Use of Predictors as a Proxy Determine the Possible Diagnosis of RTI/STIS

Yogita A Hiwarkar¹*, Dilip N. Dhekale², C.G. Kolhe³

¹Assistant Professor, Department of Community Medicine, Dr. Ulhas Patil Medical College and Hospital, Jalgaon Kh. (M.S.)

²Associate Professor, Department of Community Medicine, Dr. Ulhas Patil Medical College and Hospital, Jalgaon Kh. (M.S.)

³Medical officer, ESIS, Jalgaon.

ABSTRACT:

Background: Global estimates showed that, between 5-15% of the burden of diseases is associated with failure to address reproductive health needs. More accurate data on RTI/STIs and their underlying causes will result in more appropriate programmatic and policy responses.

Objective: To study use of predictors as proxy for determining the possible diagnosis of RTI/STIs

Material and methods: One hundred and thirty three and ninety women suffering from RTI/STI from urban slums and rural area were included in the study. Logistic regression analysis was used to determine predictors of morbidity.

Results: The predictors for RTI/STI in study participants were Parity, sanitary protection use and domestic violence at P<0.05.

KEYWORDS: Parity, Per Capita Income, Autonomy

INTRODUCTION:

Information about predictors is extremely essential to guide effective interventions, to set health-care priorities, and to target future research. The exact diagnosis of RTI/STI can be made by laboratory investigation but in a large country like India, where large number of cases can't reach laboratory because of so many reasons like non available of sufficient number of laboratory if available patients have to cover a long distance and majority of patients can't pay the investigation charges etc. Since this situation is not going to change in near future, there is an urgent need to develop an alternative method for obtaining information about the diagnosis of RTI/STIs.In these difficult situation predictors is the only ray of hope to determine the possible diagnosis of RTI/STIs. Keeping in mind the above facts and as per recommendations of the WHO study group in 1957, that in order to obtain a comprehensive picture of a health problem / disease, only vital statistics is not sufficient, more and more such studies have to be undertaken, Garg Narendra K.(2) and Garg Narendra K.and Sharma A.B.(3) , the authors have under taken this study with the objective to identify the predictors which can be used as a proxy to determine the possible diagnosis of RTI/STIs.

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 and K.E.M. Hospital, Parel, Mumbai-12 from September 2007 to November 2009. Consent of all sampled women obtained. Logistic regression analysis was used to determine predictors of morbidity.

Table-I Predictors of RTI/STI in the study participants:

Variables	B	S.E.	Sig.	Exp(B)	95.0% C.I. for EXP(B)
Variables	B	S.E.	Sig.	Exp(B)	Lower	Upper
PCI	0.725	0.479	0.13	2.065	0.807	5.285
Type of Family	0.597	0.423	0.158	1.817	0.793	4.163
Parity	1.099	0.419	0.009	3.001	1.321	6.819
Sanitary protection	0.979	0.49	0.046	2.661	1.019	6.947
Invasive FP method use	-0.831	0.427	0.052	0.436	0.189	1.007
Condom use	-0.011	0.66	0.987	0.989	0.271	3.604
Domestic violence	1.462	0.456	0.001	4.315	1.764	10.551
Autonomy	0.706	0.383	0.065	2.026	0.957	4.29
Pregnancy in adolescence	0.255	0.423	0.547	1.29	0.563	2.955

Variables taken in to consideration were as follows-

(a) Per Capita Income (PCI)

(b) Type of Family,

(d) Sanitary Protection

(e) Invasive Family Planning (F.P) method

(f) Condom used

(g) Domestic Violence

(h) Autonomy

(i) Pregnancy in Adolescence

All variables were entered in model by using ENTER method in SPSS. P-value of 0.05 was considered as significant. Omnibus test for model coefficients was significant. (P-value< 0.05). Hosmer Lemeshow goodness of fit test was non-significant (P=0.76) indicating that model fits the data.

Women were asked about do they have autonomy by asking whether they can make decisions regarding visiting her friends or mothers home, seeing a doctor, keeping money aside for personal use and having time to do things for herself. The scores are added and responses are divided into three categories, no, moderate and full autonomy.

OBSERVATIONS AND DISCUSSION:

On analysis of the collected data it was observed that the predictors for RTI/STI in study participants were Parity, sanitary protection use and domestic violence at P<0.05. women having parity more than two, three times more likely of having RTI/STI than participants having two or less children (Odds Ratio = 3.001). Women who do not use sanitary protection were having 2.66 times more chance of developing RTI/STI than those who used it. Women having lifetime experience of domestic violence were having 1.76 times more likelihood of having RTI/STI. The RTI/STI was found to be more in women who had three or more children followed by those who do not have children and then women who have 1-2 children. In urban slum, 65% of women, having three or more children had RTI and 60% of those who do not have children had RTI. In rural area, 85% of women who had more than 3 children were having RTI/STI while 63% of women who do not have children had RTI. The association is statistically significant with chi square value of 9.08 at DF=2 and P=0.011 and 15.34 at DF=2 and P<0.001 in urban and rural area respectively (Table-I).

Ruchi Sogarwal and L. K. Dwivedi (4) in their study found that the prevalence of reproductive morbidity was noticeably higher among those women who had five or more children among the non-tribal. On the contrary, among the tribal, the prevalence rate was higher among women who had not given birth.

Parashar A et al (5) found that maximum number of RTI cases 33 (64.7%) were found in women with parity 4 followed by 50% of those with parity 6, 46.2% in those with parity 5, this relationship was statistically significant.

Lowest (2.4%) prevalence of RTIs was found in nullipara and highest (44.9%) in grand multipara (p<0.001) in study done by Monica Rathore et al.(6)

Age at marriage was not significantly associated with presence of RTI/STI in both urban and rural areas but in study done by Parashar A et al(5)the prevalence of RTIs was more in those who got married before the age of 15 years.

Although not statistically significant the prevalence of RTI was more in women who had history of induced abortion in past. As abortion is one of the surgical intervention during which infection can occur. In urban area, 62% of women with h/o abortion had RTI while 49% of those who do not have h/o abortion had RTI. In rural area, 85% of women with h/o abortion had RTI and 60% of those without such history had it.

It is also important to study the sanitary protection used during menses because if unclean cloths are used during menstruation it can introduce infection in reproductive tract. The resulting infections are due to overgrowth of normal vaginal flora, resulting from unhygienic practices, which causes local as well as ascending infection including pelvic inflammatory diseases. In urban area, 55% of women using cloth had RTI while only 38% of women using sanitary pad had RTI. In rural area, only four women were using sanitary pad and prevalence of RTI was more in those using cloth (65%) as compared to those using sanitary pad (25%). The association was statistically significant with chi square value of 3.78 at DF=1 and P<0.05 in urban area. These findings are in line with the study conducted by Parashar A et al(5) in which they found that majority of the women used any type of cloth, whether clean or unclean and prevalence was comparatively very high in them with Chi square value of 100.21 and p<0.001.

To study the relationship between contraceptive methods and presence of RTI/STI, contraceptive methods were classified as invasive and non invasive method. Invasive methods include tubectomy and Intra Uterine Devices and noninvasive methods include hormonal pills, condom, etc. The statistically significant association was found between type of contraceptive used and presence of RTI/STI. Chi square value was 6.45 at DF=1 and p<0.01 in urban and 11.35 at DF=1 and p<0.01 in rural area.

The use of condom was found to be protective against RTI. The association was statistically significant with chi square value of 6.91 at DF=1 and P<0.01. 56% of women not using condom had RTI while only 31% of those using condom had it.

Operative procedure of tubal ligation and introduction of foreign body (IUCD) in uterine cavity make women more prone for ascending infection from lower genital tract. Similarly, U.S. Women Health study also observed that IUCD users were 1.6 times more prone for PIDs and WHO studies in 12 countries observed that IUCD users were 2.3 times more prone for PIDs. Bang et al and Brabin et al (7) in their studies revealed that there was association of invasive methods of contraception with RTIs.

The findings of the study are in line with findings of Brabin et al (8), who observed that 30.5% of PID cases had undergone tubal ligation, which is one of the most common gynaecological surgical interventions. A nationwide prospective study (1970 to 1976) (9), also observed that the principal adverse effects after tubal sterilization were menstrual irregularities, dysmenorrhia and PIDs.

Parashar A et al (5) found that the prevalence of RTIs was significantly low in those women who were using barrier methods. Barrier contraceptives are known to provide protection against RTI/STIs. The prevalence of RTIs was more mong IUD users and those using terminal methods of contraception.

Similar findings were found by Jasmin Helen Prasad et al⁽¹⁰⁾ and Savita sharma et al.⁽¹¹⁾

Statistically significant association was found between h/o pregnancy during adolescence and presence of RTI/STIs with chi square value of 5.01 at DF=1 and P=0.025 in urban and 6.69 at DF=1 and P=0.01 in rural area. The RTI was found to be more in those women who had pregnancy during adolescence (63%) than those who do not had (45%) in urban setting. Similarly, in rural area, prevalence was more in women who had pregnancy during adolescence (75%).

Lifetime experience of domestic violence was also associated with presence of RTI/STI. The association was statistically significant with chi square value of 10.56, DF=1, P=0.001 in urban and 9.34, DF=1, P=0.002 rural area. The morbidity was more in women who experienced domestic violence (69%) than those who did not (43%), in urban area. Similarly in rural area 80% of women who had experience of domestic violence had RTI/STI while only 50% of those who do not had domestic violence had it.

Ruchi Sogarwal and L. K. Dwivedi (4) mentioned that domestic violence does not directly affect the woman’s health but it is a proxy variable for woman’s status in a household and also in a society where she lives. It exerts a negative impact on woman’s behavior and indirectly it also restricts the woman’s mobility. Another mechanism through which it works is that beating leads to unwanted and unsatisfying sex and further prompts the partner towards extra marital sex and these problems affect women’s health.

In study done at Goa by Vikram Patel (12) logistic regression analyses identified that following variables were individuallyassociated (P < 0.1) with vaginal discharge, after adjustingfor socioeconomic factors. These were verbal abuse,sexual violence, and concerns regarding the husband's extramaritalrelationships (among married women); low social integrationand autonomy scores; high Common Mental Disorder and somatoform disorder symptomscores.

The statistically significant association was found between autonomy and presence of RTI/STI, with chi square value of 19.71 at DF=2 and P<0.001 in urban and X² = 19.71, DF=2, P<0.001 in rural area. It was found that as level of autonomy increased the prevalence of RTI/STI decreased. RTI/STIs was found to be more in women who do not have autonomy (75%)in urban area and among women who had moderate autonomy(82.2%) in rural area.

Gender power imbalances and lack of autonomy are leading underlying factors for women's vulnerability to STIs. Women's limited control over resources in many settings compounds their lack of decision-making and makes them socially and economically dependent on their husbands or partners in matters of sex and reproduction as well as in the area of health care, including care during pregnancy and childbirth or at the time of abortion. Other barriers are lack of intimacy, poor communication with partner (on subjects such as sex, pregnancy, and safe abortion and delivery practices) and cultural norms emphasizing female chastity. Physical and sexual violence leading to high levels of coercive sexual relations and sexual abuse, both during childhood as well as within marriage, are also major health problems (13).

CONCLUSION:

From above observations and discussion the authors reached to the conclusion that three main predictors (i) parity (ii) Sanitary protection and (iii) Domestic violence can be used as proxy for determining the possible diagnosis of RTI/STIs which may prove reliable and cost effective tool.

ACKNOWLEDGEMENT:

Authors are thankful to Dr. A.K. Bansal, Ex-Professor and HOD, Dept of Community medicine, Government medical college, Jagdalpur (Bastar) for his guidance and encouragement in preparing this manuscript, without help of whom this manuscript could not have come in this format.

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Received on 09.04.2013

Modified on 22.04.2013

Accepted on 10.05.2013

Research J. Pharmacology and Pharmacodynamics. 5(4): July–August 2013, 237-240