1. Evidence-based Self-management: Translation of Knowledge into a Self-management Tool for Patients with Urinary Incontinence
Jayna M. Holroyd-Leduc, MD FRCPC
Associate Professor, Division of Geriatrics
University of Calgary

2. Disclosure Slide No Conflicts of Interest to Disclose
Project Funding Sources
University of Toronto Dean’s Fund New Staff Competition
CIHR Operating Grant

3. Learning Objectives 1) To explain the concept of self-management
2) To discuss the value of evidence-based self-management tools for patients
3) To identify that knowledge can be translated for direct use by patients

4. Self-Management
A process whereby persons function on their own behalf in the areas of:
Health promotion
Disease prevention
Disease management
Is decisions and actions taken by an individual to cope with and improve a health issue
Bhuyan BMC Public Health 2004; Health Canada 2006

5. Self-Management
Estimated 65-85% of all health care is provided by individuals or family without professional intervention
Bhuyan BMC Public Health 2004
Important component of chronic disease management
Can lower health service use by 7-17%
Low cost way of providing health care
Fries Health Aff 1998; Tsai Am J Manag Care 2005

6. Self-Management Works through 2 mechanisms: 1) Providing information
2) Improving personal self-efficacy
(the belief that by personal behaviour one may
affect health)
Fries Health Aff 1998

7. Self-Management To be effective it requires:
1) Access to relevant health information
2) Goal setting
3) Organization of resources
4) Implementation of problem-solving strategies
Clark J of Aging & Health 1991

8. Self-Management
Role for the professional health care system to facilitate self-management
Direct translation of knowledge to patients using evidence-based self-management tools

9. Why Self-Management for Urinary Incontinence?
In the next 20 years >4 million Canadian women will suffer from urinary incontinence
Incontinence is associated with significant morbidity:
Poor quality of life and poor self-rated health
Depression and social isolation
Decline in ADLs

10. Why Self-Management for Urinary Incontinence?
Majority with incontinence report the issue is of great concern
Only 25% feel it is being adequately addressed by their health care provider
Despite available evidence-based treatment options, less than 50% of incontinent women have talked to a health care provider
Tannenbaum CMAJ 2005; Holroyd-Leduc JAMA 2004

11. Development and Evaluation of an Evidence-based Self-management Tool for managing Urinary Incontinence Risk Factors

12. Development of the Tool
Funded through University of Toronto Dean’s Fund New Staff Competition
Used evidence from a systematic review to determine modifiable risk factors
Holroyd-Leduc JAMA 2004
Conducted Focus Group of Health care providers to determine risk factors to include in tool
Conducted literature review of behavioural strategies to modify chosen risk factors

13. Development of the Tool
Drafted the tool
Conducted 2 Patient Focus Groups to critique tool
Vetted final tool through 2 Health care Experts
Translated the tool into French

14. The Developed Tool Paper-based tool Grade 6 reading level
Requires no instruction for use

15. The Developed Tool
Includes 6 risk factors and associated change strategies:
Pelvic floor muscle exercises
Caffeine intake
Excess weight
Constipation
Vision and hearing problems
Smoking
Outlines how to monitor symptoms
voiding diaries pre- and post-change

16. Evaluation of the Tool CIHR-funded grant Conducted at 2 sites
University of Calgary (English)
University of Montreal (French and English)
Interrupted-time series design
6 month study (3 pre- and 3 post-intervention)
Targeted enrolment of 100 (50 per site)

17. Evaluation of the Tool Included Women > 50 years with
Any type of incontinence
Minimum of 2 episodes/week

18. Evaluation of the Tool Exclusions
Received treatment within past 2 years
Started on incontinence meds within past 6 months
Related complications requiring further investigation
Cognitive impairment (MMSE <24/30)
Unable to communicate in English
Would not consent to participate

19. Evaluation of the Tool Hypotheses Usage rate would be 75% or higher
Usage of the tool would result in an increase in Self-Efficacy
Improvement in Self-Efficacy would correlate with decrease in leakage episodes and improved Quality of Life

20. Evaluation of the Tool Primary Outcome:
Successful usage of the tool (targeted > 75%)
Secondary Outcomes:
Impact on self-efficacy
(Geriatric Self-efficacy Index for UI)
Change in leakage episodes
(Bladder diaries)
Change in Quality of Life
(Urogenital Distress Inventory-6 and Incontinence Impact Questionnaire-7)

21. Evaluation of the Tool Analyses: Primary Outcome (Usage Rate)
Percentage and 95%CI
Secondary Outcomes
Linear mixed effects modelling

22. Results -DemographicsN
103 (90 completed)
Age (Mean + Range)
63 (44-84)
Post secondary Education
66%
White Race
93%
Married
45%
Health Status
Poor-Fair
Good
V.Good-Excellent 12 39 49
Co-morbidities
Diabetes
Stroke
HTN
Arthritis
Back problems
Hearing impairment
Visual impairment 8% 5%
26%
39%
33%
23%
51%

23. Post-intervention Month
Results - Usage Rates
Post-intervention Month
Percentage (95% CI) 1
84 (75-90) 2
90 (82-94) 3
93 (86-97)
Overall
95 (88-98)

24. Results- Risk Factors Modified
Percent(95% CI)
Pelvic Floor Exercises
89 (82-94)
Caffeine Intake
55 (45-65)
Body Weight
23 (16-33)
Constipation
15 (9-23)
Vision/Hearing
2 (1-7)
Smoking
0 (0-4)

25. Results – Self Efficacy
Geriatric Self-Efficacy Index for Urinary Incontinence
15 items
Min score 0 – Max score 150
Higher score = better self efficacy
Significant Improvement
Month
Mean (SD) 1
67 (25) 2
63 (24) 3
62 (24)
INTERVENTION 4
70 (26) 5
76 (26) 6
76 (28)

26. Results – Quality of Life
Urogenital Distress Inventory -6 (UDI-6)
Evaluates symptom distress
Scored out of 100
Higher score = more distress
Significant improvement
Month
Mean (SD) 1
44 (20) 2
43 (19) 3
45 (21)
INTERVENTION 4
37 (21) 5
33 (22) 6
32 (23)

27. Results – Quality of Life
Incontinence Impact Questionnaire – 7 (IIQ-7)
Evaluates life impact of incontinence
Scored out 100
Higher scores = more impact
Non-significant Improvement
Month
Mean (SD) 1
29 (25) 2
26 (23) 3
27 (23)
INTERVENTION 4
24 (24) 5
20 (24) 6
20 (23)

28. Results – Impact of Self Efficacy on QoL
There was a positive relationship between Self Efficacy and Quality of Life
Improvement in Urogenital Distress (non-significant)
decrease of 0.09 ( ) in UDI-6 for every 1 pt increase in Self Efficacy Index
Improvement in Incontinence Impact
decrease of 0.2 ( ) in IIQ-7 for every 1 pt increase in Self Efficacy Index

29. Results- Difficulty with Tool
Difficulty understanding information in the tool:
10 % (6-18%)
Difficulty understanding the directions in the tool:
10% (5-17%)

30. Bottom Line Self-Management is an important part of health care
Evidence-based self-management tools can be effective for improving chronic diseases
Tools should be developed using
High quality evidence (e.g. systematic reviews)
Input from health care experts and end-users

31. Special Thanks To Co-Investigators Sharon Straus Cara Tannenbaum
Kevin Thorpe
Dave Davis
Heidi Schmaltz
Heather Armson
Research Assistants
Barbara Artiuch
Julie Michaud
Data-base Support
Jean Gagnon