Thresholds of morbidity among women in a peri-urban community of Maharashtra, India: conceptual and methodological issues

Gender inequities in treatment-seeking for sexual and reproductive health amongst adolescents: Findings from a cross-sectional survey in India

CONTEXT

India's adolescent health policy aims to improve sexual and reproductive health, especially amongst the most vulnerable. There is limited evidence on how gender influences treatment-seeking patterns amongst unmarried adolescents.

METHODS

We analyzed data from 11,651 unmarried adolescent boys and girls aged 15-19 from a cross-sectional survey conducted in two large states of India. We conducted sex-disaggregated analyses to estimate the prevalence of symptoms of genital infections and compare treatment-seeking patterns. We identified correlates through multivariable regression and used a conceptual framework to explore structural, household, social and individual factors that influence gender inequities in adolescent sexual and reproductive health.

RESULTS

One in five unmarried adolescents reported symptoms of genital infections, such as burning or discharge, in the past three months. Factors associated with reporting symptoms varied between boys and girls, except for a common correlation with symptoms of depression. At least two-thirds of boys sought treatment, compared to approximately one in four girls (rural: 66.2% boys, 23.1% girls; urban: 69.4% boys, 30.7% girls). Boys primarily sought care from medical shops or private facilities, while girls used both private and government services. Amongst boys, having friends and being in school was associated with seeking treatment (aOR: 11.47; 95% CI: 2.75, 47.87; aOR: 1.95; 95% CI: 1.24, 3.07, respectively). Odds of seeking treatment were higher amongst girls with exposure to any mass media (aOR: 1.93; 95% CI: 1.25, 2.99) and who had discussed puberty with a parent (aOR: 1.98; 95% CI: 1.32, 2.98).

CONCLUSION

Stark sex differentials in factors associated with symptoms and in treatment-seeking illustrate how structural gender inequities, such as access to economic resources and education, influence sexual and reproductive health amongst adolescents. Along with health system interventions, addressing gender inequities calls for strategies to strengthen parental engagement, social support and girls' access to resources.

Cervical cytology and associated factors among tribal women of Karnataka, India

BACKGROUND

Reproductive well-being is a crucial element of women's health. Due to the asymptomatic nature of gynaecological morbidities, women rarely seek medical advice in the initial period leading to delayed diagnosis and poor prognosis of subsequent disease. The present study aimed to explore the cervical cytology and its associated risk factors among women from tribal communities of the southern part of coastal Karnataka, India.

METHODS

Papanicolaou (Pap) smear test was performed among 1140 women from three tribal populations, to detect cervical lesions, infections and reactive changes. A semi-structured questionnaire was administered to collect data on socio-demographic and reproductive characteristics of the study population.

RESULTS

The most predominant gynaecological complaint among the participants was severe lower back ache (77.6%), followed by white discharge per vagina (29.0%) and menstrual irregularities (25.9%). Of the 1140 women screened, 12.4% showed cervical microbial infections, 23.6% were reported to have reactive changes, and 0.2% had epithelial cell abnormalities in the cervix. Cervical microbial infections were found to be associated with younger age group, low socio-economic status and younger age at sexual debut.

CONCLUSION

Most of the symptoms suggestive of gynaecological morbidities reported in this study are preventable or treatable. Strengthening ongoing cervical cancer screening programme and implementation of health education programmes among tribal population would be the right policy approach to prevent, detect and treat these symptoms at an early stage and to achieve acceptable health outcomes among tribal women.

Services for women's sexual and reproductive health in India: an analysis of treatment-seeking for symptoms of reproductive tract infections in a nationally representative survey

Background

Women’s health policy in India has had a longstanding focus on maternal health and family planning. Recent policy highlights the importance of expanding women’s access to a broader range of sexual and reproductive health services. However, there has been very limited analysis of national survey data to examine the current status of treatment utilisation, variation across states and progress over time.

Methods

This paper examines women’s treatment patterns for reproductive tract infections in India, based on data collected in the National Family Health Survey, a cross-sectional, nationally representative household survey conducted between 2015-16. The survey covered 699,686 women between the ages 15 and 49, of which 91,818 ever sexually active women responded to questions related to symptoms of reproductive tract infections. We estimate prevalence of reported symptoms and treatment-seeking, describe regional variation and utilise multivariable logistic regression to identify factors associated with women’s treatment-seeking patterns.

Results

Thirty-nine percent of women who reported symptoms of reproductive tract infections sought any advice or treatment. Women’s reported treatment-seeking in India has not changed since the last national survey a decade earlier. Reported symptoms and treatment-seeking varied widely across India, ranging from 64% in Punjab to 8% in Nagaland, with no clear regional pattern that emerged. Seventeen percent of symptomatic women sought services in the public sector, an improvement from 11% in 2005–06. Twenty-two percent utilised the private sector, with wide variation by states. National-level multivariable logistic regression indicated that treatment-seeking was associated with age, higher education, higher household wealth and having been employed in the past year. Women in the 25–35 age group had higher odds (aOR1.27; 95% CI: 1.10,1.50) of seeking treatment compared to both younger (15–19 years) and older (35 years and above) women, along with women with more than eight years of schooling (aOR: 1.23; 95% CI: 1.05,1.44) and from richer wealth quintiles (aOR: 1.53; 95% CI: 1.35,1.83).

Conclusion

Women’s use of services for reproductive tract infections remains a challenge in most parts of India. Our findings highlight the need to address barriers to seeking care and to improve measurement of gynaecological ailments in national surveys.

The effect of community health worker-led education on women's health and treatment-seeking: A cluster randomised trial and nested process evaluation in Gujarat, India

Background

A community–based health insurance scheme operated by the Self–Employed Women’s Association in Gujarat, India reported that the leading reasons for inpatient hospitalisation claims by its members were diarrhoea, fever and hysterectomy – the latter at the average age of 37. This claims pattern raised concern regarding potentially unnecessary hospitalisation amongst low–income women.

Methods

A cluster randomised trial and mixed methods process evaluation were designed to evaluate whether and how a community health worker–led education intervention amongst insured and uninsured adult women could reduce insurance claims, as well as hospitalisation and morbidity, related to diarrhoea, fever and hysterectomy. The 18–month intervention consisted of health workers providing preventive care information to women in a group setting in 14 randomly selected clusters, while health workers continued with regular activities in 14 comparison clusters. Claims data were collected from an administrative database, and four household surveys were conducted amongst a cohort of 1934 randomly selected adult women.

Results

30% of insured women and 18% of uninsured women reported attending sessions. There was no evidence of an intervention effect on the primary outcome, insurance claims (risk ratio (RR) = 1.03; 95% confidence interval (CI) 0.81, 1.30) or secondary outcomes amongst insured and uninsured women, hospitalisation (RR = 1.05; 95% CI 0.58, 1.90) and morbidity (RR = 1.09; 95% CI 0.87, 1.38) related to the three conditions. The process evaluation suggested that participants retained knowledge from the sessions, but barriers to behaviour change were not overcome.

Conclusions

We detected no evidence of an effect of this health worker–led intervention to decrease claims, hospitalisation and morbidity related to diarrhoea, fever and hysterectomy. Strategies that capitalise on health workers’ role in the community and knowledge, as well as those that address the social determinants of diarrhoea, fever and the frequency of hysterectomy – such as water and sanitation infrastructure and access to primary gynaecological care – emerged as areas to strengthen future interventions.

Effectiveness and safety of ferric carboxymaltose compared to iron sucrose in women with iron deficiency anemia: phase IV clinical trials

BACKGROUND

Iron deficiency anemia (IDA) is a significant problem worldwide particularly in women. The aim of the study was to evaluate the effectiveness and safety of intravenous ferric carboxymaltose (FCM) in comparison to iron sucrose (IS) in women with IDA.

METHOD

Two hundred patients at Department of Obstetrics and Gynaecology, Sher-i-Kashmir Institute of Medical Sciences Medical College and Hospital, Jammu & Kashmir, India identified with IDA were enrolled for the study. Intravenous FCM and IS were both given as per the protocol. Change in the laboratory parameters such as hemoglobin (Hb), mean corpuscular value, and serum ferritin levels at two weeks and four weeks interval after the treatment was recorded.

RESULT

A significant increase in the mean Hb was observed from 7.76 ± 0.709 to 13.25 ± 0.606 in patients treated with FCM and 7.64 ± 0.710 to 11.59 ± 0.733 g/dL (P < 0.001) in patients treated with IS after four weeks of therapy. The rise in mean corpuscular volume was from 66.82 ± 5.24 to 86.76 ± 3.765 and 68.05 ± 5.56 to 93.80 ± 3.80 and rise in serum ferritin levels were from 8.32 ± 1.787 to 38.94 ± 6.095 μg/L and 8.16 ± 1.540 to 27 ± 8.175 μg/L in patients treated with FCM and IS respectively after four weeks of therapy. No serious adverse effects were reported.

CONCLUSION

Parenteral therapy is effective in IDA, but FCM elevates hemoglobin level and restored iron stores faster than IS with minimum adverse drug reactions.

TRIAL REGISTRATION NUMBER

ISRCTN14484575 Dated: 15-12-2017 retrospectively registered. https://doi.org/10.1186/ISRCTN14484575.

Tension Among Women in North India: An Idiom of Distress and a Cultural Syndrome

The existing literature on Indian ethnopsychology has long asserted that somatization is a key aspect of experiences of distress. The study of idioms of distress arose out of work done in India (Nichter in Cult Med Psychiatry 5(4):379-408, 1981), but ironically, little subsequent work has systematically explored idioms of distress in this part of the world. This ethnographic study focused on the term tension (tenśan) and its relation to a cultural syndrome among women in urban North India. This syndrome appears to involve rapid-onset anger, irritation, rumination, and sleeplessness as key symptoms. It is often linked to specific circumstances such as domestic conflict and is associated with the stresses of modern urban life. People who report more symptoms of tension had consistently higher scores on the Hopkins Symptoms Checklist-25 for depression and anxiety. In this cultural context where psychiatric care is highly stigmatized, the language of tension can aid providers of mental healthcare (many of whom, in India, are not psychiatrists or psychologists) to identify and communicate effectively with potential patients whose mental healthcare needs might otherwise go unaddressed.

What 'outliers' tell us about missed opportunities for tuberculosis control: a cross-sectional study of patients in Mumbai, India

Background

India's Revised National Tuberculosis Control Programme (RNTCP) is deemed highly successful in terms of detection and cure rates. However, some patients experience delays in accessing diagnosis and treatment. Patients falling between the 96^th and 100^th percentiles for these access indicators are often ignored as atypical 'outliers' when assessing programme performance. They may, however, provide clues to understanding why some patients never reach the programme. This paper examines the underlying vulnerabilities of patients with extreme values for delays in accessing the RNTCP in Mumbai city, India.

Methods

We conducted a cross-sectional study with 266 new sputum positive patients registered with the RNTCP in Mumbai. Patients were classified as 'outliers' if patient, provider and system delays were beyond the 95^th percentile for the respective variable. Case profiles of 'outliers' for patient, provider and system delays were examined and compared with the rest of the sample to identify key factors responsible for delays.

Results

Forty-two patients were 'outliers' on one or more of the delay variables. All 'outliers' had a significantly lower per capita income than the remaining sample. The lack of economic resources was compounded by social, structural and environmental vulnerabilities. Longer patient delays were related to patients' perception of symptoms as non-serious. Provider delays were incurred as a result of private providers' failure to respond to tuberculosis in a timely manner. Diagnostic and treatment delays were minimal, however, analysis of the 'outliers' revealed the importance of social support in enabling access to the programme.

Conclusion

A proxy for those who fail to reach the programme, these case profiles highlight unique vulnerabilities that need innovative approaches by the RNTCP. The focus on 'outliers' provides a less resource- and time-intensive alternative to community-based studies for understanding the barriers to reaching public health programmes.