In northeast Thailand, epidemiological data suggest that the prevalence of major reproductive tract infections (RTIs) among women is relatively low, as is the incidence of cervical cancer. Other seemingly good news is that many women have Pap smear tests performed, due in part to a campaign to promote the tests to identify cervical cancer.
However, the reproductive health of women of northeast Thailand is far more complex than it appears to be based on epidemiological data alone. A community-based survey conducted in 1997 and 1998 by investigators at Mahidol University in Thailand and the University of Arizona, USA, revealed that gynecological symptoms self-reported by women of reproductive age in the rural Kohn Kaen province of northeast Thailand were high: 70 percent of surveyed women had reported such symptoms over the previous two years, and 58 percent to 71 percent of these complaints were recurrent. Furthermore, qualitative research methods used by the investigators showed that these symptoms were of substantial concern to the women, greatly affecting their health-seeking behavior, use of medication, sexual relations, and peace of mind. These reactions to gynecological symptoms, regardless of whether symptoms were associated with clinically identifiable RTIs, were an important health issue in their own right, the researchers concluded.1
The investigators cited the study as illustrative of why high-quality social science research is an important complement to high-quality epidemiological research on RTIs and an evidence-based approach to care provision.
"Reproductive tract infections in women are a difficult area for both study and intervention," the researchers noted. "They are often asymptomatic, difficult to diagnose even in the presence of symptoms, frequently stigmatized and therefore not easily discussed in surveys or during history taking, and problematic for epidemiological data collection due to the invasiveness and personal discomfort associated with gynecological exams. One consequence of these difficulties is that data collected through various methods including surveys of self-reported symptoms, clinical examinations, and laboratory assessments each capture only partial information and therefore tend to result in different pictures of the scope and nature of women's health problems in a given population."
The community-based survey was given to a sample of 1,028 women of reproductive age. Selected from 16 villages across three districts of the province of Khon Kaen, the women were chosen to reflect the age structure of the province, and were diverse in terms of marital status and economic activity. The survey revealed women's reports of gynecological complaints, Pap smear clinic attendance, self-medication, and use of health services for gynecological problems. This initial research was followed by two months of qualitative research using a combination of participant observation, structured and semi-structured interviews, and focus group discussions with women of reproductive age from six villages in districts that had been surveyed originally. Another month of qualitative research in the same six villages produced detailed case histories of 50 women self-reporting chronic or recurrent gynecological problems. Married women who had reported recurrent symptoms on the initial survey were selected for in-depth interviews. Further interviews with men about women's gynecological problems, as well as perceptions and behaviors associated with sexually transmitted infections (STIs), were conducted. Information about medication availability, drug-purchasing patterns for gynecological problems, and medication marketing was collected through interviews and documentation in village grocery shops and pharmacies. Finally, a month of health service research that included exit interviews was carried out in hospitals and clinics, and in-depth interviews with health providers were conducted.
Women's greatest concern, the research showed, was that gynecological symptoms signaled problems that would result in cervical cancer. (Forty-nine of 50 women who, during in-depth interviews, reported recurrent gynecological and abdominal symptoms believed that the symptoms could become cancer.) Due in part to the intensive cervical cancer education and screening campaign in the region, women were well aware of the disease and many mistakenly believed that it was quite common. Women estimated the incidence of cervical cancer to be up to 500 times the actual incidence of 28 cases per 100,000 women.
| Pimpawun Boonmongkon/Mahidol University |
 |
| A staff member at a rural reproductive health clinic in the Kohn Kaen province of northeast Thailand makes a follow-up appointment with a patient. |
Driven by their fear of cervical cancer and the stigma associated with gynecological problems, 80 percent of the 1,028 surveyed women attempted self-treatment when they developed such problems, the cause of which was often unknown to them. The ready availability of antibiotics made self-treatment easy. In 50 in-depth case studies, women frequently reported using tetracycline, which is a medically inappropriate treatment for many gynecological problems, such as Candida infections. Antibiotic use actually makes Candida infections worse.
If symptoms persisted, women often sought help at government health facilities. The community-based survey revealed that about two-thirds of women reported first visiting government health stations. There, qualitative research showed, the majority of treatment was medically inappropriate, with providers saying that they felt poorly trained and poorly equipped to diagnose and treat patients with gynecological complaints. If symptoms persisted, women typically were referred to the district hospital, where they usually received Pap smears. Meanwhile, other women sought Pap smears on their own (usually because of concern about vaginal discharge and cancer), further contributing to the increasing Pap smear rates captured by epidemiological data. While a Pap smear could eliminate the fear of having cervical cancer, few women received what they most likely needed: information about and treatment for symptoms of RTIs that could be easily managed, if not cured.
During in-depth interviews, many women reported enduring unpleasant and painful gynecological symptoms for long periods, sometimes years. Meanwhile, many lived with the fear that those symptoms would culminate in cancer and death. Some women thought that their ailment would progress to cervical cancer more quickly if they had sexual relations. Thus, they could either continue sexual relations that had become painful and frightening or withhold sex. Withholding sex was seen by women as being risky since partners might be tempted, as a result, to engage in extramarital relations and then acquire serious STIs, including HIV/AIDS.
