MATERIAL AND METHOD:

One hundred and thirty three and ninety women suffering from RTI/STI of urban and rural area respectively were taken as sample. The study was conducted in an urban slum and in the field practice area of rural health training centre of Seth G.S.Medical College, Mumbai-12 between September 2007 and November 2009. All sampled women were married and in reproductive age group. Prior consent from each sampled patient was taken. The data was collected in a predawn and pretested proforma.

For testing knowledge the questions about cause of disease, curability of disease were asked, for testing attitude and practices questions about person with whom information regarding reproductive health related problem was shareed, treatment sought or not were asked.

Treatment seeking behavior is defined as part of several" illness or health seeking behavior" of women to manage their symptoms associated with reproductive morbidity. Information about treatment seeking behavior, place of the previous treatment sought and if treatment was not sought then the reasons behind that were asked in detail. Whenever available, the records of, the treatment taken or the investigations done were seen.

OBSERVATIONS AND DISCUSSION:

On analysis of the collected data it was observed that in urban area, 72 (54.13%) women said that they are unaware about the cause of symptoms, 39 (29.32%) doesn’t think that it is an infection, 51 (38.3%) feel that it is due to CuT insertion and 11 (8.27%) feel that it is the effect of weakness. While in rural area, 60 (54%) women said that they are unaware about the cause of symptoms, 25(27.7%) feel that it is due to tubectomy or Cut insertion, 18 (20%) doesn’t think that it is an infection, 8 (8.88%) feel that it is due to supernatural power or curse of the God and 13 (14.14%) feel that it is the effect of weakness (Table-I).

TABLE-I: Perception of the cause of symptoms of RTI/STIs in study participants

Perception of the cause of symptom	URBAN		RURAL
Perception of the cause of symptom	n=133	%*	n=90	%*
Doesn’t think that it is an infection	39	29.32	18	20
CuT insertion/ Tubectomy operation	51	38.34	25	27.77
Transmitted from husband	7	5.26	2	2.22
Sexual relationship with many persons	6	4.51	1	1.11
Effect of weakness	11	8.27	13	14.14
Melting of bones	2	1.5	3	3.33
Dietary factors	4	3	7	7.77
Stress	3	2.25	0	0
Not maintaining hygiene	5	3.75	0	0
Supernatural power/Curse of God	2	1.5	8	8.88
Don’t know	72	54.13	54	60

*Since participants gave multiple responses the total percentage would add up to more than 100.

In urban area, 100(45.45%) women feel that RTI/STI is curable 32 (14.55%) feel that it is not and others said they don’t have any knowledge about this whereas in rural area, 37 (28.03%) feel that it is curable , 27(20.45%) feel that it is not and others don’t know about curability of RTI/STI (Table-II; Figure-I).

TABLE-II: Awareness about curability of RTI/STI in study subjects

STI curable	URBAN		RURAL
STI curable	Frequency	Percent	Frequency	Percent
Yes	100	45.45	37	28.03
No	32	14.55	27	20.45
Don’t know	88	40	68	51.52
Total	220	100	132	100

FIGURE-I: Awareness about curability of RTI/STI in study subjects

When asked about with whom they first discussed the issue related to reproductive morbidity, in urban area out of 133 women who complained any symptom, 84 (63.15%) women said that they discussed the issue with their husband while 34 (25.56%) women did not discuss the problem with anyone. In rural area, 48 (53.33%) women did not discuss the problem with anyone and 37 (41.1%) discussed it with their husband (Table-III; Figure-II & III). (Table-IV; Figure-IV) revealed that in urban area, 61 (45.86%) women did not seek treatment at all, 35 (26.31%) went to government hospital and 32 (24.06%) went to private hospital for treatment of reproductive morbidity. In rural area, 54 (60%) women did not seek treatment at all, 19 (21.11%) went to government hospital and 15 (16.66%) went to private hospital for treatment of reproductive morbidity. (Table-V) shows that the most common reason for not seeking treatment in urban area was, 21(34.4%) women considered the problem self-limiting. Other reasons were shyness 17(27.86%), fear of internal examination 13(21.31%) and lack of female provider in the nearby health facilities14 (22.9%).Similarly in rural area, the most common reason was, 24 (44.4%) women considered the problem to be self-limiting. Other reasons were no idea were to go 13 (24.07%), fear of internal examination 11 (20.37%) and lack of female provider in the nearby health facility (22.2%).

TABLE-III: Person with whom information regarding reproductive health related problem was shared

Discussed the issue with	URBAN		RURAL
Discussed the issue with	n =133	%	n =90	%
None	34	25.56	48	53.33
Husband	84	63.15	37	41.11
Mother in law or elderly women in family	10	7.5	3	3.33
Friend or neighbor	5	3.75	2	2.22
Total	133	100	90	100

TABLE- IV: Health seeking behavior related to reproductive morbidity among study participants:

Treatment sought from	URBAN		RURAL
Treatment sought from	n = 133	%	n = 90	%
Treatment not sought	61	45.86	54	60
Government hospital	35	26.31	19	21.11
Private clinic	32	24.06	15	16.66
Traditional medicine	1	0.75	2	2.22
Medical shop	4	3.0	0	0
Total	133	100	90	100

TABLE-V: Reasons for not seeking treatment in study subjects

Reasons for not seeking treatment	URBAN		RURAL
Reasons for not seeking treatment	n =61	%*	n =54	%*
Considered self limiting	21	34.4	24	44.4
Shyness	17	27.86	8	14.8
Indifference towards health	10	16.39	8	14.81
No idea what to do	7	11.47	13	24.07
Fear of internal examination	13	21.31	11	20.37
Economic reasons	3	4.91	8	14.8
Morning timing of OPD	6	9.83	9	16.6
Lack of female doctor	14	22.9	12	22.2
Home remedies	4	6.5	7	12.96

* Since participants gave multiple responses the total percentage would add up to more than 100.

FIGURE-II: Person with whom information regarding reproductive health related problem was shared in urban area

FIGURE-III: Person with whom information regarding reproductive health related problem was shared in rural area

FIGURE-IV: Health seeking behaviour

Dr. G. Rangaiyan et al (1) also got the similar perceptions about the etiology of symptoms in their study. The various causes mentioned in their study were excess body heat (40 per cent), witchcraft (37 per cent), abortion (not done properly) (35 percent), female sterilization (30 per cent), contraceptives (28 per cent), childbirth (26 per cent), abortion (23 per cent), tension (10 per cent) and promiscuity (6 per cent).

In study done by Alka Sehgal et al (2), 40% of the women had no specific perception of disease causation, while the rest related it to some abnormality. Fifty percent of the women thought that no treatment was required for these problems. 82% of women blamed the use of contraception directly or indirectly for their disease(s). Very few women blamed supernatural powers for their complaints. Menstrual problems and vaginal discharge are commonly associated with food habits.

In study done by A J Singh (3), most of the respondents ascribed vaginal discharge to weakness (kamjori), melting of bones (haad galna) and body heat (garmi). In study done by Rani Bang et al (4), 80% of women had talked to someone else about their gynecological problem, 76% of whom talked to their husbands. So, if men become aware of reproductive health and women's suffering, they can persuade women to seek health care. Comparable results were found in the study done by Alka Sehgal (2), in which only 47.2% sought consultation for gynecological diseases. The majority of women sought consultation from an unqualified local practitioner or from a health care clinic.

Jasmin Helen Prasad et al(5) in their study found that among symptomatic women, 65% had not sought any treatment for their gynecologic problems. Of the 35% who had sought treatment, 21% of them had opted for home remedies or traditional medicine, 57% had approached unqualified private practitioners and 13% had gone to CHAD Hospital. Only 9% had sought medical care at the government primary health centers.

While in study done by Dr. G. Rangaiyan et al (1) these figures are quite less. In their study only 15 per cent of the women ever sought treatment for one or more gynecological problems and the remaining, either took some home remedies or did not seek any treatment at all. Jasmin Helen Prasad et al (5). In their study among symptomatic women, 65% had not sought any treatment for their gynecologic problems. Of these women, 58% reported that they felt the symptom was not alarming and so there was no need for treatment. Other less common reasons were absence of a female provider in the nearby health care center, lack of privacy and distance from home. The reasons given for not seeking care were similar to those reported in other studies in India: stigma and embarrassment, lack of privacy, lack of female doctors at health facilities and treatment cost.

Parikh et al (6) mentioned cost of treatment and male physician were main deterrents for not seeking treatment. Dr. G. Rangaiyan et al(1)mentioned the important reason for not seeking the treatment was the women ignored gynecological symptoms and accepted them as a part of their general ill-health and reproductive life. Other reasons generally cited for not seeking any treatment were shyness and Husband or in-laws do not like them to go for treatment.A J Singh et al (3) mentioned reasons for non-consultation were - took it as normal (12), shyness (2), cost (2), no cure (2) or others (11- no escort, can tolerate, do not know where to go etc).

The findings of the various studies conducted by various researchers were more or less similar to the findings of the present study.

CONCLUSION:

From above observations and discussion the authors reached to the conclusion that women tend to consider many symptoms as normal and do not seek treatment until discomfort is quite high and so apparently remain infected for a long time. Other reasons for not seeking treatment were shyness, fear of internal examination and lack of female provider in the nearby health facilities. Copper T insertion, weakness, body heat, melting of bones, sexual promiscuity, poor hygiene and diet were told as the major causes of vaginal discharge. Most of the women feel shy to discuss this problem with someone, so many a times they don’t tell about it to anyone. Most of them discussed their problem with their husband or elderly women in family. Most of the women in urban area first go to private clinic and if no relief then they go to government hospital. A Flow-Chart, has been developed which may be used as road map, ,which shows that by incorporating the gift of modern technology judiciously i.e. audiovisuals aids etc. (Bansal A.K.et al (9) and Garg Narendra K. et al (10)), community (women) may be motivated to adopt healthy life style by improving the utilization of health facilities and planning as per flow chart and thus can save billions of rupees of the nation in terms of man day's lost due to illness and expenses incurred on treatment.