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Does Urinary Incontinence Affect Middle-Aged and Older Women's Time Use and Activity Patterns?

Nancy H. Fultz, PhD^*, Gwenith G. Fisher, PhD and Kristi Rahrig Jenkins, PhD

From the *Institute for Research on Women and Gender and the Institute for Social Research, University of Michigan, Ann Arbor, Michigan.

Address reprint requests to: Nancy H. Fultz, PhD, Institute for Research on Women and Gender, University of Michigan, G135C Lane Hall, 204 South State Street, Ann Arbor, MI 48109–1290; e-mail: nfultz{at}umich.edu.

	ABSTRACT

TOP ABSTRACT MATERIALS AND METHODS RESULTS DISCUSSION REFERENCES

 
OBJECTIVE: To investigate the relationship between urinary incontinence and women's levels and hours of participation in 31 activities.

METHODS: A subset of panel members from the Health and Retirement Study completed the self-administered Consumption and Activities Mail Survey questionnaire in 2001. These data were linked with Health and Retirement Study 2000 data. Analyses were limited to 2,190 female Consumption and Activities Mail Survey self-respondents born in 1947 or earlier. Logistic regression was used to predict activity participation. Linear regression was used to predict the number of hours of participation.

RESULTS: The hypothesis that urinary incontinence affects women's time use and activity patterns was supported. Compared with the continent women, the incontinent women were less likely to have house cleaned, shopped, physically shown affection, or attended religious services in the recent past; and were more likely to have watched television or made music by singing or playing an instrument. Compared with continent activity participants, incontinent participants reported significantly fewer hours spent walking, communicating with friends and family by telephone or e-mail, working for pay, using a computer, and engaging in personal grooming and hygiene.

CONCLUSION: These findings substantiate prior work on the relationship between urinary incontinence and quality of life, and suggest a useful route for educating patients about the impact of urinary incontinence. Clinicians must be alert to opportunities for encouraging incontinent women to be active. It is also important to consider the implications for time use and activity patterns when advising patients about treatment and management options.

LEVEL OF EVIDENCE: II-2

The potential for urinary incontinence to affect time use and activity patterns has important implications for quality of life. Maintaining activity levels has been linked to successful aging; that is, to a low risk of disability, high mental and physical function, and an active engagement with life.¹⁴ Specific evidence of the protective effects of activities includes findings that discretionary activities are positively associated with health-related quality of life,¹⁵ that volunteer and paid work is related to subsequent good health and survival,¹⁶ that leisure activities are associated with a reduced risk of dementia,¹⁷ and that social interactions buffer the effects of widowhood on functional decline.¹⁸ Not all activities are necessarily positive, however. On the negative side, for example, television watching and other sedentary behaviors are related to obesity and type 2 diabetes.¹⁹

The possibility that incontinent women engage in a less beneficial array of activities could be an explanation on the pathway between urinary incontinence and psychological distress. A common way to assess the impact of urinary incontinence on activities is to use a condition-specific health-related quality of life instrument such as the Incontinence Quality of Life Instrument²⁰ or the Incontinence Impact Questionnaire.²¹ Typically, these inventories include activities such as sleep, sex, and recreation that might be curtailed because of involuntary urine loss. Incontinent respondents are asked to report the extent to which they believe their activities are impaired or are of concern because of urine loss. Comparing the self-assessments of urinary incontinence from before and after surgical or behavioral interventions can provide useful clinical outcome data.

For population-based epidemiologic studies, however, the use of generic (that is, not tied to a specific condition) quality-of-life measures can offer some advantages (for related discussion and examples, see Fultz and Herzog⁴). Thus, an alternative method for assessing whether urinary incontinence interferes with activities would be to directly compare continent and incontinent respondents’ reports about their time use. The recent Consumption and Activities Mail Survey supplement to the Health and Retirement Study presented a unique opportunity in that regard. The Health and Retirement Study is a large-scale nationally representative panel survey of middle-aged and older adults. Respondents are interviewed every 2 years about a variety of economic and health topics, including urinary incontinence.

Our present analyses investigated continent and incontinent women's participation in 31 activities. Included were activities that incontinent women might be expected to perform less often (eg, physical exercise), and activities that incontinent women might be expected to perform more often (eg, health maintenance). We examined the percentages of continent and incontinent women who reported recent participation in the activities and the amount of time that they spent on each. We also investigated whether any differences in time use and activity patterns might be attributable to sociodemographic and health factors rather than to urine loss per se. We hypothesized that urinary incontinence would exert an independent effect on women's time use and activity patterns.

	MATERIALS AND METHODS

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The Health and Retirement Study is an ongoing survey of middle-aged and older Americans, conducted by the University of Michigan with funding from the National Institute on Aging. It is designed to study labor force, health, and family transitions, and the impact of those transitions on economic resources, claims on structured programs such as Medicare, and informal assistance and transfers between family members. The survey began in 1992. Respondents are interviewed every 2 years using a mixture of telephone and face-to-face modes. The Health and Retirement Study currently represents people born in 1947 or earlier and their spouses of any age. A new cohort of respondents is added to the study every 6 years.

The core Health and Retirement Study sample was selected using a multistage area probability design. This nationally representative sample was augmented with oversamples of minority respondents. To ensure adequate coverage of the oldest Americans, another portion of the sample was selected with known probabilities from a listing of Medicare enrollees. Initial response rates for the 4 current age cohorts varied between 70% and 82%. Reinterview response rates have been above 90% across cohorts and waves of data collection.

Complete information about the design and conduct of the study is available through the Health and Retirement Study Web site at http://hrsonline.isr.umich.edu. Public use files from the Health and Retirement Study do not contain any direct identifiers of the respondents. Data are also screened for the possibility of indirect identification of respondents (eg, through the cross-tabulation of multiple variables). The University of Michigan IRB-Health Sciences approved our analyses for exemption.

The Consumption and Activities Mail Survey questionnaire was mailed to a random subsample of 5,000 Health and Retirement Study panel households in 2001. In an effort not to overburden Health and Retirement Study respondents, panel members were ineligible for the mail-out study if they or their spouses were involved in another Health and Retirement Study supplemental study and/or they were interviewed by proxy for the 2000 Health and Retirement Study core interview. In cases where more than 1 Health and Retirement Study panel member resided in a selected household, 1 respondent was randomly selected to participate. A total of 3,866 of the 5,000 Consumption and Activities Mail Survey questionnaires are included in the early release (version 1.1) of the data set, for a response rate of 77%—not adjusted for mortality or undeliverable questionnaires. The present analyses are limited to 2,190 cases where an age-eligible female respondent completed the Consumption and Activities Mail Survey questionnaire for herself. Respondents that did not self-identify as white or Caucasian, black or African American, and/or Hispanic were excluded because of their very small number. One respondent who would otherwise have been eligible was missing data on incontinence status and was dropped from the analyses.

Questionnaire development for the Consumption and Activities Mail Survey utilized literature reviews, focus groups, cognitive interviews, expert panel consultation, and a formal pretest. The 31 activities selected for inventory are shown in Appendix 1. These activities were chosen to represent a broad array of social, productive, cognitive, and physical activities. For activities that were assumed to be relatively frequent, respondents were asked for the number of hours spent in that activity in the previous week. For activities that were assumed to be less frequent, respondents were asked for the number of hours spent in the activity in the previous month. For each activity, a box was provided for respondents to check if no time was spent on the activity in the previous week/month. Respondents were instructed to record the actual time spent, not an estimate of the usual amount, even if the previous week/month was unusual. The instructions also noted that travel time to and from an activity should be included in the report for that activity.

Urinary incontinence is measured at each wave of the Health and Retirement Study core interview with the following questions: "This might not be easy to talk about, but during the last twelve months, have you lost any amount of urine beyond your control?" and (if "yes") "On about how many days in the last month have you lost any urine?" For the present analyses, women reporting at least 1 day of involuntary urine loss in the previous month were considered incontinent. Because the Consumption and Activities Mail Survey questionnaire did not address urinary incontinence, we determined respondents’ (in)continence status on the basis of their 2000 Health and Retirement Study data.

The multivariable models included standard sociodemographic controls (age, race/ethnicity, household net worth, education, urban versus rural residence, and marital status). We also controlled two aspects of health status that could affect both urinary incontinence and activity patterns: comorbidity and functional impairment. Comorbidity was assessed as the number of health conditions that the respondent reported (from a maximum of 8: high blood pressure, arthritis, diabetes, cancer, lung disease, heart disease, stroke, hearing and/or vision impairment). Functional impairment was measured as the number of tasks that the respondent would find difficult (from a maximum of 9: walking several blocks; sitting for 2 hours; getting up from a chair after sitting long periods; climbing several flights of stairs; stooping, kneeling, crouching; reaching or extending arms above shoulders; pulling or pushing large objects; lifting or carrying weights equivalent to a full bag of groceries; picking up a dime from a table). These variables were based on self-reported information collected at Health and Retirement Study 2000.

The analyses were conducted using SAS 8.2 (SAS Inc., Cary, NC) and IVEware (Institute for Social Research, Ann Arbor, MI) to allow for the weighting and complex sample design of the Health and Retirement Study data. Each activity is measured as a continuous variable from 0 to 84 hours for the previous week's activities and from 0 to 372 hours for the previous month's activities. The upper bounds of 84 and 372 hours were imposed at the time of analysis to keep the few outlier values from exerting undue influence over the results. Based on the decision that no activity would be allowed to exceed an average of 12 hours per day, 84 equals 12 hours times 7 days, and 372 equals 12 hours times 31 days.

Ordinary linear regression would not be an appropriate analytic model for these data because of the "floor effect" of the 0 responses. That is, 0 is the lowest value possible (there cannot be a negative number of hours) and there are relatively large proportions of 0 responses across the activities. Left censored regression would be a more appropriate strategy; such models assume, however, that the same structural and stochastic processes apply to both the 0 (censored) cases as to the noncensored cases, without testing that assumption. Because it is not obvious that the same structure would apply to whether or not an activity is performed and to the number of hours of performance among participants, we chose to model these two components separately. We used logistic regression to estimate the relative likelihood of continent and incontinent women's participation in each activity (coded as a 0/1 indicator variable). We then used linear regression to estimate the relative number of hours spent on the activities (coded as 1–84 or 372 hours) by continent and incontinent participants (ie, excluding the 0 responses).

After describing the sample characteristics (Table 1) and the level of participation in each activity (Table 2), we present 2 tables of coefficients representing the relationships between urinary incontinence and the activities (Tables 3 and 4).Table 3 predicts whether or not the activity was performed at all, whereas Table 4 predicts the number of hours that participants spent on the activity. The first columns of coefficients in Tables 3 and 4 show the unadjusted relationships between urinary incontinence and the activities. The second columns of coefficients are from the multivariable models (ie, the coefficients are adjusted for the covariates).

	RESULTS

TOP ABSTRACT MATERIALS AND METHODS RESULTS DISCUSSION REFERENCES

 
Table 1 summarizes the sociodemographic and health characteristics of the women in this study. About 22% of our analysis sample reported urine loss in the previous month. Table 2 provides an overview of activity participation and time use for these women. Note that the activities from "watching television" through "showing affection" refer to the prior week, whereas "helping others" through "home improvements" refer to the prior month. Table 2 suggests that higher percentages of continent women engaged in the majority of activities. The few exceptions are for relatively sedentary activities such as watching TV. Once an activity was undertaken, continent and incontinent women appear to have devoted similar amounts of time to it. Where there are differences in the hours of participation, they tend to be consistent with the differences in levels of participation. For example, a greater percentage of incontinent women treated or managed a medical condition of their own and, among those who did, the incontinent women reported more hours.

Table 3 presents the odds ratios and 95% confidence intervals from the logistic regressions of activity participation on urinary incontinence. The first column shows that the continent and incontinent women had significantly different odds of participation for more than one third of the activities. Compared with the continent women, the incontinent women were less likely to have walked, worked for pay, used a computer, house cleaned, washed and ironed clothes, shopped, prepared meals, physically shown affection, attended religious services, taken care of finances, attended a movie or other cultural event, or performed home improvements. In contrast, the incontinent women were more likely to have treated or managed an existing medical condition of their own.

The adjusted odds ratios in the second column of Table 3 suggest that sociodemographic and health characteristics account for some of the differences found in the first column. Significant differences between the continent and incontinent women remained, however. The incontinent women continued to be less likely to have house cleaned, shopped, physically shown affection, or attended religious services. Interestingly, with the introduction of the covariates, the incontinent women's greater likelihood of watching television and singing or playing a musical instrument became statistically significant.

Table 4 shows the results of regressing the number of hours for each activity on urinary incontinence and the covariates. This table includes only the respondents that reported having participated in the activities (ie, reported a number of hours greater than 0). As was suggested by Table 2, urinary incontinence appears to have somewhat less impact on the number of hours of participation in an activity than on the distinction between participation and nonparticipation. Compared with continent women, incontinent women reported significantly fewer hours walking, communicating with friends and family by telephone or e-mail, working for pay, using a computer, and engaging in personal grooming and hygiene.

	DISCUSSION

TOP ABSTRACT MATERIALS AND METHODS RESULTS DISCUSSION REFERENCES

 
Our results support the hypothesis that urinary incontinence affects women's time use and activity patterns. The effect was somewhat stronger for determining participation (or not) than for predicting the number of hours of participation. The affected activities tended to be those involving physical or social efforts. Cognitive activities typically done alone (eg, reading) were less influenced.

That urinary incontinence exerted an independent effect on activities in the public sphere, even in the fully adjusted models, suggests that it is the urine loss per se that is responsible, rather than sociodemographic or health differences between the continent and incontinent women. This finding is consistent with incontinent women's self-perceptions of the condition. After interviewing female urodynamics patients, Norton²² concluded, "Rather than physically preventing activities, incontinence makes people anxious, embarrassed and unwilling to undertake a wide range of activities that form a major component in the ‘quality of life,’ while not being essential to life itself." Similarly, Fultz et al²³ noted that concerns about social embarrassment were evident in incontinent women's survey responses, and Lagro-Janssen et al¹³ asserted that the fear of having an odor was of "utmost concern" to incontinent women.

The finding that urinary incontinence is associated with fewer hours working and walking is also important. Prior cost analyses of urinary incontinence have estimated only the direct costs of the condition²⁴ or have focused on older adults, who are less likely to be in the workforce.²⁵ Our results provide preliminary data for estimates of the indirect costs of urinary incontinence through lost wages. Quantifying the implications of fewer hours spent walking might be harder, but physical inactivity has been linked to a multitude of health risks that can reduce quality of life.²⁶ The concern that incontinence may contribute to a more sedentary lifestyle is reinforced by our finding that incontinent women are more likely than continent women to watch television.

Strengths of the study include a large, nationally representative sample of middle-aged and older women, the comprehensive inventory of activities measured in the Consumption and Activities Mail Survey, and the ability to link the activity data to covariates measured in the Health and Retirement Study. Limitations include the fact that all data were self-reported, without external verification. Both urinary incontinence and time use may be subject to measurement and response effects. We believe, however, that any bias in activity reports (eg, reporting higher numbers of hours for socially desirable activities) would be in the same direction and of the same magnitude for continent and incontinent respondents. If so, our conclusions about the differences between these groups would remain valid. If respondents were to underreport incontinence, then our results would likely be a conservative estimate of the differences.

Any true change in continence status between the 2000 Health and Retirement Study interview and the 2001 Consumption and Activities Mail Survey would also serve to attenuate relationships. Despite this lag between the 2000 Health and Retirement Study and the Consumption and Activities Mail Survey, our analysis is essentially cross-sectional; we cannot establish temporal order or causality among the variables. It is reasonable to assert that urinary incontinence affects activities, but it is also possible that activities influence (in)continence status. For example, a woman starting work as a teacher may have less time available for physical exercise. Weight gain due to physical inactivity—combined with limited bathroom breaks—could precipitate urine loss. Indeed, the relationship between urinary incontinence and activities is likely to be complex, which would require longitudinal data to fully address.

The present findings substantiate prior work regarding the deleterious effect of urinary incontinence on quality of life. Moreover, the present findings suggest a useful route for clinicians to educate patients about the impact of urinary incontinence. Given the stigma that still attends issues of emotional health, patients may be more comfortable with a discussion of activity and time constraints than of depression and self-esteem. Because incontinent women may be more willing to acknowledge a change in activity patterns than feelings of despair, this approach might also yield a more valid representation of the total burden of the condition. Clinicians should be alert to opportunities for encouraging incontinent women to be active. It is also important to consider the implications of urinary incontinence treatment and management strategies for time use and activity patterns when advising patients about their options. In the interests of maintaining well-being, women must be given sufficient information to make informed decisions about this aspect of urologic health.

APPENDIX 1
How many hours did you actually spend last week:

1. Watching programs or movies/videos on TV?
   
2. Reading newspapers or magazines?
   
3. Reading books?
   
4. Listening to music?
   
5. Sleeping and napping (including at night)?
   
6. Walking?
   
7. Participating in sports or other exercise activities?
   
8. Visiting in person with friends, neighbors, or relatives?
   
9. Communicating by telephone, letters or e-mail with friends, neighbors, or relatives?
   
10. Working for pay?
    
11. Using the computer?
    
12. Praying or meditating?
    
13. House cleaning?
    
14. Washing, ironing, or mending clothes?
    
15. Yard work or gardening?
    
16. Shopping or running errands?
    
17. Preparing meals and cleaning up afterward?
    
18. Personal grooming and hygiene, such as bathing and dressing?
    
19. Caring for pets?
    
20. Physically showing affection for others through hugging, kissing, etc?
    How many hours did you spend last month:
    
21. Helping friends, neighbors, or relatives who did not live with you and did not pay you for the help?
    
22. Doing volunteer work for religious, educational, health-related, or other charitable organizations?
    
23. Attending religious services?
    
24. Attending meetings of clubs or religious groups?
    
25. Taking care of finances or investments, such as banking, paying bills, balancing the checkbook, doing taxes, etc?
    
26. Treating or managing an existing medical condition of your own?
    
27. Playing cards or games, or solving puzzles?
    
28. Attending concerts, movies, or lectures, or visiting museums?
    
29. Singing or playing a musical instrument?
    
30. Doing arts and crafts projects, including knitting, embroidery, or painting?
    
31. Doing home improvements, including painting, redecorating, or making home repairs?
    

	Footnotes

 
Funding Support: This research was supported through the Building Interdisciplinary Research Careers in Women's Health (BIRCWH) career development program of the National Institutes of Health (K12 HD01438, Dr. Fultz). The National Institute on Aging (U01 AG09740) funds the collection, processing, and dissemination of Health and Retirement Study data, which were used for this article. The authors thank Daniel H. Hill for statistical consultation. An earlier version of these findings was presented at the 56th Annual Scientific Meeting of the Gerontological Society of America, November 2003, San Diego, California.

Received March 23, 2004. Received in revised form July 31, 2004. Accepted August 12, 2004.

doi:10.1097/01.AOG.0000143829.21758.3c

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Fultz, N. H. Articles by Jenkins, K. R. Search for Related Content PubMed PubMed Citation Articles by Fultz, N. H. Articles by Jenkins, K. R. Related Collections Epidemiology/public health General gynecology Geriatrics Urogynecology