Development and validation of a prototype multimedia application to enhance health education on the pelvic floor muscles among pregnant and puerperal women in Brazil

Introduction

Background

The pelvic floor muscles (PFMs) are responsible for supporting the pelvic organs, urinary and fecal continence, and sexual functions (1). Pregnancy and childbirth are major risk factors for PFM disorders such as urinary and fecal incontinence, pelvic organ prolapse, and sexual dysfunction (2-4). Thus, a highly accessible health education is needed about PFM anatomy (5), function (1), and potential for dysfunction (6) within the perinatal year (2,3), as drawn from the scientific literature (4).

Rationale and knowledge gap

There are known limits to pregnant women’s education access about the pelvic floor and their functions via clinicians (7,8), hence direct to consumer health instruction has merit. A study indicate that women feel the need to receive more information about PFM and that acquiring knowledge in this regard can reduce anxiety related to the development of PFM dysfunctions (4). In addition, women who receive knowledge underlying the importance of PFM during pregnancy exhibit increased satisfaction with the childbirth experience (9).

Among the therapeutic treatments available to prevent PFM dysfunction, pelvic floor muscles training (PFMT) is a minimally invasive first-line treatment for PFM disorders that can be performed during pregnancy and after delivery (10). Evidence indicates that PFMT performed during pregnancy can reduce the risk of developing urinary incontinence (UI) pre- and postpartum by approximately 62% (11) and improve the quality of life of women with UI disorders (12).

Unfortunately, not all women have access to information on PFM, their functions and the benefits of PFMT (4). Therefore, there is a need to develop technological tools to expand women’s knowledge in this context (13).

Objective

Thus, the general objective of the present project was to develop and validate an accessible and free multimedia application (app) that provides health education on PFM, primarily focusing on pregnant women as the target audience. This manuscript is written following STROBE reporting checklist (available at https://mhealth.amegroups.com/article/view/10.21037/mhealth-22-40/rc) (14).

Methods

This research is descriptive and transversal, in the modality of technological production, developed in the Laboratory of Research in Women’s Health, Department of Physiotherapy. This study was approved by the Ethics Committee of the Federal University of São Carlos (CAAE:40121820.30000.5504) and was conducted in accordance with the Declaration of Helsinki (as revised in 2013). All participants agreed to participate and provided their informed consent in electronic format.

The research was conducted from March 2021 to March 2022 across three stages, namely, bibliographic review and language adequacy; multimedia app prototype development methodology; and validation of the multimedia app by specialists in the fields of health and technology as well as by pregnant and postpartum women.

Bibliographic review and language adequacy

This first stage consists of conducting a theoretical-scientific survey that supports the selection of information contained in the app interface. To survey the relevance of health education promoted by the app, an electronic search strategy was performed using combinations of keywords with the Boolean operators AND, OR, and NOT. The search was performed in the PubMed database using the Medical Subject Headings (MeSH) tool, based on the following health descriptors: health education, pregnant women, pregnancy, pelvic floor, and pelvic floor disorders.

The inclusion criteria comprised content on anatomy, function, and dysfunction of the pelvic floor in pregnant and postpartum women; physical therapy assessment and intervention in PFM disorders in pregnant and postpartum women; PFM preparation strategies for childbirth; health education aimed at pregnant women; and the benefits and barriers associated with this practice. In addition, the language used in the survey was adapted to make it accessible to the target audience, making it possible for the population to understand the content.

Multimedia application prototype development methodology

During the prototype development stage, this study used the contextualized instructional design (CID), which consists of the intentional and systematic action of planning, developing, and applying specific didactic situations, incorporating mechanisms that favor contextualization and human learning (15). Thus, based on the CID model, the Multimedia app includes the following steps.

Analysis phase

The educational objectives, content, and technological infrastructure were defined in the creation of a diagram to guide the construction of the tool (Appendix 1).

Design phase

Definitions of pedagogical concepts that promote learning, planning, and production of didactic content; definition of topics and writing of screens; selection of media; and the design of the interface (layout) were established.

Development phase

The Android^® operating system (Google, United States) was selected for the development of the mobile platform based on its popularity and use in different types of devices (smartphones, tablets, cell phones, etc.). The app was developed and hosted on a Wix platform (https://pt.wix.com).

Implementation phase

In this phase, the configuration of educational technology tools and resources was carried out. Furthermore, an environment for downloading the app was configured on the Internet and installed on a mobile device.

Validation of the multimedia App

The app validation was performed in two stages. First, experts in the area of health and technology were consulted. Second, pregnant and postpartum women validated the data. Specialists of the health and technology, pregnant and puerperal women aged 18 years or older were included in this study. Pregnant and puerperal women were invited to participate in the research through the dissemination of the project on social media (i.e., facebook, and instagram). Experts interested were communicated electronically via e-mail by the researchers. There was the attempt to recruit a diverse population in terms of age, level of schooling and country region. Were excluded participants who refused to sign the Free and Informed Consent Term (FICT), which outlined the objectives and purpose of the project. The FICT was provided on Google Forms, and all participants were able to download a copy.

After demonstrating interest in participating in the validation, the professionals received an e-mail with the procedures for the validation process of the educational material: the link to access the app content, hosted on the Wix platform, and the instrument validation questionnaire, which included some objectives and essay questions to enhance the contribution of suggestions for improvement. Furthermore, the changes proposed by the specialists were analyzed and implemented. Thereafter, the prototype was validated by pregnant and postpartum women, as well as by future users of the material.

For the proper evaluation of the application, a specific instrument was adapted and used to assess competencies and assess the importance of the content in this educational material (16,17). Particularly, the following criteria were evaluated: functionality, content, language, illustrations, design, innovation, and satisfaction with the application. The validation form was composed of questions related to educational aspects, didactic resources of the app, and the environment’s interface. The possible answers were based on the Likert (18) scale which includes: 1, strongly disapprove; 2, disapprove; 3, approve; 4, strongly approve (Table 1). Furthermore, additional comments and suggestions on each criterion to improve the educational material could be provided in a blank field at the end of each session.

Statistical analysis

The data obtained were tabulated and analyzed using Microsoft Excel for Windows^® 2010. For the distribution of sociodemographic and clinical data, descriptive analysis was performed using frequency (absolute and relative), measures of central tendency (mean), and dispersion (standard deviation).

The analysis of the app validation and its content was conducted using the Content Validity Index (CVI) (19), which allows verification of the usability/acceptability of a prototype app evaluated for both technical ease and appropriateness of content selection. According to the literature, a cutoff score exceeding 0.80 is ideal for validating educational materials (20). Furthermore, the percentage of absolute agreement was calculated, which consisted of the sum of positive responses from the evaluators divided by the total number of evaluations performed. The minimum level of consensus required in the literature was 75% (21).

Results

In the literature review, 1,141 studies were identified. Initially, duplicate studies were excluded. Then, the selection by titles was performed, followed by a selection of abstracts and, later, the full content of the articles. Nine articles were selected as a result of the literature review (Figure 1).

Figure 1 Flowchart of study selection.

Review papers from this study were used to support the content included in the educational material. Table 2 describes the selected articles.

From the choice and organization of the content, it was necessary to analyze the best strategies to display this information. Particularly, this project aimed to enhance the understanding of the educational material among the target audience (i.e., pregnant and puerperal women). Consequently, simple expressions were used to avoid jargon from the health area, to maintain an informative, clear, and accessible language. Furthermore, the process was conducted using illustrations and videos. Moreover, images with subtitles were used, highlighting the basics required for understanding and avoiding excessive information that could discourage further reading and understanding of the material. The videos were created to synthesize content using animations that facilitated understanding.

Upon completing the content, evaluation strategies were created to include different perspectives of the subject. In this context, health and technology professionals (TP) and pregnant and postpartum women were invited.

The application validation content was initially conducted by 13 health professionals (HP) (81.3%) and three technology experts (18.7%). The socio-demographic data, including academic background and areas of operation, are described in Table 3.

Table 4 presents the data underscoring the CVI for each item of the assessment instrument. The analysis was divided into HP and TP. In general, most of the evaluated criteria reached CVI values above the cutoff proposed by the literature of 0.80. Only Items 1.1 and 3.1, from the validation with TP, exhibited a lower CVI than expected. However, the average of the material was 0.89 among the experts, which was above the necessary cutoff.

The professionals who participated in the validation suggested several improvements such as adding a video that could explain navigation across the app. They also suggested using more didactic language in the illustrations.

All evaluations were considered and analyzed, resulting in new modifications to the material for validation with the target audience. Table 5 presents the participants’ suggestions.

In the content validation stage with the target audience, 13 pregnant women (86.7%) and 2 postpartum women (13.3%) were recruited, with a mean age of 31.4±6.23 years. The outstanding sociodemographic data are presented in Table 6.

Table 7 presents the CVI obtained from the app validation for pregnant and postpartum women. All evaluated criteria reached values above the 0.80 cutoffs. The average material was 0.93 among the target audience, indicating a high agreement.

After this validation process by specialist professionals and target audience, the app prototype was finalized for the health education of pregnant and postpartum women on PFM. The images of the application pages are illustrated in Figure 2.

Figure 2 The layout of the developed multimedia app prototype.

Discussion

Pregnant women have a limited understanding of the functions and dysfunctions of the PFM (7), despite its extreme importance. In addition, practices such as intense medicalization, disrespect for the autonomy of the pregnant woman, and unnecessary interventions (i.e. episiotomy and instrumental birth), among others, contribute to increased risks for motherhood, childbirth, and puerperium (22).

Expanded access to this content will promote enhanced autonomy for pregnant women by ensuring that they have the necessary information to make important decisions about prenatal care and childbirth interventions that may impact PFM function. Gaining such knowledge increases the likelihood that these women will feel safe and satisfied with their choices. According to the guidelines established by the National Policy for Integral Attention to Women’s Health, improving the women’s quality of life through health promotion, aiming at integrated healthcare, is necessary during this period of pregnancy and puerperium (22).

App creation is based on the growing use of technologies by the population (23) and seeks to build tools that act as facilitators in accessing new knowledge. Asklund et al. [2017] (24) created a mobile app for stress UI treatment in women and found a decrease in symptoms and an increase in quality of life. In addition, previously proposed educational materials were analyzed to have a basis on which contents should be addressed and an understanding of how to apply them and their possible results (25,26). In agreement with previous studies, our study showed a high level of agreement between experts and the target audience. Thus, the app may be an effective tool for education de mulheres with health issue similar.

The item “functionality” presented CVI among TP below the literature cutoff. This can be explained by the experience of higher-performance tools hosted in app stores. However, it is essential to note that other users of this material had a good experience. Furthermore, the “language” criterion was evaluated by TP below the cutoff. Therefore, the content was reviewed before being sent to pregnant women.

As the global average of educational materials reached a CVI value higher than that proposed in the literature, the content can be considered validated. Except for the two items already mentioned, the evaluations of professionals and the target audience showed a high level of agreement, demonstrating the effectiveness of the tool for pregnant and postpartum women. Therefore, the material will contribute to disseminating information about PFM and PFMT during pregnancy, providing a knowledge base for users who will benefit and make choices informed by scientific evidence.

This study had limitations concerning the sample size and diversity of pregnant and postpartum women. In addition, most participants exhibited a high level of education, which may have facilitated their understanding of the material. Evaluation by an ampler and a more diverse group of women could have contributed to different suggestions, resulting in further improvement. Moreover, the use of the app requires access to the Internet and mobile tools. However, many pregnant individuals do not have unlimited access to these technologies (27).

Conclusions

The application presented a CVI of 0.91, an agreement level between professionals of 93.7%, and between pregnant and postpartum women of 95.8%. The overall agreement was 94.8%, which was considered validated. Thus, the educational material on this app is expected to contribute to the dissemination of information on PFM and its importance, functions, and dysfunctions. Making this knowledge widely accessible can promote health education for pregnant and postpartum women, enhance their autonomy to make decisions with a scientific basis underscoring prenatal care and childbirth, and improve their quality of life. This application was developed and validated with the intention that pregnant and puerperal women have direct access to this information, however, we believe that this educational resource can also be used by HP.

In the future, we intend to insert the application in operating system stores and carry out new tests to identify performance, compatibility, and errors related to the operating system. In addition, we also intend to analyze the adherence and self-efficacy of using this application in pregnant and puerperal women.

Acknowledgments

Funding: This study was financed in part by Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq), Coordenação de Aperfeiçoamento de Pessoal de Nível Superior-(CAPES)-Finance Code 001 and São Paulo Research Foundation (FAPESP) (Project No. 2018/26718-9).

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://mhealth.amegroups.com/article/view/10.21037/mhealth-22-40/rc

Data Sharing Statement: Available at https://mhealth.amegroups.com/article/view/10.21037/mhealth-22-40/dss

Peer Review File: Available at https://mhealth.amegroups.com/article/view/10.21037/mhealth-22-40/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://mhealth.amegroups.com/article/view/10.21037/mhealth-22-40/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. This study was approved by the Ethics Committee of the Federal University of São Carlos (CAAE:40121820.30000.5504) and was conducted in accordance with the Declaration of Helsinki (as revised in 2013). All participants agreed to participate and provided their informed consent in electronic format.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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