Quality of life among women with symptoms of gynecological morbidities: results of a cross-sectional study in Karachi, Pakistan.

AIMS: A population-based cross-sectional study design was used to study the effects of symptoms of various gynecological morbidities (GM) on health-related quality of life (HRQoL) of women, residents of squatter settlements of Karachi, Pakistan. MATERIAL AND METHODS: This cross-sectional study was conducted in squatter settlements of Karachi from September 2012 to August 2013, with 1002 married, non-pregnant women. After obtaining written informed consent from every participant, a structured questionnaire was used to collect information about symptoms of GM and their effect on four domains of HRQoL (physical, social, functional and financial domains). RESULTS: Of 1002 women who participated in the study, 578 reported suffering from one or more symptoms of GM. The most commonly reported symptoms were foul-smelling vaginal discharge, dysmenorrhea and uterovaginal prolapse while the least reported symptom was post-coital bleeding. Symptoms of GM were found to have a negative impact on HRQoL. Approximately one-third of women with the symptoms of GM reported having negative influences on the physical, financial and functional domains of HRQoL with social domain being comparatively less affected. Compared to other symptoms, dysmenorrhea and uterovaginal prolapse were reported to be mostly associated with poor HRQoL of women. CONCLUSION: The concept of HRQoL has been kept marginal and inconspicuous by clinicians. In order to achieve the psychosocial satisfaction of the patient, the focus needs to be diverted to all domains of HRQoL.

The burden of bacterial vaginosis: women's experience of the physical, emotional, sexual and social impact of living with recurrent bacterial vaginosis.

BACKGROUND: Bacterial vaginosis is a common vaginal infection, causing an abnormal vaginal discharge and/or odour in up to 50% of sufferers. Recurrence is common following recommended treatment. There are limited data on women's experience of bacterial vaginosis, and the impact on their self-esteem, sexual relationships and quality of life. The aim of this study was to explore the experiences and impact of recurrent bacterial vaginosis on women. METHODS: A social constructionist approach was chosen as the framework for the study. Thirty five women with male and/or female partners participated in semi-structured interviews face-to-face or by telephone about their experience of recurrent bacterial vaginosis. RESULTS: Recurrent bacterial vaginosis impacted on women to varying degrees, with some women reporting it had little impact on their lives but most reporting it had a moderate to severe impact. The degree to which it impacted on women physically, emotionally, sexually and socially often depended on the frequency of episodes and severity of symptoms. Women commonly reported that symptoms of bacterial vaginosis made them feel embarrassed, ashamed, 'dirty' and very concerned others may detect their malodour and abnormal discharge. The biggest impact of recurrent bacterial vaginosis was on women's self-esteem and sex lives, with women regularly avoiding sexual activity, in particular oral sex, as they were too embarrassed and self-conscious of their symptoms to engage in these activities. Women often felt confused about why they were experiencing recurrent bacterial vaginosis and frustrated at their lack of control over recurrence. CONCLUSION: Women's experience of recurrent bacterial vaginosis varied broadly and significantly in this study. Some women reported little impact on their lives but most reported a moderate to severe impact, mainly on their self-esteem and sex life. Further support and acknowledgement of these impacts are required when managing women with recurrent bacterial vaginosis.

Fabricated illness: working within the family system to find a pathway to health.

The term medically unexplained symptoms refers to a clinical presentation where the child's symptoms and impairment cannot be explained by any known organic pathology, and may include conversion disorders, somatoform pain disorders, factitious disorder, and factitious disorder by proxy. In this case study, we present our treatment of a 9-year-old girl with a 2-year history of medically unexplained abdominal cramping and vaginal discharge. During the 9 months that we worked with this family, we were never able to clarify in our own minds the source of the child's symptoms--that is, who was responsible for their induction or who was the instigator or maintainer of the exaggerated symptoms. Nor did we come to fully understand the function of the symptoms in the family system. Our case report does not answer either of these questions. Instead, we describe how we worked with the family despite the ongoing ambiguities as to why the symptoms were occurring and who was inducing them. The functional outcome was disappearance of symptoms, return to full school attendance, and improved parenting behavior.

The relaxation exercise and social support trial-resst: study protocol for a randomized community based trial.

BACKGROUND: Studies suggests a possible link between vaginal discharge and common mental distress, as well as highlight the implications of the subjective burden of disease and its link with mental health. METHODS/DESIGN: This is a community-based intervention trial that aims to evaluate the impact of a psycho-social intervention on medically unexplained vaginal discharge (MUVD) in a group of married, low-income Lebanese women, aged 18-49, and suffering from low to moderate levels of anxiety and/or depression. The intervention consisted of 12 sessions of structured social support, problem solving techniques, group discussions and trainer-supervised relaxation exercises (twice per week over six weeks). Women were recruited from Hey el Selloum, a southern disadvantaged suburb of Beirut, Lebanon, during an open recruitment campaign. The primary outcome was self-reported MUVD, upon ruling out reproductive tract infections (RTIs), through lab analysis. Anxiety and/or depression symptoms were the secondary outcomes for this trial. These were assessed using an Arabic validated version of the Hopkins Symptoms Checklist-25 (HSCL-25). Assessments were done at baseline and six months using face-to face interviews, pelvic examinations and laboratory tests. Women were randomized into either intervention or control group. Intent to treat analysis will be used. DISCUSSION: The results will indicate whether the proposed psychosocial intervention was effective in reducing MUVD (possibly mediated by common mental distress). TRIAL REGISTRATION: The trial is registered at the Wellcome Trust Registry, ISRCTN assigned: ISRCTN: ISRCTN98441241.

Process evaluation of a psychosocial intervention addressing women in a disadvantaged setting.

OBJECTIVES: This paper presents the process evaluation of a community-based randomized psycho-social trial aimed to enhance reproductive and mental health outcomes of disadvantaged women living in the southern suburb of Beirut-Lebanon. Process evaluation of public health interventions involves the monitoring and documentation of interventions' implementation to allow for better understanding of planned outcomes and of intervention effectiveness. METHODS: A community-based randomized trial was conducted. The intervention consisted of 12 sessions (of combined 30 minutes of relaxation exercises and 75 minutes of structured support groups) delivered twice per week over a period of six-weeks. A process evaluation was conducted during the implementation of the intervention. This process evaluation aimed to ensure that the intervention was delivered and implemented as planned, as well as to monitor women's satisfaction and attendance. The main components of the process evaluation included: dose delivered, dose received, and reach. Closed ended questionnaires were administered before/after/during each intervention session. Data was entered and analyzed using SPSS. Analysis revolved around simple frequency distribution for categorical variables and means (SD) for continuous variables. Limited bivariate analysis (using CHI Square and Anova) was done. RESULTS: RESULTS indicated that the delivery, implementation, and reach of the intervention were favorable. Participation was acceptable and satisfaction rates were very high. CONCLUSION: These favorable findings pertaining to intervention satisfaction, reach and participation highlight a number of lessons for future intervention studies in the context of disadvantaged settings. They also support the importance of involving the local community members in intervention planning, implementation and evaluation early on. We believe that the community involvement in this trial directly and significantly contributed to the results of this process evaluation.

Treatment seeking, vaginal discharge and psychosocial distress among women in urban Mumbai.

Vaginal discharge (safed pani in Hindi, meaning "white water") is one of the leading symptoms for which women in India seek care. Treatment-seeking for safed pani is disproportionately high among poor women, representing a physical, emotional and financial burden for low-income families. Safed pani is only rarely indicative of a reproductive tract or sexually transmitted infection. The discrepancy between symptom reports and observed pathology has led some researchers to characterize safed pani as a culturally based expression of more generalized negative life situation. Data are drawn from two prevention intervention studies (2002-2006 and 2007-2012) conducted in economically marginal communities in Mumbai. Results show that husbands as problem generators and spousal abusers and women's greater perceived empowerment and reported tension are significantly associated with safed pani. These results provide the basis for identifying women at greater risk for psychosocial distress and providing supports at the locations at which they seek treatment.

The psychological and social contexts of complaints of abnormal vaginal discharge: a study of illness narratives in India.

OBJECTIVE: Epidemiological studies have reported strong associations between psychosocial adversity and complaints of abnormal vaginal discharge (AVD) in South Asia. We aimed to explore the mechanism of these associations through qualitative research. METHOD: We carried out serial in-depth interviews with 42 married women with the complaint of AVD who were purposively selected from a sample of 2494 women recruited into a population-based cohort study in Goa, India. The interviews elicited illness narratives of their complaint, focusing on causal attributions and help-seeking behaviors. RESULTS: Women explicitly link their personal experiences of social adversity and stress (such as marital problems and heavy workloads) with their complaints of AVD. The complaint of tiredness, a core feature of depressive and somatoform disorders, and complaint of "tension" were commonly associated with AVD through bidirectional causal interpretations. Reproductive events, particularly related to the menstrual cycle and contraception, comprise another set of causal attributions. Many women hold multiple causal attributions. Most women sought health care, both biomedical and traditional, and their narratives indicate reinforcement of their causal attributions by health care providers. However, treatments were often discontinued or changed due to lack of symptomatic relief, side effects, or costs. CONCLUSIONS: Reproductive health policy and practice must explicitly acknowledge and integrate research findings on psychosocial associations of AVD to promote a holistic and evidence-based approach for this common complaint in women in South Asia.

Durbolota (weakness), chinta rog (worry illness), and poverty: explanations of white discharge among married adolescent women in an urban slum in Dhaka, Bangladesh.

I carried out ethnographic fieldwork among 153 married adolescent girls, aged 15-19, in a Dhaka slum from December 2001 to January 2003, including 50 in-depth interviews and eight case studies. I also held discussions with family and community members. In this article, I focus on popular understandings of vaginal discharge being caused by durbolota (weakness) and chinta rog (worry illness), as mentioned by young women. Eighty-eight young women reported that they had experienced white discharge, blaming it on a number of factors such as stress and financial hardships, tensions in the household, marital instability, hunger anxiety, and reproductive burdens. For married adolescent women in the urban slum, white discharge has many levels of meaning linked to the broader social, political, and material inequalities in their everyday lives.

Common genital complaints in women: the contribution of psychosocial and infectious factors in a population-based cohort study in Goa, India.

BACKGROUND: The genital complaint of abnormal vaginal discharge is common in South Asia. We describe the risk factors for the incidence of the complaint in women of reproductive age. Method Population-based cohort study in Goa, India. Out of 3000 randomly selected women, 2494 women participated. The outcome was an incident case of the complaint of abnormal vaginal discharge at 6 months (T1) and 12 months (T2) review. RESULTS: In total 71 (3.6%, 95% CI 2.8-4.5%) of the 2000 eligible women reviewed at T1 reported the complaint; and 80 (4.0%, CI 3.2-5.0%) of the 1999 women who did not complain of abnormal vaginal discharge at T1 reported it at T2. Multivariate logistic regression analysis identified the following factors as associated with the complaint: younger age (OR 0.26, CI 0.1-0.5 for women aged 40-49 years compared with women aged 18-24 years); illiteracy (OR 1.48, CI 0.9-2.4); religion (Muslim women OR 3.15, CI 1.7-6.0 compared with Hindu women); women's concerns regarding their spouse's extramarital relationships (OR 3.46, CI 1.2-10.0); current BV infection (OR 1.87, CI 1.2-2.9); somatoform complaints (OR 3.30, CI 1.7-6.5 for the highest somatoform score quartile compared with the lowest); and depression and anxiety (OR 1.55, CI 0.9-2.6 for the highest mental health score quartile compared with the lowest). CONCLUSIONS: Reproductive and sexual health programmes must strengthen the capacity of practitioners to assess and treat bacterial vaginosis and psychosocial problems in women with complaints of abnormal vaginal discharge.

Why do women complain of vaginal discharge? A population survey of infectious and pyschosocial risk factors in a South Asian community.

BACKGROUND: Vaginal discharge is a common complaint, particularly among women in Asia. Although presumed to be caused by reproductive tract infections (RTIs), the association between the complaint and the presence of RTIs is weak. This study aimed to investigate the risk factors of the complaint of vaginal discharge. METHODS: We conducted a community-based survey of 3000 women aged 18-50 years, randomly sampled from a population in Goa, India. Women who gave informed consent were invited to participate in a structured interview, which elicited data on the primary outcome (the experience of current abnormal vaginal discharge) and psychosocial exposures: gender adversity; symptoms of somatoform disorders; and common mental disorders (CMD). All women were required to provide vaginal and/or urine samples for diagnosis of RTIs using gold standard laboratory tests. Risk factors were analysed using logistic regression with the binary outcome of the complaint of vaginal discharge. RESULTS: Of the 2494 women (83%) who agreed to participate, 14.5% complained of having an abnormal vaginal discharge. Stress was the most common causal attribution for the complaint. The final multivariate model found that high scores for CMD (OR 2.16, 1.4-3.2) and somatoform disorders (6.23, 4.0-9.7) and the use of an intrauterine contraceptive device (1.86, 1.0-3.4) were independently associated with the complaint. Low literacy (0.54, 0.4-0.8) and age >40 years (0.29, 0.2-0.4) were associated with a reduced risk. RTI were not associated with the complaint (1.24, 0.9-1.6). CONCLUSIONS: Psychosocial factors have the strongest association with the complaint of vaginal discharge. Syndromic management algorithms need refinement so that women with complaints that are non-infectious in aetiology are offered psychosocial interventions.