Do Women have Adequate Knowledge about Pelvic Floor Dysfunctions? A Systematic Review

Fante, Júlia Ferreira; Silva, Thais Daniel; Mateus-Vasconcelos, Elaine Cristine Lemes; Ferreira, Cristine Homsi Jorge; Brito, Luiz Gustavo Oliveira

doi:10.1055/s-0039-1695002

Acessibilidade / Reportar erro

Brasil

Revista Brasileira de Ginecologia e Obstetrícia

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Brasil

Español English

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Sumário

Review Article • Rev. Bras. Ginecol. Obstet. 41 (08) • Aug 2019 • https://doi.org/10.1055/s-0039-1695002 copy

Do Women have Adequate Knowledge about Pelvic Floor Dysfunctions? A Systematic Review

Será que as mulheres têm conhecimento adequado sobre as disfunções do assoalho pélvico? Uma revisão sistemática

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objective

We sought to investigate whether women present adequate knowledge of the main pelvic floor disorders (PFDs) (urinary incontinence - UI, fecal incontinence - FI, and pelvic organ prolapse - POP).

Data

sources A systematic review was performed in the MEDLINE, PEDro, CENTRAL, and Cochrane databases for publications from inception to April 2018. Selection of studies A total of 3,125 studies were reviewed. Meta-analysis was not possible due to the heterogeneity of primary outcomes and the diversity of instruments for measuring knowledge. The quality of the articles included in the analysis was evaluated with the Newcastle-Ottawa Scale (NOS) adapted for cross-sectional studies.

Data collection

Two authors performed data extraction into a standardized spreadsheet.

Data synthesis

Nineteen studies were included, comprising 11,512 women. About the methodological quality (NOS), most of the studies (n= 11) presented a total score of 6 out of 10. Validated questionnaires and designed pilot-tested forms were the most frequently used ways of assessing knowledge. Some studies were stratified by race, age, or group minorities. The most used questionnaire was the prolapse and incontinence knowledge questionnaire (PIKQ) (n= 5). Knowledge and/or awareness regarding PFD was low to moderate among the studies. Urinary incontinence was the most prevalent PFD investigated, and the most important risk factors associated with the lack of knowledge of the pelvic floor were: African-American ethnicity (n= 3), low educational level (n= 4), low access to information (n= 5) and socioeconomic status (n= 3).

Conclusion

Most women have a gap in the knowledge of pelvic floor muscle dysfunctions, do not understand their treatment options, and are not able to identify risk factors for these disorders.

Keywords:
knowledge; pelvic floor; urinary incontinence; systematic review

References	Study Design/Period	Country	Sample (n)	Mean age ± SD (range)	Objectives
Freitas et al (2018)⁸8 de Freitas LM, Bø K, Fernandes ACNL, Uechi N, Duarte TB, Ferreira CHJ. Pelvic floor muscle knowledge and relationship with muscle strength in Brazilian women: a cross-sectional study. Int Urogynecol J Pelvic Floor Dysfunct 2018; •••. Doi: 10.1007/s00192-018- 3824-y https://doi.org/10.1007/s00192-018- 3824...	CS/From January 2016 to October 2017	Brazil	133	53.3 (13.8)	To assess the level of knowledge about PFMs and the relationships between PFM knowledge and the ability to contract the PFMs, PFM strength, and prevalence of UI.
Arbuckle et al (2018)⁹9 Arbuckle JL, Parden AM, Hoover K, Griffin RL, Richter HE. Prevalence and awareness of pelvic floor disorders in adolescent females seeking gynecologic care. J Pediatr Adolesc Gynecol 2018;••• . Doi: 10.1016/j.jpag.2018.11.010 https://doi.org/10.1016/j.jpag.2018.11.0...	CS/From August 2015 to June 2016	United States of America	216	17 ± 2.1 (14–17; 18–21)	To determine the prevalence and awareness of pelvic floor disorder (PFD) symptoms among adolescent females. Patient awareness of these disorders and awareness of pregnancy as a risk factor for PFD were also investigated
Cardoso et al (2018)¹⁰10 Cardoso AMB, Lima CROP, Ferreira CWS. Prevalence of urinary incontinence in high-impact sports athletes and their association with knowledge, attitude and practice about this dysfunction. Eur J Sport Sci 2018;18(10):1405-1412. Doi: 10.1080/17461391.2018.1496146 https://doi.org/10.1080/17461391.2018.14...	CS/March–June 2016	Brazil	118	21.6 ± 2.7	To evaluate the prevalence of UI in female athletes practicing high-impact sports and its association with knowledge, attitude, and practice (KAP).
Neels et al (2016)¹¹11 Neels H, Wyndaele JJ, Tjalma WA, De Wachter S, Wyndaele M, Vermandel A. Knowledge of the pelvic floor in nulliparous women. J Phys Ther Sci 2016;28(05):1524-1533. Doi: 10.1589/jpts.28.1524 https://doi.org/10.1589/jpts.28.1524...	CS/NI	Belgium	212	21.6 (18–27)	To evaluate the knowledge of PFF in young nulliparous women.
Parden et al (2016)¹²12 Parden AM, Griffin RL, Hoover K, et al. Prevalence, awareness, and understanding of pelvic floor disorders in adolescent and young women. Female Pelvic Med Reconstr Surg 2016;22(05):346-354. Doi: 10.1097/SPV.0000000000000287 https://doi.org/10.1097/SPV.000000000000...	CS/2014–2015	United States of America	1092	23.5 ± 3.1 (19–30)	To characterize lower urinary tract and PFS prevalence, awareness of these symptoms in women in general and in their family members
Dunivan et al (2015)¹³13 Dunivan GC, Komesu YM, Cichowski SB, Lowery C, Anger JT, Rogers RG. Elder American Indian women's knowledge of pelvic floor disorders and barriers to seeking care. Female Pelvic Med Reconstr Surg 2015;21(01):34-38. Doi: 10.1097/SPV.0000000000000103 https://doi.org/10.1097/SPV.000000000000...	CS/NI	Mexico	144	77.7 ± 9.1 (55–90)	To evaluate knowledge about UI and POP among elder southwestern American-Indian women and to assess knowledge by comparing questionnaire scores of these American-Indian women to historic controls.
Mandimika et al. (2015)¹⁴14 Mandimika CL,Murk W, McpencowAM, et al. Racial disparities in knowledge of pelvic floor disorders among community-dwelling women. Female Pelvic Med Reconstr Surg 2015;21(05):287-292. Doi: 10.1097/SPV.0000000000000182 https://doi.org/10.1097/SPV.000000000000...	CS/Febr2010–Aug2011	United States of America	416	52.5 ± 18.0; 38.3 ± 15.2; 50.2 ± 17.5 (19–98)	To compare PFD knowledge among women of different racial/ethnic groups, focusing on aspects of knowledge that are more likely to influence patient behavior, including PFD risk factors and treatment options.
Day et al (2014)²⁶26 DayMR,Patricia LW,Loughran S,O'Sullivan E. Community-dwelling women's knowledge of urinary incontinence. Br J Community Nurs 2014;19(11):534-538. Doi: 10.12968/bjcn.2014.19.11.534 https://doi.org/10.12968/bjcn.2014.19.11...	PS/NI	Ireland	36	NI – included 50+	To describe community-dwelling Irish women's knowledge of UI.
Perera et al (2014)¹⁵15 Perera J, Kirthinanda DS, Wijeratne S, Wickramarachchi TK. Descriptive cross sectional study on prevalence, perceptions, predisposing factors and health seeking behaviour of women with stress urinary incontinence. BMC Womens Health 2014; 14:78. Doi: 10.1186/1472-6874-14-78 https://doi.org/10.1186/1472-6874-14-78...	CS/3 weeks	Sri Lanka	400	41.94 (21–88)	To determine the prevalence, degree of severity, identify associated factors and study the perceptions and health seeking behavior of women with SUI attending a health care facility.
Shrestha et al (2014)¹⁶16 Shrestha B, Devkota B, Khadka BB, et al. Knowledge on uterine prolapse among marriedwomen of reproductive age in Nepal. Int J Womens Health 2014;6:771-779. Doi: 10.2147/IJWH.S65508 https://doi.org/10.2147/IJWH.S65508...	CS/NI	Nepal	4,693	30.0 ± 7.4	To assess UP knowledge among married women of reproductive age and to determine the association between UP knowledge and socioeconomic characteristics.
Mandimika et al. (2014)¹⁷17 Mandimika CL,MurkW,MühlhäuserMcPencowA, et al. Knowledge of pelvic floor disorders in a population of community-dwelling women. Am J Obstet Gynecol 2014;210(02):165.e1-165.e9. Doi: 10.1016/j.ajog.2013.10.011 https://doi.org/10.1016/j.ajog.2013.10.0...	CS/ Feb 2010–Aug 2011	United States of America	431	49.2 ± 17.9 (19–98)	To investigate baseline knowledge and demographic factors associated with a lack of knowledge about UI and POP.
Good et al (2013)¹⁸18 Good MM, Korbly N, Kassis NC, et al; Society of Gynecologic Surgeons Fellows Pelvic Research Network. Prolapse-related knowledge and attitudes toward the uterus in women with pelvic organ prolapse symptoms. Am J Obstet Gynecol 2013;209(05): 481.e1-481.e6. Doi: 10.1016/j.ajog.2013.06.001 https://doi.org/10.1016/j.ajog.2013.06.0...	CS/ May2011–Aug 2012	United States of America	213	58.9 ± 14.1	To describe patient knowledge about POP diagnosis and treatment, and patient attitudes regarding the uterus in women seeking care for POP symptoms.
Morhason-Bello et al (2012)¹⁹19 Morhason-Bello IO, Ojengbede OA, Adedokun BO, Okonkwo NS, Kolade C. Theories of urinary incontinence causation: aetiological descriptions by sub-Saharan Africanwomen. Eur J Obstet Gynecol Reprod Biol 2012;162(01):109-112. Doi: 10.1016/j.ejogrb. 2012.01.023 https://doi.org/10.1016/j.ejogrb...	CS/NI	Nigeria	1,955	34.8 (15–65)	To describe the perceived causes of UI and factors associated with awareness of causes of UI among women in the community.
Kang (2009)²⁰20 Kang Y. Knowledge and attitudes about urinary incontinence among community-dwelling Korean American women. J Wound Ostomy Continence Nurs 2009;36(02):194-199. Doi: 10.1097/01.WON.0000347662.33088.c9 https://doi.org/10.1097/01.WON.000034766...	CS/NI	Korea	182	51.2	To explore knowledge and attitudes about UI among Korean-American women with incontinence and provide initial information.
Shah et al (2008)²¹21 Shah AD, Shott S, Kohli N, Wu JM, Catlin S, Hoyte L. Do racial differences in knowledge about urogynecologic issues exist? Int Urogynecol J Pelvic Floor Dysfunct 2008;19(10):1371-1378. Doi: 10.1007/s00192-008-0639-2 https://doi.org/10.1007/s00192-008-0639-...	CS/ March–December 2006	United States of America	126	35.7	To assess the knowledge of UI and POP of white women versus non-white women.
Wong et al (2006)²²22 Wong T, Lau BY, Mak HL, Pang MW, Cheon C, Yip SK. Changing prevalence and knowledge of urinary incontinence among Hong Kong Chinese women. Int Urogynecol J Pelvic Floor Dysfunct 2006;17(06):593-597. Doi: 10.1007/s00192-006-0072-3 https://doi.org/10.1007/s00192-006-0072-...	CS/3 months	China	540	(17–77)	To assess the prevalence, knowledge, and behavior of the search for treatment of UI by Chinese women.
Kubik et al (2004)²⁴24 Kubik K, Blackwell L, Heit M. Does socioeconomic status explain racial differences in urinary incontinence knowledge?AmJ Obstet Gynecol 2004;191(01):188-193. Doi: 10.1016/j.ajog.2004.03.084 https://doi.org/10.1016/j.ajog.2004.03.0...	CS/May2002–Febr2003	United States of America	212	(35–80)	To investigate if UI knowledge is different between white and minority groups, and if there is an association between SES and UI knowledge, and if SES explains differences in UI knowledge between white and minority race/ethnic groups.
Kim et al (2004)²³23 Kim JS, Lee EH, Park HC. Urinary incontinence: prevalence and knowledge among community-dwelling Korean women aged 55 and over. Taehan Kanho Hakhoe Chi 2004;34(04):609-616. Doi: 10.4040/jkan.2004.34.4.609 https://doi.org/10.4040/jkan.2004.34.4.6...	CS/ Dec2002–Jan2003	Korea	276	(55–97)	To examine the prevalence of UI and UI-related knowledge among community-dwelling Korean women aged 55 and over.
Kubik et al (2004)²⁴24 Kubik K, Blackwell L, Heit M. Does socioeconomic status explain racial differences in urinary incontinence knowledge?AmJ Obstet Gynecol 2004;191(01):188-193. Doi: 10.1016/j.ajog.2004.03.084 https://doi.org/10.1016/j.ajog.2004.03.0...	CS/May2002–Febr2003	United States of America	212	(35–80)	To investigate if UI knowledge is different between white and minority groups, if there is an association between SES and UI knowledge, and if SES explains differences in UI knowledge between white and minority race/ethnic groups.

References	Quality	Independent Variables	Questionnaires	Results
Freitas et al (2018)⁸8 de Freitas LM, Bø K, Fernandes ACNL, Uechi N, Duarte TB, Ferreira CHJ. Pelvic floor muscle knowledge and relationship with muscle strength in Brazilian women: a cross-sectional study. Int Urogynecol J Pelvic Floor Dysfunct 2018; •••. Doi: 10.1007/s00192-018- 3824-y https://doi.org/10.1007/s00192-018- 3824...	Selection: ✸✸✸Comparability: ✸Outcome: ✸✸	Knowledge/ PFM	Designed questionnaire but no information if pilot-tested; ICIQ-UI-SF	Most of the women presented no PFM knowledge, with a mean total score of 0.48 (±0.97). The ICIQ-UISF mean score was 7.1 (±6.8). There were weak correlations between PFM knowledge and age (r −0.2044/ p = 0.01), and PFM knowledge and parity (r −0.19568/p= 0.02). Pelvic floor muscle knowledge was higher among women with higher education levels (p= 0.0012) and those who had previously performed PFM training (p< 0.001).
Arbuckle et al (2018)⁹9 Arbuckle JL, Parden AM, Hoover K, Griffin RL, Richter HE. Prevalence and awareness of pelvic floor disorders in adolescent females seeking gynecologic care. J Pediatr Adolesc Gynecol 2018;••• . Doi: 10.1016/j.jpag.2018.11.010 https://doi.org/10.1016/j.jpag.2018.11.0...	Selection: ✸Comparability: ✸Outcome: ✸	Awareness; PFD	ISI-P; FISI; ISI-2; POPDI-6; Designed questionnaire but no information if pilot-tested	The majority of respondents had at least heard about UI and FI (62.9%). The prevalence of any UI was 31.5 %. Approximately 29% of adolescents reported an interest in learning more about pelvic floor disorders. Early education regarding PFS may lead to prevention or empowerment to seek treatment as adolescents age.
Cardoso et al (2018)¹⁰10 Cardoso AMB, Lima CROP, Ferreira CWS. Prevalence of urinary incontinence in high-impact sports athletes and their association with knowledge, attitude and practice about this dysfunction. Eur J Sport Sci 2018;18(10):1405-1412. Doi: 10.1080/17461391.2018.1496146 https://doi.org/10.1080/17461391.2018.14...	Selection: ✸✸✸✸Comparability: ✸Outcome: ✸✸	IU; KAP	KAP; ICIQ-SF; QOL; Designed and pilot-tested questionnaire	The prevalence of UI in 118 athletes was 70% (82). Regarding the KAP survey, 31% of the athletes (37) demonstrated adequate knowledge, 53% (63) adequate attitude, and zero adequate practice. Athletes with adequate knowledge were 57% less likely to develop UI.
Neels et al (2016)¹¹11 Neels H, Wyndaele JJ, Tjalma WA, De Wachter S, Wyndaele M, Vermandel A. Knowledge of the pelvic floor in nulliparous women. J Phys Ther Sci 2016;28(05):1524-1533. Doi: 10.1589/jpts.28.1524 https://doi.org/10.1589/jpts.28.1524...	Selection: ✸✸✸Comparability: ✸Outcome: ✸	Knowledge of PFF	Designed and pilot-tested questionnaire	Using a VAS scale (0–10), the women rated their knowledge about the pelvic floor as a mean of 2.4 (SD 2.01). A total of 93% of the women were insufficiently informed and requested more information; 25% had concerns about developing UI, and 14% about FI. Many of the women were unaware what pelvic floor training meant.
Parden et al (2016)¹²12 Parden AM, Griffin RL, Hoover K, et al. Prevalence, awareness, and understanding of pelvic floor disorders in adolescent and young women. Female Pelvic Med Reconstr Surg 2016;22(05):346-354. Doi: 10.1097/SPV.0000000000000287 https://doi.org/10.1097/SPV.000000000000...	Selection: ✸✸✸Comparability: ✸Outcome: ✸✸	PFS (UI, POP, FI, PFS's knowledge)	Designed questionnaire but no information if pilot-tested	There was no difference between groups in awareness of family members with UI, FI, or POP symptoms (p≥ 0.24). Young women were more likely to have received education regarding UI; (aOR 2.6, 95% CI 1.8–3.6), FI (aOR, 3.3; 95% CI, 2.2–4.8), POP (aOR, 2.9; 95% CI, 2.1–4.2), and have greater understanding regarding the causes of UI (aOR, 2.9; 95% CI, 1.7–4.8), FI (aOR, 1.6; 95% CI, 1.1–2.3), and POP (aOR, 1.9; 95% CI, 1.3–2.9).
Dunivan et al (2015)¹³13 Dunivan GC, Komesu YM, Cichowski SB, Lowery C, Anger JT, Rogers RG. Elder American Indian women's knowledge of pelvic floor disorders and barriers to seeking care. Female Pelvic Med Reconstr Surg 2015;21(01):34-38. Doi: 10.1097/SPV.0000000000000103 https://doi.org/10.1097/SPV.000000000000...	Selection: ✸✸✸Comparability: ✸Outcome: ✸	UI, POP's Knowledge	PIKQ; BICS-Q	The mean (SD) for PIKQ of UI score was 6.6 (3.0) (similar to historic gynecology controls 6.8 [3.3], p= 0.49), and the mean (SD) for PIKQ on POP score was 5.4 (2.9) (better than historic gynecology controls 3.6 [3.2], p< 0.01).
Mandimika et al (2015)¹⁴14 Mandimika CL,Murk W, McpencowAM, et al. Racial disparities in knowledge of pelvic floor disorders among community-dwelling women. Female Pelvic Med Reconstr Surg 2015;21(05):287-292. Doi: 10.1097/SPV.0000000000000182 https://doi.org/10.1097/SPV.000000000000...	Selection: ✸✸✸Comparability: ✸Outcome: ✸✸✸	PFD's Knowledge stratified by race	PIKQ	African-American women presented higher odds for lack of knowledge in UI and POP etiology (aOR 3.05 95%CI [1.70–5.47] and aOR 2.15 95%CI [1.18–3.91], respectively) but no difference with regard to UI and POP diagnosis.
Day et al (2014)²⁶26 DayMR,Patricia LW,Loughran S,O'Sullivan E. Community-dwelling women's knowledge of urinary incontinence. Br J Community Nurs 2014;19(11):534-538. Doi: 10.12968/bjcn.2014.19.11.534 https://doi.org/10.12968/bjcn.2014.19.11...	Selection: ✸✸Comparability: ✸Outcome: ✸✸	UI's Knowledge	UIK	Participants had poor knowledge of UI, especially in relation to risk, prevention, treatment, and management factors. Less than 20% of the participants indicated they had been given information on bladder and bowel health issues
Perera et al (2014)¹⁵15 Perera J, Kirthinanda DS, Wijeratne S, Wickramarachchi TK. Descriptive cross sectional study on prevalence, perceptions, predisposing factors and health seeking behaviour of women with stress urinary incontinence. BMC Womens Health 2014; 14:78. Doi: 10.1186/1472-6874-14-78 https://doi.org/10.1186/1472-6874-14-78...	Selection: ✸✸✸Comparability: ✸Outcome: ✸✸	SUI; Perceptions and Health seeking behavior	Designed and pilot-tested questionnaire	Stress urinary incontinence was perceived as an illness by 210 (52.5%) subjects. Stress urinary incontinence was significantly associated with pregnancy, parity, vaginal delivery, complicated labor, diabetes mellitus, chronic cough, constipation, and fecal incontinence (p< 0.05).
Shrestha et al (2014)¹⁶16 Shrestha B, Devkota B, Khadka BB, et al. Knowledge on uterine prolapse among marriedwomen of reproductive age in Nepal. Int J Womens Health 2014;6:771-779. Doi: 10.2147/IJWH.S65508 https://doi.org/10.2147/IJWH.S65508...	Selection: ✸✸✸Comparability: ✸Outcome: ✸✸	UP's Knowledge	Designed and no information if pilot-tested	Fifty-three percent had never heard about UP. Among women who had heard about UP, 37.5% had satisfactory knowledge. Any knowledge about UP was associated with both urban and rural settings, age group, and education level. However, satisfactory knowledge about UP was associated with administrative region, ecological zones, caste/ethnic group, and age group of women
Mandimika et al (2014)¹⁷17 Mandimika CL,MurkW,MühlhäuserMcPencowA, et al. Knowledge of pelvic floor disorders in a population of community-dwelling women. Am J Obstet Gynecol 2014;210(02):165.e1-165.e9. Doi: 10.1016/j.ajog.2013.10.011 https://doi.org/10.1016/j.ajog.2013.10.0...	Selection: ✸✸✸Comparability: ✸Outcome: ✸✸	UI; POP	PIKQ	There is a global lack of knowledge about UI and POP among community-dwelling women, with more pronounced knowledge gaps among nonwhite women.
Good et al (2013)¹⁸18 Good MM, Korbly N, Kassis NC, et al; Society of Gynecologic Surgeons Fellows Pelvic Research Network. Prolapse-related knowledge and attitudes toward the uterus in women with pelvic organ prolapse symptoms. Am J Obstet Gynecol 2013;209(05): 481.e1-481.e6. Doi: 10.1016/j.ajog.2013.06.001 https://doi.org/10.1016/j.ajog.2013.06.0...	Selection: ✸✸Comparability: ✸Outcome: ✸✸✸	POP's Knowledge	Designed and no information if pilot-tested	Prolapse-related knowledge is low in women seeking care for prolapse symptoms.
Morhason-Bello et al (2012)¹⁹19 Morhason-Bello IO, Ojengbede OA, Adedokun BO, Okonkwo NS, Kolade C. Theories of urinary incontinence causation: aetiological descriptions by sub-Saharan Africanwomen. Eur J Obstet Gynecol Reprod Biol 2012;162(01):109-112. Doi: 10.1016/j.ejogrb. 2012.01.023 https://doi.org/10.1016/j.ejogrb...	Selection: ✸✸✸Comparability: ✸Outcome: ✸✸	UI	Designed and no information if pilot-tested	There was a lower odd of awareness of the UI etiology among women less than 30 years, with lower level of education, from rural areas, with five or more children and without history of urine leakage.
Kang (2009)²⁰20 Kang Y. Knowledge and attitudes about urinary incontinence among community-dwelling Korean American women. J Wound Ostomy Continence Nurs 2009;36(02):194-199. Doi: 10.1097/01.WON.0000347662.33088.c9 https://doi.org/10.1097/01.WON.000034766...	Selection: ✸✸✸Comparability: ✸Outcome: ✸✸	IU; Knowledge	Incontinence quiz	Results suggest that Korean-American women are less knowledgeable and have more negative attitudes toward UI than the general population.
Shah et al (2008)²¹21 Shah AD, Shott S, Kohli N, Wu JM, Catlin S, Hoyte L. Do racial differences in knowledge about urogynecologic issues exist? Int Urogynecol J Pelvic Floor Dysfunct 2008;19(10):1371-1378. Doi: 10.1007/s00192-008-0639-2 https://doi.org/10.1007/s00192-008-0639-...	Selection: ✸✸✸Comparability: ✸Outcome: ✸✸	UI; POP	PIKQ	Punctuation mean for white women was higher than non-white at UI scale (p =.019), but not at POP scale (p =.354). Regardless of race, both groups had a higher knowledge for UI than for POP.
Wong et al (2006)²²22 Wong T, Lau BY, Mak HL, Pang MW, Cheon C, Yip SK. Changing prevalence and knowledge of urinary incontinence among Hong Kong Chinese women. Int Urogynecol J Pelvic Floor Dysfunct 2006;17(06):593-597. Doi: 10.1007/s00192-006-0072-3 https://doi.org/10.1007/s00192-006-0072-...	Selection: ✸✸✸✸Comparability: ✸Outcome: ✸✸	UI	UDI-6/ IIQ-7	A total of 78.3% of the interviewed women did not know that UI is a disease, and 60.6% of them thought urine loss is a normal part of the aging process.
Kim et al (2004)²³23 Kim JS, Lee EH, Park HC. Urinary incontinence: prevalence and knowledge among community-dwelling Korean women aged 55 and over. Taehan Kanho Hakhoe Chi 2004;34(04):609-616. Doi: 10.4040/jkan.2004.34.4.609 https://doi.org/10.4040/jkan.2004.34.4.6...	Selection: ✸✸✸✸Comparability: ✸Outcome: ✸	UI's Knowledge	Questions derived from BFLUTSQ and Incontinence Quiz	More than 50% of respondents incorrectly agreed that “UI is the result of normal aging”. Only 20.9% knew that there were exercises that control urine leakage after strain. Older women who had sought treatment had higher mean score for UI-related knowledge.
Kubik et al (2004)²⁴24 Kubik K, Blackwell L, Heit M. Does socioeconomic status explain racial differences in urinary incontinence knowledge?AmJ Obstet Gynecol 2004;191(01):188-193. Doi: 10.1016/j.ajog.2004.03.084 https://doi.org/10.1016/j.ajog.2004.03.0...	Selection: ✸✸✸✸Comparability: ✸Outcome: ✸✸	UI's Knowledge; SES	Incontinence Quiz	White women scored better than minority women on the incontinence quiz. Socioeconomic status explains racial differences in total UI knowledge.
Keller (1999)²⁵25 Keller SL. Urinary incontinence: occurrence, knowledge, and attitudes among women aged 55 and older in a rural Midwestern setting. J Wound Ostomy Continence Nurs 1999;26(01):30-38	Selection: ✸✸✸✸Comparability: ✸Outcome: ✸	UI's Knowledge	Incontinence Quiz	Over half of the 117 respondents incorrectly indicated that incontinence is a normal result of advanced age, almost one third of the respondents incorrectly believed that most people become incontinent by the time they reach the age of 85.

Variables	References
African-American ethnicity	Mandimika et al (2014, 2015),¹⁴14 Mandimika CL,Murk W, McpencowAM, et al. Racial disparities in knowledge of pelvic floor disorders among community-dwelling women. Female Pelvic Med Reconstr Surg 2015;21(05):287-292. Doi: 10.1097/SPV.0000000000000182 https://doi.org/10.1097/SPV.000000000000... ¹⁷17 Mandimika CL,MurkW,MühlhäuserMcPencowA, et al. Knowledge of pelvic floor disorders in a population of community-dwelling women. Am J Obstet Gynecol 2014;210(02):165.e1-165.e9. Doi: 10.1016/j.ajog.2013.10.011 https://doi.org/10.1016/j.ajog.2013.10.0... and Shah et al (2008)²¹21 Shah AD, Shott S, Kohli N, Wu JM, Catlin S, Hoyte L. Do racial differences in knowledge about urogynecologic issues exist? Int Urogynecol J Pelvic Floor Dysfunct 2008;19(10):1371-1378. Doi: 10.1007/s00192-008-0639-2 https://doi.org/10.1007/s00192-008-0639-...
Low educational level	Mandimika et al (2014),¹⁷17 Mandimika CL,MurkW,MühlhäuserMcPencowA, et al. Knowledge of pelvic floor disorders in a population of community-dwelling women. Am J Obstet Gynecol 2014;210(02):165.e1-165.e9. Doi: 10.1016/j.ajog.2013.10.011 https://doi.org/10.1016/j.ajog.2013.10.0... Good et al (2013),¹⁸18 Good MM, Korbly N, Kassis NC, et al; Society of Gynecologic Surgeons Fellows Pelvic Research Network. Prolapse-related knowledge and attitudes toward the uterus in women with pelvic organ prolapse symptoms. Am J Obstet Gynecol 2013;209(05): 481.e1-481.e6. Doi: 10.1016/j.ajog.2013.06.001 https://doi.org/10.1016/j.ajog.2013.06.0... and Morhason-Bello et al (2012)¹⁹19 Morhason-Bello IO, Ojengbede OA, Adedokun BO, Okonkwo NS, Kolade C. Theories of urinary incontinence causation: aetiological descriptions by sub-Saharan Africanwomen. Eur J Obstet Gynecol Reprod Biol 2012;162(01):109-112. Doi: 10.1016/j.ejogrb. 2012.01.023 https://doi.org/10.1016/j.ejogrb...
Low access to information	Neels et al (2016),¹¹11 Neels H, Wyndaele JJ, Tjalma WA, De Wachter S, Wyndaele M, Vermandel A. Knowledge of the pelvic floor in nulliparous women. J Phys Ther Sci 2016;28(05):1524-1533. Doi: 10.1589/jpts.28.1524 https://doi.org/10.1589/jpts.28.1524... Parden et al (2016),¹²12 Parden AM, Griffin RL, Hoover K, et al. Prevalence, awareness, and understanding of pelvic floor disorders in adolescent and young women. Female Pelvic Med Reconstr Surg 2016;22(05):346-354. Doi: 10.1097/SPV.0000000000000287 https://doi.org/10.1097/SPV.000000000000... and Dunivan et al (2015)¹³13 Dunivan GC, Komesu YM, Cichowski SB, Lowery C, Anger JT, Rogers RG. Elder American Indian women's knowledge of pelvic floor disorders and barriers to seeking care. Female Pelvic Med Reconstr Surg 2015;21(01):34-38. Doi: 10.1097/SPV.0000000000000103 https://doi.org/10.1097/SPV.000000000000...
Low socioeconomic status	Shrestha et al (2014),¹⁶16 Shrestha B, Devkota B, Khadka BB, et al. Knowledge on uterine prolapse among marriedwomen of reproductive age in Nepal. Int J Womens Health 2014;6:771-779. Doi: 10.2147/IJWH.S65508 https://doi.org/10.2147/IJWH.S65508... Morhason-Bello et al (2012),¹⁹19 Morhason-Bello IO, Ojengbede OA, Adedokun BO, Okonkwo NS, Kolade C. Theories of urinary incontinence causation: aetiological descriptions by sub-Saharan Africanwomen. Eur J Obstet Gynecol Reprod Biol 2012;162(01):109-112. Doi: 10.1016/j.ejogrb. 2012.01.023 https://doi.org/10.1016/j.ejogrb... and Kubik et al (2004)²⁴24 Kubik K, Blackwell L, Heit M. Does socioeconomic status explain racial differences in urinary incontinence knowledge?AmJ Obstet Gynecol 2004;191(01):188-193. Doi: 10.1016/j.ajog.2004.03.084 https://doi.org/10.1016/j.ajog.2004.03.0...

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