Lack of knowledge about sexually transmitted infections among women in North rural Vietnam

Sexually transmitted infections (STI) constitute a huge health and economic burden for low-income countries [1]. The presence of an STI, particularly an ulcer-causing STI, can enhance the acquisition and transmission of HIV [2]. The serious long-term complications of STI in women and newborns are well-documented [3–5]. Furthermore, STI imply considerable social consequences particularly for women, including stigmatisation, domestic abuse and even abandonment. In low-income countries, women are more vulnerable to reproductive health problems with serious sequelae of STI, and less likely to receive appropriate and timely care than women in high-income countries [3]. Low STI knowledge has been shown to be connected with unsafe sex practices and HIV [6]. In low-income countries, STI often go undiagnosed and untreated due to lack of knowledge and/or non-availability of healthcare facilities. Little emphasis on educational and other efforts to prevent infection occurring in the first place is one of common reasons why STI control programmes often fail in low-income countries [1].

In Vietnam, the potential for significant HIV and STI epidemics has been documented [7]. Annually, more than 130,000 STI cases are reported nationwide [report of the National Institute of Dermato-Venereology, Vietnam, 2007], which probably represent an underreporting of the true situation because of self-medication [8], treatment by drug sellers [9], and non-reported STI cases from private providers. Furthermore, there is a rapid increase in new HIV cases, of which the majority are believed to have been sexually transmitted [10]. STI is common among high-risk groups [11–13] and also not uncommon in the general population [14]. Urbanisation and social transition in Vietnam have resulted in labour migration, which can lead to unsafe sexual behaviour including increasing STI/HIV risks [5]. The existence of misconceptions about STI among people in the community [15] as well as delay in seeking care for STI among women in rural areas [16] have been shown recently. Data on knowledge about STI in Vietnam are limited [17]. Most studies of STI-related knowledge are based on purposive samples [15, 18, 19], at STI treatment facility [16], or have focused on high-risk groups [20]. Understanding people's knowledge regarding STI could provide an important basis for the development of interventions to promote early healthcare-seeking behaviour and protective practice for STI, and avoid its complications.

The aim of this study was to investigate knowledge of STI among women aged 15–49 in rural Vietnam and, further to evaluate possible associations between socioeconomic factors and STI knowledge.

The most important finding in our study was the low level of basic knowledge regarding STI among the respondents. The average overall knowledge score was as low as 6.5 (of 40 possible correct answers). There were relatively low proportions of women who could correctly answer about suspected symptoms, causes, curability and complications of STI. Urethral discharge in men, an important symptom of STI was neglected by the study respondents, and majority of the women did not report knowledge of any symptom of STI. Meanwhile, the concepts that bad hygiene, sex during menses or soon after delivery, multiple childbirths or abortions are "causes" of STI, and untreated STI can lead to HIV/AIDS also existed among the respondents. These findings are consistent with other qualitative studies in Vietnam showing limited knowledge [15, 18] and misconceptions regarding STI among people in the community [15, 19].

Our study showed a certain number of the study women did not know if STI can be prevented, and a low percentage of women gave correct answers about STI prevention. Condom use is considered the single, most efficient, available means to reduce the sexual transmission of both HIV and STI [23]. Nevertheless, in Vietnam, low knowledge of condom use for STI prevention among the general population has been previously shown [24]. A study in India also shows 22% of young girls do not know about condom use could protect people from STI [25]. Among our respondents however, especially among the unmarried women, this knowledge was even less. Whereas, studies show that 92% of young people in Ho Chi Minh city know that the use of condoms protects against HIV [26], and that there is existence of adequate knowledge of HIV but little concern for STI among female sex workers [20]. The difference could possibly be due to an unbalanced effort that has been given to the combat against HIV/AIDS since 97.5% of the government funds were allocated for HIV/AIDS prevention and care, while only 2.5% were for STI control activities [27]. This might put people at increased risk because of poor concern for STI. Besides, nearly half of our respondents either did not know the necessity of partner treatment or claimed that it was not necessary. Insufficient knowledge regarding STI prevention and partner treatment among the study women may result in neglecting the risks of unsafe sex.

Studies have shown that in a high-income society, better knowledge is not related to income or residence but related to higher education [28, 29], having ever had sex [29], and STI history [28, 30]. Being knowledgeable about RTI was related to higher probability of self-reported symptoms has been shown among rural Chinese women [31]. Our results showed that the overall STI knowledge was higher among married women and among those who had had self-reported symptoms during the past six months. Women with low education or low economic status had less knowledge of STI than those with higher education or economic category. Moreover, the results demonstrated an obvious association between low STI knowledge and residency in the mountainous and highland areas. This may reflect the fact that women with low education and from rural or remote areas wait before seeking care for STI [16]. Lack of awareness of STI consequences among our respondents may have led delayed treatment.

In our study, up to one-third of the unmarried women reported no knowledge about STI. Moreover, the women under the age of 20 demonstrated the lowest level of STI knowledge. This may be partially due to the sensitive nature of the issue and feelings of shame among women, especially unmarried women, when talking about STI [15, 18].

To our knowledge, one new finding in our study is the impact of experience of induced abortion, but not of childbirth, on STI knowledge. Those who have experienced an induced abortion might have been provided information, by healthcare providers, about the prevention of unwanted pregnancies, which is associated with STI knowledge. However, women who go to health facilities for childbirth might not receive information about diseases related to sexuality. Thus, how healthcare providers phrase their information may play an important role in improving people's STI knowledge.

Furthermore, the analysis showed that the intra-cluster correlation coefficient was significantly greater than 0 (p < 0.01), which indicated the existence of relations between knowledge levels of women in each cluster. This may be caused by information acquired from peers/friends within the cluster. This could be easily understood by the fact that women having symptoms usually seek help or advice from peers/friends and healthcare providers [15]. Studies in Vietnam and elsewhere show that HIV/AIDS information is derived mainly from friends [32], healthcare providers [32], and mass media [20, 24, 32]. Therefore, peer/friend education, informal conversations between women within clusters, mass communication, and the use of healthcare providers as means of providing information to the community should be taken into consideration when designing and implementing intervention programmes.

In conclusion, low levels of STI knowledge among the study respondents reflect the potential importance of health education interventions to improve STI knowledge for the general population. Young and unmarried women, the most vulnerable population should be specifically targeted. Integration of STI and HIV/AIDS into health education materials could be considered. Intervention programmes should be diversified and tailor-made for each group. The association between experience of induced abortion and higher level of STI knowledge implies the role of HCPs in health education.