Aboriginal and Torres Strait Islander women’s appraisal of continence information brochures

Prabha Lakhan; Kalisha Soe; Audrey Burgin; Annie Fonda; Noel Hayman

doi:10.1071/CJ24040

RESEARCH ARTICLE (Open Access)

Next Contents Vol 31(1)

Aboriginal and Torres Strait Islander women’s appraisal of continence information brochures

Prabha Lakhan ^A ^* , Kalisha Soe ^A , Audrey Burgin ^A , Annie Fonda ^A and Noel Hayman ^A ^B

+ Author Affiliations

- Author Affiliations

^A Southern Queensland Centre of Excellence in Aboriginal and Torres Strait Islander Primary Health Care, Aboriginal and Torres Strait Islander Health Directorate, Metro South Health, 37 Wirraway Parade, Inala, Brisbane, Qld 4077, Australia.

^B The University of Queensland, Faculty of Medicine, Herston, Qld, Australia.

^* Correspondence to: prabha.lakhan@health.qld.gov.au

Australian and New Zealand Continence Journal 31, CJ24040 https://doi.org/10.1071/CJ24040

Submitted: 27 June 2024 Accepted: 16 October 2024 Published: 4 February 2025

© 2025 The Author(s) (or their employer(s)). Published by CSIRO Publishing on behalf of the Continence Foundation of Australia. This is an open access article distributed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License (CC BY-NC-ND)

Abstract

Aim

The aim of this study was to evaluate the usefulness of seven brochures for Aboriginal and Torres Strait Islander women with urinary incontinence (UI).

Method

Twenty-three Aboriginal and Torres Strait Islander women, aged between 40 and 76 years, experiencing UI and attending an urban Aboriginal and Torres Strait Islander primary healthcare service, participated in semi-structured digitally recorded interviews. They appraised seven brochures, developed by the Continence Foundation of Australia, for use by Aboriginal and Torres Strait Islander communities. Participants were provided with one brochure at a time to read and comment on its usefulness; presentation including appropriateness of the artwork, colours, structure and design; any improvements; and whether the brochures should be provided to all women with UI. A thematic analysis of the interview contents was conducted by two researchers.

Results

The interviews identified four main themes including usefulness of the information presented in the brochures; readability and comprehensibility of the information; suggestions for refining the brochures; and usefulness of brochures to Aboriginal and Torres Strait Islander women. All women found the information in all the brochures useful, easy to read and understand, and recommended that they should be provided to Aboriginal and Torres Strait Islander women with risk factors for developing, or those with UI. A few suggestions to refine the brochures were identified.

Conclusions

This study has provided evidence that the brochures are a valuable resource for raising awareness about UI among Aboriginal and Torres Strait Islander women attending urban Aboriginal and Torres Strait Islander primary healthcare settings.

Keywords: Aboriginal, incontinence, information brochures, Torres Strait Islander, women, written health information.

Introduction

Urinary incontinence (UI) refers to loss of voluntary control of urine, with a higher prevalence in women than men, and can significantly impact the quality of life.¹^–⁴ Persons with UI may not seek assistance from health professionals for many reasons including believing that it is a normal part of childbirth or aging; an unawareness of the different methods for managing UI; and feelings of embarrassment and shame.⁵ Increased awareness about UI and its management may encourage persons to seek assistance and reduce its impact on everyday living.

Primary healthcare settings are ideal for implementing health promotion initiatives to raise awareness about UI. Effective communication of health information is an important component of these initiatives.⁶ A combination of verbal and written information can assist in greater information retention and recall and patient satisfaction.⁷^–⁹ Written information such as leaflets and brochures can be used for communicating health-related information and strengthening health literacy, especially in busy primary healthcare services.⁷ Health promotion tools, including resource kits, play an important role in health promotion programs for Aboriginal and Torres Strait Islander communities.¹⁰ However, it is important that these resources meet the needs of persons with different levels of health literacy.¹¹ A greater use of simple non-technical language, and illustrations and pictures are useful for providing health information to persons with lower levels of health literacy.⁷

Since significant amounts of time and resources are invested in the development of information resources, it is important to evaluate their readability, comprehensibility and effectiveness in communicating information.⁸^,¹² Examination of readability includes the visual and linguistic aspects that enable the messages to stand out against the background, such as print size and spacing between words, and use of graphics and colours. Evaluation of comprehensibility includes vocabulary and grammatical structure or syntax and cohesiveness between sentences. Each new sentence should be short and cover new content, be linked to the previous sentences, and able to be interpreted easily.⁸^,¹² Effectiveness in communication of the information can be assessed by examining the reader’s success in grasping the intended messages and actual use or application of the information such as whether he/she has understood and will apply/use the information; or has not understood and will not apply/use the information; or has understood but decided not to apply/use the information.⁸^,¹²

The Continence Foundation of Australia (The Foundation) provides a range of resources, including information brochures, that are designed for use by Aboriginal and Torres Strait Islander peoples (also respectfully referred as Indigenous hereafter). The original suite of 17 brochures on different aspects of incontinence were developed in 2002 for use by all Aboriginal and Torres Strait Islander peoples.¹³^,¹⁴

Aboriginal artwork was incorporated in the design of the brochures. The content is presented using dot points, illustrations and pictures. Two reviews, conducted in 2010 and 2015, focused on the continuing cultural appropriateness; language and illustrations used in the brochures; accuracy and currency of the clinical content; and consistency and standardisation of terms across the suite of brochures.¹³^–¹⁵ The 2010 review was initiated following feedback from Health Workers in rural and remote communities who had completed incontinence training programs, developed by The Foundation. The review identified that while the brochures were meeting the needs of Aboriginal and Torres Strait Islander communities living in metropolitan and regional communities, the brochures needed to be adapted for use in remote Aboriginal and Torres Strait Islander communities.¹³^,¹⁴ The review included a project advisory group comprising continence nurse specialists working in rural/remote regions of Queensland, rural Western Australia, and rural New South Wales and including a co-investigator (AB) from Brisbane. Consultation with Aboriginal and Torres Strait Islander communities is essential in the development of information resources.¹⁶ Health Workers and Remote Aboriginal and Torres Strait Islander communities in five states and the Northern Territory participated in consultations. Final versions of 12 more culturally specific brochures, with greater use of everyday language and visual presentations of information, were developed following consultations on the draft revised brochures with Aboriginal and Torres Strait Islander communities in six states and the Northern Territory.¹⁴ The Foundation used the Cultural Respect Framework for Aboriginal and Torres Strait Islander Health 2004–2009, as their guiding principle and worked closely with the Batchelor Institute of Indigenous Tertiary Education to develop the brochures.¹³^,¹⁴ An expert group of six clinicians, including one of the co-investigators (AB) with experience in working with Aboriginal and Torres Strait Islander peoples were involved in the 2015 review of the terminology and language used in the 12 brochures, to enable use by all Aboriginal and Torres Strait Islander communities in Australia, not just those living in remote communities. A communication agency conducted a formal review of language to ensure the needs of persons with low literacy were met and messages were communicated correctly to Aboriginal and Torres Strait Islander peoples.

No studies have reported on the evaluation of these brochures by Aboriginal and Torres Strait Islander women attending an urban Indigenous primary healthcare service.

Aim

This study aimed to evaluate the usefulness of seven brochures, which described different aspects of managing UI and were especially applicable to women.

Methods

Aboriginal and Torres Strait Islander community governance and ethics committee approvals

This study was supported and approved by the Inala Community Jury for Aboriginal and Torres Strait Islander Health Research¹⁷ and Metro South Human Research Ethics Committee (HREC/2019/QMS/47628). Verbal feedback of the study findings and a copy of the manuscript were provided to all members of the Inala Community Jury for comments prior to submission for publication.

Study design

A qualitative study design, using a semi-structured interview guide, was used in this study. The research was conducted according to the following six core values: spirit and integrity; cultural continuity; equality; reciprocity; respect; and responsibility, when conducting research with Aboriginal and Torres Strait Islander peoples and communities.¹⁸ This research was conducted at the Southern Queensland Centre of Excellence (SQCoE) in Aboriginal and Torres Strait Islander Primary Health Care, which strives to be a culturally safe and appropriate environment for Aboriginal and Torres Strait Islander people, and respectful of their culture and heritage. The SQCoE offers primary healthcare services and many integrated speciality services, and the community engagement team helps maintain its close connection with the community. Research conducted at the SQCoE actively involves the Aboriginal and Torres Strait Islander community and follows research processes that ensure that the research is conducted respectfully and responsibly within the six core values. The Inala Community Jury for Aboriginal and Torres Strait Islander Health Research ensured that the research was conducted with respect and integrity, was not harmful to the community, and followed the six core values. The research team acknowledges the Traditional Custodians, the Turrbal and Yuggera peoples, on whose lands (now known as Brisbane) this research was conducted; the wisdom and knowledge of Aboriginal and Torres Strait Islander peoples; their ways of being, knowing and doing; and their right to self-determination, described under the data collection procedure section. Women were also asked about their preferred terminology for urine and incontinence, and these were used during the interview.

This research was led by a female non-Indigenous Australian investigator (PL) with experience in conducting qualitative research and with the health of Aboriginal and Torres Strait Islander peoples attending an urban Aboriginal and Torres Strait Islander primary healthcare service, and with past experience as a registered nurse. The senior investigator (NH) is an Aboriginal man, senior General Practitioner (GP), Clinical Director, and founder of the SQCoE. Most interviews were conducted by a female non-Indigenous Australian co-investigator (AB), a clinical nurse and employee, with a continence nurse specialist qualification. A few interviews were conducted by a female Aboriginal clinical nurse and employee, and co-investigator at commencement of the study (who withdrew after ceasing employment while interviews were in progress), or by a female non-Indigenous co-investigator and employee (PL).

The two investigators responsible for recruiting and interviewing participants were provided with information and brief training about recruitment procedures and qualitative research by the lead investigator with experience in conducting qualitative research. Training was provided on data collection and recruitment; conduct of qualitative interviews; data synthesis; the importance of valuing and respecting the participants experiential knowledge of UI; and the six core values of conducting research with Aboriginal and Torres Strait Islander peoples; understanding the stigma and sensitive nature of UI and using strategies to enable women feel safe and comfortable when sharing their knowledge; reflecting on their own knowledge and experiences as clinical nurses; and strategies to reduce their own pre-conceived ideas about UI when conducting interviews. The two interviewers conducted a practice interview with each other before commencing interviews with women.

Participants and setting

A purposive sample of Aboriginal and Aboriginal and Torres Strait Islander women experiencing UI and attending the SQCoE between August 2019 and February 2020, with a diagnosis of UI in their medical records, who did not have any cognitive impairment and were able to read and converse in English were eligible for participation in the research. All eligible participants were also receiving clinical care at the primary healthcare service, including some who may have received care provided by four of the investigators at the commencement of the study (two GPs and two clinical nurses). Strategies were employed during the recruitment to avoid women feeling obliged to participate, or not wishing to provide any negative aspects when reviewing the brochures, described below.

Data collection procedure

All GPs providing clinical care during the study were provided with information about the study including recruitment procedures for eligible women, and clinical nurses involved in the recruitment and interviews. A two-step recruitment process was used to avoid the participants feeling obliged to take part in the study. Aboriginal, Torres Strait Islander, and Aboriginal and Torres Strait Islander women experiencing UI were provided with brief information verbally about the research by the GPs at the end of their medical consultation. Names of women interested in the research were provided to either of the recruitment Clinical Nurses, who provided brief information about the study either on the same day or another mutually convenient day and time. Women were also informed that they were not to feel obliged to participate in the study because they were receiving clinical care at the service, and participation or non-participation would not have any effect on the care provided to them. Women interested in participating were provided detailed verbal information, and a written copy of the Participant Information Sheet. The consent form and voluntary nature of participation was explained, and all questions were answered. Two participants completed the consent form at this time. A mutually convenient day and time was organised for the digitally-audio-recorded semi-structured interview to be conducted at SQCoE.

Each participant was greeted by the interviewer upon arrival at the reception desk, and accompanied to the interview room. She was welcomed and thanked for her participation. The participant was informed that she could change the position of her chair in the room to where she felt most comfortable. She was offered a selection of beverages (water, tea or coffee) and informed that the interview could be stopped if she needed a break. The interview was conducted in a single room with a table used for placing the recorder and brochures. General social and informal method of conversation, including information that the interviewer and participant would have a ‘yarn’ about the research, was used to help her feel relaxed and comfortable. The interviewer introduced herself, her role at SQCoE and in the research. The conversation then transitioned into the research phase including completion of consent forms. The interview procedure was explained, including not being addressed by name during the interview to maintain anonymity. According to each participant’s wishes, an Aboriginal Health Worker (employee) was present at the beginning of 3 and not present for 20 interviews.

Most of each interview (ranging between 30 and 40 min) focused on the participant’s experiences of living with UI and its management (not described in this paper), followed by an appraisal of one or more of their preferred brochures, dependent on the available time. The seven brochures were shown to each participant, the purpose of the brochures was explained, and women selected the brochures they wished to, or were able to critique, within their available time. Participants were provided one brochure at a time to read, seek clarification and comment on usefulness; presentation (simplicity of the language, font size of letters, pictures and illustrations, size and thickness of the brochure); appropriateness of the artwork, colours and design; any improvements; and value of each brochure to Aboriginal and Torres Strait Islander women including those with UI.

Responses were summarised and confirmed with each participant following the evaluation of each and all brochures, to ensure trustworthiness of the interview interpretation and opportunity for the participant to agree, disagree or provide additional information. The interviews were ceased when participants were not providing any new information, indicating data saturation was reached.

Reciprocity in research was ensured by providing participants with copies of brochures they requested for themselves and/or their family members, and the Foundation’s website and telephone number. Participants were offered a copy of their transcript for their comment (none wished to receive a copy). If it was identified during the interview that any of the women required a review by the GP, arrangements were made for the participant, with their consent, for a consultation with the GP, at a time convenient to the participant and the urgency of their need. Each participant was thanked and provided an AU$25 supermarket voucher for sharing their knowledge.

Synthesis of interview information

The interviews were transcribed verbatim by a transcription company. The consolidated criteria for reporting qualitative research (COREQ) was followed in the conduct and reporting of this study.¹⁹ Contents of each transcribed interview relating to evaluation of the brochures was imported into the software program NVIVO (ver. 12), coded and recoded under main headings which were collapsed into broader themes by one of the investigators (PL). The second investigator (KS), an Aboriginal Research Assistant, also independently coded each interview manually to identify the main ideas and themes. Similar main ideas and themes were identified by both investigators; names for each theme were discussed and agreed.

Results

The 23 female participants, 3 Aboriginal and Torres Strait Islander and 20 Aboriginal, were aged between 40 and 76 years (mean 59, s.d. ±9.1, median 62). The details of the seven brochures evaluated in this study are outlined in Table 1.

Table 1.Brief content of each brochure evaluated in this study.

Name of brochure	Topics covered
Diabetes and bladder or bowel problems. Let’s yarn about this.	Association between diabetes and bladder or bowel problems. Functions of the bladder and bowel. Excess sugar in blood and bladder or bowel problems. Actions to avoid bladder and bowel problems (includes pictures of foods and beverages to use and those to avoid).
Women’s bladder problems. Let’s yarn about women’s business.	Functions of a healthy bladder: holding capacity, frequency of emptying, able to get to toilet without leaking. Causes that can trigger UI. List of actions to avoid UI. List of reasons for seeking help.
Pelvic floor muscle exercises for women: Let’s yarn about women’s business.	Information about pelvic floor muscles (picture of normal and saggy muscles) and its association with incontinence. Illustration showing organs in abdominal cavity including bladder and bowel. Causes and consequences of weak muscles including pictures of normal and saggy pelvic floor muscles. Actions to take to maintain pelvic floor muscle strength, including pictures of healthy foods. Instructions for performing pelvic floor muscle exercises. Reasons for seeking medical assistance.
Pads, clothes and bedding to help if you are getting wet. Let’s yarn about this.	Role of containment pads and pants, including pictures and descriptions. Disposal of used pads. Washable pads and pants. Suitable clothes to wear. Bed pads, mattress covers, pillow covers, doona covers, chair pads to prevent these from getting wet. Products (including pictures) to prevent UI in persons with mobility problems or are bed bound e.g. chair toilet, urinal, condom drainage. Accessing/purchasing the above items including government subsidised items.
Constipation (Hard poo). Let’s yarn about this.	General information about constipation including normal bowel movements and explanation and anatomical picture of the digestive tract. Effects of constipation on bladder function, including increased pressure on the bladder which contributes to leakage, worsening of the bladder problem, and an increased urge to urinate frequently. Actions to prevent constipation including pictures. Foods that prevent constipation (including pictures of some high fibre foods). Tips about maintaining good toilet habits. List of changes in bowel motions that require assistance from doctor or health worker.
Training the bladder. Let’s yarn about this.	Role and functions of a healthy bladder, bladder training. Illustrations of kidneys and bladder, including partially full (one-third) and a full bladder. Reasons for feeling the urge to urinate, including pictures of foods to avoid and illustration of a human body showing the brain and spinal cord with nerves supplying bladder. Actions to enable bladder to hold more urine. How to tell if bladder is holding more urine. Reasons for seeking help from a health professional.
Help getting to the toilet. Let’s yarn about this.	Reasons for help in getting to toilet. Problems with using the toilet. List of helpful actions to take.

All brochures included list of health professionals for assistance and the National Continence Helpline telephone number. A blank ‘Notes’ page was included in all the brochures except ‘Women’s Bladder problems’.

Source: all brochures developed by the Continence Foundation of Australia were accessed from https://www.continence.org.au/get-help/resources.

Eight (35%) participants appraised all the seven brochures, six (26%) appraised six, five (22%) appraised five, one (4%) appraised four, two appraised three (9%) and one (4%) participant appraised one of the seven brochures. The ‘Diabetes and bladder or bowel problems’ and ‘Women’s bladder problems’ brochures were appraised by most participants.

All participants carefully read each page of the brochure either quietly, aloud, or both and provided comments for each page and then for the whole brochure. Four main themes identified from the participants evaluations included usefulness of the information presented in the brochures; readability and comprehensibility of the information; suggestions for refining the brochures; and usefulness of brochures to Aboriginal and Torres Strait Islander women.

Usefulness of the information presented in the brochures

All participants identified that the information presented in all the brochures was useful, including assisting them in asking questions when they felt there was something wrong with their health, as described by the following participant.

… there could be things happening to you and you don’t know what to ask or you don’t know what to say… how to put it. But in here you think, ah, hah, that’s me … [‘Diabetes…’ brochure. Participant 20]

They identified specific types of useful and new information from the brochures, see Box 1.

Box 1.Examples of useful information and suggestions for enhancing content of the brochures.

Examples of useful information

Pelvic floor muscles exercises for women: Anatomical information about the organs and pelvic floor muscles; role of pelvic floor muscles in preventing UI; causes of weakened saggy pelvic floor muscles; instructions for performing muscle strengthening exercises.

‘Training the bladder’ and ‘Women’s bladder problems…’: purpose of the bladder; a normal functioning bladder emptied about five times a day; reasons for the bladder not functioning normally; list of actions to help in normal bladder functioning, as described below.

I … like this one [Training the bladder brochure], … how to tell if your bladder is holding a wee, to do that count [how many times you are going to the toilet] and then do it after a month to see if it actually is holding more, …, I should do that myself. [Participant 2]

‘Diabetes and bladder or bowel problems’: associations between diabetes and UI; lifestyle changes required to prevent UI, such as avoiding fizzy and caffeinated drinks or reducing sugar intake, described below.

… it cuts out all the things I like… I’m really bad with coffee and tea, and I’ve been drinking a bit of Pepsi Max, so I’m bad with sugar too… I love these things [pictures of beverages to avoid]. [Participant 16]

‘Constipation’: association between constipation and UI; correct toilet seating position; useful tips for avoiding constipation; encouraging women to initiate conversation about this sensitive condition.

‘Help getting to the toilet’: reasons for not able to, and tips to get to the toilet in time, such as wearing suitable clothes and using aids such as a commode.

‘Pads, clothes and bedding to help if you are getting wet’: effective containment products and aids for protecting furniture and bedding, described below.

And the chairs [pads] … people don’t know about them… I didn’t know [urinals for women]. [Participant 1]

No, I didn’t know [items available for home e.g. mattress covers]. Where do you get these from? [Participant 10]

Telephone number of the National Continence Helpline (all seven brochures), as described below.

… good to know that you can speak to somebody [National Continence helpline]. And not feel frustrated… is there anyone I can speak to without having to make an appointment to go and see the doctor, and wait, and wait …especially if they’re trying to care for somebody at home…and starting to feel frustrated … [Participant 4]

Suggestions for enhancing the brochures

Women’s bladder problems:

Insert a ‘Notes’ section;
Insert a picture of a female figure on the front and back page to highlight that the brochure was specifically for women;
More pictures and less words for people having difficulty reading written information, described below.
I think it’d be great … where literacy’s a problem … I think there needs to be more pictures, there’s a lot of words here …. [Participant 6]

‘Constipation’ brochure:

Insert a tick (√) next to the picture of healthy foods;
Include another picture with a cross (X) to include unhealthy foods;
Include information about foods that help in softening the stool such as pawpaw; and dietary advice to include foods such as kangaroo meat, described by the following participant.
… they talk about healthy diet and maybe also incorporate bush tucker… things like kangaroo meat… Whether those things are helpful. [Participant 21]

‘Pelvic floor muscle exercise’ brochure:

Number each page in the brochure
Provide clearer instructions for performing the exercise, described below.
if you’re doing these exercises, do you do them lying down or standing up? - - -That’s confusing… you think about exercising those and it says you shouldn’t feel your buttocks squeezing together. You are holding your breath. Your stomach muscle is moving. That’s quite confusing… makes it harder. [Participant 16]

‘Diabetes and bladder and bowel problems’ brochure:

Insert additional pictures and a ‘tick’ beside pictures of healthy foods, described below.
If you’ve got a cross [next to pictures of unhealthy foods], why not put a big tick up here [pictures of healthy foods]? That makes it easier for people that don’t want to read everything… And even though it says here with your blood sugar and bladder, as well as alcohol, I need to see a picture of beers or wines … another sign that says this needs to be controlled. It just needs to be a little bit more visual. [Participant 6]

‘Pads, clothes and bedding…’ brochure:

Lesser use of formal language in some instances, such as use of ‘toilet chair’ instead of ‘commode’.

Participants also used knowledge gained from their experiences to evaluate usefulness of the information. For example, participants agreed with information [‘Help getting to the toilet’ brochure] that presence of back pain contributed to difficulty getting to the toilet, and a bedside commode was helpful in avoiding UI. Experiential validation of other brochure information included precipitating factors for UI (coughing, laughing, childbirth, obesity); recommended interventions, such as daily exercises and high fibre diet; drinking water instead of caffeinated drinks and using distraction techniques for bladder training as described by the following participants:

other things you can do to help. Try to keep the bladder filling up. Drink water every day [Information listed in brochure]. I do drink fluid… I only have one cup of tea a day. I don’t drink grog or alcohol. [Don’t let your poo get hard brochure]. I eat a lot of fruit and grains. [‘Training the bladder’ brochure. Participant 20]

I only have one coffee in the morning… maybe a cup of tea … within a month or so. Fizzy drinks I just don’t touch. Water is the best. [‘Diabetes and bladder and bowel problems’ brochure. Participant 19]

I’ve tried that [distraction technique] … it has worked, especially if … I’ve been to the toilet 15 minutes earlier and … I need to go to the toilet, … I really try and think of something else or I try and keep myself busy doing something else so I’m not thinking about going to the toilet; that actually works … [Training the Bladder brochure, Participant 2]

Participants also identified information that they disagreed with, or had trouble implementing, such as clothing colour to hide any leakage, techniques to reduce urge and frequency of voiding, listed in the ‘Training the bladder’ brochure, as described by the following participants.

It says dark colours can help you hide a leak but they don’t… maybe black but not blues … I found that a florally dress or a skirt … hid it so much better. [‘Pads, clothes and bedding…’ Participant 2]

I don’t agree with [hold as long as you can]. Yes, [bit hard for me]. [Participant 3]

walk slowly to the toilet, don’t rush [information in brochure]. Sometimes I bust… I’ve got to run to the [toilet] … drink less caffeine. … well I can’t do without my coffee… [Participant 6]

I wish mine [voiding] only had five times a day, and once during the night [information about a healthy bladder]. Mine can be 12 times a day, and four times a night. And that’s without tea,… coffee, … fizzy drinks that can stimulate the bladder. [Participant 4]

Readability and comprehensibility of the information in the brochures

All participants identified techniques used to enhance the readability and comprehensibility of information.

Simple, non-offensive language and concise information

None of the information in the brochures was considered sensitive or offensive including the words ‘wee’, ‘urine’ and ‘leak wee’. Inclusion of the phrase ‘lets yarn about this’ in the titles of each brochure was described as especially appropriate for Aboriginal and Torres Strait Islander peoples. Information in the brochures was concise, including title of one of the brochures ‘Training the bladder’, considered amusing but appropriate, and written in simple, clear language, using large font sizes described in the following quotes.

That explains what the bladder does … what can cause the bladder to leak. It’s in clear, simple English. [‘Women’s bladder problems…’ brochure. Participant 16]

I like it because it’s very simple, …very straight to the point and it’s like that’s exactly what I’ve got. [‘Women’s bladder problems…’ brochure. Participant 17]

It’s not offensive … easy to follow… understand. Everything there that’s supposed to be there. [‘Women’s bladder problems…’ brochure. Participant 18]

Common, everyday words … short, easy words that everyday people can understand, and read more easily. [‘Help getting to the toilet’ brochure. Participant 4]

… you get a lot of pamphlets and they’re, really tiny words and it makes it hard to see, the sizing of the words [in the brochures] are really good. [All brochures, Participant 2].

Illustrations and diagrams enhanced comprehensibility

None of the illustrations or pictures were considered offensive and complemented the written information, described by the following participants.

I think it’s good because of the diagrams… It’s … showing what a perfect bladder looks like with all the muscle, and then you’ll see the saggy pelvis… [‘Women’s bladder problems’ brochure Participant 17]

The pictures are great, relates to our people because there’s a lot of Indigenous art. And it’s about being healthy because there’ a lot of pictures of healthy food. And I can look at the last picture [health worker, nurse etc] without reading it and say that people are caring about each other here, that there’s people to care without even reading it. [‘Women’s bladder problems…’ brochure. Participant 16]

I don’t see nothing wrong with the pictures. Very explainable. Not offensive. [‘Women’s bladder problems…’ brochure. Participant 1]

Everything stands out, nothing that’s going to be offensive … [word] poo’s not offensive to me. [‘Constipation’ brochure. Participant 18]

Overall structure and design

The same consistent structure used for presentation of information in all the brochures enhanced readability and comprehensibility. Generally, each brochure began with introductory information about the topic; followed by association between the topic heading and incontinence; list of helpful tips and when help should be sought; and list of people who could assist, including the National Continence helpline. The ‘Notes’ section at the end of six brochures was useful for writing information for their ongoing use.

The design of brochures, including visibility of content being limited to the front title and back page (acknowledgement of the Australian Government Department of Health, Continence Foundation of Australia logo, names of artists and designers), ensured privacy when the brochure on sensitive topics such as constipation was being read in public areas, described by the following participant.

I’d even read it out in the waiting room. It wouldn’t bother me at all … because it’s not showing your bladder or your bowel… all the information is inside … people, if seeing it, they’re only seeing the cover. They’re not seeing what you’re actually reading about and so I think it’s very good, keeps it all very private. [‘Constipation’ brochure. Participant 17].

Participants commented positively about the colours of the brochures, especially the earthy brown colours. The artwork used in the brochures was admired by participants. They described that Aboriginal and Torres Strait Islander people would get a ‘buzz’ out of it, and immediately recognise these as being for their specific use, as described by the following participants.

The artwork is beautiful. It’s an eye catcher… [‘Women’s bladder problems’ brochure. Participant 1]

Any Aboriginal person and Torres Strait [Islander person] would get a buzz out of the artwork. [‘Training the bladder’ brochure. Participant 23]

I like the colour and artwork. I can see straight away that it’s for Aboriginal and Torres Strait Islander people … [‘Pelvic floor muscle exercises’ brochure. Participant 6]

The artwork is really good. If I went to a stand and there was this one, and there was just a normal one, I’d grab this one. [‘Training the bladder’ brochure. Participant 21]

Suggestions for enhancing the brochures

Suggestions for refining the brochures included different title page design for each of the seven brochures. This would avoid readers thinking that all the brochures were addressing one topic only, especially when they were in a hurry and had not read the titles carefully, described by the following participant.

People would look at them and think it’s all the same brochure. And I don’t know how you’d get around that… a change of colour?… Or is there some way you can compact it into a proper little booklet? … probably expensive … [Participant 23]

Other suggestions for changes to five of the brochures are described in Box 1.

Usefulness of brochures to Aboriginal and Torres Strait Islander women

Participants provided several reasons for providing the brochures to Aboriginal and Torres Strait Islander women attending primary healthcare settings, see Box 2.

Box 2.Reasons for providing the brochures to Aboriginal and Torres Strait Islander women attending primary healthcare settings

The brochures have useful and helpful information.
… the information, particularly the diabetes one, I think is very helpful. [Participant 5]
Relevant and able to relate to information.
… because you can relate to it. It’s part of you… and you think oh, that’s what’s happening to me … It doesn’t make you feel like you’re the only one it’s happening to … they’re designed to better inform people … [‘Constipation’ brochure Participant 17].
… this is deadly… it describes our bladder problems really good … I’ve been doing pelvic exercises too. And that helps. Even when you’re just sitting down, do your pelvic exercise. [‘Women’s bladder problems’ brochure. Participant 19].
Simple language and use of pictures helps with reading and understanding the information.
Yeah, definitely [give brochures to other women]. They’re very simple … even if you can’t read all the words, the pictures should help … with explaining. [‘Diabetes and bladder and bowel problems’ brochure. Participant 16].
Brochures are a useful training resource for carers.
definitely [give brochure to other women]… whether they’re caring for somebody who has a continence problem, or … experiencing the problem themselves… they are a good training tool, as well as opening up the question to women … are you having a problem? [‘Pads, clothes and bedding…’ brochure. Participant 4]
Promotion of incontinence as a common problem
I think it’s just a reminder that everybody goes through it … eventually, and no matter what age you are or sex, it does happen. I think that’s good to put these in there as well. Just the little reminders that it could happen to anybody. [Participant 11]
Assists women to ask questions without feeling ashamed.
I’ll show them [brochures] to my friends ‘cause I’ve got friends who are ashamed to talk about things like this and I tell them, ‘Don’t be ashamed, be game.’ [Participant 19]

Discussion

Participant evaluations of the brochures, a health promotion tool developed in consultation with Aboriginal and Torres Strait Islander peoples, have provided valuable information about the usefulness of the seven brochures in raising awareness about UI. The brochures are also a medium for asking questions, validating information they already knew or recommendations they were already practicing. A review of studies published between 2002 and 2012 identified three components in the development, implementation and evaluation of health promotion tools for Aboriginal and Torres Strait Islander peoples in Australia. This included information being evidence-based; the specific context or environment where the tool was to be used and use of facilitation processes instead of passive dissemination alone.¹⁰ The brochures evaluated in this study were developed in consultation with Aboriginal and Torres Strait Islander communities and Health Workers including those in regional and remote regions, the evidence for information was obtained from literature and expert clinician advisory groups and brochures have been reviewed regularly to ensure the information remained current and met the needs of Aboriginal and Torres Strait Islander communities.¹³^–¹⁵

Assessment of information resources for Aboriginal and Torres Strait Islander communities include readability, understandability and actionability (ability to identify the actions that can be taken from the information provided), and cultural relevance.¹²^,²⁰ Participants in this study appraised these components of the brochures, including describing the criteria for cultural relevance and identified many positive characteristics including the many visual design features and artwork that enhanced readability and promoted a sense of ‘ownership and belonging’ and ensured that any sensitive or potentially embarrassing content remained hidden until opened by the reader. Other studies have also emphasised the use of simple, everyday language, less text and greater use of pictures, ticks and crosses, and cultural relevance of the information such as inclusion of Aboriginal and Torres Strait Islander male and female figures and the Aboriginal flag.²¹^–²³ Diaz et al.¹² have identified the lack of an assessment tool for evaluating cultural relevance of health resources and described seven criteria that could be used. The use of four of these assessment criteria by participants in this study supports the validation of these criteria for future studies.

The study findings have important implications for primary healthcare services in the facilitated dissemination of information presented in the brochures and raising awareness and managing UI. Aboriginal and Torres Strait Islander peoples have identified the importance of being informed about their medical conditions and information to be provided in respectful, relevant, simple, easy to understand, non-medical language using a variety of methods such as simple drawings, pictures and anatomical models.¹²^,²⁰^,²⁴^–²⁸ Passive dissemination of written information has the potential to be interpreted differently by readers and it is important that health professionals use the brochures to highlight the relevant information about UI and its management.⁸ This would allow women to familiarise themselves with contents of the brochures with assistance from the health professional, seek clarification of any information, highlight the information relevant for them in management of UI, and reinforcement of the information with repeated longer-term use.

The study findings also provide evidence that the brochures are a valuable resource for Aboriginal and Torres Strait Islander women, with participants requesting copies of brochures for their and/or their family members use and recommending that they should be accessible to women attending the primary healthcare service, including those with UI. However, all participants in this study had not been aware of these brochures, or that they were available electronically from The Foundation’s website.

Strengths and limitations

The open-ended semi-structured interview method used for evaluation of the brochures was a strength of the study. Women were able to closely engage with the brochure content, read each piece of information at their own pace and ask questions about any aspects of the brochures that they did not understand or required clarification. Other strategies implemented to avoid this bias included informing participants of the reason for the review of the brochures; the value of their positive and negative feedback; the lack of any impact on the care they were receiving; and the anonymity of their feedback in all disseminations of the findings. There was no evidence to suggest the possibility of social desirability bias. Women had carefully read each brochure, asked questions about information they did not understand or were unaware, contents they agreed with based on their personal experiences, and provided reasons for their positive and negative comments about the contents.

Participants in this study identified the strategies used in presentation of health information that enhanced their readability, comprehensibility and the effective communication of information. This information will be valuable in the future development of other culturally appropriate health information resources and brochures for Aboriginal and Torres Strait Islander peoples, and in development of assessment criteria for information resources.

The conduct of the study in one urban primary healthcare setting is a limitation of the study. The findings may not reflect the experiences and views of other Aboriginal and Torres Strait Islander women residing in other communities, especially those living in regional and rural communities, where English may be the second or third spoken language, or where women may not have access to information about incontinence and its management, or have easy access to specialist health professionals such as urogynecologists and pelvic floor physiotherapists.

The few suggestions for improvement, for example the greater use of everyday language such as ‘toilet chair’ instead of a ‘commode’ will be helpful for the Foundation in future planned revisions to the brochures, including a comprehensive needs analysis to commence in 2026, to be followed by a review of the brochures (e-mail communication, The Continence Foundation of Australia staff member, 8 October, 2024).

A systematic review of Aboriginal and Torres Strait Islander health promotion tools identified the importance of evaluating the effectiveness of health promotion tools in improving health outcomes following their long-term use.¹⁰ This study has provided a preliminary assessment of the brochures by women. Further studies are needed into long-term impacts of these brochures in increasing awareness, understanding and managing UI in other primary healthcare settings.

Conclusion

Written health information leaflets and brochures are one of the commonly used strategies in provision of information about health conditions and their management. This evaluation of brochures on continence by Aboriginal and Torres Strait Islander women with UI has provided evidence that it is a valuable resource for raising awareness about UI and its management among Aboriginal and Torres Strait Islander women attending urban Aboriginal and Torres Strait Islander primary healthcare settings.

Data availability

The data that support this study cannot be publicly shared due to ethical and privacy reasons.

Conflicts of interest

PL was and continues to be employed as a Senior Research Officer at the site where this study was conducted. She does not provide clinical care to clients. KS is currently employed as an Indigenous Research Assistant and Client Support Officer at the site where this study was conducted. She was not employed at the site during the recruitment and data collection phase of the study. AB was employed as a Clinical Nurse at the site where this study was conducted. She was involved in recruitment and interview of some of the participants in this study. AF was and continues to be employed as a GP at the site where this study was conducted. She provided brief information to some of the women with continence about the study and may have provided clinical care to some study participants. NH is the Clinical Director of the site where this study was conducted and may have provided clinical care to some study participants.

Declaration of funding

This study was supported by funding from the Australian Bladder Foundation, managed by the Continence Foundation of Australia.

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