Indian Journal of Sexually Transmitted Diseases and AIDS
ORIGINAL ARTICLE
Year
: 2020  |  Volume : 41  |  Issue : 1  |  Page : 58--62

Rapid Assessment of low utilisation of sexually transmitted infection services amongst high risk groups in designated sexually transmitted infection clinics of Bhopal” – A Qualitative Study


Devendra Gour1, Manju Toppo1, Dinesh K Pal1, Angelin Priya1, Daneshwar Singh2, Nisha Singh1,  
1 Department of Community Medicine, Gandhi Medical College, Bhopal, Madhya Pradesh, India
2 Department of Community Medicine, Government Medical College, Rajnandgaon, Chhattisgarh, India

Correspondence Address:
Dr. Manju Toppo
Department of Community Medicine, Gandhi Medical College, Bhopal, Madhya Pradesh
India

Abstract

Introduction: High-risk groups (HRGs) have limited access to appropriate information and sexual and reproductive health services. They are a highly marginalized subgroup and their social stigma is a barrier for the use of health care and treatment. Objectives: (1) To assess the knowledge regarding sexually transmitted infection (STI) infections among HRGs. (2) To identify the reasons and barriers associated with low utilization of services among HRGs. Materials and Methods: Qualitative study conducted in three HRGs of Bhopal for 3 months. Six focus group discussions were done among three HRGs namely intravenous drug users (IDUs), commercial sex workers (CSWs), and men having sex with men (MSM). Issues related to STIs were asked to all the respondents and detailed responses were recorded by the voice recorders and noted down. The audio recordings were translated and transcribed into English. Transcribed data content were analyzed manually in various themes. Results: Knowledge regarding STI/reproductive tract infection: The knowledge of HRGs regarding STDs was assessed. Almost all the CSWs of the group were having considerable knowledge regarding signs and symptoms about STI. MSM were having good knowledge about STIs. Most of the IDUs had a very limited and scarce knowledge about STI. Most of the CSWs shared their problems regarding STI with family members followed by doctor. Almost all the MSMs approached the counselor first before approaching a doctor and preferred to consult a doctor in a government hospital. Majority of IDUs said that they prefer to go to government hospital for getting treated for such conditions while a few prefer for private hospitals. Conclusion: Majority of HRGs are seeking health care from government health facilities while the MSMs and transgender faced discrimination at these facilities and nongovernmental organizations (NGOs) played a major role in promoting better health-seeking behavior among them. The HRGs freely discussed their problems with the NGOs.



How to cite this article:
Gour D, Toppo M, Pal DK, Priya A, Singh D, Singh N. Rapid Assessment of low utilisation of sexually transmitted infection services amongst high risk groups in designated sexually transmitted infection clinics of Bhopal” – A Qualitative Study.Indian J Sex Transm Dis 2020;41:58-62


How to cite this URL:
Gour D, Toppo M, Pal DK, Priya A, Singh D, Singh N. Rapid Assessment of low utilisation of sexually transmitted infection services amongst high risk groups in designated sexually transmitted infection clinics of Bhopal” – A Qualitative Study. Indian J Sex Transm Dis [serial online] 2020 [cited 2020 Nov 25 ];41:58-62
Available from: https://www.ijstd.org/text.asp?2020/41/1/58/286995


Full Text

 Introduction



Sexually transmitted infections (STIs) are a major public health problem especially in developing countries like India. Studies suggest that 6% of the adult population in India is infected with one or more STIs. Individuals suffering from STIs are not only susceptible to get infected with HIV/AIDS but also play an important role in the transmission of STIs and HIV/AIDS to others. Research indicates a synergy between STIs and HIV transmission and in turn enhances transmission among high-risk group (HRG) such as Men having sex with men, intravenous drug users (IDUs), commercial sex workers (CSWs), and their clients.[1] An estimated 1,22,000 STI patients are documented in the STI clinics of Madhya Pradesh. But, are these STI services being availed by the High Risk Groups ? Insights into the factors that make people decide why, when, and where to seek care can improve the programs that focus on STI control. Given the scope of this public health challenge and the importance of prompt treatment and follow-up to reduce future STI-related risk behavior, we sought to qualitatively explore these issues knowledge and perception regarding STI among HRGs that is CSWs, IDUs, and men having sex with men (MSM).

Objective

To assess the knowledge regarding STI among HRGsTo obtain a range of perspectives on health-seeking behavior among themTo explore the reasons and barriers associated with low utilization of services among HRGs.

 Materials and Methods



An exploratory qualitative study among HRGs was undertaken. The study subjects were HRGs such as CSWs, IDUs, and MSM including transgenders (TGs). Three non-governmental organizations (NGOs) working with each group of HRGs in Bhopal were chosen to support the study team. These NGOs are a team of frontline workers working with Madhya Pradesh State Aids Control Society (MPSACS) helped in accessing the HRGs. The study team comprised of 2 co-principal investigator and 2 surveyors who conducted 6 focus group discussions (FGDs) at these NGO offices of Bhopal. A set of two FGDs were conducted in each HRGs comprising of 6 FGDs. There were 8–10 respondents in each group issue related to STIs were asked to all the respondents and detailed responses were recorded by the voice recorders and noted down also and translated and transcribed into English. FGDs were conducted on various themes, namely, knowledge regarding STI, its names, mode of transmission, signs and symptoms, regarding prevention, usage of condoms, utilization of services, and various aspects of health-seeking behavior. Data from the HRGs were analyzed using a content analysis approach. Verbatims have been recorded and shown in Italics.

 Results



Baseline characteristics of high-risk groups

Socio-demographic characteristic of HRG showed that the majority of the CSWs interviewed were in the NGO office, fifteen were street based, six of them were brothel-based, and two of them were home based. Among IDUs, all were either unemployed, rag pickers or were drivers. MSMs were mostly professional students and 10.8% of MSM were TGs.

Majority of the High Risk groups(CSW, IDU, MSM) belonged to the age group 20-39 years.10.8 % of MSMs were of adolescent age group.

About 75% of HRGs were Hindus followed by 24.09% of them being Muslims. The literacy status of HRGs showed 20.9% of HRG are illiterate of which the least illiterate was found in MSM. Around 58.4% HRG have reported that they had started or completed secondary school. A good number of MSMs, i.e., 35.83% were graduates since they were engineering students pursuing their studies.

Focus group discussion findings of high-risk group

Knowledge about sexually transmitted infections

Knowledge regarding symptom of sexually transmitted infection

During the focused group discussion, the knowledge of HRGs regarding STIs was assessed. Almost all the CSWs of the group were having considerable knowledge about STI. Almost everyone stated that the most common genital symptom of STI is white discharge, ulcer followed by itching. Most of the IDUs had a very limited and scarce knowledge about STI. MSMs had good knowledge about STIs and was able to accurately define STIs. Knowledge regarding STIs was highest among TGs. They were able to specifically name the STIs. Most of the CSWs and MSMs knew that they were suffering from STI after the appearance of a symptom such as itching, burning micturition, pain during sex and ulcers. Most of the IDUs could not give the satisfactory response when they were asked about how they knew if they had such a disease (STI). Their knowledge was fully related to HIV.

Secretion of white water, ulcers, itching in the private areas, often accompanied with thick, yellow, foul smelling discharge along with burning micturition, pain during and after sexual intercourse followed by swelling (CSW).

Not aware how dangerous the problem is, it can be anything, only thing we know is that if we do not clean the area there is a chance of blisters and ulcers (IDU).

Syphilis, herpes, gonorrhea, etc., and fungal infections. There is watery discharge and pus in the private areas, leading to weakness in sexual organ (TG).

Knowledge regarding nong\enital condition of sexually transmitted infection

Almost all of CSWs, MSMs, and IDUs had no knowledge regarding nongenital condition of STI. None of them gave the correct response regarding this condition. The most common responses were fever and nonspecific symptoms. A few TG mentioned correctly the nongenital conditions of STI.

Mouth ulcers, lesions all over the body, infection with HIV, hepatitis B, C, herpes, piles and TB (TG).

Knowledge regarding mode of transmission of sexually transmitted infection

Knowledge regarding mode of transmission of STIs, majority of HRGs echoed that the most common cause of STI was intercourse without the use of condom and that it also could be transmitted by having sex with multiple partners. Most of the IDUs had limited knowledge regarding the reasons (causes) responsible for causing STI. They had accurate knowledge about HIV and its mode of transmission. Almost all of them had a considerable (good) knowledge about who are at risk of acquiring STI.

“Intercourse with more than one individual,” those who indulge in illicit relationships like unprotected sexual intercourse, without the use of condom both ladies and gents may develop problems. Due to unhygienic conditions during menstruation, not maintaining cleanliness. If a male has some private problem and then he undergoes sexual intercourse with her female, the female may also develop the problem (CSW).

Due to “use of common needles” “Blood is the main source leading to the infection” “Transmitted from mother to child” “Relations with multiple partners” “Use condom, stay safe”(IDU).

“Intercourse without condom can lead to HIV, needle injury can also lead to the infection, blood can also lead to the infection” (TG).

Knowledge regarding prevention against sexually transmitted infection

Condom use was viewed by most of the HRGs as a method for preventing transmission against STI. They also emphasized on regular HIV testing. They responded that they obtain condom mostly from government hospital, NGOs, and medical shops. Sometimes, customers those who are aware enough also brought condoms along with them.

Use condom while having sex “Seek doctor's advice timely and get tested for HIV at every 3 months interval”(CSW).

Some sensible customers bring condoms along with them” “We receive condom from NGO office or Government hospital which are sufficiently available here” (CSW).

Almost all of them were of the opinion that information, education, and communication played an important role in spreading awareness in the prevention of STIs along with the use of barrier contraceptive. This opinion was well summarized by the statement. Almost all the IDUs had good knowledge regarding the prevention of STIs. They mainly stressed on the use of condom and avoiding multiple sex partners.

“People should be aware, more the awareness better the prevention, if the sex worker is infected then counseling and treatment should be done, they should be advised to use condom as well” (MSM).

“One should visit doctor as soon as the person is infected or the symptoms appear, people should be made aware about safe sexual intercourse” (TG).

“Always use new syringe, baby of the pregnant mother could be saved” “Have patience” “This could be prevented by the use of condom” (IDU).

Knowledge regarding complications of sexually transmitted infection

HRGs felt that STIs are dangerous, because they cause complications and lead to infertility AIDS cancer and death.

“Can lead to HIV, cancer and can also cause death” (CSW).

Most of them were aware about the fact that if they do not go for treatment, there is a risk of their sexual partners acquiring the same disease. Furthermore, there is a risk of deterioration of their own.

Health-seeking behavior

IDUs said that they preferred to go to government hospital for getting treated for such conditions while a few prefer for private hospitals. Alternative care seeking was seen in the form of self-medication and home-based treatments.

“We apply either coconut oil or Kapoor on the lesions in order to heal it” (IDU).

“Either malham, oil or boroplus” “First we visit Government hospitals” “We go to Katju, 1250 or Hamidia” (all are nearby Government hospitals) (IDU).

Sharing health-related problems

Most of the CSWs shared their problems regarding STI with family members, followed by Doctor. They also shared their problems with their friends and also asked about what they should do. Almost all MSM approached the counselor first before approaching a doctor. Most of the IDUs preferred to consult a doctor in a government hospital.

“We sometimes share our problems with any trustworthy family member, or else we go to a doctor” (CSW).

“We tell it to a counselor first then visit a doctor in the Government hospital for the treatment, seldom we have to go to a private hospital as well” (MSM).

Partner treatment

All of the HRGs admitted and were assertive that their partners were infected with STI and their partners also should be treated.

Yes, a lot. He had red discoloration on the skin so I got him the treatment kit from here but the infection has recurred. The infection is slight so kit No. 1 has been prescribed” (TG).

The utilization of health services

Preference for place of treatment

Public service was the most preferred choice for treatment among most of the HRGs. As public services were found to be more accessible, less costly, and good provider treatment.

“Medicine is free, we are able to save a lot of money” “Not everybody is rich enough to get treatment in private hospital” “Treatment is good in Government hospital as well” “we can freely discuss with the female doctor without hesitation” “If NGO staff accompany us, we do not have to spend even Rs. 5/- for the slip” (CSW).

“A lot of money is spent, nowadays doctors are also taking Rs. 500-500/- as fees” “Money making is more in private hospital” (CSW).

Private doctors write a lot of investigations which are very expensive, there are lot of quacks in the market as well” (CSW).

The IDUs too agreed that treatment is free of cost in government hospital while a lot of money has to be spent on treatment in private clinics.

All the MSMs have their own individual preferences regarding treatment options. Most of them had to wait for one full day in government hospital before they could receive proper treatment either due to the absence of specialist doctor or long endless line of patients in the clinic.

“The entire day gets ruined, if not done we have to return the next day, they examine us one day and send us for the investigations, the next day, If the specialist doctor is not there, then we have to return the next day as well” (MSM).

Availability of condoms

All of them agreed regarding the availability of condoms in abundance on the local level.

“No, we never had deficiency of condoms” “We never let the deficiency occur, always keep it stocked beforehand” (CSW).

All the IDUs agreed that condom is readily available to them without any problem.

“Condoms are available in the NGO office and the Government hospital, often distributed by workers' the recipients are also told that if not used it can lead to diseases” (IDU).

Available at tea stalls, pharmacy, and even at pan stalls, there is a box for addicts so that they can go and get it for themselves” (IDU).

Depending on nongovernmental organizations for health care

All the HRGs were of the opinion that NGOs responded promptly in relation to their health issues. All of them agreed that they are helpful in relation to confidentiality and are concerned about us. They agreed that not much time is wasted in obtaining treatment in government hospitals if they go with the members of NGO.

“We share our problems with the NGO counselor, he understands us and keeps it a secret. We do not face any problems when we visit the doctor along with the NGO staff because they represent us and talk to the doctor. The staff from the NGO calls us and asks us whether we need more condoms, and if any need felt they provide us with the same immediately” (CSW).

Behavior of health provider

All of the TGs reported stigmatization from health-care providers when accessing health care services. They are not given equal attention as compared to other patients.

“We have to stand in queues, doctors do not even examine us properly because of the community we belong to, especially if you are a transgender” (TG).

Almost all of the MSMs were not satisfied with the level of services that are provided by the government and have suggested improvements.

“More number of STI clinics and HRG centres should be established” (MSM).

Satisfaction with the treatment received

All of the IDUs agreed regarding the availability of proper method/modes of treatment. They said that they are satisfied with the type of treatment modalities available nowadays.

“The treatment facilities are better now, earlier we were avoided, nothing was available, we were often asked to visit the next day”(IDU).

“Now it is very clear, it only takes 5–10 min of waiting period for the doctors to examine, all the medicines are available there only, now they do not discriminate us” (IDU).

 Discussion



Our study found that the knowledge regarding STI was lowest among the IDUs followed by female CSWs and the MSMs and TGs. Most of the CSWs predicted that they might be having STI after the appearance of symptom such as itching, burning micturition, pain during sex, and ulcers. Similar findings were reported in a study done by Saleem et al., in Rawalpindi. Almost all of them had considerable knowledge that condom can prevent transmission of STD. They also emphasized on regular HIV testing. Similar findings were also seen by Ghimire et al., in Nepal. The health-seeking behavior was seen as self-medication which was either home-based treatment or traditional medicines, which was also seen by in other studies.

Most of the participants preferred visiting government clinic as it was free of cost. In a study by Saleem et al.[2] in Rawalpindi, Pakistan, all the vulnerable population utilized the public health facility. The present study found that the financial consideration was a major factor when seeking help, compared to accessibility to health-care facilities and the stigma or shame of having an STI. The disrespectful behavior of health provider, waiting in long queues contributed to the barriers in low utilization of STI clinics. These findings were also seen in Ghimire et al.,[3] in Nepal where inappropriate clinic or hospital opening times, perceived low quality of the service providers, poor communication between the client and the providers; judgmental and disrespectful attitudes of the service providers and inadequate training in sexual health provision were seen as health service-related or structural barriers.

Satisfaction level was good in all the groups as their symptoms were relieved in our study as well as study by Ghimire et al. The trust and support of the NGOs had positively affected the HRGs, the outcome of which was visible in their reliability toward the workers in providing health care.

 Conclusion



Findings of the study suggest that designing health education messages about STI symptoms and the benefits of treatment that are targeted at low-socioeconomic groups and the general population might be an immediately feasible measure that can be implemented to reduce the effects of STI in Madhya Pradesh. The ability to seek help or medical care for STIs is vital for early care; hence, greater emphasis should be given to increase their knowledge, sign and symptoms of STI to all HRGs through meaningful discussion around the disease and sexual matters. Special focus and attention should be paid to IDUs regarding various complication of STIs and creating and promoting awareness regarding safe injection practice. Ensuring partner management will bring out more number of infected cases for treatment at earlier stage. Support of MPSACS to NGOs in building the capacity of STI clinics and providers will result in better service provision and ultimately resulting in better utilization of STI services in the state. The availability of doctor at NGO's office/center will definitely help STI patients to take timely and proper treatment. This will also save time and work days loss of STI patients. Public health-care facilities should be made more accessible. Proper environment and facilities for confidential services should be made available at all public clinics to ensure privacy to reduce men and women fear of shame when attending such clinics for their STI treatment.

Financial support and sponsorship

This study was supported by the Indian Council of Medical Research.

Conflicts of interest

There are no conflicts of interest.

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