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Background: Adequate access to sexual and reproductive health services is associated with better results. Analyzing the differences in access and outcomes of sexual and reproductive health (SRH) by share of poverty at the regional level makes it possible to measure the magnitude of the challenge of inequity. This paper aims to estimate the magnitude of health inequality in SRH in Ecuador for the period 2009-2015., Methods: This study analyzed health inequalities in sexual and reproductive health indicators (obstetric and abortion complications, caesarean and home deliveries, adolescent fertility, and maternal mortality) for 2009 and 2015 comparing provinces in Ecuador. The absolute and relative gaps were estimated between provinces grouped by the percentage of individuals in multidimensional poverty; the slope index of inequality and the relative index of inequality were estimated as measures of gradient; and finally, the concentration index was also estimated., Results: The analysis identified that obstetric complications, abortion complications, and cesareans have tended to increase from 2009 to 2015, without relevant differences between provinces ordered by poverty. Adolescent fertility decreased in the country as well as the inequality in its distribution among provinces: the CI was - 0.046 in 2015, down from - 0.084 in 2009. Home deliveries as a ratio of total deliveries have a decreasing trend with mixed results in terms of inequality: while there is a decrease in the absolute gap from - 211.06 to 184.4 between 2009 and 2015, the concentration index increased from - 0.331 to - 0.496. Finally, the maternal mortality rate increased in the period, also with greater inequality: from an absolute gap of - 39.30 in 2019, up to - 46.7 in 2015. In the same direction, the CI went from - 0.127 to - 0.174., Conclusions: Ecuador faces major challenges in terms of both levels and inequalities in SRH outcomes and access to services. These inequalities related to poverty highlight the persistence of social inequities in the country. These health inequalities affect the wellbeing of Ecuadorian women but they are amendable. There is a need for pro-equity interventions, with stronger efforts in areas (provinces) with larger socioeconomic vulnerabilities.

This paper explores the reproductive health-related information seeking of low-income women that has been found to be affected by digital divide disparities. A survey conducted with 70 low-income women explores what information sources women use for reproductive health-related information seeking, what process they go through to find information, and if they are using sources that they trust. The findings of this study detail a two-step information-seeking process that typically includes a preference for personal, informal sources. Women of this income group often rely upon sources that they do not consider credible. While there have been many studies on the end effects of a lack of accurate and accessible reproductive health information, little research has been conducted to examine the reproductive healthcare information-seeking patterns of women who live in poverty.

Individuals who menstruate grapple with diverse challenges in menstrual and reproductive health. This includes financial burdens, societal stigmas, and negative mental and physical health implications. Period poverty, marked by insufficient access to menstrual products, education, and sanitation, remains a prevalent and poorly addressed issue. Alarming statistics highlight the extent of this problem and shed light on the staggering number of individuals lacking access to essential menstrual products. The discourse extends to the safety and accessibility of a diverse array of menstrual products. A comprehensive comparison of the cost of available period products was conducted using data obtained from various retail websites. The often-overlooked potential indirect expenses and profound impacts on quality of life were also discussed. Amidst other public health initiatives, pharmacists have emerged as pivotal advocates and educators. Pharmacists are poised to drive initiatives that increase access to menstrual products through public health education and advocacy. By providing education on different menstrual product options, pharmacists can empower individuals to make informed decisions based on their needs. This perspective illuminates the complex impacts of menstruation on individuals and proposes that pharmacists can play a role in overcoming barriers to access. The proposed strategies, rooted in education, research, and advocacy, pave the way for enhancing access, reducing stigma, and elevating the quality of life for those navigating the intricate complexities of menstruation. [ABSTRACT FROM AUTHOR]

High levels of adolescent pregnancy and child marriage rates in low- and middle-income countries is an issue of concern to many stakeholders, including in Zambia where almost one-third of women give birth before age 18. The aim of this paper is to explore and analyse social norms concerning adolescents' sexual behaviour within the context of an intervention trial in rural communities in southern Zambia. It is based on a qualitative study applying individual interviews, focus group discussions and participatory research methods. We apply the distinction between injunctive and descriptive norms to demonstrate that adolescent girls are caught between conflicting norms. Injunctive norms express that premarital sex, contraceptive use, and discussions about sex between adults and youths are socially condemned. At the same time poor girls are reported to feel pressure towards having sexual relations for the economic benefits such relations can bring, and this practice is considered so common that it amounts to a descriptive norm. Norms and structural conditions combine to create a disabling and disempowering environment for adolescent sexual and reproductive health, which limits girls' agency and exposes them to unwanted pregnancies. [ABSTRACT FROM AUTHOR]

Background: Persons with disabilities comprise more than one billion people in the world, yet they are one of the most discriminated groups and face significant health disparities. Particularly in developing countries, which contain 80% of the entire population with disabilities, these individuals experience major barriers in accessing sexual and reproductive health (SRH) services. Education is an important factor that greatly affects individuals' SRH service utilization. Hence, we sought to investigate the relationship between education and SRH service utilization for persons with disabilities in Bangladesh. Methods: Using an explanatory sequential mixed-methods design, a total of 5000 persons with disabilities were surveyed for the quantitative component and 15 mini-ethnographic case studies were conducted with persons with disabilities for the qualitative component. Chi-squared tests and logistic regression analyses were performed on the survey data, while the qualitative interviews were coded and their SRH themes synthesized accordingly. Results: Our quantitative findings show that education statistically significantly increases persons with disabilities' SRH service utilization of antenatal care, delivery care, postnatal care, and family planning (P < 0.05). Interestingly, for persons with disabilities, primary education shows increased adjusted odds of family planning use but is likely not enough to increase antenatal care, delivery care, or postnatal care use; secondary or post-secondary education may be required to improve utilization of these latter services. Qualitative findings support the association between higher education levels and greater SRH service use. Persons with disabilities of lower educational attainment held misinformation and distrust in SRH services and experienced mistreatment by SRH healthcare providers, discouraging them from seeking future SRH services. Conclusions: We report that higher formal education level is associated with greater SRH service use for persons with disabilities in Bangladesh. Formally educating persons with disabilities expands their SRH knowledge and familiarity with SRH services, as well as leads to more economic opportunities so they can afford SRH services. Increasing formal education levels for persons with disabilities, paired with integrating comprehensive sexuality education (CSE) in their schools, will likely help close the gap in SRH health disparities for this vulnerable population. Plain Language Summary: Out of more than one billion persons with disabilities in the world, 80% of them live in developing countries. Persons with disabilities commonly face discrimination and health disparities, particularly experiencing major barriers in accessing sexual and reproductive health (SRH) services. Education is a key factor that often leads to social and economic empowerment, which positively contributes towards individuals' SRH service utilization. In this paper, we examined the relationship between education and SRH service utilization for persons with disabilities in Bangladesh. We surveyed persons with disabilities across all of Bangladesh on their utilization of SRH services and conducted mini-ethnographic case studies with selected participants to more deeply understand their SRH issues and SRH service utilization. Our survey findings show that education significantly increases persons with disabilities' SRH service utilization of antenatal care, delivery care, postnatal care, and family planning in Bangladesh. Interestingly, for persons with disabilities, primary education may only be able to increase family planning use while secondary or post-secondary education may be required to increase antenatal care, delivery care, and postnatal care use. Our qualitative findings support the association between higher education levels and greater SRH service use. Persons with disabilities of higher education prioritized obtaining formal SRH services from qualified health care providers, even when financially constrained, while lower educated participants tended to be misinformed and distrustful of formal SRH services. We recommend helping persons with disabilities attain higher formal education levels and including comprehensive sexuality education (CSE) in their schools, as it likely will reduce SRH health disparities for this vulnerable group. [ABSTRACT FROM AUTHOR]

Background: Adolescent pregnancy carries both health and economic risks for the pregnant girl and resulting baby, and it is common in Zambia. Providing alternative methods of preventing early pregnancy than abstinence is regarded as culturally and religiously unacceptable in most parts of the country. The community dialogue approach is being tested to address norms and beliefs around early pregnancy, marriage and school dropout, and is based on Paulo Freire's transformative communication approach. The objective of this paper was to understand parents' perspectives on the application of the community dialogue approach in addressing adolescents' early pregnancy and school dropout in a cluster randomized controlled trial in rural Zambia. Methods/design: This was a case study design. We nested the study in the community dialogue intervention arm of the Research Initiative to Support the Empowerment of Girls trial in Zambia. Dialogue meetings were held and economic support was provided for a period of 27 months from September 2016 until November 2018. We held focus group discussions in November 2018 with guardians/parents in six schools in Chibombo District of Central Province. All the discussions were audio recorded and transcribed verbatim. Thematic analysis was used to analyze the data. Results: The guardians/parents perceived the community dialogue to be a relevant approach for addressing social and cultural norms regarding early pregnancy, marriage and school dropout. It was embraced for its value in initiating individual and collective change. The facilitators' interactive approach and dialogue in the community meetings coupled with the use of films and role plays with the parents, lead to active participation and open discussions about sexual and reproductive health (SRH) topics during the community dialogue meetings. Group interactions and sharing of experiences helped parents clarify their SRH values and subsequently made them feel able to communicate about SRH issues with their children. However, cultural and religious beliefs among the parents regarding some topics, like the use of condoms and contraceptives, complicated the delivery of reproductive health messages from the parents to their children. Conclusion: The study indicated that the community dialogue was appreciated by the parents and helped in addressing cultural barriers to discussing SRH issues between generations. Plain language summary: Adolescent pregnancy carries health and economic risks for the pregnant girl and her baby. However, many adolescent girls in Zambia become pregnant and this is partly due to social norms around fertility and marriage. Community dialogue meetings may be useful in order to discuss norms and beliefs around early pregnancy, marriage and school dropout and encourage reflection around cultural practices in the communities. A cluster randomized controlled trial in rural Zambia tested the effects of organizing community dialogue meetings and providing economic support for families with adolescent girls for a period of 27 months, from 2016 to 2018. The objective of this case study was to understand parents' perspectives on the use of the community dialogue approach. Focus group discussions were held in November 2018 with guardians/parents in six schools in Chibombo District of Central Province. The guardians/parents perceived the community dialogue to be a relevant approach for addressing social and cultural norms regarding early pregnancy, marriage and school dropout. The facilitators' interactive approach in the community meetings coupled with the use of films and role plays, lead to active participation and open discussions about sexual and reproductive health topics during the community dialogue meetings. Group interactions and sharing of experiences made the guardians feel able to communicate about sexual and reproductive health issues with their children. However, cultural and religious beliefs among the parents regarding the use of condoms and contraceptives made it difficult for them to touch upon this topic. [ABSTRACT FROM AUTHOR]

This paper presents the findings of a research study in Thane District, Maharashtra, India, on access to sexual and reproductive health and rights (SRHR) for women and girls of Nomadic and Denotified Tribes (NT-DNT). NT-DNT communities face stigma and violence due to their historically criminalised status and nomadic lifestyle. Their precarious legal, social, and economic status has a negative impact on women's SRHR. Existing literature on this subject is sparse, and studies by researchers from within the community, which could bring about organic and community-led change, are almost non-existent. This study, carried out by a woman from a Nomadic Tribe, presents an insider's perspective on the experiences of and factors underlying the violation of the SRHR of girls and women of NT-DNT communities. The study used a human rights-based participatory methodology with qualitative methods including three focus group discussions with 21 women and 10 in-depth interviews with women and key informants from NT-DNT communities. The findings describe the gender, community, and health system barriers which hinder women's and girls' access to SRHR. Issues such as language barriers between the women and medical fraternity, criminalisation by the police, and extreme deprivation – more intense than faced by the general poor – are unique to women of these communities. The NT-DNT communities face extreme deprivation of basic resources such as identity documents, shelter, sanitation, education support, workplace safety, and transportation, which further deny women their sexual and reproductive rights. The paper aims to amplify these women's voices to advocate for better SRHR services for women and girls of NT-DNT communities. [ABSTRACT FROM AUTHOR]

Introduction. Recent experiences from global outbreaks have highlighted the severe disruptions in sexual and reproductive health services that expose women and girls to preventable health risks. Yet, to date, there is no review studying the possible impact of outbreaks on sexual and reproductive health (SRH). Methodology. Studies reporting outbreaks impacting sexual and reproductive health and pregnancy outcomes were identified using MEDLINE, Embase, and ISI-WoS. Reported impacts were reviewed at systems, community, and legislative levels. Results. The initial run listed 4423 studies; the 37 studies that met all inclusion criteria were mainly from Latin America and Africa. Studies on outbreaks of diseases like Zika and Ebola have documented declines in facility-based deliveries, contraceptive use, and antenatal and institutional care due to burdened healthcare system. Service usage was also impacted by a lack of trust in the healthcare system and system shocks, including workforce capacity and availability. At the community level, poverty and lack of awareness were critical contributors to poor access to SRH services. Assessing the target population's knowledge, attitude, beliefs, and behavior and using health literacy principles for communication were fundamental for designing service delivery. Online resources for SRH services were an acceptable medium of information among young adults. In outbreak situations, SRH and pregnancy outcomes were improved by implementing laboratory surveillance, free-of-cost contraceptive services, improved screening through professional training, and quality of care. In addition, mobile health clinics were reported to be effective in remote areas. Knowledge Contribution. In outbreaks, the interventions are categorized into preoutbreak, during, and postoutbreak periods. The proposed steps can help to improve and do course correction in emergencies. Though conducted before the COVID-19 crisis, the authors believe that lessons can be drawn from the paper to understand and mitigate the impact of the pandemic on sexual and reproductive health services. [ABSTRACT FROM AUTHOR]

Comprehensive sexuality education (CSE) seeks to improve young people's knowledge, attitudes and practices in relation to sexual and reproductive health, sexual and social relationships, and dignity and rights. In Ethiopia, young people with disabilities and young women involved in sex work are particularly vulnerable to sexual violence and poor sexual health, yet face stigma and accessibility challenges that continue to exclude them from information, support and services. Because they are often out of school, these groups are also often excluded from programmes that are largely delivered in school settings. This paper explores the challenges faced by these groups of young people in accessing inclusive and age-appropriate sexual and reproductive health knowledge and services in the Ethiopian context and the implications for delivering CSE. The research included literature review, mapping analysis and interviews with young people from those two groups and with service providers and programme implementers. Our findings indicate that young people with disabilities and young women involved in sex work face myriad barriers to accessing information and services that support positive and healthy sexuality, relationships and rights. However, changes over the past decade to national and regional governance structures and a political environment in which CSE has become increasingly contested have generated siloed approaches to the provision of sexual and reproductive health information and services, and poor linkages to complementary services including violence prevention and social protection. It is vital that efforts to implement comprehensive sexuality education are informed by these challenges in the wider policy environment. [ABSTRACT FROM AUTHOR]

Policy Points: Improvements in reproductive health lead to improvements in women's economic empowerment. Contraceptive use improves women's agency, education, and labor force participation; higher maternal age at first birth (reducing adolescent childbearing) increases the likelihood of school completion and participation in the formal labor market; and having fewer children increases labor market participation. Reproductive health is not just a benefit to a woman's individual rights, but her gateway for breaking free from her poverty trap and improving the welfare of herself, her children, and her household. Context: Women's access to employment, business opportunities, and financial resources is critical to achieving the United Nations Sustainable Development Goals over the next 15 years. With increased attention to women's economic empowerment among donors and policymakers across the globe, this moment is a pivotal one in which to review the current state of the research on this topic. Methods: We reviewed the Population and Poverty (PopPov) Research Initiative results from the past 10 years with attention to the causal link between reproductive health improvements and women's economic empowerment, in addition to seminal research that informed our understanding of the link. Findings: Our review of PopPov findings revealed that improvements in reproductive health do lead to improvements in women's economic empowerment; expanding contraceptive use improves women's agency, education, and labor force participation; higher maternal age at first birth (reducing adolescent childbearing) increases the likelihood of school completion and participation in the formal labor market; and having fewer children increases labor force participation. Conclusions: Gaps remain in measuring women's work and in the full exploration of women's economic empowerment. More research is needed regarding the long‐term impact of reproductive health improvements on women's economic empowerment, as some studies have shown that at times unintended negative consequences occur after early positive improvements. [ABSTRACT FROM AUTHOR]

Objectives The maternal and child health (MCH) community, partnering with women and their families, has the potential to play a critical role in advancing a new multi-sector social movement focused on creating a women's reproductive and economic justice agenda. Since the turn of the twenty-first century, the MCH field has been planting seeds for change. The time has come for this work to bear fruit as many states are facing stagnant or slow progress in reducing infant mortality, increasing maternal death rates, and growing health inequities. Methods This paper synthesizes three current, interrelated approaches to addressing MCH challenges-life course theory, preconception health, and social justice/reproductive equity. Conclusion Based on these core constructs, the authors offer four directions for advancing efforts to improve MCH outcomes. The first is to ensure access to quality health care for all. The second is to facilitate change through critical conversations about challenging issues such as poverty, racism, sexism, and immigration; the relevance of evidence-based practice in disenfranchised communities; and how we might be perpetuating inequities in our institutions. The third is to develop collaborative spaces in which leaders across diverse sectors can see their roles in creating equitable neighborhood conditions that ensure optimal reproductive choices and outcomes for women and their families. Last, the authors suggest that leaders engage the MCH workforce and its consumers in dialogue and action about local and national policies that address the social determinants of health and how these policies influence reproductive and early childhood outcomes. [ABSTRACT FROM AUTHOR]

This study assesses the impact of a voucher project that targeted vulnerable and poor pregnant women in Uganda. Highly subsidised vouchers gave access to a package of safe delivery services consisting of four antenatal visits, safe delivery, one postnatal visit, the treatment and management of selected pregnancy-related medical conditions and complications, and emergency transport. Vouchers were sold during the project's operational period from 2016 to 2019. This study covers 8 out of 25 project-benefiting districts in Uganda and a total of 1,881 pregnancies, including both beneficiary and non-beneficiary mothers. Using a matching design, the results show a positive effect on the survival of new-born babies. The difference in the survival rate between the control group and the treatment group is 5.4% points, indicating that the voucher project reduced infant mortality by more than 65 per cent. [ABSTRACT FROM AUTHOR]

Intoduction: Transactional sex (TS) is common in areas of sub-Saharan Africa, motivated by reasons beyond financial support. Through this qualitative study we sought to understand the motivation driving TS among adolescent schoolgirls in rural western Kenya where rates are reportedly high. Identifying and understanding drivers within the local context is necessary for implementation of successful public health policy and programming to reduce the associated harms impacting health and wellbeing. Methods: To understand the drivers of sexual behaviors, individual views, and sociocultural norms, we spoke with schoolgirls, male peers, parents and teachers. The three latter groups may influence, encourage, and shape girls' views and behaviors and thus contribute to the perpetuation of cultural and societal norms. Results: One hundred and ninety-nine participants took part across 20 FGDs; 8 comprised of schoolgirl groups, and 4 each of schoolboy, parent or teacher groups. Through thematic analysis, poverty emerged as the key driver of TS and a normative behaviour amongst secondary school girls. Subthemes including parental influence, need for menstrual pads, pressure from boda boda drivers, peer pressure, and blame were part of a complex relationship linking poverty with TS. Discussion: We conclude that whilst TS is perceived as inevitable, normal and acceptable it is not really a choice for many girls. Exploring ways to encourage communication between families, including around menstruation, may help enable girls to ask for help in acquiring essential items. In addition, education at a community level may shift social norms over time and decrease the prevalence of age-disparate TS among schoolgirls and older, wealthier men in the community. [ABSTRACT FROM AUTHOR]

Background: Nearly 100 million people are pushed into poverty every year due to catastrophic health expenditures (CHE). We evaluated the impact of cash support programs on healthcare utilization and CHE among households participating in a cluster-randomized controlled trial focusing on adolescent childbearing in rural Zambia. Methods and findings: The trial recruited adolescent girls from 157 rural schools in 12 districts enrolled in grade 7 in 2016 and consisted of control, economic support, and economic support plus community dialogue arms. Economic support included 3 USD/month for the girls, 35 USD/year for their guardians, and up to 150 USD/year for school fees. Interviews were conducted with 3,870 guardians representing 4,110 girls, 1.5--2 years after the intervention period started. Utilization was defined as visits to formal health facilities, and CHE was health payments exceeding 10% of total household expenditures. The degree of inequality was measured using the Concentration Index. In the control arm, 26.1% of the households utilized inpatient care in the previous year compared to 26.7% in the economic arm (RR = 1.0; 95% CI: 0.9--1.2, p = 0.815) and 27.7% in the combined arm (RR = 1.1; 95% CI: 0.9--1.3, p = 0.586). Utilization of outpatient care in the previous 4 weeks was 40.7% in the control arm, 41.3% in the economic support (RR = 1.0; 95% CI: 0.8--1.3, p = 0.805), and 42.9% in the combined arm (RR = 1.1; 95% CI: 0.8--1.3, p = 0.378). About 10.4% of the households in the control arm experienced CHE compared to 11.6% in the economic (RR = 1.1; 95% CI: 0.8--1.5, p = 0.468) and 12.1% in the combined arm (RR = 1.1; 95% CI: 0.8--1.5, p = 0.468). Utilization of outpatient care and the risk of CHE was relatively higher among the least poor than the poorest households, however, the degree of inequality was relatively smaller in the intervention arms than in the control arm. Conclusions: Economic support alone and in combination with community dialogue aiming to reduce early childbearing did not appear to have a substantial impact on healthcare utilization and CHE in rural Zambia. However, although cash transfer did not significantly improve healthcare utilization, it reduced the degree of inequality in outpatient healthcare utilization and CHE across wealth groups. [ABSTRACT FROM AUTHOR]

Internally displaced women are underserved by health schemes and policies, even as they may face greater risk of violence and unplanned pregnancies, among other burdens. There are an estimated 450,000 internally displaced persons in India, but they are not formally recognised as a group. Displacement has been a common feature in India's northeast region. This paper examines reproductive and maternal health (RMH) care-seeking among Bru displaced women in India. The study employed qualitative methodology: four focus group discussions (FGDs) were held with 49 displaced Bru women aged 18–45 between June and July 2018; three follow-up interviews with FGD participants and five in-depth interviews with community health workers (Accredited Social Health Activists – ASHAs) in camps for Bru displaced people in the Indian state of Tripura. All interviewees gave written or verbal informed consent; discussions were conducted in the local dialect, recorded, and transcribed. Data were indexed deductively from a dataset coded using grounded approaches. Most women were unaware of many of the RMH services provided by health facilities; very few accessed such care. ASHAs had helped increase institutional deliveries over the years. Women were aware of temporary contraceptive methods as well as medical abortion, but lacked awareness of the full range of contraceptive options. Challenges in accessing RMH services included distance of facilities from camps, and multiple costs (for transport, medicines, and informal payments to facility staff). The study highlighted a need for comprehensive intervention to improve RMH knowledge, attitudes, and practices among displaced women and to reduce access barriers. [ABSTRACT FROM AUTHOR]

In this paper, we present the results of a qualitative study by a non-profit organisation implementing a community-based urban adolescent development programme. The study highlights the sexual and reproductive health and rights (SRHR) situation of marginalised young women in a developed state of India. Our findings, based on in-depth interviews with young women and frontline health providers, show that structural factors, such as economic and social stratifiers, gender norms and cultural beliefs, result in further marginalisation of young women. In turn, marginalisation adversely affects the realisation of SRHR through discriminatory practices around menstruation and lack of control in matters related to sexuality, contraception, pregnancy and safe abortion. Rights to the highest standards of sexual and reproductive health (SRH) care are compromised. Health system factors like providers' attitudes and knowledge, commodity supplies, and indifference to ensuring delivery of contraceptives and other services often result in unplanned pregnancies and affect the quality of young women's SRH care. Whatever information and support adolescents and young women get is from local community-based organisations. We conclude that structural determinants and violations of fundamental rights to education, equal opportunities and participation constitute a significant barrier to the enjoyment of SRHR by the marginalised young women in the study. Unless these are addressed, government policies and programmes to promote young people's SRHR will not benefit young women from disadvantaged communities. Partnership and complementarity between government programmes, adolescents and health rights civil society organisations are recommended to promote rights-based, equitable adolescent and youth-friendly services to this vulnerable population. [ABSTRACT FROM AUTHOR]

Background: The adolescent (ages 15-19) and young adult (ages 20-24) years are a crucial time as many sexual and reproductive health (SRH) transitions take place in these years. The study of youth SRH transitions in sub-Saharan Africa is limited due to a paucity of longitudinal data needed to examine the timing and circumstances of these transitions.Methods: This paper uses recently collected longitudinal data from select urban areas in Kenya and Nigeria that include a large youth sample at baseline (2010/2011) and endline (2014). We control for unobserved heterogeneity in our modelling approach to correct for selectivity issues that are often ignored in similar types of analyses.Results: We demonstrate that the transition patterns (i.e., sexual initiation, first marriage, and first pregnancy/birth) differ within and across the urban areas and countries studied. Urban Kenyan youth have more premarital sex and pregnancy than youth from the Nigerian cities. Further analyses demonstrate that more educated and wealthier youth transition later than their less educated and poorer counterparts.Conclusions: The findings from this study can be used to inform programs seeking to serve young people based on their varying reproductive health needs in different contexts over the adolescent and young adult years. [ABSTRACT FROM AUTHOR]

The article presents abstracts of articles related to children's health and care which include "Social (pragmatic) communication disorders and autism spectrum disorder," by G. Baird and C. F. Norbury, " Poverty and child health in the UK: using evidence for action," by S. Wickham and colleagues, and "Predictors of poor school readiness in children without developmental delay at age 2," by B. B. Nelson and colleagues.

Access to medication abortion—the use of medications rather than a surgical procedure for pregnancy termination—is an essential reproductive healthcare service. Following the overturn of Roe v. Wade and federal abortion protections in the United States, medication abortion and telemedicine for abortion are increasingly vital. Black, Latinx, and lower-income women in the United States already experience disproportionate barriers to abortion care and interpersonal and structural violence—interconnected, social systems that police bodily autonomy. This current study examined qualitative data from a larger community-led, reproductive justice project on medication abortion perspectives among Black and Latinx women in a large, urban center in Georgia. We used thematic analysis to examine interviews (N = 82) with key informants (n = 20) and interviews (n = 32) and focus groups (n = 30) with Black and Latinx women ages 18–51 years. Four violence-related themes were identified: (a) sexual assault and intimate partner violence as reasons for abortion; (b) reproductive coercion by partners and family members; (c) reproductive coercion by predominantly White providers; and (d) abortion bans, the legacy of enslavement, immigration enforcement, and poverty as structural violence. Shifting family planning care to be patient- and community-centered, in conjunction with policy advocacy to change oppressive systems, is critical. [ABSTRACT FROM AUTHOR]

Background: In many contexts, women with disability have less access to sexual and reproductive health information, screening, prevention, and care services than women without disability. Women with disability are also known to be more likely to experience physical and sexual violence than women without disability. In the Philippines, health service providers often have little awareness of the sexual and reproductive experiences of women with disability and limited capacity to provide services in response to their needs. Very limited data are available to inform development of disability-inclusive sexual and reproductive health, and violence prevention and response, services in the country. This paper presents the protocol for W-DARE (Women with Disability taking Action on REproductive and sexual health), a three-year program of participatory action research that aims to improve the sexual and reproductive health of women with disability in the Philippines.Design: W-DARE is a disability-inclusive program that will use mixed methods to 1) increase understanding of factors influencing the sexual and reproductive health of women with disability, and 2) develop, implement and evaluate local interventions to increase supply of and demand for services. W-DARE will generate data on the prevalence of disability in two districts; the wellbeing and community participation of people with and without disability, and identify barriers to community; and describe the sexual and reproductive health needs and experiences, and service-related experiences of women with disability. These data will inform the development and evaluation of interventions aiming to improve access to sexual and reproductive health services, and violence prevention and response services, for women with disability. Local women with disabilities, their representative organisations, and SRH service providers will be involved as members of the research team across all stages of the research.Discussion: This three-year study will provide evidence about factors undermining the sexual and reproductive health of women with disability in a lower-middle income country, and provide new insights about what may be effective in increasing access to services in settings of limited resources. Findings will be relevant across Asia and the Pacific. Analysis of the program will also provide evidence about disability-inclusion in participatory action research approaches. [ABSTRACT FROM AUTHOR]

An introduction to articles in the issue is presented that focus on how sex, sexualities, and education continue to be constructed in South Africa, including underground sexual cultures that involve online sexually explicit materials and pornography, Black African male teachers engaged in same-sex sexual relations, and barriers that prevent teaching for sexual diversity.

Gunnar Inghe (1910–1977) was a founding father of Scandinavian social medicine and the first editor of the Scandinavian Journal of Social Medicine. He worked as a physician for social care clients in Stockholm from 1944 to 1961 and was professor in social medicine from 1961 to 1975. We (F.D. and U.J.) were his last two PhD students. As we were recollecting the 50-year history of the Scandinavian Journal of Public Health in 2022, it became evident to us how relevant Gunnar Inghe's work, 45 years after his death, still is for today's social medicine, population health research and policy in Scandinavia. We shall explain why with five examples of Inghe's work: reproductive health, health of paupers, foundation of the discipline, international solidarity and collaboration between medical and social care. [ABSTRACT FROM AUTHOR]

By 2050, the Global South will contain three-quarters of the world's urban inhabitants, yet no standardized categorizations of urban areas exist. This makes it challenging to compare sub-groups within cities. Sexual and reproductive health and rights (SRHR) are a critical component of ensuring that populations are healthy and productive, yet SRHR outcomes within and across urban settings vary significantly. A scoping review of the literature (2010–2022) was conducted to describe the current body of evidence on SRHR in urban settings in the Global South, understand disparities, and highlight promising approaches to improving urban SRHR outcomes. A total of 115 studies were identified, most from Kenya (30 articles; 26%), Nigeria (15; 13%), and India (16; 14%), focusing on family planning (56; 49%) and HIV/STIs (43; 37%). Findings suggest significant variation in access to services, and challenges such as gender inequality, safety, and precarious circumstances in employment and housing. Many of the studies (n = 84; 80%) focus on individual-level risks and do not consider how neighborhood environments, concentrated poverty, and social exclusion shape behaviors and norms related to SRHR. Research gaps in uniformly categorizing urban areas and key aspects of the urban environment make it challenging to understand the heterogeneity of urban environments, populations, and SRHR outcomes and compare across studies. Findings from this review may inform the development of holistic programs and policies targeting structural barriers to SRHR in urban environments to ensure services are inclusive, equitably available and accessible, and direct future research to fill identified gaps. [ABSTRACT FROM AUTHOR]

Background: Available evidence suggests that menstrual health and management have been impaired during the COVID-19 syndemic. However, research in this area is scarce, and it is failing to voice the experiences of women and people who menstruate regarding their menstrual experiences. Objectives: This study aimed to explore the experiences of menstrual health and menstrual management among women and people who menstruate in the Barcelona area (Spain) during the COVID-19 syndemic. Design: This is a qualitative study, conducted taking a critical feminist approach, is embedded in the 'Equity and Menstrual Health in Spain' project. Methods: It includes photo-elicitation individual interviews with 34 women and people who menstruate in the area of Barcelona (Spain). Data were collected in person and through telephone calls between December 2020 and February 2021. Analyses were performed using Thematic Analysis. Results: Main findings navigated through the menstrual changes experienced by some participants, especially women living with long COVID-19, and the barriers to access healthcare and menstrual products during COVID-19. While some participants experienced menstrual poverty, this did not appear to be exacerbated during COVID-19. Instead, access to menstrual products was compromised based on products' availability and mobility restrictions. Menstrual management and self-care were generally easier, given that menstrual experiences were almost exclusively relegated to private spaces during lockdown periods. Conclusions: Our findings highlight the need to further research and policy efforts towards promoting menstrual health and equity, considering social determinants of health, and taking intersectional and gender-based approaches. These strategies should be further encouraged in social and health crises such as the COVID-19 syndemic. [ABSTRACT FROM AUTHOR]

Objective: A literature review was conducted to analyze the impact of COVID-19 on documented preexisting determinants of adolescent pregnancy in sub-Saharan Africa such as poverty, inequitable gender norms, low access to education, and reproductive health services. Methods: The terms "sub-Saharan Africa," "Gender Norms," "Poverty," and "Adolescent Pregnancy" were used to search the literature for preexisting determinants of adolescent pregnancy in academic and grey literature. "COVID-19" was added to investigate the potential consequences of the pandemic. The literature revealed similar experiences in adolescent girls during the Ebola outbreak, which lead to the analysis of government and healthcare official responses to previous epidemics. Results: The literature review revealed that the relationship between identified micro (inequitable gender norms, transactional sex, sexual and gender-based violence, early marriage, and menstruation) and macro (poverty, education, and healthcare) factors contributing to adolescent pregnancy were exacerbated by the COVID-19 pandemic. Conclusion: Three realistic targets including, expanding and communicating available reproductive health resources, prioritizing the role of women in the economy, and ensuring return to school should be included as part of current COVID-19 mitigation programs. Additionally, these interventions should be incorporated in future public health preparedness plans to reduce the risk of adolescent pregnancy during public health emergencies. [ABSTRACT FROM AUTHOR]

Copyright of Reproductive Health is the property of BioMed Central and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Assessing the gap between rich and poor is important to monitor inequalities in health. Identifying the contribution to that gap can help policymakers to develop interventions towards decreasing that difference. To quantify the wealth inequalities in health preventive measures (bed net use, vaccination, and contraceptive use) to determine the demographic and socioeconomic contribution factors to that inequality using a decomposition analysis. Data from the 2015 Immunisation, Malaria and AIDs Indicators Survey were used. The total sample included 6946 women aged 15–49 years. Outcomes were use of insecticide-treated nets (ITN), child vaccination, and modern contraception use. Wealth Index was the exposure variable and age, marital status, place of residence, region, education, occupation, and household wealth index were the explanatory variables. Wealth inequalities were assessed using concentration indexes (Cindex). Wagstaff-decomposition analysis was conducted to assess the determinants of the wealth inequality. The Cindex was −0.081 for non-ITN, −0.189 for lack of vaccination coverage and −0.284 for non-contraceptive use, indicating a pro-poor inequality. The results revealed that 88.41% of wealth gap for ITN was explained by socioeconomic factors, with education and wealth playing the largest roles. Lack of full vaccination, socioeconomic factors made the largest contribution, through the wealth variable, whereas geographic factors came next. Finally, the lack of contraceptive use, socioeconomic factors were the main explanatory factors, but to a lesser degree than the other two outcomes, with wealth and education contributing most to explaining the gap. There was a pro-poor inequality in reproductive and child preventive measures in Mozambique. The greater part of this inequality could be attributed to wealth, education, and residence in rural areas. Resources should be channeled into poor and non-educated rural communities to tackle these persistent inequities in preventive care. [ABSTRACT FROM AUTHOR]

Termination of pregnancy (TOP) is considered an important component of sexual and reproductive health internationally, but there are known barriers in Australia and countries worldwide. This study investigated the issues for GPs regarding aiding access to TOP and providing early medical abortion (EMA) services for Tasmanian women. Specifically, the aims of the study were to identify the knowledge and attitudes of Tasmanian GPs regarding TOP services and to determine which known barriers to providing EMA are most significant for GPs in Tasmania, Australia. A survey was developed and piloted based on previous qualitative research that identified known barriers to accessing TOP. Surveys were posted to all identified GPs in Tasmania with a reply-paid envelope. In all, 211 (27.4%) responses were returned. GPs identified difficulty accessing TOP services, particularly for rural women and those on a low income. Almost half the GPs, excluding conscientious objectors, indicated they would be interested in providing EMA services, but perceived barriers were significant. The most significant barriers related to accessing appropriate training and support. There was uncertainty around financial reward, support services, medical indemnity and access to the medical abortifacient medications mifepristone and misoprostol. In conclusion, accessing TOP remains an issue for Tasmanian women. Many Tasmanian GPs are interested in providing EMA services if barriers are addressed, but there is a lack of knowledge about the practicalities of implementing EMA. Providing practical support to GPs and increasing knowledge pertaining to EMA provision in general practice could improve access in primary care. [ABSTRACT FROM AUTHOR]

In the tribal region, risk of death among neonates is influenced to a great extent by factors related to the mother such as situation of the mother prior to and post pregnancy, care received before, during and after pregnancy, birth order, and care received by the child during the first few years of his/her life. There is paucity of basic epidemiological data on reproductive health outcomes of displaced people (Hynes et al. in JAMA 288(5):595–603, 2002). Therefore, this study aims to examine the social factors responsible for neonatal deaths among displaced tribal communities in India. Sequential exploratory study design was used to collect data from displaced tribal communities in the state of Odisha and Chhattisgarh during 2016–2017. A purposive sampling method was used to select the sample from the definite population. Results indicate that in total 115 (59.3%) women had experienced at least one child deaths. Analysis of neonatal deaths suggests that about 39.2% women experienced at least one or more neonatal death during the last 5 years. Women who chose to deliver at home experience higher neonatal deaths (47.1%) in comparison to the women who delivered at the health facility (26.0%). The logistic regression analysis indicate that mothers education, place of delivery, utilization of the services, possession of Below Poverty Line (BPL) card and Particularly Vulnerable Tribal Group (PVTG) status are significant predictors of neonatal mortality. The probability of occurrence of neonatal mortality is 60% lower for literate women as compared to the illiterate women. Findings of the study identified three phases of delay that affect displaced tribal women in accessing and receiving health care services. Displaced tribal women are late in recognizing health problems of neonates and delay in seeking medical care due to rooted cultural barriers. Women who participated in this study had low levels of risk perception about delivering children at home and visiting traditional healer for the treatment. This is mainly due to their personal experiences of uneventful deliveries conducted by mothers-in-law or Traditional Birth Attendants (TBA) and sociocultural beliefs. There is need for provision of culturally sensitive instruction to service providers. This would further motivate service providers to sensitize the displaced tribal communities on various free healthcare services available to them. [ABSTRACT FROM AUTHOR]

Anaemia has prevailed as a mild to severe public health problem in Ethiopian women of reproductive age. Many studies carried out on anaemia have been limited to subnational assessments and subgroups of women. The effects of potential factors thought to affect anaemia and severity levels of anaemia have not been well considered. Therefore, this study identifies individual, household and community level factors associated with anaemia among women of reproductive age in Ethiopia applying multilevel ordinal logistic regression models. Proportional odds assumption was tested by likelihood ratio test. About 35.6% of the variation on anaemia was due to between household and community level differences. Pregnancy (adjusted odds ratio [AOR] = 2.30, 95% confidence interval [CI]: 1.82, 2.91), HIV (AOR = 2.40, 95% CI: 1.76, 3.25), giving birth once (AOR = 1.2, 95% CI: 1.05, 1.40), giving birth more than once (AOR = 1.4, 95% CI: 1.19, 1.71), living with five or more family members (AOR = 1.24, 95% CI: 1.05, 1.47), living in poorest households (AOR = 1.34, 95% CI: 1.2, 1.61) and rural area (AOR = 1.57, 95% CI: 1.28, 1.92) were associated with greater odds of more severe anaemia compared with their respective counter parts. Secondary and above education (AOR = 0.83, 95% CI: 0.70, 0.97) and use of pills, implants or injectable (AOR = 0.67, 95% CI: 0.59, 0.77) were associated with lower odds of more severe anaemia. Anaemia prevention and control programmes need to be strengthened for women living with HIV/AIDS and during pregnancy. Household poverty reduction and social protection services need to be strengthened and integrated in anaemia prevention and management activities in women. [ABSTRACT FROM AUTHOR]

The objective of this qualitative study was to understand Nepali female sex workers' (FSWs) condom negotiation strategies. In 2016, we conducted 30 semi-structured, in-depth interviews with street- and brothel-based FSWs residing in Kathmandu, Nepal. Participants reported that their first entry into sex work typically occurred between the ages of 17–32, and the average duration of women's involvement with sex work was 8 years. FSWs reported high knowledge and awareness of condoms, and many women had used various sexual and reproductive health services. FSWs used three types of negotiation strategies: withholding or refusing sex, providing risk information, and direct request. While some FSWs believed that these strategies were useful and successful, we found that, for some women, condom negotiation strategies were difficult to implement due to fear of abuse and threats of violence by clients. Condom negotiation was further complicated by poverty and substance abuse, and several narratives revealed the influence of gender and social norms on safe sexual practices. The findings highlight the need for improved sexual health interventions that incorporate a range of negotiation strategies and techniques (e.g., nonverbal communication and reward strategies) and aim to mitigate harm and violence against FSWs. [ABSTRACT FROM AUTHOR]

Objectives: The aims of the study were to investigate the reproductive health challenges in Nigeria of male and female street beggars and the use of reproductive health services by female street beggars.Methods: The study had a cross-sectional descriptive design. An interviewer-administered questionnaire, designed by the authors, was used to elicit information from 100 male and female street beggars recruited over a 4 week period in Ife-Ijesa zone, south-western Nigeria. Information was obtained about male and female participants' reproductive health challenges (symptoms and issues) and female participants' use of reproductive health services.Results: More than a third of participants were aged ≥60 years (37%), 57% were men, 82% were from the Hausa tribe and 92% were Muslims. The main reasons given for street begging were poverty (30%) and physical handicap (66%). Although most of the street beggars were aware of the availability of reproductive health services (81%) and where to access them (89%), only a small proportion of female street beggars had given birth in hospital (9.3%) and family planning services (32.6%).Conclusion: Street beggars are a poor and vulnerable group with reproductive health challenges. They have difficulty accessing reproductive health services because of physical disabilities and related low socioeconomic status. [ABSTRACT FROM AUTHOR]

Background: Until recently, global public health initiatives have tended to overlook the ways that social factors shape adolescent health, and particularly how these dynamics affect the specific needs of adolescents in relation to information about puberty, menstruation and sexual health. This article draws on mixed methods data from rural and urban areas of Ethiopia to explore how access to health information and resources - and subsequently health outcomes - for adolescents are mediated by gender and age norms, living in different geographical locations, poverty, disability and migration. Methods: Data was collected in 2017–2018 for the Gender and Adolescence: Global Evidence (GAGE) mixed-methods longitudinal research baseline in three regions of Ethiopia (Afar, Amhara and Oromia). Quantitative data was collected from over 6800 adolescents and their caregivers, with qualitative data obtained from a sub-sample of 220 adolescents, their families and communities. Adolescent participants shared their experiences of health, illness and nutrition over the previous year; their knowledge and sources of information about sexual and reproductive health and puberty; and their attitudes toward sexual and reproductive health. Regression analysis was used to explore differences by gender, age, rural/urban residence, and disability status, across a set of adolescents' health knowledge and other outcomes in the quantitative data. Intersectional analysis was used in analysing the qualitative data. Results: Analysis suggested that gender inequality intersects with age, disability and rural/urban differences to shape young people's access to information about puberty, with knowledge about this topic particularly lacking amongst younger adolescents in rural areas. Drought and lack of access to clean water exacerbates health challenges for adolescents in rural areas, where a lack of information and absence of access to preventive healthcare services can lead to permanent disability. The research also found that gaps in both school-based and alternative sources of education about puberty and menstruation reinforce stigma and misinformation, especially in rural areas where adolescents have higher school attrition rates. Gendered cultural norms that place high value on marriage and motherhood generate barriers to contraceptive use, particularly in certain rural communities. Conclusions: As they progress through adolescence, young people's overall health and access to information about their changing bodies is heavily shaped by intersecting social identities. Structural disadvantages such as poverty, distress migration and differential access to healthcare intersect with gender norms to generate further inequalities in adolescent girls' and boys' health outcomes. [ABSTRACT FROM AUTHOR]

The dominant discourse of menstrual hygiene management presents successful containment of menstruation as crucial to "successful" Western femininity. Yet, little research in "developed" contexts has examined how compromised "menstrual hygiene management"—as in instances of menstrual poverty—shapes gender identity construction. In this discursive feminist study designed to address this oversight, we analyzed identity work in 12 narratives from economically deprived young women in Aotearoa (New Zealand). The results show how the politics of disgust govern talk and practice regarding menstruation in ways that engender both compliance and attempts at resistance. The results provide insights useful for designing interventions and suggest further research into menstrual poverty in developed contexts. [ABSTRACT FROM AUTHOR]

Background: Little information exists about individuals born outside of the United States who seek abortion services from U.S.-based providers. Baseline data are necessary to identify future changes in the profile of this population. Materials and Methods: Using the Guttmacher Institute's Abortion Patient Survey, we pooled two national samples of individuals obtaining abortions from 2008–2009 to 2013–2014 to provide data on 17,873 respondents, 16% of whom were immigrants. We estimated the distribution of immigrant and U.S.-born respondents across demographic and circumstantial characteristics such as age, poverty level, and gestational age at abortion. We compared the distribution of characteristics by nativity status using chi-square tests. Results: The majority of immigrants obtaining abortions were in their 20s (51%), had poverty-level (50%) or near poverty-level incomes (23%), and had graduated from high school (78%). Almost half (45%) were uninsured and a similar proportion had been in the United States for less than 10 years (44%); nearly one-quarter completed their survey in Spanish. Compared with U.S.-born respondents, a larger proportion of immigrants were older, uninsured, and had not completed high school. A smaller proportion of immigrants compared with nonimmigrants had their abortions after 12 weeks (8% vs. 11%) or traveled over 50 miles to obtain their abortion (9% vs. 16%). Conclusions: Particularly with the continued rise in both restrictive abortion and immigration policies in the United States, it is critical to monitor how immigrants' use of and access to abortion services are impacted in the changing environment. Ensuring that policies and clinical practices facilitate abortion access for immigrants will serve to better support the reproductive health needs of all women. [ABSTRACT FROM AUTHOR]

Background: The postpartum care visit (PPCV) plays an important role in ensuring the well-being of mother and infant. This study sought to assess correlates of PPCV attendance among women who are at high risk of nonattendance. Materials and Methods: This study used deidentified medical claims data from Virginia Premier—a nonprofit Managed Care Organization that provides health insurance for Medicaid beneficiaries. The association between various correlates and PPCV attendance was examined using multiple logistic regression analyses. Results: Of the 25,692 women in the study, more than half (50.5%) did not attend a postpartum visit. Racial/ethnic minorities and women receiving the majority of their care at hospitals, Health Departments, or Federally Qualified Health Centers were more likely to attend their postpartum visit. Women who smoked and those who did not attend prenatal care had reduced odds of postpartum visit attendance. Age, education, and delivery method were not found to be significantly associated with PPCV attendance. Conclusions: Our results highlight factors associated with attendance of PPCVs in low income populations. The continued disparity in postpartum care utilization compels additional efforts to improve access to health services across socioeconomic and demographic boundaries. [ABSTRACT FROM AUTHOR]

Copyright of Tropical Medicine & International Health is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Background: Adolescent pregnancies pose a risk to the young mothers and their babies. In Zambia, 35% of young girls in rural areas have given birth by the age of 18 years. Pregnancy rates are particularly high among out-of-school girls. Poverty, low enrolment in secondary school, myths and community norms all contribute to early childbearing. This protocol describes a trial aiming to measure the effect on early childbearing rates in a rural Zambian context of (1) economic support to girls and their families, and (2) combining economic support with a community intervention to enhance knowledge about sexual and reproductive health and supportive community norms. Methods/design: This cluster randomized controlled trial (CRCT) will have three arms. The clusters are rural schools with surrounding communities. Approximately 4900 girls in grade 7 in 2016 will be recruited from 157 schools in 12 districts. In one intervention arm, participating girls and their guardians will be offered cash transfers and payment of school fees. In the second intervention arm, there will be both economic support and a community intervention. The interventions will be implemented for approximately 2 years. The final survey will be 4.5 years after recruitment. The primary outcomes will be "incidence of births within 8 months of the end of the intervention period", "incidence of births before girls' 18th birthday" and "proportion of girls who sit for the grade 9 exam". Final survey interviewers will be unaware of the intervention status of respondents. Analysis will be by intention-to-treat and adjusted for cluster design and confounders. Qualitative process evaluation will be conducted. Discussion: This is the first CRCT to measure the effect of combining economic support with a community intervention to prevent adolescent childbearing in a low- or middle-income country. We have designed a programme that will be sustainable and feasible to scale up. The findings will be relevant for programmes for adolescent reproductive health in Zambia and similar contexts. [ABSTRACT FROM AUTHOR]

The article offers a review of prevention and intervention programs for determining intimate partner violence (IPV) in Sub-Saharan Africa, and mentions prevalence, determinants, and impact of IPV interpreted against the social ecological theory; prevention programs and community building in Africa.

The influence of disadvantaged or deprived community on individuals' health risk-behaviors is increasingly being documented in a growing body of literature. However, little is known about the effects of community characteristics on women's sexual attitudes and behaviors. To examine community effects on married women's safer sex negotiation attitudes, we analyzed cross-sectional data from the 2011 Bangladesh Demographic and Health Surveys on a sample of 15,134 married women in 600 communities. We estimated two multilevel logistic regression models. Model 1, which included only individual-level variables, showed that women's autonomy/empowerment, age, and HIV knowledge had significant associations with their safer sex negotiation attitudes. We did not find any socioeconomic status gradient in safer sex negotiation attitudes at the individual level. Adding community-level variables in Model 2 significantly improved the fit of the model. Strikingly, we found that higher community-level poverty was associated with greater positive safer sex negotiation attitudes. Prevailing gender norms and overall women's empowerment in the community also had significant effects. While research on community influences calls for focusing on disadvantaged communities, our research highlights the importance of not underestimating the challenges that married women in economically privileged communities may face in negotiating safer sex. To have sufficient and equitable impact on married women's sexual and reproductive health, sexual and reproductive health promotion policies and programs need to be directed to women in wealthier communities as well. [ABSTRACT FROM AUTHOR]