2016 respectively. As it has shown in Table 2, the study has shown the effect of each variable on the women's autonomy in refusing risky sex in 2016. Among independent variables, two variables such as working status and residence had an insigni cant association with women's autonomy in refusing risky sex.

Discussion
From 2011 to 2016, the autonomy of women in refusing risky sex was declined from 78.9% to 69.5% (by 9.4%). For this declination of the autonomy of women in refusing risky sex the possible justi cation might be because of the role of civil society organizations that work. In comparison with women aged less than 24 years old, older women (25-34 years old) were less likely autonomous in refusing risky sex. Similar to this study nding, on women autonomy in health care decision making (15,21), household decision making (22), and on controlling and exercising their reproductive rights (23) age had a signi cant association. The nding of this study disclosed a direct relationship between women's status and autonomy in refusing risky sex. Other studies (10, 24) also found a positive association between women's autonomy with their educational status. Women's autonomy in refusing risky sex is positively associated with wealth index status. Correspondingly, other studies focused on household decisionmaking (22,25). Similar to other studies (26, 27) nding, this study revealed Muslim women's autonomy. This might be because "it has been argued that Islam restricts women's freedom to a greater extent than other religions" (28).

Conclusion And Recommendation
The autonomy of women in refusing risky sex has declined from 2011 to 2016. This infers that currently women are more victimized refusing risky sex than previously. Hence, possible interventions like empowering women shall be taken to save women from certain health problems of risky sexual behavior. Among independent variables: age, educational status, wealth index, and religion of women, as well as the current regions of women, were signi cantly associated with women's autonomy in refusing risky sex.
The study nding revealed that women aged from 25-34, illiterate women, women from poor households, Muslim women, women from Benishangul Gumuz and Harari regions were less autonomous in refusing risky sex. Therefore, although declining autonomy of women in refusing risky sex is a serious problem in general, women aged from 25-34, illiterate women, women from poor households, Muslim women, women from Benishangul Gumuz and Harari regions in particular needs special attention of stakeholders such as non-governmental organizations, women, and children affairs o ce, and women's association. The roles of these stakeholders might focus on preventive and curative approaches. Holding open discussions among women each other and also providing training that can boost women's self-con dence as well as their understanding of women's rights and the impacts of risky sex are categorized under preventive technique. As a curative technique, arranging and providing legal support and guidance and counseling techniques are also essential roles.

Declarations
Author's contributions MDA involved from the inception to design, acquisition of data, analysis, and interpretation, and drafting the manuscript, and edit the manuscript for the nal submission. Ultimately, the author read and approved the nal manuscript.