Hungarian Women’s Health Care Seeking Behavior and Knowledge of Urinary Incontinence and Pelvic Organ Prolapse: A Cross-Sectional Study

Abstract

Importance

Adequate knowledge about pelvic floor disorders could lead to increased health care-seeking behavior, improved symptoms, and quality of life.

Objectives

The aims of the present study were to evaluate Hungarian women’s knowledge about pelvic floor disorders and to assess health care-seeking behavior.

Study Design

We conducted a cross-sectional survey from March to October 2022 using self-administered questionnaires. The Prolapse and Incontinence Knowledge Questionnaire was used to assess Hungarian women’s knowledge about pelvic floor disorders. The International Consultation of Incontinence Questionnaire–Short Form was used to gather information about the symptoms of urinary incontinence.

Results

Five hundred ninety-six women were included in the study. Urinary incontinence knowledge was deemed proficient in 27.7% of participants, while pelvic organ prolapse knowledge was deemed proficient in 40.4% of participants. Greater urinary incontinence knowledge was significantly associated (P < 0.001) with higher level of education (P = 0.016), work in a medical field (P < 0.001), and ever practiced pelvic floor muscle training (P < 0.001), whereas greater pelvic organ prolapse knowledge was significantly associated (P < 0.001) with higher level of education (P = 0.032), work in a medical field (P < 0.001), ever practiced pelvic floor muscle training (P = 0.017), and ever had pelvic organ prolapse (P = 0.022). Of the 248 participants who reported a history of urinary incontinence, only 42 (16.93%) women sought care. Care seeking was higher among women who were more knowledgeable about urinary incontinence and among women with more severe symptoms.

Conclusions

Hungarian women had limited knowledge about urinary incontinence and pelvic organ prolapse. Health care seeking among women with urinary incontinence was low.

WHY THIS MATTERS

Although the prevalence of pelvic floor disorders is growing significantly, many women do not seek care. Misinformation and lack of knowledge about pelvic floor disorders may contribute to delay or avoidance of medical care, which leads to higher financial costs and increases the risk of worse health outcomes. On the contrary, adequate knowledge could lead to earlier treatments, improved symptoms, and quality of life. Determining the level of knowledge women have about these conditions could play an important role in establishing appropriate educational interventions.

Simply Stated

Pelvic floor disorders, including urinary incontinence (urinary leakage) and pelvic organ prolapse (a vaginal bulge), have a serious negative impact on women’s physical, psychological, and social well-being. Our goals were to assess Hungarian women’s knowledge about these conditions and to investigate whether they seek medical attention. We found that Hungarian women had limited knowledge about urinary incontinence and pelvic organ prolapse. Women with lower level of knowledge had lower educational attainment, had not worked in a medical field, and had not practiced pelvic floor muscle training. Only a small percentage of women (16.9%) with urinary incontinence sought medical attention for this issue. Women were more likely to seek medical care if they had greater knowledge and more bothersome urinary leakage.

Pelvic floor disorders (PFDs), including urinary incontinence (UI) and pelvic organ prolapse (POP), represent a major health care issue affecting millions of women worldwide. The prevalence of any UI in women can vary from 5% to 70%, with most studies reporting 25–45% prevalence.¹ The prevalence of POP can range from 1% to 65%, depending on whether pelvic examination (10–50%), symptoms (1–31%), or both (20–65%) were used to identify the presence of POP.² As a result of increasing obesity and population aging, the prevalence of UI is predicted to increase by 55%, while the prevalence of POP is estimated to increase by 46% between 2010 and 2050.³ Pelvic floor disorders often occur in combination. Presenting the symptoms of one PFD might increase the likelihood of having another concurrent PFD.^4,5

Even though UI and POP are not life-threatening conditions, the symptoms can have a serious negative effect on daily activities.⁶ Moreover, these conditions adversely affect women’s physical, psychological, and social well-being. Negative self-perception, depression, social isolation, embarrassment, and social stigma are often linked to PFDs.⁷

Despite the high prevalence and severe impact of PFDs on quality of life, a large number of women do not report their symptoms.⁸ From fifty to seventy-five percent of women experiencing UI do not seek care.⁹ Although longer duration and more severe distress of PFDs may contribute to increased health care-seeking behavior, treating a PFD only after it reaches an advanced stage has less satisfactory results and higher financial costs.¹⁰ The economic burden of surgical treatments for UI is substantial. The cost of surgical therapy was found to be 4 times greater than the expenditures of pharmacological and behavioral therapies combined.¹¹ The study of Szabó et al¹² is currently the largest study of continence care in Hungary. According to their results, 68% of the participants had UI. Thirty percent of the participants with UI did not go to a general practitioner and 66% of them did not go to a specialist.

Adequate knowledge about PFDs could lead to earlier treatments and improved symptoms and quality of life.^13,14 On the contrary, misinformation and lack of knowledge about PFDs may contribute to delay or avoidance of medical care, which leads to decreased access to treatment.¹⁵

Assessing the level of knowledge women have about these conditions could play an important role in establishing appropriate educational interventions.¹⁶ However, most studies assessing PFD knowledge were carried out in the United States and China,¹⁷ thus, examining other populations could add substantially to our understanding of the level of knowledge women have about PFDs on a global level.

The aims of the present study were to evaluate Hungarian women’s knowledge about UI and POP, to examine possible factors related to a lack of knowledge about these conditions, and to assess health care-seeking behavior regarding UI.

MATERIALS AND METHODS

The present cross-sectional study was undertaken from March to October 2022. A convenience sampling technique was used to select participants. A self-administered survey was created by using Microsoft forms. We forwarded an invitation to participate in the study via email to different primary care clinics. We also used different social media type platforms such as specific groups on Facebook, Telegram, and WhatsApp. The invitation contained the online survey link and information regarding the purpose of the study. Inclusion criteria included women 18 years or older, ability to read and write Hungarian, and the provision of consent to participate.

The first part of the survey included questions about sociodemographic characteristics, current pregnancy and obstetric history, pelvic floor muscle training (PFMT), and history of PFDs.

The primary outcome of interest was knowledge about UI and POP, assessed by the Prolapse and Incontinence Knowledge Questionnaire (PIKQ). The questionnaire consists of 2 distinct scales: the first one, PIKQ-UI, focuses on UI knowledge, whereas the second one, PIKQ-POP, measures knowledge about POP. Each scale includes 12 questions related to the etiology, diagnosis, and treatment options of UI and POP. For each question, the following 3 possible responses are given: (1) “Agree,” (2) “Disagree,” or (3) “I don’t know.” One point is given for every correct answer, while the incorrect answer or the answer of “I don’t know” are scored with zero point. The total score of each scale can range from 0 to 12, with higher scores indicating greater knowledge.¹⁸ Knowledge proficiency, representing a higher level of knowledge in comparison with the average, was established as scores of 80% or greater for PIKQ-UI (≥10 questions answered correctly) and 50% or greater for PIKQ-POP (≥6 questions answered correctly).¹⁹

The Hungarian version of the International Consultation of Incontinence Questionnaire–Short Form (ICIQ-SF) was used to gather information about the symptoms of UI. It contains questions related to the following 6 characteristics: (1) birth date, (2) gender, (3) the frequency of UI, (4) leakage amount, (5) type of UI, and (6) the impact of UI. Scores of frequency of UI, leakage amount, and impact of UI are added together for a total score of 0–21, with higher scores suggesting more severe symptoms.^20,21 Pelvic organ prolapse was assessed by the following question: “Do you usually have a bulge or something falling out that you can see or feel in your vaginal area?”²² The following questions were used to assess health care-seeking behavior: “Have you ever sought care/help for urinary incontinence?” “Have you ever sought care/help for pelvic organ prolapse?”¹⁰

The study was registered by the U.S. National Institutes of Health (clinicaltrials.gov, Identifier NCT NCT05567900) and approved by National Scientific and Ethical Committee (lV/1596-3/2022/EKU). Participation in the study was voluntary and no identifying information was collected from the participants. Informed consent was obtained before completing the self-administered questionnaire.

All statistical analyses were performed with SPSS version 28.0 (SPSS, Inc, Chicago, Ill). The level of statistical significance was set at P < 0.05. Descriptive statistics were used to present the data (mean, standard deviation, median, interquartile range, percentage). The Pearson χ² test of association was conducted to assess associated factors of UI prevalence and knowledge proficiency regarding UI and POP. Multivariate linear regression was used to estimate the association between knowledge levels and background characteristics. The Mann-Whitney U test was used to compare ICIQ-SF and PIKQ-UI scores between women who had sought health care for UI and women who had not.

RESULTS

Initially, a total of 612 respondents returned the questionnaire. Among them, 4 respondents reported their gender as male and 12 women did not complete the PIKQ. Overall, 596 women were included in the study (Fig. 1). The background characteristics of study participants are summarized in Table 1.

FIGURE 1.

Flowchart of study participants. PIKQ, Prolapse and Incontinence Knowledge Questionnaire.

TABLE 1.

Demographics and Characteristics of the Study Participants

Characteristics	Mean (SD) or n (%)
Age, mean (SD), y	33 ± 12.8
BMI, mean (SD)	24.1 ± 4.9
Highest education level
Eighth grade or less	7 (1.1%)
High school	262 (43.9%)
College/university	327 (54.8%)
Marital status
Married	282 (47.3%)
Not married	313 (52.6%)
Work in a medical field
Yes	91 (15.2%)
No	505 (84.7%)
Parity
Nulliparous	278 (47.8%)
Parous	303 (52.1%)
Any urinary incontinence
Yes	248 (42.2%)
No	339 (57.7%)
Types of urinary incontinence
Stress urinary incontinence	150 (69.4%)
Urge urinary incontinence	33 (15.2%)
Mixed urinary incontinence	33 (15.2%)
Pelvic organ prolapse
Yes	32 (7%)
No	428 (93%)
Ever practiced pelvic floor muscle training
Yes	241 (51.3%)
No	228 (48.6%)

BMI, body mass index (calculated as weight in kilograms divided by height in meters squared).

Urinary incontinence knowledge was deemed proficient in 27.7% of participants (n = 596), while POP knowledge was deemed proficient in 40.4% of participants (n = 596). The results of the PIKQ are presented in Table 2.

TABLE 2.

PIKQ Scores of the Study Participants

	Participants (N = 596)
	Score	Percentage
PIKQ-UI
Mean ± SD	7.2 ± 3	60.1 ± 25.3
Median (IQR)	8 (5–10)	66.6 (41.6–83.3)
PIKQ-POP
Mean ± SD	4.5 ± 3.3	37.5 ± 28.2
Median (IQR)	5 (1–7)	41.6 (8.3–58.3)

PIKQ, Prolapse and Incontinence Knowledge Questionnaire; POP, pelvic organ prolapse; IU, urinary incontinence.

Regarding UI knowledge, the lowest scores were for questions related to etiology (52.7% of the participants [n = 596] answered correctly), whereas questions related to treatment received the highest scores (69.4% of the participants [n = 596] answered correctly). Regarding POP knowledge, the lowest scores were for questions related to diagnosis (33% of the participants [n = 596] answered correctly), whereas questions related to treatment received the highest scores (42.3% of the participants [n = 596] answered correctly). We summarized the PIKQ-UI and PIKQ-POP questionnaires for each question in Table 3 and Table 4.

TABLE 3.

PIKQ-UI Questionnaire by Correct Respondents

Question Number	Type	Question	Correct Answer	n (%)
1	Etiology	UI (loss of urine or leaky bladder) is more common in young women than in old women.	Disagree	409 (68.6%)
2	Etiology	Women are more likely than men to leak urine.	Agree	315 (52.9%)
3	Treatment	Other than pads and diapers, not much can be done to treat leakage of urine.	Disagree	363 (60.9%)
4	Diagnosis	It is not important to diagnose the type of urine leakage before trying to treat it.	Disagree	469 (78.7%)
5	Etiology	Many things can cause urine leakage.	Agree	461 (77.3%)
6	Treatment	Certain exercises can be done to help to control urine leakage.	Agree	452 (75.8%)
7	Etiology	Some medications may cause urinary leakage.	Agree	151 (25.3%)
8	Treatment	Once people start to leak urine, they are never able to control their urine again.	Disagree	444 (74.5%)
9	Diagnosis	Doctors can do special types of bladder testing to diagnose urine leakage.	Agree	181 (30.4%)
10	Treatment	Surgery is the only treatment for urinary leakage.	Disagree	353 (59.2%)
11	Etiology	Giving birth many times may lead to urine leakage.	Agree	264 (44.3%)
12	Treatment	Most people who leak urine can be cured or improved with some kind of treatment.	Agree	442 (74.2%)

PIKQ, Prolapse and Incontinence Knowledge Questionnaire; UI, urinary incontinence.

TABLE 4.

PIKQ-POP Questionnaire by Correct Respondents

Question Number	Type	Question	Correct Answer	n (%)
1	Etiology	POP (bulging of the vagina, uterus, bladder, or rectum) is more common in young women than in old women.	Disagree	210 (35.2%)
2	Etiology	Giving birth many times may lead to POP.	Agree	241 (40.4%)
3	Etiology	POP can happen at any age.	Agree	267 (44.8%)
4	Treatment	Certain exercises can help to stop POP from getting worse.	Agree	338 (56.7%)
5	Etiology	Symptoms of POP may include pelvic heaviness and/or pressure.	Agree	156 (26.2%)
6	Diagnosis	A good way for a doctor to diagnose POP is by examining the patient.	Agree	196 (32.9%)
7	Treatment	Once a patient has POP, not much can be done to help her.	Disagree	327 (54.9%)
8	Etiology	Heavy lifting on a daily basis can lead to POP.	Agree	244 (40.9%)
9	Treatment	Surgery is one type of treatment for POP.	Agree	242 (40.6%)
10	Diagnosis	Doctors can run a blood test to diagnose POP.	Disagree	188 (31.5%)
11	Treatment	A rubber ring called a pessary can be used to treat symptoms of POP.	Agree	79 (13.3%)
12	Etiology	People who are obese are less likely to get POP.	Disagree	194 (32.6%)

PIKQ, Prolapse and Incontinence Knowledge Questionnaire; POP, pelvic organ prolapse.

There was a statistically significant association between UI knowledge proficiency and level of education (P = 0.005), age (P = 0.001), work in a medical field (P < 0.001), POP knowledge proficiency (P < 0.001), and previous practice of PFMT (P < 0.001).

We found a statistically significant association between POP knowledge proficiency and level of education (P = 0.033), age (P < 0.001), work in a medical field (P < 0.001), previous practice of PFMT (P < 0.001), ever had POP (P = 0.001), and ever sought care for POP (P = 0.010).

On multivariate analysis, greater UI knowledge remained significantly associated (R² = 0.122, F = 14.690, P < 0.001) with the following factors: higher level of education (P = 0.016), work in a medical field (P < 0.001), and previous practice of PFMT (P < 0.001), whereas greater POP knowledge remained significantly associated (R² = 0.141, F = 12.937, P < 0.001) with higher level of education (P = 0.032), work in a medical field (P < 0.001), previous practice of PFMT (P = 0.017), and ever had POP (P = 0.022).

Almost half of participants (42.2%, n = 587) had experienced UI. Urinary incontinence prevalence was associated with older age (P = 0.001) and parity (P = 0.001).

Of the 248 participants who reported a history of UI, 75.5% completed the ICIQ-SF scale with a mean score ± SD of 7.9 ± 3.5. Among them (n = 248), only 42 women (16.9%) sought health care. Women who had sought care had significantly higher PIKQ-UI (U = 3310.00, P = 0.016) and ICIQ-SF total score (U = 3358.50, P = 0.021).

DISCUSSION

In the present study, Hungarian women had limited knowledge about PFDs. Nearly one quarter of the participants (27.7%) demonstrated UI knowledge proficiency, whereas less than half of the participants (40.4%) showed POP knowledge proficiency. These findings concur well with the results of Mandimika et al.²³ They conducted a cross-sectional survey to evaluate women’s knowledge about UI and POP in New Haven County, Connecticut. Of the 431 participants, 28.8% showed UI knowledge proficiency, while 51.9% of them demonstrated POP knowledge proficiency. Similarly, Chen et al¹⁶ conducted a cross-sectional survey to assess UI and POP knowledge among 346 English-speaking women presenting to the following 3 types of primary care clinics: (1) geriatric, (2) community based, and (3) hospital based. They found that 28% of their respondents demonstrated UI knowledge proficiency, whereas 46% of them showed POP knowledge proficiency.

We found that both UI and POP knowledge were significantly associated with level of education, previous practice of PFMT, and work in a medical field. Pelvic organ prolapse knowledge was also significantly associated with previous POP. In the current literature, work in a medical field and previous POP history seems to correlate with PFD knowledge.^15,16,23 However, there are mixed results regarding the association between POP knowledge and level of education. In the study of Mckay et al,¹⁵ similarly to our results, educational attainment retained significance for both UI and POP knowledge. In contrast, educational attainment in some other studies showed significant correlation with UI knowledge only.^16,23

The association between previous practice of PFMT and knowledge of UI and POP has not been widely studied. In a recent cross-sectional study, despite the high level of knowledge regarding UI and POP, the majority of respondents (57.4%) did not practice PFMT. However, higher POP knowledge was associated with increased frequency of participation in PFMT.²⁴ Further research is needed to better understand the impact of PFD knowledge on PFMT practice.

In accordance with the present findings, previous studies have found that health care seeking for UI among women was low.^10,25,26 Based on previous findings, several barriers to care seeking for UI had been identified: increased level of symptom bother,^10,25,27,28 misconceptions and inadequate knowledge about UI,^15,25 shame, embarrassment,²⁷ lack of time,²⁹ fear of doctor or surgery,^27,30 and costs.^10,27 The lack of time on the part of the patient and within the framework of health care, fear, embarrassment, and shame can be decreased by using a self-administered questionnaire, for example, the Australian Pelvic Floor Questionnaire^31,32 completed during the waiting period can reduce the patient’s embarrassment, the time, and the costs of care. Misconceptions and inadequate knowledge could be one of the most easily modifiable factors by raising awareness of PFDs.^18,25

More research is needed to establish appropriate educational interventions, which effectively increase knowledge among Hungarian women. Enhancing knowledge regarding PFDs and their treatment options may help improve care seeking behavior and the quality of life of many Hungarian women who have these conditions.

One limitation to this study is the online recruitment. Although the sample size is relatively large, the use of a self-administered online survey made it impossible to verify the accuracy of the respondents’ answers. Another limitation for the study is the limitation to the population regarding who has access to the internet. In addition, our results have limited generalizability to the population at large. In the current literature, socioeconomic status and ethnicity also seem to correlate with knowledge about PFDs.³³ However, in the present study, these variables were not assessed.

Hungarian women had limited knowledge about UI and POP. Levels of knowledge about UI and POP were associated with individuals who had a lower educational status, did not work in a medical field, and did not do PFMT. Health care seeking for UI was low, especially among women with milder symptoms and less knowledge about the condition.