VET656 Public Health And Epidemiology

Project summary

Reproductive tract infections (RTIs) are usually caused due to organisms that are typically existing in the reproductive tract, or brought from the external environment during medical procedures and/or sexual contact. These dissimilar but overlying classes of RTI are called sexually transmitted infections (STIs), endogenous, and iatrogenic, imitating how they are developed and spread (Tibary & Fite, 2013). RTIs affect the upper portion of the reproductive system of women namely, the ovary, fallopian tubes, and the uterus, and the lower part that comprises of the cervix, vagina, and the vulva. While endogenous infections arise from an infectious agent that was already existing in the body in an asymptomatic form, iatrogenesis occurs due to the activity of one or more than one healthcare professionals who promote the use of certain services and products that fails to support the health goals. Sexually transmitted infections (STDs) are in turn spread due to sexual activity, especially vaginal intercourse, oral sex, and anal sex (Anderson et al., 2013).

RTIs are considered as the most essential incidents that lead to perinatal and maternal mortality and morbidity every year. Some of the serious health complications that are related to RTIs include pelvic inflammatory disease, ectopic pregnancy, miscarriage, congenital infection, preterm labour, and stillbirth. RTIs might also result in the onset of chronic disabilities such as, genital cancer, infertility and death. Augmented risk of AIDS is another concern of RTIs (De Boer et al., 2014). The proposal will be a cross-sectional study where the prevalence of RTIs among married women belonging to the reproductive age group will be assessed, followed by exploring their health seeking behaviour from their responses. The research approach will follow an epidemiological survey where a medical survey will be conducted with the aim of discovering the rates of reproductive tract infection among women in Perth. The findings of the survey will be coded and analysed into specific data patterns called themes, to devise different ways by which the disease can be prevented from spreading.

Rationale and Background

The burden of untouched RTIs is particularly substantial for women because these contagions are frequently asymptomatic or the indications are not identifiable. Illness and mortality connected to RTIs rob the society of significant contributions made by females in terms of social, economic, and cultural development (Moore et al., 2015). Though RTIs creates an impact on females in both industrialised and developing countries, these infections are considered as a crucial public health concern in areas of the world that has lack of adequate resources (Hassan, 2015). Demographic variations in developing nations have led to an intense upsurge in the number of teenage and young adult females and males in their maximum sexually active years that converts into a greater amount of the populace at risk for RTIs (Silasi et al., 2015).

Reports from the World Health Organization suggests that an estimated 1 million sexually transmitted infections (STIs) affect people every day, on a global scale. Of 357 million new infections, trichomoniasis, syphilis, and gonorrhoea are most widespread. While most STI signs and symptoms are not easily recognised, syphilis affects more than 900 000 pregnant women, thus leading to adverse birth outcomes, mother-to-child transmission, and infertility (WHO, 2016).

Lis, Rowhani-Rahbar and Manhart (2015) conducted a meta-analysis of female RTI and Mycoplasma genitalium infection and found significant association between the infection and elevated risks of preterm birth (OR, 1.89 [95% CI, 1.25–2.85]), cervicitis (OR, 1.66 [95% confidence interval {CI}, 1.35–2.04]), and spontaneous abortion (OR, 1.82 [95% CI, 1.10–3.03]). Upon conducting a cross-sectional study among married women, findings of another study provided evidence for the prevalence of 17.3% of RTI. Some of the most common signs and symptoms that were reported by female sufferers were dyspareunia (26.7%), urinary (frequent urination 53.3%, dysuria 57.8%), unusual vaginal discharge (24.4%), and vaginal itching (22.2%) (Philip, Benjamin & Sengupta, 2013). In the words of Narayankhedkar, Hodiwala and Mane (2015) vaginitis is one of the most prevalent RTIs in women who are sexually active. Some of the common symptoms that accompany this kind of RTI include vulval itching, vaginal discharge, malodour, abdominal pain, and dysuria.

Verma, Kumar Meena and Banerjee (2015) also conducted a comparative prevalence study and suggested that urban and rural areas demonstrated similar prevalence rates of RTIs (42.3% and 42%, respectively). While 73% affected women sought treatment in the urban areas, as less as 45.6% from the rural regions had health seeking behaviour. Conduction of a house-to-house survey among women belonging to the reproductive age in rural communities suggested that peri-vulval itching and white discharge were the common complaints. RTI had a 70% prevalence in community, and 67% among females who attended Out Patient Departments (OPD) (Mehta, Parikh & Bala, 2016).

The prevalence rates are supported by Rohilla et al. (2015) who confirmed syndromic diagnosis of RTI among 92 patients from a tertiary care centre. Thus, the dominance of laboratory confirmed RTIs was 27% in the target population. Considering the fact that the prevalence and incidence of RTIs are found to greatly vary between different regions, within a certain country, there is a need to focus on exploring the prevalence rates at a particular region (Perth).

Study goals and objectives

Research aim

The primary aim of the research is to explore the prevalence of reproductive tract infections (RTIs) and associated health seeking behaviour among married women, of the reproductive age group, in Perth, WA.

Specific objectives

• To determine the prevalence of RTI among married females
• To explore the health seeking behaviour, in relation to RTI among married women
• To assess the association between prevalence rates of RTI with pre-determined socio-demographic variables
• To prepare and distribute pamphlets for promoting awareness on RTI

Study design and methods

Research design

The research is intended to be conducted in the form of a cross-sectional, community based study. Cross-sectional surveys aim to gather essential information for drawing inferences about a certain population of interest, at a particular time frame (Lebo & Weber, 2015). Cross-sectional surveys have also been pronounced as snaps of the inhabitants, on whom data is collected. The study will be conducted from December 2018 to April 2019.

Study area

Perth ranks fourth in the population ranking in Australia, and is divided into 250 suburbs and 30 local government areas. The research will be conducted across three suburbs of Perth namely, Churchlands, Waterford, Ashendon, and South Perth, and two government areas namely, Town of Cambridge and Shire of Ashburton.

Sampling design

Sampling will be done by randomisation technique. The sampling method will assist in removal of selection bias between the women who form the target population. The eligibility criteria is given below:

Inclusion criteria:

• All married women of reproductive age
• Women of the following age group who have had presented with complaints that are suggestive of RTI
• Married women of reproductive age who had been referred to the six healthcare centres across the selected regions

Exclusion criteria:

• Women who have been residing in Perth for less than 6 months
• Women beyond reproductive age who have had experienced RTI symptoms

Following obtaining a list of women who are considered eligible for the research, home visits will be scheduled, where the objective and technique of the study will be explained, besides ensuring confidentiality of their replies.

Sample size calculation

This refers to the act of selecting the number of participants to be included in the statistical sample (Charan & Biswas, 2013). Owing to the fact that cross-sectional studies are conducted for estimating certain population parameters, like the prevalence of RTI in this case, the below given formula will be used:

Data collection

A pre-tested, pre-designed, semi-structured interview will be used for questioning the eligible married women. The interview will comprise of both closed and open ended questions. The interview will comprise of the following parts:

• Questions for assessing the socio-demographic features of the subjects, data related to identification namely, age, religion, address, socioeconomic status, and occupation
• Questions on marriage and menstrual history
• Questions related to obstetric history
• Questions that will explore knowledge of the women on RTIs and their history of previous occurrence (if any)
• Questions on presence of any signs and symptoms related to RTI, their onset, and frequency of occurrence in past one year
• Questions that will assess their treatment seeking conduct for the disease

Data analysis

Data analysis would utilise the SPSS version 21.0 software. This will help in calculating the proportions and percentages for symptom prevalence and help seeking behaviour (DiMaggio, 2013). A fisher exact test and chi square test will also be used for calculating the significance of the results in univariate analysis. Presence of ‘p’ value of less than 0.05 will be considered significant for the results.

Ethical considerations

The objective, aims and procedure of the cross-sectional research will be explained to all married women, the community nurses, and gynaecologists. Complete confidentiality will be maintained, with regards to patient information, during all stages of the study. The women will be given the opportunity to withdraw from the research or refuse to participate at any point of time. Prior to conduction of the interview, an informed consent will be taken from all women and the Human Research Ethics Committee.

Limitations

The study will not be able to obtain information on the history of several sexual partners. A larger sample size will be required to validate accuracy of the findings. Receiving a non-response to some question of the interview might also lead to bias.

Study impact

The primary impact of the study will be related to gaining a sound understanding of the prevalence of symptoms that relate to RTI, in relation to different behavioural, obstetric, and socio-demographic factors in the women population of Perth. The expected outcomes of the study are that women belonging to all kinds of socioeconomic background will report similar prevalence rates of RTI. However, while married women belonging to higher economic background and with greater educational attainment are expected to demonstrate more treatment seeking behaviour, those belonging to poor social status and with less education are anticipated to manifest less of such behaviour. The results will be used to educate the women about the indications of RTI, their deterrence, and the prominence of timely management in both rural and urban areas. The epidemiological study findings will also be disseminated across government departments to help them take necessary initiatives for tackling this public health issue. This will also help in ensuring the availability of the RTI cure kits across primary healthcare centres to upturn the utilisation of government services.

Project management arrangements

The project will involve two researchers, women belonging to the reproductive age group from Perth, their husbands, two community nurses, and gynaecologists from the respective health centres from where the women will be selected. The Human Research Ethics Committee of the university should also be consulted to seek their approval, prior to conduction of the research on human participants. Six healthcare centres located across Perth and their corresponding doctors from the gynaecology department shall also be prior informed about the objective and plan of action. The two community nurses will be selected from Perth Community Care Centre. Hence, the disciplines of nursing, women reproductive health, and institutional ethics review will be involved in the project. An individual with methodological expertise in statistical calculations will also be involved in validation of the statistically pooled data.

References

Anderson, C., Gallo, M. F., Hylton-Kong, T., Steiner, M. J., Hobbs, M. M., Macaluso, M., ... & Warner, L. (2013). Randomized controlled trial on the effectiveness of counseling messages for avoiding unprotected sexual intercourse during sexually transmitted infection and reproductive tract infection treatment among female sexually transmitted infection clinic patients. Sexually transmitted diseases, 40(2).

Charan, J., & Biswas, T. (2013). How to calculate sample size for different study designs in medical research?. Indian journal of psychological medicine, 35(2), 121.

De Boer, M. W., LeBlanc, S. J., Dubuc, J., Meier, S., Heuwieser, W., Arlt, S., ... & McDougall, S. (2014). Invited review: Systematic review of diagnostic tests for reproductive-tract infection and inflammation in dairy cows. Journal of Dairy science, 97(7), 3983-3999.

DiMaggio, C. (2013). Introduction. In SAS for Epidemiologists (pp. 1-5). Springer, New York, NY.

Hassan, H. E. (2015). Infertility profile, psychological ramifications and reproductive tract infection among infertile women, in northern Upper Egypt. Journal of Nursing Education and Practice, 6(4), 92.

Lebo, M. J., & Weber, C. (2015). An effective approach to the repeated cross?sectional design. American Journal of Political Science, 59(1), 242-258.

Lis, R., Rowhani-Rahbar, A., & Manhart, L. E. (2015). Mycoplasma genitalium infection and female reproductive tract disease: a meta-analysis. Clinical Infectious Diseases, 61(3), 418-426.

Mehta, M., Parikh, S., & Bala, D. V. (2016). Prevalence of Reproductive Tract Infection (RTI) Amongst Reproductive Age Women in Rural Area: A Missed Opportunity. Retrieved from https://www.iapsmgc.org/index_pdf/201.pdf 

Moore, K. R., Cole, S. R., Dittmer, D. P., Schoenbach, V. J., Smith, J. S., & Baird, D. D. (2015). Self-reported reproductive tract infections and ultrasound diagnosed uterine fibroids in African-American women. Journal of women's health, 24(6), 489-495.

Narayankhedkar, A., Hodiwala, A., & Mane, A. (2015). Clinicoetiological characterization of infectious vaginitis amongst women of reproductive age group from Navi Mumbai, India. Journal of sexually transmitted diseases, 2015.

Philip, P. S., Benjamin, A. I., & Sengupta, P. (2013). Prevalence of symptoms suggestive of reproductive tract infections/sexually transmitted infections in women in an urban area of Ludhiana. Indian journal of sexually transmitted diseases, 34(2), 83.

Rohilla, R., Agarwal, J., Qureshi, S., & Kalyan, R. (2015). Prevalence of Reproductive Tract Infections/Sexually Transmitted Infections and Their Determinants in Women of Reproductive Age Group, Attending STI Clinic at a Tertiary Care Centre in Lucknow, India. Age, 20(4), 7.

Silasi, M., Cardenas, I., Kwon, J. Y., Racicot, K., Aldo, P., & Mor, G. (2015). Viral infections during pregnancy. American journal of reproductive immunology, 73(3), 199-213.

Tibary, A., & Fite, C. L. (2013). Reproductive tract infections. Equine Infectious Diseases. Elsevier, 84-103.

Verma, A., Kumar Meena, J., & Banerjee, B. (2015). A Comparative Study of Prevalence of RTI/STI Symptoms and Treatment Seeking Behaviour among the Married Women in Urban and Rural Areas of Delhi. International journal of reproductive medicine, 2015.

World Health Organization. (2016). Sexually transmitted infections (STIs). Retrieved from https://www.who.int/news-room/fact-sheets/detail/sexually-transmitted-infections-(stis).