Sexually transmitted infections (STIs) represent a major public health problem in developing countries including Bangladesh. Millions of individuals specially women and girls in these countries suffers from SITs and RTIs and in most cases do not receive proper care. RTIs/STIs are a significant cause of morbidity and morality in both men and women, especially in women of the reproductive age.
RTIs refer to three different types of infections which affect the reproductive tract.
1. Sexually transmitted diseases,
2. Eudogenous infection (non sexually acquired infection) most common RTIs worldwide.
3. latrogenic infections occur when the cause of infections ( a bacterium or other micro-organism ) is introduced into the reprodu’ctive tract through a medical procedure such as menstrual regulation, induced abortion. the insertion of IUD or during child birth or improperly performed medical or surgical procedures.)
The burden of the reproductive tract infection is not shared equally around the world. The people those are from developing countries suffer more from these diseases than that of the developed countries due to no availability and inaccessibility, to health services and social and cultural prejudices and practices.
STI accounts for 15% of the total disease burden worldwide (WHO) and affect both men and women. It i~s estimated that there are 333 million new cases of STI per anum and that 10 to 15 million people are infected with human immunodeficiency virus worldwide every year. South east Asia is an important
area for STIs, with an estimated 150 million new cases intl 995 (WHO: 1995).
Over 30 different organi~m can be transmitted through sexual activity. They can cause symptoms and consequences including the following: genital ulcers, inflamnation , pain, infertility, ectopic pregnancy, spontaneous abortion, fetal wastage and premature delivery and neonatal blindness and infection.
The prevalence of RTIs/STIs is still underestimated, these diseases are emerging as a growing public health problem in Bangladesh due to lack of literacy, the conservative environment associated with various religious, cultural and social taboos act as a major obstacle to obtain information about actual situation of RTIs and STIs. As a consequence, wide spread RTIJSTI transmission continues to risky sexual behavior, gender and power imbalance, shame and stigma and weakness in the healthcare system (Khan RF and Akhter HF! 2001).
Each year 1.3 million women die of reproductiw health problem that are largely preventable. Estimated annual death among women from reproductive tract infections and theii~ consequences in 1995 are 87,000 maternal deaths from crucial cancer. due to infection with human pap illoma virus that also’ caused genital warts, 75,000 deaths from Syphilis and complication of Chlamydia and gonorrhoea and additional 425,000 still births as a result of this disease. About 5% of women around the world are unable to bear children due to some inherited and hormonal disorder but a much large number are unable to do so because their reproductive tracts have been damaged by infection. Among the men the annual estimated number of death from Syphilis, Clamydia and guorrhoca is approximately 20,000. Each year I out of 20 teenagers contact a sexually transmitted disease, some of which can cause lifelong disabilities, such as infertility or even death.
Prevention and treatment of RTIs/STIs are very important because RTI enhanced HIV transmission-physical damage to skin or the. mucosa or biological infections are responsible for this enhance. Number of RTIs have been shown to increase the risk of transmission of HIV by two- 15 fold and some those characterized by open sores and bleeding as much as 24 fold. The prevention and control of RTIs is an important HIV prevention strategy. In some the risk of new HIV infections attributed to RTIs is 40% or more. This means that 40% fewer cases of HIV woulds occurred. S’fls and RTIs are important in their own right. Globally, STIs (not including HIV) are leading cause of healthy life lost in women aged 15 to 45 years.
The potential of spread of HIV from high risk groups to general population in central Bangladesh, shows that the clients female sex workers include rickshaw-pullers, men who have sex with men and IDUs. Many of the client groups are married. Therefore once HIV enters any of these communities, it has the potential to spread rapidly to the general population.
The syndromic management, endorsed by the WHO is based on identifying the various syndromed managing the patient’s using the respective flow chart or algorithm. Which has been used in the urban primary health care centers after giving them training. The syndromic approach has been shown to be valid, ~feasible and cost effective in most settings and has been applied successfully in different countries throughout the world. (7) Early and effective diagnosis and RTIs/STI’s one of the major components for an effective HIV infection prevention programme.
In Bangladesh the technical standard and service delivery protocol for management of RTIs an d STIs has recently been developed based on the syndromes approach for STI case management adapted from WHO guidelines. The ‘protocol is approved by the technical review committee and is to be followed by all levels of health care providers.
In syndromes management of RTI/STI , four basic health education massages known as the 4 “C”s are used for educating and counseling patients and I or their patients.
The 4 “C”s:
Compliance with treatment
Counseling for prevention
Condoms with thonstration of correct use
Contact tacitly and treatment
Initiatives taken for the prevention and treatment of STIs both in urban and rural areas there arc limitations, particularly in government facilities, to provide quality and comprehensive service for RTI/STI. By 2002, about 5000 health personnel had been trained. This member is however quite small compared to need. It is estimated that. only about 18% of all doctors, 15% of nurses. about half of the lab technicians and almost all the managers received training on syndromic management of RTI/STI. (Haider S.J. 2002). There are also limitations in the availability of necessary logistic (drugs and instruments) of the syndromic approach. Besides providers of these facilities are not skilled in risk assessment, physical assessment, physical examination, counscHsing and partner management. There are- alsq constraints with ‘privacy and confidentiality.
A clinic based study by (Chowdhury N.M. et al 1995) done among women and reproductive age group in urban area showed RTI prevalence of 60%. In Bangladesh the conservative environment created by the deep rooted religious. cultural and ‘social values act as hindrance for obtaining’ information about actual situation of RTIsISTIs.
Globally as estimated by ‘WHO reproductive ill health accounts for 36.6% of the total disease burden in women. Socio economically Bangladesh is developing country with broad based population pyramid that indicate the higher population of younger age group.
Socio demographic profile high risk group in Bangladesh:
1. Commercial sex worker (C SW)
2. Intravenous drug users (IDUs)
3. Migrant worker
4. Professional blood donor
5. Trucks and transport workers
6. other categories: Garment workers, sailors, prisoners, pregnant and lactating mothers.
In 1991, WHO published recommendation for the comprehensive management of the patient with RTI/STI within the bro~tder context of control, prevention and care programs for RTI/ST1 and HIV infection. WHO convened and Advisory Group meeting on Sexually Transmitted Disease Treatment in May 1999 to review and update treatment recommendations in the light of receni developments.
There are 3 approaches for the treatment of any disease including of RTI/STI:
Clinical, etiological and syndromic. Clinical and etiological approaches are only possible in urban facilities where the services of expert clinicians and expert pathologists together with facilities are available. The World Health Organizations! Global prevention of AIDS (WHO! GPA) has developed set of standard syndromic flowcharts that take into account the most common etiologists from each syndrome. The NIPHP of the ministry of health and family welfare has developed a technical standard and service delivery protocol for the management of RT1s/STIs. This protocol is used by the providers at the primary level health facilities.
In developing cOuntries laboratory, diagnosis of most conditions can be difficult, and is often unavailable in the setting of primary health care (PHC) clinics. The syndromic approach is thought to be siniple, feasible and cost effective.
For proper service delivery providers effiencys regarding syndromic management of RTI!STI is important, So providers effiency must be leveled with scoring. NGOs are an important source of RTI/STI service delivery particularly in urban areas as a part of the ESP programme in the field of reproductive health.
RTI/STI related interventions implemented by NGOs are of two kinds. communication related and provisions of services. The NGO service delivery program (NS~DP), a countrywide program funded by USAID and implemented ~by 42 NGOs, is a large urban based NGO program coveringl4 districts and interventions by a number of other small NGOs including strong components of RTI/STI services. The STI/ AIDS network that has a membership of 103 NGOs, mostly at the grassroots level , , and including NGO who have interventions in the area of RTI/STI related communication and BCC.
In Bangladesh the private sector providers are the first point of contacts of patients in more than two third cases. Though a significant proportion of the doctors in private practice are government employees, the knowledge of the syndromic approach has also remained confined to a handful of trained doctors in the government and NGO sectors, and has not disseminated to the private sector.GOB and NGO are giving training to doctors, nurses’, paramedics or syndromic management.
Prevention and control of STIs is an integral part of the comprehensive reproductive health services as called for in the WHO Global strategy on Reproductive health. These global strategy for the prevention and control of sexually transmitted infections 2005-2010 presents strong economic and public health reasons for an accelerated global response to STIs in order to reverse the spread of HIV and lower maternal and child mortality so management practice of RTI/STI is very much important for protecting our community, country and world.
BACKGROUND
Sexually transmitted infections arc passed between people through sexual contact. Agents of infection include bacteria, viruses and other microorganisms that can enter a person’s urethra, vegan, mouth or anus. Some cause no symptoms at all, and some are easily treatable. Others result in severe long term consequences and can not be treated. HIV. the virus that causes AIDS. can lead to death. (13)
Very little research has been done to assess the prevalence of RTI. In Bangladesh high percentage of ( about 19,000) women die annually due to pregnancy related causes ( 11% associated with infection and 21% associated with abortion). Although sexually transmitted infection (STI) have been causing significant morbidity and mortality of the years, it is only with the advent of the human immunodeficiency infections that STI control is now receiving high priority in both developed and developing countries.
Since over 80% HIV infections are transmitted sexually, sexually transmitted infection can have a very significant and positive impact on the AIDS epidemic. We should therefore put our efforts for delivering the best STI care in our communities. (3)
The population of infertility caused by reproductive tract infections is estimated at 15-40%. (7)
Women in the traditional society of Bangladesh, who are unable to bear child are vulnerable to divorce and ostracism from the family.
The major cause of RTI in women are STDs. poor obstetric care and unsafe abortion.
According to 1994 international conference on population and development (ICPD), the definition of reproductive health is one of the essential components of reproductive health care and includes STDs and prevention of HIV. human Sexually and gender relation. Bangladesh as one of the signatory countries is :committed to implement recommendation of (ICPD), program of action the government of Bangladesh has developed several national mechanisms and strategies.
Efforts have been undertaken in Asia Co increase public awareness and response to RTIs; The most recent of which’ were a regional meeting hosted by the health action information network (HAIN) and the satellite symposia during the Fourth asia pacific congress on AIDS in 1997. What emerged form the discussion was the recognition that not much is known about the social and cultural context of RTls on how people perceive their reproductive health and risk for illness. There is no clear overall picture of the magnitude of the problems for RTIs at the national and regional level in terms of prevalence rates, public health response and local knowledge skills and experiences. The fact we do not know enough about reproductive health morbidity to effectively addressed women’s well being and quality of life.
Social stigma and hence the culture of silence are attached to sexual and reproductive problems. the genesis of’ which are invariably perceived to be women. Even when women f’eel that the vaginal discharge is not normal and~ perhaps even dangerous there is a tendency to seek treatment from traditional health such as kabiraj and herbalist. Women often pass on home remedies to each other based on their passed experience or what they have heard from someone else.
Epidemiological data worldwide as ~vell as in South-East Asia show that the major mode of’ HIV transmission is through sexual intercourse and that HIV is pnmarily sexually transmitted disease.
in an effort to standardize and improve clinical practice. the \VH() has developed the syndromes approach diagnosis is based on the identification of’ syndromes. which are combinations of symptoms (reported by the client) and signs (observe during clinical diagnosis).
The recommended treatments are effective for all the diseases that could cause the identified syndrome. The most up to date drugs are recommended and dosage explained. Generally the treatment is provided during the patients first visit. Without the used to return to the clinic before initiating 1herap.
Liealth education, prevention counseling, condom promotion. the importance ol treatment adherence, and partner referral are all recommended by the algorithms as an integral part of effective management. WHO has produced flow charts and guidelines for the syndromic approach. Following are the most common syndrome of RTIs.
1. Urethral discharge
2. Vaginal discharge
3. Genital ulcer
4. Lower abdominal puin
5. Scrotal swelling
6. Inguinal bubo
7. Neonatal conjunctivitis
JUSTIFICATION:
Diagnosis and treatment of reproductive tract infections arc complicated by confusion that surrounds the definitions and characteristics of various conditions, when different criteria are used for diagnosis inconsistent prevalence rates and over treatment can result. In order to avoid these confusion and improve management of suck infections, standardized explanation must he given internationally.
Sexually transmittance infections are now recognized as a serious global threat to the health of population. The WI-lO estimated in l999that as many as 340 million new cases of curable STIs occurs each year.
1-11 V/AIDS now represents a global pandemic. There is no cure for this Si I. and it results in death. It is believed that 36 million people now live with 11W and AIDS over 90% of them in developing countries. In 2000. about 5.3 million people were newly infected with HIV [13J. As Bangladesh is in South East Asian Region and the neighbour of India ~vhere prevalence of HIV is more so our country is in a great risk of having the disease. In south East Asia 6 million adults and children are estimated to living with Ill V/AIDS among them largest number of people about 4 million are from India. IIJ
In an effort to standardize and improve clinical practice. the WHO has developed sydroinic approach.Periodic assessment of the management practice of RTI/STI always needed to fulfill the need assessment. It may be noticed whether patients follow their recommended treatment and is related to whether patients related for treatment and change their provides of health care. Providers’ skill and knowledge about treatment guideline should he clear. RTIs are great health problem in our country so for the prevention and control the transmission the diseases. syndromic management take a vital role in this aspect. Most of the cases didn’t reported to the service providers due to lack of awareness regarding RTIs . to reduce maternal morbidity and mortality this approach is appreciated everywhere..
Prevention of reproductive tract infections and treatment of symptomic infections as part of urban primary health care, is one of the important component of reproductive health.Syndromic management of’ reproductive tract infections in low resources setting is a practical tool of diagnosis and treatment for the health workers. The National Integrated Population and Health programs ( NIPHP), the Ministry of Health and Family Welfare has developed a technical standard and service-delivery protocol which is used by the providers at the primary level health facilities.
The World Health Organization/Global Prevention of AIDS(WHO/GPA) has developed a set of’ standard syndrornic flowcharts that take into account the most common etiologies for each svndr~pie. Because the seven RTI/STI syndromes are easy to identify. it has been possible to devise a flow chart for each one. in Bangladesh. the Technical standard and service delivery Protocol for Management of’ RTI S and STIs has recently been developed based on the syndromic approach for Si] case management adapted from WI-lO guidelines. This protocol is approved by the Technical Review Committee and is to be followed by levels of health care providers.
In syndromic management laboratory investigation is not essential so this would be effective where logistic and manpower is not sufficient. It .is standardizes at all levels of the health care systems. Easy to trained the health care providers. Simple and easy to follow up. Cost effective. Easy availability of drugs. So by this way this management reduces morbidity. mortality and consequences of reproductive tract infections. So without regular assessment of management practice no approach can sustained for long time.
This study is designed to assess the management practice of RTIs/STIs patient which is practiced in urban primary health care centers in Dhaka city in Bangladesh which are serving since 7th April 2001 till now (5years).
RTIs/STIs are major ‘~health problems in developing countries. Several epidemiological an~d biological studies showed that the fact both RTIs/STIs.,. especially those associated with genital ulceration, enhance the transmission of HIV. In 1994, the international conference on population and development (ICPD) in Cairo recommended that control of RTIs/STIs should be considered one of the essential components of reproductive health. In Bangladesh. both Health and Population sector Programme (IIPSP) and the National Integrated Population and 1-lcalth Programme (NIPHP) have prioritized the issue as one of the key components of reproductive health care in the essential service package (ESP). These programmes address behavior change communication (BCC) management of RTIs/STIs cases, including referral of partner and promotion of condom in the prevention and control of RTIs/STIs.
One of the key issue relating to the prevention of RTIs/STIs including HIV. AIDS. in early detection and treatment of the disease. preferably at the point of client’s first contact with the health systemd, in developing countries, laboratory diagnosis of most conditions can be difficult. and is often unavailable in settings of primary health(PHC) clinics. However, the syndromic approach to case management of RTIs/STIs provides health workers in low resource settings a practical tool for diagnosis and treatment. This approach is based on a group of symptoms and sings associated with a number of well-defined etiologies. The WHO developed and has been promoting this since the early 1980s. Although the syndromic approach to managing clients with STIs are currently is using in many developing countries, evaluation of its feasibility is essential considering each country individually in the socio-economic context.
The NIPHP, in collaboration with the Ministry of Health and Family Welfare (MOHFW), GoB reviewed the WHO flowcharts of syndromic maiiagement of RTIs/STIs adapted form use in Bangladesh, and developed a technical standard and service delivery protocol. The protocol used by the providers at the PHClevel service-delivery sites. For efficient and successful implementation, a review of management practice of this approach at the urban primary health care centers are required considering their steps of RTIs/STIs, practice of syndromic management and protective measures taken by the providers, their skill on record keeping system are necessary.
• RTIs are a group of disease that causes infection of the genital tract and include
• sexually transmitted infections, non sexually transmitted infections like endogenous infections caused by the over growth of the organisms normally presented in the reproductive tract and iatrogenic infections caused by the improperly performed procedure.
There are three categories of RI Is:
1. Endogenous. on sexually transmitted infections are a result of over growth of the organisms normally present in vagina.
2. latrogenic infections (e.g. infections included during child birth or inappropriate performance of family planning or surgical procedures), and
3. Sexually transmitted diseases (STD) which arc passed between people through sexual contact.
According to the site and etiological agent, the types of RTIs can categorized as follows:
1. Infections of the lower tract
a. Infections of v~ulva: candidiasis. syphiliticulcer. infections of the bartholin gland.
b. Vaginitis: tricornoniasis, bacterial vaginosis.
2. infectionliof the upper tract
Infections of upper tract are commonly known as pelvic inflammatory disease (PID) these usually include infections of the uterus. fallopian tubes ovaries or pelvic peritonitis, if left untreated. Infections originating in the lower reproductive tract may result in ascending infection of the upper tract increases dramatically in medical procedure IIJD (Intrauterine device) insertion. menstrual regulation. induced abortion, and childbirth under unhygienic condition.
Difference between Rh and STI:
There is a clear distinction between the terms “Reproductive Tract infection (RTI) and sexually transmitted infection (STL)”.RTI includes all infections of the reproductive tract, whether they ‘are sçxually transmitted or not e.g vaginal discharge due to Bacterial vaginosis ~ candidiasis. On the other hand, infections commonly transmitted by sexual contact, such as human immune deficiency virus (HIV),hepatitis B etc, do nOt usually infect reproductive tract.
ND when caused by intervention of a service provider (iatrogcnic)i.e improper technique with IUD insertion is an RTI but a STD when it is due to gonorrhoea. RTI also include post abortion and post delivery infections due.to unhygienic practices and procedures.
Mode of transmission of RTI/STI:
1. Unprotected penetrative sexual intercoursc( vaginal or anal)e.g Gonorrhoea Syphilis
2. Mother to child:
• During pregnancy: HIV syphilis
• At delivery: Gonorrhoea, l-IIV
• Afterbirth: IIIV
3. Through blood and blood products:
Syphilis. I-IIV, Hepatitis-B
4. Syringes and needles:
• Use of contaminated syringes, needles by intravenous drug users. and accidental pricks for doctors. nurses.
Common factors that influences HIV and! or SIT Transmission: STIs.
• Failure To follow safer sex practices,(such as using condoms)
• Not following the full prescribed treatment
•Failure to trace and treat sexual partner
Others factors: poverty, political stability, early sexual activities and vulnerable occupations are susceptible to acquire STI/HIV transmission. It is good to also mention other risky behaviors like multiple sex partners and IV drug use etc. and expand on the sex practice like mutually faithful partner. correct and consistent use of condoms, and non penetrating sex and abstinence.
Public health consequences of RTI/STI:
In women:
• Chronic abdominal pain or infertility
• Death due to sepsis, entopic • Mental illness (syphilis) In men
• Urethral stricture
• Infertility
• HIV infections: Sit patients are more likely to become with HIV when exposed to the virus and also more likely to transmit if they are infected
• Mental illness (syphilis)
in newborn
• Congenital malformation ~.
• Potentially blinding eye, infections or pneumonia
• Perinatal deaths including still birth
Social and economic consequences
• Physical and psychological discomfort of the individual
• Conflict between couples leading to beating, divorce and commercial sex
• Cost of treatment
• Days of productivity loosed
• Others
Without treatment 55-85% of women with PID may become infertile
PID increases the risk of ectopic pregnancy by 7-10 folds
10-30% of untreated men who had gonorrhoea developed epididymitis and 20- 40% among them become infertile
Nebnatal conjunctivitis if untreated may cause permanent damage of vision 1-6% affected infants.
There is a close linkage between STI and HI WA IDS
• Presence of STI increases the transmission of HIV
• HIV increases spread of other STI by prolonging their duration and thus infertility
Both ulcerative and non-ulcerative STI facilitates HIV transmission. Ulcerative Si! like syphilis increases HIV transmission to a greater degree then non-ulcerative STI like gonorrhoea.
Linkage between STI and HI V/AIDS:
pregnancy and cervical cancer
• Spontaneous abortion
• Intra uterine death of foetus’
• HIV infection: STI patients are mbre likely to become infected with HIV when exposed to the virus and also more likely to transmit HIV if they are infected
• Pre-term delivery
Benefits of early and effective R1’J/STI care:
• Prevents further spread of STI/RTI
• Prevents development of serious complications such as PID, infertility. ectopic pregnancy. still birth and congenital infection or abnormality. + blindness of neonates
• Helps to prevent future transmission of HIV infection
Steps of RTIs/STIs case management:
Comprehensive STI/RTI case managemeht is not limited to reaching a correct diagnosis and providing therapy. It also aims at reducing and preventing further risk- taking behavior and at ensuring that sexual partners are approximately managed and treated.
Steps are
a) History taking
b) Examination
c) Education and counseling
d) Treatment
e) Clinical follow up(lO)
History- taking ad examinations are particularly two very important skills in syndromic diagnosis of RTs/STIs cases. This will enable the service provision to decide on which flow chart to use and treat the patient appropriately.
The following four steps of information are needed
I) General history
2) Medical history
3) History of present illness
4) Sexual history
History Taking format
1) Establish~es report with client (greets the client, ensure privacy, uses languages understandable to customer etc.
Oral coitus
Anal coitus
7) Number of life time sexual partner How many women and how many men?
8) Did you us~ condom
History of past medical and sexual health:
Others (Diabetes, Hypertension, thyroid
problem)
Treatment history of recent problems ~
• Any treatment received? -Physical examination:
• Ensure cleanliness
• Sufficient light
• Explain procedures to client and obtain of consent
• Wash hands, wear gloves
Routine examination of male/female patient:
• General appearance
• Skin and mucus membrane
• Oral cavity ( any ulcer/lesion/patch)
• Lymph nodes
• Hair loss
Routine examination of male:
• Abdominal examination- inguinal lymph node
• Genitalia
Pubic area< Pubic hair! scabies /Iice/any lesion)
• Penis
– Prepuce (ulcer/lesion)
– Urethral meatus ( any discharge if necessary milking the urethra)
– Shaft (UlcerfLesion)
– Scrotum (scrotal swelling- right or~eft both)
– Testis( swelling/tenderness/any abnormality)
– Vas ( any abnormality)
• Rectal examination
– Any discharge or ulcer
– Tone
– Fissure. haemorrhoids or mass lesions.
Routine examination of female:
• Abdominal examination
– Palpate abdomen for any mass, tenderness and muscles guard in lower abdomen
– Inguinal Lymph node
• Inspect external genitalia — warts abnormal discharge/bleeding sores ulcer and pubic hair
• Pervaginal spec’ulum examination
– inspect• the cervix for discharge color, erosion any growth friability of cervix
– inspect the vaginal wall for abnormal v~ginaL discharge warts growth ulcer sores, cystocele or rectocele
• perform bimanual vaginal examination
– locate the cervix and feel for consistency. growth. cervical motion tenderness
– palpate the uterus to detect the position. size, shape. mobility and tenderness
• genitalia
– Pubic area (( Pubic hair/ scabies /lice/any lesion)
• Rectal examination
– Any discharge or ulcer
– Tone
– Fissure, haemorrhoids or mass lesions.
Diagnosis and treatment
For diagnosis and treatment, the study ceferred to the management flowcharts of seven syndromes of the technical sfandard (6). Each of these flowcharts started with a RTI/STI symptom. The management of RTI/STI had to be according to the clients complaints that matched with the symptoms of thc~e flowcharts. In the case of clients with more than one such complaint, the study considered diagnosis following the flow charts separately for each complaint, except in the case of the client with vaginal discharge with lower abdominal pain was considered for diagnosis and treatment. For the symptom of vaginal discharge, the study considered flowchart with speculum examination for the diagnosis and treatment as the study clinic had facilities’~ for speculum.
RTI /STD CounscIin~:
• Inform client about the nature of RTI/STD
• Inform clients regarding risk level
• Sexual behavior
• Personal risk factors
• Protective behavior
• Drug use
• Any other risk factors
Inform clients regar(ting partners risk level:
1. Sexual behavior
2. Personal risk factors
3. Protective behavior
4. drug use
5. Any other risk factors
Inform about prevention and treatment:
6. Importance of complete full treatment
7. Importance of partners treatment
8. provide contact tracing card
9. spread of RTI/STD during the treatment
10. help the patient to change risky behavior
11. Identify barriers to change
12. If she is pregnant. protect the baby
13. Discuss safer sex
negotiation and decision making among partner
14. Plans follow up visit with client if needed Clinical follow-up: follow up visit is necessary1to see the compliance of treatment and if the symptoms persists in that case it is need to be referred in secondary or tertiary level hospital for further proper management
RTI cases need t be referred in the following situation:
• Patient does no despond to the treatment (persistence cases)
• Patient needs confirmation of the diagnosis by laboratory tests
• Patient has confusing or complex syndrome.
The syndromic management endorsed by the WHO is best on identifying the various syndromes and managing the patients by using the respective flowchart algorithm, it has been to be valid, feasible and cost effective in most settings and has been applied successfully in different countries through out the world.
The syndrome is simply a collection of symptoms. The patient’s complains of and the signs observed by the service providers while examining the patient
Approaches of RTI diagnosis:
Various approaches of Rh diagnosis:
• Etiological approach
• Clinical approach
• Syndromic appFoach
Syndromic approach (based on recognizing syndromes): syndromes are collection of symptoms and easily recognizable signs. This gives the opportunity to treat the patient at the primary level. requires little skill and the provided treatment ideals with majority of the organisms responsible to producing each syndrome. For example, tin the syndrornic approach: one should diagnosis as urethral discharge (syndrome) as opposed to Gonorrhea and Chlamydia.
STI Syndromes and identifying the Syndromes:
Although RTI/STI are caused by many different organisms, these organisms give rise to only a limited number of syndromes
Followings are the most common syndrome of RTISTI:
1. Urethral discharge
2. Vaginaldischarge –
3. Genital ulcer
4. Lower abdominal pain
5. Scrotal swelling
6. Inguinal bubo
7. Neonatal conjunctivitis
Advantages of the syndromic approach:
• Reduces probability of incorrect clinical diagnosis by dealing with more likely positive agents
• Presents and alternative when laboratory support is not available
• Standardize treatment at all levels of the health care system
• Allows patients to be treated effectively at the first visit
• Uniformity in collecting data
• Easy availability of drugs (stock)
• Can be used cvc~ at primary healthcare level
• Easy to train the health care providers
• Simple and easy to follow
• Cost effective
Disadvantages of the syndromic approach:
• Possibility of over treatment
• Under exposure to potential side effects of drug due to over treatment
• Cannot be used for asymptomatic patient (except upon risk assessment for females)
• Healthcare provider feels uncomfortable not to be able to use his/her clinical experience.
Use of flowcharts for syndromic management of RTI/STI:
WHO/GPA has developed a set of standard syndromic flowcharts that take into account the most common etiologies for each syndrome. Because the seven RTIs syndrome are easy to identify, it has been possible to device a flowchart for each one. These flowcharts have been adopted to local Bangladesh circumstances and needs. See annexure lis
Each flowchart is broadly made up of a series of three steps. These are:
• The clinical problems (the patients presenting symptom)
The decision that need to be taken.
The action that need to be carried out.
Once trained service provider will find the flow charts easy to use. so that it will be possible for non STI specialists at any health facility to manage STI cases also.
Other benefits of the flow charts are:
• Promptness of treatment, because STI services can be made available at any first-line health facilities. Patients are thus treated at their first visit.
• Wider access to treatment, since treatment is available at more health centers, so a wider population can be covered.
s Opportunities for introducing preventive and promotive measures such as through education, condom distribution.
Counseling: it is one of the important criteria in syndromic management. Steps
1. inform patient about his/her RTI/STI, its implication and treatment.
2. help patient to trace his/her sexual partner.
3. assesspatients risk level.
4. identify any barriers to changing risky behavior.
5. inform patient his/her risk level.
6. help patient to changes in his/her behavior.
Regarding syndromes management we should remember 4Cs
• Compliance with treatment.
• Counseling for prevention.
• Condoms with demonstration of correct use.
• Contact tracing ai\d treatment.
So, by syndromic management the objective of prevention of RTI/STI can be achieved, those arc,
• To reduce the morbidity and mortality due to RTIs/STI.
• To reduce the risk of l-IIV infection.
• To reduce the incidence of RTI/STI and HIV.
Facilities and skills for prevention concerning syndromic management:
Practicing infection prevention steps are essential in management of RTI/STI cases. The infection prevention steps include high-level disinfection (HLD) practice, decontamination. cleaning, and autoclaving. The study considered specific procedures and requirements as essential in relation to infection prevention during syndromic management of RTIs/STIs. The procedures included steps followed during pelvic examination: decontamination, cleaning. and sterilization of used instruments after speculum examination; sterilization of cotton and reusable gloves: and disposal of used gloves and swabs.
Essential steps of infection-prevention during pelvic examinatIon included washing of hands before beginning phys~ical examination; draping of client appropriately for pelvic examination; fixing of lights and washing of hands before putting new disposable or sterile re-usable gloves; adoption of the non touch technique for speculum and bimanual examination; use of sterilized vaginal speculum and cotton gauze for speculum examiqation; and finally, putting the used speculum, gloves, and cotton gauze in a bucket for decontamination after speculum examination.
The decontamination procedure included: placing of all used instruments in chlorine solution for not less then 10 minutes immediately after completion of examination; disposal of waste material in a leak proof container; and wiping
of examination table on other surfaces contaminated during examination by 0.5% chlorine solution.
The necessary cleaning procedure included: placing of decontaminated instruments in a container with clean waiter and mild, non abrasive detergent. Washing of all instruments with brush o~ cloth until visibly clean; and finally, rinsing of all surfaces of instruments with clean water.
Sterilization included: boiling of all instruments at a rolling boil for 20 minutes and autoclaving of cotton, gauze and re-usable gloves1 for 20-30 minutes contaminated solid waste disposable included incineration and dumping. (8)
BANGLADESH PICTURE:
Prevalence of STIs / RTIs:
The actual incidence and prevalence of RTIs/ STIs are difficult to measure because many of the patients suffering from RTIs / STIs conceal their diseases. Female commercial sex workers (CSWs) are considered to be an important source of ST1s and a high-risk population for STIs and HIV. In Bangladesh there are approximately 100000 CSWs whor are distrihuted over urban. semi urban and rural areas. They are either organized in brothels of work as independent sex workers (Choudhury M R, Ct al . 1997). An etiological study of STIs was conducted among female commercial sex workers in 1998 in Dhaka,which showed that 84% were positive for C trachomatis. 45.5% were positive for T. vaginalis, 32.6% were seropositive for~T. Pallidum, 62.5% were seropositive for HSV – 2. and 51% had infections with two or more pathogens (Rahman M et al. 20d0)( I)
2.0 % and 2.9 % respectively. Overall, 35% of the women had antibodies to Hepatitis B core antigen. 0.9% had HSV, and 12% HSV-2 infection. Repeated serological examination indicated that only 32% of women with serological evidence of syphilis had active disease. risk factors for N. gonorrhoeae/C. trachomatis infection were husband not living at home or suspected of being unfaithful. HSV-2 infectin was associated suspected of being unfaithful. HSV2 infection was associated with the same risk factors and with a polygamous marriage (J Bogaerts et al. 2001) A population based survey of RTIs/STIs prevalence whichwas conducted in a rural area also showed low prevalence of STIs, with only 3% of married women having a current infection (including 1% with chlamydial infection or gonorrhoea) and 1% of men having either chalamydia infection or rccentiuritrcatcd syphilis infectin (hawkers S et a! 2002) Under a hospital besed study wht~n the blood samples of 800 pregunant women who came for antenatal check-ui, were analyzed by teh Rapid Plasma Reagin (RPR) method and by ELISA , they indicated a low prevalence of syphilis (3%) and high levels of HBsAg positive (5.5%) and anti-HCV positiv~ (3.4%) resprctively. None of them was HIV positive (Hussain M Ct at. 1997)
Bangladesh. like many other develping countries in the world, is undergoing rapid urbanization accompained by highratcs of internal and external migration. male out-migrants are rates of internal and external migration. Male out-migrants are mostly young, less educated, single, and seek job opportunities aboroad, mainly a Asian countries. A medical screening of 43.213 Bangladesh Job seekers was carried out during the period 1994 to 1996. Serological tests revealed that 4.4% of individuals were positive for hepatitis B surface antigen (HbsAg), 1.7% for Treponema pallidum hemagglutingtion (TPITIA) and only 0.2 % for antibody to human immunó~Jeficiency virus (Anti-l-IIV). These results may represent a cross-section view of the prevalence of different infectious diseases and abuse of drugs among the yong adult population of Bangladesh ( Rumi MAK Ct at 2000)
Truck drivers have been identified as having high-risk life ,styles for STDs. As elsewhere, work conditions in Bangladesh for truck drivers and helpers are conductive to high-risk sexual activity (frequent absence from home and easy access to sex workers located near truck stops). The high prevalence of HSV-2 (25.8%) and to a lesser extent syphilis (5.7%) and the lower levels of condom use (73% never using) despite high numbrs of casual sexual partners (S40/n’~. illustrate the importance of promoting condom use, particularly in commercial sexual encounters, to men in Banglade’s trucking industry (Gibney L et at. 2002) The level of HSV -2 (32%) syphilis (5.7%) and gonorrhoea (6.3%) infections among the women living in close proximity to truck stands was very similar to the rate in a cross sectional population based study conducted between January and December 1998 at the Tejgaon truck stand in Dhaka (Gibney L e al 2001)
As in the developing world, drug addiction is increasing in angladesh. The sexual life of addicts is in a vulnerable state where risky sex behavior is common. A found that seven percent of the addi~ts were found to be bisexual. where 87% of then~ had multiple sex partners of either commercial of residential category. Most of the drug addicts (72%) did not use condoms and 57% of them were observed to have sexual diseases. The drug addicts (38.7%’~. who used mostly injectin (87%) shared needles. Young adults (79%) 3CC~”dary ecucated (46%), were found be highly involved in addiction. Coriosity and feirnd’s incitements (50.2%) were revealed as the most important influencing factors for taking drugs. Frustration, poverty, family breakdown or instability, etc. are also found to influence addiction (Islam Sk N et at. 2000)
The table below shows RTI/STI prevalence information for different
population groups reported by Various studies other than the national
surveillance surveys ___________ _____________
Study Population Percent Number
Brothel based female sex workers 6.8-57 296
Street based female sex workers 84 269
IDU 4-28.6 241
Pregnant Woman 3-5.5 800 ]
Women (non-sex worker) 1.6-32 384
Female patient 2.3-54 1534
Female patients with vaginal dischar__ 2.3-47 345 1
Truck drivers and helpor 0.8-25.8 388
(Roub U et al 2002)
The Government of Bangladesh set up a surveillance system in 1998 to track
sexual and drug taking behaviors that carry the risk of STIsIHIV infection.
The country has been divided into 5 areas for the purpose of this survey. Central, Northeast. Northwest, Southeast and Southwest. The 3rd and the 4th rounds of national HIV and behavioral surveillance showed high prevalence of ulcerative STIs especially in the IDUs which indicate the increased risk of HTV spreading in the country. Among the IDUs which indicate the increased risk of HIV spreading in the country. Among the IDUs the syphilis prevalence rate changed from 18.2% in 2000-2001 tO 19.4% in 2001-2002 at a site in Central Bangladesh. The 4th surveillance also showed that the IDUs also had very high rates of Hepatitis C (ranging from 59.8% to 79.5%) But the reported level of syphilis among the brothel based sex workers decreased form 43.2% in 2000-2001 to 40% in 2001-2002 and at the same time for street based sex worker. syphilis prevalence rate decreased form 42.7% in 2000-2001 to 29.8% in 200 1-2002.
The syphilis rate among male sex workers decreased froml8.2% to 14.2% and among MSM from 5.3% to 3.7% in 20~10-2001 and 2001-2002 accordingly. Hotel based sex workers, many of whom are new to the trade, had the lowest syphilis rates 11.4% among the female sex workers in 4th surveillance. Amor~g the male clients of sex workers (5.0%) also had higher rates of syphilis at a site in Central Bangladesh in 200 1-2002 (MOHFW. 2001 and 2003.)
CSWs in Dhaka 29% of these women were not treating their symptoms and the highest proportion (48%) had bought medicine shops, followed by traditional practitioners at 36% (Wasserheit J N, 1998)
The percent distribution of the ever-married women and currently married men by knowledge of signs and symptoms associated with sexually transmitted infections (STLs) other than HI V/AIDS, according to background characteristics. 89%of women and 81% of men did not know of any STI other than AIDS. Although about 6% of respondents knew about STIs, they were not aware of any symptoms of STIs. 9% of men and 2% of women were able to cite two or more symptoms of STIs.(source:Mitra and associates, and ORC Macro,200 1.)
Initiatives takeii for the prevention and treatment of STJs
In both urban and rural areas there are limitations, particularly in Government facilities, to provide quality and comprehensive services for RTIs/STIs. By 2002, about 5000 health personnel had been trained. This number is however quite small compared to the need. It is estimated that only about 18% of all doctors, 15% of nurses, about half of the lab technicians and almost all the managers received training on syndromic management of RTIs/ STIs (Hai4er S J, 2002). There are also limitations in the availability of necessary logistics (drugs and instruments) of the syndromic approach. Besides. Providers of these facilities are not skilled in risk assessment, physical assessment, physical examination, counseling and partner management. There are also constraints with privacy and confidentiality. Therefore, in the government facilities. particularly at.. the rural level this approach has not been organized till date (MOHFW, 1999) However, following the training the reported number of ST1s cases being managed at different levels of government~ facilities has incresased. although there is absence of a comprehensive Management information System(MIS).
In Bangladesh, the private sector providers are the first point of contact of patients in more than two-third cases. In rural areas, where the government ha~ a well laid out infrastructure~ only aout 18% of service recipients accessed the government sector (Hawkes S et al. 2002). Though a significant proportion of the doctors in private parctice are government employees, the knowledge of the syndromic approach has also remained confined to a handful of trained doctors in the government and NGO sectors, and has not been desseminated to the private sector.
HIV/AIDS
Estimated rates
The first HIV- positive case in BangIadd~h was detected in 1998. According to
Government ‘sources, a total of 248 HI’V positive cases have been reported
mostly among males. So far 26 of these HIV infected patients have developed
AIDS, among whom 20 have died (MOHFW, 2002). Thus, in 2002 a total of
60 new HI V/AIDS cases were detected by confirmatory tests: 37(29 males and
8 females) at the Department of Virology, Bangabandhu Sheikh Mujib Medical University (BSMMU); 7 (6 males and 1 fema1e~ at BIRDEM; 6 (6 males and 1 female) Armed Forces ,Institute of Pathology. (AFIP); and 10 (7 males and 3 females) at ICDDR, B (UNAIDS, 2002) The Department of Virology. BSMMU repotted the detection of 219 HIV – Positive cases on the basis c~f~ confirmatory tests up to December 2002
Potential spread of I-IIV from high-risk groups to general pd~ulation, Central Bangladesh shown below;
In the context of a conservative society such as Bangladesh. the issues surrounding sexuality and STDs are stifled, stigmatized and hence hidden. Economic inequity, inequity and endemic poverty in Bangladesh society also facilitate the transmission of viruses like HIV and make people vulnerable to infection. Adolescents who are the most vulnerable segment of population hav~ access to little or no information and services for sexual and reproductive health issues in Bangladesh. There are some internal and external factors that make Bangladesh more vulnerable to HI V/AIDS.
Internal Factors:
ci Lack of awareness: Only 37% of unmarried adolescent boys and 29% of unmarried adolescent girls know about HI V/AIDS and STD (MOHF’~. 2002)
High-risk behaviors
lack of Knowledge on reproductive health and sex education.
Rapid urbanization: Increasing mobility of people form village to urban slums leading to vulnerability to HIV infection through high-risk behavior.
Reluctance and inability of people to seek health care services.
Lack of empowerment of women: Unaware and unemployed womenare more vulnerable to HIV infection than men.
Existence of promiscuity: Increasing trend of practice of extramarital and premarital sexual relationship in Bangladeshi society.
External factors:
High prevalence of HIV in neighboring countries: Bangladesh is surrounded by countries with high prevalence of HIV and has highly permeable international borders.
High Mobility 01 economically active. people: Around you JOD seekers unaware of l-IIV/AIDs go abroad every year as migrant workers and many of them come back after being infected y HIV (South-south center, Dec( – 2000)
Areas for action:
There is a lack of skilled technical manpower like trained doctors especially in syndromic management of Sits, pathologist and technician to carry out RTIs/STIs/1-UV tests and nurses in the healthcare facilities. An effective policy along with the periodic supervision of the pathology centers by the concerned authority, training of the doctors, technicians and finally external quality assurance programmes. are urgently needed for providing quality services in Bangladesh.
Strong political commitment.
Strategies:
The major strategies adopted by the Government are to prevent HIV transmission, reduce the impact of HIV/AIDS on individuals and the community, prevent STD transmission and provide STD management.
The following strategies need to be considered for implementing specific programmes related to HI V/AIDs:
Advocacy and Epidemiological Surface;
Behavior change support and IEC.
Promotion of condom use
STD management;
Safe and appropriate use of blood transfusion adhering to universal safety regulations.
HI V/AIDS counseling, care and legislation.
Global situation:
Reproductive Tract infections (RTIs) are a significant cause of morbidity and morality in both men and women, especially in women reproductive age.
Infections rates are highest in Africa, reflecting the population’s poor access to health care as well as social and cultural prejudices. Women in Southern Africa have the highest rate of infertility in the world. In Botswana, Lesotho, Namibia, and Zimbabwe about one women in five is unable to have the number of children she desires. The World Health Organization (WHO) estimate show that in 1995, 150 million new case of sexually transmitted disease occurred in
South East Asia and 65 Million in the Sub Sharan Africa. That is why WHO has it major focus in the,South East Asia Sub Shahran Africa.
Bangladesh picture
Save the children (USA) conducted a study on prevalehce of RTIs/STDs in a rural area of Bangladesh. The over all RTIs prevalence was found to be 56% in study population. 13% of the study population on 23.3% of RTIs cases were STDs. Morbidity of the respondent, economic condition, certain occupation of the husband and infertility of the women were found to have significant positive association. The prevalence is found more in literate women with well to do economic background. Currently married women had increased rise of RT1s /STDs prevalence. This study draw a conclusion that magnitude of RTIs is unacceptably high in the study population.
Awareness regarding RTIs is low. About half of the RTIs cases did not think about the symptoms or ignore it is a disease. In rural study major portion of the RTIs cases could be diagnosed by symptomatic lead question.
An elegant and one of the most quoted studies a population-based study carried Out of (Wasserheit et al 1989) found 22% of the enrolled women in rural Matlab were suffering from reproductive t(act infections. Pelvic Infection was diagnosed by tenderness during pelvic exam or by positive culture for an etiological agent. Cervical and vaginal infections were diagnosed by culture for an etiologic agent.They found the highest unadjusted prevalence rates in women using tubecomy (5 5%) and IUD (3 8%) ~4)
Chowdhury, et a!, 1995 conducted a study in one of the urban Dhaka based clinics of Bangladesh women’s health coalition. The study samples include regular clients of the clinic, newly registered clients but excluded antenatal and lactating woman. The mean age at marriage of the respondents was 15.5 years and age at first childbirth was between 16-18 years. This reveals the study initiation of sexual activity. Majority (78%) of the respondents were housewives. The longest proportion of those employed included garment workers (47%), followed by service holder (24%) followed by service holder (24%) Median value for expenditure was Tk. 3000 About 18% complained of vaginal discharge, 4% complained of lower abdominal pain. Severity one percent of women had more than one symptom. Of those who reported multiple symptoms, 64% complained of vaginal discharge, 4% complained of lower abdominal pain: Severity one percent of women had more then one symptoms. Of those who reported multiple symptoms, 64% of the women had vaginal discharge along with lower abdominal pain notqaccompanied by diarrhoea, 20% complained of vaginal itching along with discharge, and 7% complained of lower abdominal pain along with menstrual problem or during maturation.
Only 5.8% of all women did not complain of any symptoms related to RTI. Over 94% reported one or more symptoms suggestive of reproductive tract infection.
Service data collected in 1994 from the Health and Family Welfare centers (H& FWCs and Satellite Clinics (SCs) ~t Abhaynagar, a upazila of Jessore district of Bangladesh, showed that more than 5% of the women came with white discharge ‘ as their chief complaint. During June-October 1995, 100 Clients who attended the two iI&FWCs and 16 SCs for treatment of RTI were observed and interviewed. Ninety of them were housewives and 69% of them were using contraceptive methods. White discharge was’ the most common symptom reported by 98% of the clients, 31% reported lower abdominal pain and 30% complained of itching in genitalia ulcer (1%) and burning during maturation by 10% of husbands. None of the clients were condom users. Most clients reported that they had not continuously suffered. but had experienced intermittent periods of well-being. The mean duration of suffering was 4.5 years for the clients could bedew to unhygienic delivery practices and improper IUD insertion, which further strengthens the association between these factors.
The various clinics of Marie stops society found the prevalence of RTI/STD to be 23% . The most frequent symptom was vaginal discharge followed servilities and PID. Arpong the three major group of clients i.e sex workers. garments factory worker and general clients, to whom the clinics provided services, the prevalence of vaginal discharge was the highest among the garments worker, the highest cervicitis among the general clients and PID among the sex workers. The five cases of genitaLlesions were all found among sex workers.
On study one quality of service regarding RTI/STDs case management by syndromic approach in selected clinic (UFHPS) in Dhaka city (Chowdhury M et at 2001)found overall case management by the trained by the trained providers was appreciable with few lacking. The mean age of the female respondents was 26.3 years. More than half of the respondents (51%) opinion was that the attitude of the providers was ‘fair’ in 39% of cases, history for high risk assessment was not taken and 17% patients experienced excess pain during physical examination. Time given to patients examination appeared sufficient to 77.5% clients, and quality of services appeared satisfactory to 55% clients. Basic privacy was maintained in almost all cases.
Various countries and organization including Bangladesh have been emphasizing on quality of services adopting different modalities and programs for last few decades in the field of Reproductive tract disease. Sexuality transmitted disease (STD) referred as silent plague in now a global concern. Inperspective of Bangladesh the importance is more due to its high prevalence and it is implicit on spread of HI V.~’6~
Another study was done by (Rahman S et al 2000) at Shibalya, a upozila of Manikganj district, Bangladesh. The clinic introduced the syndromic approach for the management of RTIs and the clinic staff followed “technical standard and service delivery protocol for management o~ RT1~/ Stis” Acceptability of syndromic management included compliance of providers and clients with the syndromic approach for case management included compliance of providers and clients with thesyndromic approach for case management of RTIs/STIs.’6~
According to a recent study of ICDDRB Ciprofloxacin is becoming increasingly resistance to Neisseria gonorrhoea. Result of a study on monitoring of drugs resistant to STI microorganisms among sex workers showed that in 1997, resistance to ciprofloxacin among the isolates was about 9% which was about 37% at the end of 1998 49% at the end of 1999 76% at the end of 2001 the resistance was about 87%.
Recently due to ciprofloxacin resistance, cap Cefixime & Tab. Azitromycin is using instead of Tab. Ciprofloxacin – since 6 month Marie Stopes. OGSB (Obsetertics & Gynecology Society of Bangladesh). Mirpur Adopt3ed this treatment in syndromic management guide line.
Assurance of privacy is an important~ factor that has to be particularly considered in case of RTIs cIients.~6~
In one study (Rahman S et al 2001) showed all the equipment for disinfection were adequate and in good condition. However, autoclave machine and incineration were not available. (6)
Providers Perceplioiz:
The village doctors said that STD patients were female. A large number of these patients suffers form leucorrhea. Although many female patients with different types of complacations come to them but they do not have the opportunity to see the infected area with then own eyes for proper diagonosis. Due to social and strict religious barriers, village doctors have to diagonose only by hearing their problems.(14)
One of the village do~tor mentioned that herbal medicine was more effective for STDs rather than allopathic medicine. The village reproted that patients usually do not come to them at the primary stage of their infection.
Perception is too much the limited study of mistake, distortion, illusion and the like. Wertheimer would have called it the study of psychological blindness.
What are the factors that make it possible for healthy people .ot preceived reality more efficiently, to predict the futuçe more accurately to perceive more easily.( 19)
Regarding provider’s needs-
a) Training
b) Information
c) Infrastructure
d) Supplies
e) Guidance
1’) Back-up
g) Respect
h) Encouragement
i) Feedback
j) Self-expression.
So. Providers perception will be the excellent if above needs fulfill by them.(2o
In country workshop, Training of trainers (TOT) on Syndromic management of RTIs/ STDs (24-27 May 1997(21)
In a review of the literature on syndromic management of RTIs and assess its usefulness among family planning population in developing contries. They focus on several~ factors in our review of the algorithms discussed in the literature.
Validity: It must truly measure tha condition it is designated to identify.
Reliability: Consistently giving the same results when used repeatedly.
Risibility: Simple enough to use in the field.
•Acceptability: To both the provider and to the client.
•Affordability: Administered at a reasonable cost.(23)
In women, the commonest single cause of infertility in tubule obstruction or
pelvic adhesions mostly due to RTIs/STDs.
GATHER approach may also be helpful for RTI/STI counseling. Here the word
GATHER which stands for.
G – Greeting client in a friendly and helpful way.
A – Asking clients about their family planning needs.
T – Telling clients about available family planning methods.
H – Helping clients to decide which they want.
E – Explaning how to use the method chosen.
R – Planning return visits. (24)
On review publication Rahman S et al, 1999 the over all review reveals that RTI/STD are prevalent in Bangladesh Peoples awareness about RTI./STD is not sufficient. All forms of risky sexual behavior exist in the country, but
appropriate and uniform. Behavior Change communication (BCC) materials on RTI.STD are not availa~ile. In the management of RTI/STD at the primary
Health Care (P1-IC) level, the syndromic approach and antènatal screening for syphilis seem to bo feasible. The seeking of treatment to unqualified
parishioners for RTI/STD is quite high. Males prefer pharmacies as a first line provider for STD services. Male responsibilities in the decision-making
processes required for preventing and management of RTI/STD have not received adequate attention. (25)
In the absence of early diagnosis and accurate therapy. RTIs may result in infertility, ectopic pregnancy, chronic pelvic pain, cervical neol \ plasia. fretal wastage, low birth weight, and congenital infection, and may therefore. severely comprise the health and productivity of women. the survival of the children, and the success of family planning programs
Clinicians and public health planners alike must begin to address these treatable syndromes through service arid research initiatives in socially acceptable settings such as family planning, antenatal and MCH clinics.
So. clients satisfaction and providers perception is interlinked in this research.
Global Strategy for STI prevention and control is to B1reak the chain of transmission
Development process:
The Global Strategy for the Prevention and control of Sexually Transmitted Infections 2005-2010 was ‘developed through an inclusive and broad consultative process within WHO and with external partners and Member States. It was led by the STI team within the Department of Reproductive Health and Research (RHR) of the WHO Family and Community Health FCH) Cluster at WHO headquarters in Geneva. This document incorporates elements from WHO regional STI strategies and consultations including those due to Human Immunodeficiency Virus. It is complementary to the WHO HIV/AIDs Strategy for the Health Sector and to the WHO Reproductive Health Strategy.
Ata Glance
New vaccines against human papilloma virus infection could stop the untimely death of approximately 240000 women from cervical cancer every year in resource-poor settings.
In pregnancy, untreated early syphilis will i~esult in a stillbirth rate of 25% and be responsible for 14% of neonatal deaths-an overall perinatal morality of about 40%. Syphilis prevalence in pregnant women in Africa, for example, ranges from 4% to 15%.Worldwide, up to 4000 newborn babies become blind eveiL~y year because of eye infections attributable to untreated maternal gonococcal and chlamydial infectins.
Treatment of bacterial STIs, especially those causing urethritis, in HIVpositive men reduces the seminal 1-IIV viral load and, thus. HIV transmission.
More than 340 million new cases of sexually transmitted bacterial and protozoal infections occur throught out the world every year.
STIs are the main preventable cause of infertility. Between 10% and 40% of women with untreated’ chalamydial int~ction develop symptomatic pelvic inflammatory djsease (PID) . Post-Infection tubal damage is responsible for 30-40% of cases of female infertility. Furthermore, women who have had pelvic inflammatory disease are 6-10 times more likely to develop an ectopic (tubal) pregnancy than those who have not, and 40-50% of ecthpic pregnancies can be attributed to previous p~elvic inflammatory disease. (19)
Human papilloma virus infection results in approximately 500 000 cases of ~ cervical cancer, causing about 240 000 deaths annually.., mostly in resource-poor settings.
The fifth MDG seeks to reduce maternal morality by three quarters by 2015. Prevention of pelvic inflammatory disease will contribute to this goal by preventing the death toll related to ectopic pregnancy. Prevention of human papilloma virus infection will reduce the number of women dying form cervical cancer.
To prevent adverse pregancy outcome:
Untreated STIs are associated with congenital and perinatal. infections in newborn, particularly in the areas where Is have not been controlled.
In pregnant women with untreated early syphilis, 25% of pregancies result in stillbirth and 14% in neonatal death – an overall perinatal morality of about 40% . Syphilis prevalence in pregnant women in Afreca, for example, ranges from 4% to 15% . Up to 35% of pregnancies among women with untreated gonococcal infection result in spontancouns abortions and premature deliveries, and up to 10% in perinatal deaths . In the absence of prophylaxis, 30-50% of infants born to mothers with untreated gonorrhoe~ and up to 30% of infants born to mothers with untreated chlamydial infection will develop ophthalmia neonatorum, which ca~i lead to blindness World wide. .1000-4000 new born babies become bli!3d every year because of this condition. (24)
Universal institution of an effective intervention to prevent congenital syphilis will prevent an estimate 492 000 stillbirths and perinatal deaths per year in Africa alone . In terms of cost-effectiveness, in Mwanza, the United Republic of Tanzania, with a prevalence of active syphilis of 8% in pregnant women.
A cost – effective intervention for HIV prevention:
Improved case management of STIs is one of the interventions that has been scientifically proven to reduce the incidence of HIV infection in the general population . If the services are targeted to a particular population group with a high likelihood of transmissidn, the cost-effectiveness becomes even more pronounced.
A public health approach to STI prevention and control (innovative approach)
Effective prevention and care of STIs can be achieved using a combination of responses. STI service delivery should be expanded to ~mbrace the public health package that includes the following.
Promotion of safer sexual behavior.
Promotion of early health-care seeking behavior.
Integration of STI prevention and care in such a manner that STI prevention and care services are implemented horizontally across all primary health-care services, including reproductive health (RH) and HIV programmes. Successful and cost-effective integrated programmes for STI, HIV and tuberculosis control have been documented in a number of countries. The care is usually given by the same health-care providers at the primary health centre level. Such an approach is both attractive and cdst-saving for client and health system alike.
oA comprehensive approach to STI case management encompassing:
identification of the STI syndrome; appropriate antimicrobial treatment for the syndrome; education and counseling on STIs, including HIV:
condom promotion, and partner notificatid’h.
In addition, syndromic management of women presenting with vaginal discharge has proven problematic as a tool for the detection and managemciit of cervical infecins, particularly in areas of low STI prevalence. This has necessitated the requirement for affordable, rapid STI diagonistic tests. Such tests have been slow in development and, where available, they are still too
•expensive for governments to incorporatc~ into STI care.
AIMS AND SCOPE OF THE STRATEGY
PURPOSE AND OBJECTIVES:
The purpose of the Global Strategy is to provide a frai~ework to guide the planning and implementation of a accelerated global response for the prevention and control of STIs (within the frame work of the WHO Reproductive health strategy) in order to accelerate progress towards the attainment of international development goals and to complement the WI- U Global Health-Sector Strategy for I-IIV/AIDS 2003-2007. In particular. the strategy will focus on achievement of the following objectives.
To increase the commitment of national governments and national and international development partners for STI prevention and control.
To promote mobilization and reallocation of resources and ensure that resources are focused on priority programmatic areas where they ~re likely to have the greatest impact.
To ensure that policies, laws and initiatives that are supportive of nonstigmatizing and culture-sensitive and gender-sensitive STI Programmes will in place in all countries by 2015.
To harness th,~ strengths and capacities of all partners and institutions in order to scale up and sustain interventions for STI prevention and control.
The global response to STIs will be guided by two operational components. Operational component 1.
A global STI technical strategy that can be adapted at the country and regk~na1 levels. The technical strategy will explore innovative ways to package ~nd deliver them. It will address key challenges such as:
the unavilablity or unsuitability of services for priority target populations (for example, adolescents and sex workers);
the diagonosis and treatmen~ of sub-clinical and asymptomatic infections;
the shortcomings of the syndromic approach in women;
the management of sexual partners:
the improvement of health-care provider attitudes:
the need for better data for planning purposes.
Operational component 2.
A global STI advocacy campaign to raise awareness kind mobilize resources worldwide alongside other initiatives such as the elimination of congenital syphilis, control and eradication of curable genital ulcer diseases and control of genital herpes and genital human papilloma virus infections.
RESEARCH OBJECTIVES
General Objectives:
• To assess the management of RTI/STI patients in selected Urban Primary Health Care centers in Dhaka city.
Specific objectives:
1. To find out the steps of RTI/STI diagnosis in the urban primary health care centers under
Study.
2. To assess the state of practice of syndromic management protocol for
RTI/STI patient
3. To determine the protective measures taken by the service providers
during and after
Patients examination
4. To see the reporting system by record review.
Research question:
Are the RTI/STI patients being managed according to standard protocol in some selected Urban Primary Health Care centers i~ Dhaka city
STUDY AREA
Study area includes Six urban primary health centers which are now called city health care centers which project is now earned out by Marie Stopes Clinics Societ~ in collaboration with Dhaka city corporation and aided by Al)13 (Asian development bank). It was started on 7th may. 2001. MSCS( Marie Stopes Clinic Society) is a non government organization. This urban primary health care centers are situated in Moharnmadpur area including some arc in Rayer Bazar area. Among the six one center is merged with their city maternity center which is situated in Bashbari at Mohammadpur area. Others arc situated in Salimuaalh Road. NurjahaN Road and Humayon Raod. The centers are about 5-8 Km from NIPSOM. Researcher used bus upto ~1oharnmadpu~ DUS stand and then rickshaw to the centers. Both way fair is (20±20) Tk 40. Atmosphere of the centers were good. Cooperation of the clients and providers were overall good. Researcher visited the centers in the morning and in the evening in the office hour which is from 9.00 am to 4.00 pm . Their disposal system is excellent centers were well equipped with manpower. instruments and medicines.
The reason for selecting the place was
A good member of study subjects would he available at a time.
Cooperation by the authority
good road access which was convenient for the researcher to reach and “ork form the place of residing
cost effective .
Update record keeping system.
VARIABLES
Domain.A:
Steps of the diagnosis of RTIs/STIs
Establishes Rapport with clients/Registration
– Greeting (waiting time)
– Privacy
– Understandable language
2. History taking
– General information
– Medical history
– Sexual history
3. Examination General Local
4. Education and Counseling
5. Treatment
6. Clinical Folloup
I. Domain’s:
Syndromic management of STIs/RTIs:
1. Syndromic approach
2. Types of RTIs’
3. Symptoms of RTIs
4. Flow chah or algorithm of syndromic management
5. Counseling for RTI/STI patient
6. Availability of recommended drugs
7. Complications of medicine
8. Advantage of syndroniic management of RTIs/STIs
9. Disadvantage of syndromic management of RTIs/STIs
10. Consequences of RT1s1STIs
1 1. Privacy in history taking and during physical examination
12. Clinical follow-up
13. Referral
1)0 ma in .C:
Protective, measures taken by the providers
I. 1-land washing. Gloves wearing
2. Instrument tray with cover
3. Waste disposal bucket(blue color)
4. Sterilization t~cilities(hoiling /srerilizcr. autoclave machine)
5. Red color bucket with 0.5% chlorine solution( decontamination)
6. Green color bucket with clear water for cleaning
7. incinerator
Domain.D:
Record keeping system
1. RT1/S1’l register khata
2. Partner management card
3. ESP card
4. Computer
OPERATIONAL I)EFINITION:
• RTI It is the infection which can be defined a infection which infect the reproductive tract trough improper infection prevention technique during medical procedures or by over growth of organis is normally present in the reproductive tract or trough intimate sexual contact.
• STI : These are the infections that coi~niunicates only by sexual contact and causes infection of the reproductive tract only (That is upper and lower reproductive tract)
• Steps of RTI/STI diagnosis: It refers to registration. history taking genera’ information, physical examination both general and lo~al with speculum examination, sexual history. education and counseling about prevention and treatment of both the client and partner and then clinical follow-up.
•Syndrornic approach: Syndromes are collection of symptom and easily recognizable signs. This gives the opportunity to treat the patient at the primary level, requires little skill and the provided treatment deals with majority of the organism responsible for producing each syndrom. For example. in the syndromic approach. one would diagnose and treat urethral discharge (syndrom) as opposed to gonorrhoea and clarnydia.
• Flow chart: WHO Gfobal prevention of’ AID(GPA) has developed a set of standard syndromic flow charts that take into account of the most comme
• etiologies for each syndrom. The flow charts called “algorithm” are in fact a decision and action tree. Each flowchart begi~s wiTh a patients complain and guides users through a series of decision and action ending with an instruction on how tb manage the patient. There are seven flow charts for syndromic management of RTI/STI. Flow chart should be included in the annexure part. Recently due to resistance of’ ciprofloxacin. cap cefixirne to cap stat and tab azithromicin to tab stat is prescribing.
•Counseling: It is a face to face personal communication in which one person helps another to make decision and then acts on them.
• In context of RTI/STD it is imperative that the client feels that she/he is actively involved in the decision making necessary to affect a change in sexual behavior and in compliance of own and partners treatment.
• Counseling for patients of RTIs/STIs is very important in syndromic
management.
• l:our(4) Cs,
• Compliance with treatment
• Counseling for prevention
• Condoms with demonstration of correct use
• Contact tracing and treatment.
• Privacy: In this study privacy meant to manage a RTI/STI client in a room having relative auditory and visual seclusion with physical examination facilities and an attached toilet.
• Physical examinati?n: Examination of whole body including private parts
for arriving at a.diagnosis of the infections.
• Compliance with treatment: It is the taking of medicine completely without which recovery is not possible
• Clinical follow-up: It is the follow-up visit which is necessary to see the compliance with treatment and if persist then it need to be refer in secondary or tertiary level hospitals.
• Referral: Syndromic approach to RTI/STI case management alone can not take the responsibility of RTI/STI control of a country. they may need to be referred in the following situations:
• Patient does not respond to the treatmertt(persistence cases)
• Patient needs confirmation of the diagnosis by laboratory test
• Patient has confusing or complex syndrom.
• Infection prevention: Practicing infection prevention steps are essential in management of RTI cases. The infection prevention steps includes high level disinfection(HLD) practice. decontamination, cleaning and autoclaving.
• Decontamination: Here decontamination meant keeping the instruments in to 0.5% chlorine solution for destroying the microorganisms alter examination (vaginal speculum, sponge holding forceps etc.).
•Partner management or contact tracing and treatment: It means tracing
of all the sexual partners of patients treated for RTI/STI. It is one of the key steps in RTI/STI mauagemcnt and is essential when once a patient has been diagnosed to have RTI/STI. The patient should be made aware of how important it is to have his/her partners to be treated, because the patient will be at risk of re-infection until his/her partners are not treated,
• Record keeping: All centers have registrar book for RTI/STI managed cases in which it includes the name, age, address, complains, management. partner management, follow-up, counseling of clients and partner for
HI V/AIDS.
• Cleaning material: It includes clear w;~ter. soap. 5%chlorine solution in a red colored bucket.
• Instruments for per vaginal examination: Vaginal spcculumspot light. sponge holding forceps. gloves, kidney tray. lifter, cotton balls etc.
• Instruments for general examination: BI~ mechinc. stethoscope.
thermometer, weing mechine, tongue deppresor.
Limitation
1 had faced some limitation during this study :
1. Time was very short. so study included 133 respondents only as a result this study
may not have similar results as obtained form large-scale study.
2.The service providers were too busy give their interview.
3. Some clients did not want to give
METHODOLOGY
STUDY DESIGN:
This is a cross sectional descriptive study was carried out with the major objective to find out the steps of RTIs/ST\s diagnosis, protective measures taken by service providers. And the practice of syndromic management protocol and record keeping system by record review in urban primary health care centers in Dhaka city.
TIME OF STUDY:
From march to june2006.
STUDY POPULATION:
The source of population are the outdoor patients of some urban primary health care centre in Mohammadpur area in Dhaka city no age or sex restriction in this study providers who are giving syndromic management are selected for study populationfin this study here also no sex restriction.
The selection criteria for the patients on attendant:
– patients suffering from RTIs /STIs and managed by syndromic management
– patients who are willing and give herbal consent to be interviewed only are included in this study.
selection criteria of service providers:
working in the ~rnentioned urban primary healthcare centers (medical officers, nurses, paramedics, health workers and managers)
willing to participate and give herbal consent to take part in the study are included.
SAMPLE SIZE:
The study is a qualitative as well as quantitative one and about the sample size there is no rigidity. As study population is selected purposively so the formula is not necessary to calculate for this study.
DATA COLLECTION INTRUMENTS:
Checklist was completed, as per instruction by observation of the centers and interview questionnaire has been prepared for both the clients and providers. All providers efficiency are leveled on self rating score in five levels
5 = Excellent
4 = Good
3 Average
2 = Fai’~
1 = Poor.
Answers should be selected in another sheet and marks would be given as per researcher requirement. Provider’s efficiency to assess the management practice practiced in urban care primary health care centers
Providers efficiency Information questions and answers:
| Sl No | Questions | Excellent | Good | Average | Fair | Poor |
| 5 | 4 | 3 | 3 | 1 | ||
| 8 | What do you mean by syndromic approach? | Based on recognizing syndromes Syndromes are collection of and easily recognizabel sign. This gives the opportunity to treat the patients at the primary level requires little skill and provided treatment deals with majority of the organisms. | Based on recognizing syndromes. | Collections of signs |
Idea not clearNo Comments
9What are the types of Reproductive Tract Infections?Three types, 1, Non sexually transmitted RTIs, 2. Sexually transmitted RTIs. 3 Sexually transmitted disease not infecting the reproductive tract organsTow types,
1. Non sexually
2. Sensually.Trichomoniasis,
Candidiasis
Syphylis
Gonorrhoea
Syphylis
Gonorrhea
No Comments10What do you mean by flow chartFor 7 syndromes, 7 flow charts are there Recetly due resistant of Ciproflaxacin, Cefixime & Azithromycin isMentioned 6 syndromes,Can mentioned only 5 treatment only 5 syndromesOnly mentioned 2 syndromesNo Comments11What do you counsel your patientsI. Compliance with treatment-2, Counseling for preventoin 3. Condoms with demonstratoin of correct use 4. Contact tracing & treatment.Can motioned only 3 from left colummCan mentioned only 2f rom left columnCan mentioned only 1 from left columnNo Comments
| 12 | What do you mean by privacy in this case management |
| If answer only 3 from left column | If answer only 2 from left Column |
If answer only 1 from left Column
No Comments
13What are common complication of medicines prescribing in RTI/STI.For 1. Metronidazole Nausia, Vomiting
2. Drug residtance if irregular in treatment
3. In case of pregnancy aboid tetracyclineIf answer only 2 from left Column
If answer only 1 from left Column
Idea not clear
No Comments14What are advantages of Syndromic Management in Reproductive Tract Infections1. Reduces probability of incorrect
clinical diagnosis by dealing with most
likely sensitive agent.
2. Presents and alternative when
laboratory support is not available.
3. Standardize treatment at all revels of
the health care system.
4. Allows patients to be treated electively
at their first visit.
5. Uniformity in collecting data
6. Easy availability of drugs
7. Can be used even at primary health care
level
8. Easy to train the health care provicers
simple & easy to follow
~. Cost effective.
If mentioned 7If mentioned 5If mentioned 1 to 4No Comments
| 15 | What are the disadbangtages of sydromic Management in Reproductive Tract Infections |
| If mentioned 3 | If mentioned 2 | If mentioned 1 | No Comments |
16How do you dispose used gauze, cotton
- Dispose in a bucket (Blue Color)
- Wash the bucket daily
- Incineration
If mentioned 2If mentioned 1Idea not clear
No Comments17How do you sterilize gloves
- After each examination keep in the chlorine solutoin (0.5%) for ten minutes which kills HIB/Hepatities BCD virus,
- wash properly
- Autoclave
- Can use disposable gloves
If mentioned 3If mentioned 2If mentioned 1No Comments18What do you mean by infection prevention steps
- HDL (High Level Disinfection)
- After each exam keep in the chlorine solution (0.5) for ten minutes which kills HIV/Hepatities BCD virus
- Cleaning
- Auto clave
If mentioned 2 but can mentioning percentagte of cholrine solutioin & timeIf mentioned 1Idea not clear
No Comments
| 19 | What are consequences of RTIs/STIs |
| If mentioned 6 | If mentioned 5 | If mentioned 1 to 4 | No Comments |
20How do you maintain records of RTIs/STIs Patients
- E.S.P Cards
- Registrar Khata
- Partner management card
- Computer
If mentioned 3If mentioned 2If mentioned 1
No Comments
SAMPLING TECHNIQUES:
No sampling technique arc uscd. Samples should be selected purposively.
DATA COLLECTION PROCEDURE:
Before the study should be carried out in the selected place. questionnaire is developed according to the oblectives. variables of the study.
The questionnaire was pre tested among some clients and providers in urban primary health care centers in Mohamm~idpur~ in Dhaka city to see its validity and reliability of questionnaire. Finalization oF the questionnaire and checking was done for necessary modi Iteation and correction.
Permission approach by the researcher from respected guide and NIPSOM authority and accordingly permission of the Managing Director was obtained. There after the clients and providers were approached and tht~ purpose of the study was explained to each potential clients and providers and their verbal consent t to participate in the study was obtained. Each consenting client and provider was individually interviewed face to face by using the interview questionnaire and by observation checklist was completed as per instruction. All possible measures were taken. kr maintaining privacy.
DATA PROCESSiNG AND ANALISIS:
Data entry. checking and analysis- collected data should be entered into a IBM-compatible PC using a d~ta base software. Generated data should be then subjected to in-depth statistical analysis using (statistical package for social science) SPSS. After generating a frequency distribution table at the fist instance, crossed tabulation (Cl-Il-square. fisher’s, exact test where needed) should be generated as an whenever needed.
More over a self retainii~g score has been done on the basis of total correct answer to see the efficiency of the providers in management practice in~ RTI/STI cases. the score that are used are. excellent = 5. good=4. average =3.
Fair2. Poor =1.
CHAPTER-S
RESULT
The study was conducted among 83 client and 26 service providers of one Urban primary health care project. The project area is six. Which runs by the NGO. MARIE STOPES CLINIC SOCIETY in collaboration, with Dhaka city corporation. funded by Asian development Bank at Mohammadpur in Dhaka
•city. It has six primary health care centers flOW named as city health care center. The objectives were to find out the st~s o~ RTI/STI diagnosis. determine protective measures taken by service providers during patient examination, and assess” the state of practice of syndromic management of RTI/STI patients an,d record keeping system. In summery table I shows the percentage regarding the steps of management which includes history of present-illness, past-illness. physical examination, counseling and clinical follow-up.
The findings of data analyses and their interpretation are presented hereinafter.
Summary Table
Table I. Distribution of the Clients by steps of management (N =
Steps of diagnosis No %
History of present illness 79 95.2
History of past illness 82 98.8
Physical examination 83 100.0
Counseling 76 91.6
Clinical follow up 78 – – 94.0
Total will not correspond to 100% because of multiple response.
Table I demonstrate that in majority of the cases steps of diagnosis were followed. History of present and past illness was taken in 95.2°i~ and 98.8% cases respectively. Counseling and clinical follow up was done in 91.6°/o and 94% cases respectively.
Table II. Distribution of the Clients by present complaints (N = 83*)
Cardinal complaints No %
Vaginal discharge 69 83.1
.Urethral discharge 03 3.6
Genital ulcer 13 15.7
InguinalBubo 01 1.2
Lower abdominal pain 16 19.3
Scrotal swelling 03 3.6
Neonatal conjunctivitis 02 2.4
Others 04 — 4.8
91.7
Total will not correspond to 100% because of multiple response.
Table II shows the distribution of Clients by present complaints. Majority (83.1°/o) of the complained of vaginal discharge. followed by lower abdominal pain 19.3% and Genital ulcer 15.7%. Very few Clients complained of urethral discharge (3.6%). inguinal Bubo (1 .2°/o). scrotal swelling.
Table HI. Distribution of the service provider by sex (N = 26)
Sex No %
Mate 02
Female 24 92.3
100.0
Table 111 shows that majority (92.3%) of the service providers was female and only 2(7.7%) were males.
Table IV. Distribution of the Service provider by management efficiency (N = 83*)
Management efficiency
Discrete activities ______________________________________
Excellent Good Average Fair Poor
(4) (3) (2) (1)
Sydromic approach 6(23.1) 7(26.9) 9(34.6) 1(3.8) 3(1 L..5)
Types of RTIs/STIs 7(26.9) 11(42.3) 4(15.4) 3(11.5) 1(3.8)
Flow-chart of SM 8(30.8) 6(23.1) 3(11.5) 7(26.9) 2(7.7)
Counseling 2(76.9) 5(19.2) 00 00 1(3.8)
Privacy 22(84.6) 3(11.5) 00 1(3.8) 00
Complication of 1(3.8) 8(30.8) 2(7.7) 11(42.3) 4(15.4)
medicine
Merits of SM 1(3.8) l(46.2) 2(7.7) 10(38.5) 1(3.8)
Demerits of SM 00 10(38.5) 32(7.7) 12(46.2) 2(7.7)
Disposal of clinic waste 26(100.0) 00 00 00 00
Sterilization procedure 26(100.0) 00 00 00 00
Consequence of RTIs 00 7(26.9) 2(7.7) 12(46.2) 5(19.2)
Record keeping system 1(3.8) 10(38.5) 2(7.7) 6(23.1) 6(23.1)
Table IV demonstrates the distribution of service-providers by management efficiency. Majority of the Service provider attained either ‘excellent’ or ‘good’ score on all the discrete activities.
Table V. Distribution of the Service provider by management efficiency based on combined score(N = 83*)
Management No . %
Efficiency
Excellent(60—49) IG, 38.5
Good (48 — 37) 08 30.8
Average (36 — 25) 08 30.8
Fair(24— 13) 00 00
Poor(12) ____ 00 00
99.10
Table V demonstrates the management efficiency of the service providers based on combined score of 60 for 12 discrete activities. The total scores attained by the respondents were categorized into five categories with 60-49 being the excellent and 12 being the Poor with Good. Average & and Fair in between them. Based on the score attained by the respondents 38.5% were categorized into Excellent.. 30. 8% Good and the rest 30.8% Average.
Table VI. Association between age and management efficiency of service provider (N = 83*)
Management efficiency
Age (yrs) p-value
Excellent Good Average
(n=10) (n=8) (n=8)
30 3(3ØØ)* 3(37.5) 3(37.5)
30 — 40 5*50.0) 5(62.5) 4(50.0) 0.77 1
_40 2(20.0) 00 1(12.5)
*Figures in the parentheses denote corresponding %.
# Data were analyzed using Chi-square (x2) Test: level of significance was
0.05.
Table VI demonstrates the association between age and management efficiency. Half of the excellent efficiency was found among age group 30—40 years. 62.5% of the Good efficiency was also found in the same age group. However, no age group was found to be significantly associated with management efficiency (p = 0.771).
Table VII. Association between sex and management efficiency of Service providers (N = 83*)
Management efficiency
Sex pvalue#
Excellent Good Average
(n = 10) (n= 8) (n = 8)
Male 00 1(12.5) 1(12.5)
0.508
Female 10(100.0) 7(87.5) 7(87.5)
*Figures in the parentheses denote corresponding %.
Data were analyzed using Chi-square (x2) Test: level of significance was 0.05. Table VII shows the association between sex and management efficiency. Neither male nor female sex was found associated with management efficiency. As only 2 service-provider were of male sex association between
Summary Table
Table I. Distribution of the Clients by steps of management (N =
Steps of diagnosis No %
History of present illness 79 95.2
~.History of past illness 82 98.8
Physical examination 83 100.0
Counseling 76 91.6
Clinical follow up 78 – – 94.0
* Total will not correspond to 100% because of multiple response.
Table I demonstrate that in majority of the cases steps of diagnosis were followed. History of present and past illness was taken in 95.2°i~ and 98.8% cases respectively. Counseling and clinical follow up was done in 91.6°/o and 94% cases respectively.
Table II. Distribution of the Clients by present complaints (N = 83*)
Cardinal complaints No %
Vaginal discharge 69 83.1
.Urethral discharge 03 3.6
Genital ulcer 13 15.7
InguinalBubo 01 1.2
Lower abdominal pain 16 19.3
Scrotal swelling 03 3.6
Neonatal conjunctivitis 02 2.4
Others 04 — 4.8
91.7
* Total will not correspond to 100% because of multiple response.
Table II shows the distribution of Clients by present complaints. Majority (83.1°/o) of the complained of vaginal discharge. followed by lower abdominal pain 19.3% and Genital ulcer 15.7%. Very few Clients complained of urethral discharge (3.6%). inguinal Bubo (1 .2°/o). scrotal swelling.
Table HI. Distribution of the service provider by sex (N = 26)
Sex No %
Mate 02
Female 24 92.3
100.00
Table 111 shows that majority (92.3%) of the service providers was female and only 2(7.7%) were males.
Table IV. Distribution of the Service provider by management efficiency (N = 83*)
Management efficiency
Discrete activities ______________________________________
Excelle Good Average Fair Poor
nt (4) (3) (2) (1)
Sydromic approach 6(23.1) 7(26.9) 9(34.6) 1(3.8) 3(1 L..5)
Types of RTIs/STIs 7(26.9) 11(42.3) 4(15.4) 3(11.5) 1(3.8)
Flow-chart of SM 8(30.8) 6(23.1) 3(11.5) 7(26.9) 2(7.7)
Counseling 2(76.9) 5(19.2) 00 00 1(3.8)
Privacy 22(84.6) 3(11.5) 00 1(3.8) 00
Complication of 1(3.8) 8(30.8) 2(7.7) 11(42.3) 4(15.4)
medicine
Merits of SM 1(3.8) l(46.2) 2(7.7) 10(38.5) 1(3.8)
Demerits of SM 00 10(38.5) 32(7.7) 12(46.2) 2(7.7)
Disposal of clinic waste 26(100.0) 00 00 00 00
Sterilization procedure 26(100.0) 00 00 00 00
Consequence of RTIs 00 7(26.9) 2(7.7) 12(46.2) 5(19.2)
Record keeping system 1(3.8) 10(38.5) 2(7.7) 6(23.1) 6(23.1)
Table IV demonstrates the distribution of service-providers by management efficiency. Majority of the Service provider attained either ‘excellent’ or ‘good’ score on all the discrete activities.
Table V. Distribution of the Service provider by management efficiency based on combined score(N = 83*)
Management No . %
Efficiency
Excellent(60—49) IG, 38.5
Good (48 — 37) 08 30.8
Average (36 — 25) 08 30.8
Fair(24— 13) 00 00
Poor(12) ____ 00 00
99.10
Table V demonstrates the management efficiency of the service providers based on combined score of 60 for 12 discrete activities. The total scores attained by the respondents were categorized into five categories with 60-49 being the excellent and 12 being the Poor with Good. Average & and Fair in between them. Based on the score attained by the respondents 38.5% were categorized into Excellent.. 30. 8% Good and the rest 30.8% Average.
Table VI. Association between age and management efficiency of service provider (N = 83*)
Management efficiency
Age (yrs) p-value
Excellent Good Average
(n=10) (n=8) (n=8)
30 3(3ØØ)* 3(37.5) 3(37.5)
30 — 40 5*50.0) 5(62.5) 4(50.0) 0.77 1
_40 2(20.0) 00 1(12.5)
*Figures in the parentheses denote corresponding %.
# Data were analyzed using Chi-square (x2) Test: level of significance was
0.05.
Table VI demonstrates the association between age and management efficiency. Half of the excellent efficiency was found among age group 30—40 years. 62.5% of the Good efficiency was also found in the same age group. However, no age group was found to be significantly associated with management efficiency (p = 0.771).
Table VII. Association between sex and management efficiency of Service providers (N = 83*)
Management efficiency
Sex pvalue#
Excellent Good Average
(n = 10) (n= 8) (n = 8)
Male 00 1(12.5) 1(12.5)
0.508
Female 10(100.0) 7(87.5) 7(87.5)
*Figures in the parentheses denote corresponding %.
,4 Data were analyzed using Chi-square (x2) Test: level of significance was 0.05. Table VII shows the association between sex and management efficiency. Neither male nor female sex was found associated with management efficiency. As only 2 service-provider were of male sex association between
Table VIII. Association between length of job and management efficiency of Service providers (N = 83*)
Management efficiency
Length of job p_value#
(yrs) E~ccllent Good Average
_____ _____ (n10) (n=8) (n=8)
<5 6(60.0)* 4(50.0) ~5(62.5)
0.864
_ 5 4(40.0) 4(50.0) 3(37.5)
*Figures in the parentheses denote corresponding %.
# Data were analyzed using Chi-square (x2) Test: level of significance was
0.05.
Table VIII presents the association between length of job and management efficiency. Sixty percent of the excellent efficiency was found among the service providers with length of service below 5 year3. The length of service was not revealed to be associated with management efficiency of the service providers
(p = 0.864).
Table IX. Association between official status of service providers and management efficiency (N = 83*)
Management efficiency
Status of service p-valued
providers Excellent Good Average
____ (n10) (nf8) (n=8)
Medical officer 6(60.0) 3(37.5) 00
0.029
Others 4(40.0) 5(62.5) 8(lOb.0)
*Figures in the parentheses denote corresponding %.
# Data were analysed using Chi-square (X2) Test: level of significance was
0.05.
Table IX demonstrates the association between official status of the service providers and management efficiency. Sixty percent of the excellent service was provided by the medical officers compared to 40% by nurses and paramedics. The status of the service providers tends to be significantly associated with management efficiency (p 0.029).
Table X. Distribution of the Service Providers by protective measure
(N = 83*)
Efficiency
Protective measure ______ ____________
Excellent Good Average Fair Poor
_____ ______ (5) (4) (3) (2) (1)
Disposal of clinic waste 26(100.0) 00 00 00 00
Infection prevention 26(100.0) 00 00 00 00
steps ______________ _________ ________________________
Table X describes the protective measure adopted in the clinic. Disposal of clinic waste and infection prevention steps was 100% achieved.
Table XL Distribution of the Service providers by record keeping system of the RTI/ST1 Patients (N = 26*)
Efficiency
Record keeping system
Excellent Good Average Fair Poor
(5) (4) (3) (2) (1)
1(3.8) 10(38.5) 2(7.7) . 6(23.1) 7(26.9)
Table Xl shows that 3 8.5% of the record keeping system was good. followed by 23.1% fair, another 26.9% poor. 7.75 average and only 1(3.8%) excellent.
Table XII. Distribution of the Clients by other services provided (N =
83*)
Other services provided No %
• Partner management 37 44.6
Medicine supplied 79 95.2
– Referred for better Management 05 6.0
* Total will not correspond to 100% because of multiple response.
Table Xli demonstrates approximately 45% of the Clients told that their partners were managed . 95.2% informed that they received medicine from the clinic and 94% told that need of follow up visit was consulted as well.
Table Xlii.. Distribution of the Clients by age (N = 83)
Age (yrs)* No
<20 06 7.2
20—30 35 42.2
_ 30 42 50.6
* Mean age = (27.42 ± 7.32); Range = (11 —45) years.
Table XIII shows that half (50.6%) of the Clients were 30 years of age or more. followed by 20 — 30 years 42.2% and below 20 years only 7.2%. The mean age of the respondents was 27.42 ± 7.32 years and the lowest and highest ages were 11 and 45 years respectively.
Table XIV. Distribution of the Clients by occupation (N = 83)
Occupation No
Service 25 30.1
Business 01 1.2
I-louse-wife 36 43.4
Labour 06 7.2
Others 15 18.1
Table XIV describes that 43.4% of the Clients were house-wives. 30.1% service-holders. 7.2% labour and 18.1% were occupied with other jobs.
Some are parts:
Management Practice of Rti Sti Patients in Urban Primary Health Care Centers (Part 1)
Management Practice of Rti Sti Patients in Urban Primary Health Care Centers (Part 2)
