Effect of Health Education Program about Vaginitis on Knowledge and Practices of Elderly Women
1Nour El-Houda Moustafa, 2Nermeen Mahmoud Abd-Elaziz,                                        3Thoria Mohamed Mahmoud, 4Safaa Rashad Mahmoud
1Assistant prof. Obstetric and Gynecological Nursing Department, Faculty of Nursing Sohag University, Sohag, Egypt
2Assistant prof.  Gerontological Nursing Department, Faculty of Nursing, Assiut University. Assiut,  Egypt
3Lecturer in Community Health Nursing Department, Faculty of Nursing, Sohag University, Sohag, Egypt,
4Assistant prof. Community Health Nursing Department, Faculty of Nursing, Assiut University, Assiut, Egypt
Corresponding author E-mail: safaar@aun.edu.eg
Abstract: Atrophic vaginitis is one of the most significant determining factors of sexual function and urogenital health, with a considerable effect on the quality of life of postmenopausal women. It affects 10 to 40% of postmenopausal women worldwide. Aim: the study aimed to assess knowledge and practices of elderly women about atrophic vaginitis and to assess the impact of health education program on improving knowledge and practice of elderly women regarding atrophic vaginitis. Subjects and Methods: Quasi-experimental study design was used and conducted at out-patient clinics of Sohag University Hospitals, 100 elderly women were participated in this study. An interview structured questionnaire developed by the researchers that included four parts was used to collect necessary data; personal characteristics, women's history of vaginitis, their knowledge, and practices. The questionnaire was filled two times before and after program implementation. Results: 49% of the participated women reported that they had history of vaginitis and none of them seek medical help. The total knowledge of participated women improved highly significantly following the program intervention from 9.00±5.16 to 16.71±3.91 grades (p<0.001). Also, the total practice score of women recorded a statistically significant rise following the program intervention from 1.53±0.98 to 2.36±1.20 grades (p<0.05). Conclusion: Educational health programs for atrophic vaginitis are very beneficial and proved their importance in raising women knowledge and improving their practices. Recommendation: Application of other educational health programs to improve awareness, practice, and attitudes in addition to helping women adopt coping strategies for other postmenopausal manifestations.
Keywords:  Atrophic Vaginitis, Health Education, knowledge, Postmenopausal Women, Program, practice.
1.   INTRODUCTION
Menopause is an unavoidable normal period in a woman’s life which is accompanying with numerous physical and psychological changes that can be substantial enough to interrupt the normal life of woman experiencing it. As the number of women has increased in the menopausal age group because of improvements in health care and unrestricted initiatives toward healthy living, the experience of age-related diseases shows not only a distinct challenge for clients, but also for health care givers who expected to submit substitutes that are protective and promote quality of life (Goldstein, 2010 and Goswami, 2013).
Vaginal atrophy, also known as atrophic vaginitis or urogenital atrophy is very prevalent and inconvenient issue among numerous postmenopausal women. More than 40% of postmenopausal women will expose evidence of vaginal atrophy, and around 20-25% will try to find medical intervention for the uncomfortable symptoms. The disease is characterized by dryness and itching in the vagina and vulva, frequent infections of the bladder or vagina, dyspareunia and dysuria. Whilst atrophic vaginitis inescapable, it very prevailing and perhaps difficult to prevent. For that early detection and prompt treatment are more effective for most women (Nappi & Kokot-Kierepa ,2012 and Mac Bride et al., 2010).
Vaginal atrophy may lead to unpleasant symptoms, unsatisfactory sexual activity, poor partner relationship, and a diminished quality of life. Early detection and appropriate treatment of vaginal atrophy can improve sexual health and overall quality of life. Decrease estrogen level in elderly women results in vaginal atrophy with an accretion in dryness, thinning of tissues, and reduced pH. This can lead to difficult intercourse and urinary tract infection (Sobecki, etal 2012, Parish etal 2013, and Tuntiviriyapun, etal 2015).
Early detection of vaginitis in early stages may be difficult, firstly because of unreported cases or as a result of insufficient assessment or treatment by practitioners. Many researches displayed that the use of topical estrogen can relieve these symptoms, which way lead to women’s reassurance. The clinician should be aware to recognize physiologic changes during pelvic examination and simply discuss the topic. Assuring terms of prevention and health maintenance is the key for clinicians when involved with women’s health care (Panay & Maamari, 2012 and Godha et al, 2018).
Vaginitis should be not to be an inevitable outcome of menopause or other causes that lead to decrease estrogen levels. Effective diagnosis and treatment can prevent progress of atrophic vaginitis or decrease existing symptoms (Archer, 2010).  Attention of the various options for submission of estrogen replacement, as well as alternative therapies, highly enhances a physician's competence to describe treatment that is appropriate to a patient's needs. In the suitable situation, reassurance of sexual activity is also an essential source of non-pharmacological interventions which many women may not be informed. (Al-Baghdadi & Ewies, 2009, and Palacios et al, 2015)
Significance of the study
Vaginal atrophy is one of the most significant determining factors of sexual function and urogenital health, with a considerable effect on the quality of life. Women suffering from symptoms related to vaginal atrophy should be diagnosed and treated immediately to avert inevitable consequences. Vaginal atrophy still deficient realized by women attending health-care centers and are often reluctant to consult or complain about it. Treatment with vaginal estrogen is easy, secured, and can change a woman’s quality of life. It is important for physician to start discussion with postmenopausal women about their urogenital health to assure that symptoms are discovered early and suitably treated. Prompt treatment should be begun and before irreversible atrophic alterations have happened (Goldstein, 2010, and Yadav & Dayal, 2017).
In Egypt, especially the Upper Egypt region, women are not so open to talk about the problem of vaginitis. If the condition of atrophic vaginitis persists, it may lead to serious infection. Early diagnosis and treatment may prevent the progress of vaginal atrophy or control existing symptoms. 
Aim of the study
1-	To assess the knowledge and practice of elderly women about atrophic vaginitis. 
2-	To assess the impact of health education program on knowledge and practice of elderly women regarding atrophic vaginitis
2.   SUBJECTS AND METHODS
Study design:
Quasi-experimental design is used in the current study
Settings:
The study was conducted at gynecological out-patient clinics of Sohag University Hospitals.  
Subjects:
Convenience sample of 100 elderly women who accepted to participate in the study.
Inclusion criteria:
•	Women ≥ 60 years.
•	Alert and able to communicate.
Exclusion criteria:
•	Patients with neurological and psychological disorders.
Study hypotheses:-
1-The health educational program will improve knowledge of elderly women about vaginitis. 
2-Health educational program will improve women's practices and may reduce the risk of its serious consequences. 
Tool:
An interview structured questionnaire that developed by the researchers after intensive revision of related literature was used in this study. It included four main parts:-
Part 1: Personal data, such as age, education level, marital status, and residence. 
Part 2: women's history of vaginitis, itching, abnormal vaginal discharges, bad odor secretions, and dryness & pain during intercourse.
Part 3: Data concerning knowledge. This part include twenty questions to assess women knowledge of elderly women about Atrophic Vaginitis (AV), such as meaning of AV, signs and symptoms, causes or risk factors, bad consequences of AV, and ways of prevention and control. Each true answer has one mark; the total was 20 marks 
Part 4: Data concerning practices for avoiding AV (9 statement with response of Yes/ No), such as ensure the cleanliness and effective dryness of vaginal area, avoid using vaginal lotions unless prescribed by the doctor, avoid using soap or perfumed products for vaginal area, avoid using strong detergents to wash underwear, use cotton underwear, change underwear or sanitary pads constantly, clean from front to back after elimination and not vice versa, periodic vaginal examination and doctor consultation
Validity and reliability:
The face and content validity was measured by asking 5 experts in the field of Obstetric nursing, community health nursing, and Obstetric medicine to revise the tool. Their comments were considered and the necessary modifications were done. Test- retest reliability was used with 30 women prior to the start of the study to assess the reliability of the tool (r=0.77)
Scoring system:
For knowledge of elderly women about Atrophic Vaginitis, each correct answer had scored 1, and incorrect answer had scored 0, the total score was 20 marks.  For Practices to avoiding AV, each correct practice had scored 1, and incorrect practice had scored 0, the total score was 9 marks.    The scores of the items were summed-up and the total divided by the number of the items, giving a mean score for the part. These scores were converted into a percent score, and means and standard deviations were computed. Knowledge was considered satisfactory if the percent score was 60% or more and unsatisfactory less than 60%.
The questionnaires were filled in 2 occasions; before and after the program intervention.
THE HEALTH EDUCATION PROGRAM:
The program included 6 main sections: 
Section 1: Brief discussing about postmenopausal period and its manifestations
Section 2: Vaginitis definition and its types, with focusing on atrophic vaginitis, normal and abnormal vaginal discharge.
Section 3: Symptoms of vaginitis, such as itching, burning during urination, discharges with offensive odor, and pain during intercourse.
Section 4: Focusing on the risk factors and complications of AV.
Section 5: Focusing on the treatment of AV and the coping strategies used to adapt to its discomforting manifestations.
Section 6: Discussing the practices for avoiding AV, in addition to raising the awareness of the participants about the importance of commitment to sanitary habits through general advices such as; seek consultant (health care provider is the best source of information for questions and concerns related to this problem), using Vaginal lubricants and moisturizers as ordered, keep genitals region clean and dry, avoid wearing clothes that are tight in the crotch, also regular sex can help keep vaginal tissues healthy.
Pilot study:
A Pilot study was applied on 10 elderly women drawn from the previous settings, to test tool's clarity and to estimate the time required for filling the tools. Those elderly women were included in the study.
Field work: 
The current study was implemented over a period of 6 months from the beginning of November 2017 to the end of April 2018 Before starting educational program sessions, the researchers interviewed each woman individually, given brief explanation about the objectives of the study and their oral consent was obtained, then each one of them asked to answer the questionnaires to assess their knowledge and practice before application of the health education program as a pretest. Each sheet took 15–20 minutes to be completed. Then these women were divided into small groups of 3-4 for the educational program which conducted in teaching room of gynecology clinic in out-patients clinics at Sohag University Hospital. The program was implemented over one session that ranged from 2-3 hours. Presentation, group discussion, and telephone counseling were used as teaching methods; also, illustrated colored booklet is used as media of teaching. After implementation of the educational program, post-test was done to assess the impact of program on the participated women’s knowledge and practice.
ETHICAL CONSIDERATIONS
The approval of ethical committee of the Faculty of Nursing was obtained. Women were informed of the purpose of the study and its consequences with confirming confidentiality of data and their right to withdraw from the study as they need. Oral consent were obtained from the participated women
STATISTICAL ANALYSIS
Data were analyzed using the software, Statistical Package for Social Science, (SPSS) version 20. Frequency distribution with its percentage and descriptive statistics with mean and standard deviation were calculated. Chi-square, t-test, correlations were done whenever needed. P values of less than 0.05 were considered significant.
3.   RESULTS
Table 1: Distribution of the studied women according to their personal characteristics (No. = 100)
Character	No.	%	
Age			
60- <65	38	38.0	
65- <70	44	44.0	
70- <75	6	6.0	
≥ 75	12	12.0	
Mean ± SD	66.2+5.0	
Residence			
Urban	19	19.0	
Rural	81	81.0	
Marital Status			
Married	62	62.0	
Widow	34	34.0	
Divorced	4	4.0	
Education			
Illiterate	74	74.0	
Basic education	17	17.0	
Secondary	8	8.0	
University	1	1.0	
History of  vaginitis			
Yes	49	49.0	
No	51	51.0	
Abnormal secretions 			
Yes	51	51.0	
No	49	49.0	
Presence of  bad odor secretions			
Yes	36	36.0	
No	64	64.0	
Complaint of  itching or burning sensation			
Yes	47	47.0	
No	53	53.0	
Dryness & pain during intercourse (no. 62)			
Yes	19	30.6	
No	43	69.4	
Table 1 shows that the mean age of the participating women was 66.2+5.0 years, 81% of them are living in rural area. A total of 62% of women were married by the time of the study and 74% of studied women were illiterate. (49%) of them reported that they had history of vaginitis and none of them seek medical help. Also, they reported that they complained of abnormal discharges, bad odor secretions, itching or burning sensation (51%, 36%, & 47%) respectively. (30.6%) of married women stated that they feel dryness and pain during sexual intercourse.
Table 2: Relationship between total knowledge score of the participating elderly women and some of their Personal characteristics (No. = 100)
Variable	Pre	Post	
	Un satisfactory	Satisfactory	P. value	Un satisfactory	Satisfactory	P. value	
	No.	%	No.	%		No.	%	No.	%		
Total	49	49.0	51	51.0		92	92.0	8	8.0		
Age groups											
60-<65	23	46.9	15	29.4	0.171	35	38.0	3	37.5	0.114	
65-<70	20	40.8	24	47.1		42	45.7	2	25.0		
70-<75	1	2.0	5	9.8		4	4.3	2	25.0		
≥ 75	5	10.2	7	13.7		11	12.0	1	12.5		
Residence											
Urban	12	24.5	7	13.7	0.170	18	19.6	2	25.0	0.712	
Rural	37	75.5	44	86.3		74	80.4	6	75.0		
Marital status											
Married	34	69.4	28	54.9	0.298	53	57.6	4	50.0	0.657	
Widow	13	26.5	21	41.2		34	37.0	4	50.0		
Divorced	2	4.1	2	3.9		5	5.4	0	0.0		
Education											
Illiterate	36	73.5	38	74.5	0.315	68	73.9	7	87.5	0.794	
Basic education	10	20.4	7	13.7		15	16.3	1	12.5		
Secondary	2	4.1	6	11.8		8	8.7	0	0.0		
University	1	2.0	0	0.0		1	1.1	0	0.0		
Table 2 illustrated that there is no statistically differences between total knowledge score of participated women and some of their personal characteristics as age group, level of education, or residence in pre and post the health education program. 
Table 3: distribution of studied elderly women according to their knowledge total score in pre and post program
	Program / Knowledge	Mean	Std. Deviation	P value	
	Pre / Knowledge	9.00	5.16	0.001	
	Post/  Knowledge	16.71	3.91		
Table 3 shows that the total knowledge of participated women improved highly significantly following the interventional program from 9.00±5.16 to 16.71±3.91 grades (p<0.001) 
Table 4: distribution of studied elderly women according to their practice total score in pre and post program.
	Program / Practice	Mean	Std. Deviation	P value	
	Pre / Practice	1.53	0.98	0.001	
	Post/  Practice	2.36	1.20		
Table 4 shows that the total practice score of women recorded a statistically significant rise following the interventional program from only 1.53±0.98 to 2.36±1.20 grades (p<0.05) 

Figure 1: Total knowledge score of the studied women in pre and post implementation of the program
Figure 1 revealed that there was a highly significant statistically differences regarding the total score of knowledge in pre and post health education program implementation (p= 0.001).
4.   DISCUSSION
While atrophic vaginitis is common among postmenopausal women, just 20% to 25% of affected women ask medical intervention from the physician. Women are unprepared to discuss their concerns with their healthcare providers for various causes: embarrassment, cultural taboos, common worry about treatments, and fear about physician reactions to debate of their symptoms. Meanwhile, healthcare providers may too be unprepared to discuss these matters likewise. Even though there are also many causes for clinician reluctance, some of the most common include lack of experience regarding sexual evaluation and treatment strategies, lack of time, and doubtfulness about treatment alternatives  (Reiter, 2013 and Wilson, 2018).
It is also widely thought that knowledge of women about atrophic vaginitis is limited. In addition, unsanitary practices may contribute to development and aggravation of the disease, which refers to the urgent need of interventional educational health programs to raise women awareness and improve their regular practices (Nappi and Kokot-Kierepa, 2012).
The results of the present study revealed that although about half of the studied women had a history of vaginitis, abnormal secretions, and itching or burning, they didn't seek medical assistance; this may be related to embarrassment and the sensitive nature of sexual issues especially among women live in rural area (the majority of studied women were from rural area). However, women may benefit when receive essential information about the likely benefits of achieving or maintaining sexual health in their postmenopausal years. 
These results were in agreement with the results of survey conducted by Nappi & Kokot-Kierepa, 2010; they found that more than two-fifths of the postmenopausal women had experienced atrophic vaginitis. Also, Nappi & Kokot-Kierepa, 2012; in their international survey revealed that almost half of all respondents women reported experiencing vaginal symptoms. The surveys show that the majority of postmenopausal women do not debate their symptoms and there were sever lack information regarding efficient treatment. 
The current study was in the same line with findings of Frank et al.,2013 who study the insight and attitudes of postmenopausal women, their results illustrated that almost half of Canadian women had experienced abnormal vaginal symptoms since they became menopause, and the most common symptom was vaginal dryness, however, most of women who had experienced those symptoms didn't seek  the assistance of a health-care providers, 
As regards to the total knowledge of women in the present study, It was clear that a significant improvement following the health educational program (p=0.01). These findings coincide with many previous programs (Cumming et al., 2007 &Nappi and Kokot-Kierepa, 2009). Both studies focused on improving women knowledge about postmenopausal symptoms, especially AV and also discussed the coping strategies to the disease and its manifestations.
The present study also showed that the total practice score of subjects recorded a statistically significant rise following the interventional program (p<0.05). Our findings consist with that of Cumming et al. (2007) who also noticed a significant improvement in women practice and attitude towards AV.
In general, the implementation of the program proved success in raising women knowledge about postmenopausal symptoms, especially vaginitis. The program also introduced a bird look over the types of vaginitis and a worm look over the risk factors and manifestations of AV. Further, the lecturing program helped women to understand the biological nature of their problems and discussed the coping strategies that can help women adapt to the discomforting symptoms of AV. 
Moreover, the program recorded success in modifying the regular practices of the participants and changing their insanitary behaviors in order to avoid AV or at least relieve its bothering symptoms.
It is also worth pointing out that it is hard to compare the success achieved by our program and that of other similar programs because simply other programs were implemented on different samples of different socio-demographic, educational and cultural backgrounds, and the programs should be designed to suit the targeted samples. Further, other programs used different tools to assess the knowledge and practice of the participants.
5.   CONCLUSION
In conclusion, educational health programs for AV are very beneficial and proved their importance in raising women knowledge and improving their practices. 
6.   RECOMMENDATIONS
Future aspects of research should focus on drawing a considerable picture upon the postmenopausal manifestations, especially in deprived areas and measure women knowledge and attitude regarding these manifestations. Then, educational health programs should be implemented to improve the awareness and attitudes in addition to helping women adopt coping strategies for such problems.
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