Urinary incontinence (UI) is highly prevalent in Korea; reported prevalence rates vary from 40.8% to 58.5% in community-dwelling women.1–3 Among frail women, who receive home health care services or live in nursing homes, the prevalence of UI is much higher, at 64.6% to 79.7%.4 , 5 Women with UI often experience impaired activities of daily living, social isolation, anxiety, and depression.6 , 7 Moreover, the severity of UI is associated with impaired health-related quality of life and mental health.8 , 9 Despite its negative consequences, older Korean women tend to have limited awareness of UI as a disease resulting in lower help-seeking behaviors.10 The proportion of women seeking professional care is low; between 4.0% and 20.8% of Korean women are undergoing active therapy for their UI.2 , 3 , 11 , 12
Two previous studies reported that women in Korea lack knowledge regarding UI.13 , 14 There are few community-based UI educational programs designed to increase knowledge and self-management skills, while self-management programs for arthritis, diabetes mellitus, and hypertension are routinely provided through community health centers in Korea.15 Community-based education on UI is essential to improve knowledge related to UI, and to enable individuals to manage and live with UI in order to achieve the best possible quality of life.
Self-management strategies aid individuals with chronic conditions to manage symptoms and retain an optimal state of wellness over the course of the illness.16 Strategies for UI self-management include modifying fluid intake, improving pelvic floor muscle function, habit or bladder training, weight management, smoking cessation, and constipation management. A systematic review on the effect of conservative treatments for UI such as bladder training and pelvic floor muscle exercises noted a reduction in symptoms.17 However, only a few studies have evaluated the effects of combined education and behavioral interventions.18 A Cochrane review of lifestyle intervention for UI reported few studies that evaluated the effect of reducing alcohol intake, avoiding constipation and straining, smoking cessation, or improving physical activity on incontinence.19 In addition, most UI intervention studies set in Korea have focused on single interventions, such as pelvic floor muscle training, habit or bladder training, muscle strength training, or yoga rather than an intervention bundle.20–24
Considering the low health-seeking behaviors of persons with UI,2 , 3 we assert that community-based educational programs should be made easily accessible to affected patients. Thus, we developed and evaluated a UI self-management program for community-dwelling older women, based on evidence-based interventions and guided by principles of self-management.16 , 25 A previous study found that the program effectively generated a short-term (5-week) decrease in the severity of UI symptoms and increase in UI knowledge and attitudes scores.26 Considerable evidence supports short-term efficacy of various self-management programs on various chronic diseases other than UI but improvements tended to diminish over time.27–29 The purpose of this study was to examine whether the improvement generated by UI self-management programs at 5 weeks could be maintained at 1 year in a group of community-dwelling older women with UI residing in Korea.
A nonrandomized, control group design with serial measurements was used to evaluate long-term effects of a 5-week UI self-management program. Data were collected at 3 time points: before the intervention (baseline, T1), immediately after the intervention (T2), and 1 year after the intervention (T3).
Convenience sampling was used to recruit participants for the intervention/experimental or control groups. The experimental group was recruited from a primary health care post (PHCP) at Sosa village in rural South Korea. The control group was recruited from different areas located more than 1 mile away. Primary health care posts are public health facilities for residents in rural areas, where access to health services is limited. Inclusion criteria were (1) women 55 years and older; (2) mild to moderate UI score on the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF; sum of total scores ≤12); and (3) willingness and ability to participate in weekly 90-minute group sessions for 5 weeks. Women with nonambulatory status; persistent pelvic pain; those taking medications to treat bladder problems; or participation in another health project that might influence outcomes of this intervention were excluded.
Investigators recruited participants via meetings with village representatives from Sosa village; these meetings included a village leader, president of the senior group, and president of the village women's society. The purpose of this meeting was to explain study goals and procedures. Throughout the meeting, the investigators gained their trust and encouraged long-term commitment. Individual participants were then recruited via local announcements, distribution of leaflets, posters in senior community centers, and word of mouth. Two nonrandomized groups were recruited, one from the Sosa village PHCP (experimental group) and second from the Hyuncheon (capital city of Gangwon Province, Korea) PHCP (control group). The ICIQ-SF score was assessed to identify UI severity. Participants were informed they would undergo the course either immediately or 1 year later (control group). All participants provided written informed consent. Ethical approval for the study was obtained from the institutional review board of Gangneung-Wonju National University in Korea (GWNUIRB-2013-21).
Sample Size Analysis
The sample size was calculated using the G*power 3.1 program.30 Analysis indicated that 32 people (16 people for each group) were needed to detect large effects (F = 0.35) for within-between interactions in a repeated-measure analysis of variance (ANOVA), with a significance level of 0.05 and a power of 0.80. An effect size of 0.35 was estimated from the findings of a previous study on the effectiveness of a self-management program among community-dwelling adults in Korea.31
Forty-four participants (25 in the experimental group and 19 in the control group) were recruited. A total of 37 women (23 in the experimental group and 14 in the control group) met eligibility criteria (one eligibility criterion, score on the ICIQ-SF was determined as part of baseline evaluation). The attrition rate was 29.7%, including 6 participants in the experimental group and 5 participants in the control group. Dropouts were attributable to hospitalization during data collection period, difficulty traveling to attend study procedures, and lack of interest (Figure 1).
The community-based UI intervention was designed to decrease the severity of UI and related lower urinary tract symptoms, while increasing knowledge and improving attitudes toward UI. The educational program content was focused on modifying factors associated with urinary leakage, such as dietary and fluid intake, bowel irregularity, obesity, smoking, physical inactivity, and weakened pelvic floor muscles. These factors were derived from the UI risk factor modification tool developed by Holroyd-Leduc and colleagues.25 In accordance with principles of self-management advocated by Lorig,32 enhancement of self-efficacy such as progressive goal setting, action planning, modeling with having peers, performance feedback, and reflective discussions, and vicarious experiences were emphasized. The content and activities of the five 90-minute group sessions are outlined in Table 1. Sessions were delivered once a week for 5 weeks. The content included a lecture, instructions related to pelvic floor muscle exercises, and assignments related to action plans (exercises and a daily bladder diary). Considering participants' age and low health literacy, a sketchbook (14 × 10 inches) with colorful stickers was provided to complete the bladder diary. The intervention was held during the agricultural off-season (because most participants were farmers), and carried out in a senior community center (to maximize accessibility). Sessions were given by a single community health practitioner at the Sosa PHCP, who served was the main lecturer; along with 3 investigators (A.S., S.P., and J.C.D.) who acted as co-lecturers. At least 2 home care nurses were stationed at nearby county health centers to assist the participants and lecturers.
Demographics (eg, age, sex, education level, and parity) and UI-related characteristics (eg, duration of UI symptoms, UI diagnosis, and treatment history) were recorded at baseline using a form developed for purposes of the study. The study's main outcome measures were severity of UI, UI knowledge, and UI attitudes.
The Korean version of the ICIQ-SF was used to measure UI severity. The ICIQ-SF was developed and validated by Avery and colleagues33; it comprises 3 scored items (frequency, amount, and overall impact on quality of life) and an unscored self-diagnostic item for episodes of urine leakage. The total score was calculated as the sum of the responses to 3 items and ranged 1 to 21. Higher scores indicated greater severity of UI. A total of 5 points or less indicated mild UI; a score of 6 to 12 moderate UI; 13 to 18 indicated severe UI; and 19 to 21 indicated very severe UI.
Urinary incontinence knowledge and attitude were assessed via the UI knowledge scale (UIKS) and the UI attitude scale (UIAS) developed and validated by Yuan and colleagues34 , 35 The UIKS comprises 30 items with forced dichotomous choices (1 = correct; 0 = false or do not know) and 6 subscales including risk factors (5 items), symptoms (5 items), impact of UI (5 items), prevention (5 items), treatment (5 items), and management (5 items). Higher knowledge scores indicated more knowledge about UI. The UIAS has 15 items scored with a 4-point Likert scale, ranging from 1 (strongly disagree) to 4 (strongly agree). Negatively phrased items were reverse coded so that higher scores indicated more positive attitudes toward UI care. The internal consistency of the original instruments was 0.69 for the UIKS and 0.70 for the UIAS. In the current study, the Cronbach α was 0.72 for the UIKS and 0.58 for the UIAS.
The original English language version of both scales was translated into Korean by the 3 authors (A.S., S.P., and J.C.D.) with the original author's permission after using a translation-back-translation procedure. Two authors (A.S. and S.P.) translated the original instrument into Korean and then the back-translation into English was performed by another author (J.C.D.), who is bilingual and bicultural. All 3 authors reviewed inadequate expressions/concepts of the translation and any discrepancies between the forward-translation and the back-translation. A pretest was conducted to identify unclear content with 10 older women who did not participate in the self-management program. After clarification and modification of several items to accommodate the Korean culture, the final version was developed.
Data were collected using a pencil-and-paper method with participation of the investigators and 3 trained nurses pursuing postbaccalaureate graduate degrees; assistance was offered because most participants had low health literacy. The ICIQ-SF, UIKS, and UIAS scores were measured prior to the intervention (December 6, 2013), immediately following the intervention (January 3, 2014) and 1-year postintervention (January 12, 2015). After data collection was completed, participants from the control group were invited to participate in the intervention, which was the same UI self-management program provided to the experimental group. The intervention for the control group was held between December 2015 and January 2016.
Data were analyzed via the SPSS software, version 23.0 (Statistical Package for the Social Sciences Inc, Chicago, Illinois). Descriptive statistics, χ2 test, Fisher exact test, t test, or Mann-Whitney U tests were used to compare baseline characteristics of the experimental and control groups.
Repeated-measures ANOVA with a Bonferroni post hoc test was conducted to compare changes in the total ICIQ score and UI knowledge over time. The Friedman test was performed to analyze differences in UI attitude scores over time due to the abnormal distribution of samples. A post hoc analysis with Wilcoxon signed rank tests and Bonferroni correction was used to assess UI attitude, resulting in a significance level of P < .017. The Shapiro-Wilk test was used to assess the normality of dependent variables, Levene test for homogeneity of variance, and Mauchly's test for sphericity to validate the repeated-measures analysis. A P value < .05 was considered significant.
There were no statistically significant differences in group characteristics at baseline (Table 1). The mean age in the experimental and control groups was 71.5 and 73.9 years, respectively. In both groups, a majority of participants were either uneducated or did not study beyond elementary school (76.4% in the experimental group vs 100% in the control group). The duration of UI in the experimental group was 7.5 years versus 9.4 years in the control group. The mean ICIQ-SF score was 11.6 in the experimental group versus 11.0 in the control group. UI-related knowledge was scored 19.1 in the experimental group versus 18.1 in the control group (Table 2).
Effects of Intervention Over Time
Repeated-measures ANOVA showed significant main effects of group and time on ICIQ-SF scores (F = 17.31, P < .001; F = 8.45, P = .001, respectively). There was a significant interaction between group and time (F = 22.54, P < .001). Descriptive statistics showed that the ICIQ-SF score gradually decreased from pretest to 5 weeks and 12 months in the intervention group (mean ± SD, pretest 11.8 ± 3.02; 5 weeks 5.4 ± 3.05; 12 months' test 4.9 ± 3.06). In contrast, the mean ICIQ-SF score increased over the 12-month data collection period in the control group (pretest 11.0 ± 5.24; 5 weeks 10.4 ± 4.90; 12 months 15.7 ± 4.03, Figure 2). Post hoc analysis via the Bonferroni correction revealed significant differences in the ICIQ-SF score between pretest and 5 weeks, and pre-test and 1 year in the experimental group. In the control group, the ICIQ-SF score at 1 year was significantly different from that at pretest and 5 weeks.
No significant improvement in total UI knowledge score over time was found in the intervention group, although they showed a slight increase in UI knowledge from pretest to week 5 postintervention (19.1 ± 3.34 vs 21.0 ± 2.60, P =.190) compared with those in the control group. There was a statistically significant difference in UI attitude over time in the experimental group (χ2 = 6.76, P = .034). The post hoc test using the Wilcoxon signed rank test revealed no significant differences between the 3 time points (Table 3).
We examined the long-term effects of a 5-week UI self-management program for older women with UI focusing on its effects on lower urinary tract symptoms, along with UI knowledge and attitudes. We previously demonstrated that this intervention program had short-term effects in terms of decreasing the symptoms of UI and improving the knowledge of and attitudes toward UI.26 While severity of UI and related lower urinary tract symptoms persisted over the 12-month data collection period in this study, changes in UI knowledge and UI attitudes did not.
Sustained UI and related lower urinary tract symptoms are consistent with Dougherty and associates,36 who showed that behavioral management approaches including self-monitoring, bladder training, and pelvic muscle exercises with biofeedback contributed to UI improvement for 2 years among older women living in rural areas. Sustained improvements were also observed by Sjöström and colleagues,37 who reported findings of a randomized controlled trial that used an Internet-based UI treatment program comprising pelvic floor muscle training alone revealed an improvement of UI symptoms at 1 and 2 years after treatment.
Lindh and coworkers38 reported that increasing age was a predictor of the long-term success of a 3-month pelvic floor muscle training program. In contrast, 4 other studies examining the short-term effects of UI behavioral treatments have found that age was not a predictor of outcome.39–42 Lindh and coworkers38 postulated that older people may have experienced greater long-term benefit from the intervention because they had more time to perform the exercise. Borello-France and colleagues43 evaluated predictors of adherence to multicomponent behavioral interventions for women 18 years and older (average age 50 years) and reported that difficulty finding time for the pelvic floor muscle exercise was the most common barrier to adherence. The mean age of our participants was 70 years, suggesting that age might have influenced the long-term success of the intervention. Nevertheless, the number and type of UI interventions differed between studies, and further research is needed to determine the influence of age and other factors on long-term adherence to a UI self-management intervention or intervention bundle.
In addition to the individual interventions, we employed strategies for promoting long-term adherence to health behavioral interventions such as ongoing care from nurses, skill training for overcoming barriers to long-term compliance, social support, and techniques specific to the target behavior advocated by others.25 , 44 Additional research is needed to determine the added benefit of such techniques on UI self-management programs.
Increases in mobile health technology-assisted interventions have occurred since data collection for this study was completed.45 Ross and Wing46 reported successful behavioral interventions using a smart phone app that incorporated lifestyle management and self-monitoring of adherence for weight loss. Further research on the long-term effect of UI self-management educational programs involving smartphone interventions and its availability to the elderly as an extended care intervention is needed to determine whether this technology improves adherence to UI self-management strategies.
We also found that some short-term improvements in UI knowledge and attitudes were not maintained at the 1-year follow-up. For example, we found a statistically significant increase in UI knowledge and attitudes immediately after the intervention in our short-term study, but this change did not persist when participants were measured 1 year following the intervention.26 Our finding that UI knowledge was not sustained over time may be attributable to the age of our participants, or to their low level of education and health literacy. In addition, it may reflect an inherent limitation of the intervention such as lack of follow-up care. A study of older adults with low health literacy revealed that interactive games were more effective at improving knowledge of medication safety than provision of a brochure, though retention was assessed only at the 30-day follow-up in this study.47
Our participants expressed negative attitudes toward UI that did not change over time. Attitudes reflect a person's beliefs and values.48 Research suggests that many incontinent women express inaccurate beliefs that UI is an inevitable and embarrassing part of the aging process.12 A change in UI beliefs and attitudes may require regular provision of community-based education, along with national health policies or strategies aimed at diminishing the social stigma associated with UI.
STRENGTHS AND LIMITATIONS
We evaluated effects of a behavioral and educational program for managing UI and related lower urinary tract symptoms over a 12-month period; to our knowledge, this is one of only a few studies evaluating long-term effects of self-management intervention bundled on UI in community dwelling women.36 , 37 There are several limitations to this study. Participants were not randomly assigned to intervention of control groups; however, analyses revealed no significant differences between demographic or pertinent clinical characteristics of the groups. Nevertheless, randomized controlled trials are needed to reduce the risk of selection bias. The attrition rate in the control group was 35.7% after 1 year. This lost to follow-up rate might have affected the results of our study. The reliability of the UIAS was low. The Korean language version of the UIAS used in our study was verified through a back-translation process and a pilot test to identify unclear content; nevertheless, the translation may have been influenced by the participant's age and lower health literacy levels. Further refinements for this instrument are indicated to more fully determine the validity of the Korean language version of this instrument.
We evaluated the efficacy of a UI self-management program for community-dwelling Korean women that proved effective in UI and related lower urinary tract symptoms over a 1-year period. Additional evaluation and interventions are needed to ensure long-term retention of UI knowledge and attitudes. We advocate education of community health practitioners in PHCPs; these providers have an ongoing relationship with community members, who regularly use a range of primary health care services provided by community health practitioners. Thus, community-based approaches with administrative support such as budget, material, and human support are also needed to enable them to play a significant role as mediators of good UI self-management behaviors.
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