Educational Interventions on Reducing Stress Urinary Incontinence Episodes among elderly Women

Introduction

Stress Urinary incontinence (SUI) considers the most common and distressing health problem among the aging population especially older women, associated with a profound negative impact on the quality of life. Its prevalence estimates 30 to 50% and increases with age among community-dwelling older adults and represents 50 to 60% among nursing home residents. Women are at more risk for SUI three times more than men, because of anatomic, social, and cultural status and also because of the effects of pregnancy, delivery, and menopause (National Association for Continence, 2017).

Stress incontinence is considered the most common type among elderly women affects more than 30 percent of elderly adult women population Worldwide. It is defined as a leakage of urine resulting from weakened perineal muscles combined with sudden increased intra-abdominal pressure (Kocak I, et al., 2014).There are several risk factors associated with stress urinary incontinence include; advanced age, race, higher parity, menopause, hysterectomy, obesity, heavy lifting at work, chronic cough or constipation, family history, dietary habits, lifestyle, and pathological disorders as diabetes (Herzog A R& Fultz N H., 2016).

With aging there is a decrease in bladder elasticity, which decreases bladder capacity and requires the older adult to void more frequently, and a decrease in the strength of the bladder muscle, likewise, estrogen deficiency in postmenopausal women causes atrophy of the urethral epithelium, resulting in a decreased efficiency of the urethral sphincters (Touhy A., 2013).

Although stress urinary incontinence is not a life-threatening disease, the loss of bladder control can affect social, psychological, occupational, physical and sexual aspects on elderly women (Sirls LT& Rashid T., 2015). Stress urinary incontinence causes wetness, bad odor, discomfort, skin breakdown, pressure ulcer, and urinary tract infection as physical problems; also, it can be associated with low self-esteem, depression, and social isolation as a result of the shame and embarrassment (Ghafouri A, et al., 2014).

Management of urinary incontinence should start with non-invasive measures because the benefits are associated with low risk and limited expense. Lifestyle modifications, including (smoking cessation, management of constipation, avoidance of excessive fluids, with a reduction in consumption of caffeine, carbonated beverages, diet beverages, frequent intake of small amounts of fluids up to 2 L a day), timed voiding measures or voiding at intervals that are tailored to each woman (typically every 2 to 3 hours) during the day and pelvic floor muscle exercises instruction. Behavioral therapy was successful greater than 70% reduction in incontinence episodes (Lukacz, et al., 2017).

Nurses play an important role in improving patients’ UI by understanding the experiences of individuals experiencing UI, providing healthcare, and implementing behavioral therapy methods. Managing the incontinent patient is an integral component of nursing practice and can be a challenging and rewarding aspect of nursing care (Arkan, et al., 2018).

Significance of the Study

Urinary incontinence  (UI) considering  a common problem, its incidence is twice as high in women as it is in men, and has a significant social, psychological, occupational, sexual, and economic impact, and leading to a substantial decrease in the quality of life (Esparza, et al., 2018). Several studies conducted in Egypt that recorded a high incidence of SUI among elderly women living in the community as well as those living in institutions , there are limited studies in Upper Egypt focusing on educational interventions for solving this health problem.

Aim

To evaluate the effect of an educational intervention on reducing stress urinary incontinence episodes among elderly women.

Research hypothesis

-          The educational interventions included (Pelvic muscle exercise, Toilet training, and lifestyle modifications will reduce stress urinary incontinence episodes among elderly women.   

Research Design:

Quasi-experimental research design was utilized to fulfill the aim of this study.

Subjects:

A purposeful sample of fifty elderly women was selected according to the following inclusion criteria.

Inclusion criteria:

-          Females of 60 years and older suffering from stress urinary incontinence.

-          Have at least one episode of involuntary urine loss /week.

-          Cases of no previous or current urinary incontinence treatment.

Exclusion criteria: 

-          Females with any cognitive problems and psychological disorder affecting on alertness and communication.

-          Uncontrolled pathological disorders as (spinal injury, stroke, neurogenic bladder)

Setting:

The study was conducted in Geriatric Nursing Home of Ministry of Social Solidarity and in Geriatric Club of The Red Crescent Society at Minia Governorate, Egypt.

Study Duration:

The data were collected over a period of nine months starting from June 2018 to February 2019.

Tools of data collection

Two tools were used for data collection as the following:

1. Tool I: A Structured interview questionnaire sheet was developed by the investigator after reviewing recent related literature to collect the necessary data from the participants.Adopted from (Yoshida M etal.,2017) &( Newman D& Wein A.,2009) It was collected by the researcher at the first interview 

It was divided into 2 parts:

Part I: (Demographic Data):  As age, marital status, education, occupation, job before retirement, place of residence, with living condition.

Part II: Medical Profile:  Covered history of: Chronic diseases, weight, height and body mass index, obstetric/gynecological, medications, mobility, caffeinated fluid intake, and bowel habits).

2- Tool II: Revised urinary Incontinence Scale (RUIS ) adopted from (sandvic & et al., 2000).

This scale consisted of 5 questions includes; urine leakage related to feeling of urgency, urine leakage in relation to physical activity (laughing, coughing or sneezing) small amounts of urine leakage, how often did they experience urine leakage?, and how much urine did they lose each time?, People respond to (RUIS) questions by selecting one particular response option from the set of standard response options for each question. These response options were scored by using the numbers presented in brackets to the right of each response option. The RUIS total score is then calculated by adding up a person’s score for each question. Adding the score for each of the five questions results in a possible score range of 0 - 16. After that an ISI score calculated by multiplying the scores from questions 4 and 5, resulting in a score range from 0 to 12, where a 0 score represents no incontinence, scores from 1 to 12 are grouped into the following four severity levels: 

 1 - 2 = slight     3 - 6 = moderate    8 - 9 = severe   12 = very severe 

This tool was used before and after educational intervention  and health instructions to evaluate its effect on reducing stress urinary incontinence episodes.

Educational brochure:

It was formulated by investigator after extensive literature review and revised by experts. It covered thedefinition of stress urinary incontinence, its causes, and lifestyle modifications in order to control the problem included (limited caffeinated beverages, avoid heavy ligting, controlling chronic constipation etc..),  pelvic muscle exercise (Kegel exercise) importance and how to perform it, and instructions given when practicing Kegel exercise, and bladder training technique.

Tools validity:

The tools were tested for content validity by a jury of five experts in the field of the study and the necessary modifications were done.

Reliability of tools

To establish reliability, alpha Cronbach’s was used to check the stability of the internal consistency of the study instruments which revealed that the tools of the study were reliable as indicated by the value of (0.87).    

Pilot Study

A pilot study was carried out on 10% (5 women) of the total sample to test feasibility, objectivity, and applicability of the data collection tools.  The pilot study sample was included in the actual study sample because no modifications needed.

Ethical Consideration

Approval was obtained from ethical committee in the Faculty of Nursing, the director of Geriatric Nursing Home of Ministry of Social Solidarity, and the director of Geriatric Club of The Red Crescent Society. Oral consent was obtained from the elderly women and explanation about the study was given to them included the aim of the study. Confidentiality and anonymity of each subject were ensured through coding of all data and protecting the obtained data, voluntary participation, and the right to refuse participation in the study were emphasized to subjects.

Procedure

Data collection for this study was carried out during through the period from June 2018 to February 2019, on the morning, from 9:00 am to 2:00 pm, 2 days per week.. Firstly, the investigator introduced her-self to the women, explained the general purpose of the study & asked them to give an oral consent for their participation.

The data was collected by the investigator in the first interview which took about 15-20 minutes from each client at the previous mentioned settings, after that the content of the educational brochure introduced for them concerning the behavioral therapy to reduce the episodes of stress urinary incontinence.

Session plan

Session plan designed according to attention span of the elderly women. Three sessions at three different days were organized for each group of(2to3) women & each session took about 30- 40 minutes.Session one covered intreusing self and collected interviewing sheet ,session two teaching kegel steps and modification of life style and session three educate toilet tranning . The investigator used discussion, demonstration, and re-demonstration as a teaching method. At the end of each session the investigator allowed the woman to ask questions for clarification and gave a conclusion about content, after that the investigator gave them (a brochure) prepared in Arabic language including all items of educational intervention (Pelvic floor muscle exercises, and instructions about preventing constipation and avoidance of lifting heavy objects, and limited caffeinated beverages), and photos to remember them about how to apply these instructions by themselves at their homes. 

The investigator followed the adherence of the participants to the educational instruction and to ensure that they are able to perform Kegel exercise as it explained for them accurately by visits or by phone through three times of follow up (after  2 week, 4 weeks, 8 weeks). 

The Second tool, (RUIS) was used for participants after 12 weeks of the educational intervention to evaluate the effect of selected behavioral therapy on reducing episodes of stress urinary incontinence for them.

Statistical analysis of data:

Data were analyzed using the statistical package for social science (SPSS) version 20. Numerical data were expressed as means and SD. Quantitative data were expressed as frequency and percentage. For quantitative data; comparison between two variables were done using t-test, and comparison between more than two variables used ANOVA test paired t-test. Relations between different numerical variables were tested using Pearson correlation. Probability(P-value) less than 0.05 was considered significant and less than 0.01 was considered highly significant .

Results

Table (1): Frequency Distribution of the Studied Sample According to their personal Data (N=50).

Table (1) Shows that (44%) of the studied sample has age 65-69 years old with a mean age of 68.92+5.39 years old. Also the table displays that (54%, 58%, and 54%) were working ,  had moderate education, and living in rural areas respectively .As regards job before retirement, it was found that (54%) have heavy work, finally 32% of them were living with the extended family and (46%) were married.

Figure (1): Distribution of the studied sample according to the predisposing factors of stress urinary incontinence (N=50).

Figure (1) demonstrates that,  the most predisposing factors for stress urinary incontinence founded among the studied sample are (pregnancy more than two times, normal delivery more than two times, caffeine intake, choric constipation, and obesity with percentages of  (92%, 86%, 78%, 72% &70%) respectively.

Table (2): Comparison between Urinary Incontinence Severity levels at Pre & Post educational intervention among the studied Sample (N=50).

Table (2) reflects that, the severity of stress urinary incontinence episodes were declined after the implementation of educational intervention to 8% compere with 24% before with highly statistically significant differences (p=.001).

Table (3): Comparison between mean average score of Revised Urinary Incontinence Scale (RUIS) before and the implementation of educational intervention for Studied Sample (N=50)

* p≤0.05 (significant) T-test: P – value based on independent sample t-test.

This table : Shows there were a highly statistically significant differences between total mean average score of revised urinary incontinence scale at pre& post selected behavioral therapy (p=.001). 

Table (4): Relation between Personal Data and the Severity Levels of the Revised Urinary Incontinence Scale (N=50).

                                * p≤0.05 (significant)

Table (4) shows that, there were highly statistically significant differences between (age, education, occupation, job before retirement, and location) and theRevised Urinary Incontinence Scale (RUIS)  score after nursing intervention  , in which severity of stress urinary incontinence episodes declines among age group( 60:64)years, high education, not have heavy work, and those living in urban areas  (p=.001) during posttest.