Emerging Interventions Mind Over Matter: Healthy Bowels, Healthy Bladder

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Brice Hodges
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1 Emerging Interventions Mind Over Matter: Healthy Bowels, Healthy Bladder Heidi W. Brown, MD, MAS Assistant Professor, Urogynecology June 15, 2016

2 Support WI Multidisciplinary K12 Urologic Research Career Development Program (NIH K12DK100022)

3 Overview What s the problem? What s the intervention? What s been done so far? Who has been involved? Preliminary findings / next steps

4 The Problem

5 Incontinence > 60% of older US women > $30 billion / year

6 Effective treatments exist, but most people don t seek care

7 The Solution

9 3 2-hour sessions every other week for 8-15 women Health information Self-efficacy theory Personalized goal setting & tracking Group work activities Sharing, trouble shooting, brainstorming

The Past: Pilot testing Recruitment, enrollment, consent Pre-test Survey Post-test Survey Post-test Focus Group $25 3 mos Follow-up Mail Survey $25 Session 1 2 wks 2 wks Session 2 Session 3

10 The Past: Pilot testing Recruitment, enrollment, consent Pre-test Survey Post-test Survey Post-test Focus Group $25 3 mos Follow-up Mail Survey $25 Session 1 2 wks 2 wks Session 2 Session 3 Community partner & facilitator debriefing Preworkshop training Direct observation & semi-structured interview Direct observation & semi-structured interview Findings presented to Advisory Board

11 Pilot testing Spring 2016 * Oregon * Fitchburg * Beaver Dam

12 The Players

13 Pilot Test Outcomes Workshop Participants: Symptoms improved Self-efficacy increased Acceptability high Community Partners: Feasibility high Acceptability high Perceived value high

14 The Future: RCT

15 Want to join us? cell:

17 Essential Components of Original Workshop Through a dynamic and friendly facilitator, to: Discuss taboo & myths about incontinence Present normal bladder function Define incontinence & describe types Clearly establish: not part of normal aging can be cured, prevented or improved Describe risk factors & easy solutions Explain pelvic floor exercises & urge control Explain and motivate self-empowerment

18 Additional components Address normal and abnormal bowel function Define constipation & accidental bowel leakage Provide information about medical therapy & care-seeking Personalized goal-setting Group support & trouble-shooting Small group problem-solving Symptom tracking and self-reminders

19 Workshop Overview Session 1: Bowel and Bladder 101 Pelvic Floor Muscle Exercises Dietary Fiber and Stool Consistency Session 2: Pelvic Floor Muscle Exercises Fluid Intake and Urine Leakage Self Efficacy Session 3: Pelvic Floor Muscle Exercises Seeking Healthcare Long-term Goals Format: Information delivery Reference handouts Small group work Sharing, trouble shooting, brainstorming Postcards & symptom trackers for goal setting

20 Empowerment is when YOU take charge of YOUR health How well did It work? What can I do? Did it work? YOU identify if there is a PROBLEM Will I do it? Are the target symptoms better? How will I do it?

21 Postcard prestamped Filled out privately during session Shared one goal during wrap up each time Instructor mailed 3 days later

23 8.5 x 11 folded into booklet 1 page per week 20 pages for long-term tracking Wanted more space to record fiber intake

Small group scenario Dorothy is 72. She is 5 4 and weighs 200 lbs. She is trying to lose weight, so she drinks lots of coffee and diet soda during the day.

24 Small group scenario Dorothy is 72. She is 5 4 and weighs 200 lbs. She is trying to lose weight, so she drinks lots of coffee and diet soda during the day. She wakes up at 6 am and goes to bed at 10 pm. She has urinary urgency and frequency and sometimes leaks both urine and stool while rushing to the toilet. She wakes up once overnight to void. Dorothy s doctor asked her to keep a 24 hour bladder tracker.

25 Dorothy s 24 hour Bladder Record Time Void Intake 6 am 20 oz 12 ozcoffee 8:30 12 oz 12 oz coffee 9:15 6 oz 9:45 6 oz 12 ozdiet coke 11:30 5 oz 1pm 21 oz 16 ozcoffee 2:45 8 oz 3:00 4 oz 12 ozdiet coke 12 ozcoffee Time Void Intake 4:15 9 oz 16 oz water 4:25 11oz 12 oz diet coke 6:00 15 oz 12 ozdiet coke 8:00 10 oz 8 ozwater 10 pm 5oz 2 am 10 oz 14 voids in 24 hours, 1 overnight Total intake = 124 oz 1 oz = 30 ml

26 Is Dorothy drinking the right amount of fluid? drinking the right types of fluids? drinking at appropriate times? emptying her bladder appropriately?

27 What changes could Dorothy make in the amount of fluid she drinks? the types of fluids she drinks? her timing of fluid intake? her bladder emptying?

28 What did we observe? Too much content for the time allotted Confusion with handouts Script with posters problematic especially for Bowel & Bladder 101 Pelvic floor exercises: Not enough time or clarity Script was repetitive Seating matters!

Participant Ratings of Workshop Components 100 90 80 70 60 50 40 30 20 10 0 88 83 83 17 17 12 0 0 0

29 Participant Ratings of Workshop Components Not Helpful Somewhat Unhelpful Very Helpful

30 Comments reinforced lack of time... Handouts should be talked about so people know what is on them. Facilitator should talk slower. Make the time a little longer so you get to understand the exercises better. Actual practice of exercises at each session.

31 What focus groups told us Berlin and Montello groups both said: Not enough time for information given Problems with trackers Handouts: prefer a 3-ring binder

32 Focus Groups Differed Berlin Montello Expert video/animations Yes No Scenarios: small group Need work Loved them Prior Familiarity Some Yes Ongoing informal support Yes No

33 Facilitator s insights Not enough time for content and discussion Suggests 2 hours per session (as in Stepping On) Older adults do not absorb information quickly Move Self-Efficacy to Session 1

34 Facilitator s insights Posters: challenging to maneuver Technical information: difficult to deliver Integrating technical content or stories via video would be great, but

35 Here s what we are changing Guided pelvic floor exercises all sessions Fiber Intake less confusing Fiber resource handout in Session 1 Self-efficacy in Session 1 90 minutes 2 hours Group work: 2 small 1 large

36 Here s what we are changing Handouts in a 3-ring binder - divided by session Revise pelvic floor script Revise tracking book Recommend horseshoe seating Video for bowel & bladder 101

37 Self-Management of Incontinence Wilde et al Am J Nurs 114(1): 38-45

38 Modifications: Structure 160-minute workshop minute workshop sessions (every other week) Snack break incorporated midway through each session Group size similar (8-15)

39 Modifications: Content How the bladder works how the bladder & bowels work Similar pelvic floor muscle exercises and fluid recommendations New info: fiber and stool type New problem-solving & maintenance New info: care-seeking tools

40 Modifications: Components Self-management packet goal setting incorporated into each session Symptom and goal tracker booklets Reminder postcards between sessions Small group activities incorporated

41 Modifications: Delivery PowerpointSlides Large posters with color handouts to take home Lecture interspersed with small group activities Slight language modifications (passing wind passing gas)

Please complete this voiding diary and questionnaire. Bring both of them with you to your next appointment with your provider.

Please complete this voiding diary and questionnaire. Bring both of them with you to your next appointment with your provider. To begin the diary, please choose two days when you will be at home. The two