Barriers to continence promotion in the

1
Barriers to continence promotion in the Middle
East

Dr Vasan S S UroAndrologist Director- Ankur,
Bangalore Head - Dept of Neurourology
Incontinence Director- Manipal Andrology
Reproductive Services (MARS)
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Incontinence

• The involuntary leak of urine constitutes a
  major urinary disorder in the community
• Important in the medical community, but
• Perception and management by family physicians
• is still largely inadequate
• Incontinence can lead to decreased physical and
  psychological well-being and to social problems.
• (Teunissen TA et al)

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• The experienced emotional consequences and
  physical limitations vary between people, with
  not all patients seeking help
• Ageing of the population of immigrants can be
  expected to lead to more cases of urinary
  incontinence
• (Lagro-Janssen TLM, Teunissen TAM et al)

4

• Very few Muslim women consult their GP because of
  incontinence
• From studies on Muslim women and migrants in
  general, we can surmise that they will be more
  ashamed of incontinence, suffer different
  consequences in their daily lives and have to
  overcome more barriers to seek and accept help
  than indigenous western European women
• (Saleh N, Rizk, Wilkinson K. Et al)

5

• Sample, 562 subjects (70.4) believed that UI was
  abnormal and worth reporting to a doctor
• Coping mechanisms among incontinent women
  included frequent washing (58.3) and wearing a
  protective perennial pad (42.4), changing
  underwear frequently (41.3), decreasing fluid
  intake (19.8) and stopping all work (4.9)
• Sufferers were most troubled by their inability
  to pray (64) and their marital relationship
  (47), limitation of their social activities
  (20), difficulty in doing housework (14) and
  inconvenience during shopping (13)
• Most (71.9) of the incontinent subjects were
  self-conscious, ashamed of themselves and
  troubled by guilt (P lt 0.001) 56 found it most
  embarrassing to discuss UI with their husbands
• The majority of women (51.9) believed child
  birth to be the major cause of UI, followed by
  ageing (49.5), menopause (34.2) and paralysis
  (25.3)

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Treatment Methods for Incontinence by Family
Physicians

• Pelvic Floor Exercises 14
• Professional Advice 8
• Behavioral Therapy
• Professional Advice
• Pelvic Floor Exercises 38
• Drug Therapy
  44

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• Women adhered closely to bodily cleanliness
  considered incontinence to be dirty

8

• As Muslims, they were obliged to perform ritual
  prayers preceded by ablution five times per day
  and the urinary incontinence breached their
  status of ritual purity

9

• They have to wash more often experienced this
  as a heavy burden
• In a number of the women, shame formed a reason
  why they could not talk to anybody about the
  incontinence, not even with the doctor

10

• Urinary incontinence has a huge impact on their
  daily lives as it breaches their status of ritual
  purity
• Half of the women were deeply ashamed - did not
  visit the doctor
• Shame on the part of the patient and
  miscommunication the doctor - to inadequate
  care
• One-third of the women felt - GP had not taken
  them seriously
• Knowledge - anatomy, physiology available
  treatments was mostly lacking

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• In addition, women did not understand the aim of
  the exercises from physiotherapist.
• The majority of women preferred help from a
  female doctor

12

• Devout Muslims have to perform ablutions (Wudhu)
  before each of the ritual prayer sessions
  prescribed at five set times each day (as-Salaat)
• The majority of the study group (n 25) reported
  that in the past, they had been able to complete
  several of the prayer sessions with one and the
  same ritual purification, whereas now, they had
  to repeat it every time
• The ablution is no longer considered to be valid
  after passing urine, vaginal discharge, faeces or
  flatus from the genital organs or anus
• Consequently, the incontinence was affecting
  their worship of the Islam faith

13

• I can't guarantee that after ablution I will
  retain the state of purity
• Having to wash myself 5 to 7 times a day is
  really starting to get me down
• Sometimes I can't pray because there is nowhere I
  can wash

14

• Before praying your body and underwear need to be
  really clean.
• How can I do that when I'm staying with other
  people? That I find really difficult.
• A man wants a healthy wife who also wants sex.
• I am getting really fed up with having to wash
  myself and change my clothes all the time, these
  are the biggest problems.

15

• They believed Allah had sent them this condition
  - they owed it to Him to seek the best possible
  treatment.
• is qadr, predestinated

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• According to three of the four large Islamitic
  Schools of Jurisprudence (Shafi'i, Hanafi and
  Maliki), a prayer is not valid without prior
  ablution
• For medical reasons, Muslims do not have to
  follow all the prescriptions in some situations,
  such as Ramadan for example
• Therefore, it was felt that it would not be
  inconceivable to also excuse (Ma'zur) women with
  urinary incontinence

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Solutions

• To develop a system to help the sufferer
  understand incontinence and its consequences and
  the treatment options
• This could be done by establishing a national
  multidisciplinary consumer committee that will
  develop and issue standardized incontinence care
  guidelines
• A preliminary consensus conference will be the
  basis for the development of guidelines
• Another important strategy for this issue also
  discussed is the establishment of local
  multidisciplinary continence clinics, interest
  groups, outreach programs

18

• To bring diverse groups together (general public,
  community organizations, business, healthcare
  providers, individuals with incontinence,
  government) in partnership to make incontinence a
  priority health issue in terms of resources and
  focus
• Working with other organizations such as seniors'
  groups, fitness, pre post-natal, menopause,
  disability, womens wellness promotion
  organizations, will facilitate the efficient
  broadening of public education and sensitization
  to the issue of incontinence
• Disseminate general information leaflets on
  incontinence

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• To improve public knowledge about incontinence is
  devising guidelines for industry to improve
  accuracy and effectiveness of advertising content
• Releasing accurate and authentic information to
  reach the public through TV, magazines and
  industry brochures
• These vehicles represent important media through
  which to reach the public on an ongoing basis
  with key high-impact messages about incontinence

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Professional knowledge

• To improve knowledge about incontinence (e.g.
  medical, nursing, physiotherapy, pharmacy, social
  workers) and develop continence as a care
  requirement for all major facilities
• Developing important messages which will help
  increase professional sensitization to this
  issue, and which would appear continuously in
  professional publications

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Issuing guidelines for doctors on management
1. To ask for incontinence
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Incontinence Physicians dont ask and Patients
dont tell Spontaneous reporting age
group 65-74 48 age group 75-84 68
Especially younger people dont report
spontaneously
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Problem 1 the doctor doesnt ask the patient
doesnt complain Aim To increase awareness
for incontinence amongst doctors To convince
the doctors that he is capable to deal with
incontinence
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Issue guidelines in the management of
incontinence ? 1. To ask for incontinence 2. If
the patient reports incontinence To perform a
basic assessment ? type of incontinence ?
potentially reversible conditions To decide
whether to initiate therapy or to refer to the
specialist
25
Management of incontinence Problem 2 poor
knowledge how to manage incontinence Aims To
increase knowledge ? basic assessment
26
Management of incontinence ? Basic assessment
History / Symptoms Clinical assessment
Urine analysis Postvoid residual urine
assessment Bladder diary
27
Management of incontinence Problem 2 poor
knowledge how to manage incontinence Aim to
increase knowledge ? basic assessment ? how to
manage incontinence in an outpatient setting
28
Management of incontinence Problem 3 Time
spent Normal consultation 3 - 5 min
Extented consultation 11 - 15 minsmall children,
elderly people
29
Management of incontinence in an outpatient
setting Also specialists e.g. urologists and
gynecologists do forget to ask for
incontinence Even they do not realize that
within the group of patients with incontinence 30
are unrecognised and only treated for other
diseases
30
Continence Awareness Days GPs are informed and
invited to get an update on incontinence the days
before / during an evening seminar Evening
seminars could be organised on a district basis
in cooperation with the local Board of Doctors
31
Evening Seminars on Incontinence for in
collaboration with the local Board of
Doctors Topics Epidemiology of
incontinence Basic assessment how to take
history, to aks for symptoms, main steps of
clinical investigation, urine analysis, bladder
diary, assessment of residual urine
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• Management of incontinence
• Networking of doctors with specialists
• A short Manual on basic assessment and basic
  management of incontinence
• Incontinence Tool Box for the doctors - GP
• Manual on management of incontinence
• bladder diary
• urine measuring flask
• video on pelvic floor training
• List of specialists and physiotherapists
  interested in incontinence therapy training
  centres

33
Management of incontinence in nursing homes and
homes for the elderly Most of the management
is done by the nursing staff Pads are the
first choice of management
34
Management of incontinence in nursing homes and
homes for the elderly Toiletting or
micturition training is rarely provided Due to
a lack of knowledge especially on the doctors
side Due to shortage of personal on the
nursing side
35
What needs to be done to improve management
Providing better education on the students- and
postgraduate level Convince the GP that active
treatment of incontinence is possible and
mandatory Increasing awareness of incontinence
within the population Motivating the patient
for active treatment
36
What needs to be done to improve the
management The GP should learn which patient
could be treated at least initially by
her-/himself and who has to be sent to the
specialist The authorities of the National
Health Care System must be convinced that the
assessment of incontinent (elderly) patients
takes time and that adequate payment / resources
must be provided
37
Incontinence Help Society to improve the
management of incontinence Information on a
district level in cooperation with the local
Board of Doctors in evening seminars, especially
in conjunction with Continence Awareness Days
Manual of the management of incontinence in an
outpatient setting, especially for the GP, in
cooperation with the GP Board of Doctors
38
Incontinence Help Society to improve the
management of incontinence Incontinence Kit
for the GP Comprehensive lectures on
incontinence for postgraduate doctors becoming
GPs
39
How to start ConclusionConsumer level

• Establish a national multidisciplinary and
  consumer committee that will develop and issue
  standardized incontinence care guidelines
• First step for this strategy will be to develop a
  core group of individuals,
• The results of the consensus conference will be
  the basis for the development of preliminary
  guidelines
• Another important strategy - establishment of
  local multidisciplinary continence clinics,
  interest groups, and outreach programs
• This is critical to facilitating service access
  for individuals in the various local areas
• (Canadian Continence Foundation)

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How to start ConclusionConsumer level

• To bring diverse groups together (general public,
  community organizations, business, healthcare
  providers, individuals with incontinence,
  government) in partnership to make incontinence a
  priority health issue in terms of resources and
  focus
• Strategy Establish links with other interest
  groups, organizations and associations dealing
  with incontinence issues. Working with other
  organizations such as seniors' groups, fitness,
  pre-and post-natal, menopause, disability,
  women's' and wellness promotion organizations, as
  well as key events like the International Year of
  Older People will facilitate the efficient
  broadening of public education and sensitization
  to the issue of incontinence
• The first step in this process will be to
  disseminate general information packages on
  incontinence and continence awareness days / week
• The idea of redefining the word
  "life-threatening" to include "threat to quality
  of life" was also discussed as an important
  element to increasing the overall resources and
  priority allotted to incontinence as a health
  issue

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How to start ConclusionConsumer level

• To improve public knowledge about incontinence
• Develop advertising guidelines for and with
  industry to improve accuracy and effectiveness of
  advertising content
• Discussion addressed the fact that industry uses
  far-reaching vehicles to reach the public, like
  TV, magazines and industry brochures
• These vehicles represent important media through
  which to reach the public on an ongoing basis
  with key high-impact messages about incontinence
• One of the key messages will be to encourage
  individuals to seek help from healthcare
  professionals and from Local continence Foundation

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How to start ConclusionProfessional level

• To develop a system in long-term care that
  encourages and rewards continence rather than
  incontinence
• Develop continence as a care requirement for
  licensing/accreditation for all facilities
• The first step will be to gather information
  provincially and nationally about existing
  standards, and then to develop a process to
  advocate for inclusion of continence as a care
  requirement

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How to start ConclusionProfessional level

• To improve professional knowledge about
  incontinence (e.g. medical, nursing,
  physiotherapy, pharmacy, social workers).
• Review all health professional education
  programs, to better understand to what extent
  incontinence is included
• This will be a first step toward making
  recommendations for changes with regard to
  incontinence focus, in health professional
  undergraduate, graduate and post-graduate
  education programs
• Another general strategy discussed for this issue
  addressed the importance of developing a few
  important messages which will help increase
  professional sensitization to this issue, and
  which would appear continuously in professional
  publications

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How to start ConclusionProfessional level

• The need to provide professionals with an
  understanding of the incontinence experience from
  the consumer's point of view
• The need for research and product development for
  treatments and management options which meet
  actual consumer needs
• The need for a common vocabulary to describe and
  measure the impact of urinary incontinence
• The need to broadly disseminate public knowledge
  with regard to what questions to ask about
  incontinence and who to ask
• The experience of continence organizations around
  the world has shown that the media are the key to
  raising awareness, and that, to gain media
  attention, a hook such as a book tour or a vote
  on public washrooms is required
• Worldwide, however, it has proved a challenge to
  find a media hook that does not compromise the
  key message