2015 Motivational Interviewing in Women's Pelvic Wellness Education Project
Phase: NA
Conditions: Pelvic Floor Disorders, Urinary Incontinence (UI), Pelvic Prolapse Conditions
Sponsor: Ottawa Hospital Research Institute

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2015 MOTIVATIONAL INTERVIEWING IN WOMEN'S PELVIC WELLNESS EDUCATION 
PROJECT 
Kristmanson, Dorian, MSc, MD1; Black, Amanda, MD, MPH, FRCSC1,2; White, Ruth, RN1,2; 
Wen, Shi Wu, PhD1,2; Schachter, Joyce, MSc, MD, FRCSC1  
1University of Ottawa, Department of Obstetrics and Gynecology, Ottawa, Canada 
2Ottawa Hospital Research Institute, Ottawa, Canada 
 
Funded by a grant from Pfizer Pharmaceuticals  
 
 
 
 
 

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Abstract 
Pelvic floor disorders can significantly affect a woman’s quality of life, yet many feel 
uncomfortable openly discussing these topics. Treatments include lifestyle modification, 
medications, and/or surgery. Decisional conflict arises when patients have difficulty choosing 
between several viable treatment options. Factors contributing to decisional conflict include 
biased information, poor peer support, and unaddressed fears. Effective counselling may help 
address these factors. Objectives of this pilot study are to assess: (1) the impact of a small-group 
workshop on pelvic floor disorders (urinary incontinence (UI), or pelvic organ prolapse (POP)) 
on decisional conflict regarding treatment options; and (2) participant satisfaction with the 
workshop in terms of quality of information shared, comfort with discussing pelvic health in a 
group setting, and perceived benefits of a nurse continence advisor and psychologist.  Women ≥ 
18 years old with urinary incontinence or pelvic organ prolapse will be randomized at the time of 
their first urogynecology consultation to usual care or a 90 minute workshop on either UI or POP. 
Five to 10 women will attend each workshop led by a nurse continence advisor and a 
psychologist. In both groups, decisional conflict will be measured using the validated Decisional 
Conflict Scale (DCS) at baseline and at the first follow-up clinic appointment. Satisfaction with 
the workshop will be assessed by a post-workshop survey.  Demographic data will be compared 
between groups using t-tests for continuous data and chi-square tests for categorical data.  Change 
in DCS score will be compared using t-tests. Linear regression analysis will be performed to 
identify predictors of decisional conflict. This pilot study will assess the feasibility and 
acceptability of an educational workshop on pelvic floor disorders and its potential impact on 
decisional conflict. Results of this study will inform future development of interdisciplinary, 
patient-centred approaches to enhanced decision making in women’s health.  

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I. Rationale and Background Information 
Pelvic floor dysfunction, according to the IUGA (International Urogynecological 
Association)/ICS (International Continence Society), is a general term encompassing urinary 
incontinence (UI), pelvic organ prolapse (POP), anal incontinence, sensory abnormalities of the 
lower urinary tract, defecatory dysfunction, and chronic pelvic pain syndromes. The IUGA/ICS 
defines the symptoms of pelvic organ prolapse as a departure from normal sensation, structure or 
function, experienced by the woman in reference to the position of her pelvic organs. Objectively, 
POP is the descent of one or more of the anterior vaginal wall, posterior vaginal wall, the uterus, 
or the apex of the vagina. The IUGA/ICS definition of urinary incontinence is the complaint of 
involuntary loss of urine, or the observation of involuntary loss of urine on examination, and can 
be sub-categorized further as stress, urge, or mixed urinary incontinence. 1 
Risk factors for UI and POP include age, parity, obesity, and history of pelvic radiation. 
2,3 Bump et al. (1998) proposed a comprehensive model for the development of female pelvic 
floor dysfunction. In this model, pelvic support and function is influenced by interactions between 
predisposing factors (i.e. race, connective tissue, anatomic, neurologic, genetic), inciting factors 
(i.e. childbirth, nerve injury, muscle injury, radiation, tissue disruption, surgery), promoting 
factors (i.e. constipation, obesity, smoking, medication, comorbidities), decompensating factors 
(i.e. aging, dementia, poor mobility), and intervening factors (behavioural modification, 
pharmacologic, devices, surgical). 4 This model is useful for both understanding the etiology of 
pelvic floor dysfunction and for developing both primary and secondary prevention strategies to 
address them.   
Pelvic floor dysfunction is common and occurs more frequently in women. Urinary 
incontinence and pelvic organ prolapse are the two most common manifestations of pelvic floor 
dysfunction. The prevalence of UI ranges from 13.1-49.7% while the prevalence of POP of any 
severity is approximately 41%. Cystocele is the most frequently encountered form of POP (34%), 
followed by uterine prolapse (14%), and rectocele (13%). 2  
Treatment options for UI and POP fall into two modalities: conservative treatment 
(behaviour modification, pelvic floor muscle therapy, pharmacologic therapies, pessaries) and 
surgical intervention. Although an initial trial of conservative management is usually undertaken, 
many women will eventually have surgery. In 1995, the estimated lifetime risk of undergoing one 
operation for pelvic floor disorders was 11.1% by age 80. 5 Based on current population 
demographics and the increasing prevalence of obesity, it is projected that over the next five 
decades the demand for incontinence and prolapse care will significantly increase. 6  
Despite the high prevalence of pelvic floor dysfunction in women, it is well accepted that 
far fewer seek treatment for their symptoms. Patient-reported barriers to seeking treatment 
include lack of knowledge about their condition and available treatments, the perception that their 
symptoms are a normal part of ageing or childbirth, or are not appropriate for medical 
intervention. 7 Left untreated, the symptoms of pelvic floor dysfunction, can be debilitating, 
leading to functional decline, social isolation, sexual dysfunction, withdrawal from employment 
or leisure activities, and loss of independence. 8  
Lack of knowledge about pelvic floor dysfunction, in addition to being a barrier to 
appropriate treatment, can undermine decision-making and the process of informed consent.  

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Many patients do not feel adequately informed about their condition and seek additional resources 
to supplement the counselling provided by their physician.  Of 458 consecutive patients 
presenting to a urogynecology outpatient clinic, only 20% of patents felt they had sufficient 
knowledge about their diagnosis, and of the 80% who felt inadequately informed, most consulted 
their primary care physician or used the internet to obtain more information. 9 Nonetheless, 
women with pelvic floor dysfunction have a desire both to be well informed and involved in 
decision-making, and most women seeking care for pelvic floor dysfunction prefer an active or 
collaborative role in decision-making. 10  
An essential component of patient-centered care, shared decision-making promotes active 
participation of the patient in discussing a care plan. Shared decision-making has been defined as 
‘an approach where clinicians and patients share the best available evidence when faced with the 
task of making decisions, and where patients are supported to consider options, to achieve 
informed preferences”. 11 This approach may be especially applicable in clinical situations such as 
pelvic floor dysfunction, where quality, not quantity, of life is at stake. In these cases, effective 
counselling and decision-making support is essential for the development of an acceptable 
treatment plan. 
Women presented with several viable treatment options, each with respective drawbacks 
and benefits, may experience decisional conflict, which can result in emotional distress, isolation, 
and vulnerability. Decisional conflict can be defined as “the uncertainty about which course of 
action to take when choice among competing actions involved risk, loss, regret, or challenge to 
personal life values”. 12 Antenatal testing, hormone replacement therapy for menopause, 
hysterectomy for abnormal uterine bleeding, ovarian cancer screening, and treatment for 
incontinence are all situations specific to women’s health in which decisional conflict may arise. 
12 O’Connor et al. (1995) developed the decisional conflict scale (DCS), a validated scale that 
measures (a) perceived uncertainty between options, (b) factors contributing to uncertainty 
(feeling uninformed, unclear about values, unsupported in decision making), and (c) factors 
contributing to effective decision making (feeling the choice is informed, values-based, likely to 
be implemented, and satisfaction with the decision). 13 A total decisional conflict score from 0 (no 
decisional conflict) to 100 (extremely high decisional conflict) is given, as well as five sub-scores 
for each factor listed above.  
Designed to facilitate shared decision-making, decision aids are evidenced-based tools 
that empower patients to make high quality, well-deliberated and informed decisions. A 2014 
Cochrane Review reported high-quality evidence that shared decision-making and decision aids 
increase patient knowledge about treatment options and reduce decisional conflict; increase 
participation in decision-making and promote of more accurate perceptions of risk (moderate 
quality evidence); and increase congruence between the chosen option and patient values (low 
quality evidence). 14  Decision aids have also been shown to significantly reduce the number of 
patients choosing major elective surgery (i.e. prophylactic mastectomy for BRCA 1/2 gene 
carriers, cardiac revascularization, orchiectomy). 14 A large randomized controlled trial of 894 
British women with benign abnormal uterine bleeding, found that when nurses administered a 
structured interview to women immediately before their consultation with the surgeon with the 
goal of clarifying their preferences for treatment, women were more satisfied with their 
involvement in decision-making and overall costs were reduced, as women were more likely to 

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choose conservative therapy over hysterectomy. 15  
Among women making treatment decisions for pelvic floor dysfunction, there is limited 
data on the impact of shared decision-making or decision aids on decisional conflict. In one 
recent study, in which 103 women with pelvic organ prolapse were randomized to either standard 
clinician-led, one-on-one counselling or standard counselling plus a decision aid, the addition of a 
decision aid to standard counselling did not significantly reduce decisional conflict or influence 
the choice of conservative treatment over more invasive surgery 16.   
Shared decision-making may be difficult to implement in a busy office practice where 
information exchange is time-limited. Most studies on shared decision-making have focused on 
the physician-patient interaction, and as such, the most commonly reported barrier to 
implementing this practice is lack of time for effective counselling. 17 Recognizing the importance 
of the entire healthcare team in patient-centered care, interprofessional models of shared decision 
making have been developed 18 and validated 19, and may help address this time constraint barrier. 
Although there is a growing body of evidence to suggest that small-group educational workshops 
increase patient knowledge about pelvic floor dysfunction and improve symptoms and quality of 
life 20,21, no studies to date have explored how group counselling sessions lead by non-physician 
health professionals affect decisional making in women with pelvic floor dysfunction.  
The interprofessional model proposed by Légaré et al. 18 takes into account three 
conceptual levels of shared decision making: the individual level, in which the patient, once 
presented with a decision, collaborates with various healthcare professionals as she progresses 
through the phases of making choice.  The second level takes into account how the interactions 
between members of different healthcare professions influence the decision-making process. 
Finally, the third level considers how the team functions within the environment in which it is 
embedded (health policies, social context, and professional organizations).   
This model also explicitly introduces the concept of a “decision coach”, a health 
professional (often a nurse, social worker, or psychologist) who’s role involves being an 
empathetic but impartial team member who guides a patient through the decision making process. 
22 Decision coaching involves assessing patients’ degree of decisional conflict and factors 
contributing to uncertainty, delivering decision-making support by providing evidenced-based 
information or patient decision-aids, ensuring understanding, clarifying values, monitoring 
progress in decision-making, and screening for barriers preventing implementation of a chosen 
decision.  In the context of pelvic floor disorders, the decision coach may play an important role 
in guiding women through the decision making process. 
There are few studies on how decision coaching can help women with prolapse and 
incontinence reach a satisfactory decision about treatment.  This study aims to use the principals 
of shared decision making to address decisional conflict surrounding treatment for pelvic floor 
disorders. Specifically, we will evaluate the feasibility and acceptability of small group 
workshops on pelvic organ prolapse and urinary incontinence led by a nurse continence advisor 
and a psychologist (decision coach). We will also assess impact of the workshop on decisional 
conflict. Results of this study will inform future development of interdisciplinary, patient-
centered approaches to enhanced decision making in women’s health.  

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II. Study Objectives, Hypotheses 
Primary objective: To evaluate how a structured workshop on pelvic floor disorders impacts 
decisional conflict with regard to seeking treatment for pelvic organ prolapse and urinary 
incontinence.  
Secondary objective: To assess patient satisfaction with the quality of information shared during 
the workshop, their comfort with discussing pelvic health in a group setting, and the perceived 
benefits of a nurse continence advisor and psychologist.  
 Hypotheses:  
1. 
A nurse and psychologist-led workshop on pelvic floor disorders will result in 
decreased decisional conflict compared to standard individual physician-led 
counselling.  
2. 
Participants will be satisfied with the quality of information shared and will feel 
comfortable discussing pelvic health in a group setting 
Primary Outcome & Measure: Change in "Decisional Conflict" between baseline and follow-
up, as measured by the Decisional Conflict Scale. 
Secondary Outcome & Measure: Participant satisfaction with the group workshop.  This will be 
measured using a survey administered immediately following the workshop 
 
 

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III. Study Design and Methodology 
This pilot study will be a structured as a randomized control trial in which eligible 
participants will be recruited at the time of their first urogynecology consultation. Participants 
will be randomized into two groups: (1) standard care (follow up with urogynecologist as usual) 
or, (2) a workshop on either urinary incontinence (UI) or pelvic organ prolapse (POP), with a 
follow-up urogynecologist appointment after attendance at the workshop (Figure 1). 
Randomization will be done using a computer generated randomization sequence in 
blocks of 4 or 6. Sequentially numbered envelopes will contain the randomization result, with the 
group only revealed at time of randomization. Health care providers will be blinded to the 
treatment group, but participants will be unblinded to treatment group due to the nature of the 
intervention.  
Patients randomized to the intervention group will be asked to select a workshop on either 
UI or POP based on which pelvic floor disorder they perceive to be most bothersome. Two 
identical workshops on different dates will be offered for each topic and participants will be 
required to attend one to be included in the study.  
The workshop will be approximately 90 minutes in length. The first 15 minutes will be an 
information session on either UI or POP led by a Nurse Continence Advisor. The following 60 
minutes will comprise a psychologist-led group discussion. The structured discussion will 
encourage participants to share experiences, thoughts, and feelings on pelvic floor disorders. 
Resistances and barriers to seeking treatment will be discussed. Decision-making processes will 
be explored. During the final 15 minutes, participants will be asked to complete a survey to 
evaluate the workshop. The survey will assess satisfaction with the information provided, quality 
of group discussion, comfort level with the group experience, and their satisfaction with the roles 
of the nurse continence advisor and psychologist.  
Using a questionnaire, the following demographics will be collected at baseline: age, 
marital status, education level, household income, ethnicity, predominant type of pelvic floor 
dysfunction (urinary incontinence, prolapse, both), and previously attempted treatment 
modalities. Electronic medical records will also be accessed to confirm the principal diagnosis. 
The Decisional Conflict Scale (DCS) and the Control Preferences Scale (CPS) will also be 
administered at the baseline visit.  
The DCS is a validated scale that measures (a) perceived uncertainty between treatment 
options, (b) factors contributing to uncertainty (feeling uninformed, unclear about values, 
unsupported in decision making), and (c) factors contributing to effective decision making 
(feeling the choice is informed, values-based, likely to be implemented, and satisfaction with the 
decision). 13 The CPS is a validated tool that assesses the degree to which patients wish to be 
involved in treatment decision-making. 10 The CPS is a one-item questionnaire with a five-point 
scale that describes various degrees of involvement in decision-making. Lower scores on the CPS 
indicate stronger preferences for an active role in decision making while higher score indicate a 
preference for a passive or collaborative role.  
Analysis of results 
Baseline socio-demographic data will be compared between groups using t-tests for 

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continuous data and chi-square tests for categorical data.  Differences in decisional conflict scores 
between the intervention and control groups will be compared using unpaired t-tests.  Linear 
regression will be done to identify significant predictors of decisional conflict in this population. 
IV. Study Population/Recruitment/Consent process 
Sample size 
For this pilot study, we estimate that recruiting a total of 80 participants will be feasible 
based on the volume of new consults to the Riverside Hospital Urogynecology Clinic. With a 
minimum 50 percent participation rate, this would result in a total sample size of 40-80 
participants (20-40 per study group). 
Inclusion criteria 
• 
Women ages >18 years old 
• 
Urinary incontinence and/or pelvic organ prolapse 
• 
First visit with urogynecologist 
 
Exclusion criteria 
• 
Anal incontinence 
• 
Previous pelvic radiation therapy 
• 
Non-English speaking 
• 
Requirement for a Substitute Decision Maker 
• 
Inability to attend the workshop 
• 
Unwilling to attend an English-language workshop 
• 
Unwilling to complete English-language surveys 
Recruitment & Consent 
Participants in the study will be patients identified from the Riverside Urogynecology Clinic 
at their first consultation visit. The day prior to the clinic, the SMS and vOASIS will be checked 
for participants attending clinic who meet eligibility requirements.  Suitable participants agreeing 
to research contact through the Consent to Research Contact process will be approached in person 
by the Research Coordinator at the time of their first urogynecological consultation.  
For patients who have not previously consented to research but who are deemed suitable 
for the study by their urogynecologist, the physician will also obtain permission for research 
personnel to approach the patient to discuss the study. The OBIEE tool will be used to identify 
patients who have agreed to research contact. Medical charts will be reviewed for eligibility in 
vOASIS prior to patient approach to potential participants meet eligibility criteria. Informed 
consent will be obtained by the research coordinator in person. The consent is identical between 
the treatment and control groups. 
The standard of care for pelvic floor disorders is gynecology/urogynecology consultation 
with appropriate counselling with regard to potential treatments. There will be no additional 
activities that will be performed on research participants regardless of group assignment. 
Participants in the intervention group will attend a group workshop during which they may 

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participate in a discussion on pelvic floor disorders led by a nurse continence advisor and 
psychologist. Participation in this workshop will not delay treatment for their condition. 
 
Participants in the intervention group risk feeling uncomfortable or embarrassed 
discussing sensitive information, or hearing other participants’ sensitive information, in a group 
setting. Participants in this research study who are randomized to the intervention group may 
benefit from the decision-making support and additional knowledge received in the group 
workshop on pelvic floor dysfunction. Following the workshop they may feel more 
knowledgeable about their condition and more comfortable with choosing a treatment for their 
specific condition. They may feel more comfortable knowing that other women may be 
experiencing the same thoughts and emotions surrounding their diagnosis. If the participant no 
longer wishes to participate in the study, she may withdraw early.  
We will provide participants with reimbursement of parking fees incurred during the 
initial clinic visit, the follow up clinic visit, and, the group workshop (for participants randomized 
to this group). 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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V. Appendix 
 
 
Figure 1: Study Flowchart

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Baseline Questionnaire (Please complete to the best of your ability) 
 
 
Age: 
18-30 ☐ 
31-40 ☐ 
41-50 ☐ 
51-60 ☐ 
61-70 ☐ 
71-80 ☐  
81+ ☐ 
 
Educational Level: 
Grade school   ☐ 
 
High School 
☐ 
 
 
College Diploma  ☐ 
Bachelor’s degree  ☐ Post-Graduate degree  ☐ 
 
Professional Degree  ☐ 
 
Ethnicity: 
White  ☐ 
 
Black  ☐ 
 
Chinese  ☐  
 
Filipino ☐ 
 
South Asian (i.e. East Indian Pakistani, Sri Lankan etc.)  ☐ 
Latin American  ☐ 
 
Arab ☐ 
 
West Asian (i.e. Iranian, Afghan etc.) ☐ 
 
Southeast Asian (i.e. Vietnamese, Cambodian, Malaysian, Laotian, etc.) ☐ 
Korean ☐ 
 
Japanese ☐  
First Nations ☐ 
Other ☐ ______ 
 
Type of Pelvic Floor problem:  please check ALL that apply: 
Pelvic organ prolapse (cystocele, rectocele, uterine prolapse) 
☐ 
Urinary incontinence (involuntary leaking urine) 
 
 
 
☐ 
Both pelvic organ prolapse and urinary incontinence 
 
 
☐ 
 
Which problem are you MOST concerned about?  Please choose ONE only: 
Pelvic organ prolapse ☐ 
Urinary incontinence ☐ 
 
Which treatments have you previously had for these problems?  Check ALL that apply: 
None ☐ 
Lifestyle modification (decrease caffeine, increase fluid intake) 
☐ 
Kegel exercises 
☐ 
Pelvic floor physiotherapy 
☐ 
Medication 
☐ 

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Pessary 
☐ 
Surgery 
☐

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The Control Preferences Scale 
Please circle the statement that most accurately reflects your preferences regarding your 
role in making a decision regarding the treatment of your pelvic floor problems: 
1. I prefer to make the final decision  
2. I prefer to make the final decision after seriously considering my doctor’s 
opinion  
3. I prefer that my doctor and I share responsibility for the decision  
4. I prefer that my doctor makes the decision after he/she seriously considers 
my opinion  
5. I prefer my doctor to make the decision  
 
 

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Decisional Conflict Scale

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Post-Workshop Quesionnaire 
Date of Workshop:  
 
Please rate the following statements:  
 
 
 
4 = strongly agree    3 = agree   2 = disagree   1 = strongly disagree 
 
Information session 
The Nurse Continence Advisor was knowledgeable 
4 
3 
2 
1 
The information provided was useful to me 
4 
3 
2 
1 
I was satisfied with the length of the information session  
4 
3 
2 
1 
 
Group Discussion 
 
 
 
 
I was comfortable with the size of the group  
4 
3 
2 
1 
If you disagree, the group was: 
Too big 
Too small 
The psychologist created relevant group discussion 
4 
3 
2 
1 
I felt comfortable discussing these topics in a group setting 
4 
3 
2 
1 
The discussion brought out feelings I may not have discussed 
with my doctor 
4 
3 
2 
1 
I was satisfied with the length of the group discussion 
4 
3 
2 
1 
 
Overall Workshop 
 
 
 
 
I would recommend this workshop to a friend or family 
member  
4 
3 
2 
1 
I would attend another session if given the opportunity 
4 
3 
2 
1 
I would prefer to discuss these issues alone with my doctor 
4 
3 
2 
1 
The nurse continence advisor was essential to the group 
experience 
4 
3 
2 
1 
The psychologist was essential to the group experience  
 
 
 
 
Overall, this workshop was beneficial 
4 
3 
2 
1 
 
 
(see next page)

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What changes will you make in your decision for treatment as a result of this 
workshop? 
 
 
 
 
Tell us about one thing you found most valuable in this workshop 
 
 
 
 
 
What would you change about this workshop? 
 
 
 
 
Other comments 
 
 
 
 
 
 
 
 
 
 
 
 
 

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