Urinary incontinence (UI)

Transcription

1 Incontinence in Women: Effect of Expectancy to Regain Control and Severity of Symptoms On Treatment Outcomes Carolyn Krause Thelma Wells Susan Hughes Carol Brink Robert Mayer Urinary incontinence (UI) is a common problem for women of all ages. The prevalence of UI in women is estimated at 10% to 30% for women aged 15 to 64 years (Fantl et al., 1996). A landmark American study of UI in noninstitutionalized people age 60 years and over, using a multistage probability sample, found a prevalence of 38% in women (Diokno, Brock, Brown, & Herzog, 1986). Associated with poor self-reported health, UI may have a negative effect on women s lifestyle and quality of life (DuBeau, Levy, Mangione, & Resnick, 1998; Jeter, Carolyn Krause, PhD, RN, is Vice President of Clinical Services/Chief Nurse Executive, Visiting Nurse Association of Wisconsin, Aurora Health Care, Milwaukee WI. Thelma Wells, PhD, RN, FAAN, FRCN, is Helen Denne Schulte Professor of Nursing, University of Wisconsin-Madison, Madison, WI. Susan Hughes, MS, RN, is a Senior Research Specialist, University of Wisconsin-Madison, Madison, WI. Carol Brink, MS, RN, is Clinical Associate Professor of Nursing, University of Rochester, Rochester, NY. Robert Mayer, MD, is Associate Professor of Urology, University of Rochester Medical School, Rochester, NY. Urinary incontinence (UI) is a common problem for women of all ages. Associated with poor self-reported health, UI may have a negative effect on women s lifestyle and quality of life. Because UI is not commonly discussed between women or between women and their care providers, the extent of its impact on their lives is not fully understood. This study provides insight into how a woman s perceived or subjective opinion of the severity of UI and her belief in the ability to regain control of UI influence the effectiveness of treatment. Wagner, & Bavendam, 1997; Patrick et al., 1999; Robinson et al., 1998; Temml, Haldinger, Schmidbauer, Schatzl, & Madersbacher, 2000). Women who suffer from UI must be proactive, vigilant, and conscious of their activities and the locations of toilets in order to prevent embarrassment due to unexpected leakage. Because UI is not commonly discussed between women or between women and their care providers (Diokno et al., 1986; Roberts et al., 1998), the extent of its impact on their lives is not fully understood. This study provides insight into how a woman s perceived or subjective opinion of the severity of UI and her belief in the ability to regain control of UI influence the effectiveness of treatment. Background and Literature Review Although perceived severity of UI is related to both psychological and social attributes of a woman (Grimby, Milsom, Molander, Wiklund, & Edelund, 1993; Lagro-Janssen, Smits, & van Weel, 1992; Patrick et al., 1999; Robinson et al., 1998; Temml et al., 2000), there is no consensus on how to measure slight, moderate, or severe UI (Steeman & Defever, 1998). However, an actual objective measure may be less important than the woman s perception or subjective view of UI severity. Since the patient s point of view has the most relevance to the patient, it must be taken into account. Clinician interest focused on the patient s perspective, combined with a continuing relationship, has shown increased satisfaction with care and improved compliance with a treatment program (Fischer et al., 1999). In contrast, the common practice of a provider-imposed Note: This research was supported by grant NRO1917 from the National Institute of Nursing Research. This article is based on a poster presentation at the Gerontological Society of America Annual Meeting, San Francisco, CA, UROLOGIC NURSING / February 2003 / Volume 23 Number 1

2 view of severity may discount personal significance of a UI problem and force many women to manage it alone. Self-Management of UI Self-management is a predominant theme in the literature about UI in women. Over onethird of elderly women did not report UI to their physician because they did not feel it is important enough to mention (Mitteness, 1987). Other common beliefs by patients and health care providers alike include: (a) UI is normal as part of aging or after having vaginal deliveries, and (b) that surgery is the only effective treatment. Therefore, self-management is used frequently because women have little expectation for medical solutions or physician interest in the problem. Personal control also allows women to normalize or view UI as a naturally occurring problem similar to menstruation (Dowd, 1991; Skoner & Haylor, 1993). Strategies include use of pads, limiting fluids, rescheduling diuretic medications (or possibly not taking them), reducing or eliminating caffeine, modifying activities, frequent toileting, and knowing the location of toilets (Mitteness, 1987; Skoner & Haylor, 1993). Some of these strategies may have a detrimental effect on other health conditions. UI is seen as particularly troublesome when self-management strategies fail and leakage can be detected or the UI occurs in large amounts (Ouslander & Abelson, 1990; Skoner & Haylor, 1993). Physicians are more likely to be consulted only as severity and social restrictions increase (Sandvik, Kveine, & Hunskaar, 1993). However, only one-third of those who raised the issue with their physician were satisfied with the response. Consequently, self-management methods remain a major strategy. To effectively help women deal with UI, health care providers need to know if a woman has UI, try to understand the impact it has on her life, and investigate how she uses selfmanagement strategies. Except for surgical intervention, most of the treatments for UI require the woman to be actively involved in the treatment. Therefore, patient compliance and participation are of the utmost importance if medical or self-management treatments are to be successful. Programs must be designed in conjunction with the woman while taking her lifestyle and beliefs into consideration. Quality of Life Urinary incontinence has an effect on the quality of life (QOL) of women. This impact seems to vary depending on the type, duration, severity, and the woman s age (Dugan et al., 1998; Sandvik et al., 1993; Seim, Hermstad, & Hunskaar, 1997). Urinary incontinence may be more distressing to younger women than older women (Dugan et al., 1998; Naughton & Wyman, 1997; Sandvik et al., 1993; Valerius, 1997; Vinsnes & Hunskaar, 1991). There is evidence that, as women age, they become more accustomed to the UI and have learned to successfully manage it or minimize the symptoms (Naughton & Wyman, 1997). Any treatment by itself may help reduce the psychosocial impact (Lee, Reid, Saltmarche, & Linton, 1995; Seim et al., 1997). There is conflicting evidence about whether the type of UI increases psychological distress, but several studies indicate that women with urge UI have more mental distress (Grimby et al., 1993; Sandvik et al. 1993; Seim et al., 1997; Stern & Stanton, 1991; Vinsnes & Hunskaar, 1991). This may be due to difficulties in self-management because of the feeling of lack of control resulting from the inability to regulate urge UI (Chiverton, Wells, Brink, & Mayer, 1996). The ability or inability to control urine loss seems to be frequently viewed by women as largely in their control (Ashworth & Hagan, 1993; Dowd, 1991). Although a higher incidence of depression has been found in women with UI, the concept of mastery or a sense of being in control, rather than depression, was a mediating factor in the impact of UI on QOL (Chiverton et al., 1996). Purpose The major purpose of this secondary study was to determine if the perceived or subjective severity and the expectancy belief in the ability to regain control affect subjective wetting outcomes and the impact of UI on the lives of women. It also sought to determine if there were differences in health belief factors between the 159 women who completed the study and the 127 women who dropped out of the study after the diagnostic phase. Framework The Health Belief Model (HBM) was chosen as the framework for this study because it is based on the actions individuals take to control their health along with beliefs underlying those actions. The HBM hypothesizes that health-related action depends on the occurrence of three classes of factors: (a) sufficient motivation to make health issues important or relevant, (b) the belief that one is susceptible to a serious health problem or there is a perceived threat to one s health, and (c) the belief that (following) complying with a health recommendation or treatment would reduce the threat at an acceptable cost (Rosenstock, Strecher, & Becker, 1988). For example, individuals will take action to control an illhealth condition if they believe the action would be beneficial in reducing the severity of the condition and if the anticipated barriers to taking the action are outweighed by the benefits (Strecher & Rosenstock, 1997). The HBM is especially relevant to intervention research in UI because the perception of UI severity and the belief in the need to take action seem to be highly individualized. Hypothesis In using the HBM as the framework for this study, the main hypothesis was that women would have greater success and UROLOGIC NURSING / February 2003 / Volume 23 Number 1 55

3 satisfaction with a treatment program for UI if they have a high perceived severity of UI, high expectation in the ability to regain control, and believe the treatment program has more benefits than barriers. Research Questions Secondarily, the study investigated the following research questions: (a) What are the differences in selected health belief factors between women who completed the entire study and women who dropped after the diagnostic phase? (b) What is the difference in selected health belief factors among four expectancy/ wetting groups? (c) What are the effects of selected health belief factors on posttreatment UI outcomes? Variables Variables in the study reflect components of the HBM including: (a) individual perceptions, (b) modifying factors, and (c) likelihood of action (which includes perceived barriers and benefits, self-efficacy, and likelihood of change) (Strecher & Rosenstock, 1997) (see Table 1). Individual perception was measured by the perceived severity of UI. Modifying factors were age and perceived health status. Likelihood of action/perceived benefits and barriers was measured by the degree to which the woman felt she would like the treatment, whether the treatment would help her, and whether she would have time for the treatment. Likelihood of action/self-efficacy was measured by the woman s belief in the expectancy to regain control of UI. Likelihood of action/likelihood of change (or the outcome variable) was measured by the perceived improvement in UI after treatment, the effect of UI on the subject s life, the amount of perceived shame, and inconvenience. Methods This study was a secondary analysis of a 5-month randomized controlled clinical trial which evaluated pelvic muscle Health Belief Model (HBM) Category Individual perceptions Modifying factors Likelihood of action Table 1. Framework HBM Component Perceived susceptibility/ severity of disease Demographics Knowledge Perceived barriers Perceived benefits Self-efficacy Likelihood of change (Outcomes) Corresponding Study Health Belief Component Perceived severity of urinary incontinence (UI) Age Perceived health status Will you like the treatment? Will the treatment help you? Will you have time to do the treatment? Likelihood to regain control of UI? Perceived improvement of UI Inconvenience feelings exercise as a treatment for stress UI (Wells, Mayer, Brink & Brown, 1999). Two hundred eighty-six women with a mean age of 56 (SD 12.76) were randomly assigned to 5 months of treatment in one of four groups: control, general health promotion, active pelvic muscle exercise, and resistive pelvic muscle exercise. Outcomes, evaluated by subject opinion, diary, pad test, and urodynamics, included pelvic muscle strength, urethral pressure, and wetting. One hundred fifty-nine women (mean age 56.9, SD 12.47) completed the treatment phase of the study. Findings demonstrated a significant treatment effect for pelvic muscle EMG strength and urethral pressure gain score. There was no significant treatment effect for any of the wetting measures demonstrating that the increased pelvic muscle strength did not improve wetting outcomes; however, there was an overall time effect in improvement in self-reported wetting measures regardless of treatment group. This result suggested that perhaps health beliefs of women across treatment groups influenced the improvement in perceived severity of UI despite a lack of objective significance, thus prompting this secondary analysis. Based on previous analysis (Krause, Wells, Hughes, Brink, & Mayer, 1998) the majority of variance on the UI wetting variables was explained by the perceived severity of UI. To more closely examine how the severity of wetting and the expectancy to regain control of UI influenced the wetting outcomes, the women were categorized into four groups based on their belief in the ability to regain control and their perceived amount of wetting. The resulting group combinations 56 UROLOGIC NURSING / February 2003 / Volume 23 Number 1

4 Table 2. Health Belief Model Measures (N total =159) Health Belief Component Perceived severity of urinary incontinence (UI) Age Perceived health status Did the treatment help you? Did you have time to do the treatment? Did you like the treatment? Likelihood to regain control of UI Perceived improvement of UI Inconvenience feelings * Pretreatment mean ** Posttreatment mean were: (a) high expectancy/high wet (N=19 or 12%), (b) high expectancy/low wet (N=60 or 38%), (c) low expectancy/high wet (N=34 or 22%), and (d) low expectancy/low wet (N=44 or 28%). Two subjects were omitted from analysis due to missing responses on one or both categories bringing the usable N to 157 (N total =159; N usable =157). The high expectancy group considered it very likely or likely they would regain control and the low expectancy group considered it very unlikely, unlikely, or unsure they would regain control. The high wetting group scored 6 to 10 on a scale of wetting from 1 (no leakage) to 10 (a lot of leakage) and the low wetting group scored 1 to 5. Mean 4.6** 56.9* 1.9* 3.4** 3.6** 3.3** 3.4* 5.1** 2.2**.93** 1.88** SD Range = no leakage 10 = a lot = Excellent 4= Poor = not at all 4 = a great deal = highly unlikely 5 = highly likely = not at all 10 = 100% 1-4 1= not at all 4= a lot Sample The sample in this analysis consisted of the 159 women who completed the 5-month study. The women had selfdescribed uncontrolled urine loss and/or excessive toileting frequency. Diagnostically, 76% of the women had stress and 24% mixed (combination of stress and urge) UI. All 159 women were independent in self-care and generally healthy. Twenty-six percent rated their health as excellent, 62% as good, 11% as fair, and 1% as poor. Twenty-nine percent had completed seventh grade through high school, and 71% had completed some college through graduate school. Measures Table 2 summarizes results for the various measures. Some were obtained only upon entry into the study, some at completion only, and some were measured both at entry and exit. Individual perceptions: Perceived susceptibility/severity of disease. Perceived or subjective severity of UI was measured by asking the women to think about urine control difficulty in terms of leakage episodes over the past week and to use a scale of 1 (no urine leakage) to 10 (a lot of urine leakage) to represent the severity. Women were asked this question at entry into the study, at each evaluation time during the treatment phase, and at the conclusion of the study. In this analysis the baseline and outcome severity measures were used. Objective severity was measured by diary and at pretreatment ranged from 0 to wetting episodes per 24 hours. Zero occurred because some women wet less frequently than once per week. The mean number of episodes was 2.2 per 24 hours (SD 2.27). The correlation between the objective diary severity and the subjective scale severity was r=.51 (p=.000). Modifying factors: Age and perceived health status. Age and perceived health status were collected at entry into the study. Health status was measured by asking subjects to rate their health as excellent, good, fair, or poor. Likelihood of action: Perceived benefits and barriers. Perceived benefits of treatment were measured by the question, Do you think your treatment program helped you? Responses were not at all, a little bit, moderately, and a great deal. This question was asked at each study visit and at the conclusion of the study. Because this secondary analysis study was examining the posttreatment effect on life, the posttreatment results were used. The questions were phrased prospectively or retrospectively depending on when they were asked. UROLOGIC NURSING / February 2003 / Volume 23 Number 1 57

5 Table 3. Means, Standard Deviation (SD), and T-Test Results for Selected Health Belief Factors Between Women Who Completed Study and Women Who Dropped Out Dependent Variable (Posttreatment) Completed (N=159) Dropped (N=127) df t p Age Self-health perception Perceived severity of UI Expect regain control Inconvenience Treatment will help Like treatment M SD M SD **.000** Time for treatment * * p=.05 ** p=.01 Perceived barriers to treatment were measured by the questions, Did you have time for your treatment? and Did you like your treatment? Responses for the time question were not at all, once in a while, usually, and always. Responses for the like question were not at all, a little bit, moderately, and a great deal. These questions were asked at the same time as Do you think the program has helped you? Likelihood of action: Selfefficacy. The expectancy to regain control of UI was conceptualized for this analysis as a proxy measure for self-efficacy and was measured by the question, How likely do you think it is for you to regain control of your urine? This question was asked at entry into the study. Responses included highly unlikely, somewhat unlikely, somewhat likely, highly likely, and don t know. Likelihood of action: Likelihood of change (outcomes). Perceived improvement in UI was measured at the conclusion of the study by asking the women to rate the amount of improvement on a scale of 1 to 10 with 1 being no improvement to 10 being a great deal of improvement. The effect of UI on life now measurement used in this study was collected after conclusion of the treatment. The responses included not at all, a little bit, quite a bit, and a lot. This variable was reflected in the question, How much does UI affect your life? The feelings were measured by asking the subjects to circle words that described how the UI made them feel. Factor analysis divided the words into the two scales: ashamed feelings and inconvenience feelings. The strength of feeling was a frequency sum of words selected in each scale. The ashamed scale had a possible response of 0 to 7 words and the inconvenience scale 0 to 4 words. Measurement used in the study was collected after conclusion of the treatment. Reliability and Validity The measures were part of a self-administered questionnaire that was reviewed by specially trained and monitored nurse practitioners. Questions related to severity of UI and beliefs regarding UI were developed based on the experience and expertise of the investigators in working with women with UI. Data Analysis and Results The results of this study reinforce that the perceived or subjective severity of UI plays an important role in the impact of UI on the lives of women. Results did not substantiate the hypothesis that women who had more severe wetting but stronger belief in the ability to regain control would have better treatment outcomes. Their outcomes were better than the low expectancy/high wet group but not statistically significant. The significant differences occurred between the high and low wet groups both within and across the expectancy groupings, which may suggest that the perceived amount of wetting plays a stronger role in the treatment outcomes than the belief in the ability to regain control. Research question 1. What are the differences in selected health belief factors between women who completed the entire study and women who dropped out after the diagnostic phase? The women who dropped out were less likely to think the treatment would help, they would like the treatment, or would have time to do the treatment (see Table 3). A two-tailed t-test for independent groups was used to test for differences in the selected 58 UROLOGIC NURSING / February 2003 / Volume 23 Number 1

6 Table 4. MANOVA: Significant Main Effects and Interactions Using Wilks Lambda Criterion Overall Perceived severity of UI Like treatment Table 5. Dependent Variable Means With Significant Differences Among Four Expectancy/Wetting Groups Significant Dependent Variables Perceived severity of UI Wilks Lambda.527 *p=.05 There were no significant mean differences between the four groups for the liking of the treatment variable. health belief factors between the women who completed the treatment phase of the study and the women who dropped out of the study before the treatment began. The two groups differed significantly on the three benefits/barriers variables of Do you think the treatment will help? (t=3.35, p=.001), Will you like the treatment? (t=3.64, p=.000), and Will you have time to do the treatment? (t=2.04, p=.05). However, there were no significant differences between the women who dropped out and the women who completed treatment on age, perception of health, UI severity, F Expectancy/ Wetting Groups High/High (N=19) High/Low (N=60) Low/High (N=34) Low/Low (N=44) High/High (N=19) High/Low (N=60) Low/High (N=34) Low/Low (N=44) High/High (N=19) High/Low (N=60) Low/High (N=34) Low/Low (N=44) Hypothesis df Mean * 5.7* 3.8* * 2.7* 2.1* 1.4* 0.52* 1.7* 0.63* Error df expectancy to regain control, effect of UI on life, ashamed or inconvenience feelings. Research question 2. What is the difference in selected health belief factors among four expectancy/wetting groups? The differences in selected health belief factors among the four expectancy/wetting groups were analyzed using MANOVA. An overall MANOVA demonstrated significant differences between these groups by the Wilks Lambda Criterion (F=2.58, df=30, 317.6, p=.000). The dependent variables that contributed significantly to the group differences were perceived p severity of UI (F=10.57, df=3,117, p=.000), effect of UI on life (F=7.98, df=3,117, p=.000), ashamed feelings (F=5.82, df=3,117, p=.001), and liking the treatment (F=2.75, df=3,117, p=.046) (see Table 4). Followup ANOVA revealed, in three of these four variables (perceived severity, effect of UI on life, and ashamed feelings), the group of women with low expectancy/high wetting (N=34) had the highest severity score, the highest effect on life score, and the highest ashamed score (see Table 5). Consistently for these variables, the group with the next highest score was the high expectancy/high wet (N=19), followed by low expectancy/low wet (N=44), and high expectancy/low wet (N=60). The variables that were not significant between the groups were age, self-health perception, inconvenience feelings, and barriers/benefits to the treatment ( Will the treatment help you? and Will you have time for the treatment? ). Research question 3. What are the effects of selected health belief factors on posttreatment UI outcomes? Four simultaneous multiple regression models were used to predict four measures of UI (the effect of UI on life, the scales of ashamed feelings and inconvenience feelings, and overall UI improvement). The block of predictor variables were the selected health belief factors used in the study (see Table 6). R 2 was 0.45 for the effect of UI on life, 0.16 for ashamed feelings, 0.32 for inconvenience feelings, and 0.38 for overall improvement in UI. All were statistically significant beyond the 0.01 level. Perceived severity of UI made the most significant contribution to the model for all of the outcomes and was the only significant variable for the effect of UI on life and the scale of ashamed feelings. Other significant contributors to inconvenience feelings included age (lower age), selfhealth perception (better health perception), perceived UI severity, and feeling the treatment did not help. The perceived severity (less severe) and the degree to which the woman like the treatment, UROLOGIC NURSING / February 2003 / Volume 23 Number 1 59

7 Table 6. Effects of Selected Health Belief Factors on UI Outcomes: Multiple Regression Analysis (N=159) Likelihood of Change Categories of the HBM Selected Health Belief Factors Effect of UI on Life Beta Scale of Ashamed Feelings Beta Scale of Inconvenience Feelings Beta UI Improvement Beta Individual perception Perceived UI severity.62***.25*.36*** -.37*** Modifiers Age *.07 Self-health perception **.12 Self-efficacy Expectancy to regain control Likelihood of action Time for treatment Liked treatment *** Treatment helped * See note R Adjusted R F 13.49*** (7,115) 3.17** (7,115) 7.62*** (7,115) 11.52*** (6,116) *p=.05 **p=.01 ***p=.001 Note: Did treatment help? variable removed from model due to similar meaning as How much did you improve? contributed significantly to the outcome of overall UI improvement. Discussion The women s perceived barriers to treatment are an important consideration before initiating a treatment program as indicated by the results of the analysis of the women who chose to drop out of the study. If a woman does not like or is not comfortable with the type of treatment, does not believe the treatment will help, or does not have time to do the treatment, it is not surprising that follow-through with the treatment program may be a problem, as self-management is an important component of a UI treatment plan. Further research is needed to clarify if a treatment plan that is individually developed based on the woman s beliefs and lifestyle factors would be more successful and if using the HBM to design intervention programs for women with UI may increase the likelihood of successful outcomes as perceived by the program participants. The HBM seems to be as applicable to helping women with UI as it is for other health behavior programs. Because there are few definitive treatments for UI, self-management may play a major role in success of treatment. Nursing Implications The role of the urologic nurse is key in helping women assess the impact of UI on their life and identify the benefits and barriers of the treatment program in order to assess if the benefits outweigh the barriers for each individual woman. Understanding and assessing what factors regarding UI are most important to the woman will assist the nurse and other health care providers to determine the best treatment program. People who initiate a request or raise a problem with their provider are likely to be committed to taking action and participating in development of a treatment plan. However, knowing that many women do not raise UI as a problem with their provider and knowing the psychosocial consequences of UI, it is imperative that nurses take the lead in helping women assess and identify it as a health problem. Limitations This study was a secondary analysis of data collected for a study evaluating pelvic muscle exercise as a treatment for stress urinary incontinence. The original study was not designed to examine psychosocial issues but the variables were collected to evaluate 60 UROLOGIC NURSING / February 2003 / Volume 23 Number 1

8 This study reinforces that perceived severity of UI might have a major influence on treatment outcomes and on the psychosocial impact of UI. adherence to treatment. The measures used in the study were designed for the study and have not been tested with other samples. Conclusion This study reinforces that perceived severity of UI might have a major influence on treatment outcomes and on the psychosocial impact of UI. Classifying women with UI by combining perceived or subjective severity of UI and expectancy belief in the ability to regain control may assist in designing appropriate treatment programs and in understanding how UI may impact life. The health belief model and health belief factors provide a potential theoretical framework and a foundation for further research into designing treatment programs for women who suffer from UI. The benefits and barriers to treatment, the expectancy to regain control, and the perceived severity of UI are essential factors in treatment success and may have more influence on the outcome than the actual treatment. References Ashworth, P., & Hagan, M. (1993). The meaning of incontinence: A qualitative study of non-geriatric urinary incontinence sufferers. Journal of Advanced Nursing, 18, Chiverton, P., Wells, T., Brink, C., & Mayer, R. (1996). Psychological factors associated with urinary incontinence. Clinical Nurse Specialist, 10, Diokno, A.C., Brock, B.M., Brown, H.B., & Herzog, A.R. (1986). Prevalence of urinary incontinence and other urologic symptoms in non-institutionalized elderly. Journal of Urology, 136(5), Dowd, T. (1991). Discovering older women s experience of urinary incontinence. Research in Nursing and Health, 14, DuBeau, C.E., Levy, B., Mangione, S.M., & Resnick, N.M. (1998). 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