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Year : 2014  |  Volume : 2  |  Issue : 1  |  Page : 16-25

Value of logistics in sexual health services: a hospital based perception

1 Assistant Professor, Department of Community Medicine, MGM Medical College & LSK Hospital Kishanganj-855 107, Bihar, India
2 Assistant Professor, Department of Community Medicine, MGM Medical College & LSK Hospital Kishanganj-855 107, India
3 Additional Professor, Community Medicine and Family Medicine, All India Institute of Medical Science, Jodhpur, Rajasthan-342005, India

Date of Web Publication7-Aug-2018

Correspondence Address:
G Sarker
Assistant Professor, Department of Community Medicine, MGM Medical College & LSK Hospital Kishanganj-855 107, Bihar
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2347-6486.238790

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Introduction: Sexually Transmitted Infections (STI) are of major public health significance in most parts of the world affecting rural population in India. Taboos surrounding sexuality lead to a situation where people, particularly women, seeking sexual health care are stigmatized. The study was conducted to explore the availability and effectiveness of sexual health services at the STI clinic of a rural tertiary health care institute in the eastern India.
Methods: This observational health care facility based study for the period of one year included all the newly enrolled 301 patients reported with sexual health problems in the STI clinic. Data were compiled to assess socio-demographic and behavioral profile of the cases attending STI clinic.
Results: Average daily male and female attendees in the clinic were 31.32 ± 0.61 and 14.71 ± 0.23 respectively. 79.51 % of male patients were reported to have sex with commercial sex workers and only 6.11 % patients used condom during last sexual contact. It was found that VDRL was most commonly suggested investigation. About 34.91% patients were demonstrated the use of condom. 75 % health care providers felt that the constraints in the STI clinic were lack of manpower, followed by irregular supply of drugs and lack of equipments.
Conclusion: Results of this study suggest the need for regionalized STI care systems to implement evidence-based guidelines and to identify resources that are required to optimize care with future planning, implementation and evaluation of STD control strategies; as well as provide baseline information for future for the control of the STIs.

Keywords: Sexually Transmitted Infections, Healthcare Providers, Perception

How to cite this article:
Sarker G, Shahnawaz K, Pal R. Value of logistics in sexual health services: a hospital based perception. J Integr Health Sci 2014;2:16-25

How to cite this URL:
Sarker G, Shahnawaz K, Pal R. Value of logistics in sexual health services: a hospital based perception. J Integr Health Sci [serial online] 2014 [cited 2021 Nov 30];2:16-25. Available from: https://www.jihs.in/text.asp?2014/2/1/16/238790

  Introduction Top

Sexually transmitted Infections (STI) include other conditions besides the classical Venereal Diseases to cover asymptomatic infections with overall morbidity rate as higher for men.[1], [2] STIs remain a major public health problem in most parts of the world and South-East Asia including India.[3] Forty million new cases are reported per year with an estimated 3-4 % of the rural population; one tenth actually attend STI facilities.[4] Half of Gonorrhea in women is symptomatic with no ‘felt need’ to seek health care in absence of female doctors with deprivation of optimum intervention. Besides, failure to diagnose and treat STI at an early stage results in serious complications and squeal including infertility, fetal wastage, ectopic pregnancy, cancer and death. STI control had always been low in priority for health planning, though WHO put STI just behind Malaria and Tuberculosis.[4] A community based assessment of impact of STI care is difficult to ascertain due mainly to confidentiality, stigma and constraints of manpower, time and money. The present study was conducted at the STI clinic of tertiary care teaching institute in the eastern India to find out availability and effectiveness of hospital based sexual health services.

  Methodology Top

This observational follow up study was conducted for a period of one year in the STI clinic.

Sample Frame: The predominantly rural study population consisted of two categories; (a) New patients attending the OPD of STI clinic, (b) STI care providers, viz. Physician, Social Welfare Officer, Nursing Staff, Medical Technologist and Pharmacists.

Sampling Method: From new patient attendees 4025 (male 2750, female 1275) of previous year, expected number of male and female attendees for 9 month period of data collection (39 weeks approximately) was estimated to be 2062 and 956 respectively. Of the expected attendance, 10 % were selected making the study sample of 206 male and 95 female (n=301) participants; in spite of repeated persuasion, data collection of one male and five females could not be completed leading to sample size of 295.

Study Instrument: A pretested partially close-ended questionnaire contained questions relating to socio-demographic variables was developed on an anonymous interview schedule developed at the department by erudite advice from the faculty members with the assistance from public health experts. By initial translation, back-translation, retranslation followed by a pilot study in a comparable population the questionnaire was custom-made for the study before the actual study. From the retrospective data analysis, it was noted that the daily average new male and female patients attending the OPD of the clinic were 9.22 and 4.32 respectively. Primary investigator collected the data two days each week for 39 weeks.

Data collection procedure: The study conformed to the Helsinki declaration and approved by institution authority. All the patients and their caregivers were explained about the purpose of the study that the data will be exclusively used for the purpose of research. They were ensured strict confidentiality that their identity will never be disclosed at any point of time and a voluntary written informed consent was obtained from each of the participants of the study. For this study, new patient was defined as any participant enrolled for the first time in the STI clinic. Considering the average patient load in the STI clinic, the study was conducted in the preset two days in a week for optimum compliance of the health care provider as well as of the study participants. On the first day, with the help of lottery method, only female patients were selected for interview and the subsequent day only male patients were interviewed; in next day female patients again were interviewed and continued so on to meet the required sample size. In case of male patients, first case was selected from the first two patients attending the OPD, with the help of currency note technique and subsequent cases were selected by systematic random sampling i.e. every alternate case. Four patients were interviewed per day from an average daily attendance of about 9.22 patients. In case of female patients, four patients were selected by consecutive sampling from an average daily attendance of about 4.32 patients. Regarding privacy, conversation between physician and counsellor with patient could not be overheard or seen by waiting patients or other staffs with no interruption by other health care staff during consultation and examination. During registration the pre-designed schedule was handed over to the study participants who carried this schedule to the principal investigator. The time of consultation (starting and end) was noted down by the principal investigator himself. Next, when the participants went for collection of drugs (if necessary), the time period, from the submission of drugs collection slip to the actual delivery of drugs was noted down by the pharmacist in the same schedule. These selected participants were followed up during their repeated visits for final diagnosis and investigation and drug collection. The face to face interview technique was additionally employed by the Principal Investigator to improve compliance in case of illiterate participants.

Data Analysis: The collected data were subjected to preliminary data inspection, cleaning. Descriptive interpretation was carried out to find the nature and reason for noncompliance. Chi-square test with Yates correction was used for the comparison.

  Results Top

Average daily male and female attendees in the clinic were 31.32 ±0.61 and 14.71 ± 0.23 respectively.

Most of the participants belonged to age group of 25-34 years (43.06%); 53.23 % were primary educated and 9.49 % were illiterate; 48.29 % of male and 86.67 % of females were married [Table 1]. Among males, 79.51 % had sex with commercial sex workers in last encounter though half had sex with their partners within 12 months. Only 6.11% used condom during last sexual encounter with no statistically significant gender difference. (x2 =0.07, df=1, p > 0.05)[Table 2].
Table 1: Socio-demographic profile of the patients attending STI Clinic

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Table 2 Distribution of the patients according to the sexual behaviour

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Overall 36.09 % of male and 41.12 % of females had STI symptoms at least 28 days before attending for treatment. VDRL was the most commonly advised investigation (82.03%), followed by urine (27.45%) and Gram stain for cervical/ vaginal discharge (13.22%)[Table 3].
Table 3 Distribution of the patients according to provided health care

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In total, 56.94 % received prescribed drugs from the STI clinic [Table 4].
Table 4 Sources of Prescribed drugs for STI patients

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Advice regarding importance of full course of treatment was provided to 54.63 % male and 63.33 % females; 36.58 % male and 33.11% of females received condom demonstration. After clinic registration, 82.71% waited between 16 and 30 minutes for consultation; 94.58 % were consulted by physician up to 5 minutes; 65.61 % waited up to 5 minutes for collection of drugs [Table 5].
Table 5 Distribution of the patients attending the STI Clinic according to the frequency of IEC activities and the time taken for the different OPD services

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Investigation was done for 82.92 % males; 47.31 % received counseling. In case of females, 92.22 % were investigated followed by 57.77 % and 45.55 % being counselled and received full course of treatment [Table 6].
Table 6 Distribution of Patients attending STI Clinic according to their Compliance

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Physician behavior satisfied 34.91%, 73.38 % satisfied with Social Welfare Officer, 85.78 % with Medical Technologist (Laboratory) and 8.47 % with registration clerk [Table 7].
Table 7 Perception of patients regarding behavior of various categories of health care providers

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All Physicians, Social welfare Officer, Medical Technologist Laboratory and Pharmacist received at least one training on STI of three days duration [Table 8].
Table 8 Training attended on STI by various categories of health care providers

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Seventy five percent of Health care providers perceived the constraints as lack of manpower; half perceived irregular supply of drugs; 25% pointed lack of equipments [Table 9].
Table 9 Type of Constraints as perceived by the health care providers

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Optimum knowledge and health providing behavior of Social Welfare Officer was noted as 72.72%, in Medical Technologist (Laboratory) 45.45%, in nursing personnel 36.36% and in Pharmacist 27.27% [Table 10].
Table 10 Knowledge health-providing behavior of various healthcare providers

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  Discussion Top

The present study was conducted in a tertiary health care institution, where considerable numbers of cases of STIs are expected to attend and receive treatment and thereby reflect the magnitude of services available and their effectiveness at the same time.

Age and sex distribution of patients:

Among the study population (male 69.49 %, female 30.51%) highest (43.06%) was from 25-34 years. Other studies showed highest observed age range as 15-29 years.[5] For most of notifiable STIs, the highest rates of incidence were observed between 20-24 years, followed by 25-29 years and 15 to 19 years age group.[1] The observed difference was quite obvious because of under reporting of STI.[4] The female attendees were less with the taboo surrounding sexuality and STI lend to a situation where women, seeking health care for STI were stigmatized.[4] Further in the present study, male patients constituted about 69.49 %; whereas Roy et al reported 83 %.[7]

Educational Status:

In the present study, 53.23 % patients were primary educated and 20.33 % educated up to secondary level. The study conducted by Roy et al showed that 55 % of the STI patients were educated up to high school.[7] However, nothing can be commented from this observed difference of primary and high school educated attendants in these two clinics, as educational status may also be different in the reference population in these two study areas.

Marital Status:

In the present study 37.63 % were unmarried; among the unmarried 5.56 % were female. Study conducted by Roy et al also showed that 48 % were unmarried.[7] However, negligible proportion (5.56%) of unmarried female attendees might be because of gross-under reporting[6] and asymptomatic infection;[4] besides overall morbidity rate less among women.[1]

Sexual partners:

Regarding the question on the last sexual experience of the participants, 55.25% reported having sexual encounter with the commercial sex workers (CSW) and 32.55 % with their spouses. Other study showed that STI occured more commonly in CSWs and their clients and long distance truck drivers.[5]

Time of last sexual contact:

In the present study it was observed that half had sex with their partners within last 12 months, 38.64 % within 4 weeks and 6.10 % patients had sex with their partners more than 12 months. National AIDS Programme evaluation survey showed that regular partnerships were defined solely in terms of duration. Any sexual relationship that last for at least 12 months was classified as regular and others as non-regular.[8]

Use of Condom:

During last sexual encounter, condom use was low (6.11%) in the present study compared to other studies in India and abroad; gender difference in condom use was not statistically significant (x2 =.07 d.f. =1, p >0.5). Barrington et al conducted a cross-sectional survey among 380 male partners of female sex workers in La Romana of Dominican Republic noted that consistent condom use with the most recent female sex worker partner was 66 %. Participants had received encouragement towards condoms use from 83 % of contacts.[9] Pettifor et al, revealed that over last four-week follow-up period, condom was absent in 49.18 % with main partners and 35.59 with clients.[10] Deering et al noted that the condom use was 22.60% with husband or cohabiting partner and40.30% with non-paying partners which was comparable to the findings of our study.[11]

Laboratory Investigations:

In our study VDRL test was advised for 75.60 % males and 96.67 % female, followed by Routine urine examination in 30.73 % male and 20 % female; gram staining for 3.90 % male and 34.45 % females; 27.78 % females were advised for vaginal smear for Trichomoniasis. Further it was observed that 93 male and 8 females presenting with penile ulcer and ulcer vulva respectively; 64 male and 60 females presented with discharge. Under-estimation of STI case load was accentuated further by non-compliance for the investigation; five males and 24 females had undergone gram staining for genital discharge. VDRL examination rate was very high (Males 71.70%, Females 88.89%). Finally, the results of Laboratory investigation revealed that among the commonly performed test, VDRL positivity was high (Male 4.39%, Female 8.89%); gram stain positivity were in 1.95 % and 1.11 % male and females respectively. Incidentally four out of six HIV test among male and four out of 12 among females were positive. Thus, in spite of very low rate of HIV screening of patients attending STI clinic, 1.95 % of male and 4.44 % of female were HIV positive.

Sources of prescribed drugs:

It was revealed from our study that the clinic alone was the commonest drug distribution depot for 295 (56.94 %) patients; 17.96 % from both STI clinic and Chemist shop; remaining 11.18 % from Chemist shop only.

Among the 254 patients who received treatment, 66.14 % received drugs from STI clinic, 20.86 % from both STI clinic and chemist shop and 12.99 % from chemist shop only. Benjarattanaporn et al. reported that 39 % of men with STD seen initially at drugstores, 29 % at private clinics and 19 % Government Clinics.[12] Study conducted by Kilmarx et al. on CSW showed that 54 % of treated cases received treatment from pharmacy.[13] Yet Roy V et al noted that 15.5 % patients with STI had attended Government health facilities.[7]

Health education and condom promotion activities:

It was observed that activities like health education and condom promotion were far from satisfactory with explanation of illness, importance of full course of treatment as well as risk of acquiring HIV/AIDS were explained to only half of the patients of both sexes. Advice for condom use, its supply and demonstration were even worse; 49.49 %, 36.94 % and 34.91 % respectively.

Time taken for different OPD services:

Total service time considering all the components were up to 40 minutes for 92.75 % of the STI patients. Time taken from registration of patients up to consultation with physician was averagely 20.41 ± 7.42 minutes for male and 18.62 ± 5.91 minutes for female patients. Consultation examination time for male and female patients was 3.32 ± 1.73 and 3.71 ± 1.7 2 minutes respectively. Waiting time for drugs collection for male and female patients were 6.62 ± 3.0 and 6.82 ± 2.51minutes respectively. Again total service time (for all components) was 30.22 ± 8.91 and 29.93 ± 7.0 minutes for male and female patients respectively.

Study conducted by Ghosh BN showed that majority (70.4 %) of patients had to wait for less than 30 minutes at most of the points[14]. Above study also showed that per capita physicians time for examination/consultation were 3.32 and 3.71 minutes for male and female patients' respectively. It was almost equal with the present study findings for the said activity.

Patients' compliance to advice at the STI clinic:

We observed that 82.92 % of males and 92.22 % of females were investigated. Almost half of the patients received full course of treatment i.e. 53.17 % for male and 45.55 % for females. Almost same proportion received counseling from the HCPs. Request of 51.89 % male and 76.38 % female were heeded to in connection with case management.

Perception of patients regarding the behavior of HCPs:

In the present study 34.91% patient satisfied with the behavior of physician, 73.38 % satisfied with Social Welfare Officer, 85.78 % satisfied with Medical Technologist (Laboratory) and only 8.47 % satisfied with registration clerk. About 90 % of the clients in respect of doctors assessment expressed their level of satisfaction either as satisfactory or good in a study conducted by Das Palash et al on client satisfaction in RCH services.[15]

Constraints as perceived by the HCPs:

In the present study it was observed that according to perception of HCPs mostly, 75 % opined that shortage of manpower is the main problems. Next important problem were identified as irregular supply of drugs 50% and lastly lack of equipment 25% compounded the problem.

Training status of HCPs STI:

All Physician, Social welfare Officer, Medical Technologist Laboratory and Pharmacist received at least one training on STI of three days duration. STI review Meeting organized by NACO revealed that NACO had trained a cadre of 45 National and 587 State resource faculties across all states during 2007–08, identified 46 institutes for STI training and 19 Institutes for counselor training; all faculty members were trained. The state resource faculties in turn conducted trainings of STI/RTI clinic staff. The state and regional resource faculty have trained a total of 2224 persons in 2008-09 and 3046 persons in 2009-10 against the target of 5592 (54.5%).[16] Training of health supervisors and multipurpose workers was better than that of medical officers in most of the states. Tripura reported negligible training of all the health functionaries because of specific local problems. In Assam and Maharashtra, medical officers in all (100%) health facilities were diagnosing and treating leprosy cases, as compared with Himachal Pradesh (30%). However, lower involvement of GHS staff in recording and reporting was noted in Assam, Andhra Pradesh.[17]

Knowledge and health providing behavior of HCPs on STI:

In the present study, the knowledge and health providing behavior of Social Welfare Officer was 72.72 %, Medical Technologist (Laboratory) 45.45 %, Nursing staff 36.36 % and Pharmacist was 27.27 %. In a study from Hyderabad city, conducted in Government Health Services dispensaries in Hyderabad in order to assess KAP and some operational parameters, medical officers consistently demonstrated higher knowledge, followed by nursing staff and paramedical workers.[18]

Strengths of the study:

There is no published report on the evaluation of the sexual health services at the STI clinic from this part of India. Further, the reasons for improvement of attendance of the missing stakeholders were taken into account in the study.

Limitations of the study: We had several limitations. Firstly, in our resource poor setting, in presence of specialized counseling unit the STI victims turned out was less because of prejudice. Secondly, many patients were lost to follow up. Thirdly, the STI clinics was not community based. Hence even with our best efforts we had to compromise on clinic based study in the busy OPD.

Future directions of the study: Future researches have to be directed to solve several important unanswered questions dealing with the diagnosis and the treatment of the STI in the era of HIV/AIDS pandemic. Regarding prognostic importance by assessing clinical outcome, determination of compliance to predict optimum care a tailor made management strategies are more likely to be adopted and sustained.

  Conclusion Top

To sum up, this study provide baseline information to help future planning, implementation and evaluation of STI control strategies with evaluation of primary and secondary STI health care services to the grass root level. The practice of the interventions of STIs differ broadly needing dedicated STI management groups to identify the appropriate care as controversy still exist in the selection of the cases for widespread and standardized adoption of this intervention with strategies to improve compliance of female care seekers.

  References Top

Park K. Park's Textbook of Preventive and Social Medicine. Jabalpur, India: Banarasidas Bhanot Publishers; 21st ed. 2011: p. 303-4.  Back to cited text no. 1
Sunder Lal. Text Book of Community Medicine Medicine. New Delhi, India: CBS Publishers & Distributors Private Limited; 2nd ed. 2010:p.407.  Back to cited text no. 2
WHO. Management of Sexually Transmitted Diseases at District and PHC Level.New Delhi;1997:1-5.  Back to cited text no. 3
Country Scenario. National AIDS Control Organisation. MOHFW. 1997-98; 1-40.  Back to cited text no. 4
Management of STD patients. Transmission and control of STD/HIV Module 1 to 6; NACO MOHFW. GOI. New Delhi.1993: 7-9.  Back to cited text no. 5
Lal Shiv. Sexually Transmitted Diseases control programme in India; A public Health Approach. Indian J. of public Health : 1993 ;37(2): 33-36.  Back to cited text no. 6
Roy V, Bharvaga P, Bapna JS, Reddy BS.Treatment seeking behaviour in sexually transmitted diseases. Indian Journal of Public health : 1998; 42(4): 133-35.  Back to cited text no. 7
WHO. Evaluation of a National AIDS Programme. Global programme on AIDS. Section I. Geneva 1994: 6.  Back to cited text no. 8
Barrington C, Moreno L, Rosario S, Kerrign D. Social networks and consistent condom use among male partner of female sex workers in the Dominican Republic. The 134th annual meeting and exposition of American Public Health Association Nov 2006.  Back to cited text no. 9
Pettifor A, Turner AN, Swezey T, Khan M, Raharinivo MSB, Randrianasolo B, et al. Perceived control over condom use among sex workers in Madagascar: a cohort study. BMC Women's Health 2010:10(4):1-7.  Back to cited text no. 10
Deering KN, Bhattacharjee P, Bradley J, Moses SS, Shannon K, Shaw SY, et al. Condom use within non-commercial partnerships of female sex workers in southern India. BMC Public Health 2011;11(6):S11.  Back to cited text no. 11
Benjarattanaporn P, Lindan CP, Mills S, Barclay J, Bennett A, Mugrditchian D et al. Men with sexually transmitted diseases in Bangkok: where do they go for treatment and Why? AIDS : 1997; 11(1): 587-95.  Back to cited text no. 12
Kilmarx PH, Limpakarnjanarat K, Louis Michael EST, Supawitkul Somsak, Korattana Supaporn, Mastro TD. Medication use by FSWs for treatment and prevention of STDs, Chiang Rai, Trhailand. Sexually transmitted diseases: 1997: 24(10): 593-98.  Back to cited text no. 13
Ghosh B.N. A. case study of management of the outpatient system in a health centre located in a slum area. Indian society of health administrators.1990: 28-32.  Back to cited text no. 14
Das P, Basu M, Tikadar T, Biswas GC, Mridha P, Pal R. Client satisfaction on Maternal and Child Health services in rural Bengal. Indian J Community Med: 2010:35(4):478-81.  Back to cited text no. 15
Report of STI review meeting at New Delhi in 2010.  Back to cited text no. 16
Pandey A, Patel R, Rathod H. Inter-state variations in integration of leprosy services into general health system in low/ moderately endemic states of India. Indian J lepr 2006;78: 245-59.  Back to cited text no. 17
Rao PV, Rao SL, Vijayakrishan B, Chaudhury AB, Peril S, Reddy BP, et al. Knowledge, attitude and practices about leprosy among medical officers of Hydrabad urban district of Andhra Pradesh. Indian J Lepr 2007; 79: 27-43.  Back to cited text no. 18


  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10]


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