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Does menstrual hygiene management and water, sanitation, and hygiene predict reproductive tract infections among reproductive women in urban areas in Ethiopia?

ABSTRACT: Reproductive tract infections (RTIs) are a public health concern in Ethiopia. However, the relationship between menstrual hygiene management (MHM) and water, sanitation, and hygiene (WASH) factors to RTIs have not been well addressed. A community-based cross-sectional study was conducted from January to March 2019 among 602 systematically selected reproductive-age women aged 15-49 years in Dessie City. Data were collected using a questionnaire and a direct observation checklist. RTIs were identified by the presence during one year before data collection of one or more signs of vaginal discharge, itching/irritation or ulcers/lesions around the vulva, pain during urination and sexual intercourse, and lower abdominal pain and lower back pain. Data were analyzed using multivariable logistic regression analysis with 95%CI (confidence interval). The self-reported prevalence of RTIs was 11.0%(95%CI:8.5-13.7%) during one year prior to the survey. The most commonly reported symptoms of RTI were burning micturition (9.1%) and vaginal discharge (6.1%). Three-fourths 443(75.0%) of households used traditional pit latrines and the majority of the study participants 527(89.2%) did not meet the basic access requirement of 20 liters of water per capita per day. The majority 562(95.1%) of the study participants did not have multiple sexual partners during the last year and 97.8% did not practiced sexual intercourse during menstruation. The most common type of blood-absorbent material used was a sanitary pad 497(84.8%) followed by cloth 89(15.2%). Factors significantly associated with RTIs were using unclean latrines (AOR: 4.20; 95%CI:2.00-8.80), not washing hands with soap before touching the genital area (AOR: 3.94; 95%CI:1.49-10.45), history of symptoms of RTIs in the past year (AOR: 5.88; 95%CI:2.30-14.98), having multiple sexual partners in the past year (AOR: 4.46; 95%CI:1.59-12.53), changing absorbent material only once per day (AOR: 8.99; 95%CI:4.51-17.92), and washing the genital area only once per day during menstruation (AOR: 5.76; 95%CI:2.07-16.05). The self-reported prevalence of RTI showed that one women experienced RTI among ten reproductive-age women. Designing a women's health policy that focuses on ensuring availability of WASH facilities and improving MHM at the community level is key for sustainably preventing RTIs.

SUBMITTER: Ademas A

PROVIDER: S-EPMC7444535 | biostudies-literature | 2020

REPOSITORIES: biostudies-literature

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Does menstrual hygiene management and water, sanitation, and hygiene predict reproductive tract infections among reproductive women in urban areas in Ethiopia?

Ademas Ayechew A Adane Metadel M Sisay Tadesse T Kloos Helmut H Eneyew Betelhiem B Keleb Awoke A Lingerew Mistir M Derso Atimen A Alemu Kassahun K

PloS one 20200821 8

Reproductive tract infections (RTIs) are a public health concern in Ethiopia. However, the relationship between menstrual hygiene management (MHM) and water, sanitation, and hygiene (WASH) factors to RTIs have not been well addressed. A community-based cross-sectional study was conducted from January to March 2019 among 602 systematically selected reproductive-age women aged 15-49 years in Dessie City. Data were collected using a questionnaire and a direct observation checklist. RTIs were identi ...[more]

PMID: 32822377

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Project description:BackgroundPoor menstrual hygiene practices influence school girls' dignity, well-being and health, school-absenteeism, academic performance, and school dropout in developing countries. Despite this, menstrual hygienic practices are not well understood and have not received proper attention by school WASH programs. Therefore, this study examined the extent of good menstrual hygiene practices and associated factors among high school girls in Dessie City, Amhara Region, northeastern Ethiopia.MethodsA school-based cross-sectional study was employed to examine 546 randomly selected high school students in Dessie City, northeastern Ethiopia. Pretested interviewer-administered questionnaires and a school observational checklist were used for data collection. EpiData Version 4.6 and the Statistical Package for the Social Sciences Version 25.0 were used for data entry and analysis, respectively. Bivariate and multivariable logistics regression analyses were employed to identify factors associated with good menstrual hygiene practices. During bivariable analysis, variables with P-values less than 0.25 were retained for multivariable analysis. In the multivariable analysis, variables with a P-value less than 0.05 were declared to be significantly associated with good menstrual hygiene practices.ResultsOf the respondents, 53.9% (95% CI [49.6, 58.2]) reported good menstrual hygiene practices. The following factors were found to be significantly associated with good menstrual hygiene practices: age range 16-19 years (AOR = 1.93, 95% CI: [1.22-3.06]); school grade level 10 (AOR = 1.90, 95% CI: [1.18-3.07]); maternal education (primary) (AOR = 3.72, 95% CI: [1.81-7.63]), maternal education (secondary) (AOR = 8.54, 95% CI: [4.18-17.44]), maternal education (college) (AOR = 6.78, 95% CI: [3.28-14.02]) respectively]; having regular menses [AOR = 1.85, 95% CI: (1.03-3.32); good knowledge regarding menstruation (AOR = 2.02, 95% CI: [1.32-3.09]); discussing menstrual hygiene with friends (AOR = 1.79, 95% CI: [1.12-2.86]), and obtaining money for pads from the family (AOR = 2.08, 95% CI: [1.15-3.78]).ConclusionWe found that more than half of high school girls had good menstrual hygiene practices. Factors significantly associated with good menstrual hygiene practices include high school girls age 16-18 years, girls grade level 10, maternal education being completed primary, secondary and college level, having regular menses, good knowledge regarding menstruation, discussing menstrual hygiene with friends and obtaining money for pads from the family. Therefore, educating of high school student mothers about MHP should be a priority intervention area to eliminate the problem of menstrual hygiene among daughters. Furthermore, in order to improve the MHP among high school girls, further attention is needed to improving knowledge regarding menstruation among high school girls, encouraging high school girls' families to support their daughters by buying sanitary pads and promoting discussions among friends about menstrual hygiene. Schools need to focus on making the school environment conducive to managing menstrual hygiene by increasing awareness of safe MHP and providing adequate water/sanitation facilities.

Project description:IntroductionEven though menstruation is a normal biological process, adolescents are facing managing their menstruation when they are at school. It causes girls to miss their class on average three days every month. Studies in some countries showed that the magnitude of menstrual hygiene management problems is higher in rural adolescent girls, but little is known in the Ethiopia context. The objective of this study was to assess and compare menstrual hygiene management practices among rural and urban schoolgirls, Northeast, Ethiopia.MethodsAn institution-based comparative cross-sectional study was employed among 1078 schoolgirls (539 urban and 539 rural) from February to March 2020. The participants were selected using a multi-stage sampling technique. A structured self-administrative questionnaire and observational checklist were used for data collection. Bivariate and multivariable logistic regression analysis with a 95% confidence interval was employed. A P- value less than 0.05 was used to declare statistical significance.ResultsOverall, the magnitude of good menstrual hygiene practice was 52.9% (95%CI: 50.3%-56.5%), which was 65.9% (95% CI: 62.8%-70.7%) among urban and 39.9% (95% CI: 36.2%-44.6%) among rural schoolgirls. Among urban schoolgirls, the odds of good menstrual hygiene management practice was higher for girls aged below 18 years (AOR = 1.58, 95%CI: 1.05-2.39), learned about menstrual hygiene at school (AOR = 1.89, 95%CI: 1.21-2.97), heard about menstrual hygiene before menarche (AOR = 4.98, 95%CI: 2.71-9.13), and discussed menstrual hygiene with parents (AOR = 2.56, 95%CI: 1.25-5.27). Whereas, the odds of good menstrual hygiene management practice was higher among those who were knowledgeable on menstrual hygiene (AOR = 5.47, 95%CI: 3.68-8.12), those who learned about menstrual hygiene at school (AOR = 1.75, 95%CI: 1.13-2.70), and girls who heard about menstrual hygiene before menarche (AOR = 3.34, 95%CI: 1.44-7.76) in rural schoolgirls.ConclusionsThough the overall menstrual hygiene practice was low, it was relatively better among urban schoolgirls. This calls for more effort to solve these problems and achieve sustainable development goals. Therefore, education and awareness creation on menstrual hygiene for schoolgirls, even before menarche at both settings should be strengthened. Encouraging parent-adolescent discussion on menstrual hygiene would have paramount importance, particularly to urban schoolgirls.

Project description:IntroductionAdequate menstrual health and hygiene (MHH) is necessary for women's health and equity of all menstruators. Female sex workers (FSW) require good MHH to prevent discomfort and exposure to pathogens. No studies have evaluated water, sanitation, and hygiene (WASH) conditions of FSW. We report on a cross-sectional WASH assessment at FSW venues in Kisumu, western Kenya.MethodsStakeholders identified 77 FSW venues in Kisumu, of which 47 were randomly sampled and visited between April-May 2023. A standardized structured survey of WASH conditions was deployed by trained research staff using Android tablets after proprietor's consent. WASH scores ranging 0-3 were computed based on point each for direct observation of water available, soap available, and acceptable latrine. MHH scores ranging between 0-4 were computed (one point each) for direct observation of: currently available soap and water, locking door on a usable latrine, functional lighting, and a private area for changing clothes or menstrual materials, separate from the latrine(s). WASH and MHH scores were compared by venue type using non-parametric Kruskal-Wallis tests, and non-parametric Spearman rank tests.ResultsFull WASH criteria was met by 29.8% of venues; 34.0% had no adequate WASH facilities; 46.8% had no female latrine; and 25.5% provided soap and water in private spaces for women. While 76.6% had menstrual waste disposal only 14 (29.8%) had covered bins. One in 10 venues provided adequate MHM facilities. Poorest WASH facilities were in brothels and in bars, and three-quarters of bars with accommodation had no MHH facilities.DiscussionWASH and MHH services were sub-optimal in the majority of FSW venues, preventing menstrual management safely, effectively, with dignity and privacy. This study highlights the unmet need for MHH support for this population. Poor MHH can deleteriously impact FSW health and wellbeing and compound the stigma and shame associated with their work and ability to stay clean. Acceptable and cost-effective solutions to sustainably improve WASH facilities for these populations are needed.Trial registrationClinicaltrial.gov NCT0566678.

Project description:BackgroundThis study was undertaken to discover whether the vaginal microbe of women at childbearing age is different among groups defined by urogenital tract infections, childbearing history and menstrual cycle, respectively.ResultsThis was a multiple case-control study of women at childbearing age who were assigned to case or control groups according to their states of urogenital tract infections. The participants were also grouped by childbearing history and menstrual cycle. Vaginal swabs were collected and stored at - 70 °C until assayed. The V3-V4 region of 16S rRNA gene was amplified using PCR and sequenced on the Illumina MiSeq platform. We tested the hypothesis of whether the relative abundance of microbial species in vaginal microbiota was varied with urogenital tract infections, childbearing history and menstrual cycle. The vaginal microbial richness (Alpha diversity measured by PD_whole tree) was decreased in normal women (without reproductive tract infections) than in those with bacterial vaginosis (BV), and decreased in pregnant women than in other groups of non-pregnancy. Similarly, women from groups of normal and in pregnancy had lower beta diversity on measure of unweighted_unifrac distance in comparison to those of infected and non-pregnant. The top 10 genus relative abundance, especially Lactobacillus, which was the most dominant genus with the relative abundance of 71.55% among all samples, did not differ significantly between groups of childbearing history and menstrual cycle analyzed by ANOVA and nonparametric kruskal_wallis. Lactobacillus iners and Lactobacillus helveticus have the most abundance, totally account for 97.92% relative abundance of genus Lactobacillus. We also found that a higher L.helveticus/L.iners ratio is more likely to present in normal women than in the infected and in pregnant than in non-pregnant, although these comparisons lack statistical significance.ConclusionsThe relative abundance of dominant bacterial taxa in vaginal microbial communities of women at childbearing age were not different among groups of childbearing history and menstrual cycle. Women from groups of in pregnancy and without reproductive tract infections had lower alpha and beta diversity. The composition of the main lactobacillus species may shift upon phases of a menstrual cycle and the status of reproductive tract infections.

Project description:BackgroundUrinary tract infections and reproductive tract infections pose significant health risks, particularly among women living in challenging conditions. Unhygienic menstrual practices can exacerbate these risks, impacting physical and psychological well-being.ObjectivesThis study assessed the association between unhygienic menstrual care and self-reported urinary tract infection/reproductive tract infection symptoms among refugee women. In addition, it explored the association between these symptoms and mental health, specifically depressive symptoms.DesignThis study adopted a cross-sectional observational design.MethodsThis study was conducted between January and March 2023, involving 387 reproductive-age refugee women. Data collected included sociodemographic information and urinary tract infection/reproductive tract infection symptoms. In addition, we used the Menstrual Practice Needs Scale to evaluate menstrual hygiene practices and the Patient Health Questionnaire-9 for depressive symptoms. Statistical analysis was performed using Python version 3.9.12.ResultsOf 387 refugee women, 92.25% reported having urinary or reproductive tract infection symptoms in the previous 3 months. Factors like older age (odds ratio = 1.764, 95% confidence interval = 1.083-2.873, p-value = 0.023), lower family income (odds ratio = 0.327, 95% confidence interval = 0.138-0.775, p-value = 0.011), lower educational level (odds ratio = 0.222, 95% confidence interval = 0.068-0.718, p-value = 0.012), and being married (odds ratio = 0.328, 95% confidence interval = 0.188-0.574, p-value < 0.001) were significantly associated with urinary or reproductive tract infection risk. Difficulties obtaining menstrual products and thus reusing them increased the odds of urinary or reproductive tract infection diagnosis (odds ratio = 2.452, 95% confidence interval = 1.497-4.015, p-value < 0.001). Women with urinary or reproductive tract infection symptoms exhibited higher Patient Health Questionnaire-9 scores than those without (12.14 ± 5.87 vs 9.99 ± 5.86, p-value < 0.001, respectively).ConclusionThis study highlights a high prevalence of urinary or reproductive tract infection symptoms among refugee women residing in camps in Jordan, which was associated with poor menstrual hygiene practices and depressive symptoms. To reduce the urinary tract infection/reproductive tract infection burden in marginalized communities, public health initiatives should enhance healthcare accessibility, provide reproductive education, and promote holistic well-being practices for refugee women.

Project description:PurposeThis study assesses the inclusion of disability in Nepal's policy and guidance relevant to water, sanitation and hygiene (WASH), and menstrual hygiene management (MHM) in comparison to gender. We investigated both policy formulation and implementation, using the Kavrepalanchok district as a case study.Materials and methodsWe used the EquiFrame framework, adapted for disability and gender, and focusing on WASH and MHM. Ten Nepali policies and guidance documents were reviewed and scored for quality against the framework, which included 21 core concepts of human rights. We also interviewed key informants to consider the inclusion of disability in the implementation of MHM interventions. We applied stratified purpose sampling to 12 government officials and service providers working in Kathmandu and the Kavrepalanchock district; conducted in-depth interviews and analysed data thematically using Nvivo 11.ResultsDisability was inadequately covered within the policy documents, and MHM policy commitments for disability were almost non-existent. Participation of people with disabilities in policy development was limited; within Kavrepalanchok, policy commitments were not implemented as intended and disability service providers were unable to allocate government resources. Inadequate data on disability and MHM resulted in limited professional understanding of the issues, as service providers had no training. A narrow WASH infrastructure approach to improving MHM for people with disabilities was prioritised. MHM interventions were delivered in schools; these failed to reach children with disabilities who are often out of school. Finally, there were indications that some caregivers seek sterilisation for people with disabilities who are unable to manage menstruation independently.ConclusionThough the Constitution of Nepal enshrines gender equality and disability inclusion, there are consistent gaps in attention to disability and MHM in policies and practice. These omit and exclude people with disabilities from MHM interventions. Investment is required to generate evidence on the MHM barriers faced by people with disabilities, which would then be drawn on to develop training on these issues for professionals to improve understanding. Subsequently, policy makers could include more concepts of human rights against disability in relevant policies and service providers could implement policy commitments as intended.

Project description:BackgroundThe Geshiyaro project is a 5-year intervention to assess the impact of community- and school-based water, sanitation, and hygiene (WaSH) interventions on reducing infection with soil-transmitted helminths (STH) and schistosome parasites in combination with deworming in Wolayita zone, Ethiopia.MethodsA population-based, cross-sectional census and parasitological mapping activity was conducted between 2018 and 2019. Individuals in the census were identified using either a registered study ID card or biometric fingerprint to enable linkage of their household WaSH data with baseline STH and schistosome prevalence for risk analysis.ResultsPrevalence of STH was 15.5% for any STH species, 9.47% for Ascaris lumbricoides, 1.78% for Trichuris trichiura, and 7.24% for hookworm. Intestinal schistosomiasis (Schistosoma mansoni) infection prevalence was 0.85% by Kato Katz, 21.6% by POC-CCA trace positive (Tr +), and 13.3% trace negative (Tr-). Microhaematuria was 2.77%, with 0.13% of people examined with S. haematobium eggs detected by urine filtration. At the household level, increased (> 30 min) time taken to collect drinking water, sharing a latrine, and lack of handwashing facilities were all associated with a greater risk of A. lumbricoides, hookworm, and S. mansoni infection. Not disposing of infant stool at the household and clothes washing/recreational freshwater contact were significantly associated with higher risk of schistosomiasis infection. Aggregating WaSH data at the community level showed odds of A. lumbricoides, hookworm, and T. trichiura infection were significantly lower as both community sanitation coverage and access to improved drinking water improved.ConclusionsThe principal finding of this study is that lack of access to WaSH, such as improved drinking water and shared toilet and hand-washing facilities, were linked to an increased risk of infection with STH and schistosome parasites. These associations are difficult to establish at an individual household level because of wide variability in access between houses but are detectable when coverage is aggregated at the community level. Maintenance of WaSH facilities as well as increased access within the whole community is important in influencing the community-wide prevalence of infection with STH and schistosome parasites.

Project description:Adequate menstrual hygiene management (MHM) requires access to water and sanitation and can be challenging for many women and girls living in resource-poor settings. Inadequate MHM has been associated with urogenital infections. The aim of this study is to assess the impact of a combined household-level piped water and sanitation intervention on MHM practices and urogenital infection symptoms (UGS) among women living in rural communities of Odisha (India). This study was nested within a pair-matched cohort study designed to assess impact of the Gram Vikas MANTRA program, which provided household-level piped water, bathing areas and latrine to all households in intervention villages, on diarrheal disease (primary outcome). The program did not specifically promote menstrual hygiene practices. Forty-five intervention villages were randomly selected from a list of those where implementation was previously completed at least five years before and matched to 45 control villages. Data for the main study was collected in four rounds from June 2015 to October 2016. For the MHM sub study, household surveys were administered in round four to randomly selected women aged 18 or older among study households from the 90 villages, to assess self-reported MHM practicesand urogenital infections symptoms. MHM practices were deemed adequate if they met some of the criteria developed on the basis of international monitoring that the GV program could modify (adequate frequency of absorbent change, washing the body with soap and privacy for managing menstruation). Multilevel mixed-effects logistic regression with a random effect distribution at the level of the pair and village was used to estimate the effect of the intervention on adequate MHM practices (primary outcome) and reported UGS (secondary outcome). A total of 1045 women (517 from intervention and 528 from control) were included in the study. Women who lived in the villages receiving the intervention, were more likely to report adequate MHM practices than those in control villages (Adjusted OR (AOR) 3.54, 95% Confidence Interval (CI): 1.86-6.78). 14.51% and 15.53% of women living in the control and intervention villages reported having at least one UGS. There was no evidence of an intervention effect on reported UGS (AOR = 0.97, 95%CI: 0.64-1.46). While household latrines or bathing areas with access to piped water improve the environment that enable MHM practices related to privacy, the provision of such facilities alone had only a moderate impact in adequate MHM and did not have an effect on self-reported UGS. More targeted inventions that include behavior change strategies and that address other barriers may be necessary to improve MHM practices.

Project description:BackgroundWomen in rural settings particularly in schools suffer more from stigma and lack of services and facilities during menstruation. However, the issue has not received proper attention from school water sanitation and hygiene programs. And this study was aimed to identify knowledge and practice of menstrual hygiene, and associated factors.MethodInstitution based cross-sectional study was employed among 441 school girls in Mekidela city. EpiData Version 4.6 and the Statistical Package for the Social Sciences Version 25.0 were used for data entry and analysis, respectively. Bivariable and multivariable logistic regression was employed to identify factors associated with the outcome variables. Variables with a p-value<0.25 in the bivariable analysis were a candidate for multivariable logistic regression and p-value<0.05 in the multivariable analysis was used to declare significant association.ResultsOf the respondents, 64.9% reported good knowledge of menstrual hygiene management. In multivariable analysis; grade level (grade 11 & 12) [adjusted odds ratio (AOR) = 2.23, 95% C.I (1.19-4.16)], age ≥ 19 years [AOR = 3.45, 95% C.I (1.78-6.69)], residence [AOR = 1.90, 95% C.I: (1.12-3.23)], know sanitary pads [AOR = 2.67, 95% CI: (1.19-6.00)] and learned about menstrual hygiene [AOR = 1.71, 95% CI: (1.02-2.87)] found to be associated with knowledge. About 62.4% have good menstrual hygiene practices. Knowledge on menstrual hygiene [AOR = 1.73, 95% C.I (1.07-2.80)], know about reproductive tract/sexually transmitted infections [AOR = 2.46, 95% CI: (1.37-4.43)], having private shower [AOR = 2.04, 95% C.I 2.04(1.24-3.37)] and residence [AOR = 3.76, 95% C.I:(2.18-6.51)] were factors associated with practice.ConclusionOverall nearly two-third of respondents had good knowledge and good practice of menstrual hygiene management. Factors significantly associated with their knowledge included age, grade level, residence, learning on menstrual hygiene, and knowledge of sanitary pads. Residence, knowledge on menstrual hygiene, know about sexually transmitted infections and having a private shower were found to be associated with practice of menstrual hygiene management. In general, our finding indicates that menstrual hygiene was unsatisfactory among adolescent school girls and more should be done on the factors identified.

Project description:BackgroundAlthough several studies have been conducted on COVID-19 knowledge, attitude and prevention practices among healthcare workers and the general population, there has not been any study among taxi drivers in Ethiopia, including Dessie City and Kombolcha Town, the lack of which hinders providing evidence-based interventions to this target group. Thus, this study was designed to contribute to proper planning of COVID-19 intervention measures among taxi drivers in Dessie City and Kombolcha Town, Ethiopia.MethodsA cross-sectional study was conducted among 417 taxi drivers in Dessie City and Kombolcha Town during July to August, 2020. The data was collected using a structured questionnaire and an observational checklist. The collected data was checked, coded and entered to EpiData version 4.6 and exported to Statistical Package for the Social Sciences (SPSS) version 25.0 for data cleaning and analysis. The outcome variables of this study were good or poor knowledge, positive or negative attitude and good or poor frequent hand hygiene practices towards COVID-19. Bivariate (Crude Odds Ratio [COR]) and multivariable (Adjusted Odds Ratio [AOR]) logistic regression analysis were employed to identify factors significantly associated with good knowledge, positive attitude and good frequent hand hygiene practices among taxi drivers. Significance level of variables was declared at a p < 0.05 from the adjusted analysis.Main findingsOut of the total 417 taxi drivers, 69.8% [95% CI: 65.2-73.9], 67.6% [95%CI: 63.1-72.2] and 66.4% [95% CI: 62.1-71.0] of the drivers had good knowledge, positive attitude and good frequent hand hygiene practices, respectively. Educational level (AOR = 7.55, 95% CI = 4.55-12.54), place of residence (AOR = 5.41, 95% CI = 1.4-20.08) and attitude towards COVID-19 prevention (AOR = 1.67, 95% CI = 1.02-2.74) were factors associated with good knowledge about COVID-19. Further, age of taxi drivers greater than 30 years (AOR = 3.01, 95% CI = 1.76-5.13), educational level of secondary or above (AOR = 3.16, 95% CI = 1.88-5.31), income (AOR = 3.36, 95% CI = 1.48-7.61), and knowledge about COVID-19 (AOR = 2.1, 95% CI = 1.21-3.54) were factors associated with positive attitude towards COVID-19 prevention. In addition, attitude towards COVID-19 (AOR = 5.5, 95% CI = 3.40-8.88) and educational level (AOR = 1.84, 95% CI = 1.15-2.95) were the factors associated with good frequent hand hygiene practices.ConclusionWe concluded that the rates of good knowledge, positive attitude and good frequent hand hygiene practices were relatively low among taxi drivers in Dessie City and Kombolcha Town. We strongly recommended providing training about COVID-19 prevention measures for taxi drivers that considers age, education status and attitude areas essential to improve their knowledge, attitude and frequent hand hygiene practices to prevent the spread of COVID-19.

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Does menstrual hygiene management and water, sanitation, and hygiene predict reproductive tract infections among reproductive women in urban areas in Ethiopia?

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Does menstrual hygiene management and water, sanitation, and hygiene predict reproductive tract infections among reproductive women in urban areas in Ethiopia?

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