Abstract
BACKGROUND: Contradictory evidence exists on whether medicine explicates social disparities in health perceptions. This study evaluates healthcare systems as mesocosms to understand social differences in spousal violence perceptions in sub-Saharan Africa, concretely, cohort differences in victim decisions in spousal violence (VDSV). CONCEPTUAL FRAMEWORK: Medical dominance theory criticizes medical power asymmetry, while socio-ecological theory illuminates social disparities in human behavior. This study investigates socio-behavioral patterns in medicine as parallels to spousal violence behaviors, analyzing how power asymmetry influences VDSV in sub-Saharan Africa. METHODS: A cross-sectional study analyzed data from the latest Demographic and Health Surveys (2001-2024) across 31 countries, focusing on 193,232 women aged 15-49 years and their VDSV patterns: none, Discordant, and Other types. Unadjusted odds ratios (ORs) examined associations between VDSV patterns and birth cohorts (BCs) while adjusting for confounders. Interaction terms assessed the impact of neighborhood ethnic diversity, relationship power differences, and healthcare access. A two-level hierarchical multinomial logistic regression model analyzed VDSV variation, considering individual, cluster, and household-level confounders with random country effects. Spatial interpolation addressed geographical clustering. Analyses were performed using the McLogit package in R (Version 4.4.0). RESULTS: Across BCs, a greater percentage change in predicted marginal probabilities was observed for Other type VDSV compared to Discordant VDSV. Overall, women with recent healthcare access had smaller percentage changes; those with a large relationship power difference, especially, showed the opposite trend. Notably, observed healthcare access effects persisted beyond socioeconomic disparities. DISCUSSION: Higher VDSV amongst younger birth cohorts suggests lower SV-accepting attitudes. VDSV differences across healthcare access intimate anti-violence intervention exposure effects; relationship power differences play moderating roles. Persistent adjusted healthcare access effects suggest roles for narrowing socio-health inequalities in SSA. CONCLUSION: The study results advocate for macro-societal policies within healthcare that address social issues, particularly through theory-based approaches. Future research may evaluate the potential influence of healthcare funding cuts.