Hypothesis / aims of study
A frequently used questionnaire within urology is the bladder diary. Patients are asked for information on the amount, timing and frequency of micturition and fluid intake. The degree of urge and of urine leakage is also recorded, as is the time of rising and sleeping. The data is entered into a table for 24 hours. Properly completed, it provides valuable, objective information that can be obtained inexpensively. The use of the bladder diary is included in several international guidelines. However, the usefulness of the bladder diary depends heavily on complete and accurate data. However, completing the questionnaire is not easy: often a bladder diary is returned empty or incorrectly filled in.
For the first time, we performed a qualitative study to investigate whether an animated fill-in instruction increases understanding of what is expected, compared to the regular textual fill-in instruction. Using the qualitative study design, we investigated the problems patients encounter and their causes.
Study design, materials and methods
Adults who had never completed a bladder diary before separately studied 1 of 2 versions of bladder diaries: the regular bladder diary with textual fill-in instruction (TBD), or the regular bladder diary without textual explanation but with the fill-in instruction in the form of an animation (ABD). People were asked to indicate in their own words how to fill in the bladder diary using the think-aloud method. In this method, a patient tells aloud what they think while filling in the questionnaire, which gives the researcher insight into the method of filling in such as order of answering the questions, which parts are not well understood (based on text or layout) or the reason why questions remain incomplete. This was followed by a standardized interview.
Predefined items were scored. A distinction was made between spontaneous responses and responses after undirected encouragement (such as, for example, "What would you do if I wasn't here?"). Targeted questions were then asked about possible improvements to the bladder diary, the text used in the filling-in instruction (TBD group), or possible improvements to the animation (ABD group). Education level and mother tongue were noted. Interviews continued, paying attention to equal distribution of education level, until no new insights were obtained.
Results
The TBD group consisted of 17 participants [med 63 years, 2 non-native speakers] and the ABD group consisted of 16 participants [med 59 years, 3 non-native speakers]. The bladder diary proved difficult for people of all education levels to understand because of the terminology used. In particular, the terms "urge", "involuntary" and "millilitre" were difficult to understand. The layout also made understanding difficult: completing a questionnaire in the form of a table is troublesome for some participants. The required understanding of numbers also made completing the questionnaire difficult.
4 TBD participants submitted the bladder diary blank (3 of them with low education level, 1 with high education level). The animated fill-in instruction combined clear language with comprehensible visuals, which improved comprehension of the bladder diary for all educational levels (see table). Participants in the ABD group filled in amount, timing and frequency of micturition and fluid intake more adequately than participants in the TBD group, with particularly better results seen among participants with low education levels. Participants in the ABD group also more adequately filled in their incontinence and urge symptoms and whether exchange bandages took place.
Of the 33 participants, 7 missed the opportunity to disclose information about urination, such as pain. The interview also showed that all non-native-speaking participants appreciated clarification of the text with visuals: understanding of how to complete the questionnaire improved and there was less uncertainty among these participants to complete the questionnaire.
Interpretation of results
In this qualitative study, the bladder diary with a textual fill-in instruction proved difficult to understand regardless of education level, leading to incomplete and inadequately completed questionnaires. An animated fill-in instruction improved comprehension for participants of all education levels, leading to more complete questionnaires with more valid data. For non-native-speaking participants, the animated fill-in instruction was easier to understand.
An animated fill-in instruction for the bladder diary, possibly complemented by a visual enhancement of the list itself, could lead to better completion quality and more reliable information.