REPRODUCTIVE HEALTH PROBLEMS AND TREATMENT SEEKING BEHAVIOURAMONG MEN IN TAMIL NADU

Transcription

1 CHAPTER VII REPRODUCTIVE HEALTH PROBLEMS AND TREATMENT SEEKING BEHAVIOURAMONG MEN IN TAMIL NADU

2 CHAPTER VII REPRODUCTIVE HEALTH PROBLEMS AND TREATMENT SEEKING BEHAVIOUR AMONG MEN IN TAMIL NADU 7.1 INTRODUCTION In the recent years, much attention has been paid to reproductive health status of men especially after the International Conference on Population and Development (lcpd) held in Cairo in In India, reproductive health care services for men were largely ignored by the public health programmes in the initial phase. However, the Reproductive and Child Health (RCH) programme now includes reproductive health care services for men especially treatment for Reproductive Tract Infection (RTI)/Sexually Transmitted Infection (STI). Efforts have therefore been made to assess the need for such services. In the District Level Household Survey-Reproductive and Child Health (DLHS-RCH-2) survey carried out between 2002 and 2004, the men in the sample were asked a series of questions about awareness of RTIISTI and HIV/AIDS, symptoms of RTIISTI, and treatment seeking behaviour. Husbands of. currently married women in the age group of years in the sample, that is currently married men with wife in the age range years, were interviewed irrespective of their (husband's) own age. In this chapter, we examine the prevalence of RTIISTl and treatment seeking behaviour among currently married men in Tamil Nadu. First, the prevalence of any symptom of RTI/STI and treatment seeking behaviour are discussed. The prevalence rate is based on self-reported symptoms. Finally, the logistic regression and multinomial regression models are invoked to understand the net influences of socio-economic and demographic factors on the prevalence of RTIISTI and treatment seeking behaviour. 7.2 LEVELS OF PREVALENCE OF SYMPTOMS OF RTI/STI AND TREATMENT SEEKING BEHAVIOUR Prevalence of Symptoms of RTI/STI Table 7.l presents prevalence of various symptoms of RTIISTI among currently married men in Tamil Nadu. The prevalence (actually period prevalence for a period of three months) is 154

3 quite low as reported. Only 2.8 percent of men in Tamil Nadu have reported experiencing some symptom of RTIISTI during the reference period of three months prior to the survey. Ainong all symptoms, difficulty/pain while urinating or frequent urination (1.1 percent), itching/irritation around genital (1.2 percent) were the most commonly reported ones by the respondents. In addition, less than one percent of men reported any sore/rash/redness on genital or anal area, any discharge from penis and swelling of testes or in groin area (penis). Table 7.1: Prevalence of Various Symptoms of Reproductive Tract Infection/Sexually Transmitted Infection among Currently Married Men, Tamil Nadu Types of RTIISTI Symptom Any discharge from penis Any sore/rash/redness on genital or anal area Difficulty/pain while urinating or very frequent urination Swelling of testes or in groin area (penis) Itching/irritation around genital Anyone symptom of RTI/STI Number of Men Interviewed Number of Men who Reported the symptom ,751 Source: Computed from DLHS RCH, data file. Note: I. Based on self reponed symptoms during three months prior to the survey. 2. The percentages are computed after applying survey samp1e weights and the number of men given is unweighted. 3. The percentages fot different symptoms do not add up to the percentage for any symptoms due to multiple responses. Percent of Men who Reported the Symptom ,751 The severity of symptoms of RTl/STl is indicated in Table 7.2, which gives the distribution of symptomatic men by number of symptoms. About 3.6 percent reported three or more symptoms ofrtiisti and nearly one-fifth (19.5 percent) reported two or more symptoms of RTIISTI. 155

4 Table 7.2: Percent Distribution of Currently Married Men who Reported at least One Symptom of RTI/STI by Number of Symptoms, Tamil Nac1u Number of Symptoms Reported One symptom Two symptoms Three symptoms F our symptoms ~_t~~~_~~~ptoms At least one symptom Average number of symptoms Source: Computed froni DLHS-RCH, data file. «:;= Among those men who reported any symptom of RTlISTI. Nole:.._ _._._..._._..... Number of Men _ _...._-_. I. Based on self reponed symptoms during three months prior to the survey. 2. The percentages are computed after applying survey sample weights and the number ofmeo given is unweighted Treatment Seeking for RTIISTI Percent of Men Not all the men with RTIISTI will seek treatment for it; while some may not feel that the symptoms are serious enough to warrant treatment some others may be too shy to do so and for some there may not be awareness of or access to treatment. It is important, therefore, to see the extent of treatment seeking. Besides we would also like to see whether public health facilities are utilised or do men obtain treatment from the private health facility. The DLHS ReH survey data anow an examination of these aspects. About half (45.5 percent) of men who had reported any symptom of RTI/STI sought treatment (Table 7.3); private health facility (27.6 percent) is more favoured than public health facility (16.0 percent), and other facility (3.0 percent). Men had sought treatment generally from non-governmental organisationltmst hospital/clinic (12.9 percent), chemist/medical shop (8.4 percent) among private medical facility and from government/municipal hospital (7.6 percent), community health centre/mral hospital (5.5 percent) among public health facility for symptom of RTIISTI. Table 7.3 shows that majority of men who had reported anyone symptom of RTIISTI, had sought treatment from doctors (33.1 percent) followed by chemist/medical shop (9.1 percent) and home remedy (2.4 percent). 156

5 Table 7.3: Source of Treatment for Reproductive Tract Infection/Sexually Transmitted Source of Treatment Infection among Currently Married Men, Tamil Nadu Public Health Facility Government/municipal hospital Government dispensary UHC/UHP/UFWC CHC/rural hospital Primary health centre Health sub-centre Government ISM hospital/clinic Private Health Facility NGO/trust hospital/clinic Private hospital/clinic Private ISM hospital/clinic Chemist/medical shop Other Person Providing Treatment Doctor Male health worker Traditional healer Relatives/friends Number of Men Percent Among Those who Reported Symptom OJ Sought Treatment ISM practitioner Home remedy Chemist/medical shop Other _ _ _ _ Sought treatment Did not seek any treatment no Missing J 0.3 no Total Number of Men Source: Computed from DLHS-RCH, data file. UHC= Urban Health Centre: UHP= Urban Health Post; UFWC= Urban family Welfare Centre: CIfC= Community Health Centre: ISM= Indian System of Medicine: NGO= Non-Governmental Organisation; na= Not Applicable. Note: I. The percentages arc compulcd after app}ying survey sample weights and the number of men given is unweighted. 2. Total number and perccmages may add to more than because of multiple responses. 157

6 7.3 DIFFERENTIALS IN PREY ALEN ee OF RTI/STI AND TREATMENT SEEKING BEHAVIOUR Prevalence of Symptoms ofrtiisti Overall in Tamil Nadu, the prevalence of reproductive tract infection/sexually transmitted infection among men is low (2.8 percent). Variations across regions of Tamil Nadu in the prevalence rate are low in absolute tenns but notable in relative terms; the prevalence of symptom of RTIISTI ranges from 3.7 percent in the Southern region and 1.7 percent in the Inland region. The prevalence of RTI/STI varies across the socio-economic background of men. Table 7.4 clearly demonstrates that prevalence rates are the highest among men residing in rural areas, belonging to the Hindu religion, belonging to Scheduled Castes (SC)/Scheduled Tribes (ST), those with low level of education, with low household standard of living, and young men (15-24 years). The prevalence could conceivably vary by awareness of sexual health matters (since it is based on self-reports) and also by condom use and availability of health facility in the community (as this could lead to greater awareness and better reporting). In order to see this, special tabulations were made (Table 7.5). The prevalence ofrtiisti is relatively low among condom users. There is considerable evidence that the prevalence of RTIISTI is relatively high among men who are not aware of HIV/AIDS (5.1 percent), men whose wife reported experience of RTIISTI (7.3 percent) and men living in the villages that have connected to all weather road (4.0 percent). 158

7 Table 7.4: Percent of Currently Married Men Who Reported any Symptom of Reproductive Tract Infection/Sexually Transmitted Infection by Various Background Characteristics, Tamil Nadu Percent who Reported Number of Background Characteristics Any Symptom of Men RTI/STI Interviewed Region Coastal-northern 2.7 5,641 Coastal 4.0 6,076 Southern 3.1 7,257 Inland 1.7 4,777 Residence Rural ,338 Urban ,413 Religion Hindu ,132 Muslim 1.2 1,272 Others (Christian) 2.1 1,347 Caste abc ,902 SC/ST 3.6 6,431 Others Education Non-literate 3.6 4,340,L 0-5 years of schooling' 3.8 4, years of schooling 2.6 9, and above years of schooling 1.5 5,313 Standard of living Low 3.7 6,888 Medium 3.1 9,812 High 1.4 7,051 Age of men (Years) , , , , ,706 All Men ,751 Source: Computed from DLHS-RCH, data file. t= Literate men with no years of schooling are included. Note: I. Based on se1f-reported symptoms during three months prior to the sun'ey. 2. The percentages are computed after applying survey sample weig.hts and the number of men given is unweighled. 3. Total number of men may nol add to n due to missing cases. 159

8 Table 7.5: Percent of Currently Married IVIen Who Reported any Symptom of Reproductive Tract Infection/Sexually Transmitted Infection by Indicators of Contraceptive Use, Awareness and Health Facility, Tamil Nadu Indicators Condom use Non-user User Aware ofrti/sti Not aware Aware Aware ofhiv/aids Not aware Aware Wife experienced any symptom of RTIISTI No Yes All Men For the Rural Sample VilJage connected by all weather road No Yes Distance to transport facility Up to 2 Km. More than 2 Km. Distance of village from district HQ Up to 50 Km. More than 50 Km. Health facility in the village No health facilitv J With health facility Health provider in the village No health provider in the village With hea1th provider in the village All Men in the Rural Sample Percent who Reported Any Symptom of RTIISTI Sourt'~: Computed from DlHS-RCH, data file. HCF Headquaner Note: I. Based on self-reported symptoms during three months prior to the survey. 2. The percentages are computed after applying survey sample weights and the number of men given is unweighted. 3. Total number of men may not add to n due to missing cases Number of Men Interviewed 23, ,719 18, ,267 19,630 4,121 23,751 2,906 10,432 9,739 3,599 9,596 3,742 6,118 7,220 10,523 2,815 13,

9 7.3.2 Treatment Seeking for RTIISTI Among those who reported some symptoms, more than two-fifths sought treatment from any source. As noted earlier, 103 took treatment from the public health facility, 174 from the private health facility, and 18 from other facility. Some took treatment from both public and private health facilities, but the number is very small, eight. For the purpose of further analysis, they are included only in the category of private health facility. Similarly, those who did not specify the type of facility (others) are also included in the private health facility category. As the numbers of such persons are very small, this re-classification makes very little difference but the analysis is simplified, with only three categories: public health facility, private health facility, and no treatment. There are considerable differences with socio-economic background of men in seeking treatment for their symptoms. In treatment seeking from the public health facility large differentials are seen by region, education, household standard of living, age of men, and awareness of HIV/AIDS (Tables 7.6 and 7.7). Illiterate men and those in the age group of years have a high tendency to seek treatment from the public health facility for RTI/STI. Besides, men residing in the southern region, those belonging to the other backward castes, men with 11 and above years of schooling, high household standard of living, in the age of 45 and above years, users of condom, and aware of HIV/AIDS are more likely to seek treatment from the private health facility. 161

10 Table 7.6: Percentage Distribution of Currently Married Men Who Sought Treatment for Symptoms of Reproductive Tract Infection/Sexually Transmitted Infection by Type of Health Facility and Background Characteristics, Tamil Nadu Treatment Seeking Behaviour (in ~ercent) Number Treatment Treatment of Men from from who Background Characteristics No Public Private Total Reported Treatment Health Health Any Facility Facilitv Symptom " Region Coastal-northern Coastal 5l Southern Inland Residence Rural Urban Religion Hindu Muslim x x x x 16 Others (Christian) (62.5) ( 12.5) (25.0) Caste OBC SC/ST Others x x x x 2 Education Non-literate years of schoo]ingt years of schooling ] and above years of schooling 75 Standard of living Low Medium High Age of men (Years) (60.5) (11.6) (27.9) B ] All Men Source: Computed from DLHS-RCH, data file. I ) = Based on 2S-49 unweighled cases. x =:; Percentage no1 shown; based on less 1han 25 unweighted cases. t = Literate men with no years of schooling are included. Not(": I. The percentages are: computed after applying survey sample weights and the number of men given is un\... cighled. 2. Total number of men may not add to n due to missing cases. 162

11 Table 7.7: Percentage Distribution of Currently Married Men Who Sought Treatment for Symptoms of Reproductive Tract Infection/Sexually Transmitted Infection by Type of Health Facility and Contraceptive Use, Awareness and Health Facility, Tamil N adu Treatment Seeking Behaviour {in percent} Number Treatment Treatment of Men Indicators No from from who Treatment Public Private Total Reported Health Health Any Facilitv.. Facility Symptom Condom use Not-user User x x x x 7 A ware of RTI/STI Not aware Aware Aware of HI VIA IDS Not aware (83.3) (3.3) (13.3) Aware \Vife experienced any symptom of RTIISTI No Yes Ever discussed RTI/STI problem with wife No Yes AHMen !QE_!!I_~J~_'!!:~ S~~.!~. Health facility in the vjljage No health facility 57.8 With health facilitv All Men in the Rural Sample 53.4 Sour~e: Compuled from DlHS-RCH dala file ( ) = Based on unweigllled cases. x = Percentage not shown; based on ~ess than 25 unweighted cases. Note: L The percentages are computed after applying survey sample weights and the number of men given is unweighted. 2. Total number of men may not add to n due to missing cases. 7.4 FINDINGS FROM MULTIVARIATE ANALYSIS Logistic Regression and Multi-level Logistic Regression: Prevalence of Symptom ofrtiisti In the analysis of prevalence of symptom of RTIISTI, the binary logistic regression and multi-level logistic regression model has been used because the dependent variable is dichotomous: reported symptom and not reported symptom. Table 7.8 presents regression coefficients, standard errors along with odds ratios for selected variables from the logistic regression and multi-level logistic regression analysis of prevalence of RTI/STI. The

12 influences of various variables as seen in this analysis are 'net' of the influences of other variables included in the regression. Men belonging to the coastal region are significantly more likely, but those from the Inland region less likely to have RTIISTI compared to men belonging to the southern region. The probability of prevalence of RTIISTI is found to be significantly low among Muslim men than among Hindu men. Men with 6 and above years of schooling and men who belong to high standard of living are found to be significantly less likely to be affected by RTI/STI than illiterate and those with low standard of living respectively. The prevalence of RTIISTI is significantly less likely in the age group of 45 and above years than men in the age groups of25-29 years. The reported prevalence of RTIISTI is significantly higher among those who were aware of RTl/STI compared to men who were not aware. But this could be reciprocal effect as well, since prevalence of symptoms could influence awareness. On the other hand, the prevalence ofrti/sti is observed to be significantly low among men aware of HI VIA IDS than men not aware of HIV/AIDS. Men whose wife reported experience of symptom of RTI/STI are significantly more likely to report symptom of RTIISTI c?mpared to men whose wife did not report symptom of RTI/STI. Similarly, men living in villages that have connected to all weather road have significantly more likely to be affected by RTI/STI than men living in villages without connected to all weather road. However, men living in villages with more than two km. are significantly less likely to report symptom of RTl/STI when other variables are controlled. Since the sampling design of the DLHS-RCH-2 was two-stage, with village as the Primary Sampling Unit (PSU) and households selected within the village, there is possibility of contextual effect. Hence a multi-level logistic regression analysis was also carried out (details discussed in the methodology) al10wing random intercept at the village (PSU) level. The results are given in the last three columns of Table 7.8. There is a significant random effect indicating some village or community influence. However, it can be seen that in most cases, the coefficients from the multi-level analysis are fairly close to those from the standard logistic regression analysis and with the same sign. For only one category of region (coastalnorth) does not sign change; though but the level of significance changes for some categories 164

13 but the overall picture is essentially the same in both the models. Overall, multi-level analysis, though superior in principle to the usual logistic regression, the influences of various factors are well captured by the usual model, and hence in the remaining analysis, multi-level analysis is not used Multivariate Logistic Regression: Treatment Seeking for RTI/STI In the analysis of treatment seeking behaviour for RTIISTI, the present study has used multinomial logistic regression model because the response variable has more than two categories: no treatment, treatment from public health facility, and treatment from private health facility. It is important to see both whether men seek treatment for RTIISTI but also whether they do so from the public sector or the private sector. As mentioned earlier in section those who took treatment from both public and private health facilities and those who did not specify the sector are deemed to have taken treatment from the private health facility for the purpose of analysis; such cases are very few. Besides, religion, use of condom, and awareness of HIV/AIDS variables are excluded from the multivariate analysis because many categories of these have less than 50 unweighted cases. Table 7.9 presents summary results of two sets of coefficients, standard errors and odds ratios, for treatment from the public health facility vis-a-vis no treatment, and treatment from the private health facility vis-a-vis no treatment. Men living in the Inland region are significantly less likely to seek care for RTI/STI from the private health facility compared to men living in the southern region. Caste does not have any significant effect on treatment seeking behaviour when other variables are controlled. Men with high school or higher education are significantly more likely to seek care from the private health facility than illiterate men. As expected, men with high standard of living are significantly more likely to seek care for RTIISTI from the private health facility compared to men with low standard of living. Men who ever discussed RTIISTI symptom with their wife are statistically significantly more likely to seek care for symptom of RTI/STI from the public health as well as private health facilities compared to other men. Again, there could be reciprocal effect, taking treatment leading to discussion with wife. ] 65

14 Table 7.8: Results of Logistic Regression and Multi-level Logistic Regression Analysis of the Prevalence of Reproductive Tract Infection/Sexually Transmitted Infection by Background Characteristics, Currently Married Men, Tamil Nadu Background Characteristics Logistic Regression Multi-level Logistic Regression B S.E. Odds Ratio B S.L Odds Ratio Region Southern (RC) Coastal-nonhero Coastal " ' Inland " Religion Hindu (RC) Muslim ' Others (Christian) Caste OBC(RC) SC/ST ' Others Education Non-literate (RC) 0-5 years of schooling I 0 years of schooling ' II and above years of schooling " Standard oflhing Low (Re) Medium High " Age of men (Yean) (Rq ' " Condom use No (Re) Yes Aware of RTIISTJ No (Re) Yes ' ' Aware of HI VIA IDS No (RC) Yes " Wife experiencfd s) mptom of RTI/STI No (Re) Yes " " Village connected b~ on weather ro:ld No (Re) Yes *.$ " Distance to transport facility Up to 2 Km. (RC) More than 2 Km " Dishmce ohinoge from district If Q Up to 50 Km. IRC) More than 50 Km Health facility in the,illage No health facility (RC) With health facility Health pro, idtr in the, illage No health provider in the village (RC) With health provider in the village Random effnu-t- PSU 'evel no no na Constant Number ofworneo log likelihood J Pseudo R Squar~(Nagelkerk~) 0.09 RC- Reference Category. na= Not Applicable. = Indicates significant level at ** = Indic31CS significant level at 0.0 I. ~ = Since the multi-level model is in the logistic form. no level-one residual arises (see Snijders and Bosker, 1999: 216). ]66

15 Table 7.9: Results of Multinomial Logistic Regression Analysis of Seeking Treatment for Reproductive Tract Infection/SexuaUy Transmitted Infection by Background Characteristics, Currently Married Men, Tamil Nadu Public Health Facilities/ Private Health Facilities/ Background Characteristics No Treatment No Treatment B S.E. Odds Ratio B S.E. Odds Ratio Region Southern (RC) Coastal-northern Coastal Inland ** Caste Non-SC/ST (RC) SC/ST Education Non-literate (RC) 0-5 years of schooling years of schooling * II and above years of schooling * Standard of Jiving Low(RC) Medium High * Age of men (Years) (RC) Aware of RTI/STI No (RC) Yes Wife experienced symptom of RTI/STI No (RC) Yes * ** Ever discussed RTI/STI symptom with wife No (RC) Yes ** ** Health facility in the village/residence Rural area: No health facility (RC) Rural area: With health facility Urban area Intercept Number of cases 650-2log likelihood ] Pseudo R Sguare (Nagelkerke} 0.27 RC- Reference Category. = Indicates significant level at u= Indicates significant level at

16 7.5 SUMMARY The prevalence of RTIISTI is very low among married men, 2.8 percent, as reported by themselves. It is possible that many men did not report symptoms due to shyness and the actual prevalence is higher, but this is a limitation of a large survey especially about sexual health. Slightly less than half among those who reported symptoms sought treatment, majority of them from the private health facility than the public health facility; most sought treatment from physicians. The Multi-level logistic regression analyses clearly observed that men belonging to the coastal region, men belonging to the SC/ST, in the age group of years, aware of RTIISTI, whose wife experienced symptom of RTI/STI, and living in the village that have connected to au-weather road are significantly more likely to report symptom of RTVSTI compared to the corresponding reference category. In addition, among those who reported symptoms of RTVSTI, men aware of HIV/AIDS, men whose wife experienced symptoms, and who ever discussed about RTlISTI symptom with their wife are more likely to seek treatment from the public health facility. Young men (15-24 years) are less likely to seek treatment than men in the age group of years. On the other hand, men who belong to the Inland region, men with 6-] 0 and ] 1 and above years of schooling, high standard of living, aware of HIV/AIDS, whose wife experienced symptom of RTIISTI, and who ever discussed RTI/STI symptom with their wife are more likely to seek treatment for symptoms from private health facility compared to reference category. 168