Treatment seeking, vaginal discharge and psychosocial distress among women in urban Mumbai

Urinary and reproductive tract infection symptoms and menstrual hygiene practices in refugee camps in Jordan: A cross-sectional study

BACKGROUND

Urinary tract infections and reproductive tract infections pose significant health risks, particularly among women living in challenging conditions. Unhygienic menstrual practices can exacerbate these risks, impacting physical and psychological well-being.

OBJECTIVES

This study assessed the association between unhygienic menstrual care and self-reported urinary tract infection/reproductive tract infection symptoms among refugee women. In addition, it explored the association between these symptoms and mental health, specifically depressive symptoms.

DESIGN

This study adopted a cross-sectional observational design.

METHODS

This study was conducted between January and March 2023, involving 387 reproductive-age refugee women. Data collected included sociodemographic information and urinary tract infection/reproductive tract infection symptoms. In addition, we used the Menstrual Practice Needs Scale to evaluate menstrual hygiene practices and the Patient Health Questionnaire-9 for depressive symptoms. Statistical analysis was performed using Python version 3.9.12.

RESULTS

Of 387 refugee women, 92.25% reported having urinary or reproductive tract infection symptoms in the previous 3 months. Factors like older age (odds ratio = 1.764, 95% confidence interval = 1.083-2.873, p-value = 0.023), lower family income (odds ratio = 0.327, 95% confidence interval = 0.138-0.775, p-value = 0.011), lower educational level (odds ratio = 0.222, 95% confidence interval = 0.068-0.718, p-value = 0.012), and being married (odds ratio = 0.328, 95% confidence interval = 0.188-0.574, p-value < 0.001) were significantly associated with urinary or reproductive tract infection risk. Difficulties obtaining menstrual products and thus reusing them increased the odds of urinary or reproductive tract infection diagnosis (odds ratio = 2.452, 95% confidence interval = 1.497-4.015, p-value < 0.001). Women with urinary or reproductive tract infection symptoms exhibited higher Patient Health Questionnaire-9 scores than those without (12.14 ± 5.87 vs 9.99 ± 5.86, p-value < 0.001, respectively).

CONCLUSION

This study highlights a high prevalence of urinary or reproductive tract infection symptoms among refugee women residing in camps in Jordan, which was associated with poor menstrual hygiene practices and depressive symptoms. To reduce the urinary tract infection/reproductive tract infection burden in marginalized communities, public health initiatives should enhance healthcare accessibility, provide reproductive education, and promote holistic well-being practices for refugee women.

Trends in age of tobacco use initiation over time in Bangladesh, India and Pakistan: analysis of cross-sectional nationally representative surveys

OBJECTIVE

Tobacco use begins at an early age and typically leads to a long-term addiction. The age of initiation for tobacco use is not well studied in South Asia, where 22% of tobacco smokers and 81% of smokeless tobacco (SLT) users reside.

METHODS

Data from the nationally representative Global Adult Tobacco Surveys in India, Bangladesh and Pakistan were analysed to examine patterns of initiation among smokers and smokeless tobacco users.

RESULTS

Data on 94 651 individuals were analysed, of which 13 396 reported were ever daily smokers and 17 684 were ever SLT users. The proportion of individuals initiating tobacco use before the age of 15 years has increased over time. The rates of SLT initiation among those aged 15-24 years increased markedly in Bangladesh (by 7.8%) and Pakistan (by 37.7%) between 1983 and 1999-2000. Among males, the increase in SLT initiation was higher in individuals aged below 15 years compared with other age groups in India and Bangladesh. Smoking initiation among females aged below 15 years has also significantly increased in India over time. Compared with the initiation of tobacco smoking before the age of 15 years, a greater increase in the proportion of SLT users was observed in urban areas.

CONCLUSION

Our findings indicate that the proportion of youth initiating tobacco (both smoking and smokeless) before the age of 15 years has increased over time in all three countries. Moreover, variations in age at initiation for different types of tobacco products across countries, and by rurality, were noticeable. Younger youths (aged up to 15 years) should therefore be a priority population for tobacco control interventions. Strategies such as raising the legal age of tobacco sale and use to 21 years, and, other measures under WHO Framework Convention on Tobacco Control (FCTC), may prevent underage use and avert lifelong addiction to tobacco products.

Mixed-Method Investigations Uncovering Tension, PTSD Symptoms, and Trauma-Related Difficulties Among Indian Women from Slums Reporting Gender-Based Violence

Indian women exposed to gender-based violence (GBV) report experiencing cultural concepts of distress, such as tension, and trauma-related difficulties. However, tension and trauma-related sequalae have not been explicitly explored. The present study examined the symptoms, causes, and coping strategies associated with tension among slum-residing Indian women reporting GBV (N = 100). This study also explored linkages between tension and posttraumatic stress disorder (PTSD) symptom severity. Qualitative results among a subsample of women (n = 38) indicated tension was commonly reported. Tension was characterized by varied affective, behavioral, cognitive, and somatic components and was most commonly caused by interpersonal stressors. Participants described various coping strategies to manage tension, including avoiding, cognitively reframing, considering consequences, distracting themselves, seeking medical, religious and/or spiritual assistance, finding social support, and tolerating tension. Barriers to coping were stigma, hopelessness about present circumstances, and negative reactions from others. One-way analysis of covariance with Bonferroni-adjusted post hoc results (N = 100) indicated that participants with higher tension exhibited significantly higher PTSD symptom severity as compared to participants reporting no tension. Altogether, the polyvalence of tension suggested that it requires idiographic assessment. Tension appears responsive to skills consistent with evidence-based psychological treatments for Indian women from slums reporting GBV.

Phenomenology, disability and sexual functioning in female Dhat syndrome: a study of tertiary care gynaecology outpatients

Background

Dhat syndrome, a clinical condition related to semen loss in urine often found among males in India, has rarely been described as a separate clinical condition in females. Women with the syndrome complain of passing vaginal discharge and can be excessively concerned and preoccupied with it, often attributing various physical symptoms to the loss of vaginal fluids.

Aims

This study aimed to assess the sociodemographic and clinical profiles of female patients with Dhat syndrome and their perceived stress, disability and sexual functioning.

Methods

Sociodemographic details of 70 females with non-pathological vaginal discharge were evaluated with a semistructured sociodemographic assessment. The phenomenology of the vaginal discharge was assessed with the Scale for Assessment of Female Dhat Syndrome Questionnaire. Anxiety and depressive symptoms were measured with the Hospital Anxiety and Depression Scale. Perceived stress in the past month and disability caused by the illness were assessed with the Perceived Stress Scale and the World Health Organization Disability Assessment Scale. In addition, the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Level 2 Somatic Symptoms Scale was administered to rate the severity of somatic symptoms, and sexual functioning was evaluated using the Female Sexual Function Index (FSFI) scale for women who had had sexual intercourse in the past month.

Results

The mean age of onset vaginal discharge was 23.0 (6.6) years. Biological factors, such as urinary tract infection, were the commonly attributed cause of the loss of vaginal fluids. Psychiatric comorbidity and perceived moderate stress in the past month were found in 38.6% and 68.6% of female patients with Dhat syndrome, respectively. Disability scores tended to be low. Among the females having had sexual intercourse in the past month, 48.3% had FSFI scores indicative of a female sexual disorder.

Conclusions

The clinical presentation of women with non-pathological vaginal discharge is similar to that of males with Dhat syndrome. It requires comprehensive assessment and management that targets the biological, social and psychological factors and cultural issues.

"I put a stone on my heart and kept going": An explanatory model of how distress is generated and regulated among Indian women from slums reporting gender-based violence

Clinical variation in the expression of panic disorder, depression and anxiety, and posttraumatic stress disorder (PTSD) has have been documented across cultures. However, local (emic) cultural models that explain how people make sense of their illness experiences remain relatively understudied in India among trauma-exposed populations. Further, the integration of emic findings into clinical care is limited, underscoring the need for emic perspectives following trauma to improve the development or adaptation of trauma-focused treatments in India. This study describes an emic explanatory model of distress, which includes idioms of distress, perceived causes of distress, and coping/help-seeking behaviors among Indian women from slums reporting gender-based violence. This explanatory model can be used as a culturally grounded way to develop clinical case conceptualizations to adapt and deliver psychological treatments for this under-served population.

A pilot study adapting and validating the Harvard Trauma Questionnaire (HTQ) and PTSD checklist-5 (PCL-5) with Indian women from slums reporting gender-based violence

Background

Despite high rates of gender-based violence (GBV) in India, culturally sensitive measures that examine universal and culturally relevant trauma reactions are lacking. Although the Harvard Trauma Questionnaire (HTQ) has been used in India, no study has adapted the measure in full for use with this population. Similarly, the  PTSD checklist-5 (PCL-5) has not yet been validated in India. This study describes the adaptation, validation, and results from the adapted HTQ, and embedded PCL-5, for Indian women from slums reporting GBV.

Method

This study used the adaptation framework proposed by the HTQ measure developers. The adapted HTQ contained a (1) trauma screen relevant for stressors faced by Indian women from slums, (2) description of the index trauma, (3) description of any ongoing stressors, (4) universal trauma reactions (i.e., PTSD measured by the PCL-5), and culturally relevant trauma reactions (i.e., idioms of distress measured by a scale developed for the study). This measure was piloted on 111 women from Indian slums in face-to-face interviews. Trauma characteristics, types of ongoing stressors, and psychometric properties of the PCL-5 and idioms of distress scale were explored. These scales were validated against measures of depression (PHQ-9), anxiety (GAD-7), and somatic complaints (PHQ-15).

Results

The majority of participants (77%) reported physical beatings, 18% reported unwanted sexual touch, and 28.8% reported infidelity as the primary emotional abuse. Further, 96.7% of GBV was perpetrated by partner or family member and over half reported ongoing stressors (e.g., poverty-related strain). The PCL-5 embedded in the HTQ yielded good internal consistency (Cronbach’s alpha = .88) as did the idioms of distress scale with deletion of one item (Cronbach’s alpha = .80). Both scales were externally valid, yielding large correlations with depression, anxiety, and somatic complaints (rs between .54 and .80, ps < .05).

Discussion

This is the first study to develop a comprehensive measure of trauma exposure with universal and culturally relevant trauma reactions in India. This study also enhances HTQ usage in India by delineating all the steps in the adaptation process. Results can inform the development of trauma-focused interventions for Indian women from slums.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12905-022-01595-3.

Distress Due to Nonpathological Vaginal Discharge: A New Face of Dhat Syndrome in Females

Female Dhat syndrome (FDS) is not yet an established clinical entity, but nonpathological vaginal discharge has been discussed in the scientific literature for quite a long time. Various studies have reported the existence of the phenomenon of nonpathological vaginal discharge. All the existing literature on Dhat syndrome was reviewed. Studies have reported that nonpathological vaginal discharge has a high prevalence among the rural and urban populations of Indian women (around 30%). The symptom of vaginal discharge has been an area of concern for a sizable proportion of women in the community, and anxiety related to this has been a frequent reason to seek medical attention. The ideas associated with vaginal discharge are similar to Dhat syndrome in males. The variations of associated symptomatology, course of illness, and somatization of the complaint make it challenging to diagnose and treat. The diagnostic criterion needs careful evaluation; management needs an appropriate multidisciplinary approach by various health team members, including psychological interventions and adjunct pharmacotherapy in effectively managing the FDS. Dhat syndrome in females has similar phenomenology to that in males. Unfortunately, this is under-researched and hence, underdiagnosed.

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

Background

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

Methods

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

Results

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

Conclusion

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

Sexual intimacy and marital relationships in a low-income urban community in India

Data from a six-year study of married women's sexual health in a low-income community in Mumbai indicated that almost half the sample of 1125 women reported that they had a negative view of sex with their husbands. Qualitative interviews and quantitative survey data identified several factors that contributed to this diminished interest including: a lack of foreplay, forced sex, the difficulty of achieving privacy in crowded dwellings, poor marital relationships and communication, a lack of facilities for post-sex ablution and a strong desire to avoid conception. Women's coping strategies to avoid husband's demands for sex included refusal based on poor health, the presence of family members in the home and non-verbal communication. Factors that contributed to a satisfactory or pleasurable sexual relationship included greater relational equity, willingness on the part of the husband to not have sex if it is not wanted, a more 'loving' (pyaar karna) approach, women able to initiate sex and greater communication about sexual and non-sexual issues. This paper examines the ecological, cultural, couple and individual dynamics of intimacy and sexual satisfaction as a basis for the development of effective interventions for risk reduction among married women.

Correlates of domestic violence perpetration reporting among recently-married men residing in slums in Pune, India

Domestic violence (DV) is prevalent in low-income and slum-dwelling communities in India. To date, the focus of DV prevention in resource-poor settings has largely been with women. We herein aim to identify correlates of DV perpetration to help inform future primary prevention efforts that focus on behavioral change in men. Utilizing a cross-sectional design, potential correlates of DV perpetration were explored among a geographically-clustered random sample of 100 recently-married men residing in slums in Pune, India. In multivariable regression, DV perpetration was associated with less time spent alone in the relationship post-marriage (standardized β = -0.230, p<0.01), not attaining the “husband ideal” (standardized β = -0.201, p<0.05), poor resilience (standardized β = -0.304, p < .01), having limited definitions of behaviors constituting DV (standardized β = -0.217, p<0.05), and reporting greater jealousy if the participant’s spouse were to talk to men outside the family (standardized β = 0.272, p<0.01). The identified correlates should inform components of future DV primary prevention interventions that target men as potential perpetrators or the couple as a unit.

An approach to mental health in low and middle income countries: a case example from urban India

Women in low and middle income countries (LMICs) facing poverty, challenging living conditions and gender inequality often express their emotional difficulties through physical health concerns and seek care at primary health facilities. However, primary care providers in LMICs only treat the physical health symptoms and lack appropriate services to address women's mental health problems. This paper, presents data from the counseling component of a multilevel, research and intervention project in a low income community in Mumbai, India whose objective was to improve sexual health and reduce HIV/STI risk among married women. Qualitative data from counselor notes shows that poor mental health, associated with negative and challenging life situations, is most often expressed by women as gynecological concerns through the culturally-based syndrome of tenshun. A path analysis was conducted on baseline quantitative data that confirmed the relationships between sources of tenshum, emotional status and symptoms of common mental disorders (CMDs). Based on these findings, the authors propose a need for culturally appropriate primary care services for LMICs that would integrate mental and physical health. This approach would reduce mental health morbidity among women through early intervention and prevention of the development of CMDs.

Use of smokeless tobacco by Indian women aged 18-40 years during pregnancy and reproductive years

Objectives

This paper discusses patterns of daily smokeless tobacco (SLT) use and correlates of poly SLT use among married women aged 18–40 years in a Mumbai slum community with implications for tobacco control.

Methods

Using a mixed methods approach, the study included a structured survey with 409 daily SLT users and in-depth interviews with 42 women. Participants for the survey were selected using a systematic sampling procedure (one woman in every fourth eligible household). Univariate and bivariate analysis, and multiple logistic regressions were conducted to identify demographic and social factors associated with women’s use of poly SLT products. To illustrate survey results, in-depth interviews were analyzed using Atlas ti software.

Results

Sixty-four percent of the women surveyed used only one type of SLT; of these, 30% used mishri, 32% used pan with tobacco and the rest used chewed tobacco (11%), gul (17%) or gutkha (10%). Thirty-six percent used more than one type of SLT. Poly SLT users chewed or rubbed 50% more tobacco as compared to single users (mean consumption of tobacco per day: 9.54 vs. 6.49 grams; p<0.001). Women were more likely to be poly SLT users if they were illiterate as compared to literate (adjusted odds ratio [AOR]=1.67; 95% confidence interval [CI]=1.07-2.71), if they had lived in Mumbai for 10 years or more, versus less than ten years (AOR=1.67, 95% CI=1.03-2.71); and if their husband was a poly SLT user as compared to a non SLT user (AOR=2.78, 95% CI=1.63-4.76). No differences were noted between pregnant and non-pregnant women in SLT consumption patterns.

Conclusions

Tobacco control policies and programs must focus specifically on both social context and use patterns to address SLT use among women of reproductive age with special attention to poly SLT users, an understudied and vulnerable population.

A model for translating ethnography and theory into culturally constructed clinical practices

This article describes the development of a dynamic culturally constructed clinical practice model for HIV/STI prevention, the Narrative Intervention Model (NIM), and illustrates its application in practice, within the context of a 6-year transdisciplinary research program in Mumbai, India. Theory and research from anthropology, psychology, and public health, and mixed-method ethnographic research with practitioners, patients, and community members, contributed to the articulation of the NIM for HIV/STI risk reduction and prevention among married men living in low-income communities. The NIM involves a process of negotiation of patient narratives regarding their sexual health problems and related risk factors to facilitate risk reduction. The goal of the NIM is to facilitate cognitive-behavioral change through a three-stage process of co-construction (eliciting patient narrative), deconstruction (articulating discrepancies between current and desired narrative), and reconstruction (proposing alternative narratives that facilitate risk reduction). The NIM process extends the traditional clinical approach through the integration of biological, psychological, interpersonal, and cultural factors as depicted in the patient narrative. Our work demonstrates the use of a recursive integration of research and practice to address limitations of current evidence-based intervention approaches that fail to address the diversity of cultural constructions across populations and contexts.

Women's empowerment and its differential impact on health in low-income communities in Mumbai, India

This paper examines the relationship of empowerment to women's self-reported general health status and women's self-reported health during pregnancy in low-income communities in Mumbai. The data on which this paper is based were collected in three study communities located in a marginalised area of Mumbai. We draw on two data sources: in-depth qualitative interviews conducted with 66 married women and a survey sample of 260 married women. Our analysis shows that empowerment functions differently in relation to women's reproductive status. Non-pregnant women with higher levels of empowerment experience greater general health problems, while pregnant women with higher levels of empowerment are less likely to experience pregnancy-related health problems. We explain this non-intuitive finding and suggest that a globally defined empowerment measure for women may be less useful that one that is contextually and situationally defined.

Understanding psychological distress among mothers in rural Nepal: a qualitative grounded theory exploration

BACKGROUND

There is a large burden of psychological distress in low and middle-income countries, and culturally relevant interventions must be developed to address it. This requires an understanding of how distress is experienced. We conducted a qualitative grounded theory study to understand how mothers experience and manage distress in Dhanusha, a low-resource setting in rural Nepal. We also explored how distressed mothers interact with their families and the wider community.

METHODS

Participants were identified during a cluster-randomised controlled trial in which mothers were screened for psychological distress using the 12-item General Health Questionnaire (GHQ-12). We conducted 22 semi-structured interviews with distressed mothers (GHQ-12 score ≥ 5) and one with a traditional healer (dhami), as well as 12 focus group discussions with community members. Data were analysed using grounded theory methods and a model was developed to explain psychological distress in this setting.

RESULTS

We found that distress was termed tension by participants and mainly described in terms of physical symptoms. Key perceived causes of distress were poor health, lack of sons, and fertility problems. Tension developed in a context of limited autonomy for women and perceived duty towards the family. Distressed mothers discussed several strategies to alleviate tension, including seeking treatment for perceived physical health problems and tension from doctors or dhamis, having repeated pregnancies until a son was delivered, manipulating social circumstances in the household, and deciding to accept their fate. Their ability to implement these strategies depended on whether they were able to negotiate with their in-laws or husbands for resources.

CONCLUSIONS

Vulnerability, as a consequence of gender and social disadvantage, manifests as psychological distress among mothers in Dhanusha. Screening tools incorporating physical symptoms of tension should be envisaged, along with interventions to address gender inequity, support marital relationships, and improve access to perinatal healthcare.

Association of somatoform disorders with anxiety and depression in women in low and middle income countries: a systematic review

BACKGROUND

Across cultures, women are more likely than men to report somatoform disorders (SD), depression and anxiety. The aim of this article is to describe the co-morbidity of SD with depression/anxiety and to investigate the possible mechanisms of this relationship in women in low and middle income countries (LMIC).

METHODS

We reviewed two databases: MEDLINE and PsycINFO from 1994 to 2012 for studies which assessed the association between any SD and depression/ anxiety in women from LMIC. Our focus was on community and primary healthcare based studies. Both quantitative and qualitative studies were included.

RESULTS

A total of 21 studies covering eight LMICs were included in our analysis. Our findings suggest a strong association between SD and depression/anxiety (with odds ratios ranging from 2.5-3.5), though we also observed that the majority of women with SD did not have depression/anxiety. The likely mechanisms for this association are multidimensional, and may include shared aetiologies, that both conditions are in fact variants of the same primary mental disorder, and that one disorder is a risk factor for the other. Anthropological research offers a number of frameworks through which we can view these mechanisms.

CONCLUSION

The current evidence indicates that service providers at the primary care level should be sensitized to consider SD in women as variants of CMD (Common Mental Disorders) and address both groups of disorders concurrently. Further research should explicitly seek to unpack the mechanisms of the relationship between SD and CMD.