Trends in Reproductive Tract Infections and Barriers to Seeking Treatment among Young Women: A Commu...

Rejoice Puthuchira Ravi, Ravishankar Athimulam Kulasekaran

  Open Access OPEN ACCESS  Peer Reviewed PEER-REVIEWED

Trends in Reproductive Tract Infections and Barriers to Seeking Treatment among Young Women: A Community Based Cross Sectional Study in South India

Rejoice Puthuchira Ravi1,, Ravishankar Athimulam Kulasekaran2

1Consultant, IRHD, Kottayam, Kerala, India

2Assistant Professor, Department of Population Studies, Annamalai University, Tamilnadu, India

Abstract

Background: Reproductive morbidities lead to wide range of health consequences like ectopic pregnancy, pelvic inflammatory disease, miscarriage, infertility and other multiple consequences. The study aim was to find out the prevalence of reproductive tract infections (RTIs) and barriers to seeking health care services among young married women in rural areas of Thiruvarur district of Tamilnadu state in India. Methods: A community based cross-sectional study was conducted in 28 villages selected using multistage sampling technique for selecting 605 women in the age group of 15-24 years during July 2010-April 2011. Data analysis was by use of Statistical Package for Social Sciences version-17, with statistical significance set at p-value of 0.05 and odds ratio were calculated. Results: The prevalence rate of RTIs was observed to be 14.5%. Itching/Irritation over vulva, Thick white discharge and Pain in lower abdomen (not related to mensus) were most commonly experienced symptoms. Bivariate analysis indicated statistically significant association between educational level, occupational level and standard of living index (SLI) with presence of self-reported symptoms of RTIs among the study population. The chance of getting RTIs symptom was less among women living in high SLI (OR=0.168) than among women living in low SLI. The agricultural labourers were 1.145 times more likely to experience RTIs symptom than non workers category (OR= 0.251). More than half of the women were received treatment against perceived RTIs; all were treated in public health institutions. Conclusion: Perception of symptoms as normal, expensive treatment, feeling of shy, lack of female health workers were identified as major barriers for non seeking treatment for RTIs. Improving literacy and increasing awareness level about sexual and reproductive health is needed to reduce the incidence of RTIs among rural population.

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Cite this article:

  • Ravi, Rejoice Puthuchira, and Ravishankar Athimulam Kulasekaran. "Trends in Reproductive Tract Infections and Barriers to Seeking Treatment among Young Women: A Community Based Cross Sectional Study in South India." American Journal of Epidemiology and Infectious Disease 1.4 (2013): 53-58.
  • Ravi, R. P. , & Kulasekaran, R. A. (2013). Trends in Reproductive Tract Infections and Barriers to Seeking Treatment among Young Women: A Community Based Cross Sectional Study in South India. American Journal of Epidemiology and Infectious Disease, 1(4), 53-58.
  • Ravi, Rejoice Puthuchira, and Ravishankar Athimulam Kulasekaran. "Trends in Reproductive Tract Infections and Barriers to Seeking Treatment among Young Women: A Community Based Cross Sectional Study in South India." American Journal of Epidemiology and Infectious Disease 1, no. 4 (2013): 53-58.

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1. Introduction

Many women and men suffer from reproductive tract infections (RTIs). RTIs often cause discomfort and economic productivity [1]. The most serious long-term sequelae arise in women: pelvic inflammatory disease (PID), cervical cancer, infertility, spontaneous abortion and ectopic pregnancy, the latter of which may lead to maternal death [2]. These RTIs carry a high economic burden as well as enormous health consequences. RTIs have overlapping categories, called endogenous, sexually transmitted and iatrogenic, reflecting how they are acquired and spread [3]. RTIs are most important causes of maternal and peri-natal morbidity and mortality. Serious complications of these RTI include entopic pregnancy, PID, preterm labor, miscarriage, still birth, congenital infection, infertility, genital cancer and risk of HIV infection [4].

Reproductive tract infections are a group of infectious diseases caused by bacteria, viruses, Chlamydia, Mycoplasma and other pathogens invading the genital tract. RTIs can cause serious physical and psychological harm such as infertility, intrauterine growth retardation, premature labour, and increased vulnerability to HIV/AIDS, and may cause a heavy social and economic burden to the families [5]. Female RTIs usually originate in the lower genital tract as vaginitis or cervicitis and may produce symptoms such as abnormal vaginal discharge, genital pain, itching and burning feeling with urination. However, a high prevalence of asymptomatic disease occur which is a barrier to effective control. At present, RTIs have become international public health problem, especially in developing countries. Female Sexual Workers (FSWs) constitute the group documented as being the most exposed population to sexually transmitted infections (STIs), and also are the high prevalence rate population of RTIs.

Global prevalence of reproductive morbidities accounts 22% for women. Over 340 million curable sexually transmitted/reproductive tract infections and more incurable STIs occur annually. These were particularly highest in South Asia and Sub-Sahara Africa [6]. RTIs are recognized as a major public health problem and rank second after maternal morbidity and mortality - as the cause of healthy life loss among sexually active women of reproductive age in developing countries [7]. They can have severe consequences, including infertility, ectopic pregnancy, chronic pelvic pain, miscarriage, and increased risk of HIV transmission [8]. It has been shown that certain infections can increase the chances of HIV transmission. Unfortunately, symptoms and signs of many infections may not appear until it is too late to avoid such consequences and damage to the reproductive organs. Under this circumstance, present study was to find out the prevalence of reproductive tract infections (RTIs) and barriers to seeking health care services among young married women in rural areas of Thiruvarur district of Tamilnadu state in India.

2. Materials and Methods

2.1. Study Area

According to 2001 census, Thiruvarur district was the highest Scheduled Castes populated district and also backward district in Tamilnadu state. All women were living with their husbands and had given at least one birth one year prior to the survey.

2.2. Study Design

A community based cross-sectional study was conducted in 28 villages selected using multistage sampling technique for selecting 605 women in the age group of 15-24 years during July 2010-April 2011.

2.3 Selection of the Blocks

Thiruvarur district had totally ten blocks, which comprise 573 revenue villages. In the first stage, five blocks were selected which represent the geographical distribution of the study district. The selected blocks were Nannilam from north, Thiruvarur from east, Tiruturaipundi from south, Valangaiman from west and Mannargudi from central part of the study district.

2.4. Selection of the Villages

There were 352 revenue villages in these selected five blocks. In the second stage, all the villages which had 50% of scheduled castes population were selected. I.e. 87 villages were selected. For covering entire block, one third of the villages (5/6 villages) were selected from each block by simple random sampling method. Thus, 28 villages were selected for the research purpose.

2.5. Selection of the Respondents

In the third stage, house listing operation was carried out prior to the data collection to provide the necessary frame for selecting the households for the study. Totally 6376 houses were listed in all the five blocks. Identification of eligible young married women (15-24 years) in each household was the next step in the research. There were 1164 households with the target population (39 households had two couples). Totally 1203 women in the age group of 15-24 were identified.

Systematic random sampling technique was applied for selecting 21/22 respondents from each village. In order to take care of non-response due to various reasons, an extra 10% of respondents were included in the sample. i.e. 661 respondents were selected for the interview. Totally, 605 respondents were completed the interview and 32 respondents declined to participate interview. The response rate of the research study was 91.5%.

2.6. Data Collection Tools

The respondents were assessed using a structured interviewer administered questionnaire which was pretested in Chidambaram Taluk near Annamalai University, about 102 km away from Thiruvarur district.

2.7. Data Analysis

Results were summarized and presented as frequencies and percentages and also Chi-square test was used for assessing the statistical significance at p-value.

2.8. Descriptive Statistics of the Selected Variables for Logistic Regression Analysis

Logistic regression is regularly used when there are only two categories (dichotomous) of the dependent variables. It determines the impact of multiple independent variables presented simultaneously to predict membership of one or other of the two dependent variable categories. An examination of the descriptive statistics of a variable is important for identifying and summarizing the characteristics of the sample or population with respect to the variables. All the variables have been classified as categorical variables as appropriate.

2.9. Dependent Variables

All the women years were asked whether they had experienced any symptoms of Reproductive tract infections last six months prior to the survey. These Reproductive tract infections were considered as dependent variables. (‘0’ = Not experienced Reproductive Tract Infections and ‘1’ = Experienced Reproductive Tract Infections).

2.10. Independent Variables

Independent variables chosen for the analysis were age of women, religion, education, occupation, type of family, SLI, age at marriage, duration of marital life, age at first birth, birth order, exposure to mass media and distance of health care facility. Age and education were used as covariate variables in this logistic regression analysis.

2.11. Ethical Approval

The syndicate review board at Annamalai University, Tamilnadu state, India has approved the research entitled “Reproductive and Sexual Health status of Scheduled Castes Youth in Thiruvarur district, Tamilnadu, India” for the degree of Doctor of Philosophy (Ph D) in Population Studies with effect from 05-07-2012.

3. Results

3.1. Incidence of RTIs

All the women who participated in this research study were asked whether they had experienced any infections of RTIs for the last six months prior to the study and the results are tabulated. The (Figure 1) shows that 14.5% SC women experienced any one type of RTIs in the study area. The result also reveals that 8.9% of women were suffered from ‘Itching/ Irritation over vulva’ and another 4.6% of women experienced ‘Thick white discharge’ and a similar proportion of women were suffered ‘Pain in lower abdomen (not related to mensus)’. It is also noticed that less than one-fifth of women suffered from ‘Pain during urination’ (2.6%).

Figure 1. Percentage distribution of women who experienced various symptoms of RTIs (Multiple responses, N= 605)
3.2. Incidence of RTIs by Background Characteristics

The (Table 1) discusses the result of bivariate analysis of prevalence on RTIs according to their socio-economic and demographic with respect to independent variables representing age, education, occupation, SLI, age at first marriage, birth order, exposure to mass media and distance to health care facility. The proportion of women who experienced RTIs was slightly higher among women in the age of 24 years (15.6%) than the younger women (13.8% among 21-23 years). Education was found to have the strongest association with the prevalence of RTIs among women. The women who experienced RTIs was four times higher among illiterate (40.6%) than the women who completed higher secondary and above (10%) (X2 = 62.09 and p= .000). The analysis of prevalence of RTIs and women’s occupation reveal a considerable difference. Nearly one-fifth of women who were working in agricultural sector experienced RTIs (18.1%) whereas this proportion for women working in non-agriculture sector was 4.9%. The SLI of women was found to have a positive association with the incidence of RTIs of women. The women in households in the high SLI was less likely to experience RTIs (1.9%) than women in households in the low SLI (23.5%) (X2 = 27.08 and p= .000). The women who married at later age (22+ years) were less likely to experience RTIs (10.5%) than those who married at an early age (27.8% among <18 years). The age at marriage had strong and statistically significant association with prevalence of RTIs (X2 = 20.41 and p= .000). The higher birth order pregnancies were more likely to experience RTIs (21.2%) than lower birth order pregnancies (10.7%). The (Table 1) reveals that the women who experienced RTIs were less among women who had more exposure to mass media (8.7%) than less exposed (18.7%) (X2 = 11.75 and p= .001). The finding shows that women who experienced RTIs had insignificant association with distance of health centre.

Table 1. Percentage distribution of women by Prevalence of RTIs according to background characteristics

3.3. Logistic Regression Examining the Effect of Background Characteristics on Prevalence of RTIs

The (Table 2) shows the results of analysis made by binary logistic regression whether the women experienced RTIs with background characteristics. It is observed from analysis that education of women, occupation of women and Standard of living index were statistically significant with prevalence of RTIs. All other independent variables such as age of women, religion, type of family, age at marriage, duration of marital life, age at first birth, birth order, exposure to mass media, and distance to health care facility were not associated with the prevalence of RTIs among study population.

The logistic regression analysis discloses that when compared with illiterate women, women with higher education (secondary and above) were less likely to experience RTIs (OR=0.183). It is noticed (Table 2) that agricultural labourers were 1.145 times more likely to experience RTIs to the reference (non-workers) category (OR= 0.251). It is also observed that the chance of getting RTIs was less among women living in high SLI (OR=0.168) than among women living in medium SLI (OR=0.255) and the reference category (low SLI).

Table 2. Logistic regression examining the effect of background characteristics on RTIs

3.4. Treatment for RTIs

The (Table 3) shows women who sought treatment for reproductive tract infections among study population. A half of the women were received treatment (52.3%) and the remaining 47.7% of women did not receive any kind of treatment for their sexual health problems among scheduled caste women. More than half of women had undergone the treatment for ‘Pain during urination’ (56.2%). Around one third of women who had experienced the ‘Thick white discharge’ had taken treatment (32.1%) and one fifth of women who experienced Itching/Irritation over vulva’ problems and ‘Pain in lower abdomen not related to mensus, were received treatment for their sexual health problems (22.2% and 21.4% respectively).

Table 3. Percentage distribution of women who received treatment for various symptoms of RTIs (Multiple responses)

3.5. Reasons for not Received Treatment for RTIs

The (Figure 2) shows that the women who did not received treatment against RTIs, 82.3% of women were due to perception of symptoms as normal, more than three fourth of women reported due to shyness (78.3%), lack of female health workers (69.6%) and inconvenient location of health facility (60.9%). Other reasons being reported includes expensive treatment (39.1%) and lack of availability of treatment (37%).

Figure 2. Percentage distribution of women by reasons for not received treatment for RTIs (Multiple responses, N=42)

4. Discussion

Through this study, we tried to highlight the magnitude of prevalence and barriers to seeking treatment for reproductive tract infections among women in rural areas of Tamilnadu state. The prevalence rate of RTIs was observed to be 14.5% among the population in the study area. Itching/Irritation over vulva, Thick white discharge and Pain in lower abdomen (not related to mensus) were most commonly experienced symptoms. Bivariate analysis indicated statistically significant association between educational level, occupational level and standard of living index (SLI) among the study population. The chance of getting RTIs symptom was less among women living in high SLI (OR=0.168) than among women living in low SLI. The agricultural labourers were 1.145 times more likely to experience RTIs symptom than non workers category (OR= 0.251). It has been shown that certain infections can increase the chances of HIV transmission. Unfortunately, symptoms and signs of many infections may not appear until it is too late to avoid such consequences and damage to the reproductive organs. The morbidity associated with RTIs also affects the economic productivity and quality of life of many individual women and men, and consequently, of whole communities [9].

More than half of the women were received treatment against perceived RTIs (52.3%); all were treated in public health institutions. Perception of symptoms as normal, feeling of shy, lack of female health workers, distance of health facility, expensive treatment and lack of availability of treatment were identified as major barriers for non seeking treatment for RTIs among the study population. According to District Level Household Survey (DLHS -3) survey in Thiruvarur district, 46.6% of women received treatment for RTIs [10]. To date, prevention and control of RTIs, especially among young married women, is a low priority among rural women. Awareness of women regarding RTIs certainly helps in prevention and control of those problems. It is a challenging task to raise awareness regarding RTIs in women because of the social standing of women which distances them from the right source of information and also because of the taboos regarding the discussions on issues like safe sex, unsafe sexual practices, etc. The prevention of transmission of infection (primary prevention) is at present receiving increased attention because of the global epidemic of HIV/AIDS and the identification of several sexual infections as risk factors for the spread of HIV [11, 12, 13, 14, 15]. Young women are more vulnerable than men to infection with sexual infections and to its complications (such as infertility, cancer and inflammatory diseases). Biologically women are more susceptible to most sexual infections than men, partly because of the greater mucosal surface exposed to a greater quantity of pathogens during sexual intercourse [15].

In India, married women are reluctant to seek medical treatment because of lack of privacy, lack of a female doctor at the health facility, the cost of treatment and their subordinate social status [16]. This reluctance is exacerbated when symptoms are embarrassing, as they are with RTIs, especially among young women [17]. The health-seeking behavior of women is not as improved as desired. The married women are reluctant to seek medical treatment because of lack of privacy, lack of female doctors at the health facility, cost of treatment and their inferior social status. RTIs have an additional element of shame and humiliation for many women because they are considered unclean. Women do not seek treatment for RTIs due to lack of awareness, asymptomatic nature of RTIs and lack of treatment facilities [18, 19]. The correct knowledge and awareness of the problem among the masses is more important than tackling the problem. When majority of the community people have one or other problem of RTIs, there may be possibility to perceive the prevalence of RTIs to be normal. This will make the health-seeking attitude of people very much delayed. Moreover, sexually transmitted infections and reproductive tract infections are the disease which are associated with some sort of socio-cultural stigmas [20].

There are different socio-demographic economic, sexual, medical and behavioural factors related to RTIs. The less educated women are more likely to affect RTIs due to lack of knowledge. Educated women are more capable to seek the source of treatment and they can use health care facilities more efficiently. Educated women can process health related information from mass media. They can make good investment in terms of health. In rural areas, most of the deliveries take place at home and not being assisted by health practitioner. Morbidity during delivery often results into RTIs. The probability of RTIs increases due to the weakness in women body. Women from the rural areas and lower income groups are more likely to affect sexual problems.

5. Conclusions

Perception of symptoms as normal, feeling of shy, lack of female health workers, distance of health facility, expensive treatment and lack of availability of treatment were identified as major barriers for non seeking treatment for RTIs among the study population. Therefore more information is required in rural area through mass media and also more health care facilities at the door step of rural women are best-touted option. In order to make better maternal and child health, the health worker needs to provide knowledge and treatment to high-risk behaviour women. Likewise, behaviour and communication change and proper sexual health information are the best options to reduce the prevalence of sexual health problems among rural women. There is need for female counselor at each health facility to discuss the sexual health problems and explain correct treatment within a short period of time. It concludes that, improving literacy and increasing awareness level among married women especially adolescence about reproductive health is needed to reduce the incidence of RTIs among rural population.

Statement of Competing Interests

The authors declare no competing interest.

Acknowledgement

We thank the Annamalai University, Tamilnadu, India, Institutional Ethics Committee and the Dean, who permitted us to conduct the study. We also thank the respondents for their priceless information.

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