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The vulnerability of women to HIV infection makes establishing predictors of women's involvement in extra-marital partnerships critical. We investigated the predictors of extra-marital partnerships among women married to fishermen. The current analyses are part of a mixed methods cross-sectional survey of gender-matched interviews with couples and 12 focus group discussions FGDs with 59 couples. Using a proportional to size simple random sample of fishermen as our index participants, we asked them to enrol in the study with their spouses.

The consenting couples were interviewed simultaneously in separate private rooms. In addition to socio-economic and demographic data, we collected information on sexual behaviour including extra-marital sexual partnerships. We analysed these data using descriptive statistics and multivariate logistic regression. For FGDs, couples willing to participate were invited, consented and separated for simultaneous FGDs by gender-matched moderators. The resultant audiofiles were transcribed verbatim and translated into English for coding and thematic content analysis using NVivo 9.

The prevalence of extra-marital partnerships among women was 6. Factors that were independently associated with increased likelihood of extra-marital partnerships were domestic violence aOR, 1. Conversely, women's age — more than 24years aOR, 0. Domestic violence, denial of a preferred sex positions, longer erect penis, younger age and increased sexual satisfaction were the main predictors of women's involvement in extra-marital partnerships.

Integration of sex education, counselling and life skills training in couple HIV prevention programs might help in risk reduction. Editor: Matt A. This is an open-access article distributed under the terms of the Creative Commons Attribution , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

The funders had no role in study de, data collection and analysis, decision to publish, or preparation of the manuscript. Competing interests: The authors have declared that no competing interests exist. Extra-marital partnerships have been associated with HIV infection in marriages and a range of psycho-social problems [1] — [5]. Marriage has consistently been reported as one of the risk factors for HIV infection partly due to extra-marital partnerships of one or both spouses in the context of low or no condom use [6] , [7].

Spouses involved in unprotected extra-marital sex act as conduits through which HIV enters marriages whose partners were hitherto concordant negative. Apart from HIV and other STIs as health conditions associated with extra-marital partnerships, major adverse cardiovascular events MACE have also been observed for those at risk of such events [8] , [9]. Cardiac deaths observed in situations of extra-marital sex are associated with psychological stress due to the need for discretion and haste during such encounters [9].

Psycho-social problems associated with extra-marital partnerships, whether actual or suspected, are many and varied. Despite the negative consequences of extra-marital partnerships, the behaviour is reported in many cultures across the world.

Notwithstanding the problems of under-reporting especially among women due to cultural constraints [15] , the prevalence of extra-marital partnerships in sub-Saharan Africa appear to be much higher in men compared to women [16] , [17]. As such, existing studies on extra-marital partnerships in sub-Saharan Africa have mainly focused on men while treating women in marriages merely as victims [18] — [21]. Even though the prevalence of extra-marital partnerships may be lower among women, concomitant effects may be equal or greater than men given women's biological and socio-cultural vulnerabilities [22].

Thus, there is urgency in identifying and addressing factors that predispose women to extra-marital partnerships. Many factors have been identified as predictors of men's involvement in extra-marital partnerships. Most of these factors relate to intrapersonal, interpersonal and contextual attributes [23] , [24]. The common intrapersonal factors that have been isolated as predictors of extra-marital sex include: age, gender, religiosity, education and income levels while the interpersonal factors commonly cited are sexual and marital satisfaction, marital commitment and partner attachment levels and; the main contextual factor is travelling and physical separation [2] , [25].

Since studies that cited these factors as predictors of extra-marital partnerships in sub-Saharan Africa are focused mostly on men, there is need for similar studies with focus on married women in sub-Saharan Africa. Married couples in Kenya as elsewhere in sub-Saharan Africa have been observed to engage in extra-marital partnerships which may increase their risk of HIV infection especially in the context of low or no condom use within marriage [26] , [27].

The practice of polygamy that is common in this region may further complicate the issue extra-marital partnerships especially among more egalitarian women. More importantly, fishing communities along Lake Victoria are reported to commonly engage in high risk sexual behaviour and have high HIV prevalence rates of up to Understanding predictors of extra-marital sex among women is critical in deing prevention interventions that address risky sexual behaviour, the likely marital HIV infections as well as other associated negative consequences such as domestic violence, divorce and spousal homicides.

Although numerous studies have been deed to identify predictors of men's involvement in extra-marital partnerships, few studies have focused on women. Thus, this paper seeks to fill this gap by identifying predictors of extra-marital partnerships that place women and their spouses at increased risk for HIV infection.

All participants gave written informed consent before participation in the study. This was part of a larger cross-sectional mixed methods study conducted among married couples from fishing communities on Lake Victoria of Kisumu County, Kenya between September and June to establish the prevalence and determinants of couple sexual concurrency. This paper aims to determine the predictors of extra-marital partnerships among married women using structured interview data and to put these findings into context using focus group discussion data.

Detailed description of the methods used in this study have been given elsewhere [31]. We conducted a total of structured interviews with married couples from 33 beaches. On each beach, we first obtained a list of all fishermen and then with the help of beach management officials made a second list of fishermen who they knew or suspected were married and between ages 18—45; this minimized our screen-to-enrol ratio see Kwena and colleagues for details [31]. Individual fishermen were randomly selected from the list of married fishermen on each beach. Marriage in this context was defined as any two people of the opposite sex who have lived together in a union sanctioned by state-mandated authorities as husband and wife for at least three months.

The selected fishermen were approached and asked if they were willing to participate in a study that enrolled couples. Willing couples were asked to come to the study clinic for study-related procedures that included eligibility screening, consenting and face-to-face interviews. The interview covered a of topics that included: socio-economic and demographic details, marital and sexual relationships and of sexual partners in six months preceding the study.

For those who had sexual partners beyond the spouse in the preceding six months, we asked details of the extra-marital partners including the type, end dates of the relationship and if the relationship was on-going. Our outcome variable was extra-marital sex which we operationalized as any sexual relationship s developing after and running parallel to marital relationships. We categorized women into two groups: women reporting extra-marital sex in the preceding six months and those not involved in extra-marital sex over the same reference period.

We considered the following key predictor variables based on our theoretical convictions and well as existing literature:. We directly asked participants for information on various socio-demographic and economic variables. The variables on which we collected information on included: current age, level of education, occupation, type of marriage whether monogamous or polygamous , physical separation from spouse, HIV test result disclosure.

We described in details elsewhere how we constructed measures of domestic violence, male dominant sex roles and sexual satisfaction [31]. The nine items measured actual experience of violence within the households based on the way questions were framed. Slap you? Slap her? Kick, drag or beat her up? The scale ranged from 0—9 where zero score indicates lower perpetuation of domestic violence and 9 higher perpetuation of domestic violence. Male dominance in sex roles and sexual satisfaction scales were adapted and modified from commonly used psychometric measures [33] , [34].

The scale ranged from 0—24 where zero indicates endorsement of respect for women in a relationship and 24 indicates male dominance and disrespect of women in sex roles. As such, higher scores on this scale reflect endorsement of sexual standards that disrespect women. The scale ranged from 0—75 where zero indicates lower sexual satisfaction and 75 show greater sexual satisfaction. Higher scores on this scale indicate stronger sexual satisfaction with the spouse. We included this variable because of the interest and controversies that surround men's pursuant of penile enlargement ostensibly to sexually satisfy their spouses while women do not necessarily approve of it [35].

Penis size was measured through self-report by both men and women. Using a inch ruler as a guide, we asked men to estimate their fully erect penis size and we asked women to estimate their spouses fully erect penis. Since these were perceived estimates from the two spouses, the observed discrepancies were resolved by taking an average of the two responses obtained. For categorical variables, the study examined the responses from the two partners logically and opted to go with the response from a partner who might have had no apparent reason to mislead.

For instance, the study asked both partners the of wives the man had. If the woman reported two and the man one, the study considered the woman's response as correct because of desirability bias that may be inherent in the men's response on this issue. Data was entered on-site in CSPro 4. We used both descriptive and inferential — mainly logistic regression — methods to arrive at conclusions. After the descriptive analyses, we conducted a series of bivariate analyses testing the association of one explanatory variable at a time with the outcome which is women's extra-marital relationships in the past six months.

This was essential in order to shortlist variables for multivariable analysis since we had a large of independent variables. This inclusion level was chosen as the most conservative value in practice that gives a chance to each variable that may not be ificant at the usual 0. For the 12 focus group discussions conducted, six were with either gender. Ten of the 12 FGDs had 10 participants each and 2 had 9 participants.

The participants in the FGDs and face-to-face interviews were mutually exclusive such that no couple participated in both. The flexibility of focus groups as qualitative method enabled us to evoke meaningful and culturally salient responses and thus helped uncover entrenched issues pertaining to extra-marital partnerships in this fishing community to supplement quantitative data. The of FGDs was determined by saturation point, which is a point where no new information is forthcoming on the various themes we were pursuing.

All the 33 fishing beaches within Kisumu County participated and we made purposeful efforts to include married couples from all the beaches. Participants were identified in collaboration with the beach management units during the community mobilization and preparation for the study. The FGD guide was developed in English and translated and back-translated in to the local language Dholuo for verification.

Fishermen, who were over 18 years old, married and knowledgeable of the fishing community, were our index participants. Similar to structured interview participants, FGD participants were approached, briefed about the study and asked whether they were willing to be recruited in the study with their spouses.

Those willing were asked to inform their spouses about the study and find out if they were also interested. The interested couples were then invited to come for focus group discussions. When the couples invited arrived at the study clinic, they were given the full details about the study and consented together as a couple before being separated into different rooms for group discussions.

The group discussions for the separated spouses took place concurrently to avoid partners influencing each other's responses during the discussions. For confidentiality purposes, partners of a couple were given same tag that the moderator called out each time they wanted to speak instead of their names.

The tags also helped us to link views from the same couple on different issues. The discussions were recorded by voice-activated digital recorder and later ed into password-protected folders on the study computer. On average, the focus group discussions took 1.

The discussions were conducted by gender-matched moderators with the themes deliberately limited to cover group normative behaviour and diversity of views in the group. We covered a wide range of issues which included courtship and marriage in fishing communities, relationship and sexual satisfaction, extra-marital relationships, consequences of extra-marital relationships and possible interventions to reduce extra-marital relationships in the fishing communities.

All FGDs were conducted in Dholuo and the resultant audiofiles transcribed verbatim and later translated into English by a trained transcriptionist. Preliminary data analysis and preparation started and continued in tandem with data flow from the field. We scanned through the transcripts as they became available to develop broad codes and eventually fine codes. The broad codes represented the thematic areas that our study was focused on under which we had several fine codes. Analysis of the transcripts followed grounded theory tenets that allow analytical themes to emerge from voices of participants.

Specifically, we analyzed data by constant comparative method which is an inductive analysis derived from grounded theory [37]. Under this method, one piece of data, for instance, one interview or one statement or one theme, is taken and compared to all other pieces of data that are either similar or different to identify what makes the piece of data different or similar to other pieces of data.

This helps in defining sub-themes during the process of transcripts reading, exploration and coding responses. Using NVivo 9 QSR International Pty Ltd, Melbourne, Australia qualitative data analysis software, we coded the transcripts, categorizing the data into broad codes themes and in each identified fine codes subthemes. Coding reports were discussed in a series of meetings held among the lead author and the study staff to refine the coding framework.

For this paper, we captured the following broad codes relating to sexual concurrency from the transcripts: a marital relationships, b attributes of sexual satisfaction and, c the role of penis size in women's extra-marital partnerships. A total of women married to fishermen were enrolled to participate in the structured interviews with a median age of 24 IQR 21—28 mostly The majority of the women Slightly more than a quarter of the women A quarter of the women The median duration of marriage was 6. The median monthly income for the women was USD Overall, 6. Thirty one women 5. Twenty seven percent of the women suspected their spouses to be involved in extra-marital relationships.

While Women who reported extra-marital partnerships were more likely to have been denied either sex or preferred sex position. One quarter

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