Elsevier

Social Science & Medicine

Volume 71, Issue 11, December 2010, Pages 1921-1926
Social Science & Medicine

Factors associated with partner referral among patients with sexually transmitted infections in Bangladesh

https://doi.org/10.1016/j.socscimed.2010.09.009Get rights and content

Abstract

Understanding the demographic, behavioural and psychosocial factors associated with partner referral for patients with sexually transmitted infections (STIs) is important for designing appropriate intervention strategies. A survey was conducted among STI clients in three government and three non-governmental organization-operated clinics in Dhaka and Chittagong city in Bangladesh. Demographic and psychosocial information was collected using a questionnaire guided by the Attitude-Social Influence-Self Efficacy model. Partner referral data were collected by verification of referral cards when partners appeared at the clinics within one month of interviewing the STI clients. Of the 1339 clients interviewed, 81% accepted partner referral cards but only 32% actually referred their partners; 37% of these referrals were done by clients randomly assigned to a single counselling session vs. 27% by clients not assigned to a counselling session (p < 0.0001). Among psychosocial factors, partner referral intention was best predicted by attitudes and perceived social norms of the STI clients. Actual partner referral was significantly associated with intention to refer partner and attitudes of the index clients. Married clients were significantly more likely to refer their partners, and clients with low income were less likely to refer partners. Intervention programmes must address psychosocial and socio-economic issues to improve partner referral for STIs in Bangladesh.

Introduction

Partner referral by patients with sexually transmitted infections (STIs) is an important public health intervention in STI management (Clark et al., 2007, Oxman et al., 1994). Partner referral is important to (1) inform partners at risk about their possible exposure to the infection, (2) prevent re-infection of the index patients and interrupt the chain of transmission, and (3) reduce the number of asymptomatic carriers in a population (Rothenberg, 2002). Partner referral could be accomplished in one of three ways: through the STI patients themselves, by healthcare providers, or by joint responsibility of both the patients and the providers (Macke et al., 1998, Rothenberg, 2002).

In general, HIV prevalence is very low in Bangladesh, with less than 1% prevalence rate among the most-at-risk populations except for the injecting drug users group, where prevalence was reported to be 7% in one surveillance site (Azim et al., 2008). A study among female sex workers reported gonorrhoea, chlamydial infection, trichomoniasis prevalence rates of 35.8%, 43.5%, and 4.3%, respectively (Nessa et al., 2004). STI management services in Bangladesh differ by type of service providers and settings. Most primary health care centres, and non-government organization (NGO) clinics follow the World Health Organization’s (WHO) recommended syndromic management protocol, but general physicians and secondary or tertiary level health care providers generally follow the management protocol in medical textbooks, with or without support from laboratory investigations (National AIDS/STD Programme, 2006). Information on partner referral and management practices in Bangladesh is very limited. Service delivery data from primary health care clinics in rural Bangladesh have indicated that service providers only rarely recommend partner referral to STI clients (Ahmed et al., 1999). There is no published information on patients’ perspectives of partner referral, particularly on their knowledge, attitudes, social norms, and perceived barriers. Understanding these factors is important for designing appropriate intervention strategies to promote partner referral (Joffe et al., 1992, Potterat et al., 1991).

The Attitude-Social Influence-Self Efficacy (ASE) model (De Vries, Dijkstra, & Kuhlman, 1988) has been used to explain the relationship between psychosocial factors and various types of health-related behaviour, such as partner referral for STI, smoking secession, and breast feeding (Bolman et al., 2002, Kools et al., 2005, Nuwaha et al., 2001). According to the ASE model, behaviour (i.e., referral of one’s sexual partner) is best predicted by intention, which in turn is influenced by attitudes, social influences, and self-efficacy (see Fig. 1). Among the psychosocial factors, the attitude of a person towards a given behaviour refers to the extent to which a person has a favourable or unfavourable evaluation of the behaviour. The social norm deals with the perceived social influence on whether to perform or not perform the given behaviour. The outcome beliefs refer to the perceived likelihood that performing the behaviour will lead to certain consequences; this includes beliefs about positive outcomes and beliefs about negative outcomes. Self-efficacy refers to the judgment of how confident one is about executing actions required to deal with challenging situations (Bandura, 1982, Nuwaha et al., 2001).

Several demographic, behavioural and psychosocial factors have been reported to be associated with partner referral among STI patients (Clark et al., 2007, Hennessy et al., 2002, Rothenberg, 2002). Among demographic factors, sex of index patients and type of sexual partnership were found to be closely associated with partner referral outcomes; women referred partners more than men did, and steady/spousal partners were more likely to be referred than casual partners (Faxelid et al., 1996, Katz et al., 1988, Steen et al., 1996, van de Laar et al., 1997). Intention to perform a future behaviour (e.g., sexual partner referral) is expected to be determined by psychosocial factors, namely attitudes, perceived social norms and self-efficacy (Bauman et al., 2002, Kools et al., 2005, Markham et al., 2004). One study from Uganda found that intention to refer a partner was strongly associated with actual partner referral and was influenced by attitude, social norm and self-efficacy related to partner referral (Nuwaha, Faxelid, Neema, Eriksson, & Hojer, 2000). Intention has been found to be associated with other behaviours such as use of condoms (Gillmore, Morrison, Lowery, & Baker, 1994) and smoking cessation (Bolman et al., 2002) but not with initiation of breast feeding (Goksen, 2002).

Our study aimed to understand the relationship of partners’ referral intention with their actual referral behaviour among patients diagnosed with STIs in Dhaka, Bangladesh. We tested two hypotheses: (1) Psychosocial factors including attitudes, social norms, outcome beliefs, and self-efficacy relating to partner referral are associated with the intention of partner referral among index STI clients; and (2) Intentions of index STI patients to notify their sexual partners are associated with actual partner referral behaviour after adjusting for other psychosocial and socio-demographic factors.

Section snippets

Study cohort and participants

The study was conducted between March 2007 and December 2007 in three government and three NGO operated clinics in Dhaka and Chittagong districts in Bangladesh. The study clinics were selected based on their higher than average daily volume of STI patients as determined during a formative study. In each clinic, patients diagnosed with STIs (i.e., index case) of age 18 years and older who had engaged in sexual intercourse in the last three months were invited to participate. Diagnosis of STIs

Results

All of the 1416 clients diagnosed with symptoms suggesting STIs and approached to participate in the study agreed, but 77 of them were found ineligible. Slightly over half (53%) of these 1339 index STI clients were recruited from the NGO clinics, 55% were female and 74% were married at the time (Table 1). One third of the clients had less than $100 per month income, and 18% of them were illiterate. Thirty-nine percent of the clients had engaged in sex with a commercial sex partner in last three

Discussion

These findings indicate that a single counselling session influenced STI clients taking a partner referral card and ensuring their partner came to the clinic. Findings also indicate that the intention to refer primary partners was associated with sexual partners, attitudes, and behavioural beliefs. Actual referral behaviour was predicted best by marital status, income, intentions and attitudes. Partner referral intentions were found to be positively associated with actual partner referral

Acknowledgements

This research study was funded by the Australian Agency for International Development (AusAID) and by National Institutes of Health (NIH) training grant support (#5 D43 TW010035-07). ICDDR,B acknowledges with gratitude the commitment of AusAID and NIH to the Centre’s research efforts.

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