Perceptions of Pelvic Floor Dysfunction and Rehabilitation Care Among Women in Southeast China After Radical Hysterectomy: a Qualitative Study

Objective: To investigate the perceptions of pelvic oor dysfunction and rehabilitation care among women after radical hysterectomy and to explore ways to improve quality of care. Methods: Thirty-six women who underwent radical hysterectomy at a hospital in southeast China were enrolled via purposive sampling. One-on-one semistructured in-depth interviews were conducted. The texts were analyzed via qualitative content analysis (Graneheim & Lundman). Results: Four themes were attained: serious lack of knowledge of PFD and rehabilitation care; heavy psychological burden; different coping styles to PFD; and great eagerness to receive multiparty support on PFD rehabilitation care. Conclusion: The women had a low cognition of pelvic oor dysfunction and rehabilitation care after radical hysterectomy. Poor awareness of pelvic oor dysfunction among women is one of the reasons they do not ask for support from the society and even from family members. Knowledge of pelvic oor dysfunction should be shared and disseminated to the society to raise public awareness of this medical condition. Moreover, knowledge of medical insurance should be popularized, especially in rural areas in southeast of China. Family-centered care is an important way to support women with pelvic oor dysfunction.


Introduction
Radical hysterectomy is one of the most recommended surgical procedures for gynecological malignancies owing to its high cure rate [1]. However, radical hysterectomy substantially changes the overall structure of the pelvis, thereby increasing the incidence of pelvic oor dysfunction (PFD) [2].
Disruption of local nerve supplies and distortion of anatomical relationships in the pelvic oor after this operation may be main reasons that lead to diseases related to PFD [3].
PFD is a common but not fully understood disease. Its main symptoms are urinary incontinence, constipation, pelvic organ prolapses, and sexual dysfunction [4]. These symptoms impose heavy physical and mental burden to women and greatly in uence their daily lives [5] and psychological health [6], such as by negatively impacting their self-care activity and family and work relationships. A study reported that the prevalence of PFDs in low-and middle-income countries is 25% [7]. A recent meta-analysis of adult Chinese women noted that the prevalence of urinary incontinence is 31.1%, and it has been at a high level since 2005 [8]. Pelvic organ prolapses also affect 9.67% of urban Chinese women [9]. A study in the USA showed that 66.8% of participants are not aware of pelvic oor rehabilitation to address PFD [5]. To the best of our knowledge, perceptions of PFD and rehabilitation care among Chinese women after radical hysterectomy have not been explored yet.
For women who develop PFD after undergoing radical hysterectomy, rehabilitation therapy and care are often the primary choice in postoperative rehabilitation; this treatment modality can remarkably improve PFD symptoms and prevent its development [10]. Ideally, rehabilitation care for women with this condition should be implemented in the early postoperative period to ensure recovery from this condition [11]. However, women's perceptions of PFD considerably in uence their choice and adherence to treatment and care [12]. Therefore, the aim of this study was to investigate the perceptions of PFD and rehabilitation care among women who underwent radical hysterectomy to explore ways to improve quality of care.

Materials And Methods
This study was conducted at a provincial hospital in southeastern China from March 2019 to July 2019.
Women who underwent radical hysterectomy were recruited via purposive sampling according to their education levels, i.e., junior secondary education (9 years), senior secondary education (12-13 years), and higher education (15-19 years) [13]. The inclusion criteria were as follows: underwent radical hysterectomy, including open radical hysterectomy (ORH) and laparoscopic radical hysterectomy (LRH), had no serious complications, mental state was normal, uent in Mandarin, and signed informed consent. Participants were excluded if they were unable to complete the interview because of insu cient interview time or were emotionally unstable during the interview. This study was approved by the Ethics Committee of the First A liated Hospital of Fujian Medical University (FAHFMU [2018] No. 073). All methods in the study were performed in accordance with the Declaration of Helsinki.
Data were collected via semistructured individual interviews. A self-development interview guide consisting of nine questions about perceptions of PFD and rehabilitation care was used for data collection (Table 1). Following the interview guide, a researcher (Y. L.) interviewed each participant faceto-face for 30-45 min in a separate and quiet room at the hospital. The interviewer noted the nonverbal behavior of the participants. The entire interview was recorded using a digital audio recorder, and then the researcher (Y. L.) transcribed the participants' responses verbatim within 24 h after each interview. Table 1 Interview guide: Questions about perceptions of pelvic oor dysfunction and rehabilitation care among women after radical hysterectomy.
• What do you know about female pelvic oor function?
• If a woman has pelvic oor dysfunction (such as urinary incontinence), what do you think the cause is?
• How does radical hysterectomy affect you?
• What is your biggest concern after radical hysterectomy?
• How do you think radical hysterectomy will affect pelvic oor function?
• What will you do to treat pelvic oor dysfunction?
• What do you think about the rehabilitation care of pelvic oor function?
• How do you think rehabilitation care of pelvic oor function will affect you?
• What are the factors that affect your rehabilitation care of pelvic oor function?
Data were analyzed using the qualitative content analysis described by Graneheim and Lundman [14]. The analysis included manifest and latent content analysis as follows: (1) the text was read several times to obtain a whole sense of the participants' perception of PFD; (2) the text content was divided into meaning units according to the meaning of expression; (3) the meaning units were compressed and extracted into codes; (4) differences and similarities between codes were compared, and then the sorted codes with commonality were grouped into categories, i.e., manifest content analysis; and (5) the research team fully considered the social and cultural contexts of the interview content, discussed the formed codes and categories, and linked the underlying meanings to form themes, i.e., latent content analysis.

Results
Thirty-six women who met the inclusion criteria participated in this study. The median age of the participants was 48 years (42-58). Among the participants, 12 had a low educational level, 12 had a middle educational level, and 12 had a high educational level ( Table 2). Four themes were formed from the interview texts: serious lack of knowledge of PFD and rehabilitation care; heavy psychological burden; different coping styles to PFD; and great eagerness to receive multiparty support on PFD rehabilitation care. b Classi ed according to the education statistic data in 2018 [13].
The rst theme (serious lack of knowledge of PFD and rehabilitation care) consisted of two categories: limited knowledge of PFD and some knowledge of PFD but limited knowledge of pelvic oor rehabilitation care (Table 3). During the interview, most participants said that they were unaware of PFD. However, after learning the symptoms of PFD, some of the participants suggested that their advanced age and childbirth might have caused their PFD, but they were unsure if PFD was related to their radical hysterectomy. With regard to dealing with PFD, they did not know how to perform rehabilitation care, although some of them recognized the e cacy of this treatment modality. Several women said that they would not seek pelvic oor function rehabilitation care if they did not have symptoms of PFD. Therefore, the participants were unaware of the importance of early rehabilitation care after surgery. One woman stated that "The symptoms were normal, you know…so big surgery…It is not a disease. It needs to be slowly recovered. Do not need to see doctor for it." Table 3 Categories, codes, and meaning units included in the rst theme (serious lack of knowledge of PFD and rehabilitation care). Abbreviation: PFD, pelvic oor dysfunction.
The second theme (heavy psychological burden) was further categorized into fear and worry, shame and self-contempt, and guilt and self-blame (Table 4). Some women felt afraid and worried after they developed PFD symptoms; a woman said, "I fear, I fear that the urine cannot be closed…After I walk a little bit, urine can go itself." Some of them were afraid to know pertinent information on the disease; one of them reported, "I do not want to ask (doctors)…Knowing too much will hurt me even more". A few of them were worried about the development of the disease; they said, "Of course, I am anxious. I am worried day and night that pelvic oor dysfunction cannot be cured and develop... I cannot fall sleep all night." In general, the participants felt shame and stigma; one woman stated, "It is a terrible thing. I will feel ashamed if I say it (silence). People will say something bad if they know it…" Moreover, they felt selfcontempt because they lost their uterus, which meant that they lost their femininity and they considered that they were no longer a full female. Furthermore, a few of them narrated that their family had spent a lot of money for their treatment. Despite the intervention, they did not fully recover and remained sick because PFD appeared after the operation. Hence, they felt guilty and blamed themselves. Several women showed their apologies to their husband for asexual life; a woman expressed, "I'm sorry for him (husband), I can only let him do whatever he wants." Table 4 Categories, codes, and meaning units included in the second theme (heavy psychological burden). Abbreviation: PFD, pelvic oor dysfunction.

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The third theme presented two coping styles to PDF: one was being positive and the other was being passive (Table 5). Most women with PFD described that they adjusted their mentality, actively sought information on this condition, actively treated the disease, and focused on their recovery. A woman indicated, "First found it out from internet how to deal with it. Then, I went to the hospital for help…I am doing whatever the doctor says." However, a woman chose not to seek treatment and merely accepted her situation as "destiny". Some women only went to see a doctor when their symptoms started to affect their lives. A woman completely stop seeking help because of her advanced age; she said, "My life is de nitely getting worse because of the symptoms...I didn't see doctor. Life is getting worse day by day if you are old. It doesn't matter." Table 5 Categories, codes, and meaning units included in the third theme (different coping styles to PFD). Abbreviation: PFD, pelvic oor dysfunction.
The fourth theme was great eagerness to obtain multiparty support for PFD rehabilitation care; it included family support, professional support, and social support (Table 6). All women asked for understanding and support from their family, especially from their husband. A woman mentioned, "I do not know whether my husband permit me see doctor or not. I will come if my husband let me come." In addition, most of the participants hoped that health care staff could provide professional knowledge, skill support, and care for them. They stated that they would adhere to the health care staff's suggestions. The participants also hoped to receive social support. A woman said that she wanted to receive nancial support from the government. They believed that poor awareness of PFD in the society was one of the reasons they did not seek support from the society and even from family members. A woman said, "Although I often read popular medical magazines, I was blank in this eld before the doctor told me about the knowledge of pelvic oor dysfunction. I do think it is not known well by people in society. How can we get understanding and support from people around and society?" Table 6 Categories, codes, and meaning units included in the fourth theme (great eagerness to receive multiparty support on PFD rehabilitation care).

Discussion
Radical hysterectomy unavoidably damages pelvic oor tissues [2]. Early postoperative rehabilitation can effectively restore pelvic oor functions and reduce the incidence of PFD [15]. Perception is to use selfcognition to explain sensory signals across multiple spatial and temporal scales; thus, perception leads to action [16]. Therefore, perceptions of PFD and rehabilitation care are the key to the recovery of pelvic oor functions for women after radical hysterectomy.
The participants in this study had a serious lack of knowledge of PFD and rehabilitation care. Most of them did not know that radical hysterectomy would result in PFD. The rst reason might be that all participants had a malignant tumor. They focused on the treatment and surgical removal of tumor and neglected the impact of the procedure on pelvic oor functions. This observation was consistent with the rule of perception, that is, humans focus on more important tasks in a complex environment [17]. The second reason might be the poor public awareness of PFD that seriously in uenced the attitudes and behaviors of the women toward rehabilitation care of PFD. A low social popularization of diseases would lead to misconceptions about the disease among patients and other people in their social circle [18]. A study showed that discussing PFD symptoms among friends is one of the factors that prevent women from actively seeking medical treatment [19]. The third reason might be insu cient health education about PFD in hospitals and the society. Health education from professionals is one of the most economical and effective ways for improving awareness of diseases among patients and the public [20,21]. However, a systematic review noted a huge gap in knowledge of PFD among most women [22].
Therefore, knowledge of PFD and rehabilitation care should be popularized and strengthened in hospitals and the society via multiple channels, such as brochures, posters, internet, television, and radio.
The occurrence of PFD after radical hysterectomy brings women not only great physical suffering but also huge psychological trauma. In this study, the women feared their diseases and postoperative changes in their body. Given that they lost their uterus after the operation and owing to the speci city of PFD symptoms and location, the women stated that they suffered from negative feelings, such as shame and guilt, which seriously affected their quality of life. The present study indicated that, among the participants, losing their uterus meant losing their femininity, an observation also reported by a previous study [23]. A qualitative study of the psychological consequences of pelvic oor trauma after vaginal birth also reported that the women plunged in negative emotions, such as anxiety, stigma, and failure [24]. Another study showed that feelings of shame about the disease is the main factor why women do not see a doctor [25]. However, the women in the present study a rmed that they were eager to receive professional help. Therefore, health care professionals should focus on the psychological and mental health of affected women, strengthen their con dence that they would recover, and enhance their sense of self-worth sense while conducting health education/pelvic oor function rehabilitation care. In addition, an excellent intervention might be to organize a group of women who suffers from PFD with the assistance of health care professionals. Doing so might alleviate their suffering, and they could receive understanding and support from each other.
The interviews revealed that most of the participants adopted a positive coping mechanism in the face of PFD after radical hysterectomy. However, some of them adopted a negative coping mechanism, such as seeing a doctor only when the symptoms had affected their lives, gave up seeking help, and accepted their condition as their fate. Several reasons may explain these observations. First, some of them believed that PFD is an inevitable suffering brought by aging, and disease management is unnecessary in their old age. This belief was similar to that described by Vethanayagam et al. [26]. Second, the public's misconceptions on PFD stigmatized the women with this disease because of poor social awareness. The stigma reduces the possibility of women disclosing their illness and seeking help [27]. Third, owing to the overarching in uence of traditional Chinese concepts, some women in rural areas have a low degree of self-identity and largely rely on their husbands when it comes to making decisions about major family affairs [28]. As wives and mothers, women in traditional Chinese culture assume the responsibility as caregivers in the family, prioritizing family obligations over their own health and hiding their own needs to decrease the burden and not impose on the family [29]. These reasons not only highlighted the importance of popularizing PFD knowledge in the society but also emphasized the importance of improving women's self-identity. An effective support system for individuals can reduce psychological burden, improve the level of disease response, and ultimately promote disease recovery [30]. With regard to family support, the participants hoped to receive understanding and support from their families, especially from their husbands. A study reported that cooperation between husbands and wives is necessary in the prevention and treatment of chronic diseases, such as PFD [31]. The closer the family relationship is, the stronger the couple's coping ability will be, and the better they can deal with the problems caused by the disease [32]. Given that PFD is related to privacy and sex, understanding and support from husbands are especially important. Therefore, family-centered care is an important way to support women with PFD. Health care professionals should focus on husbands, help women receive understanding and support from family members, and encourage family members to actively participate in women's rehabilitation care.
Moreover, the participants hoped to receive social support. Social support can not only promote patients' healthy behaviors but also promote their compliance with medical regimens [33,34]. A low income usually negatively affects people's awareness of diseases and willingness to seek medical treatment [35].
Owing to the increasing number of patients with PFD, basic medical insurance for pelvic oor function rehabilitation care is also necessary to reduce the nancial burden on women and increase their willingness to seek medical help. The medical insurance system in China covers all Chinese citizens living in the country. Thus, people can enjoy preferential medical treatment at a relatively low price [36].
However, some women from rural areas revealed during the interviews that they did not have medical insurance, suggesting that the public, especially in rural areas, not only lacks knowledge of PFD but also of medical insurance.
This study has several limitations. First, the data may not be su cient. The results might have been affected by some nuances in the translation of the texts from Chinese to English. Nevertheless, a qualitative study through detailed interviews and observations can provide insights into individuals' thoughts, behavior, and understanding in life [37]. This study offered evidence on the low cognition of PFD and rehabilitation care after radical hysterectomy among women and the society. This study explored the underlying reasons and speci ed various ways to improve the quality of care for women with PFD.
In conclusion, this study explored the low cognition of pelvic oor dysfunction and rehabilitation care among women living in southeast China after radical hysterectomy. The poor awareness of PFD in the society is one of the reasons women did not seek support from the society and even from family members. Therefore, knowledge of PFD must be popularized to raise public awareness of this condition.
In rural areas in southeast of China, knowledge of medical insurance must also be popularized. Familycentered care is an important way to support women with PFD.

Declarations
Ethics approval and consent to participate

Availability of data and materials
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
Y. L. participated in the design of the study, data collection, data analysis and writing the main manuscript text. A. L. participated in the design of the study, data collection, data analysis and preparing the manuscript. L. G. participated in the design of the study, data analysis, preparing the manuscript, interpretation, and critical revision of the manuscript for important intellectual content. Z. Z. participated in data analysis, interpretation, and critical revision of the manuscript for important intellectual content. Y.
W. participated in data analysis, interpretation, and critical revision of the manuscript for important intellectual content. H. Y. participated in data analysis, preparing the manuscript. X. J. participated in data analysis, preparing the manuscript. All authors read and approved the nal manuscript.