Knowledge and Practices of Women Regarding Risk Factors and Preventive Measures of Vaginal Prolapse

Background: Vaginal prolapse is a gynecological health issue that affects millions of women worldwide. It occurs when the vaginal canal descends below its normal position. This is a frequent disorder among women that hurts their quality of life. The current study aimed to assess the knowledge and practices of women regarding risk factors and preventive measures for vaginal prolapse. Subjects and method: Design: A descriptive correlational research design was utilized. Between July and December 2020. Subjects: the researcher employed purposive sampling techniques on 355 women aged 19 to 49 at seven government maternity and child centers in Port Said. Tools: The data was collected by using an interview questionnaire. The Results: The majority of women surveyed (69.6%) had insufficient general knowledge regarding vaginal prolapse (49.8%) had heard of vaginal prolapse from a medical team, and more than half of the women surveyed in the sample (56.9%) thought that preventive methods for vaginal prolapse were satisfactory (antenatal, postpartum, and postpartum). Finally, there was a significant positive link between women's general understanding of vaginal prolapse and their general practice of it (P=0.000). Conclusion: Women had inadequate total knowledge regarding vaginal prolapse. The vast majority of women practice antenatal, natal, and postnatal measures to prevent the occurrence of vaginal prolapse. Recommendations: It was recommended that a vaginal prolapse awareness program for women in their reproductive years must be implemented to prevent its occurrence.


INTRODUCTION
Vaginal prolapse is one of the most serious and common gynecological health issues that women face, negatively impacting their quality of life. Prolapse of the anterior vaginal wall, posterior vaginal wall, or cervical prolapse occurs when one or more vaginal walls or the cervix are lowered from their normal position. Vaginal prolapse affects approximately 30% of women of childbearing age and more than 50% of women over the age of 50. However, this may be due to a combination of cultural factors, traditional beliefs, and sexism, as many women refuse to seek medical care (Parajuli and Lawot, 2020).
Prolapse was found in 56 percent of Egyptians, 5.5 percent of Italians, 53.6 percent of Iranians, 1.9 percent of Californians, and 19.1 percent of Pakistanis. In young mothers who have recently given birth to one or two children, the rate is significantly greater (5-8%) (Virkud, 2016). However, due to numerous birth rates and early marriages, evidence of the frequency of genital prolapse in Egypt is limited (Mohammed, Mahmoud, & Abd-Elhafeez, 2020). Women with vaginal prolapse may have vaginal, urinary, and bowel symptoms, such as vaginal protrusion and dyspareunia, urine incontinence, and frequent and incomplete bladder emptying; gastrointestinal symptoms include gas or fecal incontinence, straining during bowel movements (Horst, Valle, Silva & Gascho, 2017).
Many factors can cause vaginal prolapse, including aging-related injuries, inappropriate behavior during childbirth, especially in multiparous women (those who have given birth more than three times), obesity, the birth of a large fetus, chronic cough, and chronic constipation, all of which result in muscle tension loss (Pal, 2016). According to Mahmoud and Abd-Elhafeez (2020), vaginal prolapse can be prevented by boosting awareness among women about preventive measures.
Vaginal prolapse can be treated in a variety of ways, both non-surgical and surgical. In obese women who are currently having surgical therapy for vaginal prolapse, non-surgical treatments such as pessaries, pelvic floor muscle exercises, or both may help with symptom relief and weight loss (Aryal et al, 2017). Women can play a crucial role during childbirth by assisting them in expressing their demands without fear and teaching them the necessity of correct precautions and care at an early stage. Women must have a thorough understanding of vaginal prolapse.

Significance of the Study
Vaginal prolapse is a worldwide health issue that affects women of all ages. Because of the related symptoms and the need for repeated surgical treatments, it hurts women's quality of life (Elsayed, Ahmed & Gaheen, 2016). It is a major gynecological issue in both developed and developing countries, affecting millions of women who are of reproductive age or have reached menopause. The global prevalence of vaginal prolapse in women under the age of 45 is estimated to be between 2 and 20%; whereas one in every nine women in the United States will have pelvic floor surgery over her lifetime, 30% of these women will need subsequent surgery (Yohannes, Hadra, Aychilu & Tulu, 2019). Egyptian prolapse is a common occurrence (56 percent ).
Women's lack of awareness about vaginal prolapse can lead to a variety of major reproductive health issues. As a result, you must exercise greater caution to avoid these issues (Rashad, Fadel & El-Nemer, 2018). As a result, women should be tested for vaginal prolapse knowledge and practice. As a result, the goal of this study was to analyze women at the University of Port Said in Egypt's knowledge and practice of vaginal prolapse risk factors and preventive strategies.

AIM OF STUDY:
To assess the knowledge and practices of women regarding risk factors and preventive measures for vaginal prolapse

Sample Size:
A sample of 355 women was determined by using the following sample size equation: Tools for data collection are three as follows: The researcher developed the interview questionnaire sheet after reading the relevant current and previous literature. There were three parts First part: It is used to evaluate women's general characteristics, such as age, residence, level of education, occupation, and income, as well as medical, surgical, familial, reproductive, and gynecological history.
Second part: Vaginal prolapse knowledge questionnaire; It was developed by researchers following a thorough review of the literature (Lyatoshinskaya, Gumina, Popov, Koch, Hagmann & Umek, 2016). To measure women's knowledge of vaginal prolapse, it will be translated into Arabic. It covers vaginal prolapse definitions, risk factors, symptoms, complications, prevention, and treatment.

Scoring system:
A correct answer receives a score of (2), an incorrect answer receives a score of (1), or the answer is unknown. The total score for female vaginal prolapse knowledge is 16, with adequate knowledge scoring 60% and inadequate knowledge scoring 60%. (scores below 9) and 60 percent have adequate knowledge (scores 9-16).
Third part: Vaginal prolapse preventive practices questionnaire; This section discusses the preventive and anticipatory efforts that women take to avoid vaginal prolapse, such as engaging in vigorous exercise such as lifting heavy weights, and leading a healthy lifestyle.
Scoring system : Correctly completed exercises receive (2) points -Exercises that are not completed or are not completed correctly will receive (1) point. The final result is as follows: -A satisfactory practice rate of more than 60%. -while if less than 60 percent, the practice is unsatisfactory.

Pilot Study:
A pilot study was done to evaluate the tools' clarity, feasibility, and application. Before the data collection phase began, the study was done in June 2020, with 10% of the women interviewed (32). Women who took part in the pilot study are included in the overall sample size. The pilot study also gave investigators experience dealing with the issues and familiarity with the setting, as well as the time needed to fill out data collection forms in the data collection tool. As needed, changes were made.

Tools validity:
The tools were reviewed for content validity by a jury of nine experts in the field of obstetrics and gynecological nursing and medicine to ascertain their content validity. They were requested to express their opinions and comments on the developed tool. The tools were modified according to jury opinions and suggestions such as clarifying some statements, and retranslation of certain words. This phase was carried out in six weeks.

Reliability:
The reliability of tools was tested by using Cronbach's Alpha coefficient test by measuring the internal consistency of the developed tool; Cronbach's Alpha coefficient test was 0.871 for knowledge and 0.930 for practice which refers to be reliable.

Fieldwork:
Data collection began in July 2020 and finished in December 2020. The researchers visited the gynecological clinics of the previously mentioned facilities and units from 9:00 a.m. to 2:00 p.m. after receiving consent from the directors of the centers and units. Three times a week until the sample size reaches the desired level (355). When each woman was told about the study's goal and provided oral informed permission, all ethical considerations were addressed. Participants' information will be kept private and confidential, and it will only be used for research reasons. After that, the researchers met with each woman in person and collected the essential information. For data analysis, the responses were reviewed and aggregated.
Statistical Design: Following data collection, the acquired data was coded, sorted, tabulated, and analyzed using the SPSS program according to each data type. To portray qualitative data, numbers and percentages are used. The mean and standard deviation are used to describe quantitative data. To compare qualitative variables, (X2) is employed. A pvalue of less than 0.05 denotes a significant level value, a p-value of less than 0.001 denotes a highly significant level value, and a p-value of more than 0.05 denotes a non-significant result.   Table (2): revealed that more than two-thirds (82.5%) of women don't follow a healthy diet to maintain ideal body weight and don't reduce consumption of stimulants such as tea and coffee. Few of them (7.6%) keep regular exercise weekly. Above half of them (67.95%) don't treat coughs immediately. However, (41.7%) of women avoid constipation. Less than one-third (27.3%) avoid lifting heavy objects, also about half of them (43.1%) do not smoke and do not expose to negative smoking. About (17.5%) of them go to the doctor without worrying to complain about the genital system to take the appropriate action.   shows that there is a highly significant relation between women's knowledge & both educational level and occupation ( p-value =0.000**), while no significant relation was found between women's knowledge and age, marital status, and income (pvalue is more than 0.05).

Table (6):
shows that there is a significant relation between practices with educational status (p-value is less than 0.05), while no significant relation was found between practice and both age, marital status, occupation& family income ( p-value is more than 0.05.

Figure (2):
Shows that there is a positive correlation between overall knowledge and overall practice.  (n=355).

Items
Incorrect answer Correct answer

DISCUSSION:
Vaginal prolapse is a prevalent gynecological health concern that affects women all over the world. This is a community-based cross-sectional descriptive study that includes seven Port Said districts. The major aim of the study was to assess the knowledge and practices of women regarding risk factors and preventive measures for vaginal prolapse.
In this study, the majority of the participants were not aware of vaginal prolapse, while the rest were aware. More than half of the sample were incorrect about the factors that keep the female reproductive system in a proper posture. The findings of the study conducted in Bhaktapur and teaching hospitals in Kathmandu were practically identical.
The survey discovered that two-thirds of women knew what prolapse meant, whereas the other third didn't know or misunderstood it.
The findings demonstrate that women were aware of the causes of vaginal prolapse, with almost half of the respondents correctly answered the question, similar to a survey done by Pokharel, Jain, and Gupta, (2016) among women attending a gynecological clinic in Kathmandu, Nepal. About two-thirds of women answered incorrectly about the symptoms of vaginal prolapse, according to Tamrakar (2012), who found comparable results in Kaski. While the majority of the respondents answered correctly, they claimed vaginal bleeding and foul-smelling discharge, followed by a feeling of something coming down the birth canal.
In this study, less than one fifth of the sample were aware of how to prevent vaginal prolapse. Kegel exercises, which play a vital role in preventing and treating vaginal prolapse, were discovered to be unknown by less than one third of respondents.
An earlier study by Pandey (2015) &Elsayed, Ahmed, andGaheen (2016) found similar results as they found that only a small percentage of the study participants were aware of preventive strategies such as Kegel exercises. Mishera (2020) also found that less than half percent of married women were aware of prolapse preventive methods.
The study revealed that the majority of the participants had inadequate total knowledge about vaginal prolapse. The mean knowledge value was 2.439 ± 2.591.
Various studies, such as Elsayed, Ahmed, and Gaheen (2016), which investigated the knowledge and practice of risk factors for vaginal prolapse among outpatient women at two Tanta hospitals, found that the majority of the studies had a low level of female knowledge.
When Pandey (2015) assessed married women's awareness of preventing uterovaginal prolapse in a teaching hospital in Kathmandu, he found that near one third had a good understanding. In addition, Bhurtel, Mandal, and Shah (2019) discovered that more than half percent of Nepali women of reproductive age had inadequate knowledge of uterine prolapse. Furthermore, Mishra and Shrestha (2020) discovered that more than half of respondents had poor knowledge of genital prolapse. In contrast, Parajuli, and Lawot (2020) investigated awareness of uterine prolapse among parous women in Kaski Pokhara and reported that more than two-thirds of parous women were aware of uterine prolapse.
Concerning the measures, women take to prevent vaginal prolapse before pregnancy or childbirth. The findings revealed that about one fifth of women ate a balanced diet, reduced stimulant usage, had their cough treated immediately and avoided carrying out heavy objects. Also near half of them avoided constipation. More than half of women did n't smoke and did n't expose to negative smoking, and about one-fifth will seek medical treatment without hesitation. Pokharel, Jain, and Gupta (2016) researched gynecological women and discovered that the majority of respondents lost significant weight throughout pregnancy and daily activities. Pelvic organ shedding owing to flaws in the pelvic support system, also known as pelvic organ prolapse, is a relatively common condition, according to Biroly and Lamberti (2018).
This research proposes methods for preventing vaginal prolapse during pregnancy and childbirth. More than half of women are cared for by trained staff during childbirth with regular prenatal visits, About one third of the sample avoid heavy lifting during pregnancy, more than one third prevent cough or constipation during pregnancy and avoid both cough and constipation during pregnancy. Women continue to apply downward pressure only throughout the second stage of labor, and few of them did regular pregnancy-appropriate exercises, particularly pelvic floor movements (Kegel exercises). Because vaginal prolapse happens when the pelvic floor muscles become too weak to maintain the organs in place, frequent pelvic floor exercises are the best strategy to prevent it (Huang & Chang, 2020).
Practices on the precautions that women take to prevent vaginal prolapse after giving birth. Two-thirds of women utilized adequate birth control methods, while half of women maintained their optimum weight and avoid Cough and constipation, one-third of them eat a healthy diet and drink enough water, one-quarter avoid weight lifting, only one-fifth get enough rest and relaxation and few of them routinely exercise, especially those that strengthen the pelvic floor muscles. These findings are similar to those of Mishera (2020), who reported similar postpartum vaginal prolapse prevention strategies.
In regards to the comprehensive approach that women take as a preventative step against vaginal prolapse. The majority of women investigated had satisfactory vaginal prolapse prevention, according to the current study. This finding is supported by Acharya (2016), who looked at the factors that influence uterovaginal prolapse in Nepalese multiparous women, and Divya et al. (2015), who looked at the knowledge of uterovaginal prolapse in women at the Sree Balaji School of Medicine and Hospital.
These findings, on the other hand, contradict those of Elsayed, Ahmed, and Gaheen (2016), who found that the majority of the women investigated had difficulty preventing uterine prolapse.
This study discovered a significant relation (p=0.000) between women's total knowledge of vaginal prolapse and their general characteristics such as educational level and occupation. There were no significant connections with income, marital status or age at marriage, on the other hand. The findings of this study are partially in line with those of Singh, Lama, and Maharjan (2016), who discovered a substantial (P=0.001) link between respondents' knowledge and educational status. The findings contradict those of Mandimika, Murk, and McPencow (2014), who found that being older and having a middling home income were both related to poor knowledge.
In addition, Ibrahim, Fadel, and El-Nemer (2018)  The current data revealed a substantial relation between total practice and educational status, as well as a significant P-value (0.001). Roshdy (2013) found a positive correlation between overall self-care practices related to uterine prolapse and their general data, which included women's level of uterine prolapse practice versus its characteristics, education level, prior knowledge of guidelines, and also showed a positive correlation between overall self-care practices related to uterine prolapse and their general data.
The current study found a significant statistical correlation between general knowledge and general practice among the women tested and (p 0.000), respectively.
Khanal et al. (2020) found a significant positive connection between "Knowledge and attitudes about prolapse among married women of childbearing age in India" and "Knowledge and attitudes about prolapse among married women of childbearing age in India." Mohammed, Mohamed, N., Abdelhalem, and Abozied (2022) found the same results.
Examine the impact of nursing intervention packages on the prevention of uterine prolapse in third-trimester pregnant women.

CONCLUSION:
Women of childbearing age who live in low-income households have inadequate knowledge concerning vaginal prolapse., the vast majority of women adopt antenatal, postpartum and postpartum precautions to prevent vaginal prolapse.

RECOMMENDATIONS:
A vaginal prolapse awareness program is recommended for women of childbearing age to help them avoid vaginal prolapse. More research is needed to apply women's health education programs to increase their awareness of risk factors and preventive measures to avoid vaginal prolapse.