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  Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 37  |  Issue : 2  |  Page : 162-166
 

A situational analysis of sexual and reproductive health issues in physically challenged people, attending a tertiary care hospital in New Delhi


Apex Regional STD Teaching, Training and Research Centre, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India

Date of Web Publication13-Oct-2016

Correspondence Address:
Sumathi Muralidhar
Apex Regional STD Teaching, Training and Research Centre, Room No. 553, 5th Floor, OPD Building, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0253-7184.188481

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   Abstract 

Background and Objectives: Physically challenged people constitute the most stigmatized sections of society, and are excluded from outreach programs, besides being considered sexually inactive. They have unaddressed sexual and reproductive healthcare (SRH) issues, predisposing them to sexual abuse and sexually transmitted infections (STIs). The huge paucity of data in this field prompted us to undertake this study. Materials and Methods: A cross-sectional survey was conducted on 100 people with more than 40% of permanent disability, attending various out/inpatient facilities of a tertiary care hospital in New Delhi, India. A structured, pretested questionnaire was used to assess SRH issues. Samples were collected from consenting individuals for diagnosis of various STIs, wherever relevant. Statistical analysis was done using Pearson's Chi-square test, considering significant at P <0.05. Results: Most people were in the age group of 15–30 years. Limbs were most commonly affected, and the use of assistive devices was statistically related to income levels (P = 0.045), 43% was married and 41% had children. Contraceptive usage was 33%, with a significant association (P = 0.03) with education levels. Issues related to sexual health included conditions ranging from nerve sensation loss in genitalia to fertility and gynecological issues, only 10% had received sexual counseling during rehabilitation. There were several misconceptions prevalent regarding HIV and STIs; 35% of the samples tested positive for chlamydia IgG. Interpretation and Conclusions: This is a pioneer study on a grossly neglected issue in India. There is a dire need to overcome hurdles and address the SRH issues of physically challenged people to achieve the universal WHO goal of “Health for All.”


Keywords: Counseling, disability, disabled, reproductive health, sexual health


How to cite this article:
Agarwal U, Muralidhar S. A situational analysis of sexual and reproductive health issues in physically challenged people, attending a tertiary care hospital in New Delhi. Indian J Sex Transm Dis 2016;37:162-6

How to cite this URL:
Agarwal U, Muralidhar S. A situational analysis of sexual and reproductive health issues in physically challenged people, attending a tertiary care hospital in New Delhi. Indian J Sex Transm Dis [serial online] 2016 [cited 2017 May 27];37:162-6. Available from: http://www.ijstd.org/text.asp?2016/37/2/162/188481



   Introduction Top


Physically challenged people constitute 10% of the world population,[1] and are often the most stigmatized and marginalized sections of the society, often being excluded from progressive policies. Besides, they are incorrectly assumed to be sexually inactive, especially in a country like ours, where sex and sexuality are considered taboo subjects under the dark canopy of traditional and cultural values, and hence, deprived of the care and services of sexual and reproductive health (SRH).[2]

The lack of access to sufficient sex education and ignorance about sexuality issues place them at a high risk of physical and sexual abuse, forced sterilizations and abortions, with little access to physical, psychological, and judicial interventions. Cognitive and language disabilities, and limited contraceptive options, may even predispose them to unwanted pregnancies and risk of contracting sexually transmitted infections (STIs) including HIV, along with their associated complications such as infertility and cancers. Therefore, though excluded from the outreach programs, physically challenged people have greater SRH care needs than their able bodied counterparts.[3],[4],[5]

As quoted by Thoroya A. Obaid, the ex-executive director of UNFPA: “The international goal to achieve universal access to reproductive health cannot be achieved unless physically challenged people are brought into the mainstream and included in policies and programs to improve SRH.”[6]

The huge paucity of data in this field helped conceive this study, which aimed at carrying out a situational analysis of the SRH issues of physically challenged people, attending a tertiary care hospital.


   Materials and Methods Top


The study was a cross-sectional survey conducted at the Regional STD Teaching, Training, and Research Centre on physically challenged people attending various out/inpatient facilities of a tertiary care hospital in New Delhi, over a period of 3 months.

Sample size

A total of 100 people having some permanent disability (according to standard Indian definition) were interviewed on various aspects of sexuality; blood samples were also collected from consenting individuals for serological diagnosis of some STIs.

Inclusion criteria

  • Persons in the reproductive age group, i.e., between 15 and 60 years
  • Persons with at least 40% disability (according to Indian standards) for a minimum period of 6 months
  • Persons willing and consenting to participate in the study
  • In case of psychiatric or neurological disorders, persons who were able to comprehend the question that was being asked or he/she with an attendant to answer the questionnaire.


Those who could not fulfill the said criteria were excluded.

The study commenced only after obtaining clearance from the Institutional Ethics Committee.

Informed written consent was taken from all individuals who were willing to participate in the study. Data were collected using a structured pretested questionnaire on various aspects of SRH to know about the knowledge, attitude, and practices of disabled people toward SRH issues. On an average, 15–20 mins was spent for interview of each participant. Blood samples were collected under all aseptic measures whenever applicable, which were transported immediately to the reference laboratory at Regional STD Teaching, Training, and Research Centre, where they were centrifuged for serum separation. The serum was stored at an appropriate temperature till the time of testing.

Laboratory investigations

The serological tests performed included rapid test for HIV antibody as per the NACO testing guidelines, venereal disease research laboratory (VDRL) test for antibody to Treponema pallidum, herpes simplex virus (HSV-II) IgM ELISA for antibody to herpes simplex type 2 virus, chlamydia IgG and IgM ELISA for antibodies to Chlamydia trachomatis, hepatitis B surface antigen (HBsAg) detection by ELISA for hepatitis B virus, and rapid test for antibodies to hepatitis C virus (HCV). All subjects were counseled adequately prior to sample collection.

All the laboratory tests were performed as per the procedures prescribed by the standard guidelines, using kits that were procured through governmental procurement procedures. Strict confidentiality rules were adhered to as regards patients' data and tests. Data were compiled using MS Excel 2007 and analyzed using IBM- SPSS Software Licensed version 21.0 SPSS version 20 (Armonk, NY: IBM Corp.). Chi-square test was deployed to find the statistical association between various variables. P < 0.05 was considered significant.


   Results Top


The study group included 76 males and 24 females. Most of the study subjects were in the age group of 15–30 years (38%), followed by 31–40 years (35%), and 27% were above the age of 40 years. The literacy rate was 78%, with majority of them having attended mainstream schools. Most subjects belonged to the upper lower class according to revised Kuppuswamy scale.[7]

The most common mode of disability acquisition was trauma (59%), followed by infections such as polio, tuberculosis, and encephalitis (27%); other causes (14%) included joule/thermal burns and stroke. Most of the cases encountered had been disabled for either <1 year (31 persons) or for more than 20 years (33 persons).

There was an increase in unemployment after disability. In addition, there was a shift from heavy manual work to sedentary work post acquiring the disability. There was also a decrease in the average monthly income among disabled people, as many had to switch over to alternate employments. However, some of the people who had acquired their disability at an early age took advantage of various disability benefits and had adequate income.

Ninety percent of persons had acquired disability; the parts affected are shown in [Figure 1]:
Figure 1: Body parts affected in persons with disabilities

Click here to view


  • Patients with limb deformities included those with rotational deformities, contractures, and amputations at various levels
  • The people with spinal deformities had scoliosis and kyphosis, and various degrees of paralysis-paraplegia, quadriplegia, with/without sensory losses/paresthesias
  • In the category of defective mental functioning, subjects suffered from cerebrovascular accident leading to avascular necrosis and consequent disability. It also included people with organic brain disease and epilepsy. There were also a few patients with mental retardation.


Majority of the subjects faced some sort of problem in routine activities such as transportation (81%), Indian-style toilet use (59%), bathing (55%), feeding (26%), and talking (7%); however, the use of assistive devices was limited only to 52% which mostly included transportation assistance ranging from walking sticks and wheelchairs to shoe modifications for lesser degree of disability. P value correlating income with the use of assistive devices was 0.045.

Only 15 people had received vocational training (computer typing and sewing) after acquiring the disability, while the rest either had secure jobs or were dependent on others for living.

Among the studied subjects, 10% also reported experiencing depression and undergoing treatment, whereas 69% had belief in faith healer services and only 28% had a health insurance.

Married persons included 43% of the study population, out of which, 41 people had children (19 had 1–2 children and 7 had >4 children), 8% of the subjects had physically challenged spouses, and a total of 9% were dependent on a relative for care of their children.

Among the married subjects, forty were sexually active, while three were not sexually active following disability; among the unmarried, 20% were sexually active. Contraceptive usage, however, was limited to 33% of the study group, condoms being the most common method, followed by IUDs, hormonal and permanent methods. P value correlating contraceptive usage with education was 0.03.

Sexual health-associated issues among physically challenged people

  1. Condition in genitalia:
    • Discharge: 2
    • Burning micturition: 2
    • Unclean genitalia: 5
    • Pyocele/hydrocele: 4
  2. Nerve sensation in genitalia:
    • Complete loss: 10
    • Partial loss: 11.


Reproductive health-associated issues

  • Erectile dysfunction: 2
  • Ignored by partner: 3
  • Problem using contraception: 2
  • Repeated abortions: 2.


Gynecological and fertility issues among females

  1. Fertility issues:
    • Uterine fibroids: 3
    • Blocked  Fallopian tube More Detailss: 2
    • Vaginal itch: 1
    • Uterine prolapse: 2
    • Small uterus: 1
  2. Menstrual issues:
    • Irregular menses: 5
    • Dysmenorrhea: 2
    • Amenorrhea: 1
  3. Reproductive issues:

    • Repeated abortions: 2
    • Stillbirth: 1
    • Neonatal death (respiratory distress): 1.


Despite these problems, only 10% of the patients had received sexual counseling from their health-care providers during rehabilitation and only 22% of the women opted for regular gynecological visits.

Awareness about HIV and STIs was 57%. There were 21% patients who had knowledge of HIV, but no knowledge on other STIs [Figure 2]. P value relating education and knowledge of spread and prevention of HIV was 0.01.
Figure 2: Attitude related to the prevention of HIV infection

Click here to view


P value relating to knowledge of HIV prevention and education was 0.029.

The serological tests for HIV antibody, VDRL, HSV, HBsAg, and HCV were negative in all the tested samples; however, IgG was positive for C. trachomatis in seven samples (35%).


   Discussion Top


The male:female ratio in this study was 19:6. This is almost double of the Census of India, 2011 figures, which states the male:female ratio of disabled population as 12.6:9.[8] The differences in gender and literacy rates could have arisen because the study is a hospital-based survey, and hence, might not have many female attendees. Besides, the duration of the study was very short, i.e. 3 months which is not adequate to generate epidemiological data.

The majority of the respondents belonged to the age group of 20–30 years. This is in concordance with the young population characteristics of India.[9]

In this study, the most common disabled body parts were limbs (both upper and lower), trauma being the most common causative factor, and males formed the most commonly affected group; this corresponded to the National Sample Survey Organization, 2002 data, which identified difficulty in movement as the most prevalent disability.[10]

Among the physically challenged respondents, a significant proportion of 43% were married; while according to the 2011 Census, 16.8% of the general Indian population were married. Besides, 41% of the subjects also had children. This clearly defies the myth branding physically challenged people as being sexually inactive. However, 9% of the physically challenged subjects were dependent on a relative for the care of their children. This indicates that disability had a negative impact on parenting and childcare as well.

The contraceptive usage among disabled subjects was 33%, which had dropped down after acquiring the disability according to a few respondents. In a study by the same department on STI/reproductive tract infection (RTI), the contraceptive usage among normal women was found to be 38.4%, i.e., higher than in physically challenged people.[10] This could be explained by lower fertility, lesser frequency of sexual intercourse, difficulty in using a particular contraception, and increased sexual problems following disability.

In this study, 78% of the population were aware of HIV, the figures being less compared to a Malawi study, in which 87.3% respondents were aware of HIV. Although extensive outreach programs have been launched by the Government of India, a number of misconceptions are still prevalent regarding its spread and prevention, which need to be addressed.

Serum samples could be collected and analyzed from twenty subjects only, and the most common RTI found was chlamydia infection in 35%. This could be an indication of a widely prevalent sub-clinical infection in the disabled population, since none of them reported any signs and symptoms of STIs. The lack of symptoms could also be attributed to the loss of nerve stimulation in the genitalia. Hence, regular screening for such infections is essential.

The laboratory investigations for all the other STIs (HIV, VDRL for T. pallidum, herpes simplex, hepatitis B, and hepatitis C) were negative. In a study done by the same department for the prevalence of STIs in general population, syphilis was found to be the most common STI, followed by genital herpes and other viral infections.[11] The seronegativity of other STIs despite lower contraceptive use in this study group could be on account of lesser people with multiple sexual partners and/or lower fertility. The sample size is, however, very small to calculate the prevalence of these diseases and hence, more studies are needed to augment the data.


   Conclusions Top


This study is a pioneering research on a neglected but important subject among the Indian population. Though physically challenged people form a large part of society, their sexual and reproductive needs have always been put away, though they need more assistance on account of their disability.

The major hurdles to quality sexual health identified were problems in using a particular contraceptive and fertility problems from lack of nerve sensation to problems in childbirth. The most common STI encountered during the study was chlamydia infection (although sub-clinical).

There is a marked variation from the trends among the general population, whether it is the knowledge about STIs/RTIs and HIV or attitudes toward sexual issues to adoption of healthy practices.[12]

Since a healthy sexual life is imperative to the holistic health-care approach, there is a dire need to address the basic SRH issues of physically challenged people to ensure the achievement of the universal WHO goal of “Health for All.”

Financial support and sponsorship

This study was conducted as part of the ICMR-Short Term Studentship project. (ICMR-STS) supported by Indian Council for Medical Research.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
United Nations Enable. Fact Sheet on Persons with Disabilities. New York: United Nations; 2007. Available from: http://www.liverpoolvct.org/index.php?PID=187 & showsubmenu=187. [Last accessed on 2013 Oct 05].  Back to cited text no. 1
    
2.
Mulindwa IN. Study on reproductive health and HIV/AIDS among persons with disabilities in Kampala, Katakwi and Rakai districts. Commissioned by DWNRO with support from action aid Uganda. DWNRO (Disabled Women's Network and Research Organisation) 2003; p. 18-22.  Back to cited text no. 2
    
3.
Becker H, Stuifbergen A, Tinkle M. Reproductive health care experiences of women with physical disabilities: A qualitative study. Arch Phys Med Rehabil 1997;78 12 Suppl 5:S26-33.  Back to cited text no. 3
    
4.
Dyke DC, Mcbrien DM, Sherbondy A. Issues of sexuality in Down syndrome. Down Syndr Res Pract 1995;3:65-9.  Back to cited text no. 4
    
5.
Office on Disability. Fact Sheet on Sexually Transmitted Diseases and Disability. U.S. Department of Health and Human Services; 2010. Available from: http://www.hhs.gov/od/about/fact_sheets/stdchapter 25.html. [Last accessed on 2013 Oct 07].  Back to cited text no. 5
    
6.
WHO/UNFPA Guidance Note. Promoting Sexual and Reproductive Health for Persons with Disabilities. Geneva: WHO; 2009. Available from: http://www.who.int/reproductivehealth/publications/general/.[Last accessed on 2013 Oct 07].  Back to cited text no. 6
    
7.
Kumar N, Gupta N, Kishore J. Kuppuswamy's socioeconomic scale: Updating income ranges for the year 2012. Indian J Public Health 2012;56:103-4.  Back to cited text no. 7
  Medknow Journal  
8.
Available from: http://www.censusindia.gov.in/Census_And_You/disabled_population.aspx. [Last accessed on 2013 Oct 07].  Back to cited text no. 8
    
9.
Available from: http://www.censusindia.gov.in. [Last accessed on 2013 Oct 07].  Back to cited text no. 9
    
10.
Disabled Persons in India. Report No. 485 (58/26/1). NSS 58th Round (July-December 2002). National Sample Survey Organization. Ministry of Statistics and Programme Implementation. Government of India; December, 2003.  Back to cited text no. 10
    
11.
Ray K, Bala M, Bhattacharya M, Muralidhar S, Kumari M, Salhan S. Prevalence of RTI/STI agents and HIV infection in symptomatic and asymptomatic women attending peripheral health set-ups in Delhi, India. Epidemiol Infect 2008;136:1432-40.  Back to cited text no. 11
    
12.
Ray K, Bala M, Gupta SM, Khunger N, Puri P, Muralidhar S, et al. Changing trends in sexually transmitted infections at a regional STD centre in North India. Indian J Med Res 2006;124:559-68.  Back to cited text no. 12
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