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ORIGINAL ARTICLE
Year : 2018  |  Volume : 63  |  Issue : 6  |  Page : 469-474
Stigma associated with sexually transmitted infections among patients attending suraksha clinic at a tertiary care hospital in northern India


1 Department of Dermatology, Venereology and Leprosy, King George's Medical University, Lucknow, Uttar Pradesh, India
2 Department of Community and Family Medicine, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
3 Department of Microbiology, King George's Medical University, Lucknow, Uttar Pradesh, India
4 Department of Psychiatry, King George's Medical University, Lucknow, Uttar Pradesh, India

Date of Web Publication2-Nov-2018

Correspondence Address:
Dr. Swastika Suvirya
Department of Dermatology, Venereology and Leprosy, King George's Medical University, Lucknow, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijd.IJD_145_18

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   Abstract 


Context: Illnesses affecting sexual organs and its correlation with improper sexual behavior lead to a negative attitude and discriminating behavior towards people affected by such disorders. Aim: The aim was to study the stigma associated with sexually transmitted infections (STIs) among patients attending Suraksha clinic at a tertiary care hospital in northern India. Settings and Design: This was a hospital-based cross-sectional study. Subjects and Methods: The present study was conducted at Suraksha (STI) clinic, King George's Medical University, Uttar Pradesh. A total of 487 STI patients (clinically and/or laboratory-confirmed) were contacted telephonically, of which 49 finally participated in the study. Stigma was assessed using modified and pretested version of India HIV-related stigma scale adapted in context to sexually transmitted diseases. Statistical Analysis: Quantitative variables were expressed as mean with standard deviation, and independent sample t-test was used to compare the mean values. P < 0.05 was considered statistically significant. Results: Mean scores of enacted, vicarious, felt normative, and internalized stigma for 49 patients (out 487) who finally participated in the study were 0.04±0.11, 0.55±0.70, 1.21±0.96, and 0.86±0.67, respectively. Unmarried/divorced/separated patients had significantly higher vicarious and felt normative stigma scores as compared to married individuals. Mean score for felt normative stigma was significantly higher among homosexual/bisexuals in comparison to heterosexual individuals. Conclusions: Efforts should be directed towards the provision of integrated services through sexual health-oriented campaigns to address the stigma associated with STI in a more comprehensive way.


Keywords: Sexually transmitted infections, stigma, suraksha clinic


How to cite this article:
Suvirya S, Shukla M, Pathania S, Banerjee G, Kumar A, Tripathi A. Stigma associated with sexually transmitted infections among patients attending suraksha clinic at a tertiary care hospital in northern India. Indian J Dermatol 2018;63:469-74

How to cite this URL:
Suvirya S, Shukla M, Pathania S, Banerjee G, Kumar A, Tripathi A. Stigma associated with sexually transmitted infections among patients attending suraksha clinic at a tertiary care hospital in northern India. Indian J Dermatol [serial online] 2018 [cited 2018 Dec 14];63:469-74. Available from: http://www.e-ijd.org/text.asp?2018/63/6/469/244809





   Introduction Top


Sexually transmitted infections (STIs) are a group of illnesses which are caused by infections transmitted by sexual contact through exchange of semen, vaginal fluid, blood and other fluids; or by direct contact with the affected body areas of people with STIs. More precisely STIs are defined as loose constellation of infections and syndromes that are epidemiologically heterogeneous, but all of which are almost always or at least often transmitted sexually.[1] STIs (both nonulcerative and ulcerative) during the past few decades have emerged as one of the major public health problems affecting both developing and developed countries. The trend and pattern of STIs used to vary from region-to-region, especially in large nations like India.[2] As per statistics released by the National AIDS Control Organization 2016–2017, HIV prevalence rate in the general population in the country is 0.26% and in STI clinic HIV prevalence is 2.5%.[3] Apart from contributing to the substantial burden of mortality and morbidity it also leads to huge psychosocial consequences both at the individual as well as at the community levels. STIs still persist as a major social pathology having a significant impact on the mindset of people. More or less STIs are considered as a matter of shame and stigma in a community.

Stigma refers to the devalued status that society attaches to a condition or attribute.[4] Stigma can be broadly described under four domains, namely, enacted, vicarious, felt normative, and internalized. Enacted stigma refers to overt acts of discrimination and hostility directed at a person because of his or her perceived stigmatized status; while felt normative stigma refers to subjective awareness of stigma.[5] On the other hand, internalized stigma refers to the extent to which an individual accepts stigma to be valid and accept their discredited status as valid.[6] Vicarious stigma often reflects the perceptions shaped by stories of discrimination against other individuals.[4] Those who have been diagnosed with STI often experience these sorts of experiences such as shame, anxiety and embarrassment, fear of isolation, rejection, and not being sexually desirable, thereby leading to a feeling of decreased self-esteem.[7],[8],[9] Women with sexually transmitted diseases (STDs) often suffer from the feeling of being “dirty” with fear of negative reactions from others.[8] STIs have a detrimental effect on mental, social as well as emotional domain of an individual. Therefore, the forthcoming consequences of diagnosis are difficult to handle emotionally, and most of them are afraid that they will loose their family support and hence do not want to disclose their condition.[10] This reluctant behavior regarding disclosure of status leads to adverse consequences regarding health-seeking practices. Actually, it turns up to a significant barrier in the clinical management of these patients. STI-related stigma has also been known as an important barrier for STI screening.[11] Moreover, the stigma associated with STI predisposes female adolescents to hide their sexual behavior from healthcare providers.[12]

Though there are studies on these aspects in many parts of the world, similar studies from India are few. We undertook the present study to have an idea of the situation prevalent.


   Subjects and Methods Top


Study design

This was a hospital based cross-sectional study.

Study settings

The study was conducted at the Suraksha Clinic (STI clinic), King George's Medical University, a Tertiary Care Hospital in Uttar Pradesh, India.

Study participants

STI patients (clinically and/or laboratory confirmed) aged ≥18 years registered at Suraksha clinic.

Study duration

September 2016–2017.

Sampling methodology

Before the commencement of the study, approval was sought from the Institutional Ethics Committee of King George's Medical University. Then a coordinated and well-planned attempt was made to contact telephonically 487 line listed patients. Most of the times during the initial visit, patients were not aware of their symptomatic condition being an STI. Knowledge of the same was provided at the Suraksha clinic by the physician. So for them to understand the real situation and feel the stigma-related experience in due course, a minimum period of 3 months was maintained between the diagnosis and telephonic contact. Each patient was tried to be contacted telephonically maximally for three times during the whole study period. Meanwhile, all the patients were briefed about the purpose of study assuring that further clinical assistance will be provided to them during their visit if required. Furthermore, the patients were assured that their identity and data gathered through them will be kept confidential. Out of the total patients approached telephonically, only 49 patients (47 males and 2 females) turned up and gave consent for participation.

Data collection tool

Once the patients visited the facility, they were rebriefed again about the objectives of the study and written informed consent was taken before the final data collection. Sociodemographic characteristics of patients were recorded on a predesigned and pretested schedule. Details were rechecked from master client register as well as counselor register. Since HIV as well as STI, both share common social, psychological as well as behavioral aspects, the stigma associated with STI was assessed using modified and pretested version of India HIV-related stigma scales adapted in context to STDs. The instrument was used to measure the four components of stigma, i.e., enacted, vicarious, felt normative, and internalized. It consists of 10 items each (selected from an initial pool of 21, 20, 15, and 15, respectively, keeping the Indian context in view and their adaptation in the study settings).[4] For each enacted stigma item responses were no (0) or yes (1) while for vicarious stigma each item scaled on 4 points ranged from 0 (never) to 3 (frequently). In items for felt normative responses were given on a 4-point scale ranging from 0 (no one) to 3 (most people) and for internalized stigma responses were given on a 4-point scale running from 0 (not at all) to 3 (a great deal). Higher the scores obtained indicated a greater level of stigma among STI patients.

Data analysis

Data were compiled and analyzed using the statistical software Statistical Package for the Social Sciences (SPSS version 20.0 IBM Corp., Armonk, NY, USA). All quantitative variables (scores) were expressed as mean ± standard deviation. Independent sample t-test was used to compare the mean values. All values of P < 0.05 were considered as statistically significant.


   Results Top


Out of total 487 STI patients who were approached telephonically, only 49 (10.1%) turned up finally for participation in the study and reported to the department for sharing their experiences relating to the stigma associated with STI. The remaining 438 (89.9%) patients did not report to the department even after having several times of telephonic conversation. Various reasons were stated by these 438 patients conveying their inability to revisit the hospital. Reasons such as busy routine schedule, long travel distance, conveyance problem, and lack of money were the most commonly cited by the patients. Apart from that some contact phone numbers were found either beyond network reach or switched off.

In the present study, majority (89.8%) of the responding STI patients were aged 35 year or below, and almost all (95.9%) were male. The responders mainly belonged to the Hindu religion (81.6%) and had an intermediate or above level of education (79.6%). About two-fifth (40.8%) of them were employed in private sector jobs, and more than two-third (69.4%) had income above 1 lakh per annum. Among those STI patients who did not turn up (nonresponders) for participation in the study, three-fourth (74.6%) were aged 35 years or below. Majority of them were male (79.9%) and belonged to the Hindu religion (86.3%). More than half (60.5%) of the nonresponders were married. The study found that about 40% of the nonresponders were educated up to high school followed by 36.3% having intermediate level of education. More than one-fifth (22.1%) of the nonresponders were unemployed, and a similar proportion was employed in private sector jobs. The annual income of the nonresponders could not be retrieved as they did not present themselves for face-to-face interviews [Table 1].
Table 1: Bio-social characteristic of the sexually transmitted infection patients attending Suraksha clinic (n=487)

Click here to view


The present study reported that the most common STI among the respondents was herpes genitalis (28%) followed by secondary and latent syphilis (26.5 and 24.5%, respectively). About two-third of the responders had heterosexual preference and had disclosed the STI status to other, most preferably to friend/partner (41.2%) followed by spouse (38.2%). In majority of the responders (87%), STI was absent in spouse. Among the nonresponders, the most common STI infection was genital warts (26.5%) followed by latent syphilis (21.7%) and molluscum contagiosum (21.7%). In about 99.5% of the patients, the presenting case of STI was relapse. The majority (87.4%) of the nonresponders had heterosexual preference, and almost all (99.5%) of them had not disclosed the STI status to others. Furthermore, STI was absent in the spouses of almost all of the nonresponders (99.3%) [Table 2].
Table 2: Clinical characteristic of the sexually transmitted infections patients attending Suraksha clinic (n=487)

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The mean scores were 0.04±0.11, 0.55±0.70, 1.21±0.96, and 0.86±0.67 for enacted stigma, vicarious, felt normative stigma, and internalized stigma, respectively, among the 49 STI patients who finally participated in the study. All the scores for respective stigma measures were found to be below average. On analysis, unmarried/divorced/separated patients were having significantly higher vicarious and felt normative stigma scores as compared to married individuals (P < 0.05). Furthermore, mean score for felt normative stigma was significantly higher among homosexual/bisexuals in comparison to heterosexual STI patients. However, no significant difference was observed in mean scores in context to age-group, gender, religion, educational status, employment status, annual income, history of STI in the past and disclosure of STI status for enacted, vicarious, and felt normative or internalized stigma (P > 0.05) [Table 3].
Table 3: Distribution of sexually transmitted infection patients by bio-social, behavioural and clinical characteristic with mean levels of stigma indices (n=49)

Click here to view



   Discussion Top


Limited studies are present in context to the stigma associated with STIs other than HIV. The present study was an attempt to explore the various biosocial, behavioral and clinical characteristics, and their association with stigma. A unique approach was adopted to measure the same under the domains of enacted stigma, vicarious stigma, felt normative stigma, and internalized stigma which were implicated in perspective of STDs.

Out of total 487 STI patients (clinically and or laboratory confirmed), only a small proportion, about 10.1%, finally turned up and reported to the department for participation in the study. Since most of the STIs get cured after the first few visits, patients usually do not need to come back to the health facility again. Furthermore, various reasons were cited on their behalf mentioning their inability to participate in the study. However, their view must be interpreted in the light of the fact that STIs were considered as a matter of shame and stigma in the Indian population;[4] which might be playing an intervening and hidden role for citing different indirect reasons for nonparticipation in the study. The low participation rate somehow itself reflected indirectly toward the stigma-related experiences felt by STI patients.

The baseline characteristics of both responders and nonresponders were quite similar on the proportionate comparison. However, the proportion of homemakers were higher among nonresponders as compared to responders. This somehow reflected the fear and stigma in the mindset of Indian homemakers about STI. In addition, the homemakers were also dependent on others for taking them for clinical consultations. Furthermore, the proportion of first time diagnosed symptomatic cases were higher among nonresponders. Patient with relapsing or chronic STIs often fear that their illness might recur and may progress. Hence, they agreed to come for assessment to maintain a continuity of care and compliance. The proportion of homosexual or bisexual was higher in the responder group. The higher response rate among homosexuals or bisexuals indirectly pointed toward the low perception of internalized stigma by these groups.

In the present study, mean scores for different stigma measures were found to be below average. When the data were analyzed in relation to enacted stigma no significant difference was observed in context of biosocial/clinical/behavioral characteristics. This insignificant difference showed that these independent characteristics did not play any intervening role to predict any specific discriminatory experience felt by patients due to their STI status.[4]

On the other hand, vicarious stigma captured the frequency with which patients had heard stories about individuals being mistreated because of STI.[4] The scores were significantly higher among those patients who were unmarried/divorced/widowed/separated. This finding might be attributed to the fact that these group had more frequent talks related to these sort of experiences with their friends with same marital status. Married males and females both in Indian set up are quite busy in their family lives and give little preference to such type of talk on experiences.

Furthermore, the felt normative stigma scores were significantly higher for patients who were unmarried/divorced/widow/separated, i.e., they expected a higher number of people in their community to be engaged in discriminatory behavior or endorsed stigmatizing belief. Furthermore, felt normative stigma scores were significantly higher among homo/bisexual individuals. These homosexual or bisexual individuals thus bore a double burden of stigma, i.e., one associated with their sexual preference;[13] and the other stigmatizing attitude from the community associated with STIs.

However, no significant difference was observed for internalized stigma scores in relation to biosocial/behavioral characteristics or clinical variables. Furthermore, the scores were much lower than average. This reflected that these patients, although suffering from STI, did not accept stigma to be valid and believe the STI patients should not be treated in a discriminatory manner or targeted of stigmatizing beliefs.

The study, however, had some limitations. Since only a small proportion of STI patients turned up and reported to the department finally, the findings might not be generalizable. Furthermore, the temporal relation between the STI and the stigma could not be definitely established. However, the major strength of the study was in the fact that, the research was unique in its own in the Indian context.


   Conclusions Top


The low participation of STI patients indirectly reflected the stigma associated with STI. Single individuals (unmarried/divorced/separated) had significantly higher scores for vicarious and felt normative stigma as compared to married individuals. Furthermore, felt normative stigma scores were significantly higher among homosexual/bisexuals as compared to heterosexual STI patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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Marfatia YS, Sharma A, Joshipura SP. Overview of sexually transmitted diseases. In: Valia RG, Valia AR, editors. IADVL Textbook of Dermatology. 3rd ed. Vol. 59. Mumbai: Bhalani Publishing House; 2008. p. 1766-78.  Back to cited text no. 1
    
2.
UNAIDS Report on the Global AIDS Epidemic; 2013. Available from: http://www.files.unaids.org/en/media/unaids/contentassets/documents/epidemiology/2013/gr2013/UNAIDS_Global_Report_2013_en.pdf. [Last assessed on 2016 Feb 13].  Back to cited text no. 2
    
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NACO. Department of AIDS Control Ministry of Health and Family Welfare. Annual Report; 2016-2017. Available from: http://www.naco.gov.in/sites/default/files/NACO%20ANNUAL%20REPORT%202016-17.pdfhttp://www.naco.gov.in/sites/default/files/NACO%20ANNUAL%20REPORT%202016-17.pdf. [Last assessed on 2017 Mar 22].  Back to cited text no. 3
    
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Steward WT, Herek GM, Ramakrishna J, Bharat S, Chandy S, Wrubel J, et al. HIV-related stigma: Adapting a theoretical framework for use in India. Soc Sci Med 2008;67:1225-35.  Back to cited text no. 4
    
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Scambler G. Epilepsy. London: Routledge; 1989.  Back to cited text no. 5
    
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Herek GM. Understanding sexual stigma and sexual prejudice in the United States: A conceptual framework. In: Hope D, editor. Contemporary Perspectives on Lesbian, Gay, & Bisexual Identities: The 54th Nebraska Symposium on Motivation. New York: Springer; 2008.  Back to cited text no. 6
    
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Darroch J, Myers L, Cassell J. Sex differences in the experience of testing positive for genital chlamydia infection: A qualitative study with implications for public health and for a national screening programme. Sex Transm Infect 2003;79:372-3.  Back to cited text no. 7
    
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Duncan B, Hart G, Scoular A, Bigrigg A. Qualitative analysis of psychosocial impact of diagnosis of Chlamydia trachomatis: Implications for screening. BMJ 2001;322:195-9.  Back to cited text no. 8
    
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Lindberg C, Lewis-Spruill C, Crownover R. Barriers to sexual and reproductive health care: Urban male adolescents speak out. Issues Compr Pediatr Nurs 2006;29:73-88.  Back to cited text no. 9
    
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Fortenberry JD, McFarlane M, Bleakley A, Bull S, Fishbein M, Grimley DM, et al. Relationships of stigma and shame to gonorrhea and HIV screening. Am J Public Health 2002;92:378-81.  Back to cited text no. 10
    
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Cunningham SD, Tschann J, Gurvey JE, Fortenberry JD, Ellen JM. Attitudes about sexual disclosure and perceptions of stigma and shame. Sex Transm Infect 2002;78:334-8.  Back to cited text no. 11
    
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Cunningham SD, Kerrigan D, Pillay KB, Ellen JM. Understanding the role of perceived severity in STD-related care-seeking delays. J Adolesc Health 2005;37:69-74.  Back to cited text no. 12
    
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Huy HA, Ross M, Risser JM, Nguyen HT. Determinants of homosexuality related stigma among men who have sex with men in Hanoi, Vietnam, Int J Sex Health 2014;26:200-16.  Back to cited text no. 13
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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