Perceptions and Treatment Seeking for Abnormal Uterine Bleeding among Women: A Qualitative Study

doi:10.21203/rs.3.rs-5009235/v1

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Perceptions and Treatment Seeking for Abnormal Uterine Bleeding among Women: A Qualitative Study

https://doi.org/10.21203/rs.3.rs-5009235/v1

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Background

Barriers in seeking professional help for abnormal uterine bleeding (AUB) contribute to poor social, mental, emotional well-being of women in the Indian community. This study was undertaken to assess the perception and treatment seeking behaviour for AUB among women of reproductive age (WRA) group in rural Haryana.

Methods

A qualitative study was conducted using in-depth interviews (IDIs) and focused group discussions (FGDs) with various stakeholders, including WRA, accredited social health activists (ASHA), multipurpose health workers (MPW), and gynaecologists. Thematic analysis was done to analyse both IDIs and FGDs.

Results

Four key domains were identified: perceptions about AUB, treatment-seeking behaviour, perceived impact, and barriers to seeking treatment. According to WRA, AUB was characterized by changes in the frequency, duration, amount, and quality of menstrual bleeding. They believed that AUB is associated with factors such as anaemia, weakness, Copper-T insertion, consumption of specific food items as well as inadequate nutrition. MPWs and ASHAs further added that AUB can lead to headaches, anaemia, uterine infections, stroke, and fainting. Barriers hindering seeking treatment included lack of accessible healthcare facilities, long queues in hospitals, high travel and medication costs, limited availability of female doctors, lack of support from family, illiteracy and a fear of potential side effects of drugs.

Conclusions

Gaps were identified in the understanding of causes as well as complications of AUB. Limited availability of female doctors, healthcare facilities, and insufficient family support pose major barriers to seeking treatment while the stigma surrounding menstrual health prevents open discussions within families.

AUB

Qualitative study

Perception regarding AUB

Treatment-seeking behaviour

A normal menstrual cycle is defined by frequency (every 24–38 days), regularity, heaviness (between 5–80 ml) and duration (lasting for 4.5 to 8 days). ⁽¹⁾ Abnormal uterine bleeding (AUB), including the sub-term heavy menstrual bleeding (HMB), refers to excessive, erratic or prolonged blood loss that interferes with a woman’s physical, mental, social well-being as well as quality of life. ^(1–3) Since some components of the diagnosis are subjective, it is difficult to determine the exact prevalence. AUB is reported to occur in 3–30% of women between menarche and menopause. Etiology of AUB can be classified as “related to uterine structural abnormalities” and “unrelated to uterine structural abnormalities”, and can be further categorised as Polyp, Adenomyosis, Leiomyoma, Malignancy and hyperplasia, Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, and Not otherwise classified. AUB can lead to complications like anaemia, hypotension, shock, infertility, and even death. Hence, it should be treated as early as possible to restore the normal menstrual health of the affected female. ⁽¹⁾ Barriers for seeking treatment for AUB fall under three themes: poor health literacy, taboo, and health care provider preferences. ^{(4, 5)} The absence of appropriate knowledge regarding AUB has come across as a major barrier for women seeking treatment for the same.^{(6, 7)} AUB has a major impact on health-related quality of life (HRQoL) leading to decreased productivity and absenteeism from work ^(8–10). A study estimated indirect costs due to AUB - heavy bleeders worked 3.6 weeks fewer per year than non-heavy bleeders. The work-loss from increased blood flow is estimated to be $1692 annually per woman. ⁽¹¹⁾

Treatment seeking barriers to AUB occur at the level of both patients (health literacy, social taboo) as well as healthcare (lack of female gynaecologists). A better understanding of the perceptions and beliefs of women of reproductive age (WRA) group regarding AUB will pave the way towards addressing these issues at a community level. The aim of this study was to understand the perception and treatment seeking behaviour for abnormal uterine bleeding (AUB) among women of reproductive age (WRA) group in rural Haryana.

The qualitative study was conducted in the months of September - November 2022 in Sahupura Village, under Primary Health Centre (PHC) Dayalpur, Faridabad, Haryana. The stakeholders included women of reproductive age (WRA) group, accredited social health activists (ASHA), multipurpose health workers - females (MPW), and gynaecologists. Key stake holders were chosen following purposive sampling strategy.

Ethical approval for the study was obtained from the Institutional Ethics Committee, AIIMS, New Delhi (reference number: IECPG-726/29.09.2022). All participants were provided with the Participant Information Sheets (PIS) and written informed consent was taken. All records were kept confidential.

Operational definitions - AUB (Abnormal Uterine Bleeding): Any abnormality in – regularity (variation: 2–20 days), frequency (24–38 days), heaviness of flow (up to 3 pads a day) or duration of flow (4–8 days) of menses.⁽¹⁾ WRA (Women of Reproductive Age): Women between 18–49 years of age.

Students were trained in qualitative research methodology prior to the data generation. In-depth interviews (IDIs) and focused group discussions (FGDs) were conducted using guides with the stakeholders till the data reached saturation. A total of nine IDIs were conducted (3 each with WRA and ASHA workers, 1 with MPW, and 2 with gynaecologists) along with four FGDs - one with WRA less than 30 years-age group, two with WRA more than 30 years-age group and one with WRA with low socioeconomic status. FGDs and IDIs were conducted in the local language (Hindi) and were audio recorded and transcribed verbatim. Transcripts were analysed manually in Hindi language, and later translated to English language to avoid findings being lost in translation. Transcribed word files were password protected and verified. The data was recorded and analysed using the six steps prescribed by Braun and Clarke. Steps included were – familiarising with the data, generation of codes, sorting and analysing the coded data to fit in the overarching themes, reviewing the identified themes and refining followed by defining and naming of themes, and finally, writing the results in line with the outlined themes.⁽¹²⁾ Sociograms were used to present the interaction in FGDs.

Four key domains of this study were perceptions about AUB, treatment seeking behaviour, perceived impact and barriers to seeking treatment. (Table 1)

Table 1

Identified key domains and themes
S. no.	Domains	Themes
1	Perceptions about AUB	• About normal menses • About abnormal uterine bleeding • Causes of abnormal uterine bleeding • Complication of abnormal uterine bleeding • Risk groups
2	Treatment seeking behaviour	• Decision to consult • Preferred place • Preferred doctor • Preferred treatment and acceptance
3	Perceived impact	• Perceived impact
4	Barriers to seeking treatment	• Gender of doctor • Unavailability of health care facilities • Poor family support • Poor financial status • Problems with government hospitals • Poor knowledge • Personal reasons

Perceptions about AUB

WRA describe normal menses as which last for 3–5 days, occur every 27–30 days with variation of 1–2 days. They describe abnormal uterine bleeding as any change in the frequency, duration, amount and quality of normal menstrual bleeding.

Majority of WRA believe usage of 3 pads or more a day is abnormal. Majority believe that cycles of more than 35 days or less than 10 days, or duration of more than 8–9 days is abnormal.

According to MPW/ ASHA, abnormal uterine bleeding referred to cycle length of 15–20 days, duration of more than 3–5 days and amount of more than 3 pads per day or a need to change pad every 2–3 hours.

IDI WRA - “If a lady says that she has to change pads 3 or more than 3 times in a day then it is abnormal.”

IDI MPW- “It should last for 3–5 days, more than that is abnormal.”

WRA believe that AUB increases with age, intake of improper food and nutrition. MPW also believe that improper nutrition leads to abnormal uterine bleeding. The gynaecologist stated that consumption of junk food might lead to anovulatory cycles and PCOS which may subsequently lead to abnormal uterine bleeding, but not result in any structural causes of AUB.

WRA- “Consumption of hot water, hot milk, tea, almonds, curd, buttermilk and cold food (like cold drink, ice-cream) also lead to abnormal uterine bleeding.”

MPW- “There is a belief in the community that the causes of abnormal uterine bleeding include consumption of pickle, lemon, jaggery, papaya and hot food.”

Gynaecologist- “It's a myth, actually food doesn't affect unless it’s an anovulatory cause like junk food leading to anovulatory cycles or PCOS, but structural causes are not mostly due to any food habits; they can eat whatever they want, but less oily food is obviously preferred.”

WRA and ASHA believe that common causes of AUB are anaemia and generalised weakness. Other causes include cancer, infection, high blood pressure (BP), white vaginal discharge, cardiac diseases, fibroids and consumption of medicines for cough, cold, GI infections and abortion.

Gynaecologists reported that the common causes of AUB observed by them in their clinics were fibroids, adenomyosis, ovarian cyst, improper intake of contraceptive pills, consumption of medicines for abortion, hormonal disturbances (like hypothyroidism) and PCOS.

WRA- “Women whose Hb equal to or more than 12 face the problem of AUB less frequently, whereas women whose Hb is less than 12 face this problem more frequently.”

According to WRA, common complications of AUB are infections, malaise, light headedness and vision problems. Other complications include low BP, anaemia, fibroids, headache, and problems while conceiving in future. According to MPW and ASHAs, the complications of AUB are weakness, headaches, severe anaemia, uterine infections, stroke and fainting. Gynaecologist stated that the most common sequelae of AUB is anaemia.

MPW said- “Heavy bleeding, Fainting, Stroke and low BP can occur. Also, uterine infections can happen.”

Treatment seeking behaviour (Fig. 1)

Most of the WRA sought medical care only when the problem of AUB did not resolve on its own, while some sought immediate consultation for any abnormality in menses. Gynaecologist stated that most of the women sought medical care after a few abnormal menstrual cycles, and many seek care only after marriage even if symptoms presented before.

WRA- “I think about it only when the problem seems to be getting out of hand.”

Gynaecologist- “Sometimes, some complaints like discharge PV, they must be having before marriage also, but they are able to show up only after marriage.”

Most of the WRA said that they preferred to visit government hospitals as they got better relief there, but due to excessive patient load, long queues and waiting time, they had to go to private clinics. According to the gynaecologist, a lot of women seek help from the nearest provider, irrespective of whether they are certified or not.

WRA- “The doctors at government hospitals are much better, but because of the huge number of patients, it takes a lot of time to get my turn.”

Gynaecologist- “Normally they go to the nearest doctor, whoever is available, whether the person is MBBS or not, whether that person is an RMP or anyone. Normally they go to those persons.”

Most of WRA preferred to visit female doctors compared to male doctors. Gynaecologist also believed the same.

WRA- “No one wants to talk to a male doctor; they feel that they can discuss their problems more openly with female doctors.”

Majority of WRA were using home remedies to treat AUB. Some of WRAs were following doctor’s advice. The gynaecologist said that the treatment options and preferences varied with the age group of the woman and whether or not she wanted to have children in the future.

WRA- “These days the desi medicines are in prevalence, which provide a lot of relief.”

WRA- “If the period is too long, I usually eat something cold. That usually solves the problem.”

Perceived Impact

WRA told that AUB impacts on physical health and also affects school/college going girls as they have to take leave from school/college.

MPW and ASHA stated that AUB had an impact on mental, social, physical health of the patient. Gynaecologist said that AUB leads to weakness and malaise that affects the ability to do daily routine work. As it has stigma attached to it, it affects mental as well as sexual health. Also, there is lack of support from the elderly people of the family as they fail to understand her condition.

WRA- “She is not able to handle her chores well and maintain a healthy relation with her kids due to the heavy bleeding, her mind gets disturbed, and she stays tensed.”

Barriers to seeking treatment

WRA faced different barriers in seeking care due to the lack of knowledge about AUB being a significant problem, being busy in household chores, lack of support from family, hesitance to share concerns regarding the problem, unavailability of female doctors, lack of nearby health care facilities, high costs of travel and treatment, long queues and waiting times at the hospitals and worrying about side-effects from medications.

WRA- “I worry that it will cost a lot of money for travelling.”

WRA- “Mother-in-law tells her, I’ve borne this for so many years, and you aren’t able to handle even this much.”

WRA- “In government setups, you have to stand in a queue. A lot of the time, they don’t see the patient properly and talk rudely.”

WRA- “Those who are not well read, they are not able to openly discuss their problems.”

Gynaecologist- “The only restriction coming to this hospital (government) is the large number of patients who are there. They know they have to wait. They must get the card made in time and they must wait in the OPD. They know they have to spare at least the first half of the day if they want to show here. That’s the only restriction.”

Principal findings

The study found that there are varying levels of understanding regarding AUB. WRA believed that AUB is associated with increasing age and improper nutrition. WRA and MPW thought that Copper-T, abortion, anaemia can lead to AUB. The primary hindrance to seeking appropriate treatment was not only a lack of understanding about abnormal menses, but also the hesitancy to discuss these issues due to the social stigma attached, and limited availability of female doctors as well as healthcare facilities.

Comparison with available data: Henry et.al reported lack of knowledge regarding normal menses being a major barrier to treatment seeking. ⁽¹³⁾ The major inhibiting factor for women in our study was not the lack of knowledge about AUB, rather, other deterrent factors like hesitancy in discussing their problems. DeStephano et.al reported that in case of perimenopausal irregular bleeding, women gathered information from many sources and were unable to understand how to make sense of the symptoms. ⁽¹⁴⁾ Liu et.al reported that HRQoL of women with AUB was below the 25th percentile of the general female population of the same age range. ⁽¹⁵⁾ Henry et.al reported that AUB had a significant and traumatic impact on the QoL of the affected females. ⁽¹³⁾ This is in-line with our study findings which report that WRA have to face mental, social and physical problems because of AUB. Brito et.al also reported that women with AUB-L faced limitations to social and professional activities. ⁽¹⁶⁾ In our study, women faced symptoms like weakness, malaise which affected their physical strength and their ability to perform daily chores. Laksham et.al reported women with menstrual disorders faced poor QoL in physical, psychological and social domains. ⁽¹⁷⁾ The WRA in our study also reported that they had to face mental trauma because of their conditions as they were unable to discuss their issues, even with their own family members. Henry et.al in a systematic review of qualitative studies reported that lack of female practitioners was a major barrier to seeking treatment for AUB. ⁽⁴⁾ A similar barrier was observed in our study, where women found it difficult to locate female doctors nearby. Lack of resources and time hindered their ability to travel for seeking medical consultation. Henry et.al also reported negative experiences of females with practitioners which was not the case in our study; the negative experiences WRA in our study faced were mainly due to longer waiting lines while consulting in government healthcare facilities. Henry et.al also reported females feeling embarrassed as AUB is considered a taboo topic. Similar findings were reported in our study, where females felt uncomfortable discussing these issues with their family members due to the historical social stigma attached with these.

Clinical implications

Findings from the study provide a deeper understanding of the perceptions of women and societal factors in play affecting their treatment seeking behaviour for AUB. This would guide policy makers to form strategies addressing barriers like poor knowledge, and non-availability of female doctors to improve healthcare for women in India.

Research implications

Insights from the study signify the need for implementation research in the area to improve quality of care and reduce the existing disparities for women health.

Strengths and Limitations: Data was generated and analysed in Hindi. Analysis was done verbatim, and the analysed statements were later translated into English to prevent nuances from getting lost in translation. We included different stakeholders in order to explore various perspectives about AUB.

The interviews were conducted by primarily by male investigators, which might have caused some hesitancy; however, female investigators were present in all, and led most of the IDIs and FGDs.

There are gaps in the understanding of AUB among WRA. Most women prefer to seek care from government facilities but failed due to multiple factors. AUB directly and indirectly impacts mental, social and physical health of the females, and affects their ability to perform daily chores. Scarcity of female doctors and healthcare facilities, and poor family support are major treatment seeking barriers. Our findings underscore the importance of implementing a comprehensive approach to enhance access to healthcare. The approach shall include: targeted awareness campaigns about AUB, open discussions on menstrual health, ensuring that healthcare facilities are more readily accessible, and fostering collaboration among all levels of health care providers.

Ethics approval and consent to participate: Ethical approval for the study was obtained from the Institutional Ethics Committee, AIIMS, New Delhi (reference number: IECPG-726/29.09.2022). All participants were provided with the Participant Information Sheets (PIS) and written informed consent was taken.

Consent for publication: Not applicable

Availability of data and materials: Data involving interviews and group discussions that supports the findings of the study is available from the corresponding author [SP] upon reasonable request

Competing interests: No financial or non-financial competing interests

Funding: None

Authors’ contributions:

RK, SP, SK, IG, HG and AQRC were involved in the conception and design of the study. IG, HG and AQRC were responsible for data collection and conducted the majority of the analysis, while RK, SP, SK offered consistent technical guidance throughout the process. IG and HG drafted the initial manuscript, with contributions to revisions from PM, HRS, RK, SP, SK. All authors thoroughly reviewed and approved the final version of the manuscript.

Acknowledgements: None

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No competing interests reported.

Healthbeliefmodel.jpg
Figure S1: Health belief model for barriers and facilitators for abnormal uterine bleeding

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You are reading this latest preprint version

Perceptions and Treatment Seeking for Abnormal Uterine Bleeding among Women: A Qualitative Study

Status:

Version 1

Abstract

Background

Methods

Results

Conclusions

Figures

Introduction

Methodology

Results

Perceptions about AUB

IDI MPW- “It should last for 3–5 days, more than that is abnormal.”

Treatment seeking behaviour (Fig. 1)

WRA- “These days the desi medicines are in prevalence, which provide a lot of relief.”

Perceived Impact

Barriers to seeking treatment

WRA- “I worry that it will cost a lot of money for travelling.”

Discussion

Conclusion

Declarations

References

Additional Declarations

Supplementary Files

Status:

Version 1