To assess the effectiveness of pelvic floor health education initiatives, it is essential to be able to measure women's knowledge in this area. Validated questionnaires for assessing women's knowledge in this domain are rare. The questionnaires most commonly used in the literature are specific to one type of symptom (urinary incontinence or prolapse). Other authors, who wanted to assess women's knowledge of pelvic floor dysfunctions in a more global way, by integrating the urinary, genital and digestive systems, have developed their own questionnaire. In most cases, there is no or only partial psychometric validation of these measurement tools. Among the tools identified in the literature, the Antwerp Pelvic Floor Knowledge Questionnaire (APFK-Q) is one of the most comprehensive. This approach, which integrates the urinary, digestive, and genital tracts, is consistent with recommendations for global multimodal management of patients. It was originally developed in Dutch (1) (2). The aim of this study was to culturally adapt the APFK-Q to the French language and to assess its psychometric properties.

Two versions of the questionnaire were sent to us by the authors: a long version with 32 knowledge items plus a numerical scale to measure the self-perceived level of knowledge, and a shorter version intended for primiparous women. Our cultural adaptation work focuses on the long version.
The translation procedure was developed according to recommendations for the transcultural adaptation of a questionnaire. We independently requested translations from two bilingual healthcare professionals: a nurse and a midwife whose mother tongue was French. A multidisciplinary committee of experts in pelvic floor health synthesised these two translations. The resulting French version was back-translated by a healthcare professional with no knowledge of the original questionnaire, whose mother tongue was Dutch. The aim of this step was not to obtain a version identical to the original questionnaire, but to reveal any misunderstandings amplified by the back-translation.
After cultural adaptation into French (translation/back-translation), a pre-test was carried out with 5 non-healthworker women to assess their general understanding during individual interviews.
Acceptability was assessed on two samples of women: a group of non-healthworker women and health students. Twenty-three non-healthworker women agreed to take part in a test-retest to assess reproductibility. Agreement of responses was measured for each question using Cohen's kappa coefficient. Sensitivity to change was assessed before and after a pelvic floor health education workshop. For this analysis, the expected correct answers for each item were discussed by a panel of experts. The proportion of correct answers was compared before and after the workshop using McNemar's Chi2 test. Readability and the reading level required for optimal comprehension were assessed using the Flesch and Flesch-Kincaid tests respectively.

Five women who were not healthworkers took part in the pre-test. They were aged between 16 and 55, with a parity of between 0 and 3. They expressed 3 comprehension difficulties which were modified in the French version.
One hundred and twelve non-caregiver women and 29 student midwives agreed to complete the questionnaire for the first time. Their average age was 34.9 years and 23.0 years respectively. The vast majority (93%) of the women who were not healthworkers had a higher level of education.
Seventy percent (n=72) of the women and 72% (n=21) of the female health students reported no comprehension difficulties. Agreement was very good (k > 0.8) for 46% of the items and good (0.6 to 0.8) for 25% of the items. The proportion of correct answers was significantly higher for 67.8% of items after the pelvic floor health education workshop. The French version of the APFK-Q was judged to be easy to understand according to the Flesch test, with a score of 60.6. The school level required for optimal comprehension was estimated at 8th grade.

Our study enabled us to identify the wording in the French version that was difficult to understand and to correct it. The majority of women reported no comprehension difficulties and the rate of unanswered questions was less than 10%. Reproducibility was moderate to very good for 87% of the items. Sensitivity to change was verified for 68% of the items. A 8th grade reading level is required for optimal comprehension.
Cultural adaptation of a questionnaire into another language facilitates comparison between studies by allowing the same interpretation of results despite different languages and cultures. Rather than designing a new questionnaire, we have chosen to optimise the work of an existing research team, demonstrating our commitment to building on established foundations and contributing to the harmonisation of practices in the field of pelvic floor health. This approach also enhances the validity and reliability of the measuring instruments used.
The lack of evidence on hygienic and dietary practices that protect pelvic floor health also limits the identification of essential prevention messages that women should be aware of. Further research is needed to clarify this area and determine the optimal content of a questionnaire on pelvic floor health knowledge.

The French version of the APFK-Q is an acceptable, reproducible and easily understood questionnaire that provides a broad description of women's knowledge of the pelvic floor sphere. Sensitivity to change was confirmed for the majority of items, making it a useful tool for assessing the impact of pelvic floor health education initiatives.
To date, this is the only psychometrically validated questionnaire available in French to assess women's knowledge on this subject.
By taking into account the many avoidable risk factors linked to lifestyle, specific action can be taken to prevent pelvic floor dysfunction. This approach also has its place in the management of women who are already symptomatic, with a view to improving their quality of life or optimising the effectiveness of rehabilitation, surgery or other treatments. We believe that pelvic floor health promotion and education is currently underdeveloped.  We therefore hope that this questionnaire will encourage the development and evaluation of relevant initiatives in this area.

Neels H, Wyndaele JJ, Tjalma WAA, De Wachter S, Wyndaele M, Vermandel A. Knowledge of the pelvic floor in nulliparous women. J Phys Ther Sci. mai 2016;28(5):1524-33.
Neels H, Tjalma WAA, Wyndaele JJ, De Wachter S, Wyndaele M, Vermandel A. Knowledge of the pelvic floor in menopausal women and in peripartum women. J Phys Ther Sci. nov 2016;28(11):3020-9.