Population-based survey on STI-associated symptoms and health-seeking behaviours among Iranian adults

Educational interventions to improve women's preventive behavior of sexually transmitted infections (STIs): study protocol for a randomized controlled trial

BACKGROUND

Sexually active women aged 18 to 48 are within the population at risk for acquiring sexually transmitted infections. Some STIs can cause serious complications in women's reproductive health. Accordingly, this practical randomized trial aims to evaluate the effect of an interventional education based on the ISD model on improving preventive behaviors for Iranian women.

METHODS

Women aged 18-48 years that refer to Tehran Municipality Health Houses will be invited to join the study. Recruitment will continue until a sample of 150 women participants. The study will be conducted using a mixed-methods protocol in three phases. In the first phase, women's educational and learning needs about STIs will be identified using a qualitative approach. In the second phase, the results from the qualitative approach will be used to design a training program based on an ISD model. The educational intervention will be performed in the third phase. Participants will be randomly allocated into two groups: (1) the intervention group and (2) the control group. Data will be collected using STI Four-Scale of Preventive Behaviors at baseline, immediately, 1-month, and 3-month follow-up assessments. The impact of the intervention on the promotion of preventive behaviors from STIs will then be evaluated.

DISCUSSION

This study provides an educational program for empowering and promoting behaviors that prevent STIs. If the designed interventions in the present study are effective, it has practical potential to be generalized for Iranian women at risk of STIs.

TRIAL REGISTRATION

ClinicalTrials.gov IRCT20200602047638N1 . Registered on 22 May 2021 with the IRCTID, V1.0.

A mobile-based educational intervention on STI-related preventive behavior among Iranian women

While rates of sexually transmitted infections (STIs) in Iran are alarming, little is known about preventive sexual behaviors. The purpose of this article was to assess the effect of a mobile-based educational program to promote preventive behaviors regarding STIs in Iranian women. Using Roger's protection motivation theory, the following measures were developed as the study's conceptual framework: STI knowledge, STI vulnerability, STI prevention self-efficacy and STI prevention intentions. These variables were measured by the Persian version of a valid Korean four-scale tool. Data from 76 women were analyzed: 37 women in the smartphone application (Experimental) group and 39 in the control group. Health Education Sexually Transmitted Infections Application was developed as a smartphone application training program. Participants were tested at three-time points: pre-test (baseline), post-test 1 (immediately after the program's completion) and post-test 2 (16 weeks after the program's completion). Significant group differences were found at different times in STI knowledge, vulnerability, prevention self-efficacy and prevention intentions. The smartphone application was effective in sustaining the effects of the educational program in the experimental group. The development of appropriate teaching materials on sensitive public health issues, such as STIs to promote individual self-learning skills is suggested.

Estimating the Number of Genital Warts Cases in Bushehr City (Southwest Iran) in 2019 Using the Multiplier Method

Background: There is an information gap concerning the prevalence of genital warts infection in Iran. Objectives: The present study aimed to estimate the number of genital warts cases in the city of Bushehr using the multiplier method, which previously there was no accurate information. Methods: This 2019 cross-sectional study directly counted the number of cases of genital warts referred to private and public clinics in Bushehr City over a month (June). In July, a survey was conducted on the general population of the city in order to obtain information with reference to the number of people with a history of genital warts in the last month and to assess the patients who were referred to a healthcare center. We also interviewed physicians and midwives. Eventually, the number of genital warts cases calculated using the multiplier method (S = P1/P2 × m formula). In order to accurately estimate the confidence interval, a Monte Carlo analysis was used in STATA version 14. Results: The number of genital warts cases referred to a provider in the investigated month, separated by general practitioners, dermatologists, gynecologists, midwives, urologists, and infectious diseases specialists, was estimated at 258, 195, 77, 48, 22, 22, and 9, respectively. Conclusions: The estimated number of genital warts cases in the study population was significantly higher than the reported cases for the investigated month by the Bushehr University of Medical Sciences Centers for Disease Control and Prevention (CDC). Understanding the true number of cases of genital warts can help policymakers in designing genital wart control and prevention programs for the general population and at-risk individuals.

Declining trends in HIV and other sexually transmitted infections among female sex workers in Iran could be attributable to reduced drug injection: a cross-sectional study

OBJECTIVE

The HIV trend among female sex workers (FSWs) is understudied. We assessed the prevalence and trend of HIV and five other STIs among FSWs in Iran.

METHODS

We recruited FSWs (1337 in 2015, 1005 in 2010) from 21 sites in 13 cities in two cross-sectional biobehavioural surveys. Eligible FSWs were women aged ≥18 years who reported selling sex to more than one male client in the past 12 months. Consenting FSWs were interviewed using a behavioural questionnaire and tested for HIV and five other STIs. We considered study sites as clusters in the analysis and two-sided Fisher's exact test to compare the HIV prevalence between the two survey rounds.

RESULTS

HIV prevalence was 2.1% in 2015 (vs 4.0% in 2010, p=0.007). Lifetime drug injection was reported by 6.1% of participants in 2015 (vs 14.6% in 2010, p=0.003). In 2015, among FSWs with history of lifetime drug injection, HIV prevalence was 8.6% (vs 9.8% in 2010, p=0.425). The prevalence of other STIs in 2015 was 0.4% (95% CI 0.2 to 1.0) for syphilis, 1.3% (95% CI 0.8 to 2.1) for gonorrhoea, 6.0% (95% CI 4.8 to 7.4) for chlamydia, 11.9% (95% CI 8.5 to 16.5) for trichomoniasis and 41.8% (95% CI 39.2 to 44.5) for human papillomavirus.

CONCLUSIONS

HIV prevalence among FSWs in Iran decreased, but remains considerably high. The decrease in HIV prevalence compared with 2010 might be explained by a decrease in drug injection. Other STIs are also high in this population. Harm reduction programmes need to be continued and scaled up among this underserved population in Iran.

Latent class analysis of symptoms for sexually transmitted infections among Iranian women: Results from a population-based survey

A preliminary symptom-based screening test would lower the financial burden of sexually transmitted infections (STIs) caused by clinical testing. To develop such a screening method, we should first identify the most specific STI symptoms. We aim to distinguish the specific STI symptom(s) that are most likely to be found in the truly infected individuals. We used data from a population-based survey that was conducted in Iran, in 2014. Using Latent Class Analysis (LCA) in R software, we classified 3049 Iranian women, 18-60 years old, with reference to seven self-reported STI-associated symptoms. Using LCA, we categorized nearly 1% of women as "probably STI-infected". Above 70% of participants reported the "seven symptoms" that are associated with STIs, except for genital ulcer. These symptoms could be used to distinguish healthy participants from infected ones. The "probably healthy" class incorporated about 77% of the participants. Lower abdominal pain and abnormal vaginal discharge were the most frequently reported symptoms of this class. The LCA determined classes along with the WHO syndromic guidelines for STI diagnosis can help physicians to make a more accurate diagnosis. Hence, cost-effectively, only patients who are classified as probably infected need to be referred to medical laboratories for further investigations.

How and Where Do We Ask Sensitive Questions: Self-reporting of STI-associated Symptoms Among the Iranian General Population

Background: Reliable population-based data on sexually transmitted infections (STI) are limited in Iran and self-reporting remains the main source of indirect estimation of STI-associated symptoms in the country. However, where and how the questions are asked could influence the rate of self-reporting. In the present study, we aimed to assess what questionnaire delivery method (ie, face-to-face interview [FTFI], self-administered questionnaire [SAQ], or audio self-administered questionnaire [Audio-SAQ]) and setting (ie, street, household or hair salon) leads to more reliable estimates for the prevalence of self-reported STI-associated symptoms.

Methods: This cross-sectional study was conducted in winter 2014 on a gender-balanced (50.0% men) sample of 288 individuals aged 18–59 years old in Kerman, Iran. Respondents were recruited in (a) crowded public places and streets, (b) their households, and (c) hair salons. Data was collected on history of current and 6-month (ie, past 6 months) STI-associated symptoms. Three different methods including FTFI, SAQ and or Audio-SAQ were applied randomly in households and non-randomly in streets and hair salons to collect data among the respondents. Generalized estimating equation (GEE) was used to compare the settings and methods separately.

Results: A total of 2.8% of men and 9.4% of women self-reported at least one STI-associated symptom. Respondents were significantly more likely to report STI-associated symptoms when completing questionnaires on the street compared to their household (P = .0001). While women were less likely to report symptoms in FTFI compared to SAQ (P = .036), no significant differences were found between men’s responses across different methods (P = .064).

Conclusion: Further research is needed to evaluate the effect of different combinations of methods and settings to find the optimal way to collect data on STI-associated symptoms.

Sex- and age patterns in incidence of infectious diseases in Germany: analyses of surveillance records over a 13-year period (2001-2013)

Sex differences in the incidence of infections may indicate different risk factors and behaviour but have not been analysed across pathogens. Based on 3.96 million records of 33 pathogens in Germany, notified from 2001 to 2013, we applied Poisson regression to generate age-standardised incidence rate ratios and assessed their distribution across age and sex. The following trends became apparent: (a) pathogens with male incidence preponderance at infant and child age (meningococcal disease (incidence rate ratio (IRR) = 1.19, 95% CI 1.03-1.38, age = 0-4); influenza (IRR = 1.09, 95% CI 1.06-1.13, age = 0-4)), (b) pathogens with sex-switch in incidence preponderance at puberty (e.g. norovirus (IRR = 1.10, 95% CI 1.02-1.19 in age = 5-14, IRR = 0.96, 95% CI 0.93-0.99, age ⩾ 60), (c) pathogens with general male incidence preponderance (bacterial/parasitic infections with campylobacter, Yersinia and Giardia), (d) pathogens with male incidence preponderance at juvenile and adult age (sexually transmitted or vector-borne infections (combined-IRR = 2.53, 95% CI 2.36-2.71, age = 15-59), (e) pathogens with male preponderance at older age (tick-borne encephalitis - IRR = 2.75, 95% CI 1.21-6.24, listeriosis - IRR = 2.06, 95% CI 1.38-3.06, age ⩾ 60). Risk factor concepts only partly serve to interpret similarities of grouped infections, i.e. transmission-related explanations and sex-specific exposures not consistently explain the pattern of food-borne infections (b). Sex-specific differences in infectious disease incidence are well acknowledged regarding the sexually transmitted diseases. This has led to designing gender-specific prevention strategies. Our data suggest that for infections with other transmission routes, gender-specific approaches can also be of benefit and importance.

Understanding sexual healthcare seeking behaviour: why a broader research perspective is needed

BACKGROUND

Despite effective and accessible treatments, many sexually transmitted infections (STIs) in high-income countries go untreated, causing poor sexual health for individuals and their partners. Research into STI care has tended to focus on biomedical aspects of infections using patient samples and prioritised attendance at healthcare services. This approach overlooks the broader social context of STIs and healthcare-seeking behaviours, which are important to better understand the issue of untreated infections.

MAIN BODY

This paper is structured around three main arguments to improve understanding of help-seeking behaviour for STIs in order to help reduce the burden of untreated STIs for both individuals and public health. Firstly, biomedical perspectives must be combined with sociological approaches to align individual priorities with clinical insights. More research attention on understanding the subjective experiences of STI symptoms and links to healthcare-seeking behaviour is also needed. Secondly, a focus on non-attendance at healthcare services is required to address the patient-centric focus of STI research and to understand the reasons why individuals do not seek care. Finally, research using non-patient samples recruited from outside medical contexts is vital to accurately reflect the range of behaviours, beliefs and health issues within the population to ensure appropriate and effective service provision. We suggest piggy-backing other research on to existing studies as an effective way to recruit participants not defined by their patient status, and use a study recruiting a purposive non-patient sample from an existing dataset - Britain's third National Survey of Sexual Attitudes and Lifestyles (Natsal-3) as an illustrative example.

CONCLUSION

STIs are common but treatable, however a range of social and cultural factors prevent access to healthcare services and contribute to the burden of untreated infection. Different conceptual and empirical approaches are needed to better understand care-seeking behaviour and reduce the gap between social and biomedical advancements in managing untreated infection.

Narrative review of women's health in Iran: challenges and successes

BACKGROUND

In each society, the health of women in different periods may be endangered by an unequal distribution of resources, facilities, and gender prejudices. The present study evaluated the time trend of Iranian women's health between 1990 and 2013.

METHODS

This narrative review includes an integration and descriptive summary of the existing evidence on trends and criteria of different aspects of women's health from social determinant point of view. The evidence was drawn from peer-reviewed, cross-national or large-scale studies, official sources of the Ministry of Health, reviews, and online scientific databases published between 1990 and 2013.

RESULTS

The average life expectancy of Iranian women has increased from 44.15 years in 1960 to 75.75 years in 2012; in most deprived provinces of Iran, however, this criterion is about 67.3 years, and in the capital it is 75.8 years. In 2011, 43.37 % of DALYS, 36.21 % of YLL, and 1.92 % of YLD were dedicated to women; these figures were 3.63 % lower than they were in 2003. Although a significant reduction has occurred in maternal mortality rate, which dropped from 83 to 23 per 100,000 between 1990 and 2013, there is no equal distribution in maternal mortality across the country as manifested by the unfavorable conditions of border provinces (SD = 19.2). The prevalence of HIV/AIDS is an alarming health problem among Iranian females, increasing approximately 546 % between 2007 and 2015. As for mental health, depression in women was ranked first among diseases in 2011 compared to a second place ranking in 2003. As regards social health, the delinquency of women has increased in recent years compared to men with women committing more crimes related to drugs and actions against virtue. The annual report of the United Nations for the gender gap index in 2013 ranked Iran as 130 among 136 countries (from 0.622 in 2000 to 0.584 in 2013).

CONCLUSION

Generally, over the last three decades, the health indices of Iranian women have grown in aspects of physical, mental, and social health. Remarkable differences can be seen among female health indices based on geographic location and in comparison with men. To promote an improved health status for Iranian women, the root causes of the discrepancies must be identified and a comprehensive national plan must be established.