Health seeking behavior and prevalence of self-reported symptoms of reproductive tract infection among women of reproductive age group in Dehradun District, Uttarakhand

ABSTRACT

Background:

Reproductive tract infections (RTIs) are a common health issue among women in developing countries and can have serious long-term consequences. Health-seeking behavior (HSB) is essential in preventing, diagnosing, and managing RTIs. Aim: To determine the prevalence of self-reported symptoms of RTIs, HSB, and treatment utilization among women in the reproductive age group using a validated questionnaire developed for the Indian context.

Methods:

A mixed-method approach was utilized. Health-seeking questionnaire items were generated after a brainstorming session with healthcare workers. Multistage sampling was employed to recruit 306 women aged 15–49 years from three villages/wards of rural and urban areas to estimate the prevalence of symptoms of RTIs. Descriptive and inferential statistics were used for data analysis. Binary logistic regression was employed to assess the predictors of care-seeking behavior.

Results:

All 24 items of the HSB questionnaire were deemed accepted as the content validity ratio (CVR) was more than 0.99 and retained as the content validity index (CVI) was more than 0.80. Out of 306 women, 26.7% revealed a history of vaginal discharge, primarily white with a sticky mucoid texture. 91.5% exhibited low perceived susceptibility to RTI/STI, 90% elicited high perceived severity, 95% showed high perceived benefit, and 36% scored high on perceived barrier. Perceived barriers included the belief that symptoms were within the realm of normality, shyness in discussing symptoms, and societal fear of judgment over character.

Conclusion:

Though 82% heard of RTI/STI, only half of them were aware of the mode of transmission. Prevalence of Vaginal discharge was reported by 27%. Participants exhibited low perceived susceptibility and high to moderate perceived barriers.

Introduction

Reproductive tract infections (RTIs) or sexually transmitted infections (STIs) are most common among women of reproductive age group, and they are responsible for a significant burden of morbidity and mortality.[1] These infections in India and other developing countries rank among the top five health conditions. National Family Health Survey has also reported that 39.2% of women in India have one or more of the reproductive tract infections.[2] RTIs present with various symptoms, such as lower abdominal pain, abnormal vaginal discharge, and genital ulcers.[3] If left untreated, RTI can lead to complications like pelvic inflammatory disease, infertility, puerperal sepsis, and pregnancy wastage.[3] The emergence of HIV (human immunodeficiency virus) has exacerbated the preexisting issue, as both illnesses exhibit a strong interrelationship.[4]

Most of the women have a negligent attitude towards the symptoms of STI till the appearance of complications. Despite the availability of health services, symptomatic women bear silence due to feelings of shyness and social stigma. Health-seeking behavior (HSB) helps to reduce the cost of treatment, disability, and occurrence of complications from STIs.[5] The healthcare-seeking action of women reflects the attentiveness of the disease and the adequacy of the healthcare facility in a community. A multitude of interconnected factors influence the health-seeking behavior of women regarding RTI. For designing an effective control program, it is useful to look at those factors open to intervention by health professionals. Various studies have been conducted on RTIs and the Health-seeking behavior of women, albeit with a predominant focus on urban and slum areas. To the best of our knowledge, there are no Indian studies that have explored the healthcare-seeking behaviors and predictors of HSB of both rural and urban women regarding reproductive tract infections. With this background, our study aimed to estimate the prevalence of self-reported reproductive tract infection (RTI) symptoms and the healthcare-seeking behavior of women in rural and urban areas of Dehradun district, Uttarakhand, using a validated questionnaire developed for the Indian context.

Objectives

Among the women of reproductive age group,

1. To develop and validate the HSB questionnaire using the health belief model.

2. To estimate the prevalence of self-reported symptoms of RTIs/STIs in the past three months.

3. To examine the health-seeking behavior of women regarding RTIs/STIs.

4. To determine the predictors for treatment-seeking of RTIs/STIs.

Materials and Methods

Study design and setting

This was an exploratory mixed-method study (qual – Quan). The qualitative study was conducted to develop the HSB questionnaire related to RTI/STI. This questionnaire was used in the quantitative part of the study. The cross-sectional study was carried out in three blocks (Chakrata, Doiwala and Raipur) of the district Dehradun, Uttarakhand.

Study participants and sampling

We have included women in the age group of 15–49 years. Women who did not give consent, pregnant and lactating, history of hysterectomy, attained menopause, known case of any psychiatric illness were excluded from the study. A multistage random sampling technique was employed. The detail of the recruitment of the participants is given in Figure 1.

Figure 1.

Recruitment of study participants

Data collection tool

The questionnaire consisted of four parts: Part A: Basic socio-demographic details, Part B: Awareness related to RTI/STI, Part C: Questions related to experiencing any symptoms of RTI/STI in the last 3 months and treatment taken, Part D: HSB about RTI/STI.

HSB questionnaire

Our twenty-four-item HSB questionnaire had four domains with responses on a five-point Likert scale to assess an individual’s perceived susceptibility and severity toward STI and their perceived benefits and barriers to taking action to prevent or treat the condition. The responses were categorized as SA (Strongly Agree), A (Agree), N (Neutral), D (Disagree), SD (Strongly Disagree), and NR (Not Rated) scored as 1 to 5. The categorization was done by dividing the total scores into quartiles [Table 1]. Except for perceived susceptibility, other factors were categorized as low, medium, high, and very high from lower class to higher class. For perceived susceptibility, the order was reversed due to the nature of the questions. The development of the questionnaire is described below.

Table 1.

Scoring and categories of factors in health seeking behavior questionnaire

Factor	No of items	Min to max score	Categories (low, medium, high, very high)
Perceived susceptibility	6	6–30	6–12, 12–18, 8–24, 24–30
Perceived severity	5	5–25	5–10, 10–15, 15–20, 20–25
Perceived benefit	4	4–20	4–8, 8–12, 12–16, 16–20
Perceived barrier	9	9–45	9–18, 18–27, 27–36, 36–45

Data collection technique

Qualitative part

We conducted two brainstorming sessions with five staff nurses and nine field healthcare workers (females) in two Primary health centers. They were prior informed about the objective of the study to list the items specific to the health belief model domains of perceived susceptibility (I cannot get RTI because__), perceived severity (if I get RTI or STI then_____), perceived benefit (Getting treatment for RTI is important because_____) and perceived barrier (I had/will not take treatment for RTI/STI because______). In the first session, the participants were encouraged to list as many items as possible. All the items were enlisted on a paper without any further discussion. Approximately 10 min were spent on each domain. At the end, all the items were reviewed for duplication, and group consensus was taken. This was followed by a second session in another health center. The previous list of items was displayed, and the participants were asked to add items to the list. The duplications were removed at the end. Both sessions lasted for 60 min. Thirty-one items were generated. Researchers assessed items for duplications. Finally, a 24-item questionnaire was developed. The questionnaire was validated by three experts from public health and two from the gynecology department. The relevance was assessed using a four-point Likert scale- not relevant, somewhat relevant, quite relevant, highly relevant and the necessity by a three-point Likert scale- ”not necessary, useful but not essential, essential.” Final questionnaire was translated into Hindi and back-translated into English by two independent bilingual translators. Any discrepancies were discussed and clarified. Pilot testing was done on ten participants to clarify items in the questionnaire.

Quantitative part

We prepared a blueprint of visits to each block with the help of field workers. The first house was selected randomly, and then consecutively adjacent 20 households were selected to collect 15–20 participants. If there were more than one eligible woman in the household, only one was randomly selected. If no eligible participants were available in the household during the visit, that was recorded as “not available” and those who refused to participate were reported as “non-responders.” After obtaining written informed consent, participants were interviewed.

Sample size

Using 4 pq/L² with a 95% confidence limit and 5% absolute error, L = 0.05, P = 11.3%,[6] sample size calculated with a 10% non-respondent rate was approximately 180. With a design effect of two, the sample size was determined to be 360. Thereby, 180 women from rural and urban areas were approached for study. Approximately 100–120 were recruited from each block, with an equal distribution of 50–60 individuals from both rural and urban areas. In rural areas, these women were selected from three villages, with 15–20 women from each village. Similarly, in urban areas, 15–20 women were selected from each of the three wards.

Statistical analysis

Questionnaire development

For the questionnaire validation, the I-CVI (Item Content Validity Index) and Content Validity Ratio (CVR) were calculated. A CVI of more than 0.80 was retained in the questionnaire.[7,8] The CVR was given by the formula, CVR = (Ne − N/2)/(N/2), in which the Ne is the number of panelists indicating “essential” and N is the total number of panelists.[9] The cut-off for CVR value is over 0.99.[9]

Quantitative cross-sectional survey

All quantitative data are expressed as mean and standard deviation and qualitative data as numbers (percentages). IBM SPSS version 25 software was used for data analysis. Binary logistic regression was employed to assess the predictors of health-seeking behavior. A P value less than 0.05 was considered a significant level.

Ethical consideration

The research protocol was in accordance with the guidelines of the Declaration of Helsinki. The Institutional Ethics Committee of AIIMS Rishikesh has approved the study (Ethical code: AIIMS/IEC/22/194, Approval date: 22-04-2022). Written informed consent from participants was taken, ensuring confidentiality and anonymity of collected data.

Results

All items of the HSB questionnaire were accepted as CVR was more than 0.99. All items were retained as CVI exceeded 0.80.

Considering 25 (6.9%) non-responders and 29 (8%) eligible women, who were not available for participation, a total of 306 participants were recruited in the study. The mean age of the participants was 31.9 (6.9) years. Most were Hindus (80.7%) and unskilled or unemployed (90.2%). Most of them belonged to the lower middle class (27.5%). Most of them completed secondary school (31%) or graduated (28%), and 90% of them were married [Table 2].

Table 2.

Socio-demographic profile of the participants

Variables	n (%)
Variables
Age, Mean (SD)	31.9 (6.9)
Age at marriage, Mean (SD)	17.4 (6.8)
Religion, n (%)
Hindu	247 (80.7)
Muslim	59 (19.3)
Occupation, n (%)
Unskilled workers and unemployed	231 (90.2)
Semi-skilled workers	10 (3.9)
Professional and semi-professional	9 (3.5)
Arithmetic skilled jobs and skilled workers	6 (2.3)
Socio-economic class*, n (%)
Upper class	35 (13.0)
Upper middle class	58 (21.6)
Middle class	48 (17.8)
Lower middle class	74 (27.5)
Lower class	54 (20.1)
Education, n (%)
Illiterate	15 (5.8)
Primary and middle school	36 (14.0)
Secondary school	82 (31.9)
Higher secondary school	39 (15.2)
Graduate	74 (28.8)
Post-graduate	11 (4.2)
Marital status, n (%)
Married	250 (90.9)
Unmarried	19 (6.9)
Widow	6 (2.2)

*Classification based on modified BG Prasad scale

Awareness regarding RT/STI

Most participants (82%) had heard of RTI/STI, while 18% never heard about it. Relatives or friends (50%) were the most common sources of information, followed by television (22%) and healthcare workers such as ASHAs (22%) and doctors (15%). Forty-six percent of the participants were unaware of the mode of transmission. Approximately 20% of respondents held the belief that transmission occurs only because of engaging in dangerous sexual practices with individuals who have several sexual partners and unsafe injections, while 16% expressed the view that transmission is attributed only to engaging in unsafe sexual practices with sex workers [Table 3].

Table 3.

Awareness of the participants regarding RTI/STI

Variables	n (%)
Ever heard of RTI/STI	252 (82)
The source of information regarding STI/RTI
Relatives and friends	155 (50.3)
Health worker/ASHA	70 (22.9)
Television	69 (22.6)
Doctor	48 (15.7)
School/teachers	21 (6.7)
Newspapers/books/magazines	19 (6.2)
Others	45 (14.7)
The Knowledge regarding the mode of transmission of STI/RTI
Unsafe injections	65 (21.2)
Unsafe sex with partners who have multiple partners	59 (19.2)
Unsafe sex with sex workers	49 (15.9)
Unsafe delivery	47 (15.3)
Unsafe intrauterine devices	45 (14.7)
Homosexual sex	44 (14.3)
Unsafe abortion	28 (9.1)
Don’t know	141 (45.9)

Clinical profile of the participants

Eighty-two participants (26.8%) had a history of vaginal discharge in the last three months, primarily white-colored (81.3%) with a sticky mucoid texture (59.3%) and foul-smelling (47%). The most common associated symptom was Itching over the vulva (14%). Half of the participants (54%) had discussed their symptoms with their husbands. Nearly 37% had ever visited a health facility for treatment, the most common being a private facility (63.5%) [Table 4]. The prevalence of any RTI/STI in rural and urban areas was 22.3% and 39.5%, respectively.

Table 4.

Clinical profile of the participants

Variables	n (%)
History of vaginal discharge in the last three months, n (%)	82 (26.8)
Color of the discharge, n (%)
White	65 (81.3)
Colorless	8 (10)
Yellowish	5 (6.3)
Texture of the discharge, n (%)
Sticky mucoid	48 (59.3)
Frothy	14 (17.3)
Pus like (purulent)	14 (17.3)
Curdy	1 (1.2)
Foul smelling discharge, n (%)	39 (47.6)
Other associated problems, n (%)
Itching or irritation over vulva	45 (14.7)
Low back ache	27 (8.3)
Pain during urination	23 (7.5)
Pain in lower abdomen not related to menses	21 (6.9)
Pain during sexual intercourse	21 (6.9)
Painful blister like lesions in and around vagina	12 (3.9)
Spotting after sexual intercourse	11 (3.6)
Boils/ulcers/warts around vulva	9 (2.9)
Participants discussed these problems with their husband, n (%)	53 (54.6)
Participants sought treatment for the symptoms n (%)	36 (37.1)
Health care facility visited, n (%)
Private	62 (63.5)
Government	35 (36.5)

Health-seeking behavior of the participants

The proportion of participants, who had low perceived susceptibility to RTI/STI was 91.5%, while around 90% had high perceived severity. Majority of them (95%) felt benefits of seeking health care for RTI while 36% of them exhibited high levels of perceived barriers [Figure 2].

Figure 2.

Health-seeking behaviour of the participants

The responses from the participants suggested low perceived susceptibility. They could keep themselves very clean (93%) and perceived that their partners also had no symptoms (90%). They wash their clothes daily (94%), and a significant proportion of individuals (98%) exhibit heightened attention to hygiene during menstruation. The responses from the participants suggested high perceived severity. Most of them (84%) agreed that they can suffer from serious illness. They also perceived that they could have cancer in the future (58%) and could not bear children if not treated early (85%). They perceived that they could spread the infection to their partner (83%) and will always suffer from myalgia or weakness if they contract an STI (69%) [Figure 3].

Figure 3.

Distribution of participants as per perceived susceptibility and severity. A.1 I keep my self very clean. A.2 My partner do not have it. A.3 I don’t have any symptoms. A.4 I wash my personal clothes daily. A.5 I take extra precaution of cleanliness during menses. B.1 I am in monogamous relationship/not sexually active. B.2 I can suffer from serious illness. B.3 I can have cancer in future. B.4 I cannot bear child if not treated early. B.5 I can spread it to my partner. B.6 I will always suffer from myalgia, weakness etc

The responses from the participants suggested high perceived benefits. Participants perceived that health-seeking behavior would help them to lead a healthy and respectful life (94%). They perceived they could conceive (86%) and give birth to a healthy child. They also perceived that they would not transfer the disease to their partner (83%). Regarding perceived barriers, approximately 54% of individuals believed that the symptoms were within normalcy and would naturally diminish over time. Approximately 46% of individuals experienced reticence in disclosing their symptoms to others. Approximately 40% of individuals reported perceiving that their character will be subject to suspicion by others. Twenty to thirty percent were unaware of the treatability and place for treatment, and they thought the treatments were expensive. Nearly 18% reported that the health centers/hospitals are far away, and they do not have time to visit doctors (10%) and 10% of the participants did not have access to female health workers [Figure 4].

Figure 4.

Distribution of participants as per perceived benefits and perceived barrier. C.1 It will Help me to lead a healthy life. C.2 It will Help me to lead a respectful life. C.3 I will be able to conceive and give birth to healthy child. C.4 I Will not transfers disease to my partner. D.1 These symptoms are normal and it subsides on its own. D.2 I am shy to talk about is symptoms to anyone. D.3 People will doubt my character. D.4 I am not aware if its treatable. D.5 I am not aware of where to go for treatment. D.6 Treatment are Expensive. D.7 Health centers/hospitals are far away. D.8 I do not have time to visit doctor/health worker. D.9 I do not have known/have access to female health worker/doctor

Only 37% took consultation for their symptoms. Two factors i.e. perceived susceptibility and age were found to be significant predictors. We found that `for a one-point increase in perceived susceptibility, the odds of not visiting the health center decreased by 0.09 and for one unit increase in age, the odds of not visiting the health center decreased by 0.08. (P < 0.05) [Table 5].

Table 5.

Factors associated with care seeking behavior

Variables	Log odds	Adjusted Odds ratio	Sig.
Perceived susceptibility	0.91	−0.09	0.048
Perceived severity	1.04	0.04	0.48
perceived benefits	1.06	0.05	0.52
Perceived barrier	0.99	−0.01	0.72
Age	0.92	−0.08	0.04
Rural (a)/Urban (b) (1)	0.97	−0.03	0.96
Religion (1)	1.66	0.51	0.51
Constant	38.59	3.65	0.12

Discussion

This was a community-based study with equal representation of rural and urban areas. A health belief questionnaire was developed and administered to understand the health-seeking behavior related to RTI. Based on symptoms, 27% of participants had RTI. Even though 82% knew of RTI/STI, over half did not know how it spread. Participants learned about RTI via family and friends. Though half of them discussed their symptoms with their spouse, only one-third sought medical attention. Most participants rated the severity as high and susceptibility as low. The participants had high perceived benefits and barriers, especially for specific domains, such as being shy to tell anyone about the symptoms, people doubting their character, and not knowing where to get treatment.

Several studies in India have shown a wide range of RTI/STI prevalence rates, from 11% to 72%.[10,11,12] These rates vary significantly across different regions of the country, with higher prevalence in urban areas compared to rural areas. Studies in West Bengal, Chandigarh, Eastern India, and Tamil Nadu reported prevalence rates of 13.6%, 35.5%, 43.6%, and 50%, respectively.[13,14,15,16] In our study, rural areas had a 22.3% prevalence of self-reported RTI, while urban areas had a higher rate of 39.5%. Studies from Surat and Delhi have further supported this trend, with higher prevalence rates in urban areas.[17,18] They have attributed this urban-rural disparity to factors like urbanization, internal migration (selective male migration), and the concentration of high-risk populations in urban areas. We could also attribute these differences to internal migration, seasonal migration, and a growing population in urban areas compared to rural areas.

Even though three-fourths of our participants were aware of RTI, half of them lacked knowledge about specific modes of transmission. A study from south India reported that 88% of their participants were aware of the mode of transmission of RTI.[19] A study among college-going students from India also found that 90% of the participants were aware of RTI and 75% were aware of their transmission modes.[20] The low awareness of the mode of transmission of RTI in our study should be explored further. The previous study identified teachers, the internet, and the media as the prime sources of information regarding RTI. In our study, relatives, friends, and healthcare workers were the most common sources of information regarding RTI. Only one-third of participants sought healthcare for RTI/STIs in our study reported. This is lower than the 47% of women who sought advice from healthcare providers in a study by Samanta et al.[15] Treatment utilization rates among Indian women in various community-based studies range from 16% to 55%.[2] Interestingly, a Chinese study found that 30% of participants opted for self-treatment through pharmacies.[21]

We have observed a low perceived susceptibility to contracting STI among our participants. The low perceived susceptibility and higher age was a significant predictor for low health care-seeking behavior, which can be attributed to the lack of knowledge regarding RTI/STI. The participants had high perceived barriers to HSB-related to RTI/STI. An alarming proportion of women in our study believed that the symptoms were normal. Newton-Levinson et al.[22] identified five main domains of the barriers to seeking medical care for STI services for adolescents: lack of knowledge about STIs and services, barriers related to the service availability, lack of integration and acceptability of services, confidentiality concerns and experiences of shame and stigma. Participants from our study also revealed that they often refrain from disclosing their symptoms, face skepticism about their character, and lack knowledge about the mode of transmission and appropriate treatment options of RTI/STI. A community-based study in Delhi, India, also recognizes feelings of embarrassment, failure to recognize the significance of the problem and lack of time as a barrier to health-seeking behavior for RTI/STI.[23] The findings of a study conducted by Kalichman et al.[24] in South Africa have reported that apprehensions and anxieties regarding the reactions of partners, particularly rage and violent outbursts, operate as substantial impediments to the process of partner notification. We could not elicit explicit responses regarding the fear of violent partner reactions from our participants. A field trial study conducted in vulnerable women to find the effectiveness of the Health Belief Model (HBM) in promoting behavioral modifiers that lead to STIs, reported a significant improvement in perceived threat, perceived benefits, perceived barriers, and perceived self-efficacy after the intervention.[25] Based on the findings from our study, we highly suggest educational interventions with emphasis on understanding the susceptibility, threats, benefits, barriers in relation to STIs.

Limitations

During the survey period, a significant number of individuals relocated to the plains due to harsh weather and winter. The obtained sample size was 306, which fell short of the intended sample size of 360, resulting in a shortfall of 13%. Female respondents tended to avoid discussion on symptoms of RTI, requiring a significant amount of time to establish a rapport with them. The accurate determination of the incidence of RTI/STI can only be achieved by laboratory-based investigations, while the prevalence reported in a study is merely an approximation.

Conclusion

Though 82% heard of RTI/STI, only half of them were aware of any one mode of transmission. Friends and relatives, followed by field workers and television, were the main sources of information. RTI was a significant health problem among women, with a prevalence of self-reported vaginal discharge of 27%. The prevalence was higher in urban than rural areas. Only two-fifths visited the health centers for the symptoms, mostly private. Participants exhibited low perceived susceptibility and high to moderate perceived barriers mostly related to stigma and lack of adequate knowledge about symptoms and treatment availability. Low perceived susceptibility and age were the significant predictors for care seeking among symptomatic women.

Recommendations

• Women should be educated about transmission mechanisms and safe practices through targeted awareness efforts.

• Improve collaborations with healthcare professionals to provide women with accurate and reliable information.

• Nurturing a friendly, non-judgmental environment encourages women to seek timely and appropriate healthcare.

• Improve public healthcare facilities and boost female providers.s

• Address financial barriers: Subsidizing treatment expenses, health insurance coverage etc.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

We are thankful to NACO for providing us with financial support and technical help for completing this project.