Help-seeking behavior among women currently leaking urine in Nigeria: is it any different from the rest of the world?

Abstract

Objective

We examined help-seeking behaviors and factors influencing their choice of hospital care in women currently leaking urine.

Materials and methods

This study was part of a multistage community survey conducted among 5001 women in Nigeria who participated in the Ibadan Urinary Incontinence Household Survey. Help-seeking behavior was analyzed among 139 respondents currently leaking urine within the population surveyed.

Results

The mean age of those currently leaking urine was 35.7 years (standard deviation = 15.8). Only 18 (12.9%) had ever sought help, of which 15 had received hospital care. Logistic regression analysis showed that the odds of seeking hospital care was higher among less educated women (odds ratio [OR] = 4.05, 95% confidence interval [CI]: 1.17–13.89) and among those with severe incontinence (OR = 4.20, 95% CI: 1.24–14.29). Reasons mentioned for not seeking hospital care include a belief that the condition is not life-threatening (51.2%), do not believe there is treatment (18.2%), lack of funds (1.7%), too shy to disclose (2.5%), afraid of complications (1.7%), other (2.5%), and no reason (22.3%).

Conclusion

This study shows that very few women, currently experiencing urinary incontinence have sought medical care (approximately 1 in 10); and that the barriers identified are similar to those identified in previous studies, except that these women lack the necessary funds to seek care.

Introduction

Lower urinary tract symptoms are a global health issue, particularly amongst women. This is supported by epidemiological data from both facility and community settings.^1,2 The International Incontinence Society recently defined urinary incontinence (UI) as “any form of urine leakage” so as to include the entire population of individuals who have either complained or are currently having urine leakage.^1,3 Subtle differences in the working research definition of UI used in various studies have accounted for the wide reported range of UI prevalence.^1,2 Recently, a study of an African community was published by Ojengbede et al which revealed that 7.2% of women experienced urinary leakage at some point in their lives, while 2.8% were currently leaking urine, with stress-associated UI being the most common type.⁴

Women’s medical help-seeking behavior is influenced by several factors, including the general understanding and interpretation of the disease itself, type and severity of the medical condition, available information regarding treatment opportunities, economic reasons, and the type of health care financing system that operates in such health care settings.^5–8 Furthermore, the prevailing sociocultural views of a particular medical condition could either be enabling or inhibiting to seeking help by the sufferer.^7,9 Previous studies have also revealed that associated or causal factors of health-seeking behaviors of women and men are largely dependent on their specific cultural and national differences, irrespective of other competing factors.^10,11 For instance, a wide disparity in the reasons for seeking help exist among women in Western countries compared to their counterparts with similar morbidities has been noted in the Middle East.^12,13 This suggests that the reasons behind women’s help-seeking behaviors may not apply to African women because of the different sociocultural perceptions of UI as morbidity.

Previous studies have shown that women with UI manifest their help-seeking behaviors in a different manner than women with other medical morbidities.^6,8 Reasons for such behavior include fear of surgery; embarrassment or humiliation;¹⁴ lack of knowledge; apathy of health care workers; lack of convincing information and assurance that their health problem can be resolved; beliefs that the condition is not life-threatening, but rather is a normal part of aging process; failure of previous treatment; and impact on quality of life, among others.^15,16 Predictors for help-seeking behaviors by women complaining of UI include education level, severity of symptoms, and the impact of symptoms.^16,17 However, the influence of age as an independent predictor varies. Yu et al¹⁸ found no age-related association with help-seeking behaviors, but Hannestad et al¹⁹ reported increasing age as positive predictor of seeking treatment.

While knowledge regarding help-seeking behaviors amongst women is advancing and has recently been better characterized, there appears to be lack of information from sub-Saharan Africa (SSA) on this topic. Research regarding help-seeking behavior in this environment is necessary because there are some behaviors that may be peculiar or specific to this setting. Factors influencing help-seeking behaviors may include availability of specialists, ‘out of pocket’ health care financing, sociocultural taboos, poor access to quality service, and popularity of traditional medicine practice. Additionally, poverty, ignorance, and disease are still prevalent in this region. The combination of these factors has placed women from SSA on a different level than their peers in the developed world regarding behavioral adaptations and response to help-seeking among women with UI.

Thus, this study aims to identify help-seeking behaviors among women who are currently experiencing UI in the SSA community, while discussing the factors that influence access to hospital care services. We also describe the potential reasons why women with UI may not wish to seek help.

Materials and methods

The current study took place to investigate UI patterns among women in the city of Ibadan, Oyo, the third most populated city in Nigeria, and the largest city in terms of geographical area.⁴ According to the 2006 census, the population count in Ibadan is 25,550,593 and includes 11 local government areas. The Ibadan Household Urinary Incontinence survey was a large-scale community survey that included women aged 15 years and older residing in both rural and urban areas to collect data such as birth history, knowledge and history of urine leakage, and women’s access to care and support.

A three-stage stratified cluster multistage sampling method was used for this study. The sample was drawn from a sampling frame of all rural and urban localities in the city. The first stage of selection involved stratifying local government areas (LGA) in Ibadan into rural and urban areas as classified by the National Population Commission, and subsequently selecting two samples from each stratum. Stage 2 involved selecting enumeration areas within localities, while Stage 3 involved selecting households and individual respondents. All regions in each local government area were stratified into rural and urban localities, with settlements of less than 20,000 inhabitants classified as semi-urban. The household response rate was 95.7%, while the individual response rate was 98.9%.

Ethical approval was obtained from the Oyo state Ethical Review Committee. Oral informed consent was obtained from each respondent before questionnaire administration. When a respondent chose not to participate, the questionnaire was returned as a refusal.

An interviewer-administered questionnaire was used to obtain information regarding respondents’ sociodemographic characteristics, obstetric and gynecological history, history of UI, and associated symptomatology. The questionnaire, written in the English language, was translated into the local language of Yoruba and back-translated to English. This investigation examining help-seeking behavior involved questions regarding history of UI, care, and support. UI in this study was defined as involuntary urine leakage as reported by the participant. Women were asked the following questions: ‘Have you ever leaked urine?’ and ‘Are you currently leaking urine?’ ‘Currently leaking urine’ meant leakage of urine within 1 month before the interview. Women who answered ‘yes’ to the question pertaining to current urine leakage were then asked the following questions: ‘Have you ever sought help for the leakage of urine?’ ‘If yes, where did you seek treatment,’ and ‘What treatment was given to you?’ Women who reported that they never sought help were asked the following question: ‘What was the reason that you did not receive any care?’ Severity of UI was based on reported symptom frequency as categorized by Minassian et al.²⁰ Severe UI was defined as a daily occurrence of symptoms or presence of symptoms lasting up to few days a week. Moderate UI was defined as symptoms occurring a few times per month, and mild was occurrence of symptoms a few times per year.

Questionnaires were edited daily by the field supervisors and also by investigators. Data were entered using Epidata software (Epidata, Odense, Denmark) that ensured that skip patterns and other data entry checks could be used. Subsequently, data were processed and exported into SPSS software (v 15; SPSS Inc, Chicago, IL) for analysis. Summary statistics, such as means, frequencies, and proportions, were used to summarize variables. Chi square tests were used to identify associations between categorical variables. Logistic regression analysis was conducted to determine significant predictors of outcomes. A total of 95% confidence intervals (CI) were reported for estimates.

Results

A total of 139 women reported that they were currently leaking urine. The mean age of the women was 35.7 years (standard deviation [SD] = 15.8), ranging in age from 15–85 years. Approximately half (51.1%) of the women were aged 20–39 years. Currently married women accounted for the highest proportion (N = 95, 69.3%), followed by single/never married (N = 30, 21.6%), and separated/divorced (N = 14, 10.1%). The number of women from rural and urban locations was 58 (41.7%) and 81 (58.3%), respectively. The number of nulliparous women was 32 (23%), while 14 (10.1%) had a parity of 1, 57 (41%) had 2–4, and 36 (25.9%) had five or more children. Over half (52.5%) of the women had completed secondary education, while 18.7% of the women had primary or secondary education, and 10.1% had no formal education.

Eighteen (12.9%) women had sought help for urine leakage, 15 (10.8%) had sought help from hospitals, and 3 (2.2%) had sought help from mission homes or religious organizations. The only treatment modality reported being used by the women was medication. In one case, a woman visited a hospital and was told that the condition was normal.

Table 1 shows the associations between women’s help-seeking behavior as it pertains to UI and associated characteristics of these women. According to bivariate analysis, significant associations were observed between help-seeking behaviors and both age (P = 0.047) and education (P = 0.005). A higher proportion of older women and those with lower education were more likely to seek care. There were no significant associations between stress (P = 0.533), urge (P = 0.471), or mixed incontinence (P = 0.670). However, a significantly higher proportion of those with severe incontinence sought care when compared with milder forms of UI (P = 0.014). According to logistic regression analysis, the odds of seeking hospital care were higher among women with lower education when compared to those with higher education (OR = 4.05, 95% CI: 1.17–13.89) and among those with severe incontinence (OR = 4.20, 95% CI: 1.24–14.29).

Table 1.

Relationship between seeking hospital care and variables

Variable (N)	Bivariate analysis		Logistic regression
	Sought hospital care	Chi square (P-value)	Odds ratio	95% CI
Location
Rural (58)	5 (8.6)	0.487 (0.485)
Urban (81)	10 (12.3)
Age (years)
<40 (88)	6 (6.8)	3.933 (0.047)	0.60	0.18–2.05
≥40 (51)	9 (17.6)
Education
Primary or less (40)	9 (22.5)	7.998 (0.005)	4.05	1.17–13.89
Secondary or higher (99)	6 (6.1)
Stress incontinence
Yes (102)	10 (9.8)	0.388 (0.533)
No (37)	5 (13.5)
Urge incontinence
Yes (53)	7 (13.2)	0.519 (0.471)
No (86)	8 (9.3)
Mixed incontinence
Yes (24)	2 (8.3)	0.182 (0.670)
No (115)	13 (11.3)
Severe incontinence
Yes (24)	6 (25.0)	6.083 (0.014)	4.20	1.24–14.29
No (115)	9 (7.8)

Notes: The values in bold are statistically significant odds ratios and confidence intervals.

Abbreviations: N, number; CI, confidence interval; OR, odds ratio.

Among the 121 women who had never sought care, reasons for not seeking care are shown in Table 2. There were 62 (51.2%) women who felt the condition was normal or non-life-threatening, and 22 (18.2%) who did not believe that treatment was necessary. Other reasons given included being too shy to seek health care services (3 women, 2.5%), not having the funds to access health care (2, 1.7%), being scared of complications during treatment (2, 1.7%). Twenty-seven women (22.3%) did not provide a reason for not seeking treatment.

Table 2.

Distribution of reasons for not seeking care

Reason	Frequency	Percentage (N = 121)
Condition is not life-threatening	62	51.2
Do not believe that treatment is available	22	18.2
Lack of funds	2	1.7
Too shy to disclose the condition	3	2.5
Afraid of complications during treatment	2	1.7
Others	3	2.5
No reason	27	22.3

Abbreviation: N, number.

Discussion

In this study, it was found that only 12.9% of women have sought any form of help for UI in SSA, while 10.8% had consulted medical personnel. Other studies that have reported that approximately 20% to 50% of women seek help for UI.¹⁶ A plausible reason for the lower rate found in the present study is that our study design was limited to the women who were currently leaking, while other studies included any women who had experienced leakage at any point during their lives.^12,16 Second, the low rate reported in this study may simply be a general reflection of the low rate of women’s help-seeking behaviors, particularly as it pertains to accessing medical services in SSA – a perspective that also accounts for the high maternal mortality rate in this region.^21,22 Interestingly, a handful of participants in this study sought spiritual assistance for their morbidity. Studies have shown that Nigerian women consult spiritualists and herbalists for their medical problems, a practice that has been documented for other morbidities.^21,23 Often, these women suffer complications during the process of utilizing these unorthodox treatments, which sometimes results in mortality. It is also important to note that a health worker can reassure a patient that UI is a normal condition. A single participant shared this experience, which reflects the general perception of end-users of medical service. Poor professional knowledge can have catastrophic consequences that may limit opportunities for cure afterwards.

The practice of help-seeking in the hospital among women currently leaking urine is associated with education level and UI severity. A strong association of UI severity and help-seeking behaviors was observed in this study as well as in other studies.¹⁶ In contrast to other studies, this study shows that women with lower or no education are more likely to seek help when compared to those with higher education. Other factors (such as age and type of incontinence) that potentially influenced the likelihood with which a woman sought medical consultation were not found to be significant predictors of help-seeking behaviors in this study. One potential reason for the lack of association across these factors may have been the relatively small sample size. It has been postulated by others that the higher likelihood of help-seeking with increasing age may not be due to age alone, but due to the cumulative effects of the long duration and severity of the morbidity.¹⁹

Women described the reasons why they did not seek medical attention for their UI. While most of the reasons reported by the women in our study reflected the reasons noted in other studies, women in our study did not indicate that lack of funds was a barrier to them seeking health care services. The most common reasons for not accessing health care services for UI as reported by the women in our study were that UI is not life-threatening, and there is an overarching belief that the condition is not treatable. These two common reasons for not seeking health care services for UI may not necessarily suggest poor insight to the disease alone; rather, it is a reflection of the prevalent negative disposition towards medical consultation in Nigeria. Misconceptions exhibited by this group of women must be addressed with adequate mobilization and education regarding the causes, implications, and treatment for UI, directing these women towards hospital consultation. This advocacy will need the support of experts, policymakers, women’s organizations, and other relevant bodies that focus on women’s health. Furthermore, it is possible that the lack of funds mentioned by some women during the course of other studies reflects the out-of-pocket health care financing system operating in Nigeria, which affects the majority of the populace.^24,25 This approach has limited women living in poverty from accessing quality health care service.

This study attempted to provide information regarding help-seeking behaviors of women in Nigeria with UI; however, the results should be interpreted cautiously for the following reasons. First, the population studied includes more young women than elderly women. Second, we did not inquire further regarding the reasons mentioned by those that did not seek information. Third, information regarding the outcome of care amongst those who sought medical treatment was not available. Despite these limitations, a strong point of this study is that it was conducted within the community. Additionally, this is the first SSA study to examine this problem, and the results of this study have filled a gap in the global knowledge in the literature.

In conclusion, very few women (approximately 1 in 10) who currently have UI have sought medical care; barriers mentioned were similar to those described in other settings, except that lack of funds was also measured. Further studies in this area are necessary to fully understand women’s attitudes towards medical services.