Knowledge, Attitude and Practice of Migrant Workers’ Wives on HIVAIDS in Bangladesh

TECHNICAL REPORT ON
KNOWLEDGE, ATTITUDE AND
PRACTICE OF
MIGRANT WORKERS’ WIVES ON
HIV/AIDS IN BANGLADESH
Study conducted by
Eminence
with support from World Health Organization
September 2011

Key Words
HIV/AIDS
HIV Transmission
HIV Prevention
Immigrant Workers
Women and HIV/AIDS
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ACKNOWLEDGEMENT
This study was made possible by the generous support of World Health Organization, Bangladesh.
We thank Dr. Durga Prasad Bhandari (Medical Officer–HIV/AIDS) and Dr. Md. Enamul Haque
(National Consultant–HIV/AIDS) for their continuous mentorship and advice. We also would like
to acknowledge the respondents from the study area for their enormous support and cordial
reception of the data collectors during entire data collection period. Our gratitude is also extended
to the Eminence study team including Sohana Samrin Chowdhury (Senior Assistant Coordinator),
Umme Kulsum Lucy (Management Trainee) and Md. Tarek Hossain (Assistant Coordinator) for the
successful completion of this project.
This work would have been impossible without the dedicated and sincere efforts of all our young
and enthusiastic data collectors.
Last but not the least, we express our heartfelt gratitude to the people of Bangladesh. Without
their patience and cooperation, it would have been impossible to conduct such a study.
Dr. Md. Shamim Hayder Talukder
Chief Executive Officer
Eminence

ABBREVIATIONS AND ACRONYMS
AIDS Acquired Immune Deficiency Syndrome
FGD Focus group discussion
FWA Family Welfare Assistant
FWV Family Welfare Volunteer
HIV Human Immuno Deficiency Virus
II In-depth interview
KAP Knowledge, attitude and practice
KII Key informant interview

STUDY TEAM
Principal Investigator
Dr Md Shamim Hayder Talukder
Research Associate
Sohana Samrin Chowdhury
Research Assistant
Umme Kulsum Lucy
Md Tarek Hossain

EXECUTIVE SUMMARY
In Bangladesh, the targets under MDG-6 are to halt the spread of HIV/AIDS, malaria and other
diseases by 2015 and reverse the spread of the diseases. The increasing trend of HIV/AIDS
positively indicates that country is on the brink of a nationwide crisis. Mobility is a key
structural factor that has been linked to increased HIV incidence and vulnerability globally.
Bangladeshi migrant workers suffer problems found among other internal and international
migrant groups including socioeconomic and power inequalities, limited social capital,
loneliness, and coping with different cultural norms relating to sex. HIV transmission from
international migrant workers who have returned and are HIV positive has been mostly
restricted to their spouses, although the degree of spousal transmission and couples in which
one person is HIV positive and putting the other at high risk has not been evaluated
methodically in Bangladesh. Given the large numbers of people on the move, ensuring the rights
and access to HIV prevention, treatment and care and support services for the wives of these
migrant workers is a crucial component of an effective regional response to HIV. Therefore, it is
important to analyze the knowledge, attitude and practice level of these groups of women.
Therefore, the present study aims to analyze the knowledge, attitude and practice of wives of
the emigrant workers of Bangladesh and factors that may influence their health decisions. Seven
(7) districts from seven (7) administrative divisions of the country were selected purposively as
the study area. The study areas include Tangail (Dhaka division), Comilla (Chittagong division),
Moulovibazar (Sylhet division), Meherpur (Khulna division), Dinajpur (Rangpur division),
Barisal (Barisal division) and Serajganj (Rajshahi division). Women at their reproductive age
from selected households of these seven districts, whose heads are/used to be a migrant
worker, was the study subject. Respondents also include health service professionals from the
study areas. The general knowledge/perception, attitudes, and practices were assessed through
qualitative study method while a quantitative socio economic survey was also done to attain
information related to respondents’ age, education, income and expenditure. The tools include
in-depth interview (II), focus group discussion (FGD) and key informant interview (KII). In total,
70 IIs and 7 FGDs with 63 women participants were done while a short survey of the socio-
economic status of all 133 women was conducted through structured questionnaire.
Background characteristics of respondents
The highest numbers of respondents belong to group 26-30 years and lowest number are in 36-
40 years while majority of the husbands also belong to group 26-30 years. More than 80% of
our total respondents have studied from class one to ten with 15.9% who are illiterate. Majority
of women are engaged in household activities and few were engaged in agricultural activities
while their husbands are engaged in service (42%), day labor (32%) and working in restaurants
(11%). Majority of the husbands (76.2%) had been staying abroad for one to three years. These
husbands had been working mostly in Dubai (23.8%), Saudi Arabia (19%), Malaysia (14.3%)
and Singapore (11.1%). Monthly income for two third of the respondents’ family ranges
between ≤10 thousand taka to 20 thousand taka. Around three fourth (73%) of these families
have a monthly expenditure of 10 thousand taka or less.

Knowledge on HIV/AIDS
Every respondent in our study was aware of the existence of HIV in Bangladesh and all of them
considered it as an infectious disease. There was very low level of knowledge on the sources of
HIV/AIDS infection. Knowledge regarding transmission modes was not satisfactory since only
12 out of 70 women interviewees are aware that HIV is transmitted by the sharing of needles by
drug users, receiving blood from an infected person and from mother-to-child transmission.
Majority of the II respondents consider ‘illegal sexual relationship (before marriage or outside
marriage)’ as ‘unsafe sex’ while vaginal sex is considered as the only way of getting infected.
Those who reported previous blood transfusion experience (n=13), did not have any idea if the
blood was tested or not. Also, 52 out of 70 respondents believe that HIV could be transmitted
through insect bites, by having bath in the same pond with an infected person. Moreover,
smoking cessation, keeping the environment clean are suggested as ways of preventing HIV.
Attitudes towards HIV/AIDS
There is still a lot of prejudice and stigma to HIV/AIDS in the communities. However, unlike
most of the FGD respondents, during in depth interview, mostly accepting and positive attitude
has been found among the women towards people living with HIV. There remain small
proportions that demonstrate fear, ignorance and possibly will perpetuate stigma in the
community against people living with HIV/AIDS. Attitude towards an infected husband is highly
positive. Only 5 out of 70 II respondents expressed willingness to use condom if their husbands
get infected. All the other women said that they will not use condom with their HIV positive
husbands if the husbands prohibit doing so. Also, they will keep the husband’s HIV status a
secret and may not even seek medication if there is a chance of the news breaking out. Similar
expressions have been recorded in case of having an HIV positive child. However, half of the II
respondents showed unwillingness to send their child to a school where she knows a neighbor’s
HIV positive child studies.
Practices about HIV/AIDS
Among our 70 in-depth interview respondents, six women reported having sexual partner
besides their husbands. None of these women have ever used condom with their partners. ‘No
use of condom’ is reported in the study areas among the selected women during their last sexual
intercourse. Those who have ever used condom, have used it for the first 3 months to 3/4 years
after getting married, as a tool for contraception. Fifty-six of our respondents have been unable
to identify if the husband has been tested for HIV or not; rest of them said that their husbands
have gone for HIV test before they left the country and have been found HIV negative. Yet, they
could not state anything about a re-test. While articulating reasons of not using condom,
respondents who did not have any children, stated that, they avoid condom since they desire to
become pregnant. Respondents, who already have children and do not want anymore, avoid
condom use as they have been practicing other contraceptive methods (mostly pill and IUD).
Knowledge on and attitude towards voluntary counseling and testing (VCT)
Only twelve out of 70 respondents have shown an interest to test for HIV, provided that it can
be done at the upazila health complex although the idea of voluntary counseling and testing

(VCT) is completely new to our respondents. The commonest reason for not wanting to undergo
HIV testing is the feeling of not being at risk and assuming HIV test to be expensive. However,
after learning about VCT service and its modalities, 62 respondents expressed their willingness
to seek counseling and testing service for themselves, with 44 women willing to do the same for
their husbands.
Barriers to HIV/AIDS knowledge acquiring and suggested recommendation to overcome
them
The most common barriers include ‘feeling hesitation to talk about HIV/AIDS,’ ‘HIV/AIDS is
considered as a prohibited topic’ and ‘unfriendly attitude of family members.’ Some of the
respondents feel that, their illiteracy prevents them from knowing about HIV from printed
media, many of the respondents find print media (newspaper, pamphlet, magazine) to be more
effective source of communicating HIV knowledge. As discussion on HIV and related issues are
not warmly welcomed in the community and within the family, women fail to receive necessary
information on HIV through electronic media.
Recommendations
The present study clearly shows that the average level of knowledge regarding HIV
transmission is relatively low and that serious misperceptions, such as the belief that
transmission can occur through mosquito bites are fairly common. Practice of low condom use,
fear of social discrimination and marital disharmony poses further risk to these women.
Empowering the women in terms of sexual decision making as well as communicating
comprehensive HIV knowledge through community volunteer or peer group should be in place
immediately. . The VCT services should be made available specially to this group of women so
that they can receive support in understanding their test result and its implications, whether the
result is positive or negative.

Table of Contents
Introduction and Justification............................................................................................................................................................1
Objective of the research .....................................................................................................................................................................3
General objective ...............................................................................................................................................................................3
Specific objectives..............................................................................................................................................................................3
Definition of concepts......................................................................................................................................................................3
Study areas and subjects ................................................................................................................................................................3
Methodology..............................................................................................................................................................................................4
Study design.........................................................................................................................................................................................4
Data collection.....................................................................................................................................................................................4
Tools and Instruments...............................................................................................................................................................4
Data Collection Procedure........................................................................................................................................................5
Training and supervision..........................................................................................................................................................5
Findings from Socio economic survey ...........................................................................................................................................6
Background characteristics of respondents ..........................................................................................................................6
Findings from in-depth interview....................................................................................................................................................9
Knowledge on HIV/AIDS ................................................................................................................................................................9
Attitudes towards HIV/AIDS ..................................................................................................................................................... 10
Practices about HIV/AIDS........................................................................................................................................................... 11
Knowledge on and attitude towards voluntary counseling and testing (VCT) ................................................... 11
Barriers to HIV/AIDS knowledge acquiring and suggested recommendation to overcome them ............ 12
Findings from Focus Group Discussion (FGD) ........................................................................................................................ 13
Knowing HIV/AIDS ........................................................................................................................................................................ 13
Knowledge on ways of HIV transmission................................................................................................................................ 13
Knowledge on ways of HIV prevention.................................................................................................................................... 14
Source of HIV/AIDS information ............................................................................................................................................... 15
Attitude towards HIV/AIDS........................................................................................................................................................ 15
Practices that increase HIV risk ............................................................................................................................................... 16
‘Condom’ in the context of Bangladesh................................................................................................................................. 17
Knowledge on and attitude towards voluntary counseling and testing (VCT) ................................................... 17
findings From Key Informant Interview.................................................................................................................................... 19
DDIISSCCUUSSSSIIOONN ........................................................................................................................................................................................... 21
LLIIMMIITTAATTIIOONNSS......................................................................................................................................................................................... 23
CCOONNCCLLUUSSIIOONN.......................................................................................................................................................................................... 23
AANNNNEEXXUURREE 11......................................................................................................................................................................................... 24
AANNNNEEXXUURREE 22......................................................................................................................................................................................... 25
List of Figures
Figure 1 Age group of the respondents and their husbands ..........................................................................6
Figure 2 Educational qualification of the respondents and their husbands............................................6
Figure 3 Occupation of the respondents.................................................................................................................7
Figure 4 Occupation of the respondents’ husbands...........................................................................................7
Figure 5 Duration of staying abroad........................................................................................................................8
Figure 6 Countries where the husbands work.....................................................................................................8
Figure 7 Monthly income and expenditure of the family.................................................................................8

1
IINNTTRROODDUUCCTTIIOONN AANNDD JJUUSSTTIIFFIICCAATTIIOONN
In Bangladesh, the targets under MDG-6 are to halt the spread of HIV/AIDS, malaria and other
diseases by 2015 and reverse the spread of the diseases. Bangladesh is considered to be at risk
for a large-scale HIV epidemic because of the variety and gravity of risk factors, which cause the
spread of HIV1. The first HIV case was detected in 1989 in the country and since then the cases
have been steadily increasing, as have all the potential risk factors. At the end of February 2010,
12,000 people in Bangladesh had HIV/AIDS and 500 died due to the fatal disease (CIA World
Factbook). The increasing trend of HIV/AIDS positively indicates that country is on the brink of
a nationwide crisis. The level of knowledge on HIV/AIDS and its prevention among the people is
increasing but 85 percent of men and only 67 percent of women have heard of it2. Overall 55.8
percent of currently married women are using a contraceptive method, with only 4.5 percent of
men are using condom3. All the factors present in the country may allow rapid spread of
infection leading to an epidemic. These factors include high-risk behaviour, lack of awareness,
extremely mobile populations and being surrounded by countries that have a higher prevalence
of HIV. Targeted interventions for sub-populations most vulnerable to HIV in low prevalence
and/or concentrated epidemic settings form – in line with international best practices – the core
of the national HIV response in Bangladesh.
Mobility is a key structural factor that has been linked to increased HIV incidence and
vulnerability globally4. High prevalence of sexual risk behavior has been found among work
migrants and mobile workers in many countries5, and the major role of this in HIV transmission
is well established6. Migration, both internal and external, is a facet of the Bangladeshi economy.
Bangladesh is a labor-sending country to multiple international destinations (especially the
Middle East). Bangladeshi migrant workers suffer problems found among other internal and
international migrant groups including socioeconomic and power inequalities, limited social
capital, loneliness, and coping with different cultural norms relating to sex7. According to the
Bureau of Manpower, Employment, and Training (BMET) of the Ministry of Expatriates’ Welfare
and Overseas Employment, around 900,000 Bangladeshis left the country through official
channels in 2007. Among them, 8% were females. The high numbers of international migrant
workers among those testing positive for HIV reflect this vulnerability. There are no data on HIV
prevalence in international migrant workers, however, the majority of passively reported HIV
positive cases have been among returned international migrant workers and their families. A
recent analysis of existing data on PLHIV showed that of 645 adult PLHIV who had been
1 Md Nazrul Islam Mondal, H. T. (2009). HIV/AIDS Acquisition and Transmission in Bangladesh: Turning to the Concentrated
Epidemic. Japanese Journal of Infectious Diseases.
2 National Institute of Population Research and Training (NIPORT), Mitra and Associates, and Macro International. 2009. Bangladesh
Demographic and Health Survey 2007. Dhaka, Bangladesh and Calverton, Maryland, USA: National Institute of Population Research
and Training, Mitra and Associates, and Macro International.
3 Ibid
4 Parker, R. G., Easton, D., & Klein, C. H. (2000). Structural barriers and facilitators in HIV prevention: a review of international
research. AIDS, 14 Suppl 1, S22-32.
5Zuma K, Gouws E, Williams B, et al. Risk factors for HIV infection among women in Carletonville, South Africa: Migration,
demography and sexually transmitted diseases. In J STD AIDS 2003; 14:814–817.
6 Anarfi JK. Reversing the spread of HIV/AIDS: what role has migration? In: United Nations Population Fund (UNFPA). International
Migration and the Millenium Development Goals. Selected Papers of the UNFPA Expert Group Meeting, Marrakech, Morocco, May
11–12, 2005. New York: United Nations Population Fund, 2005:99–109.
7 Soskolne, V., & Shtarkshall, R. A. (2002). Migration and HIV prevention programs: linking structural factors, culture, and individual
behavior--an Israeli experience. Soc Sci Med, 55(8), 1297-1307.

2
employed, 64.3% had previously worked abroad8
. Among the 219 confirmed HIV cases in 2002,
returning emigrant workers comprised 50.7 percent of the total. In the period 2002 to 2004, 47
of the 259 (18%) people who tested positive for HIV were either returned migrants or relatives
of migrants. Of the 102 new reported HIV/AIDS cases in 2004, 57 were identified as migrants
(55.9%). Migration history is associated with 73% of the HIV positive individuals attending VCT
units of ICDDR,B in Bangladesh. Among 326 HIV positive male attending VCT service at ICDDR,B
between 2002 and 2009, 76.4% were international migrant workers. Of the 119 HIV positive
non-migrant women, 77% were infected by their spouse who used to be an international
migrant worker.
Despite religious and conservative attitudes to non-marital sex in Bangladesh, the institution of
marriage had not prevented sexual risk behavior by men from being quite common, particularly
during periods of separation from wives9. Data also suggest that HIV transmission from
international migrant workers who have returned and are HIV positive has been mostly
restricted to their spouses, although the degree of spousal transmission and couples in which
one person is HIV positive and putting the other at high risk has not been evaluated
methodically in Bangladesh10. Neither any study has been conducted on the knowledge, attitude
and practice of the wives who are left behind by their migrant worker husbands for years.
Although the external migrant workers are greater in proportion of reported HIV positive cases
in Bangladesh, due to various reasons, this group is still out of the national HIV/AIDS
surveillance system. The UNGASS Country progress Report of Bangladesh (2010) has identified
inadequate mechanism for identification and inclusion of new vulnerable groups (eg. migrants)
as one of the major programmatic gaps that hamper achievement of scale, coverage and
delivering quality services11.
Given the large numbers of people on the move, ensuring the rights and access to HIV
prevention, treatment and care and support services for the wives of these migrant workers is a
crucial component of an effective regional response to HIV. Therefore, it is important to analyze
the knowledge, attitude and practice level of these groups of women. The data collected through
this study can assist in targeting specific HIV/AIDS prevention and care activities focusing on
the wives of migrant workers.
8 NASP, Save the Children USA, & ICDDRB. (2009). Estimating numbers of those most affected by HIV/AIDS in different locations to
support efficient service delivery, capacity building and community mobilization. Dhaka: NASP, Save the Children USA, and ICDDRB.
9 Khan ZR, Arefeen HK. Potari Nari: A Study in Prostitution in Bangladesh. Dhaka: Dana Publishers, 1989.
10 20 Years of HIV in Bangladesh: Experiences and Way Forward. The World Bank and UNAIDS. December 2009.
11 UNGASS COUNTRY PROGRESS REPORT Bangladesh. January 2008–December 2009. National AIDS/STD Programme (NASP),
Ministry of Health and Family Welfare (MoHFW), Government of the People’s Republic of Bangladesh, 30 March 2010, Dhaka

3
OOBBJJEECCTTIIVVEE OOFF TTHHEE RREESSEEAARRCCHH
General objective
This study aims to analyze the knowledge, attitude and practice of wives of the emigrant
workers of Bangladesh and factors that may influence their health decisions.
Specific objectives
To achieve the general objective the subsequent specific objectives were:
 To determine the level of knowledge of the wives of immigrant workers about HIV/AIDS
 To determine the attitude of the wives of immigrant workers about HIV/AIDS
 To determine the reported practice of the wives of immigrant workers about HIV/AIDS
and assess the risk behaviors and factors that put them at a high risk of acquiring
HIV/AIDS
 To explore the ability of the target groups to translate knowledge into behavior
 To determine the need perceived by the wives of migrant workers
DEFINITION OF CONCEPTS
Knowledge – Knowledge is defined as the basic information and understanding of HIV/AIDS.
This is whether wives of immigrant workers understand the difference between HIV/AIDS, risk
factor, modes of transmission, Voluntary Counseling and Testing.
Attitude – Attitude is the way the wives of immigrant workers think and feel about HIV/AIDS
and towards people living with HIV/AIDS, prevention, disclosure, perception of risk, care and
support.
Practice – Practices are actions/ risk of behavior. This is whether the wives of immigrant
workers understand the difference between HIV/AIDS, risk factor, modes of transmission,
Voluntary Counseling and Testing.
Study areas and subjects
Seven (7) districts from seven (7) administrative divisions of the country were selected
purposively as the study area. Data of district-wise overseas employment from 2005-2009 has
been used for this selection. Districts that have the highest concentration of emigrant workers
within a certain division were chosen as the study areas. Thus, the study areas include Tangail
(Dhaka division), Comilla (Chittagong division), Moulovibazar (Sylhet division), Meherpur
(Khulna division), Dinajpur (Rangpur division), Barisal (Barisal division) and Serajganj
(Rajshahi division). Annexure 1 presents a list of the study area in detail.
Women at their reproductive age from selected households of these seven districts, whose
heads are/used to be a migrant worker, was the study subject. Respondents also include health
service professionals from the study areas.

4
MMEETTHHOODDOOLLOOGGYY
Study design
The general knowledge/perception, attitudes, and practices were assessed through qualitative
study method while a quantitative socio economic survey was also done to attain information
related to respondents’ age, education, income and expenditure. To review the critical points of
current knowledge including substantive findings as well as theoretical and methodological
contributions to the wives of international migrant workers, library, related literature, books,
records, reports and others on the issue were extensively reviewed. Purposive selection
technique was used to identify the respondents for qualitative data collection. The tools include
in-depth interview (II), focus group discussion (FGD) and key informant interview (KII). In-
depth interviews and FGDs were carried out with wives of migrant workers (who live abroad)
while KIIs were conducted with health service professionals. Upazila health and family planning
officer (UHFPO), medical officer and local private medical practitioners were interviewed as key
informants.
Data collection
Tools and Instruments
Document Review has been a very crucial part of the design which has played an integral role all
through the study period. At the beginning of the study, documents, contents and literature
review have taken place to finalize the study instruments. Review of relevant documents
including journal articles, national and international study reports has been conducted under
this process.
Ten (10) wives of the international migrant workers from each of the districts have been
interviewed from each of the districts. Thus, 70 IIs were conducted with the wives of
international migrant workers where their knowledge, attitude and practice have been
assessed.
Within each of the selected locations from seven districts, FGD participants were selected
purposively as representative of the targeted population. This tool has been used to collect
thorough information in line with the objectives of the study. A total of 7 FGDs with 63 women
participants have been taken place.
KIIs have been conducted with the upazila health and family planning officer (UHFPO), medical
officer and local doctors. A total of 28 KIIs were conducted with four (4) such health service
professionals from each district.
A short survey of the socio-economic status of 133 women who participated at the II and FGD
was also conducted through structured questionnaire. Predefined checklists for KII, II and FGD

5
guidelines have been used as the instruments for this survey. Annexure 2 presents all the
instruments of this study.
Data Collection Procedure
Two (2) teams, each comprising of three (3) data collectors were recruited for the study. Each
team has been supervised by one (1) supervisor. The teams have travelled to the study areas
from 14 June to 1 July 2011 for data collection.
Training and supervision
Starting from of 4 June 2011, all the data collectors have been provided a 6-day in-depth
training on how to successfully conduct the data collection. The trainees have been guided
extensively on the usage of all the instruments. The Medical Officer (HIV/AIDS) from WHO-BAN
was present at one session of the training.

6
1.6 6.3 27 23.8 25.4 15.915.9 23.8 31.7 19 9.5 0
0
5
10
15
20
25
30
35
15-20 21-25 26-30 31-35 36-40 41-45
Respondents' husband (%)
Respondent (%)
9.5 61.9 19
6.3 3.2
15.9 81 1.2 0.3 1.6
0
10
20
30
40
50
60
70
80
90
Illiterate Class 1 to 10 S.S.C H.S.C Graduation
Respondents' husband (%)
Respondent (%)
FFIINNDDIINNGGSS FFRROOMM SSOOCCIIOO EECCOONNOOMMIICC SSUURRVVEEYY
Background characteristics of respondents
There are 133 women who took part in the in-depth interview and FGD from seven study areas.
The husbands of all these participants are employed outside of the country for more than one
year. For the socioeconomic survey, respondents from 15 years to 45 years are included. Figure
1 shows that highest numbers of respondents belong to group 26-30 years and lowest number
are in 36-40 years while majority of the husbands also belong to group 26-30 years.
Figure 1 Age group of the respondents and their husbands
More than 80% of our total respondents have studied from class one to ten with 15.9% who are
illiterate (Figure 2). Among the husbands, on the other hand, 19% have passed secondary
school certificate (SSC) exam, with 9.5% illiteracy rate.
Figure 2 Educational qualification of the respondents and their husbands

7
3%
32%
42%
11%
6%
3% 3%
Small business
Day labor
Service
Restaurant worker
Domestic helper
Tobacco industry worker
Others
Study shows that majority of women are engaged in household activities and few were engaged
in agricultural activities (Figure 3). Husbands of our respondents are engaged in different type
of works. Most of the husbands (42%) are engaged in service, 32% are day laborers and 11% of
them are employed in restaurants (Figure 4).
Figure 3 Occupation of the respondents
Figure 4 Occupation of the respondents’ husbands
Figure 5 shows that, majority of the husbands had been staying abroad for one to three years.
That is 76.2% of our total respondents. Total 17.5% of our respondents are staying abroad for
the last 4-6 years. Few of them are staying abroad for 7-9 years. That is 6.3% of our total
respondents. These husbands had been working mostly in Dubai (23.8%), Saudi Arabia (19%),
Malaysia (14.3%) and Singapore (11.1%), as presented in Figure 6.
Figure 7 indicates that monthly income for two third of the respondents’ family ranges between
≤10 thousand taka to 20 thousand taka. For 9.5% respondents, the monthly family income is
more than 50 thousand taka. Around three fourth (73%) of these families have a monthly
expenditure of 10 thousand taka or less.
98.4
1.6
House wife (%)
Agriculture (%)

8
76.2
17.5
6.3
1-3 years
4-6 years
7-9 years
1.6
4.8
3.2
23.8
4.8
1.6 1.6
6.3
3.2
14.3
1.6 1.6 1.6
19
11.1
0
5
10
15
20
25
31.7
34.9
0
20.6
3.2
9.5
73
15.9
0
9.5
1.6 0
0
10
20
30
40
50
60
70
80
≤ 10000 10001-20000 20001-30000 30001-40000 40001-50000 50000+
BDT
Monthly Income (%)
Monthly Expenditure (%)
Figure 5 Duration of the husband staying abroad
Figure 6 Countries where the husbands work
Figure 7 Monthly income and expenditure of the family

9
FFIINNDDIINNGGSS FFRROOMM IINN--DDEEPPTTHH IINNTTEERRVVIIEEWW
Knowledge on HIV/AIDS
In depth interview findings indicates that every respondent in our study was aware of the
existence of HIV in Bangladesh and all of them considered it as an infectious disease. There was
very low level of knowledge on the sources of HIV/AIDS infection. Only a few women knew that
sources of HIV/AIDS infection are those infected with HIV and AIDS patients, while most of the
respondents mistook people who had casual contact with AIDS as sources for HIV/AIDS
infection. Knowledge regarding transmission modes was not satisfactory since only 12 out of 70
women interviewees are aware that HIV is transmitted by the sharing of needles by drug users,
receiving blood from an infected person and from mother-to-child transmission.
Majority of the II respondents do not have any clear idea about unsafe sex. They consider ‘illegal
sexual relationship (before marriage or outside marriage)’ as ‘unsafe sex’. Most of them think
that, if a husband or a wife engages himself or herself in an illegal sexual relationship outside
marriage, HIV can infect him/her. A respondent from Comilla (Chittagong) said,
“I do not use condom during oral or anal sex as it is impossible to get pregnant
through them.”
Thus, vaginal sex is considered as the only way of getting infected. The respondents reported
that they do not have sufficient information about the sexual relationship of their husbands who
live and work abroad for a long time. Yet, except for a few (n=4), the respondents are not ready
to acknowledge that they are at a risk of getting infected by their husband. Little knowledge is
found among the women about STI and its relation to HIV as well.
They are also unacquainted with the importance of testing blood before transfusion and its
relationship with HIV transmission. Interviewees, who reported previous blood transfusion
experience (n=13), did not have any idea if the blood was tested or not. Mother-to-child
transmission is another concept with which the women are not familiar before. Thus, even
though the study population are prone to HIV infection, overall, the knowledge of HIV
transmission is poor within this group of population.
There are also some misconceptions regarding non-transmittable routes of HIV. For instance, 52
out of 70 respondents believe that HIV could be transmitted through insect bites, by having bath
in the same pond with an infected person.
Apart from abstaining sex with an infected person, the respondents could not mention any other
‘correct’ ways of HIV prevention. One of the respondents said,
“If we do not take meal with an HIV/AIDS infected person, we can prevent this
disease”.
Moreover, smoking cessation, keeping the environment clean are suggested as ways of
preventing HIV. Another respondent from Dinajpur stated,

10
“if we use mosquito-net, we can avoid HIV/AIDS”.
However, most of them have demonstrated keen interest to know more about HIV transmission
and prevention.
Attitudes towards HIV/AIDS
In-depth interview findings regarding attitudes of wives of immigrant workers suggest that
there is still a lot of prejudice and stigma to HIV/AIDS in the communities, however, unlike most
of the FGD respondents, during in depth interview, mostly accepting and positive attitude has
been found among the women towards people living with HIV. Only seven women out of 70
voiced strong unwillingness to live in the same neighborhood with HIV positive people. Yet,
some of them are afraid to have casual contact with HIV infected person (sitting together,
shaking hands). Thus, there remain small proportions that demonstrate fear, ignorance and
possibly will perpetuate stigma in the community against people living with HIV/AIDS.
Attitude towards an infected husband is highly positive. Women think that, if their husband
contracts HIV through extra marital relationship, they will not show any negative attitude
towards him. They are willing to continue their conjugal relationship with their husbands,
taking necessary care of him. Only 5 out of 70 II respondents expressed willingness to use
condom if their husbands get infected. All the other women said that they will not use condom
with their HIV positive husbands if the husbands prohibit doing so. For them, husbands’
satisfaction always comes first. Respondent from Meherpur, for example, said
“My husband generally does not like to use condom. So, if he becomes an AIDS
patient, I will take it as a test from the Almighty. I will not leave him at any cost.
Nor will I use condom with him. I will not make my husband unhappy.”
Another respondent from Comilla said,
“A husband and wife are meant to live forever. He has taken care of me all these
years. How can I leave him during his disease?”
All of them opined that they will keep the husband’s HIV status a secret and may not even seek
medication if there is a chance of the news breaking out. Similar expressions have been
recorded in case of having an HIV positive child. However, half of the II respondents showed
unwillingness to send their child to a school where she knows a neighbor’s HIV positive child
studies.
Although for HIV positive family members, the women demonstrated readiness of helping that
member out – showing positive behavior, helping them with medication; they have shown
different attitude, mostly rejecting, towards HIV positive neighbor. A respondent from Sirajganj
said,

11
“if a person from my neighboring household gets infected, s/he must not be a good
human being. S/he might have contracted the virus from illegal sex. It is not good
to remain friends with such people.”
Practices about HIV/AIDS
Among our 70 in-depth interview respondents, six women reported having sexual partner
besides their husbands. None of these women have ever used condom with their partners.
Interviews suggest that all the respondents shun condom use, be it with their husbands or other
sexual partners. Respondents also did not know that they should practice condom use during
oral and anal sex as well to prevent HIV infection. Thus, no use of condom is reported in the
study areas among the selected women during their last sexual intercourse. Those who have
ever used condom, have used it for the first 3 months to 3/4 years after getting married, as a
tool for contraception. Fifty-six of our respondents have been unable to identify if the husband
has been tested for HIV or not; rest of them said that their husbands have gone for HIV test
before they left the country and have been found HIV negative. Yet, they could not state
anything about a re-test. Six women from the study population have reported that they know
about at least one sexual relationship of their husbands before getting married; three women
suspects that their husbands might have extra-marital sexual relationship with someone else
abroad and one woman has confirmed that her husband has another sexual partner at his
workplace. However, no one from these ten women know if their husbands had/are having
safer sex practice with the other partner or not.
While articulating reasons of not using condom, respondents who did not have any children,
stated that, they avoid condom since they desire to become pregnant. Respondents, who already
have children and do not want anymore, avoid condom use as they have been practicing other
contraceptive methods (mostly pill and IUD). Some of them have superstition about using
condom such as – condom can stay in the vagina, condom can cause of infection and condom
lessens the rate of sexual pleasure. A respondent from Barisal noted,
“shastho kormi apa (community health worker) has warned me that the lubricant
of condom can infect me and my husband.”
Knowledge on and attitude towards voluntary counseling and testing
(VCT)
The idea of voluntary counseling and testing (VCT) is completely new to our respondents. Only
twelve out of 70 respondents have shown an interest to test for HIV, provided that it can be
done at the upazila health complex. Women are all convinced that HIV test is an expensive one
and it can only be administered in Dhaka (the capital city). The commonest reason for not
wanting to undergo HIV testing is the feeling of not being at risk and assuming HIV test to be
expensive. On the other hand, women who do not want their husbands to be tested, reported
‘possibility of marital disharmony’ as the main reason behind it. However, after learning about
VCT service and its modalities, 62 respondents expressed their willingness to seek counseling
and testing service for themselves, with 44 women willing to do the same for their husbands.

12
Nevertheless, women frequently stressed on the fact that if the husband is not interested to take
up the testing, they will not compel them to do so.
Barriers to HIV/AIDS knowledge acquiring and suggested
recommendation to overcome them
In-depth interview has collected various barriers that prevent the women from knowing about
HIV/AIDS more. The most common barriers include ‘feeling hesitation to talk about HIV/AIDS,’
‘HIV/AIDS is considered as a prohibited topic’ and ‘unfriendly attitude of family members.’ All of
the respondents noted that whenever they have tried to find out more on HIV/AIDS, they have
been told that it is a ‘restricted’ subject and especially woman should not talk about it much. A
respondent from Tangail noted,
“me and my sister-in-law (wife of husband’s brother) often used to talk about HIV.
However, my mother-in-law does not allow these kinds of discussion. She has
strictly prohibited us to share our sexual interrogations even with the FWA.”
While some of the respondents feel that, their illiteracy prevents them from knowing about HIV
from printed media, many of the respondents find print media (newspaper, pamphlet,
magazine) to be more effective source of communicating HIV knowledge. The rationale they
report is that print media involves only an individual reader whereas electronic media
disseminates message to a group of people. As discussion on HIV and related issues are not
warmly welcomed in the community and within the family, women fail to receive necessary
information on HIV through electronic media.

13
FFIINNDDIINNGGSS FFRROOMM FFOOCCUUSS GGRROOUUPP DDIISSCCUUSSSSIIOONN ((FFGGDD))
Knowing HIV/AIDS
Knowledge or having correct information is one of the primary steps and precursor to attitude
and behavior change. If the wives of immigrant workers are not knowledgeable about
HIV/AIDS, their attitude is negative and practices increase the risk of infection, they are likely
going to transfer the virus. Every respondent in our study was aware of the existence of HIV in
Bangladesh, while majority of our respondents have misconception, superstition and wrongly
perceived idea about HIV/AIDS.
Radio and TV are broadcasting various programs to make more people aware about HIV/AIDS.
Most of our respondents get to know about the virus and the disease through these information
channels. According to our respondents, electronic and print media such as radio, TV,
newspapers, magazines and books are the leading sources of getting knowledge of HIV/AIDS.
Mass media plays a great role in creating awareness about HIV/AIDS. Electronic, print media
and interpersonal communication are the main sources of knowledge. Many of our respondents
have heard from health workers, doctors, upazila health and family planning officer (UHFPO),
friends and neighbors about some scattered information on HIV. A negligible number of
respondents mentioned poster, signboard, advertisement posted on rickshaw as channels
through which they learned about AIDS.
Some of our respondent have wrong idea about HIV/AIDS eg.: Akhi form Titas (Comilla) said,
“I have heard that there is a killer disease called AIDS. It can be spread through
smoking cigarettes.”
Interestingly, all the FGD discussants from Sylhet district averred that Sylhet is a religiously
superior area of the country and hence, no malicious diseases like AIDS can be spread there.
Selina from Srimangal (Sylhet) stated,
“Our husbands are devotee of the Almighty. They can never have such disease.
These sexual diseases only happens to those who are not devoted enough towards
the religion.”
Knowledge on ways of HIV transmission
There is still misunderstanding about how HIV is transmitted from one person to another.
(Sternberg, P. and J. Hubley. 2004)12. Epidemiological studies have shown that the only routes of
HIV transmission are through sexual intercourse, transmission of blood, injections, HIV –
contaminated needles or syringes and transmission from an infected mother to her infant. To
12. Sternberg, P. and J. Hubley. (2004). Evaluating Men’s Involvement as a Strategy in Sexual and Reproductive Health Promotion.
Health Promotion International 19(3): 389–96

14
meet the targets and goals of HIV prevention and control, there is strong need to assess the
current levels of specific knowledge about HIV transmission. In our study, we pay great
attention to know the knowledge of those women whose husbands have been living and
working abroad.
It is seen that sexual relationship with multiple partners is perceived as the leading way of HIV
transmission by the study population of our study. All our respondents believe that being
committed with a single partner can help reduce the virus transmission. However, none of them
realized that HIV could be transmitted by having oral/anal sex with an infected person.
Similarly, that HIV is transmitted from infected mother to baby before or during birth or
through breast-feeding after birth is unknown to the wives of the immigrant workers of our
study areas. A very few respondents are able to identify sharing of needles, syringes as ways of
HIV transmission. Almost all of them, regardless of providing right information on HIV
transmission, also mistook people who have casual contact with an AIDS patient as sources for
HIV/AIDS infection.
However, a few of the respondents are able to correctly identify ways of HIV infection. Mehtaj
from Sylhet (Srimongol) said,
“If we use new injection (syringe) every time we can prevent AIDS. AIDS cannot
spread through mosquito bite.”
A numbers of myths, misconceptions prevail in the study areas. Many of our respondents
believe that HIV/AIDS can spread through mosquito and leeches bite, through sharing toilet,
smoking cigarette etc. Some of the respondents considered drinking unclean water, living in
unhygienic environment as ways of HIV transmission. It was also observed that some false
notion exists among the respondents about HIV/AIDS. For instance, a respondent from Titas
(Comilla) reported,
“HIV spread through taking bath with an AIDS patient”
while another respondent from Jugni (Tangail) said,
“We fail to keep our environment clean. That’s the reason why the germ of AIDS
finds a way to spread.”
Knowledge on ways of HIV prevention
Respondnets’ knowledge in the area of prevention was moderate to low. The women that we
have interviewed lacked knowledge about HIV testing facilities and its availability. They also did
not know that HIV testing and treatment for AIDS patients are free of charge in Bangladesh.
Keeping distance from an AIDS patient was the single most recorded response against the
question “how can HIV be prevented?” In a country where social and religious beliefs keep the
mass from discussing any sexual health problems even with medical professionals, in case of
women, HIV/AIDS is a rare topic to discuss with husbands.

15
“Not only that one should abstain sex with AIDS patient but also we should keep
away from an infected patient in every possible way,”
- reports a respondent from Gournadi (Barisal) while talking about HIV prevention.
Source of HIV/AIDS information
TV and radio are identified as the most preferred and commonly available mode for receiving
information on HIV/AIDS. Majority of the respondents did not report any barriers in
accessing information currently being provided through TV and radio, news papers and
magazines. Nevertheless, there are some who emphasized on HIV related message
dissemination through posters, signboards, family welfare assistants (FWA). Samsun from
Khulna (meherpur) said that,
“we can build an organization locally and they can make sure that everyone in this
area gets the appropriate knowledge about HIV/AIDS.”
Chinta Rani from Tangail (Dhaka) mentioned,
“all our family members generally watch TV together. Whenever an advertisement
on HIV/AIDS comes, I leave the TV room. That is because I feel shy to watch and
hear about the sexual contents in that advertisement in front of my father and
mother-in-laws. As I read newspaper by myself, it is easier to read about anything
written in there. Therefore, I have learnt about HIV mostly from newspapers and
magazines.”
Attitude towards HIV/AIDS
Generally, the respondents’ attitudes towards people living with HIV/AIDS are mixed, yet
mostly rejecting and negative. The respondents’ perceptions regarding a person with HIV/AIDS
are explored through a hypothetical question: “if any of your family member (most importantly
husband or child) or neighbor contracts HIV, would there be a change in your behavior towards
that person?” A majority of the respondents negated from eating together with the infected
person, followed by avoiding social encounters.
However, some of them indicated a few positive behavior changes as well. These group of
women thought that an AIDS patient is likely to feel depressed and aloof. Therefore, it is
essential to support them psychologically. Nevertheless, even these groups of women are also
under the impression that touching, shaking hands, sharing food from same utensil can spread
HIV. Raju Begum from Srimangal (Sylhet) said that,
“I will not avoid an AIDS patient but will be afraid to sit with him/her together”.
A negligible number of respondents stated that they have learnt from the TV that HIV/AIDS
cannot be contract by being in the company of an HIV positive person. Therefore, there will not
be any change in their behavior.

16
All the respondents agreed that they would keep this news secret if they found out their
husband or children are HIV positive. However, none of the respondents knew that there is
treatment available for HIV positive patient. Thus, FGD respondents from Srimongol (Sylhet),
for example, said,
“AIDS is an incurable disease. We will try to comfort the family member who is
infected. What else can we do?”
Samsun from Meherpur Said,
“if my child contracts HIV, I will feed him with breast milk. I do not see any harm
doing that as he will only have contacts with my skin. I know that skin to skin
contact does not spread HIV.”
Practices that increase HIV risk
Women in Bangaldesh have little control over their sexual lives and the sexual lives of their
husbands/partners (outside marriage). While discussing prevention, it became apparent that
there is a gap in women’s knowledge about the use of condom as a tool for preventing
HIV/AIDS. None of the respondents have ever heard that using condom can prevent STI or HIV.
Fatema Najmeen from Srimangal (Sylhet) said,
“my husband works in the middle east. He is a hujur and he does not like to use
condom. That’s why we have never used condom.”
It was felt by the study team that family welfare visitors (FWV) do not necessarily provide
information to the wives of immigrant workers about protecting their selves from getting
infected by their husbands (be it STI or HIV), nor do they inform the wives that besides birth
control, condom use is also a way of preventing HIV transmission. A respondent from Birganj
(Dinjpur) said that,
“after getting married, I had used condom for the first 2-3 months. However, it
causes a barrier to complete satisfaction. FWV of this area has told me that use of
condom can bring adverse situation to my sex life. Since I trust my husband
completely, I don’t think I should force him to use condom.”
Some of the respondents also have misconception about using condom. Lima, a married woman
of 25 years form Gournadi (Barisal) thought,
“regular use of condom can be helpful to look younger.”
Again, Josna from Titas (Comilla) said,
“using condom is not good for health. Couples should avoid using it.”

17
‘Condom’ in the context of Bangladesh
FGD participants have demonstrated low relationship control and this supposedly lead to
inconsistent condom use. Condom is perceived as a tool for birth control only. Using condom to
protect one’s self from STI or HIV is not popular among the study population. The respondents
do not feel that condom should be used as a preventive measure. In fact, the idea of ‘protection’
against HIV is not well received by them. They are not ready to accept the fact that their
husbands, who stay away from them for a long time, might engage themselves in risk behavior;
that in turn can increase the risk of the wives being infected.
Majority of the respondents get condom from pharmacy or family welfare assistant (FWA).
Mostly, husbands/sexual partners take the responsibility of bringing condom. Mamela from
Dinajpur (Rangpur) claimed that,
“when family welfare assistant (FWA) comes to visit me, she does not give me
condom. She tells me to go to hospital for buying condom.”
Another respondent from this area, Shopna said,
“when I went to the hospital for condom, hospital staff yelled at me saying that why
we take so many children, make an abortion, you will get money, sari’.”
Some of them think that, family welfare assistant (FWA) can keep her visit regular and provide
condom regularly. A few have suggested that if condom is made available at women shops, they
can easily buy that. Fatema from Tangail (Dhaka) said,
“Condom must be available in that place where woman can easily buy it such as we
hear about immunization program and we go there with our child. Condom should
be available in that kind of program. There we don’t feel shy to buy it.”
Knowledge on and attitude towards voluntary counseling and testing
(VCT)
During the FGD, it was evident that apart from a few respondents from Comilla and Dinajpur, no
other respondents have heard anything about VCT. Neither have they known that HIV testing is
provided free of charge in the country nor do they have tried to find out any information on HIV
testing. This is mostly because the respondents do not believe they or their husbands are at risk
of contracting HIV. In addition, women of the study areas have shown low negotiation power
regarding sexual and reproductive health. They also have limited control over their conjugal
relationship. Mimi from Gournadi (Barisal) said,
“even if I ask my husband, he will not agree to go for an HIV test.”
Another FGD respondent Hena from Meherpur (Khulna) said that,

18
“if I ask my husband to go for HIV test it will prove that I have no faith on him. This
will hamper the happiness of my family. I can not risk that.”
Thus, respondents did not show much interest on testing themselves or their husbands for HIV.
Many of the respondents reported that their husbands have mentioned to them about an HIV
test that is administered at the time of immigration. All of these results are found to be negative,
as reported by the respondents. However, no one knew that a re-test is necessary after getting
negative test results because of ‘window period.’ Meena Rani Das from Srimangal (Sylhet)
reported,
“my husband has been tested negative for HIV when he was leaving Bangladesh. It
was four and half years ago.”

19
FFIINNDDIINNGGSS FFRROOMM KKEEYY IINNFFOORRMMAANNTT IINNTTEERRVVIIEEWW
The study team has conducted interviews with twenty-eight key informants who include
upazila health and family planning officer (UHFPO), medical officer and local private medical
practitioners. The informants think that those who are going abroad for work do not have
sufficient level of education and knowledge to keep them safe from being HIV infected. These
factors put them at high risk of contracting HIV easily and make their wives prone to getting
infected by the virus. UHFPO from Sirajganj suggested,
“the workers should be oriented completely on HIV transmission and prevention
prior to immigration.”
Nironjon Sorkar from Tangail said,
“while in abroad, migrant workers do not follow our social norms, ideology and
that is why they catch HIV.”
However, 23 key informants out of 28 are unable to identify why and how the migrant workers
as well as their spouse might be at risk of HIV. Neither of the UHFPO of our study areas knew
the overall situation of HIV in their upazila. Those who could name some intervention targeted
to HIV/AIDS mentioned projects of Save the Children, Durjoy Naari Shangha and some VCT
centres. Dr Md Mizanur Rahman (UHFPO, Meherpur) noted,
“there are some NGO and government intervention taking place in my upazila
regarding HIV. To my knowledge, they mostly deal with sex workers and IDUs.”
Informant from Sirajgonj said,
“There is a private clinic in the district. They have HIV test facility.”
Surprisingly, the key informants, although being engaged in health profession for a considerable
period, lack substantial knowledge on HIV transmission and prevention. The interviewers had
to explain the routes of HIV transmission and vulnerability of women getting infected to
majority of the key informants. Jahidul Islam, a private medical practitioner from Dinajpur
opined,
“inclusion of wives of migrant workers in the most vulnerable group is not that
important. The probability of women getting infected by an HIV positive husband
can be reduced by specific intervention targeted to migrant workers – especially
during their departure from and arrival to the country.”
Not much information can be gathered from the key informants about the KAP status of wives of
international migrant workers in their areas. Only one key informant (from Sirajganj)
mentioned that there was one patient who came to him to inquire about HIV testing as she
feared of getting infected by her husband who works abroad. Dr Md Kamrul Hasan from Tangail
said,

20
“I take personal initiatives for giving health education in my area. I think it would
be beneficial if we can arrange training on HIV/AIDS for paramedic and enable
them to deliver necessary messages to mass people.”
Nironjon Sorkar from Tangail said,
“We do not have any facility for testing HIV/AIDS. People do not have any
knowledge about it and naturally they do not have any interest to know it.”
Informants have several opinions on how HIV/AIDS education can be widely spread so that the
wives who are left behind in the country by their husbands can know more about HIV. Dr Abdul
Hamid, a private practitioner from Sirajganj said,
“TV and radio are broadcasting various programs to make more people conscious
about HIV/AIDS. Newspapers are publishing features regarding this disease.
However, the fact is people have no interest to know about this disease.”
While talking about what steps should be in place to disseminate proper information and
knowledge about HIV/AIDS, majority of our respondents put emphasis on raising awareness
among the targeted population. Dr Ibrahim Khalil (Comilla) said,
“In a village we may call the important persons like – chairman, member etc. and
give them counseling on HIV/AIDS and why migrant workers and their wives are
at high risk. After that, they can spread this information among the villagers.
Group discussion (i.e. courtyard meeting) with women whose husbands live and
work abroad can be a process for this. Alongside general hospital, upazila hospital,
community health worker, family welfare assistant (FWA) can play key roles in this
process.”
They can grow awareness among the people in Bangladesh. Dr Fraruque Ahmed from Comilla
said,
“Trainings can be arranged for people who intend to work abroad for a living. In
this training, we can give them knowledge on HIV/AIDS and the risk of acquiring
HIV by them and their wives.”
Few of our respondents have also stressed the importance of engaging religious leaders in the
process of knowledge sharing.

21
DDIISSCCUUSSSSIIOONN
Poor knowledge and misconceptions about HIV/AIDS are key factors in people’s lack of efforts
at prevention. It has been shown that people need a solid factual understanding of HIV and its
transmission, access to relevant services and the confidence and social power to initiate and
sustain behavior change in order to prevent the spread of HIV/AIDS13. The present study clearly
shows that the average level of knowledge regarding HIV transmission is relatively low and that
serious misperceptions, such as the belief that transmission can occur through mosquito bites
are fairly common. BDHS 2007 reports that about one-third of ever-married women are aware
that abstaining from sexual intercourse can reduce the risk of getting HIV14. However, in our
study all 133 women correctly identified sexual transmission as one way of contracting HIV and
recognized abstinence as the major way of HIV prevention. Yet, all the study participants
shunned condom use. Previous study conducted with construction migrant workers in China
suggests that both longer time interval away from their families and working time had lowered
the likelihood of using condom among migrant workers15. Therefore, if the wives of migrant
workers remain unwilling to use condom before they are completely assured of their husband’s
HIV status, their risk of getting infected will increase to a greater extent. Consequently, women
who are sexually active with a partner having sex with people of high-risk behavior group (e.g.
sex workers, MSM), underestimate their risk of contracting HIV as well as do not consider HIV
testing as a necessity.
Survey conducted among Filipino migrant workers has showed general ambivalence and
uncertainty over the effectiveness of condom against HIV/AIDS with some people who claimed
that using it reduces a person’s ability to enjoy a sexual act 16. Similar findings are evident from
our study of migrant workers’ wives. They are ready to use condom as a method of
contraception, but do not readily accept to use it as a preventive measure against HIV.
Unconditional belief on the husbands, which stems from long practiced social conviction,
apparently prevents them from using condom.
Another study points out that approximately one-third of the 100 rural Mexican women who
had been married to immigrant temporary workers to the US felt at risk for AIDS, mostly
because they doubted their husbands' fidelity17. Unlike that study, our respondents are
generally confident that neither they nor their husbands can have HIV. These wives trust their
husbands entirely and are willing to have unsafe sex with them even if their husbands become
infected with HIV. Being single and/or live apart from their spouse was associated with visiting
commercial sex workers among Indian migrants18. It is therefore deemed necessary to provide
clear and accurate information regarding the importance of condoms.
13 Rao Gupta G, Weiss E. Women and AIDS: developing a healthy strategy. Washington DC, International Center for Research on
Women, 1993 (ICRW Policy series, No. 1).
14
National Institute of Population Research and Training (NIPORT), Mitra and Associates, and Macro International. 2009.
Bangladesh Demographic and Health Survey 2007. Dhaka, Bangladesh and Calverton, Maryland, USA: National Institute of Population
Research and Training, Mitra and Associates, and Macro International.
15 Zhou JB, Sun YH, Hao JH, Wang B, Yu C. Study on knowledge, attitude and practice regarding AIDS among migrant workers in
railway construction sites. Zhonghua Liu Xing Bing Xue Za Zhi. 2007 Jun;28(6):567-70.
16 Sahlee C. Bugna and Riza Faith C. Ybanez. Survey of Knowledge, Attitude, Behavior, and Practice Related to HIV/AIDS among
Filipino Migrant Workers. Labor Migration and HIV/AIDS. Vulnerability of Filipino Migrant Workers.
17 Salgado de Snyder VN, Díaz Pérez M, Maldonado M. AIDS: risk behaviors among rural Mexican women married to migrant
workers in the United States. AIDS Educ Prev. 1996 Apr;8(2):134-42.
18 Gupta, K.; and Singh S.K. Social Networking, Knowledge of HIV/AIDS and Risk-taking Behavior among Migrant Workers. 2000.

22
Study from Thailand indicates that there is an association between good knowledge and a
positive attitude towards HIV/AIDS19. This relationship is also evident in our study areas where
stigma and discrimination are widespread, particularly because of knowledge gap about HIV
transmission routes such as needle sharing or blood transfusion or mother-to-child
transmission. However, our qualitative study finding is contrasted by the previous study
findings conducted among overseas job seekers in Bangladesh20. The indicators found in the
present study all direct towards an unmet need for information and education about AIDS and
how HIV is transmitted, and particularly how it is ‘not’ transmitted among the women. This may
encourage them about risk-free daily casual interactions with HIV positive people.
Our study found that printed media such as newspapers, pamphlets and magazines are the most
common ways for participants to receive information about HIV/AIDS. Print media is more
accessible to the broader women community as they are not commonly allowed to watch or
hear subjects on TV or radio that deals with sexual topics.
For a number of years, HIV activists and researchers have highlighted the role gender inequality
may play in placing women at increased risk for HIV infection21. Our study has indicated that
women have very low control over their sexual relationship and are not in a position to make
decisions about safer sex practice. For similar reasons, testing for HIV is of less importance to
them, even for those who know about their husband’s pre- or extramarital sexual relationship.
Families play an important role in accessing HIV/AIDS knowledge and information for the
women. Social and religious barriers further aggravate the flow of misconception within this
group. Not being able to freely talk about HIV, even with health professionals, is fairly common
in our study areas alongside not realizing the need for comprehensive HIV knowledge. Because
there is a little attention given in communicating HIV knowledge at the root level, health
workers providing health education in the community do not have much to increase level of HIV
knowledge among the study population.
19 CARE. 2000. HIV/AIDS and Mobile Populations (workshop report). CARE International, Bangkok, Thailand.
20 Rahman, M.; Shimu, TA.; Fukui, T.; Shimbo, T.; and Yamamoto, W. Knowledge, Atitudes, Beliefs and Practices about HIV/AIDS
among the Overseas Job Seekers in Bangladesh. Public Health: January 1, 1999.
21 Weiss E, Whelan D, Gupta G. Gender, sexuality and HIV: making a difference in the lives of young women in developing countries.
Sexual and Relationship Therapy. 2000;15:233–45.

23
LLIIMMIITTAATTIIOONNSS
The present study had some limitations in the study design. Our participants are unlikely to be
fully representative of these groups nationwide as they are recruited from only seven districts.
Overcoming the financial resource constrain for a large scale study is therefore recommended.
Our study was based on self-reported information, which could be biased by the participants’
recall.
CCOONNCCLLUUSSIIOONN
Overall, results from our study demonstrated that the majority of the wives of migrant workers
had a low to moderate level of HIV knowledge, and intolerant and rejecting attitudes towards
people living with HIV/AIDS. This outcome is similar to other studies, which are performed
among migrant workers of Thailand22. All these women had heard of AIDS, but many did not
know its transmission pattern properly or had misconceptions, had not been informed about
the preventive effects of condoms and had a low perception of their individual risk. Practice of
low condom use, fear of social discrimination and marital disharmony poses further risk to
these women.
Empowering the women in terms of sexual decision making as well as communicating
comprehensive HIV knowledge through community volunteer or peer group should be in place
immediately. Detection of STI and relationship between STIs and increased HIV transmission
should also be discussed by the community level health workers. National programs responding
to the unmet needs of the migrant workers’ wives needs to be designed for large scale
population coverage.
Voluntary counseling and testing (VCT) is considered as an entry point for prevention and care
for HIV/AIDS. The VCT services should be made available specially to this group of women so
that they can receive support in understanding their test result and its implications, whether the
result is positive or negative. Through counseling, consistent condom use can also be promoted,
benefiting women’s sexual power. Such efforts should also target and involve men as partners,
essential stakeholders in improving women’s sexual decision-making power, whenever they are
available in the country.
22 Zaw, M.M. Assessment of knowledge, Attitude and Risk Behaviors Regarding HIV/AIDS among Myanmar Migrant Workers in
Bangkok, Thailand. College of Public Health, Chulalongkorn University, Bangkok, Thailand. 2003.

24
AANNNNEEXXUURREE 11
Study Areas
Division Code District Upazila Village
Dhaka 1 Tangail Sadar Baghail
Rangpur 2 Dinajpur Birgonj Birgonj
Khulna 3 Maherpur Sador Kolaidanga
Chittagong 4 Comilla Titus Ziarkandi
Shylet 5 Moulovibazer Srimongol Abasic Alaka, Surovi state,
Ramkrisno mission Road
Barisal 6 Gournadi Gouronodi Bangila
Rajshahi 7 Serajgonj Kamerkhand Shampur, Dholessor

25
AANNNNEEXXUURREE 22
Study Instruments
Socio-economic survey questionnaire
Knowledge Attitude and Practice of the Wives of Migrant workers
For HIV/AIDS in Bangladesh
World Health Organization, Bangladesh
Eminence
3/6 Asad Avenue, Dhaka 1207
Informed Consent
I am..............................................................................from Eminence , it is a research organization. To asses
Knowledge, Attitude and Practice of the wives of migrant workers for HIV/AIDS in Bangladesh, we are
conducting a SES survey, II (Indepth interview), and FGD (Focus Group Discussion) with the wives of
Migrant workers. We hope that after completing the study, we will be able to ensure successful HIV
prevention, but for that we need your full cooperation. This survey will take 25-30 minutes to complete.
Whatever information you provide will be kept strictly confidential and will not be shown to anyone.
Participation in this survey is voluntary and you can choose not to answer any or all the question.
However, we hope that you will participate in this survey since your views are important.
At this time, do you want to ask me anything about the survey?
Signature of interviewer: .................................................... Date:
Socio Economic Questionnaire
INFORMATION ABOUT THE RESPONDENT
1. SL. No
2. Name of the Respondent....................................................................
3. Age of the Respondent
4. Sex of the Respondent (Male=1, Female=2)
5. Educational qualification of the Respondent (00=Illiterate, 1-10= Class One to Class Ten,
11=SSC, 12=HSC, 13=Graduation, 14=>Post Graduation
6. Occupation (1= House Wife, 2= Domestic helper, 3= NGO worker, 4= Govt service, 5= Self
employed, 6= Agriculture, 7= Tobacco industry worker, 8= Others

26
INFORMATION ABOUT THE HUSBAND
7. Name of husband ................................................................................................................................
8. Age of husband
9. Educational qualification of the household head (00=Illiterate, 1-10= Class One to Class Ten,
11=SSC, 12=HSC, 13=Graduation, 14=>Post Graduation
10. Occupation of the husband (1= Small business, 2= Day labor, 3= Service, 5= Transport staff,
6= Restaurant worker, 7= Domestic helper, 8= Tobacco industry worker, 9=Others (Specify)
11. How long your husband in abroad? (Year)
12. Which country he live now?
INFORMATION ABOUT THE FAMILY
13. Religion of the respondent (1=Islam, 2= Hindu, 3= Christian, 4= Buddhist, 5=
others..........................................................(Specify)
14. Total number of the family member
15. How many children do you have?
16. How many earning members do you have in your family?
17. What is your monthly income?
18. What is your monthly expenditure?

27
In depth interview checklist
Assessing Knowledge Attitude Practice of the Wives of Migrant Workers
Study Conducted By: Eminence
Guidelines for In-depth Interview (with wives of the international migrant workers)
1. Have she ever heard of HIV/AIDS
 If Yes – what information does she know
2. Knows the difference between HIV and AIDS
3. Ways of HIV transmission
 Right information
 Wrong Information (ways how HIV cannot be transmitted e.g. mosquito bite, sharing food, sharing
clothes, bathing in the same pond etc.)
4. Ways of HIV prevention
 Wrong concepts
5. If a healthy looking person can be HIV positive or not
6. Condom Use (regular/irregular and/or with all partners)
 If yes – why she uses condom (birth control, HIV prevention etc.)
 If no – what prevents her from using condom (with all partners)
 Perception/ point of view of the husband/sexual partner on condom use (dig deep)
7. Sexual partner
 Sexual relationship with someone else apart from her husband
 If yes – frequency of having sex and frequency of using condom)
 Why or why not she has used condom
8. Husband’s other sexual partner (if she knows about it, inquire about their use of condom)
9. Last time she had sex and if condom was used
10. Practice of oral and anal sex and using condom
 If HIV can be prevented by using condom during vaginal, oral & anal sex (dig deep for misconception)
 If she uses condom during all sorts of sex
11. Transmission through Blood transfusion and her experience
12. Any experience of needle sharing
13. Her attitude towards her husband if he is tested HIV positive (divorce/ no divorce but will avoid having sex/
sex using condom/ others)
14. Her attitude towards a neighbor if he/she is tested HIV positive (sitting together/inviting to home/going to
their home/sharing food etc.)
15. Her attitude towards her own child if it is tested HIV positive (breastfeeding/take it regularly to doctor/
others)
16. Her perception about raising awareness on HIV prevention – what will work best for the wives of
international migrant workers
17. Social barriers that prevent her from knowing more about HIV/AIDS
18. Economic barriers that prevent her from knowing more about HIV/AIDS
19. Family barriers that prevent her from knowing more about HIV/AIDS
20. Knowledge on Voluntary Councelling and Testing (VCT) service
21. Knowledge on VCT centre and free service
22. Attitude towards taking up a VCT for herself
23. Attitude towards taking up a VCT for her husband
24. Availability of condom (dig deep for any constrain)
25. Comments

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FGD Guideline
Guidelines for Focus Group Discussion-FGD
(with wives of the international migrant workers)
1. Have she ever heard of HIV/AIDS
 If Yes – what information does she know
2. Knows the difference between HIV and AIDS
3. Ways of HIV transmission
 Wrong Information (ways how HIV cannot be transmitted e.g. mosquito bite, sharing food, sharing
clothes, bathing in the same pond etc.)
4. Ways of HIV prevention
 Wrong concepts
5. If a healthy looking person can be HIV positive or not
6. Condom Use (regular/irregular)
 If yes – why she uses condom (birth control, HIV prevention etc.)
 If no – what prevents her from using condom
 Perception/ point of view of the husband on condom use
7. Transmission through Blood transfusion and her experience
8. Any experience of needle sharing
9. Her attitude towards her husband if he is tested HIV positive (divorce/ no divorce but will avoid having sex/
sex using condom/ others)
10. Her attitude towards a neighbor if he/she is tested HIV positive (sitting together/inviting to home/going to
their home/sharing food etc.)
11. Her attitude towards her own child if it is tested HIV positive (breastfeeding/take it regularly to doctor/
others)
12. Her perception about raising awareness on HIV prevention – what will work best for the wives of
international migrant workers
13. Social barriers that prevent her from knowing more about HIV/AIDS
14. Economic barriers that prevent her from knowing more about HIV/AIDS
15. Family barriers that prevent her from knowing more about HIV/AIDS
16. Knowledge on Voluntary Councelling and Testing (VCT) service
17. Knowledge on VCT centre and free service
18. Attitude towards taking up a VCT for herself
19. Attitude towards taking up a VCT for her husband
20. Availability of condom (dig deep for any constrain)
21. Comments

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KII Checklist
Guidelines for Key Informant Interview-KII (with health service providers)
1. Perception on the fact that among women HIV positive in the country, majority are the wives of
international migrant workers – why is this happening
2. What government and non-government initiatives are taking place in your area to address their problem
3. Do you think these wives of international migrant workers need to be included in the MARP? What needs to
be done to include them in MARP?
4. If wives of international migrant workers come to you to know about HIV/AIDS or to test for HIV?
5. As a health professional, what do you think the KAP status of wives of international migrant workers in your
area?
 If it is low – what needs to be done to improve their current KAP status
 If it is high – what has contributed behind it

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