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Health-related quality of life and mental health in older women with urinary incontinence a
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YeunHee Kwak , HaeJin Kwon & YoonJung Kim
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Department of Nursing, Red Cross College of Nursing, Chung-Ang University, Seoul, Republic of Korea Published online: 15 Apr 2015.
Click for updates To cite this article: YeunHee Kwak, HaeJin Kwon & YoonJung Kim (2015): Health-related quality of life and mental health in older women with urinary incontinence, Aging & Mental Health, DOI: 10.1080/13607863.2015.1033682 To link to this article: http://dx.doi.org/10.1080/13607863.2015.1033682
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Aging & Mental Health, 2015 http://dx.doi.org/10.1080/13607863.2015.1033682
Health-related quality of life and mental health in older women with urinary incontinence YeunHee Kwak*, HaeJin Kwon and YoonJung Kim Department of Nursing, Red Cross College of Nursing, Chung-Ang University, Seoul, Republic of Korea
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(Received 5 January 2015; accepted 19 March 2015) Objectives: The purpose of this cross-sectional study was to compare health-related quality of life (QOL) and mental health between older women with and without urinary incontinence. Method: This study is a secondary data analysis using raw data from 1874 women aged 65 years or older who participated in the Korea National Health and Nutrition Examination Survey (KNHANES) IV (2008 2009), a nationally representative sample. Results: In the pain/discomfort dimension of the EuroQol-5, 25.4% of the participants experienced urinary incontinence and 14.7% did not (p D .001). In the anxiety/depression dimension, urinary incontinence was present in 8.3% of the participants and absent in 3.6% (p D 0.012). In addition, the results of an ANCOVA showed that scores in both the EuroQol visual analogue scale and the EQ-5D index were significantly lower in participants with urinary incontinence relative to those without. The risk of stress and depression in older women with urinary incontinence was approximately 2 and 1.5 times higher, respectively, than that of participants without urinary incontinence. Conclusion: Health-related QOL in older women with urinary incontinence was relatively low, while levels of stress and depression were high. Therefore, in order to improve QOL and mental health in older women, the understanding and management of urinary incontinence interventions is required. Keywords: urinary incontinence; health-related quality of life; mental health; older women
Introduction As of 2011, the disability-adjusted life expectancy for women (72.48 years) was 3.69 years higher than that of men (68.79 years), while the overall life expectancy for women (84.45 years) was 6.8 years higher than that of men (77.65 years; The Korea Institute for Health and Social Affairs, 2014). With longer life expectancy, many women spend their old age in poor health and experience various health-related issues. In particular, urinary incontinence, a geriatric disease involving involuntary leakage of urine, is frequently found in women (Milsom, 2000). The prevalence rates for urinary incontinence are 38% in American women aged 60 years or older (Anger, Saigal, Litwin, & The Urologic Diseases of America Project, 2006) and 56.3% in Korean women aged 65 years or older (Shin, Kang, & Oak, 2008), rising with increasing age. Urinary incontinence is not a life-threatening disease but a medical problem that is very inconvenient for the patient and affects the physical, mental, and social aspects of the lives of those with the condition (Heidrich & Wells, 2004). Most women who experience urinary incontinence also experience lower urinary tract symptoms, such as nocturia and urinary frequency and urgency (Shin et al., 2008), and report musculoskeletal pain, fatigue, and sleep disorders; the disease can also cause dermatitis and an unpleasant odour (Franzen, Johansson, Andersson, Pettersson, & Nilsson, 2009; Heidrich & Wells, 2004). Voiding symptoms related to incontinence can lead to embarrassment, social phobia, social isolation, economic problems,
*Corresponding author. Email: [email protected] Ó 2015 Taylor & Francis
difficulties in performing daily activities, and lower levels of subjective health status, motivation, well-being, personal growth, self-respect, and self-confidence. For these reasons, women with urinary incontinence experience various mental and social problems (Franzen et al., 2009; Heidrich & Wells, 2004; Fultz et al., 2005; Kim & Lee, 2008; Kwon & Lee, 2014; Pons & Clota, 2008; Shin et al., 2008; Trantafylidis, 2009). In addition, women with urinary incontinence have been reported to experience more depression and stress relative to those without the condition (Bartoli, Aguzzi, & Tarricone, 2010; Margalith, Gillon, & Gordon, 2004; Kim, Kim, Lee, & Son, 2013; Melville, Katon, Delaney, & Newton, 2005; Park & Kim, 2009). Depression is particularly prevalent in older individuals with urinary incontinence, as it exerts a significant influence on personal suffering and social interaction (Lekan-Rutledge, 2004). The prevalence of urinary incontinence increases with age, and a significant number of older women experience the condition, which affects their quality of life (QOL) and physical, mental, and social well-being. In addition, comorbidity of urinary incontinence and depression is more common in women relative to men and is experienced by many older women (Kim et al., 2007). Urinary incontinence has very complicated effects on the health of older women; therefore, it is necessary to investigate the disease in a more comprehensive manner that includes consideration of the physical, mental, and psychological effects of the condition rather than viewing it as a merely physical disease (Park & Kim, 2009). Various studies have been conducted to examine urinary
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incontinence with respect to prevalence rates (Anger et al., 2006; Kim & Lee, 2008; Melville et al., 2005), physical issues (Shin et al., 2008; Franzen et al., 2009), mental issues (Bartoli et al., 2010; Trantafylidis, 2009), and social issues (Lekan-Rutledge, 2004; Yip et al., 2013), and QOL (Pons & Clota, 2008; Kwon & Lee, 2014). However, in Korea, research comprises survey studies that depend upon being conducted in specific locations, such as nursing facilities (Kim & Lee, 2008), outpatient departments (Kim, Kim, Kim, Kim, & Jeon, 2011), and other areas that are highly accessible to study participants (Shin et al., 2008; Kim, Park, Jin, Kang, & Shin, 2007), and there have been few studies conducted to examine QOL and mental health in older women with urinary incontinence nationwide. As urinary incontinence is a problem concerning the urogenital organs, most older women try to hide it due to the shame they would experience with the exposure of symptoms, and symptoms of urinary incontinence worsen due to their belief that it is part of the normal ageing process; therefore, conducting studies in the community is preferable to doing so in hospitals and nursing homes (Park & Kim, 2009; Song, Son, Hong, Song, & Cho, 2007). This study was conducted to identify means of helping older women with urinary incontinence to maintain healthy lifestyles, using raw data from the Korea National Health and Nutrition Examination Survey (KNHANES) IV, which is a representative and reliable large-scale survey, to examine healthrelated QOL and mental health in older women with urinary incontinence living in the community. The specific research objectives were as follows: (1) To determine differences in general and healthrelated characteristics according to the presence or absence of urinary incontinence in older women (2) To examine the associations between urinary incontinence and health-related QOL and mental health in older women
Method Study data and participants This study used raw data from the 2nd (2008) and 3rd years (2009) of the KNHANES IV conducted by the Korea Centers for Disease Control and Prevention (KCDC) under the official approval of the institution. The KNHANES is a nationally representative and cross-sectional survey targeting non-institutionalized Korean people. Sampling was carried out to target all types of people in order to represent Korea using stratified, multi-staged, clustered, and probability designs. By introducing the rolling survey sampling method, the KNHANES IV sample became a probability sample, and the circulation sample for each survey year represents the country, and there are independent, homogeneous characteristics between circulation samples. Selected participants were sent a notice of selection prior to the commencement of the survey, via which their identities were verified, the purpose of the study was explained, and
a written consent was obtained. A week prior to the commencement of the survey, participants attended an appointment to complete health and nutrition surveys and undergo an examination. The health and nutrition surveys included one-to-one interviews and self-report questionnaires, while the examination was performed by a specialized examination team at the KCDC. In the second year of the KNHANES IV (2008), 9744 individuals were surveyed out of a potential 12,528 (survey participation rate: 77.8%; KCDC, 2009); in the third year of the KNHANES IV (2009), 10,533 individuals were surveyed out of a potential 12,722 (survey participation rate: 82.8%; KCDC, 2010). Data from 1874 participants aged 65 years or older were analysed. This was a subset of 1969 women aged 65 years or older (participation rate: 9.71%) included in the KNHANES IV secondand third-year (2008 2009) surveys (n D 20,277), with 95 individuals excluded from the analyses due to kidney failure or missing data.
Measures Urinary incontinence Participants’ urinary incontinence was analysed by categorizing ‘yes’ or ‘no’ responses indicating agreement or disagreement, respectively, with the statement ‘I currently suffer from urinary incontinence’ in the health interview survey. Health-related QOL The EuroQol-5 (EQ-5D), EQ-5D index, and EuroQol visual analogue scale (EQ-VAS), all developed by the EuroQol group, were used to measure health-related QOL (The EuroQoL Group, 1990). As a tool for measuring health-related QOL, the EQ-5D was developed to measure simple and overall health for the purpose of evaluating clinical and economic feasibility. The validity and reliability of the EQ-5D have been verified in the general South Korean population (Korea Centers for Disease Control and Prevention, 2011).The EQ-5D is composed of five dimensions including mobility, self-care, usual activities, pain/discomfort, and anxiety/depression. Responses for each dimension are chosen from ‘no problems’, ‘some problems’, or ‘severe problems’. In the EQ-5D index, health-related QOL scores are calculated using a formula to estimate the weighted value for each response to questions regarding these five dimensions, and values range from 1 point, representing perfect health status, to ¡1 point, representing health status worse than death (Lee et al., 2009). The EQ-VAS is a 20 cm vertical analogue scale on which participants rate their overall state of health from 0 (worst imaginable health state) to 100 (best imaginable health state). Mental health Stress and depression variables were used to assess participants’ mental health. For stress, the responses ‘feel very
Aging & Mental Health strongly’, ‘feel strongly’, or ‘feel somewhat’ to the question ‘How much stress do you feel in your everyday life?’ were categorized as ‘yes’, and ‘feel a little’ was categorized as ‘no’. For depression, participants responded ‘yes’ or ‘no’ to the question ‘Have you ever felt so sad or discouraged that it interfered with daily life for more than two successive weeks during the past year?’
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Covariates Covariates used as demographic and health-related variables were based on findings used in previous studies (Anger et al., 2006; Chang, Gonzalez, Lau, & Sier, 2008; Fultz et al., 2005; Kwon & Lee, 2014). Age, area of residence, education, spouse, economic status, and occupation were used as demographic variables. Area of residence was categorized as either urban or rural. Education was classified into middle school or lower, and high school or higher. With respect to the presence or absence of a spouse, living with a spouse was categorized as ‘yes’, and being single or not living with a spouse due to death or divorce was categorized as ‘no’. Economic status was determined by calculating equivalent income (average monthly household income/xnumber of household members); this was used to identify participants in the bottom 25% of the sample, based on household economic status. Occupation was classified as either presence or absence of a current employer. Waist circumference, body mass index (BMI), pregnancy frequency, smoking, drinking, regular exercise, diabetes, and hypertension were used as health-related variables. To measure waist circumference, the bottom of the last rib and the upper part of the iliac crest touched at the midaxillary line, and the midpoint of the two points was marked and measured to the nearest 0.1 cm using a measuring tape (Seca 200; Seca) following expiration. BMI was calculated and expressed as weight (kg)/height (m)2. Smoking status was classified as either current smoker or non-smoker, regardless of past smoking status. The amount of pure alcohol consumed was calculated in grams per day according to the average number of alcoholic beverages consumed and the frequency of alcohol consumption. Participants who consumed an average of 1 15 g of alcohol daily were considered mild to moderate drinkers, and participants who consumed more than 30 g daily were considered heavy drinkers (Choi et al., 2012). Regular exercise was defined as performing strenuous physical activity at least three times weekly for at least 20 minutes at a time. Statistical analysis The Statistical Analysis System (SAS) survey procedure (ver. 9.3; SAS Institute Inc., Cary NC, USA) was used to run a complex sample design based on data analysis from the survey data; this provided sampling weights from the KNHANES and nationally representative estimates. Data were presented as mean § SE for continuous variables or proportion (SE) for categorical variables. Differences in urinary incontinence according to demographic and health-
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related characteristics and QOL were presented as means (SE) or % (SE) and assessed using t tests and x2 verification. In order to determine the relationship between QOL and urinary incontinence, participants’ demographic and health-related characteristics were controlled and an analysis of covariance was performed. In order to determine the association between mental health and urinary incontinence, age, BMI, smoking, drinking, exercise, diabetes, and hypertension were adjusted, and logistic regression analysis was performed. Statistical significance of all results was tested based on a significance level of p < .05.
Results Urinary incontinence according to demographic and health-related characteristics Differences in urinary incontinence according to participants’ demographic and health-related characteristics are presented in Table 1. Greater waist circumference (p D .003) and more frequent regular exercise were observed in participants with urinary incontinence relative to those without (p D .010). There were no statistically significant differences in age, residence, education, economic status, spouse, occupation, BMI, pregnancy frequency, smoking, drinking, diabetes, or hypertension between participants with and without urinary incontinence.
Health-related QOL and mental health in older women with urinary incontinence Differences in urinary incontinence and each dimension of EQ-5D are presented in Table 2. The proportions of participants with pain/discomfort (p D .001) and anxiety/ depression (p D 0.012) were larger in participants with urinary incontinence group relative to those without. Differences in urinary incontinence ratios according to EQ-5D levels are presented in Figure 1. Urinary incontinence ratios differed significantly according to the selfcare, usual activities, and pain/discomfort EQ-5D dimensions. Those who reported some problems with urinary incontinence accounted for the largest proportion of participants in the self-care dimension, 13.4% (p D .040). Those with severe urinary incontinence problems accounted for the largest proportions of participants in the usual activities and pain/discomfort dimensions, 15.8% (p D .039) and 16.2% (p D .001), respectively. Although not statistically significant, the urinary incontinence ratios for participants with severe problems with mobility and anxiety/depression, who constituted the largest proportions of participants in the dimension, were 17.8% (p D .121) and 20.3% (p D .062), respectively. Table 3 presents the associations between healthrelated QOL and urinary incontinence and mental health and urinary incontinence. Model 1 was adjusted for age and sex. Model 2 was the result of adjusted smoking, drinking, and regular exercise from Model 1. Model 3 was the result of adjusted diabetes and hypertension from Model 2. The adjusted means for the EQ-VAS in participants with urinary incontinence were 61.22 (p D .029) in
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Table 1. Prevalence of urinary incontinence according to demographic, health-related characteristics (N D 1874). Urinary incontinence
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Characteristic
No (N D 1685) Mean § SE or % (SE)
Yes (N D 189) Mean § SE or % (SE)
p value
73.3 § 0.2 68 (2.6) 6.7 (0.8) 53.2 (1.8) 39.1 (1.4) 23.1 (1.5) 82.9 § 0.3 24.1 § 0.1 5.8 § 0.1 6.5 (0.8) 0.9 (0.2) 16.6 (1.3) 18.9 (1.2) 63.4 (1.5)
73 § 0.6 66.7(4.9) 5.4 (2) 56.6 (4.8) 38.3 (4.3) 21.8 (3.3) 85.8 § 0.9 24.7 § 0.3 6.2 § 0.3 6.3 (1.9) 0.7 (0.5) 25.5 (3.9) 20.1 (4.5) 67.4 (4.8)
0.705 0.780 0.560 0.524 0.854 0.701 0.003 0.067 0.223 0.923 0.805 0.010 0.070 0.440
Age (yr) Living place (urban) Education (high school) Economic status (Q1) Spouse (yes) Occupation (yes) Waist circumference (cm) BMI (kg/m2) Pregnancy frequency Smoking (current) Drinking (heavy) Regular exercise (yes) Diabetes (yes) Hypertension (yes)
Model 1, 60.95 (p D .017) in Model 2, and 61.14 (p D .027) in Model 3, indicating that all levels were significantly lower relative to those of participants without urinary incontinence. In addition, the adjusted means for the EQ-5D index in participants with urinary incontinence were all significantly lower relative to those of participants without: Model 1: 0.75 (p D .001), Model 2: 0.75 (p D .001), Model 3: 0.75 (p D .002). Even after adjusting for covariates, health-related QOL in participants with urinary incontinence was lower relative to that of participants without urinary incontinence. Using those of participants without urinary incontinence as a reference, odds ratios for stress in Models 1, 2, and 3 were 2.11 (95% CI: 1.41 3.16), 2.07 (95% CI: 1.38 3.10), and 2.01 (95% CI: 1.33 3.03), respectively. Odds ratios for depression in Models 1, 2, and 3 were 1.54 (95% CI: 1.04 2.27), 1.52 (95% CI: 1.03 2.25), and 1.49 (95% CI: 1.01 2.21), respectively. In other words, the risk of stress and depression was 2 and 1.5 times higher, respectively, in participants with urinary incontinence relative to those without. Discussion Among the health problems experienced by older women, urinary incontinence is often recognized as a part of the Table 2. Differences in urinary incontinence and EQ-5D. Urinary incontinence
EQ-5D Mobility Self-care Usual activities Pain/discomfort Anxiety/depression
No (N D 1685) % (SE)
Yes (N D 189) % (SE)
p value
2.8 (0.5) 2 (0.4) 4.9 (0.6) 14.7 (0.9) 3.6 (0.6)
5.3 (1.8) 2.5 (1) 8.2 (2.5) 25.4 (3.8) 8.3 (2.4)
0.082 0.678 0.094 0.001 0.012
course of ageing and can be easily overlooked in everyday life; however, it may have an impact on physical and mental well-being. Therefore, the associations between urinary incontinence and QOL and mental health should be identified in older women to allow them to maintain healthier lifestyles. The results suggested that QOL related to pain/discomfort and anxiety/depression was lower in older women with urinary incontinence relative to that of those without the condition. In addition, many of the participants with urinary incontinence experienced severe problems concerning self-care, usual activities, and pain/discomfort, and although the differences in mobility and anxiety/ depression problems were not statistically significant, there were many participants with urinary incontinence who experienced severe problems in these dimensions. However, in a study that analysed EQ-5D scores in women aged 20 years or older with urinary incontinence (Kwon & Lee, 2014), all five EQ-5D dimensions differed significantly according to participants’ average age. This finding is similar to results suggesting that older individuals with urinary incontinence experienced greater difficulty in performing activities of daily living (Chang et al., 2008; Fultz et al., 2005; Shin et al., 2008). Use of disposable pads and limiting trips and fluids are methods of selfcare in urinary incontinence, and the condition also affects usual activities such as dressing, eating, and bathing in some but not all patients (Johnson, Kincade, Bernard, Busby-Whitehead, & DeFriese, 2000). In addition, the findings from this study support those of other studies in which adults or older people with urinary incontinence experienced musculoskeletal pain, fatigue, and sleeping disorders (Franzen et al., 2009; Kim & Han, 2011). As mentioned above, urinary incontinence is a medical problem that is very uncomfortable to the patient and not only causes physical discomfort and pain but also degrades subjective health status and motivation for life and wellbeing (Heidrich & Wells, 2004). This indicates that
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Figure 1. Difference in urinary incontinence ratios according to EQ-5D levels in older women.
although it is not directly related to lifestyle, urinary incontinence has a negative impact in many physical and psychosocial areas. Therefore, older women with urinary incontinence experience discomfort due to odour and urinary frequency, among other symptoms, which causes problems with usual activities. In addition, a reduction in self-care ability in urinary incontinence results in decreased QOL. The results of this study showed that health-related QOL was lower in the EQ-5D index and EQ-VAS, even after adjusting for multiple covariates. The Medicare Health Outcomes Survey results were similar, in that urinary incontinence was identified as a significant predictor of health-related QOL using a different tool (SF-36) to that used in this study (Ko, Lin, Salmon & Bron, 2005). In addition, QOL was found to vary depending on the type of urinary incontinence experienced (Kim et al., 2007). However, QOL also decreased as the severity of urinary incontinence increased, and QOL tended to be lower as the duration of urinary incontinence increased (Coyne
et al., 2009; Oh & Kim, 2005). Therefore, at the point at which human life expectancy is increasing, frequent urinary incontinence in older women can be an important influencing factor in determining QOL, and active care, involving practices such as prevention, treatment for urinary incontinence, and development of a variety of care products for healthy and happy later years by improving QOL, is required. According to the results of the EQ-VAS, asking participants to record their health status showed that older women with urinary incontinence viewed their health status negatively. This is consistent with the second data analysis result in the Health and Aging Project for older women aged between 57 and 85 in the USA, which found that self-reported health was considered negative if participants experienced urinary incontinence (Yip et al., 2013). Thus, health-related QOL in older women with urinary incontinence was reduced, and in order to improve the quality of their lives, supplementary goods, such as pads or diapers, which may promote self-care and usual
Table 3. Health-related QOL and mental health in older women with urinary incontinence.
Model1 Urine incontinence
Model2 Urine incontinence
Model3 Urine incontinence
EQ_VAS Mean § SE
EQ-5D index Mean § SE
No Yes p value
65.28 § 0.72 61.22 § 1.8 0.029
No Yes p value No Yes p value
Stress
Depression
0.81 § 0.01 0.75 § 0.02 0.001
1 2.11 (1.41, 3.16)
1 1.54 (1.04, 2.27)
65.3 § 0.72 60.95 § 1.78 0.017
0.81 § 0.01 0.75 § 0.02 0.001
1 2.07 (1.38, 3.10)
1 1.52 (1.03, 2.25)
65.37 § 0.72 61.14 § 1.85 0.027
0.81 § 0.01 0.75 § 0.02 0.002
1 2.01 (1.33, 3.03)
1 1.49 (1.01, 2.21)
Note: Model 1 was adjusted for age and BMI. Model 2 is the result of adjusted smoking, drinking, and regular exercise from Model 1. Model 3 is the result of adjusted diabetes and hypertension from Model 2.
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activity, active mediation of exercise, and nursing interventions to relieve pain, are required. The results of this study showed that, in older women with urinary incontinence, stress is approximately twice as high and depression is about 1.5 times higher relative to those without urinary incontinence. This supports findings from studies in which adults and older women with urinary incontinence were more likely to experience depression, distress, and anxiety relative to those without the condition, and depression was negatively correlated with QOL (Bogner et al., 2004; Franzen et al., 2009; Hung, Awtrey, & Tsai, 2014; Kim et al., 2007; Ko et al., 2005; Melville et al., 2005). Therefore, urinary incontinence is a significant factor in depression in the elderly (Chang et al., 2008; Shin et al., 2008). Older women with urinary incontinence not only experience discomfort with the condition but also contend with inconvenience in their daily lives due to requirements to limit water intake and a range of activities and face psychological disorders, including depression, as a result of anxiety, tension, and embarrassment due to unpleasant odour (Oh & Kim, 2005). Therefore, given that urinary incontinence causes mental health problems, such as depression and stress, and QOL is reduced as mental health problems become more severe, it is thought that nursing interventions for mental health problems, such as depression and stress, are required to improve the QOL of older women with urinary incontinence. Regarding differences in urinary incontinence and health-related characteristics in this study, older women with urinary incontinence were found to have thicker waist circumference and exercise more regularly. Results for women aged between 30 and 90 years differed from those of studies showing that prevalence rates differed according to age and BMI (Melville et al., 2005). However, the results of a cross-sectional study targeting women aged 40 years or older who visited a health promotion centre showed a significant difference in urinary incontinence according to BMI and waist circumference (Kim et al., 2011). In the results of a survey targeting women aged 60 years or older in southern Brazil, waist circumference was found to be a significant predictor of urinary incontinence (Krause et al., 2010). Therefore, repeated studies are required to identify effective methods for measuring obesity and assessing urinary incontinence risk factors in older women. In addition, management strategies, such as exercise and diet to reduce abdominal fat in older women, are required. The results of this study showed that participants with urinary incontinence exercised more regularly. Stress incontinence has been reported to be more frequent in physically active women and athletes (Kruger, Dietz, & Murphy, 2007). However, another study found that women who perform moderate exercise were less likely to experience urinary incontinence; therefore, the nature of the correlation between exercise and urinary incontinence is unclear (Kikuchi et al., 2007). While associations could be identified, this study could not explain the causal relationship between urinary incontinence and regular exercise. Therefore, ongoing research is required to
identify the relationships between exercise intensity and obesity, urinary incontinence, and amount and duration of exercise. Urinary incontinence can be said to be a particularly important health problem in older women, because urinary incontinence causes constraints in everyday life, leads to discomfort and pain, reduces QOL, and increases stress and depression in older women. Often, urinary incontinence is simply considered a part of the ageing process, and patients tend to neglect the problem due to the shame associated with urogenital organs and odour. However, it is necessary to increase the recognition of urinary incontinence. In addition, it is necessary to diagnose stress and depression caused by urinary incontinence early, implement appropriate interventions, and provide education, support, and empathy regarding aspects of self-care, such as control of frequent urination, use of a pad during physical activity, and weight management, in older women with urinary incontinence. Interventions involving urinary incontinence management could contribute to QOL improvement and stress and depression reduction in older women. The major strengths of this study were the use of a variety of tools to assess health-related QOL and examine the associations between urinary incontinence and mental health and QOL, and representativeness and large size of the sample. Despite these strengths, the study was subject to the following limitations. First, we could not study QOL and mental health according to subtype and severity, as there was no information available regarding the subtypes and severity of urinary incontinence. Second, this was a crosssectional study and could not explain causal relationships; therefore, there is a need for further longitudinal research. Third, the study participants were all older women, and the findings cannot be generalized to other populations; therefore, future studies should involve men or women of all age groups. Despite these limitations, we believe that this study provided meaningful results, as it is the first study to clearly identify the association between urinary incontinence and mental health and QOL in older Korean women. Conclusion This study showed that health-related QOL was reduced in older women with urinary incontinence, and their stress and depression levels were higher relative to those of women without urinary incontinence. These research findings suggest that social interest and consensus regarding the condition are required in older women with urinary incontinence and that more active and specific nursing intervention programs are needed in future. In addition, a system to monitor the prevention of stress and depression and identify the optimum time for therapeutic intervention in older women with urinary incontinence is required. Through support, encouragement, consensus, promotion, and education regarding care involving factors such as exercise and diet, we should help older women with urinary incontinence to gain
Aging & Mental Health vitality and improve their QOL by improving self-care and enhancing activities of daily living. Finally, we believe that expanding financial support for community and senior citizen centres and seniors’ programs for the elderly would be helpful in improving QOL and managing chronic disease in the elderly. Acknowledgments This study was performed using raw data from the KNHANES IV was conducted by the KCDC.
Disclosure statement The authors have no conflicts of interest to declare.
Funding
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No financial support was received for this research.
References Anger, J.T., Saigal, C.S., Litwin, M.S., & The Urologic Diseases of America Project. (2006). The prevalence of urinary incontinence among community dwelling adult women: Results from the National Health and Nutrition Examination Survey. The Journal of Urology, 175(2), 601 604. Bartoli, S., Aguzzi, G., & Tarricone, R. (2010). Impact on quality of life of urinary incontinence and overactive bladder: A systematic literature review. Urology, 75(3), 491 500. Bogner, H.R., Gallo, J.J., Sammel, M.D., Ford, D.E., Americam, H.K., & Eaton, W.W. (2004). Urinary incontinence and psychological distress in community-dwelling older African Americans and Whites. Journal of the American Geriatrics Society, 52(11), 1870 1874. Chang, C.H., Gonzalez, C.M., Lau, D.T., & Sier, H.C. (2008). Urinary incontinence and self-reported health among the US medicare managed care beneficiaries. Journal of Aging and Health, 20(4), 405 419. Choi, J.Y., Ha, H.S., Kwon, H.S., Lee, S.H., Cho, H.S., Yim, H. W., . . . Park, Y.M. (2012). Characteristics metabolically obese, normal-weight women differ by menopause status: The Fourth Korea National Health and Nutrition Examination Survey. Menopause, 20, 85 93. Coyne, K.S., Wein, A.J., Tubaro, A., Sexton, C.C., Thompson, C.L., Kopp, Z.S., & Aiyer, L.P. (2009). The burden of lower urinary tract symptoms: Evaluating the effect of LUTS on health related quality of life, anxiety and depression: EpiLUTS. British Journal of Urology International, 103(3), 4 11. Franzen, K., Johansson, J.E., Andersson, G., Pettersson, N., & Nilsson, K. (2009). Urinary incontinence in women is not exclusive a medical problem: A population-based study on urinary incontinence and general living conditions. Scandavian Journal UroloNephrology, 43(3), 226 232. Fultz, N.H., Rahrig Jenkins, K., ;stbye, T., Taylor Jr, D.H., Kabeto, M.U., & Langa, K.M. (2005). The impact of own and spouse’s urinary incontinence on depressive symptoms. Social Science & Medicine, 60(11), 2537 2548. Heidrich, S.M., & Wells, T.J. (2004). Effects of urinary incontinence: Psychological well-being and distress in older community-dwelling women. Journal of Gerontological Nursing, 30(5), 47 54. Hung, K.J., Awtrey, C.S., & Tsai, A.C. (2014). Urinary incontinence, depression, and economic outcomes in a cohort of women between the ages of 54 and 65 Years. Obstetrics & Gynecology, 123(4), 822 827.
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Johnson 2nd, T.M., Kincade, J.E., Bernard, S.L., Busby-Whitehead, J., & DeFriese, G.H. (2000). Self-care practices used by older men and women to manage urinary incontinence: Results from the national follow-up survey on self-care and aging. Journal of the American Geriatrics Society, 48(8), 894 902. Kikuchi, A., Niu, K., Ikeda, Y., Hozawa, A., Nakagawa, H., Guo, H., . . . Nagatomi, R. (2007). Association between physical activity and urinary incontinence in a communitybased elderly population aged 70 years and over. European Urology, 52(3), 868 874. Kim, J.H., Kim, Y.H., Kim, J.J., Kim, S.M., & Jeon, M.J. (2011). The impact of symptomatic urinary incontinence on female sexual function in middle to old-aged Korean women. Korean Journal of Obstetrics & Gynecology, 54(12), 778 783. Kim, K.H., Park, H.J., Jin, L.H., Kang, Y.H., & Shin, K.R. (2007). The correlation among quality of life, depression, and urinary incontinence of elderly women in a urban city. Journal of the Korean Gerontological Society, 27(4), 943 962. Kim, M.S., & Lee, S.H. (2008). Prevalence rate and associated factors of urinary incontinence among nursing home residents. Journal of Korean Academic Nursing, 38(1), 92 100. Kim, M.Y., Kim, Y.H., Lee, J.Z., & Son, H.M. (2013) Symptom bother, physical and mental stress, and health-related quality of life in women with overactive bladder syndrome. Korean Journal Women Health Nursing, 19(4), 295 305. Kim, Y.H., & Han, J.S. (2011). Factors related to the quality of sleep in the elderly women. Journal of the Korea AcademiaIndustrial Cooperation Society, 12(10), 4467 4474. Ko, Y., Lin, S.J., Salmon, J.W., & Bron, M.S. (2005). The impact of urinary incontinence on quality of life of the elderly. The American Journal of Managed Care, 11(4), S103 S111. Korea Centers for Disease Control and Prevention (KCDC). (2009). Korea Health Statistics 2008: Korea National Health and Nutrition Examination Survey (KNHANES IV-1). Retrieved from http://knhanes.cdc.go.kr/knhanes/index.do Korea Centers for Disease Control and Prevention (KCDC). (2010). Korea Health Statistics 2009: Korea National Health and Nutrition Examination Survey (KNHANES IV-2). Retrieved from http://knhanes.cdc.go.kr/knhanes/index.do Korea Centers for Disease Control and Prevention. (2011). Validity and reliability evaluation for EQ-5D in Korea. Retrieved from http://www.cdc.go.kr/CDC/info/CdckrInfo0201.jsp Krause, M.P., Albert, S.M., Elsangedy, H.M., Krinski, K., Goss, F. L., & daSilva, S.G. (2010). Urinary incontinence and waist circumference in older women. Age and Ageing, 39(1), 69 73. Kruger, J.A., Dietz, H.P., & Murphy, B.A. (2007). Pelvic floor function in elite nulliparous athletes. Ultrasound in Obstetrics Gynecology, 30(1), 81 85. Kwon, C.S., & Lee, J.H. (2014). Prevalence, risk factors, quality of life, and health-care seeking behaviors of female urinary incontinence: Results From the 4th Korean National Health and Nutrition Examination Survey VI. International Neurourology Journal, 18(1), 31 36. Lee, Y.K., Nam, H.S., Chung, L.H., Kim, K.Y., Yang, H.K., Kwon, I.S., . . . Kim, Y.T. (2009). South Korean time tradeoff values for EQ-5D health status: Modeling with observed values for 101 health states. Value in Health, 12(8), 1187 1193. Lekan-Rutledge, D. (2004). Urinary incontinence strategies for frail elderly women. Journal of Urological Nursing, 24(4), 281 301. Margalith, I., Gillon, G., & Gordon, D. (2004). Urinary incontinence in women under 65: Quality of life, stress related to incontinence and patterns of seeking health care. Quality of Life Research, 13, 1381 1390. Melville, J.L., Katon, W., Delaney, K., & Newton, K. (2005). Urinary incontinence in US women: a population-based study. Archives of Internal Medicine, 165(5), 537 542.
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Milsom, I. (2000). The prevalence of urinary incontinence. ActaObstetricia et GynecologicaScandinavica, 79, 1056 1059. Oh, H.S., & Kim, M.K. (2005). Factors affecting the severity of urinary incontinence and the quality of life of women with urinary incontinence. Journal of Korean Academy of Nursing, 35(3), 469 477. Park, S., & Kim, J. (2009). The effects of lower urinary tract symptoms on depression and quality of life among women in urban areas. Journal of Korean Academy Community Health Nursing, 20(4), 522 530. Pons, M.E., & Clota, M.P. (2008). Coital urinary incontinence: Impact on quality of life as measured by the King’s Health Questionnaire. International Urogynecology Journal, 19(5), 621 625. Shin, K.R., Kang, Y.H., & Oak, J.W. (2008). The relationship of quality of sleep, depression, late-life function and disability in community-dwelling older women with urinary incontinence. Journal of Korean Academy of Nursing, 38(4), 573 581.
Song, Y.S., Son, Y.J., Hong, S.K., Song, J.E., & Cho, H.K. (2007). Anxiety, depression and quality of life of married women with urinary incontinence living in the community. The Korean Journal of Fundamentals of Nursing, 14(4), 483 492. The EuroQoL Group (1990). EuroQol A new facility for the measurement of health-related quality of life. Health Policy, 16(3), 199 208. The Korea Institute for Health and Social Affairs (2014). Healthy life expectancy in Korea. Issue & Focus, 247(8), 1 8. Retrieved from http://www.kihasa.re.kr/html/jsp/publi cation/periodical/focus/list.jsp Trantafylidis, S.C.A. (2009). Impact of urinary incontinence on quality of life. Pelviperineology, 28, 51 53. Yip, S.O., Dick, M.A., McPencow, A.M., Martin, D.K., Ciarleglio, M.M., & Erekson, E.A. (2013). The association between urinary and fecal incontinence and social isolation in older women. American Journal of Obstetrics Gynecology, 208(2), 146.e1 146.e7.
Aging & Mental Health Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/camh20
Health-related quality of life and mental health in older women with urinary incontinence a
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YeunHee Kwak , HaeJin Kwon & YoonJung Kim
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Department of Nursing, Red Cross College of Nursing, Chung-Ang University, Seoul, Republic of Korea Published online: 15 Apr 2015.
Click for updates To cite this article: YeunHee Kwak, HaeJin Kwon & YoonJung Kim (2015): Health-related quality of life and mental health in older women with urinary incontinence, Aging & Mental Health, DOI: 10.1080/13607863.2015.1033682 To link to this article: http://dx.doi.org/10.1080/13607863.2015.1033682
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Aging & Mental Health, 2015 http://dx.doi.org/10.1080/13607863.2015.1033682
Health-related quality of life and mental health in older women with urinary incontinence YeunHee Kwak*, HaeJin Kwon and YoonJung Kim Department of Nursing, Red Cross College of Nursing, Chung-Ang University, Seoul, Republic of Korea
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(Received 5 January 2015; accepted 19 March 2015) Objectives: The purpose of this cross-sectional study was to compare health-related quality of life (QOL) and mental health between older women with and without urinary incontinence. Method: This study is a secondary data analysis using raw data from 1874 women aged 65 years or older who participated in the Korea National Health and Nutrition Examination Survey (KNHANES) IV (2008 2009), a nationally representative sample. Results: In the pain/discomfort dimension of the EuroQol-5, 25.4% of the participants experienced urinary incontinence and 14.7% did not (p D .001). In the anxiety/depression dimension, urinary incontinence was present in 8.3% of the participants and absent in 3.6% (p D 0.012). In addition, the results of an ANCOVA showed that scores in both the EuroQol visual analogue scale and the EQ-5D index were significantly lower in participants with urinary incontinence relative to those without. The risk of stress and depression in older women with urinary incontinence was approximately 2 and 1.5 times higher, respectively, than that of participants without urinary incontinence. Conclusion: Health-related QOL in older women with urinary incontinence was relatively low, while levels of stress and depression were high. Therefore, in order to improve QOL and mental health in older women, the understanding and management of urinary incontinence interventions is required. Keywords: urinary incontinence; health-related quality of life; mental health; older women
Introduction As of 2011, the disability-adjusted life expectancy for women (72.48 years) was 3.69 years higher than that of men (68.79 years), while the overall life expectancy for women (84.45 years) was 6.8 years higher than that of men (77.65 years; The Korea Institute for Health and Social Affairs, 2014). With longer life expectancy, many women spend their old age in poor health and experience various health-related issues. In particular, urinary incontinence, a geriatric disease involving involuntary leakage of urine, is frequently found in women (Milsom, 2000). The prevalence rates for urinary incontinence are 38% in American women aged 60 years or older (Anger, Saigal, Litwin, & The Urologic Diseases of America Project, 2006) and 56.3% in Korean women aged 65 years or older (Shin, Kang, & Oak, 2008), rising with increasing age. Urinary incontinence is not a life-threatening disease but a medical problem that is very inconvenient for the patient and affects the physical, mental, and social aspects of the lives of those with the condition (Heidrich & Wells, 2004). Most women who experience urinary incontinence also experience lower urinary tract symptoms, such as nocturia and urinary frequency and urgency (Shin et al., 2008), and report musculoskeletal pain, fatigue, and sleep disorders; the disease can also cause dermatitis and an unpleasant odour (Franzen, Johansson, Andersson, Pettersson, & Nilsson, 2009; Heidrich & Wells, 2004). Voiding symptoms related to incontinence can lead to embarrassment, social phobia, social isolation, economic problems,
*Corresponding author. Email: [email protected] Ó 2015 Taylor & Francis
difficulties in performing daily activities, and lower levels of subjective health status, motivation, well-being, personal growth, self-respect, and self-confidence. For these reasons, women with urinary incontinence experience various mental and social problems (Franzen et al., 2009; Heidrich & Wells, 2004; Fultz et al., 2005; Kim & Lee, 2008; Kwon & Lee, 2014; Pons & Clota, 2008; Shin et al., 2008; Trantafylidis, 2009). In addition, women with urinary incontinence have been reported to experience more depression and stress relative to those without the condition (Bartoli, Aguzzi, & Tarricone, 2010; Margalith, Gillon, & Gordon, 2004; Kim, Kim, Lee, & Son, 2013; Melville, Katon, Delaney, & Newton, 2005; Park & Kim, 2009). Depression is particularly prevalent in older individuals with urinary incontinence, as it exerts a significant influence on personal suffering and social interaction (Lekan-Rutledge, 2004). The prevalence of urinary incontinence increases with age, and a significant number of older women experience the condition, which affects their quality of life (QOL) and physical, mental, and social well-being. In addition, comorbidity of urinary incontinence and depression is more common in women relative to men and is experienced by many older women (Kim et al., 2007). Urinary incontinence has very complicated effects on the health of older women; therefore, it is necessary to investigate the disease in a more comprehensive manner that includes consideration of the physical, mental, and psychological effects of the condition rather than viewing it as a merely physical disease (Park & Kim, 2009). Various studies have been conducted to examine urinary
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incontinence with respect to prevalence rates (Anger et al., 2006; Kim & Lee, 2008; Melville et al., 2005), physical issues (Shin et al., 2008; Franzen et al., 2009), mental issues (Bartoli et al., 2010; Trantafylidis, 2009), and social issues (Lekan-Rutledge, 2004; Yip et al., 2013), and QOL (Pons & Clota, 2008; Kwon & Lee, 2014). However, in Korea, research comprises survey studies that depend upon being conducted in specific locations, such as nursing facilities (Kim & Lee, 2008), outpatient departments (Kim, Kim, Kim, Kim, & Jeon, 2011), and other areas that are highly accessible to study participants (Shin et al., 2008; Kim, Park, Jin, Kang, & Shin, 2007), and there have been few studies conducted to examine QOL and mental health in older women with urinary incontinence nationwide. As urinary incontinence is a problem concerning the urogenital organs, most older women try to hide it due to the shame they would experience with the exposure of symptoms, and symptoms of urinary incontinence worsen due to their belief that it is part of the normal ageing process; therefore, conducting studies in the community is preferable to doing so in hospitals and nursing homes (Park & Kim, 2009; Song, Son, Hong, Song, & Cho, 2007). This study was conducted to identify means of helping older women with urinary incontinence to maintain healthy lifestyles, using raw data from the Korea National Health and Nutrition Examination Survey (KNHANES) IV, which is a representative and reliable large-scale survey, to examine healthrelated QOL and mental health in older women with urinary incontinence living in the community. The specific research objectives were as follows: (1) To determine differences in general and healthrelated characteristics according to the presence or absence of urinary incontinence in older women (2) To examine the associations between urinary incontinence and health-related QOL and mental health in older women
Method Study data and participants This study used raw data from the 2nd (2008) and 3rd years (2009) of the KNHANES IV conducted by the Korea Centers for Disease Control and Prevention (KCDC) under the official approval of the institution. The KNHANES is a nationally representative and cross-sectional survey targeting non-institutionalized Korean people. Sampling was carried out to target all types of people in order to represent Korea using stratified, multi-staged, clustered, and probability designs. By introducing the rolling survey sampling method, the KNHANES IV sample became a probability sample, and the circulation sample for each survey year represents the country, and there are independent, homogeneous characteristics between circulation samples. Selected participants were sent a notice of selection prior to the commencement of the survey, via which their identities were verified, the purpose of the study was explained, and
a written consent was obtained. A week prior to the commencement of the survey, participants attended an appointment to complete health and nutrition surveys and undergo an examination. The health and nutrition surveys included one-to-one interviews and self-report questionnaires, while the examination was performed by a specialized examination team at the KCDC. In the second year of the KNHANES IV (2008), 9744 individuals were surveyed out of a potential 12,528 (survey participation rate: 77.8%; KCDC, 2009); in the third year of the KNHANES IV (2009), 10,533 individuals were surveyed out of a potential 12,722 (survey participation rate: 82.8%; KCDC, 2010). Data from 1874 participants aged 65 years or older were analysed. This was a subset of 1969 women aged 65 years or older (participation rate: 9.71%) included in the KNHANES IV secondand third-year (2008 2009) surveys (n D 20,277), with 95 individuals excluded from the analyses due to kidney failure or missing data.
Measures Urinary incontinence Participants’ urinary incontinence was analysed by categorizing ‘yes’ or ‘no’ responses indicating agreement or disagreement, respectively, with the statement ‘I currently suffer from urinary incontinence’ in the health interview survey. Health-related QOL The EuroQol-5 (EQ-5D), EQ-5D index, and EuroQol visual analogue scale (EQ-VAS), all developed by the EuroQol group, were used to measure health-related QOL (The EuroQoL Group, 1990). As a tool for measuring health-related QOL, the EQ-5D was developed to measure simple and overall health for the purpose of evaluating clinical and economic feasibility. The validity and reliability of the EQ-5D have been verified in the general South Korean population (Korea Centers for Disease Control and Prevention, 2011).The EQ-5D is composed of five dimensions including mobility, self-care, usual activities, pain/discomfort, and anxiety/depression. Responses for each dimension are chosen from ‘no problems’, ‘some problems’, or ‘severe problems’. In the EQ-5D index, health-related QOL scores are calculated using a formula to estimate the weighted value for each response to questions regarding these five dimensions, and values range from 1 point, representing perfect health status, to ¡1 point, representing health status worse than death (Lee et al., 2009). The EQ-VAS is a 20 cm vertical analogue scale on which participants rate their overall state of health from 0 (worst imaginable health state) to 100 (best imaginable health state). Mental health Stress and depression variables were used to assess participants’ mental health. For stress, the responses ‘feel very
Aging & Mental Health strongly’, ‘feel strongly’, or ‘feel somewhat’ to the question ‘How much stress do you feel in your everyday life?’ were categorized as ‘yes’, and ‘feel a little’ was categorized as ‘no’. For depression, participants responded ‘yes’ or ‘no’ to the question ‘Have you ever felt so sad or discouraged that it interfered with daily life for more than two successive weeks during the past year?’
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Covariates Covariates used as demographic and health-related variables were based on findings used in previous studies (Anger et al., 2006; Chang, Gonzalez, Lau, & Sier, 2008; Fultz et al., 2005; Kwon & Lee, 2014). Age, area of residence, education, spouse, economic status, and occupation were used as demographic variables. Area of residence was categorized as either urban or rural. Education was classified into middle school or lower, and high school or higher. With respect to the presence or absence of a spouse, living with a spouse was categorized as ‘yes’, and being single or not living with a spouse due to death or divorce was categorized as ‘no’. Economic status was determined by calculating equivalent income (average monthly household income/xnumber of household members); this was used to identify participants in the bottom 25% of the sample, based on household economic status. Occupation was classified as either presence or absence of a current employer. Waist circumference, body mass index (BMI), pregnancy frequency, smoking, drinking, regular exercise, diabetes, and hypertension were used as health-related variables. To measure waist circumference, the bottom of the last rib and the upper part of the iliac crest touched at the midaxillary line, and the midpoint of the two points was marked and measured to the nearest 0.1 cm using a measuring tape (Seca 200; Seca) following expiration. BMI was calculated and expressed as weight (kg)/height (m)2. Smoking status was classified as either current smoker or non-smoker, regardless of past smoking status. The amount of pure alcohol consumed was calculated in grams per day according to the average number of alcoholic beverages consumed and the frequency of alcohol consumption. Participants who consumed an average of 1 15 g of alcohol daily were considered mild to moderate drinkers, and participants who consumed more than 30 g daily were considered heavy drinkers (Choi et al., 2012). Regular exercise was defined as performing strenuous physical activity at least three times weekly for at least 20 minutes at a time. Statistical analysis The Statistical Analysis System (SAS) survey procedure (ver. 9.3; SAS Institute Inc., Cary NC, USA) was used to run a complex sample design based on data analysis from the survey data; this provided sampling weights from the KNHANES and nationally representative estimates. Data were presented as mean § SE for continuous variables or proportion (SE) for categorical variables. Differences in urinary incontinence according to demographic and health-
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related characteristics and QOL were presented as means (SE) or % (SE) and assessed using t tests and x2 verification. In order to determine the relationship between QOL and urinary incontinence, participants’ demographic and health-related characteristics were controlled and an analysis of covariance was performed. In order to determine the association between mental health and urinary incontinence, age, BMI, smoking, drinking, exercise, diabetes, and hypertension were adjusted, and logistic regression analysis was performed. Statistical significance of all results was tested based on a significance level of p < .05.
Results Urinary incontinence according to demographic and health-related characteristics Differences in urinary incontinence according to participants’ demographic and health-related characteristics are presented in Table 1. Greater waist circumference (p D .003) and more frequent regular exercise were observed in participants with urinary incontinence relative to those without (p D .010). There were no statistically significant differences in age, residence, education, economic status, spouse, occupation, BMI, pregnancy frequency, smoking, drinking, diabetes, or hypertension between participants with and without urinary incontinence.
Health-related QOL and mental health in older women with urinary incontinence Differences in urinary incontinence and each dimension of EQ-5D are presented in Table 2. The proportions of participants with pain/discomfort (p D .001) and anxiety/ depression (p D 0.012) were larger in participants with urinary incontinence group relative to those without. Differences in urinary incontinence ratios according to EQ-5D levels are presented in Figure 1. Urinary incontinence ratios differed significantly according to the selfcare, usual activities, and pain/discomfort EQ-5D dimensions. Those who reported some problems with urinary incontinence accounted for the largest proportion of participants in the self-care dimension, 13.4% (p D .040). Those with severe urinary incontinence problems accounted for the largest proportions of participants in the usual activities and pain/discomfort dimensions, 15.8% (p D .039) and 16.2% (p D .001), respectively. Although not statistically significant, the urinary incontinence ratios for participants with severe problems with mobility and anxiety/depression, who constituted the largest proportions of participants in the dimension, were 17.8% (p D .121) and 20.3% (p D .062), respectively. Table 3 presents the associations between healthrelated QOL and urinary incontinence and mental health and urinary incontinence. Model 1 was adjusted for age and sex. Model 2 was the result of adjusted smoking, drinking, and regular exercise from Model 1. Model 3 was the result of adjusted diabetes and hypertension from Model 2. The adjusted means for the EQ-VAS in participants with urinary incontinence were 61.22 (p D .029) in
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Table 1. Prevalence of urinary incontinence according to demographic, health-related characteristics (N D 1874). Urinary incontinence
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Characteristic
No (N D 1685) Mean § SE or % (SE)
Yes (N D 189) Mean § SE or % (SE)
p value
73.3 § 0.2 68 (2.6) 6.7 (0.8) 53.2 (1.8) 39.1 (1.4) 23.1 (1.5) 82.9 § 0.3 24.1 § 0.1 5.8 § 0.1 6.5 (0.8) 0.9 (0.2) 16.6 (1.3) 18.9 (1.2) 63.4 (1.5)
73 § 0.6 66.7(4.9) 5.4 (2) 56.6 (4.8) 38.3 (4.3) 21.8 (3.3) 85.8 § 0.9 24.7 § 0.3 6.2 § 0.3 6.3 (1.9) 0.7 (0.5) 25.5 (3.9) 20.1 (4.5) 67.4 (4.8)
0.705 0.780 0.560 0.524 0.854 0.701 0.003 0.067 0.223 0.923 0.805 0.010 0.070 0.440
Age (yr) Living place (urban) Education (high school) Economic status (Q1) Spouse (yes) Occupation (yes) Waist circumference (cm) BMI (kg/m2) Pregnancy frequency Smoking (current) Drinking (heavy) Regular exercise (yes) Diabetes (yes) Hypertension (yes)
Model 1, 60.95 (p D .017) in Model 2, and 61.14 (p D .027) in Model 3, indicating that all levels were significantly lower relative to those of participants without urinary incontinence. In addition, the adjusted means for the EQ-5D index in participants with urinary incontinence were all significantly lower relative to those of participants without: Model 1: 0.75 (p D .001), Model 2: 0.75 (p D .001), Model 3: 0.75 (p D .002). Even after adjusting for covariates, health-related QOL in participants with urinary incontinence was lower relative to that of participants without urinary incontinence. Using those of participants without urinary incontinence as a reference, odds ratios for stress in Models 1, 2, and 3 were 2.11 (95% CI: 1.41 3.16), 2.07 (95% CI: 1.38 3.10), and 2.01 (95% CI: 1.33 3.03), respectively. Odds ratios for depression in Models 1, 2, and 3 were 1.54 (95% CI: 1.04 2.27), 1.52 (95% CI: 1.03 2.25), and 1.49 (95% CI: 1.01 2.21), respectively. In other words, the risk of stress and depression was 2 and 1.5 times higher, respectively, in participants with urinary incontinence relative to those without. Discussion Among the health problems experienced by older women, urinary incontinence is often recognized as a part of the Table 2. Differences in urinary incontinence and EQ-5D. Urinary incontinence
EQ-5D Mobility Self-care Usual activities Pain/discomfort Anxiety/depression
No (N D 1685) % (SE)
Yes (N D 189) % (SE)
p value
2.8 (0.5) 2 (0.4) 4.9 (0.6) 14.7 (0.9) 3.6 (0.6)
5.3 (1.8) 2.5 (1) 8.2 (2.5) 25.4 (3.8) 8.3 (2.4)
0.082 0.678 0.094 0.001 0.012
course of ageing and can be easily overlooked in everyday life; however, it may have an impact on physical and mental well-being. Therefore, the associations between urinary incontinence and QOL and mental health should be identified in older women to allow them to maintain healthier lifestyles. The results suggested that QOL related to pain/discomfort and anxiety/depression was lower in older women with urinary incontinence relative to that of those without the condition. In addition, many of the participants with urinary incontinence experienced severe problems concerning self-care, usual activities, and pain/discomfort, and although the differences in mobility and anxiety/ depression problems were not statistically significant, there were many participants with urinary incontinence who experienced severe problems in these dimensions. However, in a study that analysed EQ-5D scores in women aged 20 years or older with urinary incontinence (Kwon & Lee, 2014), all five EQ-5D dimensions differed significantly according to participants’ average age. This finding is similar to results suggesting that older individuals with urinary incontinence experienced greater difficulty in performing activities of daily living (Chang et al., 2008; Fultz et al., 2005; Shin et al., 2008). Use of disposable pads and limiting trips and fluids are methods of selfcare in urinary incontinence, and the condition also affects usual activities such as dressing, eating, and bathing in some but not all patients (Johnson, Kincade, Bernard, Busby-Whitehead, & DeFriese, 2000). In addition, the findings from this study support those of other studies in which adults or older people with urinary incontinence experienced musculoskeletal pain, fatigue, and sleeping disorders (Franzen et al., 2009; Kim & Han, 2011). As mentioned above, urinary incontinence is a medical problem that is very uncomfortable to the patient and not only causes physical discomfort and pain but also degrades subjective health status and motivation for life and wellbeing (Heidrich & Wells, 2004). This indicates that
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Figure 1. Difference in urinary incontinence ratios according to EQ-5D levels in older women.
although it is not directly related to lifestyle, urinary incontinence has a negative impact in many physical and psychosocial areas. Therefore, older women with urinary incontinence experience discomfort due to odour and urinary frequency, among other symptoms, which causes problems with usual activities. In addition, a reduction in self-care ability in urinary incontinence results in decreased QOL. The results of this study showed that health-related QOL was lower in the EQ-5D index and EQ-VAS, even after adjusting for multiple covariates. The Medicare Health Outcomes Survey results were similar, in that urinary incontinence was identified as a significant predictor of health-related QOL using a different tool (SF-36) to that used in this study (Ko, Lin, Salmon & Bron, 2005). In addition, QOL was found to vary depending on the type of urinary incontinence experienced (Kim et al., 2007). However, QOL also decreased as the severity of urinary incontinence increased, and QOL tended to be lower as the duration of urinary incontinence increased (Coyne
et al., 2009; Oh & Kim, 2005). Therefore, at the point at which human life expectancy is increasing, frequent urinary incontinence in older women can be an important influencing factor in determining QOL, and active care, involving practices such as prevention, treatment for urinary incontinence, and development of a variety of care products for healthy and happy later years by improving QOL, is required. According to the results of the EQ-VAS, asking participants to record their health status showed that older women with urinary incontinence viewed their health status negatively. This is consistent with the second data analysis result in the Health and Aging Project for older women aged between 57 and 85 in the USA, which found that self-reported health was considered negative if participants experienced urinary incontinence (Yip et al., 2013). Thus, health-related QOL in older women with urinary incontinence was reduced, and in order to improve the quality of their lives, supplementary goods, such as pads or diapers, which may promote self-care and usual
Table 3. Health-related QOL and mental health in older women with urinary incontinence.
Model1 Urine incontinence
Model2 Urine incontinence
Model3 Urine incontinence
EQ_VAS Mean § SE
EQ-5D index Mean § SE
No Yes p value
65.28 § 0.72 61.22 § 1.8 0.029
No Yes p value No Yes p value
Stress
Depression
0.81 § 0.01 0.75 § 0.02 0.001
1 2.11 (1.41, 3.16)
1 1.54 (1.04, 2.27)
65.3 § 0.72 60.95 § 1.78 0.017
0.81 § 0.01 0.75 § 0.02 0.001
1 2.07 (1.38, 3.10)
1 1.52 (1.03, 2.25)
65.37 § 0.72 61.14 § 1.85 0.027
0.81 § 0.01 0.75 § 0.02 0.002
1 2.01 (1.33, 3.03)
1 1.49 (1.01, 2.21)
Note: Model 1 was adjusted for age and BMI. Model 2 is the result of adjusted smoking, drinking, and regular exercise from Model 1. Model 3 is the result of adjusted diabetes and hypertension from Model 2.
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activity, active mediation of exercise, and nursing interventions to relieve pain, are required. The results of this study showed that, in older women with urinary incontinence, stress is approximately twice as high and depression is about 1.5 times higher relative to those without urinary incontinence. This supports findings from studies in which adults and older women with urinary incontinence were more likely to experience depression, distress, and anxiety relative to those without the condition, and depression was negatively correlated with QOL (Bogner et al., 2004; Franzen et al., 2009; Hung, Awtrey, & Tsai, 2014; Kim et al., 2007; Ko et al., 2005; Melville et al., 2005). Therefore, urinary incontinence is a significant factor in depression in the elderly (Chang et al., 2008; Shin et al., 2008). Older women with urinary incontinence not only experience discomfort with the condition but also contend with inconvenience in their daily lives due to requirements to limit water intake and a range of activities and face psychological disorders, including depression, as a result of anxiety, tension, and embarrassment due to unpleasant odour (Oh & Kim, 2005). Therefore, given that urinary incontinence causes mental health problems, such as depression and stress, and QOL is reduced as mental health problems become more severe, it is thought that nursing interventions for mental health problems, such as depression and stress, are required to improve the QOL of older women with urinary incontinence. Regarding differences in urinary incontinence and health-related characteristics in this study, older women with urinary incontinence were found to have thicker waist circumference and exercise more regularly. Results for women aged between 30 and 90 years differed from those of studies showing that prevalence rates differed according to age and BMI (Melville et al., 2005). However, the results of a cross-sectional study targeting women aged 40 years or older who visited a health promotion centre showed a significant difference in urinary incontinence according to BMI and waist circumference (Kim et al., 2011). In the results of a survey targeting women aged 60 years or older in southern Brazil, waist circumference was found to be a significant predictor of urinary incontinence (Krause et al., 2010). Therefore, repeated studies are required to identify effective methods for measuring obesity and assessing urinary incontinence risk factors in older women. In addition, management strategies, such as exercise and diet to reduce abdominal fat in older women, are required. The results of this study showed that participants with urinary incontinence exercised more regularly. Stress incontinence has been reported to be more frequent in physically active women and athletes (Kruger, Dietz, & Murphy, 2007). However, another study found that women who perform moderate exercise were less likely to experience urinary incontinence; therefore, the nature of the correlation between exercise and urinary incontinence is unclear (Kikuchi et al., 2007). While associations could be identified, this study could not explain the causal relationship between urinary incontinence and regular exercise. Therefore, ongoing research is required to
identify the relationships between exercise intensity and obesity, urinary incontinence, and amount and duration of exercise. Urinary incontinence can be said to be a particularly important health problem in older women, because urinary incontinence causes constraints in everyday life, leads to discomfort and pain, reduces QOL, and increases stress and depression in older women. Often, urinary incontinence is simply considered a part of the ageing process, and patients tend to neglect the problem due to the shame associated with urogenital organs and odour. However, it is necessary to increase the recognition of urinary incontinence. In addition, it is necessary to diagnose stress and depression caused by urinary incontinence early, implement appropriate interventions, and provide education, support, and empathy regarding aspects of self-care, such as control of frequent urination, use of a pad during physical activity, and weight management, in older women with urinary incontinence. Interventions involving urinary incontinence management could contribute to QOL improvement and stress and depression reduction in older women. The major strengths of this study were the use of a variety of tools to assess health-related QOL and examine the associations between urinary incontinence and mental health and QOL, and representativeness and large size of the sample. Despite these strengths, the study was subject to the following limitations. First, we could not study QOL and mental health according to subtype and severity, as there was no information available regarding the subtypes and severity of urinary incontinence. Second, this was a crosssectional study and could not explain causal relationships; therefore, there is a need for further longitudinal research. Third, the study participants were all older women, and the findings cannot be generalized to other populations; therefore, future studies should involve men or women of all age groups. Despite these limitations, we believe that this study provided meaningful results, as it is the first study to clearly identify the association between urinary incontinence and mental health and QOL in older Korean women. Conclusion This study showed that health-related QOL was reduced in older women with urinary incontinence, and their stress and depression levels were higher relative to those of women without urinary incontinence. These research findings suggest that social interest and consensus regarding the condition are required in older women with urinary incontinence and that more active and specific nursing intervention programs are needed in future. In addition, a system to monitor the prevention of stress and depression and identify the optimum time for therapeutic intervention in older women with urinary incontinence is required. Through support, encouragement, consensus, promotion, and education regarding care involving factors such as exercise and diet, we should help older women with urinary incontinence to gain
Aging & Mental Health vitality and improve their QOL by improving self-care and enhancing activities of daily living. Finally, we believe that expanding financial support for community and senior citizen centres and seniors’ programs for the elderly would be helpful in improving QOL and managing chronic disease in the elderly. Acknowledgments This study was performed using raw data from the KNHANES IV was conducted by the KCDC.
Disclosure statement The authors have no conflicts of interest to declare.
Funding
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No financial support was received for this research.
References Anger, J.T., Saigal, C.S., Litwin, M.S., & The Urologic Diseases of America Project. (2006). The prevalence of urinary incontinence among community dwelling adult women: Results from the National Health and Nutrition Examination Survey. The Journal of Urology, 175(2), 601 604. Bartoli, S., Aguzzi, G., & Tarricone, R. (2010). Impact on quality of life of urinary incontinence and overactive bladder: A systematic literature review. Urology, 75(3), 491 500. Bogner, H.R., Gallo, J.J., Sammel, M.D., Ford, D.E., Americam, H.K., & Eaton, W.W. (2004). Urinary incontinence and psychological distress in community-dwelling older African Americans and Whites. Journal of the American Geriatrics Society, 52(11), 1870 1874. Chang, C.H., Gonzalez, C.M., Lau, D.T., & Sier, H.C. (2008). Urinary incontinence and self-reported health among the US medicare managed care beneficiaries. Journal of Aging and Health, 20(4), 405 419. Choi, J.Y., Ha, H.S., Kwon, H.S., Lee, S.H., Cho, H.S., Yim, H. W., . . . Park, Y.M. (2012). Characteristics metabolically obese, normal-weight women differ by menopause status: The Fourth Korea National Health and Nutrition Examination Survey. Menopause, 20, 85 93. Coyne, K.S., Wein, A.J., Tubaro, A., Sexton, C.C., Thompson, C.L., Kopp, Z.S., & Aiyer, L.P. (2009). The burden of lower urinary tract symptoms: Evaluating the effect of LUTS on health related quality of life, anxiety and depression: EpiLUTS. British Journal of Urology International, 103(3), 4 11. Franzen, K., Johansson, J.E., Andersson, G., Pettersson, N., & Nilsson, K. (2009). Urinary incontinence in women is not exclusive a medical problem: A population-based study on urinary incontinence and general living conditions. Scandavian Journal UroloNephrology, 43(3), 226 232. Fultz, N.H., Rahrig Jenkins, K., ;stbye, T., Taylor Jr, D.H., Kabeto, M.U., & Langa, K.M. (2005). The impact of own and spouse’s urinary incontinence on depressive symptoms. Social Science & Medicine, 60(11), 2537 2548. Heidrich, S.M., & Wells, T.J. (2004). Effects of urinary incontinence: Psychological well-being and distress in older community-dwelling women. Journal of Gerontological Nursing, 30(5), 47 54. Hung, K.J., Awtrey, C.S., & Tsai, A.C. (2014). Urinary incontinence, depression, and economic outcomes in a cohort of women between the ages of 54 and 65 Years. Obstetrics & Gynecology, 123(4), 822 827.
7
Johnson 2nd, T.M., Kincade, J.E., Bernard, S.L., Busby-Whitehead, J., & DeFriese, G.H. (2000). Self-care practices used by older men and women to manage urinary incontinence: Results from the national follow-up survey on self-care and aging. Journal of the American Geriatrics Society, 48(8), 894 902. Kikuchi, A., Niu, K., Ikeda, Y., Hozawa, A., Nakagawa, H., Guo, H., . . . Nagatomi, R. (2007). Association between physical activity and urinary incontinence in a communitybased elderly population aged 70 years and over. European Urology, 52(3), 868 874. Kim, J.H., Kim, Y.H., Kim, J.J., Kim, S.M., & Jeon, M.J. (2011). The impact of symptomatic urinary incontinence on female sexual function in middle to old-aged Korean women. Korean Journal of Obstetrics & Gynecology, 54(12), 778 783. Kim, K.H., Park, H.J., Jin, L.H., Kang, Y.H., & Shin, K.R. (2007). The correlation among quality of life, depression, and urinary incontinence of elderly women in a urban city. Journal of the Korean Gerontological Society, 27(4), 943 962. Kim, M.S., & Lee, S.H. (2008). Prevalence rate and associated factors of urinary incontinence among nursing home residents. Journal of Korean Academic Nursing, 38(1), 92 100. Kim, M.Y., Kim, Y.H., Lee, J.Z., & Son, H.M. (2013) Symptom bother, physical and mental stress, and health-related quality of life in women with overactive bladder syndrome. Korean Journal Women Health Nursing, 19(4), 295 305. Kim, Y.H., & Han, J.S. (2011). Factors related to the quality of sleep in the elderly women. Journal of the Korea AcademiaIndustrial Cooperation Society, 12(10), 4467 4474. Ko, Y., Lin, S.J., Salmon, J.W., & Bron, M.S. (2005). The impact of urinary incontinence on quality of life of the elderly. The American Journal of Managed Care, 11(4), S103 S111. Korea Centers for Disease Control and Prevention (KCDC). (2009). Korea Health Statistics 2008: Korea National Health and Nutrition Examination Survey (KNHANES IV-1). Retrieved from http://knhanes.cdc.go.kr/knhanes/index.do Korea Centers for Disease Control and Prevention (KCDC). (2010). Korea Health Statistics 2009: Korea National Health and Nutrition Examination Survey (KNHANES IV-2). Retrieved from http://knhanes.cdc.go.kr/knhanes/index.do Korea Centers for Disease Control and Prevention. (2011). Validity and reliability evaluation for EQ-5D in Korea. Retrieved from http://www.cdc.go.kr/CDC/info/CdckrInfo0201.jsp Krause, M.P., Albert, S.M., Elsangedy, H.M., Krinski, K., Goss, F. L., & daSilva, S.G. (2010). Urinary incontinence and waist circumference in older women. Age and Ageing, 39(1), 69 73. Kruger, J.A., Dietz, H.P., & Murphy, B.A. (2007). Pelvic floor function in elite nulliparous athletes. Ultrasound in Obstetrics Gynecology, 30(1), 81 85. Kwon, C.S., & Lee, J.H. (2014). Prevalence, risk factors, quality of life, and health-care seeking behaviors of female urinary incontinence: Results From the 4th Korean National Health and Nutrition Examination Survey VI. International Neurourology Journal, 18(1), 31 36. Lee, Y.K., Nam, H.S., Chung, L.H., Kim, K.Y., Yang, H.K., Kwon, I.S., . . . Kim, Y.T. (2009). South Korean time tradeoff values for EQ-5D health status: Modeling with observed values for 101 health states. Value in Health, 12(8), 1187 1193. Lekan-Rutledge, D. (2004). Urinary incontinence strategies for frail elderly women. Journal of Urological Nursing, 24(4), 281 301. Margalith, I., Gillon, G., & Gordon, D. (2004). Urinary incontinence in women under 65: Quality of life, stress related to incontinence and patterns of seeking health care. Quality of Life Research, 13, 1381 1390. Melville, J.L., Katon, W., Delaney, K., & Newton, K. (2005). Urinary incontinence in US women: a population-based study. Archives of Internal Medicine, 165(5), 537 542.
8
Y. Kwak et al.
Downloaded by [Ryerson University] at 09:15 26 April 2015
Milsom, I. (2000). The prevalence of urinary incontinence. ActaObstetricia et GynecologicaScandinavica, 79, 1056 1059. Oh, H.S., & Kim, M.K. (2005). Factors affecting the severity of urinary incontinence and the quality of life of women with urinary incontinence. Journal of Korean Academy of Nursing, 35(3), 469 477. Park, S., & Kim, J. (2009). The effects of lower urinary tract symptoms on depression and quality of life among women in urban areas. Journal of Korean Academy Community Health Nursing, 20(4), 522 530. Pons, M.E., & Clota, M.P. (2008). Coital urinary incontinence: Impact on quality of life as measured by the King’s Health Questionnaire. International Urogynecology Journal, 19(5), 621 625. Shin, K.R., Kang, Y.H., & Oak, J.W. (2008). The relationship of quality of sleep, depression, late-life function and disability in community-dwelling older women with urinary incontinence. Journal of Korean Academy of Nursing, 38(4), 573 581.
Song, Y.S., Son, Y.J., Hong, S.K., Song, J.E., & Cho, H.K. (2007). Anxiety, depression and quality of life of married women with urinary incontinence living in the community. The Korean Journal of Fundamentals of Nursing, 14(4), 483 492. The EuroQoL Group (1990). EuroQol A new facility for the measurement of health-related quality of life. Health Policy, 16(3), 199 208. The Korea Institute for Health and Social Affairs (2014). Healthy life expectancy in Korea. Issue & Focus, 247(8), 1 8. Retrieved from http://www.kihasa.re.kr/html/jsp/publi cation/periodical/focus/list.jsp Trantafylidis, S.C.A. (2009). Impact of urinary incontinence on quality of life. Pelviperineology, 28, 51 53. Yip, S.O., Dick, M.A., McPencow, A.M., Martin, D.K., Ciarleglio, M.M., & Erekson, E.A. (2013). The association between urinary and fecal incontinence and social isolation in older women. American Journal of Obstetrics Gynecology, 208(2), 146.e1 146.e7.
