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Effectiveness of Continence Promotion for Older Women Via Community Organisations: a Cluster Randomised Trial

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Effectiveness of Continence Promotion for Older Women Via Community Organisations: a Cluster Randomised Trial BMJ Open: first published as 10.1136/bmjopen-2013-004135 on 10 December 2013. Downloaded from Open Access Research Effectiveness of continence promotion for older women via community organisations: a cluster randomised trial Cara Tannenbaum,1 Rona Agnew,2 Andrea Benedetti,3 Doneal Thomas,4 Eleanor van den Heuvel5 To cite: Tannenbaum C, ABSTRACT et al Strengths and limitations of this study Agnew R, Benedetti A, . Objectives: The primary objective of this cluster Effectiveness of continence randomised controlled trial was to compare the ▪ promotion for older women First study to provide level 1 evidence that con- effectiveness of the three experimental continence via community organisations: tinence promotion is an effective strategy for a cluster randomised trial. promotion interventions against a control intervention improving urinary symptoms among untreated BMJ Open 2013;3:e004135. on urinary symptom improvement in older women with community-dwelling older women. doi:10.1136/bmjopen-2013- untreated incontinence recruited from community ▪ Participants were recruited via community orga- 004135 organisations. A second objective was to determine nisations with representation across diverse whether changes in incontinence-related knowledge socioeconomic strata. ▸ Prepublication history for and new uptake of risk-modifying behaviours explain ▪ Rates of knowledge acquisition and behaviour this paper is available online. these improvements. change provide an explanatory mechanism for To view these files please Setting: 71 community organisations across the UK. the observed improvements in incontinence in visit the journal online Participants: 259 women aged 60 years and older participants receiving the combined education (http://dx.doi.org/10.1136/ with untreated incontinence entered the trial; 88% plus self-management strategy. bmjopen-2013-004135). completed the 3-month follow-up. ▪ Only self-reported outcomes and crude dichot- omous measures of behaviour change were col- Received 27 September 2013 Interventions: The three active interventions Revised 5 November 2013 consisted of a single 60 min group workshop on lected so results must be interpreted with Accepted 7 November 2013 (1) continence education (20 clusters, 64 women); caution. (2) evidence-based self-management (17 clusters, 70 women); or (3) combined continence education and self-management (17 clusters, 61 women). The control http://bmjopen.bmj.com/ intervention was a single 60 min educational group Conclusions: Continence education combined with workshop on memory loss, polypharmacy and evidence-based self-management improves symptoms of osteoporosis (17 clusters, 64 women). incontinence among untreated older women. Community Primary and secondary outcome measures: The organisations represent an untapped vector for delivering primary outcome was self-reported improvement in effective continence promotion interventions. incontinence 3 months postintervention at the level of Trial registration: ClinicalTrials.gov ID number the individual. The secondary outcome was change in NCT01239836. the International Consultation on Incontinence on September 30, 2021 by guest. Protected copyright. Questionnaire (ICIQ) from baseline to 3-month follow- up. Changes in incontinence-related knowledge and behaviours were also assessed. Results: The highest rate of urinary symptom INTRODUCTION improvement occurred in the combined intervention Urinary incontinence is more frequent than group (66% vs 11% of the control group, prevalence breast cancer, heart disease or diabetes difference 55%, 95% CI 43% to 67%, intracluster among older women, but remains a stigma- correlation 0). 30% versus 6% of participants reported tised and untreated condition despite its – significant improvement respectively (prevalence high prevalence.1 4 In the USA, Canada, the difference 23%, 95% CI 10% to 36%, intracluster UK and other European countries, up to correlation 0). The number-needed-to-treat was 2 to 40% of women aged 65 years and older achieve any improvement in incontinence symptoms, and 5 to attain significant improvement. Compared to experience involuntary urine leakage, but – 1–4 For numbered affiliations see controls, participants in the combined intervention little more than 15 30% seek care. Even end of article. reported an adjusted mean 2.05 point (95% CI 0.87 to fewer physicians feel competent evaluating 56 3.24) greater improvement on the ICIQ from baseline or treating incontinence. Urinary incontin- Correspondence to to 3-month follow-up. Changes in knowledge and self- ence is associated with obesity, cardiovascular Dr Cara Tannenbaum; cara. reported risk-reduction behaviours paralleled rates of disease, diabetes, depression, social isolation, [email protected] improvement in all intervention arms. decline in function, falls, nursing home Tannenbaum C, Agnew R, Benedetti A, et al. BMJ Open 2013;3:e004135. doi:10.1136/bmjopen-2013-004135 1 BMJ Open: first published as 10.1136/bmjopen-2013-004135 on 10 December 2013. Downloaded from Open Access – admission and onerous out-of-pocket expenses.6 10 In and Asian caregiver associations.16 Organisations were many cases incontinence can be improved, and even contacted strategically by convenience sampling, word of cured, when evidence-based diagnostic and treatment mouth and referral. A research coordinator approached – strategies are appropriately applied.61114 community organisations to join the trial by telephone, It is a commonly held misconception that incontin- email and newspaper advertising. ence is a normal part of ageing.15 Not-for-profit organi- The inclusion criteria for participants were women sations seek to raise continence awareness worldwide aged 60 years and older who reported urinary incontin- and promote treatment for incontinent individuals. ence at least once weekly on the International Media campaigns, brochures and public awareness lec- Consultation on Incontinence Questionnaire (ICIQ), tures attempt to destigmatise incontinence and increase and who were not under active treatment for incontin- help-seeking, but the effectiveness of these initiatives for ence. For privacy reasons, many community organisa- reaching their target population remains unknown.15 tions were uncomfortable screening their members for Transmission of public health education via community incontinence in advance, so eligibility to participate in organisations is an unexplored strategy for improving the trial could only be ascertained by the research urinary symptoms.16 Data from randomised trials are coordinator on the day of delivery of the intervention.16 needed to determine whether the delivery of an Eligibility to participate in the trial was established by evidence-based continence intervention via community asking all attendees at the workshop to complete a base- organisations is an effective method for treating line screening questionnaire on arrival. At this time, a incontinence. study information sheet and a consent form were distrib- The primary objective of this cluster randomised con- uted to all participants. All women, regardless of eligibil- trolled trial was to compare the effectiveness of the ity or desire to enrol in the trial, were permitted to stay three experimental continence promotion interventions for the workshop. Only those women who wished to against a control intervention on urinary symptom enrol in the trial submitted the signed consent form to improvement in older women with untreated incontin- the workshop facilitator following the delivery of the ence recruited from community organisations. A second intervention, however all attendees were encouraged to objective was to determine whether changes in submit the baseline screening questionnaire even if they incontinence-related knowledge, attitudes and new were continent or did not wish to participate in the trial. uptake of risk-modifying behaviours explain improve- ments in incontinence. We hypothesised that continence Interventions education combined with evidence-based self- The interventions were applied at the level of each management would yield the greatest improvement in cluster. The three experimental interventions to be incontinence symptoms, measured at the level of the tested were continence education, self-management individual, 3 months postintervention. including the distribution of an evidence-based risk http://bmjopen.bmj.com/ factor reduction tool for incontinence, and a combined intervention that included both components. The sham METHODS control intervention was a lecture on health promotion Study design and oversight for older women that addressed topics other than incon- A four arm, parallel-group, controlled, cluster rando- tinence. All interventions were delivered once in group mised trial was conducted. The study design, recruit- format to 8–16 women by the same facilitator at a venue 16 ment methods and interventions have been reported. of the organisation’s choosing, and lasted 60–90 min. Clustering was at the level of the community organisa- A slide presentation with a pre-established script pre- on September 30, 2021 by guest. Protected copyright. tion, from whence participants were recruited. The pared for the facilitator was delivered at each workshop. choice of a cluster design served to prevent contamin- The continence promotion intervention incorporated ation between participants in the same community elements of constructivist learning that challenged older organisation. The trial was designed by two of the adults’ erroneous
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