Risky Sexual Behavior and HIV Infection Among Ghanaians Aged 15–49: Evidence From the Ghana Demographic Health Survey 2003 and 2014

Abstract

Objective:

The study assessed the dominant risk factors associated with risky sexual behavior (RSB) and further quantify its influence on HIV infection among Ghanaians aged 15–49 years using the Ghana demographic and Health Survey (GDHS).

Methods:

A cross-sectional study using two rounds of the GDHS (2003 = 7448 and 2014 = 10169). RSB and HIV infection were the study outcomes. The study employed dominant analysis to rank the important risk factors associated with RSB. Meta-analysis was conducted to obtain heterogeneity in the prevalence of HIV infection by RSB. The Logistic Inverse Probability Weighting (LIPW) model was employed to estimate the average treatment effect (ATE) of RSB on HIV infection.

Results:

The prevalence of RSB decreased from 6.0% (95%CI = 5.4–6.6) in 2003 to 5.7% (95%CI = 5.0–6.4) in 2014. The overall growth rate showed a decrease of 2.5 percentage points, although this change was not statistically significant. Generally, dominant analysis showed that over 60% impact of the factors associated with RSB was being male. HIV prevalence ranged from 1.98% (95%CI = 1.6–2.3) in 2003 to 1.59 (95%CI = 1.21–1.98) in 2014 and the overall growth rate was decreased by 10.4%, however, statistically not significant. The overall HIV prevalence was approximately 1.8% (95%CI = 1.52–2.03) with the highest occurring among participants who engaged in RSB (a negligible Higgins’s I² value of 25.4%, p = .260). The average HIV infection, if all participants were to engage in RSB, was approximately two per 100 participants significant in both years [estimate for 2003 = 0.017 (0.013–0.021) while 2014 = 0.016 (0.012–0.019)].

Conclusion:

The prevalence of RSB and HIV infection from 2003 to 2014 showed no significant decline. Even though most factors were associated with RSB, over the two rounds of GDHS, being male was the most important factor that predisposes an individual to RSB. The findings from this study recommend a community-based intervention through health promotional activity in the form of behavioral change by adopting a gender-sensitive approach. HIV program implementers should be aware that RSB is paramount among males.

Keywords

Risky sexual behavior HIV Ghana

Introduction

The Human Immunodeficiency Virus (HIV) remains a major cause of mortality in Africa.¹ A cumulative total of about 79.3 million people have been infected with HIV since the start of the epidemic with significant heterogeneity in the burden of HIV infection across the globe. In 2020, Sub-Saharan Africa was home to approximately 67% of the estimated 37.7 million people living with HIV (PLHIV) globally.² Ghana has a low-level generalized HIV epidemic with an estimated prevalence rate of 1.7% among people aged 15–49 years.³ Most of the country’s new HIV infections occur in key populations such as female sex workers (FSW), men who have sex with men, people who inject drugs (PWIDs), and middle-aged adults.^4,5

Ghana over the years adopted high-impact HIV activities intending to stop new infections. These activities were focused on key populations, children, and mothers through care and treatment, provision of condoms and lubricants, and targeted behavioral change interventions.⁴ A modest decline in new HIV infections in Ghana has been achieved within the past two decades through the concerted efforts of the National AIDS Control Program and the Ghana AIDS Commission with support from the Government of Ghana, United States President’s Emergency Plan for AIDS Relief (PEPFAR), Joint United Nations Program on HIV/AIDS (UNAIDS) and Global Fund.^2,4

Risky sexual behaviors (RSBs) or “high risk sexual behaviors” such as early age of sexual debut, condomless sex or inconsistent use of condoms, transactional sex, or sexual intercourse with multiple partners increase the chances of HIV or other negative outcomes.^6–8 Even though some population-based studies have shown a higher frequency of RSBs among young people.^8,9 A study has also suggested that despite a physiological decline in sexual function with age, a higher prevalence of RSBs might exist among older people.¹⁰ Behavioral interventions that appreciate population-specific factors that contribute to RSB are among the interventions perceived to be essential in promoting sexual health.¹¹ Given that HIV infections are common in individuals who engage in RSBs, this article, sought to assess the prevalence of RSB and associated factors (adopting dominant analysis to determine the relative impact of RSB risk factors) and further quantify its influence on HIV infection among Ghanaians (15–49 years). Findings from this study might inform the development of tailored behavior-change interventions for the country.

Methods

Study Description

The Ghana Demographic and Health Survey (GDHS) data for 2003 and 2014 were used for this study (secondary data analysis). The two surveys were both conducted across the then 10 regions of Ghana. DHS are nationally representative household surveys that provide data for a wide range of monitoring and impact evaluation indicators in the areas of population, health, and nutrition. The secondary data that was used in GDHS rounds were four and six (2003 and 2014 GDHS). This study did not consider the 2008 GDHS because the main outcome variable (HIV infection) was not assessed during the 2008 GDHS year.

Study Design

The sample of each survey year was obtained using a two-stage stratified (rural-urban differential) cluster sampling design across the countries’ 10 administrative regions. The first stage involved the independent selection of clusters consisting of enumeration areas (EAs). The second stage involved systematic sampling from a list of households in all the selected EAs. The number of households enlisted in each EA made up the EA size. A household was selected and all persons aged 15–49, who were permanent residents of the selected households or were visitors who stayed in the household the night before the survey were eligible for the study. Those who consented to partake in the study were interviewed in each survey year. Details of the GDHS sampling design can be obtained from the GDHS report.¹²

Study Participants

The study involved Ghanaian women and men in their reproductive years of 15–49 years. This age group was considered because the GDHS assessed RSB among all women and men aged 15–49 years.¹³ This present study involved GDHS 2003 and 2014 years for men and women aged 15–49 years because HIV infection was only assessed in these two surveys. The total number of women aged 15–49 years interviewed in GDHS for 2003 and 2014 were 5691 and 9396, respectively, while 4517 and 3855 men were involved, respectively. This current study involved 7448 and 10169 participants for the 2003 and 204 GDHS, respectively.

Outcome Measures

The primary and secondary outcomes considered were HIV infection and RSB.

Primary Outcome

For HIV infection variable, the DHS HIV testing methodology allowed women and men aged 15–49 to be tested in an informed, anonymous, and voluntary manner. Each respondent received free HIV educational materials, counseling, and information on where to take an HIV test before being tested.¹⁴ Following consent, blood spots from a finger prick were collected on filter paper and transferred to a laboratory for examination. The laboratory technique included an initial enzyme-linked immunosorbent assay (ELISA) test, followed by a second ELISA test for all positive tests and 5%–10% of negative tests. A fresh ELISA or a Western Blot was conducted for patients who had discordant results on the two ELISA tests. The HIV test results data were linked to individual questionnaires with no personal identifiers to protect anonymity. All respondents received educational materials and were directed to free voluntary counseling and testing (VCT). The guidelines for measuring national HIV prevalence in the population-based survey were strictly adhered to by GDHS.¹⁴

Secondary Outcome

For RSB, an algorithm was adopted using two categories of independent variables. The first case scenario was multiple sexual partners which was assessed among participants over the past 12 months preceding the survey. Participants who had two or more sexual partners were considered to have multiple sexual partners. The second scenario was participants with a higher risk of sexual behavior. This variable was generated to ascertain the number of participants who had had sexual intercourse with an individual other than a spouse or a non-cohabiting partner within the 12 months preceding the survey. The third case scenario was participants who did not used condom the last time they had sexual intercourse with a person who was neither their spouse nor lived with. If participants satisfied the above three conditions (i.e., having had multiple sexual partners, had a higher RSB and not using condom during last intercourse with a person who was neither their spouse nor lived with), they were considered as having RSB.

Data Analysis

Weighted estimations were employed by adjusting for the design nature of GDHS (adjusting for the primary sampling units, stratification, and the sampling weights for participants). The Rao-Scott χ² was used to evaluate the statistical association between RSB and the independent variables.

The Poisson regression model was used for our analysis to assess factors associated with RSB and dominant analysis was further employed to rank the relative importance of the risk factors. The Logit Inverse Probability Weighting (LIPW) model was employed to estimate the average treatment effect (ATE) of RSB on HIV infection to achieve the hypothetical objective. LIPW corrects for missing data by using estimated probability weights which are based on the fact that each subject is only observed in one of the possible outcomes. The random effects of meta-analysis models using Higgins’s I-squared statistic (I²) were used to assess variations between countries. The conceptual framework defining the hypothetical idea of the study and the process to achieve the study objective can be found in Supplementary Figure 1.

Figure 1.

Risky Sexual Behavior HIV Prevalence Among Ghanaians Aged 15–49, Evidence from GDHS 2003 and 2014.

The overall growth rate of RSB and HIV infection for GDHS years 2008 and 2014 was estimated using the formula $r = (\sqrt[n]{\frac{P_{1}}{P_{0}}}) - 1$ ; where r =growth rate, P₁ the current indicator estimate (2014 GDHS), and P₀ = the past estimate (2003 GDHS). The growth rate measures the rate of the changing pattern of RSB and HIV infection over the study periods.

Results

The study involved 17617 Ghanaian women and men aged 15–49 years across 2003 and 2014 GDHS years (7448 and 10169, respectively). The mean ± SD was 31.7 ± 8.8 years and the sex ratio was approximately 1:2 for males versus females, respectively. The prevalence of RSB among participants was 5.8% (95%CI = 5.4–6.3). The prevalence of RSB decreased from 6.0% (95%CI = 5.4–6.6) in 2003 to 5.7% (95%CI = 5.0–6.4) in 2014. The overall growth rate showed an insignificant reduction of 2.5% (Supplementary Table 1 and Table 2).

Table 1.

Factors Associated with Risky Sexual Behavior Among Ghanaians Aged 15–49, Evidence from GDHS 2003 and 2014.

Variable	Year of Study		Pooled Data
	2003	2014
	aPR[95%CI]	aPR[95%CI]	aPR[95%CI]
Region
Upper East	ref	ref	ref
Western	3.97[1.89–8.32]***	4.74[2.89–7.76]***	4.80[3.18–7.23]***
Central	6.14[2.88–13.11]***	3.91[2.35–6.53]***	4.87[3.19–7.44]***
GT. Accra	5.54[2.72–11.26]***	3.93[2.31–6.69]***	4.66[3.06–7.09]***
Volta	4.63[2.20–9.72]***	2.70[1.57–4.63]***	3.44[2.23–5.30]***
Eastern	4.47[2.13–9.37]***	2.51[1.48–4.28]***	3.27[2.13–5.01]***
Ashanti	3.59[1.75–7.38]***	1.51[0.84–2.71]	2.34[1.51–3.63]***
Brong Ahafo	4.97[2.46–10.06]***	2.25[1.32–3.83]***	3.28[2.16–4.98]***
Northern	2.19[1.04–4.57]*	1.11[0.62–1.99]	1.51[0.91–2.38]
Upper West	2.01[0.89–4.54]	1.25[0.65–2.41]	1.51[0.91–2.49]
Sex of participant
Female	ref	ref	ref
Male	7.83[5.83–10.50]***	9.97[7.92–12.55]***	8.99[7.53–10.74]***
Educational level
No education	ref	ref	ref
Primary	1.47[1.02–2.12]*	2.27[1.45–3.55]***	1.74[1.32–2.30]***
Secondary	1.92[1.41–2.60]***	3.00[1.98–4.54]***	2.28[1.79–2.91]***
Higher	2.92[1.95–4.37]***	3.43[2.14–5.50]***	2.94[2.19–3.96]***
Marital status
Married	ref	ref	ref
Never married	1.94[1.46–2.56]***	1.35[1.07–1.72]*	1.62[1.35–1.94]***
DSW	1.86[1.34–2.56]***	1.60[1.16–2.21]**	1.69[1.35–2.12]***
Knowledge of contraceptive methods
No	ref	ref	ref
Yes	5.51[4.19–7.26]***	7.30[6.26–8.52]***	5.22[4.64–5.86]***
Awareness of FP
No	ref	ref	ref
Yes	2.00[1.38–2.92]***	1.29[1.05–1.58]**	1.47[1.23–1.75]***
Perception about condom use
Low	ref	ref	ref
High	1.28[1.04–1.57]**	1.38[1.15–1.66]***	1.34[1.17–1.54]***
Currently using contraceptive
No	ref	ref	ref
Yes	1.92[1.59–2.32]***	1.56[1.31–1.85]***	1.73[1.52–1.96]***
Knowledge about HIV
Poor	ref	ref	ref
Low	1.36[1.01–1.85]*	1.50[1.15–1.94]***	1.47[1.21–1.79]***
High	1.52[1.10–2.08]**	1.66[1.24–2.23]***	1.70[1.37–2.10]***

Note: GT = Greater; DSW = Divorced/Separated/Widowed; FP = Family Planning; HIV = Human Immunodeficiency Syndrome; aPR = adjusted Prevalence Ratio; CI = Confidence Interval; p value Notation: *p < .05; **p < .01, ***p < .001.

Risk analysis showed that factors associated with RSB were usually specific to the year of the GDHS. Detailed results can be found in Supplementary Table 3.

Even though the risk factors identified varied across the years, being a male-participant prevalence ratio was found to be significantly high. In 2003, the analysis showed that being a male significantly increased the risk of RSB by approximately eightfold (adjusted prevalence ratio [aPR] = 7.83, 95%CI = 5.83–10.50) while in 2014, the prevalence ratio increased to about tenfold (aPR = 9.97; 95%CI = 7.92–12.55). The overall risk ratio was, however, about ninefold (aPR = 8.99; 95%CI = 7.53–10.74) (Table 1).

Generally, from the dominant analysis, the most important risk factor of RSB among participants was the sex of participants. Sex differential showed that being a male participant was the most important significant factor across the GDHS years. Sex differential constituted over 60% of the overall impact (approximately 60.1% in 2003, 64.5% in 2014 and 64.0% for the pooled data). The 2003 GDHS and the pooled data revealed educational level as the second most significant factor, contributing approximately 7.6% and 7.0% in the 2003 GDHS and the pooled data, respectively. Education emerged as the third most significant factor in 2014 contributing approximately 6.3% of the impact (Table 2).

HIV prevalence ranged from 1.98% (95%CI = 1.6–2.3) in 2003 to 1.59 (95%CI = 1.21–1.98) in 2014. The overall growth rate was reduced by 10.4% which was not statistically significant (Supplementary Table 1). From the meta-analysis, the overall estimate of HIV prevalence across the GDHS study years was approximately 1.8% (95%CI = 1.52–2.03) as presented in Figure 1 (a negligible Higgins’s I² value of 25.4%, p = .260). In terms of RSB, participants who were involved in RSB were observed to have a higher prevalence of HIV infection compared with their counterparts who were not involved in RSB [2003 = 2.43(1.70–3.15) vs. 1.68(1.36–2.00) with Higgins’s I² = 70.55%, p = .07 and 2014 = 1.74(1.38–2.11) vs. 1.61(1.22–1.99) with Higgins’s I² = 0.00%, p = .610] (Figure 1).

Table 2.

Dominant Analysis Showing Top 10 Relative Importance of Factors Significantly Associated with Risky Sexual Behavior Among Ghanaians Aged 15–49, Evidence from GDHS 2003 and 2014.

2003 GDHS			2014 GDHS			Pooled data
Key Predictor	SDS	Rank	Key Predictor	SDS	Rank	Key Predictor	SDS	Rank
Sex of participant	0.6014	1	Sex	0.6454	1	Sex	0.6389	1
Education	0.0759	2	Region	0.0833	2	Education	0.0699	2
Age at first sex	0.0575	3	Education	0.0634	3	Region	0.0526	3
Watching TV	0.0428	4	Number of HH members	0.0461	4	Age at first sex	0.0404	4
Listening to radio	0.0377	5	Age of participant	0.0323	5	Number of HH members	0.0368	5
Age of participant	0.0359	6	Age at first sex	0.0303	6	Age of participant	0.0341	6
Wealth index	0.0335	7	Wealth index	0.0224	7	Watching TV	0.0278	7
Number of HH members	0.0247	8	Listening to radio	0.0204	8	Wealth index	0.0271	8
Place of residence	0.0198	9	Watching TV	0.0163	9	Listening to radio	0.0266	9
Awareness of FP	0.0191	10	Sex of HH	0.0162	10	Sex of HH	0.0158	10

Note: SDS = Standardized Dominant Statistics, TV = Television, FP = Family Planning, HH = Household Head; GDHS = Ghana Demographic Health Survey.

The influence of RSB on HIV infection as presented in Table 3 depicted a significantly increased likelihood of acquiring HIV infection in participants who were involved in RSB. Analysis showed that generally, the average HIV infection if all participants were to engage in RSB, would significantly increase to 16 per 1000 population aged 15–49 years (95%CI = 13–19 per 1000 population aged 15–49 years). Similar estimates occurred within the study years as presented in Table 3.

Table 3.

Influence of Risky Sexual Behavior on HIV Infection Among Ghanaians Aged 15–49, Evidence from GDHS 2003 and 2014.

Risky Sexual Behavior	GDHS Year		Pooled
	2003	2014
	ATE[95%CI]	ATE[95%CI]	ATE[95%CI]
No	ref	ref	ref
Yes	0.017[0.013–0.021]***	0.016[0.012–0.019]***	0.016[0.013–0.019]***

Note: ATE = Average Treatment Effect; CI = Confidence Interval. Ref denotes reference category used for inferences; ref = Reference Category. Analysis adjusted for Sex of Household head, wealth index, the number of household members, frequency of radio listening, frequency of watching television, region, place of residence, source of drinking water, sanitation, sex of participant, age of participants, educational level, marital status, age at first sex, knowledge on contraceptive, awareness of family planning, perception about condom use, currently using contraceptive, known place for HIV test, Comprehensive Knowledge about HIV.

Discussion

This study showed that the risk of contracting HIV varied greatly by the type of exposure or conduct of an individual. It established a significant relationship between RSB and HIV infection among participants. The GDHS collected blood sample exclusively for HIV infection testing during two specific years (2003 and 2014).

RSB and the most Important Risk Factor Among Ghanaians Aged 15–49, Evidence From GDHS 2003 and 2014

Despite a decrease in the prevalence of RSBs from 2003 to 2014, this study showed that generally, approximately six out of every hundred participants engaged in RSBs albeit not statistically significant. It was about one-and-a-half times lower than the French individuals aged between 15 and 54 years.⁹ The differences in the operational definitions of RSBs might explain the difference in the prevalence rates. This current study used a composite of the two components (i.e., participants who had multiple sexual partners and having had a high-risk sexual partner) to define an individual with an RSB. The French study however used one of the two components (i.e., having multiple partners or failure to use a condom with a new partner) to describe an individual with RSB. This could explain their higher RSB prevalence. On the other hand, if the minimum number of partners to define an individual with multiple partners in this study had been more than two, the RSB prevalence could have been lower. A meta-analysis by Asres et al. also demonstrated a higher total estimated prevalence (17.6%) of RSB among 207,776 women aged 15–49 years from 28 less developed countries between years 2003 and 2009.¹⁵ The lower prevalence of RSBs in this study compared to the RSB prevalence in such vulnerable groups and key populations at risk for HIV infection^16–18 is not surprising. Additionally, the lower prevalence of RSB as found in this study could be due to the study participants involved and the nature of the study design. This study adopted a nationally cross-sectional study design among reproductive-age individuals while the other scholars involved an institutional-based study involving patients and students.^16–18

Our study showed that being a male was associated with a ninefold likelihood of engaging in RSB. Generally, from dominant analysis, the most important risk factor of RSB among participants was the sex of participants showing that being a male participant was the most important significant factor contributing over two-thirds of the impact. A meta-analysis of seven articles by Amare et al. who examined the epidemiology of RSBs among Ethiopian students also showed a greater likelihood of males practicing RSBs⁶ even though the sex differentials in RSB were lower in that study compared to that found in our study. This sex difference could be due to several factors such as over-reporting and under-reporting of multiple sexual partners in men and women, respectively, linked to societies’ perceptions of gender norms and roles.¹⁹ Additionally, in Sub-Saharan African countries and other developing countries, the median age at first marriage is lower in women (by age 20) compared to that of men.²⁰ However, except for the exposure of pregnancy, women who especially live in societies that have banned extramarital sexual relations or share beliefs that perceive extramarital sexual relations as being sacrilegious will least likely engage in RSBs.²¹ Some men believe that pursuing multiple and or concurrent partners are important features of masculinity hence engage in such risky behaviors.²² Some societies also measure a man’s sexual prowess by the number of sexual partners that particular man has.²³ All these traditional norms place males at risk of negative consequences. Young men also tend to become sexually active earlier²⁴ while females usually engage in sexual interactions as part of a long-term committed relationship based on love and trust,²⁵ this could also explain this current significant finding. Contrastingly, the reverse finding in the sex differential of RSB suggested that transactional sex, forced sex by males in or outside the school settings, failure of females to declare safer sex practices and the decision to use a condom during sexual intercourse, being the prerogative of the male might have collectively resulted in the over fourfold likelihood of observing RSBs among female students compared to male students in Guduru, Ethiopia.²⁶

Influence of RSB and HIV Infection Among Ghanaians Aged 15–49, Evidence From GDHS 2003 and 2014

This study sheds light on the dynamics of HIV infection across the variations of RSB and the geographical settings. The study further assesses the influence of RSB on HIV infection among participants in Ghana. It was heart-warming to find that the change in the prevalence of HIV infection in Ghana from 2003 to 2014 showed no significant difference. The methodology for calculating HIV prevalence was changed several years ago and this could be responsible for the drop in HIV prevalence.²⁷ In addition, the prevalence of HIV infection generally among the participants was however approximately two per hundred population, relatively high in 2003. The HIV infection rate in this study could be partly attributed to RSB. The current HIV infection rate is similar to the 1.6% prevalence rate observed by Ali and his colleagues.²⁸

Concerning RSB status, the prevalence was relatively high among participants who were involved in RSB and the meta-analysis showed negligible heterogeneity. The influence of RSB on HIV infection was enormous with the current finding revealing that RSBs increase the risk of HIV infection among participants. Globally, RSB is associated with HIV infection.²⁹ A cross-sectional population-based survey similar to this study design conducted in South Africa interestingly established that RSB was associated with unawareness of HIV-positive status.³⁰ Meaning that individuals who engage in RSB are mostly not aware of their HIV status which indicates a threat to HIV public health intervention.

Implication for Public Health Practice

In furtherance of the Sustainable Development Goal (SDG) of leaving no one behind and achieving a world free of HIV/AIDS by 2030, the Government of Ghana is working toward achieving the HIV/AIDS 95–95–95 targets by 2030. The prevalence of RSB from 2003 to 2014 showed no significant decline. In Ghana, research has demonstrated that individuals do not consider themselves as being at risk of contracting HIV infection.³¹ This study however elucidates the influence of RSBs on HIV infection, demystifying the individual perspectives noted by Afriyie and Essilfie.³¹ RSB must be critically factored in both community and institutional health promotional activities via a gender-sensitive approach. Although Ghana has seen a decline in HIV infection rate since 2015,²⁸ critical attention must be paid to RSB as it influences HIV infection in Ghana.

Limitation

Despite the study’s established significant findings, some limitations cannot be overlooked. Even though RSB was assessed using several factors, the assessment was based on the 12 months preceding the survey which may have been influenced by recall and social desirability biases. However, the definitions for RSB were based on previous studies and a definition from Demographic Health Survey statistics. In addition, some degree of bias in the estimation of the study outcomes may have been introduced because the study did not consider the 2008 GDHS. The current study had no control over that since 2008 GDHS did not measure HIV infection. The cross-sectional design of the study did not allow for inferences to be made regarding causality. However, a treatment-effect model was adopted to address such an issue. This study provides a better understanding of the current prevalence and the association between RSB and HIV infection in Ghana which can be used to tailor HIV prevention and intervention strategies.

Conclusion

The prevalence of RSB and HIV infection from 2003 to 2014 showed no significant decline. Even though most factors were associated with RSB, over the two rounds of GDHS, being a male was the most important factor that predisposed an individual to RSB. To achieve the target for SDG 3 (to end the epidemics of HIV/AIDS by 2030), the findings of this study strongly advocate for the implementation of targeted community-based intervention programs focused on health promotion activities. Specifically, adopting a gender-sensitive approach is recommended to effectively facilitate behavioral changes within the community. These intervention programs should be tailored to address HIV health concerns and behaviors prevalent within the community, ensuring that they are not only comprehensive but also culturally and contextually appropriate.

Supplemental Material

Supplementary material for this article is available online.

Footnotes

Acknowledgements

The authors are grateful to MEASURE DHS for providing the data for this research work.

Author Contributions

JT, GE-F and AEY conceptualized the study. JT sought approval for access to the GDHS data. JT and AEY undertook the statistical analysis. JT, IA, SMS, GE-F and AEY drafted the initial manuscript. SAA and KT read and provided intellectual content revisions and suggestions for clarity and precision. All authors read and approved the final review manuscript.

Availability of Data and Materials

Data for this analysis was requested and granted by the Monitoring and Evaluation to Assess and Use Results Demographic and Health Surveys (MEASURE DHS) department. The minimal dataset used to support the findings of this study is third party data available upon request from https://dhsprogram.com/data/dataset_admin/login_main.cfm

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Ethical Approval

The GDHS protocol underwent ethical review and approval by both the Ghana Health Service Ethical Review Committee and the ICF Institutional Review Board. The ICF IRB ensures full compliance with U.S. regulations, particularly the Department of Health and Human Services’ guidelines for the protection of human subjects (45 CFR 46).

Funding

The authors received no financial support for the research, authorship and/or publication of this article.

Informed Consent

Written informed consent was obtained from each participating woman during data collection. Strict protocols were followed to uphold privacy and confidentiality throughout the process.

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