A survey of urinary incontinence and health literacy among female rehabilitation professional therapists

Abstract

[Purpose] The aim of the study was to determine the prevalence of urinary incontinence, background factors, general health literacy, and knowledge of urinary incontinence among female rehabilitation professionals. [Participants and Methods] We conducted an anonymous online survey of 73 female rehabilitation professionals who worked in a general hospital. The survey collected data on demographics, number of urinations, incontinence-related disorders, and childbirth history. Moreover, the severity of urinary incontinence, urinary incontinence-related quality of life, and general health literacy were assessed. [Results] Urinary incontinence was reported by 49.3% participants. Those with urinary incontinence were older, had a higher number of births, and reported higher rates of vaginal delivery and perineal incision than those without urinary incontinence. One item of the quality of life that was related to urinary incontinence, “personal relationships”, was influenced by the frequency of micturition while the other items were related to the severity of urinary incontinence. [Conclusion] Female rehabilitation professionals have a higher prevalence of urinary incontinence than women in general population as shown in previous studies (Onishi, 2023). Therefore, it is important to understand the work characteristics that predispose individuals to urinary incontinence and to create a toilet-friendly workplace environment.

INTRODUCTION

Urinary incontinence is considered a problem significant health issue among females, and the prevalence of urinary incontinence is reported to be 25.5% in Japanese females, and 15% for younger females in particular¹⁾. Therefore, addressing urinary incontinence is an important concern for females of all ages.

Urinary incontinence is caused by various factors including, aging, pregnancy, and childbirth^2,3,4,5,6,7), obesity⁸⁾, and low back pain¹⁾. Additionally, occupational factors may contribute to its development. The risk of urinary incontinence is likely higher in rehabilitation professionals. Many female rehabilitation professionals return to work after childbirth⁹⁾, many of whom have weakened pelvic floor muscles after childbirth and complain of urinary incontinence due to factors such as a work environment in which it is difficult to go to the toilet at the right time, in addition to a work content that increases abdominal pressure and increases the risk of back pain due to patient care activities, etc. The inability to use the toilet at the appropriate time further exacerbates the problem.

Urinary incontinence interferes with physical activity and impacts social life¹⁰⁾. In addition, it has been reported that urinary incontinence causes social stress and significantly reduces the quality of life (QOL) by limiting the ability to go out and interact with others¹¹⁾. However, only 6% of patients seek medical care for postpartum urinary incontinence¹²⁾. Despite its effects on social life and quality of life, urinary incontinence remains a sensitive issue, and many patients may feel unable to discuss it or seek medical help.

Rehabilitation professionals, who regularly provide education and guidance to patients, are expected to have a high level of health literacy. They should be capable of obtaining, understanding, and applying information to improve symptoms of urinary incontinence. However, the relationship between health literacy and knowledge about urinary incontinence remains clear. Most studies on the prevalence of urinary incontinence have focused on the elderly, and there is a lack of research regarding individuals under the age of 65, particularly those in the workforce. Additionally, women working in rehabilitation professions are considered to be at higher risk for urinary incontinence, but the extent of this risk is not well understood. While rehabilitation professionals are generally assumed to have higher health literacy than other groups, it is unclear how much information they have about urinary incontinence.

The purpose of this study was to determine the prevalence of urinary incontinence and its associated factors, as well as the general health literacy and knowledge of urinary incontinence among female rehabilitation professionals. Information on the prevalence of urinary incontinence and health literacy regarding urinary incontinence among rehabilitation professionals would be useful for workplace management in healthcare organizations with many females. This could contribute to creating a more comfortable and supportive working environment for women.

PARTICIPANTS AND METHODS

This cross-sectional observational study used an anonymous web-based questionnaire. The study period was from September to October 2024. The participants were female rehabilitation professionals in general hospitals. The targeted rehabilitation professions were physical therapists, occupational therapists, and speech therapists. At the beginning of the questionnaire, it was clearly stated that personal privacy was guaranteed and that the survey results would not be used for any purpose other than research. The survey was promoted through posters presenting the purpose of the study, research methods, and QR codes for responses. The posters were displayed at the study facilities. This study was approved by the Ethics Review Committee of the International University of Health and Welfare (24-TA-015).

The questionnaire comprised a combination of open-ended questions. Questions included age, occupation, height, weight, pregnancy, frequency of toilet use during the day and night on workdays and holidays, history of urological or gynecological disease, lower back pain, hip pain, menstrual cycle (number of cycle days or menopause), and whether the female had ever given birth. In addition, information on the number of births, mode of delivery (vaginal, instrumental, or cesarean), presence or absence of peritectomy or perineal tear, birth weight, birth height, and head circumference was obtained from the participants who had given birth.

The International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF)¹³⁾ was used to investigate the degree of urinary incontinence symptoms, including quality of life (QOL). The score ranges from 0 to 21, with higher scores indicating more severe urinary incontinence symptoms and a greater impact on quality of life. The total score was calculated for the three items, excluding the self-assessment item. Patients were classified into four severity categories: 0, no urinary incontinence; 1 to 5, mild urinary incontinence; 6 to 12, moderate incontinence; and 12 to 21, severe incontinence. Respondents who selected “leaks when coughing or sneezing” or “leaks during physical activity or exercise” for the self-diagnostic question on urinary incontinence subtypes were classified as having abdominal pressure incontinence, while those who selected “leaks before getting to the toilet” were classified as having urge incontinence. Responses to the symptoms of both abdominal pressure and urge incontinence were classified as mixed incontinence. All other responses were classified as other urinary incontinence¹⁾. Participants who had experienced urinary incontinence were asked to freely describe any movement, posture, or situation that concerned them during their work.

QOL assessment for dysuria was performed using the King’s Health Questionnaire Japanese version (KHQ), a quality-of-life scale specific to dysuria. Respondents were asked to answer 21 questions regarding the extent to which urinary problems affected their daily lives. They were evaluated in nine domains “general health perceptions”, “incontinence impact”, “role limitations”, “physical limitations”, “social limitations”, “personal relationships”, “emotions”, “sleep and energy” and “severity measures” scored from 0 to 100 according to the score calculation method for each domain. Higher scores indicated more severe QOL impairment.

The European Health Literacy Survey Questionnaire Japanese version (HLS-EU-Q47)¹⁴⁾ was used as the health literacy assessment tool. The HLS-EU-Q47 uses Sorensen’s conceptual model of comprehensive health literacy, which consists of three domains (health care, disease prevention, and health promotion) and four competencies (acquisition, understanding, evaluation, and utilization). There were 47 questions, and the responses were on a 5-point Likert scale: “1. very easy”, “2. somewhat easy”, “3. somewhat difficult”, “4. very difficult”, and “5. don’t know/not applicable”. The scores were scored on a four-point scale from “very difficult” (1 point) to “very easy” (4 points), with “don’t know/not applicable” responses being considered missing values. Standardized scores ranging from 0 to 50 points were calculated using the formula “(mean −1) × (50/3)” for overall health literacy, which consists of all items, and for the three domain-specific health literacy (health care, disease prevention, and health promotion)¹⁵⁾.

The analyses in this study were as follows: (1) The prevalence of urinary incontinence and the percentage of urinary incontinence types and severity were calculated from the ICIQ-SF scores. (2) Comparison of characteristics between people with and without urinary incontinence. Age, years of experience, BMI, and KHQ scores for each UI domain for urinary incontinence were analyzed using a t-test. Toilet frequency, ICIQ-SF scores, urinary incontinence literacy, and number of births were examined using the Mann–Whitney test. Comparisons were made using the χ² test for the presence or absence of gynecological disease, back pain, hip pain, mode of delivery, and perineotomy. (3) To determine the health literacy characteristics of female rehabilitation professionals, HLS-EU -Q47 scores were compared with those of previous studies. In addition, the HLS-EU-Q47 scores for each region according to the presence or absence of urinary incontinence were compared using an unpaired t-test. (4) To examine factors affecting urinary incontinence-related quality of life, multiple regression analysis (stepwise method) was performed using KHQ scores in each domain as the dependent variable and factors that differed significantly by urinary incontinence status as independent variables. All analyses were performed using SPSS ver. 25.

RESULTS

Data from the questionnaire were obtained from 73 participants (mean age: 32.4 ± 8.7 years) (valid response rate: 96.1%). Thirty-six participants reported having urinary incontinence symptoms, with a prevalence of 49.3%. The severity of urinary incontinence was mild in 24 patients (77.4%) and moderate in 7 patients (22.6%). The most common type of urinary incontinence was abdominal pressure incontinence, affecting 20 patients (64.5%), followed by urge incontinence and mixed incontinence, both affecting 5 patients (16.1%) each. Regarding the movements and timing of urine leakage during work, the largest number of respondents (10, 25%) were concerned about leakage during sneezing, while 12 (30%) were concerned during movement training such as standing up, standing assistance, and walking assistance, and 8 (20%) were concerned when they were too busy to go to the restroom.

Table 1 shows a comparison with and without urinary incontinence. The group with urinary incontinence was significantly older (t=2.6), had more frequent deliveries (U=435.5), and had a higher rate of vaginal delivery (χ²=11.0) and peritectomy (χ²=8.5) than the group without (all p<0.05). In addition, the group with urinary incontinence used the toilet significantly more frequently during the day on workdays (U=482.5) and holidays (U=471.5) than the group without (p<0.05). Both groups with (Z=−4.4) and without (Z=−4.4) urinary incontinence used the toilet significantly less frequently during the workday than on holidays (p<0.05).

Table 1. Comparison of characteristics with and without urinary incontinence.

	Urinary incontinence group	No urinary incontinence group	p-value
	(n=36)	(n=37)
Age (years)	35.0 ± 9.4	29.8 ± 7.2	*
Years of experience (years)	11.6 ± 8.6	8.1 ± 7.1
Occupation (n)	Physical therapist: 23	Physical therapist: 30
	Occupational therapist: 9	Occupational therapist: 4
	Speech therapist: 4	Speech therapist: 3
Body mass index (kg/m2)	21.5 ± 3.2	20.8 ± 2.3
Gynecological diseases (n)
Yes	10	9
No	26	28
History of lower back pain (n)
Yes	14	14
No	22	23
History of hip pain (n)
Yes	3	6
No	33	31
Number of births (n)	1 [0–3]	0 [0–3]	**
Birth control (n)
Vaginal delivery	14	4	*
Instrumental delivery	2	1
Imperial cutting	3	1
Perineal incision (n)
Yes	16	5	**
No	20	32
Toilet frequency During the work day (n)	3.3 ± 1.1†	2.7 ± 1.6†	*
Toilet frequency Nighttime on workdays (n)	0.9 ± 2.1	1.1 ± 2.3
Toilet frequency During the day on holidays (n)	4.8 ± 1.4†	4.1 ± 1.5†	*
Toilet frequency holiday nights (n)	0.6 ± 1.3	0.9 ± 2.0
Urinary incontinence literacy (score)	6 [3–12]	6 [3–12]
Experience with pelvic floor muscle training (n)
Yes	30	17	**
No	6	20
KHQ score
General health perception	36.1 ± 18.3	35.1 ± 18.1
Incontinence impact	17.6 ± 21.8	3.6 ± 10.5	**
Role limitations	6.5 ± 12.1	0.9 ± 3.8	*
Physical limitations	12.0 ± 15.7	0.9 ± 5.5	**
Social limitations	3.7 ± 7.0	0.6 ± 3.7	*
Personal relationship	2.9 ± 10.0	0.0 ± 0.0
Emotions	13.9 ± 19.2	0.3 ± 1.8	**
Sleep and energy	6.9 ± 10.8	0.5 ± 2.7	**
Severity measures	12.6 ± 12.5	4.5 ± 7.0	**

Mean ± SD. Median [range].

**p<0.01, *p<0.05.

Urinary incontinence group vs. No urinary incontinence group.

^†p<0.05.

Work day vs. Day on holiday.

KHQ: the King’s Health Questionnaire Japanese version.

In the KHQ assessment, the group with urinary incontinence scored significantly higher than the group without urinary incontinence in all domains except “general health perceptions” and “personal relationships” (p<0.05). There was no significant difference between the two groups in HLS-EU-Q47 and urinary incontinence literacy (p>0.05).

In a multiple regression analysis conducted to examine the factors that influence the results of the KHQ evaluation, the number of bathroom visits during the day on holidays (β=0.32) was extracted for the “personal relationships” domain (R²=0.09, p<0.05), and the ICIQ-SF for the other domains.

DISCUSSION

In this study, 49.3% of female rehabilitation professionals reported experiencing urinary incontinence. This result was found to be higher than that in young and middle-aged Japanese participants (25.5%)¹⁾. This result is striking and underscores the relevance of urinary incontinence as a pressing female health issue, as the prevalence of complaints in female rehabilitation occupations was approximately twice as high as in surveys of females in general. In a previous study of similarly aged nurses, the prevalence of urinary incontinence was 29.7%. Seventy percent of nurses had mild urinary incontinence and 88.7% had abdominal pressure incontinence⁷⁾. Nurses also have a high incidence of urinary incontinence due to abdominal pressure during position changes; however, the prevalence of urinary incontinence among the participants in this study was higher than that among nurses.

Regarding the specific symptoms of urinary incontinence, 64% of respondents reported abdominal pressure incontinence, likely linked to the nature of their work, which includes movements that elevate abdominal pressure, along with situations where unexpected force is applied as patients are assisted with mobility. Additionally, the work environment, where access to restrooms may be limited, could exacerbate these issues, contributing to the higher prevalence of urinary incontinence in this population. The characteristics of the participants with urinary incontinence, included age, number of births, vaginal delivery, and perineal incision, as in previous studies, and these results were like those in previous studies¹¹⁾. Childbirth, vaginal delivery, and perineotomy are thought to lead to the weakening of connective tissues such as pelvic floor muscles, which may induce urinary incontinence^{1,2,3,4,5,6,7)}. In addition to these structural weaknesses, female rehabilitation professionals are often involved in activities that increase abdominal pressure and make it difficult for them to go to the toilet, making their symptoms even more severe. The urinary incontinence complainants were found to use the toilet more frequently during the day off, but significantly less frequently on workdays, suggesting that it is essential to create an environment in which it is easy to go to the toilet. For example, the work schedule could be managed so that workers can easily go to the restroom without holding back. It would also be desirable to build more women’s restrooms.

Health literacy scores did not significantly differ between people with and without urinary incontinence. As the participants of this study were rehabilitation professionals, they showed higher values in the “general health literacy”, “health care domain”, and “disease prevention domain” than in previous studies of the Japanese public. These results suggest that female rehabilitation professionals, regardless of whether they had urinary incontinence or not, have a high level of health literacy and therefore could access and use information about their urinary incontinence problems. Therefore, it is important to educate rehabilitation professionals about information and measures to prevent and improve urinary incontinence before and after its onset. Young and pre-pregnant employees should be informed about the likelihood of urinary incontinence due to life stage changes, especially after childbirth. Posters and workshops may be used for these purposes. Additionally, prevention and improvement methods, such as pelvic floor muscle training, should be introduced.

In addition, the severity of urinary incontinence symptoms affected most of the QOL measures. The results for “personal relationships” showed that the higher the frequency of toilet use during the daytime on days off, the lower the QOL, indicating a negative impact on private time as well. The results indicate that prevention and improvement of urinary incontinence symptoms are important to maintain and improve female work-life balance.

In conclusion, this study emphasizes that female rehabilitation professionals are at increased risk for urinary incontinence due to their work environment and job demands. It is essential to promote workplace policies that improve restroom access and to provide education on pelvic floor muscle exercises and other preventive measures. These steps are critical for reducing urinary incontinence symptoms and improving the overall well-being and work-life balance of these professionals.

The findings of this study will be useful in managing physical therapy workplaces. This study revealed that the risk of urinary incontinence is higher among rehabilitation professionals following life stage changes, such as aging and childbirth. It is necessary to educate younger and pre-pregnant women about urinary incontinence and the importance of pelvic floor muscle training for prevention and symptom improvement. These initiatives will improve the quality of life, productivity, and long-term employment of female rehabilitation professionals.

This study had two main limitations. First, the number of participants was too small to analyze multiple groups. Furthermore, the study was not able to provide a comprehensive understanding of the impact of urinary incontinence on work. This is because it was a random questionnaire survey, and it was not possible to obtain detailed information about the participants’ job descriptions.

Conflict of interest

The authors declare no conflict of interest.