Abstract
Purpose:
The purpose of this study was to examine the feasibility of delivering a bladder control self-management program through a multi-user health kiosk, and to evaluate the program’s effect on urinary incontinence (UI) and incontinence-specific quality of life (QoL).
Design:
Secondary analysis of data collected during participants’ interactions with the Bladder Control Module (BCM) from the parent study.
Subjects and Setting:
One hundred eleven participants from the parent study were eligible to be included in this secondary analysis. Their mean age was 72.8 years and most were female (n=95, 85.6%); 81 (75.7%) identified themselves as Caucasian. Each participant could access the BCM at a health kiosk situated at one of several sites: senior centers, subsidized senior housing, retirement communities, and a public library.
Methods:
The BCM comprised 6 sessions self-administered at least one week apart. Content focused on lifestyle modification, pelvic floor muscle training, bladder (habit) retraining, with encouragement of behavioral self-monitoring between sessions. Feasibility of delivering the intervention was measured by the proportion of participants completing each session. The effect of the BCM on incontinence episodes and incontinence-specific QoL was measured, respectively, by a 7-day bladder diary and the Incontinence Impact Questionnaire Short Form.
Results:
Sixty-one of the 111 eligible participants accessed the BCM. Participants recording incontinence episodes in their baseline bladder diary and completing at least three BCM sessions experienced significant decreases in median total UI (p=0.01), urge UI (p<0.001), and stress UI (p=0.02) episodes per day. Incontinence-related QoL sgnificnatly improved (p=0.03).
Conclusions:
Our findings support the potential effectiveness of providing community-based, kiosk-enabled access to a conservative behavioral intervention designed to improve incontinence-related outcomes among older adults with UI. Additional research with a larger sample is warranted.
Keywords: urinary incontinence, self-management, e-health, older adults, behavioral interventions
INTRODUCTION
Urinary incontinence (UI) is a common, chronic, yet underreported condition that impacts approximately 20 million women and 6 million men in the United States.12 More than 4 in 10 (43.8%) community-dwelling adults age 65 or older report urinary leakage.10 Incontinence is associated with an increased risk for urinary tract infection, falls and fractures, incontinence-associated dermatitis, depression, and anxiety. It is also associated with higher hospitalization rates, decreased sleep quality, impaired social and physical relationships, and impaired health-related quality of life (QoL).16 The Centers for Disease Control and Prevention estimated the cost of UI to be $19.5 billion among adults residing in the USA, including $14.2 billion among community residents.10
Due to social stigma, embarrassment, and the misperception of UI as a natural part of aging, people who experience UI symptoms often delay or abstain from seeking medical attention and care. Kinchen and colleagues13 found that only 38% of women with symptoms initiated a conversation about UI with their primary care physicians. Similarly, Burgio and coworkers5 reported 37.6% of adults aged 65–79 years (N=1104) they studied discussed their UI symptoms with a health care provider.8
Behavioral interventions including lifestyle modification, pelvic floor muscle training (PFMT), and bladder retraining are recommended as first-line treatments of stress, urge, and mixed urinary incontinence.8 However, much of the evidence in support of these interventions has been derived from protocols that require significant clinician engagement and multiple, face-to-face visits for individuals with UI to acquire the knowledge and skills needed to modify their behavior and minimize symptoms. Given the limited time allotted for a typical office or home visit and the multiple health care needs of many older adults, in particular, there is little opportunity to deliver behavioral interventions in those settings.
A review of the literature found several studies evaluating internet-based self-management programs for a variety of chronic health problems. We examined outcomes for the few studies that examined the effect of e-health self-management interventions on UI9 ad found that they focused primarily on middle-aged women, not older adults. Three studies that were conducted in Sweden with women (mean ages: 44.4 to 54.4 years) promoted UI self-management through websites and mobile applications on smartphones that yielded significant reductions in lower urinary tract symptoms (LUTS) including UI related symptoms.2,4,19 Barriers to older adults’ utilization of e-health interventions include age-related cognitive, sensory, and physical impairments and motivational issues, such as when the benefits are not perceived to be readily and quickly evident during use.23 Lack of access is another barrier, particularly for older adults with limited financial resources. How older adults with UI would respond to a technology-enabled, self-management program designed to address these barriers is unclear.
The purpose of our study was to examine the extent to which community-dwelling older adults with UI would access and complete a bladder control self-management program offered through a community-based, multi-user health kiosk, and to evaluate the effect of such an intervention on their urinary incontinence and/or incontinence-specific QoL. Study aims were: 1) identify the proportion of eligible participants who accessed a bladder control self-management program; 2) analyze associations between participant characteristics and accessing the program; 3) determine the proportion of participants who completed each session of the program; and 4) describe changes in incontinent episodes and incontinence-specific QoL among eligible participants.
METHODS
We completed a secondary analysis of data collected during participants’ interactions with the Bladder Control Module (BCM), a self-management program with a pre/post, quasi-experimental design offered through the parent study known as the Health Kiosk Project. The parent study was a translational, observational study funded by the Agency for Health Research and Quality (5R01HS022889) and designed to understand the perceptions, motivations, and patterns of usage of community-based, multi-user health kiosks available to community-dwelling older adults.
Sample and Setting
Participants in the parent study were recruited from 12 sites where health kiosks were deployed: senior centers, low-to-moderate income senior housing, continuing care retirement communities, and a public library. Each kiosk consisted of a desk and adjustable chair, secured on-board computer, touchscreen monitor, printer, seated scale, blood pressure monitoring device, and grip dynamometer. The kiosk enabled participants to respond to surveys, engage with educational intervention modules, self-monitor behavior between kiosk visits, and track progress in response to suggested self-management strategies. Participants could also view and print instructions, tracking forms, and summaries of selected findings from their periodic assessments for the Health Kiosk Project.
Those who agreed to participate in the parent study provided informed consent prior to beginning their baseline assessments. Assessments included a battery of measures self-administered at the kiosk followed by performance-based functional measurements obtained on site during an in-person session with members of the Project team. Participants were offered the opportunity to complete intervention modules focused on a variety of topics (e.g., sleep, emotional health, lifestyle, bladder control) if their assessment findings suggested they had a particular problem. They were also offered the opportunity to complete one or more of these modules even if they were not experiencing problems identified in the module. Participants were able to repeated modules as many times as desired.
Participants were included in this secondary analysis if they had consented to participate in the parent study; inclusion criteria for the parent study were: 60 years of age or older, and having met at least one of the following criteria resulting in in being eligible to receive a recommendation to complete the BCM: 1) scored ≥ 4 on the Bladder Control Self-assessment Questionnaire (BCSQ)3; 2) scored ≥ 2 out 10 on the desire to improve bladder control in the next 6 months; 3.) bladder control indicated as first or second highest priority among health behaviors the participant wanted to improve in the next 6 months; or 4.) affirmative response to BCSQ items “Is it difficult to hold urine when you get the urge to go?” or “Do you leak urine?” Participants who accessed the BCM voluntarily without meeting the above criteria were excluded from the secondary analysis. Study procedures were reviewed and approved by the University of Pittsburgh Institutional Review Board (protocol STUDY21040086).
Instruments and Outcomes
Sociodemographic and pertinent clinical data were collected as part of a baseline assessment in the parent study included age, gender, race, marital status, household size, caregiving status, education, employment status, and ability to pay for basic needs. Clinical characteristics included vision, hearing, assistive device use, pertinent medical conditions including depression and anxiety, and number of prescription medications taken on a regular basis.
The feasibility of delivering a bladder self-management program via health kiosk was quantified as the proportion of eligible participants who completed sessions of the Bladder Control Module. Those who completed the “Consider the Bladder Control Module” but did not agree to proceed with the BCM were asked whether they declined due to lack of time, lack of concern about bladder control, the need for more information, or some other reason.
Participants were asked to keep a 7-day bladder diary complete between BCM sessions. The frequency of any incontinence episode was reported on the bladder diary. Participants were instructed to report any urinary leakage, ranging from a few drops to larger volumes of urine loss. Stress UI was classified as urine leakage when coughing, laughing, lifting, or changing positions. Urge UI was classified urine leakage immediately during urinary urgency. Wyman and colleagues24 examined the test-retest reliability of a one-week bladder diary and found it a reliable method of evaluating the frequency of incontinent episodes.
Incontinence specific QoL was measured using the Incontinence Impact Questionnaire Short (IIQ-7) instrument.21 This 7-item questionnaire was developed by identifying items in each subscale of the original 30-item Incontinence Impact Questionnaire (IIQ) that best predicted its subscale score. Participants rated the effect of urine leakage on household chores, physical recreation, entertainment activities, travel more than 30 minutes from home, social activities, emotional health, and feeling frustrated. The response options for each item are: “not at all” (0), “slightly” (1), “moderately” (2), or “greatly” (3). To allow for missing responses and calculate an average score, the scores on items responded to were summed and divided by the number of items answered. This score was then multiplied by 33 1/3 to put the total score on a scale of 0–100, with higher total scores indicating greater negative impact on QoL. Uebersax and colleagues21 reported high correlations between IIQ-7 scores and the total and subscale scores on the original IIQ (0.88 to 0.97) and significant positive correlations with the number of incontinence episodes, pad test results, and improvements following treatment of incontinence.
Study Procedures
Participants who returned to the kiosk and completed the brief “Recommendations” module were encouraged to complete the bladder control self-management module. If they next completed the “Consider the Bladder Control Module,” they learned what engaging in the BCM would entail and, if willing, agreed to proceed to the BCM. A minimum of seven days separated one session from the next, and participants received chances in a weekly cash drawing at each site for each session completed.
During the first session of the BCM, “Assessments and Bladder Control Basics,” participants completed baseline measures regarding bladder function, continence history (i.e., fluid and caffeine intake, LUTS, frequency of incontinence episodes, and triggers for UI) along with the impact of incontinence on QOL. Several questions were designed to identify serious LUTS such as chronic pain of the lower urinary tract or episodes of grossly visible hematuria requiring medical evaluation. If participants reported any potentially serious symptoms, they were contacted by a nurse on the team and referred to their primary care provider for further evaluation before proceeding with the module. The first session also introduced how bladder function works and lifestyle changes that may reduce incontinence symptoms and related LUTS.
Images and video clips from “Treating Urinary Incontinence: A Guide to Behavioral Treatment Methods for Patients and Caregivers” (used with permission from Family Health Media, Charlottesville, VA) were interspersed throughout this session and each subsequent BCM session, to illustrate and reinforce the educational content presented textually with voice-over. At the end of each session participants were asked to print a 7-day bladder diary form and complete it at home. At the beginning of the next session, they were invited to enter their diary data at the kiosk and offered graphical feedback depicting the trend in their incontinence episodes over time.
The second session, “Behavioral Treatment of Incontinence,” introduced the benefits of doing pelvic floor muscle exercises (PFME) to prevent or lessen UI episodes. Instructions on how to begin a PFM strengthening program and how to perform the exercises were also presented. Participants were asked to specify how many fewer incontinence episodes per week they aimed to achieve within 4 weeks. The third session, “Strategies to Prevent or Stop Leaking,” encouraged participants to adopt strategies to prevent involuntary urine loss during activities that increase intra-abdominal pressure or accompanied by urinary urgency. The fourth session, “What Else Can Help to Stay Dry,” delivered information about bladder retraining, including when it could be helpful and how to implement it. The fifth session, “Making New Bladder Habits Stick,” reviewed PFME and bladder retraining principles and promoted ways of sustaining adherence to the bladder self-management strategies introduced in previous sessions. During the sixth session, “Bladder Control Checkpoint,” baseline measures were again self-administered.
Outcome Measures
Study outcomes for Aim 1 and Aim 3, which described the proportion of participants who accessed and completed all or part of the BCM, were measured by session completion. The outcomes for Aim 2 reflected whether accessing the BCM (yes or no) was related to selected participant characteristics (age, sex, race, marital status, household size, caregiving status, education, employment status, ability to pay for basic needs, difficulty with vision, hearing aid use, assistive device use, number of medical conditions, current depression, current anxiety, and number of prescription medications) that were self-reported during the assessments for the parent study and whether participants accessed the BCM (yes/no). Aim 4 outcomes measured changes in the daily total number of episodes of urinary incontinence overall (total UI), stress urinary incontinence (stress UI), and urge urinary incontinence (urge UI), and changes in the IIQ-7. For each incontinent outcome, episodes/day was calculated at baseline and during the last BCM session completed by dividing the total number of episodes reported by the number of bladder diary days (maximum 7) for which each type of UI was recorded. The percent change in episodes was calculated using the following formula: % change in incontinence episodes (total UI, stress UI, and urge UI) = (episodes per day at baseline – episodes per day at last completed BCM session/episodes per day at baseline) × 100.
Data Analysis
Data were analyzed using IBM SPSS version 27 (IBM Corp. Armonk, NY) and Excel version 16.54 (Microsoft Corp, Redmond, WA). Data were screened for normality, missing variables, and outliers. A p-value of <0.05 was considered statistically significant. If participants repeated the BCM more than once, only data from their first completion of the module were included in our analyses.
Descriptive statistics, based on the distribution of the variables, were used to describe the overall sample as well as the subset of the sample for Aim 4. For Aim 1, the proportion of eligible participants who accessed and completed the BCM, and Aim 3, the proportion of participants who completed each session of the BCM, data were analyzed descriptively using frequencies and percentages. Participants were included in the analysis for Aim 3 if they completed at least one session of the BCM. To be included in analysis of change in incontinence episodes for Aim 4, participants needed to report at least one incontinent episode during session 2, complete at least 3 sessions of the BCM, and provide diary data in the last session completed. Data from participants who completed all 6 sessions were used to evaluate change in incontinence-specific quality of life.
For Aim 2 each demographic and clinical variable was collapsed into two categories due to the small sample size. Bivariate analysis was performed to examine the association between each variable and accessing the BCM. The Chi-square test was used to compare categorical variables. The Mann-Whitney U test was used to compare the two continuous variables, age and number of self-reported medical problems, as neither was normally distributed. A p-value of 0.20 was used to select among these variables to include in the multivariate analysis. Self-reported current depression was also included based on the finding of Burgio and coworkers5 that older adults who reported UI symptoms to a healthcare provider tended to have higher depression scores (p=0.06). Logistic regression was then performed to determine which characteristics were independently associated with accessing the BCM.
Since none of the incontinence variables for Aim 4 were normally distributed, the median and range were calculated to describe the percent change for each variable. The Wilcoxon signed-rank test was used to compare daily incontinent episodes for each type (total UI, stress UI, and urge UI) reported at baseline and during the last BCM session completed. For the same reason, the Wilcoxon signed rank test was performed to compare IIQ-7 scores from session 1 and session 6.
RESULTS
One hundred thirteen (46.7%) of the 242 participants from the parent study were eligible to receive the recommendation to complete the Bladder Control Module. Two participants were excluded due to being younger than 60 years of age. Thus, 111 (45.9%) of the 242 participants were eligible to be included in this secondary analysis. Their mean age was 72.8 years and most were female (n=95, 85.6%); 81 (75.7%) identified themselves as Caucasian. Thirty-eight (34.2%) were currently married or living with a significant other, and 57 (51.8%) lived alone. Eighteen (16.2%) assumed caregiving responsibility for another person. The sample was well-educated, as 79 (71.2%) had at least some college education, and the vast majority (n=81, 85.6%) were retired. More than half (n=60, 54.5%) reported difficulty paying for their basic needs (Table 1).
Table 1.
Sample characteristics (N=111)
| Characteristic | n | % |
|---|---|---|
| Age in years: mean (SD); median (range) | 72.8 (7.9); 72.0 (60–92) | |
| Female | 95 | 85.6 |
| Caucasian race | 81 | 75.7 |
| Currently married/living with significant other | 38 | 34.2 |
| Live alone | 57 | 51.8 |
| Caregiver for another person | 18 | 16.2 |
| Some college education | 79 | 71.2 |
| Retired | 95 | 85.6 |
| Somewhat or very difficult to pay for basic needs | 60 | 54.5 |
| Difficulty seeing (even with glasses/contacts) | 14 | 12.6 |
| Use a hearing aid | 23 | 20.7 |
| Use assistive device during ambulation | 19 | 17.3 |
| Number of self-reported medical problems: mean (SD); median (range) | 3.5 (2.1); 3.0 (0–12) | |
| Self-reported medical problems | ||
| Number of prescription medications taken on a regular basis | ||
Nearly all participants (109, 98.2%) reported health-related issues. Impaired vision and hearing aid and assistive device use were endorsed by 1 in 5 to 8 participants. Participants reported a mean of 3.5 medical problems, the most common were arthritis (n=87, 79.1%), hypertension (n=72, 64.9%), and dyslipidemia (n=47, 42.7%). The vast majority (n=102, 91.9%) reported taking prescription medications regularly, with 22 (19.8%) taking one or two, 40 (36.0%) taking three or four, and 40 (36.0%) taking five or more. Clinical characteristics, including the prevalence of medical problems such as depression and anxiety, reported by at least 10% of participants, are summarized in Table 1.
Aim 1. Proportion of Eligible Participants Who Accessed the Bladder Control Module
Seventy-six (68.5%) of the 111 eligible participants completed the “Consider the Bladder Control Module” and 65 (58.6%) indicated agreed to engage in the activities of the BCM. Sixty-one of these participants proceeded to access the BCM, comprising 55.0% of the eligible participants and 80.3% of those who completed the “Consider the Bladder Control Module.” Reasons for not agreeing to participate included lack of time, lack of bladder concerns or leaking, need for more information, and currently working on another kiosk module.
Aim 2. Associations between Participant Characteristics and Accessing the Bladder Control Module
Retirement status (p=0.04) was the only variable significantly related to accessing the BCM. Fifty-six retired participants (58.9%) accessed the BCM, as did 5 (31.3%) who were currently employed or actively engaged in volunteer activities. Anxiety was the other characteristic that met the threshold for inclusion in the multivariate analysis (p=0.20). Among 32 participants who reported anxiety, 40.6% (n=13) accessed the BCM and 59.4% (n=19) did not (p=0.07). Results of the bivariate analyses are presented in Table 2.
Table 2.
Characteristics of participants who did (n=61) or did not (n=50) access the Bladder Control Module
| Characteristic | Accessed BCM† | Did Not Access BCM | Test statistic p-value |
||
|---|---|---|---|---|---|
| n | % | n | % | ||
| Age in years, median (range) | 72.0 (60–92) | 73.0 (60–90) | U‡=1589.5 p=0.70 |
||
| Gender | |||||
| Race | |||||
| Married/living with significant other | |||||
| Household size | |||||
| Education | |||||
| Employment status | |||||
| Difficulties in paying for basic needs | |||||
| Serious difficulty seeing even with glasses or contact lenses | |||||
| Medical problems, median (range) | 3.0 (0–10) | 3.5 (1–12) | U=1389.5 p=0.42 |
||
| Current depression | |||||
| Current anxiety | |||||
| Usage of assisted devices | |||||
| Prescribed medicines | |||||
Bladder Control Module
Mann-Whitney U test
Current anxiety, employment status, and current depression were entered into the logistic regression model which included data for 106 participants; 5 participants’ data were excluded because of missing values for one or more of these 3 predictor variables. The model correctly classified 91% of participants who accessed the BCM, but only 43% of those who did not. Overall, 69% of participants were correctly classified (p<0.001), indicating that the model including these variables was significantly better than the null model. Being retired (OR=6.15, p=0.007; 95% CI 1.65–22.95) and reporting current depression (OR=7.88, p=0.007; 95% CI 1.76–35.37) were associated with increased odds of accessing the BCM. Reporting current anxiety reduced the odds of accessing the BCM (OR=0.10, p=0.001; CI 0.03–0.41).
Aim 3. Percentages of Participants Who Completed Each Session of the Bladder Control Module
Sixty-one of the eligible participants completed BCM session 1. Seven (11.5%) individuals only completed session 1. Among the remaining participants, 40 (74.1%) completed all 5 intervention sessions (no intervention was delivered during session 6, the “Bladder Control Checkpoint”), 2 (3.7%) completed 4 sessions, 3 (5.6%) completed 3 sessions, and 9 (16.7%) completed 2 sessions.
Aim 4. Changes in Incontinence Episodes and Incontinence-specific Quality of Life
Baseline incontinence-related characteristics for the 37 participants whose data were analyzed for this aim are summarized in Table 3. Twenty-five (67.6%) reported mixed UI, eleven (29.7%) reported urge UI only, and one (2.7%) reported stress UI only. Participants experienced a median of 2 incontinence episodes (range: 0–8) during waking hours and one during the night (range: 0–6). Seventeen (45.9%) reported incontinence episodes during both day and night. Sixteen (43.2%) used absorbent products during the day and 15 (40.5%) used them at night. The median number of voids was 5 during the day and 2 at night. On average, participants consumed 5 (range: 0–16) servings (glasses or cups) of non-caffeinated beverages and 2 (range: 0–10) servngs of caffeinated beverages per day. Five participants (13.5%) reported that they were doing pelvic floor muscle exercises at baseline, at which point the median score on the IIQ-7 was 9.6 (range: 0–76.2).
Table 3.
Incontinence-related characteristics of participants included in analyses for Aim 4 (n=37)
| Characteristic | n | % | Mean | SD | Median | Range |
|---|---|---|---|---|---|---|
| Type of urinary incontinence | ||||||
| Incontinent episodes | ||||||
| Absorbent products used | ||||||
| Daytime voids/day | 5.4 | 1.6 | 5.0 | 3–9 | ||
| Nocturia episodes/night | 2.1 | 1.6 | 2.0 | 0–5 | ||
| Cups (glasses) of caffeinated drinks/day | 2 | 1.9 | 2.0 | 0–10 | ||
| Cups (glasses) of non-caffeinated drinks/day | 5.0 | 2.9 | 5.0 | 0–16 | ||
| Incontinence-related quality of life (IIQ-7)† | 15.0 | 16.5 | 9.5 | 0–76.2 | ||
| Currently doing pelvic floor muscle exercises |
Incontinence Impact Questionnaire Short Form
Thirty-two of the 37 participants (86.5%) completed at least 3 BCM sessions. Although most (n=27, 84.4%) completed all five BCM intervention sessions, 3 (9.4%) completed only the first four sessions and 2 (6.3%) completed only the first three sessions. The median total UI episodes per day decreased from 2.1 at baseline to 1.4 at the last BCM session completed (p=0.01). There was a median 34.6% percent reduction in total UI episodes, with 14 participants (43.8%) reporting more than 50% improvement and 3 reporting no UI episodes at their last completed BCM session.
Seventeen (53.1%) of the 32 participants were eligible for inclusion in the analysis examining changes in stress UI. Among these participants, there was a median decrease from 1.6 to 0.6 episodes per day (p=0.02), resulting in a median reduction of 49.2% stress UI episodes. Eight participants (47.1%) reported more than 50% improvement and 4 reported no stress UI episodes at their last BCM session.
Among the 22 (68.8%) participants included in analysis of changes in urge UI, episodes per day improved from a median of 1.1 to 0.2 (p<0.001), with a median 61.8% decrease. Most participants (n=17, 77.3%) reported more than 50% improvement, and 5 participants (22.7%) reported no urge UI at their last BCM session.
Thirty-two participants (86.4%) completed the IIQ-7 during both session 1 and session 6, the “Bladder Control Checkpoint.” Among these participants there was a significant improvement in incontinence-related QoL, with the median IIQ-7 score decreasing from 9.5 to 4.8. At both time points there was wide variability in IIQ-7 scores (from 0 to 76.2). Findings in relation to Aim 4 outcomes are summarized in Table 4 and Table 5.
Table 4.
Outcomes: Incontinent episodes and incontinence-specific quality of life
| Outcome | n | Median | Range | p-value† |
|---|---|---|---|---|
| Total incontinent episodes/day | 32 | |||
| Stress incontinent episodes/day | 17 | |||
| Urge incontinent episodes/day | 22 | |||
| IIQ-7* score | 32 |
Wilcoxon Signed Rank test
Bladder Control Module
Incontinence Impact Questionnaire Short Form
Table 5.
Reduction in incontinent episodes from baseline to last completed BCM† session (n=32)
| Type of Episode | n | Median | Range | >50% improvement | Cured‡ | |
|---|---|---|---|---|---|---|
| % | % | n | % | n | ||
| All incontinent episodes | 32 | 34.6 | −441.8–100.0 | 14 | 43.7 | 3 |
| Stress incontinent episodes | 12 | 49.3 | −133.3–100.0 | 8 | 47.1 | 4 |
| Urge incontinent episodes | 22 | 61.8 | −12.5–100.0 | 17 | 77.3 | 5 |
Bladder Control Module
No incontinence episodes reported at the last completed BCM session
DISCUSSION
Findings from this secondary analysis suggest that older adults with UI can self-administer and benefit from a bladder control self-management program offered via a community-based, multi-user health kiosk. Statistically significant and clinically meaningful reductions in incontinence episodes and improvement in incontinence-related quality of life were found among participants of the Health Kiosk Project who reported UI and completed at least 3 intervention sessions of the Bladder Control Module. These findings suggest that enabling older adults with UI to adopt conservative behavioral strategies aimed at mitigating their symptoms, whether due to stress, urge, or mixed incontinence, can be accomplished without face-to-face interaction with a clinician.
Nearly 7 in 10 participants (68.5%) eligible to receive the recommendation to consider engaging with the BCM actually did so. Similar rates were observed for completing at least one BCM session (80%) and all five intervention sessions (74%). Although these levels are encouraging, two steps among the study activities for the Health Kiosk Project likely contributed to attrition in relation to our bladder control self-management program. In addition to self-administering surveys at the kiosk, participants had to meet with a member of our team for the performance-based portion of their assessments before they could view the brief “Recommendations” module followed by “Consider the Bladder Control Module.” Only after taking these steps and agreeing to do the BCM could they access it.
Depression was associated with higher odds of accessing the BCM, whereas anxiety lowered the likelihood of kiosk use. Although studies examining characteristics associated with UI have reported higher rates of depression and anxiety among individuals with UI than those without UI,6 we have identified only two studies that examined these conditions in relation to treatment-seeking for UI. Burgio and coworkers5 found that older adults seeking treatment for UI tended to have higher depression scores, which aligns with our findings. However, inconsistent with our findings is the work of Waetjen and colleagues22 who reprted no association between anxiety and seeking treatment for UI. Reasons for this inconsistency may be differences in how anxiety was measured or in the age of participants in the two studies. Waetjen and colleagues22 measured anxiety as the number of years with anxiety, while our participants were asked about current anxiety. All participants in our study were 60 years of age or older, with a mean age of 73.2 years. In contrast, Waetjen’s group22 enrolled middle-aged women between 42 and 52 years of age. Among studies that have examined self-management interventions for UI, only one examined characteristics associated with accessing the program. Bokne and colleagues4 compared the age and education level of those who signed up and completed their internet-based, self-management program to those who signed up but did not complete the program. They reported no significant differences, which is consistent with our findings.
We were not surprised to find that retired participants were significantly more likely to access the BCM than those who were currently working or engaged in regular volunteer activities. Although we could locate no other studies that examined employment status in relation to treatment-seeking for UI, this finding makes intuitive sense because our kiosks were located in settings where older adults live or are known to frequent, and retirement conceivably would allow more time to visit the kiosk.
Showing participants how to perform pelvic floor muscle exercises and bladder retraining techniques, encouraging them to monitor their performance of these techniques at home, and providing visual feedback depicting the trend of the UI data they had entered at the kiosk resulted in participants experiencing, on average, one-third fewer urinary incontinence episodes overall on a daily basis. It yielded even greater reductions (approximately 50% to 60%) in daily episodes of stress UI and urge UI, respectively. These findings are with other studies evaluating e-health delivered UI interventions,2,3,19 even though different measurement instruments were used across studies. Ae measured UI via findings from a 7-day bladder diary; in contrast, the three comparison studies used the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form, a self-report questionnaire.2,3,19
The significant improvement in incontinence-related QoL we observed is in line with results reported by Asklaud and colleagues2 who measured incontinence-specific QoL using the International Consultation on Incontinence Questionnaire Female Lower Urinary Tract Symptoms Modules. Although median IIQ-7 scores in this secondary analysis suggest that UI did not have a large impact on participants’ QoL, the range of pre- and post-BCM scores was large (from 0 to 76.2 out of 100). This variability suggests that while UI made little perceptible impact on some participants’ lives, it was considered highly intrusive by others.
Limitations
Several limitations exist in this study due to the methods implemented in the Health Kiosk Project and the nature of secondary analysis. Participants in the parent study were recruited via convenience sampling, which limit the generalizability of our findings to individuals with characteristics similar to those of our participants. Because we relied upon data collected to achieve the aims of the parent study, data pertaining to participants’ continence history were not collected until BCM session 1. Thus, comparison of continence characteristics between those who did and did not access the BCM could not be performed. Because we performed a secondary analysis with anonymized data, we were not able to follow up with participants to learn why some chose not to access the module at all or did not complete all sessions of the module.
The BCM protocol included no face-to-face contact with the Health Kiosk Project team, and feedback regarding the bladder diary data participants entered at the kiosk was limited to graphed data displays presented on the kiosk screen. As a result, there was no opportunity to clarify missing data or inconsistencies evident in continence history or diary data. As is true of all self-report measures, using a bladder diary to measure incontinence may introduce reporting bias. Finally, the single group, pre-post quasi-experimental design of the BCM, as implemented in the parent study, limited our ability to make causal inferences about the effect of the BCM on UI and incontinence-specific quality of life. Without a control group and randomization of participants to either the BCM or a control condition, we cannot rule out other potential explanations for our findings.
Despite these limitations, this study had a number of strengths. This is the first study focused on delivering a bladder control self-management program through a multi-user health kiosk available to community-dwelling older adults who were not actively seeking medical treatment for UI. Unlike previous studies that primarily focused on younger individuals, particularly women, this study included both male and female participants. The array of settings where kiosks were deployed for the parent study provided us with data from a diverse sample that included older adults who typically have less opportunity or limited access to user-friendly technologies and self-help health resources to monitor and manage their UI-related behaviors.
Future Research
Additional research with a larger sample is needed to confirm the effectiveness of the BCM in reducing UI and improving incontinence-specific QoL among community-dwelling older adults. Whether delivered through a multi-user health kiosk or modified for delivery through a phone app or website, future studies should include a comparison control group and randomly assign participants to intervention conditions, to elucidate the causal relationship between the self-management approach and urinary incontinence outcomes of interest. A larger sample would also permit examination of variables that predict the response to the intervention. Benefit could also accrue from eliciting the perspective of participants who self-administer technology-enabled bladder control self-management programs, to better understand what motivates them to initiate and sustain their use or to opt out at the outset or short of completion. This knowledge could inform development of procedures to increase utilization of these programs.
CONCLUSIONS
Our findings suggest that delivering a self-management program such as the Bladder Control Module through a community-based, multi-user health kiosk to older adults with UI is feasible. This delivery method provided access to conservative behavioral interventions that have previously been shown to improve urinary incontinence and incontinence-related quality of life, though without the need for face-to-face interaction with a clinician. Such an e-health application has the potential to reach and benefit community-residing older adults who endure UI symptoms due to social stigma or lack of resources and information, giving them strategies to reduce or eliminate the incontinence episodes that intrude upon their daily life.
Acknowledgment
This project was funded under grant number 5R01HS022889 from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services (HHS). The authors are solely responsible for this document’s contents, findings, and conclusions, which do not necessarily represent the views of AHRQ. Readers should not interpret any statement in this report as an official position of AHRQ or of HHS. None of the authors has any affiliation or financial involvement that conflicts with the material presented in this report.
Contributor Information
Yuchen Zhang, School of Nursing, University of Pittsburgh, Pittsburgh, PA.
Sandra Engberg, School of Nursing, University of Pittsburgh, Pittsburgh, PA.
Karen L. Courtney, School of Health Information Science, University of Victoria, British Columbia, Canada.
Jacob K. Kariuki, School of Nursing, University of Pittsburgh, Pittsburgh, PA.
Judith Tabolt Matthews, University Center for Social and Urban Research, University of Pittsburgh, Pittsburgh, PA.
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