Older Women's Experiences of Living With Urinary Incontinence

Research

Accepting and Adjusting: Older Women's Experiences of Living With Urinary Incontinence Gunnel Andersson Jan-Erik Johansson

U

rinary incontinence (UI) is often described as a major public health problem, estimated to affect about 500.000 persons in Sweden (total population 9 million) [SBU, 2000). In a previous study, 19% of thü total sample (27% of women and 10% of men) between 18 and 79 years of age residing in one county in Sweden reported UI (Andersson. Johansson. Garpenholt. & Nilsson. 2004). Despite this, the majority of persons with UI do not seek (Hannestad. Rortveit. Sandvik. & Hunskaar. 2000; Hmiskaar, Lose. Sykes, & Voss. 2004: Minassian, Drutz, & Al-Badr, 2003; Vandoninck et al. 2004) or do not

Gunnel Andersson, MSc. RN, is a Staff Nurse, the Department of Urology. Department oí Clinical Medioine. Orebro University Hospital and Centre for Evidence-Based Medicine and Assessment of Medical Technology Orebro. Sweden. Jan-Erik Johansson, MD, is a Professor, the Department of Urology, Department of Clinical Medicine. Orebro University Hospital and Centre for Evidence-Based Medicine and Assessment of Medical Technology. Orebro. Sweden. Kerstin Niisson. MD, PhD, is Senior Consultant. Department of Obstetrics and Gynaecology. Department of Clinical Medicine. Orebro University Hospital and Centre for Evidence-Based Medicine and Assessment of Medical Technology. Orebro. Sweden. Eva Sahlberg-Blom, PhD, RN, is Senior Lecturer. Department of Health Sciences. Orebro University. Orebro. Sweden.

Kerstin Nilsson Eva Sahlberg-Blom In-depth interviews were performed with 11 Swedish women who contacted a district nurse to obtain sanitary protection. Three key constituents (themes) emerged: 'learning to iive with it despite difficuities," "other aînesses are more important,"and "reiuctance to seek care." The essence of the phenomenon of living with urinary incontinence (UI) was expressed as "a situation to accept and adjust to." Keywords: Urinary incontinence (UI), women's heaith, plienomenological study, coping, seeking care. Purpose The aim of this study was to describe experiences of living with urinary incontinence (UI) among persons who do not desire further assessment and treatment. Methods This was a qualitative, descriptive interview study, and the method was phenomenological. Eleven women were interviewed; ail had been in contact with a district nurse to obtain a prescription for sanitary protection. None of the women desired further treatment for UI. Findings The women described living with Ui as a manageable problem

desire (Andersson et al.. 2004; Perry et al,. 2000) care and treatment. It was learned in an earlier study that the degree of severity of UI is of decisive importance for the desire for treatment. Individuals who reported that they did not

with which they had learned to iive. They showed strength and desire to manage on their own. In many cases, other heaith problems overshadowed leakage problems. Several women saw heaith care services as a barrier that needed to be overcome before help could be obtained. Three key constituents emerged in the anaiysis: "iearnlng to iive with it despite difficulties." "other iilnesses are more important," and "reluctance to seek care." For these women, the essence of the phenomenon of living with urinary incontinence (Ui) can described as "a situation to accept and adjust to." Level of Evidence - VI

have daily complaints were more likely to report that they did not desire treatment than those with more troublesome UI (Andersson. Johansson. SahlbergBlom, Pettersson, & Nilsson, 2005). This was also the case with other

Note: The authors wish to thank the district nurses at Skebacks Primary Health Care Centre for their help in recruiting interviewees, as well as Professor Britt-Marie Ternestedt for her invaluable advice. Financial support for this study was provided by the Orebro County Council's Research Fund. The authors also wish to thank the Center for Health Care Sciences for its valuable advice and support.

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studies (Burgio, Ivés, Locher, Arena, & Kuller, 1994; Cetinel et al, 2007; Rekers, Drogendijk. Valkenburg, & Riphagen, 1992; Teimissen & Lagro-Janssen, 2004). It is not possible to establish unequivocally that persons with severe and disabling UI seek medical help while those with milder complaints refrain from doing so. Several studies have shown that many individuals do not desire treatment despite problems with frequent and annoying Ul (Andersson et al., 2004; Hannestad et al, 2000; Minassian et al., 2003; O'Donnell, Lose, Sykes, Voss, &Hunskaar, 2005). However, there is a lack of knowledge about people's experiences of living with UI and their need for care and medical help. One way of gaining deeper knowledge of this is to use a qualitative approach, which allows for a better understanding of how those who are troubled by Ul, but who do not desire treatment, experience living with UL The aim of this study was to describe experiences of living with UI among persons who did not desire further assessment and treatment of their complaints. METHODS

This was a qualitative, descriptive interview study. To increase understanding of the interviewees' experiences of living with UI and how it has affected their ordinary life (life-world), a phenomenological method was chosen. The foundation of the phenomenological method is the life-world philosophy. In order to attain knowledge, the researcher must tiun to "the things themselves" and arrive at the meaning of the phenomenon under study; it is the essence of the phenomenon that is sought, that is, its non-varying content or core (Giorgi & Giorgi, 2003b). By applying this method to the study, the research team hoped to render implicit experiences explicit by examining women's narratives about what it is like to live with UI. Of importance is each researcher's ambition to place his or her understanding (earlier experiences, different

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knowledge, and theories) in parentheses (bracketing) and to relate as openly as possible to the phenomenon under study. One often-cited phenomenological method was developed by Giorgi; this is the method used in the present study (Giorgi & Giorgi, 2003a, 2003b).

Table 1. Characteristics of the Participants Participants

DATA COLLECTION

To identify persons with Ul. the district nurse office at one primary health care center was contacted by a member of the study team. In Sweden, as part of the Health Care Service, incontinent individuals receive absorbent products by obtaining a prescription after visiting a district nurse ofñce. Therefore, persons with UI who had received a prescription for sanitary protection from the district nurse, but who at the time of contacting the nurse had not desired further assessment or treatment, were invited to participate in the study. This selection process resulted in a group of individuals who bad defined themselves as sufficiently troubled by urine leakage to contact the district nurse for a prescription but who presently did not desire further treatment. The district nurse briefly informed these individuals about the study and asked whether the principal investigator (GA) could contact them by telephone to arrange a time and place for an interview. Seventeen women and one man between 57 and 89 years of age agreed to he contacted. Of these, 11 women agreed to participate in the interviews (see Table 1). Those who chose not to participate cited reasons such as "no pronounced complaints." "have sought medical help," "do not wish to be recorded during the interview," "too busy," or "bed-ridden." All participants except one chose to be interviewed in their home. Written, informed consent was obtained following oral and written information about the study. The interviewer (GA), who is a registered niu-se and uroterapeut (a nurse specialized in investigation and treating people

with UI and other urinary bladder disorders) working in a urologie department, conducted all interviews. The study was approved by the regional research ethics committee. Eacb interview started with, "Tell me what it is like to live with urine leakage." Additional questions were asked, such as, "How do you feel about [UI]?", "How do you handle leakage in everyday life?", and "Would you like to tell me more?" Part of the interview also dealt with the fact that the interviewees bad chosen not to seek further assessment and treatment of Ul. Questions included, "Have you told a doctor about Ul?", "Are you planning to seek care fore UI?", and "Why don't you seek care for UI?" All interviews were audiorecorded and later transcribed verbatim. Theoretical saturation was reached after interviews with 11 women were completed. DATA ANALYSIS The analysis consisted of different stages that led to elucidation of women's experience of living with UI and their decision to not seek further assessment and treatment of their urine leakage. This method is consistent witb the phenomenological methods outlined by Giorgi & Giorgi (2003a; 2003b). Specific steps in the process of data analysis included: • The interview text from each

UROLOGIC NURSING / April 2008 / Volume 28 Number 2

Table 2. Meaning Units in the interview Texts that Were Transformed (Condensed) Three Times, Resuiting in the Constituent "Learning to Live with it, Despite Difficuities" Original Meaning Units

1st Transformation

2nd Transformation

3rd Transformation

I Constituent

But it's annoying, and if I'm going somewhere, then I don't take it [furosemide (Lasix®')]. Because it's not possible if i'm maybe going on a bus trip and leaving in the morning, you never know...

The interviewee reports experiencing her urine leakage as so annoying that when she plans to go on a bus trip, for example, she does not take her turosemide because if she did, she would not be sure she would manage the trip.

The interviewee reports not taking her medicine if she is to take a trip somewhere so that she can feel certain she will have no leakage.

The interviewee reports that if she takes a trip somewhere, she refrains from taking her diuretic medication so she can feel secure. She says it's a problem she has learned to live with by using proper, tested sanitary protection. She always takes extra protection when taking a trip.

Learned to live with it, despite difficulties.

lo, I have to praise these sanitary pads because I've learned to live with it [incontinence], but of course it's annoying, I can't deny it.

The interviewee reports experiencing urine leakage as annoying even though she has learned to live with sanitary protection, which is a great help to her.

The interviewee reports experiencing urine leakage as annoying, but she says by using sanitary protection, she has learned to live with the problem.

Well of course it's a bit of a problem, but you have to live with it.

The interviewee reports that having urine leakage is a problem, but she feels it's something she has to live with.

Leakage is a problem, but she feels she must live with it.

Yes, I always go out with one of these [a sanitary pad] in my handbag so I can go in some place where I can...if it happens.

The interviewee reports that she always has extra sanitary protection with her if she is going somewhere so she can change.

The interviewee reports always taking extra sanitary protection with her when she goes out.

JlilU i-Ji.

=,vi

interview was read through in order to obtain an overall impression. • Each interview text was divided into meaning units (the text was read carefully and slashes were inserted to mark shifts in meaning). • Each interview text was transformed (condensed) two or three times to capture the meanings in the phenomenon. This led to the emergence of constituents (themes) that could be formulated (see Table 2). • After synthesis of key constituents, the essence of the phenomenon of living with UI emerged. A co-analyst experienced in phenomenological analysis then read several of the interview texts and conducted a separate analysis. Subsequent discussions

revealed consensus concerning the structure that emerged. The trustworthiness of a phenomenological study is dependent on the fact that the interview is subjective and that it is the interviewee's experiences that emerge. The researcher must be aware of his or her own values and experiences and endeavor to put these aside [Giorgi & Giorgi, 2003b). This was of importance due to the interviewer's specialized competence (such as UI). By awareness and being close and open to the narratives, the interviewer/primary author (GA) bracketed her experiences. RESULTS

Eleven women participated in in-depth interviews (see Table 1). All had different life situations; for example, several were quite active in clubs or


associations and other activities, while others were confined to their homes because of health problems. Despite these differences, there were similarities in their experience of living with UI. Three key constituents emerged. "Learning to live with it, despite difficulties" indicates that the women had learned to live with the urine leakage. "Other illnesses are more important" highlights the fact that for many, urine leakage is ¡ust one complaint among many health problems. "Reluctance to seek care" reveals the women's difficulties in their encounters with the health care service. The three key constituents could be integrated to form the essence of the phenomenon of living with UI, which can be described as "a situation to accept and adjust to."

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Learning to Live with It, Despite Difficulties For all interviewed urine leakage was experienced as a normal and expected complaint. Participants believed that the body weakens with age and as a result of childbirth earlier in life. They described many years of urinary leakage, which had been minor at first but which gradually increased with time. Living with urinary leakage was something they became used to and learned to live with. Ms. H. stated, "I've gone through menstruation, had children, and learned to live with this during my life. So that's made me feel secure, and I think...this is also a part of life." The women described their feelings about living with urinary leakage as annoying and unpleasant, wet, and rotten; some also described embarrassment. One woman described it as being like B return to childhood. Ms. W. explained, "When the urine news, I'm thinking, it's crazy: it's like return to childhood. Yes I do...but you had to try to accept and look upon things with a little humor even though it is tragic." Despite this, the women expressed a desire to manage on their own. By learning about their own bodies and knowing when leakage occurred, they were able to find their own solutions to the problem. They identified ways of minimizing leakage [for example, by using the toilet often and knowing locations of accessible toilets). The women reported increased leakage following intake of diuretic medications. Refraining from taking such medications on days when activities were planned resulted in reduced leakage, and it was not necessary to limit their social life. According to Ms. L., "Yes, I have cheated [with the diuretic medications] some days; you easily do. If you are going to a party, I'm absolutely not taking the medication because then you never know what's happening." Several women reported that meeting with others and sharing their experiences of living with UI

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had given them insight into how others dealt with the problem. In this way, they had acquired more knowledge and practical advice. Other interviewees, however, said they chose more carefully when and with whom they talked about their problems. Ms. E. said, "When we have the same problem...of course, you don't sit in the town square and talk about it...you discuss problems and what kind of protection you use." All interviewees used sanitary protection and several stressed the importance of using proper and tested protection to feel secure. The fear of smelling urine caused them to change sanitary protection often and to take great care in personal hygiene. Other aids were used in addition to sanitary protection, such as a portable toilet placed beside the bed or a suitable chamber pot to take along when traveling. Several described methods, such as pelvic floor muscle exercises, vaginal estrogen creams, fluid restriction, and exercise. Using sanitary protection and other solutions allowed the women to live the life they wanted to live, but for some, the urinary leakage could be quite troublesome, for instance, in connection with a cold or coughing. Others experienced UI problems as so minor that they never felt hindered from doing what they wished to do. Ms. P. explained, "I exercise, and I love to go cycling...1 travel a great deal, and there haven't been any problems. But when you're going to climb up Machu Picchu, for instance — the steps are very high - then maybe it's hard to pinch it oft' at the same time." Other Illnesses Are More Important In addition to UI. most women had other illnesses and complaints, such as deteriorated joints and other serious illnesses, including cancer. Several women reported that these problems, not urinary leakage, kept them from living the life they wanted to live. Ms. H. described, "Because of this business [referring to a

lung tumor], my condition has [gotten] worse. I've almost always exercised, done gymnastics, and cycled and walked a lot. But all that's been very limited these past months." Several women described how various illnesses had necessitated regular and sometimes frequent visits to the doctor for an examination, treatment, or operation. Seeking care also for urinary leakage on such occasions was experienced as unmanageable. The problems they perceived as most severe caused them to visit the doctor, but other complaints had to wait. Ms. R.H. explained, "I've never considered queuing up for an operation for that [Uli as long as things are going as well as they are. I had a hip joint operation last autumn. It was more important to have that done." Several women felt they were too old for treatment and that possible measures would probably not be successful in someone of their advanced age. Ms.N. relayed, "I'm not afraid of being operated on, of course, but you never know if you're going to get better or worse. When you're old, you can get worse." Moreover, one woman with a severe muscular disease believed that the disease caused her urine leakage, and because the disease was incurable, she thought the urinary leakage was also incurable. Reluctance to Seek Care The final constituent that emerged was the women's difficulty to make contact with health care services, and particularly, with a physician. This meant that they avoided such contact as long as possible. Several women believed things would be easier if they had a family physician whom they could contact when necessary. Some participants described a relationship with a physician they knew, felt comfortable with, and with whom they could have a confidential conversation, but for some reason or another, this contact had ceased. Seeing a new physician at every visit meant spending time


talking about previous illnesses and prescription renewals. Ms. N. said, "I've seen three [doctors] within a short time, but then they've all quit." The women also expressed fear that they would not be taken seriously if they sought help for iirinary leakage and that the health care provider would make light of the problem. Ms. E. stated. "If someone had asked me labout Uli, it would have heen different. But then you think, what would the response be if I niune...would they play it down and say it wasn't important?" Ms. L. added, "I was in Ithe] hospital for two and a half months, and in that time, they could have told me that I can get help for the UI." During a visit to the doctor, one woman complained about urinary leakage, hut her com(ilaint had not elicited any comments or further measures. This had caused her to assume that seeking help for UI is not meaninghil. Some interviewees said they believed that one should have pain symptoms when seeking care and that othor problems will not be taken seriously. One woman [Ms. P.), who had repeatedly tried to receive treatment for a suspected urinary tract infection, said, "Then I tried to get help at my primary health care center, and I think in the end they thought I was a hypochondriac because they never found any bacteria. But still my problems were just as great." The women's unwillingness to seek care sometimes occurred because leakage had started as a complication of an operation or that others they knew had described their own negative experiences of treatment. There were also notions of painful examinations and treatments. DISCUSSION

The aim of tho present study was to describe experiences of living with UI among persons who did not desiro further assessment and treatment of their complaints. Rosearchers describe the experiences of 11 older women who

were all sufficiently troubled by urinary leakage to visit a district nurse to get a prescription for sanitary protection, but who did not desire furthor assessment and treatment. The women described UI as a manageable problem they had learned to live with, along with other health problems. They showed a strength and desire to manage by themselves. The problem was seen as a part of life, which correlates with a previous study of female UI [Shaw, Tansey, Jackson, Hyde, & Allan, 2001). Women formed their own understanding of urinary leakage - as an expected part of life and in terms of its causes and response to treatment. This understanding resulted in an adaptation of their expectations for life. Participants' knowledge of when urinary leakage occurred helped them fiud solutions that allowed them to live their life as they wished and to perceive themselves as healthy. This approach is not specific to persons with UI. Scherman, DahJgren, and Lowhagen [2002) followfid a group of individuals with asthma for several years. It was concluded that these individuals used various strategies to protect themselves from becoming "patients" or "sufferers." By distancing themselves from the medical perspective, they avoided taking on the role of being ill and were able to see themselves as the same person as before [Scherman et al., 2002). Many have described UI as a taboo subject, and a problem entailing highly negative feelings of shame and embarrassment (Ashworth & Hagan, 1993; Kinn & Zaar, 1998; Roe, Doll, & Wilson, 1999). The women in the present study expressed negative feelings about UI but also a surprising openness and willingness to share their problems with others. They showed strength in handling their difficulties by themselves and creativity when developing strategies for reducing urinary leakage. In a study by Bradway (2005), women expressed the importance of learning to control instead of being controlled.


These attitudes can help women maintain a positive self-image and may also protect them from becoming "sufferers" (Scherman et al., 2002). Although many older women remain healthy, the olderly often have complex health problems (Hellstrom & Hallberg, 2001; Stenzelius, Westergren, Thorneman, & Hallberg, 2005). Several women in the present study gave other illnesses priority over UI when contacting health care services. Some expressed difficulties in making contact with the health care service, and as a result, they sought help only when it was necessary. While they were able to control their UI so that it did not affect their everyday life, they gave it low priority in relation to other complaints. While it is important to address the concerns of individuals with UI as well as to make care availahle to those in need, it is also important to accept women's notions of UI as an expected part of aging and to accept their desire to be independent. Moreover, there is a growing debate regarding the medicalization of more and more symptoms. Critics consider that ordinary human problems are being rendered pathological and that healthy individuals are being encouraged to accept tbe notion that they require medical care [Verweij, 1999). Some also suggest that this medicalization often is driven by commercial and market interests [Conrad, 2005). On the other hand, symptoms that are otherwise ignored have been brought forward into the light, and that this is a positive development for the individual. Most older adults are awaro of how the hody ages and that there is increased risk of disease and functional impairment as one ages; this awareness results in an adaptation of their expectations for life. An awareness and acceptance of complaints, such as UI, exists where an individual's own conscious solutions provide independence and allow everyday social life to continue as he or she wishes.

llf)

There are many studies that describe strategies and self-care behaviors (such as staying near bathrooms, voiding frequently, restricting fluid intake, wearing sanitary products) to manage UI (Diokno et al., 2004; Engberg, McDowell, Burgio, Watson, & Belle, 1995; Locher, Burgio, Goode, Roth, & Rodriguez. 2002). hi Sweden, sanitary protection can be proscribed without any cost for the individual, in contrast to countries where those with incontinence usually buy their own protection. It is positive for those who need sanitary protection to control their daily life more easily. Conversely, this type of self-care may result in negative consequences if people who could be treated are missing an opportunity for cure by implementing other Ul treatments, such as pelvic muscle exercises, medications, or surgical procedures. STRENGTHS AND LIMITATIONS OF THE STUDY

A qualitative method was chosen for this study, which allowed women's own thoughts, feelings, and experiences of living with Ul to be studied. This approach allowed these researchers to better understand the problem of Ul and may be seen as an important complement to the more common survey studies, which mostly inclnde questionnaires with fixed response alternatives. Study participants constituted a convenience sample that can be seen as a limitation, but they all had very different life situations and economic status, and represented the diversity of experience found among the elderly. Study participants provided rich and varying experiences of living with UI. One limitation in the study was that all women were Caucasian and had the samo ethnic and culture background; bowever, studying individuals of different etbnicities demands special knowledge as well as a suitable study design. It would also have been interesting to interview individuals witb urinary leakage who bad not contacted tiie district nurse at all. Finding sucb participants would have

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been exceedingly difficult and perhaps even unethical because this is a group of individuals who have chosen not to contact the health care service. In addition, the initial ambition was to elucidate men's experiences of UI, but it proved to be difficult to find men wbo were willing to participate in the study. RECOMMENDATIONS AND IMPLICATIONS

There are many ways in which care might be improved for individuals witb UI, although some may consider UI a condition they have to accept and can control in their daily life. For example, health care personnel could introduce the topic of urine leakage when older individuals visit a primary care health center or outpatient urology practice. In Sweden, where absorbent product requests are initiated by contact with a district nurse, providing clear information on UI and possible treatment alternatives in connection with prescribing sanitary protection and otber aids could increase patients' knowledge of UI and minimize negative ideas about treatment. In a study of general help-seeking behavior among the elderly, lack of information, low expectations, fear of consequences, and resignation were important factors underlying people's decision not to seek help ¡Walters, Ilifte, & Orrell, 2001). These findings are largely in accordance with the present results and may be one of the reasons why some individuals with relatively severe leakage refrain from seeking care. Adequate information and improved access to incontinence care could make the situation easier for many with severe Ul as well as for those with multiple medical conditions, including UI. CONCLUSION

This study group of older women exhibited the desire and ability to manage on tbeir own. Participants showed a strength and openness that allowed them to share their experiences witb others and be open to practical

advice. In many cases, otber health problems that were considered more important overshadowed their leakage problems. In addition, women in this study expressed difficulties in making contact with the health care service. This is a significant issue that affects UI care and possibly quality of life, and therefore, warrants further study. B References Andersson. CJohaasson, I.E., Garpenholt,Ö., & Nikson. K. (2004). Urinary incontinence - Prevalence, im|3act on daily living and desire for treatmenl. A poptüation-based study. Scandinavian Journal Andersson, G., fohansson. J.E., SalilbergBlom. E., Petterssun. N., & Nilsson, K. (2005). Urinary incontinence - Why refraining from tnîatment? A population-liased study, Samdinnvian ¡oumal of Urology e-Nephrology, 39(4), 301-307. Ashwortli. PD.. & Hagan, M.T. (1993). The meaning of incontinence: A qualitative study of non-geriatric urinary incontinence sutferers. Journal of Advanced Nursing. 18(9), 1415-1423. Bradway. C. (2005). Women's narratives of long-term urinary incontinence. Urologie Nursing, 25(5). 337-344. Burgio, K.L, Ives, D.G., Loclier, I.L., Arena, V.C.. & KuUer, L.H. (1994). Treatment seeking for urinary' incontinence in older adults. Journal ofiJw Ainnrican Geriatrics Sociffty. 42(2), 208-212. Cetinel. B., Demirkesen, O., Tarcan, T., Yalcin, O.. Kocak, T , Senocak, M., et al. (2007). Hidden female urinary incontinence in urology ajid obstetrics and gynííi:ology outpatient clinics in Turkey: What are the determinants of bothersome luinary incontinence and help-seeking behavior? International Urogynccology Journal and Pelvic Floor Dysfunction. 18{6], 659-664. Conrad. P. (2005). The sliifting engines of medicatization. Journal of Health and Social Behavior. 4611), 3-14. Diokno. A.C., Buigio. K., Fultz, N.H., Kinchen, K.S., Ohenchain, R., & Bump. R,C. (2004). Medical and selfcare practices reported by women with urinary incontinenc:e. American Journal of Managed Care. iO(2 Pt .1), 69-78. Engberg. S.|., McDowell. B.J.. Burgio, K.L., Watson, J.E., & Belle, S. (1995). Selfcare behaviors of older women with urinary incontinence. Journal of Geroniohgical Nursing. 2J(8), 7-14. Giorgi, A.. & Ciorgi. B. (200.3a). The descriptive phenomenological psychological method. In P. C^mic, J.E. Rodes, & 1. Yardley (Eds.). Qualitative reseaix:h in psycbolo^ (pp. 243-273). Washington. DC: American Psychology A.ssociation. Gioi^i, A., & Giorgi, B. (2003b). Phemomenology. In J.A. Smith (Ed.). Qualitative psycholo^: A practical


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Cy/lo Room lumvol TIT manual SUNA has created this valuable resource for urologie nurses new to the "cysto" room {a dedicated operating room for cystoscopy, or biadder procedures). Edited by Marie Page, BSPA, RN, CURN, the Cysto Room Survival Manual: Guidelines for Urologie Endoscopy ñúúresses common biadder procedures, care and sterilization of instruments, common abbreviations, urologie medications and solutions, handiing specimens in the OR, and positioning patients under anesthesia. The manual details each procedure's purpose, the supplies and instruments needed, as weil as any speciai notes about the procedure. The manual comes with neariy 30 iaminated preference cards detailing the same information found in the text that nurses can use on the job.

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