Youths' satisfaction with sexual transmitted infections services providing in vientiane capital, laos 2019
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MINISTRY OF HEALTH
UNIVERSITY OF HEALTH SCIENCES, FACULTY OF PUBLIC HEALTH
AND
MINISTRY OF EDUCATION AND TRAINING - MINISTRY OF HEALTH
HANOI UNIVERSITY OF PUBLIC HEALTH
AKSONE VONGKHILY
YOUTHS’ SATISFACTION WITH SEXUALLY TRANSMITTED
INFECTIONS SERVICES PROVIDED IN
VIENTIANE CAPITAL, LAOS 2019
MASTER OF PUBLIC HEALTH
CODE: 8720701
HANOI, 2020
MINISTRY OF HEALTH
UNIVERSITY OF HEALTH SCIENCES, FACULTY OF PUBLIC HEALTH
AND
MINISTRY OF EDUCATION AND TRAINING - MINISTRY OF HEALTH
HANOI UNIVERSITY OF PUBLIC HEALTH
AKSONE VONGKHILY
YOUTHS’ SATISFACTION WITH SEXUAL TRANSMITTED
INFECTIONS SERVICES PROVIDING IN
VIENTIANE CAPITAL, 2019
MASTER OF PUBLIC HEALTH
CODE: 8720701
SUPERVISORS:
DR KHAMPHENG PHONGLUXA DR DUONG MINH DUC
HEAD OF DEPARTMENT OF LECTURER, DEPT.OF POPULATION-REPRODUCTIVE
COORDINATION AND RESEARCH HEALTH FACULTY OF SOCIAL SCIENCES - HEALTH
INFORMATION MANAGEMENT, EDUCATION & BEHAVIOUR,
LAO TROPICAL AND PUBLIC HANOI UNIVERSITY OF PUBLIC HEALTH
HEALTH INSTITUTE
HANOI, 2020
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ACKNOWLEDGEMENTS
This independent study would not have been possible without the help and support of
many people.
I am very grateful to the Ministry of Health of the Lao PDR and the LEARN project for
funding my studies at the University of Health Sciences (UHS), the Lao-THPI in Laos and
the Hanoi University of Public Health (HUPH) in Vietnam. The help from the Vientiane
Women’s and Youth Center for Health and Development of the Laos Women’s Union,
Vientiane Capital, and all their staff is also gratefully acknowledged for allowing me to
study at the UHS in Laos and the HUPH in Vietnam.
I would like to offer thanks to my thesis advisors Dr. Khampheng Phongluxa, MD,
MSc, PhD, Head of the Department of Coordination and Research Information
Management, at the Lao Tropical and Public Health Institute and Dr. Duong Minh Duc,
PhD., Lecturer, the Faculty of Social Sciences, Health Education and Behaviour, HUPH,
who steered me in the right the direction whenever they thought I needed it.
I would also like to acknowledge the valuable comments and encouragement from the
examination chair of my Independent Study Committee. and also wish to thank the
external member of the Independent Study Committee.
I am most grateful to the directors of the Vientiane Youth Center and the National
Dermatology Center, whose facilitators kindly agreed to help and participate in this
research. This study could not have been completed without their generous assistance.
I am grateful as well to all the lecturers, teachers and staff of the UHS, the Lao-TPHI
and HUPH for their continuous assistance and helpful advice.
I would like to offer special thanks to Dr. Somphou Outensackda and my classmates
for their kindness during the period of my studies at UHS and HUPH.
Finally, I would like to thank my family for their love, understanding, support, and
encouragement during the time I studied in Laos and Vietnam.
Mrs. Aksone VONGKHILY
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ABBREVIATIONS & ACRONYMS
AIDS Acquired Immune Deficiency Syndrome
HIV Human Immune-deficiency Virus
Lao PDR Lao People’s Democratic Republic
LPRYULYU Lao People’s Revolutionary Youth Union/Lao Youth Union
NDC National Dermatology Centre
VYC Vientiane Youth Centre
SRH Sexual and Reproductive Health
STIs Sexual Transmitted Infections
STDs Sexual Transmitted Diseases
UNFPA United Nations Population Fund
YFS Youth Friendly Service
WHO World Health Organization
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CONTENTS
ACKNOWLEDGEMENTS ......................................................................................... I
ABBREVIATIONS & ACRONYMS ......................................................................... II
LIST OF TABLES .....................................................................................................VI
SUMMARY ............................................................................................................ VIII
INTRODUCTION ........................................................................................................ 1
RESEARCH OBJECTIVES ......................................................................................... 2
CHAPTER 1 ................................................................................................................. 3
LITERATURE REVIEW ............................................................................................. 3
1.1. YOUTH ................................................................................................................. 3
1.2. SEXUALLY TRANSMITTED INFECTIONS (STIS) ......................................... 3
1.3. SEXUALLY TRANSMITTED INFECTIONS AMONGST YOUTHS AROUND
THE WORLD AND IN LAOS .................................................................................... 4
1.3.1. STI OCCURRENCE AMONGST YOUTHS AROUND THE WORLD ....... 4
1.3.2. STIS AMONGST YOUTHS IN LAOS ........................................................... 4
1.4. STI SERVICES IN THE WORLD........................................................................ 5
1.5. STI SITUATION AND SERVICES FOR YOUTH IN LAOS ............................. 5
1.6. THE LAO GOVERNMENT POLICY ON STIS .................................................. 7
1.7. STI SERVICES IN VIENTIANE CAPITAL........................................................ 7
1.8. CONCEPT OF SATISFACTION ......................................................................... 8
1.8.1. PATIENT SATISFACTION WITH STI SERVICES ........................................ 9
1.9 ASSOCIATED FACTORS AFFECTING YOUTH SATISFACTION WITH STI
SERVICES ................................................................................................................. 12
1.10. CONCEPTUAL FRAMEWORK ...................................................................... 15
CHAPTER 2 ............................................................................................................... 17
METHODOLOGY ..................................................................................................... 17
2.1. STUDY POPULATION ...................................................................................... 17
2.1.1 INCLUSION CRITERIA .................................................................................. 17
2.2.2 EXCLUSION CRITERIA ................................................................................. 17
2.2. STUDY SITE AND DURATION OF DATA COLLECTION .......................... 18
2.3. STUDY DESIGN ................................................................................................ 18
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2.4. SAMPLE SIZE .................................................................................................... 18
2.5 SAMPLING METHOD........................................................................................ 19
2.6 DATA COLLECTION ......................................................................................... 19
2.7 VARIABLES OF THE STUDY .......................................................................... 20
2.8 RESEARCH INSTRUMENT AND MEASUREMENT ..................................... 21
2.8.1 RESEARCH INSTRUMENT ........................................................................... 21
2.8.2 MEASUREMENT OF YOUTHS’ SATISFACTION....................................... 22
2.8.3 MEASUREMENT OF EXPECTATIONS WHEN RECEIVING STI SERVICES
.................................................................................................................................... 23
2.9. DATA ANALYSIS METHOD ........................................................................... 24
2.10. ETHICS STATEMENT .................................................................................... 24
CHAPTER 3 ............................................................................................................... 26
RESULTS ................................................................................................................... 26
3.1 SOCIO-DEMOGRAPHIC CHARACTERISTICS .............................................. 26
3.2 YOUTH’S SATISFACTION WITH STI SERVICES ......................................... 28
3.3 MEDICAL SITUATION OF THE YOUTH AND THEIR EXPECTATIONS WHEN
RECEIVING THE SERVICES .................................................................................. 34
3.3.1 MEDICAL SITUATION MOTIVATING THE YOUTHS TO VISIT THE STI
SERVICES ................................................................................................................. 34
3.3.2 EXPECTATIONS WHEN RECEIVING STI SERVICES ............................... 36
3.4 UNIVARIATE LOGISTIC REGRESSION ANALYSIS OF THE ASSOCIATION
BETWEEN THE SOCIO-DEMOGRAPHIC FACTORS AND THE YOUTHS’
SATISFACTION WITH THE STI SERVICES......................................................... 39
3.5 UNIVARIATE LOGISTIC REGRESSION ANALYSIS OF THE ASSOCIATION
BETWEEN THE MEDICAL SITUATION OF THE YOUTH, THEIR EXPECTATIONS
WHEN RECEIVING STI SERVICES AND THEIR SATISFACTION WITH THE
SERVICES ................................................................................................................. 42
3.6 UNIVARIATE ANALYSIS OF THE ASSOCIATION BETWEEN EXPECTATIONS
WHEN RECEIVING STI SERVICES AND THE SATISFACTION WITH THE
SERVICES ................................................................................................................. 45
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3.7 MULTIVARIATE LOGISTIC REGRESSION ANALYSIS OF THE FACTORS
ASSOCIATED WITH THE YOUTH’S SATISFACTION WITH THE STI SERVICES
.................................................................................................................................... 45
CHAPTER 4 ............................................................................................................... 48
DISCUSSION............................................................................................................. 48
CONCLUSION .......................................................................................................... 59
RECOMMENDATIONS ........................................................................................... 60
REFERENCES ........................................................................................................... 61
ANNEX ...................................................................................................................... 70
ANNEX 1: TABLE OF DEFINITIONS AND MEASUREMENT OF VARIABLES IN
THE STUDY .............................................................................................................. 70
ANNEX 2: QUESTIONNAIRE ................................................................................ 73
ANNEX 3: INFORMED CONSENT FORM FOR ADOLESCENTS ..................... 80
ANNEX 4: PARENTAL/LEGAL GUARDIAN’S CONSENT FORM ................... 81
ANNEX 5: LAO ETHICAL APPROVAL................................................................ 82
ANNEX 6: VIETNAM ETHICAL APPROVAL ..................................................... 83
ANNEX 7: THESIS COMMENTS ............................................................................ 84
ANNEX 8: MINUTES OF EXPLANATION ............................................................ 91
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LIST OF TABLES
Table 3.1: Distribution of socio-demographic characteristics of youths visiting the STI services
at the Vientiane Youth Center and the National Dermatology Center (n=217) .................. 26
Table 3.2: Interpersonal manner of health providers .................................................................. 28
Table 3.3: Counselling skills of providers ................................................................................... 29
Table 3.4: Physical environment.................................................................................................. 30
Table 3.5: Availability of services ............................................................................................... 30
Table 3.6: Accessibility of services ............................................................................................. 31
Table 3.7: Affordability of fees ................................................................................................... 32
Table 3.8: Efficiency of services ................................................................................................. 32
Table 3.9: Overall satisfaction of youth towards STI services in Vientiane Capital (n=217) .... 33
Table 3. 10: STI symptoms motivating youths to visit the STI services (n=217) ...................... 34
Table 3.11: Diagnosis of the sexually transmitted infections (n=217) ........................................ 34
Table 3.12: Current status of STI infection (n=217)................................................................... 35
Table 3.13: Distribution of health care facilities that the youth have utilized (n=217) ............... 36
Table 3.14: Expectations about the manner of the service providers (Respect, Friendliness,
Concern and Courtesy) (n=217) .......................................................................................... 36
Table 3. 15: The status of youth’s expectations when receiving STI services (n=217) .............. 38
Table 3.16: Level of satisfaction with STI services (n=217) ....................................................... 39
Table 3.17: Association of socio-demographic factors and the satisfaction with STI services
(n=217) ................................................................................................................................ 39
Table 3.18: Association between the medical situation of the youth and their satisfaction with
the services .......................................................................................................................... 42
Table 3.19: Association between expectations when receiving STI services and the satisfaction
with the services .................................................................................................................. 45
Table 3.20: Associated factors and youth’s satisfaction with STI services ................................. 45
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Independent Study Title Youth Satisfaction with the Provision of Sexually
Transmitted Infection Services in Vientiane Capital,
2019
Author Mrs. Aksone VONGKHILY
Degree Master of Public Health
Major Field/ Faculty/ University University of Health Sciences, Faculty of Public
Health, and Hanoi University of Public Health
Independent Study Advisors Dr. Khampheng Phongluxa
Head of Department of Coordination and Research
Information Management, Lao Tropical and Public
Health Institute
Dr Duong Minh Duc
Lecturer, Department of Population and Reproductive
Health, Faculty of Social Sciences - Health Education
& Behaviour, Hanoi University of Public Health
Academic Years 2018-2020
viii
SUMMARY
Sexually transmitted infections (STIs) are a major burden for disease control worldwide,
particularly among youths. In the Lao PDR, youths acquire STIs due to an insufficient
knowledge of safe sex and STIs, as well as poor access to sexual and reproductive health
services. Patient satisfaction enhances the image of health care facilities and translates
into increased service use. The aim of this study is to investigate the youths’ satisfaction
with STI services in Vientiane Capital, and identify its associated factors.
A cross-sectional analytical study was applied using quantitative methods. The study
interviewed 217 youths aged 15-24 who were seeking care at the STI Unit of the Vientiane
Youth Center (VYC) and the National Dermatology Center (NDC). The collected data
was entered into the Epidata program (Version 3.1) and then transferred to the STATA
software (Version 14.2) for further analysis. Descriptive and inferential statistics analyses
were performed to determine the factors associated with satisfaction relating to STI
services.
The findings showed that of 217 youths, 74.6% were aged 21-24 years, 78.8% were single
and 78.3% of them belonged to the Lao ethnic group. Almost three fifths of the students
were male, and nearly 40% had attended university, while over two fifths were currently
enrolled as students. More than a third of the youths had a monthly income of between
1.1-1.5 million LAK. Pertaining to their satisfaction with STI services, more than four
fifths of youths were pleased with the STI services. The most significant factors identified
associated with a satisfaction with STI services were having a monthly income of between
1.1-1.5 million LAK, having experienced a visit to STI services before and expecting to
receive good services (AOR).
In conclusion, this study has demonstrated that most youths are satisfied with the provision
of STI services in Vientiane Capital. Youths with a moderate income, a prior experience
of using STI services and who held positive expectations while receiving services were
found to be the influencing factors linked to a satisfaction with STI services. Therefore,
to increase STI service use among youths, youth friendly services including the promotion
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of the availability of STI services and capacity building measures to strengthen health staff
should be encouraged as focus activities in the future.
Keywords: STI services, satisfaction, youth, Vientiane Capital.
1
INTRODUCTION
Sexually transmitted infections (STIs) are infections that are commonly spread by
sexual activity, especially vaginal intercourse, anal sex and oral sex. Many times STIs initially
do not cause symptoms. This results in a greater risk of passing the disease on to others.
Symptoms and signs of disease may include vaginal discharge, penile discharge,
ulcers on or around the genitals, and pelvic pain (Willey, 2008).
STIs are a major burden of disease worldwide. Each year, 357 million new cases of
curable STIs occur with the highest rates amongst youths aged 20-24 years followed by 15-19
year olds. STIs can be caused by bacteria (gonorrhea, syphilis, chlamydia), parasites
(trichomoniasis), and viruses (human papillomavirus, genital herpes, HIV). The reduction of
STI cases is described as an important component of the health sector when achieving the
Sustainable Development Goals (SDGs) (WHO, 2016).
According to global comparisons, STIs occurring amongst young people in Asia-Pacific
countries are the highest with a total number of the four most common diseases accounting for
70.8 million cases in the SE Asian region, and 108.7 million cases in the Western Pacific region
(Chan, 2011).
In the Lao PDR, youth acquire STIs due to having an insufficient knowledge of safe sex
and STIs, a low risk perception, and poor access to sexual and reproductive health products and
services (Andrews, 2015). Men of the 20-29 year age group are most commonly infected. There
are serious and growing epidemics in several neighboring countries of the Lao PDR which by
reasons of increasing population mobility, both within and across Lao borders, human
trafficking, and the improvement of transportation networks are making the country
increasingly vulnerable (WHO, 2015).
Satisfaction can be defined as the extent of an individual’s experience compared with
his or her expectations. A patients’ satisfaction is related to the extent to which general health
care needs and condition-specific needs are met. Satisfaction is one of the core outcome
measures for health care (Mohan & Kumar, 2011). Users’ satisfaction is defined as a
measurement that determines how happy they are with a facility’s products, services, and
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capabilities. Hence, an organization’s main focus must be to satisfy its users. Customer
satisfaction does not just impact the business' bottom line, it also impacts team morale and
retention rate. To make money, businesses need customers. Ideally these customers are happy,
tell their friends about the facility and keep coming back (Zahorik & Rust, 2019).
Information about the study sites
The Vientiane Youth Center (VYC) and the National Dermatology Center (NDC) are
health care facilities located in Vientiane Capital, which provide comprehensive consultations,
and youth-friendly sexual and reproductive health (SRH) services geared for youths aged 10 to
24 years, as well as responding to the needs of migrant youths. There has been no empirical
evidence collected about the satisfaction with the services provided by the VYC and NDC.
Many factors could influence the satisfaction of the youths with the services such as the cost of
services, the hours of services and waiting time to receive services, transportation, accessibility
to prevented care, and youth-friendly sexual and reproductive health services (Vientiane Youth
Center, 2018).
So far, no information on the satisfaction of youths with STI services provided at these
two facilities is in existence, hence this study seeks to provide an assessment of the satisfaction
of the youths visiting the VYC and NDC. This quantitative study will examine the youths’
satisfaction with STI services and associated factors to determine the level and scope of
satisfaction at the two study sites in Vientiane Capital. The results of this study could be of
critical importance for improving these services.
RESEARCH OBJECTIVES
The current research aims:
1. To investigate the youths’ satisfaction with STI services provided in Vientiane Capital
in 2019.
2. To explore factors that are associated with the youths’ satisfaction with STIs services
provided at health facilities in Vientiane Capital in 2019.
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CHAPTER 1
LITERATURE REVIEW
This chapter presents the main definitions, epidemiology and reviews of the literature
related to STI services in the world and in the Lao PDR, in particular youth satisfaction with
STI services and their associated factors in the Lao PDR.
1.1. Youth
The Lao government policy defines youth as “a young population that has a vast future
potential for economic growth and support”. According to the adolescent and youth situation
analysis of Laos, young people is the combination of adolescents (10 – 19 years) and younger
youth (20 – 24 years) (LYU & UNFPA, 2014).
1.2. Sexually Transmitted Infections (STIs)
Sexually Transmitted Infections (STIs) are infections that are commonly spread by
sexual activities, especially vaginal intercourse, anal sex and oral sex. For many cases, STIs
initially do not cause symptoms. The result is a greater risk of passing the disease from one
person to others. The symptoms and signs of disease may include vaginal discharge, penile
discharge, ulcers on or around the genitals, and pelvic pain. The STIs can be transmitted to an
infant before or during childbirth and may result in poor outcomes for the baby. Some STIs
may cause problems with the ability to get pregnant (Kassim, 2017).
Through sexual activities, more than 30 different bacteria, viruses and parasites are being
transmitted. Bacterial STIs include chlamydia, gonorrhea, and syphilis. The viral STIs include
genital herpes, HIV/AIDS and genital warts. Parasitic STIs include trichomoniasis. While they
are usually spread during sex, some STIs can be transmitted by non-sexual contact such as
donor tissue, blood, breastfeeding or during childbirth. STI diagnostic tests are usually easily
available in the developed world, but this is often not the case in developing countries
(Korenromp et al, 2019).
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1.3. Sexually transmitted infections amongst youths around the world and in Laos
1.3.1. STI occurrence amongst youths around the world
Incidence and prevalence estimates suggest that young people aged 15–24 years acquire
half of all new STIs. Up to 80% of curable STIs occur in developing world settings, and
adolescents and young adults have the highest rates of these infections.
In Australia, data indicates that sustained and increasingly high rates of STIs among
young people are an immediate concern. A variety of socio-cultural factors, such as increased
duration between sexual debut and the formation of long-term partnerships, low rates of
condom use, and poor access to services, made young people vulnerable to STIs. As a
consequence, young people were named as a priority group in the 2010 National Sexually
Transmissible Infections Strategy (Middleton & McDonald, 2013).
1.3.2. STIs amongst youths in Laos
In the Lao PDR, there has been an increasing vulnerability to the HIV/AIDS and STI
epidemic. The growing young population has a large impact on the reproductive health status
of the country. Key indicators of vulnerability in Laos are the practice of unsafe sex, an
increased HIV prevalence, a low risk perception among vulnerable groups and young people,
a low level of knowledge about STIs and HIV/AIDS, and poor access to sexual and
reproductive health products and services (WHO, 2018). For example, there has been a high
prevalence of sexually transmitted infections (1.8%), especially among the most-at-risk
population which includes men who have sex with men, sex workers, People who inject drug.
STIs were the most pervasive infectious diseases confronting adolescents. Strong evidence has
shown several biological mechanisms through which STIs facilitate HIV transmission thus
increasing both HIV infectiousness and HIV susceptibility. In Laos most people infected are
heterosexual men aged 20-29 years. The serious and growing epidemics in several of Laos’
neighboring countries, increasing population mobility, both within and across Laos’ borders,
the trafficking of women, girls and boys, and improved transportation networks make the
country increasingly vulnerable to HIV/AIDS (National Center for HIV/AIDS and STI Control,
2015).
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1.4. STI services in the world
In 2001, the WHO organized a global consultation on adolescent friendly health
services. One of ten consensus statements was that adolescents are unable and or unwilling to
obtain the (general) health services they need. A 2005 review of research from 1999 focused
on the need for adequate STI services and identified barriers that adolescents experience
when obtaining the needed STI services. Such barriers have been classified into four
categories: availability, accessibility, acceptability and equity. Understanding what the current
barriers are globally, and by region, could provide an understanding of what challenges still
exist. STI services are often grouped in a larger cadre of SRH services in many settings.
Given the increased number of STIs, access to sexual and reproductive health services is vital
for sexually active youths and adolescents. However, health services in many countries do not
fully address these needs. This is especially true for sexually transmitted infections and may
be worse in countries with fewer resources dedicated to health care (Newton-Levinson et al.,
2016).
1.5. STI situation and services for youth in Laos
Sexually transmitted infections in youths are a greatly and continuously under-researched
subject, and there are important gaps in our knowledge of the behavioural, socio-economic and
geographic correlates of STIs and of the various service delivery models. For over a decade,
the WHO has set out guidelines on Adolescent Health for Health Care Providers in order to
promote healthy development in adolescents, and to prevent and respond to health problems
challenging this population group. Health-care providers (HCP) have important contributions
to offer for reproductive and sexual health information and services, and these are becoming
more available for young people to make services equitable, accessible, acceptable, appropriate
and effective. The intention is that adolescents and young people will have the information they
need to make responsible decisions and access the relevant health services. In addition, the
WHO has addressed adolescent responsive health systems because adolescents have rising and
significant needs from health services. They pose different challenges for the health-care
system than children and adults, due to their rapidly evolving physical, intellectual and
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emotional development. The key concepts of adolescent responsive health systems include the
transition from adolescent-friendly projects to adolescent-responsive health systems targeting
Universal Health Coverage, services geared for adolescent needs going beyond sexual and
reproductive health, adopting quality standards for quality improvement, and health
professionals benefitting from pre-service training with a knowledge of adolescent health and
development and their implications for clinical practice (WHO, 2016).
The Lao Country Report on STI services revealed that there were difficulties resulting
from the increasing demand among key affected populations including female sex workers,
men who have sex with men, injecting drug users, persons with multiple sex partners, and
young people when availing health services. STI prevalence in Laos was still high among the
affected population in 2014 (Ministry of Health, Chair of the National Committee for the
Control of AIDS, and UN). As Laos has a young population with a majority (60%) of its citizens
belonging to the under 25 year age bracket there is an increasing number of young people who
are sexually active. More young women are engaging in exotic entertainment (bar hostesses)
and sex work. Young men who have sex with men often had multiple male partners. Low
condom uses and low access to STI treatment were also observed. Among sex workers and
clients, behaviours like the use of alcohol and drugs as well as the inconsistent use of condoms
aggravated their high-risk situations. In so far as married men and women were concerned, the
use of the male condom as a contraceptive remained low. Furthermore married men only used
condoms with people other than their wives (National Center for HIV/AIDS and STIs Control,
2015).
The Lao People’s Revolutionary Youth Union and UNFPA report in 2018 disclosed that
the prevalence of sexually transmitted infections, including chlamydia and gonorrhoea, was
high. In urban settings, there was greater access to information about STIs, but for a variety of
reasons young people did not adopt safe sex practices. In rural settings, and particularly in rural-
off road settings, the lack of sexual and reproductive health knowledge and poor access to
condoms and other forms of contraception contributed strongly to both unplanned pregnancies
and to STIs. In addition to the direct morbidity associated with these infections, STIs increased
the transmission and susceptibility to HIV infection (LYU and UNFPA, 2018).
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1.6. The Lao government policy on STIs
The Lao PDR has committed to several international strategies and declarations on
HIV/AIDS including the National Strategic and Action Plan (NSAP) for HIV/AIDS and
Sexually Transmitted Infections Prevention and Control (2011‐2015 and 2016- 2020), in which
the Ministry of Health is responsible for coordinating and implementing the national response.
The NSAP for HIV/AIDS and STIs Prevention and Control is linked to two key milestones,
namely to confirm the Lao government’s commitment to reaching MDG 6 (Combat
HIV/AIDS, Malaria and Other Major Diseases) and the Three Zeros strategy, which is a global
approach in efforts towards zero new HIV infections, zero AIDS-related deaths and zero
discrimination. It provides a clear vision for future HIV/AIDS research and policy, in which all
partners have been involved in these milestones. STI prevention and control is a component of
the NSAP for national implementation (National Center for HIV/AIDS and STIs Control,
2015).
1.7. STI services in Vientiane Capital
STI services are available in each genecology and obstetrics care unit of health care
facilities in Vientiane Capital. However, only two health care facilities, namely the National
Dermatology Center (NDC) and the Vientiane Youth Center (VYC), are well regarded by
young people who seek care for STI services. This is because the NDC mainly serves in the
treatment of genital warts and gonorrhoea, and the VYC serves in the counselling of SRH
including STIs and the treatment of STIs for young people (Manivong, 2018).
There are some concerned institutions, associations and organizations providing
technical support related to sexual and reproductive health including the STI services in
Vientiane Capital. The National Center for HIV/AIDS and STIs is the center for control and
the surveillance of HIV/AIDS. It provides support to the voluntary counselling and HIV testing
(VCT) unit including the STI services which mainly focus on capacity building and distributing
essential medical equipment and lab materials (National Center for HIV/AIDS and STIs
Control, 2015). Besides this there are some NGOs and associations that provide training on
sexual and reproductive health including STI services to health staff, and counselling regarding
8
sexual and reproductive health including STIs and its prevention to young people in Vientiane
Capital (Lao PHA, 2018). Thus, the training of health workers in STI diagnosis and treatment
has been scaling up over the years, and STI service coverage has also been increased in tandem
(LYU and UNFPA, 2018).
Although data is now available for STI prevalence among sex workers, MSM and drug
users, the general STI prevalence data is limited. This reflects some structural challenges in the
health sector, such as a weak Health Management Information System (HMIS), especially in
the private sector, where most STI patients seek treatment. The LYU also reports on STI
services. It has recognized that there are many factors which cause the prevalence of STIs
including a lack of or limited access to adolescent and youth-friendly sexual and reproductive
health counselling. In addition, there are other inhibiting factors such as limited information
and services for both, married and unmarried young people, the cost of services, the attitudes
of health workers, self-censorship, a fear of social stigmas and the perceived lack of
confidentiality which discourage youth to seek health services and information (LYU and
UNFPA, 2018).
1.8. Concept of satisfaction
“Satisfaction” is either implicitly or explicitly defined as an “evaluation based on the
fulfilment of expectations” (Williams, 1994). Patient satisfaction is still the most commonly
used indicator for measuring the quality in health care. Patient contentment affects clinical
outcomes, patient retention and medical malpractice claims (Pomerai, 2017).
Satisfaction in other contexts is defined as a measurement determining how happy the
service users are with the provider’s products, services and capabilities. User satisfaction
information includes surveys and ratings that can help an establishment determine how to best
improve or change its products and services. An organization’s main focus must be to satisfy
its users. Ideally the users are happy, tell their friends about the services and keep coming back
(Dukers-Muijrers et al., 2012).
Satisfaction with STI services in this research is an important indicator for measuring the
quality of sexually transmitted infection services for youths at health facilities in Vientiane
9
Capital. This study will also measure how the youths’ satisfaction affects clinical outcomes,
retention levels, medical malpractice claims, and the efficiency of services. Moreover, this
satisfaction is an indicator to measure the success of the STI service providers at the health
facilities in Vientiane Capital.
1.8.1. Patient satisfaction with STI services
Patient satisfaction plays a key role in health care reforms and service delivery including
SRH and STI services. Many of the previous surveys cited below which were conducted in
different settings reported about the patients’ satisfaction towards STI services in past decades.
Interpersonal manner of health providers
The interpersonal manner of a health care provider is one important factor for the
satisfaction with health care services. A previous study showed that friendly, respectful and
responsive cashiers and clinical assistants, providing satisfactory explanation on how to use
prescribed drugs were associated with overall satisfaction at the clinic level (Michael et al.,
2017). Other valuable elements to consider when seeking to achieve satisfaction with health
services include the clinician skills like listening, respect to the patient and spending enough
time (Mehta et al., 2005), and the attitude of the health care provider to patients, namely that
they have provided helpful information and maintained confidentiality (Weston et al., 2009).
Besides these the clinician’s communication style and manner when exchanging information,
the patient’s low education and poor health, and the patient’s gender is in concordance with
the clinician’s gender are also important factors when striving of higher satisfaction with health
care services (Azizam & Shamsuddin, 2015). Napoles’ team revealed that patient-centered
decision making was positively associated with a satisfaction with physicians, health care and
physician’s recommendations. Meanwhile discrimination was negatively associated with a
satisfaction with physicians and health care. Unclear communication was associated with a
lower satisfaction with physicians among Spanish-speaking Latinos (Nápoles et al., 2009).
Moreover, politeness and respect shown by midwives, nurses and doctors were important
factors for the satisfaction with outpatient department services (Net, 2007).
UNIVERSITY OF HEALTH SCIENCES, FACULTY OF PUBLIC HEALTH
AND
MINISTRY OF EDUCATION AND TRAINING - MINISTRY OF HEALTH
HANOI UNIVERSITY OF PUBLIC HEALTH
AKSONE VONGKHILY
YOUTHS’ SATISFACTION WITH SEXUALLY TRANSMITTED
INFECTIONS SERVICES PROVIDED IN
VIENTIANE CAPITAL, LAOS 2019
MASTER OF PUBLIC HEALTH
CODE: 8720701
HANOI, 2020
MINISTRY OF HEALTH
UNIVERSITY OF HEALTH SCIENCES, FACULTY OF PUBLIC HEALTH
AND
MINISTRY OF EDUCATION AND TRAINING - MINISTRY OF HEALTH
HANOI UNIVERSITY OF PUBLIC HEALTH
AKSONE VONGKHILY
YOUTHS’ SATISFACTION WITH SEXUAL TRANSMITTED
INFECTIONS SERVICES PROVIDING IN
VIENTIANE CAPITAL, 2019
MASTER OF PUBLIC HEALTH
CODE: 8720701
SUPERVISORS:
DR KHAMPHENG PHONGLUXA DR DUONG MINH DUC
HEAD OF DEPARTMENT OF LECTURER, DEPT.OF POPULATION-REPRODUCTIVE
COORDINATION AND RESEARCH HEALTH FACULTY OF SOCIAL SCIENCES - HEALTH
INFORMATION MANAGEMENT, EDUCATION & BEHAVIOUR,
LAO TROPICAL AND PUBLIC HANOI UNIVERSITY OF PUBLIC HEALTH
HEALTH INSTITUTE
HANOI, 2020
i
ACKNOWLEDGEMENTS
This independent study would not have been possible without the help and support of
many people.
I am very grateful to the Ministry of Health of the Lao PDR and the LEARN project for
funding my studies at the University of Health Sciences (UHS), the Lao-THPI in Laos and
the Hanoi University of Public Health (HUPH) in Vietnam. The help from the Vientiane
Women’s and Youth Center for Health and Development of the Laos Women’s Union,
Vientiane Capital, and all their staff is also gratefully acknowledged for allowing me to
study at the UHS in Laos and the HUPH in Vietnam.
I would like to offer thanks to my thesis advisors Dr. Khampheng Phongluxa, MD,
MSc, PhD, Head of the Department of Coordination and Research Information
Management, at the Lao Tropical and Public Health Institute and Dr. Duong Minh Duc,
PhD., Lecturer, the Faculty of Social Sciences, Health Education and Behaviour, HUPH,
who steered me in the right the direction whenever they thought I needed it.
I would also like to acknowledge the valuable comments and encouragement from the
examination chair of my Independent Study Committee. and also wish to thank the
external member of the Independent Study Committee.
I am most grateful to the directors of the Vientiane Youth Center and the National
Dermatology Center, whose facilitators kindly agreed to help and participate in this
research. This study could not have been completed without their generous assistance.
I am grateful as well to all the lecturers, teachers and staff of the UHS, the Lao-TPHI
and HUPH for their continuous assistance and helpful advice.
I would like to offer special thanks to Dr. Somphou Outensackda and my classmates
for their kindness during the period of my studies at UHS and HUPH.
Finally, I would like to thank my family for their love, understanding, support, and
encouragement during the time I studied in Laos and Vietnam.
Mrs. Aksone VONGKHILY
ii
ABBREVIATIONS & ACRONYMS
AIDS Acquired Immune Deficiency Syndrome
HIV Human Immune-deficiency Virus
Lao PDR Lao People’s Democratic Republic
LPRYULYU Lao People’s Revolutionary Youth Union/Lao Youth Union
NDC National Dermatology Centre
VYC Vientiane Youth Centre
SRH Sexual and Reproductive Health
STIs Sexual Transmitted Infections
STDs Sexual Transmitted Diseases
UNFPA United Nations Population Fund
YFS Youth Friendly Service
WHO World Health Organization
iii
CONTENTS
ACKNOWLEDGEMENTS ......................................................................................... I
ABBREVIATIONS & ACRONYMS ......................................................................... II
LIST OF TABLES .....................................................................................................VI
SUMMARY ............................................................................................................ VIII
INTRODUCTION ........................................................................................................ 1
RESEARCH OBJECTIVES ......................................................................................... 2
CHAPTER 1 ................................................................................................................. 3
LITERATURE REVIEW ............................................................................................. 3
1.1. YOUTH ................................................................................................................. 3
1.2. SEXUALLY TRANSMITTED INFECTIONS (STIS) ......................................... 3
1.3. SEXUALLY TRANSMITTED INFECTIONS AMONGST YOUTHS AROUND
THE WORLD AND IN LAOS .................................................................................... 4
1.3.1. STI OCCURRENCE AMONGST YOUTHS AROUND THE WORLD ....... 4
1.3.2. STIS AMONGST YOUTHS IN LAOS ........................................................... 4
1.4. STI SERVICES IN THE WORLD........................................................................ 5
1.5. STI SITUATION AND SERVICES FOR YOUTH IN LAOS ............................. 5
1.6. THE LAO GOVERNMENT POLICY ON STIS .................................................. 7
1.7. STI SERVICES IN VIENTIANE CAPITAL........................................................ 7
1.8. CONCEPT OF SATISFACTION ......................................................................... 8
1.8.1. PATIENT SATISFACTION WITH STI SERVICES ........................................ 9
1.9 ASSOCIATED FACTORS AFFECTING YOUTH SATISFACTION WITH STI
SERVICES ................................................................................................................. 12
1.10. CONCEPTUAL FRAMEWORK ...................................................................... 15
CHAPTER 2 ............................................................................................................... 17
METHODOLOGY ..................................................................................................... 17
2.1. STUDY POPULATION ...................................................................................... 17
2.1.1 INCLUSION CRITERIA .................................................................................. 17
2.2.2 EXCLUSION CRITERIA ................................................................................. 17
2.2. STUDY SITE AND DURATION OF DATA COLLECTION .......................... 18
2.3. STUDY DESIGN ................................................................................................ 18
iv
2.4. SAMPLE SIZE .................................................................................................... 18
2.5 SAMPLING METHOD........................................................................................ 19
2.6 DATA COLLECTION ......................................................................................... 19
2.7 VARIABLES OF THE STUDY .......................................................................... 20
2.8 RESEARCH INSTRUMENT AND MEASUREMENT ..................................... 21
2.8.1 RESEARCH INSTRUMENT ........................................................................... 21
2.8.2 MEASUREMENT OF YOUTHS’ SATISFACTION....................................... 22
2.8.3 MEASUREMENT OF EXPECTATIONS WHEN RECEIVING STI SERVICES
.................................................................................................................................... 23
2.9. DATA ANALYSIS METHOD ........................................................................... 24
2.10. ETHICS STATEMENT .................................................................................... 24
CHAPTER 3 ............................................................................................................... 26
RESULTS ................................................................................................................... 26
3.1 SOCIO-DEMOGRAPHIC CHARACTERISTICS .............................................. 26
3.2 YOUTH’S SATISFACTION WITH STI SERVICES ......................................... 28
3.3 MEDICAL SITUATION OF THE YOUTH AND THEIR EXPECTATIONS WHEN
RECEIVING THE SERVICES .................................................................................. 34
3.3.1 MEDICAL SITUATION MOTIVATING THE YOUTHS TO VISIT THE STI
SERVICES ................................................................................................................. 34
3.3.2 EXPECTATIONS WHEN RECEIVING STI SERVICES ............................... 36
3.4 UNIVARIATE LOGISTIC REGRESSION ANALYSIS OF THE ASSOCIATION
BETWEEN THE SOCIO-DEMOGRAPHIC FACTORS AND THE YOUTHS’
SATISFACTION WITH THE STI SERVICES......................................................... 39
3.5 UNIVARIATE LOGISTIC REGRESSION ANALYSIS OF THE ASSOCIATION
BETWEEN THE MEDICAL SITUATION OF THE YOUTH, THEIR EXPECTATIONS
WHEN RECEIVING STI SERVICES AND THEIR SATISFACTION WITH THE
SERVICES ................................................................................................................. 42
3.6 UNIVARIATE ANALYSIS OF THE ASSOCIATION BETWEEN EXPECTATIONS
WHEN RECEIVING STI SERVICES AND THE SATISFACTION WITH THE
SERVICES ................................................................................................................. 45
v
3.7 MULTIVARIATE LOGISTIC REGRESSION ANALYSIS OF THE FACTORS
ASSOCIATED WITH THE YOUTH’S SATISFACTION WITH THE STI SERVICES
.................................................................................................................................... 45
CHAPTER 4 ............................................................................................................... 48
DISCUSSION............................................................................................................. 48
CONCLUSION .......................................................................................................... 59
RECOMMENDATIONS ........................................................................................... 60
REFERENCES ........................................................................................................... 61
ANNEX ...................................................................................................................... 70
ANNEX 1: TABLE OF DEFINITIONS AND MEASUREMENT OF VARIABLES IN
THE STUDY .............................................................................................................. 70
ANNEX 2: QUESTIONNAIRE ................................................................................ 73
ANNEX 3: INFORMED CONSENT FORM FOR ADOLESCENTS ..................... 80
ANNEX 4: PARENTAL/LEGAL GUARDIAN’S CONSENT FORM ................... 81
ANNEX 5: LAO ETHICAL APPROVAL................................................................ 82
ANNEX 6: VIETNAM ETHICAL APPROVAL ..................................................... 83
ANNEX 7: THESIS COMMENTS ............................................................................ 84
ANNEX 8: MINUTES OF EXPLANATION ............................................................ 91
vi
LIST OF TABLES
Table 3.1: Distribution of socio-demographic characteristics of youths visiting the STI services
at the Vientiane Youth Center and the National Dermatology Center (n=217) .................. 26
Table 3.2: Interpersonal manner of health providers .................................................................. 28
Table 3.3: Counselling skills of providers ................................................................................... 29
Table 3.4: Physical environment.................................................................................................. 30
Table 3.5: Availability of services ............................................................................................... 30
Table 3.6: Accessibility of services ............................................................................................. 31
Table 3.7: Affordability of fees ................................................................................................... 32
Table 3.8: Efficiency of services ................................................................................................. 32
Table 3.9: Overall satisfaction of youth towards STI services in Vientiane Capital (n=217) .... 33
Table 3. 10: STI symptoms motivating youths to visit the STI services (n=217) ...................... 34
Table 3.11: Diagnosis of the sexually transmitted infections (n=217) ........................................ 34
Table 3.12: Current status of STI infection (n=217)................................................................... 35
Table 3.13: Distribution of health care facilities that the youth have utilized (n=217) ............... 36
Table 3.14: Expectations about the manner of the service providers (Respect, Friendliness,
Concern and Courtesy) (n=217) .......................................................................................... 36
Table 3. 15: The status of youth’s expectations when receiving STI services (n=217) .............. 38
Table 3.16: Level of satisfaction with STI services (n=217) ....................................................... 39
Table 3.17: Association of socio-demographic factors and the satisfaction with STI services
(n=217) ................................................................................................................................ 39
Table 3.18: Association between the medical situation of the youth and their satisfaction with
the services .......................................................................................................................... 42
Table 3.19: Association between expectations when receiving STI services and the satisfaction
with the services .................................................................................................................. 45
Table 3.20: Associated factors and youth’s satisfaction with STI services ................................. 45
vii
Independent Study Title Youth Satisfaction with the Provision of Sexually
Transmitted Infection Services in Vientiane Capital,
2019
Author Mrs. Aksone VONGKHILY
Degree Master of Public Health
Major Field/ Faculty/ University University of Health Sciences, Faculty of Public
Health, and Hanoi University of Public Health
Independent Study Advisors Dr. Khampheng Phongluxa
Head of Department of Coordination and Research
Information Management, Lao Tropical and Public
Health Institute
Dr Duong Minh Duc
Lecturer, Department of Population and Reproductive
Health, Faculty of Social Sciences - Health Education
& Behaviour, Hanoi University of Public Health
Academic Years 2018-2020
viii
SUMMARY
Sexually transmitted infections (STIs) are a major burden for disease control worldwide,
particularly among youths. In the Lao PDR, youths acquire STIs due to an insufficient
knowledge of safe sex and STIs, as well as poor access to sexual and reproductive health
services. Patient satisfaction enhances the image of health care facilities and translates
into increased service use. The aim of this study is to investigate the youths’ satisfaction
with STI services in Vientiane Capital, and identify its associated factors.
A cross-sectional analytical study was applied using quantitative methods. The study
interviewed 217 youths aged 15-24 who were seeking care at the STI Unit of the Vientiane
Youth Center (VYC) and the National Dermatology Center (NDC). The collected data
was entered into the Epidata program (Version 3.1) and then transferred to the STATA
software (Version 14.2) for further analysis. Descriptive and inferential statistics analyses
were performed to determine the factors associated with satisfaction relating to STI
services.
The findings showed that of 217 youths, 74.6% were aged 21-24 years, 78.8% were single
and 78.3% of them belonged to the Lao ethnic group. Almost three fifths of the students
were male, and nearly 40% had attended university, while over two fifths were currently
enrolled as students. More than a third of the youths had a monthly income of between
1.1-1.5 million LAK. Pertaining to their satisfaction with STI services, more than four
fifths of youths were pleased with the STI services. The most significant factors identified
associated with a satisfaction with STI services were having a monthly income of between
1.1-1.5 million LAK, having experienced a visit to STI services before and expecting to
receive good services (AOR).
In conclusion, this study has demonstrated that most youths are satisfied with the provision
of STI services in Vientiane Capital. Youths with a moderate income, a prior experience
of using STI services and who held positive expectations while receiving services were
found to be the influencing factors linked to a satisfaction with STI services. Therefore,
to increase STI service use among youths, youth friendly services including the promotion
ix
of the availability of STI services and capacity building measures to strengthen health staff
should be encouraged as focus activities in the future.
Keywords: STI services, satisfaction, youth, Vientiane Capital.
1
INTRODUCTION
Sexually transmitted infections (STIs) are infections that are commonly spread by
sexual activity, especially vaginal intercourse, anal sex and oral sex. Many times STIs initially
do not cause symptoms. This results in a greater risk of passing the disease on to others.
Symptoms and signs of disease may include vaginal discharge, penile discharge,
ulcers on or around the genitals, and pelvic pain (Willey, 2008).
STIs are a major burden of disease worldwide. Each year, 357 million new cases of
curable STIs occur with the highest rates amongst youths aged 20-24 years followed by 15-19
year olds. STIs can be caused by bacteria (gonorrhea, syphilis, chlamydia), parasites
(trichomoniasis), and viruses (human papillomavirus, genital herpes, HIV). The reduction of
STI cases is described as an important component of the health sector when achieving the
Sustainable Development Goals (SDGs) (WHO, 2016).
According to global comparisons, STIs occurring amongst young people in Asia-Pacific
countries are the highest with a total number of the four most common diseases accounting for
70.8 million cases in the SE Asian region, and 108.7 million cases in the Western Pacific region
(Chan, 2011).
In the Lao PDR, youth acquire STIs due to having an insufficient knowledge of safe sex
and STIs, a low risk perception, and poor access to sexual and reproductive health products and
services (Andrews, 2015). Men of the 20-29 year age group are most commonly infected. There
are serious and growing epidemics in several neighboring countries of the Lao PDR which by
reasons of increasing population mobility, both within and across Lao borders, human
trafficking, and the improvement of transportation networks are making the country
increasingly vulnerable (WHO, 2015).
Satisfaction can be defined as the extent of an individual’s experience compared with
his or her expectations. A patients’ satisfaction is related to the extent to which general health
care needs and condition-specific needs are met. Satisfaction is one of the core outcome
measures for health care (Mohan & Kumar, 2011). Users’ satisfaction is defined as a
measurement that determines how happy they are with a facility’s products, services, and
2
capabilities. Hence, an organization’s main focus must be to satisfy its users. Customer
satisfaction does not just impact the business' bottom line, it also impacts team morale and
retention rate. To make money, businesses need customers. Ideally these customers are happy,
tell their friends about the facility and keep coming back (Zahorik & Rust, 2019).
Information about the study sites
The Vientiane Youth Center (VYC) and the National Dermatology Center (NDC) are
health care facilities located in Vientiane Capital, which provide comprehensive consultations,
and youth-friendly sexual and reproductive health (SRH) services geared for youths aged 10 to
24 years, as well as responding to the needs of migrant youths. There has been no empirical
evidence collected about the satisfaction with the services provided by the VYC and NDC.
Many factors could influence the satisfaction of the youths with the services such as the cost of
services, the hours of services and waiting time to receive services, transportation, accessibility
to prevented care, and youth-friendly sexual and reproductive health services (Vientiane Youth
Center, 2018).
So far, no information on the satisfaction of youths with STI services provided at these
two facilities is in existence, hence this study seeks to provide an assessment of the satisfaction
of the youths visiting the VYC and NDC. This quantitative study will examine the youths’
satisfaction with STI services and associated factors to determine the level and scope of
satisfaction at the two study sites in Vientiane Capital. The results of this study could be of
critical importance for improving these services.
RESEARCH OBJECTIVES
The current research aims:
1. To investigate the youths’ satisfaction with STI services provided in Vientiane Capital
in 2019.
2. To explore factors that are associated with the youths’ satisfaction with STIs services
provided at health facilities in Vientiane Capital in 2019.
3
CHAPTER 1
LITERATURE REVIEW
This chapter presents the main definitions, epidemiology and reviews of the literature
related to STI services in the world and in the Lao PDR, in particular youth satisfaction with
STI services and their associated factors in the Lao PDR.
1.1. Youth
The Lao government policy defines youth as “a young population that has a vast future
potential for economic growth and support”. According to the adolescent and youth situation
analysis of Laos, young people is the combination of adolescents (10 – 19 years) and younger
youth (20 – 24 years) (LYU & UNFPA, 2014).
1.2. Sexually Transmitted Infections (STIs)
Sexually Transmitted Infections (STIs) are infections that are commonly spread by
sexual activities, especially vaginal intercourse, anal sex and oral sex. For many cases, STIs
initially do not cause symptoms. The result is a greater risk of passing the disease from one
person to others. The symptoms and signs of disease may include vaginal discharge, penile
discharge, ulcers on or around the genitals, and pelvic pain. The STIs can be transmitted to an
infant before or during childbirth and may result in poor outcomes for the baby. Some STIs
may cause problems with the ability to get pregnant (Kassim, 2017).
Through sexual activities, more than 30 different bacteria, viruses and parasites are being
transmitted. Bacterial STIs include chlamydia, gonorrhea, and syphilis. The viral STIs include
genital herpes, HIV/AIDS and genital warts. Parasitic STIs include trichomoniasis. While they
are usually spread during sex, some STIs can be transmitted by non-sexual contact such as
donor tissue, blood, breastfeeding or during childbirth. STI diagnostic tests are usually easily
available in the developed world, but this is often not the case in developing countries
(Korenromp et al, 2019).
4
1.3. Sexually transmitted infections amongst youths around the world and in Laos
1.3.1. STI occurrence amongst youths around the world
Incidence and prevalence estimates suggest that young people aged 15–24 years acquire
half of all new STIs. Up to 80% of curable STIs occur in developing world settings, and
adolescents and young adults have the highest rates of these infections.
In Australia, data indicates that sustained and increasingly high rates of STIs among
young people are an immediate concern. A variety of socio-cultural factors, such as increased
duration between sexual debut and the formation of long-term partnerships, low rates of
condom use, and poor access to services, made young people vulnerable to STIs. As a
consequence, young people were named as a priority group in the 2010 National Sexually
Transmissible Infections Strategy (Middleton & McDonald, 2013).
1.3.2. STIs amongst youths in Laos
In the Lao PDR, there has been an increasing vulnerability to the HIV/AIDS and STI
epidemic. The growing young population has a large impact on the reproductive health status
of the country. Key indicators of vulnerability in Laos are the practice of unsafe sex, an
increased HIV prevalence, a low risk perception among vulnerable groups and young people,
a low level of knowledge about STIs and HIV/AIDS, and poor access to sexual and
reproductive health products and services (WHO, 2018). For example, there has been a high
prevalence of sexually transmitted infections (1.8%), especially among the most-at-risk
population which includes men who have sex with men, sex workers, People who inject drug.
STIs were the most pervasive infectious diseases confronting adolescents. Strong evidence has
shown several biological mechanisms through which STIs facilitate HIV transmission thus
increasing both HIV infectiousness and HIV susceptibility. In Laos most people infected are
heterosexual men aged 20-29 years. The serious and growing epidemics in several of Laos’
neighboring countries, increasing population mobility, both within and across Laos’ borders,
the trafficking of women, girls and boys, and improved transportation networks make the
country increasingly vulnerable to HIV/AIDS (National Center for HIV/AIDS and STI Control,
2015).
5
1.4. STI services in the world
In 2001, the WHO organized a global consultation on adolescent friendly health
services. One of ten consensus statements was that adolescents are unable and or unwilling to
obtain the (general) health services they need. A 2005 review of research from 1999 focused
on the need for adequate STI services and identified barriers that adolescents experience
when obtaining the needed STI services. Such barriers have been classified into four
categories: availability, accessibility, acceptability and equity. Understanding what the current
barriers are globally, and by region, could provide an understanding of what challenges still
exist. STI services are often grouped in a larger cadre of SRH services in many settings.
Given the increased number of STIs, access to sexual and reproductive health services is vital
for sexually active youths and adolescents. However, health services in many countries do not
fully address these needs. This is especially true for sexually transmitted infections and may
be worse in countries with fewer resources dedicated to health care (Newton-Levinson et al.,
2016).
1.5. STI situation and services for youth in Laos
Sexually transmitted infections in youths are a greatly and continuously under-researched
subject, and there are important gaps in our knowledge of the behavioural, socio-economic and
geographic correlates of STIs and of the various service delivery models. For over a decade,
the WHO has set out guidelines on Adolescent Health for Health Care Providers in order to
promote healthy development in adolescents, and to prevent and respond to health problems
challenging this population group. Health-care providers (HCP) have important contributions
to offer for reproductive and sexual health information and services, and these are becoming
more available for young people to make services equitable, accessible, acceptable, appropriate
and effective. The intention is that adolescents and young people will have the information they
need to make responsible decisions and access the relevant health services. In addition, the
WHO has addressed adolescent responsive health systems because adolescents have rising and
significant needs from health services. They pose different challenges for the health-care
system than children and adults, due to their rapidly evolving physical, intellectual and
6
emotional development. The key concepts of adolescent responsive health systems include the
transition from adolescent-friendly projects to adolescent-responsive health systems targeting
Universal Health Coverage, services geared for adolescent needs going beyond sexual and
reproductive health, adopting quality standards for quality improvement, and health
professionals benefitting from pre-service training with a knowledge of adolescent health and
development and their implications for clinical practice (WHO, 2016).
The Lao Country Report on STI services revealed that there were difficulties resulting
from the increasing demand among key affected populations including female sex workers,
men who have sex with men, injecting drug users, persons with multiple sex partners, and
young people when availing health services. STI prevalence in Laos was still high among the
affected population in 2014 (Ministry of Health, Chair of the National Committee for the
Control of AIDS, and UN). As Laos has a young population with a majority (60%) of its citizens
belonging to the under 25 year age bracket there is an increasing number of young people who
are sexually active. More young women are engaging in exotic entertainment (bar hostesses)
and sex work. Young men who have sex with men often had multiple male partners. Low
condom uses and low access to STI treatment were also observed. Among sex workers and
clients, behaviours like the use of alcohol and drugs as well as the inconsistent use of condoms
aggravated their high-risk situations. In so far as married men and women were concerned, the
use of the male condom as a contraceptive remained low. Furthermore married men only used
condoms with people other than their wives (National Center for HIV/AIDS and STIs Control,
2015).
The Lao People’s Revolutionary Youth Union and UNFPA report in 2018 disclosed that
the prevalence of sexually transmitted infections, including chlamydia and gonorrhoea, was
high. In urban settings, there was greater access to information about STIs, but for a variety of
reasons young people did not adopt safe sex practices. In rural settings, and particularly in rural-
off road settings, the lack of sexual and reproductive health knowledge and poor access to
condoms and other forms of contraception contributed strongly to both unplanned pregnancies
and to STIs. In addition to the direct morbidity associated with these infections, STIs increased
the transmission and susceptibility to HIV infection (LYU and UNFPA, 2018).
7
1.6. The Lao government policy on STIs
The Lao PDR has committed to several international strategies and declarations on
HIV/AIDS including the National Strategic and Action Plan (NSAP) for HIV/AIDS and
Sexually Transmitted Infections Prevention and Control (2011‐2015 and 2016- 2020), in which
the Ministry of Health is responsible for coordinating and implementing the national response.
The NSAP for HIV/AIDS and STIs Prevention and Control is linked to two key milestones,
namely to confirm the Lao government’s commitment to reaching MDG 6 (Combat
HIV/AIDS, Malaria and Other Major Diseases) and the Three Zeros strategy, which is a global
approach in efforts towards zero new HIV infections, zero AIDS-related deaths and zero
discrimination. It provides a clear vision for future HIV/AIDS research and policy, in which all
partners have been involved in these milestones. STI prevention and control is a component of
the NSAP for national implementation (National Center for HIV/AIDS and STIs Control,
2015).
1.7. STI services in Vientiane Capital
STI services are available in each genecology and obstetrics care unit of health care
facilities in Vientiane Capital. However, only two health care facilities, namely the National
Dermatology Center (NDC) and the Vientiane Youth Center (VYC), are well regarded by
young people who seek care for STI services. This is because the NDC mainly serves in the
treatment of genital warts and gonorrhoea, and the VYC serves in the counselling of SRH
including STIs and the treatment of STIs for young people (Manivong, 2018).
There are some concerned institutions, associations and organizations providing
technical support related to sexual and reproductive health including the STI services in
Vientiane Capital. The National Center for HIV/AIDS and STIs is the center for control and
the surveillance of HIV/AIDS. It provides support to the voluntary counselling and HIV testing
(VCT) unit including the STI services which mainly focus on capacity building and distributing
essential medical equipment and lab materials (National Center for HIV/AIDS and STIs
Control, 2015). Besides this there are some NGOs and associations that provide training on
sexual and reproductive health including STI services to health staff, and counselling regarding
8
sexual and reproductive health including STIs and its prevention to young people in Vientiane
Capital (Lao PHA, 2018). Thus, the training of health workers in STI diagnosis and treatment
has been scaling up over the years, and STI service coverage has also been increased in tandem
(LYU and UNFPA, 2018).
Although data is now available for STI prevalence among sex workers, MSM and drug
users, the general STI prevalence data is limited. This reflects some structural challenges in the
health sector, such as a weak Health Management Information System (HMIS), especially in
the private sector, where most STI patients seek treatment. The LYU also reports on STI
services. It has recognized that there are many factors which cause the prevalence of STIs
including a lack of or limited access to adolescent and youth-friendly sexual and reproductive
health counselling. In addition, there are other inhibiting factors such as limited information
and services for both, married and unmarried young people, the cost of services, the attitudes
of health workers, self-censorship, a fear of social stigmas and the perceived lack of
confidentiality which discourage youth to seek health services and information (LYU and
UNFPA, 2018).
1.8. Concept of satisfaction
“Satisfaction” is either implicitly or explicitly defined as an “evaluation based on the
fulfilment of expectations” (Williams, 1994). Patient satisfaction is still the most commonly
used indicator for measuring the quality in health care. Patient contentment affects clinical
outcomes, patient retention and medical malpractice claims (Pomerai, 2017).
Satisfaction in other contexts is defined as a measurement determining how happy the
service users are with the provider’s products, services and capabilities. User satisfaction
information includes surveys and ratings that can help an establishment determine how to best
improve or change its products and services. An organization’s main focus must be to satisfy
its users. Ideally the users are happy, tell their friends about the services and keep coming back
(Dukers-Muijrers et al., 2012).
Satisfaction with STI services in this research is an important indicator for measuring the
quality of sexually transmitted infection services for youths at health facilities in Vientiane
9
Capital. This study will also measure how the youths’ satisfaction affects clinical outcomes,
retention levels, medical malpractice claims, and the efficiency of services. Moreover, this
satisfaction is an indicator to measure the success of the STI service providers at the health
facilities in Vientiane Capital.
1.8.1. Patient satisfaction with STI services
Patient satisfaction plays a key role in health care reforms and service delivery including
SRH and STI services. Many of the previous surveys cited below which were conducted in
different settings reported about the patients’ satisfaction towards STI services in past decades.
Interpersonal manner of health providers
The interpersonal manner of a health care provider is one important factor for the
satisfaction with health care services. A previous study showed that friendly, respectful and
responsive cashiers and clinical assistants, providing satisfactory explanation on how to use
prescribed drugs were associated with overall satisfaction at the clinic level (Michael et al.,
2017). Other valuable elements to consider when seeking to achieve satisfaction with health
services include the clinician skills like listening, respect to the patient and spending enough
time (Mehta et al., 2005), and the attitude of the health care provider to patients, namely that
they have provided helpful information and maintained confidentiality (Weston et al., 2009).
Besides these the clinician’s communication style and manner when exchanging information,
the patient’s low education and poor health, and the patient’s gender is in concordance with
the clinician’s gender are also important factors when striving of higher satisfaction with health
care services (Azizam & Shamsuddin, 2015). Napoles’ team revealed that patient-centered
decision making was positively associated with a satisfaction with physicians, health care and
physician’s recommendations. Meanwhile discrimination was negatively associated with a
satisfaction with physicians and health care. Unclear communication was associated with a
lower satisfaction with physicians among Spanish-speaking Latinos (Nápoles et al., 2009).
Moreover, politeness and respect shown by midwives, nurses and doctors were important
factors for the satisfaction with outpatient department services (Net, 2007).