Introduction
“Nothing wrong to say no” everyone should learn to say ‘no’ to anything they think is inappropriate or when they are in no mood to entertain any request. However, it’s easier said than done. Sometimes, a woman may not be interested in having sex, and yet she struggles to reject her husband’s advances or requests. The simple reason is that girls in the Indian society grow up believing that it’s the duty of a wife to keep her husband happy (Sharma et al., Reference Sharma, Pandit, Pathak and Sharma2013).
Sexually transmitted infections (STIs), HIV, and unintended pregnancy take an immense toll on women’s reproductive health in developing countries. Yet, preventive programs are lacking since married women’s risks are frequently underestimated in these areas (Jesmin and Cready, Reference Jesmin and Cready2014). Globally, every day, there are more than one million new cases of STIs among people aged 15-49 years, and each year this accounts for more than 376 million new cases. According to the most recent statistics, one in every 25 persons worldwide has at least one of these STIs, with some people having several infections at the same time (WHO, 2019 and Ostrach & Singer, Reference Ostrach and Singer2012). In India, around 11% of women aged 15-49 who have ever had sex, report having an STI or symptoms of STI (IIPS & ICF, 2017). Being married has been reported to escalate women’s risk of contraction of STIs (Hirsch et al., Reference Hirsch, Meneses, Thompson, Negroni, Pelcastre and Del Rio2007; Tenkorang, Reference Tenkorang2012).
Prior studies have concentrated on the sexual behavior of high-risk groups and their associated vulnerabilities in India. In contrast, literature on the factors influencing risky sexual behavior among married women is still lacking, even though there is enough evidence that many are at a high risk of contracting an STIs mainly because of their husbands (Magadi, Reference Magadi2011; Shannon et al., Reference Shannon, Strathdee, Shoveller, Rusch, Kerr and Tyndall2009; McInnes et al., Reference McInnes, Bradley and Prestage2011 and Chakrapani et al., Reference Chakrapani, Newman, Shunmugam and Dubrow2010). Husband are the source of STI/STD, including HIV, for wives in India as they may be sexually active with more than one woman or be involved in unprotected sex with multiple-partner (Vishwakarma and Sharma, Reference Vishwakarma and Sharma2019). There are several reasons that men involved in multiparters sexual behaviour such as social status–boosting reputation, establishing bragging rights, and desiring to tell friends that they had sex with someone famous (Meston & Buss, Reference Meston and Buss2007). The sexual behaviors of husbands with their wives are closely associated with their controlling behaviors, alcohol consumption, control over resources, and household decision-making (Garcia-Moreno et al., Reference Garcia-Moreno, Jansen, Ellsberg, Heise and Watts2006; Abramsky et al., Reference Abramsky, Watts, Garcia-Moreno, Devries, Kiss, Ellsberg, Jansen and Heise2011; Dalal, Reference Dalal2011; Antai, Reference Antai2011; Tumwesigye et al., Reference Tumwesigye, Kyomuhendo, Greenfield and Wanyenze2012 and Kwagala et.al., Reference Kwagala, Wandera, Ndugga and Kabagenyi2013). While fidelity, equality, and fundamental rights are anticipated within marriage, marital partners may not wholly be shielded from vulnerability if either spouse engages in risky sexual activities outside the union.
It is worth mentioning that to reduce married women’s risk for STIs/STD, it is crucial to understand the factors associated with safer sex practices, which include sexual attitudes, beliefs, and power dynamics between sex partners (Jesmin and Cready, Reference Jesmin and Cready2016; Pulerwitz et al., Reference Pulerwitz, Gortmaker and DeJong2000; Oyediran et al., Reference Oyediran, Odutolu and Atobatele2011). In developing countries, women’s control over their reproductive health, particularly their ability to negotiate safer sex, is an essential step in achieving other opportunities, such as economic success, education, and equality (Sonfield et al., Reference Sonfield, Hasstedt, Kavanaugh and Anderson2013). Therefore, having the ability to negotiate time and conditions of sex can be a precursor to women’s ability to control the consequences of risky sex, with consequences for various sexual and reproductive health outcomes (Feyisetan and Oyediran, Reference Feyisetan and Oyediran2020).
In the context of Concerning gender relations associated with reproductive health, the 1994 International Conference on Population and Development (ICPD) acknowledged that men have considerable authority or control in most areas of women’s lives. The ICPD also recognized the value of improving the union’s contact between men and women on sexuality and reproductive health issues and their mutual responsibility for better health outcomes (Johnson, Reference Johnson2013).
Against this backdrop, the present study analyzes married women’s attitudes towards negotiating safer sex in two specific contexts, that is, if women believe in refusing to have sex with the husband if they know that he has a sexually transmitted disease (STD), and, if they know that he has sex with other women, with a focus on husband’s controlling behavior and marital power relations. The specific objective of the study was to determine the socio-demographic and economic correlates of attitudes towards negotiating safer sex among married women in India using the latest round of the National Family Health Survey (NFHS-4, 2015-16).
Materials and Methods
The study obtained data from the fourth round of the Indian National Family Health Surveys (NFHS-4) conducted during 2015-16. The survey was carried out under the supervision of the Ministry of Health and Family Welfare’s, Government of India. NFHS is a nationally representative survey that provides data on various aspects of population, family planning, maternal and child health, child survival, HIV/AIDS and STIs, reproductive health, rights, and nutrition in India.
The survey adopted a uniform sample design for all the states of the country. Multistage sampling was used to select samples from rural and urban areas in each state. A two-stage sample selection, using Probability Proportional to Size (PPS), was done in the rural areas, whereby villages were selected, as Primary Sampling Units (PSUs)in the first stage, and then households were randomly selected from within each PSU in the second stage. Likewise, in the urban areas, wards were selected with PPS sampling in the first stage. Then, Census Enumeration Blocks (CEBs) from each sampled ward in the second stage. Finally, in the third stage, households were randomly selected from within each selected CEB.
A total of 699,686 women aged 15-49 were interviewed for the survey and asked about their attitude towards negotiation of safer sexual relationships with their husbands. Women were asked if they refuse to have sexual intercourse with their husband if he had a sexually transmitted disease and if he had sex with other women. Information on controlling behaviour and power relations was collected from the ever-married women only in the state module. Among the total surveyed women (122,351) in the state module, 92,306 were ever-married. Therefore, the present study included 92,306 ever-married women aged 15-49 years.
Dependent variables
Attitude towards safer-sex negotiation was taken as the dependent variable. The survey included two questions to assess the extent to which women perceived that they could negotiate safer sex with their husbands. These questions were (1) would you refuse sex with your husband if you already knew that he had a sexually transmitted disease? and (2) would you refuse sex with your husband if you knew he was having sex with other women? Women could answer these questions either ‘Yes’ or ‘No’. Women who answered ‘Yes’ to both questions were held to believe in negotiation about safer sex and coded ‘1’ on the dependent variable; women who did not answer ‘Yes’ to both questions were held not to believe in negotiation about safer sex and coded ‘0’ on the dependent variable. Further, significant factors associated with the negative attitude towards negotiation has been determined.
Predictor variables
Independent variables were broadly grouped into two categories: one, the demographic and socioeconomic factors, and, two, explains the controlling behaviour and power relations. Variables under the demographic and socioeconomic characteristics included age (15-24, 25-34, 35-44, and 45-49 years), educational attainment of woman and her husband (no education, primary, secondary, higher secondary, and above), social caste group (Scheduled Caste(SC), Scheduled Tribe (ST), Other Backward Class (OBC), non-SC/ST/OBC), place of residence (urban and rural), religion (Hindu, Muslim, Christian, Sikh, Others), wealth quintile (poorest, poorer, middle, richer and, richest), amount of money earned (more than the husband, less than the husband, about the same and doesn’t earn any money) and alcohol use by husband (no, yes).
In India, tribal communities are endogamous social groups made up of families or communities linked by social, economic, religious, or blood connections, geographical connection, and dialect, and usually led by a recognized leader (Majumdar Reference Majumdar1958). Caste is a Hindu society’s hereditary class differentiated by varying degrees of ceremonial purity or impurity, as well as social position, and is endogamous in nature (Ghurye Reference Ghurye1961). The tribal and caste groupings recognized by the president of India under Article 341 and 342 of the Indian Constitution are referred to as “Scheduled Tribe” and “Scheduled Caste” (Mukherjee, Reference Mukherjee2013). The term “backward class” is used by the Indian government to categorize population that are educationally or socially disadvantaged (Gurulingaiah, Reference Gurulingaiah2021.).
Under the controlling behaviour and power relations category were included four variables, that is, household decision-making of women, attitude towards wife-beating for refusing sex with husband, fear of husband, and marital control displayed by husband. The variable household decision-making was constructed into two categories (yes/no) by using three indicators namely if women participated in decision making for their own health care, for major household purchases, and for visits to family/relatives. Women who participated (alone or jointly) in any one of three household decisions were considered as having autonomy in decision making (Yes), and those who have say ‘no’ considered as having no autonomy (No).
Similarly, to construct the degree of marital control displayed by husband, information was sought on whether the husband demonstrated one or more of the following controlling behaviors: was jealous or angry if the wife talked to other men, frequently accused her of being unfaithful, did not permit her to meet her female friends, tried to limit her contact with her family, insisted on knowing where she was at all times, and did not trust her with money. Husband’s control was then categorized into four categories as: no control (if husband did not control wife for any of the given reasons), low control (if husband controlled wife for any one or two of the reasons), medium control (if husband controlled wife for any three or four of the given reasons), and high control (if husband controlled wife for any five or all six of the given reasons).
To measure the attitude towards wife beating, women were asked if they agreed that it was justified for a husband to hit or beat his wife for her refusal to have sex with him (yes, no). Fear of husband was divided into three categories: never afraid, afraid most of the time, and sometimes afraid.
Methods
Bivariate and multivariate statistical techniques were used to understand the interplay between attitude towards negotiation of safer sexual relationships with husband and the selected background characteristics, with a major light on controlling behaviour and power relations.
A multilevel logistic regression model with a random intercept was used to understand the clustering of the respondents within the PSUs or the ‘community’. Multilevel models are particularly appropriate and used for research designs where data are structured at more than one level for example village level, community level and state level (Rabe-Hesketh & Skrondal Reference Rabe-Hesketh and Skrondal2012). In a preliminary analysis, a ‘baseline’ or an intercept model was examined only to assess the extent of the dependent variable’s variation between ‘communities’ and the advisability of using a multilevel modeling strategy. According to the results (not shown), the intraclass correlation coefficient (r) was 0.23, indicating that 23% of the variation in a negative attitude towards negotiating safer sex was allied with differences between the PSUs. Furthermore, based on a likelihood ratio test, the null hypothesis that this variation is zero (and a multilevel model not required) was rejected (p<0.001; Rabe-Hesketh & Skrondal, Reference Rabe-Hesketh and Skrondal2012).
In the multilevel analysis, a systemic model building procedure was adopted, and altogether two models were estimated. Model 1 included socio-demographic and economic variables such as respondent’s’ age, respondent’s and her husband’s educational attainment, place of residence, caste affiliation, household wealth, religious affiliation, earnings of respondent, and alcohol consumption by husband. Model 2 included household-making, wife-beating attitude towards wife-beating, fear of husband, degree of marital control and the variables of Model 1. Estimating the models in this way allowed identification of factors that reduced the significance of each model’s variable of interest. Further, likelihood ratio tests and Akaike’s information criterion (AIC) were used to compare the goodness-of-fit of the two models. The difference in deviance (-2 log-likelihood) of the two nested models had a χ2distribution with degrees of freedom equal to the additional number of predictors in the larger model. Akaike’s information criterion is an alternative measure of fit that adjusts for model complexity (that is, number of predictors).
Data were analyzed using the Stata 15.0 version software. Appropriate sampling weights were used to analyze the data.
Results
Descriptive analysis
Overall, 17% ever married women did not believe in negotiating safer sexual relations with the husband. An almost equal proportion of ever-married women (79% each) believed in doing so under the condition that the husband had an STI (N=73890) and that the husband was having sex with other women (N=73949).
Table 1 presents the percent distribution of ever-married women aged 15-49 years who believed in negotiating for safer sex if they knew their husband had an STD and if they knew their husbands had sexual relationships with other women. With the increasing age of women, attitude towards negotiating for safer sex declined. Women and their husbands’ educational level played an essential role in shaping the women’s attitude towards negotiating sex with the husbands. From the results, it’s clear that the proportion of women who believed in negotiating for safer sex increased with an increase in the level of education of both women and their husbands (Table 1). Around 13% of women belonging to other social caste groups (other than SCs, STs, and OBCs) not believed in negotiation. A larger proportion of women (79%) belonging to other religions believed in negotiating for sex for all both of the two reasons compared to Hindu and Muslim women (around 75 percent each). In terms of wealth quintile, the richest women scored notably higher on attitude towards negotiating for safer sex with husbands for both the reasons (80% richest compared to 75% poorest). The proportion of women who believed in negotiating for safer sex was smaller (69%) in the case of those earning more than their husbands than those earning less than or equal to their husbands (75%). Women who have decision making power in household, around 80% of women believed in negotiating for safer sex in both the cases, that is, when they knew that their husband had an STD or when they knew that their husband was having sex with other women, which is higher than those who do not have decision making power. The reason behind this is that women who wielded decision making power in the family showed more inclination negotiating for safer sex.
Table 1. Attitude towards negotiation for safe sex if she knows her husband has STD and has sex with other women among ever married women age 15-49 years, NFHS-4, India, (N=92, 306)
Among women who did not justify wife-beating for refusing sex, about three-fourths (75.8) believed in negotiating for safer sex for all two reasons (Table 1). There was no significant difference among women in the case of husband’s alcohol use. A slightly higher proportion of women who were afraid of their husbands most of the time believed in negotiating for safer sex than those who were never afraid and those who were sometimes afraid. Controlling behavior of husband pushed women away from believing in negotiating for safer sex; the higher degree of marital control, the greater the proportion of women who did not believe in negotiating for safer sex (Table 1).
Multivariate analysis
Table 2 presents the results of the multilevel logistic regression. Model 1 examines the effect of each demographic and socioeconomic control on the negative attitudes towards negotiating for safer-sex among ever-married women after adjusting for the effects of the other covariates included in the study. Model 2 adds to Model 1, four measures related to controlling behaviour and power relations, namely household decision-making, justification of wife-beating for refusing sex, fear of husband, and degree of marital control.
Table 2. Multilevel logistic regression models predicting no negotiation for safer sex attitudes among Indian ever married women, 2015-16
Note: *** p # 0.001, **p # 0.01, *p # 0.05 (one-tailed tests) ®Reference category.
Results of Model 1 show that women aged 25-34 years (19%, p<0.05), those whose husbands had secondary level education (17%, p<0.01), those who belonged to other castes (19%, p<0.05), those from the Muslim religion (22%, p<0.05), and those from the richest wealth quintile (28%, p<0.01) were less likely to believe in no negotiating for safer sex. Women who earned less than the husband (31%, p<0.01) and those who earned about the same (20%, p<0.01) were also less likely to believe in no negotiating for safer sex, which brings out that these factors had a significant positive effect on the negotiation of a safer sexual relationship with the husband. The addition of four measures of controlling behavior and power relations to Model 2 significantly improved the fit of the model (χ2=280.98, df=32, p<0.01 & AIC= 12178.03) (Table 2, Model 2). All four had the expected effect, with women having more decision-making power (29%, p<0.01), and low control (9%, p<0.05) being less likely to have believe in no negotiating for safer sex with the husband. On the other hand, women who justified wife-beating for refusing sex (12%, p<0.1), those who feared their husband most of the time (22%, p<0.05), as well as those who feared them sometimes (15%, p<0.05) were more likely to not believe in negotiating for safer sex with the husband. The effects of the demographic and socioeconomic controls on the negative attitudes towards belief in a negotiating for a safer-sex changed little with the inclusion of the four measures of controlling behaviour and power relations (Model 2). However, all the demographic and socioeconomic controls emerged as significant factors for not believing in negotiating for safer sex, and also coupled with no negotiation in the same direction (Model 2).
Discussion
Using a nationally representative sample of India, we found that the manifestation of negative attitude towards negotiating safer sex among women in India originates at multiple levels of the community in which the women live with 23 percent variation exist with differences between the PSUs. Although most of the variables at the individual and household levels demonstrated a significant association with negative attitude towards negotiating safer sex. The prevailing norms at larger socio ecologies (community level) are also significantly associated with the negative attitude towards negotiation for safer sex in India.
Our results provide evidence of the influences of the husband’s controlling behavior and power dynamics in the household on women’s attitude towards negotiating for safer sex. We found an affirmative and significant relationship between attitudes towards negotiating safer sex with husbands and married women who reported controlling behavior of husbands, who justified wife beating for refusing sex, and who were afraid of husband.
Patriarchies worldwide share some commonalities such as older male’s rule over most women and some men; male legitimized influence over development, reproduction, and sexuality of women; gender roles and power, and inequality-based relations. Women, in India, have long stayed at home as housewives, making them depend on their male counterparts and face different obstacles in a male-dominated culture. After an extensive struggle, women are slowly getting empowerment in sectors like education, politics, workforce, and even within the households (Mondal, Reference Mondal2015). It cannot be denied that women in India have made tremendous progress in nearly seven decades of independence. However, they still have to battle many handicaps and social evils that hinder their advancement and social upliftment (Raju & Jantara, Reference Raju and Jatrana2016). For Instance, in many parts of India, lowest female literacy rate, domestic violence, female infanticide and dowry are the social evils that still remain in the roots of the society. The results of this study support the findings of the previous research that sheds light on how the ability of an Indian woman to negotiate protective sex depends on the extent to which she can exercise some independence or influence decision-making in the household (Yujjro, 2017; Feyisetan and Oyediran, Reference Feyisetan and Oyediran2020 and Siddhanta and Singh, Reference Siddhanta and Singh2017)
Justification of wife-beating for refusing sex with husband and fear of husband most or some of the times were associated with increased odds of having a negative attitude towards safer sex. The odds of not believing in negotiating for safer sex also increased with increasing degree of marital control. However the relationship, was found significant only in case of having low level of marital control.
Several schools of thought have arisen from previous research that highlight that the risks of sexual vulnerabilities are higher among women who experience sexual and gender-based violence. Gender power differential, typically followed by partner violence, increases women’s fear, and the risk of risky sex, consequently raising the risk of STIs, including HIV (Pederson et al., Reference Pederson, Greaves and Poole2014; Turmen, Reference Türmen2003; Johnson and Hellerstedt, Reference Johnson and Hellerstedt2002; Raiford et al., Reference Raiford, Seth and DiClemente2013). The same logic underlies some of the other past studies, which clearly state that women who justify wife-beating face more sexual violence than those who disagree with the practice. This is because they rationalize, accept, and internalize norms that justify such violence (Santhya et al., Reference Santhya, Haberland, Ram, Sinha and Mohanty2007; Wahed and Bhuiya, Reference Wahed and Bhuiya2007; Siddhanta and Singh, Reference Siddhanta and Singh2017). Prior research has shown that norms about appropriate sexual behavior for women may restrict their ability to express sexual agency and power in their relationships with their partners. Hence, women survive under their partner’s control, whom they are mostly afraid of (Vander Drift et al., Reference Vander Drift, Agnew, Harvey and Warren2013).
Previous studies from all over the world similarly highlight the difficulties faced by abused women in negotiating sex. Married women specifically are more likely to face violence when they ask their husbands to use condoms, as it is often seen as an admission of marital infidelity (Go et al., Reference Go, Sethulakshmi, Bentley, Sivaram, Srikrishnan, Solomon and Celentano2003; Goldstein, Reference Goldstein1994; Wingood and DiClemente, Reference Wingood and DiClemente1997 and Pallikadavath and Stones, Reference Pallikadavath and Stones2003). Prior studies have also indicated that male partner’s’ controlling behaviour is associated with violence (Krantz, and Vung, Reference Krantz and Vung2009). As measured by demographic surveys, controlling behavior in the form of extreme possessiveness, jealousy, and attempts to isolate the spouse from their family and friends, is a significant predictor of intimate partner violence and physical and sexual violence (Antai, Reference Antai2011; Kwagala et al., Reference Kwagala, Wandera, Ndugga and Kabagenyi2013; Wandera et al., Reference Wandera, Kwagala, Ndugga and Kabagenyi2015 and Nankinga et al., Reference Nankinga, Misinde and Kwagala2016). Intimate partner violence may heighten an individual’s emotions of dread and helplessness while seeking to negotiate safer sex practises, making him/her less likely to seek condom usage and thereby increasing the risk of STI acquisition (Ulibarri et al., Reference Ulibarri, Strathdee, Lozada, Magis-Rodriguez, Amaro, O’Campo and Patterson2010; Braham et al. Reference Braham, Skakoon-Sparling, Kilimnik and Milhausen2019).
Other significant predictors of safer-sex negotiation attitudes include age, husband’s education, caste, religion, wealth quintile, and women’s economic existence. Prior research on South Asian women has shown somewhat mixed results for age. A study by Jesmin et al. (Reference Jesmin, Chaudhuri and Abdullah2013) documented that even if young women have more knowledge about the risks of HIV, they are often in a miserable position due to the fact that they lack control over their husband’s extramarital relations and inability to protect themselves against forced penetrative sex within intimate relationships. On the other hand, though most males perceive women’s sexual rights favorably, in terms of behavior, they consider coercion to be a right over their wives. Women often seem to have a relatively limited control over their reproductive health outcomes and are less likely to discuss sex-related topics with their husbands due to shyness, lack of sexual knowledge, and limited control over household decisions (Khan et al., Reference Khan, Townsend and D’Costa2002: Jejeebhoy and Bott, Reference Jejeebhoy and Bott2005: Acharya et al., Reference Acharya, Ram, Jejeebhoy, Singh, Santhya, Ram and Mohanty2009). However, in this study, being younger was associated with increased odds of believing in negotiating with their husband for safer sex. It could be that the younger generation is now more aware of its sexual rights and less likely to confront sexual norms passively if those norms limit its sexual freedom and desire (van Reeuwijk and Nahar, Reference Van Reeuwijk and Nahar2013). This could be due to the impact of sex education provided in schools. The data are relatively recent (2015-16), and our results probably reflect the ongoing transformation of sexual norms in India.
Previous studies have articulated the concept that working women are at an increased risk of being subjected to forced sex within marriage (Santhya et al., Reference Santhya, Haberland, Ram, Sinha and Mohanty2007, Acharya et al., Reference Acharya, Ram, Jejeebhoy, Singh, Santhya, Ram and Mohanty2009 and Siddhanta and Singh, Reference Siddhanta and Singh2017). Conversely, according to our study, the amount of information on this topic is sufficient to argue that women’s economic existence, resulting from the increasing wealth quintile, is associated with decreasing odds of negative attitude towards safer sex. Women who earn more than or equal to their husband are more likely to believe in negotiating for safer sex with the husband. With economic growth and more women entering the workforce, the patriarchal mentality faces growing challenges. More and more women becoming financially self-reliant, translates into greater overall freedom as they push back on tradition-assigned socio-cultural boundaries. Women in India have started to make their choices, instead of letting the males decide for them. Men who feel being under pressure from these newly emancipated women counteract the change in the power dynamics with violent domination, the most execrable manifestation of this being the rapes we are seeing (Unies, Reference Unies2009; Sharma, Reference Sharma2016; Shakti, Reference Shakti2017 and Silva, & Klasen, Reference Silva and Klasen2021).
Our study has a few limitations. First, due to the nature of the secondary data utilized in this study, the idea of attitude towards negotiating safer sexual relations was limited to only two elements that the researcher believed best reflected the typical conditions in which a woman would decline to participate in sex with her husband. Second, because the study’s variables included self-reported sexuality attitudes, there is a fear that the findings may have been skewed by the social desirability response bias. Furthermore, while large-scale surveys like the NFHS give nationally representative data, it is critical to augment this data with qualitative research to confirm and contextualize the findings.
Conclusions and Recommendations
Our findings conclude that the power of negotiating for safer sex, as measured in the study, does not protect women who have controlling partners or women those who live under the umbrella of their husband’s power. Therefore, the findings of the study recommend that interventions promoting sexual well-being must deal with negative male perceptions and expectations perpetuating unhealthy sexual habits and gender ties. It is also desirable to foster marital fidelity and better communication within the marriage and empower women to work with their partners to take care of their well-being. Additionally, the study concludes that despite being financially empowered and holding rights in the household decision-making, women somehow still lack negotiation power in individual decision-making related to their reproductive and sexual rights. These social or cultural improvements do not lead to a qualitative change in women’s lives, affecting their physical and mental health in the process.
Acknowledgments
The authors are grateful to all the National Family and Health Survey project coordinators for their unremitting efforts in generating such critical information on sexual and reproductive health and related factors as part of the NFHS data set in its various rounds.
Availability of data and material
The datasets generated and/or analyzed during the current study are available in the [DHS] repository, [www.dhsprogram.com]
Authors’ contributions
DV has conceived the idea. DV and SS designed the study and analyzed the data from NFHS. DV and SS have written the manuscript, SKS and SK have reviewed the manuscript. SS has edited the manuscript. All the authors interpreted the results, drafted the manuscript, reviewed the key findings, and finalized it.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Declaration of Competing Interests
The authors declared that they had no competing interests in financial and non-financial matters.
Ethical Approval
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. There is no need of ethical approval of the data because the data is in public domain in DHS website.
Informed consent
Informed consent was obtained from all individual participants included in the study.
