Association Levels Between Results from a Therapeutic Educational Program on Women Suffering from Genito-pelvic Pain Penetration Disorder and Their Socioeconomic Status

The World Health Organization (WHO) establishes that sexual health is fundamental for the overall well-being of a person. It sets a biopsychosocial model that enables the access to information about sexuality and the availability to receive a sexual health service and to create a surrounding that promotes sexual health (World Health Organization, 2022). WHO relates the social and economic context of a person to its sexual health, and the potential influence that these factors might have in the development of sexual disorders (Castellanos-Torres et al., 2013).

Genito-pelvic pain penetration disorder (GPPPD), also known as dyspareunia or vulvodynia (with incidence rates of 6.6% in Spain) (Gómez et al., 2019), is one of the most common sexual disorders. It consists of a heterogenous group of disorders that affect the person’s capacity to experiment sexual pleasure or to respond sexually, producing a painful response instead (Thomas & Thurston, 2016). Dyspareunia and vulvodynia are often intermixed terms, with vulvodynia not necessarily involving the presence of pain during sexual intercourse. Also, dyspareunia can be classified in either primary or secondary, and based on its location in superficial or deep (Tayyeb & Gupta, 2021). Scientific literature classifies GPPPD in several ways, and its development is associated with a type of altered pain response, known as nociplastic pain. This type of pain develops in the absence of harmful stimuli and can associate primary or secondary hyperalgesia and allodynia (Siqueira-Campos et al., 2022). Many therapeutical options have been proposed to approach GPPPD from physiotherapy, such as electrotherapy, myofascial release, and exercise (Fuentes-Márquez et al., 2019; Klotz et al., 2018), and education has been outlined as a cost-effective resource that can potentially be very beneficial for these patients (Brünahl et al., 2018; Champaneria et al., 2012). Out of the available resources than can assess the social and economic factors that might influence the development and processing of GPPPD, one of the most robust determinants of mental and physical health and well-being is the socioeconomic status (SES) questionnaire. It is a self-administered questionnaire that assesses diverse measurements to establish social class or economic levels. Out of the many measurements that can be assessed, the American Psychological Association (APA) suggests education, income, and occupation as the most recommended measurements (American Psychological Association, 2022).

Due to the possible influence that social and economic factors could have over patients suffering from GPPPD treated with an educational approach, it is necessary to establish the levels of association between these outcomes. Therefore, the objective of this study is to assess if there is a correlation between the results obtained from a therapeutic educational program in patients suffering from GPPPD, and their socioeconomic status, assessed with their age, educational level, household monthly income, and job rank.

Participant flow chart is shown in Fig. 1. Out of the initially recruited participants, inclusion and exclusion criteria were passed through, and a total of 69 participants were finally included. Participants were then randomized to an intervention or a control group. Once the intervention ended, 4 participants were lost to follow-up, all of them due to voluntarily refuse to take post-intervention assessments.

 Participant’s baseline characteristics and socioeconomic status level frequencies are summarized in Table 1. Participant’s mean age was similar in every group. Regarding educational level, all participants had at least a level 4, and most of them (n = 33, 48%) had a level 5. With respect to monthly household income, the vast majority, n = 60 (87%), of participants were grouped in the middle-levels of income. Finally, involving job rank, participants were more frequently allocated to jobs that required no degree at all (n = 27, 39%) or that required a college degree (n = 19, 28%).

Results from the ANOVA are summarized in Table 2. Significant improvements (p < 0.05) were found both in the face-to-face group and the online group regarding pain intensity, assessed with the VAS, and in pain catastrophizing in the online group, assessed with the PCS. Non-significant improvements were also found in pain catastrophizing in the face-to-face group, pain attitudes for both groups, assessed with the SOPA-B, and sexual functioning, assessed with the FSFI.

Results from the correlation analysis with every outcome assessed with the SES are presented in Tables 3, 4, 5 and 6. Regarding age, there is no significant (p < 0.05) interaction between the results obtained and the age of the participants, meaning that participants improved in every outcome independently from their age. Educational level, household monthly income, and job rank showed no interaction too, meaning these outcomes had no relevant influence in the improvement participants experimented.

This study assessed the correlation levels of the results of a therapeutic educational program in patients suffering from GPPPD and their socioeconomic status. Analyzing the association between these outcomes, no significant correlation levels were observed, meaning that the improvement these patients experimented regarding pain-related and sexual functioning outcomes was independent from their age, educational level, household monthly income, or job rank.

People with a lower socioeconomic status have poorer health outcomes in many diseases, especially diseases with pain-processing dysfunctions such as fibromyalgia (Fitzcharles et al., 2014) or musculoskeletal pain (Macfarlane et al., 2009; Bergman et al., 2001), due to financial issues, access to health interventions, or low adherence rates to medical recommendations. Our study had a relatively young sample (32.8 years) composed of women suffering GPPD. Other studies (Fitzcharles et al., 2014) that did find significant correlation levels did so with older samples or samples composed by women and men, suggesting both age and gender could be relevant.

Every outcome assessed in this study is subjective and depends on the patient’s perception of their pain and sexual functioning, so results may not truly reflect the health status of participants. Also, only significant improvements were found in both groups for pain intensity, assessed with VAS, and only in one of the groups for pain catastrophizing, assessed with PCS, the rest of the improvements were non-significant. Possibly, with better results, there could be a significant influence of socioeconomic factors. Adherence rates to the programs could also be relevant. Participants in the online group could access the program anywhere and at any time during the week; therefore, this could have enabled higher adherence rates in this group, explaining the better results.

Authors also chose to use both Pearson’s correlation index and Spearman’s rho statistic to do the correlation analysis. Other studies used between-group comparisons with a t-test (Armour et al., 2020), multiple hierarchical regression analyses (Fliesser et al., 2018), or Poisson regression analysis (Landry & Bergeron, 2009). Since there is no gold standard statistical assessment, in this case, authors decided to replicate statistical analyses performed in similar studies to establish correlation levels, using Pearson’s correlation index to correlate continuous variables (results and age) (Landry & Bergeron, 2009) and Spearman’s statistic to establish correlation between continuous (results) and categorical (educational level, household income and job rank) variables (Armour et al., 2020).

Our study has limitations. First, out of the multiple options that could be chosen to assess SES, we only chose three major measurements. Household income and job rank are factors that do not influence health outcomes equally during the whole life of a patient, so these must be understood within the sample we are analyzing, which is relatively young. However, the level of education has been validated as a reliable, accurate, and consistent measurement of SES (Liberatos et al., 1988; Shavers et al., 2007), chosen as the best predictor of good health (Wnkleby et al., 1992; Braveman et al., 2005), and it is to be understood as a factor that does not generally change overtime.

Also, for every measurement, we established levels according to specific guidelines that adhere to the author’s country, and these levels might change according to the educational program, economy, and job classification of different countries. Despite this, authors tried to choose classification systems with many categories in every measurement, assuring as many social gradients applied to the social spectrum as possible (Braveman et al., 2005).

Results from this research suggest that a therapeutic educational program improves pain intensity, pain-related outcomes, and sexual functioning in patients with persistent pelvic pain, independently from their age, educational level, household monthly income, or job rank.