The Urban Health Study (UHS) undertaken in 2002-2003 provided the baseline survey data for the proposed intervention in Hey el Sellom. The UHS sample consisted of 3,100 households from three communities (Nabaa, Burj el Barajneh and Hay el Selloum) located in Beirut's poor and rapidly changing suburbs. All ever-married women (n = 1899) found in these selected households were subsequently interviewed to provide data on the social context of health, among which reproductive health.
The UHS findings indicated that abnormal vaginal discharge was a common complaint in Hey el Selloum. 38% of ever-married women aged 15-59 years in Hey el Sellom [1
] complained of vaginal discharge, of whom 71% reported being 'bothered' by the complaint. Of those reporting vaginal discharge, 64% already consulted a health provider or planned to do so, of whom only a few actually reported having reproductive tract infections.
It has been estimated that more than half of the women in the Arab world suffer from symptoms associated with reproductive health problems; and the most commonly reported symptom is vaginal discharge [2
]. Increasing evidence, on the other hand, indicates the poor association between reported symptoms of reproductive health problems and medically diagnosed diseases [5
]. Vaginal discharge, being the most common reported gynaecological symptom of RTIs, has recently received more attention [1
]. Patel V. et al
., (2005), in a population-based survey conducted in Goa, India, showed the lack of association between complaints of vaginal discharge and the presence of medically diagnosed reproductive tract infections (RTIs). In another community-based study, conducted in three villages of Giza in Egypt, a similar finding was also observed. 77% of interviewed women in the study reported abnormal vaginal discharge, among whom 52% actually suffered from the presence of one or more RTIs [5
]. In addition to the UHS, a study in Lebanon [6
] conducted in Nebi Shite- Lebanese community, which shares similar socio-demographic characteristics to Hey el Sellom, showed similar observations. 24.5% of the women in the Nebi Shite survey reported vaginal discharge, while only 9.3% of these women actually suffered from RTIs.
From a woman's perspective, the subjective burden of self-perceived illness and abnormality can be as important as a result of disease due to a biomedical confirmed condition. For example, in Muslim communities, vaginal discharge is considered troublesome because it affects the woman's prayer requirements to be "clean" [7
]. Self-perceived illness and abnormality also affect health-seeking behaviour, leading often to unnecessary spending on health care and ineffective management [8
]. In fact, the syndromic management of vaginal discharge can lead to inappropriate treatment of a large proportion of women, as well as unnecessary spending on treatment of non-existing RTIs [8
An alternative explanation to MUVD has been recently suggested. Several observational studies confirmed the contribution of anxiety and depression to medically unexplained gynaecological symptoms, such as pelvic pain and abnormal vaginal discharge [5
]. Taking the already discussed UHS, the sub-sample analysis pertaining to Hey el Selloum sample, showed that a large proportion of women (42%) reported mental distress- as assessed by GHQ-12. Moreover, multivariate analysis showed that mental distress was significantly associated with reported abnormal vaginal discharge, after adjusting for relevant risk factors and reported RTIs [23
]. Women considered stress to be a main cause of their discharge [24
] and identified mental as well as psychological health as important elements contributing to their perception of good reproductive health [4
]. The UHS also showed that both mental distress and reported gynaecological health problems were negatively associated with social support [25
Along the same line, population-based studies from South Asia show significant associations between complaints of vaginal discharge and psychosocial stress, in addition to psychosomatic symptoms such as dizziness, backache, and weakness [12
]. Qualitative studies in India indicated that women typically associate complaints of discharge with mental stress and related symptoms such as tiredness [12
]. On the other hand, social support is consistently associated with common mental disorders (CMD) and physical conditions [27
]. Improvements in social support were shown to lead to lower consultation rates [27
] and reduced sickness absences [29
These findings have important implications for alternative intervention strategies. Our proposed psychosocial intervention carried out in this trial (consisting of relaxing exercise and social support) aims to reduce MUVD as a result of reducing CMDs. There are only a few randomized controlled trials (RCTs) for the treatment of CMDs in the developing world [30
]. Most of these studies have used traditional psychological models such as Cognitive Behavioural Therapy and/or Interpersonal Therapy to alleviate CMDs [34
]. However, some studies in the West have shown the effectiveness of simpler alternative approaches such as problem solving [36
] and group support strategies [30
]. Similarly, different RCTs have demonstrated that progressive muscle relaxation and/or guided imagery can alleviate depressive symptoms by enhancing self efficacy and decreasing persistent unexplained physical symptoms [43
We conducted a community-based randomized trial, comparing the experimental group (who were administered the psychosocial intervention) with the control group (who served as a treat later group). The research question is the following: Does a community based psycho-social intervention (combined structured social support groups and progressive relaxing exercises) alter complaints from medically unexplained vaginal discharge among low-income married women, aged 18-49 and residing in Hey el Sellom?