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MINISTRY OF EUDCATION AND TRAINING MINISTRY OF HEALTHNATIONAL INSTITUTE OF HYGIENE AND EPIDEMIOLOGY Nguyen Minh Quang PREVALENCE AND INFLUENCING FACTORS OF THE LOWER REPRODUCTIVE TRACT

MINISTRY OF EUDCATION AND TRAINING MINISTRY OF HEALTH

NATIONAL INSTITUTE OF HYGIENE AND EPIDEMIOLOGY

Nguyen Minh Quang

PREVALENCE AND INFLUENCING FACTORS OF THE LOWER REPRODUCTIVE TRACT INFECTIONS AMONG FEMALE SEX WORKERS IN THE CENTRE FOR TREATMENT -REHABILATION - EDUCATION - SOCIAL LABOUR II HANOI AND EVALUATION OF THE INTERVENTIONSSpeciality: Social Hygiene and Health Administration

2 Do Hoa Binh, MD., PhD

Ha Noi - 2013

THE THESIS WAS COMPLETED NATIONAL INSTITUTE OF HYGIENE AND EPIDEMIOLOGY

The thesis will be defended at the Assessment Commetee at Institute Level

The defend at National Institute of Hygiene and Epidemiology

Time: date month 2013

The thesis stored at:

- National Library

- National Institute of Hygiene and Epidemiology Library

1 Nguyen Minh Quang, Bui Van Nhon, Ngo Van Toan (2012),

“Prevalence of lower genital tract infections among female sex workers

in Hanoi Social Education Labor Centre in 2009-2011”, Journal of Medical Research, Volume 80, N03

2 Nguyen Minh Quang, Bui Van Nhon, Ngo Van Toan, Do Hoa Binh,Nguyen Thi Thuy Duong (2012), “Risk behaviors of the lower sexualtract infections among female sex workers in Hanoi Social Education

Labor Centre in 2010”, Journal of Preventive Medicine, Volume XXII,

N0 6 (133)

3 Nguyen Minh Quang, Bui Van Nhon, Ngo Van Toan, Do Hoa Binh,Nguyen Thi Thuy Duong (2012), “Effectiveness of interventionmeasures to prevent the lower genital tract infections in female sex

workers at Centre 02 in Hanoi city, 2010-2012”, Journal of Preventive Medicine, Volume XXII, N0 6 (133)

1 Rationale of the thesis

WHO defined that infections of lower reproductive tract (LRTI) are genitials infections including STDs and others.LRTIs are common, dificult to determine exactly the the incident rates of the differente teritories, especial in sexworkers (SW) The rate of LRTI is general high from 41-47% in the world In Vietnam, a study in 2005 reported81.3% abnormal of reproductive tract, including 66.6% LRTI, closely related to HIV, sinificant hight in FSW.Risks of LRTI in FSW are lack of knowledge and practising to prevent STD, including unsafty exual, less ofcondom using, many kinds of sex partners, unsatisfy contraception The stydy on efectiveness of LRTI preventivemeasures was carry out and it is pointed that the most effected solution is using condom for all sexual intercourses

In Vietnam, there are some stydies in effectiveness of prevention HIV, however the systematic studies on LRTI arevery rare This sudy aims to indicate the risk factors and efectiveness of interventions, in order to improve the

knowledge and practising to prevent LRTI in FSWs , who are concentrated for treatment, rehabilation, educationand social labor in the Center II, Ba Vi, Hanoi The subjects of study are:

1 Describe the incidences and risk behaviors of LRTIs in female sex workers, who are concentrated in the Center for Treatment, Rehabilitation, Education and Social Labor II of Hanoi in 2011.

2 Evaluate the effectiveness of interventions to prevent lower genital tract infection for female sex workers and improve the knowledge of sexually transmitted infections for medical staffs in the Center for Treatment, Rehabilitation, Education and Social Labor II of Hanoi, period 2011-2012.

2 New contributions of the thesis

This is the first systemetic study on LRTI with evaluations on incidences and efectiveness of interventions, in order

to improve the knowledge and pratising for FSW, who were being in the Center II

The thesis has proved the evidence on effectiveness of interventions by training, LRTI screening for FSW andperformance on training to improve knowledge on managing LRTI for medical staffs of the center The thesis hasidentified the high incidence of LRTI in FSW and the role of condom using to prevent LRTI for all sexualintercoureses with all clients, it is also mentioned the effect of media education, advantage of initiative health care

to reduce LRTI diseases in FSW

The study results are used ful for the policy and planning programs in order to expand this intervention modul forthe other centers over the nation

3 Scientific and practical meanings of the thesis

Scientific meaning: The study uses community intervention design, meets to subjects of research , data collectionand analysis are exactly , has proved remarkable effectiveness on interventions by media education, initiativehealth care for FSW, has improved knowledge of managing LRTI for medical staffs of the center

Practical meaning: The results of the thesis has performed the effectiveness of the intervention model to helpplanners and policy makers as well as presventing LRT for FSW and improve knowledge and pratising STDmanaging for health workers, base on that to expand this intervention model for other centers over the nation

4 The layout of the thesis

The thesis is presented in 124 pages, excluding appendixes and is divided into:

Introduction: 2 pages

Chapter 1: Overview: 35 pages

Chapter 2: Subjects and Methods of study: 198 pages

Chapter 3: Research Results: 36 pages

Chapter 4: Discussion: 27 pages

Conclusions: 2 pages

Recommendations: 1 page

There are 41 tables, 11 charts

The appendix includes 151 references (57 Vietnamese, 94 English), Questionnaires sheet, List of FSW , List ofstaffs involved in the training

Chapter 1 OVERVIEW 1.1 Basic conceptions of LRTI:

By WHO, infections of lower reproductive tract (LRTI) are infection disease caused by or not by sexualtransmition disease (STD) including vulgaris, vaginalis and cervicitis

1.2 Prevalance of LRTI and risk behaviors

1.2.1 Prevalence of LRTI

Gonorrhea: caused by Streptococcus Gonorrhea Studies in 5 provinces showed the incidence is 3.2 % Nguyen

Trong Thuc reported on his Sentinel surveillence

Research in 4 southest province, the Gonorrhea incidence in FSW was 4.64 % This ratio is higher in the North andMiddle of Vietname, the research in 5 North border provinces described with 11.9% Gonorrhea in FSW TheGonorrhea ratio in the neiboring contries are 5.7 % in Cambodia and 9.5 % in China

Syphilis: caused by Treponema pallidum Research in 5 border provinces of Vietnam showed the incidence rate is

10.7 % in general, highest is Quang ninh (24.8 %) and Lai Chau (20.2 %) and 03 remains provinces of Dong Thap ,

An Giang, Kien Giang have rates ranging 5.7 - 9.4 %

Chlamydiasis: is one of STD cause by Chlamydia,a parasite stained Gram (-) color A research in Provinces of

Mekong Delata indicated 3.5 % FSW has positive with Chlamydia Foreign researches on FSW reported incidencerate ranging 12% -2 7.0 % in Asia and Europe countries

Trichomatis: caused by Trichomonas, a parasite of anaerobic protozoa, round shape with diameter 10-20 m The

incidence rate ranging 2-2.5 % in general and 50-70 % in FSW over the world In Vietnam LRT Trichomatisincidence rate 8.13 % in FSW and 0.84 % in pregnants are reported

Fungal LRTI: cause by Candidas Albicans and some time by other strains Candidas Albicans is also causing

fungal diseases in many organs such as the skin and mucosal infections, Septicaemia, endocarditis, meningitis The

incidence in Haiphong province is 10.7%, highest among 5 researched provinces Research in 2005 showed fungalLRTI incidence rate is 11.9 % of FSW in 4 South provinces

Reproductive papiloma: caused by Human Papiloma Virus (HPV) Typical sumptoms are red-brown soft warts,

glomerate in vulva, vagina, cervix The lessions evoke itching, discomfort due to increasing secretion, easy to bleed

by touch Dianosistic based on physical symptoms, cervix luminate, HPV determine by PCR technique HPVpapiloma has high ratio in FSW, accounting for 9.2 %

Reproductive Herpes: caused by Herpes Simplex Virus type I, II It 's leading to obstetric accidences such as

miscarriage, premature give birth, premature placental detachment Research in Hai Phong province showed theincidence rate in FSW is 3.9 % in FSW, 32.8 times higher than the lower risk groups

Complex microbial LRTI - vulgaris, vaginalis: the pathogens are nonspecific, diversity Clinic symptoms are

homogeneous liquid discharge with white or gray color, stinking smell Some local and overseas studies reportedthe incidence rate of complex microbial vulgaris, vaginalis without symtoms are quite hight (50-70 %)

1.2.2 Factors and risk behaviors afects to LRTI in FSW

Age is an important factor of LRTI in teenagers Studied in Central Institute of Dermatology of Vietnam

2003-2005 and other researches indicated the incidence rate tend to be higher in women over 20 years old than thewomen under 19 years old

The incidence rate of LRTI is usually higher in group has low education and and unstable careers This is also adifficult matter on education to improve practising of LRTI prevention In fact, the low education group has shownthe poor knowledge of LRTI and unsafty sexual activities, unsafety injection that entrain to high incidence of HIVand LRTI

Career is important factor related to LRTI and HIV infection, the incidence rate are 14.7 %; 13.1%; 13.1 % and 8.4

%, correlatively in the groups of workers, freelances, market sellers and students

Having unsafty sex is risk to be infected HIV and LRTI, in countries with high prevalences of HIV & LRTI, wererecognised the main cause of very low rate of condom using (condoms) In a study in the southern provincesshowed that 65% of female sex workers do not use condoms during sexcourses, HIV prevalence in this groupwas 5.2% and the proportion accounted for LRTI is high (above 80%) Average number of customers / month

is one of the high-risk factor to be infected HIV and STD in FSWs Research by Centre for Disease Preventionand Control showed up to 80% of cases LRTI does not use condoms regularly, compared with 2% of LRTIcases in FSWs often use of condoms in sexcourses with clients and partners The initiative to get the tests ofLRTI is meaningful in preventing infection LRTI for their clients, husband / partner and also help the women

be able to access the treatment in cases of LRTIs

1.3 The LRTI prevention models

1.3.1 Communication programs for behavior change

The main purpose of communication programs for behavior change is to increase awareness, knowledge,understanding of transmission LRTI and prevention measures for all the people, forthe high risk groups, eapecialFSWs Communication programs for behavior change aims to access the high-risk groups, differentiate to the othermedia is for community This program also provide information of to prevent LRTIs and provide services, whichsupport to change behaviors and maintain safety sex by using condoms, resist drug abuse and personal hygieneguide

1.3.2 The program of 100% condom using

The program encourages FSWs to use condom for 100% sexual intercourses (says as program 100% condom) isnot simply to provide condom, but it includes many activities to improve the awareness, knowlege aboutdistribution of condoms, peer education and screening of STD and reproductive tract infections The aims ofprogram is to prevent and reduce HIV and LRTI with effectiveness and low cost

1.3.3 Program of Management LRTI

The person, sho is sufered from LRTI diseases likely to be HIV infected more than 2-9 time compare with theordinary subject Therefore, early detection and treatment of STD are not only make sense to restrict the spread ofHIV through sexual, also are meaningful in management, monitoring LRTI among indicated population

1.3.4 Peer education program

Peer education program is reachable enough to understand that "the sharing of knowledge, skills and lifeexperiences between those who have the same characters of social and ecomomy such as age, gender, occupation,religion, hobbies, in order to change their behaviors" Peer education program is also called "program ofcommunication accessibilities" In many countries, people have implemented the programs to reduce harm incommunity such as peer education

Chapter 2 SUBJECTS AND METHODS 2.1 Object, location and study duration

The study was conducted at the Center II for Rehabilitation, Education, Social Labor, belongs to Department ofLabour, Indisable and Social Affairs of Hanoi, located in Yen Bai commune, Ba Vi district.

2.1.3.Duration of research and data collection

From 1/2011 - 12/2012, at Ba Vi district, Hanoi

2.2 Research Methodology

2.2.1 Study Design

An intervention experimental design, without comparative

2.2.2 Research sample and sampling

2.2.2.1 Female Sex Workers:

Sample sizes:

2 2 1

2 2 2 1 1 1 )

2 / 1 ( 2

]1()1([)

1(2[

p p

p p p p Z

p p Z

n n

n1: sample size before intervention

n2: sample size after intervention

p1: prevalence of FSW using condoms for all sexual intercourses, before intervention (estimated 52 %)

p2: prevalence of FSW using condoms for all sexual intercourses, after intervention (estimated 65 %)

p: (p1 + p2) / 2, Z1- / 2: reability coefficient, determined at 95 % (=1.96)

z1-: force sample (= 80%)

Total: 407 FSWs were studied

Sampling: The FSWs were selected by the single random sampling, based on a list of all FSWs, who are training

in Center II, Ba Vi, Hanoi

2.2.2.2 Medical staffs

All medical staffs included all 15 doctors, nurses who are working in Center II, Ba vi, Hanoi to be selected in thestudy.

2.2.3 Process and means of data collection

2.2.3.1 Process of data collection

2.2.3.2 Means of data collection

The interview questions sheet contains: the administrative part, personal characteristics, risk behaviors of FSWsand knowledge, skills of medical staffs Clinical examination leaflet, blood tests, discharge test

2.2.4 Technical tests

The testing techniques to find pathogens were performed under the guidlines of WHO and the Central Hospital ofDermatology

2.2.5 Content and intervention process

Examination, treatment for FSWs and monitoring of clinical and laborator expressions Communication andeducation activities focused on prevention of sexually transmitted diseases, which is currently conducted at the

Center, included: organized the direct education, communication via leaflets, media by film/television, consultdirectly Training for medical staffs to perform screening, exam and treatment of LRTI and STDs for FSWs.

2.2.6 Analysis

The data has been analysis and presented by frequency and % ratio Test χ2 and p value expressed the differencebetween independent variable and dependent variable Estimation Test (OR) and 95% CI was used to identify therelation between LRTI ratio and individual characteristics, risk behaviours of FSWs Multivariable regress analysis to beused for error exclussion of indipendent and depend variables relationship Effectiveness indicator to be count fordetermining of intervention effects

2.2.8 Ethics in Research

The objects have informed the aims of study and to be volunteered All information is secured by encription andused for this dtudy only The research author have not to utilitize any inlegal supplemtation or service during studyprocess

Chapter 3 RESULTS OF STUDY 3.1 Some personal characteristics of FSWs

Among 407 FSWs, the youngest is 15 years old and the oldest is 40 years old Mean age was 26.8 ± 6.29 years,minimum 15 and maximum is 40 years old Most FSWs were currently concentrated on training in the Center areKinh ethnic group, accounting for 59%, the proportion of FSWs used to live in rural areas is very high, accountingfor 93.4% Before to be FSWs, most of them were worked in agriculture (63.6%), continuous by groups of joblessand freelance (14.3% and 14%) The education level of FSWs was low, averaging 6 ± 3.8 years FSW illiteracy ratewas 14%, primary school was 28%, secondary school was 45.5% and high school was 12.5% only

Medical staffs group ≤ 30 years has highest for proportion (60.0%) Mean age was 29.8  6.6 years old There are 60

% of medical staffs are women, highest proportion is nurse (46.7 %) Working experience of medical staffs devided 02groups: under 5 years, accountd for 46.6 % including 3 staffs just got 01 working year; 5-10 years and 11-20 years,accounted for 26.7 % One of them has trained of LRTI treatment (6.6 %)

3.2 Incidence prevalence, influent factors and risk behaviors of female sex workers

3.2.1 The clinical symptoms of LRTIs

In FSWs, the rate of at least one symptom associated with LRTI when entering the Center was 34.2% The mostcommon symptoms reported in FSWs is abnormal vaginal discharge (24.8%), followed by itching in the genitalarea (14.7%), abdominal pain (13.3%) Other symptoms were genital sores (10.6%), sharp pain urine (9.3%) andlowest was genital ulcers (8.4%)

Single vulgaris

Single vaginalis

Single cervicitis

vaginalis

Vulga-Exposed cervical

Chart 3.9 The lession morphology of lower genital/reproductive tract infections

The most common infection was vulvo-vaginalis (49.9%), single vaginalis (21.9%), single cervicitis (8.8%).Especially with 7.9% of FSWs had cervical cervicitis

T.Vaginalis Gonorrhea Syphilis Complex

microbial

Fungal

Chart 3:10 Ratio of pathogens of lower genital tract infection (n = 273)

When entering the center, rate of complex microbial infection in FSWs was highet, accounted 44.7%, following byfungal infection 10.1%, Trichomonas, 4.4%, syphilis 2.5% and gonorrhea is lowest, accounted for 0.5%

3.2.3 Analysis the affected factors and pathogens of lower genital tract infections in FSWs

Table 3.17 The relation between pratising/whored time and LRTIs

6569

27.241.1

10.6 0.38-0.81FSW group < 18 years old had a higher rate than the FSW group > 18 years old (70% compared with 66.2%).There was 58.7% FSWs had whored time ≥ 1 month The rate of LRTI in FSW group of whored time ≥ 1 months

is higher than FSW group of whored time < 1 month (72.8% compared with 58.9%) This difference was statisticmeaning

Table 3.18 The relationship between the average sex client and LRTI

Number of the clients

≥ 20 clients

9638139

66.270.466.8

491669

33.829.633.2

11.21.00.58-2.530.64-1.65