Reproductive Tract Infections/ Sexually Transmitted Infections in Rural Haryana: Experiences from the Family Health Awareness Campaign
Author(s): A. Acharya, K. Yadav, N. Baridalyne
Vol. 31, No. 4 (2006-10 - 2006-12)
A. Acharya, K. Yadav, N. Baridalyne
Introduction
Family Health Awareness Campaign (FHAC) was launched
by the National AIDS Control Organization (NACO), Ministry
of Health, Government of India, to create awareness in the
community regarding RTI/STD/HIV-AIDS through home visits
and village-based camps and encourage clients suspected
to have RTI/STD to seek early treatment. It was started in
the year 1999 and since then has been conducted annually.
Reproductive tract infections (RTI) including sexually
transmitted diseases (STD) are increasingly recognized
as a major cause of morbidity in India. The importance of
the control of RTI has increased with the introduction of the
HIV/AIDS epidemic in the country. The risk of becoming HIV
infected after a single sexual exposure is increased 10-30
fold in the presence of a genital ulcer.1
Thus more attention has begun to be focused on STD
prevention and care as a means to HIV prevention. The
Family Health Awareness Campaign is an effort to address
some of the key issues related to reproductive health in
the community especially in the rural areas and other
marginalized populations. It is a strategy through which
target population is sensitized towards these problems and
all efforts are being made for early detection and treatment
of RTI/STD by full involvement of the community.1
Objectives: (1) To determine the distribution of RTI
symptoms by syndromic approach. (2) To determine the
socio-demographic characteristics of patients attending
FHAC camps. (3) To study the possible association of
selected patient characteristics like Age at first coitus,
Literacy, Parity, and Menstrual Hygiene and Contraception with
RTI. (4) To find out the response of those identified with RTI
towards FHAC.
Material and Methods
This study was conducted at PHC Dayalpur which is under
Comprehensive rural health services project (CRHSP),
Ballabhgarh, Distt. Faridabad in northern India. At present
there are two primary health centers (PHCs) comprising of
fi ve subcentres, each catering to a population of around
38000. The healthcare in these villages is provided along
the national pattern. The family health awareness campaign
was launched from 1/9/2003 to 6/9/2003 (six days) at PHC
Dayalpur in different villages. The health workers have been
trained for organization of these camps. One week before the
camp the health workers made house visits, the purpose of
which was to fill contact card, tell about RTI and camp details.
The total population of the PHC is 37,716 and total no of
households is 3870. Average number of households per sub
centre was 800, 130 houses per day/sub centre= 65 houses
per day per worker were visited. The camps were held at
various subcentres covering all the 17 villages under PHC
Dayalpur (separate camps at each village could not be held
due to constraint of time and logistics).
On the day of the camp, patients were brought from their
respective villages to the site of the camp. Informed verbal
consent was taken from the patients before conducting the
interviews and physical examination. A semi-structured
interview schedule was filled up before examination.
The interview schedule contained information on general
demographic characteristics, obstetric history, contraception,
menstrual and related disorders, and questions’ pertaining to
syndromic approach by NACO. Lady Medical Officer (AA)
examined the female patients as per syndromic approach
with speculum examination and was followed by treatment
of partner. Records of the patient details were maintained
by male/female workers. Their demographic characteristics,
identifi cation number, symptoms, treatment given were noted
and follow up was done by the health workers during their
routine domiciliary visits.
Counseling
Group level: Health talk was given at the camp before
examination wherein HIV/AIDS, High risk behavior and
personal hygiene (menstrual) were discussed.
Individual level: After examination each person was given
a brief health talk reiterating the above points by health
assistants / medical officer.
Follow up was done by health workers during their domiciliary
visits using the unique (identifi cation) number and at the
Extension Health Clinics (EHC) by doctors. Analysis: Data
was entered and analyzed in EPI info 2002 and SPSS version 11.0.
Results
There Health workers contacted and distributed cards to
13199 people between 15-49 years, out of which 7259
were males and 5940 were females. Total number of persons
referred to the primary health centre for any of RTI/STD
problems were 841 males and 898 females. The number of
females and males who actually attended the camp were
266 (29.6%) and 4(0.47%) respectively. The interview schedule could be completed for 260 female patients only, as the other
6 (2.25%) refused to participate. The males were excluded
from the study as the number was very less.
As per their age distribution, majority (77%) belonged to
the age group 20-39 years. The mean age was 29.8 (S.D
8.04) years. 97.6% (254) women attending the camp were
Hindus, 2.3% were Muslims. Majority of the women were
housewives (94.6%) by occupation. Most (55%) of them
were illiterate, those educated up to primary were 16.2 %
(42) followed by middle school by 17.3 % (45) and high school
by 11.5 % (30).
Two hundred and forty four (93.8%) women were currently
married followed by never married in 3.5%. Four women
(1.5%) were widowed and 3 were divorced or separated and
the difference was statistically significant (p=0.000).
One hundred fifty four (61.36%) women were married before
18 years of age and the rest at 18 or above age.
The age at first coitus was less than 18 years in 57.37% (144)
women. More than half (57.8%) women had <3 children,
34.6% had >4 children and 7.6% were nulliparous. Majority
of the women (40.57%) did not use any contraception, 37.7%
had undergone permanent sterilization. About 12% used
condoms and few used oral pills (3.27%) and intrauterine
devices (6.14%) respectively.
Menstrual periods were regular in 60% of women. 87.6 %
(225) women used clothes for sanitary protection. Napkins
brought from shop were used by few in 5.1% (13) women.
Out of those who used cloth, 67.11% (151) discarded it
after use, 24 women (10.66%) reused after changing layers
and 21(9.33%) women reused after washing. Out of 257
women who used sanitary protection (3 women had attained
menopause), 5.4% (14) never changed the pads, 65.8%
(169) changed one to two times, and 28.9% (74) changed
more than 3 times.
All the 17 women in 15-19 age groups were using clothes
as sanitary protection during menstruation. No association
was observed between adequate menstrual hygiene (defined
as use of sanitary napkins or use of clothes which were
discarded or reused after washing) and age with p value =
0.306. (Table I).
Majority of the females (95.3%) said that they cleaned
their private parts during menstruation. Similar number
of women said that it was important to maintain hygiene
during menstruation. Abnormal vaginal discharge was the
most common self reported symptom by 64.2% women
followed by low back pain in 63.8% (166). Other symptoms
complained by the patients were genital itching in 30.76%
(80), genital burning in 25% (65), low abdominal pain in
48.8% (127), dysmenorrhoea in 54% (139), dyspareunia in
36.5% (95) women, genital prolapse in 22.3%(58). Increased
frequency of micturition was complained by 13.5% (35) of
women (Table II). However, on per speculum examination,
vaginitis was found in 51.5%, cervicitis in 11.5% and PID in
8.5%, prolapse of uterus was found in 5.8% (15) women.
Only one patient had genital ulceration.
Table I. Women’s Age Versus Materials Used for Sanitary Protection.
Sanitary Protection
AGE
Clothes
Napkins bought
from shop
Nothing
Others
Total
15-19
17
0
0
0
17
20-29
105
5
0
5
115
30-39
70
5
0
10
85
40-49
33
3
1
3
43
Total
225
13
1
18
260
p = 0.000
Table II. Distribution of Patients with Self-Reported Symptoms N=260.
Self-Reported
symptoms
Frequency
(percentage)
1.
Abnormal vaginal discharge
167
(64.2)
2.
Low back pain
166
(63.8)
3.
Dysmenorrhoea
139
(54)
4.
Low abdominal pain
127
(48.8)
5.
Dyspareunia
95
(36.5)
6.
Genital itching
80
(30.76)
7.
Genital burning
65
(25)
8.
Genital prolapse
58
(22.3)
9.
Increased frequency of micturition
3 5
(13.5)
There was no statistically significant association between age
at first coitus and vaginitis (p=0.592), cervicitis (p=0.985),
PID (P=0.451), parity (p=0.824). Similarly, there was no
statistically significant association between literacy status
(p=0.247) and current contraception use (p=0.573) All the
above patients were treated according to the syndromic
approach. They were followed up after 2 weeks by the health
workers in their respective villages and intern doctors at the
extension health clinics (EHC).
Discussion
In this study, out of 898 women who were contacted by
health workers for any problem of RTI/STI, only 266 (29.6%)
women actually attended the camp. Still worse was the male
participation as out of 841 men who were referred by health
workers, only 4(0.47%) turned up. The drop out rate was
very high, 99.53% for males and 70.40% for females This
shows that in spite of the load of RTI/STI in the community
being very high people are reluctant to come forward for
treatment. This maybe due to strong social stigma attached
to these diseases. Secondly, since these camps were held on working days, it would have been difficult for the men to
attend as this would lead to loss of a day’s earnings.
Majority of the patients coming to the camp belonged to
the village where the camp was organized (data not given)
although a vehicle was provided to bring patients from
adjacent villages (Each camp was supposed to cater to 2-3
adjacent villages). The response rate from non-camp villages
was less because the adjacent villages are at a distance of
5-7 km and generally people are reluctant to leave their daily
household chores and come to the camps to seek treatment
for RTI/STIs.
Abnormal vaginal discharge, self reported by the women
was 64.2% which is quite high. This may be probably
because these women were specifi cally made aware of this
FHAC camp and were told about the symptoms of RTI/STI
by the health workers. In a study done in Agra2, vaginal
discharge was reported by 54.4% and in a study done in
Meerut it was 42%3. On per Speculum examination vaginitis
was found in 51% which is similar to a study carried out in
Chandigarh (52%)4. Similarly Cervicitis was seen in 11.5%
and PID in 8.5% in the present study. In the study carried
out in Chandigarh re-settlement colony cervicitis was found
in 20.8% and PID in 14.6% which is slightly higher than the
present study4.
An important finding of this study was that only 5.1% women
used sanitary pads as absorbents and the rest used home
made pads out of clothes. This may be probably because
the women belonged to the rural area where accessibility and
affordability to sanitary napkins is less. Out of those who used
cloth, 151(67.11%) women discarded it after use, 24 women
(10.66%) reused after changing layers and 21(9.33%) women
reused after washing. As more than half of the women were
suffering from vaginitis, use of home made clothes which are
not clean may be an important risk factor for Reproductive
tract infections.
In a study carried in an urban resettlement colony, south
Delhi5, one-third women used sanitary pads as absorbents.
This is higher than the present study probably because it
was an urban resettlement colony where the awareness
regarding personal hygiene might be high. In the same study
7.6% women re-used cloth after washing and cleaning which
is similar to the present study (9%).
Association between different RTI and various sociodemographic
characteristics like age at first coitus, literacy,
parity, menstrual hygiene and contraception were not found
to be statistically significant (p>0.05).
Conclusion
It was seen that in spite of sensitizing the population during
house-to-house visits in FHAC only 29.6% (266 out of 898)
of women identifi ed as having RTI symptoms attended FHAC
camps and response was even worse for men.
There is a need to enhance the health seeking behavior of
population in relation to RTI/STDs and increase the accessibility
of health services. This can be achieved through continuous
health education activities regarding RTI/STD/HIV/AIDS.
Other community resources like the anganwadi workers,
can contribute by disseminating information about RTI/STI to
the adolescent girls, pregnant and lactating females. School
teachers can also take up the responsibility of giving health
education regarding personal hygiene, menstrual hygiene
etc.
References
- http://www.nacoonline.org/prog_sche_campaign.htm
Accessed July 2004
- Nandan D, Gupta YP, Krishnan V, Sharma A, Misra SK.
Reproductive tract infections in women of reproductive age
group in Sitapur/Shahajanpur District of Uttar Pradesh. Indian
J Public health. 2001: 45 8-13.
- Jain S, Singh JV, Bhatnagar M, Garg SK, Chopra H, Bajpai
SK. Reproductive Tract Infections among rural women in
Meerut. Indian J Med Sci 1999; 53:359-60.
- Singh MM, Devi R, Garg S, Mehra M Effectiveness of
Syndromic Approach in management of Reproductive tract
infections in women. Indian J Med Sci 2001; 55:209-14.
- N. Baridalyne, V.P. Reddaiah. Menstruation: Knowledge,
Beliefs and Practices of Women in the Reproductive Group
residing in an Urban Resettlement colony of Delhi. Health and
Population Perspectives 2004; 27 9-16.
Centre for Community Medicine, All India Institute of Medical
Sciences, Ansari Nagar, New Delhi 110029.
E- mail: [email protected]
Received: 14.10.04
A. Acharya, K. Yadav, N. Baridalyne
Introduction
Family Health Awareness Campaign (FHAC) was launched by the National AIDS Control Organization (NACO), Ministry of Health, Government of India, to create awareness in the community regarding RTI/STD/HIV-AIDS through home visits and village-based camps and encourage clients suspected to have RTI/STD to seek early treatment. It was started in the year 1999 and since then has been conducted annually. Reproductive tract infections (RTI) including sexually transmitted diseases (STD) are increasingly recognized as a major cause of morbidity in India. The importance of the control of RTI has increased with the introduction of the HIV/AIDS epidemic in the country. The risk of becoming HIV infected after a single sexual exposure is increased 10-30 fold in the presence of a genital ulcer.1
Thus more attention has begun to be focused on STD prevention and care as a means to HIV prevention. The Family Health Awareness Campaign is an effort to address some of the key issues related to reproductive health in the community especially in the rural areas and other marginalized populations. It is a strategy through which target population is sensitized towards these problems and all efforts are being made for early detection and treatment of RTI/STD by full involvement of the community.1
Objectives: (1) To determine the distribution of RTI symptoms by syndromic approach. (2) To determine the socio-demographic characteristics of patients attending FHAC camps. (3) To study the possible association of selected patient characteristics like Age at first coitus, Literacy, Parity, and Menstrual Hygiene and Contraception with RTI. (4) To find out the response of those identified with RTI towards FHAC.
Material and Methods
This study was conducted at PHC Dayalpur which is under Comprehensive rural health services project (CRHSP), Ballabhgarh, Distt. Faridabad in northern India. At present there are two primary health centers (PHCs) comprising of fi ve subcentres, each catering to a population of around 38000. The healthcare in these villages is provided along the national pattern. The family health awareness campaign was launched from 1/9/2003 to 6/9/2003 (six days) at PHC Dayalpur in different villages. The health workers have been trained for organization of these camps. One week before the camp the health workers made house visits, the purpose of which was to fill contact card, tell about RTI and camp details. The total population of the PHC is 37,716 and total no of households is 3870. Average number of households per sub centre was 800, 130 houses per day/sub centre= 65 houses per day per worker were visited. The camps were held at various subcentres covering all the 17 villages under PHC Dayalpur (separate camps at each village could not be held due to constraint of time and logistics).
On the day of the camp, patients were brought from their respective villages to the site of the camp. Informed verbal consent was taken from the patients before conducting the interviews and physical examination. A semi-structured interview schedule was filled up before examination.
The interview schedule contained information on general demographic characteristics, obstetric history, contraception, menstrual and related disorders, and questions’ pertaining to syndromic approach by NACO. Lady Medical Officer (AA) examined the female patients as per syndromic approach with speculum examination and was followed by treatment of partner. Records of the patient details were maintained by male/female workers. Their demographic characteristics, identifi cation number, symptoms, treatment given were noted and follow up was done by the health workers during their routine domiciliary visits.
Counseling
Group level: Health talk was given at the camp before examination wherein HIV/AIDS, High risk behavior and personal hygiene (menstrual) were discussed.
Individual level: After examination each person was given a brief health talk reiterating the above points by health assistants / medical officer.
Follow up was done by health workers during their domiciliary visits using the unique (identifi cation) number and at the Extension Health Clinics (EHC) by doctors. Analysis: Data was entered and analyzed in EPI info 2002 and SPSS version 11.0.
Results
There Health workers contacted and distributed cards to 13199 people between 15-49 years, out of which 7259 were males and 5940 were females. Total number of persons referred to the primary health centre for any of RTI/STD problems were 841 males and 898 females. The number of females and males who actually attended the camp were 266 (29.6%) and 4(0.47%) respectively. The interview schedule could be completed for 260 female patients only, as the other 6 (2.25%) refused to participate. The males were excluded from the study as the number was very less.
As per their age distribution, majority (77%) belonged to the age group 20-39 years. The mean age was 29.8 (S.D 8.04) years. 97.6% (254) women attending the camp were Hindus, 2.3% were Muslims. Majority of the women were housewives (94.6%) by occupation. Most (55%) of them were illiterate, those educated up to primary were 16.2 % (42) followed by middle school by 17.3 % (45) and high school by 11.5 % (30).
Two hundred and forty four (93.8%) women were currently married followed by never married in 3.5%. Four women (1.5%) were widowed and 3 were divorced or separated and the difference was statistically significant (p=0.000). One hundred fifty four (61.36%) women were married before 18 years of age and the rest at 18 or above age. The age at first coitus was less than 18 years in 57.37% (144) women. More than half (57.8%) women had <3 children, 34.6% had >4 children and 7.6% were nulliparous. Majority of the women (40.57%) did not use any contraception, 37.7% had undergone permanent sterilization. About 12% used condoms and few used oral pills (3.27%) and intrauterine devices (6.14%) respectively.
Menstrual periods were regular in 60% of women. 87.6 % (225) women used clothes for sanitary protection. Napkins brought from shop were used by few in 5.1% (13) women. Out of those who used cloth, 67.11% (151) discarded it after use, 24 women (10.66%) reused after changing layers and 21(9.33%) women reused after washing. Out of 257 women who used sanitary protection (3 women had attained menopause), 5.4% (14) never changed the pads, 65.8% (169) changed one to two times, and 28.9% (74) changed more than 3 times.
All the 17 women in 15-19 age groups were using clothes as sanitary protection during menstruation. No association was observed between adequate menstrual hygiene (defined as use of sanitary napkins or use of clothes which were discarded or reused after washing) and age with p value = 0.306. (Table I).
Majority of the females (95.3%) said that they cleaned their private parts during menstruation. Similar number of women said that it was important to maintain hygiene during menstruation. Abnormal vaginal discharge was the most common self reported symptom by 64.2% women followed by low back pain in 63.8% (166). Other symptoms complained by the patients were genital itching in 30.76% (80), genital burning in 25% (65), low abdominal pain in 48.8% (127), dysmenorrhoea in 54% (139), dyspareunia in 36.5% (95) women, genital prolapse in 22.3%(58). Increased frequency of micturition was complained by 13.5% (35) of women (Table II). However, on per speculum examination, vaginitis was found in 51.5%, cervicitis in 11.5% and PID in 8.5%, prolapse of uterus was found in 5.8% (15) women. Only one patient had genital ulceration.
Table I. Women’s Age Versus Materials Used for Sanitary Protection.
| Sanitary Protection | |||||
|---|---|---|---|---|---|
| AGE | Clothes | Napkins bought from shop |
Nothing | Others | Total |
| 15-19 | 17 | 0 | 0 | 0 | 17 |
| 20-29 | 105 | 5 | 0 | 5 | 115 |
| 30-39 | 70 | 5 | 0 | 10 | 85 |
| 40-49 | 33 | 3 | 1 | 3 | 43 |
| Total | 225 | 13 | 1 | 18 | 260 |
p = 0.000
Table II. Distribution of Patients with Self-Reported Symptoms N=260.
| Self-Reported symptoms |
Frequency | (percentage) | |
|---|---|---|---|
| 1. | Abnormal vaginal discharge | 167 | (64.2) |
| 2. | Low back pain | 166 | (63.8) |
| 3. | Dysmenorrhoea | 139 | (54) |
| 4. | Low abdominal pain | 127 | (48.8) |
| 5. | Dyspareunia | 95 | (36.5) |
| 6. | Genital itching | 80 | (30.76) |
| 7. | Genital burning | 65 | (25) |
| 8. | Genital prolapse | 58 | (22.3) |
| 9. | Increased frequency of micturition | 3 5 | (13.5) |
There was no statistically significant association between age at first coitus and vaginitis (p=0.592), cervicitis (p=0.985), PID (P=0.451), parity (p=0.824). Similarly, there was no statistically significant association between literacy status (p=0.247) and current contraception use (p=0.573) All the above patients were treated according to the syndromic approach. They were followed up after 2 weeks by the health workers in their respective villages and intern doctors at the extension health clinics (EHC).
Discussion
In this study, out of 898 women who were contacted by health workers for any problem of RTI/STI, only 266 (29.6%) women actually attended the camp. Still worse was the male participation as out of 841 men who were referred by health workers, only 4(0.47%) turned up. The drop out rate was very high, 99.53% for males and 70.40% for females This shows that in spite of the load of RTI/STI in the community being very high people are reluctant to come forward for treatment. This maybe due to strong social stigma attached to these diseases. Secondly, since these camps were held on working days, it would have been difficult for the men to attend as this would lead to loss of a day’s earnings. Majority of the patients coming to the camp belonged to the village where the camp was organized (data not given) although a vehicle was provided to bring patients from adjacent villages (Each camp was supposed to cater to 2-3 adjacent villages). The response rate from non-camp villages was less because the adjacent villages are at a distance of 5-7 km and generally people are reluctant to leave their daily household chores and come to the camps to seek treatment for RTI/STIs.
Abnormal vaginal discharge, self reported by the women was 64.2% which is quite high. This may be probably because these women were specifi cally made aware of this FHAC camp and were told about the symptoms of RTI/STI by the health workers. In a study done in Agra2, vaginal discharge was reported by 54.4% and in a study done in Meerut it was 42%3. On per Speculum examination vaginitis was found in 51% which is similar to a study carried out in Chandigarh (52%)4. Similarly Cervicitis was seen in 11.5% and PID in 8.5% in the present study. In the study carried out in Chandigarh re-settlement colony cervicitis was found in 20.8% and PID in 14.6% which is slightly higher than the present study4.
An important finding of this study was that only 5.1% women used sanitary pads as absorbents and the rest used home made pads out of clothes. This may be probably because the women belonged to the rural area where accessibility and affordability to sanitary napkins is less. Out of those who used cloth, 151(67.11%) women discarded it after use, 24 women (10.66%) reused after changing layers and 21(9.33%) women reused after washing. As more than half of the women were suffering from vaginitis, use of home made clothes which are not clean may be an important risk factor for Reproductive tract infections.
In a study carried in an urban resettlement colony, south Delhi5, one-third women used sanitary pads as absorbents. This is higher than the present study probably because it was an urban resettlement colony where the awareness regarding personal hygiene might be high. In the same study 7.6% women re-used cloth after washing and cleaning which is similar to the present study (9%).
Association between different RTI and various sociodemographic characteristics like age at first coitus, literacy, parity, menstrual hygiene and contraception were not found to be statistically significant (p>0.05).
Conclusion
It was seen that in spite of sensitizing the population during house-to-house visits in FHAC only 29.6% (266 out of 898) of women identifi ed as having RTI symptoms attended FHAC camps and response was even worse for men.
There is a need to enhance the health seeking behavior of population in relation to RTI/STDs and increase the accessibility of health services. This can be achieved through continuous health education activities regarding RTI/STD/HIV/AIDS. Other community resources like the anganwadi workers, can contribute by disseminating information about RTI/STI to the adolescent girls, pregnant and lactating females. School teachers can also take up the responsibility of giving health education regarding personal hygiene, menstrual hygiene etc.
References
- http://www.nacoonline.org/prog_sche_campaign.htm Accessed July 2004
- Nandan D, Gupta YP, Krishnan V, Sharma A, Misra SK. Reproductive tract infections in women of reproductive age group in Sitapur/Shahajanpur District of Uttar Pradesh. Indian J Public health. 2001: 45 8-13.
- Jain S, Singh JV, Bhatnagar M, Garg SK, Chopra H, Bajpai SK. Reproductive Tract Infections among rural women in Meerut. Indian J Med Sci 1999; 53:359-60.
- Singh MM, Devi R, Garg S, Mehra M Effectiveness of Syndromic Approach in management of Reproductive tract infections in women. Indian J Med Sci 2001; 55:209-14.
- N. Baridalyne, V.P. Reddaiah. Menstruation: Knowledge, Beliefs and Practices of Women in the Reproductive Group residing in an Urban Resettlement colony of Delhi. Health and Population Perspectives 2004; 27 9-16.
Centre for Community Medicine, All India Institute of Medical
Sciences, Ansari Nagar, New Delhi 110029.
E- mail: [email protected]
Received: 14.10.04
