Aging, pregnancy, and childbirth are commonly seen as causes for pelvic floor disorders (PFDs).1,2 Pelvic floor disorders include urinary incontinence, fecal incontinence, and pelvic organ prolapse. However, several other factors including being overweight (body mass index [BMI], 25–29), obese (BMI, 30–39), and extremely obese (BMI, ≥40) have major impacts on pelvic floor function.3 Obesity is an alarmingly growing epidemic worldwide. In 2011, 66.5% of women of all races in the United States had a BMI greater or equal to 25; of these, 36.5% were obese and 8.3% were extremely obese.4
Body mass index has been shown to have a direct increasing adverse effect upon the pelvic floor and therefore is associated with a high prevalence of PFDs.5 This is due to the significant correlation between BMI and increasing intra-abdominal pressure resulting in increased stress on the pelvic floor.6 The incidence of women with 1 or more PFDs who are obese exceeds 30%.7 This high prevalence is concerning given the fact that only a fourth to a third of women actively seek medical help for PFDs.8 Studies have shown that weight loss can improve incontinence in obese women.9
Treatments for PFDs are commonly self-initiated, and therefore, educational methods that will influence women to make changes need to be studied and implemented. Several studies have shown that electronic videos are an effective way of educating patients about complex disorders.10,11 The use of electronic videos to educate patients has been shown to be a useful tool in increasing patient knowledge.12 As previously studied, the main goal of health education is to change behavior because improved knowledge is the most appropriate outcome measure for the evaluation of education-based health promotion.13
The purpose of this pilot study was to assess the effect of supplemental electronic video education on patient's self-assessed perception of knowledge about the relation between PFDs and obesity in a prospective randomized controlled trial.
MATERIALS AND METHODS
This was a randomized controlled trial that was approved by the Avera institutional review board. Subjects were recruited from the Avera Medical Group Urogynecology clinic in Sioux Falls, SD over a 4-week period from June to July 2015. The academic urogynecology clinic consists of one urogynecologist and support staff. All women seeking medical treatment for PFDs were offered enrollment based on eligibility. Inclusion criteria included women with a BMI of 25 kg/m2 or higher, proficiency in English language and literacy. No other exclusion criteria were used. As a pilot study, there were no data available to determine the sample size of the present study. A power calculation was not done. Because of the limited 4-week time frame, a convenience sample was used.
Subjects were recruited by a single physician. The physician explained the research study in detail and obtained their written consent. After consent, subjects were randomized into either (1) group A, a standard visit and an 8-minute video, or (2) group B, a standard visit only. Randomization was performed with computer-generated number blocks of 4 prepared by an investigator with no clinical involvement in the trial. The allocation sequence was concealed from the physician enrolling and assessing participants, in sequentially numbered, opaque, and sealed envelopes. Corresponding envelopes were opened only after enrolled participants completed the standard visit and it was time to allocate the intervention.
A standard visit was performed by the physician and included PFD evaluation with a history and physical examination as well as a comprehensive counseling session. This was a standardized, unscripted session that included identifying the patient's modifiable risk factors and discussing conservative management. Standardized diagrams were used to illustrate PFDs. Every woman included in this study was counseled about obesity and conservative management using diet and exercise. Once the standard visit was concluded, the subjects were taken to a private room by the nurse and were instructed to open the sealed envelope, which included a cover letter and 3 questionnaires. The cover letter instructed patients to either watch the video and then fill out the questionnaires (group A) or to fill out the questionnaires (group B). The nurse ensured that all study patients received the educational video as assigned on randomization. The video was in the room, ready to play on a laptop used specifically for this study.
An 8-minute video entitled “Understanding Pelvic Floor Disorders” was created using Microsoft PowerPoint and the software Articulate. The video outline is shown in Table 1. Abnormal pelvic floor conditions such as incontinence and prolapse are described with figures and in terms of common symptoms. Conservative nonsurgical treatment options such as diet, fluid intake modification, smoking cessation, weight control, pessary use, and medications are discussed in detail. Surgical options are mentioned. Women are encouraged to implement conservative therapies before seeking surgical treatment. An emphasis is placed on weight control through diet changes and exercise.
The primary outcome with respect to the study was to measure a difference in self-assessed perception of knowledge questionnaire scores between the 2 study groups. A secondary outcome was to measure a difference in self-assessed motivation to lose weight between the two study groups. Three sets of questionnaires were used to collect data for this study.
A postvisit survey consisting of 5 questions using a Likert scale with answers ranging from 1 to 5, 1 being strongly disagree and 5 being strongly agree, was used to measure participant's self-assessed perception of knowledge. A sixth question included a blank space to answer, “What from this visit helped you understand your pelvic floor disorder or problem the most?” A combined Urogenital Distress Inventory and Incontinence Impact Questionnaire (UDI6-IIQ71) was used as a control to measure the variety of symptoms and the degree of bother from these symptoms. Lastly, a physical activity survey was used to collect demographical data such as age, race, marital status, and educational level. It also asked patients to identify their barriers to exercising such as personal motivation or lack of community facilities. In addition, patients rated their confidence in losing weight after the visit.
Personal identifying data such as name and date of birth, as well as diagnosis (ie, incontinence or prolapse) were not collected to protect the anonymity of the study participants. The collected data were analyzed statistically using an unpaired t test, Wilcoxon rank sum test, and analysis of variance. Analysis was performed using SPSS v15.0, and P ≤ 0.05 was considered to be statistically significant. Data are presented as mean and standard deviation.
Over the course of 4 weeks, 48 women seeking treatment for various PFDs were asked to participate and 48 women enrolled into the study. Of these, 40 women completely filled out all questionnaires, 20 in group A and 20 in group B. The 8 who did not completely fill out all questionnaires, 5 from group A and 3 from group B, were excluded from the data analysis as shown in Figure 1.
Demographics for both groups are summarized in Table 2 and were gathered from the physical activity questionnaire. There were no significant differences between the 2 groups in any of the demographic characteristics. One hundred percent of patients in both groups self-identified as White Caucasian. The mean (SD) age for all participants was 57.4 (2.1) years with a range of 32 to 80. The mean (SD) BMI for all participants was 35.8 (1.1) kg/m2 with a range of 25.7 to 57.4.
The mean (SD) score for answers for the UDI6-IIQ71 questionnaire was 46.2 (18.4) and 40.6 (23.6) for group A and group B, respectively (P = 0.4), as shown in Table 2. There was no significant difference between the 2 groups indicating that both groups had similar symptoms and thus were comparable.
The mean answers for questions 1 to 5 on the postvisit questionnaire were analyzed with unpaired t tests, equal variances not assumed. Wilcoxon rank sum test produced similar results and are not presented here. Data were found to be normally distributed.
Results of the postvisit questionnaire showed that 90% (18/20) of women in group A agreed or strongly agreed that their visit increased their understanding of PFDs relative to obesity, whereas 70% (14/20) of women in group B agreed or strongly agreed. The overall mean (SD) answer score for the questionnaire (questions 1–5) was 3.9 (0.8) for group A and 3.5 (1.1) for group B (P = 0.002). When corrected for age with analysis of variance, the overall mean answer was still found to be statistically significantly different (P = 0.04). The sum of answer scores to questions 1 to 5 for both groups is shown in Figure 2.
Results from the physical activity survey showed that 90% (18/20) of women in group A claimed that they were motivated or devoted to making a lifestyle change or to losing weight, compared with 75% (15/20) in group B. However, there was no statistically significant difference between the 2 groups in terms of motivation to lose weight (P = 0.4).
This pilot study is the first randomized controlled trial to look at the effect of electronic video education on patient's self-assessed perception of knowledge about PFDs in relation to obesity. In a group of White Caucasian women with a BMI of 25 or greater, electronic video education had a positive effect on their self-assessed perception of knowledge. The study did not test actual knowledge, but rather the perception of participant's own understanding. Participants who received the electronic video education (group A) scored higher on the postvisit survey, which asked if their visit increased their knowledge of PFDs and how they relate to obesity. Although the video encouraged participants to lose weight and implement dietary changes, the study did not yield a statistically significant difference in participant's motivation to lose weight.
Video education can be an effective method to increase patient's self-assessed knowledge. One major strength of video education is the advantage of reproducibility as the same information is delivered the same way each time the video is used. In contrast, reproducibility of verbal education relies on proper training and is prone to human error.14 Although scripted verbal education has the ability to provide reproducible education, we chose not to use it in our study because we wanted the results to reflect normal clinic procedures.
The age range of 32 to 80 years in group A along with the other demographic data of participants who successfully watched the video and completed all questionnaires suggests that electronic video education can be easy to use in patients of various ages and education levels. Although this study used a computer laptop to present the video, videos can easily be distributed over the internet. Because most patients have internet access, online videos that patients can refer back to have the potential of helping improve their retention and comprehension about their disorder. Studies have shown that increased patient comprehension and retention is associated with improved clinical outcomes.15
Although not tested in our study, other studies have shown that video education has the potential to reduce physician and staff time without sacrificing knowledge when compared with prolonged counselling.14,16 Electronic video educational methods can be more efficient as increasing time constraints in the clinic limit the amount of time providers spend with each patient.10 Studies have shown that providers are increasingly adopting the use of electronics in the clinic for a variety of uses, and therefore, the use of electronics for education appears to be plausible.9–11
Some limitations were identified in the study. First, this is the first existing study to assess the use of electronic video in educating patients about PFDs in correlation to obesity; therefore, direct comparisons to other research are not possible. Second, limited time led to recruitment of a small sample size over a 4-week period. Third, all participants identified as White and therefore this study is not representative of women from other racial groups. This may be due to the fact that this study was conducted on 1 site as a sample of convenience and most of the patients who present to this clinic are Caucasian. Fourth, standardized pre-assessments were not given to assess patient's self-assessed knowledge beforehand. Fifth, increased perception of knowledge and motivation were self-assessed and are not exclusive determinants of health literacy. Lastly, the postvisit survey was not tested in a focus group, was not analyzed for language, and was not validated for use in this study.
The use of supplemental electronic video education has the potential of being a powerful complement to a standard provider-led visit. This method was studied in a group of overweight and obese women with a range of ages and educational levels. The results suggest that the electronic video education can have a positive effect on patient's self-assessed perception of knowledge about PFDs in relation to obesity. As electronics become more widely used in the clinic, their use for educational methods will likely have a positive outcome.11
Future studies with a larger sample size are needed to verify these results. In addition, investigations using ethnically diverse populations and the development of language appropriate videos should be explored.
Funding was provided by the University of South Dakota Sanford School of Medicine. The authors would like to thank Evelyn Schlenker, PhD, William Schweinle, PhD, and Matthijs D. van der Zee for their statistical contributions.
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