Care seeking interval - an indirect measure of sexually transmitted infections related stigma: a prospective observational study

INTRODUCTION

Sexually transmitted infections are a major public health concern in developing countries. Regardless of the presence or absence of symptoms all STIs can lead to major complications if left untreated. According to 2008 WHO estimates, 499 million new cases of curable STIs (syphilis, gonorrhoea, chlamydia, and trichomoniasis) occur annually throughout the world in adults aged 15–49 years.¹In India, it is estimated that 5% of the adult population has STI symptoms.² Beyond the immediate impact of the infection, STDs can have serious consequences such as pelvic inflammatory disease, adverse pregnancy outcomes, infertility and cervical cancer.³ Some STDs can increase the risk of acquisition of human immunodeficiency virus (HIV). This warrants early treatment which prevents the complications and also reduces the risk of transmission. However, many patients do not seek early treatment due to the stigma associated with the diseases. Stigma refers to the devalued status that society attaches to a condition or attribute.⁴ Stigma about STDs/HIV may lead to a delay in care seeking which allows for continued transmission and greater probability of adverse sequelae. The delay in seeking treatment can be due to many factors such as socio-demographic factors, behavioural factors, factors related to the disease, support and cognitive factors. So, we conducted a study to describe care seeking behaviour of patients, barriers to accessing STI services and the factors associated with its delay.

METHODS

This was a cross sectional study conducted between April 2018 to May 2019 in STD OP of Department of Dermatology, Venereology and Leprosy, Govt. Stanley medical college, Chennai, Tamil Nadu, India. The aim of this study is to assess healthcare-seeking behaviour of patients and the factors associated with its delay which could be a measure of fear of stigmatisation. The study population included Symptomatic STD patients of both sexes >18 years who attended OP. After obtaining permission from institutional ethical committee and individual informed consent, a semi structured interviewer administered questionnaire was used to collect Data in regional language under the broad domains of socio-demographic characteristics, clinical characteristics, behavioural characteristics, support, cognitive factors and geographical access. The questions in this questionnaire were built upon existing literature^5,6 by exploring respondent’s knowledge, attitude and practice about STD. Those who were not willing to answer questionnaire were excluded from the study. Delayed health care seeking behaviour was considered when patients sought care after 7 days of the onset of their STI symptoms. The statistical package SPSS (version 16) was used for analysis and proportions were calculated for nominal data, mean and standard deviation were used for continuous data. For categorical variable chi-square test were used for comparing difference of proportion. P value <0.05 was considered as statistically significant. Symptoms included were genital ulcer, genital discharge, growth in genitalia, swelling over genitalia/inguinal region, genital itching, skin rash and others (Table 1).

Care seeking interval following the onset of symptoms is noted for each patient. Determinants of delay in the questionnaire included fear of disclosure/stigma, self-treatment, expected spontaneous resolution, lack of time, lack of awareness, fear of genital examination, feeling of embarrassment, and fear of breach of confidentiality (Table 1).

RESULTS

Total number of patients who attended STD OP during the study period was 1854. Out of them 1009 were willing to participate in the study which included 492 males and 517 females with STI symptoms. Majority of the males and females belonged to 20–35 age groups, were married, with primary school level of education and belonged to the lower income group (Table 2). Out of them 54% were considered to have sought early health care within 7 days and the remaining 46% sought care after 7 days (Figure 1) ,the reasons for the delay being fear of disclosure (52%), self treatment (19%), expecting spontaneous resolution (12%), lack of awareness (8%),and other causes like lack of time, distance of health care facilities, fear of confidentiality and genital examination (9%) (Figure 2). Ulcer (34%) was the most common symptom in males followed by dysuria (22%), discharge per urethra (20%), growth (16%) and other symptoms like increased frequency of micturition and itching (8%) (Figure 3). In females, the major symptoms were genital discharge (32%), ulcer (25%), growth (24%), itching (13%) and other symptoms like dysuria and increased frequency of micturition (6%) (Figure 4).

DISCUSSION

The transmission of STD in the community depends on the duration of infectiousness of the infected individuals, probability of exposure of susceptible to infectious persons and the efficiency of sexual transmission when such exposure occurs. When the treatment is delayed, the duration of infectiousness is increased and the chance of spread in the community is high. Delayed health care seeking is one of the major impediments to successfully prevent and control STI. In our study, socio-demographic factors such as age, education, income, and marital status did influence the timely treatment of the disease in both sexes. In our study, ulcer, genital discharge and growth were the major complaints noted. In a study done by sabeena et al, herpes genitalis (34.1%), condylomata acuminata (20%), syphilis (17.6%), nongonococcal urethritis (12.9%), gonorrhea (10.5%), chancroid (2.3%), and trichomoniasis (2.3%) were the STIs noted in the decreasing order of frequency. ⁶

In the current study, nearly half of the study participants sought care after the seventh day of onset of symptoms. In a study done by Sabeena et al, 58.1% patients delayed in seeking care and most of the patients did so if their disease was not associated with severe symptoms.⁶ in our study, the most common reason for the delay in health care seeking was their fear of disclosure of symptoms followed by self treatment and expectation of spontaneous resolution. In a study done by Rejoice puthuchira et al perception of symptoms as normal, feeling shy, lack of female health workers were identified as major barriers for not seeking treatment.⁵ None of the patients with symptoms used condoms consistently similar to a study done in Zambian patients where 57% reported sex after the onset of symptoms and consistent condom use was reported in only 15%.⁷

Thus, care seeking interval may be regarded as an indirect measure of stigma associated with STI which would further increase the risk of acquiring complications and transmitting the disease. Addressing concerns about stigma and educating the public about timely health care could help reduce the complications of STDs and is of paramount importance. Health promotion should encourage symptomatic patients to seek care quickly, and to avoid sexual contact before treatment.⁸ Consistent condom use as an important preventive measure needs to be stressed.⁹ This definitely will help arrest the transmission among high risk adult population thereby improving the quality of patient’s life.

CONCLUSION

This study emphasizes the need of information, education, and counselling about STI. Integrated approach is strongly suggested for creating knowledge and awareness to control the spread of sexual health problems (including HIV/AIDS) among young people. Appropriate preventive strategies are essential and should be of highest priority because of the potential of such infections to spread particularly among the youth. This raises the necessity to conduct further studies to evaluate the awareness and educate the general population.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the institutional ethics committee.

REFERENCES

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