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Indian Journal of Community Medicine

Efficacy of Syndromic Approach in Management of Reproductive Tract

Author(s): J.S. Thakur, H.M. Swami, SPS Bhatia

Vol. 27, No. 2 (2002-04 - 2002-06)

Deptt. of Community Medicine, Government Medical College & Hospital, Chandigarh 160047

Abstract:

Research question: What is the efficacy of syndromic approach in management of RTIs?

Objective: To find out the magnitude of reproductive tract infections (RTIs) and to assess the efficacy of syndromic approach in their management.

Setting: Rural area of Union Territory of Chandigarh. Participants: All persons in the reproductive age (15-45 years) group in the village.

Results: A total of 138 cases of RTIs were found with a prevalence of 9% with 128(17.7%) females and 10(1.2%) males. Commonest presentation among females was vaginal discharge (17.6%) followed by lower abdominal pain (9.5%) and among males uretheral discharge (50%). Consultation rate in the past was only 16.5%. All the cases were advised treatment on the basis of WHO syndromic approach but only 91(65.9%) came forward despite two home visits. Only 60(65.9%)took complete treatment and 50(83.4%) of them were cured of their symptoms as compared to 3(9.7%) with partial treatment after one month follow up. The main reason for partial treatment was financial cost (58%) and perceived side effects (29%). Only 30% spouses came forward for treatment.

Conclusion: Besides financial constraints, there are social and educational barriers to the prevention and treatment of RTIs in rural areas. Although syndromic approach was found to be effective for those who took complete treatment but concerted efforts are required to overcome barriers and regular motivation, to achieve treatment compliance.

Keywords: Reproductive tract infections, Syndromic approach

Introduction:

Sexually transmitted diseases (STDs) are a major public health problem in both developed and developing countries, but prevalence rate is apparently higher in developing countries, where STD treatment is less accessible. WHO has advocated syndromic approach for their management as many health care providers lack time or equipment to diagnose RTIs with laboratory tests. This approach which bases diagnosis on a group of symptoms & signs and treating all diseases that could cause the syndrome, could make diagnosis more accurate without extensive laboratory tests and allow treatment with a single approach. Technical advisory subcommittee on STDs of National AIDS Control Organization (NACO) of India approved this approach in 19931.

Material and Methods:

This study was conducted in a rural area of Union Territory of Chandigarh in 1998 by randomly selecting a village covering a population of 5000. All the persons in the age group of 15-45 years were included in the study. All the pregnant and puerperal women were excluded. Data was collected by undertaking a household survey of the area by a team of medical social worker and an Intern, one of them was a female. Interview of the persons in the reproductive age was done by using a predesigned and pretested proforma. If house was locked or one of the member was away, a second visit was undertaken. Interview schedule consisted of household data, presenting symptoms with duration, treatment taken in the past, current contraceptive use etc.

The RTI cases found during the survey were called for detailed examination at Rural Health Training Centre, Palsora under department of Community Medicine located in the same village and were provided treatment based on syndromic approach1. The patients were followed up for one month to find out the outcome of treatment. Patients who were relieved of their symptoms after follow up were considered as cured and those having some relief were taken as partially cured.

Results:

There were 1532 persons in the age group of 15-45 years, out of which 52.9% were males. A total of 138 cases of RTIs were found giving a prevalence of 9% with 128(17.7%) females and 10(1.2%) males. Half (50%) of the cases were illiterate with 16.6%, 15.9% and 13.7% respectively had educational level up to primary, middle and matric.

Table I: Distribution of various reproductive tract infections in relation to sex and duration.

Presenting symptoms Females Males Duration (years)
n=722 (%) n=810 (%) <1 1-5 5-10 >10
Vaginal discharge 127 (17.6) - - 57 57 10 3
Lower abdominal pain 69 (9.5) - - 36 24 7 2
Vaginal discharge + Lower abdominal pain 68 (9.4)   - - - - -
Uretheral discharge 1 (0.1) 5 (0.6) 4 2 - -
Genital ulcer 1 (0.1) 1 (0.1) 1 1 - -
Inguinal swelling/bubo - - 3 (0.4) 2 1 - -
Scrotal swelling - - 2 (0.2) 2 - - -
Any other 1 (0.1) - - - - - -

The distribution of various RTIs in relation to sex and duration is shown in Table I. Commonest presentation among females was vaginal discharge (17.6%) followed by lower abdominal pain (9.5%). Vaginal discharge was present in all cases of lower abdominal pain except one. Among males, uretheral discharge was present in 5 out of total 10 RTI cases. Mean duration of RTI cases was 22 months and majority of (84%) cases occurred in last 5 years. Consultation rate for the RTIs was 16.7% as 108 cases out of 128 in females and 7 out of 10 males had not taken any treatment in the past. Treatment history and follow up of cases is shown in Table II.

Table II: Treatment history and follow up of RTI cases.

Treatment details Total cases n=138 (%)
Treatment advised 138 (100)
Treatment taken 91 (65.9)
Complete 60 (65.9)
Partial 31 (34.1)
Outcome of complete treatment (n=60)
Cured 50 (83.4)
Partially cured 7 (11.6)
No relief 3 (5.0)
Reasons for partial treatment (n=31)
Cost of drugs 18 (58.1)
Perceived side effects 9 (29.0)
Too many tablets 4 (12.9)
Treatment of spouse (n=91) 27 (29.7)

Out of 138 cases, 91(65.9%) came forward for treatment despite paying at least two home visits for convincing the defaulters. The main reason given by defaulters was lack of interest and concern for their problem. Out of 91, only 60(65.9%) completed the treatment and remaining took partial treatment. Of those who completed treatment, 50(83.4%) were cured of their symptoms as compared to 3(9.7%) getting cured who took partial treatment and it was found to be statistically significant (p<0.01). Main reason for partial treatment was financial (58.1%) followed by side effects (29%) and taking many tablets (13%). Only 30% of spouses came forward for the treatment.

Discussion:

Prevalence of vaginal discharge of 17% in the present study is comparable to another study undertaken in slum women of Chandigarh2. In another recent community based study, among commercial sex workers in Calcutta, vaginal discharge was found in 48% cases which may be due to high risk behaviour3. Majority of women tolerate vaginal discharge of varying degree for a long time before they consult a doctor. Our study revealed that overall consultation rate for RTIs was quite low. Bang et al4 also reported that 92% women in their study were found to have one or more gynaecological or sexual disease but only 8% of them had a gynaecological examination in the past even though 55% were aware of having some gynaecological disorder. A consultation rate of 45% was reported for slum women of Chandigarh2. Even 34% of patients did not come forward for treatment despite at least two home visits for the purpose. Reasons for low consultations were illiteracy, simply ignored the symptoms due to lack of concern and awareness for the problem and some women were too shy to come to health centre regarding a symptom pertaining to her private parts which has also been reported by others2. Only two third of those who opted for treatment, completed their treatment and rest took partial treatment. It was found that those who completed the course of treatment, the cure rate of presenting symptom was 83.3% which is comparable to two Rwandan towns5. The main reasons for partial treatment were cost and perceived side effects in 29% which has been reported by others also6.

Besides financial constraints, there are social and educational barriers to the prevention and treatment of RTIs in rural areas of Chandigarh as has been highlighted by others also2,6. Although efficacy of syndromic approach for treatment of RTIs was high, as a cure rate of 83% could be achieved among 60 cases who opted for complete treatment, but 78(56.5%) cases either did not come forward for treatment or took partial treatment. Efforts need to be directed towards overcoming barriers and regular motivation is required to achieve high treatment compliance. Family health awareness campaign started by Govt. of India twice a year since 1998 for early diagnosis and treatment of RTI cases is a right step in right direction keeping in view the magnitude of the problem.

Acknowledgement:

The Authors are thankful to Ms. Renu Kumari, Mrs. Amrit Kaur, Ms. Seema Kumari, Medical Social Workers for their help in data collection.

References:

  1. National AIDS Control Organization. Simplified STD treatment guidelines. Ministry of Health and Family Welfare, Govt. of India, New Delhi 1993.
  2. Palai P, Singh A, Pallai V. Treating vaginal discharge in slum women. Bulletin PGI 1994; 28: 107-10.
  3. Das A, Jana S, Chakraborty AK, Khodakevich L, Chakravorti MS, Pal NK. Community based survey of STD/HIV infection among commercial sex workers in Calcutta (India). J Com Dis 1994; 26(4): 192-6.
  4. Bang RA, Bang AT, Baitule M, Choudhary Y, Sarmukaddam S, Tale O. High prevalence of gynaecological diseases in rural Indian women. The Lancet 1989; 1: 85-8.
  5. Steen R, Soliman C, Majyambwani A et al. Notes from the field: Practical issues in upgrading STD services based on experience from Primary health care facilities in two Rwandan towns. Sex Transm Infect 1998; 74: 5159-65.
  6. Kumar R, Kaur M, Aggarwal AK, Mahandiratta L. Reproductive tract infections and associated difficulties. World Health Forum 1997; 18: 80-2.
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