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Body Image in the Pelvic Organ Prolapse Questionnaire: development and validation

Published:March 13, 2014DOI:https://doi.org/10.1016/j.ajog.2014.03.019

      Objective

      The purpose of this study was to develop and validate a prolapse-specific body image questionnaire.

      Study Design

      Prolapse-specific body image themes that were identified in our previous work served as a framework for the development of a question pool. After review for face and content validity and reading level, the question pool was reduced to 21 items that represent predominant themes and that form the initial Body Image in Pelvic Organ Prolapse (BIPOP) questionnaire. Women with symptomatic prolapse of Pelvic Organ Prolapse Quantification (POPQ) of more than stage II were enrolled from 2 academic urogynecology practices; they completed questionnaires on pelvic floor symptoms and distress, general body image, depression, self-esteem, and the BIPOP questionnaire, and they underwent the POPQ. We field-tested the BIPOP questionnaire with approximately 200 participants; 10 women completed cognitive interviews, and 100 women repeated the BIPOP questionnaire to assess test-retest reliability.

      Results

      Two hundred eleven participants were enrolled, and 201 women had complete data. Participants had mean age of 60.2 ± 10.5 years, were predominantly white (98%), were partnered (80%), and had median POPQ stage III. Cognitive interviews confirmed comprehension and clarity of questions and acceptability of length and subject matter. Exploratory factor analysis was performed in an iterative process until a parsimonious, 10-item scale with 2 subscales was identified (subscale 1 represented general attractiveness; subscale 2 represented partner-related prolapse reactions). Cronbach's α score for the subscales were 0.90 (partner) and 0.92 (attractiveness). Correlations between related questionnaires and BIPOP subscales were strong and directionally appropriate. Test-retest correlations on both total and subscale measurements were high.

      Conclusion

      We developed and validated a prolapse-specific body image measurement that has face and content validity, high internal consistency, strong correlation with general prolapse and body image measures, and strong test-retest reliability.

      Key words

      Symptomatic pelvic organ prolapse is estimated to affect up to 3% of the female population >20 years of age.
      • Nygaard I.
      • Barber M.D.
      • Burgio K.L.
      • et al.
      Prevalence of symptomatic pelvic floor disorders in US women.
      Prolapse can affect a woman's quality of life greatly and can include social, psychologic, occupational, domestic, physical, and sexual well-being.
      • Rogers G.R.
      • Villarreal A.
      • Kammerer-Doak D.
      • Qualls C.
      Sexual function in women with and without urinary incontinence and/or pelvic organ prolapse.
      Prolapse can result in dramatic anatomic changes to the urogenital tract and is a hidden disfigurement of which only the woman and her intimate contact(s) typically are aware. Prolapse negatively affects a woman's body image (BI) when assessed with general and modified BI measures.
      • Jelosevek J.E.
      • Barber M.D.
      Women seeking treatment for advanced pelvic organ prolapse have decreased body image and quality of life.
      • Lowder J.L.
      • Ghetti C.
      • Moalli P.
      • Zyczynski H.
      • Cash T.F.
      Body image in women before and after reconstructive surgery for pelvic organ prolapse.
      BI is a psychologic construct that refers to an individual's perceptions of and attitudes towards her own body.
      BI affects many aspects of psychosocial functioning, and body dissatisfaction is associated with anxiety and depression.
      In our previous study with focus group-based qualitative methods to identify prolapse-specific BI themes, women reported that their prolapse made them feel less feminine, unattractive, different, isolated, and self-conscious.
      • Lowder J.L.
      • Ghetti C.
      • Nikolajski C.
      • Oliphant S.S.
      • Zyczynski H.
      Body image perceptions in women with pelvic organ prolapse: a qualitative study.
      In addition, women reported significant apprehension about losing a relationship with a partner because of their prolapse because of the impact it had on intimacy.
      • Lowder J.L.
      • Ghetti C.
      • Nikolajski C.
      • Oliphant S.S.
      • Zyczynski H.
      Body image perceptions in women with pelvic organ prolapse: a qualitative study.
      Women often reported completely avoiding or changing sexual practices in response to “not feeling desirable” or feeling “gross” because of their prolapse.
      • Lowder J.L.
      • Ghetti C.
      • Nikolajski C.
      • Oliphant S.S.
      • Zyczynski H.
      Body image perceptions in women with pelvic organ prolapse: a qualitative study.
      These findings help to further elucidate the interaction of BI and prolapse on sexual function. Lowentstein et al,
      • Lowenstein L.
      • Gamble T.
      • Sanses T.V.
      • et al.
      Sexual function is related to body image perception in women with pelvic organ prolapse.
      who used patient self-reported questionnaires, found that sexual function was related strongly to a woman's self-perceived BI and bother from prolapse, irrespective of the degree of anatomic prolapse. BI related to prolapse, when assessed with a general BI measurement, improved after reconstructive surgery.
      • Lowder J.L.
      • Ghetti C.
      • Moalli P.
      • Zyczynski H.
      • Cash T.F.
      Body image in women before and after reconstructive surgery for pelvic organ prolapse.
      In work by Sung et al,
      • Sung V.W.
      • Rogers R.G.
      • Barber M.D.
      • Clark M.A.
      Conceptual framework for patient-important treatment outcomes for pelvic organ prolapse.
      BI was identified as 1 of 5 important themes for prolapse-specific patient-related outcomes.
      BI is an important and emerging theme in understanding the impact of pelvic floor disorders. However, current prolapse-specific health-related quality-of-life measures do not assess the impact of these conditions on a woman's BI. The use of prolapse-specific BI measures as a tool in prolapse research will allow us to understand the full impact of prolapse on women and better assess treatment outcomes. To date, authors who have attempted to explore prolapse-related BI have either modified existing questionnaires or used proxy measures,
      • Jelosevek J.E.
      • Barber M.D.
      Women seeking treatment for advanced pelvic organ prolapse have decreased body image and quality of life.
      • Lowder J.L.
      • Ghetti C.
      • Moalli P.
      • Zyczynski H.
      • Cash T.F.
      Body image in women before and after reconstructive surgery for pelvic organ prolapse.
      • Patel M.
      • Mellen C.
      • O'Sullivan D.M.
      • LaSala C.A.
      Impact of pessary use on prolapse symptoms, quality of life, and body image.
      because a prolapse-specific BI questionnaire does not yet exist. The goal of this study was to develop and validate a prolapse-specific BI questionnaire from themes that were identified in our previous qualitative work.

      Study Design

      Measure development

      Prolapse-specific BI themes that were identified in our previous work were used as a framework for the development of potential questions for use in our measure.
      • Lowder J.L.
      • Ghetti C.
      • Nikolajski C.
      • Oliphant S.S.
      • Zyczynski H.
      Body image perceptions in women with pelvic organ prolapse: a qualitative study.
      Five individuals (4 urogynecologists, 1 qualitative researcher) wrote candidate items based on the general themes of sexuality and intimacy, sense of femininity and attractiveness, and concealment.
      • Lowder J.L.
      • Ghetti C.
      • Nikolajski C.
      • Oliphant S.S.
      • Zyczynski H.
      Body image perceptions in women with pelvic organ prolapse: a qualitative study.
      The items were written to assess the 4 previously described components of BI: (1) perception (self-rated severity), (2) affect (satisfaction or dissatisfaction, bother, self-consciousness), (3) behavior (avoidance, concealment), and (4) cognition (beliefs or thoughts associated with the condition).
      • Streiner D.L.
      • Norman G.R.
      Health measurement scales: a practical guide to their development and use.
      Candidate items were written for an 8th-grade reading level with both affirmative and negative versions. To evaluate the initial pool of 75 candidate items, we assessed face validity and used modified methods that had been described by Walsh et al
      • Walsh T.R.
      • Irwin D.E.
      • Meier A.
      • Varni J.W.
      • DeWalt D.A.
      The use of focus groups in the development of the PROMIS Pediatrics Item Bank.
      to evaluate item clarity, assumptions, and knowledge; we then eliminated items that did not meet these criteria. We chose the affirmative versions of the questions to avoid reverse scoring issues and subject burden with positive and negative question versions. We reviewed the remaining items for theme redundancy and selected or eliminated items by consensus decision. We chose 21 items for the initial version of the Body Image in Pelvic Organ Prolapse questionnaire (BIPOP), and all items used the same 5 Likert scale responses (strongly agree, agree, neither agree nor disagree, disagree, strongly disagree). We created 2 versions of the instrument for partnered and nonpartnered women, because themes of sexuality and intimacy and some aspects of attractiveness could seem less relevant to women without partners. We modified phrasing of questions in the nonpartnered version to reflect how a woman without a partner might feel in the situation described. As an example, the nonpartnered version was phrased “Because of my prolapse, I would worry that my partner might avoid being intimate with me,” compared with the partnered version “Because of my prolapse, I worry that my partner might avoid being intimate with me.” Instructions for administration and scoring were incorporated into the questionnaire. A higher BIPOP score indicated better BI and less impact of prolapse on BI. In the initial version of the BIPOP, items were scored from 1-5, and 2 items were reverse-coded. The BIPOP is scored as a mean score because the generation of a mean value automatically accounts for missing data by excluding values from missing items in both the numerator and the denominator when the mean is calculated. Scoring options for both a mean and total are available.

      Initial measurement evaluation

      We approached women who were seeking care at the University of Pittsburgh and the Medical University of South Carolina after the institutional review boards at both sites approved the study. Women who were ≥18 years old with stage ≥II symptomatic prolapse by POPQ examination were offered participation. Symptomatic prolapse was defined as answering “Yes” to 1 or both of the following questions from the Pelvic Floor Distress Inventory: (1) “Do you usually have a sensation of bulging or protrusion from the vaginal area?” and (2) “Do you usually have a bulge or something falling out that you can see or feel in the vaginal area?” Women were excluded if they were asymptomatic or unable to complete informed consent and study forms, which was determined by clinician judgment. Participants signed informed consent at enrollment. The South Carolina site was involved later in the study to help complete recruitment.
      Cognitive interviews were performed at the study outset to determine whether any candidate items needed modification, whether the items were not understood as intended, and to further confirm face and content validity. At the Pittsburgh site only, participants were offered participation in the cognitive interviews until 5 partnered and 5 nonpartnered participants were enrolled. These 10 women completed the study questionnaires and then were interviewed about the BIPOP by a research assistant who used an interview guide to assess (1) comprehension, (2) decision processes, such as motivation and social desirability, (3) response processes, (4) relevance and importance, and (5) comprehensiveness.
      • Wills G.
      Cognitive interviewing and questionnaire design: a training manual: working paper #7.
      An exploratory factor analysis (EFA) that used principle components with Varimax rotation was performed on the baseline BIPOP data to determine the number of underlying factors and the candidate items that load on or associate with those factors. Factor loadings range from –1.0 to +1.0 and represent both the strength and direction of the association of a particular item with the underlying factor. The factors themselves represent groups of conceptually related items that were identified through EFA on the basis of the intercorrelations among those items. The factor analysis was also used to eliminate items based on cross-loading (ie, items that were associated at least moderately with >1 factor) or on failure to load strongly on at least 1 factor (loading, > .30). The EFA was an iterative process and was repeated until a parsimonious model was created. Next, separate EFAs were performed on the dataset by partner status (partnered or nonpartnered). Cronbach's α was calculated for the individual subscales and the total scale. When Cronbach's α is interpreted, values >0.90 are considered “excellent”; values 0.80-0.89 are considered “good”; values 0.70-0.79 are considered “acceptable,” and values <0.69 are considered “questionable.”
      • George D.
      • Mallery P.
      SPSS for Windows step by step: a simple guide and reference: version 11.0 update.

      Further evaluation of reliability and validity

      We performed several types of validity assessments throughout the development process, which included assessment of face validity, content validity, construct validity, tests of association and difference, and test-retest analyses. During the initial review of questions by the investigators and the cognitive interviews with participants, we assessed face validity (the extent to which questions appeared to measure the BIPOP construct) and content validity (the extent to which questions represented the construct). Construct validity was based on examination of the degree of association between BIPOP scores and other key measures (convergent construct validity). Tests of association and difference were performed between the BIPOP subscales and study measure, with the use of Pearson's correlations, the Student t test, and 1-way analysis of variance. Using intraclass correlation, we performed test-retest analyses of the BIPOP with data from 100 participants who completed the BIPOP once at enrollment and again 2 weeks later.
      • Marx R.G.
      • Menezes A.
      • Horovitz L.
      • Jones E.C.
      • Warren R.F.
      A comparison of two time intervals for test-retest reliability of health status instruments.

      Study measures

      The study measures included self-reported demographic items (age, race, ethnicity, and partner status), pertinent past medical and surgical history, current medications, and completion of validated questionnaires that assess general BI, symptoms and distress related to pelvic floor disorders, sexual function, depressive symptoms, and self-esteem. Expected associations between our BIPOP and the study measures are shown in Table 1. Two validated general BI measurements were used in this study: the Body Exposure during Sexual Activity Questionnaire, which was chosen because it assesses BI in intimate situations and thus serves as a proxy measure for prolapse BI, and the Body Image Quality of Life Inventory, which is a general BI measure that is designed to assess the impact of BI on quality of life.
      Table 1Measure description, expected direction of relationship for convergent construct analyses, and baseline scores
      MeasurePredicted association with Body Image in Pelvic Organ Prolapse questionnaireMeasure characteristicBaseline study scores
      Body Exposure during Sexual Activity QuestionnaireValidated assesses anxious/avoidant body focus during sexual activity; higher score reflects more self-conscious focus and avoidance; score range: 0–4
      1.7 ± 1.0
      Data presented as mean ± SD
      Body Image Quality of Life Inventory+Validated general body image measure; assesses impact of body image on quality of life; higher score represents a more positive effect of body image on one's life and a lower scores reflects a more negative effect; score range: −3 to +3
      • Bolton M.A.
      • Pruzinsky T.
      • Cash T.F.
      • Persing J.A.
      Measuring outcomes in plastic surgery: body image and quality of life in abdominoplasty patients.
      1.3 ± 1.0
      Data presented as mean ± SD
      Pelvic Floor Distress Inventory-20Validated; contains 3 subscales (prolapse, urinary, bowel); assesses symptoms of distress related to pelvic floor disorders; higher score represents more symptom bother; score range: 0–300
      • Barber M.D.
      • Walters M.D.
      • Bump R.C.
      Short forms of two condition-specific quality-of-life questionnaires for women with pelvic floor disorders (PFDI-20 and PFIQ-7).
      104.4 ± 63.0
      Data presented as mean ± SD
       Pelvic Organ Prolapse Distress Inventory40.8 ± 24.3
      Data presented as mean ± SD
       Urinary Distress Inventory36.6 ± 27.0
      Data presented as mean ± SD
       Colorectal-Anal Distress Inventory27.1 ± 23.2
      Data presented as mean ± SD
      Pelvic Floor Impact Questionnaire-7Validated; contains 3 subscales (prolapse, urinary, bladder); assesses life impact of pelvic floor disorders; higher scores represent greater impact on quality of life; score range: 0–300
      • Barber M.D.
      • Walters M.D.
      • Bump R.C.
      Short forms of two condition-specific quality-of-life questionnaires for women with pelvic floor disorders (PFDI-20 and PFIQ-7).
      47.6 (19.1–130.9)
      Data are presented as median (interquartile range).
       Pelvic Organ Prolapse Impact Questionnaire14.3 (4.8–47.6)
      Data are presented as median (interquartile range).
       Urinary Impact Questionnaire19.1 (4.9–52.3)
      Data are presented as median (interquartile range).
       Colorectal-Anal Impact Questionnaire4.8 (0.0–33.3)
      Data are presented as median (interquartile range).
      Prolapse and urinary incontinence impact of sexual function questionnaire-12Validated; assesses sexual function as impacted by pelvic floor disorders; higher scores represent better sexual function; score range: 0–48
      • Rogers R.G.
      • Coates K.W.
      • Kammerer-Doak D.
      • Khalsa S.
      • Qualls C.
      A short form of the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12).
      30.0 ± 6.2
      Data presented as mean ± SD
      Patient Health Questionnaire-9Validated; assesses depressive symptoms; higher score represents more depressive symptoms; score range: 0–27
      • Kroenke K.
      • Spitzer R.L.
      • Williams J.B.
      The PHQ-9: validity of a brief depression severity measure.
      4.0 (0–39)
      Data are presented as median (interquartile range).
      Rosenberg Self-esteem questionnaire+Validated; assesses global feelings of self-worth; higher score represents greater levels of self-esteem; score range: 0–30
      • Rosenberg M.
      Society and the adolescent self-image.
      27.4 ± 6.1
      Data presented as mean ± SD
      Lowder. Validation of a prolapse-specific body image questionnaire. Am J Obstet Gynecol 2014.
      a Data presented as mean ± SD
      b Data are presented as median (interquartile range).

      Pelvic Organ Prolapse Quantification examination

      The Pelvic Organ Prolapse Quantification examination was performed as part of clinical care as described by Bump et al,
      • Bump R.C.
      • Mattiasson A.
      • Bo K.
      • et al.
      The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction.
      was abstracted from the clinical record, and was used to define prolapse stage.

      Sample size considerations

      We estimated that enrollment of 240 women would meet our goal of 210 participants who completed the baseline study questionnaires. Our goal of 200 participants was based on a general rule of having approximately 10 participants per item for each of the 21 BIPOP items for EFA.
      • Nunnally J.C.
      Psychometric theory.
      We anticipated that approximately 20% of the participants would not return a complete baseline questionnaire dataset and thus planned to enroll up to 240 women. We planned to recruit 10 women, 5 partnered and 5 nonpartnered, to participate in the cognitive interviews. For test-retest analyses, we planned a convenience sample of one-half the cohort (approximately 100) to repeat the BIPOP measure.

      Results

      Two hundred eleven women were enrolled in this study, and 201 women had complete study questionnaires (completion rate, 95%). Mean age of study participants was 60.2 ± 10.5 years, and 83% identified themselves as postmenopausal. Participants had a median Pelvic Organ Prolapse Quantification stage of III (range, II–IV), mean body mass index of 28 ± 6 kg/m2, and 60% nonsmokers. They described their race/ethnicity as 97.6% white, 1.9% black, and 0.5% Hispanic. More than 80% of participants had a partner; 73% were married; 14% were divorced; 7% were widowed; 4% were single, and 2% were classified as “other.” Forty percent of the women reported having had a hysterectomy; 22% had previous prolapse or urinary incontinence surgery; 17% had previous breast or plastic surgery, and 2% had previous bariatric surgery. The recruitment rate between partnered and nonpartnered women was not significantly different. Two hundred one participants were enrolled at the University of Pittsburgh site between January 2011 and July 2012, and 10 participants were recruited at the Medical University of South Carolina site between February 2012 and July 2012.

      Cognitive interview and baseline scale results

      Review of the cognitive interview transcripts confirmed participants' understanding of each measure item (in comparison with the measure designers' intent) and measured comprehension, relevance, and clarity of questions and acceptability of length and subject matter. No significant changes in the candidate questions or Likert responses were made based on the cognitive interviews. Interview responses from participants who completed the questionnaires supported the face and content validity of study questions. Baseline scores for each of the study measures are listed in Table 2 and were similar to those reported previously in comparable populations.
      • Lowder J.L.
      • Ghetti C.
      • Moalli P.
      • Zyczynski H.
      • Cash T.F.
      Body image in women before and after reconstructive surgery for pelvic organ prolapse.
      • Barber M.D.
      • Walters M.D.
      • Bump R.C.
      Short forms of two condition-specific quality-of-life questionnaires for women with pelvic floor disorders (PFDI-20 and PFIQ-7).
      • Ghetti C.
      • Lowder J.L.
      • Ellison R.
      • Krohn M.A.
      • Moalli P.
      Depressive symptoms in women seeking surgery for pelvic organ prolapse.
      Table 2Initial Body Image in Pelvic Organ Prolapse questionnaire candidate items (21) with decisions from factor analysis
      • 1.
        Because of my prolapse, I worry that my partner might avoid being intimate with me.
        • ∗remained in Partner subscale
      • 2.
        I am embarrassed for my partner to see my genitals because of my prolapse.
        • —removed after 3rd EFA from Partner factor, high overlap and correlation with items 3 and 11.
      • 3.
        I am embarrassed for my partner to touch my genitals because of my prolapse.
        • ∗remained in Partner subscale
      • 4.
        I avoid intimate situations or sexual activity with my partner because of my prolapse.
        • ∗remained in Partner subscale
      • 5.
        I feel less confident about my body in intimate situations because of my prolapse.
        • —excluded on initial EFA, loaded >0.50 on >1 factor
      • 6.
        Because of my prolapse, I become anxious in intimate situations.
        • ∗remained in Partner subscale
      • 7.
        I feel less attractive because of my prolapse.
        • ∗remained in Attractiveness subscale
      • 8.
        I worry that my partner finds me less attractive because of my prolapse.
        • —excluded on initial EFA, loaded >0.50 on >1 factor
      • 9.
        I feel less attractive than other women my age because of my prolapse.
        • —removed after 3rd EFA from Attractiveness factor, high content overlap and correlation with item 7
      • 10.
        I feel less feminine because of my prolapse.
        • ∗remained in Attractiveness subscale
      • 11.
        I feel less confident about my body because of my prolapse.
        • ∗remained in Attractiveness subscale
      • 12.
        Other people's reaction to me having prolapse has made me feel worse about my body.
        • —removed after 3rd EFA from Attractiveness factor, found to be not relevant to everyone
      • 13.
        I am bothered by how my prolapse makes my genitals look.
        • —excluded on initial EFA, loaded >0.50 on >1 factor
      • 14.
        My prolapse affects how I feel about the rest of my body.
        • ∗remained in Attractiveness subscale
      • 15.
        I feel that my prolapse is the most bothersome part of my body to me.
        • —excluded on initial EFA, loaded <0.50 on any factor
      • 16.
        I try to hide my prolapse from my partner during intimate situations.
        • ∗remained in Partner subscale
      • 17.
        I feel uncomfortable wearing certain clothing (swimsuit, lingerie, pants, skirts) because of my prolapse.
        • —excluded initial EFA, loaded >0.30 on all 3 factors
      • 18.
        Because my prolapse is usually hidden by clothing, I do not feel self-conscious about my prolapse.
        • —excluded initial EFA, belonged to factor 3 only
      • 19.
        I feel older than my age because of my prolapse.
        • ∗remained in Attractiveness subscale
      • 20.
        There are other things about my body that bother me more than my prolapse.
        • —excluded initial EFA, belonged to factor 3 only
      • 21.
        Because of my prolapse I do not exercise as much as I would like to. (YES/NO) If “YES”, Because I am not exercising as much as I would like to I feel worse about my body.
        • —excluded EFA by partnership status, loaded on factor 3 for non-partnered version and weakly on factor 1 for partnered version
      EFA, exploratory factor analysis.
      Lowder. Validation of a prolapse-specific body image questionnaire. Am J Obstet Gynecol 2014.

      EFA results

      EFA of the 21 items was performed initially with data from all participants. This principle-components analysis with Varimax (orthogonal) rotation revealed 3 factors (subscales/themes) with eigenvalues >1, which explained 67% of model variance. Eigenvalues are a method of characterizing the explanatory power of each factor; the standard criteria for determining whether a given factor is “important” is that it produces an eigenvalue >1. Factor 1 explained 54% of the model variance; factor 2 explained an additional 7.5%, and factor 3 explained the remaining 5%. Based on this initial EFA, 7 candidate items were removed because these items either cross-loaded on >1 factor (loading >0.50 on 2 factors, 3 items; >0.30 on all 3 factors, 1 item), did not load strongly on any factor (<0.50 on any factor, 1 item), or loaded on the third and weakest factor only (2 items). Table 3 includes all initial candidate items and explains the decision process for either retaining or eliminating each item. The EFA was recalculated with the remaining 14 items; 2 factors were identified that explained 70% of the total model variance. Factor 1 explained 60% of the variance, and factor 2 explained an additional 10%. Cronbach's α was calculated for the candidate items that belonged to each factor: factor 1 (8 items) α = .92 and factor 2 (6 items) α = .92. With both factors, deletion of any items did not significantly improve α.
      Table 3Convergent validity assessment: association of Body Image in Pelvic Organ Prolapse subscales with other key constructs
      VariableBody Image in Pelvic Organ Prolapse questionnaire
      TotalP valueAttractivenessP valuePartnerP value
      Body Exposure during Sexual Activity Questionnaire–.700< .001–.622< .001–.672< .001
      Body Image Quality of Life Inventory.357< .001.382< .001.281< .001
      Pelvic Floor Distress Inventory-20–.385< .001–.368< .001–.347< .001
      Pelvic Floor Impact Questionnaire-7–.448< .001–.454< .001–.384< .001
      Patient Health Questionnaire-9–.387< .001–.391< .001–.324< .001
      Self-esteem Scale.256.001.280< .001.213.005
      Lowder. Validation of a prolapse-specific body image questionnaire. Am J Obstet Gynecol 2014.
      Next, a subgroup EFA was performed with the 14-item scale based on relationship status (partnered vs nonpartnered). In this analysis, 1 item loaded on a new 3rd factor (subscale) for nonpartnered participants and weakly on factor 1 for partnered women. We decided to rerun the EFA without this item. The EFA with 13 items for nonpartnered women yielded a 2-factor solution that explained 79% of model variance. The EFA for partnered women yielded a 2-factor solution that explained 72% of model variance.
      Based on these results, it appeared that 2 factors explained most model variance for both partnered and nonpartnered women. Factor 1 represented general attractiveness, and factor 2 represented prolapse-related reactions to partners. High internal consistency values for the 2 subscales (α > .90 for both) led us to examine whether additional items could be removed from the scales without sacrificing internal consistency. Based on an evaluation including a review of the content of the remaining items, inter-item correlations, and an iterative set of internal consistency (alpha) analyses, 4 additional items were removed from the measure. Of the items removed, 3 items were eliminated because of content overlap with other items in the scale and very high intercorrelations, and 1 item was not relevant to all potential women. The resulting two 5-item subscales were named based on the content of the items: attractiveness (5 items; α = .92) and partner (5 items; α = .90).

      Convergent validity analyses

      Correlations between the BIPOP subscales and the other study questionnaires are shown in Table 3. Both BIPOP subscales showed strong, significant, and directionally appropriate correlations with the pelvic floor disorders, general BI, depressive symptoms, and self-esteem questionnaires. Correlations for BIPOP subscale scores from baseline to 2 weeks were strong (partner: r = 0.77; attractiveness: r = 0.79).

      Test-retest analyses

      Baseline and 2-week mean scores for the BIPOP total and subscales were calculated and compared with a paired t test (Table 4), which revealed no statistically significant difference between scores at the 2 time points. The Intra-class Correlation Coefficient for the 10-item BIPOP measure, based on mean scores at baseline and 2 weeks, was 0.80; for the BIPOP-attractiveness subscale, it was 0.79, and for the BIPOP-partner subscale was 0.77. Final versions of the BIPOP (partnered and nonpartnered) and scoring are included in the Appendix.
      Table 4Body Image in Pelvic Organ Prolapse total and subscale mean scores
      Body Image in Pelvic Organ Prolapse questionnaireScoreP value
      All respondersBaseline2-week
       Total score2.92 ± 1.023.04 ± 1.00.80
       Attractiveness subscale score2.91 ± 1.113.04 ± 1.11.31
       Partner subscale score2.94 ± 1.113.00 ± 1.06.17
      By partner statusNonpartneredPartnered
       Total score3.19 ± 0.922.86 ± 1.03.10
       Attractiveness subscale score3.39 ± 1.002.80 ± 1.11< .01
       Partner subscale score2.86 ± 1.092.95 ± 1.00.66
      Data are presented as mean ± SD.
      Lowder. Validation of a prolapse-specific body image questionnaire. Am J Obstet Gynecol 2014.

      Reliability assessment as a total score

      Next, we wanted to determine whether the BIPOP could be scored as a total mean score and individual mean subscale scores. Cronbach's α was calculated for the 10 items of the measure (α = .93) and showed high internal consistency for the total measure. A correlation between the attractiveness and partner subscales was performed and were strong (r = 0.71). Together, these analyses confirm that the BIPOP can be scored as a total score or as individual subscales and maintain high internal consistency reliability.

      Total and subscale scores by partnered and nonpartnered status

      After completion of the psychometric evaluation of the BIPOP, we wanted to examine the additional question of whether partnered and nonpartnered women scored differently. Mean total and subscale scores were compared by partnered status to determine whether responses were comparable. There was no statistically significant difference in BIPOP total or partner subscale scores by partnered status (Table 4). In this sample, attractiveness subscale scores were statistically significant higher in the nonpartnered women compared with the partnered women (Table 4). This was a hypothesis-testing question, and any differences in scores between partnered and nonpartnered women on a subscale do not reflect any issues with measure adequacy.

      Comment

      Pelvic organ prolapse is a common pelvic floor disorder and impacts many aspects of a woman's overall health and quality of life. Poor BI and body dissatisfaction are associated with anxiety, depression, and poor psychosocial functioning. More recently, the role of prolapse on BI has been explored with the use of general or modified BI measures.
      • Jelosevek J.E.
      • Barber M.D.
      Women seeking treatment for advanced pelvic organ prolapse have decreased body image and quality of life.
      • Lowder J.L.
      • Ghetti C.
      • Moalli P.
      • Zyczynski H.
      • Cash T.F.
      Body image in women before and after reconstructive surgery for pelvic organ prolapse.
      • Lowenstein L.
      • Gamble T.
      • Sanses T.V.
      • et al.
      Sexual function is related to body image perception in women with pelvic organ prolapse.
      • Zielinski R.
      • Miller J.
      • Low L.K.
      • Sampselle C.
      • DeLancey J.O.L.
      The relationship between pelvic organ prolapse, genital body image, and sexual health.
      Women with prolapse had more negative BIs than women without prolapse. Both conservative (pessary) and surgical trials for prolapse have shown improved BI scores after intervention.
      • Lowder J.L.
      • Ghetti C.
      • Moalli P.
      • Zyczynski H.
      • Cash T.F.
      Body image in women before and after reconstructive surgery for pelvic organ prolapse.
      • Patel M.
      • Mellen C.
      • O'Sullivan D.M.
      • LaSala C.A.
      Impact of pessary use on prolapse symptoms, quality of life, and body image.
      The fact that BI is worse in women with prolapse and improves with treatment lends support to the argument that BI is an important construct to be assessed in patient-reported outcomes after medical and surgical interventions. In the plastic surgery literature, the anxiety and depression associated with body dissatisfaction is a major motivator in patients pursuing corrective surgery.
      • Kelly R.E.
      • Cash T.F.
      • Shamberger R.C.
      • et al.
      Surgical repair of pectus excavactum markedly improves body image and perceived ability for physical activity: a multicenter study.
      We believe this may also occur in women with prolapse. Medical and surgical treatments for prolapse are focused not only on improving anatomic support and providing symptom relief, but also on improving quality of life. To determine whether treatment for prolapse is successful across all outcomes of importance to women, we need valid and reliable measures to assess outcomes such as BI.
      • Sung V.W.
      • Rogers R.G.
      • Barber M.D.
      • Clark M.A.
      Conceptual framework for patient-important treatment outcomes for pelvic organ prolapse.
      We have developed and validated a prolapse-specific BI measure that is valid and reliable.
      A key strength of this study is that candidate items were derived directly from BI themes elicited from women with prolapse who participated in focus groups. A measure developed directly from themes identified with qualitative methods provides richer data to construct the measure vs simply relying on expert opinion or existing theory
      • Walsh T.R.
      • Irwin D.E.
      • Meier A.
      • Varni J.W.
      • DeWalt D.A.
      The use of focus groups in the development of the PROMIS Pediatrics Item Bank.
      • Krueger R.A.
      • Casey M.A.
      Focus groups: a practical guide for applied research.
      • Strauss A.
      • Corbin J.
      Basics of qualitative research.
      and should be more likely to capture the essence of the prolapse-BI construct compared with proxy or modified measures. Rigorous psychometric testing was performed to ensure validity (face, content, and convergent construct validity) and reliability (internal consistency and test-retest analysis). The BIPOP measure has versions for women with and without partners and should be applicable for adult women in most life stages.
      In this study, we did not assess the psychometric property of responsiveness to change. Responsiveness to change is defined as the capacity of a measure to detect change and requires demonstrating that a measure is able to show a difference when there is clinical reason to expect such a finding.
      • De Yebenes Prous M.J.G.
      • Salvanes F.R.
      • Ortells L.C.
      Responsiveness of outcome measures.
      • Barber M.D.
      • Walters M.D.
      • Cundiff G.W.
      • et al.
      Responsiveness of the Pelvic Floor Distress Inventory (PFDI) and Pelvic Floor Impact Questionnaire (PFIQ) in women undergoing vaginal surgery and pessary treatment for pelvic organ prolapse.
      Responsiveness to change typically is assessed by the use of a measure before and after intervention and evaluation of the difference in scores. Responsiveness to change testing is planned as part of the next step in the validation process for the BIPOP.
      There are some limitations of the study. The BIPOP was validated in a predominantly white population, which could impact the generalizability of this measure. Although prolapse is common in women of most ethnicities and races, body dissatisfaction related to prolapse may be expressed very differently by women of different ethnic, racial, religious, or social backgrounds. In addition, most of our patients described themselves as partnered. However, the high internal consistency between partnered and nonpartnered versions of the BIPOP lends evidence to its generalizability in both populations. Also, the 2 sites were in the Midwest and Southeast; most of the participants were enrolled from the Pittsburgh site. Women in other parts of the country or world may feel differently about the impact of prolapse on BI. Sung et al,
      • Sung V.W.
      • Rogers R.G.
      • Barber M.D.
      • Clark M.A.
      Conceptual framework for patient-important treatment outcomes for pelvic organ prolapse.
      in a study that developed a framework for patient-related outcomes in pelvic floor disorders, found similar BI themes in women with prolapse from several different regions in the United States. Future studies are needed to test the validity of the BIPOP in more diverse populations.
      The BIPOP has demonstrated properties that establish its potential as a useful prolapse-specific BI instrument. This instrument should help clinicians achieve a better understanding of the impact of prolapse on a woman's BI; once responsiveness to change has been demonstrated, it should be useful as an outcome measure for medical and surgical trials of women with prolapse. Future study of the impact of other pelvic floor disorders, such as lower urinary tract and bowel dysfunction, on BI are needed.

      Appendix

      BIPOP Questionnaire for Partnered Women

      BIPOP Questionnaire Scoring

      The Body Image in Women with Pelvic Organ Prolapse (BIPOP) Questionnaire is used to assess how prolapse affects a woman's body image. This self-report assessment uses a 5-point Likert response format. A total scale and subscale mean score (range, 1–5) can be calculated. There is a “partnered” and “non-partnered” version of the questionnaire that are scored the same.

      Scoring of the BIPOP Questionnaire

      The BIPOP Questionnaire yields a mean total and subscale scores which are the sum of the total items (total mean) and subscale items (subscale mean) divided by the number of items (10 for total mean, 5 for each subscale mean). The range of the scores are 1–5. A higher BIPOP score represents worse prolapse-related body image.

      Items 1-10 are scored as follows:

      Strongly Disagree: 1
      Disagree: 2
      Neither Agree nor Disagree: 3
      Agree: 4
      Strongly Agree: 5

      Total Scale Mean Score

      (Questions 1 + 2 +3 +4 + 5 +6 +7 +8 +9 +10)/10

      Mean Subscale Scores

      Attractiveness Subscale

      (Questions 5 + 6 +7 + 8 + 10)/5

      Partner Subscale

      (Questions 1 + 2 + 3 + 4 + 9)/5

      BIPOP Questionnaire for Nonpartnered Women

      BIPOP Questionnaire Scoring

      The Body Image in Women with Pelvic Organ Prolapse (BIPOP) Questionnaire is used to assess how prolapse affects a woman's body image. This self-report assessment uses a 5-point Likert response format. A total scale and subscale mean score (range, 1–5) can be calculated. There is a “partnered” and “nonpartnered” version of the questionnaire that are scored the same.

      Scoring of the BIPOP Questionnaire

      The BIPOP Questionnaire yields a mean total and subscale scores which are the sum of the total items (total mean) and subscale items (subscale mean) divided by the number of items (10 for total mean, 5 for each subscale mean). The range of the scores are 1–5. A higher BIPOP score represents worse prolapse-related body image.

      Items 1-10 are scored as follows:

      Strongly Disagree: 1
      Disagree: 2
      Neither Agree nor Disagree: 3
      Agree: 4
      Strongly Agree: 5

      Total Scale Mean Score

      (Questions 1 + 2 +3 +4 + 5 +6 +7 +8 +9 +10)/10

      Mean Subscale Scores

      Attractiveness Subscale

      (Questions 5 + 6 +7 + 8 + 10)/5

      Partner Subscale

      (Questions 1 + 2 + 3 + 4 + 9)/5

      References

        • Nygaard I.
        • Barber M.D.
        • Burgio K.L.
        • et al.
        Prevalence of symptomatic pelvic floor disorders in US women.
        JAMA. 2008; 300 (1311-216)
        • Rogers G.R.
        • Villarreal A.
        • Kammerer-Doak D.
        • Qualls C.
        Sexual function in women with and without urinary incontinence and/or pelvic organ prolapse.
        Int Urogynecol J. 2001; 12: 361-365
        • Jelosevek J.E.
        • Barber M.D.
        Women seeking treatment for advanced pelvic organ prolapse have decreased body image and quality of life.
        Am J Obstet Gynecol. 2006; 194: 1455-1461
        • Lowder J.L.
        • Ghetti C.
        • Moalli P.
        • Zyczynski H.
        • Cash T.F.
        Body image in women before and after reconstructive surgery for pelvic organ prolapse.
        Int Urogynecol J Pelvic Floor Dysfunct. 2010; 21: 919-925
      1. Cash T.F. Pruzinsky T. Body image: a handbook of theory, research, and clinical practice. Guilford Press, New York2002
        • Lowder J.L.
        • Ghetti C.
        • Nikolajski C.
        • Oliphant S.S.
        • Zyczynski H.
        Body image perceptions in women with pelvic organ prolapse: a qualitative study.
        Am J Obstet Gynecol. 2011; 204: 441.e1-441.e5
        • Lowenstein L.
        • Gamble T.
        • Sanses T.V.
        • et al.
        Sexual function is related to body image perception in women with pelvic organ prolapse.
        J Sex Med. 2009; 6: 2286-2291
        • Sung V.W.
        • Rogers R.G.
        • Barber M.D.
        • Clark M.A.
        Conceptual framework for patient-important treatment outcomes for pelvic organ prolapse.
        Neurourol Urodynam. 2014; 33: 414-419
        • Patel M.
        • Mellen C.
        • O'Sullivan D.M.
        • LaSala C.A.
        Impact of pessary use on prolapse symptoms, quality of life, and body image.
        Am J Obstet Gynecol. 2010; 202: 499.e1-499.e4
        • Streiner D.L.
        • Norman G.R.
        Health measurement scales: a practical guide to their development and use.
        3rd ed. Oxford University Press, Oxford (UK)2003
        • Walsh T.R.
        • Irwin D.E.
        • Meier A.
        • Varni J.W.
        • DeWalt D.A.
        The use of focus groups in the development of the PROMIS Pediatrics Item Bank.
        Qual Life Res. 2008; 17: 725-735
        • Wills G.
        Cognitive interviewing and questionnaire design: a training manual: working paper #7.
        National Center for Health Statistics, Atlanta, GAMarch 1994
        • George D.
        • Mallery P.
        SPSS for Windows step by step: a simple guide and reference: version 11.0 update.
        4th ed. Allyn & Bacon, Boston2003
        • Marx R.G.
        • Menezes A.
        • Horovitz L.
        • Jones E.C.
        • Warren R.F.
        A comparison of two time intervals for test-retest reliability of health status instruments.
        J Clin Epid. 2003; 56: 730-735
      2. Sarwer D.B. Pruzinksy T. Cash T.F. Goldwyn R.M. Persing J.A. Whitaker L.A. Psychological aspects of reconstructive and cosmetic plastic surgery: clinical, empirical, and ethical perspective. Lippincott, Williams & Wilkins, Philadelphia2006
        • Bolton M.A.
        • Pruzinsky T.
        • Cash T.F.
        • Persing J.A.
        Measuring outcomes in plastic surgery: body image and quality of life in abdominoplasty patients.
        Plast Reconstr Surg. 2003; 112: 619-625
        • Barber M.D.
        • Walters M.D.
        • Bump R.C.
        Short forms of two condition-specific quality-of-life questionnaires for women with pelvic floor disorders (PFDI-20 and PFIQ-7).
        Am J Obstet Gynecol. 2005; 193: 103-113
        • Rogers R.G.
        • Coates K.W.
        • Kammerer-Doak D.
        • Khalsa S.
        • Qualls C.
        A short form of the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12).
        Int Urogynecol J Pelvic Floor Dysfunct. 2003; 14: 164-168
        • Kroenke K.
        • Spitzer R.L.
        • Williams J.B.
        The PHQ-9: validity of a brief depression severity measure.
        J Gen Intern Med. 2001; 16: 606-613
        • Rosenberg M.
        Society and the adolescent self-image.
        Princeton University Press, Princeton, NJ1965
        • Bump R.C.
        • Mattiasson A.
        • Bo K.
        • et al.
        The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction.
        Am J Obstet Gynecol. 1996; 175: 10-17
        • Nunnally J.C.
        Psychometric theory.
        2nd ed. McGraw-Hill, New York1978
        • Ghetti C.
        • Lowder J.L.
        • Ellison R.
        • Krohn M.A.
        • Moalli P.
        Depressive symptoms in women seeking surgery for pelvic organ prolapse.
        Int Urogynecol J Pelvic Dysfunct. 2010; 21: 855-860
        • Zielinski R.
        • Miller J.
        • Low L.K.
        • Sampselle C.
        • DeLancey J.O.L.
        The relationship between pelvic organ prolapse, genital body image, and sexual health.
        Neurourol Urodyn. 2012; 31: 1145-1148
        • Kelly R.E.
        • Cash T.F.
        • Shamberger R.C.
        • et al.
        Surgical repair of pectus excavactum markedly improves body image and perceived ability for physical activity: a multicenter study.
        Pediatrics. 2008; 122: 1218-1222
        • Krueger R.A.
        • Casey M.A.
        Focus groups: a practical guide for applied research.
        SAGE Publications, Thousand Oaks, CA2009
        • Strauss A.
        • Corbin J.
        Basics of qualitative research.
        SAGE Publications, Thousand Oaks (CA)1998
        • De Yebenes Prous M.J.G.
        • Salvanes F.R.
        • Ortells L.C.
        Responsiveness of outcome measures.
        Reumatol Clin. 2008; 4: 240-247
        • Barber M.D.
        • Walters M.D.
        • Cundiff G.W.
        • et al.
        Responsiveness of the Pelvic Floor Distress Inventory (PFDI) and Pelvic Floor Impact Questionnaire (PFIQ) in women undergoing vaginal surgery and pessary treatment for pelvic organ prolapse.
        Am J Obstet Gynecol. 2006; 194: 1492-1498

      Linked Article

      • Body image for pelvic organ prolapse – a new important questionnaire has come
        American Journal of Obstetrics & GynecologyVol. 211Issue 3
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          We read with great enthusiasm the article published by Lowder et al1 regarding the construction of a body image questionnaire for women with pelvic organ prolapse (POP). We think the authors have solved a problem when exploring body image in POP studies because this variable has not been explored adequately. In our opinion, body image is the most important variable that should be questioned after surgery; after all, POP surgery is a plastic reconstructive modality that influences many immediate and late outcomes and is influenced by gynecologic and socioeconomic characteristics.
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