The role of self-efficacy in the
outcome of physiotherapy for
urinary incontinence
Demain S, Horn S, Monga A, McPherson K, Vits K
University of Southampton, England
Urinary Incontinence
Urinary Incontinence (UI) is a common
problem – 25% UK women
Negative impact on QOL
– Employment, social and family life, sexual
relations
Associated with anxiety and depression
Physiotherapy recommended as first-line
treatment (Berghmans et al, 1998 + RCOG)
Physiotherapy for UI
Pelvic floor exercises proven in Stress UI
Bladder training indicated in Urge UI
‘Self-Management’ utilised
– Pelvic Floor Exercises,
– Bladder Training & Lifestyle Management,
Unanswered Questions
Why do some women benefit more than
others from self-management?
Do psychological factors influence
outcome?
Is self-efficacy an important factor?
Self-Efficacy Theory (Bandura,1977)
Self - Efficacy :
– How well can I do it ?
Outcome Expectancy:
– If I do it, will it be effective ?
Situational (Bandura,1977)
Generalisable; (Schwarzer and Fuchs, 1996)
Self-Efficacy and
Health Behaviours
Role of SE explored in several conditions
– Rheumatoid Arthritis, Osteoarthritis,
Fibromyalgia, Cardiac disease and Chronic Pain
↑SE → enhanced participation selfmanagement
↑SE → improved outcomes
Self-Efficacy and UI
Svengalis et al (1995)
– 71 women with SUI undertaking PFE
– High SE (baseline) negatively correlated with outcome
– Due to 3 outliers with extremely high baseline SE
whose incontinence worsened
– Initial overestimation of ability ⃗ demoralisation
Alewijnse et al (2001)
– SE and severity of urine loss predict intention to
adhere to PFE
Aims
To explore the role of self-efficacy in the
self-management programme utilised in
Southampton
Are self-efficacy and outcome expectancy
beliefs related to outcome ?
How do these beliefs change during
treatment?
Sample
26 Women,18 years and over
Clinical diagnosis of stress or mixed
urinary incontinence
Procedure
PHYSIO
ASSESSMENT
SELF-MANAGEMENT
6 WEEKS
BASE-LINE
RESEARCH
INTERVIEW
PHYSIO
REVIEW
FOLLOW-UP
RESEARCH
INTERVIEW
POSTAL RETURN
SELF-EFFICACY
QUESTIONNAIRES
Outcome measures - UI
Symptom Severity Index (Black et al)
– Validated self-report measure
King’s Health Questionnaire (Kellerher
et al)
– Validated self-report QOL measure
Digital Vaginal Assessment (Laycock)
– Subjective rating pelvic floor strength
based on Oxford muscle grading
– Inter and intra-rater reliability
Incontinence SE and OE
Developed for this study, adequate internal
consistency (α = 0.681)
Pelvic Floor self-efficacy (2 questions)
– do the pelvic floor exercises correctly
– do the pelvic floor exercises several times each day
Bladder Training self-efficacy (3 questions)
– drink 3-4 pints of fluid each day
– Limit the amount of caffeine I drink
– Avoid emptying my bladder too frequently
Outcome expectancy (1 question)
– If I follow the physio exercises and advice my bladder
problem will be cured
Generalised Self-Efficacy
Modified Generalised Self Efficacy Scale
(Barlow et al, 1996)
– Validated scale: 4 point likert, 10 item,
– Example statement
“It is easy for me to stick to my aims and accomplish
my goals”
Sample Characteristics
Age (years)
mean (sd)
min-max
48.8 (7.5)
31- 64
Incontinence
(years)
median (IQR)
min-max
4.75 (13.0)
0.75 - 41
Clinical Diagnosis Stress UI
Mixed UI
62%
38%
Parity
mean (sd)
min-max
2.2 (1.0)
0-4
Surgery for
incontinence
Yes
No
8%
92%
Improvements in UI
P value
Baseline
Follow-up
Mean change
(95% CI)
SSI
Mean (sd)
Min-max
12.0(3.5)
4-18
9.6(4.1)
0-17
2.4
(0.9-3.9)
.003*
KHQ
Mean (sd)
Min-max
43.7(19.8)
7.5-79.7
34.2(19.2)
0-80.7
9.5
(6.5, 12.4)
.000*
DVA
Median (mean)
Min-max
2.0(2.2)
1.0-4.0
2.5(2.6)
1.5-5.0
* paired t-test, ** Wilcoxon’s signed rank test
0.4
(0.3,0.6)
.000**
Relationships between baseline
SE/OE and treatment outcome
Improvement in Improvement
Muscle Grade
in Symptom
(DVA)
Severity (SSI)
Improvement in
QOL (KHQ)
Pelvic
Floor SE
rho
p
433
.034
.386
.051
.005
.980
Bladder
Train SE
rho
p
-.328
.102
.261
.197
-.016
.938
Outcome
Expectancy
rho
p
.542
.006
.331
.099
-.328
.102
Generalised
Self Efficacy
rho
p
.215
.314
.423
.031
-.073
.723
Changes in Incontinence SEQ
Pelvic Floor
SE
(0-10)
Bladder
Training
SE (0-15)
Outcome
Expectancy
(0-5)
Baseline
Score
Follow-up
Score
Mean change
(95% CI)
p value
7.5 (7.4)
3-10
6.0(6.3)
2-10
-1.2
(-2.2,-0.1)
.020
12.0(12.1)
7-15
11.0(10.9)
5-15
-1.2(-2.7,0.3)
.076
4.0(3.7)
1-5
3.0(3.2)
0-5
-0.5
(-0.8,-0.1)
.012
Wilcoxon’s signed rank test
Changes in Generalised SE
median (mean)
min-max
Baseline
Generalised Self
Efficacy Scale
(0 – 40)
Follow-up
32.0(30.0) 31.0(30.2)
16.0-37.0 12.0-39.0
Mean Change
(95% CI)
P value*
0.2 (-1.4,1.7)
.600
Key Discussion Points
Limitations of correlational analysis
– Multiple testing
– Larger studies should utilise multiple
regression analysis
Key Discussion Points
Greatest improvements in PF Strength in
women with ↑ SE and ↑ OE
- What factors contribute to SE and OE in this
context?
- Qualitative studies to explore
- Clinically measure SE and OE to target
additional support
Key Discussion Points
Pelvic Floor SE and OE fell during selfmanagement
– Implications for long term outcome
“It was difficult to remember to do the exercises, they
weren’t hard to do, just hard to remember to do. I
wouldn’t consider doing it everyday for my whole life,
thought it would be easier than it is”
– How can we maintain SE and OE?
– Support via self-management groups?
Take home messages
SE and OE beliefs important
Inidicate success with physiotherapy in UI
Women may quickly lose faith in own
abilities and in treatment effectiveness
Measures to enhance and maintain SE
and OE should be employed