Multilevel factors associated with self-reported sexually transmitted infections among sexually active women in Africa: a socio-ecological analysis.

backgroundSexually transmitted infections (STIs) continue to pose a significant public health challenge globally, negatively impacting reproductive health and increasing the likelihood of infertility, complications during pregnancy, and mother-to-child transmission. Despite the increasing burden of self-reported (SR) STIs, there is limited evidence on their prevalence and associated factors across Africa. Applying the socio-ecological model (SEM), this study sought to estimate the prevalence and identify the factors associated with SR-STIs among sexually active women in Africa.

methodsThe study used the most recent Demographic and Health Surveys (DHS) conducted in 29 African countries. A weighted sample of 340,179 sexually active women who had ever had sexual intercourse in the past 12 months and had complete information on all variables of interest were included. Guided by SEM, explanatory variables were conceptually mapped onto its four levels (individual, interpersonal, community, and societal/structural). The analysis was conducted using Stata version 14.2. Descriptive, chi-square, and multilevel regression analyses were carried out. Frequencies, percentages, and odds ratios (ORs) with corresponding 95% confidence intervals (CIs) and p-values were used to present the results.

resultsThe pooled prevalence of SR-STIs among sexually active women in Africa was 18.43% (95% CI: 18.00%-18.70%), ranging from 47.9% in Liberia to 3.9% in Ethiopia. Guided by the SEM levels, significant associations were identified at the individual, interpersonal, and societal/structural levels. At the individual level, women aged 45-49 [aOR = 0.71; 95% CI = 0.66-0.76] and women whose sexual debut occurred at age 20 or older [aOR = 0.76, 95% CI = 0.73-0.79] had lower odds of SR-STIs than women aged 15-19 years and those whose sexual debut occurred before age 20 years, respectively. At the interpersonal level, women living in female-headed households had lower odds of SR-STIs [aOR = 0.96, 95% CI = 0.93-0.99]. At the societal/structural level, women in Southern Africa had lower odds of SR-STIs [aOR = 0.35; 95% CI = 0.32-0.39] than those in West Africa.

conclusionThis research revealed a high prevalence (18.43%) of SR-STIs among sexually active women in Africa, with substantial cross-country and sub-regional variation. The findings demonstrate the utility of the SEM in understanding SR-STIs, as significant factors were identified across individual, interpersonal, community, and societal/structural levels, highlighting that SR-STI risk is shaped by a complex interplay of multilevel determinants. These findings call for targeted, context-specific interventions that address factors at multiple levels, including enhancing STI education and screening as part of routine reproductive health and HIV services. Additionally, governments should implement region-specific strategies to improve reproductive health outcomes.