Reproductive Tract Infections and Treatment Seeking: Findings from a Study of Female Sex Workers in Kerala, India

Saritha NairNational Institute for Research in Reproductive

(Indian Council of Medical Research)Mumbai, India

saritha_nair@yahoo.co.ukPresented at the University of Southampton, 2005

PRESENTATION OVERVIEW

RESEARCH QUESTIONS CONTEXT METHODOLOGY FINDINGS OBSERVATIONS FROM QUALTITATIVE

DATA DISCUSSION

Research Questions

How do female sex-workers in Kerala define and explain various reproductive tract infections?

What is the correlation between the self-reported symptoms of RTIs and clinical examination?

What preventive and treatment measures do sex workers employ against perceived symptoms of RTIs?

The Context------

Socio-economic and demographic Age- 35 years Almost fifty percent have chosen

this work due to poverty About one-fourth of the sex workers

are homeless About three-fourth are literate On an average sex workers cater

three clients per day Almost eighty percent of them

consume alcohol every day

The Context contd---

Legal Not legalized Almost half of them have been arrested in

the past six months Violence and hostility

Three-fourth of the sex workers have experienced violence from perpetrators ranging from ‘local goondas’ to general public including police

Most of this has been physical in nature

Methodology

Structured interview schedule administered among 293 female street sex workers in two districts of Kerala state, India, during 2000 - 2001

Comprehensive gynecological examination of 126 sex workers

Key informant interviews Focus group discussions -sex workers In-depth interviews - sex workers

Methodology contd---

Self-reported morbidityQuestions were asked about the presence of menstrual and other gynecological problems. Information on duration and severity of symptoms was not collected.

Medical examinationStudy participants were examined by a female gynecologist.

Current Symptoms of RTIs/STIs As Reported by the Female Sex Workers

49.4

45

33.7

32.1

21.5

15

14.6

5.4

5.4

3.7

2

23.9

0 10 20 30 40 50 60

Abnormal vaginal discharge

Backache

Itching genital region

Lower abdominal pain

Painful intercourse

Burning urine sensation

Lack of control of urine/faeces

Heaviness down below while straining

Heaviness down below

Foul smelling discharge

Genital sores

Any one problem

Percentage of Sex Workers According to Various Clinically Diagnosed RTIs/STIsType of RTI Percent No. of

sex workers (N=126)

Trichomoniasis or Bacterial Vaginosis

32.5 41

Vulvovaginal Candidiasis 25.3 32

Cervicitis or Gonococcal and Chlamydial infection

15.8 20

Genital ulcers 1.6 2

Pelvic Inflammatory Disease 10.3 13

Criterion Of Diagnosis

1. Trichomoniasis or Bacterial Vaginosis. Profuse runny malodorous vaginal discharge. 2. Vulvovaginal Candidiasis. White curd-like (clumped) vaginal discharge. 3. Cervicitis or Gonococcal and Chlamydial infection. Mucopus in cervix. 4. herpes progenitalis. Multiple small blister-like lesions. 5. Syphilis and Chancroid. Genital ulcers (painful and painless sores). 6. Pelvic Inflammatory disease. Lower abdominal pain as a cause of underlying inflammatory disease will be

diagnosed if: Lower abdominal tenderness and cervical motion tenderness with one of the following is present.

Purulent vaginal or cervical discharge. Temperature > 38oC. Presence of pelvic mass (Gonococcal, Chlamydial and Anearobic infection). 7. Lymphogranuloma Venerum. Enlarged painful inguinal lymph nodes (no genital ulcer).

Percentage of Observed Agreement With the Results of Clinical Examination

68.6

96.5 88.9 93.9

0102030405060708090100

Vaginal

discharge

Genital

ulcer

PID Prolapse

uterus

Current reported symptoms of RTI/STIs and treatment seekingProblems Public

doctorPrivate doctor

Self-treatment

No treatment

N

1. Heaviness 12.5 31.2 6.23 50 16

2. When strain/cough 12.5 62.5 -- 25 16

3. Lack of control over leaking 22.2 77.8 3.6 34.9 43

4. Abnormal discharge 12.4 49.6 0.7 37.2 145

5. Itching around genitals 9.1 54.6 2.0 34.3 99

6. Painful intercourse 17.5 47.6 1.6 33.3 63

7. Foul smelling discharge 44.4 55.6 (--) 18.2 11

8. Lower abdominal pain 10.7 50.0 2.12 37.2 94

9. Sores on genitals -- 58.3 8.3 33.3 12

10.Burning while urinating 9.1 47.7 -- 43.2 44

11.Backache 18.3 39.6 0.76 41.2 131

Characteristics of sex workers seeking treatment for vaginal discharge A larger proportion of the following

categories of sex workers sought treatment Literate compared to illiterate Older (>30) compared to younger

(<30) Those who perceived risk of STDs as

compared to those who did not Those who were reached out by

intervention outreach workers

Observations From Qualitative Data: Perceived Vulnerability During the focus group discussion, one sex

worker insisted that “…there were no chances of sex workers getting AIDS because it was a disease of Bombay and till now it had not reached in Kerala… another street sex worker in the field for 20 years said, “who said that those sex workers who don’t use condoms have STDs/AIDS? In my whole life, I have not used and would not use condoms, can anyone tell me about whether I have ever been to hospital with any infection? No, they would not have an answer.

Observations From Qualitative Data: Perceived Vulnerability Talking about personal hygiene a street

based sex worker said, “I take bath regularly. For not getting any disease, we should take care of our body by cleaning ourselves and going with only neat and clean clients. Going with any clients would do us harm. As far as possible, I go with only those clients who seem to be very neat. In the room, I don’t go for sex immediately. Even if there is police raid, first I examine their penis and only if it is clean then proceed.

Observations From Qualitative Data: Perceived Vulnerability

One sex worker claimed that she knew about STIs and accordingly took care while having sex with the clients, “I assess from the looks of penis……in case they have some infections ……it would be very red and also would have boils here and there. I don’t like to go for consultation. I am my own doctor and I know what to do.”

Observations From Qualitative Data: Perceived Vulnerability

Explaining about douching, a street based sex worker in the field for last 9 years said, .. “if I feel that I had a intercourse which was not clean, then I would immediately go and wash with soap and put my fingers and wash it well. I would wash with whatever available like shampoo or bathroom lotion, for the germs should be killed. And if nothing were present I would wash with urine.”

Observations From Qualitative Data: Perceived Vulnerability

Washing with beer or coca-cola is also good treatment.”……. “On one occasion….I was so tensed that I applied Amrutanjan (locally available pain balm), so that…. The germs would die. It was burning like anything, but I felt very satisfied and was confident that nothing would have happened to me.”

Self Administered Penicillin Both As a Prophylaxis and Also Treatment

“Once in a month I go and take the penicillin injection – which is very much essential. Though I don’t have a degree. I know things much better than these new doctors know. I myself used to inject this to my friends also, they have never come up with any problem. We buy disposable syringes.”

Black Magic

“After tying this thread around my leg, I feel relieved from pain. I got this sacred thread from the poojari (priest) in the temple near the court. For whatever disease you go he will do some pooja (rites) and shower you with holy prasad (blessings). This thread should be tied around the wrist, arm or waist and after two months again I have to go there. Till then I need not worry about any disease, including AIDS.

Discussion

Despite a fairly high level of literacy among sex workers in Kerala, the treatment seeking is not appropriate and is guided by misconceptions.

Need to explore the nexus between violence, RTI/STIs, and health seeking.

Need to strengthen the outreach intervention programs.

Need to address the overall vulnerability context.