Socio-Demographic, Clinical, and Hygiene Profile of Syndromically Managed Sexually Transmitted Diseases: A Cross Sectional Study in a Tertiary Care Center in India

Background: Sexually transmitted diseases are one of the several major public health concerns, the burden of which is borne by low- and middle-income countries like India. Purpose: The purpose is to evaluate the relationship between menstrual and sanitary hygiene and sexually transmitted diseases (STD) based on syndromic diagnosis Methods: An out-patient department (OPD) based cross sectional survey to determine these associations, if any exist, which would help critically analyze syndromic management. STD was reported by the presence of vaginal/cervical/urethral discharge with or without irritation and itching, lower abdominal pain and ulcer. Results: The prevalence of STD was 66.84% with the most commonly reported symptoms being discharged (31.18%), followed by abdominal pain (17.92%) and itch-ing/irritation (12.90%), with ulcer (4.83%) being the least reported symptom. Perimenopausal age ((AOR: 0.420 [CI: 0.189 - 0.915]; p = 0.030), higher grades of education ((AOR: 0.228 [CI: 0.119 - 0.424]; p < 0.001) for second-ary), urban residency (AOR: 0.435 [CI: 0.686 - 2.733]; p < 0.001), and contraception use (AOR: 0.531 [CI: 0.308 - 0.887]; p = - 3.146] for vaginal and cervical; AOR: 1.426 [CI: 0.826 - 2.482] for urethral) were more likely to not have a toilet facility in an accessible condition. Women with sanitary napkin use had lesser odds (AOR: 0.780 [CI: 0.516 -1.180]; p = 0.293) of presentation for STD in OPD than women who used other material. Conclusion: To better manage the group of diseases that may present with symptoms of STD under syndromic approach, we propose in-terventions such as menstrual hygiene education and promotion of the use of sanitary napkins among women especially those belonging to lower so-cio-economic sections of the society.


Introduction
Globally, sexually transmitted diseases (STD) have a significant burden on sexual and reproductive health with profound morbidity and mortality. As per the WHO report in 2016, globally there is a 1 million sexually transmitted infections (STIs) are acquired with estimated new cases of 376 million every year [1]. The STI burden varies according to the region and gender and the prevalence is higher in resource-poor countries. The STI is one of the vital public health problems in India and nearly 6% of the adult population had one or more STI, with an annual incidence of around 30 -35 million episodes [2].
Adverse complication of curable STIs or STD encompasses pelvic inflammatory disease, infertility, ectopic pregnancy, pregnancy loss, stillbirth, premature rupture of membranes, premature delivery and increased risk of HIV development and transmission and the neonatal outcome includes low birth weight, respiratory depression and increased neonatal ICU admission premature labor and low birth weight [3]. The three major causative pathogens in the progression of curable genital STI are Chlamydia trachomatis, Neisseria gonorrhoeae and Trichomonas vaginalis and they are usually asymptomatic and more commonly observed in females [4].
Due to the lack of skilled healthcare workers at the healthcare facilities and also there is a delay in early diagnosis as a result of expensive and sophisticated instruments which is not available in low-resource settings. So, there is a high chance of misdiagnoses and the infections are not properly treated. In this scenario, the chance of diagnosis is reduced to 50% and there is a high risk of transmitting the infection and the complications will still remain forever. Thus  ulcer-non-herpetic, genital ulcer-herpetic lower abdominal pain and inguinal bubo [5].
Previous studies conducted in Pakistan and Namibia report that there is a lack of knowledge among healthcare workers in the syndromic management of STI [6] [7]. In addition, further studies conducted in Pakistan and six countries in West Africa showed decreased knowledge in syndromic management of STI [8] [9]. In another study conducted in Nepal, there is a low level of knowledge among healthcare workers during the management of STI/HIV [10].
Primary care providers orchestrate an important role in the management of STD since various patients with STD are asymptomatic and the infections are diagnosed during their visits in primary care setting. Previous study reports that nearly half of the diagnosed STD is from primary care clinics and nearly 80% of the STD cases are reported from non-STD clinics [11] [12].
The wide approach to STD/STI also includes some symptoms that may be related to maintenance of menstrual hygiene and adequate wash practices. Our study aimed to find such association, if any, and derive meaningful conclusions as recommendations to improve the syndromic management approach.

Materials and Methods
This was a cross sectional, observational study conducted in the Obstetrics and Gynecology outpatient department of Civil Hospital, Ahmadabad. Asarwa civil hospital in Ahmedabad is a government hospital tending to needs of the urban and rural population of Ahmedabad district, other parts of Gujarat and referred cases from parts of Rajasthan, Madhya Pradesh and Maharashtra. Our study population covers a broad spectrum of socio-demographic statuses. The patient recruitment was done from February 2019 to June 2019 (20 weeks). We recruited women visiting the gynecology section of the department by consecutive sampling.
Non-pregnant women of reproductive age (18 years and above) attending the OPD with vaginal symptoms (vaginal discharge, itching/irritation/burning, ulcer and lower abdominal pain) were included in the study. Pregnant women, puerperal women and repeating patients were excluded from the study.

Sample Size Calculation
A single proportion sample size estimation formula was used with the following assumptions was used: Zα/2 is the standard normal variable value at 95% CI (confidence interval) (α is 0.05 with 95%CI, Zα/2 = 1.96; an estimate of the prevalence (p) of RTI 50%, and 5% the margin of error (d). A design effect of 1.5 was used due to multistage sampling and a sample size correction formula was employed since the source population was less than 10,000 in the study area. A 10% non-response rate was International Journal of Clinical Medicine used to obtain 602 as an adequate sample size.

Data Collection
After identification by the treating physician based on syndromic approach of STD management, all potential study participants underwent an informed consent process in the local language (Gujarati or Hindi) and those choosing to participate provided written consent. Female surveyors administered a comprehensive pre-tested (for validity and reliability) questionnaire immediately after their visit with the attending physician and through it examined risk factors.

Statistical Analysis
The data were coded, entered into Microsoft excel 2019, and exported to R statistical analysis software version 4.0.2 used with interface R studio software for analysis. Descriptive statistics such as frequency distribution and prevalence were computed. Associations between independent variables and STI were determined using a binary logistic regression model.

Results
Among the 603 patients who visited the gynecology OPD of the hospital during the study period, 558 were enrolled in the study, 13 patients were not willing to participate in the study and 32 patients were excluded from the study.

Socio-Demographic Characteristics
The demographic characteristics of the patients were shown in Table 1 1: Reference category. Illiterate stands for not having attended both formal and informal education, primary education means Grade 1 -8; secondary education means Grade 9 -10, higher secondary means Grade = 10 -12, and graduate education means having acquired a diploma, degree, masters and others.
(63.37%) earning less than 5000 per month (63.80%). The categories of housewife and household help were taken together in occupation as the objective of study was accessibility of an inhouse toilet or separate space dedicated to maintenance of hygiene. The prevalence of sexually transmitted disease on basis of syndromic approach among reproductive-age women was 66.84% [CI: 62.76 -70.74]. The most commonly reported symptoms were vaginal/cervical discharge (31.18%), followed by abdominal pain (17.92%) and urethral discharge/irritation/itching (12.90%) and ulcer (4.83%).The symptoms which were not considered as STD according to syndromic approach included gynecological symptoms like pain or discomfort during intercourse, bleeding between periods, frequent and urgent need to urinate, or a burning sensation during urination, abnormal vaginal bleeding, particularly during or after intercourse, pain or pressure in pelvis that differs from menstrual cramps etc. They were present in 33.15% of the patients.

Availability and Usage of Toilet
Among the patients recruited in the study, a clean, isolated, toilet facility with presence of water was available to 48.38%. No significant association of this parameter was obtained with chief complain of STD according to syndromic management, however stratified analysis of each of the complaints showed that there were higher odds of not having access to such a facility among women presenting with discharge

Past Clinical History
In our study, 79.75% women reported not having an invasive gynecological pro-  Table 3.

Menstrual Hygiene Management (MHM) and Washing Practices
Unfortunately, the majority of women recruited in the study did not use sanitary napkins (66.13%). Out of all women, 31.69% denied re-using their menstrual absorbent material. 28.69% of women reused the material and changed the material twice a day, followed by once a day (26.23%) and more than twice a day

Multivariable Logistic Regression Analysis
The results of multivariable logistic regression analysis of demographic profile of patients are shown in Table 6. We found that socio-demographic factors like perimenopausal age (more than 40 years) had significantly lesser odds of pre-    not statistically significant ((p = 0.611 and p = 0.293) respectively).
The results of multivariable logistic regression analysis of menstrual hygiene and wash practices of patients are shown in Table 9. As the frequency of washing increased the odds of presenting with an STD decreased however it was not a significant decrease. Usage of water only for washing reusable material was associated with four times greater odds of presenting with STD symptoms (AOR: 4.900 [CI: 2.701 -9.116]; p < 0.001).

Discussion
The prevalence of STD symptoms in the present study is 66.84 which is  comparatively higher when compared to other states and cities of India (Punjab: 45% [13], Bangalore: 29.15% [14], Surendranagar: 56.5% [15], Delhi: 43.9% [16], Uttar Pradesh: 46.76% [17] and Tamil Nadu: 55.5% [18]. The higher prevalence in the present study might be due to the reason that the study was carried out in the OPD in a community setting and thus, we received better responsiveness. In the present study, age more than 40 years, higher education, residing in urban surrounding and using contraception during sexual intercourse was associated with lesser odds of presenting with STDs [19]. On the other hand, belonging to backward castes, minority religious groups, having experienced similar illness and any invasive gynecological procedures in the past one year, having experienced sexual intercourse between 25 -35 years and washing reusable material with only water had higher odds of presenting in the OPD with STD symptoms. [20]. Having access to a toilet facility and using hygienic sanitary napkins were also associated with lesser odds of presenting with STD symptoms but the results were not very significant. A stratified analysis of individual symptoms revealed that having presented with vaginal/cervical/urethral discharge with or without itching and irritation had higher odds of not having a toilet facility accessible to them which is line with previous study conducted in Odisha, India [21]. Mounting literature shows that a large proportion of older patients, visiting the healthcare facilities are affected with STD [22]. Married and single women had 1.58 (p = 0.576) and 1.52 (p = 0.618) times the odds of having STD symptoms in OPD than widowed women. We found that factors determining low socio-economic status like Illiteracy, minority religious groups, living in rural parts of the town and belonging to backward castes were significantly associated with higher chances of presenting with an STD complaint. A previous systematic review and meta-analysis reveals that low socioeconomic profile are associated with increased risk of STI [23]. Interestingly, in the present study an overlap exists as such low socioeconomic conditions are associated with both -higher chances of unhygienic menstrual hygiene and latrine usage and engaging in International Journal of Clinical Medicine careless unprotective sex.
In the present study, women working as a laborer had a higher odd of presenting with an STD to the OPD (COR: 1.387; [CI: 0.85 -2.26]; p = 0.179). This could be due to lesser access of toilet facility for women who work as laborer.
Women presenting with vaginal/cervical discharge were twice more likely and others with urethral discharge with or without itching and irritation were 1.43 times more likely to not have accessibility to a usable toilet facility (p < 0.001 and p = 0.204). This finding highlights the magnitude of difference that can be achieved with the promotion of clean toilet facility in reducing the STD burden in households.
The fact that females presenting with similar symptoms in the past 1 year were more likely to present with STD symptoms shows that there is a possibility of presence of a habit/ chronically unchanging practice that contributed to STD symptoms significantly. We also found that a history of STI symptoms in the year before data collection was significantly associated with the development of STI. A similar study in an urban training health center of a tertiary care hospital in India showed that STI was significantly associated with a history of STIs in the previous year [12]. We found that women with invasive procedures done in the past one year were more likely to present with STI symptoms. A similar study among women in urban slums of India showed that participants who had a history of abortion had higher odds of STI symptoms than those who had no history of abortion [24].
Das et al. [25] reported that Indian women using disposable absorbent pads were less likely to develop infections than women using reusable material, consistent with our study suggesting that women who used sanitary napkins had lesser ((OR: 0.742); p = 0.041) odds of presenting with an STD and it was not significant. The literature reports that poor sanitation may facilitate transmission where genital contact is made with infected genital fluids on the latrine toilet seat [26]. A study conducted in Dehradun, India, reported an association between STI and poor menstrual hygiene as measured by washing the genitalia less often than twice per day during menstruation [27]. Among the women who did not use sanitary napkins, our study had women who used no-reusable/disposable cotton and women who used cloth and reused them after washing. The women who used cloth had higher odds of presenting with STD symptoms than women who used cotton.

Limitations
Our study had several limitations. Some of the crude associations when reanalyzed after stratification lost their significance which may be due to the decrease in stratified sample population. We did not report women who were laboratory confirmed cases of STDs. Furthermore, the results of this study may not be representative of the occurrence and underlying factors of STDs at the national level because it was conducted only in Ahmedabad.

D. Desai et al. International Journal of Clinical Medicine
Future studies should include a wider population sample and confirm the suspected STD cases with laboratory findings to better determine the cohort of women who may present with STD symptoms according to syndromic diagnosis but actually suffer from diseases related to improper menstrual and sanitary hygiene.

Conclusion
STI is a preventable illness that does affect the public health of the country.
There still exists a barrier in the physician-patient discussion regarding sexual acts, safe sex practices and menstrual hygiene. Ever since the concept of treating STI based on syndromic approach has been proposed, the focus has shifted from eliminating the root cause of the disease to symptomatic management. Syndromic approach has effectively treated women from STI, however, it does not reduce incidence of STI as the factors that promote transmission still exist widely in the community. Although our study cannot conclude a causal relationship between unhygienic MHM practices and STI, it highlights the need for a safe, hygienic and comfortable environment for women for MHM practices, so as to reduce the colonization of sexually transmitted pathogens and thereby, reduce the risk of STI.

Recommendations
In low-and middle-income countries, for the ease of management of STDs, syndromic approach has been in place. Our study highlights important associations of STD symptoms with socioeconomic conditions and menstrual and sanitary hygiene. With small additions in the execution of syndromic management of STD a wider group of diseases can be dealt with.
In line with significant association of complains of discharge with toilet availability, we recommend ensuring hygienic places for women, particularly those belonging to low socioeconomic backgrounds and promoting its use to practice MHM. Since our study also found a crude association between the use of cotton/cloth as sanitary material and presentation with an STD symptom to OPD, we recommend that a menstrual hygiene education and if we may be too ambitious, a supply of sanitary pads should be made available to women presenting with STD symptoms. To arrest the spread of STI, it is necessary to educate the people regarding the factors that increase transmission and prevalence. Our study has stated the factors that affect the risk of acquisition of STI and the areas that our country's jurisdiction must prioritize while framing health policies. It is certainly every woman's right to practice safe MHM and it is the need of the hour to extend the public health rationale to also cover the reproductive and sexual health of the women.