This study examined the hypothesis that young women living in communities with higher levels of IPV are more likely to have premarital first sex rather than first sex in union. Support was found for this hypothesis in Mali and Kenya. In particular, in these countries, young women living in communities with higher mean levels of sexual or physical IPV were at increased risk of having engaged in premarital sex compared to women from communities with lower IPV prevalence. In Liberia, the opposite effect was found, with residence in more violent communities associated with a lower risk of premarital first sex. Community-level IPV did not appear to have an effect on the circumstances of first sex in Zimbabwe and DRC.
Unlike many studies examining sexual behavior among young people in sub-Saharan Africa, this analysis incorporates violence as a contextual risk factor. Violence is an important risk factor for HIV and other adverse RH outcomes, fostering environments that make it difficult for women to reduce their own HIV risk due to lack of control over sexual encounters. An additional strength of this study is the usage of nationally representative datasets that include the same measures of IPV, first sexual experience, and socio-demographic variables, as well as utilizing standardized training and data collection procedures. Finally, by including 20- to 29-year-olds as the population of interest, we are able to examine a cohort of young women who have nearly all sexually debuted and thus reduce bias in the results compared to typical analyses that focus on 15- to 24-year-olds, especially since many of the younger women are not yet sexually experienced.
A number of limitations must be acknowledged. First, this analysis reflects a diverse range of countries, including countries with low and high HIV prevalence, from varying regions of Africa, and that are Francophone and Anglophone. These countries were included because they were the only ones that met the criterion of having a domestic violence module and having the overwhelming majority of women living in a cluster where at least 10 women answered the domestic violence module. However, the diversity of included countries renders the creation of programmatic recommendations difficult, particularly since violence may be deeply embedded in cultural and social norms. Second, 10 women from each cluster may not accurately reflect a community's experience with IPV. Moreover DHS data are not representative at the cluster level, and clusters may not reflect natural communities. Third, the community where a young woman currently resides may not be the same community where she sexually debuted. Additionally, violence behaviors may have changed over time, and the current level of IPV may not be reflective of the environment that women faced at the time of their sexual debut. Fourth, a woman's current IPV experience may have happened in the recent past and may be associated with the circumstances of first sex but with the opposite direction of causality; women who had premarital first sex may be more likely to experience IPV than women who had first sex in union. This variable was included to permit control of a woman's own IPV experiences and to assess the effect of contextual influences above and beyond the woman's own experiences with IPV. Finally, these cross-sectional data did not permit us to explore the specific mechanism by which community-level IPV and the circumstances of sexual debut are linked; this requires more detailed data collection, possibly using qualitative or longitudinal survey data.
To our knowledge, this is the first study to examine community-level IPV in relation to the circumstances of first sex among young women. One other study has examined the role of spousal abuse norms on early and premarital sexual debut and found that higher community support of wife beating was associated with earlier and premarital sex in Kenya and Tanzania; however, the findings were in the opposite direction in Zimbabwe and Malawi . The results of our analysis support findings from other population-based research that find that context matters to RH outcomes, particularly gender inequality [30, 38]. IPV is a severe expression of gender inequality in a society and understanding if and how it influences health outcomes has important programmatic implications.
Support for our hypothesis was found in only two countries, and there was no statistically significant relationship between community-level IPV and circumstances of first sex in DRC, the country with the highest mean level of IPV. DRC differs from other countries in this study due to its post-conflict status and the ongoing violations of women's human rights, with rape used as a tool of war . These results may indicate that violence is more endemic in this society, and there is less variability across communities. Additionally, in Liberia, an unexpected result was noted, with higher mean levels of IPV being associated with less premarital first sex experience. Future research in this setting, particularly studies utilizing qualitative research methods, may shed light on these findings and whether certain protective cultural factors are present in communities with higher levels of IPV, including community-level norms around other aspects of gender inequality not examined in this study.
We hypothesized that young women living in communities with higher levels of IPV may be more likely to engage in premarital first sex due to greater exposure to forced sex or the fear or threat of violence. In countries with high levels of HIV, programs should target communities with higher levels of violence for HIV prevention efforts, as well as implement violence prevention programs in general. The findings of this and other studies indicate that context matters for RH. Individualized interventions to reduce the risk of HIV, STIs and unintended pregnancy may be limited in their effectiveness if they do not consider the context of young women's lives in their efforts.