Inequality in healthcare-seeking behavior among women with pelvic organ prolapse: A systematic review and narrative synthesis

doi:10.21203/rs.3.rs-2374891/v1

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Inequality in healthcare-seeking behavior among women with pelvic organ prolapse: A systematic review and narrative synthesis

https://doi.org/10.21203/rs.3.rs-2374891/v1

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published 03 May, 2023

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Introduction: Pelvic organ prolapse affects women’s quality of life in various aspects. However, the evidence on their healthcare-seeking behavior is limited. Therefore, this study aimed to review and synthesize the existing evidence on the healthcare-seeking behavior among women with pelvic organ prolapse.

Methods: The electronic databases PubMed, African Journals Online, Cumulative Index to Nursing and Allied Health Literature, African Index Medicus and Directory of Open Access Journal and Google Scholar were searched for relevant literature. The retrieved evidence was synthesized using narrative synthesis approach. The characteristics of included studies and the level of healthcare-seeking behavior were summarized in a table and texts. Error bar was used to show the variability across different studies.

Results: A total of 966 articles were retrieved among which only eight studies with 23,501 women (2,683 women with pelvic organ prolapse) were included in the synthesis. The level of healthcare-seeking behavior ranges from 21.3% in Pakistan to 73.4% in California, USA. The retrieved studies were conducted on four different study populations, used both secondary and primary data, and were conducted in six different countries. Error bar shows a variation in the percentage of healthcare-seeking behavior.

Conclusions: The level of Health-care seeking behavior among women with pelvic organ prolapse is low in low-income countries compared to high income countries. The characteristics of the reviewed studies are very different from each other. We recommend a large-scale study with a sub-group analysis which will help to understand the healthcare-seeking behavior.

Healthcare-seeking

pelvic floor disorder

narrative synthesis

Healthcare-seeking behavior is an individual’s action to promote maximum well-being, recovery, and rehabilitation (1). It can be viewed as a person's interaction with a certain health service. This covers details including how symptoms are viewed and handled, as well as which healthcare services are used and when (2). In general, many interactions and relationships within supportive or restrictive social systems affect healthcare-seeking behavior (3–5).

Healthcare-seeking behavior of women with pelvic organ prolapse (POP) and other pelvic floor disorders (PFD) is unsatisfactory (6–8), as disclosing the information is associated with discrimination and the disease is considered shameful (9–13). Women with POP do not seek treatment until the disease progress and worsen their quality of life (14, 15). Women's quality of life is significantly impacted by pelvic organ prolapse (16, 17). The quality of life is impacted, and this includes sexual dysfunction, prejudice, self-consciousness, a sensation of being "less feminine," distraction from daily tasks, and embarrassment from others when requesting assistance with tasks like carrying heavy goods (9, 10, 18).With all of these effects, many women adopt coping mechanisms and behaviors to reduce the negative effects of POP on their quality of life (19).

The evidence about healthcare-seeking behavior in a POP patient is inadequate (20)as the available studies in the field of the female pelvic floor are focused on pelvic floor disorder in general (17, 21) and urinary incontinence (22, 23). Moreover, the few studies that assessed the levels of healthcare-seeking behavior among POP patients so far are inconsistent. For instance, healthcare-seeking behavior was 52–64% among POP patients in Nepal (10, 11)and 15.5–40.3% in Ethiopia (13, 19, 24). This inconsistency makes it difficult to understand the level of healthcare-seeking behavior of women with POP.

Systematically reviewing the existing evidence, identifying their differences, and synthesizing the reported level of healthcare-seeking behavior helps to understand the burden of the problem. This may support the policymakers in addressing the gap by incorporating promoting strategies for health-seeking behavior. Therefore, we conducted this systematic review to systematically review the literature and narrate the available evidence on the healthcare-seeking behavior of women with POP.

Study design and search process

This was a systematic review and narrative synthesis of the literature on healthcare-seeking behavior among women with POP. Literature that assessed the healthcare /treatment-seeking behavior of women with pelvic organ prolapse was systematically reviewed. The electronic databases PubMed, Directory of Open Access Journals, Cumulative Index to Nursing and Allied Health Literature (CINAHL), African Index Medicus, and African Journals Online (AJOL)) and Google Scholar were searched for the relevant literature. For PubMed search, we used the following search terms: (“Utero vaginal prolapse" OR "vaginal prolapse" OR "pelvic organ prolapse") AND ("health-seeking behavio*” OR “health behavio* " OR "treatment-seeking behavio* OR "treatment-seeking" OR "healthcare-seeking behavio* " OR "care-seeking" OR "help-seeking" OR "health-seeking"). The reference lists of the studies were also searched for other relevant studies

Eligibility and selection criteria

Observational studies that assessed healthcare-seeking behavior of women with pelvic organ prolapse and published in the English language were included in this systematic review and narrative synthesis. Studies published since1996 and accessible online till 20 June / 2022 were searched in the databases. Qualitative studies and patient stories were excluded.

All identified articles and other documents were transferred to the EndNote version 7 reference manager and duplicates were removed. The titles and abstracts were reviewed and assessed against the inclusion criteria by two independent reviewers (MS and YA). Reasons for the exclusion of articles were marked. Eventually, the reviewers conducted a full review of the remaining articles and documents. The results of the assessment and inclusion processes were documented in the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) (25) (Supplementary file 1).

Methods for data Extraction

Two independent reviewers extracted the data from the list of eligible studies. Findings from the included studies were extracted and stored using a template prepared in Microsoft excel. Based on the recommendation (25), the following important items were extracted from each study: authors’ name, publication year, the sample size, study design, study setting, study country, data collection method, and the results (level of healthcare-seeking behavior).

Quality Assessment

The methodological quality of the studies included in the review was critically evaluated using a quality assessment tool for prevalence studies developed by the Joanna Briggs Institute (JBI) (26). The tool contains nine items/questions with Yes, No, Unknown, and Not Applicable response options. A score of 1 is given for Yes and 0 for all other options. The scores were summed up and changed to percentages. The two authors (MS and YA) independently evaluated the quality of the studies, and the differences between the two authors were resolved by consensus. Finally, the methodological quality of the studies was categorized as high quality (score above 80%), moderate quality (between 60% − 80%), and low quality (below 60%) (Supplementary file 2).

Outcome measurement

The outcome of the study was to identify the level of healthcare-seeking behavior of women with POP from studies published in reputable journals. The level of healthcare-seeking behavior was measured by the percentage of women with POP who sought healthcare.

Data Synthesis

A narrative synthesis was done by using tabulations and textual descriptions. A narrative synthesis was preferred due to the high heterogeneity of the reviewed articles. Primary synthesis was made through textual description of the main outcomes of each included study. Then tabulations were used to present the characteristics of each study. Tabulations are typically used to provide information on study design, setting of the study, study population, sample size, data collection method, and outcome of the studies (level of the healthcare-seeking behavior). These data were presented in different columns in the same table. Textual descriptions were used to narrate the findings based on the variability in the study population, study country, study setting, and data sources used in the individual studies. The level of healthcare-seeking behavior extracted from each study is summarized to show the range of healthcare-seeking behavior among women with POP. Error bars were also constructed using Microsoft Excel 2013 for the level of healthcare and its confidence interval to check for disparities among studies. The robustness of the synthesis was assessed by using the Best Evidence Synthesis (BES) method, in which only studies that meet minimal standards of methodological adequacy were included (Supplementary file 2).

Identification of studies

In this review, a total of 961 articles were identified through search of electronic databases and references of the identified studies. Among these, 945 research articles were excluded because 314 of the studies were duplicates, 630 studies does not fulfill the eligibility criteria and one study was not freely accessible (27). A total of 16 full-text articles were retrieved of which eight articles were excluded due to: few sample size (28), incomplete outcome measurement (29–31), and assessed only delay in treatment-seeking (13, 20, 24, 32). Finally, eight articles were included in the narrative synthesis (Fig. 1).

Characteristics of the included studies

The studies included in the current review were published between 2007 (33) and 2020 (19). All the eight studies included in the systematic review were cross-sectional study designs; two studies were from Nepal (10, 11); and two from USA (34), one from United Arab Emirates (12), one from Pakistan (35), one from Ethiopia (19) and one from Iran (36). The sample sizes of the included studies ranged from 115 (10) to 9021 (11). Two studies were institution-based (10, 12) and six were community based-studies (19, 33, 35–37). In general, 23,501 women (2,683 women with pelvic organ prolapse) were included in this study (Table 1).

Table 1

Characteristics of studies included in to the systematic review of healthcare-seeking behaviour among women with Pelvic organ prolapse, 2022.
Author & year	Study Place	Study subjects	Study setting	Sample size	Data collection method	Outcome variable and results	Study period	Care-seeking for POP (%)
(Adhikari and Ranju, 2018)	Nepal	Parous women with Uterovaginal prolapse	Institution- based	9021	Secondary data	1. The prevalence of uterine prolapse = 6% 2. Help/care-seeking = 64%	2011	64
(Brazell et al., 2013)	Boston, USA	POP patients	Community-based	3205	Secondary data	Healthcare-seeking behavior across different groups for prolapse was (from total of 93 patients): • 74.2% among Black women, • 76.9% among Hispanics, and • 58.3% among white women	2002–2005	68.8
(Dheresa et al., 2020).	Ethiopia	Married women who had POP	Community-based	704	Patient Interview	Healthcare-seeking behavior was: 1. 32% of women with Pelvic Floor Disorder 2. 40.3% of POP Patients, 3. 25.9% for urinary symptoms 4. 10.4% for anal incontinence	2016	40.3
(Hammad et al., 2018)	United Arab Emirates	POP patients	Institution- based	127	Patient Interview	1. Degree of bother from POP: 111 (87.4%) had activity (physical, social, or prayers) or sexual relationship affected 2. 54% of them did not seek medical treatment	2010	46
(Jokhio et al., 2020)	Pakistan	POP patients	Community-based	5064	Patient Interview	1. Prevalence of POP: 10.3%. 2. Impact of POP: 60.8% reported quality of life is greatly or moderately affected 3. Care-seeking behavior: 78.7% never sought care	2018	21.3
(Morrill et al., 2007)	California, USA	POP patients	Community-based	4,392	Secondary data	1. Prevalence of pelvic floor disorders: • POP = 13%, urinary incontinence = 27%, • Anal incontinence = 29% and • Fecal incontinence = 19% 2. Health care-seeking behaviour: • Pelvic organ prolapse = 73% • 61% for urinary symptoms and • 28% for anal incontinence. 3. Care-seeking is associated with older age, history of hysterectomy, hormone therapy, and frequent urinary tract infection	2007	73.4
(Shrestha et al., 2014)	Nepal	POP patients	Institution- based	115	Patient Interview	1. Experience of women with POP: • 85% faced major physical discomfort, • 68% urinary symptom, • 42% bowel symptom and • 73% sexual discomfort 2. 48% never sought Healthcare	2012	52
(Tehrani et al., 2011)	Iran	Reproductive age (18-45years old) POP patients	Community-based	1252	Patient Interview	The main gynecologic morbidities were: 1. Pelvic organ prolapse (41.1%), 2. sexually transmitted infection (37.6%) and 3. Menstrual disorders (30.1%). Overall, two third of these women had not sought medical care. 4. Among the participants, 391 of them had POP whereas only 152 (39.4%) of them sought healthcare	2008–2010	39.4
*^{POP = Pelvic organ prolapse}
ADHIKARI, R. & RANJU, K. 2018. Uterine prolapse and treatment seeking behaviour among women. Frontiers in Women’s Health, 84, 7650.
BRAZELL, H. D., O'SULLIVAN, D. M. & TULIKANGAS, P. K. 2013. Socioeconomic status and race as predictors of treatment-seeking behavior for pelvic organ prolapse. American journal of obstetrics and gynecology, 209, 476. e1-476. e5.
DHERESA, M., WORKU, A., OLJIRA, L., MENGISTIE, B., ASSEFA, N. & BERHANE, Y. 2020. Women’s health seeking behavior for pelvic floor disorders and its associated factors in eastern Ethiopia. International Urogynecology Journal, 31, 1263–1271.
HAMMAD, F. T., ELBISS, H. M. & OSMAN, N. 2018. The degree of bother and healthcare seeking behaviour in women with symptoms of pelvic organ prolapse from a developing gulf country. BMC Women's Health, 18, 1–7.
JOKHIO, A. H., RIZVI, R. M. & MACARTHUR, C. 2020. Prevalence of pelvic organ prolapse in women, associated factors and impact on quality of life in rural Pakistan: population-based study. BMC women's health, 20, 1–7.
MORRILL, M., LUKACZ, E. S., LAWRENCE, J. M., NAGER, C. W., CONTRERAS, R. & LUBER, K. M. 2007. Seeking healthcare for pelvic floor disorders: a population-based study. American Journal of Obstetrics and Gynecology, 197, 86. e1-86. e6.
SHRESTHA, B., ONTA, S., CHOULAGAI, B., POUDYAL, A., PAHARI, D. P., UPRETY, A., PETZOLD, M. & KRETTEK, A. 2014. Women’s experiences and health care-seeking practices in relation to uterine prolapse in a hill district of Nepal. BMC women's health, 14, 1–9.
TEHRANI, F. R., SIMBAR, M. & ABEDINI, M. 2011. Reproductive morbidity among Iranian women; issues often inappropriately addressed in health seeking behaviors. International Urogynecol Journal, 11, 863.

Healthcare-seeking behavior among women with pelvic organ prolapse Dherese et al, (19) reported healthcare-seeking behavior for Pelvic Floor Disorder (PFD) in eastern Ethiopia. They included only married women in the study. Pelvic organ prolapse was assessed by interviewing women for symptoms of urinary incontinence, anal incontinence, and pelvic organ prolapse using the following questions: “Have you ever sought care/help for urinary symptoms (overactive bladder and/or stress urinary incontinence)?”, “Have you ever sought care/help for pelvic organ prolapse?” and “Have you ever sought care/help for anal incontinence?’. In general, 32% of women with PFDs sought health care for their problem; specifically, 40.3% of POP patients sought care, while 25.9% sought care for urinary symptoms, and 10.4% for anal incontinence.

Shrestha et al, (10) conducted a study at outreach clinics in Dhading district in Nepal to assess women’s experience of utero-vaginal Prolapse and their healthcare-seeking behavior. The report shows that 48% of 115 participants never sought healthcare. Participants were included by convenience sampling at the follow-up outreach clinics.

Ramesh Adhikari and Ranju KC (11) assessed the factors that influence the experience of uterine prolapse and the care-seeking behavior among women in Nepal. They used data extracted from the Nepal Demographic and Health Survey, 2011. They confined the analysis to only women who had one or more pregnancies. The prevalence of uterine prolapse 6%, and only 64% of them sought treatment.

Fayez T. Hammed et al, (12) assessed the degree of bother, social impact, and healthcare-seeking behavior of symptoms of POP in the United Arab Emirates. They involved all Emirati women who attended three family development centers in Al Ain, the United Arab Emirates from January 2010 to January 2011. Among POP participants, 111 (87.4%) had at least one activity (physical, social, or prayers) or sexual relationship affected by POP symptoms. However, 54% of them did not seek medical treatment for different reasons.

Tehrani et al, (36) evaluated reproductive morbidities and healthcare-seeking behavior of 1252 nationally representative sample of women aged 18 to 45 years in urban areas in Iran. The three main groups of morbidities they identified were: pelvic organ prolapse (41.1%), sexually transmitted infection (37.6%) and menstrual disorders (30.1%). Overall, two third of these women had not sought medical care. Among the participants, 391 of them had POP whereas only 152 (39.4%) of them sought healthcare.

Morrill et al, (33) report characteristics associated with seeking-care for pelvic floor disorders (pelvic organ prolapse, urinary incontinence, and anal incontinence) in California, USA. They used secondary data of 4,392 women, which were collected for a continence-associated risk epidemiology study. Among 568 participants diagnosed to have pelvic organ prolapse (current and past history), 73% had sought treatment. Healthcare-seeking was 61% for urinary symptoms and 28% for anal incontinence. They reported that care-seeking for pelvic floor disorder is associated with older age, history of hysterectomy, hormone therapy, and frequent urinary tract infection.

Brazell et al, (37) evaluated the prevalence of POP across a diverse group of women, and healthcare-seeking behavior among women of different ethnic/race and socioeconomic statuses. They used secondary data collected from 3205 women for the National Institute of Health-support Boston Area community in the USA. Healthcare-seeking behavior for uterine prolapse was 74.2% among Black women, 76.9% among Hispanics, and 58.3% among white women.

Jokhio et al, (38) aimed to determine the prevalence of POP and its impact on women’s quality of life in rural Pakistan. They interviewed 5064 women and 10.3% were confirmed to have pelvic organ prolapse. Among women with POP, 60.8% reported their quality of life was greatly or moderately affected and 78.7% never sought care.

Disparities in healthcare-seeking behavior among women with pelvic organ prolapse

The reported level of healthcare-seeking behavior range from 21.3% − 73.4%, which is 21.3% from Pakistan (35), 39.4% from Iran (36), 40.3% from eastern Ethiopia (19), 46% from United Arab Emirates (12), 52–64% from Nepal (10, 11), 68.8% from Boston, USA (37) and 73.4% from California, USA (33). The error bar constructed for 95% confidence interval shows disparities across these studies (Fig. 2).

The reviewed studies have significant variability in terms of the study population, sample size, and study period. For example, the study from Iran included only reproductive age (18–45 years old) POP patients (36), while the study from Ethiopia involved only married women (19) and the study from Nepal involved only parous women (11) to assess their healthcare-seeking behaviour. The other studies involved any women who had POP. On the other hand, in three studies (11, 33, 37), health-seeking behaviour analysis was done from secondary data collected for National Demographic and Health Survey, while other studies used primary data. Three studies were conducted at a health facility (10–12) while five studies were conducted at the community level (Table 1).

Quality of included studies

Accordingly to the Joanna Briggs Institute (JBI) (26) checklist for prevalence study, five studies were of high methodological quality (score > 80%) (11, 19, 36–38) and three studies were of moderate methodological quality (quality score 60–80%) (10, 12, 33) (Supplementary file 2).

The level of healthcare-seeking behavior of women with POP is not uniform; it ranges from 21.3% (38) to 73.4% (33). This variation might be due to the difference in the characteristics of the studies. The studies included in the present review are highly different in terms of the study population, study setting, study period, and sample size. For example, some studies involved only married women with POP (19), some others involved only parous women (11) and the others involved all women with POP (12, 32, 33). This difference might be one source of difference in healthcare-seeking behavior. For instance, married women may have spousal support and seek healthcare more than the unmarried groups. Lack of support was one of the determinant factors for not seeking healthcare in Ethiopia (24).

In this review, the lowest level of healthcare-seeking behavior was reported in Pakistan (21.3%) (38) and the highest level was reported in California, USA (73.4%) (33). The low level of health care seeking in Pakistan was justified to be due to a lack of awareness about the availability of treatment and the high cost of care at that time (38). The healthcare-seeking reported from eastern Ethiopia (40.3%) (19) and Iran (39.4%) (36) were higher than the healthcare-seeking behavior report from Pakistan (21.3%). The difference could be due to differences in the inclusion criteria to recruit participants. A study from eastern Ethiopia involved only married women and the study from Iran involved only reproductive age (18–45 years) women, while the study from Pakistan involved all women. Reproductive age and married women can get a support and access money compared to their counterparts.

In this review, the level of healthcare-seeking behavior reported in Boston, USA (68.8%) (37) and California states, USA (73.4%) (33), are higher than the health-seeking behavior reported in Ethiopia (40%), Iran (39.4%), Nepal (52%), United Arab Emirate (46%) and Pakistan (21%). Among other reasons, this could be related to the difference in economic status, availability of health care, and fear of stigma. It was repeatedly reported that the common reasons for not seeking healthcare for pelvic organ prolapse in low-income countries were lack of money for transportation and healthcare payment (11, 13, 24, 39), and fear of social discrimination (19). In low-income countries, even among women who seek health care, most of them were delayed for more than a year before seeking care. Among women admitted to hospitals for POP surgery, 82% in Ethiopia (13) and 36% in Uganda (32) were delayed at least 12 months before seeking care.

This review has synthesized and revealed the level of healthcare-seeking behavior in various settings based on the best available evidence. The possible source of difference in healthcare-seeking behavior was also identified. This may increase the understanding of the inequalities in healthcare-seeking behavior. Among others, one limitation of this review is that we identified and retrieved only papers published in English language.

The review shows that the level of healthcare-seeking behavior is low in low-income countries and relatively high in high income countries. In addition, there is a gap in the literature that assessed healthcare-seeking behavior. We recommend a large-scale study with a sub-group analysis (based on study population characteristics and their income) which will help to understand the healthcare-seeking behavior in general.

Ethics approval and consent to participate

Not applicable

Consent for publication

Not applicable

Availability of data and material

All data supporting this information is included in the main document

Competing interests

All authors declare that they have no competing interest

Funding

No fund was received for this review

Authors' contributions

Siyoum, M: Project development, data extraction, manuscript writing

Alelgn, Y: Project development, data extraction, manuscript writing

Astatkie, A: Project development, manuscript writing

Teklesilase W: Manuscript writing

All authors had read and approved the manuscript

Acknowledgements

We would like to thank the authors and participants of the primary studies included in this review.

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No competing interests reported.

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Inequality in healthcare-seeking behavior among women with pelvic organ prolapse: A systematic review and narrative synthesis

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Journal Publication

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Abstract

Figures

Introduction

Materials And Methods

Study design and search process

Eligibility and selection criteria

Methods for data Extraction

Quality Assessment

Outcome measurement

Data Synthesis

Results

Identification of studies

Characteristics of the included studies

Disparities in healthcare-seeking behavior among women with pelvic organ prolapse

Quality of included studies

Discussion

Conclusions

Declarations

References

Additional Declarations

Supplementary Files

Status:

Journal Publication

Version 1