The current work is a unique study focusing on the HPV-related psychosocial burden of male and female patients with GW using the HPV-specific HIP questionnaire. Our results showed that patients with GW had a substantially higher psychosocial burden. Most importantly, by using the HIP questionnaire, this study is the first to identify the origins of psychosocial burden of GW patients for both genders. We found that female patients with GW had heavier worries and concerns than male patients, but men had heavier psychosocial burden regarding domains of self-image and interaction with doctors. The origins of the psychosocial burden were mostly from “Self Image” and “Sexual Impact” domains, which highlighted the key domains that doctors should focus on. Results from this study will be informative for prevention of GW and control efforts in China and other similar settings.
Predominant domain of psychosocial burden for patients with GW
It has been evidenced that patients with GW lost quality of life and had significantly heavy psychosocial burden by various measures such as EQ-5D, group interview, and the Short-Form (SF)-12 [8, 12–14]. However, this study was the first to provide quantitative assessment for different psychosocial domains of Chinese GW patients of both genders by HIP questionnaire. Our results would help investigate the sources of the burden and provide accompanying suggestions to relieve it. Based on our data, the sexually related domains impacted patients the most. Specifically, the “Sexual Impact” domain represented the frequency and satisfaction of sexual life, and “Self Image” domain represented feelings of attractiveness or lack thereof, shame, and disgust. These two domains showed the most significant psychosocial burden, which suggested that self-identification and sexual function were the most significant issues that patients considered. The other sexually related domain “Partner and Transmission” also showed moderate psychosocial burdens, which represented partner acceptance and concern of transmission to/from partners. Our results were supported by the UK study, which indicated that women with GW suffered most in the three domains of sexual impact (63.2), self-image (62.7), and partner issues and transmission (58.7) . These three significantly represented domains partly reflect the ingrained conception in a culturally conservative China that STIs, such as genital warts implies promiscuity. The highly-visible and recurrent nature of genital warts may directly and negatively impact libido and sexual function, possibly leading to significant psychosocial burden of negative self-image and consternation for both patient and partner.
Comparison among different countries and areas
Generally, we found that the psychosocial burden of Chinese patients with GW was heavy, with the HIP mean score of 50.49, 49.20 and 51.38 for GW patients in total, male patients, and female patients, respectively. Compared with other settings that also used HIP questionnaire for the evaluation of psychosocial burden, Chinese patients showed comparable HIP score with that of British patients (50.9), but higher scores than those of Australians (45.7) and lower scores than those of Taiwanese patients (62.5) [6, 7, 15]. Different social development and cultures may lead to this variety. Even within the mainland of China, we found differences between regions. Women in Nanjing (59.8) suffered a higher psychosocial burden both than that of the average national (52.2) and urban levels (53.2) . Specifically, we found that patients in Nanjing suffered heavier psychosocial burdens than those of Beijing within the following four domains: “Emotional Impact”, “Sexual Impact”, “Partner and Transmission”, and “Interactions with Doctors”. According to our data, most patients in Nanjing were from rural areas of the North Jiangsu and Anhui Province, and they had lower levels of educational and less knowledge about HPV-related diseases. This may partly contribute to the psychosocial burden.
Different psychosocial impact of GW between genders
Generally, women experienced a heavier psychosocial burden than men, which was also identified in a previous UK study using EQ-5D questionnaires . This study specified domains resulting to the difference. Women had a significantly heavier psychosocial burden than men within the “Worries and Concern” domain, but a lower psychosocial burden within domains of “Sexual Impact” and “Interactions with Doctors”.
Heavier worries and concern among women may stem from the following aspects. Firstly, Traditional Chinese culture requires women to be elegant, virtuous, and obey their husbands, Women are subordinate in most Chinese families, the dependence on their husband leads to be more introverted, sentimental and emotionally sensitive. Secondly, feelings of disgrace, discomfort, and shame from the GW may have women suspect extramarital affairs, and finally lead to emotive crises between couples. Another possible reason is fear of future fertility and risk of cervical cancer. However, men had more psychosocial pressure than women in domains of “Sexual Impact” and “Interactions with Doctors”. For the sexual component, a possible reason is that the dominant role in sexual activity leads men to care more about their sexual function and the ability to satisfy their partner. For “Interactions with Doctors” domain, men may be less communicative and unwilling to express their pain to doctors. Moreover, most of the doctors were women in this study, which may also lead to a more negative response from men by gender embarrassment.
Suggestions for alleviation of psychosocial burdens
We suggest developing the following methods to help healthcare providers alleviate these psychosocial burdens in addition to the current basic biological medical treatments in China.
First, the administration of hospitals and physicians should work together to help change the current biomedical therapy model to a bio-psycho-social model. An investigation in Wuhan showed that only 22.4% of general hospitals offered mental health services, among which 76.5% were in the top-level hospitals . A formal system for “Medical-psychological counseling” should be established in comprehensive hospitals, including establishing special psychological counseling departments and providing essential financial support for consultation. In addition, appropriate training for the identification of psychosocial disease should be developed for Chinese medical students and physicians, as this is currently lacking.
Secondly, we know that as a developing country, there is a huge gap between basic medical therapy and the demand of patients in China. To help alleviate the psychosocial burden, we suggest the development of innovative approaches to help with consultation. There are tiered levels of medical workers in China, including the provincial, municipal, county, and village levels. Although these medical workers receive different levels of formal medical training, even the lesser-trained workers usually function as physicians within their local communities, gaining trust and respect from their patients. We suggest physicians and other medical workers work together to provide educational lectures and counseling services during the primary stages of the aforementioned consultation system establishment. In addition, we suggest that doctors not only focus their discussion with patients on the recurrent nature and hard-to-cure status when consulted for GW, but also provide patients effective preventable measures and lead them to local medical workers for helpful consultation . The provider-patient relationship is a delicate one, and a compassionate, intelligent approach to treatment and prevention is imperative. STIs are sensitive subjects to discuss due to harsh stigmatization, and it would behoove health care providers to treat these situations as such. As for educational measures, local medical workers might also put up posters in the community and hold discussion sessions to increase awareness of disease etiology and preventive measures.
Firstly, selection biases could occur in this study due to the hospital-based, convenient sampling method we used; we also failed to assess the differences in characteristics between the study participants and those who declined to participate due to lacking of information of non-participants. Secondly, the cross-sectional data is limited for the time-dependent trend of psychosocial burdens of genital warts. Additional follow-up assessments should focus on multiple longitudinal time points after diagnoses, to help identify domains with sustainable impact and prioritize contents for consultation. Thirdly, the sample size was not large enough to acquire a high level of reliability, yet our data still provides novel information regarding specific HPV-related negative impacts of GW.