Introduction: Globally, reproductive tract infections (RTIs) are a major cause of acute and chronic illness with severe consequences. Women are at a greater risk than men and are less likely to seek treatment because of the associated stigma. Objectives: To assess the knowledge and estimate the prevalence of RTIs, and treatment seeking behavior regarding RTI. Materials and Methods: A community-based cross-sectional study was done in a peri-urban underprivileged area, in Bangalore where all ever-married women in the reproductive age group were interviewed using a pre-structured and pre-tested schedule by female medical doctors in the privacy of their homes. Results and Discussion: Of the 179 women who participated in the study, 47.5% were in the age group of 25 to 34 years with the mean age being 29.84 years (±7.92). The mean knowledge score was found to be 3.78 (±2.3) and the maximum score was found to be 10, which indicated poor knowledge regarding RTIs which was similar to other studies done elsewhere. The prevalence of RTI was found to be 26.8%, while the period prevalence of RTI for the last 1 year was 39.1%, and 60% of these women sought some form of treatment. Other studies have reported prevalence ranging from 21.9% to 92% in India. The age-specific prevalence was highest in the 15 to 19 years age group (30%), with most common symptom being white discharge per vagina (43.7%). Conclusions: Knowledge regarding RTI was poor while the prevalence of RTI was high (26.8%) and the treatment-seeking behavior was inadequate.
Keywords: Knowledge, reproductive tract infections, treatment-seeking behavior
Almost two decades after the call for universal access to reproductive health at the fourth International Conference on Population and Development in Cairo (1994) and close to fifteen years after the introduction of Reproductive and Child Health Program (RCH) by the Government of India (1997), reproductive tract infections (RTIs) continue to be a major cause of acute illness, cancer, infertility, long-term disability, and death with severe medical and psychological consequences for millions of men, women, and infants. 
RTIs are infections affecting the reproductive tract and can be endogenous infections (resulting from the organisms normally existing in the vagina), iatrogenic infections (resulting from abortions, insertion of IUD, child birth, and so on), and sexually transmitted infections.  RTIs are a major public health problem all over the world. ,,,,,,,,, Sexual and reproductive health has also been omitted from the Millennium Development Goals and remains neglected.  According to the World Health Organization (WHO), 448 million new STIs occur annually among adults aged 15 to 49 years and many are asymptomatic.  The World Bank estimates that STIs (excluding HIV) account for 8.9% of all disease burden in women aged 15 to 45 years,  thus stressing the need for control of RTIs, especially STIs in developing countries.  Though effective treatment is available for most of these infections, they often go undiagnosed and hence untreated. 
In India, the prevalence of self-reported STI/RTI in the population aged 15 to 49 years was found to be between 21.9 to 92%.  Women are at a greater risk of RTIs than men because of the physiological, cultural, social, and economic factors. , Also, women are less likely to seek treatment, even for symptomatic infections, because ofstigma associated with RTIs. 
Hence, we aimed to assess the knowledge and estimate the prevalence of RTIs, and treatment-seeking behavior among ever-married women in the reproductive age group in a peri-urban underprivileged area.
Design and setting
A community-based cross-sectional survey was donein a peri-urban underprivileged area, situated on the outskirts of Bangalore. Due to the rapid expansion of the city, a large number of underprivileged areas have come up around Bangalore. The study areais one such area which came into being about 15 years ago. The population mainly comprises of migrants from various parts of Karnataka and adjoining states.
The study population included all ever-married women (currently married, separated, divorcees, and widows) in the age group of 15 to 49 years currently residing in the above mentioned area for a period of at least one year. Those women who could not be contacted even after 2 visits and who did not give consent were excluded from the study.
The study area was mapped with the help of a house-to-house survey. All individuals fulfilling the inclusion criteria and consented were administered a pre-structuredand pre-tested interview schedule. The participants were interviewed by female medical doctors in the privacy of their homes. Confidentiality was maintained throughout the study.
Data collection instrument
The data collection instrument was an interview schedule that was prepared using the family health awareness campaign questionnaireand the WHO interview schedulefor diagnosis of STI.
The interview schedule had 4 sections;section 1 collected general demographic information; section 2 comprised of questions which tested the participant’s knowledge regarding RTI. In this section, the questions were subdivided into the following six domains: causes, symptoms, ill effects, prevention, treatment, and partner treatment.Section 3 had questions to identify if they had any symptoms suggestive of RTI and Section 4 assessed the treatment-seeking behavior of those who had symptoms suggestive of RTI.
Data were entered in Microsoft Excel and analyzed using standard statistical software packages. Frequencies and measures of central tendencies and dispersion were used to analyze the data. Chi square test was used to test the significance in order to lend statistical support.
Of the total 207 ever-married women who fulfilled the inclusion criteria, 179(86.5%) women consented to participate in the study. Of the 179 women interviewed,47.5% were in the age group of 25 to 34 years, 5.6% in 15 to 19 years, 18.4% in 20 to 24 years, 23.5% in 35 to 44years, and 5% in 45 to 49 years.The mean age of the study population was 29.84 years (S.D=7.92).Majority of the women were Hindus, i.e., 85%, while 8% were Muslims and 7% were Christians. 40.2% of the women had attained education beyond 7 th standard while only 3.9% of the participants had more than or equal to 12 years of schooling. 51% were housewives and 24% worked as housemaids. The mean age at marriage was 18.09 years (S.D=3.55) and the mean duration of marriage was 135.35 months (S.D=100.55). 87% of the women were currently married, 6% each were separated and widowed, and 1% was divorced [Table 1].
The median number of children born was 2per woman. 52.92% of the participants were using some form of contraception (Tubectomy = 49.7%; OCPs = 1.6%; Condoms = 1.1%; Copper-T = 0.5%).
Knowledge regarding reproductive tract infections
There were a total of 34 questions and they were subdivided into causes, symptoms, ill effects, prevention, and treatment (including partner treatment). Each correct response was given one mark. Maximum attainable score was 34. A score of 11 (1/3 rd of the maximum attainable score) was considered adequate knowledge. Any score below 11 was considered to be poor knowledge.The mean score was found to be 3.78 (SD = 2.3) and the maximum score was found to be 10 which indicated poor knowledge regarding RTIs in the entire study population. Only 22% of the women knew that partner also needs to be treated in case of a RTI. There was no statistical association between knowledge of the participants and any of the sociodemographic variables.
[Table 2] depicts the percentage of participants who gave at least one correct response for each set of questions.
Estimation of the prevalence of reproductive tract infections
A total of 48 (26.8%) women in the study population had at least one symptom suggestive of RTIwhile the remaining 131 (73.2%) women did not have symptom suggestive of RTI at the time of the survey.Apart from these, another 22 women gave history of at least 1 symptom of RTI in the past 1 year. So, a total of 70 women had symptoms suggestive of RTI in the past 1 year, i.e., the period prevalence of RTI for the whole year was found to be 39.1% [Table 3].
The age-specific prevalence of symptoms of RTIwas found to be highest in the15 to 19 years age group (30%) followed by among women in the age group of 25 to 34 years (28.2%) [Table 3].
The most common symptom found was white discharge per vagina (43.7%) followed by pain during intercourse (41.7%). The least common symptom was groin swelling (6.25%) [Table 4]. Statistically, presence of symptoms of RTI was significantly higher among currently married women [Table 5]. There was no statistical association between presence of symptoms of RTI and participant’s age, educational status, religion, occupation, and type of contraception used.
Treatment seeking behavior for RTI
Treatment-seeking behavior was assessed among those women who had at least 1 symptom of RTI in the past 1 year, i.e., 70 women of the 179. It was found that only 42 women (60%) sought some form of treatment while the remaining 28 (40%) did not seek any treatment. Of those who sought treatment, 69% approached a private healthcare facility while 26% approached government healthcare facilities; less than 5% went to unqualified practitioners (quacks). A majority (90.5%) of the women were compliant to the treatment prescribed. Even though 22% knew that partner also needs treatment, only 12% actually got their partners treated.
Of a total of 207 women, 179 women (86.5%) consented to participate in the study and hence formed our study group. Almost half of the participants (47.5%) were in the age group of 25 to 34 years, which was similar to a study done in Andhra Pradesh.  The median age at marriage was 18 yearswhich is similar to the national average. 
Only 3.9% of the women had more than or equal to 12 years of schooling as against the national average of 12% among women in the same age group;  while 25.7% of the study participants had never attended schools indicating the poor educational status of the study population.More than half the population (52.92%) used some form of contraception, but this was found to be less than the national average of 56.3%. 
Knowledge regarding reproductive tract infections
Knowledge regarding RTI was very poor overall. However, other studies done elsewhere also report poor knowledge among women. ,,,, Only 22% of the women knew that partner also needs to be treated in case of a RTI and only 12% of those women who had symptoms of RTI in the past 1 year had their partner also treated, which is similar to the findings reported in an earlier study where only 10% of the partners were treated. 
Estimation of the prevalence of reproductive tract infections
The percentage of self-reported cases with regard to presence or absence of RTIs was in moderate agreement with clinically and microbiologically examined cases.  The results obtained by survey method are comparable with studies which also include laboratory investigations. 
We found that 26.8% women in our study population had at least one symptom suggestive of RTI while the remaining 131 (73.2%) women did not have any symptom of RTI at the time of the survey.The period prevalence of RTI was found to be 39.1%.
Studies have reported a prevalence of RTI/STI ranging from 21.9% to 92%  in India. Also, the prevalence of RTIs is known to vary between urban, rural, and urban underprivileged population. ,, Srivastava et al.  reported a RTI prevalence of 45.22% among urban slum dwellers which is slightly higher than that found in our study which could be attributed to differences in reporting.
The age-specific prevalence of RTI was found to be highest in the 15 to 19 years age group (30%) followed by among women in the age group of 25 to 34 years (28.2%). Studies have reported the prevalence of RTI among adolescents to range from 4%  to 21.8%.  This high prevalence of infection could be attributed to early initiation of sexual activity, high sexual and reproductive activity, low level of protective cervical antibodies,  migration due to urbanization,  and trauma associated with delivery (first delivery is often more traumatic compared to subsequent deliveries) along with an increased incidence of spontaneous and induced abortion in this age group.  Statistically, presence of symptoms of RTI was significantly higher among currently married women.
The most common symptom reported was white discharge per vagina (43.7%) followed by pain during sexual intercourse (41.7%). Various studies have reported that the most common symptom of RTI among women was found to be white discharge per vagina. ,,,,,,,,
Treatment seeking behavior for RTI
It was found that only 60%of the women who had RTI in the past year sought some form of treatment. The remaining 40% did not seek any treatment and this is a cause of concern since it is a large proportion and this group of patients may suffer from severe complications of RTI/STI. Women are more prone and susceptible not only to RTI/STI but also suffer from the complications of the same.  Studies have also shown that women are shy, embarrassed, and reluctant to undergo examination (especially internal examination of the reproductive organs). ,,
Poor access to healthcare, poor knowledge or awareness, and some of the RTIs being asymptomatic have also contributed to increased prevalence of RTI/STI among women. ,,
Of those who sought treatment, 69% approached a private healthcare facility while only 26% approached government healthcare facilities. Srideviet al.  reported that Government doctors were the main source of treatment followed by private doctors which is in contradiction to the findings from our study. This difference could be attributed to the accessibility, availability, and timings of Government health facilities in the study area.
Knowledge regarding various aspects of RTI such as causes, symptoms, complications, prevention, and treatment was found to be poor. There was no statistically significant association between any of the sociodemographic variables of the women and their knowledge levels.
The prevalence of RTI was estimated to be 27%, indicating that every fourth woman residing in the underprivileged area was suffering from RTI. The period prevalence of RTI in the preceding one year was estimated to be 39.1%. The most common symptom was found to white discharge per vagina. There was a statistically significant association between marital status and development of RTI with currently married women suffering more from RTI as compared to widows, separated, and divorcees.
The treatment-seeking behavior among the participants was found to be poor, though compliance to treatment was good. Majority of the women approached a private healthcare facility for treatment. Partner treatment was found to be poor.
In community-based study, it was difficult to confirm the diagnosis by either clinical examination or laboratory support. However, studies have shown that diagnosis by survey method is as good as the clinical or microbiological method.  Secondly, though adequate precautions were taken to maintain privacy and confidentiality, since the topic was sensitive, women might have been apprehensive to reveal their problem to the interviewer. Hence, the prevalence of RTI in our study might be an under estimate.
The study has given enough evidence that there is a need to provide reproductive health services in underprivileged areas in urban areas and also in similar communities in the peri urban areas of India.There is a need to adopt culturally relevant and effective reproductive health education including menstrual hygiene to improve the knowledge of adolescents, women, and men in the reproductive age group. Since women are not forthcoming to access treatment for RTI/STI, diagnosis and treatment based on syndromic management would be of immense help to the community seeking treatment and also to healthcare providers. Studies could also be undertaken to know the prevalence of RTI/STI among men.
Source of Support: The Department of Community Health, St. John’s Medical College supported the study. There were no external sources of funding for the study., Conflict of Interest: None
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]