Searching for pelvic floor muscle exercises on YouTube: what individuals may find and where this might fit with health service programmes to promote continence.

Ann Dunbar PT, DPT, MS, WCS

September 5, 2012                                              

Primary Aim: to increase awareness of the type of video clips available to the public on pelvic floor muscle exercises (PFME) by investigating, categorizing/characterizing the clips from the perspective of the ‘wisdom of the crowd’ and to assist in developing information used for continence education.

Data Focus: used ‘snow ball’ technique for search and navigation protocol; used terms “Pelvic Floor Exercise” in YouTube search

                Excluded: clips only mentioning PFME or providing pelvic floor anatomy, clips with sexual focus,

                                clips used only to advertise a product

                Inclusions: clips useful in supporting or motivating women toward PFME

Study Design: Descriptive

Methods:  Initial search:  Internet-based search for YouTube videos about PFME. Search conducted

                  4/2011 with follow ups 1 month and 6 months later.

Data categories: health, fitness, sexual, pregnancy,

Other data collected: use of musical and visual cues, use of product promotion and whether

                 used to promote or advise on PFME;  age/gender of audience (data available from YouTube).

Results:

• Identified 22 video clips and listed with number, title, type and primary audience.
• Median increase in viewing of these clips through the 6 month study period was 59.4%
• Most common viewer age group was 35 to 64 years.

--Women between 45 and 54 were most common viewers for 9 clips (5 using a fitness approach

                            and 4 using a health approach).

                --Men between ages of 45 and 54 were most common viewers for 8 clips (majority using health

                            approach).

• Video clip variables: noted by authors but impact on audience is not studied

--Authors note humor, animation, music, other motivational factors to encourage adherence

                --Of interest: clip showing highest increase in views had been integrated into an ‘app.’

                --Health focused clips were predominantly filmed in office setting.

                --Fitness focused clips were predominantly filmed in gym setting.

                --PFME during pregnancy was focus in 14% of clips.

                --Advice in clips varied; some focused on importance of identifying PFM correctly; 3 clips used

                        model of pelvis; others described action of PFM (stop urine flow, ‘elevator,’ etc); fitness

                        focus primarily gave ‘how-to’ directions and some included abdominal exercises.

Discussion:  The initial focus in the discussion relates to the role of the UK’s National Health Service though the same applies to all health services moving from a model of treatment to one of prevention. To make this transition requires individuals to invest in their own self care. Though this is not a new concept for physical therapists, the extensive use of technology may be. YouTube is ideally set up to be able to reach the lay public and indeed the public is seeking information where, as the study notes, viewing of clips about PFME increased by 59% during the 6 month study period. The authors suggest that women of perimenopausal age are viewing a more fitness approach to PFME and that perhaps this is used to support their healthy behavior.  They further suggest that whereas some elements of pelvic floor care could not be met through the Internet (eg, pelvic floor exam to ascertain correct muscle function) the Internet is very well suited through varied media, to address challenges of adherence and motivation for PFME.  Additionally, a broad scope of appeal is present for those women who may be too embarrassed to talk with a healthcare provider or who have specific preferences in style or delivery. The authors also suggest a form of companionship may come from live video unlike the more solitary nature of PFME which may enhance motivation.

This research provides a categorization of the most widely viewed PFME videos on YouTube over a 6 month period in 2011. It highlights varied delivery and teaching approaches with male/female preferences, awareness of misinformation, use of strategies like music and graphics to enhance motivation and suggests topics for future research. It discusses the transitions of medical care where the patient has become an expert member of his/her healthcare team. This expertise has become possible through several influences of social media including apomediation. In an editorial on the topic, Eysenbach describes apomediation as a transition away from the healthcare provider being a “gatekeeper” to medical and health information to a position where the healthcare provider may “guide” patients toward accurate and relevant information. (Eysenback: 2008). The authors of this study close by asserting the importance of the involvement of healthcare providers so that the public is guided to and also provided with accurate and safe information on PFME.

Eysenbach G: Medicine 2.0: social networking, collaboration, participation, apomediation, and openness.  J Med Internet Res. 2008; 10(3):e22.

Clinical Application

1) Much research has been done on different theories to describe what motivates people in their healthcare behaviors including adherence to PFME. In your opinion, what elements are important to include in a YouTube video on pelvic floor exercise to enhance motivation? Would these elements vary according to age (women of childbearing years, perimenopause, etc).

2) Recognizing our patients as experts in their own healthcare, what do you do to be an apomediary, to guide rather than control the information your patient takes in?

Background to add to Discussion:  Theories about Health Behaviors

1) Health Belief Model: person’s readiness to undertake a change in behavior is shaped by 1) perceived susceptibility to disease or problem; 2) perceived severity of disease or problem; 3) perceived benefits of health action; 4) perceived barriers.(Rosenstock, 1966) Dolman et al used this model to predict adherence to PFM exercise in post partum women. They suggested providers could enhance adherence by providing women more information about urinary incontinence and by addressing the barriers for adherence. (Dolman et al, 1996)

2) Theory of Planned Behavior: proposes one’s intentions to follow through with a specific activity are determined by 1) positive or negative attitude toward activity; 2) person’s belief in their perceived behavioral control; 3) how the person believes other people would want them to behave. It suggests that actual performance of the behavior is a result of their perceived behavioral control and the strength of their intention. Using this model with pregnant women and follow through with PFM exercise, the authors found that effective instruction enhanced confidence in exercise performance along with the promotion of strategies to assist with setting up an exercise habit. (Whitford et al, 2011)

·         Dolman et al: Comparison between the health belief model and subjective expected utility theory: predicting incontinence prevention behavior in post partum women. J Eval Clin Pract. 1996;2(3):217-222.

·         Rosenstock IM:Why people use health services. Millbank Mem Fund Q. 1966;44(3)Suppl:94-127.

·         Whitford HM et al:An exploration of the motivation of pregnant women to perform pelvic floor exercises using the revised theory of planned behaviour. BJ Health Psych. 2011;16761-778.