Women Lift Safely! An Intervention Study to Reduce the Risks of Heavy Lifting

Local research assistants will conduct behavioral observations to examine lifting techniques.

"Observe: Is she exhaling (breath) while lifting?" 1 ="yes"; 0 = "no". Answer option 1 refers to the safe lifting technique.

A secondary self-reported score assesses perception and use of pelvic floor muscles when lifting a water-filled container through two items with answering options coded 0 (= unsafe) or 1 (=safe) will serve to validate the answers given for the safe lifting score. The pelvic floor muscle score is calculated by summing the points:

1. "Did you feel any muscles tightening during lifting?" "If yes, which ones?" 0 = "Back"; 0 = "Stomach";0 = "Legs"; 0 = "Head"; 0 = "Neck"; 0 = "Muscles of arms"; 1 ="Pelvic floor" "; 0 = "Other.
2. "How did you tighten the pelvic floor muscles?" 1 = "Imagine stopping flow of urine"; 1 = "Feeling a lift inside the pelvis"; 1 = "Feeling a squeeze inside the pelvis"; 1 = "Small tightening of muscles in lower stomach"; 0 = "I don't know"; 1 = "other".

Average of self-reported five items based on the Health Action Process Approach (HAPA model; Schwarzer, 2008), e.g. "How sure are you that you can always reduce the carried load to your weight limit?" 1 = "not at all sure" to 5 = "very sure". Higher scores indicate stronger self-efficacy.

Average of five self-reported items based on the HAPA model (Schwarzer, 2008), e.g. "How sure are you that you are able to always use safe lifting techniques?" 1 = "not at all sure" to 5 = "very sure". Higher scores indicate stronger self-efficacy.

Emotional, informational and instrumental support to reduce carried weight will be assessed self-reported by the Berlin Social Support Scale (Schwarzer \& Schulz, 2013).

Average of 9 items, e.g. "This person expressed concern about my decision to carry less weight." 1 = "not at all" to 5 = "very much". Higher scores indicate more social support.

Berlin Social Support Scale (Schwarzer \& Schulz, 2013). Average of 9 items, e.g. "This person encouraged me not to give up when trying to use safe lifting techniques." 1 = "not at all" to 5 = "very much". Higher scores indicate more social support.

Frequency will be calculated by the product of self-reported carrying trips "In the last 7 days, how many carrying trips did you conduct per day?" by days carried per week "On how many of the last 7 days did you carry loads?"

Average of three items, e.g. "How sure are you that you can always avoid to carry loads during and after pregnancy?" 1 = "not at all sure" to 5 = "very sure". Higher scores indicate stronger self-efficacy.

3 self-reported items referring to intended carried weight per trip in the first half of pregnancy, the second half of pregnancy and three months postpartum, e.g. "In the first half of your pregnancy, what weight do you intend to carry per trip?" Answer in kg.

Average of two items based on the Health Action Process Approach (HAPA model; Schwarzer, 2008), e.g. "How high do you think the risk is that you get pelvic organ prolapse if you carried loads above the weight limit?" 1 = "not at all high" to 5 = "very high". Higher scores indicate higher risk perception.

Average of two items based on the HAPA model (Schwarzer, 2008), e.g. "How high do you think is the risk that you get pelvic organ prolapse if you do not use safe lifting techniques?" 1 = "not at all high" to 5 = "very high". Higher scores indicate higher risk perception.

Average of two items based on the HAPA model (Schwarzer, 2008), e.g. "If I reduce the weight of the load I carry, I can protect myself from negative health impacts (e.g. pelvic organ prolapse)" 1 = "Agree not at all" to 5 = "agree very much". Higher scores indicate higher outcome expectancies.

Average of two items based on the HAPA model (Schwarzer, 2008), e.g. "When using safe lifting techniques, I can protect myself from negative health impact (e.g. Pelvic organ prolapse)." 1 = "Agree not at all" to 5 = "agree very much". Higher scores indicate higher outcome expectancies.

Average of two items based on the HAPA model (Schwarzer, 2008), e.g. "How strongly do you intend to always reduce carried weight?" 1 = "not at all" to 5 = "very much". Higher scores indicate stronger intention.

Average of two items based on the HAPA model (Schwarzer, 2008), e.g. "How strongly do you intend to always use safe lifting techniques?" 1 = "not at all" to 5 = "very much". Higher scores indicate stronger intention.

Action planning will be assessed based on the HAPA model (Schwarzer, 2008). The research assistant will ask "Have you made a detailed plan regarding… (1) "when to start", (2) "how", and (3) "how often" to reduce the weight of load carried?" The research assistant will code answers 1 (vs. 0) when a plan is mentioned.

Action planning will be assessed based on the HAPA model (Schwarzer, 2008). The research assistant will ask "Have you made a detailed plan regarding… (1) "when to start", (2) "how", and (3) "how often" to use safe lifting techniques?" The research assistant will code answers 1 (vs. 0) when a plan is mentioned.

Coping planning will be assessed by one item based on the HAPA model (Schwarzer, 2008): "How can you overcome difficulties that prevent you from reducing the weight of load carried?". Answer options are precoded and coping planning will be rated dichotomous 1 (vs. 0) if any plan is mentioned.

Coping planning will be assessed by one item based on the HAPA model (Schwarzer, 2008): "How can you overcome difficulties that prevent you from using safe lifting techniques?". Answer options are precoded and coping planning will be rated dichotomous 1 (vs. 0) if any plan is mentioned

Perceived barriers will be assessed by one item based on the HAPA model (Schwarzer, 2008): "What do you think, how difficult would reducing carried weight be for you?" 1 = "not at all" to 5 = "very much".

Perceived barriers will be assessed by one item based on the HAPA model (Schwarzer, 2008): "What do you think, how difficult would using safe lifting techniques be for you?" 1 = "not at all" to 5 = "very much".

Determinants identified in a prestudy (Tomberge et al., 2021):

Response efficacy: "Even if I reduce carried weight, I am not safe from getting pelvic organ prolapse." Spiritual beliefs: Two items, e.g. "Whether I get pelvic organ prolapse or not depends on gods' will rather than on my carrying behavior".

Identity: Two items, e.g. "I would feel odd if I reduced the weight I usually carry. (reverse)" Affective attitudes: Two items, e.g. "How much do you like to carry a reduced weight when carrying loads?" Attitudes on the gender division of labor: Two items, e.g. "It is a woman's task exclusively to make sure all family members and livestock have enough food and water." Normative beliefs: Four items, e.g. "How much would people who are important to you approve if you reduced carried weight?".

Decision making: Two items, e.g. "To what extent are you the only one to decide on how much weight you carry?" Answer options are 1 = e.g. "not at all" to 5 = e.g. "very much"

Determinants identified in a prestudy (Tomberge et al., 2021):

Response efficacy: "Even if I use safe lifting techniques, I am not safe from getting pelvic organ prolapse." Spiritual beliefs: Two items, e.g. "Whether I get pelvic organ prolapse or not depends on gods' will rather than on my carrying behavior".

Identity: Two items, e.g. "Using safe lifting techniques is part of my identity/ who I am." Affective attitudes: Three items, e.g. "How much do you like to use safe lifting techniques?" Attitudes on the gender division of labor: Two items, e.g. "It is a woman's task exclusively to make sure all family members and livestock have enough food and water." Normative beliefs: Four items, e.g. "How much would people who are important to you approve if you used safe lifting techniques?".

Decision making: Two items, e.g. "To what extent are you the only one to decide which techniques to use when you lift load?" Answer options are 1 = e.g. "not at all" to 5 = e.g. "very much"

Knowledge on how to carry loads in a safer way will be assessed through two self-reported items with answering options coded 0 (= correct) or 1 (= false). The safe lifting knowledge score is calculated by summing the points: "Can you tell me whether these are safe lifting techniques to reduce strain on the pelvic floor?" 0 = "Lift your toes up when lifting"; 1 = "Exhale (breath) when lifting"; 1 = "Reduce carried weight", 0 = "Use only one hand when lifting"; 0 = "Take a run-up before lifting"; 1 = "Tighten pelvic floor when lifting"; 0 = "Hold breath when lifting".

Knowledge on how to tighten the pelvic floor will be assessed through two self-reported items with answering options coded 0 (= correct) or 1 (= false). The pelvic floor knowledge score is calculated by summing the points: "Can you tell me whether the following are techniques to tighten the pelvic floor?" 1 = "Imagine to stop flow of urine"; 0 = "Bring shoulder blades together"; 1 = "Feeling a lift inside the pelvis"; 1 = "Small tightening of muscles in lower stomach"; 0 = "Bend knees"; 1 = "Lift toes up"; 0 = "Imagine to press as if going for defecation"; 1 = "Feeling a squeeze inside the pelvis".

Pain will be assessed by three items supported by the revised faces pain scale- (FPS-R) and the numerical pain rating scale (NPRS) (Pathak et al., 2018; Sharma et al., 2017) , e.g. "How much pain did you feel in your pelvis in the last 4 weeks?" 0 = "No pain" to 10 = "worst pain possible".

Strain during lifting will be assessed by two items right after lifting a water filled container, e.g. "How much strain did you feel in your pelvic floor when lifting the container?" 0 = "No strain at all" to 5= "very much strain". Higher scores indicate higher strain.

Average of expression on seven self-reported symptoms (POP-SS; (Hagen et al., 2009)).

Average of expression on five self-reported symptoms of incontinence will be assessed by a combination of selected items of the Incontinence Severity Index - 2 (ISI-2) and the Incontinence Symptom Index - Pediatric (ISI-P) (as used in (Parden et al., 2016)).

Average of eight items (EUROHIS-QOL 8-item index, (Rocha et al., 2012), e.g. "How satisfied are you with the conditions of your living place?" 1 = "not at all satisfied" to 5 = "very satisfied". Higher scores indicate higher quality of life.

Average of six self-reported items (Personal control from the revised Illness Perception Questionnaire; Moss-Morris et al., 2002), e.g. "There is a lot which I can do to control my symptoms." 1 = "agree not at all" to 5 = "agree very much". Higher scores indicate higher illness-related personal control.

One item "Please rate the severity by which carrying loads reduces your daily functioning." (Functioning rating scale; (de Jong et al., 2016)).

The quality of relationships between women and their social partners will be assessed by the average of seven self-reported items based on the Perceived Relationship Quality Components Inventory (PRQC, (Fletcher et al., 2000)); e.g. "How satisfied are you with your relationship with your social partner?" 1 = "not at all satisfied" to 5 = "very satisfied". Higher scores indicate improved relationship quality.