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Indian Journal of Community Medicine

Estimation of Prevalence of RTI's/STD's Among Women of Reproductive Age Group in District Agra

Author(s): Deoki Nandan, S.K. Misra, Anita Sharma, Manish Jain

Vol. 27, No. 3 (2002-07 - 2002-09)

Deptt. of Social and Preventive Medicine, S.N. Medical College, Agra

Abstract :

Research question: What is the prevalence of RTIs/STDs among women of reproductive age group in district Agra?

Objectives: 1. To estimate the prevalence of RTIs/STDs among women in reproductive age group by using the syndromic case definition. 2. To identify factors associated with causation of RTIs/STDs in women.

Study design: Exploratory in nature with application of quantitative and qualitative research methodology.

Setting: 60 clusters, comprising of villages in rural area and localities in urban area of district Agra.

Participants: 600 ever married women in the reproductive age group (i.e. 15-45 years).

Study period: One year (1997-98). Study variables: Age, education, number of live children, number of abortions.

Statistical analysis: Percentages, Chi square test.

Results: Prevalence of RTIs/STDs came out to be 35.2% with rural prevalence higher (49%) than urban (27%). More than two third of symptom positive women were less then 34 years of age. Commonest symptom of RTI/STD was vaginal discharge (94%) followed by lower abdominal pain (55%). Other common associated symptoms were backache (70%) and vulval itching (49%).

Keywords :RTIs, STDs, Syndromic case definition

Introduction:

RTIs/STDs are becoming a major public health problem not only in India but all over the world. WHO estimates that between 150 and 330 million new cases of curable STDs occur annually worldwide. In India, awareness of reproductive and sexual health is generally low among women and their access to health care is severely restricted. In India RTIs/STDs in women have never been given much attention till the introduction of RCH (Reproductive and Child Health) Programme in 1996, wherein, for the first time, there is a provision of RTI/STD diagnosis and treatment. Improvement of reproductive health, education and social status of women are now seen as necessary tools for future progress in fertility reduction (Pachauri S, 1992)1.

Broadly reproductive tract infections can be classified into three categories - Sexually transmitted infections, non-STDs e.g. post partum and post abortal sepsis/infections and infections caused by unhygienic menstrual practices/intrauterine procedures e.g. D&C, IUCD insertion etc. These infections can seriously affect the health of mothers and newborn, hence there is a need to recognise such illnesses.

At present, not only Indian studies on women reproductive health problems are scanty but also most available data are from hospital or clinics and so their results cannot be generalised. With this perspective, this population based study was undertaken in district Agra.

We are thankful to World Health Organization and National AIDS Control Organization for providing financial and technical support for carrying out this study.

Material and Methods:

The study was undertaken in District Agra; Multistage 30 cluster sampling technique was adopted separately for rural and urban areas, with a total of 60 clusters identified as per the standard criteria. Considering the overall prevalence of reproductive morbidity to be 16%, the minimum sample size was calculated to be 525 women with symptoms of RTIs/STDs (95% confidence limits). Ten ever married women in the age group of 15-45 years having symptoms of RTIs/STDs were included in the study from each cluster, thereby making the total sample size of 600 women.

A house to house survey was carried out in the selected clusters till 10 women per cluster with the symptoms of RTIs/STDs were identified with the use of free listing. Detailed in-depth interviews of selected women were conducted with the help of pre-designed and pre-tested schedule. Information so collected was computerized and analyzed with the help of specially designed software in Fox Pro.

Results and Discussion:

A total of 2089 households were surveyed (698 in 30 rural clusters and 1391 in 30 urban clusters). 600 women with symptoms of RTIs/STDs were selected for the study out of 1705 ever married women interviewed for the presence of RTIs/STDs.

Table I: Age-wise distribution of women with RTI/STD.

Age (years) Rural
No.
(%) Urban
No.
(%) Total
No.
(%)
<19 17 (6) 8 (3) 25 (4)
20-24 54 (18) 50 (17) 104 (17)
25-29 81 (27) 68 (23) 149 (25)
30-34 67 (22) 72 (24) 139 (23)
35-39 44 (15) 52 (17) 96 (16)
40+ 37 (12) 50 (17) 87 (15)
Total 300 (100) 300 (100) 600 (100)

Approximately half of the symptom positive women (48%) were in the age group of 25-34 years both in rural (49%) and urban areas (47%). The distribution of women in other age groups was almost similar except in those who are <19 years of age (4%). Association between prevalence of RTIs/STDs and age groups was found to be statistically significant (x2 = 13.43, p<0.01).

Table II: Total number of live children of the respondents.

No. of children Rural
No.
(%) Urban
No.
(%) Total
No.
(%)
None 28 (10) 19 (6) 47 (8)
1-2 76 (25) 95 (32) 171 (29)
3 61 (20) 76 (25) 137 (23)
4 69 (23) 59 (20) 128 (21)
5+ 66 (22) 51 (17) 117 (19)
Total 300 (100) 300 (100) 600 (100)

Prevalence was maximum in women having one or two children (25% in rural and 32% in urban), followed by 3 children (20% rural and 25% urban). Prevalence was, however, found to be far less in nulliparous women (10% rural and 6% urban). The differences were statistically significant (x2 = 10.51; p<0.02). This could be because first delivery is more traumatic and there are more chances of contracting infection. It was also observed that the prevalence of RTIs/STDs did not vary so widely following subsequent deliveries (being 23%, 21% and 19% respectively after third, fourth and fifth delivery). In another study in a sub-district of Karnataka, it was found that 70% women with a child <6 months had clinical or laboratory evidence of RTIs. However, evidence of STD infection was found in only 10%. This finding shows that infection is introduced during the process of delivery in most cases. (Bhatia and Cleland, 1995)2.

Overall, 26% women had one spontaneous abortion (27% rural and 24% urban). 6% women in rural and 13% in urban area had more than one spontaneous abortion. Besides, 9% women had one induced abortion (8% rural and 11% urban); 1% rural and much higher percentage of urban women (9%) had more than one induced abortions. These findings highlight that a woman probably gets susceptible to infections following abortion.

Table III: Distribution of respondents according to their educational status.

Education Rural
No.
(%) Urban
No.
(%) Total
No.
(%)
Illiterate 217 (72) 150 (50) 367 (61)
High school 62 (21) 87 (29) 149 (25)
Higher secondary 14 (5) 33 (11) 47 (8)
Graduate 7 (2) 30 (10) 37 (6)
Total 300 (100) 300 (100) 600 (100)

Prevalence of RTIs/STDs was found to be higher in illiterate women (61%) and also more in rural illiterate women (72%) than urban ones (50%). Prevalence shows a decrease with increase in level of education; the problem of RTIs/STDs being 25% in high school educated women, 8% in those who are higher secondary and 6% in women who are graduate and above.

Table IV: Symptoms among women as per syndromic case definition.

Symptoms Rural
No.
(%) Urban
No.
(%) Total
No.
(%)
Vaginal discharge 276 (92) 287 (96) 563 (94)
Lower abdominal pain 167 (56) 160 (53) 327 (55)
Genital Ulcer 20 (7) 36 (12) 56 (9)
Urethral discharge in
partner
21 (7) 17 (6) 38 (6)

It was found that commonest symptom of RTIs/STDs was vaginal discharge (94%) followed by lower abdominal pain (55%). Out of 563 women with vaginal discharge, 282(47%) were having curdy discharge, 224(37%) watery discharge and only 57(10%) had mixed type. 180 women (30%) told that their discharge was foul smelling. Nandan D et al3 (1997) also found that majority of women with RTIs/STDs were having vaginal discharge. However, out of them maximum were having watery discharge (64.08%) while 29.13% were having curdy discharge. Discharge was found to be offensive only in 1.94% cases. The differences may be because the latter study also undertook physical examination of women complaining vaginal discharge.

Table V: Other symptoms associated with RTIs/STDs.

Other symptoms Rural
No.
(%) Urban
No.
(%) Total
No.
(%)
Backache 210 (70) 210 (70) 420 (70)
Vulval itching 137 (46) 155 (52) 292 (49)
Burning micturition 106 (35) 135 (45) 241 (40)
Pain during intercourse 74 (25) 135 (45) 209 (35)
Pain during micturition 65 (22) 44 (15) 109 (18)
Inguinal swelling 2 (1) 6 (2) 8 (1)

Backache was the most common and bothering symptom as told by 70% of women in both urban and rural areas. Other common symptoms included vulval itching (49%), burning micturition (40%), pain during intercourse (35%) and painful micturition (18%) in decreasing order.

Table VI: Association of symptoms with age.

Symptoms Age group (years)
<19
(n=25)
20-24
(n=104)
25-29
(n=149)
30-34
(n=139)
35-39
(n=96)
>40
(n=87)
Vaginal discharge 25 (100) 100 (96.2) 138 (92.6) 128 (92.1) 91 (94.8) 81 (93.1)
Lower abd. pain 9 (36) 54 (51.9) 74 (49.7) 83 (59.7) 55 (57.3) 52 (59.8)
Genital ulcer 1 (4) 11 (10.6) 17 (11.4) 12 (8.6) 10 (10.4) 5 (5.7)
Itching 14 (56) 45 (43.3) 77 (51.7) 67 (48.2) 46 (47.9) 43 (49.4)
Burning micturition 3 (12) 32 (30.8) 70 (46.9) 54 (38.8) 41 (42.7) 41 (47.1)
Painful micturition 4 (16) 17 (16.3) 25 (16.8) 25 (17.9) 20 (20.8) 18 (20.7)
Painful intercourse 3 (12) 36 (34.6) 57 (38.3) 41 (29.5) 37 (38.5) 35 (40.2)

Figures in parentheses represent the percentages.

Regarding the association of symptoms with age, it was found that vaginal discharge along with other symptoms like lower abdominal pain, genital ulcer, itching etc. were prevalent maximum between the age group of 25-34 years, which coincides with the period of maximum sexual and reproductive activity. It was also found that as we proceed from lower age group to upper age group, first the frequency of symptoms increased upto the age of 29 years and then there was decreasing trend with increasing age.

From the study, the prevalence of RTIs/STD came out to be 35.2%. Extent of the problem was found to be nearly twice in rural women (49%) as compared to their urban counterparts (27%). Rural prevalence was found higher probably because of lack of awareness and inaccessibility of health care system. Nandan D et al3 (1997) conducted a socio-clinical study of RTIs/STDs cases in 21 villages of U.P. and reported almost same prevalence of 34.08%. Bang et al4 (1989) conducted a study in 2 villages of Maharashtra and found that 55% of women had gynaecological complaints, mostly related to menstruation, vaginal discharge or burning micturition, the relatively higher prevalence may be because the study was conducted in rural area only and also because of difference in criteria of diagnosis.

Conclusions:

The prevalence of RTIs/STDs was found to be 35.2%, with nearly twice in rural area (49%) as compared to their urban counterparts (27%). Approximately half of the symptom positive women were in the age group of 25-34 years in both rural and urban areas. Prevalence of RTIs/STDs was less in nulliparous women (10% rural and 6% urban). Prevalence was maximum in women having one or two children (25% in rural and 32% in urban), followed by 3 children (20% in rural and 25% in urban), thereby, reflecting association with parity.

Prevalence of RTIs/STDs was associated with abortions. Prevalence was found to be higher in illiterate women (61%) and also more in rural illiterate women (72%) than urban ones (50%). Prevalence showed a decrease with increase in level of education.

Commonest symptom of RTIs/STDs was vaginal discharge (94%) followed by lower abdominal pain (55%). Other common symptoms included backache (70%), vulval itching (49%) and burning micturition (40%). Vaginal discharge along with other symptoms like lower abdominal pain, genital ulcer, itching etc were prevalent maximum between the age group of 25-34 years.

Recommendations:

STDs/RTIs treatment facility should be part of primary health care in routine to increase the access.

References:

  1. Pachauri S. Womens' reproductive health: Research needs and priorities for developing countries. Paper presented at the South East Asia Regional Seminar on Social Dimensions of Health Care and Health Policy, NIHFW, New Delhi, March 1992.
  2. Bhatia C, Jagdish and Cleland John. Self reported symptoms of gynaecological morbidity and their treatment in South India, Studies in Family Planning. 1995; 26(4): 203-16.
  3. Nandan D. Improving Reproductive Health and Family Spacing in the state of Uttar Pradesh: Socio-clinical study of RTI/STD cases, CARE India. 1997.
  4. Bang RA, Bang AT, Baitule M, Chaudhary Y, Sarmukaddam S, Tale O (1989). High prevalence of Gynaecological diseases in rural Indian women, Lancet, Jan 14.
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