This cross-sectional study interviewed women attending clinics in multiple cities in Afghanistan, and found that almost four out of five women reported at least one symptom suggestive of RTI, yet less than one fourth had knowledge regarding RTI. Delayed care-seeking was also common, although it was sometimes caused by a mismanagement occurred at the previous clinic visit.
In women, RTIs typically manifest as lower genital tract infections, with symptoms such as abnormal vaginal discharge, itching, genital pain, and fever [21]. The World Health Organization (WHO) estimated that in Low Income countries in 2016 the prevalence of RTIs ranged from 2% for gonorrhoea and syphilis, to 4% for Chlamydia up to 10% for trichomoniasis [22]. This high prevalence is confirmed by community studies among Afghan refugees and communities of neighboring countries [10, 23, 24], and also, at least apparently, by the high proportion of symptomatic women found in the present work. Naturally, the prevalence of signs and symptoms estimated in this study cannot be generalized to the whole female population of Afghanistan, as the sample was drawn from women presenting to clinics, and not from the general population. Nevertheless, given the satisfactory response rate, and that all the clinics were multi-specialist, and not only for gynecology, the provided prevalence is useful to gauge the needs of Afghan women who seek healthcare.
More than half of the interviewed women reported a delay in seeking gynecological care, often because they experienced some kind of mismanagement at the healthcare provider they visited prior to the clinic where they were interviewed. A seemingly counterintuitive finding, namely that symptomatic women were more likely to delay care seeking, may be interpreted in light of the stigma that characterizes RTIs. Indeed, there is a widespread belief among Muslim population that RTIs are transmitted through extramarital sex [25], a misconception exhibited even by some healthcare professionals [26]. Hand washing was expectedly associated with a lower risk of delay, as was being sedentary, a finding that requires further exploration. Having knowledge on RTIs was negatively associated with delay, although with only borderline significance. One possible explanation of the limited impact of knowledge is that fear of stigma may affect the majority of women regardless of the severity of symptoms, inhibiting them from seeking help [25].
Regarding the women who reported a history of RTI, the history of RTI of their husbands was unexpectedly unrelated to this outcome. Indeed, to the women's knowledge, only a small fraction of the husbands had a history of RTI. This can be explained by two reasons. First, their partners might have not disclosed their STI diagnosis. Previous studies have shown that men are often uncomfortable disclosing an STI diagnosis to their partners [27, 28]. In a country with a high gender inequality as Afghanistan [6], men may be less compelled to disclose their diagnosis to their partners. Second, some common RTIs are not sexually-transmitted, such as yeast infection and bacterial vaginosis [29]. Some of the symptoms most commonly reported by our respondents, such as vaginal discharge, are related to these diseases. On the other hand, hygiene practices are generally associated with a lower risk of RTI [4], and indeed the use of sanitary pads instead of cloth resulted negatively associated with a history of RTI in our sample.
Our study found that less than a quarter of respondents had adequate knowledge about RTIs, possibly relating to the high number of illiterates among our respondents, and that RTI knowledge could presumably protect against delays in seeking care. This is consistent with a 2004 study in Kabul, Afghanistan, which found that only 24% of respondents had knowledge on RTIs, and that formal schooling was one of the determinants of STIs awareness [9]. Previous studies in the United States and Brazil showed that stigma-associated fear and anxiety led to decreased willingness of having RTI tests [16, 20]. Although studies on the extent of such stigma among Afghan women are lacking, it was explored among midwives, one quarter of which reported hesitancy to associate with RTI-infected women [15].
Concerning possible interventions, it was shown that stigma can be reduced through awareness programs [30], which should be developed considering the current societal norms and gender roles. Furthermore, the health system should be strengthened, and public-private partnership, already employed in the management of other diseases, should also be extended to RTIs in Afghan women in order to reduce the care-seeking delay [31].
Health system barriers were cited as reasons for delayed care-seeking by one third of the respondents, also an expected result. Afghanistan, as a developing country with an ongoing humanitarian crisis, has a limited number of healthcare facilities: there are only 0.3 physicians and 0.4 nurses and midwives per 1,000 people, lower than the threshold determined by the WHO (4.45 doctors, nurses and midwives per 1,000 people) [32, 33]. Since the 2021 government takeover, many healthcare professionals have left the country, and the healthcare system is paralyzed in many areas, particularly in the villages [34], where about 20% of our respondents lived in. It is also important to note that in Afghanistan, the gender roles discourage women from seeking care at medical facilities [25]. Restrictions of women’s movement without their kin or husbands (mahram), as well as the norm banning women to be examined by male doctors, have all led to reduced access to healthcare [6, 34].
Strengths and limitations
Our study is the first to describe RTI management in a large sample of Afghan women, post-Taliban takeover. To maximize the insight of the data, the data collection was conducted in a culturally-sensitive manner by our interviewers. We also translated the questionnaire into two native languages in order to improve comparability. However, our study is not without limitations. Its design relied on self-reported data, hence the possibility of recall bias. This is particularly possible for husband-related data, as we did not ask the husbands directly. To reduce the possibility of bias, particularly in terms of symptoms reporting, we limited the timeframe for the reported signs and symptoms to one month prior to the interview. One further limitation of this study is that it was conducted in clinics, where the majority of patients are assumed to have good access to healthcare and the knowledge to seek care from specific providers. Therefore, the findings may not fully represent women from very low-resource villages or those who typically rely on natural remedies such as herbalism or traditional medicine for healthcare needs.