|Year : 2020 | Volume
| Issue : 1 | Page : 17-21
Challenges encountered in community-based physiotherapy interventions for urinary incontinence among women in rural areas of Anand District of Gujarat, India
G Daxa Mishra1, Dinesh Kumar2, G Ajay Pathak3, B Smruti Vaishnav4
1 Professor, Department of Physiotherapy, KM Patel Institute of Physiotherapy, Karamsad, Gujarat, India
2 Professor, Department of Community Medicine, PS Medical College, Karamsad, Gujarat, India
3 Manager, Central Research Services, Charutar Arogya Mandal, Karamsad, Gujarat, India
4 Professor, Department of Obstetrics and Gynecology, PS Medical College Karamsad Gujarat, India
|Date of Submission||26-Dec-2018|
|Date of Decision||04-Jun-2019|
|Date of Acceptance||02-Feb-2020|
|Date of Web Publication||16-Mar-2020|
G Daxa Mishra
KM Patel Institute of Physiotherapy, Karamsad, Anand - 388 325, Gujarat
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: It is necessary to understand the way women think about their health. There is a “culture of silence” among women regarding urinary incontinence (UI). Physiotherapy is proven effective mode of therapy in case of UI. Objectives: This study aimed to explore the attitude of the women toward UI, to understand the related sociocultural factors and health-seeking behavior, and to ascertain the challenges encountered in community-based physiotherapy interventions. Methods: A qualitative study was conducted among women who refused to participate in a physiotherapy intervention for UI in the rural community of Gujarat, India. Fourteen in-depth key informant interviews were conducted using an interview guide. The responses were noted and compiled into a composite interview script. Interviews were not recorded due to nonavailability of consent. Interviews were reviewed by investigators and content analysis was carried out. Key themes were identified after multiple iterations. Results: Most of the women were unaware of the UI and believed that it may be due to their gender or due to aging. Physiotherapy interventions were disregarded due to various reasons such as shy nature, lack of priority and privacy, dependency, self-neglect, and influence of social and cultural norms. Conclusion: Cultural and social systems were more important determinants of health seeking than health systems themselves particularly when sensitive issue such as UI in women of rural Western India was concerned.
Keywords: Key informant interview, rural women, sociocultural determinants, urinary incontinence, women's health
|How to cite this article:|
Mishra G D, Kumar D, Pathak G A, Vaishnav B S. Challenges encountered in community-based physiotherapy interventions for urinary incontinence among women in rural areas of Anand District of Gujarat, India. Indian J Public Health 2020;64:17-21
|How to cite this URL:|
Mishra G D, Kumar D, Pathak G A, Vaishnav B S. Challenges encountered in community-based physiotherapy interventions for urinary incontinence among women in rural areas of Anand District of Gujarat, India. Indian J Public Health [serial online] 2020 [cited 2020 May 27];64:17-21. Available from: http://www.ijph.in/text.asp?2020/64/1/17/280774
| Introduction|| |
Women's health plays an important role in determining the health of future generation because it has an intergenerational issue. There are many ways which make women's health different from men. Although women have a longer life span as compared to men, they need more doctor visits, more disability days, higher rates of illness, and greater use of health services, even when pregnancy-related conditions were adjusted for. This paradox is a result of various factors that affect our health services including our lifestyle. To shape the health of an individual and to alleviate the suffering fully, we need to attend the social, psychological, and cultural components of people's health in addition to their physical bodies.
Many medical and gynecological problems which are major impediments to advancing women's health are not even considered and are underrepresented. Very little attention is paid to gynecological problems in nonpregnant women, and problem such as urinary incontinence (UI) is never discussed or even considered as a health issue. It is essential to focus on the quality of life affected by UI as it is preventive in nature, justifying the old-age proverb “prevention is better than cure.”
UI is an involuntary leakage of urine resulting due to pelvic floor dysfunction and is strongly associated with the female gender. The prevalence of UI in India is also quite high and ranges from 10% in rural areas to 34% in urban areas.,
Although UI is not a threat to life, it causes discomfort, shame, and loss of self-confidence and also has significant cost implications. The prevalence of this problem is underestimated because women usually do not seek treatment for their reproductive health problems and do not vocalize their symptoms. There is a “culture of silence” and low consultation rate among Indian women regarding such problems.
In this perspective, the present study has been undertaken with the aim of exploring the attitude of the women toward the problem of UI and also to understand the related sociocultural factors on their attitude and health-care-seeking behavior as well as to ascertain the challenges encountered in community-based physiotherapy interventions for UI among rural women.
| Materials and Methods|| |
This research was commenced after the Institutional Ethics Committee (IEC) of H.M. Patel Centre for Medical Care and Education (HMPCMCE; Reg. no: ECR/1123/Inst/GJ/2018) approved the study (Ref no IEC/HMPCMCE/2018/Ex. 16/18 dated June 5, 2018).
A community-based study was conducted in four villages which were randomly selected from the 27 villages adopted by our institute in the Anand district of Gujarat state. The primary study was to find the prevalence of UI, in which the sample size was calculated using WinPepi software (PEPI for Windows). Available from http://publichealth.jbpub.com/book/gerstman. The total population of target women (between the age of 20 and 70 years) in these four villages was 4291. Considering the prevalence of UI as 15% in the Indian literature with an error margin of 2.5%, a size of 784 was required for the primary study. The sample size was inflated by 20% expecting a high nonparticipation rate, considering the sensitivity of the topic.
Computerized randomization was done from the village registry available with the village health worker (VHW) to recruit women from each village as per the calculated sample size and 897 women were invited to participate in the study. A total of 883 women participated after dropout in the main study.
The current study was carried out as a spin-off from a physiotherapy interventional study for UI. Of the total 883 women screened by VHWs, 49 women were identified with UI and were included for the physiotherapy intervention. Intervention consisted of educational and motivational videos, a practical demonstration of exercises, home exercise program, and advice to do exercise at home. All these women were called for the follow-up after a week, but very few women turned up. Of 49 women, only 18 came for follow-up.
To explore the reasons for not accessing the free services provided at their doorstep, we decided to undertake the qualitative study. It was decided to conduct the Focus Group Discussion (FGD) in all four villages for the women who did not join the intervention program. Since women were reluctant to participate and were not keen to discuss this problem in a group, instead of FGD, both VHWs and investigator conducted the key informant interview in person at the homes of the participants ensuring privacy and convenience of the participants to find the reasons for their attitude using the interview guide. Written informed consent from each participant was obtained before including in the study. There was no audio or video recording of the interviews done due to feasibility and permission issues.
The interview guide was based on the inputs given not only by the VHWs but also from the women who came for regular follow-up and did exercise as per the instruction and also from women who refused to be a part of the intervention. The interviews were recorded in a notebook by the investigator. The notes were then compiled into a composite interview script by the investigator. The final analysis was based on the investigator's notes.
| Results|| |
A total of 14 in-depth interviews were conducted for the 14 women whose mean age was 42.9 years. Of 14 women, 7 were illiterate, 4 were with primary education, and 3 were with secondary education. All the women were housewives and few also additionally worked as agricultural laborers.
Description of issues explored
Based on the content analysis, the following six themes have emerged: attitude toward the problem and seeking help; caste discrimination; individual support system; priorities and lack of time; lack of privacy; and social taboo and personal belief. According to the themes, the participants' verbatim reports are mentioned in [Table 1].
|Table 1: Participants' verbatim reports on themes toward problem of urinary incontinence|
Click here to view
Theme 1: Attitude toward the problem and seeking help
It was noted that most of them were unaware of this condition being abnormal before. They were educated as a part of the study. Still, there was less effort to resolve this problem because they did not consider this as a health problem so they were ignorant about the remedy for this problem. In spite of the education on this issues prior to the intervention, many of them believed it as a normal physiological phenomenon, which was bound to happen. A few of them considered it as a problem as it affected them psychologically although they have accepted as part of their life.
Majority of the women felt that UI is not a problem and ignorance about this fact deterred them from seeking help. Quite a few did not take it as a serious issue. Those who considered it as a problem felt that no remedy was available. There were few who preferred to get treated the problem by medicine. None of them were aware that exercise could also help in dealing with this issue. Shyness also prevented them from seeking help. All the participants preferred nurse or VHW or at the most lady doctors for seeking help as they feel comfortable with them. They felt shy to talk to any male consultant.
Theme 2: Role of caste
Caste discrimination and feeling of low self-esteem due to the existence of a similar problem in the lower community was observed. Two women with UI from higher caste (Patel) refused to come for the session because of the presence of women from lower caste from the same village who were suffering from similar problems. Even when the investigator showed the keenness to conduct the session at a separate location, they bluntly refused to participate in the study. None of the women from the lower caste had any issues with common sessions.
Theme 3: Individual support system
Nonsupportive nature of family members in decision-making process regarding health issues in women also prevented them to join the intervention. For everything they did, they need to seek the permission of their mother-in-law or their husband, who mostly did not co-operate and insisted on them to focus on routine work and not to listen to others. Another lady when talked about the exercise, her in-laws said not to do anything like this. Most of the women did not have time as they were working in the field for earning apart from doing their household work. One old lady took it seriously and tried to do exercise; daughter-in-law started smiling and made fun of her.
Theme 4: Priorities and lack of time
Priority for these women was family members over her. Household chores and lack of time due to busy household activities were also the reasons given by them for not coming for the exercise (intervention). When they were asked to come for the follow–up, they could not come as there was a provision of a tractor (common vehicle), which takes them to field and bring them back home. Due to this, they could not get time for the session as they have to manage cooking as well as other work of the house and to reach on time for the tractor otherwise they will lose the wages. For these women, earning for self and the family was the priority over health. Two among them were concerned about the problem and were convinced of the exercise but could not spare time to come for the session.
Theme 5: Lack of privacy
Majority of women were part of the joint family. They were living in a small one-room and kitchen house and so space was a major constrain for them. Lack of privacy in a small house was an obstacle to do exercise at home. They were subconsciously conscious about the presence of someone and felt ashamed of doing exercise in the presence of family members as well.
Theme 6: Social taboo and personal belief
Among them, lack of priority toward health, ignorance, and inability to protest for their right, neglect about self, and blaming the destiny as the cause for the problem were observed. Most of the women said that it may be natural to have incontinence being women and more so as one grew old. During the education session, while talking about the problem, they were smiling and giggling, feeling shy to even mention the problem. They were feeling uncomfortable and were avoiding eye-to-eye contacts. When they were approached at their house door to come for the follow-up session, two of them literally got angry and said not to approach them in future for such inquiry. Few of them were fearful that if they consult the doctor about their problem, how would the family members react when they come back? Few women felt that drinking less water can cure this problem.
| Discussion|| |
It is necessary to understand the way the people think about their health if we want to change people's behavior to benefit their health. It is also important to understand their attitude toward health and the practices they follow. The purpose of conducting this study was to understand the attitude of women toward health in general and toward the problem of UI in particular.
Simple and effective treatments for UI are available in primary care, but the research has shown that many people who have incontinence do not seek services. Overall, women feel that urinary symptoms such as leakage, frequency, and nocturia were normal parts of the aging process and not serious symptoms of a disease state. This has reflected in our study as well.
The results from the literatures, including our study indicate that before reaching with the medical care, we must emphasize educating the people about the influence of their cultural misconception and societal attitude toward their health. More than the health it is their thoughts which make them psychologically disabled and the QOL gets affected. The sociocultural background from which people come plays a crucial role in seeking and accepting healthcare.,
One study has mentioned that there is a differential experience of discrimination by lower caste pregnant women in comparison to upper caste pregnant women. In our study also, caste preference was emphasized over a health issue.
The pressure of traditional customs and norms of the male domination still make women subjugated to men. Social factors such as the patriarchal family system with religious traditions and male-dominant value systems refute the empowerment, equality, and social justice to women in the real sense.
Women are deprived of decision-making positions both in society and within the family. Decisions made by others directly or indirectly affect their lives on a daily basis which make it difficult for the women to access healthcare. Developing countries have much worse scenario. Men play important and often dominant roles in making decisions that are crucial to women's reproductive health. Due to the low status of women in the Indian society, they still have to depend on their husbands to receive appropriate and adequate health care for their illnesses. Male control over social institutions, and the women are confined to household tasks. In India, in-laws influence the daughter-in-law to get a lot of things done in the name of “culture” and respect for elders. The husband rarely supports the wife and sides with the mother.
Unlike men, women are more concerned about time and money constraints, task factors, emotions, social factors, etc., while taking the decision about their health management. They have self-sacrificing behavior toward other care over self-care, for example, care of family members. In our study also, many women have given priority to care and concern of their family members over self-care.
Women's health is influenced by the factors such as cultural, societal, and spiritual aspects which are determined through biological, social, and economic contexts which are associated with their living conditions. These factors have influenced women in our study doing exercise in the presence of other family members.
Women in India have been reported to have a high tolerance threshold for seeking treatment. Embarrassments, shyness, lack of money/time, fear of surgery, and pain are usually the reasons given by women for nonconsultation.
| Conclusion|| |
Our study concludes that cultural and social systems were more important determinants of health than health systems themselves particularly when sensitive issue such as UI in women of rural western India was concerned. This is worsened by the lack of knowledge and attitude of neglect about UI. There is a definitive need to address the sociocultural issues when planning any community-based intervention for issues of women's health including UI.
Based on the findings of our study, we recommend that it is essential to emphasize the importance of UI as serious issue in health education to help women recognizing this as an issue rather than a variant of health. The education should consist of multiple strategies and be tailored to local social and caste equations. Involving family members and key supporters in planning interventions is vital as they have a significant influence on the overall health-seeking behavior of women in their families. The concept of sacrificing basic self-care needs over other issues should be discussed with due sensitivity. It must be emphasized that self-care is an important part of family care. Thus, multipronged social strategies are needed for the women to feel the need for seeking care. Other health system-related strategies will have no major impact until this is achieved.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Loutfy M, Khosla R, Narasimhan M. Advancing the sexual and reproductive health and human rights of women living with HIV. J Int AIDS Soc 2015;18:20760.
Slieker-ten Hove MC, Pool-Goudzwaard AL, Eijkemans MJ, Steegers-Theunissen RP, Burger CW, Vierhout ME. The prevalence of pelvic organ prolapse symptoms and signs and their relation with bladder and bowel disorders in a general female population. Int Urogynecol J Pelvic Floor Dysfunct 2009;20:1037-45.
Bodhare TN, Valsangkar S, Bele SD. An epidemiological study of urinary incontinence and its impact on quality of life among women aged 35 years and above in a rural area. Indian J Urol 2010;26:353-8.
] [Full text]
Abha S, Priti A, Nanakram S. Incidence and epidemiology of urinary incontinence in women. J Obstet Gynecol India 2007;57:155-7.
Singh U, Agarwal P, Verma ML, Dalela D, Singh N, Shankhwar P. Prevalence and risk factors of urinary incontinence in Indian women: A hospital-based survey. Indian J Urol 2013;29:31-6.
] [Full text]
Bedretdinova D, Fritel X, Panjo H, Ringa V. Prevalence of female urinary incontinence in the general population according to different definitions and study designs. Eur Urol 2016;69:256-64.
Kumari S, Singh AJ, Jain V. Treatment seeking behavior for urinary incontinence among north Indian women. Indian J Med Sci 2008;62:352-6.
] [Full text]
Doshani A, Pitchforth E, Mayne CJ, Tincello DG. Culturally sensitive continence care: A qualitative study among South Asian Indian women in Leicester. Fam Pract 2007;24:585-93.
Nyonator FK, Awoonor-Williams JK, Phillips JF, Jones TC, Miller RA. The Ghana community-based health planning and services initiative for scaling up service delivery innovation. Health Policy Plan 2005;20:25-34.
Waring J, Allen D, Braithwaite J, Sandall J. Healthcare quality and safety: A review of policy, practice and research. Sociol Health Illn 2016;38:198-215.
Azuh D, Fayomi O, Ajayi L. Socio-cultural factors of gender roles in women's healthcare utilization in Southwest Nigeria. Open J Soc Sci 2015;3:105-17.
Thresia CU. Health inequalities in South Asia at the launch of sustainable development goals: Exclusions in health in Kerala, India need political interventions. Int J Health Serv 2018;48:57-80.
Khubchandani J, Soni A, Fahey N, Raithatha N, Prabhakaran A, Byatt N, et al
. Caste matters: Perceived discrimination among women in rural India. Arch Womens Ment Health 2018;21:163-70.
Singh A, Arora AK. How much do rural indian husbands care for the health of their wives'. Indian J Community Med 2008;33:19-25.
] [Full text]
Karim R, Lindberg L, Wamala S, Emmelin M. Men's perceptions of women's participation in development initiatives in rural Bangladesh. Am J Mens Health 2018;12:398-410.
Riegel B, Dickson VV, Kuhn L, Page K, Worrall-Carter L. Gender-specific barriers and facilitators to heart failure self-care: A mixed methods study. Int J Nurs Stud 2010;47:888-95.
Radina ME, Armer JM, Stewart BR. Making self-care a priority for women at risk of breast cancer-related lymphedema. J Fam Nurs 2014;20:226-49.
PhD, Salar A PhD, Ghaljaei F
PhD, Seyedfatem N
PhD, Rezaei N
Ma. Understanding the contextual factors affecting women's health in sistan and Baluchestan province in Iran: A qualitative study. Int J Community Based Nurs Midwifery 2017;5:317-28.