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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 9  |  Issue : 1  |  Page : 76-82

How do urban slum women manage excessive vaginal discharge? A community-based cross-sectional study


1 Department of Nursing and Midwifery, Faculty of Allied Health Sciences, University of Sri Jayewardenepura, Nugegoda, Sri Lanka
2 Department of Community Medicine, Faculty of Medical Sciences, University of Sri Jayewardenepura, Nugegoda, Sri Lanka
3 Department of Obstetrics and Gynaecology, Faculty of Medical Sciences, University of Sri Jayewardenepura, Nugegoda, Sri Lanka
4 Department of Biochemistry, Faculty of Medical Sciences, University of Sri Jayewardenepura, Nugegoda, Sri Lanka

Date of Submission24-Dec-2020
Date of Acceptance17-Apr-2021
Date of Web Publication18-Oct-2022

Correspondence Address:
Ilankoon Mudiyanselage Prasanthi Sumudrika Ilankoon
Department of Nursing and Midwifery, Faculty of Allied Health Sciences, University of Sri Jayewardenepura, Gangodawila
Sri Lanka
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cjhr.cjhr_179_20

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  Abstract 


Background: Abnormal vaginal discharge (VD), which is a recurring problem for most of the women at reproductive age, is a good predictor for many gynecological morbidities. Many women constantly neglect abnormal VD because of the prevailing “culture of silence.” Women who live in urban slum are vulnerable to many unhealthy practices and have a high prevalence of reproductive tract infection, especially sexually transmitted infections. Hence, this study aimed to describe urban slum women' understanding, attitudes, and related practices for abnormal VD. Materials and Methods: This community-based cross-sectional study was conducted among 550 women living in urban slum in the Colombo Municipal Council area, Colombo District, Sri Lanka, during September 2015–March 2016. A multistage cluster sampling technique was used. A validated, pretested, interviewer-administered questionnaire was used to collect information from females. Data were analyzed using descriptive and relevant inferential statistics (Chi-square test and one-way analysis of variance). Results: The mean age of the women was 32.51 (standard deviation [SD] ±7.94) years. The mean knowledge score was 29.18 (SD ± 8.68). Most of the women (97.1%) had inadequate level of knowledge (<50%). A significant association was observed between the knowledge score levels with the participants' educational level (P = 0.00). Major areas of knowledge deficit include causes for pathological VD and reproductive tract infections. Majority (95.9%) agreed that abnormal VD should be taken seriously but from the women who accepted (78.2%) that VD has ever been a concern to them, only 59% had consulted a general practitioner. There was a significant relationship with having accompanying symptoms such as burning sensation and lower abdominal pain and consulting a general practitioner (P < 0.05). Conclusions: Culture-specific health education intervention measures need to be targeted in order to improve their knowledge, attitudes, and practices toward VD.

Keywords: Gynecological complaint, health-seeking behaviors, urban slum community, vaginal discharge


How to cite this article:
Sumudrika Ilankoon IM, Evangeline Goonewardena CS, Fernandopulle RC, Rasika Perera PP. How do urban slum women manage excessive vaginal discharge? A community-based cross-sectional study. CHRISMED J Health Res 2022;9:76-82

How to cite this URL:
Sumudrika Ilankoon IM, Evangeline Goonewardena CS, Fernandopulle RC, Rasika Perera PP. How do urban slum women manage excessive vaginal discharge? A community-based cross-sectional study. CHRISMED J Health Res [serial online] 2022 [cited 2022 Dec 8];9:76-82. Available from: https://www.cjhr.org/text.asp?2022/9/1/76/358819




  Introduction Top


Excessive vaginal discharge (VD) (leucorrhea) is a common distressing symptom for many women at reproductive age. It can be a symptom of vaginitis, and may be chronic or may recur after treatment[1] and it is one of the most common health concerns presenting to the hospital.[2] Changes of hormonal levels during menstrual cycle, during pregnancy, due to sexual arousal and atrophic vaginitis are the physiological causes for excessive VD.[3] The pathological causes include infectious causes (sexually transmitted infections [STIs] and non-STIs) and noninfectious causes such as iatrogenic and malignancy (cervical cancer, endometrial cancer, and vaginal cancer).[4]

The most common vaginal infection among women of childbearing age is Bacterial vaginosis which is a non-STI.[5] Rather than the etiology or a definitive diagnosis, perceptions of the characteristics of the discharge and duration might make women concerned about their body image and decrease their self-esteem.[1] Women do not seek treatment as they find VD as something shameful and uncomfortable to disclose and especially, women from South-East Asian region remain silent and thus go without treatment as they consider STIs as the cause of VD.[6]

Urban poor are marginalized socially and economically due to structural and social inequalities, a brutal political economy, and neglect by policymakers.[7] The Colombo District in the western province of Sri Lanka extends over an area of 696 km2 with a population of 2,310,135 living in urban (77.5%) rural (22.2%) and estate (0.4%) sectors of the district.[8] The metropolitan area of city of Colombo area is under the jurisdiction of Colombo Municipal Council (CMC) differs from the rest of the urban areas with respect to population density.[9] Two-thirds of Colombo city residents live in slum and shanties without basic amenities.[10]

The emerging issues among low-income urban dwellers are lack of basic amenities, insecure income, family instability, drug addiction, domestic violence, and a large number of school dropouts.[11] Further, socially marginalized communities have the highest rates of STIs and often do not have access to adequate health services.[12] Women live in urban slum communities are at risk of getting STIs and other reproductive tract infections due to their risk behaviors such as unsafe sex and prostitutions. Their knowledge and perceptions on different disease conditions and preventive strategies are important predictors to develop health promotion activities for this community. Therefore, this study aimed to assess the knowledge, attitudes, and different cultural practices associated with VD and their associated factors among females living in urban slum communities in order to develop a culture-specific health education intervention.


  Materials and Methods Top


Study design

This community-based descriptive cross-sectional study was conducted in a socially marginalized community in Colombo District, Sri Lanka, from September 2015–March 2016. The study population was females aged 18–49 years living in an urban slum for more than 6 months prior to the study. Females who were cognitively impaired at the time of the study were excluded.

Sample size and sampling

Sample size was calculated using 95% confidence level (Z = 1.96), the precision (d) as 0.05, and design effect as 1.3. After inflate the sample size by another 10% to account for nonrespondents, the final sample size was 550 females. A multistage cluster sampling with stratification was used to identify the sample of 550 females.

All the eligible slum wards (34) were selected for the study to achieve the sample size. Thereafter, 16 females aged 18–49 years (550/34) were selected from each slum ward until achieve the sample size. Starting point for sample collection in a cluster was the community center. After selecting the first house nearest to the community center, the subsequent house was selected the one which was closest to and to the right hand side of the first. From the selected houses, the female who is having closest birthday was selected to avoid taking all the females in the house. This procedure was continued until 16 eligible females were recruited from a cluster.

Study instrument

Data were collected using a validated, pretested, interviewer-administered questionnaire. The judgmental validity of the questionnaire was carried out by group of experts in the field of reproductive health including experts from Department of Gynaecology and Obstetrics, Department of Community Medicine, National Institute of Health Sciences and Family Health Bureau in Sri Lanka. English version of the questionnaire was translated into Sinhala and Tamil languages and again retranslated to English to ensure accuracy. Each correct answer was given a score of 1 and incorrect response 0. The maximum score attainable was 25. The total score was converted into percentage and knowledge was specified as good level of knowledge – >75%–100%, moderate level of knowledge – 50%–75%, and poor/inadequate level of knowledge – <50%.[13]

Ethics approval and consent to participate

Ethical clearance was obtained from the Ethics Review Committee, Faculty of Medical Sciences, University of Sri Jayewardenepura, Sri Lanka (ERC Ref No. 27/14). The procedures followed were in accordance with the ethical standards of the Declaration of Helsinki of the World Medical Association. All participants gave written informed consent before commencement of the data collection.

Statistical analysis

Data were coded and entered into Statistical Package for the Social Sciences (SPSS) software (SPSS for Windows version 20 IBM, Chicago, IL, USA) before analysis. Descriptive statistics was applied to obtain percentages and means with standard deviation (SD) for the continuous variables. Chi-square test was performed to assess the association between dependent and independent categorical variables. Pearson's test was used when at least 80% of the cells have expected frequency of 5 or more in the contingency tables (two by two). If this assumption is violated, Fisher's exact test was used. Comparisons of mean knowledge score between three or more independent categorical variables were assessed using one-way analysis of variance and post hoc comparisons were made using the Bonferroni procedure. A P < 0.05 was considered statistically significant in all tests.


  Results Top


Sociodemographic characteristics

A total of 550 females participated in the study and the mean age of the subjects was 32.51 (SD ± 7.938) years. Nearly 38% (n = 211) were Sinhalese and Buddhist. The mean duration of living in urban slum was 21.18 (SD ± 13.08) years. Two hundred and thirty-nine (43.5%) participants had primary education level and nearly 40% had educated up to ordinary level. Majority of the study participants (89.5%) were unemployed and married (92%) [Table 1]. The mean average monthly income of the participants was Rs. 2147.27 (15USD) range from Rs. 0.00 to Rs. 50,000 [Table 1].
Table 1: Knowledge score levels and other sociodemographic characteristics (n=550)

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Score for overall knowledge related to vaginal discharge

Mean knowledge score on VD among the study participants was 29.18 (SD ± 8.69). Majority of the study participants (534, 97.1%) had poor level of knowledge (<50%) and a very few of the participants (16, 2.9%) had a moderate level of knowledge (50%–75%). There were no any participants having good level of knowledge (>75%) in the study sample. A significant association was observed between the knowledge score levels with the participants' educational level (P = 0.00). None of the other sociodemographic characteristics had significant associations with the knowledge score levels.

The median knowledge score declined significantly in lower educational levels when compared to higher level of education. There was a statistically significant difference in median differences of knowledge score across all four educational groups (H = 26.99, P = 0.00) with a mean rank of 259.70 for not attended school, 243.88 for primary education, 288.44 for ordinary Level, and 346.69 for advanced level group. Post hoc test (Mann–Whitney U-test) comparisons of four groups indicate that median knowledge score was significantly higher among participants who had educated up to advanced level when compared to not attended school (P = 0.03), primary education (P = 0.00), and ordinary level (P = 0.002).

Knowledge related to vaginal discharge

About 70% of the study participants (n = 386) were of the opinion that VD is always normal. Most of them (81%) were of the opinion that the color of the VD is white. The consistency of the normal vaginal secretion was identified as thin by 55.8% and mucoid by 26.9%. Majority (91%) agreed that the odor of the normal vaginal secretion is nonoffensive.

As shown in [Table 2], majority of the study participants (83.5%) were of the opinion that “a clear, nonoffensive discharge that varies with the menstrual cycle is a normal physiological secretion,” “vaginal secretions vary with menstrual cycle” (73.3%), “women aged between 15–49 years have a normal physiological vaginal secretion” (85.1%), and “white or colored VD may be a sign of reproductive tract infections” (66%).
Table 2: Knowledge related to vaginal discharge among urban slum community (n=550)

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Knowledge related to causes for excessive vaginal discharge

The main causes for excessive VD identified by the participants were high body temperature (82.2%) and vitamin deficiency (55.6%). Nearly half of the participants identified human immunodeficiency virus as a STI (59.5%). Most of the participants (62.0%) stated that they receive information on VD from their relatives [Table 3].
Table 3: Awareness of causes of excessive vaginal discharge and sexually transmitted infections (n=550)

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Attitudes towards vaginal discharge

The majority of the study participants (96%) agreed that abnormal VD should be taken seriously and 93% agreed that, it is necessary to take treatment for offensive VD. The majority agreed excessive VD can occur due to “body heat” (85.1%), due to “body weakness” (84.2%), and due to “vitamin deficiency” (65.6%). In addition, more than half of the study participants (59.6%) agreed that it is uncomfortable to talk about VD with others [Table 4].
Table 4: Attitudes regarding vaginal discharge (n=550)

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Experience with vaginal discharge and health-seeking behaviors

Majority of the participants (n = 430, 78.2%) stated that VD has ever been a concern to them. Among them, more than 60% mentioned that itchiness and scratching is a common accompanying symptom. Nearly 59% of them had consulted a general practitioner. More than half of the participants have used Fenugreek (Uluhal) drink (62.6%) and polpala herbal drink (57%) as home remedies for excessive VD [Table 5]. There was a significant association between the employment status with the health-seeking behaviors from a general practitioner in the present study (Pearson's Chi-square, P < 0.05).
Table 5: Common symptoms, practices, and health-seeking behaviors related to abnormal vaginal discharge (n=430)

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There was a statistically significant association between seeking treatment from a general practitioner and experiencing accompanying symptoms such as lower abdominal pain (P = 0.01) and burning sensation (P = 0.00) [Table 6].
Table 6: Accompanying symptoms experienced with abnormal vaginal discharge and consultation with general practitioner (n=430)

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Perceived factors associated with health-seeking behaviors toward excessive vaginal discharge

The perceived factors associated with females' decision on self-treatment for excessive VD were identified as embarrassment in discussing with doctors (54%) and cultural view of VD (36.7%). Majority (87.5%) mentioned that feeling difficulty in discussing with a male doctor and less knowledgeable about VD (61.1%) as the reasons for them not to take medical advice for excessive VD [Table 7].
Table 7: Perceived factors associated with health-seeking behaviors towards excessive vaginal discharge

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  Discussion Top


VD is a major health concern among women of reproductive age group. The findings of this study provide insights into the current level of understanding about VD and different practices among females aged 18–49 years living in an urban slum community.

This study revealed that majority of the participants had a previous history of abnormal VD in their lifetime. This is comparable to a similar study conducted in New York City which showed that 85% of women presented with itching and VD.[14] Another study conducted among women aged 18–60 years in South Africa have found that almost half of the participants reported having an abnormal discharge at least once (47.1%).[15] Further, nearly half of the married adolescent women have experienced white VD in a Dhaka urban slum community.[7]

The knowledge level of the females of urban slum community on different a spects of VD was found to be inadequate; the mean knowledge score on VD among females in the urban slum community was 29.18 (SD ± 8.69) out of 100. Similarly, a study conducted among married women who were suffering from VD in Pakistan revealed that most of the females had no prior factual knowledge about vulvo-VD and its nature.[16] There has been a statistically significant difference in knowledge score noticed with respect to the highest educational level in the urban slum community. In another study, a significant association between educational status of the female and consultation for VD has been observed in a study conducted to assess rural women's perception and health care-seeking behavior regarding excessive VD in India.[17] Similarly, poor level of knowledge related to vulvo-VD was found among women having low educational level in a similar study conducted among women living in estate sector, Sri Lanka.[18] The poor knowledge on vulvo-VD and reproductive tract infections among the females in the present study might be related to their educational levels which keep them away from learning new things.

Similar to other studies done in Asian countries, majority of the females in the present study displayed poor knowledge on reproductive tract infections, including both STIs and non-STIs.[19],[20] Another study, brought up the idea that the overall knowledge of the respondents about the symptoms of reproductive tract infections was poor, and only nearly half agreed that VD is a symptom of reproductive tract infections.[21] In the present study, majority of the females were not aware of the causes for excessive VD such as infections including STIs, and cancer but expressed that the excessive VD is due to high body temperature, vitamin deficiencies, and consumptions of heaty food. Similar to that, women had shown lack of knowledge on VD and its causes in another study.[22] Further, similar to the present study findings, heaty food and excessive body heat were recognized as causes for excessive VD by the respondents in another study.[17] Furthermore, some studies have recognized using antibiotics, contraceptive pills, washing powder, or products used in the bath, overheating, or tight trousers and sterilization operation and sexually transmitted disease as causes for excessive VD.[23]

Misconceptions on causes of abnormal VD, which can lead to certain practices such as use of home remedies and Ayurvedic treatment, were revealed in this study. Similar to the present study, a study conducted in rural communities in India identified lack of awareness regarding causes of abnormal VD.[17] Women have mentioned that poverty/tension/worries and weakness as possible causes of VD in studies conducted in Nepal and Bangladesh.[6],[7]

Majority of the females in the present study had the attitude of any type of VD is a normal condition and it prevents them from seeking medical advice even for pathological VD. In contrast, in a study conducted in Katmandu, Nepal, more than half (51%) of the women believed that VD was not a normal condition.[6] Although the majority agreed that treatment is necessary for offensive VD, it was found in the present study that nearly 59% of women in urban slum community had consulted a general practitioner and sought medical advice. In contrast, a study conducted among women of reproductive age in Lagos, Nigeria, highlights that, VD was one of the most common symptom reported (21.8%) and majority of the women (87.9%) have sought medical advice for abnormal VD.[21] It has been explained that high prevalence of treatment seeking is due to the awareness about infertility as a complication of STIs and of the need to prevent it.[21]

In the present study, majority have mentioned that it is difficult to discuss about VD with male doctors similar to other studies.[24] Another study highlights that women were found hiding VD due to embarrassment, shyness, and environmental constraints.[16] Further, it has been found that women believe that VD is a result of a woman's fate and that it is unexplainable.[25] Furthermore, following several treatment modalities that were unsuccessful, women have been observed concluding that VDs is incurable, and they must learn to live with it.[26] Therefore, proper education on VD and related health conditions need to be given to the females in order to recognize abnormal VD.

The present study discovered that many women preferred self-treatment and homeopathic care for abnormal VD, as they were affordable, and some of them said that they visited local pharmacies and healers to manage the symptoms. Furthermore, another study by O'Dowd et al. found that one-third of women used over-the-counter remedies, mostly even without consulting the pharmacist.[24] The most commonly used home remedies for abnormal VD among urban slum community were Uluhal (Fenugreek) drink and Polpala herbal drink (Balipoovu, Aerva lanata) similar to other Sri Lankan study.[18],[27] Some South Asian Ayurveda practitioners have advised women to avoid “heaty” food such as ghee, eggs, or meat, to prevent of VD.[2]

In addition, cultural views on VD were mentioned by a few females as a reason for not seeking medical advice in the present study. Majority of the females in the present study mentioned that they have sought treatment at the end, because the condition got worse or due to fear of serious disease consequences or due to VD being intolerable. Rashid found that women seek treatment from doctors only when the discharge became “abnormal,” “smelly,” or “thick.”[7]

In a study conducted among women living in low socio-economical status in India has found that the majority of the women with VD had another coexisting gynecological complaint (94%).[28] The researchers have found that there is a strong association between the coexisting gynecological complaint and VD.[28] Similar to that, in the present study it has been found that, having other accompanying symptoms with VD, such as lower abdominal pain and burning sensation, was considered a positive predictor to seek medical advice, similar to other studies.[18],[21],[29]


  Conclusions Top


The study participants demonstrated poor understanding of different aspects of abnormal VD. Women try to hide abnormal VDs due to poor knowledge and being afraid of disclosing such matters due to social taboo attached to them. This leads to serious consequences of untreated reproductive morbidities. Adequate information is needed to be given to women regarding the normal and abnormal VD, which will help them to get early treatments for pathological VD. It is necessary to organize health education programs for the given community, making these factors the fundamental consideration.

Implications of this study

Topics such as recognition of abnormal VD, common causes for VD (including STIs, non-STIs, and malignancy), and consequences of untreated abnormal VD can be included in a culture-specific health education program for this community. Further, it is necessary to address their different cultural practices and beliefs regarding VD during the educational program. This would help women to identify abnormal VD, which improves health-seeking behaviors toward pathological VD. Further, it is essential to provide a comfortable and confidential environment for women to discuss the problem in privacy. It enhances the health-seeking behavior of women for abnormal VDs.

Acknowledgments

The authors thank all the participants, public health midwives, and the staff in the Maternal and Child Welfare Centers, CMC, for their support.

Financial support and sponsorship

The authors appreciate the institutional research grant (Grant No: ASP/06/RE/MED/2013/31) of University of Sri Jayewardenepura, Sri Lanka for financial support.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

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