Toine Lagro-Janssen

Urinary Incontinence in Women and the Effects on their Lives

The aim of this study was to assess and analyse the effects of urinary incontinence in women and to examine the relationship between these effects and the type and severity of incontinence. 110 women aged 20 to 65 who had reported urinary incontinence to their general practitioners underwent a comprehensive history and a complete urodynamic evaluation. The reported consequences of incontinence included low self-esteem, changing life-style in order to avoid potentially embarrassing situations, and all kinds of practical worries. Fear of the odour played the most important part and was mentioned as being the worst effect in 40% of the cases. Most of the women appeared to cope adequately with the unpleasant aspects of this condition. More effects were associated with urge incontinence than with stress incontinence, while there was a significant relationship between the objective severity of the incontinence and its psychosocial impact. The main conclusion is that although urinary incontinence is not a severe physical disability, a spectrum of psychological problems is associated with it. In particular, the fear of being smelt was of the utmost importance.

From gender bias to gender awareness in medical education

Gender is an essential determinant of health and illness. Gender awareness in doctors contributes to equity and equality in health and aims towards better health for men and women. Nevertheless, gender has largely been ignored in medicine. First, it is stated that medicine was ‘gender blind’ by not considering gender whenever relevant. Secondly, medicine is said to be ‘male biased’ because the largest body of knowledge on health and illness is about men and their health. Thirdly, gender role ideology negatively influences treatment and health outcomes. Finally, gender inequality has been overlooked as a determinant of health and illness. The uptake of gender issues in medical education brings about specific challenges for several reasons. For instance, the political-ideological connotations of gender issues create resistance especially in traditionalists in medical schools. Secondly, it is necessary to clarify which gender issues must be integrated in which domains. Also, some are interdisciplinary issues and as such more difficult to integrate. Finally, schools need assistance with implementation. The integration of psychosocial issues along with biomedical ones in clinical cases, the dissemination of literature and education material, staff education, and efforts towards structural embedding of gender in curricula are determining factors for successful implementation. Gender equity is not a spontaneous process. Medical education provides specific opportunities that may contribute to transformation for medical schools educate future doctors for future patients in future settings. Consequently, future benefits legitimize the integration of gender as a qualitative investment in medical education.

It can always happen: the impact of urinary incontinence on elderly men and women.

Objective. To determine the impact of urinary incontinence (UI) on the quality of life of the elderly in the general population and to identify factors with the greatest effect. Design. Qualitative and quantitative analyses of interview data. Setting. Patients from the nine family practices of the Nijmegen University Research Network. Subjects. Independently living patients aged 60 and over. Main outcome measures. All independently living patients aged 60 and over with uncomplicated UI were interviewed at home using the Incontinence Impact Questionnaire and open-ended questions. Results. In total, 56 men and 314 women were interviewed. A majority do not have such an impact. In the Incontinence Impact Questionnaire (IIQ) emotional well-being was most affected. Half to one-third of the patients felt nervous, embarrassed, or frustrated because of their incontinence. In the social domain “clothing” and “fear of odour” scored the highest impact. The most affected practical consequence in the IIQ was “going to places where you are not sure about the availability of a toilet” followed by “travelling longer than 20 minutes” and “entertainment”. Men reported higher impact scores than women, despite the fact that incontinence was less severe in men. The most important effect of incontinence reported in men was “being out of control” while most women considered “feeling impelled to take several precautions” to be the most important consequence of UI. Conclusion. UI affects nearly half of patients, particularly as regards their emotional well-being and in public activities. Men experienced more impact compared with women and experienced loss of control more often than women.

Urinary incontinence in community dwelling elderly: are there sex differences in help-seeking behaviour?

Objective – To assess sex differences in disorder- and patient-specific factors influencing help-seeking behaviour by independently living elderly people with urinary incontinence. Design – Qualitative and quantitative analyses of the collected data. Setting – Patients from nine family practices involved in the Nijmegen Monitoring Project. Subjects – Independently living elderly aged 60 or over. MAIN outcome measures – The study population consisted of participants in a study on the prevalence of incontinence among elderly people. Independently living elderly people aged 60 or over from nine family practices with uncomplicated urinary incontinence were interviewed at home using a disorder-specific questionnaire and open-ended questions. Results – In total, 56 men and 314 women were interviewed. Half of them had sought help from a general practitioner. Men sought help from their GP when they had less severe incontinence than women. Help-seeking behaviour in women was related to the duration of symptoms (odds ratio 3.66, 95% CI 1.44–9.39), the presence of incontinence-related symptoms such as constant feeling of vaginal pressure and pain in the lower abdomen (odds ratio 2.69, 95% CI 1.52–4.76) and the severity of incontinence (odds ratio 1.69, 95% CI 0.99–2.88). In men help-seeking was related to the distress experienced in daily life (odds ratio 7.10, 95% CI 1.15–43.91). Most men and women who did not seek help consider their incontinence as not being serious enough, or they had inappropriate beliefs such as that “incontinence is age-related” and “there is nothing that can be done about incontinence”. Conclusion – Help-seeking in women is determined by the duration of the symptoms, the presence of concomitant complaints and the severity of incontinence. In men help-seeking behaviour is mostly related to the distress experienced in daily life. In men and women the most important reasons for not seeking help are that they consider the incontinence not serious enough and that they believe that there are no treatment options available.

Bringing gender sensitivity into healthcare practice: A systematic review

OBJECTIVE Despite the body of literature on gender dimensions and disparities between the sexes in health, practical improvements will not be realized effectively as long as we lack an overview of the ways how to implement these ideas. This systematic review provides a content analysis of literature on the implementation of gender sensitivity in health care. METHODS Literature was identified from CINAHL, PsycINFO, Medline, EBSCO and Cochrane (1998-2008) and the reference lists of relevant articles. The quality and relevance of 752 articles were assessed and finally 11 original studies were included. RESULTS Our results demonstrate that the implementation of gender sensitivity includes tailoring opportunities and barriers related to the professional, organizational and the policy level. As gender disparities are embedded in healthcare, a multiple track approach to implement gender sensitivity is needed to change gendered healthcare systems. CONCLUSION Conventional approaches, taking into account one barrier and/or opportunity, fail to prevent gender inequality in health care. For gender-sensitive health care we need to change systems and structures, but also to enhance understanding, raise awareness and develop skills among health professionals. PRACTICE IMPLICATIONS To bring gender sensitivity into healthcare practice, interventions should address a range of factors.

Adherence to professional guidelines for patients with urinary incontinence by general practitioners: a cross-sectional study.

BACKGROUND Urinary incontinence is a common problem, affecting quality of life and leading to high costs. There is doubt about the use of clinical practice guidelines on urinary incontinence in primary care. OBJECTIVE To assess adherence levels and reasons for (non)adherence to the Guideline on Urinary Incontinence of the Dutch College of General Practitioners. Design, setting and participants A postal survey among Dutch general practitioners (GPs). MAIN OUTCOME MEASURE Adherence of GPs to the guideline. RESULTS We analysed 264 questionnaires. Almost all GPs adhered to the guideline when diagnosing the type of urinary incontinence. A bladder diary is not often used (35%). Adherence to therapeutic procedures was only high for mild/moderate stress urinary incontinence: most GPs (82.6%) used adequate advice on bladder retraining and pelvic floor muscle training. One out of four GPs agreed that adhering to the guideline is difficult, mainly owing to lack of time, staff, diagnostic tools, competences to provide this care and low motivation of patients. CONCLUSIONS Dutch GPs follow the guideline only partially: compliance with diagnostic advices is fairly good; compliance with treatment advices is low. Further research should focus on solutions how to support GPs to tackle major barriers to facilitate the adherence to guidelines (substitution of tasks to specialized nurses, reducing the threshold for referral and concentrating expertise in integrated continence care services).

How Is Gender Integrated in the Curricula of Dutch Medical Schools? A Quick-Scan on Gender Issues as an Instrument for Change.

Medical education has not taken on board the growing awareness of sex and gender differences. A nation‐wide project to incorporate sex and gender in medical education aims to establish longitudinal gender and sex specific curricula in all Dutch medical schools that move beyond sex and gender differences in reproduction. A baseline assessment was necessary to gain an overview on the state of the art of sex and gender in Dutch medical curricula and on the courses that were suitable to integrate sex and gender differences. A quick‐scan demonstrates that sex and gender differences beyond reproduction are mostly ignored. Results have been used to create the necessary commitment of policy‐makers in all Dutch faculties to take further steps towards establishing longitudinal gender‐specific medical curricula.

Few gender differences in specialty preferences and motivational factors: a cross-sectional Swedish study on last-year medical students

BackgroundToday, women constitute about half of medical students in several Western societies, yet women physicians are still underrepresented in surgical specialties and clustered in other branches of medicine. Gender segregation in specialty preference has been found already in medical school. It is important to study the career preferences of our future physicians, as they will influence the maintenance of an adequate supply of physicians in all specialties and the future provision of health care. American and British studies dominate the area of gender and medical careers whereas Swedish studies on medical students’ reasons for specialty preference are scarce. The aim of this study is to investigate and compare Swedish male and female medical students’ specialty preferences and the motives behind them.MethodsBetween 2006 and 2009, all last-year medical students at Umea University, Sweden (N = 421), were invited to answer a questionnaire about their future career and family plans. They were asked about their specialty preference and how they rated the impact that the motivational factors had for their choice. The response rate was 89% (N = 372); 58% were women (N = 215) and 42% were men (N = 157). Logistic regression was used to evaluate the independent impact of each motivational factor for specialty preference.ResultsOn the whole, male and female last-year students opted for similar specialties. Men and women had an almost identical ranking order of the motivational factors. When analyzed separately, male and female students showed both similarities and differences in the motivational factors that were associated with their specialty preference. A majority of the women and a good third of the men intended to work part-time. The motivational factor combining work with family correlated with number of working hours for women, but not for men.ConclusionsThe gender similarities in the medical students’ specialty preferences are striking and contrast with research from other Western countries where male and female students show more differences in career aspirations. These similarities should be seized by the health care system in order to counteract the horizontal gender segregation in the physician workforce of today.

What do women think about abnormal smear test results? A qualitative interview study.

The aim of the study is a report of Dutch womens views on abnormal cervical smear test results and the consequences thereof. Twenty-seven women with recent PAP III in their history were interviewed in the context of this qualitative study. GPs often do not inform patients beforehand about the ways in which abnormal cervical smear test results are communicated, and how such information should be interpreted. Women do not anticipate abnormal test results and are taken by surprise. This frequently results in fears of cancer, disappointment in their own bodies, worries about reproduction, and sexual anxiety. Stress, predisposition, and sexuality form the most frequently mentioned causes. The cervix comes to symbolize reproduction and femininity. We conclude that a PAP III result affects womens lives in an extremely negative manner. Physicians should be aware of the influence of personal characteristics of patients which determine their responses and behaviours. The benefits and disadvantages of preventive screenings should be carefully considered.

The effects of involving a nurse practitioner in primary care for adult patients with urinary incontinence: The PromoCon study (Promoting Continence)

BackgroundUrinary incontinence affects approximately 5% (800.000) of the Dutch population. Guidelines recommend pelvic floor muscle/bladder training for most patients. Unfortunately, general practitioners use this training only incidentally, but prescribe incontinence pads. Over 50% of patients get such pads, costing €160 million each year. Due to ageing of the population a further increase of expenses is expected. Several national reports recommend to involve nurse specialists to support general practitioners and improve patient care. The main objective of our study is to investigate the effectiveness and cost-effectiveness of involving nurse specialists in primary care for urinary incontinence. This paper describes the study protocol.Methods/DesignIn a pragmatic prospective multi centre two-armed randomized controlled trial in the Netherlands the availability and involvement for the general practitioners of a nurse specialist will be compared with usual care. All consecutive patients consulting their general practitioner within 1 year for urinary incontinence and patients already diagnosed with urinary incontinence are eligible. Included patients will be followed for 12 months.Primary outcome is severity of urinary incontinence (measured with the International Consultation on Incontinence Questionnaire Short Form (ICIQ-UI SF)). Based on ICIQ-UI SF outcome data the number of patients needed to include is 350. For the economic evaluation quality of life and costs will be measured alongside the clinical trial. For the longer term extrapolation of the economic evaluation a Markov modelling approach will be used.Discussion/ConclusionThis is, to our knowledge, the first trial on care for patients with urinary incontinence in primary care that includes a full economic evaluation and cost-effectiveness modelling exercise from the societal perspective. If this intervention proves to be effective and cost-effective, implementation of this intervention is considered and anticipated.Trial registrationCurrent Controlled Trials ISRCTN62722772