H.A. Afsar  ( Department of Community Health Sciences, The Aga Khan University, Karachi.Pakistan. )
M. A. Mahmood  ( Department of Community Health Sciences, The Aga Khan University, Karachi,Pakistan. )
N. Barney  ( Marie Stopes Society, The Aga Khan University, Karachi,Pakistan. )
S. Ali  ( Departments of Community Health Sciences, Aga Khan University, Karachi. )
M. M. Kadir  ( Department of Community Health Sciences, The Aga Khan University, Karachi,Pakistan. )
M. Bilgrami  ( Marie Stopes Society, The Aga Khan University, Karachi,Pakistan. )

Objective:To determine knowledge, attitude and practices regarding sexually transmitted infections in district Khairpur, Sindh, Pakistan.
Design and Methodology:A needs assessment study employing a community based survey, key informant interviews and focus group discussions was conducted in all seven sub-districts of the district. This paper is based on the results of the key informant interviews and the focus group discussions. Thirty interviews and six group discussions were held with members of the community and with the health care providers.
Results:There was little awareness regarding causes and prevention of sexually transmitted infections in the community. The situation was slightly better among health care providers. While health care providers believed that the prevalence of sexually transmitted infections is high, the community did not consider themselves at risk. The community believed that these diseases are a problem among a sub-population of male adolescents, especially those who have homosexual relations. However, due to social norms, they rarely discussed such health problems with other family members or elders. Adolescents with any sexual health problems visit hakims and quacks. The community was aware about aetiology and some of the risk factors associated with AIDS and hepatitis, most probably due to the recent public health campaigns against both diseases.
Conclusion:Considering the suspected high prevaIerice of sexually transmitted infections and the relative lack of knowledge, it is imperative that a public health intervention be initiated. This must include educating not only the community but also the health workers. The governments’ initiative to train community workers in reproductive health is a step in the right direction (JPMA 52:21, 2002).

Incidence of sexually transmitted infections (STIs), one of the most common communicable diseases in the world, is rising,despite improved methods of diagnosis and treatment¹. World over, excluding HIV and AIDS, there are about 333 million new cases of STIs per year. In 1995 in South East Asia alone an estimated 150 million new cases occurred². Evidence that STIs may facilitate human immunodeficiency virus (HIV) infection has focussed attention to the situation^3,4.
In Pakistan, a lack of research and information makes it impossible to accurately assess the prevalence of STIs or their relative increase or decrease over time. Health professionals, however, believe that the incidence of STIs in Pakistan is increasing⁵. A study conducted in Pakistan pointed to a prevalence of chlamydial infection among adult female population at 13.5%⁶. Another study conducted on prison inmates, points to a prevalence of urethritis of 21%⁷. These studies are, however, hospital or institution based that make if difficult to comment on the prevalence in the general community.
Risk groups for sexually transmitted infections include women of childbearing age, homosexuals and heterosexuals practising unsafe sex and prison inmates³. Sexually active adolescents are at a higher risk as many of them have little knowledge about prevention and have limited access to health care. They face a higher risk of infertility and cervical cancer following chlamydial infections due to greater length of exposure. The problem is compounded by the fact that diagnosis is more difficult in this age group as the condition may be asymptomatic³. A study points out that even formally literate Pakistani youth has little awareness about STIs⁸.
Despite the increasing prevalence and risk of complications such as infertility, prevention of STIs has received little attention in developing countries. The situation is complex in Pakistan due to the social and cultural barriers to addressing the problem at policy and program levels. The Government, however, has recently planned to address the issue by increasing the scope of the community health work by developing a ‘National Reproductive Health Package’ that targets sexually transmitted infections as well⁹. To develop effective educational and health care program it is necessary to attain an in-depth understanding of the current community knowledge, attitude and practices. Many studies have identified no direct relationships between sexual practices and knowledge¹⁰. Despite these infections being widespread, people may simply not consider themselves at risk. Studies are necessary to understand whether people perceive themselves at risk of acquiring STIs and the reasons for their particular beliefs.

Khairpur is a predominantly rural district of Sindh, comprising of rural cultivated land and ‘katcha’ areas bordering the river Indus. Most of the people are farmers with small land holdings. There is a wide network of government health facilities and private practitioners. However, quality of services and physical accessibility influence the utilisation of these facilities negatively. This study was part of a larger study that assessed the health needs and perceptions and health services availability, focussing particularly on reproductive health. The methods for this study included in-depth interviews and focus group discussions with the community members and health care providers. A pre-tested guideline focussing on reproductive health was used.
Purposive selection was done to identify informants from various communities and from various health care services in the district. Key informants included all different types of service providers who interact with the community for outreach or centre based care. In order to include the perspective of doctors providing services in various settings, two medical practitioners at rural health centre and basic health unit, a senior consultant at the district headquarters hospital and the doctor in-charge of reproductive health unit at the hospital were interviewed.
In order to acquire information from community perspective, informants from various communities from all seven sub-districts (talukas) were interviewed. Community based organisations working for health and social development in various talukas were approached and the objectives of the research were shared with them. These organisations were requested to identify the most active community based health care workers in various categories (traditional birth attendants, lady health workers, village based family planning workers, midwives). Similarly, through these community based organisations, community members who are actively involved in facilitating health care provision and other social services for their local communities were identified and invited to attend the focus group discussions.
A total of thirty interviews and six focus group discussions were conducted. Four group discussions were conducted with men. Two focus group discussions were held with groups of women. A note taker assisted the researchers at the sessions. The interviews were audio •recorded as well.

Table 1 provides information about the study participants.
The qualitative data of this formative research was analysed using grounded theory framework. After conducting a set of interviews, the team shared and discussed observations and made preliminary notes as a first step in grounding. Analysis of the data generated various categories of emerging information and was categorised as information concerning STIs, locally preventable health issues and social and cultural issues affecting health. The data in each category was analysed from the perspectives of the community; community based workers and the technical medical health care staff. Issues that were analysed for this paper included perceived prevalence of STIs in the community and in adolescents, causes and prevention of STIs, and sources of knowledge.

Prevalence: Majority of respondents said that they were not aware of the prevalence. However, they appeared to believe that STIs are not common in their area. Some community members suggested that people might be aware of the existence of disease in the community but might not like to discuss it because of the stigma attached. Health workers, on the other hand, thought that these diseases were common. Even though the health workers are not responsible for management of STIs, they are aware of their presence, as community members approach them for advice on such problems. Community based workers, for example, pointed that each month about 10 to 15 women consult them for symptoms suggesting STIs.
The community women interviewed did not believe that adolescents suffered from these diseases. A few women refused to answer and did not believe that STIs could occur in the younger people. Health workers also believed that STIs were not prevalent among adolescents. Male respondents, on the other hand, revealed that STIs might probably be more common in younger males, mostly among those who were having homosexual contacts. Informants perceived that homosexuality among teenage boys was common.
Causes of STIs: The community had some knowledge about AIDS. The informants believed that the community was aware about the risk factors involved. By far the most common reason cited was extra-marital sexual relations. Both community members and health workers were aware about the role of blood transfusions and sharing injection syringes and shaving blades. The concept of STIs apart from AIDS and hepatitis and the reasons for their spread were little understood. On the other hand, the information gained by the community members from their friends, inadequately trained health care providers appeared to have spread several wrong perceptions about the causes of STIs. These causes include bad hygiene, poor nutritional status, mismatching of blood during transfusion, sharing food with an infected patient and masturbation.
Methods of prevention: The community understands avoiding extra-marital sex as a way to prevent STIs. Other prevention include the use of disposable syringes, the use of new blades for shaving and screening blood before transfusion. Condoms as a method of prevention was reported only by the health workers and not by the general community. The community members see the doctors’ role as crucial in preventing STIs but could not explain exactly what the doctor could do. With the backdrop of the existing socio-cultural norms and the perception that allopathic medical sector is not appropriate for sexual health problems, men and male adolescent consult hakims, quacks and pharmacy shops to get treatment for their sexual health problems. However, services of these providers are used more for sexual potency than for STIs.
Source of knowledge: The main source of knowledge about AIDS and hepatitis seems to be the electronic media especially television and to a lesser extent, radio. Outreach workers of the National Health Program and of relatives and the Department of Population Welfare believed that the community’s knowledge about STIs is increasing as the workers provide the relevant information. The community did not appear to this view of the workers. Hakims, quacks and friends .were considered as the sources from where individuals get whatever knowledge they have about sexually transmitted infections and problems such as impotence. The salient points of the results are summarised in Table 2.

Very little published information exists on the prevalence, knowledge, attitude and practices regarding STIs in Pakistan. Initial results from our quantitative survey suggest that about 25% of women suffered from vaginal symptoms such as itching, burning on urination, odorous discharge and painful intercourse. A large number of these could well be the due to STIs. Other studies in Pakistan have pointed to a prevalence of different STIs between 13.5 and 25%6,7. In a review paper Fikree points to 12.3% prevalence of reproductive tract infections in the general community and 25% in commercial sex workers¹¹.
It appeared that the community is not only largely unaware of the extent or prevalence of these infections but also have little knowledge regarding STIs. The information they do possess is probably a result of the recent media campaigns against AIDS and hepatitis. However, it is to be noted that a recent hospital based study in Karachi among recipients of blood transfusion indicated that about 30% of them had never heard of AIDS¹². This situation points to the need to increase efforts about raising awareness in this area. There was little specific awareness about STIs in general. The level of awareness about the role of extra-marital sex, sharing of injection syringes, blood transfusions with unscreened blood, sharing shaving blades and vertical transmission in causing AIDS and hepatitis again points to the probable role of the media campaigns. In the study area, it appeared that a majority, especially the women, believe themselves as not at risk. This situation acts as a barrier to habit change¹³. An understanding of this phenomenon will help plan health promotion interventions.
STIs is considered a priority issue in the National Reproductive Health Package⁹. The National Program for Primary Health Care is in the process of planning to include this in the curriculum of the outreach community based workers. Any health care provider providing outreach care to the communities need to be appropriately trained before he/she takes on this important area of reproductive health.The perception among some of the community members that bad hygiene causes STIs, could probably be based on general ideas about the link between diseases and hygiene rather than on any specific false information available through media or health care providers.
While male community members did point to homosexuality being common among teenage boys, they could not envisage a link between homosexuality and STIs other than AIDS. At the same time, it needs to be noted that in the present cultural context boys rarely share their reproductive health problems with their elders. On the other hand, teenage boys at focus group discussions were aware of many boys who were suffering from some reproductive health problems.
The community’s reluctance to discuss the issue of STIs among girls is understandable within the socio-cultural context and the stigma attached to STIs. A recommended area for action in reproductive health is to strive for ending the stigma attached with STIs¹⁴. Many boys and girls are married in their teens with little awareness about STIs. With homosexuality being common in boys, newly wed girls become prone to STIs and their complications.
The lack of awareness coupled with the suspected high prevalence of symptoms suggesting STIs in the study population poses a major problem. When consulted, the health care providers at the largest hospital in the area informed that about 25% of women who attended the obstetrics-gynaecology outpatient department are diagnosed as having a reproductive tract infection. These women do not usually consult the physicians for symptoms suggesting reproductive tract infection, but are diagnosed at the time of examination for other conditions. While a gynaecology department of a district hospital is better equipped in terms of specialists and facilities to recognise the importance of and diagnose and manage STIs, there is a need to work with general practitioners to improve community awareness and better management and counselling of STIs. A study in Karachi pointed to the need for working with general medical practitioners for improved management and counselling in order to prevent further spread of STIs¹⁵. We believe that ‘the need to work with doctors in other urban and rural areas of Sindh is even greater in this context.
In addition to working with the community, there is a need to create awareness among the health care providers and community workers about the prevalence, lack of community awareness, consequences and the need and methods of prevention and management of STIs. There is also a need to introduce the subject in some depth in the curricula of community based workers. Involvement of male motivators alongwith the female health workers may be a step in the right direction.
In circumstances where there are severe economic pressures on a large number of community members to proyide even the most basic necessities of life, the necessity of condom use or the danger presented by poor infection control procedures at health clinics are, perhaps, not perceived as immediate concerns. It is necessary to incorporate the health messages about the causes of STIs and their prevention, particularly in those programs that reach out to the communities.

This reproductive health needs assessment research was conducted by the research team from the Aga Khan University on behalf of Marie Stopes Society, Pakistan. The research was sponsered by the Department of International Development (DFID), U.K. We are highly thankful to the communities, research participants, health care provides, district administration and managers, and the staff at the district Health and Population Welfare Departments in district Khairpur.

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