The effect of a self-care programme on urinary incontinence and self-esteem in elderly men dwelling in nursing homes in Iran

Abstract

Introduction

Whilst self-care programme involving comprehensive lifestyle plans including physical and behavioural interventions have reported positive outcomes for the aged suffering from urinary incontinence (UI), very few programmes have been implemented amongst Iranian nursing home residents, particularly in men.

Objectives

The aim of this study was to examine the effect of a self-care programme on UI and self-esteem in elderly men dwelling in nursing homes in Iran.

Materials and methods

Sixty-one elderly men (aged 60–75 years of age), at two different sites and living in nursing homes in the west of Iran, suffering from urinary incontinence were included in this study. Participants were selected using convenience sampling based on selected and randomized criteria in experimental and control groups. Data collection tools included Mini-Mental State Examination (MMSE), Rosenberg Self-Esteem Scale Questionnaire (RSES), International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF), and demographic information form. Data were analysed using SPSS vesion18 (SPSS Inc., Chicago, IL).

Results

A significant decrease in the mean scores of ICIQ-SF in the experimental group compared with the control group following intervention (p < .001). Furthermore, a significant increase was observed in self-esteem in the experimental group compared to the control group (p < .001).

Conclusion

The study findings demonstrate that the self-care programme significantly reduced UI in elderly men living in nursing homes, and that this in turn contributed to boosting their self-esteem. Implementing such an intervention has shown to be useful in managing both UI and improving self-esteem in this patient population.

Keywords:

• Self-care programme
• urinary incontinence
• self-esteem
• nursing home
• elderly men

Introduction

Urinary incontinence (UI) also known as involuntary urination is an important issue in geriatric health care and a common and distressing problem, which may have a large impact on quality of life [1]. According to the United Nations Population Fund (UNFPA), the rapidly growing, global, ageing population will increase from 12.3% to almost 22% by 2050 [2].

Iran is now faced with the phenomenon of an aging population [3]. The general census results in Iran indicate that the population of the elderly has increased roughly six times over a period of 50 years (1966–2016) and this trend is set to continue [4].

The phenomenon of an ageing population brings about its own set of challenges including health, economic and social consequences [5]. One of the most important organs that are subjected to age-related changes is the genitourinary system [6]. UI is the most common urologic disorder affecting both men and women in the United States [7,8]. The International Continence Society defines UI as an involuntary urinary leakage [9]. Whilst UI is not an urgent life-threatening event, it is a silent epidemic illness [10]. The prevalence of UI increased with age. In Markland et al.’s study, the prevalence of UI among men aged 75 years and above was higher than other age groups [11]. The prevalence of UI in community-dwelling elderly is varied in different countries and has been reported between 14% and 55% in various studies [8,12–15] and its prevalence may be even significantly higher in institutions. However, the rate of UI may be underestimated due to elder embarrassment. Some elderly people also may suppose that UI is a normal consequence of ageing and lack of knowledge as to where to seek treatment [13].

The prevalence of UI has been reported to be higher among women; it is also highly prevalent among elderly males [11,15–17]. Indeed studies have reported the higher prevalence of UI among elderly men than women. Mohd Sidik et al. reported that the prevalence of UI amongst elderly men and women in Malaysia was estimated to be as high as 18% and 3.3%, respectively [18]. In fact, the prevalence and the severity of UI among elderly nursing home residents are thought to be even higher than the general elderly community-dwelling population due to conditions such as dementia and immobility [19]. One systematic review estimated that the prevalence of UI among elderly nursing home residents was between 43% and 77% [20].

The adverse impact on the physical, social, emotional and psychological health of the elderly with UI is also well known [12,21–25]. UI is associated with pain, increase the risk of pressure ulcers, infections, fall, hypertension and fracture [20,26,27]. Furthermore, a number of studies demonstrate an association between incontinence and comorbid psychiatric disorder such as anxiety and depression which may lead to social isolation and issues of poor self-esteem [28,29]. Dugan et al. reported that depressive symptoms were more likely to be reported by adults with UI and that the degree of depression was linked to the severity of incontinence. Depression and low self-esteem in incontinent individuals negatively impact quality of life in the elderly. Despite the large number of studies on UI and its associated adverse health outcomes, the management of UI amongst male residents residing in nursing homes has been under investigated to date.

The 2013 European Association of Urology guidelines recommend the use of therapeutic interventions including conservative management, pharmacological management and surgical treatment [30]. Amongst these therapeutic interventions, conservative approaches that do not involve either pharmacological or surgical intervention and take into account simple and low cost management can be implemented at the primary care level. Indeed, self-care programmes which target comprehensive lifestyle programmes and physical and behavioural therapy are highly recommended for the population suffering from UI [31].

Self-care is an important daily set of skills, which is practised by individuals to increase and maintain health and self-esteem [32]. Self-care can substantially reduce the burden of chronic diseases especially in developing countries with an already overburdened health care system [33]. The findings of previous studies reveal that self-care is the most important form of primary health care both in developing and developed countries [34–36]. Whilst these interventions are relatively easy and inexpensive, their efficiency is highly dependent on the motivation and acceptance of the patients and communities [37]. Findings of a qualitative study in Korea identified some facilitators of self-care behaviours of nursing home residents including the awareness of their health condition, support from the staff, willingness to engage in self-care, and dwelling in the facility. Schoberer et al. demonstrated that self-care educational interventions can be used to empower nursing home residents, and educational strategies including group education, individual counselling, and the use of motivational and encouragement techniques effectively help nursing home residents to become more empowered regarding self-care behaviours [38].

In view of the rapidly growing ageing population, it is crucial to promote self-care programmes, especially nursing home residents and particularly in developing countries, to manage their long-term chronic conditions including UI. Current conservative, behavioural interventions including prompted and timely voiding, diet and fluid intake, and habit training combined with exercise have been examined among community-dwelling elderly populations with UI, but these consisted mainly for women. To date, very little is known regarding the effectiveness of these behavioural management strategies and impact on self-esteem in men residing in nursing homes. Therefore, this study aimed to examine the effectiveness of self-care training programme on UI and impact on self-esteem of men residing in nursing homes in Iran.

Materials and methods

Study design

Sixty-one, elderly male residents of nursing homes, in two different cities in the west of Iran, suffering from UI were included in this study. Elder people who suffered from UI and were dwelt in the nursing homes during the study were included.

Participants were selected using convenience sampling and based on selected and randomised criteria were divided into two groups, experimental group (n = 30) and control group (n = 31). Inclusion criteria included male residents aged between 60 and 75 years of age, a UI score of ≥3, clinical symptoms of UI for the last 6 months and willing to participate in the study. Exclusion criteria included female residents, residents with serious psychological disorders and cognitive impairment, lower urinary system malignancy and those who had not participated in more than two sessions of self-care programme.

Study instrument

Data collection was composed of three parts. The first part was the Mini-Mental State Examination (MMSE) to examine the cognitive function of participants. The overall score of MMSE ranged from 1 to 30. The cut-off point of MMSE for cognitive decline was based on the participant’s educational level that included 15 points for illiterate patients, 22 points for those with less than 12 years of education and 27 points for those with more than 12 years of education [39]. This instrument was used as a screening tool for inclusion/exclusion criteria of participants into the study. The second part was the short form of International Consultation on Incontinence Questionnaire (ICIQ-SF). This scale includes six items, the first two items are demographic variables and remaining four items evaluate UI. The mean scores of ICIQ-SF equal the sum of items 3–5 [40]. The third part of the instrument was the Rosenberg Self-Esteem Scale (RSES) [41]. This questionnaire measures global self-worth and consists of 10 items or opinions showing the real feeling of a person about each item based on four-point Likert scale, ranging from 1 (totally disagree) to 4 (totally agree), and assesses positive and negative feelings of a person about him/herself [42]. Patient demographic characteristics of participants were also collected.

The validity of the aforementioned scales has been previously validated by Anasri et al. (2010) for MMSE; Kashanian et al. (2012) and Jahromi et al. (2013) for ICIQ; and Jahromi et al. (2013) for RSES [43–46].

The ICIQ-SF and RSES content validities were also assessed and verified by the panel consisting of 10 members who were expert in the topic. The final version of the questionnaires was tested for reliability in a pilot study involving 25 patients with UI. Cronbach's alpha coefficients values for ICIQ-SF and RSES were 0.85 and 0.83, respectively.

Ethical issues and data collection

The study proposal was approved by the regional ethics committee of Ilam University of Medical Sciences. All patients who participated in the study provided informed consent.

Intervention

Following informed consent, patients’ UI was recorded and classified using the ICIQ-SF scale criteria. Patients’ UI diagnosis was also confirmed by an independent urologist for both groups. A total of 61 patients with UI diagnosis randomly assigned to either the experimental group (n = 30) or the control group (n = 31).

Patients in both groups were also asked to complete a RSES and a demographic/disease related questionnaire before the intervention. Due to poor illiteracy of most of the participants, the scales were filled by the researcher by asking questions from the participants.

The intervention for the experimental group included eight 45–60-min sessions during an eight week period (Table 1). Each session was held once a week and patients were visited every other day by the research team. In each session, first, light strengthening exercises and the pelvic floor exercise encompassing 5-s contractions were performed, followed by 10 s of rest with a frequency of 60 times per day. In addition, training was provided, by way of lectures, discussing in groups, and role-play, on ways to improve UI and the role of behavioural and lifestyle factors in the health of the urinary system.

Table 1. Topics of the 8-week self-care educational programme to manage urinary incontinence.

Week	Self-care programme outlines	Activity
1	What is UI and how does it occur Myths about UI	Educational film Group discussion Sharing experiences regarding UI
2	Diagnosis and management of UI Training regarding balance and muscle strength exercises Identifying the correct muscles for pelvic exercises	Role playing Balance and muscle strength exercises Pelvic muscle exercises Group discussion
3	Life-style modification to manage UI Bladder training Managing diet and fluid intake	Positive reinforcement Pelvic muscle exercises sharing experience regarding life style determinants of UI
4	Effective communication with care providers Smoking cessation and the role of weight control in UI	Positive reinforcement Balance and muscle strength exercises Pelvic muscle exercises
5	Managing bowel regularity The signs and symptoms of UTI How to prevent UTI	Self-management group sessions Balance and muscle strength exercises Pelvic muscle exercises
6	Training regarding ADLs Revision and reflection on the UI self-care programme	Balance and muscle strength exercise Pelvic muscle exercises Role playing
7	Other treatment options for UI When it is necessary to call the doctor regarding UI	Balance and muscle strength exercises Pelvic muscle exercises Group discussion
8	Review the summary of the UI self-care programme What should participants do regularly	Pelvic muscle exercises Group discussion Educational film

UI: urinary incontinence; UTI: urinary tract infections; ADLs: activities of daily living.

The session’s content was also provided in the form of an educational booklet, in which the majority of the content were explained pictorially to aid better understanding. The intervention was performed in face to face and group discussion manner and also the films and pictures of educational contents and exercises were shown. At each session, the previous session contents were reviewed in order to make sure that participants understood the content and so that the exercises were performing properly.

For bladder training exercises, a table was used in which the patients recorded the intervals between voiding for the first day, then, 3–5 min were added to this interval each day so as to reach the normal time. Following the 8-week intervention period, patients were followed up for a further 4 weeks. During this follow-up period, participants were monitored to ensure that they were continuing to perform their self-care training and exercise programme.

At 12 weeks, after the follow-up period, patients in the both experimental and control groups were once again asked to complete the study questionnaires. Patients in the control group received education and counselling following the completion of the study.

The data were analysed using SPSS vesion18 (SPSS Inc., Chicago, IL). Descriptive statistics such as the mean and standard deviation and inferential statistics such as Chi-square, independent and paired t-test were used for data analysis.

Results

The mean age of the patients was 68.18 years (SD 4.29). The age range was between 60 and 75 years. All patients were male. The majority were widowed (69%) and the number of single, divorced and married patients was 16.4%, 11.4% and 3.3%, respectively (Table 2). Baseline demographic characteristics of patients in experimental and control groups were similar.

Table 2. Baseline demographic characteristics.

Demographic variable	Experimental group (n = 30)	Control group (n = 31)	p Value
Age (year)
60–65	6	8	p = .062
65–70	14	12
70–75	10	11
Education
Illiterate	24	27	p = .254
Primary education	6	4
Number of children
None	12	15	p = .170
1–3	15	15
>3	3	1
Marital status
Widower	20	22
Divorced	3	4	p = .190
Single	6	4
Married	1	1

There was a statistically significant decrease in the mean scores of UI severity in the experimental compared to both the baseline and the control group at 12 weeks (p < .001 and p < .001, respectively) (Table 3). There was also a significant increase in the experimental group self-esteem scores versus baseline and versus the control group at 12 weeks (p < .001 and p < .001, respectively; Table 3).

Table 3. Self-esteem and urinary incontinence scores of participants based on type and severity in both groups at the baseline and 12 weeks.

	Control (n = 31)		Experiment (n = 31)		p Value
	Baseline	12 Weeks	Baseline	12 Weeks
ICIQ-SF	15.93 ± 1.93	15.41 ± 1.78	16.06 ± 1.55	10.60 ± 2.22*
Change from baseline to follow-up	0.51 ± 2.74		5.46 ± 2.68		<.001
RSES	15.77 ± 2.67	15.29 ± 3.40	14.80 ± 4.31	20.70 ± 4.74*
Change from baseline to follow-up	−0.48 ± 3.00		5.90 ± 6.84		<.001

Values are presented as mean ± standard deviation.

ICIQ-SF: International Consultation on Incontinence Questionnaire-Short Form; RSES, Rosenberg Self-Esteem Scale.

* p < .01 compared with baseline within the group.

Table 4 shows the severity of UI based on ICIQ-SF categories in both experiment and control groups at the baseline and 12 weeks. The majority of participants in the experimental and control group had severe UI at the baseline. However, there was a statistically significant separation between these two groups at week 12 whereby and most of the participant in the experiment group had moderate UI.

Table 4. Severity of urinary incontinence based on ICIQ-SF categories in both groups at the baseline and 12 weeks.

	Baseline		12 weeks
ICIQ-SF categories	Control (n = 31)	Experiment (n = 31)	Control (n = 31)	Experiment (n = 31)
Moderate	2 (6.5%)	0 (0%)	1 (3.2%)	27 (90%)
Severe	28 (90.3%)	28 (93.3%)	29 (93.5%)	3 (10%)
Very severe	1 (3.2%)	2 (6.7%)	1 (3.2%)	0 (0%)
p Value	.314		<.001

Discussion

This study sought to examine the effect of a self-care programme on both UI and self-esteem in elderly men dwelling in nursing homes in the west of Iran. A number of studies suggest a higher prevalence of UI among elderly women than that of men [15,17], although studies also report that men were unwilling to report their UI [14,47]. To date, few studies have examined the effectiveness of educational programmes on male UI and indeed self-esteem in Iran. This was one of the first studies investigating UI among elderly men in nursing homes in Iran as the majority of studies previously conducted were among elderly women.

No statistically significant differences were observed in either baseline demographics or other baseline assessments between the experimental group and the control group. Baseline measurements of self-esteem were low to moderate in both participant study groups. Post-test results revealed, unsurprisingly, a significant increase in the self-esteem scores of participants in the experimental group compared with the control group. Shamliyan et al. in 2009 reported that UI in community-dwelling men negatively affected self-esteem and quality of life and increased the risk of institutionalisation [15].

Consistent with our findings, Jahromi et al. (2013) in Iran and Jacomo et al. (2014) in Brazil also report positive effects of pelvic floor exercise on UI and self-esteem in elderly women [44,48]. Tennstedt et al. (2010) in Spain also examined the relationship between UI with self-esteem and quality of life and found that as the severity of UI increases, self-esteem and quality of life decrease significantly [49].

Our findings also indicate that the self-care programme was effective in decreasing the severity of UI symptoms. The effect of non-pharmacological interventions including conservative interventions and exercise on UI has been investigated in clinical studies previously. Interventions such as proper nutrition, prevention of constipation, weight loss and physical activity have been specified as ways to improve UI symptoms [21,22,50]. Our findings were consistent with De Gagne et al. (2015) study, they found a self-management programme which included modifying factors such as dietary regimen, fluid intake, smoking, weakened bowel and pelvic floor muscles, obesity, and physical inactivity were effective for UI in Korean older women living in rural regions [51]. These findings were also consistent with Siegel (2014)’s study in which pelvic floor muscle exercise was demonstrated to be helpful for UI stress that follows prostate surgery and overactive bladder [52].

Most of the participants within this study reported that they felt embarrassed about their UI problems and were not comfortable discussing their UI symptoms before this intervention. The intervention was provided mainly in groups with the elderly men themselves playing a role in the provision of education. This method of training allowed them to share their experiences and increased social participation. Given that older people living in nursing homes experience more social isolation than their community dwelling counterparts, such interventions, in addition to positive effects on the elder physical health, also improve self-esteem, quality of life and motivation for positive changes.

The findings of this study revealed that the self-care programme was effective in improving UI among elderly men living in nursing homes with limited resources for management and treatment of urinary tract disorders. The UI self-care programme was effectively implemented in nursing homes with male residents. Nursing homes in Iran usually have limited financial and specialist resources. Such interventions in these care settings may have many benefits for the elderly suffering from chronic conditions such as UI and also have benefits on their self-esteem and therefore impact positively on their quality of life.

The limitations of this study were (a) a small sample size of elderly men living in nursing homes in two cities in the west of Iran. So these findings may not necessarily be generalised to other regions of Iran. (b) The majority of the elderly people were from the lower social classes and were mostly illiterate; therefore, the provision of training was repeated several times over and beyond that of literate population. (c) The intervention was provided within a limited time and its effectiveness was evaluated shortly after the intervention. Although positive results were obtained, the question raised here is whether the improvement will continue after the end of the intervention period? Clearly, further research is required to assess the longer-term follow-up effects of self-care programmes on improving the UI and self-esteem in the elderly male. Finally, the higher prevalence of UI among elderly women in the literature has led to the fact that the majority of studies on this topic have been devoted to women. Addressing ways to improve UI in men, especially elderly men living in nursing homes would be of great interest in future studies.

Acknowledgements

The authors would like to thank Dr Jo Nettleship, Astra Health, for editorial assistance.

Disclosure statement

There are no conflicts of interest.

Additional information

Funding

The authors appreciate the support of the authorities of Ilam University of medical sciences, the health services of Ilam, the staff within the nursing homes in Ilam and Sanandaj, and the vulnerable elderly who participated in the study.