Assessing Internet Health Information on Female Pelvic Floor Disorders

Investigation of the quality and health literacy demand of online information on pelvic floor exercises to reduce stress urinary incontinence

BACKGROUND

Many women are embarrassed to discuss pelvic floor exercises with health professionals during pregnancy; instead they search the internet for information on pelvic floor exercises.

AIMS

This project investigated the quality and health literacy demand in terms of readability, understandability and actionability of information available on the internet relating to pelvic floor exercises.

MATERIALS AND METHODS

An analysis was conducted on 150 websites and 43 videos obtained from three consecutive Google searches relating to pelvic floor exercises. Websites were assessed for Health on the Net certification. Readability was assessed using a readability calculator, and understandability/actionability of website and video information was assessed using the Patient Education Materials Assessment Tool (PEMAT) for Print or Audiovisual Materials.

RESULTS

Less than one-third (24%) of the websites were certified for quality. The median readability score for the websites was grade 9 and the websites and videos both rated highly for understandability and actionability. The median understandability score for the website information was 87%, and the median actionability score was 71%. The median understandability score of the video information was 95.5% and the median actionability score was 100%. The understandability and actionability of video information was also significantly greater than that for website information (P < 0.01).

CONCLUSION

Clinicians could consider directing patients to video-based resources when advising online pelvic floor exercise resources for women during pregnancy, especially those with lower health literacy.

Barriers and enablers of pelvic floor rehabilitation behaviours in pregnant women with stress urinary incontinence: a qualitative analysis using the theoretical domains framework

BACKGROUND

Stress urinary incontinence during pregnancy is closely related to the occurrence of postpartum and long-term urinary incontinence. Early pelvic floor management is of great significance in promoting the recovery of pelvic floor tissues in pregnant women. However, effective management of urinary incontinence is far from achievable owing to the low adherence of pregnant women in partaking in pelvic floor rehabilitation. As a comprehensive framework for behavioural theory, the Theoretical Domain Framework allows for comprehensive identification of behavioural determinants. Using Theoretical Domain Framework, this study aimed to identify barriers and enablers of pelvic floor rehabilitation behaviours in pregnant women with stress urinary incontinence.

METHODS

A descriptive, qualitative design was used in this study. Face-to-face semi-structured interviews were conducted with pregnant women with stress urinary incontinence based on the Theoretical Domain Framework. The data were analysed using a combination of inductive and deductive methods.

RESULTS

Twenty pregnant women with stress urinary incontinence were interviewed. Seven themes were summarised and used to explain the pelvic floor rehabilitation behaviours of pregnant women with stress urinary incontinence. The seven themes were (1) individual knowledge and experience of pelvic floor management, (2) judgments about expected outcomes, (3) interactions of interpersonal situations, (4) environment, resources, and decision-making processes, (5) personal goal-setting and efforts towards behaviour change, (6) emotional influences on decision-making, and (7) personal characteristics. Besides the "Optimism" domain, 13 of the 14 Theoretical Domains Framework domains were found to influence pregnant patients' pelvic floor rehabilitation behaviours after deductive mapping of themes to the Theoretical Domains Framework. In addition, the inductive analysis generated a theme of personal characteristics that did not map to any of the Theoretical Domains Framework domains.

CONCLUSIONS

The pelvic floor rehabilitation behaviours of pregnant women with stress urinary incontinence are complex and are affected by many factors. The findings confirm the need for multiple interventions to support pelvic floor management in pregnant women with stress urinary incontinence, focusing on enhancing knowledge and skills in pelvic floor care and using appropriate behaviour change techniques (such as prompts) to provide a supportive environment.

Patient-Focused Websites Related to Postpartum Pelvic Floor Health: A DISCERN Quality Analysis

OBJECTIVE

The aim of the study was to evaluate the quality of patient-focused websites addressing postpartum pelvic floor health.

METHODS

The Google search engine was used to perform a search of the following 3 terms: (1) "postpartum pelvic floor (PPF)," (2) "postpartum leaking urine (PLU)," and (3) "postpartum leaking stool (PLS)." The top 20 results from each search term were evaluated using the DISCERN quality appraisal tool and Journal of the American Medical Association (JAMA) benchmark criteria by 2 independent researchers. Websites were also categorized by type. Cohen κ was performed to determine interrater reliability between reviewers. The Kruskal-Wallis test was used to evaluate the differences in DISCERN and JAMA criteria scores.

RESULTS

The weighted mean κ between the investigators for each search term was κ = 0.47 (range = 0.163 [PPF] to 0.759 [PLU]), suggesting moderate agreement between reviewers. There was a significant difference in mean DISCERN scores between the terms, with "postpartum leaking urine" yielding the highest mean score. When comparing DISCERN scores by category, society- and government-sponsored websites (mean = 55 ± 13) scored significantly higher than other categories. Using JAMA criteria, mean scores ranged between 1.83 and 2.83/4, but there were no significant differences between websites.

CONCLUSIONS

The overall quality of health information available on the internet regarding postpartum pelvic health is low. Higher-quality search results are found within society- and government-sponsored websites as well as under the search term "postpartum leaking urine." It is important for health care providers to guide their patients to websites with reliable information about postpartum pelvic floor recovery.

What Are Patients Reading? Quality Assessment of Endometriosis Information on the Internet

OBJECTIVE

Evaluate the quality of information reported online about endometriosis and period pain.

METHODS

An online search identified the top 20 websites for 4 search engines (Google, Ask, Bing, Yahoo). Videos, duplicates, and websites not containing information related to endometriosis and period pain were excluded. Three independent authors screened websites and systematically extracted data on website characteristics and on diagnosis and treatment mentions. Website accuracy and completeness were rated for a score out of 15. The Flesch readability ease score (FRES) was used to assess readability.

RESULTS

Of 34 websites included, most were news related (44.1%) and health care affiliated (26.5%). Websites with affiliations had significantly higher accuracy scores than those without. Those with references had significantly higher completeness than those without. Non-news-related websites had significantly higher accuracy and completeness than news-related websites. The most commonly reported symptoms were dysmenorrhea (97.1% of websites), infertility (88.2%), and dyspareunia (82.4%). Cancer was mentioned on 41.1% of websites. Diagnostic laparoscopy (91.0%) and ultrasound (88.3%) were the most commonly mentioned diagnostic tools. Commonly reported therapeutics included the oral contraceptive pill (79.4%), laparoscopy (70.6%), non-steroidal anti-inflammatory drugs (NSAIDs; 67.6%), and gonadotropin-releasing hormone (GnRH) agonists (64.7%). Hysterectomy (59.0%) was mentioned more than progestins (53.0%). Overall, 18 of 34 websites (53%) contained 1 or more inaccurate or misleading statements.

CONCLUSION

While most websites contained accurate statements, commonly reported misconceptions included an emphasized risk of cancer, lack of use/benefit of ultrasound for diagnosis, and a bias for surgical over medical management, where laparoscopy was mentioned more than first-line medications. This study highlights the importance of directing patients to evidence-based resources.

Out of "Site": Low Utilization of the American Urogynecologic Society's Online Patient Resources in an Observational Study Using Website Analytics

METHODS

Website metrics were extracted from Google Analytics during 2013-2019 for VoicesForPFD.org. Data included number and geography of users, source of user arrival (for example search engine, social media, advertisement), and web pages viewed. Utilization was calculated by dividing the number of website users by the estimated number of women with symptomatic PFDs in the same year from previously published prevalence estimates and U.S. Census population data. The number of page views were extracted for each web page from 2017 to 2019 to describe content use. Descriptive analyses are presented.

RESULTS

VoicesForPFD.org had 1,382,287 users during 2013-2019, predominantly in the United States. Nationally, there were 5.3 VoicesForPFD.org users for every 1,000 women with symptomatic PFDs in 2018. Users arrived primarily through organic search and advertisements; less than 1% of users arrived via social media. The pelvic organ prolapse section of VoicesForPFD.org was the most highly viewed content with 670,550 page views in 2017-2019. In the same years, the site's pages on pelvic mesh had only 21,249 page views despite high media visibility on the subject.

CONCLUSIONS

Utilization of VoicesForPFD.org by U.S. women with symptomatic PFDs is very low. More research is needed on methods to engage women online and through social media to provide them with high-quality PFD treatment information.

Readability and quality of Wikipedia articles on pelvic floor disorders

INTRODUCTION AND HYPOTHESIS

This study is aimed at evaluating the readability and quality of Wikipedia articles on pelvic floor disorders (PFD) and comparing their content with International Urogynecological Association patient education leaflets.

METHODS

Readability was assessed using six different readability scales, including the Simple Measure of Gobbledygook (SMOG) Index, which is considered superior for scoring healthcare information. Quality was assessed by three female pelvic medicine and reconstructive surgery fellows using the modified DISCERN instrument. DISCERN is validated to evaluate the quality of written consumer health information; it was subsequently modified by health education researchers to enable the evaluation of Wikipedia articles.

RESULTS

We evaluated 30 Wikipedia articles that correlated with 29 International Urogynecological Association leaflets. The mean SMOG score of the Wikipedia articles was 12.0 ± 2.1 (12th-grade reading level) whereas the mean SMOG score of the International Urological Association (IUGA) leaflets was 3.4 ± 0.3 (third-grade reading level, p < 0.001). The mean modified DISCERN score of the Wikipedia articles was 34.43 ± 5.90 (moderate quality); however, the mean modified DISCERN score of the IUGA literature was 45.02 ± 1.36 (good quality, p < 0.001).

CONCLUSIONS

Wikipedia articles on PFD are neither readable nor reliable: they require a 12th-grade-level education for comprehension and are merely rated moderate in quality. In comparison, IUGA leaflets require a third-grade education for comprehension and are rated good in quality. Urogynecological providers should provide appropriate health education materials to patients, as Wikipedia is both a popular and sometimes inaccurate resource for patients.

Evaluation of Awareness, Adherence, and Barriers of Pelvic Floor Muscle Training in Pregnant Women: A Cross-sectional Study

INTRODUCTION

Adherence to pelvic floor muscle training (PFMT) may be enhanced when the women become aware of its preventive/therapeutic role in pelvic floor disorders.

OBJECTIVE

This study is conducted to evaluate the PFMT awareness, adherence, and barriers in pregnant women.

METHOD

We studied the awareness, adherence, and barriers of PFMT in 200 pregnant women attended in prenatal care clinic in their third trimester of pregnancy using semistructured interviews with open and closed questions derived from recent literature review on PFMT.

RESULT

Fifty-four (27%) of studied women were familiar with PFMT, 175 (87.5%) of patients thought that the UI is normal during pregnancy, and 25 (32.05%) had experienced UI episodes and had consulted with their obstetrician. Twenty-one (10.5%) of patients did the PFMT exercises before their pregnancy, 14 (66.6%) of them continued their PFMT exercises during their pregnancy, and 7 (33.4%) stopped it. Concerns about miscarriage were the main reason of discontinuing the exercises during pregnancy. Routes of knowledge acquisition were the Internet in 24 cases (44.4%), health system in 13 cases (24.07%), family and friends in 11 cases (20.3%), and books/magazines in 6 cases (11.1%). Main means of mass communication (including TV, radio, and newspapers) had no role in knowledge distribution in this filed.

CONCLUSIONS

Pregnant women require more health education regarding PFMT. Health care professionals should be more involved in patient education process. Internet resources are used widely by women and need more academic/scientific supervision.

#Urogyn: What's Trending on Instagram? A Cross-sectional Observational Study

OBJECTIVE

The aim of the study was to identify the prevalence, authorship, and type of information pertaining to topics in urogynecology on Instagram via hashtag and content analysis.

METHODS

A list of 20 hashtags consisting of common urogynecologic diagnoses, procedures, and lay terms was derived from the American Urogynecologic Society's "Patient Fact Sheets." The top 9 and most recent 30 posts for each hashtag were reviewed for authorship and content type. Content type was divided into the following categories: educational; tagged but unrelated posts; pertinent patient experiences; community building and outreach; advertisements; and humor. Searches were limited to English language posts.

RESULTS

Our search yielded 561,133 posts. The 5 most popular hashtags were pelvic floor (30.6%, n = 171,855), interstitial cystitis (12.8%, n = 71,977), pelvic pain (10.0%, n = 56,505), incontinence (9.3%, n = 52,169), and prolapse (3.9%, n = 21,839). The authorship of the top 9 and most recent 30 posts (n = 537) were as follows: patients (34.6%, n = 186), allied health professionals (29.2%, n = 157), physicians (13.4%, n = 72), and other (22.7%, n = 122). Further authorship and content analysis revealed that allied health professionals authored the most informational posts (45.6%, n = 129) and patients authored the most unrelated (69.4%, n = 43), patient experience (81.7%, n = 125), community building (55.8%, n = 53), and humorous posts (38.5%, n = 10).

CONCLUSIONS

More than 500,000 posts related to urogynecology were identified on Instagram. Most posts were authored by patients and allied health professionals with a small contribution from physicians. Greater physician participation may increase the quantity of educational posts and offer a low-cost platform for networking and connecting with patients and other providers.

All Levels of Providers Can Effectively and Efficiently Teach Pelvic Floor Strength Assessment at Time of Pelvic Examination

OBJECTIVE

In women who undergo provider-guided vaginal biofeedback of pelvic floor muscle strength, we sought to determine whether the level of the provider correlates with the patient's ability to achieve adequate pelvic floor muscle contractions (PFMCs).

METHODS

From August 2017 to April 2018, patients from 2 urogynecology clinics were recruited to participate in an institutional review board-approved, prospective study examining PFMCs. Pelvic examination and teaching session were done by providers who had specific training on how to assess pelvic floor muscle strength using the validated, modified Oxford scale. Patients were asked to perform a baseline PFMC during a 2-digit pelvic examination. Thereafter, patients were counseled to relax their muscles, identify the levator ani muscles during provider teaching, and perform 3 consecutive provider-guided PFMCs. The strength of each PFMC was measured, and the time-to-teach (TTT) was recorded. The level of provider and TTT were correlated with PFMC1 to PFMC3 using Spearman correlation coefficient.

RESULTS

One hundred women participated. Obstetrics/gynecology (OB/GYN) residents (post-graduate years 1-4) evaluated 20 patients; female pelvic medicine and reconstructive surgery fellowship trainees (post-graduate years 5-7), 38 patients; OB/GYN nurse practitioners, 18 patients; generalist OB/GYN faculty, 9 patients; and female pelvic medicine and reconstructive surgery faculty, 15 patients. There was no correlation between level of provider and TTT or between level of provider and strength of PFMC1, PFMC2, or PFMC3.

CONCLUSIONS

At the time of pelvic floor muscle assessment, the level of provider does not impact teaching time or PFMC1 to PFMC3. Teaching pelvic floor muscle exercise is a cost-effective, low-resource tool to improve patient care, and providers of any level should be encouraged to teach pelvic floor muscle exercise to patients at the time of office examination.

Trends in internet search activity, media coverage, and patient-centered health information after the FDA safety communications on surgical mesh for pelvic organ prolapse

INTRODUCTION

In July 2011, the US Food and Drug Administration (FDA) issued a safety communication regarding serious complications associated with surgical mesh for pelvic organ prolapse, prompting increased media and public attention. This study sought to analyze internet search activity and news article volume after this FDA warning and to evaluate the quality of websites providing patient-centered information.

METHODS

Google Trends™ was utilized to evaluate search engine trends for the term "pelvic organ prolapse" and associated terms between 1 January 2004 and 31 December 2014. Google News™ was utilized to quantify the number of news articles annually under the term "pelvic organ prolapse." The search results for the term "pelvic organ prolapse" were assessed for quality using the Health On the Net Foundation (HON) certification.

RESULTS

There was a significant increase in search activity from 37.42 in 2010 to 57.75 in 2011, at the time of the FDA communication (p = 0.021). No other annual interval had a statistically significant increase in search activity. The single highest monthly search activity, given the value of 100, was August 2011, immediately following the July 2011 notification, with the next highest value being 98 in July 2011. Linear regression analysis of news articles per year since the FDA communication revealed r² = 0.88, with a coefficient of 186. Quality assessment demonstrated that 42 % of websites were HON-certified, with .gov sites providing the highest quality information.

CONCLUSIONS

Although the 2011 FDA safety communication on surgical mesh was associated with increased public and media attention, the quality of relevant health information on the internet remains of poor quality. Future quality assurance measures may be critical in enabling patients to play active roles in their own healthcare.

Female urinary incontinence health information quality on the Internet: a multilingual evaluation

INTRODUCTION AND HYPOTHESIS

The quality of Internet information on female urinary incontinence is considered variable. No comprehensive analysis exists to support this. We compared the quality of current Internet information for common layperson terminology on female urinary incontinence across four Western languages and a comparative analysis of website sponsors.

METHODS

World Health Organization Health on the Net (HON) principles may be applied to websites using an automated toolbar function. We used the Google search engine; 10,200 websites were identified using keywords related to female urinary incontinence and treatments in English, French, German and Spanish. The first 150 websites in each language had HON principles examined, whilst a further analysis of site sponsorship was undertaken.

RESULTS

The total number of websites for each term is variable. "Female sling surgery" had the most websites with approximately 18 million, whereas "colposuspension" had the least with only 159,890 websites. Regardless of language, very few female urinary incontinence websites were HON accredited (p < 0.0001). Linguistically, French (18%) and English (16%) had the greatest percentage of HON-accredited sites. Tertiles (thirds) of the first 150 websites returned the higher percentage of HON-accredited websites (p < 0.0001). Websites were largely sponsored by physicians/surgeons.

CONCLUSIONS

The lack of validation of most female urinary incontinence websites should be appreciated by clinicians. Additionally, discrepancies exist in the quality and number of websites across conditions, languages and also between medical and alternative terms. Clinicians should participate in and encourage the development of informative, ethical and reliable health websites on the Internet and direct patients to them.

Social networks lack useful content for incontinence

OBJECTIVE

To assess the incontinence resources readily available for patients among social networks. Social networks allow users to connect with each other and share content and are a widely popular resource on the Internet. These sites attract millions of users; however, social media are underused in the healthcare industry.

METHODS

A search for "incontinence" was performed on Facebook, Twitter, and YouTube in September 2010. The first 30 results were reviewed for each. The results were evaluated as useful or not useful and additionally catalogued as healthcare professionals, commercial products, or complementary and alternative medicine resources.

RESULTS

On Facebook, 4 results (13%) were informative, 12 (40%) advertised commercial incontinence products, and 14 (47%) had no usable information. Of the live "tweets" reviewed on Twitter, 18 (60%) linked to incontinence-related healthcare information (none were from, or referred one to, healthcare professionals), 9 (30%) advertised for commercial incontinence products, 1 (3%) advertised complementary and alternative medicine resources, and 2 (7%) were humorous. Of 4 Twitter user results, 1 was comic, 1 provided incontinence-related health information, and 2 were incontinence medical supply companies. There were 14 (47%) informational YouTube videos, of which 9 came from healthcare professionals or professional organizations. Of the remainder, 12 (40%) were commercial, 1 (3%) advertised complementary and alternative medicine resources, and the remaining 3 (10%) were not useful.

CONCLUSION

The results of our study show that social networks have insufficient useful incontinence content, especially from healthcare professionals and incontinence organizations. Medical professionals and societies should target these avenues to reach and educate patients.