Young women were involved in developing a leaflet about pelvic floor awareness with the aim of maintaining and improving pelvic floor health
In this article…
- Producing a basic health questionnaire for teenagers
- What students know about pelvic floor muscle health
- Feedback from students on information they would like to see in leaflets on pelvic floor muscle health
- Main sources of health advice for teenagers
Liz Howard-Thornton is continence nurse team leader at NHS North Lancashire; Sylvia Craine is clinical specialist physiotherapist working in continence at NHS Highland; Clare Holden is specialist continence physiotherapist at NHS Central Lancashire; and Gill Pearl is an independent practitioner and former project manager at PromoCon Disabled Living Centre, Manchester.
Howard-Thornton L et al (2011) Pelvic floor health: information for teenagers. Nursing Times; 107: 17, early on-line publication.
Pelvic floor muscle weakness may be widespread, but the first time many women learn to look after these muscles is during pregnancy.
To empower a younger generation of women to become more pelvic floor muscle aware from an earlier age, a group of health professionals produced a health questionnaire, moderated a focus group and conducted an educational session for teenagers at a community school to establish how much they knew about this topic.
The group is using this feedback to produce a leaflet aimed at teenage girls to raise awareness of pelvic floor muscle health.
Keywords: Teenagers, Health promotion, Focus group, Pelvic floor muscle exercise, Leaflet
- This article has been double-blind peer reviewed.
5 key points
- About one in four women have a bladder problem
- Female incontinence is linked to problems with weakened pelvic floor muscles damanged at childbirth
- There are many reasons why pelvic floor muscle weakness can occur; most women do not know the risk factors
- The first time many women learn how to look after their pelvic floor muscles is during pregnancy
- The internet, mothers and health promotion leaflets are sources of health advice for teenage girls
Most people who suffer with incontinence in adult life are women (Thomas et al, 1980) and an estimated one in four women have a bladder problem at some point in their lives (Hannestad et al, 2000). Studies have suggested women often fail to seek or delay seeking treatment for many years (Shaw et al, 2006; North, 1994).
Female incontinence is frequently linked to problems with weakened pelvic floor muscles damaged at childbirth (Cardozo, 1991). Even when women do not experience problems with leakage, weakened pelvic floor muscles can lead to prolapse of the bladder, bowel or womb. There are many reasons why pelvic floor muscle weakness can occur, but most women are unaware of the various risk factors.
Given these statistics, it is incredible that the first time many women begin to learn how to look after their pelvic floor muscles is during pregnancy. In November 2008, the national education sub-committee for the Association for Continence Advice (ACA) and the ACA pelvic floor special interest group identified a need to empower a younger generation of women to become more pelvic floor muscle aware from an earlier age. We hoped this would have a preventive benefit on the pelvic floor muscle health of these women during their adult life.
In September 2009, we reviewed the teenage health promotion literature available. We also sought end-user information on the suitability of this information, with the aim of developing a pelvic floor muscle health promotion leaflet for teenagers, designed by teenagers.
Health promotion leaflet
In May 2009, we carried out a literature review with a school nurse colleague. The review showed a lack of specific advice for teenage girls and women about how to look after the health of their pelvic floor muscles.
We found a few leaflets aimed at teenagers, but these usually focused on adolescence, menstruation, sexual activity, contraception, sexually transmitted infection or more general information regarding healthy living, such as diet and exercise.
We found very little evidence that any of the leaflets available had involved end-users during their development, and most leaflets were only available in hard copy from a school nurse or health professional.
We found one leaflet that had a specific focus on teenage pelvic floor muscle health; it mentioned that teenagers and parents had contributed to its content. This leaflet, Don’t Laugh Until You Read This! produced by Education and Resources for Improving Childhood Continence (ERIC) is available to download from its website.
From our discussions with the school nurse, we learnt that format, wording, colours and access to written information were important factors that influenced how this age group used leaflets.
Much health information that relates to promoting pelvic floor muscle health and reducing incontinence is published by individual authors in books and journals and via national guidance and care pathways (National Institute for Health and Clinical Excellence, 2006; Department of Health, 2000). The way this information is conveyed to teenagers appears to have received little attention. In 2007, Pearl stated: “The healthcare professional is not always best placed to judge whether a leaflet is good or not: assistance is needed from those in the target readership.”
A half-day session at a local health centre was organised, which was attended by 17 female students (aged approximately 17 years) and two teachers (one male, one female) from a local community high school.
The students were all studying health and social care. Information had been given to parents by the school and the school obtained both parental and student consent before the students took part in the session. We asked the teachers to take a passive role during the session, so as not to influence the responses given by the students.
The methods chosen were a health questionnaire, a focus group and an educational session. The format was constrained by minimal financial resources, and because the teenage volunteers were only able to meet with us on one occasion.
As far as we are aware, this workshop is the first to record the active involvement of female teenagers in the review and development of health promotion literature in relation to pelvic floor muscle function.
All 17 students completed a basic health questionnaire to establish the level of anatomical, physiological and health promotion knowledge they had comparing the heart to the pelvic floor muscle complex (Box 1).
Box 1. Health questionnaire
- What is your heart?
- Where is your heart?
- What does it do?
- How should you keep your heart healthy?
- What causes damage to your heart?
- What is your pelvic floor?
- Where is your pelvic floor?
- What does it do?
- How should you keep it healthy?
- What causes damage to your pelvic floor?
- Draw a diagram of your body showing the heart and the pelvic floor.
- We learn things about health without looking to do so. Where do you learn most about women’s health? Put the scores in the order from where you learn the most (1) to where you learn the least (18). (18 sources of information listed.)
- If you found that you needed some information about a heart problem, where would you go to find the information? Put the scores in order from where you learn the most (1) to where you learn the least (18). (18 sources of information listed.)
- If you were running in an exercise class and you suddenly wet yourself, what would you do?
- Where would you go to find out more information about this problem if you wanted it? Put the scores in order from where you learn the most (1) to where you learn the least (18). (18 sources of information listed.
- If you use the internet for this information what words would you put in to search?
- What would you do when the exercise class came round next week?
All students had a good basic knowledge of the heart and how to keep it healthy, but knew less about the pelvic floor. If they wished to know more about women’s health issues in general, they tended to seek information from mothers, magazines and best friends. If they wanted more specific details about a heart or pelvic floor problem, they would use the internet, their mothers and health leaflets the most, in that order.
Most said that, if they developed a bladder problem during an exercise class, they would leave the class or hide it and then avoid going back. Only 35% would consider seeking help for the problem. A few students had heard about pelvic floor muscle exercises from their mothers, but were not quite sure how to do them.
Both teachers were present during the completion of the health questionnaires and there was evidence of some conferring between a few students, but this was allowed as some felt more comfortable discussing their answers.
The focus group
Five students volunteered to take part in the focus group and two of us moderated the session.
The moderator’s role was not to lead discussion, but to encourage students to discuss their thoughts and ideas about the leaflets already available for teenagers, and to note the comments made (Box 2). Teachers were not permitted to take part as this would have influenced the group dynamics and possibly student responses.
Box 2. Comments regarding pelvic floor muscle exercises
- “Mum tried to teach how to do it but couldn’t get the hang of it.”
- “Mum did them when she had my sister.”
- “Heard about them at pilates class.”
- “Do them to strengthen the bladder and tighten vagina.”
The focus group took place in a separate room, in an environment that encouraged students to contribute to discussions with the reassurance that their responses were confidential.
The group examined and discussed a variety of health promotion literature aimed at teenagers and gave their comments on leaflet design, content, layout, language and terminology. The students gave useful information regarding words they would use when searching the internet to gain information (Box 3) and the characteristics of leaflets they preferred (Box 4). They also felt that there should be two leaflets, one aimed at 11-15 year-olds and another for 16-19 year-olds. They agreed that it was acceptable to discuss sex in a pelvic floor leaflet designed for over-16s.
Box 3. “Search words” that teenagers use when searching for information on the internet
- Seven students stated “weak bladder”.
- Five mentioned “bladder problems”.
- Two searched on “uncontrollable”.
- Two mentioned how to control”.
- One searched “Unnecessary”.
- One stated “Information”.
Box 4. Characteristics of leaflets favoured by teenagers
Design Size should be a small booklet that will fit in a handbag, not tri-fold leaflets as these look too formal are likely to be put in the bin. Teenagers liked information well-spaced out and they preferred glossy paper.
Content/layout Lots of colour and pictures are preferable. Cartoons are good as they have more appeal. Students were happy to have graphic pictures but not on the front cover. Students wanted pictures on the front of leaflets. They were happy to have lots of pages but broken up with pictures. They preferred cartoon style pictures, not photos and not those that looked like a science lesson. In terms of colour preferences, they did not like yellow or green, but liked purple or turquoise blue. Students were happy to have lots of information but wanted it to be in separate sections, with different colours and backgrounds.
They liked the question and answer format. They wanted information to be straight to the point with not too much writing, in a bullet point format. Short bullet points were thought to be good for younger people, but older teenagers needed to look at the rationale behind certain advice, for example, “Drink 6-8 glasses of water a day. Why?”
Language Two leaflets are needed: one aimed at 11-15 year-olds and one at 16-19 year-olds. The students did not want to read what they already knew about but also felt it was not right for 13 year- olds to be reading about what 17 year-olds wanted to know. Students did not like being referred to as “children” – they preferred “young adult” or “teenager”. They did not mind if the title of the leaflet did not tell them what it was about as they felt it would make them read on. If the leaflet was about an embarrassing subject like sex, they said they would not want that information on the front in case their parents saw it.
The students liked speech bubbles with statements from real people as it made them feel normal and that others had the same problem.
Using words like “poo” and “wee” were seen as being too childish – teenagers preferred more clinical expressions, namely “emptying bowels or bladder”. Phrases like “it’s cool” should be avoided – “it’s good” or “it’s important” were preferable. References to sex were acceptable for the 16-17-year old age group. Using poems in a leaflet was seen as silly.
Knowing pelvic floor muscle exercises will improve sex was seen as the main reason to do them. This information was most likely to encourage students to read the leaflet. Teenagers suggested the leaflet should also have a glossary of terms with simple explanations – for example, incontinence = leaking urine - to help them better understand the information.
An educational session on pelvic floor awareness and pelvic floor muscle exercises took place with the remaining 12 students and the teachers.
In both the focus group and the educational session, the teenagers wanted to know more about the role of the pelvic floor muscles in relation to sexual activity; they felt this was the information that would get them to read the leaflet.
The method used in this project was restricted as only minimal resources were available: clinicians’ time was at the discretion of employers and travel and teleconferencing expenses were met from the charitable funds of the ACA.
We were from England and the far North of Scotland, and were only able to approach one group of teenagers at one community high school, which was in England. This meant sample size and location was limited. Students were articulate, well educated and from a similar socio-economic background and ethnicity. No students within the group had significant learning or physical disabilities.
During the education session, we did not aim to collect information to inform the development of the leaflet but noted that anecdotal comments by students during the session had common themes. For example, they wanted to know more about the role of the pelvic floor muscles in relation to sexual activity.
The results of the health questionnaire raise important questions for both education and health services, in particular school nursing. Students were quite knowledgeable about the heart, its location in the body, its function and what was required to keep it healthy, whereas knowledge about the function of the pelvic floor muscle complex and its importance for women was poor.
The results offer insight into how teenagers seek health advice. General health advice appears to be gained informally via mothers, magazines and best friends, in that order, whereas advice regarding a specific problem would be sought from the internet as first point of contact, then their mothers and health leaflets. The role of the internet, mothers and health leaflets might be worthy of future study when looking at the specific health needs of this group.
The results showed that, if teenage girls suffered an episode of incontinence in an exercise class, they would avoid the situation that could bring it on again, which suggests they would limit their lifestyle if they developed incontinence. Only 35% would have considered seeking help for the problem. This finding backs up previous studies in that it suggests that women often delay seeking treatment for many years (Shaw et al, 2006; North 1994).
The results of the focus group were enlightening and gave food for thought as to how we should offer health information to this age group. Teenagers often feel patronised by the terminology used in most healthcare literature and dislike the most common format used to deliver this information in – the tri-fold leaflet. These leaflets are often chosen as they are produced at low cost and can be downloaded easily. However, if information in this format does not appeal to our target audience, they it is unlikely to be picked up by teenagers, let alone read.
Indications for leaflet development
The findings of this project have been used to develop a health promotion leaflet for young women aged 16-19 years.
The leaflet, entitled Your Pelvic Floor, will promote healthy lifestyles and exercises for the pelvic floor muscle complex.
By empowering young women to gain knowledge and health promotion information on maintaining healthy pelvic floor muscle function and continence, it is hoped that we can prevent the onset, or cure or reduce female incontinence and the associated costs in later life. Also, by raising awareness, it is hoped that young women will know how to seek help if they do develop a continence problem.
It is planned that the leaflet will be available in both hard copy version and via the internet, and could be found using search words chosen by teenagers. It will be launched at the ACA national conference in Harrogate on 9-10 May this year. It will require regular review to ensure it remains fit for purpose for its target audience.
This project, although not a formal research study, offers a valuable insight into the health promotion needs of female teenagers in relation to pelvic floor muscle function.
It highlights the important role the internet, mothers and health promotion leaflets have as primary sources of specific health information for teenage girls. It also suggests that only 35% of teenage girls know they can seek advice if they experience incontinence.
In carrying out this project, we hope to inform the future development of leaflets for female teenagers on pelvic floor muscle health promotion. NT
The authors of this article would like to acknowledge the support of the following people:
Mr J McNaughton (headmaster), Miss Claire Keys (teacher of health and social care studies) Mr Devlin
(teacher of health and social care), other staff and the sixth form students of Morecambe Community High School, Lancashire, and Julie Thexton (school nurse, Morecambe Community High School) NHS North Lancashire.
Patterson Medical provided support with graphic design and printing for the leaflet.
The working group: Association for Continence Advice (national educational sub-committee and pelvic floor special interest group) and ERIC (Education and Resources for Childhood Continence).
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