الفهرس 
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Abstract
Summary
T
he international continence society defines urinary incontinence as: the condition in which the involuntary loss of urine is a social and demonstrable problem (Shaw et al., 2019). Urinary incontinence (UI), the involuntary loss of urine, has a prevalence of approximately 25% in young women (aged 14 to 21 years) (Coyne et al., 2020), 44% to 57% in middle-aged and postmenopausal women (aged 40 to 60 years) and 75% in elderly women (aged 70 year and older (Abrams et al., 2020).
As regard to incidence in Egypt the exact magnitude of the problem of urinary incontinence (UI) in Egypt is not yet reported. But according to the urology department, Faculty of Medicine, Assuit University UI is quite common in Egypt and prevalence rates are higher when compared to other reports (Altaweel and Alharbi, 2019).
Risk factors for the 2 types of UI (stress and urgency) are based on the dysfunctional mechanism which include pregnancy, pelvic floor trauma after vaginal delivery, menopause, hysterectomy, obesity, urinary tract infection, functional and/or cognitive impairment, chronic cough, and constipation (Bent et al., 2020).
Nurses play a crucial role in the development and management of urinary care guideline s. These include health education risk assessment and counseling activities, informing client about strength and limitation of treatments care guideline (Goldacre et al., 2020).
Aim of the Study
The aim of the current study is to evaluate the effectiveness of intervention guideline on self-care of women suffering from stress urinary incontinence.
This aim was achieved through:
1- Assessing women knowledge, practices and attitude regarding stress urinary incontinence and self-care toward it.
2- Design and Implement guideline about stress urinary incontinence and self-care.
3- Evaluate the effect of guidelines on women suffering from stress urinary incontinence.
Research hypotheses
Using Guideline will improve Self Care of Women Suffering from Stress Urinary Incontinence.
The aims of the current study is to evaluate the effectiveness of intervention guideline on self-care of women suffering from stress urinary incontinence.
Study design:
A quasi-experimental study was used in this study.
The study setting:
The study was conducted at urodynamic department maternity hospital affiliated to Ain Shams University hospitals. It consists of five rooms,
First room for assessment and personal data collection and consider as a waiting area for women before examination and drinking water and be ready for examination. Second room Urodynamic room where the examination carries out for incontinent women Third room examination room where doctors meet women and write the plan of care Fourth room doctors’ office and meeting room, they have every Wednesday meeting to discuss the plan of work and special cases of the department Fifth room is secretary of the department room where they keep patients’ files and equipment.
Sampling:
Sample type: A simple random sample was used in this study.
Sample size:
• This study included 100 urinary incontinence women were 50 stress incontinent women was the study group and 50 stress incontinent women were control group. The study group implemented self-care guideline, but control group only under routine care. Both two groups were admitted at Urodynamic unit- Maternity University Hospital during 2019.
• This sample size was calculated according to the following equation Normal approximation using the Z statistic
• A = (1/q1 + 1/q0) = 4.0000
• B = (Zα+Zβ)2 = 7.8489
• Total group size = N = AB/(E/S)2 = 97.169
• With 0.95 Standard deviation and 54% effect size of the outcome in the population
• Study group equal 49
• Control group equal 49
• Q1 means Proportion of subjects that are in group 1 (study)
• Q0 means Proportion of subjects that are in group 0 (control); 1-q1 with a 95% level of confidence (β error = 5%), and a study power of 80% (β error=20%).
Sample criteria:
Inclusion criteria
• All women under diagnosed with stress urinary incontinence.
• Healthy women (free from any medical diseases except urinary incontinence and surgical free of any operations except surgery related to treatment of urinary incontinence.
• Educated women.
• Non pregnant women.
Exclusion criteria
• Women diagnosed with another types of urinary incontinence.
• Women with medical or surgical conditions.
• Illiterate women.
• Pregnant women.
• Uncooperative women.
Sample technique:
The sample of this study included all available stress incontinence women (hundred stress incontinence women) who Urodynamic unit- Maternity University Hospital. According criteria, stress incontinence women were divided randomly into two equal groups:
3) group I (study group): consisted of (50) stress incontinence women who received the intervention guideline about stress incontinence self-care in addition to medication.
4) group II (control group): consisted of (50) stress incontinence women who received routine care only.
Tools of data collection:
Five tools were utilized for collected data.
First Tool: “Structured interview questionnaire”
This tool was designed by the researcher after reviewing the related literature; it was included three main parts:
- Part I: General characteristics of study women: This part was designed to assess women’s’ personal data. It included 7 questions about patient’s age, educational level, marital status, duration of marriage, height, weight, body mass index, occupation.
- Part II: Obstetrics, gynecology and urology data: it composted of 22 questions such as; do you have family history of incontinence, number of pregnancies, number of abortions, number of delivery.
- Part III: women knowledge and attitude about stress urinary incontinence: it composted of 16 questions about women knowledge related to stress urinary incontinence
Such as do you have any information about urinary incontinence, do you know the causes of urinary incontinence, do you know the diagnostic measures for stress incontinence, …. etc. And 30 questions about attitude regarding urinary incontinence such as do you have enough time for yourself, how do you deal with stress situation, etc.
Scoring system:
Scoring system of body mass index
Body mass index was categorized as following:
o Normal weight 18.5–25
o Overweight 25–30
o Obesity < 30
Scoring system Level of knowledge:
The score for each question was categorized into three levels, and answers was coded as follow: poor = 1, average = 2, and good = 3.
Scoring system Level of total knowledge:
Was categorized into three levels as follow poor= 0 - 50%, average= 51 - 75%, good= 76 -100%.
Scoring system of women’s attitude:
Responses were measured using 3 points of Likert scale, Agree, sometimes, Disagree. A score was given for each response as follows from 1 to 3, Agree =1, sometimes=2, Disagree=3. Whereby higher score indicated stronger positive feeling of each item.
Scoring system Level of total attitude:
Was categorized into three levels as follow negative attitude
= 0 - 50%, neutral attitude = 51 -75%, positive attitude = 76 - 100%.
Second Tool: “women self-care practices check list”
- Women self-care practices check list designed and prepared by the researcher to assess women practices self-care regarding stress urinary incontinence in both study and control group.
- It was included five parts:
6- Bladder Retraining Technique it includes 8 training skills. This part was designed to assess women self-care practices regarding bladder retraining technique such as empty your bladder when get up, follow the schedule to evacuate your bladder…. etc.
7- Wearing Pad, it includes 14 training skills. This part was designed to assess women self-care practices regarding Wearing Pad technique such as wash hands before change the pads, it should made of cotton, etc.
8- Pelvic floor muscle Exercise 14 training skills (Kegel exercise) to assess women self-care practices regarding Pelvic floor muscle Exercise such as do exercise 3times*10 every day, drink less fluid before bed time, …...etc.
9- Hand hygiene it includes 10 training skills to assess women self-care practices regarding hand hygiene such as elevate your sleeves above elbow, wash between fingers, etc.
10- Perineal area hygiene includes 11 training skills. to assess women self-care practices regarding Perineal area hygiene such as keep you under cloths dry, change your pads from 4-6 hrs. maximum, ……. etc.
Scoring system of women’s practices:
The score for each question was categorized into two levels, and answers was coded as follows: not done = 1, done = 2.
Scoring system Level of total practice:
Was categorized into two levels as follow unsatisfactory=up to 70%, satisfactory= up to 100%.
Third Tool: “practices voiding diary”
It was designed to follow the change in intake, urine passed and leakage of urine before and after using the guideline developed by the Home and Community Care (HACC) and Medical Aids Subsidy Scheme (MASS) Continence Project 2012 Reviewed April 2022 (Montazeri et al., 2019).
Fourth Tool: follow up chart and women’s opinion about the guideline:
It is a card in Arabic language filled by the women designed by the researcher to assess the frequency of using the guideline and how much it is useful among study women.
Fifth Tool: Assessment the effect of the guide line on severity of stress incontinence among study women:
It included women opinion regarding guidelines sessions it include 7 questions such as do you share the guideline with others, did you find the information you need in the guideline, etc.
Supportive material: A guide booklet
A guide booklet was designed by researcher using simple Arabic language and different illustrated pictures in order to facilitate women understand.
Validity of tools:
Validity of the tool was reviewed by a jury of experts in Maternity & Obstetrics Nursing field to assure the validity, reliability and visibility of the questionnaire.
Reliability of tools:
Reliability was applied by the researcher for testing the internal consistency of the tools. Answers from repeated testing were compared by using Alpha Cronbach’s Test.
Tools Cronbach’s alpha value
Women knowledge and attitude regarding SUI (Tool 1) 91.1 %
Women practices regarding SUI (Tool 3) 84.6 %
Voiding diary (Tool 4) 83.4%
Women opinionnaire (Tool 5) 85.4%
Ethical considerations:
The aim of the study was explained to each woman before applying the tools to gain confidence and trust.
Informed consent was obtained from women to be included in this study.
No harm happened to women.
The data was collected in a confidential manner and a result was considered.
Every woman had the right to withdraw at any time without giving reasons.
The study doesn’t contradict with cultural, traditional and religious issues
The study doesn’t touch the dignity of the women.
Pilot study:
The pilot study was carried out on 10% of total sample that met the criteria of selection to test the study process clarity and application the tools to find the possible obstacles & problem that might be faced during data collection. Not modifications will be done in the tool to be suitable for the subjects and not excluded from main the study women.
Field work:
The field work of the current study was carried out through nine months started from the beginning of march 2020 to the end of November 2021. The researcher collected data after obtaining oral permission from director of Ain Shams University Maternity Hospital and agreement of the chairman of Urodynamic unit. The researcher visited the setting of the study 3days/week (Sunday, Monday and Wednesday) from 9 a.m. to 1 p.m. until the predetermined data collection time was reached and the subjects with previous characteristics mentioned were collected. The researcher introduced herself and explained the purpose of the study to the women who met the criteria for inclusion in the sample.
The researcher implements the procedure through three phases:
Preparatory phase
During this phase review of related literature has been done for construction of data collection tools and for designing the teaching booklet. The booklet was designed by the researcher using simple Arabic language and different illustrated pictures in order to facilitate women’s understanding. The researcher interviewed the SUI women by welcoming and then explained the study aim in simple terms. The initial assessment was done to the participating women in the waiting room of urodynamic unit. The researcher asked each SUI woman the questions in a simple Arabic language and filled the checklist questionnaire. The researcher collected general characteristics of women, obstetric data, predisposing factor, daily health practice, symptoms & signs of SUI and Problems associated it. The researcher started with control group then study group and the time taken to complete the checklist was about 20-30 minutes.
Implementation
The intervention was implemented to the study group through one small session of nursing intervention about general characteristics of normal and abnormal urinary system function, knowledge related to SUI as definition, causes, predisposing factors, signs & symptoms, complication, diagnostic measures and how woman can help in treating and preventing recurrence of SUI. Booklet was used as a teaching aid to help in clarifying information about SUI. During and after the teaching session, the researcher encouraged active participation of the SUI woman through asking questions and receiving feedback. This session was conducted in the waiting room of the urodynamic unit immediately after completion of the assessment. The time taken to complete this phase was about 30-45 minutes. Also, the researcher communicated with women via telephone calls for instruction and reinforcement.
Follow up and evaluation phase.
Follow-up and evaluation of progress & severity of SUI carried out every four weeks (6 Follow-up) from the implementation phase through meeting women during investigations and follow up with doctors to assess effect of intervention guideline on relieving symptoms and frequency of SUI. The researcher asked each SUI woman about symptoms and severity using follow up questionnaire such as (frequency, amount, exercise, hygiene) and the researcher. Also, the researcher asked the woman to bring the voiding diary in next visit for asses the severity of SUI and the women practices of voiding diary. Each SUI woman was followed up individually at waiting area. Evaluation started first with the control group then with the study group to avoid bias.
Administrative design
An official letter from the dean of Faculty of Nursing was delivered to director of Maternity University Hospital with a full explanation about the aim of the study. The study was conducted concerned the title, objectives, tools and the study technique were illustrated to the administrators of the previously mentioned setting to gain their cooperation which was needed to allow the investigator to meet the SUI women at urodynamic unit.
Statistical design
After data collection, each sheet was recorded; the collected data were coded, organized and categorized. Results were presented in tables and analyzed by using the statistical package for social sciences SPSS guideline s version (22). Numerical qualitative data were expressed as frequencies and percentages. Mean & standard deviation (SD) were used for quantitative data and using (X2) test for number and percentage for qualitative data. Correlation test (r) was used. Correlation and probability of error (p value) was used to examine the relation between variables.
Significant of results was considered as the following:
There is no statistically significant difference when p>0.05.
There is a statistically significant difference when p≤0.05.
There is a highly statistically significant difference when p≤0.001.
Conclusions
Based on findings of the present study, it can be concluded that:
- The results of the study supported the study hypothesis in which intervention guidelines improved women self-care related stress urinary incontinence.
- Self-care women’s knowledge, practice, and attitude of study group improved significantly than control group.
- The study showed that there were statistically significant positive correlations with the increase total knowledge practice, and attitude in post guideline is highly significant than follow up.
- There were statistically significant relations between women’s general characteristics and total score level of knowledge, practice, and attitude for study and control groups.
- There was statistically significant positive correlation between the study and control group post guideline and follow up of women’s total knowledge and total attitude and practices.
The results of the current study and research hypothesis; implementation of nursing intervention guidelines improved the knowledge, practices, and attitude of women suffering from stress urinary incontinence.
Recommendations
The findings of this present study, led to the following recommendations based on the research findings:
• Performing training programmes for improving women awareness about urinary incontinence and self-care.
• Designing posters, media at the clinics for women about the risk factors of urinary incontinence.
• Creating a further early detection clinic for SUI in outpatient department.
• Life style modifications as keep normal body mass index and daily exercise are important issues to improve women’s health.
For further research in the field:
• Study the factors that affect women utilization of urodynamic services.
• Increasing Awareness and Improving the Care of Urinary Incontinence.
• Implement Strategies to Enhance Use of Conservative Management of Urinary Incontinence in Women
• Further research with a larger sample of women suffering from urinary incontinence from other governorates in Egypt are required in order to have a better understanding for the needs of women’s knowledge and practices regarding self-care