The impact of awareness program on the knowledge and practice of women about pelvic organ prolapse

Background: Pelvic organ prolapse (POP) is one of the most common gynecological health problems among women which affect on maternal morbidity and mortality. Prolapse may seriously influence the physical, psychological and social wellbeing of woman. Recently the health care giver focuses on prevention of prolapse rather than cure. The aim of this study was evaluating and improving the knowledge and practice of women, about POP. Subjects and Methods: A convenient sample of 110 women at reproductive age attending the obstetric clinic of Beni-Suef University hospital. The knowledge of women about POP was first assessed by using interview questionnaire and pretest. The awareness program included 2 sessions. They focused on improving the awareness of the women about the POP. Later, all women were assessed again over their knowledge and practice about the eight aspects using the same posttest. Results: Baseline assessment showed that only (4.5%) women had fair knowledge about POP. Educated women, working women, and those residing urban areas had better knowledge (p<0.05). After the awareness program, the knowledge of the women improved to (96.4%) with good knowledge (p<0.001). Conclusion: The educational program had a positive impact on the knowledge and practice of women about POP. Recommendation: Regulation development of medical services especially at rural areas for early detection and diagnosis of pelvic organ prolapse. Key Words: POP- Awareness- Knowledge- Practice DOI : 10.7176/JHMN/61-11 Publication date : April 30 th 2019


Introduction
Pelvic organ prolapse (POP) is defined as loss or weakness of support to the uterus, bladder and bowel leading to their descent from the anatomical position towards or through the vaginal.The incidence of pelvic organ prolapse that showed by pelvic organ examination without sign and symptoms of women varies between 37% and 50%, while varies between 6-8% by women reported there is a sensation of a mass bulging into the vagina (Mohamed, Hassan, Sayed, Gaheen, 2016).According to study done by (Mahmoud, 2012, the study showed that, in Egypt there are 384 new cases identified had POP every year. The POP is considered a sensitive topic among women, families, and communities and also may seriously influence the physical, psychological and social wellbeing of affected women.Inappropriate maternal health care, poverty, gender discrimination related to health, nutrition, women's life cycle, heavy effort during postpartum period and domestic violence, also, no additional food during pregnancy and postpartum period, heavy work during pregnancy and inadequate postpartum care contribute to POP.Prolonged labor, over baby weight (more than 4kgm), unsafe abortions, sexual intercourse immediately after delivery, tightening of stomach using patuka (a piece of cloth used to wrap around the stomach) after delivery, hypertension and diabetes are supposed to be other causes of pelvic organ prolapse (Bø, Hilde, Staer, Jensen, et al., 2015).
Risk factors for POP includes several major risk factors, such as urinary incontinence before pregnancy, ethnicity, age at birth of first child, body mass index if ≥ 25, family history, Also 18-56%. of women become degree 2 of POP after 6 months' postpartum, Moreover, 15-40% of primiparous women have major defect of the levator ani muscle (Sfeir 2016).Over the last few years, there has been increasing interest in the role of levator ani muscle injuries in the development of pelvic organ prolapse; there was relation between levator ani defects and pelvic organ prolapse; women with levator ani defects are at least twice as likely to show clinically significant pelvic organ prolapse and experience recurrence after pelvic surgery (Raj, Lama., and Maharjan, 2016).Vaginal childbirth is probably the most important factor in the pelvic organ prolapse, at the same time the caesarean section cannot be considered as preventative for developing pelvic organ prolapse (El Kady, Tamara, Sabaa, and Hafez, 2017).
The main symptom of the prolapse is the seeing or feeling of the bulge in the vagina.The presentation of symptoms may be varying among individuals and it also depends on the severity of prolapse.The mild degree of prolapse may be asymptomatic represent with feeling of something bulging from the vagina, feeling of pressure over the perineal area, prolonged urine stream, feeling of incomplete voiding, need to change position to complete voiding, stress urinary incontinence, constipation, feeling incomplete emptying, incontinence of stool or flatus, pelvic pain, dyspareunia and bleeding after intercourse (Thapa, Rana, and Gurung, 2014).
Reduction of straining and intra-abdominal pressure could help prevent the development of prolapse.The widely accepted practice of treatment of bowel dysfunction/chronic constipation has not been tested as systematic intervention to prevent pelvic organ prolapse.Weight loss has also been suggested as a preventive measure; the few published cohort studies with short-term follow-up have shown that weight reduction is associated with subjective improvement in prolapse symptoms but, no objective change was seen in examination using the pelvic organ prolapse (Christina, Ranjita, and Arja, 2012) Conservative interventions include physical interventions to improve the function and support of the pelvic floor muscles (pelvic floor muscle training) and mechanical interventions (insertion of vaginal pessaries) to support the prolapse, they are often offered for lower grades of prolapse and to women unwilling or unfit to undergo surgery (Shylin, 2011).
Although this subject is very important, women in Egypt have limited awareness of the nature of POP, its cause, prevention and treatment techniques El Sayed1, Hassan, Sayed, (2016).On the other hand, the health care team doesn't take care of the importance of improving woman knowledge about POP.The researcher in this study believed that, improving the woman knowledge and practice about POP will decrease the complications that may occur to women, which will decrease morbidity rate and costs that will treat the previous complications.Nurse has an important role in counseling woman about pelvic floor prolapse during reproductive age, as it may be important for woman to prevent POP and its complications.This program can be provided to the woman with little effort and low cost.

Significance
Awareness of women about knowledge and practice for prevention and treatment of pelvic floor prolapse and its effect on their health is one of the factors that can improve maternal co-morbidity rate.So, it is important for maternity nurses to be aware about the impact of poor knowledge about cause of POP and its effect on woman health.Also, findings of this study will help the health care provider to apply health teaching program about POP as a routine care for woman during reproductive age to improve their health and prevent complications occurs from POP.
Little studies have been carried out in Egypt about the knowledge and awareness of pelvic organ prolapse during reproductive age.According to this consideration, this study is being undertaken to provide baseline information about pelvic organ prolapse among women attending the obstetric clinic at Beni-Suef University hospital.

Aim
The aim of the current study is to evaluate and improve the knowledge and practice of women at reproductive age, attending the obstetrics clinic of Beni-Suef University hospital, about pelvic floor prolapse.

Hypothesis
Women who follow awareness program about pelvic organ prolapse will have improvement on their knowledge and practice about POP than before.

Subjects and Methods
An interventional non-controlled research design was used in this study.A convenience sample was utilized, a total of 110 women were recruited to participate in this awareness program according to the following inclusion criteria: delivered before at least once, at age from 20-45 years old, can read and write.The setting of data collection and the sessions of the program have been given at the gynecological outpatient clinic at Beni-Suef University Hospital in Egypt.The researcher collected sample in the period between June to September 2018.

Ethical Considerations
An official permission was taken from the director of the university hospital at Beni-Suef University and the director of obstetric clinic to approve the research study.In addition, informed written consent was obtained from women who agreed to participate in the research study after the aim of the study was clarified for them and ensuring their participation is voluntary and confidentiality of all women was protected through coding of data by the research investigator.Every woman has the right to withdraw from the study at any time without giving reasons and their withdrawal would not affect the care they were receiving at the hospital.

Tool:
1. Structured interviewing questionnaire, it was developed by the researcher after comprehensive reviewing of the available literature related to the studied topic.The tool included questions related to socio-demographic characteristics such as age, residence, education, moreover; and medical and obstetric history, such as number of para, gravida, abortion, complications in the previous pregnancy, Last part of the tool included data related to sign of prolapse, type of daily exercise application.
2. Pre-and post-test, it was developed by the researcher to Assesse women knowledge about pelvic organ prolapse.Test about POP that included eight questions 1.What is POP? 2. Causes.3. Risk factors, 4. Degree of prolapse, 5. Signs and symptoms, 6.Its complications, 7. Prevention methods from POP, and 8. types of treatment.Every question included five open-ended questions.Correct answers were given a score of 1 making the score of each aspect 5 and the total score of the assessment 40.Reliability analysis for the questionnaire as detected by Cronbach's test was 0.71.Women who achieved more than 60% of total score were considered having good knowledge and those with lower scores were considered of poor knowledge.
3. Assessment the Practice used for prevention and treatment of pelvic organ prolapse, it was developed by researcher.This tool done before and after awareness program.This tool assessed women life style that used to prevent POP such as if prevent occurrences and management of constipation, management of prolonged cough, regular antenatal follow up, avoid bearing down during first stage of labor, delivered at hospital, rest and didn't carrying heavy objects for 6 weeks after delivery, take good and well balanced diet, avoid obesity, exercises that strengthen pelvic muscles such as walking, Kegel's exercise as daily habit.scoring system for this tool was as follow: -Practices done were taken (2) score.-Practices not done or did not know were taken (1) score.The total score level was as follows: -Satisfactory practices > 60%.-Unsatisfactory practices < 60%.
4. Kegel's exercise check list; it was developed by the researcher.This tool contains instructions and steps of Kegel's exercise.This tool was used to check if women can apply Kegel's exercise correctly after finished awareness program.If women done steps right take 2, women don't apply steps correctly taken 1, total score was good application > 60% and poor application < 60% Procedure: The researcher introduced herself to the women and explained the purpose of the study in order to obtain their written acceptance to be recruited in this study as well as to gain their cooperation.Data was collected through a period of three months from the beginning of June to the end of September 2018.Throughout the whole three months, the researcher attended at the obstetric clinic twice a week to recruit cases.
The study done through 3 phases; 1. interview questionnaire: The researcher collected data from women by met the women recruited for the study at gynecological outpatient clinic at the Beni-Suef University hospital.all women were interviewed individually to collect data related to socio-demographic status, present obstetrical history, as well as history of previous pregnancies and deliveries utilizing the structured interviewing tool.Interview was done by face to face with woman individually in Arabic.answers were written down in her interview questionnaire.The interview took around 15 minutes to be completed for each interview.

2-Knowledge and practice Assessment
This assessment consists of 2 parts; The 1 st part was formed specially to assist the women knowledge about pelvic organ prolapse, then the 2 nd part of assessment of was to assist the women knowledge about the different types of practices which are important and needed for each woman as daily habit to prevent the occurrence of POP.The two parts assessed by using the pretest.

3-Implementation phase:
This awareness program consists of 3 sessions; the 1 st session was related to the knowledge part of awareness program; this session took 40 minutes.The 2 nd session was related to the practical part; this session took 15 minutes.Arabic-language brochures, supported by illustrated figures and graphs, have been distributed as takehome notes.The awareness program started immediately after finishing the interview and it was carried out through two educational sessions, each session, took about 20 minutes and there was a 10-minute break between the two sessions; in the first educational session, the researcher discussed; meaning of POP, causes, risk factors, signs and symptoms, the complications, and types of treatment with women.After finishing the 1 st session, all women took break for 10 minutes, then started the 2 nd session which contained the prevention and treatment methods for POP.In this part the researcher taught the women the practices which should be done to prevent or treat POP according to practice tool (weight and constipation control, instruction and care during and after pregnancy, walking and Kegel's exercise).Then the researcher teach women how apply Kegel's exercise and instruct women about life style to control weight and constipation.
The 3 rd session was done to evaluate the women about acquired knowledge and practice from awareness program, after finishing all content of program the researcher evaluated all women by using the same questionnaire (posttest) and assessed the practice accuracy of application Kegel's exercise by using Kegel's exercise chick list.

Table (1) Socio-Demographic characteristics of the study sample
Regarding to table (1), a total of 110 women were recruited for the study.Their age ranged from 19-42 years with mean (28.7±6.2). (71.8%) were residing in rural areas, and 48.2% reported over weight.Educational level: 21.8% of the study sample were able to read and write, while 47.3 of the study sample had secondary education and highly educated mothers were 7.3 %, and regarding occupation, 70.9% of mothers in the study sample were housewives, and 70.9% of them worked 8-10 hrs.daily.(Table 1).According to the result reveled in table (2) 48.2% of women in study sample had parity 2-3, and 74.5 of them had normal vaginal delivery.Also Related to previous pregnancy complications, 69.1% of women had vaginal infection, while 13.6% of study sample had vaginal tear from their previous deliveries.The results indicated that 76.4% of women had vaginal prolapse, in addition 85.7 of them were 1 st degree of POP.(Table 2)  3) most of women (95.5%) had poor knowledge about all questions of prolapse, while (4.5%) % of women in the study had total fair knowledge about prolapse and no one had good knowledge.Table (3) Assessment knowledge of women about pelvic organ prolapse: 1), Shows the knowledge of the women about practices needed to prevent POP.93.3% of women didn't know the practice needed to prevent or treat POP, and 3.1 had appropriate care during and after pregnancy, while 1.2 % of women applied Kegel's exercise and 2.4% of women applied exercise to control their weight which can cause prolapse.There was a statistically significant difference between good knowledge about prolapse scores and level of women's education, working status, work hours, BMI and residence (p= 0.05), while No statistically significant difference was found in relation to age (p= 439) (

Discussion
This study aimed to assess and improve the knowledge and practices of women at reproductive age, attending the obstetrics clinic of Beni-Suef University hospital, about pelvic floor prolapse.This study showed that the levels of awareness about POP among women in Beni-Suef were markedly poor, only 4.5% of the assessed women had fair knowledge.This results agreed with a study done by El Sayed, Ahmed, and Gaheen, ( 2016

Figure ( 1 ),
Figure (1), Assessment the knowledge of women regarding to practices needed for prevent POP.Figure2: shows the distribution of the women according to their practices that taken as preventive or treatment for POP before and after awareness program.It was found that most of the studied women had unsatisfactory practices before program 93.3 % while after program 96.2 of women had satisfactory practice for prevention or treatment of POP.

Figure 2 :
Figure (1), Assessment the knowledge of women regarding to practices needed for prevent POP.Figure2: shows the distribution of the women according to their practices that taken as preventive or treatment for POP before and after awareness program.It was found that most of the studied women had unsatisfactory practices before program 93.3 % while after program 96.2 of women had satisfactory practice for prevention or treatment of POP.

Figure ( 2 )
Figure (2), Assessment knowledge of women about practice needed to prevent POP before and after awareness educational program (no 110) .

Figure 3 :
Figure3: Show the distribution of the women according to their accuracy application of Kegel's exercise before and after awareness program as preventive or treatment for POP.It was found that most of the women 98.8% had poor application for Kegel's exercise program, while after program 97.2 of women had good application after awareness program.

Figure ( 3 )
Figure (3), Assessment of women about accuracy application of Kegel's exercise before and after awareness program.

Table ( 2
) Obstetric Characteristics of the Study sample n=110:

Table 4
Association between socio-demographic characteristics and knowledge of about POP.

Table 5 :
Improvement of the women's Knowledge about Prolapse after attending the educational program. *p

value is considered significant.
), and Shrestha et al., (2014) who reported that more than half of the studied women