Comparison of the sexual behaviors and syndromic diagnosis between rural and urban cases in east-central India: A retrospective hospital-based study

INTRODUCTION

Sexually transmitted infections (STIs) are a major public health issue that impacts on health, social, and economic state in many developing and developed countries. The burden of sexual/reproductive tract infections (RTIs) varies according to the regions with more public health issues in resource-poor-setting. In India, STIs/RTIs affects about 6% of the adult population, which roughly estimate around 30–35 million cases/year.^[1]

Due to limited health facilities and access in developing countries like India, the syndrome approach to the management of STIs is still the cornerstone. It is already known that there are inequalities between rural and urban populations on various factors such as sociocultural, economical, educational, and physical environment.^[2] The rising economic development and urbanization have led to accelerated epidemiological transition in the of STI pattern. In many developing countries, there is still a lack of sex education which has contributed to increased STI cases, unplanned pregnancies and complications. STIs in urban areas may be attributable to a greater proportion of migrant or bridging populations.^[3,4]

The purpose of our study was to compare the sociodemographic profiles, the pattern of STIs syndrome, and sexual behavior among the rural and urban cases seeking treatment from a tertiary care center in the east-central zone of India.

MATERIALS AND METHODS

A cross-sectional hospital-based retrospective study was conducted in STIs clinic of a tertiary care center located in an urban area of an east-central India. All patients either staying and living in the rural or urban area presented to the STIs clinic were included, irrespective of age and gender from July 2022 to November 2023.

The details from the STIs clinic record included age, gender education, address, marital status, income, occupation, drug abuse, and clinical complaints. Based on the clinical symptoms, the patients were further classified into different syndromes as per the National AIDS Control Organization. The data also included sexual behavior such as the age of sexual debut number of partners, duration of the marriage, last contact encounter, type of partner (regular/casual/sex worker male/sex worker female), symptoms in a partner if any, partner occupation of the partner and number of similar episodes in the past, history of drug abuse, nature of sexual contact (protected or unprotected), were also recorded. Relevant investigations, such as human immunodeficiency virus, hepatitis B surface antigen, hepatitis C, and rapid plasma regain, were also recorded. All these data were grouped according to the address based on the rural and urban area for further comparison between different parameters.

RESULTS

During the study period, out of 925 patients attending the STIs clinic, 655 (70.8%) were from rural areas, and 270 (29.2%) were from urban areas. Among the rural cases, 604 (92.2%) were female and 51 (7.8%) were male, while among the urban cases, 219 (81.1%) were female and 51 (18.9%) were male. There was a significant difference in the proportion of STIs among males from urban areas compared to rural areas (P < 0.01). The majority of STIs cases from both rural and urban areas were aged between 20 and 40 years. However, the proportion of STI cases aged below 20 years was higher in urban areas (6.3%) compared to rural areas (2.7%) (P < 0.01).

In rural STI cases, 226 (34.5%) had education below 10^th class, while in urban areas, 99 (36.7%) had education above 12^th class. There was a significant difference in the education profile between rural and urban areas (P < 0.01), with a higher proportion of illiterate individuals in rural areas and a higher proportion of individuals with education above 10^th class in urban areas. The majority of STI cases reported were homemakers both from rural (79.7%) and urban (64.1%) areas. The proportion of married cases with STIs was higher compared to unmarried cases in both rural and urban areas. The pregnant females in rural and urban were 1.9% and 3.3% respectively. The frequency distribution of the sociodemographic profile of the participants is shown in Table 1.

Clinical symptoms based on a syndromic approach in rural and urban population

In a rural area, out of 655 cases of STIs, patients presented with lower abdomen pain in 81.7% of cases, followed by vaginal discharge in 17.1%, urethral discharge in 10.1%, cervical discharge in 4.9%, genital herpes in 4.3%, and genital ulcers secondary to syphilis in 3.7% [Figure 1]. In the urban area, out of 270 patients, clinical symptoms of lower abdomen pain were seen in 70% of cases, followed by vaginal discharge in 21.1%, urethral discharge in 11.1%, genital herpes in 10.4%, genital ulcers secondary to syphilis in 7.4%, and cervical discharge in 4.4% [Figure 1]. Genital herpes (P < 0.01) and genital ulcers secondary to syphilis (P = 0.01) were more common in urban areas. Retroviral HIV infection was present in 8 (1.2%) cases in the rural area and 3 (1.1%) cases in the urban area. Many patients presented with multiple clinical symptoms in both areas [Supplementary File 1].

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Figure 1:

The distribution of various clinical symptoms based on the syndromic approach between rural and urban area.

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DISCUSSION

This study provides a comprehensive review of the demographic, clinical, and behavioral characteristics of patients with STIs in rural and urban areas of the east-central part of India. Out of a total of 955 cases, 70.8% were from rural areas, and 29.2% were from urban areas. This disparity of representation can be explained based on the rural-urban gap, limited healthcare access, lack of health awareness, and resource constraints, thereby driving rural residents to seek better services in urban areas.^[5] Similar findings were also seen in the study by Nandan et al., the prevalence of STIs cases in the rural population (49%) was higher compared to urban area (27%).^[6] Female presented with STIs, majorly compared to males in both rural and urban areas, which is comparable with other studies.^[7-12] The distribution of STIs among males was significantly different (P < 0.01), with a higher proportion of cases in the urban areas compared to rural areas could be due to access to/health facilities, awareness, and education of STIs in urban areas. The proportion of female cases with STIs was more in rural compared to urban areas due to differences in education, lack of health facilities, less frequent STIs screening visits by healthcare personnel, and social and cultural beliefs in our study, comparable with study by Masoumirad et al.^[12]

The predominant age group in our study, presented with STIs, was 20–30 years, followed by 30–40 years in both the rural and urban areas, which was also consistent with various studies.^{[6,8,12,14,15]} A higher proportion of cases aged below 20 years was seen in urban areas compared to rural areas (P < 0.01) access to social media leading to psychological factors, experimentation of sexual needs along with incorrect sex education information and an environment which make discuss sexuality are attributed to this in various studies.^[11,16,17] There was a significant difference in the education profile between rural and urban areas, with illiterate more in rural areas and >10^th class education profile in urban areas with similar findings in other studies.^[14,15] In our study, STIs were more in female sex, married couples, young adults (20–40 years), housewife occupation, and low income groups in both areas. Similarly, in a study by Kosambiya et al. in Surat and Singh et al. in east-central India, the prevalence of STIs was higher in married housewife, lower education status, and young adults with income among the rural population.^[4,13] In the study by Kannan et al. in Tamil Nadu, the prevalence of STIs was 44.6% in married women belonging to the age group of 15–45 years.^[18] In a study by Sharma and Gupta, the rural female population of Himachal Pradesh showed significant STIs prevalence among the age group 25–34 years, married (52.4%), below 10^th class education and housewives with agriculture background.^[19] In a study by Philip et al., in urban females, the population of Ludhiana showed STIs majorly among age group 24– 25 years, housewives, monthly income ≥1000, and education profile of illiterate and primary level.^[20]

Lower abdomen pain was the predominant clinical symptom as per the syndromic approach, followed by vaginal discharge in both the rural and urban areas, which was contradictory with other studies showing vaginal, cervical, or urethral discharge as most common, followed by genital ulcer.^[8,21-23] However, in comparison, genital ulcers secondary to herpes and syphilis were more prevalent in urban areas. This could be due to differences in socio-cultural beliefs, education status, awareness level, sexual behavior, and lack of primary health care facilities among the east-central regions compared to other regions of India, which would have led to a delayed presentation like complications, such as pelvic inflammatory disease causing lower abdomen pain, at our STIs center, which is the highest referral center in the region.

There was a difference in the sexual behavior pattern among the cases of STIs between the rural and urban areas in our study. Sexual behavior parameters such as early age of onset of sexual activity, less cases of multiple sexual partners, and increased duration of gap of last sexual encounter were seen in rural population compared to urban areas. The STI cases in urban areas, despite having late onset of sexual activity, people were more engaged in high-risk behavior – like sexual contact with sex workers (11.5%), multiple partners (8.8%), unprotected sexual activity (97%), frequent sexual engagement, and drug abuse (8.2%), which also attribute to higher incidence of STIs in young adult below 20 years of age. In a study by Carey et al., 25% of patients on treatment for drug abuse or alcohol had suffered once in a lifetime with STIs.^[24] A study by Ranjan et al, in the rural population of Bihar showed 5-10% of males had multiple sexual partners. Predominant partners were female, mainly being sisters-inlaw, agricultural laborers, friend’s wife and sex workers.^[25] The sexual partners for women were brothers-in-law, distant relatives, and rich landlords. In a study by Singh et al. in the rural population of east-central India, the sexual partner was predominantly regular partner (78%), sex worker (8.5%), and causal partner (7.6%), which is similar to our study in the rural population.^[13] The majority of patients not frequently taking precautions before engaging in sexual activity was consistent with other studies.^[17] In our study, in both the rural and urban areas, the sexual partner’s occupation was a private job followed by business. However, farmers were the third common occupation of the partner in rural area while it was a government job in urban area.

CONCLUSION

This study highlights the differences in sociodemographic profile, STIs patterns, and sexual behaviors between rural and urban populations in the east-central zone of India. The findings underscored the need for interventions to address the higher prevalence of STIs in rural areas as compared to urban areas. The difference in education, occupation, and income level highlights the disparities in the sociodemographic profile of STIs cases between rural and urban areas.