Management of reproductive tract infections among health providers and in the community in Lao People s Democratic Republic

University dissertation from Stockholm : Karolinska Institutet, Department of Public Health Sciences

Abstract: Background: Reproductive tract infections (RTI), including sexually transmitted infections (STI) constitute an important health threat, both directly and through their potential effect in facilitating HIV transmission. Creating community awareness of RTI/STI and how to prevent them is essential in minimising their spread. Health providers play a critical role in controlling RTI/STI spread. No previous study on RTI/STI management among health providers and in the community was carried out in Laos. Objectives: (1) To describe antimicrobial use as self-medication for RTI/STI; (2) To clinically and microbiologically identify RTI/STI, and to monitor the antimicrobial susceptibility of N. gonorrhoeae; (3) To explore community members’ perceptions, treatment-seeking behaviour and understanding of health information about RTI/STI; and (4) To assess health providers’ reported knowledge and practice competence regarding RTI/STI management. Methods: Structured interviews were conducted with 500 community members aged 18 or above, who had used antimicrobials as self-medication for RTI/STI during the past year. They were recruited among 3056 family members in Vientiane Capital (VTC) and Champasak Province (CPS) (Paper I). In total, 1125 women aged 15-49 years attending a gynaecology out-patient department underwent a pelvic examination, and specimens were taken for laboratory testing (Paper II). Fourteen focus group discussions (FGDs) and 20 individual interviews (IDIs) were held with a total of 132 participants (76 women, 56 men) in urban and rural communities in VTC and CPS (Paper III). All 272 health providers (medical doctors/assistants, midwives/nurses and drug sellers) working with RTI/STI patients in one urban and one rural district in VTC, were invited to fill in a self-completed questionnaire including four written simulated case scenarios, and 93% participated (Paper IV). Results: Among the 500 respondents reporting antimicrobial use as self-medication for RTI/STI, 91% had bought the antimicrobials from local private pharmacies without a physician’s prescription, 58% were advised to buy the drugs from drug sellers, and 79% used antimicrobials for a non-recommended duration of time. Ampicillin (not recommended as syndromic treatment for RTI/STI) was used in 83% of all cases, in 28% combined with tetracycline (Paper I). Among 1125 women, 82% clinically presented with an RTI syndrome. Only 64% had an aetiologically diagnosed RTI, including 11% with an STI. Endogenous infections were most prevalent (candidiasis 40%; bacterial vaginosis 25%), followed by STI (Chlamydia trachomatis 4.1%; N. gonorrhoeae and Trichomonas vaginalis both 3.7%). Of the 41 N. gonorrhoeae isolates, 20% showed resistance to ciprofloxacin, 98% to penicillin, and 100% to tetracycline (Paper II). Both men and women in the FGDs and IDIs exposed some misconceptions about the causes and symptoms of RTI/STI and their cure, and reluctance to seek health care. The most common treatment-seeking behaviour was self-medication through private pharmacies, following advice mostly given by friends and drug sellers. An unwillingness to use condoms was commonly expressed. The main media sources of RTI/STI information were radio and television. Access to health information was poorer in rural areas (Paper III). Of 252 responding health providers, 34% scored below 50% regarding both the case scenarios and reported knowledge, and 87% gave inadequate advice regarding health education. Only 34% gave correct advice on contact tracing, 38% on counselling, 52% regarding compliance and 59% on condom promotion. Drug sellers scored lowest in all aspects of RTI/STI management. Urban respondents were more likely to report adequate knowledge (Paper IV). Conclusions: Strengthening RTI/STI management is recommended, including health education and promotion through interventions at community level, and to health providers, including private drug sellers. Concurrent with syndromic case management, periodic evaluations of aetiological diagnosis should be available to ensure adequacy of treatment algorithms and prescribed medications. Continuous training in syndromic approach and supervision are recommended to improve quality of RTI/STI management, particularly among health providers at private pharmacies and in rural areas. Health education messages should also be improved, particularly in rural areas.

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