Community-level influences on married women's safe sex negotiation attitudes: A multilevel study

OBJECTIVE: Sexually transmitted diseases (STDs) and their complications are one of the top five reasons that adults seek health care in developing countries. Women in these countries, particularly, are at risk of STDs and their associated problems. Negotiating safe sex is a significant correlate of safe sex practices. It is not well understood how community environment is associated with married women’s safe sex negotiation. METHODS: We used Bangladesh Demographic and Health Surveys (2011), a national representative sample of 15,187 women living in 600 communities, to examine the role of community level factors in predicting married women’s safe sex negotiation attitudes. Safe sex negotiation attitude was measured by asking if a woman justifies refusing sex with her husband when he has a sexually transmitted disease. RESULTS: Multilevel logistic regression results revealed some interesting patterns in married women’s sex negotiation attitudes. Living in communities where wife beating norms are permissive decreased women’s odds of negotiating safer sex with their husbands (odds ratio=0.534, p<0.001), while a higher proportion of poor increased the odds (odds ratio= 2.397, p< 0.01). Women’s likelihood of negotiating safe sex was greater if they lived in communities in Dhaka division (odds ratio= 2.674, p<0.001) and communities where they had greater empowerment (odds ratio= 1.744, p<0.001). We controlled for individual level age, religion, education, employment status, household wealth index, non-governmental organization membership, knowledge of STD/AIDS, freedom of movement, decision-making power, and wife-beating attitude. CONCLUSIONS: The findings highlight the importance of considering community contexts in developing women’s sexual health promotion programs.