Women's knowledge about the pelvic floor (PF) is considered essential to achieve good results on conservative pelvic floor dysfunction treatment, however knowledge about the pelvic floor muscle (PFM) anatomy, functions, dysfunctions and treatment options seems to be low between women, as well as their self-perception about PFM contraction. Validated self-reported questionnaires are important tools to be used in clinical practice and as outcome measures in research. No self-reported validated questionnaire aiming to assess both women´s knowledge and self-perception about their PF was found in the literature.  The aim of this research was to develop and validate the content of a new self-reported questionnaire aiming to assess women's knowledge and self-perception about the PFM.

This is a content validation study of a self-reported questionnaire. The study was developed following the recommendations for developing and validating the content of self-reported instruments by the patient [1]. The structure of the study followed 4 steps recommended by the Consensus based Standards for the selection of Health Measurement Instruments (COSMIN): 1. definition of the constructs, 2. construction of the conceptual model, 3. emerging from the content and 4. validation of content between the target population and professionals with assessment of the relevance, scope and understanding of the items, answer options and instructions. After the constructs were defined by the research team and the conceptual model was designed, open interviews about the topic were initially conducted including a heterogeneous sample of Brazilian women literate, with and without pelvic floor dysfunction. An interview script was developed to facilitate the qualitative interviews with the target sample of women from the community and health professionals. The health professionals included were all specialized in women's pelvic floor dysfunction  treatment. All interviews were conducted by the main researcher who is a physiotherapist with 9 years of experience working with women's pelvic floor dysfunction. All interviews were recorded, transcribed and analyzed by the research team qualitatively[1]. The number of interviews were determined by the saturation of the data. Based on data analysis the final version of the questionnaire was obtained.

The knowledge about the PFM and self- perception constructs were defined based on an extensive literature review about these topics, original research and guidelines [2,3]. The conceptual model was developed, covering important elements that surround the topic, such as knowledge about pelvic floor anatomy, PFM function, PFM assessment, PFM dysfunctions, conservative and non-conservative treatment options for PFM dysfunctions, validated instruments used in the assessment such as questionnaires and scales, among other aspects such as women´s pelvic floor muscle awareness. Nine qualitative individual semi-structured interviews carried out with a heterogeneous sample of women with a mean age of 43.22 years old, 44.44% married, 44.44% single and 11.11% divorced, 33.33% with less than 11 years of study, and 22.22% with complaints of urinary incontinence. For the semi-structured interviews, a script was used containing questions that are presented in Table 1. The first version of the questionnaire was structured containing 23 statements subdivided into 4 domains: 1- Anatomy and PFM function (containing 5 affirmations), 2- PFM dysfunctions (containing 8 affirmations), PFM perception (containing 6 affirmations) and treatment of PFM dysfunctions (containing 4 affirmations). For each statement there are three response options: yes, no, I don't know, but only one option is correct. In addition to the title - Questionnaire of Knowledge and Pelvic Floor Muscles Self-Perception, the questionnaire also contains a brief introduction about the content addressed, questions to characterize the participant with questions such as age, date of birth, number of pregnancies and deliveries, instructions for correctly completing the questionnaire, thanks at the end for having completed the entire questionnaire and instructions on how to score the questionnaire. Content validation started with the target population of the study through nine cognitive interviews carried out in a heterogeneous sample with a mean age of 48 years, 65.43% married, 44.44% with 11 years of study and 35% with complaints of previous urinary incontinence. Changes were suggested by women in relation to the terms PFM, dysfunctions, pelvis, urethra, defecation, urinary continence, anal continence, intestinal constipation and flatus, for a better understanding. The terms suggested by women in the cognitive interviews to be included were: intimate musculature, diseases, basin, pee channel, pooping, holding pee, holding poop and gas, constipation and gas. In terms of content validation among professionals, twelve individual interviews were carried out. The majority of health professionals were Physiotherapists (66%), and 4 (33%) were Physician or Nurse including clinicians, researchers and professors. Physiotherapists had a mean age of 46 years, 23 years of graduation, 90% were PhD, 10% with a master's degree and 80% were specialists in women's health certified by the Brazilian Association of Women's Health Physiotherapy. The suggestions included to increase the number of statements, divide the content of the statements and adopt the terms suggested in the content validation of the target population throughout the questionnaire.

The PF knowledge and self-perception questionnaire was developed and had its content validated by a target population sample and among health professionals working with women's pelvic floor dysfunction. In both content validations, the questionnaire proved to be understandable, relevant and comprehensive. The steps recommended by the COSMIN were strictly followed and the option of conducting cognitive interviews resulted in important suggestions that improved the tool.

The first version of a new questionnaire aiming to assess women´s knowledge and self-perception about the PFM was developed and had its content validated by the target population and health professionals. The questionnaire is ready to have its measurement properties tested.

1. Mokkink, L. B., Prinsen, C. A., Patrick, D. L., Alonso, J., Bouter, L. M., De Vet, H. C., & Terwee, C. B. (2019). COSMIN Study Design checklist for Patient-reported outcome measurement instruments. Amsterdam, The Netherlands, 1-32.
De Andrade, R. L.; BØ, K.; Antonio, F. I.; Driusso, P.; Mateu- Vasconcelos, E. C. L.; Ramos, S.; Ferreira, C. H. J. (2018). An education program about pelvic floor muscles improved women’s knowledge but not pelvic floor muscle function, urinary incontinence or sexual function: a randomised trial. Journal of physiotherapy, 64(2), 91-96.
Frawley, H., Shelly, B., Morin, M., Bernard, S., Bø, K., Digesu, G. A.,Dickinson, T., Goonewardene, S., McClurg, D., Rahnama', M. S., Schizas, A., Hove, M. S. Takahashi, S., Voelkl Guevara, J. (2021). An International Continence Society (ICS) report on the terminology for pelvic floor muscle assessment. Neurourology and Urodynamics, 40(5), 1217-1260.