Ethnic differences in women’s knowledge level and other barriers to care seeking and the true incidence and/or prevalence rate of female pelvic floor disorders

Abstract

I read with interest the article by Shah et al. about measurement of patient knowledge level of the pathogenesis, diagnosis, and available treatment options for pelvic floor disorders, using a validated Prolapse and Incontinence Knowledge Questionnaire, in a multi-ethnic cohort of women attending the gynecology clinic and its impact on health care-seeking behavior [1]. The results showed that greater patient awareness and education and in turn more frequent reporting of symptoms, diagnostic evaluation, and receipt of care could partly explain the higher incidence and/or prevalence of pelvic floor disorders observed in white women in most previous reports. The knowledge barrier found in non-white women of their study was similarly responsible for low care seeking in urinary incontinent women from the Middle East [2]. Likewise, incontinence status minimally affected individual knowledge level since pelvic floor disorders were perceived by Middle Eastern women, both continent and incontinent equally, as a neurological or senile disorder rather than an obstetric/gynecologic condition related to childbirth or menopause [3].The influence of this ethnic variation in women's background knowledge of pelvic floor disorders and subsequent care seeking is, however, frequently overlooked in incidence and/or prevalence studies of multi-ethnic and/ or multi-national patient populations. This highlights the inherent "selection" bias in estimates based on hospital data [4]. Furthermore, care seeking for female pelvic floor disorders is not only dependent on patient "internal" knowledge level but also on other "external" ethnicitybased factors [5]. These include convenience of consultation, provider gender preference, access to health care facilities, expectations from health care, language proficiency, incurred service cost, and perceptions of medical encounter [3,5]. Heit et al. recently described a 14-item modified Melnyck's barrier scale as an objective and psychometrically validated measurement tool of external barriers to care seeking in an ethnically heterogeneous group of incontinent women [5].As Shah et al. noted, the ethnology of pelvic floor disorders is poorly studied in the urogynecologic literature partly because determination of ethnicity is ambiguous, is not dichotomous, has no scientific definition, is not synonymous with race or nationality, and might be a cultural identification rather than a genetic indicator of some biological difference. However, the ethnic disparity in the incidence and/or prevalence of pelvic floor disorders cannot be entirely explained by variation in care-seeking behavior related to women's knowledge, attitude, or socioeconomic status [1,4,5]. The ethnic effect is likely multifactorial caused by differences in reproductive, demographic, cultural, and biologic variables such as parity, body mass index, lifestyle, diet, smoking, athletic exercise, position at delivery, micturition or defecation, life expectancy, collagen metabolism, and functional topography of the female pelvic floor and b...

Towards a more scientific approach to measuring barriers to seeking health care in women with fecal incontinence: the BCABL questionnaire

“…Most importantly, there is currently no validated technique for reproducible measurement of these barriers. Furthermore, barriers to seeking incontinence care, whether urinary or fecal, are influenced by confounding anthropological and societal variables including ethnicity, culture, geopolitical orientation, indigenous psychology, personality and the individual's understanding of health, experience of health and illness, and health services utilization [5,6]. Hence, most of the available qualitative research data on care seeking, that is primarily based on thematic or deductive analysis of patient narratives, is not able to demonstrate the full impact of each care barrier with a significant overlap between barriers [4].…”

“…The 16 final barrier items of the BCABL questionnaire include almost all known barriers to seeking care for FI and clearly outline the action plan agenda for improving patient access to care. This information can thus be used to support health policy initiatives and fiscal programs to expand incontinence care delivery in primary care, decrease incontinence service costs and develop patient-centered knowledge translation toolkits [2,4,6].…”

Minimizing the risk of childbirth-induced pelvic floor dysfunctions in the developing word: “preventive” urogynecology

“…The need may be higher than the actuarial reported prevalence of these dysfunctions, since the majority of women in the developing world do not seek health care [11]. Scientific reports and social monographs also consistently point to the persistence of the inverse health care law amongst women from these countries because of inequities in health care access, utilization and delivery-the availability of good-quality health care, including urogynecologic care, is inversely related to the women who need it.…”

“…Preventive urogynecologists of the developing world should assume the primary responsibility in explaining the risk of pelvic floor dysfunctions associated with pregnancy and vaginal delivery, thus improving the health literacy of their underprivileged pregnant population [11,12]. Information aids include print materials, videos and audioguided workbooks that can be used during counseling and preferably at the first antenatal visit [13].…”

“…Women can contribute by understanding the mechanisms of pregnancy-and childbirth-induced injuries, self-managing their reproductive and birthing choices, complying with prophylactic measures before and after delivery and selecting appropriate treatment options for ante-and post-partum pelvic floor dysfunctions. Preventive urogynecologists from developing countries should, therefore, recognize and support par coeur the tête-à-tête physician-patient partnership model founded on skillful communication, knowledge transfer, information sharing, coaching and question prompts for patients and interactive dialogue [11]. Finally, government strategies and community outreach programs that promote women's education, emancipation, reproductive rights and engagement in childbirth-induced pelvic floor dysfunctions should be a fundamental plank of the preventive urogynecologic agenda in the developing world.…”