DEMOGRAPHIC

AND

HEALTH

SURVEYS

DHS WORKING PAPERS

2013 No. 101

Domitilla R. Bashemera 

Martha J. Nhembo

Grace Benedict 

September 2013

This document was produced for review by the United States Agency for

International Development.

The Role of Women’s Empowerment in 

Infl uencing HIV Testing

The Role of Women’s Empowerment in Influencing HIV Testing 

Domitilla R. Bashemera 1

Martha J. Nhembo 1

Grace Benedict 2

ICF International 

Calverton, Maryland, USA 

September 2013 

1

Dodoma 

2

Mwanza, Tanzania 

Corresponding author: Domitilla A.R. Bashemera, Population Studies Department, Institute of Rural Development 

Planning, Dodoma, Miyuji Area, P.O. Box 138, Dodoma Tanzania: Phone +255 26 2302147: Fax +255 26 2301341; 

dbashemera@irdp.ac.tz 
ACKNOWLEDGEMENTS 

The authors of this paper would like to express their appreciation to those organizations 

and individuals who contributed to the successful preparation of this paper. Specifically the team 

would like to thank the facilitators Wenjuan Wang, Sarah Staveteig, Tom Pullum and Kerry 

MacQuarrie for their appropriate guidance, constructive comments and suggestions, which 

improved this manuscript. 

The program would not have been successful without permission and support from the 

Institute of Rural Development Planning; the authors appreciate the institutional support and 

encouragement. Furthermore, our thanks go to the facilitators for their participatory facilitation 

method, which made possible the contribution from participants and experience sharing. The 

authors thank the United State Agency for International Development (USAID) for fellowship 

financial support through the MEASURE DHS project at ICF International Inc. 
ABSTRACT 

Background: The study on the role of women’s empowerment and HIV testing in 

Tanzania was conducted using data from the 2010 Tanzania Demographic and Health Survey 

(TDHS).

Objective and Conceptual Framework: The study analyzed the influence of women’s 

empowerment on HIV testing. Specifically, indicators of women’s empowerment were linked to 

women’s socioeconomic characteristics and to HIV testing. Women’s characteristics include age, 

education, wealth, employment, residence and whether the woman had given birth in the five 

years preceding the survey. Women’s empowerment indicators include participation in 

household decision-making, attitudes disapproving wife beating and attitudes that women can 

refuse sex if their husbands have a sexually transmitted infection. 

Methods: The study involved 6,406 women age 15-49 and currently married and living 

together with their husbands. Descriptive analysis was used to determine the women’s 

socioeconomic characteristics. Bivariate and multivariate (logistic regression) analyses were 

used to determine the association between socioeconomic characteristics and women’s 

empowerment in influencing HIV testing. 

Results: Out of the 6,406 women, 4,246 had been tested for HIV. The odds of being 

tested were higher among women who participated in household decision-making, had 

disapproving attitudes toward wife beating, and approving attitudes toward refusal of sex. Both 

for women without a recent birth and for women who gave birth in the past five years and who 

used ANC services, empowerment is associated with higher likelihood of HIV testing. 

Key Words: Women’s empowerment, HIV testing, birth in past five years, Tanzania 

1 

INTRODUCTION 

Background 

Women’s empowerment is important for addressing the HIV epidemic. It builds women’s 

confidence to test for HIV and thus to know their HIV status and to be able to prevent 

transmission from mother to child, as well as to prevent new infections to their partners. 

Women’s access to HIV testing depends substantially on the level to which a woman has been 

empowered. It is believed that a woman who is empowered, culturally or politically or 

professionally, has confidence to decide to go for HIV testing, as she does not depend on her 

husband or partner to make decision for her on whether to test for HIV or not. 

In Tanzania, as in other countries in sub-Saharan Africa, more women are affected with 

HIV than men, at 6% and 4%, respectively, according to the 2011-2012 Tanzania HIV/AIDS and 

Malaria indictor survey (TACAIDS et al., 2013). Similarly, a study on Voluntary Counseling and 

Testing Clinics in Dar-es-Salaam, found that HIV prevalence among young women and men age 

15-24 was higher for women than men (Maman et al., 2002). 

The leading factors for women being more infected than men include a culture which 

disempowers women. For example Miller (2011) in a study on the determinants of women’s 

empowerment and HIV status in sub-Saharan Africa reported: “Increased female vulnerability to 

HIV stems from limited access to health care and lack of autonomy to make decisions regarding 

sexual health and education”. Moreover, such cultural practices as trusting men to take 

household decisions, believing that if a wife is beaten by her husband or partner it is the sign of 

love, and believing that a married woman is not allowed to use a condom for sex with her 

husband or partner whom she suspects has a sexually transmitted infection (STI) put women into 

web of silence which denies them decision-making power and makes them submissive when 

they are beaten. 

Hasbullah (2013) has reported that “violence against women remains hidden behind a 

culture of silence.” Maman and colleagues (2002) found that “lack of financial autonomy, 

control of household income, women’s inability to negotiate for condom use, lower education of 

both partners and low household income” are factors which prevent women from using HIV 

voluntary counseling and testing services in Tanzania. 
2 

Another Tanzanian study by Maman and colleagues (1999) found gender differences in 

decision-making concerning the use of HIV voluntary counseling and testing (VCT) services. 

“While men made the decision to seek voluntary counseling and testing independent of others, 

women felt compelled to discuss testing with their partners before accessing the service, thereby 

creating a potential barrier to accessing VCT services.” 

In order to address HIV/AIDS, in 2001 The Government of Tanzania adopted an 

HIV/AIDS policy “to promote early diagnosis of HIV infection through voluntary testing with 

pre- and post-test counseling and to reassure and encourage the 85%-90% of the population who 

were HIV negative to take definitive steps not to be infected, and those who were HIV positive 

to receive the necessary support in counseling and care to cope with their status, prolong their 

lives and not to infect others” (URT, 2001). 

Moreover, in 2007 Tanzania developed the provider-initiated opt-out testing through the 

National Prevention of Mother to Child Transmission (PMTCT) guideline “to promote and 

support the delivery of quality HIV prevention, care, treatment and support service” and “HIV 

counseling to ensure a dialogue between a group of clients and health care provider aimed at 

enabling clients to make informed personal decisions about their HIV testing in order to know 

sero status.” Knowledge of one’s HIV status may act to mobilize support networks, increase 

sensitivity and decrease stigma, open dialogue regarding future plans and status disclosure, and 

discourage risky sexual behaviors (Staveteig et al, 2013). 

Theory of HIV Counseling and Testing 

Some theories underlying HIV testing discuss factors that motivate and discourage 

testing at the same time. Client Motivation Theory underlies on factors motivating individuals to 

get tested for HIV. For example Kamengaa and colleagues (2001) observe that the decision to 

undergo HIV testing remains difficult for many people. This difficulty is compounded by factors 

such as stigma and discrimination, distance to services and cost of services. Various motivations 

have been reported for those who choose to be tested for HIV, including fear of having been 

exposed to HIV, feeling sick, an important life commitment (e.g., marriage, new partner), and 

requirement for a benefit (e.g., visa, scholarship). 
3 

Hullet (2006) used functional theory of attitudes and stimulation of fear in motivating 

college students to get tested for HIV. The theory advocates that value expressive appeals to get 

tested for the purpose of taking care of one’s own health could be effective if that goal is desired 

by message recipients who are sexually active and unaware of their sexually transmitted disease 

status. The effectiveness of these appeals is increased by the arousal of uncertainty and fear. 

Furthermore, the theory holds that messages advocating testing for the self-interested reason of 

one’s own health would be more effective than messages advocating testing for the goal of 

protecting ones partners. 

Kamengaa and colleagues (2001) reported that the core components of HIV counseling 

and testing include pretest counseling, HIV testing, and post-test counseling. HIV counseling and 

testing interventions are promoted as voluntary and confidential. This approach is believed to 

contribute to people’s right to know their HIV sero-status and prevent HIV transmission. It is 

based on the belief that knowledge of HIV sero-status helps in decision-making (e.g., changes in 

sexual behavior, prevention of mother-to-child transmission [PMTCT] uptake) and that access to 

treatment, care and support services from the government and other stakeholders follow from 

HIV testing. These theories concur with this study, which emphasizes the right of women to HIV 

testing. 

Greig and Koopman (2003) in their study on the explored relationships between women's 

empowerment and HIV prevention at the national and individual levels, with a focus on 

Botswana, asserts that among sub-Saharan African countries, HIV prevalence was positively 

correlated with indirect indicators of women's empowerment relating to their education (female 

enrollment in secondary education and ratio of female to male secondary school enrollment), but 

not to their economic status (women’s share of paid employment in industry and services) or 

political status (women's share of seats in national parliament). Condom use at last sexual 

encounter was positively and significantly correlated with both indicators of women's 

educational empowerment. Moreover, women's negotiating power and economic independence 

were the factors most strongly related to condom use. Economic independence was found to be 

the strongest factor likely to influence women’s negotiating power. 

Socio-demographic factors, such as marital status, area of residence, religion and 

ethnicity influenced VCT completion among males and females in different ways, while self-
4 

perceived risk of HIV, prior knowledge of VCT, and sex with a high-risk partner emerged as 

important predictors of VCT completion among both sexes. This contributed to a higher 

proportion of HIV-positive males knowing their status compared with HIV-positive females. 

TDHS 2010 and THMIS 2013 indicate, respectively, that 41% and 33% of women age 

15-49 had never tested for HIV. The effort to combat HIV includes ensuring that gender 

perspectives are incorporated into efforts to combat HIV/AIDS (Germain, 2009). Kominami and 

colleagues (2007) found that 68% of the participants had already had HIV testing. The study 

hypothesized that women’s empowerment influences HIV testing. Therefore, this study describes 

the relationship between socioeconomic characteristics, women’s empowerment and HIV 

testing. 

Conceptual Framework 

Behal (2011) has defined empowerment as “increasing the spiritual, political, social or 

economic strength of individuals and communities. It often involves the empowered developing 

confidence in their own capacities”. Empowerment is a process or an outcome/goal and can take 

place at different levels. Moreover, it is a process through which women currently most 

discriminated against can achieve gender equity (Behal, 2011). 

The conceptual framework in Figure 1 shows the relationship between three predictor 

variables thought to affect the explanatory variable, HIV testing. The predictor variables were 

classified into two parts. Women’s socioeconomic characteristics include age, level of education, 

wealth index, employment, and place of residence and given birth for the past five years. 

Women’s empowerment includes participation in decision-making, attitudes toward wife beating 

and attitudes toward refusal of sexual intercourse. 
5 

Figure 1. Conceptual Framework 

The first assumption is that women age 15-49 who are empowered decide to go for 

testing voluntarily, not just if they attend antenatal care (ANC). The determinants under this 

assumption are women taking major decisions at the household level, having the ability to refuse 

unsafe sex and not approving of wife beating. The second assumption is that there are some 

clients (women age 15-49) whose testing for HIV is initiated when they are pregnant, provided 

as part of ANC. 

In Tanzania pregnant women are eligible to attend ANC. However, not all pregnant 

women are able to attend ANC due to one reason or another, such as distance from a clinic, 

especially for the rural population, while some women fear to receive HIV-positive results, due 

to stigmatization from community members (Yang et al., 2005). Moreover, the Tanzania 

National Policy on HIV/AIDS (United Republic of Tanzania, 2001) reported that “stigma leads 

to secrecy and denial that tends to hinder openness about the HIV and prevents people from 

seeking counseling and testing for HIV.” 

ANC was considered in the conceptual framework because it is obligatory for all 

pregnant women in Tanzania to attend ANC, and through ANC attendance they get tested for 

HIV. In health facilities where there are no HIV testing services, pregnant women are referred to 

Socioeconomic characteristics 

• Age; 

• Education; 

• Wealth Index; 

• Employment; 

• Pace of residence; and 

• Given birth in the past five years. 

Women’s empowerment 

• Participation in decision-making; 

• Attitudes toward wife beating; 

• Attitudes toward refusal of 

sexual intercourse. 

Antenatal care 

(ANC) 

HIV 

testing 
6 

other health facilities for HIV testing. Therefore, the hypothesis that women’s empowerment 

influences HIV testing was considered to compare women who have given birth in the five years 

preceding the 2010 TDHS with women who did not give birth in the last five years. 

In order to attain the general objective of this study on the role of women’s empowerment 

in HIV testing, this study has to explore the relationship between women’s socioeconomic 

characteristics and HIV testing. It is assumed that empowerment stimulates women’s desire for 

HIV testing, despite the fact that all pregnant women should test for HIV. HIV testing and 

counseling serves as both critical prevention and treatment in the control of HIV epidemic 

(WHO, 2004). As Staveteig and colleagues 

(2013) have observed, “HIV testing is an essential part in providing medical care to 

persons living with HIV and key to preventing HIV transmission. For people who test HIVpositive, testing is the starting point for care and management of the disease. It is also an entry 

point for efforts to prevent infection of their sexual partners and their children. Even for people 

who test HIV-negative, the testing process is an opportunity for counseling about HIV 

transmission that may strengthen prevention efforts and reduce stigma.” 
7 

DATA AND METHODS 

Data 

The 2010 Tanzania Demographic Health Survey (TDHS) was the source of data for this 

study (NBS and ICF Macro, 2011). The survey was the fifth in a series of DHS surveys 

conducted in Tanzania since 1991-92. In addition, three AIDS Indicator Surveys (AIS) have also 

been conducted. 

Sample Design 

The sample design included women age 15-49 because “pregnant women who are HIVpositive are at risk of transmitting the virus to their infants during pregnancy, delivery, or while 

breastfeeding (Staveteig et al., 2013). Figure 1 summarizes the samples and subsamples of this 

study. The total sample comprised 10,139 women, while only married women living together 

with their husbands (n=6,412) were included in the present study because of the study’s focus on 

negotiation for HIV testing. Subsamples included women who had given birth in the five years 

preceding the survey (n=4,537) and women who had not given birth in this period (n=1,869). 

Kabeer (1999) defines empowerment as “a process by which those who have been denied 

ability/power to make strategic life choices acquire the ability to do so. For women, strategic life 

choices may include capacity to choose a marriage partner, a livelihood, whether or not to have 

children”. This definition views women’s empowerment as both a process and an end result. The 

author further argues that, for this power to come about, three interrelated dimensions are 

needed. They include access to and control of resources; agency (the ability to use these 

resources to bring about new opportunities); and achievements (the attainment of new social 

outcomes). 
8 

Figure 2. Flow chart of samples and subsamples 

To measure women’s empowerment, three variables have been developed: women’s 

participation in household decision-making, women’s attitudes toward wife beating and 

women’s attitudes toward a wife’s right to refuse sexual intercourse with her husband or partner. 

The first variable (either 0 or 1) corresponds with whether a woman is involved or not involved 

in household decision-making, an area that affects women’s lives and environment. A high score 

on this variable indicates a high level of empowerment (NBS and ICF Macro, 2011). 

The second variable (either 0 or 1) corresponds with whether the respondent accepts the 

reasons that a husband is justified in beating his wife, or does not accept these reasons. A low 

score on variable two is interpreted as reflecting greater sense of self worth and higher status of 

women (NBS and ICF Macro, 2011). The third variable (either 0 or 1) corresponds with whether 

the respondent feels that a woman is justified in refusing sexual intercourse with her husband or 

partner if she knows he has sexually transmitted infection (STI). The third variable reflects 

All women of reproductive age (15-49) 

(n=10,139) 

Never married, separated, divorced or widowed 

women (n=3,727) 

Married women and living together with 

husband/partner (n=6,412) 

Married women and living together with husband/partner with 

responses to all study variables 

(n= 6,406) 

Missing variables (n=6) 

Ever given birth in past 5 years 

n=4,537 

Not given birth in the past 5 years 

(n=1,869) 
9 

perceptions of sexual roles, women’s right over their bodies and related women’s sense of self 

and empowerment (NBS and ICF Macro, 2011). Ever given birth in the past five years was 

considered in order to differentiate women who tested for HIV on a voluntary basis (women who 

had not given birth) from women with a recent birth, as in Tanzania women during pregnancy 

are obliged to test for HIV as part of ANC. 

The distribution of these variables was linked to women’s socioeconomic characteristics 

and HIV testing. The rationale of employing these variables is based on the assumption that 

women who make decisions at the household level are more likely to have unrestricted beliefs 

about gender and are likely to disapprove the practice of wife beating and to support a woman’s 

right to refuse sex with her husband if she believes that he has an STI (NBS and ICF Macro, 

2011). 

 

Analytical Framework 

Descriptive statistics were used to examine levels of HIV testing, women’s 

empowerment, gave birth in last five years and socioeconomic variables. Bivariate analysis was 

used to identify the factors associated with the outcome variable, HIV testing. 

Logistic regression analysis was used to build multivariate model for identifying the 

factors that were independently associated with HIV testing outcome. Six models were involved 

in model 1 the relationship between women’s involvement in decision-making and HIV testing 

was studied. In model 2, the influence of women’s attitudes toward wife beating on HIV testing 

was assessed, and model 3 was employed to assess the relationship between attitudes toward a 

woman refusing sex when a husband has STIs and HIV testing. 

Moreover, a combination of three models was established to determine the effects on 

HIV testing of women’s decision-making, attitudes toward wife beating, and attitudes toward 

refusing sex if the husbands have STIs. Each of the first four models controlled for having had a 

birth in the past five years and a number of background variables, including level of education, 

age, wealth, employment and place of residence. Having given birth was added to the model in 

order to investigate the influence of women’s empowerment on HIV testing for women eligible 

to attend ANC and thus have exposure to provider-initiated (opt-out) HIV Test, and for hose who 
10 

are not obliged to attend ANC. Each model is a logistic regression of the form 

ijij HIV testing βx += ε with a vector of covariates, and odds ratios reported. 

This study addressed three categories of variables: women’s empowerment, given birth in 

the last five years and socioeconomic characteristics. The women’s empowerment category 

contained three indicators: household decision-making, attitudes toward wife beating and 

attitudes toward the right to refuse sex if husband has STIs. Given birth in the last five years was 

considered to be important, as pregnant women in Tanzania are obliged to attend ANC, where 

they get the opportunity for provider-initiated testing for HIV. Comparing this group with 

women who have not recently been pregnant disaggregates women whose HIV test was 

obligatory from women who tested voluntarily for HIV. 
11 

RESULTS

Socioeconomic Characteristics 

Table 1 shows that most women studied were between the ages of 20 and 39. Just 6% 

were age 15-19 and 20% were age 40 or older. The majority (69%) had a primary education, 

while 24% had no education and 8% had secondary and above education. About two-thirds 

(65%) were involved in agriculture and 24% in non-agricultural work, while 11% were not 

working. By level of household wealth, 40% of women were in the rich group, 39% poor, and 

22% in the middle group. Three-fourths of women lived in rural areas. 

Table 1. Women’s socioeconomic characteristics (N=6,406) 

Characteristics Frequency (weighted) Percentage 

Age 

15-19 399 6.2 

20-24 1,210 18.9 

25-29 1,338 20.9 

30-34 1,134 17.7 

35-39 1,035 16.2 

40-44 740 11.5 

45-49 549 8.6 

Education 

No education 1,524 23.8 

Primary 4,389 68.5 

Secondary 492 7.7 

Occupation 

Not working 730 11.4 

Non agriculture 1,524 23.8 

Agriculture 4,152 64.8 

Wealth 

Poor 2,509 39.2 

Middle 1,333 20.8 

Rich 2,565 40 

Residence 

Urban 1,582 24.7 

Rural 4,824 75.3 

 

Total 6,406 100.0 
12 

HIV Testing and Women’s Empowerment 

Figure 2 summarizes findings on the percentage of women tested for HIV, the percentage 

in the three categories of empowerment indicators and the percentage with a birth in the five 

years preceding the 2010 TDHS. Two-thirds of women had ever tested for HIV. For the three 

indicators of women’s empowerment, 65% of women were involved in household decisionmaking, 44% of women did not agree with any of the reasons justifying wife beating, and 72% 

of women agreed with the attitude that a wife can refuse to have sex if her husband has STIs. A 

large majority of women (71%) had given birth in the past five years. 

Figure 2. HIV testing, women’s empowerment and birth in past five Years (N=6,406) 

66.3 65.3

44.0

72.2 70.8

0

10

20

30

40

50

60

70

80

Ever tested for HIV Involved in decision

making

Not accept wife

beating

Agree women

can refuse to have

sex

Gave birth in past 5

years

Percentage
13 

Bivariate Analysis on Women’s Empowerment and HIV Testing

As Table 2 indicates, 69% of women who were involved in decision-making were tested 

for HIV, compared with 62% who were not involved in decision-making. Similarly, 69% who do 

not accept the reasons given to justify wife beating and 64% who accept justifications for wife 

beating reported that were tested for HIV, respectively. 

Table 2. Bivariate results on women’s empowerment and HIV testing (N=4,246) 

 Empowerment indicators Frequency (weighted) % X2 

Decision-making X2

=28.8***

Not involved in decision-making 1,376 62.0 

Involved in decision-making 2,870 69.0 

Attitudes toward wife beating X2

=6.7*

Acceptable 2,290 64.0 

Not acceptable 1,956 69.0 

Attitudes toward refusal to have sex X2

=49.5*** 

Not agree 1,059 59.5 

Agree 3,187 68.9 

Gave birth in past 5 years X2

=436***

Not gave birth 877 46.9 

Gave birth 3,369 74.3 

 

Total 4,246 66.3 

Table 2 also shows that 69% of women who agree that a woman can refuse to have sex 

with her husband or partner when he has STIs reported that they had ever tested for HIV, 

compared with 60% of women who do not agree that a woman can refuse to have sex. As 

mentioned, the study examined given birth in the last five years to assess HIV testing among 

women who have had the opportunity for provider-initiated HIV tests through ANC, and among 

women who make their own decision to test for HIV outside of ANC. As Table 2 shows, 47% of 

women who did not give birth in the last five years reported that they had ever tested for HIV, 

compared with 74% of women who gave birth in the last five years (and thus were likely to have 

attended ANC). All empowerment indicators and ever given birth in last past five years were 

found to be significantly associated with HIV testing. 
14 

Women’s Socioeconomic Characteristics and HIV Testing 

Women’s socioeconomic characteristics also are associated with HIV testing. Table 3 

shows that the uptake of HIV testing is much higher among women age 20-39 than among other 

age groups. Women with secondary education and above were more likely than women with 

lower levels of education to have been tested for HIV. Women who were not working and 

women who worked in non-agriculture were more likely to have been tested for HIV than 

women working in agriculture. Levels of HIV testing were higher among women from rich 

households and those living in urban areas. All characteristics were significant. 

Table 3. Bivariate analysis on socioeconomic characteristics and HIV testing (N=4,246) 

Socioeconomic indicators Frequency (weighted) % X2

Age X2=301.7***

15-19 216 54.2 

20-24 914 75.6 

25-29 974 72.8 

30-34 831 73.3 

35-39 655 63.3 

40-44 430 58.1 

45-49 225 41.0 

Education X2

=187.8***

No Education 827 54.2 

Primary 2,997 68.3 

Secondary 423 85.8 

Occupation X2

=193.6***

Not working 546 74.8 

Non-Agriculture 1,199 78.7 

Agriculture 2,501 60.2 

Wealth X2

=191.1***

Poor 1,447 57.7 

Middle 851 63.9 

Rich 1,948 76.0 

Residence X2

=187.1***

Urban 1,273 80.5 

Rural 2,973 61.6 

 

Total 4,246 66.3 
15 

Multivariate Analysis on Women’s Empowerment and HIV Testing 

Logistic regression was used to examine the relationship of the three indicators of 

women’s empowerment and of socioeconomic characteristics with HIV testing. Also, as in the 

bivariate analysis, given birth in the last five years was considered as a proxy indicator attending 

ANC. For the multivariate analysis six models were constructed. The first three models were 

analyzed to assess the direction of relationship between decision-making and HIV testing, when 

considered independently. Model 4 was analyzed to assess the relationship between decisionmaking and HIV testing, when the three models were combined. Models 5 and 6 were 

considered to compare the direction of relationship between women who gave birth and those 

who did not gave birth in last five years and HIV testing. 

Table 4 indicates the level of significance for each individual indicator’s association with 

HIV testing, and is divided into four models. In model I attitudes toward wife beating and refusal 

to have sex if husband has an STI were excluded; in model 2 decision-making and refusal to 

have sex if husband has an STI were excluded; in model 3 decision-making and attitude toward 

wife beating were excluded. Thus the first three modules addressed empowerment variables 

independently while controlling for other variables (level of education, age, wealth, employment 

and residence). In the fourth model shown in Table 5 all indicators were run together to examine 

their combined association with HIV testing. 

As Table 4 shows in the separate models, each empowerment variable is associated with 

increased odds of having tested for HIV. In model 1, women who were involved in decisionmaking were 1.3 times more likely to be tested for HIV than those who were not involved in 

decision-making. In model 2, women who do not accept the reasons for wife beating were 1.1 

times more likely to be tested for HIV than those who did not accept the reasons for wife 

beating. In model 3, women who agree with attitudes that women can refuse sex were 1.5 times 

more likely to be tested for HIV than those who do not agree that women can refuse to have sex. 

In model 4, when considering the effects of all models, women who were involved in 

decision-making were 1.3 times more likely to be tested for HIV than women who were not 

involved in decision-making. Women who do not accept the reasons for wife beating were no 

more likely to test for HIV than women who do accept one. Women believing that a woman can 
16 

refuse sex if the husband or partner has STIs were 1.5 times more likely to test for HIV 

compared with women who said a woman does not have the right to refuse sex. 

Gave Birth in the Past Five Years 

Giving birth in the five years preceding the survey turns out to be a prominent variable 

and is robust (consistent) across models. For example, in all models 1-3, women who had given 

birth in last five years were nearly four times more likely to have tested for HIV compared with 

women who had not given birth. In the combined model, the odds ratio remained at 3.8, 

indicating that women who have had a birth were more likely to test for HIV after controlling for 

all empowerment variables and background characteristics. The likelihood of having tested for 

HIV increases incrementally with education and with wealth, net of other factors. Compared 

with the youngest age group, age 15-19, women age 20-34 were significantly more likely to have 

tested for HIV, while women age 35 and older were neither more nor less likely to test than 

women age 15-19. Compared with urban women, rural women were nearly 40% less likely to 

test for HIV. 

These results are consistent, with small fluctuations to the odds ratio, across models for 

the various empowerment variables, and largely in the same direction as suggested by the 

bivariate results in Table 3. 
17 

Table 4. Multivariate analysis on women’s empowerment and HIV testing by socioeconomic 

characteristics 

Key: * = p<0.05, ** = p<0.01, and *** = p<0.001 

Model 1 (n=6,406) Model 2 (n=6,406) Model 3 (n=6,406) Model 4 (=6,406) 

OR Sig CI 95% OR Sig CI 95% OR Sig CI 95% OR Sig CI 95% 

Women’s 

empowerment 

Decision-making 1.3*** 1.1 – 1.5 - - - - 1.3** 1.1 – 1.4 

Attitude toward wife 

beating - - 1.1 0.9 – 1.3 - - 1.0 0.8 – 1.3 

Attitudes toward refusing 

sex - - - - 1.5*** 1.2 – 1.7 1.4*** 1.2 – 1.7 

Give birth in last five 

years (ANC) 3.7*** 3.2 – 4.4 3.7*** 3.1 – 4.4 3.8*** 3.2 – 4.4 3.8*** 3.2 – 4.5 

Education 

No education (RC) 1.0 

Primary 1.5*** 1.3 – 1.8 1.6*** 1.3 – 1.9 1.5*** 1.3 – 1.8 1.5*** 1.3 – 1.8 

Secondary + 3.1*** 2.1 – 4.5 3.2*** 2.2 – 4.6 3.0*** 2.1– 4.4 2.9*** 2.0 – 4.2 

Age 

15 – 19 (RC) 1.0 

20 – 24 1.7** 1.2 – 2.5 1.8** 1.2 – 2.6 1.8** 1.2 – 2.6 1.7** 1.2 – 2.5 

25 – 29 1.4 1.0 – 2.0 1.5* 1.0 – 2.1 1.5* 1.0 – 2.1 1.4 1.0 – 2.0 

30 – 34 1.5* 1.0 – 2.2 1.6* 1.1 – 2.4 1.6* 1.1 – 2.3 1.5* 1.0 – 2.2 

35 – 39 1.2 0.8 – 1.8 1.3 0.8 – 1.9 1.2 0.8 – 1.9 1.2 0.8 – 1.8 

40 – 44 1.2 0.8 – 1.7 1.2 0.8 – 1.8 1.2 0.8 – 1.8 1.2 0.8 – 1.7 

45 – 49 0.9 0.6 – 1.3 0.9 0.6 – 143 0.9 0.6 – 1.4 0.9 0.6 – 1.3 

Wealth 

Poor (RC) 1.0 

Middle 1.2* 1.0 – 1.5 1.2* 1.0 – 1.5 1.2* 1.0 – 1.5 1.2* 1.0 – 1.5 

Rich 1.5*** 1.2 – 1.8 1.5*** 1.2 – 1.8 1.5*** 1.2 – 1.8 1.5*** 1.2 – 1.8 

Employment 

Not employed (RC) 1.0 

Non-agriculture 1.1 0.8 – 1.5 1.1 0.8 – 1.6 1.1 0.7 – 1.5 1.0 0.7 – 1.5 

Agriculture 0.7* 0.5 – 0.9 0.6* 0.5 – 1.0 0.7* 0.5 – 0.9 0.7 0.5 – 0.9 

Residence 

Urban (RC) 1.0 

Rural 0.6*** 0.5 – 0.8 0.6*** 0.5-0.8 0.6*** 0.5 – 0.8 0.6** 0.5 – 0.8 

 

Const 0.6* 0.3 – 0.9 0.7* 0.4 – 1.0 0.5** 0.3 – 0.8 0.4** 0.3 – 0.8 
18 

Given Birth in the Last Five Years and HIV Testing 

This section is intended to assess whether women’s empowerment influences HIV testing 

when women attend ANC, or otherwise. Results for the multivariate regression among women 

who had a birth in the last five years (model 5) are similar to those for the full sample. Women 

who made household decisions and women who believed that a woman could refuse sex with her 

husband had 30% and 50% higher odds, respectively, for having tested for HIV. Women with 

accepting attitudes toward wife beating had lower odds of testing. 

Among women who had not had a birth in the past five years, however, only attitudes 

toward refusing sex were significantly associated with testing for HIV. While these women have 

higher odds compared with women not asserting women’s ability to refuse sex, the odds ratio of 

testing for HIV among these women was not as high as among women having had a birth in the 

last five years (OR 1.3 vs. 1.5). 

In contrast to the case for women who gave birth in the last five years, socioeconomic 

variables are more prominent in determining HIV testing for women who did not have a birth in 

the past five years (model 6). The role of education in determining HIV testing is similar for both 

samples of women, but the magnitude of education’s effect is larger for women who had not 

given birth. Among women who had a recent birth, as shown in Model 5, women with primary 

or secondary education have higher odds of having tested for HIV compared with women with 

no education. Among women without a birth in the last five years, as shown in model 6, these 

odds are 1.6 (primary education) and 4.1 (secondary education). 

The effects of age and wealth on HIV testing are likewise greater for women who have 

not had a birth in the past five years. Women age 20-24 who had given birth had 50% greater 

odds of HIV testing compared with the reference category, while among women who had not 

given birth, women age 20-24 were at more than 200% increased odds. No other age categories 

are significant. 
19 

Table 6. Multivariate analysis on women’s empowerment and HIV testing, women who gave birth 

and who did not give birth in last five years

Model 5: Gave birth last five years 

(n=4,537) 

Model 6: No birth in last five years 

(n=1,869) 

OR Sig CI 95% OR Sig CI 95% 

Women’s empowerment 

Decision-making 1.3** 1.1– 1.6 1.1 0.8 – 1.5

Attitude toward wife beating 1.1 0.9 – 1.5 1.4 0.6 – 1.3 

Attitudes toward refusing sex 1.5*** 1.2 – 1.9 1.3* 1.0 – 1.7 

Education 

No education (RC) 1.000 

Primary 1.4*** 1.2 – 1.8 1.6** 1.2 – 2..3 

Secondary + 2.1** 1.2 – 3.7 4.1*** 2.5 – 7.0 

Age 

15 – 19 (RC) 1.000 

20 – 24 1.5 0.9 – 2.4 2.4** 1.3 – 4.5 

25 – 29 1.3 0.8 – 2.0 1.7 1.0 – 3.1 

30 – 34 1.3 0.8 – 2.1 2.1** 1.3 – 3.4 

35 – 39 1.1 0.7 – 2.0 1.2 0.7 – 2.1 

40 – 44 1.0 0.5 – 1.6 1.5 0.9 – 2.5 

45 – 49 0.7 0.4 – 1.4 1.1 0.7 – 1.7 

Wealth 

Poor (RC) 1.000 

Middle 1.1 0.9– 1.4 1.5* 1.1-2.1 

Rich 1.4* 1.0 – 1.8 1.8** 1.3 – 2.5 

Employment 

Not employed (RC) 1.000 

Non-agriculture 1.1 0.7 – 1.8 1.0 0.7 – 1.6 

Agriculture 0.6* 0.4 – 0.9 0.8 0.5 – 1.2 

Residence 

Urban (RC) 1.000 

Rural 0.5 ** 0.3 – 0.7 0.8 0.5 –1.1 

 

Const 2.3* 1.1 –4.6 0.3** 0.1 – 0.7 

Key: * = p<0.05, ** = p<0.01, and *** = p<0.001

Both middle and rich wealth categories have 50-80% increased relative odds among 

women who have not given birth in the last five years, whereas only the richest category is 

significantly more likely to have tested for HIV among women who have given birth in the last 

five years. In contrast, employment and place of residence have no effect on odds of HIV testing 
20 

among women without a recent birth, although women engaged in agriculture and women in 

rural areas have lower odds for HIV testing compared with women who had given birth in the 

last five years. 
21 

DISCUSSION

The study results confirm the hypothesis that empowerment influences HIV testing, as 

does potential exposure to ANC. Women who are empowered, as measured by decision-making, 

not accepting wife beating and being able to refuse sex, are more likely to be tested for HIV than 

less empowered women. Moreover, decision-making and attitudes toward refusing sex are the 

strongest empowerment variables in our models. In contrast, women’s attitude toward wifebeating is weak in comparison, as this measure loses significance when controlling for the other 

empowerment measures. 

The findings of multivariate analysis on women’s empowerment and HIV testing show 

that women’s education, place of residence and wealth index were associated with HIV testing. 

Primary and secondary and above education levels were significantly associated with HIV 

testing in all four models. These results are consistent with findings from a study conducted in 

Ethiopia by Abebaw and colleagues (2009). In contrast, a study in Ghana by Holmes (2008) 

found that women with secondary education were less likely to accept testing for HIV than those 

with no formal or primary education. Concerning the wealth index, rich was significantly 

associated with HIV testing in three models, all except model 2. By place of residence, rural was 

associated with HIV testing in all four models. The results are consistent with a study conducted 

by Karamagi and colleagues (2006) in rural eastern Uganda, which found that “HIV testing was 

significantly lower in multipara women as they had lower perceived risk of HIV”. 

Our hypothesis was that empowerment would be more influential in HIV testing for 

women who did not have a recent birth and, therefore, may have not had opportunity for 

provider-initiated, opt-out testing through ANC. It was our belief that empowerment would not 

determine testing among women who gave birth in the last five years because testing in this 

context may be more routine and require less motivation, while testing outside of ANC may 

require more initiative and will. This was not the case, however. 
22 

CONCLUSION

This study provides nationally representative statistics related to women’s empowerment 

and HIV testing among married women age 15-49 in Tanzania. The role of women’s 

empowerment in influencing HIV testing identified in this study will be a guide for future 

interventions and policies aiming at empowering women and encouraging HIV testing in the 

country. HIV testing is associated with women’s participation in decision-making, not accepting 

wife beating, giving birth in past five years (receiving ANC) and refusal to have sex with a 

husband if he has STIs. Among women’s socioeconomic characteristics, education, age 20-34 

and wealth index were associated with HIV testing. In contrast, rural residence, age 15-19 and 

age 44-49 and employment in agriculture had no association with HIV testing. 

HIV testing is still a challenge in Tanzania, as 34% of married women age 15-49 in the 

TDHS had never tested for HIV. Therefore, more efforts should aim at raising awareness on HIV 

testing among women, especially women involved in agriculture and women residing in the rural 

areas. Moreover, the government through the Ministry of Health (MoHC) and the Ministry of 

Community Development Gender and Children (MCDGC) should find the mechanism of 

empowering women to enable them to go for HIV testing on a voluntary basis. Also, women 

should be educated on the importance of HIV testing. 

Further analysis should be done on women’s economic empowerment, such as resource 

ownership, income and the way they are likely to influence HIV testing and receipt of HIV test 

results. Research should be done on the attitude toward refusal to have sex if husbands are 

infected with STIs, as this predictor variable could be one of the factors for the persistence of 

HIV/AIDS in Tanzania and many other parts of Africa. 

More data analysis should be done on availability of and access to ANC services in rural 

areas. Further, more research on the extent to which women’s empowerment is influencing HIV 

testing across the regions of Tanzania is also needed to enable the availability of information on 

the variation among regions. 
23 

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