Stesura Seveso Archivio Italiano di Urologia e Andrologia 2023; 95, 2 108 ORIGINAL PAPER muscle training is the most recommended treatment method, especially for stage 1 stress urinary incontinence (4). Thus, pelvic floor muscle training (PFMT) has been rec- ognized as the first-line therapy for urinary incontinence (5). Women with the symptom of stress and mixed uri- nary incontinence who had the treatment of PFMT showed improvement in their symptoms of UI (4). The rationale for doing PFMT is to maximize the urethral pressure and improve the voluntary contraction of the muscle by improving pelvic floor muscle strength (6). In Malaysia, the prevalence of UI among women was 17.3% while for antenatal cases it was 34.3% during their third trimester (3). However, compared with Turkey, the prevalence of UI among pregnant women was high, with almost 80% with stress urinary incontinence (7). A study among antenatal women in Kelantan showed women had a low level of knowledge regarding PFMT with only 5.8% doing PFMT (8). The result showed that the women knew the information regarding PFMT (9). Whereas another finding in Selangor stated that 46.6% of pregnant women had a good attitude towards PFMT (10). There is no standardized measurement tool that can be used to discern the type, severity, or bother attributed to UI at one time. In government hospitals and clinics throughout Malaysia, a variety of forms of UI screening were identified. Presently, to identify all the symptoms, women had to complete multiple questionnaires in one setting, and the healthcare professionals then had to determine how to interpret and assimilate the results of these different measures. One of the instruments with high accuracy levels to discern the types of urinary incon- tinence is Michigan Incontinence Symptom Index (M-ISI) (11). Unlike other UI questionnaires, the M-ISI covers different aspects of UI that were essential for women's care and research. It also has been proved that the thresh- old scores for the M-ISI could be used to screen for clin- ically relevant urinary incontinence (11). This study provided a simple and comprehensive instru- ment to measure types, severity, and bother related to UI among childbearing women. The aims were to identify the knowledge, attitude, and practice towards pelvic floor muscle training, to measure the UI using a validated M- ISI questionnaire, and to identify the association between the UI and PFMT among childbearing women. Objectives: This study aims to identify knowledge, attitude, and practice of pelvic floor muscle training (PFMT) and to identify the prevalence of urinary incontinence. Materials and methods: The method used was a cross-sectional study. Self-administered knowledge, attitude, and practice ques- tionnaires were distributed among childbearing women attend- ing Maternal & Child Health Clinics in the East Coast region of Malaysia. Results: The findings revealed that most respondents (N = 896) had good or moderate knowledge (80.1%) and attitudes (77.3%) regarding PFMT but most of them (87.2%) still lacked practice. However, there was no association between urinary inconti- nence and PFMT practice. On the contrary, married women showed a higher risk of urinary incontinence. Conclusions: The practice of pelvic floor muscle training should be recommended and emphasized to childbearing women by healthcare professionals. KEY WORDS: Attitude; Knowledge; Pelvic floor muscle training; Practice; Urinary incontinence; M-ISI. Submitted 10 March 2023; Accepted 18 March 2023 INTRODUCTION Urinary incontinence (UI) is one of the worldwide health problems but is not considered life-threatening (1). Most of the victims did not share their problems and kept silent until they were interviewed by healthcare professionals. A study identified factors that affect help-seeking behavior: not accepting incontinence as a disease, shame, non-opti- mal health care system, negative support of essential oth- ers and reduced quality of life (2). The risk factors for UI include menopause, increased body mass index, straining hard during defecation, coffee consumption and depres- sion (3). The management of UI was divided into two, which are conservative and non-conservative treatment. The non- conservative treatment is the medical or surgical treat- ment, whereas the conservative treatment is non-costly. One of the conservative treatments is, pelvic floor muscle training, or known as Kegel’s exercise. In 1948, Dr. Kegel, who invented the Kegel exercise, stated that the cure rate after training pelvic floor muscles for women with differ- ent types of incontinence was 84%. Besides, pelvic floor Knowledge, attitude and practice towards pelvic floor muscle training among childbearing women Nur Fairuz Mohd Fauzey 1, Siti Mariam Muda 2, Haliza Hasan 2, Zalina Nusee 3, Muzaitul Akma Mustapa Kamal Basha 2 1 Kulliyyah of Nursing, International Islamic University Malaysia, Kuantan, Malaysia; 2 Department of Special Care Nursing, Kulliyyah of Nursing, International Islamic University Malaysia, Kuantan, Malaysia; 3 Department of Obstetrics & Gynecology, Kulliyah of Medicine, International Islamic University Malaysia, Kuantan, Malaysia. Presented as conference papers at the 8th V-BINC at FON Universitas Indonesia. DOI: 10.4081/aiua.2023.11298 Summary Archivio Italiano di Urologia e Andrologia 2023; 95, 2 Nur Fairuz Mohd Fauzey, Siti Mariam Muda, Haliza Hasan, Zalina Nusee, Muzaitul Akma Mustapa Kamal Basha 109 MATERIALS AND METHODS The study used a quantitative research method with cross- sectional design. It was conducted at five government Maternal & Child Health Clinics in the East Coast Region in Malaysia (Kelantan, Terengganu, Pahang). The populations were childbearing women who attended the Maternal and Child Health Clinic. The inclusion criteria were Malaysian women, aged 18 to 45 years old, and able to read in Malay. The exclusion criteria included menopausal women, a history of mental health problems, and diag- nosed chronic illness. The study included 2 parts: the first part was the recruitment process, and the second was the administration of two sets of questionnaires, M-ISI screen- ing test and a survey on knowledge, attitude, and practice of pelvic floor muscle training. Figure 1 shows the process of recruitment of participants in this study. The sample size was calculated using the open-source cal- culation OpenEpi Version 3 using the Odds Ratio (OR) from a previous study (10). Using a 20% non-response factor, it was decided to have a total of 1219 childbearing women involved in the study. All the data obtained from the study were recorded and statistically analysed using Statistical Package for Social Science Software, version 26.0. Basic details of the partici- pants and urinary incontinence were analysed using descriptive statistics, including mean and standard devia- tion or median with interquartile range for non-normally distributed data. A Chi-square test was used to identify the association between urinary incontinence and pelvic floor muscle training and logistic regression was done to identify the predictors of urinary incontinence among childbearing women. This study obtained approval from the Research Committee at International Islamic University Malaysia (IIUM) (IREC 2021-008) and National Medical Research Register (NMRR) (NMRR-19-4172-51098). All participants consented and were involved in this study on a voluntary basis. RESULTS A total of 896 participants answered all questions yield- ing a 74% completion rate, with the power of the study being 100%. Age distribution is shown in Table 1. There were 506 participants (58.0%) who were multigravida (usually 3-5 pregnancies), while 30% were primigravida who had first-time experience in pregnancy. The majori- ty of the participant were Malay (99.5%), and the highest educational level was diploma/degree holder (48.8%). More than half of the participants (52.6%) were house- wives, and in terms of monthly income, the majority of the participants (78.2%) were categorized in the lower household income group (B40), earning less than RM4,850 per month. The number of women with UI using the M-ISI question- naire was 173, with an estimated prevalence of 19.3% (Table 2). As reported in table 3, 43.0% of the respon- dents had good knowledge of PFMT. Most of the child- bearing women had a moderate attitude toward PFMT (55.9%) and poor practice toward PFMT (87.2%). As reported in Table 3, 43.0% of the respondents had good knowledge of PFMT. Most of the childbearing women had Table 1. Socio-demographic characteristics. Characteristics Frequency Percentage (%) Age (years) (n = 887) < 20 28 3.2 21-30 432 48.7* 31-40 361 40.7 > 41 66 7.4 Marital status (n=883) Single 23 2.6 Married 850 96.3* Widow 10 1.1 Gravida (n = 873) Nulligravida 14 1.6 Primigravida 262 30.0 Multigravida 506 58.0* Grand multigravida 91 10.4 Ethnicity (n = 885) Malay 881 99.5* Chinese 2 0.2 India 2 0.2 Educational level (n = 864) Primary school 17 2.0 Secondary school 401 46.4 Diploma/Degree 422 48.8* Master/PhD 24 2.8 Occupation (n = 854) Housewife 449 52.6* Self-employed 92 10.8 Government sector 175 20.5 Private sector 135 15.8 Student 3 0.4 Monthly income** (n = 832) B40 (bottom 40%) 651 78.2* M40 (middle 40%) 168 20.2 T20 (top 20%) 13 1.6 *The highest score in each item; **Malaysian household income classification. Table 2. The prevalence of urinary incontinence. Urinary incontinence Frequency Percentage (%) Yes 173 19.3 No 723 80.7 Figure 1. The process of recruitment of participants. Archivio Italiano di Urologia e Andrologia 2023; 95, 2 110 Pelvic floor muscle training among childbearing women a moderate attitude toward PFMT (55.9%) and the major- ity reported a poor practice of PFMT (87.2%). Table 4 depicted that there was a significant association between the level of knowledge of PFMT and UI (p = 0.001); it also showed a significant association between the level of attitude toward PFMT and UI (p = 0.009) but no significant association between level of practice of PFMT and UI (p > 0.05). Good knowledge of PFMT (adjusted OR = 0.69; 95% CI 0.41-1.19) and moderate knowledge of PFMT (adjusted OR = 0.70, 95% CI 0.43-1.14) were negative predictors of UI, meaning that women with good/moderate knowl- edge are less likely prone to UI compared to those with poor knowledge. However, other socio-demographic fac- tors, such as being married women, showed to be statis- tically significant towards the risk to be UI (p = 0.040). DISCUSSION The prevalence of UI among childbearing women in this study, which included the East Coast region of Malaysia, was lower than the one reported in a previous study, which evaluated the rate of UI among women aged > 18 years (12). However, the prevalence may vary with the place, population, and questionnaire that have been used. The various definitions of incontinence, the use of differ- ent questionnaires, settings, procedures, and the validity of self-report data all contributed to the variation in epi- demiological data about the prevalence rate of UI (5). This study found that most of the childbearing women had a good knowledge of PFMT, similar to the previous study conducted at one of the teaching hospitals in Malaysia (13). However, the respondents demonstrated a moderate attitude towards PFMT, contrary to the findings previously observed among antenatal women in Kelantan (14). The pregnant women felt that PFMT had positive effects on their health, such as improved incontinence, pelvic organ prolapse, quality of life and increased sexual satisfaction (15). There was a positive change in attitude score after attending antenatal class (16), and as a result, education was a critical factor in improving women’s atti- tudes and motivation towards PFMT. The finding from this study showed that married women had a significant association with UI. Married women were more likely to have UI than single women because they tend to have an older age, which becomes a risk fac- tor for UI (17). Being married women, earlier age at mar- riage, high parity, and old age were associated with the increase in UI among women in Lahore (18). Women do not practice PFMT, possibly due to a lack of information or awareness about doing this exercise during antenatal or postnatal periods. This can be seen in another study in which 44% of them reported lack of knowledge about the exercise and 96% stated that there was no guidance from healthcare professionals during the postpartum period in promoting PFMT (19). CONCLUSIONS This study revealed that, although overall knowledge and attitude towards PFMT were good, women did not practice the exercise regularly. Thus, it is recommended to health- care professionals to play an essential role by providing more information as well as raising awareness about PFMT. The best method to give the information effectively is dur- ing consultation sessions and the antenatal class. Acknowledgments: We would like to thank all partici- pants involved in this study for their help and support. Funding: This study was supported by the Fundamental Research Grant Scheme for Research Acculturation of Early Career Researchers (RACER) under Ministry of Higher Education Malaysia. Acknowledgement of financial support: This work was supported by Fundamental Research Grant Scheme for Research Acculturation of Early Career Researchers (RACER) under Ministry of Higher Education Malaysia. REFERENCES 1. Mohd Yusoff D, Awang S, Kueh YC. Urinary incontinence among pregnant women attending an antenatal clinic at a tertiary teaching hospital in North-East Malaysia. J Taibah Univ Med Sci. 2019; 14:39. Table 3. The level of knowledge, attitude and practice towards pelvic floor muscle training. Level Frequency Percentage (%) Knowledge towards pelvic floor muscle training Good 385 43.0 Moderate 332 37.1 Poor 179 20.0 Attitude towards pelvic floor muscle training Good 192 21.4 Moderate 501 55.9 Poor 203 22.7 Practice towards pelvic floor muscle training Good 32 3.6 Moderate 81 9.2 Poor 772 87.2 Table 4. Association between level of knowledge, attitude, and practice towards pelvic floor muscle training with urinary incontinence. Variable Urinary incontinence χ2 P-value Yes (n = 173) n (%) No (n = 723) n (%) Knowledge Good 61 (35.3) 324 (44.8) 14.195 0.001 Moderate 60 (34.7) 272 (37.6) Poor 52 (30.1) 127 (17.6) Attitude Good 30 (17.3) 162 (22.4) 9.368 0.009 Moderate 89 (51.4) 412 (57.0) Poor 54 (31.2) 149 (20.6) Yes (n = 169) n (%) No (n = 716) n (%) Practice Good 1 (0.6) 31 (4.3) 5.851 0.054 Moderate 18 (10.7) 63 (8.8) Poor 150 (88.8) 622 (86.9) Significant value, P-value < 0.05. Archivio Italiano di Urologia e Andrologia 2023; 95, 2 Nur Fairuz Mohd Fauzey, Siti Mariam Muda, Haliza Hasan, Zalina Nusee, Muzaitul Akma Mustapa Kamal Basha 111 2. Fakari FR, Hajian S, Darvish S, Alavi Majd H. Explaining factors affecting help-seeking behaviors in women with urinary incontinence: a qualitative study. BMC Health Serv Res. 2021; 21:1-10. 3. Kaur Dhillon H. Urinary incontinence amongst Malaysian women in Selangor: prevalence, types and risk factors. World J Public Health. 2019; 4:10. 4. Ptak M, Ciećwiez S, Brodowska A, et al. The Effect of Pelvic Floor Muscles Exercise on Quality of Life in Women with Stress Urinary Incontinence and Its Relationship with Vaginal Deliveries: A Randomized Trial. Biomed Res Int. 2019; 2019:5321864. 5. Abrams P, Smith AP, Cotterill N. The impact of urinary inconti- nence on health-related quality of life (HRQoL) in a real-world pop- ulation of women aged 45-60 years: results from a survey in France, Germany, the UK and the USA. BJU Int. 2015; 115:143. 6. Malhotra N, Chahal A. The effectiveness of pelvic floor exercises on symptoms in females with stress urinary incontinence. Biosci Biotechnol Res Commun. 2018; 11:681. 7. Özdemir K, Şahin S, Özerdoğan N, Ünsal A. Evaluation of urinary incontinence and quality of life in married women aged between 20 and 49 years (Sakarya, Turkey). Turk J Med Sci. 2018; 48:100-9. 8. Ahmed Ibrahim W. Assess levels of knowledge, attitude and prac- tice of the married women about pelvic floor muscles exercise. Int J Sci Res. 2015; 6:2319. 9. Rosediani M, Nik Rosmawati NH, Juliawati M, Norwati D. Knowledge, attitude and parctice towards pelvic floor muscle exercise among pregnant women attending antenatal clinic in Universiti Sains Malaysia Hospital, Malaysia. Int Med J. 2012; 19:37. 10. Jaffar A, Mohd-Sidik S, Nien FC, et al. Urinary incontinence and its association with pelvic floor muscle exercise among pregnant women attending a primary care clinic in Selangor, Malaysia. PLoS One. 2020; 15:e0236140. 11. Suskind AM, Dunn RL, Morgan DM, et al. A screening tool for clinically relevant urinary incontinence. Neurourol Urodyn. 2015; 34:332-5. 12. Baykuş N, Yenal K. Prevalence of urinary incontinence in women aged 18 and over and affecting factors. J Women Aging. 2020; 32:578-90. 13. Jarni MF, Mohamad MY, Kamarudzaman N. Knowledge, atti- tude, and practice (KAP) towards pelvic floor muscle exercise among the female population attending the Obstetrics and Gynaecology Clinic at Sultan Ahmad Shah Medical Centre (SASMEC@IIUM). International Journal of Allied Health Sciences. 2021; 5:2521-2529. 14. Muhammad J, Muhamad R, Husain NRN, Daud N. Pelvic floor muscle exercise education and factors associated with implementa- tion among antenatal women in Hospital Universiti Sains Malaysia. Korean J Fam Med. 2019; 40:45. 15. Temtanakitpaisan T, Bunyavejchevin S, Buppasiri P, Chongsomchai C. Knowledge, attitude, and practices (KAP) survey towards pelvic floor muscle training (PFMT) among pregnant women. Int J Womens Health. 2020; 12:295-9. 16. Habib M, Sohail I, Nasir M, Nasir F. Awareness, knowledge and practices of pakistani women towards pelvic floor muscle exercises (PFMES) during pregnancy. J Soc Obstet Gynaecol Pak. 2020; 10:121. 17. Al Kiyumi MH, al Belushi ZI, Jaju S, al Mahrezi AM. Urinary incontinence among omani women prevalence, risk factors and impact on quality of life. Sultan Qaboos Univ Med J. 2020; 20:45. 18. Jawad Z, Malik A, Khan S. Prevalence of Urinary Incontinence in Women in Lahore: severity, associated factors and impact on daily life. Age. 2021; 15:5. 19. Alharqi HM, Albattawi JA. Assessment of Knowledge and Attitude of Women Towards Postpartum Exercise. J Nurs Health Sci. 2018; 7:16. Correspondence Nur Fairuz Mohd Fauzey Kulliyyah of Nursing, International Islamic University Malaysia, Kuantan, Malaysia Siti Mariam Muda (Corresponding Author) sitimariam@iium.edu.my Haliza Hasan Muzaitul Akma Mustapa Kamal Basha Department of Special Care Nursing, Kulliyyah of Nursing, International Islamic University Malaysia, Kuantan, 25200, Malaysia Zalina Nusee Department of Obstetrics & Gynecology, Kulliyah of Medicine, International Islamic University Malaysia, Kuantan, Malaysia Conflict of interest: The authors declare no potential conflict of interest.