Women's perceptions and responses towards abnormal vaginal discharge: Focus Group Discussions in a socially marginalized community
Objective:Vulvo-vaginal discharge, which is a common gynaecological complaint, can be a normal phys- iological discharge or a symptom of an underlying reproductive tract infection, genital tract neoplasm, or other reproductive tract disorder. It is pertinent to differentiate physiological discharge from a pathological vulvo-vaginal discharge in order to prevent complications of untreated reproductive tract infections. Women are not seeking health advices for most of their gynaecological health issues and have different cultural practices to manage them. This study was conducted to explore the different cultural practices associated with vulvo-vaginal discharge among females aged 18–49 years living in an estate community in Colombo district, Sri Lanka.
Methods:This descriptive qualitative study used three Focus Group Discussions (FGDs) with a total number of 20 women. Transcribed verbatim data were analyzed using qualitative content analysis.
Results:Majority of the participants were Indian Tamils (n = 17, 85%) and Hindu (n = 15, 75%). Most (65%) of women were employed in the estate labour and educated up to grade 11 (n = 13). The major themes identified in the present study were difficulty in differentiating normal from abnormal vaginal discharge, lack of knowledge on causative factors, cultural influences and beliefs, unstable/limited source of income, fear of disclosing, and lack of support system. Many participants explained that they have difficulty in accessing health care as they are busy with their employment, household work, fear of internal examination, and fear of being admitted to the hospital ward. The common practice was to use home remedies such as polpala herbal drink (Balipoovu, Aerva lanata) or Neeramulliya (Asteracantha longifolia Linn) herbal drink, king coconut, Sauw (sago) Kanji, Uluhal (Fenugreek), and Aloe vera juice prior consulting medical advice for abnormal vaginal discharge.
Conclusions:The findings of this study revealed the need of support for women in estate sector for their repro- ductive and sexual health matters. There is a high need of public health care worker’s guidance and counselling to overcome barriers for health care utilization in this community.
Women experience one or more symptoms of gynaecologic morbidity between the time from puberty to the postmenopausal period and it can compromise the sexual and reproductive health of women. Persistent vaginal discharge can cause considerable distress to many women. Vulvo-vaginal discharge is a common symptom of gynae- cological morbidities especially reproductive tract infections/ sexually transmitted infections (STIs).[4,5]
The World Health Organization (WHO) estimates that 340 million new cases of curable sexually transmitted infec- tions (STIs) occur every year throughout the world and the majority is from the developing countries. STIs appear to be steadily rising and there is a very high vulnerability to STIs among both young men and women in age cohort 15–39 years in Sri Lanka. World Health Organization (WHO), estimates that 32% of the disease burden among women in the reproductive age group worldwide is due to sexual and reproductive health problems. The burden of morbidity and mortality worldwide resulting from sexually transmitted pathogens compromises quality of life, as well as sexual and reproductive health and newborn and child health.
Delayed treatment for reproductive tract infections can cause serious effects such as infertility, ectopic pregnancy, and cervi- cal cancer. Sociocultural and behavioural factors that affect gynaecological morbidity and the impact of these morbidities on women’s lives have not been studied in Sri Lanka. Many women use self-treatments with over-the-counter prepara- tions for vaginal discharge prior to consulting a doctor.
The estate sector is defined as areas with plantations where there are 20 or more acres in land and 10 or more resident labourers. The estate population of Sri Lanka is 4.4% of the country’s total population. Estate people are confined within the structure, thus creating ‘residential labour’ which was totally dependent on the management for all aspects of their life. They have poor health and education outcomes relative to the rest of the country and they live in congested and unsanitary housing, with little access to social services due to the isolated locations of the estates, poor connections to nearby villages and linguistic differences. This increases the chances of many unhealthy practices and possibility of transmitting diseases. Little is known about the combined effects of economic conditions, social, and cultural factors on estate women’s understandings of reproductive matters. Thus, the present study aimed to assess cultural practices and health seeking behaviours related to vaginal discharge within estate communities to understand the sociocultural context.
MATERIALS AND METHODS
Design and sample
This descriptive qualitative study explored women’s experi- ences, understanding, and different cultural practices related to vulvo-vaginal discharge in a selected socially marginalized community in Colombo District, Sri Lanka. Descriptive qualitative studies typically have been used to present general summaries of phenomena or events in ordinary language. Three Focus Group Discussions (FGDs) were conducted in two randomly selected estates. All groups comprised of six to seven women of a total of 20 women.
Permission to conduct this research in the estate sector was obtained from the Plantation Human Development Trust and Managers from the relevant estates. Ethical clearance was obtained from Ethics Review Committee, Faculty of Medical Sciences, University of Sri Jayewardenepura, Gangodawila, Nugegoda, Sri Lanka. Written informed consent was obtained from the participants. Audio recordings were done and no personal identifiers were recorded or transcribed. Participants were paid for their transport expenditure.
The social workers from each estate contacted the females aged 18–49 years irrespective of their marital status living in the estates for a continued period of not less than six months and females who had experienced episodes of vaginal discharge previously or at the time of the study were included in the study. FGDs were conducted in a place where privacy was maintained.
A sociology graduate, who was trained by the principal inves- tigator and one of the supervisors of the study, facilitated the discussions as the moderator. The principal investigator acted as a field note-taker and operated the tape-recorder and wrote down observations concerning the interaction between participants as well as group dynamics including non-verbal communications. Time taken for each FGD varied from 45 to 90 minutes.
A semi-structured FGD guide was used to facilitate FGDs including open-ended questions about awareness about vulvo-vaginal discharge and their concerns and treatment seeking behaviours related to vulvo-vaginal discharge. This FGD guide was validated judgmentally by experts in the field of Obstetrics and Gynaecology, Community Medicine and Nursing [Table 1].
|Questions: Focus Group Guide|
|1||What do you know about vaginal discharge?|
|2||At what point do you think that vaginal discharge is excessive?|
|3||What can be the reasons for vaginal discharge?|
|4||What are the concerns you have in relation to vaginal discharge?|
|5||Do you think women take treatments for excessive vaginaldischarge? If not, why they do not take treatments?|
|6||If yes, what type of treatment methods they practice?|
|7||What do you think the first line treatment women practicefor excessive vaginal discharge?|
|8||What are the factors associated with women’s decision on treatment for excessive vaginal discharge?|
Transcripts were prepared from the audio recordings and the field notes. Transcribed verbatim data were analyzed using qualitative content analysis according to Graneheim and Lundman. The transcribed verbatim were read care- fully and meaning units that were relevant to each research question were identified. These meaning units were then summarized to condensed meaning units which were used to develop codes. Codes were then sorted by similarities and dissimilarities and abstracted into sub-categories and catego- ries, as emerged from the text itself rather than imposing the researcher’s own pre-determined ideas. The categories for all FGDs were discussed under different themes depending on the objectives. Finally, these emergent categories were used to create themes in a way to link the underlying meanings of the entire data set. Researchers cross-checked each step of content analysis in order to establish authenticity and trustworthiness of the research, and ensured that the line of thinking and interpretation are clear to the readers and true to the data.
A total number of 20 women participated in all three FGDs (FGD1: 7, FGD2: 7, FGD3: 6). Majority of the study sample consisted of Indian Tamils (n = 17, 85%) and Hindu (n = 15, 75%). Mean age of the participants was 33.1 (SD ± 7.25) years. Most of them had studied up to grade 11 (65%). All the participants were married (100%) and majority (75%) had a nuclear type family [Table 2].
|Variables||Frequency (n)||Percentage (%)|
|Up to GCE O/L||13||65.0|
|Up to GCE A/L||01||5.0|
The analysis comprised of six themes, namely, difficulty in differentiating normal from abnormal vaginal discharge, lack of knowledge on causative factors, cultural influences and beliefs, unstable/limited source of income, fear of disclosing, and lack of support system [Figure 1].
Key findings under each main theme have been given using appropriate verbatim quotes to illustrate those findings. The numbers within brackets () refer to a particular woman’s age and the relevant FGD.
Theme 1: Difficulty in differentiating normal from abnormal vaginal discharge
Group participants frequently mentioned that they have no clear understanding about normal or abnormal vagi- nal discharge. Few of them mentioned that if the discharge is white or clear and watery, it is normal and if it occurred continuously and if yellow coloured, it can be a disease. Most of the women expressed that they had a previous history of vaginal discharge and it is a usual condition. Some expressed that their relatives had it too.
‘If the discharge is normal, it is white or clear in colour. If there is continuously yellow coloured discharge, it can be a disease’…, ‘One of my sisters had it and she was very weak. She lost her weight too’ (35 years, FGD 1).
‘if it is normal, it will not have a smell. But when it is abnormal, it might have a bad odour’ (33 years, FGD 1).
‘I also had it. I went to take treatment and it was cured after that. Doctor said that it is due to body heat’ (40 years, FGD 3).
‘I have not heard about it and I have not experienced it’ (30 years, FGD 2).
‘I have it sometimes and I don’ know when to take medicine. It reduce with time. But sometimes it is a trouble. Don’t know what to do’ (33 years, FGD 2).
Theme 2: Lack of knowledge on causative factors
Majority of the participants explained that abnormal vagi- nal discharge is caused by body heat, sexually transmitted diseases, heavy work, and consumptions of heaty food. They were not aware about any other conditions leading to abnor- mal vaginal discharge. Only few said that this can be due to a sexually transmitted infection.
‘I also had vaginal discharge and I got treatment. Then doctor told me that it is due to excess body heat’ (40 years, FGD 3).
‘I heard that this is due to melting of bones and it can cause subfertility’ (34 years, FGD 2).
‘I don’t know exactly, but I think this can be due to a sexually transmitted disease’ (28 years, FGD 2).
Some other participants mentioned that excessive vaginal discharge can be due to heavy work.
‘If we work more, we can get excessive discharge. It can be due to melting bone, especially in joints’ (36 years, FGD 1).
This highlights the inability of recognizing normal and abnor- mal vaginal discharge and awareness about possible causes in this community.
Theme 3: Cultural influences and beliefs
The participants mentioned itchiness, burning sensation, lower abdominal pain, back pain, and wetness as other diffi- culties they faced with excessive vaginal discharge. What they have done to reduce this was washing the perineal area with mild warm water.
‘I have lower abdominal pain when I have excessive vaginal discharge. I get itchiness too. Then I wash the area by using mild warm water in order to reduce burning and itchiness’ (28 years, FGD 2).
Many women have used different home remedies in order to manage vaginal discharge as they had difficulty in disclosing the condition to a doctor.
‘Even though I had it, I didn’t tell anyone. I didn’t tell anyone because I thought it is usual for all women after delivery of a baby. I got used to drinking a herbal drink for this’ (32 years, FGD 1).
‘My sister got this and my mother took her to an Ayurveda doctor. He gave some herbal drink and now she is ok. She was very thin and weak previously’ (33 years, FGD 1).
‘I got this while I was young and I didn’t get treatment. Only I was given polpala herbal drink (Balipoovu, Aerva lanata) or Neeramulliya (Asteracantha longifolia Linn) herbal drink by my mother. But after getting married, I got medicine from a private doctor’ (31 years, FGD 1).
‘This is due to excessive body heat. Therefore we drink herbal drinks to reduce body heat such as king coconut, sago (Sauw) Kanji, Fenugreek (Uluhal) in to glass of water and drink’ (29 years, FGD 2).
Theme 4: Unstable/limited source of income
Many participants explained that they have difficulty in accessing health care as they are busy with their employment, household work, fear of internal examination, and fear of being admitted to the hospital ward.
‘Some women are afraid to go to hospital as they will be admit- ted to the ward. If so there is no one to look after their children. Some others are also afraid of internal examination by doctors. So they do not go to hospital’ (32 years, FGD 2).
Participants expressed that they have limited time to do all their household work and think about their health. Their priority concern is to earn money. Their main source of income is wage employment on a plantation. As excerpts of their statements revealed,
‘We work in the estate from morning 6 am to evening 2 pm and some days extra work till 6 pm. So we do not have time to go to take treatment. If we do not go to work, we do not get money. Therefore we go for work even if we are not well’ (28 years, FGD 2).
Theme 5: Fear of disclosing
Women expressed the reasons for not taking health advice or treatment as fear of examination and hospitalization.
‘We do not have anyone to tell but we discuss our problems while working in the field. Then we get to know some home remedies’ (31 years, FGD 1).
‘Because of shyness, we do not talk about this’ (28 years, FGD 2).
‘Afraid to go to the doctor. Because we have to face vaginal examination’ (32 years, FGD 2).
Thus, for these women the only way of getting information is through the networking with fellow workers in the field or rubber factory. Further, they are afraid of disclosing health matters related to reproductive and sexual health due to stig- mas and discrimination from the society they belong to.
‘Unmarried girls do not talk about this because of shyness. They are afraid that they will be recognized as a bad person who has engaged in intercourse with a man’…. (35 years, FGD 2).
Theme 6: Lack of support system
Women expressed that they do not have a good support system. They were isolated and stigmatized by the society. Therefore they were not taking medical advice and follow home remedies to manage vaginal discharge.
‘Some girls are afraid to tell their mothers as they are very cruel. If we tell our mothers, they will blame us. But some mothers are good’ (33 years, FGD 2).
‘When unmarried girls face this problem, they do not talk about this because of shyness and being afraid of the society. They keep silent and only talk with each other while working. They are afraid that this is due to a bad behaviour and they will be recognized by others as bad persons.’…. (38 years, FGD 3).
‘We work in the estate from morning to evening. At the end of the day we are very tired. Have to cook and feed children. Also sometimes husband will come after drinking alcohol and lot of problem at home. Even there are fights and find very little time to watch television either. There is no way to hear about health issues and learn anything’ (25 years, FGD 2).
The present study shows that women aged 18–49 years living in estate community show different cultural practices and health seeking behaviours related to vaginal discharge. There are limited resources and support for the women who live in estate sector in Sri Lanka due to many sociocultural reasons. Even though resources are available for them to use, their usage is questionable. As the poverty and well-being is multi-dimensional, according to the present study, limited income was a main factor for women to ignore their health condition. As the majority of the study participants had not received up to secondary level education, they have never learnt about reproductive health or sexual health. The theme unstable/limited source of income emerged as the women work as labourers and ignore their self-care.
This group of women is at risk of reproductive and sexual health matters due to lack of knowledge, poor educational level, and lack of exposure to outside world. Since majority of women work in the estates and have no time, they are unable to gather information from various forms of media. Similarly, Fatima and Khan explained that, most of the women had ignored their health problems due to different factors like home responsibilities, domestic chores, children, and exces- sive burden of work at home.
Majority of women had difficulty in differentiating normal vaginal discharge from abnormal vaginal discharge. Similarly, identification of vaginal discharge as a suspected symptom associated with the reproductive tract infections was poor among women in some studies.[15,16] Similarly, most of the participants were unaware about the phenomena associated with the menstrual cycle and were confused about vagi- nal discharge, although they were suffering from vaginal discharge for a long time. Lack of awareness was a theme emerged in their study and they mentioned that due to lack of knowledge, majority of the participants ignored this problem and did not share it with anybody.
Similar to the findings of the present study, women explained vaginal discharge as “a consequence of consuming specific categories of food (chicken, red meat)” and “due to a weak- ness (after having children); water from the bone starting to flow as discharge.”[17-19] Majority of the study participants agreed that poor personal hygiene is another cause for abnor- mal vaginal discharge, and it has been expressed in many studies as well.[16-19] Some of the participants perceived that vaginal discharge occurs due to the melting of bones. In addition, similar to the findings of the present study, very few females had expressed infections as a cause for abnormal vaginal discharge, in another study conducted in USA. But in the present study heaty food consumption and body heat were mentioned as the main reasons.
Most of the participants agreed that they use many home remedies and use Ayurveda treatments prior to medical advice due to the sensitive nature of the subject. Similar to that, women are reluctant to discuss vaginal symptoms even with their physicians, worrying that they might be seen as sexually promiscuous. Therefore, one reason for using home remedies for abnormal vaginal discharge other than seeking medical advice might be due to fear of labelling them. Many women have tried home remedies such as polpala herbal drink (Balipoovu, Aerva lanata) or Neeramulliya (Asteracantha longifolia Linn)herbal drink, king coconut, Sauw (sago) Kanji, Uluhal (Fenugreek), and Aloe vera juice. Further avoidance of wearing tight trousers, hot baths, over- the-counter medicines, washing perineal area frequently, use of salt baths, and use of natural yoghurt have been found to be practiced in other communities.
In the present community expressed many cultural and social factors that have an impact on their health and how they perceive their health. A negative impact of women’s qual- ity of life, due to the shame and frustration over recurring symptoms and being socially isolated and inhibited in both their private and work life has been identified. It is neces- sary to organize health education programme for the given community by taking this in to consideration. A more refined and sensitive reproductive and sexual health strategy can be developed, which will be in tune with the cultural beliefs and expectations of estate women in Sri Lanka.
The findings of the present study shows that females from estate community agreed that it is uncomfortable to talk about vaginal discharge with others and mentioned embar- rassment in discussing with doctors, cultural view of vagi- nal discharge, feeling difficulty in discussing with a male doctor, and less knowledgeable about vaginal discharge as the reasons for them not to take medical advice for excessive vulvo-vaginal discharge. The findings highlight the need of providing additional health support services for the estate community in order to prevent transmission of STIs and to prevent unhealthy practices.
AcknowledgmentThe authors thank all the participants and the social workers for their support.
Declaration of patient consentThe authors certify that they have obtained informed written consent was obtained from the participants prior enrollment to the study.
Financial Support and SponsorshipAuthors thank University Research Grant (ASP/06/RE/ MED/2013/31), University of Sri Jayewardenepura, Sri Lanka for financial support.
Conflicts of InterestThere are no conflicts of interest.
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- MATERIALS AND METHODS
- Theme 1: Difficulty in differentiating normal from abnormal vaginal discharge
- Theme 2: Lack of knowledge on causative factors
- Theme 3: Cultural influences and beliefs
- Theme 4: Unstable/limited source of income
- Theme 5: Fear of disclosing
- Theme 6: Lack of support system