The role of self-efficacy in the The role of self-efficacy in the outcome of physiotherapy for outcome of physiotherapy for
urinary incontinenceurinary incontinence
Demain S, Horn S, Monga A, McPherson K, Vits KDemain S, Horn S, Monga A, McPherson K, Vits K
University of Southampton, EnglandUniversity of Southampton, England
Urinary IncontinenceUrinary Incontinence
Urinary Incontinence (UI) is a common Urinary Incontinence (UI) is a common problem – 25% UK womenproblem – 25% UK women
Negative impact on QOLNegative impact on QOL– Employment, social and family life, sexual Employment, social and family life, sexual
relationsrelations
Associated with anxiety and depressionAssociated with anxiety and depression
Physiotherapy recommended as first-line Physiotherapy recommended as first-line treatment treatment (Berghmans et al, 1998 +(Berghmans et al, 1998 + RCOG)RCOG)
Physiotherapy for UIPhysiotherapy for UI
Pelvic floor exercises proven in Stress UIPelvic floor exercises proven in Stress UI
Bladder training indicated in Urge UIBladder training indicated in Urge UI
‘ ‘Self-Management’ utilisedSelf-Management’ utilised– Pelvic Floor Exercises,Pelvic Floor Exercises,– Bladder Training & Lifestyle Management,Bladder Training & Lifestyle Management,
Unanswered QuestionsUnanswered Questions
Why do some women benefit more than Why do some women benefit more than others from self-management? others from self-management?
Do psychological factors influence Do psychological factors influence outcome?outcome?
Is self-efficacy an important factor?Is self-efficacy an important factor?
Self-Efficacy Theory Self-Efficacy Theory (Bandura,1977)(Bandura,1977)
Self - Efficacy : Self - Efficacy : – How well can I do it ?How well can I do it ?
Outcome Expectancy: Outcome Expectancy: – If I do it, will it be effective ?If I do it, will it be effective ?
Situational Situational ((Bandura,1977) Bandura,1977)
GeneralisableGeneralisable;; (Schwarzer and Fuchs, 1996) (Schwarzer and Fuchs, 1996)
Self-Efficacy and Self-Efficacy and Health BehavioursHealth Behaviours
Role of SE explored in several conditionsRole of SE explored in several conditions– Rheumatoid Arthritis, Osteoarthritis, Rheumatoid Arthritis, Osteoarthritis,
Fibromyalgia, Cardiac disease and Chronic PainFibromyalgia, Cardiac disease and Chronic Pain
↑↑SE SE → enhanced → enhanced participation self-participation self-managementmanagement
↑↑SE SE →→ improved outcomes improved outcomes
Self-Efficacy and UISelf-Efficacy and UI
Svengalis et al (1995)Svengalis et al (1995)– 71 women with SUI undertaking PFE71 women with SUI undertaking PFE– High SE (baseline) negatively correlated with outcomeHigh SE (baseline) negatively correlated with outcome– Due to 3 outliers with extremely high baseline SE Due to 3 outliers with extremely high baseline SE
whose incontinence worsenedwhose incontinence worsened
– Initial overestimation of ability Initial overestimation of ability ⃗ ⃗ demoralisationdemoralisation
Alewijnse et al (2001)Alewijnse et al (2001)– SE and severity of urine loss predict intention to SE and severity of urine loss predict intention to
adhere to PFEadhere to PFE
AimsAims
To explore the role of self-efficacy in the To explore the role of self-efficacy in the self-management programme utilised in self-management programme utilised in Southampton Southampton
Are self-efficacy and outcome expectancy Are self-efficacy and outcome expectancy beliefs related to outcome ?beliefs related to outcome ?
How do these beliefs change during How do these beliefs change during treatment?treatment?
SampleSample
26 Women,18 years and over 26 Women,18 years and over
Clinical diagnosis of stress or mixed Clinical diagnosis of stress or mixed urinary incontinenceurinary incontinence
ProcedureProcedure
PHYSIOASSESSMENT
SELF-MANAGEMENT6 WEEKS
PHYSIOREVIEW
BASE-LINERESEARCHINTERVIEW
FOLLOW-UPRESEARCH INTERVIEW
POSTAL RETURN SELF-EFFICACY
QUESTIONNAIRES
Outcome measures - UIOutcome measures - UI
Symptom Severity IndexSymptom Severity Index (Black et al)(Black et al)– Validated self-report measureValidated self-report measure
King’s Health Questionnaire King’s Health Questionnaire (Kellerher (Kellerher et al)et al)– Validated self-report QOL measureValidated self-report QOL measure
Digital Vaginal Assessment Digital Vaginal Assessment (Laycock)(Laycock)– Subjective rating pelvic floor strength Subjective rating pelvic floor strength
based on Oxford muscle gradingbased on Oxford muscle grading– Inter and intra-rater reliabilityInter and intra-rater reliability
Incontinence SE and OEIncontinence SE and OEDeveloped for this study, adequate internal Developed for this study, adequate internal consistency (consistency (αα = 0.681) = 0.681)Pelvic Floor self-efficacy (2 questions)Pelvic Floor self-efficacy (2 questions)– do the pelvic floor exercises correctly do the pelvic floor exercises correctly – do the pelvic floor exercises several times each daydo the pelvic floor exercises several times each day
Bladder Training self-efficacy (3 questions)Bladder Training self-efficacy (3 questions)– drink 3-4 pints of fluid each daydrink 3-4 pints of fluid each day– Limit the amount of caffeine I drinkLimit the amount of caffeine I drink– Avoid emptying my bladder too frequentlyAvoid emptying my bladder too frequently
Outcome expectancy (1 question)Outcome expectancy (1 question)– If I follow the physio exercises and advice my bladder If I follow the physio exercises and advice my bladder
problem will be curedproblem will be cured
Generalised Self-EfficacyGeneralised Self-Efficacy
Modified Generalised Self Efficacy Scale Modified Generalised Self Efficacy Scale (Barlow et al, 1996)(Barlow et al, 1996)
– Validated scale: 4 point likert, 10 item, Validated scale: 4 point likert, 10 item, – Example statementExample statement
““It is easy for me to stick to my aims and accomplish It is easy for me to stick to my aims and accomplish my goals”my goals”
Sample CharacteristicsSample CharacteristicsAge (years)Age (years) mean (sd)mean (sd)
min-maxmin-max
48.8 (7.5)48.8 (7.5)
31- 6431- 64
Incontinence Incontinence (years)(years)
median (IQR)median (IQR)
min-maxmin-max
4.75 (13.0)4.75 (13.0)
0.75 - 410.75 - 41
Clinical DiagnosisClinical Diagnosis Stress UIStress UI
Mixed UIMixed UI
62%62%
38%38%
ParityParity mean (sd)mean (sd)
min-maxmin-max
2.2 (1.0)2.2 (1.0)
0-40-4
Surgery for Surgery for incontinenceincontinence
YesYes
NoNo
8%8%
92%92%
Improvements in UIImprovements in UI
BaselineBaseline Follow-upFollow-up Mean change Mean change (95% CI) (95% CI)
P value P value
SSISSI
Mean (sd)Mean (sd)
Min-maxMin-max
12.0(3.5)12.0(3.5)
4-184-18
9.6(4.1)9.6(4.1)
0-170-17
2.42.4
(0.9-3.9) (0.9-3.9)
.003* .003*
KHQKHQ
Mean (sd)Mean (sd)
Min-maxMin-max
43.7(19.8)43.7(19.8)
7.5-79.77.5-79.7
34.2(19.2)34.2(19.2)
0-80.70-80.7
9.59.5
(6.5, 12.4) (6.5, 12.4)
.000*.000*
DVADVA
Median (mean)Median (mean)
Min-maxMin-max
2.0(2.2)2.0(2.2)
1.0-4.01.0-4.0
2.5(2.6)2.5(2.6)
1.5-5.01.5-5.0
0.40.4
(0.3,0.6) (0.3,0.6)
.000** .000**
* paired t-test, ** Wilcoxon’s signed rank test* paired t-test, ** Wilcoxon’s signed rank test
Relationships between baseline Relationships between baseline SE/OE and treatment outcomeSE/OE and treatment outcome
Improvement in Improvement in Muscle Grade Muscle Grade (DVA)(DVA)
Improvement Improvement in Symptomin Symptom
Severity (SSI)Severity (SSI)
Improvement in Improvement in QOL (KHQ)QOL (KHQ)
Pelvic Pelvic
Floor SEFloor SE
rho
p
433433
.034.034
.386.386
.051.051
.005.005
.980.980
Bladder Bladder
Train SETrain SE
rho
p
-.328-.328
.102.102
.261.261
.197.197
-.016-.016
.938.938
Outcome
ExpectancyExpectancy
rho
p
.542.542
.006.006
.331.331
.099.099
-.328-.328
.102.102
GeneralisedGeneralised
Self EfficacySelf Efficacy
rho
p
.215.215
.314.314
..423423
.031.031
-.073-.073
.723.723
Changes in Incontinence SEQChanges in Incontinence SEQ
Baseline Baseline ScoreScore
Follow-upFollow-up
ScoreScore
Mean change Mean change (95% CI) (95% CI) p valuep value
Pelvic Floor Pelvic Floor SESE
(0-10)(0-10)7.5 (7.4)7.5 (7.4)
3-103-10
6.0(6.3)6.0(6.3)
2-102-10
-1.2-1.2
(-2.2,-0.1)(-2.2,-0.1).020.020
Bladder Bladder TrainingTraining
SE (0-15)SE (0-15)
12.0(12.1)12.0(12.1)
7-157-15
11.0(10.9)11.0(10.9)
5-155-15-1.2(-2.7,0.3)-1.2(-2.7,0.3) .076.076
OutcomeOutcome
Expectancy Expectancy (0-5)(0-5)
4.0(3.7)4.0(3.7)
1-51-5
3.0(3.2)3.0(3.2)
0-50-5
-0.5-0.5
(-0.8,-0.1)(-0.8,-0.1).012.012
Wilcoxon’s signed rank testWilcoxon’s signed rank test
Changes in Generalised SEChanges in Generalised SE
median (mean)median (mean)
min-maxmin-max Mean ChangeMean Change
(95% CI)(95% CI)P value*P value*
BaselineBaseline Follow-upFollow-up
Generalised SelfGeneralised Self
Efficacy ScaleEfficacy Scale
(0 – 40)(0 – 40)
32.0(30.0)32.0(30.0)
16.0-37.016.0-37.0
31.0(30.2)31.0(30.2)
12.0-39.012.0-39.00.2 (-1.4,1.7)0.2 (-1.4,1.7) .600.600
Key Discussion PointsKey Discussion Points
Limitations of correlational analysisLimitations of correlational analysis– Multiple testingMultiple testing– Larger studies should utilise multiple Larger studies should utilise multiple
regression analysisregression analysis
Key Discussion PointsKey Discussion Points
Greatest improvements in PF Strength in Greatest improvements in PF Strength in women with ↑ SE and ↑ OEwomen with ↑ SE and ↑ OE- What factors contribute to SE and OE in this What factors contribute to SE and OE in this
context?context?- Qualitative studies to exploreQualitative studies to explore- Clinically measure SE and OE to target Clinically measure SE and OE to target
additional support additional support
Key Discussion PointsKey Discussion Points
Pelvic Floor SE and OE fell during self-Pelvic Floor SE and OE fell during self-managementmanagement– Implications for long term outcomeImplications for long term outcome
““It was difficult to remember to do the exercises, they It was difficult to remember to do the exercises, they weren’t hard to do, just hard to remember to do. I weren’t hard to do, just hard to remember to do. I wouldn’t consider doing it everyday for my whole life, wouldn’t consider doing it everyday for my whole life, thought it would be easier than it is”thought it would be easier than it is”
– How can we maintain SE and OE?How can we maintain SE and OE?– Support via self-management groups?Support via self-management groups?
Take home messagesTake home messages
SE and OE beliefs importantSE and OE beliefs important
Inidicate success with physiotherapy in UIInidicate success with physiotherapy in UI
Women may quickly lose faith in own Women may quickly lose faith in own abilities and in treatment effectivenessabilities and in treatment effectiveness
Measures to enhance and maintain SE Measures to enhance and maintain SE and OE should be employed and OE should be employed