Women empowerment and sexually transmitted infections: Evidence from Bangladesh demographic and health survey 2014.

BACKGROUND: Sexually transmitted infections (STIs) among women have led to substantial public health and economic burdens in several low-middle-income countries. However, there is a paucity of scientific knowledge about the relationship between empowerment and symptoms of STIs among married Bangladeshi women. This article aimed to examine the association between women empowerment and symptoms of STIs among currently married Bangladeshi women of reproductive age.
MATERIALS AND METHODS: We extracted data from the Bangladesh Demographic and Health Survey (BDHS), conducted from June 28, 2014, to November 9, 2014. We utilised cross-tabulation, the conceptual framework and multivariable multilevel mixed-effect logistics regression to explore the association between women's empowerment indicators and women's self-reported symptoms of genital sore and abnormal genital discharge. All of the analysis was adjusted using cluster weight.
RESULTS: We found that among 16,858 currently married women, 5.59% and 10.84% experienced genital sores and abnormal genital discharge during the past 12 months, respectively. Women who depended on husbands to make decisions regarding their health care (AOR = 0.75, 95% CI = 0.67-0.84), significant household purchases (AOR = 0.79, 95% CI = 0.71-0.88), and visiting family or relatives (AOR = 0.72, 95% CI = 0.64-0.80) were less likely to report signs of abnormal genital discharge. Women who could make joint healthcare decisions with their husbands were also less likely to report genital sores (AOR = 0.78, 95% CI = 0.67-0.90).
CONCLUSION: Genital sores and abnormal genital discharge were prevalent across all parameters of women empowerment among currently married women in Bangladesh. Our estimates show that the husband plays a significant role in decision-making about sexual and reproductive health. Efforts need to be invested in establishing culturally relevant gender policies which facilitate the involvement of women in joint decision-making.

Introduction

Sexually transmitted infections (STIs) pose substantial public health threats and burdens, particularly among women of reproductive age and their children. According to global estimates, over 900,000 pregnant women are have been infected with syphilis [1]. As of 2016, syphilis gave rise to approximately 350,000 adverse birth outcomes, including stillbirth [1]. STIs such as syphilis, Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis have triggered several symptoms, including genital sores and abnormal genital discharge. These STIs are linked to numerous health complications, including the risk of HIV transmission [2-5]. A systematic review based on studies from 30 low- and middle-income countries (LMIC) indicate that STIs among women are quite common across the different geographical settings even if the range of prevalence varies. For example, Neisseria gonorrhoeae was found to be 1.2%-4.6%, syphilis ranged from 1.1%-6.5%, Chlamydia trachomatis was approximately 0.8%-11.2%, and Trichomonas vaginalis ranged from 3.9%-24.6% [6]. Moreover, a cohort study among South African women depicted that the presence of genital discharge, genital sores or epithelial disruptions were strongly associated with HIV seroconversion [5]. In LMIC, the substantial STIs burden can be attributed to inadequate healthcare access, delayed or inadequate detection, and economic inequality of women [7, 8]. Moreover, another literature review based in 13 countries showed that Muslim women generally had poor knowledge about STIs signs and symptoms, prevention, diagnosis, and management. The review also revealed misconceptions that fueled blame and judgmental attitudes towards women who were infected [9].

In Bangladesh, a low number of STIs cases are reported due to insufficient knowledge, the social stigma attached to STIs, and a scarcity of affordable sexual healthcare options [10]. However, the 2014 Bangladesh Demographic and Health Survey (BDHS) reported that 10.8% and 5.8% of ever-married (i.e., currently married, divorced, widowed, and separated) women aged 15–49 years experienced genital discharge and genital sores, respectively [11]. Furthermore, literature showed that women were reluctant to disclose sexual health issues and seek healthcare due to the societal stigma associated with sexual health [10]. These social taboos even dissuaded them from confiding about their symptoms of STIs with their intimate partners. These circumstances led to their health issues remaining overlooked, thus gradually becoming chronic and complicated [12].

Women empowerment, which has a multifaceted and nuanced association with health, is crucial for safeguarding their health and their families’ welfare [13]. In particular, recent literature demonstrated the relationship between various contexts and dynamics of women empowerment and their health [13-16]. Moreover, several studies indicated that gendered power dynamics in intimate relationships had deterred women from making sexual and reproductive health (SRH) decisions [17]. Many women living with HIV and STIs cannot exercise their rights to seek SRH-related healthcare due to gender inequality, both within the society and their intimate partnerships [17]. Likewise, evidence from LMIC shows that women empowerment is associated with healthcare-seeking behaviours, the use of contraceptives, household decision-making, employment status, and freedom of movement [18]. In Bangladesh, a similar association was reflected between women’s autonomy and healthcare service uptake [13, 19]. As most women in Bangladesh are submissive to their partners’ requests, this influences their sexual and reproductive health [20]. Evidence from previous studies in Bangladesh had also indicated that participation in income-generating activities positively affected women’s ability to make household decisions such as major purchases, healthcare for themselves and their family members, and engagement in recreational activities [21]. Although they could not assume autonomy over their income, these initiatives allowed them to alleviate previous power imbalances, thus ultimately protecting them from intimate partner violence (IPV) [22]. Thus, self-care empowerment is one of the prerequisites for preventing unsafe sexual behaviours, which could lead to STIs [23]. This type of empowerment could enable women to refer their married partners for STIs care, whereas women who experience economic vulnerability and limited empowerment struggle to guide their partners [24].

Bangladesh has made promising progress in alleviating gender disparity, ranking 68th out of 156 countries as per the World Economic Forum’s annual gender gap report of 2021 [25]. Women constitute half of the population, and their participation in the workforce has grown exponentially [26]. It would be challenging to accomplish the Sustainable Development Goal (SDG) that pertains to gender equality if the health and wellbeing of a substantial number of women remain overlooked [27]. Therefore, it is integral to ensure autonomy and self-empowerment to effectively negotiate and exercise their sexual and reproductive health rights to their intimate partners. However, in Bangladesh, the relationship between women empowerment and symptoms of STIs have not been thoroughly investigated or evaluated during their reproductive age. Moreover, there is a paucity of primary and secondary evidence in Bangladesh that illuminates the connection between women empowerment and symptoms of STIs.

Therefore, this study aimed to analyse nationally representative population-based data and present findings of the association between women empowerment and self-reported genital discharge and genital sores. The findings from this exercise can assist policymakers in developing gender-sensitive and empowering STIs preventive policies and broad healthcare system policies which could address social health determinants and, thus, ultimately prevent STIs.

Materials and methods

Study design and sampling technique

We used data from the BDHS 2014, a nationally representative cross-sectional survey. Since the most recent publicly accessible BDHS 2017 data does not contain STIs and HIV-related data, BDHS 2014 served as the final dataset for our research objective. The survey was conducted between June and November 2014 by the ICF International (USA), National Institute of Population Research and Training (NIPORT) and Mitra and Associates [11]. The sampling method was a two-stage stratified sampling strategy of the households. During the first stage, 600 enumeration areas (EAs), consisting of 207 urban and 393 rural EAs, were selected using the probability-proportionate-to-size approach. An EA was defined as a village, small village or part of a large village. Secondly, a systematic sample of 30 households was selected from each EA to provide statistically reliable estimates of key demographic and health variables [11]. The sampling procedure has been detailed in the BDHS 2014 report [11]. From 18,000 sampled residential homes, 17,300 residential households were surveyed, and 17,886 ever-married women were interviewed. Women were interviewed using a questionnaire to elicit information about their background characteristics, information about their partners and HIV/AIDS-related information. Informed consent was obtained from the respondents before conducting the interview. The questionnaire was adapted, pretested and validated as per the context of Bangladesh Since its inception, the complete questionnaire and data collection procedure were rendered publicly accessible [11]. This study restricted the analysis to 16,858 currently married women who had experienced abnormal genital discharge or genital sores within the past 12 months preceding data collection (Fig 1).

Fig 1

A flow chart of study population selection from Bangladesh demographic health survey (BDHS) 2014.

Outcome variables

This study examined two different outcome variables (1) genital sores; and (2) abnormal genital discharge among currently married women aged 15–49 years. Table 1 includes a detailed explanation of the two outcome variables. According to the BDHS-2014 survey, abnormal vaginal discharge or presence of genital sore was considered as self-reported STIs or symptoms of STIs [11].

Table 1

Explanation of outcome variables.

Variables	Explanation
Abnormal genital discharge	Women aged 15–49 years had abnormal (or bad-smelling) genital discharge in the past 12 months. It was re-coded and categorised as: Yes (Yes), No (No and Don’t know)
Genital sore	Women aged 15–49 years had a genital sore or ulcer in the past 12 months. It was grouped as Yes (Yes), No (No and Don’t know)

Explanatory variables

All of the independent variables are illustrated in Table 2. They were chosen based on the existing literature [11, 13, 28–31]. The household wealth index was evaluated by BDHS 2014 using scores derived from the principal component analysis of various household amenities, possessions and assets [11]. In our analysis, women’s socio-demographic variables were expressed as age categories, women’s education, husband’s education, residence, division and wealth index. The indicators of women empowerment included employment status, freedom of movement, control over their earnings, participation in decision-making in the household and acceptance of physical battery of wives (wife-beating) (Table 2).

Table 2

Explanation of explanatory variables.

Variables	Explanation
Age group (in years)	Self-reported age of women at the time of survey categorised into 15–19 Years; 20–24 Years; 25–29 Years; 30–34 Years; 35–39 Years; 40–44 Years; 45–49 Years
Women education	The highest level of education attained by women classified in terms of No education; Primary; Secondary; and Higher
Husband’s education	The highest level of education attained by husband classified in terms of No Education; Primary; Secondary; Higher
Wealth index	The composite index of household goods, services and assets. It was derived using the principal component analysis to produce a standard factor score, divided into five equal parts and grouped as Poorest (Lowest), Poorer (Second), Middle, Richer (Fourth), Richest (Highest)
Place of residence	Types of the place of residence: Urban; and Rural
Division	The division where the respondent resided at the time of the survey: Barisal; Chittagong; Dhaka; Khulna; Rajshahi; Rangpur; Sylhet
Exposure to media	This composite variable derived from three different variables including 1) reading newspaper 2) watching television 3) listening to the radio at least once a week and grouped as: No exposure; Exposure to 1–2 media; Exposure to all three media
Women empowerment indicators
Employment status	Employment status of the resident at any given time in the past 12 months: Yes (currently working, worked in the past year, presently working or have a job but on leave within the last seven days); No (no)
Control over own earning	The person who usually decides how to spend the respondent’s earnings: Respondent alone; Respondent and husband; Husband alone/someone else
Women’s participation in decision-making
Own health care	Women’s participation in decision-making about their healthcare: Respondent alone; Respondent and husband; Husband alone; Someone else
Major household purchases	The person who decided the purchase of significant household products: Respondent alone; Respondent and husband; Husband alone; Someone else
Child health care	Women’s participation in taking decisions regarding child care: Respondent alone; Respondent and husband; Husband alone; Someone else
Visit family or relatives	Women’s participation in decision-making regarding visiting family or relatives: Respondent alone; Respondent and husband; Husband alone; Someone else
Women’s acceptance as justifying wife-beating	Justifying women’s acceptance attitudes towards wife-beating by their husband for the following five reasons (burning food; arguing with husband; going out without telling husband; neglecting the children, and refusing to have sex with husband) and grouped as: Not justified; Any of the five reasons

Statistical analysis

We analysed all socio-demographic characteristics and women empowerment indicators using descriptive statistics (i.e., frequency, percentage, cross-tabulation, mean and standard deviation) to describe attributes of currently married women and understand the prevalence of the two STIs symptoms. Sampling weight was adopted from the BDHS database and used to conduct all analyses. Based on empirical knowledge from previous research and the authors’ scientific expertise, a computational framework approach was used to examine the causal pathway between outcome variables and explanatory variables (Fig 2) [13, 30–35]. In the conceptual framework, women empowerment indicators and women’s socio-demographic characteristics were both directly and indirectly linked to genital discharge and genital sores where the single direct arrows depict direct links. Women’s demographic characteristics and empowerment indicators indirectly affect the outcomes through safe sex knowledge, practice and health-seeking behaviour. Due to inadequate data, only direct links were considered for model building purposes. For example, as confounders such as age group, women education, husband’s education, wealth index, division, exposure to media, place of residence were perceived to affect the imagined relationship between women empowerment indicators and outcomes of interest, they were included in the final multivariable model to control these potential confounding effects.

Fig 2

The conceptual framework illustrating the causal pathway between women empowerment indicators and outcome of interest.

We examined the relationship between women empowerment indicators and outcome variables using multilevel mixed-effect logistic regression. To demonstrate the clustering of primary sampling units (PSU), we initially ran an empty model/null model with no explanatory variables to investigate the variance of the outcomes. Then, explanatory variables were applied concurrently. The multilevel mixed-effects model consisted of the two effects. The fixed effect equation depicted the relationship between explanatory and outcome variables wherein the random effect was determined using variance and inter-cluster correlation (ICC). The likelihood ratio (LR) test was performed to check model adequacy.

Bivariable multilevel mixed-effect logistic regression analysis was performed to estimate the direct effect of women empowerment indicators on outcomes. The results are presented as crude/unadjusted odds ratio (UOR) with a 95% confidence interval. Finally, the multivariable multilevel mixed-effect model was performed to estimate adjusted odds ratios (AOR) with 95% confidence intervals while adjusting the potential confounders selected from the conceptual framework. The significance level was considered as p <0.05. The analysis was performed using Stata 15 software (Stata Corp. 2013. Stata Statistical Software: Release 13. College Station, TX: Stata Corp LP.)

Results

Table 3 shows the symptoms of genital sore and abnormal genital discharge experienced by 16,858 currently married women. We found that the proportion of women who reported signs of genital sores and abnormal genital discharge was 5.59% and 10.84%, respectively. The average age among study samples was 30.51 years, where the average ages of women with genital sores and abnormal genital discharge symptoms were 30.58 and 30.10, respectively. We also found that higher proportions of women who reported genital sores originated from the Dhaka division (25.27%). Similarly, among those who reported signs of abnormal genital discharge, 36.99% completed their secondary education, 22.41% came from a household of median wealth, 75.04% lived in the rural area, and 32.81% were from the Dhaka division. Table 3 also shows that participating in various household decisions and acceptance towards wife-beating were significantly associated with self-reported symptoms of genital sore and abnormal genital discharge. The highest percentage of women who experienced signs of genital sore relied on their husbands’ decisions on various aspects of their lives, including their healthcare (43.78%), purchasing significant household products (47.69%), child healthcare (51.17%) and visiting family or relatives (47.75%). Similarly, the percentages for the women who reported abnormal genital discharge symptoms were 43.38%, 45.9% and 45.08%, respectively. 67% of women with symptoms of abnormal genital discharge agreed that wife-beating was not justified for any reason whereas, 67% of women who reported genital sores decided that wife-beating was not justified for any reason (Table 3).

Table 3

Distribution of women’s self-reported experience of genital sore and abnormal genital discharge according to their socio-demographic characteristics and women empowerment indicators.

	Currently married women
Variables	Total	Genital sore		Abnormal genital discharge
	%(n)	%(n)	p-valuea	%(n)	p-valuea
Overall	100.0(16858)	100.0(943)		100.0(1827)
Age group (in the year)
Mean ± SD	30.51 ± 0.09	30.58 ± 0.32		30.10 ± 0.23
15–19	11.78(1985)	6.15(58)		20.9(382)
20–24	18.78(3165)	22.04(208)		20.83(380)
25–29	19.28(3250)	21.87(206)		11.55(211)
30–34	17.32(2919)	20.43(193)	<0.001	10.77(197)	<0.001
35–39	12.77(2153)	11.12(105)		6.03(110)
40–44	11.12(1875)	11.48(108)		20.9(382)
45–49	8.96(1511)	6.91(65)		20.83(380)
Women education
No education	23.42(3949)	20.96(198)		21.95(401)
Primary	29.16(4916)	32.71(308)	0.143	34.29(626)	0.002
Secondary	38.58(6503)	38.9(367)		36.99(676)
Higher	8.84(1490)	7.44(70)		6.76(123)
Husband education
No education	27.96(4712)	27.65(261)		29.31(535)
Primary	27.76(4680)	30.09(284)	0.524	30.73(561)	0.002
Secondary	30.17(5085)	29.7(280)		28.91(528)
Higher	14.11(2379)	12.57(118)		11.06(202)
Wealth index
Poorest	18.37(3097)	17.21(162)		19.13(349)
Poorer	19.12(3223)	22.75(214)		21.68(396)
Middle	20.14(3395)	21.2(200)	0.136	22.41(409)	0.002
Richer	21.1(3557)	19.61(185)		19.88(363)
Richest	21.28(3587)	19.24(181)		16.9(309)
Place of residence
Urban	27.93(4709)	25.7(243)		24.96(456)
Rural	72.07(12149)	74.3(700)	0.227	75.04(1370)	0.039
Division
Barisal	6.23(1051)	9.75(92)		7.16(131)
Chittagong	18.52(3122)	25.04(236)		17.12(313)
Dhaka	34.74(5857)	25.27(238)		32.81(599)
Khulna	10.25(1729)	11.45(108)	<0.001	12.86(235)	0.043
Rajshahi	11.91(2007)	13.26(125)		13.35(244)
Rangpur	11.54(1946)	8.6(81)		10.46(191)
Sylhet	6.8(1147)	6.63(63)		6.23(114)
Exposure to media
No exposure	36.99(6235)	36.25(342)		37.42(683)
Exposure to any 2 media	61.54(10375)	62.63(590)	0.790	61.73(1127)	0.169
Exposure to all 3 media	1.47(247)	1.12(11)		0.86(16)
Women empowerment indicators
Employment Status
No	65.69(11072)	58.61(553)	<0.001	62.08(1134)	0.01
Yes	34.31(5784)	41.39(390)		37.92(693)
Control over their own earning
Respondent alone	32.02(1668)	34.14(121)		33.95(217)
Respondent and husband	54.13(2819)	49.33(175)	0.21	51.25(328)	0.518
Husband alone/someone else	13.85(721)	16.53(59)		14.8(95)
Women’s participation in decision-making
Own health care
Respondent alone	14.12(2381)	16.47(155)		17.02(311)
Respondent and husband	50.73(8550)	43.78(413)	0.002	43.38(792)	<0.001
Husband alone/someone else	35.15(5925)	39.76(375)		39.6(723)
Major household purchases
Respondent alone	8.3(1399)	10.67(101)		11.54(211)
Respondent and husband	52.98(8930)	47.69(450)	0.005	45.9(838)	<0.001
Husband alone/someone else	38.72(6528)	41.64(393)		42.57(777)
Child health care
Respondent alone	16.35(2732)	16.34(152)		18.12(329)
Respondent and husband	54.17(9054)	51.17(477)	0.148	50.56(917)	0.106
Husband alone/someone else	29.48(4928)	32.5(303)		31.32(568)
Visit family or relatives
Respondent alone	9.84(1659)	11.79(111)		11.32(207)
Respondent and husband	52.88(8910)	47.75(450)	0.017	45.08(823)	<0.001
Husband alone/someone else	37.28(6281)	40.46(381)		43.6(796)
Women’s acceptance as justifying wife-beating
Not justified	72.62(12242)	67.31(634)		69.17(1263)
Any of five reasons	27.38(4615)	32.69(308)	0.012	30.83(563)	0.008

a p-values were calculated using the Pearson Chi-square test.

Note: As a result of missing values, the total may not equal 100.0 percent.

Association between women empowerment indicators and abnormal genital discharge and genital sores

Table 4 explores the association between women’s empowerment indicators and their experience of genital sores and abnormal genital discharge symptoms. In the empty model, the probability of women’s self-reporting genital sores and abnormal genital discharge varied significantly according to the clustering of the PSUs (genital sore, σ2 = 0.43, 95% CI = 0.31–0.58; abnormal genital discharge, σ2 = 0.10, 95% CI = 0.23–0.40). The ICC in the empty model indicated that differences between the clusters accounted for 11.00% and 8.00% of the total variance in women’s genital sores and abnormal genital discharge, respectively.

Table 4

Bivariable and multivariable multilevel mixed-effect logistic regression analysis to explore the association between women empowerment indicators and women’s self-reported experience of genital sore and genital discharge in the past 12 months of the survey, 2014 Bangladesh.

Women Empowerment indicators	Genital sore		Abnormal genital discharge
	UORa (95% CI)	AORb (95% CI)	UORa (95% CI)	AORb (95% CI)
Employment status
Yes	1.37*** (1.19–1.58)	1.36*** (1.18–1.57)	1.15** (1.03–1.30)	1.14** (1.02–1.27)
No	Reference	Reference	Reference	Reference
Control over their own earning
Respondent alone	0.91 (0.64–1.29)	0.92 (0.65–1.31)	0.96 (0.73–1.27)	0.98 (0.74–1.30)
Respondent and husband	0.78 (0.57–1.08)	0.80 (0.57–1.10)	0.83 (0.64–1.08)	0.85 (0.66–1.11)
Husband alone/someone else	Reference	Reference	Reference	Reference
Women’s participation in decision-making
Own health care
Respondent alone	1.05 (0.86–1.28)	1.04 (0.85–1.27)	1.11 (0.95–1.28)	1.14 (0.98–1.32)
Respondent and husband	0.79*** (0.67–0.90)	0.78*** (0.67–0.90)	0.74*** (0.66–0.82)	0.75*** (0.67–0.84)
Husband alone/someone else	Reference	Reference	Reference	Reference
Major household purchases
Respondent alone	1.24 (0.98–1.57)	1.22 (0.97–1.55)	1.36*** (1.15–1.61)	1.39*** (1.17–1.65)
Respondent and husband	0.86** (0.75–0.99)	0.86 (0.74–1.00)	0.78*** (0.70–0.87)	0.79*** (0.71–0.88)
Husband alone/someone else	Reference	Reference	Reference	Reference
Child health care
Respondent alone	1.97 (0.76–1.15)	0.91 (0.74–1.13)	1.07 (0.92–1.24)	1.09 (0.93–1.27)
Respondent and husband	0.88 (0.75–1.02)	0.87 (0.74–1.01)	0.88** (0.78–0.98)	0.89 (0.79–1.00)
Husband alone/someone else	Reference	Reference	Reference	Reference
Visit to family or relatives
Respondent alone	1.14 (0.91–1.43)	1.12 (0.89–1.42)	1.01 (0.85–1.19)	1.03 (0.87–1.23)
Respondent and husband	0.86 (0.75–1.00)	0.86 (0.74–1.00)	0.71*** (0.63–0.79)	0.72*** (0.64–0.80)
Husband alone/someone else	Reference	Reference	Reference	Reference
Women’s acceptance as justifying wife-beating
Not justified	Reference	Reference	Reference	Reference
Any of five reasons	1.28** (1.10–1.47)	1.26** (1.08–1.46)	1.22** (1.09–1.37)	1.19** (1.07–1.33)
Random effect results	Null model		Null Model
PSU variance (95% CI)	0.43 (0.31–0.58)		0.10 (0.23–0.40)
ICC	0.11		0.08
LR Test	χ2 = 115.66, p<0.001		χ2 = 179.87, p<0.001

**p-value < 0.05.

***p-value < 0.001.

aUOR represents unadjusted odd ratios which were calculated using bivariable binary logistic regression; CI indicates confidence interval

bAOR represents adjusted odd ratios which were calculated using multivariable binary logistic regression where variables used for adjustment: age group, women education, husband’s education, wealth index, division, exposure to media, place of residence.

Three indicators were significantly associated with genital sores: women’s employment status, participation in health care decision-making and women’s acceptance of wife-beating. We found that employed women were 1.36 times more likely to report genital sores compared to unemployed women. In addition, women who were able to make healthcare decisions with their husbands were 22% less likely to report genital sores (AOR = 0.78) compared to women in the counter reference category. Moreover, women who accepted wife-beating for any of the five listed justified reasons had a higher likelihood of reporting genital sores (AOR = 1.26) (Table 4).

Five indicators were also found to be significantly associated with abnormal genital discharge, such as: women’s employment status, their involvement in decision-making about their healthcare, major household purchases, visits to family or relatives and their acceptance of wife-beating. Women were 1.14 times (AOR = 1.14) more likely to experience symptoms of genital discharge than unemployed women. Conversely, the odds of having genital discharge symptoms were lowest among women who relied on their husbands to make decisions regarding significant household purchases, their own healthcare, visiting family or relatives (i.e., 0.79, 0.75, 0.72, respectively compared to the reference category). In addition, women who accepted wife-beating for any of the five mentioned reasons were 1.19 times more likely to report abnormal genital discharge compared to the reference sample. Besides, women’s control over their earnings, involvement in significant household purchases, child healthcare, and decision-making about visiting family members or relatives were not significantly associated with self-reported genital sores. Likewise, we found no significant association between women’s control over their earnings or child health care decision-making and women who experienced abnormal genital discharge symptoms (Table 4).

Discussion

In this study, 5.59% and 10.84% of the respondents reported genital sores and abnormal genital discharge, respectively. We found a significant relationship between the indicators of women empowerment and their likelihood of reporting symptoms of STIs such as genital sores or abnormal genital discharge. Women who actively participated in joint decision-making with their husbands or partners regarding their family’s healthcare were significantly less likely to report symptoms of STIs. Joint decision-making about visiting family or making significant purchases also lessened their likelihood of reporting symptoms of STIs. Notably, we discovered that women with a history of employment were more likely to report symptoms of STIs. Likewise, women who justified their husbands’ wife beatings under various circumstances were more likely to report symptoms of STI. These findings generate crucial insights that warrant further deliberation, particularly within the patriarchal socio-cultural context in Bangladesh.

The benefit of joint decision-making calls into question the individualistic autonomy model, which portrays women as independent and autonomous characters who are also shouldered with the responsibility to make the decision [36-38]. However, within the South Asian social framework, where the women’s status is inherently tied to men by emotional interdependence, the autonomy framework may not be contextually appropriate [37, 38]. Rather, receiving support from the husband fosters better service utilisation and uptake of necessary healthcare among women [39]. It is highly likely that joint discussions and deliberations about a decision are more likely to produce better outcomes for the women [39]. Previous studies in Bangladesh also suggest that joint participation in making household decisions may precipitate better results than independent decision-making, thus undermining the concept of women’s unilateral decision-making [37]. These findings support a solid argument for an environment that enables couples to consult, negotiate and overcome conflicting preferences and goals about family issues.

However, women’s involvement in joint decision-making is not a smooth process. Women’s educational status and the socio-economic status of their families of origin are conceptualised as prerequisites for their decision-making abilities [40]. Women with higher levels of education are more likely to be involved in decision-making with their husband. Her involvement in income-generating activities further potentiates her capacity in the household [41]. Women with greater household decision-making powers are more likely to uptake sexual and reproductive health services than those with less power [42-44]. In the egalitarian setting of Tamil Nadu in India, women’s economic activity positively influenced decision making, an unlikely phenomenon in the gender-conservative context of several locales of India [45]. In recent times, women’s employment in garments and microfinance-based development programs in Bangladesh has considerably increased the scope for women empowerment. Because of these particular initiatives, women are now gaining more control over their sexual and reproductive life by delaying marriage and childbirth, for instance [46, 47]. All these factors significantly contribute to a gradual shift in gender norms and nurture greater independence and economic power in the family for women, which ultimately enhances the uptake of certain sexual and reproductive health services.

Although the involvement of women in income-generating activities is hypothesised as a critical factor in empowerment, our analysis underscored a few crucial aspects. For example, we found that women empowerment during the past year resulted in the reporting of more genital sores and abnormal genital discharges. Global evidence suggests that being employed and spending longer working hours, along with substance abuse, peer pressure, and inadequate guardianship, may increase their propensity towards unsafe sexual exposure, especially for teenage and young women [48-50]. If occupational safety is not ensured, women may become isolated and vulnerable at their workplace, which could exacerbate the possibility of sexual exposure [49]. Therefore, policy planners need to ensure a safe working environment for women if they want to continue engaging them in income-generating activities.

In addition, our study presented that women who justified reasons for wife-beating attitudes were more likely to report both abnormal genital discharge and genital sores. The perception of IPV as a “similar notion” resonated in other LMIC like Nigeria and Zambia, which embody similar patriarchal norms [51, 52]. Women living in an environment that normalises wife-beating were more likely to be younger, less educated and from a lower socio-economic background, as they blamed themselves for such incidents, thus further enabling perpetrators to continue this behavior [53, 54]. These findings add to the body of knowledge that shows the effects of IPV on Bangladeshi women, including unwanted pregnancies, induced abortions, miscarriage and stillbirth [55]. IPV needs to be acknowledged as a social malignancy that insidiously affects women’s physical and emotional welfare, thereby underpinning women empowerment initiatives as an evidence-based solution [22]. Thus, policymakers must carefully design programs that empower women through education and microfinance, encourage women to speak out about IPV and establish social and legal structures that protect women in such situations and strengthen the IPV prevention paradigm.

In a predominantly Muslim country like Bangladesh, the conservative socio-economic environment is not conducive to public discussions about sexual health issues and behaviours. Furthermore, the lack of appropriate knowledge about STIs prevention and transmission has elevated the risk of STIs transmission. Due to their lack of awareness about STIs and their associated harms, it is unlikely that women can discuss these issues with their husbands, thus limiting their scope for safer sex negotiation [56]. Women empowerment initiatives would provide women with greater economic autonomy to reject men, multiple partners, insist on safer sex and frequently discuss HIV/STIs vulnerabilities with male partners [57-59]. Thus, economic empowerment initiatives need to consider STIs prevention efforts to foster their economic empowerment while providing them with resources to protect themselves from STIs.

Our analysis was based on data collected in a national survey with high response rates. To ascertain national representation, the multistage sampling procedure used in the survey was adjusted using sampling weights. The variables in the study were related to socio-demographic characteristics and women empowerment. Models were developed to illustrate the association between women empowerment and the symptoms of STI, genital sores, and foul-smelling genital discharge, which could aid policymakers and activists in designing interventions to reduce symptoms of STI through women empowerment initiatives. However, this study presented some limitations. Even though a later survey was conducted in 2017 and published, the dataset did not contain any STIs-related information. Since these data were not available, a similar analysis cannot be demonstrated. Moreover, due to the sensitive and stigmatised nature of STIs and sexual health, respondents may not completely disclose their sexual health information, thus leading to social desirability bias or self-reporting bias. Strictly maintaining anonymity and confidentiality at the time of data collection minimises the occurrence of these biases, thus preventing inaccurate estimates of association or underestimation of risk parameters. In addition, according to the standard definition of STIs, laboratory diagnostics are required, along with clinical signs and symptoms. However, as BDHS is a population-based survey, there were no provisions for confirmatory diagnostics for participants with self-reported symptoms of STI. Therefore, to determine STIs status, further studies are needed to utilise clinical diagnostic approaches, which would elicit a more in-depth understanding of the association between STIs and women empowerment among currently married women.

Conclusion

In this study, we have shown that women’s joint decision-making can be considered a reliable marker of women empowerment in Muslim societies such as Bangladesh, which normalises male dominance. This collective decision-making capacity was eventually linked to lower reported symptoms of STIs, thus highlighting the benefits of egalitarian gender norms on women’s sexual and reproductive health. Women need to attain equitable empowerment to negotiate participation in joint decision-making and exercise their rights in their families and society. Thus, it is integral for women to attain education, health awareness and economic stability. Moreover, additional mechanisms need to be explored to encourage couple communication strategies to improve relationship dynamics. Policy decisions should consider contextual and evidence-based findings to formulate acceptable gender policies for facilitating a better life for women.

19 Apr 2021

PONE-D-21-00487

Women empowerment and sexually transmitted infections: Evidence from Bangladesh demographic and health survey 2014

PLOS ONE

Dear Dr. Khan,

Thank you for submitting your manuscript to PLOS ONE. I have now received the review reports from the two reviewers. I have also read the manuscript with interest. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please see my comments below, along with the reviewer’s reports.

Line 113 mentioned that “All the independent variables are shown in Table 1”. It will be Table 2.

The authors have not constructed an empowerment scale/index. They used the indicators as a separate variable.

The division has been written as ‘Province.’

The authors have presented a conceptual framework where knowledge about safe sexual behavior and treatment-seeking behavior for STI symptoms have been mentioned. However, I did not see any such variable in the list of explanatory variables and the results.

The reported sample 16858 does not match with the DHS report. The same goes for the proportion of women who reported having signs of genital sores and abnormal genital discharge. Please check the original report.

In table 3, the authors have reported findings of the variable “Control over their ow earnings”. However, the ‘n’ is different from the total. However, no explanation has been provided.

Line 162 mentioned, “Please consider revisiting the use of “impact” as the current study design does not allow the authors to see the impact.

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Reviewer #1: On Abstract

- The second sentence of your abstract is not clear. What poses difficulties and what remains untreated? I think you should read it again and try to make it clear. It can be rephrased as … many women remain untreated

- Please write the word cross-tab in full

- Change the and in “All the analysis was adjusted for multistage sampling design and cluster weight.” to …. using cluster weight

- The sentence that presents multivariate results is not clear. Please read it again and present it clearly. I think it should be presented as

Multivariate analysis revealed that women’s lower reporting of STIs symptoms was significantly…..

- The figures in the abstract should be presented with one decimal place.

On Manuscript

- Your introduction needs thorough editing. Many of the sentences lack joining words and the manuscript is full of grammatical errors.

- You should have some literature that connects other selected variables to real studies. The introduction is silent about these connections yet they are also study vaiables.

- The first sentence of the introduction is not clear. Seems you are joining two parts that are disconnected.

- Line 62 misses … in developing countries.

- Line 62 It has also been reported that there is higher HIV transmission among reproductive-age women

- Line 65 misses … and genital herpes

- Lines 90-93 are confusing about the dataset used in this study. You state that the 2017 BDHS did not have STI/HIV data but then conclude that you used the 2017 BDHS. I think line 92 should read …, BDHS 2014 …

-

- Since you have two outcomes, the subsection in line 105 should be outcome variables

- The word “referent” in the multivariate table should be changed to “reference”

- In the discussion, the sentence on line 215 should end on independently otherwise, the addition renders it confusing.

- Line 220-223 is very questionable for women of reproductive age. Is this in the context of your community. It may only apply to the teenagers and young women. If so, please indicate this clearly. Otherwise many of the women of reproductive age may not be under any guardians!

- In the conclusion, I think the issue of joint decision making can also be facilitated by encouraging couple communication. If it is applicable in the Bangladesh Context, please include it.

Reviewer #2: I have gone through the MS carefully. The author(s) have tried to identify the impact of women’s empowerment on sexually transmitted infections STIs). However, my observations are as follows:

Abstract:

The abstract is well written.

Introduction:

Introductory section is very short. The authors urged that (P. 9, L. 60-62) abnormal genital discharge is a common occurrence caused mostly by Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis and is associated with a higher risk of HIV transmission precisely developing countries. Citing of some findings from developing countries which showed that having STIs in a woman increases HIV would increase the quality of the MS. Are those infections limited to HIV, or some other diseases like cancer?

Materials and Methods:

Some following issues are not clear in this section:

(i) I am not sure when the MS was submitted. The latest BDHS data sets conducted in 2017-18 are released by the end of November or in early of December, 2020. If so, why the authors have not used most recent data?

(ii) A flow chart of selection of the 16,858 from 17,886 women may improve the quality of the MS.

(iii) Since the data have been gathered through a multi-stage procedure, why di not the authors use multilevel logistic regression analysis. The empirical studies suggest that women’s empowerment are associated with clusters. I would suggest employing multilevel logistic regression analysis to quantify the unobserved effects on having any STI among married women captured by clusters.

(iv) How the missing values were managed by stata?

Discussion:

This section is well written.

Conclusion:

This section is well written.

Overall comments:

The authors have examined an important public health issues. Overall, the writing is good, well arranged, and lucid. However, some grammatical issues should be checked throughout the MS. In this study, to my opinion, the main backdrops are data and methodological issues as noted above. Hence it needs a revision. Prior to publish the MS, the above mentioned issues should be taken into consideration and clarified.

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Reviewer #1: No

Reviewer #2: Yes: S. M. Mostafa Kamal

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23 Jun 2021

Response to Editor Comments

1.Line 113 mentioned that “All the independent variables are shown in Table 1”. It will be Table 2.

Response: Thank you. We have corrected it in line 144 of the unmarked manuscript file.

2.The authors have not constructed an empowerment scale/index. They used the indicators as a separate variable

Response: Thank you for highlighting this important concern, we appreciate it. It was possible to employ a women empowerment index, such as the Survey-based Women's Empowerment Index-1. However, rather than using a composite score, we were interested in investigating how different women empowerment indicators might affect women's self-reported abnormal genital discharge and genital sores differently2.

Reference:

1. Ewerling F, Lynch JW, Victora CG, van Eerdewijk A, Tyszler M, Barros AJ. The SWPER index for women's empowerment in Africa: development and validation of an index based on survey data. The Lancet Global Health. 2017 Sep 1;5(9):e916-23.

2. Mainuddin A, Begum HA, Rawal LB, Islam A, Islam SS. Women empowerment and its relation with health seeking behavior in Bangladesh. J Family Reprod Health. 2015;9(2):65.

3.The division has been written as ‘Province.’

Response: Thank you. In the context of Bangladesh, the term “province” is not officially used. The word “Division” is an officially accepted term. We have corrected it in Table 2, Line 148, 194, Table 3, Table 4 of the unmarked manuscript file (Table 2, Line 117, 145, 148)

4.The authors have presented a conceptual framework where knowledge about safe sexual behavior and treatment-seeking behavior for STI symptoms have been mentioned. However, I did not see any such variable in the list of explanatory variables and the results

Response: Thank you for your comment. Women's socio-demographic characteristics and indicators of women's empowerment have direct and indirect effects on abnormal genital discharge and genital sores. A single direct arrow indicates a direct effect. Women’s demographic characteristics and empowerment indicators indirectly also affect outcomes through safer sex knowledge and practices and health-seeking behaviour. Since we do not have data on safer sex knowledge, practices and health-seeking behaviour, our model exclusively focused on the direct effect. Now we have revised the statistical analysis section and explained it in Lines 158–169 of the unmarked manuscript file.

5.The reported sample 16858 does not match with the DHS report. The same goes for the proportion of women who reported having signs of genital sores and abnormal genital discharge. Please check the original report

Response: Many thanks for your comment. Our sample size was different from the BDHS sample size because the BDHS report [Table 3.1 (page 29) and Table 12.7 (page 184)] calculated the prevalence among ever-married women, which included married, widowed, divorced, and women who were no longer living together (sample size=17,868). However, we limited our analysis to currently married women and thus used a sample size of 16,858 women. We referenced it in the study design and sampling technique section, line 130-132 of the unmarked manuscript file.

6.In table 3, the authors have reported findings of the variable “Control over their ow earnings”. However, the ‘n’ is different from the total. However, no explanation has been provided.

Response: We appreciate your comment. In table 3, now we have included a footnote that as a result of missing values, the total may not equal 100.0 percent.

7.Line 162 mentioned, “Impact of women empowerment on abnormal genital discharge and genital sores”. Please consider revisiting the use of “impact” as the current study design does not allow the authors to see the impact.

Response: We appreciate this concern. We have revised it to the association between women empowerment indicators and abnormal genital discharge and genital sores in line 211-212 in the unmarked manuscript file.

___________________________________________________________________________________

Response to Reviewer 1 Comments

On Abstract

Comment 1: The second sentence of your abstract is not clear. What poses difficulties and what remains untreated? I think you should read it again and try to make it clear. It can be rephrased as … many women remain untreated

Response: We appreciate your suggestion. We used the term "difficulty" and "untreated" to refer to "challenges" and "undiagnosed." However, in the unmarked manuscript, we revised lines 29-33 in the previous edition and inserted them in line -23-27.

Comment 2: Please write the word cross-tab in full

Response: Thank you for the suggestion. It has been inserted in unmarked manuscript lines 28-32. In addition, we revised the materials and methods section to reflect the fact that we used multilevel mixed-effect logistic regression as suggested by reviewer 2.

Comment 3: Change the and in “All the analysis was adjusted for multistage sampling design and cluster weight.” to …. using cluster weight

Response: We appreciate the suggestion. In line 32 (lines 35-36 in the previous edition or version?) of the unmarked manuscript, we have inserted the phrase using cluster weight.

Comment 4: The sentence that presents multivariate results is not clear. Please read it again and present it clearly. I think it should be presented as Multivariate analysis revealed that women’s lower reporting of STIs symptoms was significantly…..

Response: Thanks for the suggestion. We re-read and revised lines 34–39 of the unmarked manuscript (lines 38-41 in the previous version) as per your recommendation.

Comment 5: The figures in the abstract should be presented with one decimal place.

Response: Thank you for highlighting this. We have rounded the figures only in the abstract section.

On Manuscript

Comment 6: Your introduction needs thorough editing. Many of the sentences lack joining words and the manuscript is full of grammatical errors.

Response: We appreciate this suggestion. We have re-read and edited the introduction section thoroughly line-by-line, attempting to correct grammatical and syntax errors throughout the manuscript.

Comment 7: You should have some literature that connects other selected variables to real studies. The introduction is silent about these connections yet they are also study vaiables.

Response: We appreciate your recommendation. We revised the introduction section extensively, attempted to connect the study variables, and added some literature from lower-middle income countries.

Comment 8: The first sentence of the introduction is not clear. Seems you are joining two parts that are disconnected.

Response: Many thanks. We have revised this according to your suggestion.

Comment 9: Line 62 misses … in developing countries.

Response: We appreciate your diligence in following up on this. In line 55-65 of the unmarked manuscript, we added some literature pertaining to developing countries.

Comment 10: Line 62 It has also been reported that there is higher HIV transmission among reproductive-age women

Response: Thank you, we have deleted line 62 after thoroughly rewriting the introduction.

Comment 11: Line 65 misses … and genital herpes

Response: We appreciate your feedback, and we have removed line 65 after a detailed revision of the introduction.

Comment 12: Lines 90-93 are confusing about the dataset used in this study. You state that the 2017 BDHS did not have STI/HIV data but then conclude that you used the 2017 BDHS. I think line 92 should read …, BDHS 2014 …

Response: Thank you for highlighting this. It was a typing error, and we apologize for this. Now we have corrected it in line 114-118 of the unmarked manuscript (line 90-94 in the previous edition)

Comment 13: Since you have two outcomes, the subsection in line 105 should be outcome variables

Response: Thank you for the suggestion. We have been split sentence and added a few sentences. The new edition lines ran from 136 to 140, replacing the previous edition line of 106-109.

Comment 14: The word “referent” in the multivariate table should be changed to “reference”

Response: Many thanks, we have modified this in the table as suggested.

Comment 15: In the discussion, the sentence on line 215 should end on independently otherwise, the addition renders it confusing.

Response: Thanks for your comment. The clause in line 215 currently ends separately, and a clarification has been provided ('Also' has been omitted from the following sentence). The line is 253 in the unmarked version.

Comment 16: Line 220-223 is very questionable for women of reproductive age. Is this in the context of your community. It may only apply to the teenagers and young women. If so, please indicate this clearly. Otherwise many of the women of reproductive age may not be under any guardians!

Response: We appreciate this suggestion. The statement was made in reference to teenage and young women, which we have addressed now (Line-295). The previous version has a line number of 223.

Comment 17: In the conclusion, I think the issue of joint decision making can also be facilitated by encouraging couple communication. If it is applicable in the Bangladesh Context, please include it.

Response: Thanks for the suggestion. We agree with this, and we revised the conclusion (Line-346 in unmarked manuscript) which was Line-299 & 300 in the previous version.

_____________________________________________________________________________________

Response to Reviewer 2 Comments

Introduction

Comment 1: Introductory section is very short. The authors urged that (P. 9, L. 60-62) abnormal genital discharge is a common occurrence caused mostly by Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis and is associated with a higher risk of HIV transmission precisely developing countries. Citing of some findings from developing countries which showed that having STIs in a woman increases HIV would increase the quality of the MS. Are those infections limited to HIV, or some other diseases like cancer?

Response: Thank you for discussing this important question. Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis are not only responsible for HIV propagation but also for the transmission of many other diseases such as cancer. We extensively re-read the literature and accordingly have revised the introduction section as per the reviewer’s recommendation. In addition, we provided specific literature pertaining to developing nations. The unmarked manuscript contains updated lines 49-111, while the previous edition included lines 55–87.

Materials and Methods

Comment 2: I am not sure when the MS was submitted. The latest BDHS data sets conducted in 2017-18 are released by the end of November or in early of December, 2020. If so, why the authors have not used most recent data?

Response: Thank you for highlighting this. At the time of submission (December 2020, https://dhsprogram.com/data/available-datasets.cfm), the BDHS 2017-18 data set was available. However, we were unable to find any data on STIs in the 2017-18 BDHS. Although the variables exist in the dataset, we did not find any observations for them.

Comment 3: A flow chart of selection of the 16,858 from 17,886 women may improve the quality of the MS.

Response: Thank you for your suggestion. We have included a flow chart in the TIFF file, titled "A flow chart of study population selection from the Bangladesh demographic health survey (BDHS) 2014."

Comment 4: Since the data have been gathered through a multi-stage procedure, why did not the authors use multilevel logistic regression analysis. The empirical studies suggest that women’s empowerment are associated with clusters. I would suggest employing multilevel logistic regression analysis to quantify the unobserved effects on having any STI among married women captured by clusters.

Response: We would like to thank the reviewer for raising this crucial suggestion regarding employing the multilevel logistic regression model. We previously considered the marginal model and adjusted the weight adopted from BDHS in our analysis. However, we have now re-run our analysis using multilevel mixed-effect logistic regression. Moreover, we have revised the statistical analysis section (lines 155-184 in the new edition), the results section (lines 213-240 in the new edition), and table-4 to reflect these changes. In addition, we have updated our discussion section in line with the results section.

Comment 5: How the missing values were managed by stata?

Response: Thank you for highlighting this issue. We did not employ any statistical analysis process such as missing at random or missing completely at random to manage missing values in our analysis. We conducted the analysis using the available complete data in the sample. In the BDHS report the authors did not conduct any missing value operation rather they reported if the missing value were presents. We have added a footnote to Table-3 to indicate that the total may not equal 100.0 percent due to missing values.

Submitted filename: Responses to Reviewers.docx

Click here for additional data file.

26 Oct 2021

7 Nov 2021

Response to Journal Requirements

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Response: Thank you very much. It is really appreciated. We modified certain references during the Round 1 revision. The following is a list of changed references.

Retracted references (lines 520-642 in track changed version)

1. Fabrizio S, Kolovich L, Newiak M, Agarwal A, Yin RJ. Pursuing Women's Economic Empowerment. (IMF Web site): Accessed July 13, 2019. https://www.imf.org/en/Publications/Policy-Papers/Issues/2018/05/31/pp053118pursuing-womens-economic-empowerment. , 2019.

2. Gibson CJ, Huang AJ, McCaw B, Subak LL, Thom DH, Van Den Eeden SK. Associations of Intimate Partner Violence, Sexual Assault, and Posttraumatic Stress Disorder With Menopause Symptoms Among Midlife and Older Women. JAMA Intern Med. 2019;179(1):80-7. Epub 2018/11/20. doi: 10.1001/jamainternmed.2018.5233. PubMed PMID: 30453319.

3. Treves-Kagan S, El Ayadi AM, Morris JL, Graham LM, Grignon JS, Ntswane L, et al. Sexual and Physical Violence in Childhood Is Associated With Adult Intimate Partner Violence and Nonpartner Sexual Violence in a Representative Sample of Rural South African Men and Women. J Interpers Violence. 2019:886260519827661. Epub 2019/02/09. doi: 10.1177/0886260519827661. PubMed PMID: 30735091

5. Prakash R, Singh A, Pathak PK, Parasuraman S. Early marriage, poor reproductive health status of mother and child well-being in India. J Fam Plann Reprod Health Care. 2011;37(3):136-45. Epub 2011/06/02. doi: 10.1136/jfprhc-2011-0080. PubMed PMID: 21628349

6. Kaljee LM, Green M, Riel R, Lerdboon P, Tho le H, Thoa le TK, et al. Sexual stigma, sexual behaviors, and abstinence among Vietnamese adolescents: implications for risk and protective behaviors for HIV, sexually transmitted infections, and unwanted pregnancy. J Assoc Nurses AIDS Care. 2007;18(2):48-59. Epub 2007/04/04. doi: 10.1016/j.jana.2007.01.003. PubMed PMID: 17403496; PubMed Central PMCID: PMCPmc2063998

9. Ilankoon IMPS, Goonewardena CSE, Perera PPR, Fernandopulle R. Vaginal Discharge Women's Health Seeking Behaviours And Cultural Practices. 2015.

10. Gomes CMM, Giraldo PC, Gomes FdAM, Amaral R, Passos MRL, Gonçalves AKdS. Genital ulcers in women: clinical, microbiologic and histopathologic characteristics. Brazilian Journal of Infectious Diseases. Apr. 2007;11(2).

11. Sheffield JS, Wendel GD, Jr., McIntire DD, Norgard MV. Effect of genital ulcer disease on HIV-1 coreceptor expression in the female genital tract. The Journal of infectious diseases. 2007;196(10):1509-16. Epub 2007/11/17. doi: 10.1086/522518. PubMed PMID: 18008231.

24. Hebling EM, Guimaraes IR. Women and AIDS: gender relations and condom use with steady partners. Cad Saude Publica. 2004;20(5):1211-8. Epub 2004/10/16. doi: /S0102-311x2004000500014. PubMed PMID: 15486663.

25. MacPherson EE, Sadalaki J, Njoloma M, Nyongopa V, Nkhwazi L, Mwapasa V, et al. Transactional sex and HIV: understanding the gendered structural drivers of HIV in fishing communities in Southern Malawi. J Int AIDS Soc. 2012;15 Suppl 1:1-9. Epub 2012/06/22. doi: 10.7448/ias.15.3.17364. PubMed PMID: 22713352; PubMed Central PMCID: PMCPmc3499929.

26. Bloom SS, Wypij D, Gupta MD. Dimensions of women’s autonomy and the influence on maternal health care utilization in a north Indian city. Demography. 2001;38(1):67-78.

33. Haque SE, Rahman M, Mostofa MG, Zahan MS. Reproductive health care utilization among young mothers in Bangladesh: does autonomy matter? Women's Health Issues. 2012;22(2):e171-e80

Added references (lines 654-807 in track changed version)

1. Korenromp EL, Rowley J, Alonso M, Mello MB, Wijesooriya NS, Mahiane SG, et al. Global burden of maternal and congenital syphilis and associated adverse birth outcomes-Estimates for 2016 and progress since 2012. PLoS One. 2019;14(2):e0211720. Epub 2019/02/28. doi: 10.1371/journal.pone.0211720. PubMed PMID: 30811406; PubMed Central PMCID: PMCPMC6392238.

2. Prevention CfDCa. Syphilis - CDC Fact Sheet. Available from: https://www.cdc.gov/std/syphilis/stdfact-syphilis.htm.

4. Organisation WH. Sexually transmitted infections (STIs) February 28 2019. Available from: https://www.who.int/news-room/fact-sheets/detail/sexually-transmitted-infections-(stis).

5. Wand H, Ramjee G. Assessing and evaluating the combined impact of behavioural and biological risk factors for HIV seroconversion in a cohort of South African women. AIDS care. 2012;24(9):1155-62.

6. Davey DJ, Shull H, Billings J, Wang D, Adachi K, Klausner J. Prevalence of curable sexually transmitted infections in pregnant women in low-and middle-income countries from 2010 to 2015: a systematic review. Sexually transmitted diseases. 2016;43(7):450.

7. Chesson HW, Mayaud P, Aral SO. Sexually transmitted infections: impact and cost-effectiveness of prevention. 2017.

8. Mayaud P, Mabey D. Approaches to the control of sexually transmitted infections in developing countries: old problems and modern challenges. Sexually transmitted infections. 2004;80(3):174-82.

9. Alomair N, Alageel S, Davies N, Bailey JV. Sexually transmitted infection knowledge and attitudes among Muslim women worldwide: a systematic review. Sexual and reproductive health matters. 2020;28(1):1731296.

10. Jahangir YT, Arora A, Liamputtong P, Nabi MH, Meyer SB. Provider Perspectives on Sexual Health Services Used by Bangladeshi Women with mHealth Digital Approach: A Qualitative Study. International Journal of Environmental Research and Public Health. 2020;17(17):6195

14. Kabir A, Rashid MM, Hossain K, Khan A, Sikder SS, Gidding HF. Women’s empowerment is associated with maternal nutrition and low birth weight: Evidence from Bangladesh Demographic Health Survey. BMC women's health. 2020;20:1-12

15.James-Hawkins L, Peters C, VanderEnde K, Bardin L, Yount KM. Women’s agency and its relationship to current contraceptive use in lower-and middle-income countries: A systematic review of the literature. Global Public Health. 2018;13(7):843-58

16. Ahmed S, Creanga AA, Gillespie DG, Tsui AO. Economic status, education and empowerment: implications for maternal health service utilisation in developing countries. PloS one. 2010;5(6):e11190

18. Yaya S, Uthman OA, Ekholuenetale M, Bishwajit G. Women empowerment as an enabling factor of contraceptive use in sub-Saharan Africa: a multilevel analysis of cross-sectional surveys of 32 countries. Reproductive health. 2018;15(1):1-12

19. Afroja S, Rahman M, Islam L. Women’s Autonomy and Reproductive Healthcare-Seeking Behavior in Bangladesh: Further Analysis of the 2014 Bangladesh Demographic and Health Survey.

20. Story WT, Burgard SA. Couples’ reports of household decision-making and the utilisation of maternal health services in Bangladesh. Social science & medicine. 2012;75(12):2403-11.

21. Parvin GA, Ahsan SR, Chowdhury MR. Women empowerment performance of income generating activities supported by Rural Women Employment Creation Project (RWECP): A case study in Dumuria Thana, Bangladesh. The Journal of Geo-Environment. 2004;4(1):47-62.

22. Schuler SR, Lenzi R, Badal SH, Bates LM. Women’s empowerment as a protective factor against intimate partner violence in Bangladesh: a qualitative exploration of the process and limitations of its influence. Violence against women. 2017;23(9):1100-21.

23. Boroumandfar Z, Kianpour M, Zargham A, Abdoli S, Tayeri K, Salehi M, et al. Changing beliefs and behaviors related to sexually transmitted diseases in vulnerable women: A qualitative study. Iranian journal of nursing and midwifery research. 2017;22(4):303.

24. Alam N, Streatfield PK, Khan SI, Momtaz D, Kristensen S, Vermund SH. Factors associated with partner referral among patients with sexually transmitted infections in Bangladesh. Social science & medicine. 2010;71(11):1921-6.

25. World Economic Forum, Global Gender Gap Report 2021, Insight Report. Geneva, Switzerland: World Economic Forum, 2021

26. Organization IL. Labor force participation rate, female (% of female population ages 15+) ( modeled ILO estimate)- Bangladesh January 29, 2021. Available from: https://data.worldbank.org/indicator/SL.TLF.CACT.FE.ZS?locations=BD

27. Osborn D, Cutter A, Ullah F. Universal sustainable development goals. Understanding the Transformational Challenge for Developed Countries. 2015

34. Hernán MA, Hernández-Díaz S, Werler MM, Mitchell AA. Causal knowledge as a prerequisite for confounding evaluation: an application to birth defects epidemiology. American journal of epidemiology. 2002;155(2):176-84.

35. Victora CG, Huttly SR, Fuchs SC, Olinto M. The role of conceptual frameworks in epidemiological analysis: a hierarchical approach. International journal of epidemiology. 1997;26(1):224-7.

43. Haque SE, Rahman M, Mostofa MG, Zahan MS. Reproductive health care utilisation among young mothers in Bangladesh: does autonomy matter? Women's Health Issues. 2012;22(2):e171-e80.

51. Adriel Monkam Tchokossa RN B, Timothy Golfa RN M, Omowumi Romoke Salau RN M, FWACN AAO. Perceptions and experiences of intimate partner violence among women in Ile-Ife Osun state Nigeria. International Journal of Caring Sciences. 2018;11(1):267-78

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54.Jesmin SS. Married women’s justification of intimate partner violence in Bangladesh: Examining community norm and individual-level risk factors. Violence and victims. 2015;30(6):984-1003.

55. Silverman JG, Gupta J, Decker MR, Kapur N, Raj A. Intimate partner violence and unwanted pregnancy, miscarriage, induced abortion, and stillbirth among a national sample of Bangladeshi women. BJOG: An International Journal of Obstetrics & Gynaecology. 2007;114(10):1246-52.

Response to Reviewer Comments

1. Line 34 lacks and between cross-tab and logistic regression

Response: Thank you. We have already amended it in the Round 1 revision. We have removed the “ cross-tab, logistic regression” (line 34 in track changed version). We have now included “cross-tabulation, the conceptual framework technique and multivariable multilevel mixed-effect logistics regression” ( line 38 in track changed version; line 30 in clean version)

2. Line 37, express figures in the same format. I see that some of them presented to one decimal place yet others are presented to two decimal places. Make this consistent throughout the manuscript

Response: Thank you for highlighting this important concern. We appreciate it. We have presented numbers in a similar format. (lines 47-53 in track change version; lines 33-39 in clean version)

3. Line 57 should be women’s well-being

Response: Thank you. We appreciate it, but we have already revised our introduction in Round 1 (lines 81-97, 107-115,124-144, 151-161,167-171 included in Round 1 ). We have already removed “women well-being” ( line 78 track changed version) and revised 1st paragraph ( lines 81-97 in track changed version; lines 49-65 in cleaned version).

4. Line 62 : reported to lead to

Response: We are grateful for your consideration. However, our introduction was previously revised in Round 1(lines 81-97, 107-115,124-144, 151-161,167-171 included in Round 1). We've previously removed “line 62” ( line 100 track changed version) and included revised sentences (lines 107 to 115 in track changed version; lines 66-74 in cleaned version).

5. Line 105: Outcome variables

Response: Many thanks for your comment. We have amended the statement (line 196 in track changed version; line 135 in cleaned version )

6. In table 1, I think you refer to recoded not recorded

Response: We appreciate your comment. In table 1, now we have changed “recored” to “recoded”.

7. In table 3, control and decision making variables are not presented well. The names of the categories are cut – some words are below the lines. I think you can consider having the table in a smaller font so that the names of the variables and their categories appear in whole.

Response: We appreciate this concern. We have corrected it (both in track changed version & cleaned version)

8. In table 4, the word is reference not referent

Response: We appreciate this concern. But we have already updated table 4 according to the Round 1 revision. We also changed “referent” to ”reference” ( Table 4 both in track changed version & clean version). We have also format Table 3 and Table 4 ( both in track changed version & clean version )

9. Line 213, use have instead of has

Response: Thank you for the suggestion. We have already updated line 213 according to the Round 1 revision (lines 375-385,422-444,447-455,473-477 included in Round 1). We have now rewritten it as “ In this study, 5.59% and 10.84% of the respondents reported genital sores and abnormal genital discharge, respectively.” ( line 375-376 in track changed version; lines 252-253 in cleaned version)

10. Line 214, in not from

Response: Thank you for the suggestion. We have already modified line 214 according to the Round 1 revision (lines 375-385,422-444,447-455,473-477 included in Round 1). We have now rewritten it as “ Women who actively participated in joint decision-making with their husbands or partners regarding their own and child's health were significantly less likely to report STI symptoms.” ( line 378-379 in track changed version; lines 255-256 in cleaned version)

11. Line 239, delete help

Response: Thank you for the suggestion. We have already modified line 239 according to the Round 1 revision (lines 375-385,422-444,447-455,473-477 included in Round 1). We have now rewritten it as “ Receiving support from the husband benefits women in terms of better resource utilisation and the uptake of necessary health services” ( line 391-392 in track changed version; lines 267-268 in cleaned version)

12. You need a final English edit for the manuscript

Response: Thank you. We have adequately corrected the English mistake.

Submitted filename: Responses to Reviewers.docx

Click here for additional data file.

17 Dec 2021

22 Jan 2022

Comment 1 : Congratulations for reaching this far.

The manuscript needs more editing for typographical errors. These are not major but need to be checked so that it reads better. Specifically, some sentences lack joining words, do not read well and the tenses are not correct, which I believe the authors can sort. For example the first sentence in the Statistical analysis section

Response: We are grateful for your consideration. As per your feedback, we have eliminated the typographical errors and performed a thorough line-by-line edit of the manuscript to facilitate better expression.

Comment 2 : I realize that you use STI and STIs as an acronym for sexually transmitted infections interchangeably, I suggest you use one for consistency.

Thank you for your suggestion. Now we have used the term STIs consistently in the manuscript. We have also described STI as STIs and also written symptoms of STIs in line 69, 73, 77, 78, 84, 112, 123, 126, 130, 136, 163, 180, 279, 282, 284, 349, 350, 353,355, 365,367, 372, 374,382.

Comment3 : Additionally, LMIC/LMICs/LMIC countries are used interchangeably. There is need to check them for consistency

Response: We appreciate your comment. We have replaced LMICs as LMIC in line 69, line 97.

3. In the Abstract, What does “conceptual framework technique” mean

Response: Many thanks. Conceptual frameworks assist the use of multivariate approaches by managing complicated hierarchical interrelationships between variables in light of social and biological knowledge. The conceptual framework depicts causal pathways between the outcome and explanatory variables based on empirical knowledge from previous study findings and the researchers’ experience. The factors included in the multivariable model have been chosen using this causal / hierarchical relationship. However, it seems that the word “technique” has added some confusion. That is why, in the manuscript, we have just included “conceptual framework” instead of “conceptual framework technique” (lines 157- 168).

35.Victora CG, Huttly SR, Fuchs SC, Olinto M. The role of conceptual frameworks in epidemiological analysis: a hierarchical approach. International journal of epidemiology. 1997;26(1):224-7.

4. Line 55, begin the sentence with A instead of In, so the sentence should read “A systematic review of studies in 30 low- and middle-income countries (LMIC) showed that STI among women remain ……”

Response: Thank you for highlighting the issues. We changed it in Round 1, and it is currently written in the form you suggested. That is why it has remained unchanged in this version.

5. In table 2 change “Women participate in a variety of decision-making processes” to “Women’s participation in decision-making”

Response: Thank you. We have changed “Women participate in a variety of decision-making processes” to “Women’s participation in decision-making” in Table 2, Table 3, Table 4.

Submitted filename: Responses to Reviewers.docx

Click here for additional data file.

2 Feb 2022

Women empowerment and sexually transmitted infections: Evidence from Bangladesh demographic and health survey 2014

PONE-D-21-00487R3

Dear Dr. Khan,

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PLOS ONE

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Reviewers' comments:

7 Feb 2022

PONE-D-21-00487R3

Women empowerment and sexually transmitted infections: Evidence from Bangladesh demographic and health survey 2014

Dear Dr. Khan:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

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