Effects of Continence in Children

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Effects of Continence in Children Essay

Continence promotion, education and primary
prevention involves informing and educating the public
and health care professionals that urinary incontinence
and faecal incontinence are not inevitable, but are
treatable or at least manageable. In addition, other
bladder disorders such as bladder pain syndrome/
painful bladder syndrome/interstitial cystitis and pelvic
organ prolapse can be treated successfully. Taboos
on mentioning disorders of the bladder and bowel are
gradually lifting in most cultures. Effects of Continence in Children Essay Two decades ago it
was almost impossible to have urinary incontinence
discussed in the media. Today, in most countries,
consensus panels, government funding of continence
initiatives and practice guidelines have been developed
in the area of urinary and faecal incontinence, and
many are referenced in this chapter. Around the world,
expert panels have suggested that urinary and faecal
incontinence be combined through a multidisciplinary
approach to further research priorities.

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Thus, there have been advances in promoting
awareness of both urinary and faecal incontinence.
Popular magazines, local and national papers, radio,
and television, regularly cover topics on urinary
incontinence in most developed countries. Many
countries have run national or local public awareness
campaigns, usually spearheaded by a national
continence organisation. Many also have confidential
help lines, which can be accessed anonymously. The
World Wide Web provides a convenient source of
health information for a growing number of consumers.
Some experts believe that persons with incontinence
might get valuable advice and comfort by using
interactive services such as the chat rooms on the
internet. However, in developing countries, public
information and campaigns through these mediums
is limited or non-existent.Effects of Continence in Children Essay
This chapter updates previous International
Consultation on Incontinence (ICI) chapters on three
areas: continence promotion, education and primary
prevention.
The majority of information available in these areas
is on urinary and faecal incontinence which are the
primary focus of this chapter. The first section reviews
continence awareness by discussing health promotion
and care-seeking behaviours for these conditions. It
is evident that progress has been made in the
promotion of continence on a worldwide basis but not
much has changed in help-seeking behaviour for
these disorders.
There is a lack of evidence on translating awareness
into behavioural change and on what triggers helpseeking behaviour. Information is provided on
continence promotion programs and advocacy through
service delivery, models of care and worldwide
organizations. Although there is a great deal of
published information on building public and health
care professional awareness of incontinence, there is
minimal information on the effectiveness of changing
public and professional attitudes and knowledge about
it. Documentation of the success of campaigns is
lacking and should be measured by behavioural
changes and ultimately by improved patient outcomes.
Asecond topic reviewed in this chapter is the education
of professionals in the areas of urinary incontinence,
faecal incontinence, pelvic organ prolapse and bladder
pain syndrome. The use of medical guidelines and care
pathways will be discussed. Finally, as these conditions
are prevalent but often ignored by sufferers and
professional, the third topic addressed is primary
prevention with identification of modifiable risk factors.
There is a need for further research to substantiate
the benefits of primary preventative strategies,
including long term follow-up.Effects of Continence in Children Essay
I. INTRODUCTION
Continence Promotion, Education &
Primary Prevention
D. K. NEWMAN
C. H. EE, D. GORDON, V. S. SRINI, K. WILLIAMS
B. CAHILL, B. GORDON, T. GRIEBLING, K. NISHIMURA, N. NORTON
1646
LITERATURE SEARCH
The online databases Medline, Embase, Biosis, Cinahl,
Pychinfo, ERIC and Cochrane were searched, with
focus on literatures published in and after 2003. The
following search terms were used: awareness,
consumer, education, urinary incontinence (UI), faecal
incontinence (FI), incontinence, continence, continence
awareness, continence promotion, health education,
public education, public awareness, pelvic organ
prolapse (POP), interstitial cystitis (IC), bladder pain
syndrome (BPS), painful bladder syndrome (PBS)
and outcome measures. Non-English language papers
were noted but excluded from the review unless they
contained English-language abstract providing
sufficient information.

  1. BACKGROUND
    For a health-related issue like incontinence, the
    altruistic reason to educate consumers – referring
    mainly those with incontinence and their family
    members or informal caregivers, as well as individuals
    at risk – must be to increase awareness of incontinence
    and the benefits of prevention and management, with
    the noble goals of eliminating stigma, promoting
    disclosure and care-seeking, and reducing suffering
    [1]. Much of the health promotion efforts related to
    continence issues are undertaken by the many nongovernmental continence organisations, professional Effects of Continence in Children Essay
    and advocacy groups listed in Appendix I. Although
    in some countries, there is also strong governmental
    support, including a national advocacy on achieving
    an effective health literacy system. Components of
    such a system involving many levels of educational,
    health-care, and community service providers have
    been identified and include: (a) an information
    dissemination system providing materials that are
    readable, comprehensible, trustworthy, and culturally
    sensitive; (b) a coordinated health literacy learning
    system; (c) a measurement and assessment system;
    (d) a formal and informal health advice system,
    including a hotline, handbook, and online support;
    and (e) a health care professional educational system
    [2].
    Consumer education in terms of having access to
    information about incontinence in this age of digital
    technology is a non-issue, especially for those internet
    users who tend to have a higher literacy level [2]. In
    light of the reluctance of those affected by stigmatized
    illnesses such as incontinence to seek treatment or
    to ask health care professionals for information, the
    internet may prove to be a useful tool for patient
    education and public health outreach. [3, 4].
    The internet is widely accessible and frequently
    searched for health information. Recent estimates
    indicate that around 20% of U.S.A. adults use the
    internet for health information [5]. Among those who
    do not use the internet, 60% are aware of publicly
    available internet access points within their community
    [6]. Also, the internet can be searched anonymously
    and informally. People with low levels of education and
    low socioeconomic status are less likely to use the
    internet [7]. Health care professionals can assist
    consumers to find reliable information sources by
    providing details of reputable web sites [8].Effects of Continence in Children Essay
    In a national survey of internet users in the U.S.A., [9]
    Berger 2005, found a trend among people with a
    stigmatized illness such as UI to more likely report that
    using the internet increased their health care utilization
    and communication with a health care provider.
    A Google search for “urinary incontinence (UI)” and
    “faecal incontinence (FI)” yielded about 1.7 million and
    62,800 websites respectively; “interstitial cystitis (IC)”
    – 828,000 sites, “painful bladder syndrome (PBS)” –
    38,000 sites and “pelvic organ prolapse (POP)” –
    120,000 sites. Many were repetitions. For “continence
    promotion”, the yield was about 6,450 sites, and for
    “continence awareness (CA)”, it was about 2,840. There
    was reference to 114 sites for “continence awareness”
    and “UI” or “FI”; 35 sites for “continence awareness” and
    “IC”, and 40 sites for “continence awareness” and
    “POP”. Many of the sites were related to nongovernment organisations such as the International
    Continence Society (ICS), the National Association for
    Continence (NAFC) and the Interstitial Cystitis
    Association (ICA), and the International Foundation for
    Functional Gastro-intestinal Disorders (IFFGD).
    a) Health promotion
    Efforts to promote continence may be enhanced by
    adopting evidence based theories and methods from
    the field of health promotion. Health promotion was
    defined by the Ottawa Charter for Health Promotion
    in 1986 as “the process of enabling people to increase
    control over and to improve their health” [10]. Hence,
    health promotion is an important factor in primary,
    secondary and tertiary prevention efforts directed at
    individuals, communities and populations with or at risk
    of developing incontinence.
    Health promotion frameworks can be used to plan
    and evaluate the effectiveness of strategies and
    programs used to promote continence. When planning
    health promotion interventions consideration needs to
    be given to the demographic features of target groups
    including age, gender, culture, language and
    socioeconomic background. Health promotion
    strategies need to address issues such as accessibility,
    availability of transport and the cost of health promotion
    programs [11]. Other considerations include communication strategies. As noted above, there is an
    increasing trend for consumers to search and obtain
    information from the internet.Effects of Continence in Children Essay
    II. CONTINENCE AWARENESS
    1647
    Palmer and Newman [12] reported on a U.S.A. health
    promotion project conducted in 2000 to determine
    the needs of senior citizens concerning bladder control
    issues. Focus groups of older adults attending health
    seminars in urban, community and church settings
    were conducted. The primary objective of the project
    was to determine the understanding of older adults in
    the areas of general health and their beliefs
    surrounding the problem of UI. The 82 participants
    were predominantly African-American women
    representing all socio-economic levels. Seniors
    expressed confusion when asked if “overactive
    bladder, bladder control issues and urinary
    incontinence” were the same condition. Most seniors
    said they felt comfortable about discussing bladder
    control issues, but most admitted that their physician
    had never asked them, nor had they raised the issue.
    However, they did discuss UI with family members and
    friends and they were aware that many persons with
    whom they socialize might have a problem with UI.
    The majority of seniors answered “no cure” when
    asked if treatments were successful.
    b) Care-seeking (help-seeking) behaviour
    Despite the considerable impact of incontinence on
    quality of life (QoL), many people never seek help for
    their incontinence and are thus uncounted [13]. Current
    research in the area of care–seeking (also referred to
    as “help-seeking” or health-seeking”) behaviour
    (seeking help from a health care provider or
    professional) in women with UI has determined that
    fewer than 38% sought help for their condition, and
    they waited more than a year to do so [14]. A European
    survey reported that patients wait from 2 to 11 or more
    years before seeking treatment [15]. Huang et. al.[16]
    reported that fewer than 50% of women in the U.S.A.Effects of Continence in Children Essay
    with clinically significant UI reported seeking treatment.
    This was despite the fact that all women in this study
    had heath insurance that would pay for services and
    had continuous access to a primary care provider.
    Women with stress UI are more likely to seek help
    when there is severe leakage that is having a
    significant impact on their QoL [17]. Shaw and
    colleagues [18] surveyed adult women attending
    primary care practices in UK and of those who noted
    UI symptoms (n=3273), only a total of 15.8% of women
    with stress UI, 32.3% of those with urge UI and 33.7%
    with mixed UI had sought help for urinary symptoms
    during the preceding 12 months. This study also found
    that when women sought help for UI, only one-third
    will receive appropriate treatment [17].
    Men tend to be less proactive in health seeking
    behaviour. Gender specific strategies to address this
    should be considered [19]. Men with lower urinary
    tract symptoms (LUTS) have been found to seek help
    less frequently than women [20]. Conversely, a study
    into the prevalence of UI in men in the U.S.A. found
    that whilst only 50% of men with continence issues
    sought help, these men consulted their doctor within
    12 months of the onset of symptoms [21]. This time
    period is much shorter than the length of time taken
    by women to seek help [21]. Men are more likely to
    seek help for LUTS if they have had advice from
    others or received information in the media, than
    seeking help as a result of their symptoms [22]..
    In a population-based study in Sweden (a supplement
    to a comprehensive survey of public health and general
    living conditions), a postal questionnaire comprising
    12 questions on UI received a response rate of 64.5%
    from 15,360 randomly selected residents (aged 18–79
    years) [23]. The prevalence of UI was 19% (when
    defined as “any leakage”) and most considered their
    problems to be minor. Only 18% of those with UI
    desired treatment. Of the 17% who had reported
    severe problems that interfered with daily life, 42% did
    not want treatment. The authors suspect that lack of
    knowledge, worries about different procedures and
    negative expectations may be important factors. They
    concluded that UI may not be an unrecognised major
    problem except for a limited group, and suggested that
    healthcare resources should be optimized to identify
    and meet the needs of those who are most afflicted.
    Muller [24] reported on several epidemiologic surveys
    conducted over a 5 year period by the U.S.A.
    continence advocacy group, the NAFC. These surveys
    indicated that UI and overactive bladder (OAB) are
    prevalent problems and that most people do not
    understand these conditions. In one survey, conducted
    in 2000, only 26% of respondents (18% of men and
    33% of women) reporting bladder control symptoms
    had discussed them with a doctor. This survey
    attempted to examine bathroom-related attitudes and
    behaviours and found that most feel the bathroom is
    a “haven” for refuge while others feel it represents a
    symbol of incarceration because of the preoccupation
    with the need to be near one frequently.Effects of Continence in Children Essay

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Bathroom privacy, cleanliness and ease of accessibility
were voiced as concerns with only 20% of respondents
noting that they are comfortable using a bathroom
outside their home. A second survey by this group
was conducted online (over the internet) and includes
1,025 interviews of U.S.A. adults (ages 30 to 70).
This survey showed that women wait longer (average
6.5 years) than men (4.2 years) to seek out a diagnosis
for their symptoms.
Barriers to seeking help for continence issues have
been frequently identified in the literature and include
embarrassment, social stigma and the mistaken belief
that incontinence is either inevitable, untreatable and
a normal part of aging [25]. Women with POP have
also reported that fear and embarrassment are barriers
to seeking help. Other barriers include the perception
that incontinence and LUTS are not serious [26].
However symptoms such as nocturia have been linked
with serious consequences such as falls and
associated morbidity in older adults.
1648
Bladder and bowel continence is an adjustment to
the social norm, especially in Western cultures, which
have developed acceptable rules and behaviour for
bladder and bowel emptying. [27, 28]. If incontinence
occurs in adulthood, persons revive those childhood
beliefs and begin to internalize their condition causing
a decrease in self-esteem and feelings of not being
“normal” [29]. These barriers are shared by the public
as well as by many health care providers [30].
Unfortunately, factors that promote health seeking
behaviour for continence issues remain less well
researched and the triggers for help-seeking behaviour
are complex and multifactorial. With chronic problems
like UI, FI, POP and BPS/IC/PBS, it is important to
understand what triggers the patient to consult a
health care provider [28].. Older people may be keen
to seek help if they are concerned that a health issue
such as incontinence impacts on their ability to remain
independent and living in the community [31].
In certain parts of the world, the gender of the person
with UI may be a factor in help-seeking behaviour
and the gender of the health care provider may be a
barrier. Doshani and colleagues [32] explored views
and experiences of South Asian Indian women with
UI and found that feelings of embarrassment were
present, especially with male health care providers.Effects of Continence in Children Essay
Rizk [33] identified reasons why women in the United
Arab Emirates (UAB) were not seeking medical help
for UI. Data from questionnaires was collected on
400 women (mean age 54.2) out of 448 enrolled
subjects and noted that, 81 (20.3%) admitted UI and
only 25 of these (30.9%) had sought medical advice.
The reasons were embarrassment (38.2%), choice of
self-treatment because of low expectations from
medical care (38.2%), preferring to discuss the matter
with friends, and assuming that UI is normal (23.3%).
Women with UI were troubled by their inability to pray
(90%) and to have sexual intercourse (33.3%). Saleh
[34] found similar results when surveying women in
Qatari who reported that UI interfered with their ability
to pray (64%) because of lack of cleanliness and need
to void and 47% reported that UI interfered with marital
relationships.
Rizk and colleagues [35] also investigated the
prevalence and help-seeking behaviour of women (n
= 400, mean age 37.9) with FI using the same method.
Fifty-one participants (11.3 %) admitted FI; 26 (5.8 %)
were incontinent to liquid stool and 25 (5.5 %) to solid
stool. Thirty-eight patients (8.4 %) had double (urinary
and fecal) incontinence. Sixty-five patients (14.4 %)
were incontinent to flatus only but not to stools. Only
21 incontinent patients (41 %) had sought medical
advice. Women did not seek medical advice because
they were embarrassed to consult their physician
(64.7 %), they preferred to discuss the difficulty with
friends, assuming that FI would resolve spontaneously
(47.1 %) or was normal (31.3 %), and they chose
self-treatment as a result of low expectations for
medical care (23.5 %). Women with FI were bothered
by the inability to pray (92.2 %) and to have sexual
intercourse (43.1 %). These studies note that both
UI and FI are common yet underreported by UAE
women because of cultural attitudes and inadequate
public knowledge. These authors felt that male provider
gender may also be a barrier to seeking health care
in Middle Eastern women with UI. They were also
surprised to find that women perceive their problem
to be a neurological or “senile” disorder rather than
related to childbirth or menopause.
There are several strategies that can be used to
promote help-seeking behaviours and they need to
include those that are culturally appropriate [36, 37].Effects of Continence in Children Essay
Minority and disadvantaged groups have lower rates
of health seeking behaviour for UI that may relate to
a number of factors such as access to care and
socioeconomic factors [38]. . Understanding the
reasons why people do or do not seek treatment for
incontinence is hampered by the ethnic homogeneity
of the existing data as most is derived primarily from
white Caucasian populations and there is a lack of
comparisons with ethnic minority populations.
Factors that enhance or enable people to change
health behaviours include advice given by physicians
[39]. Opportunities to promote continence can present
themselves during other health screening activities
such as cervical cancer screening [40]. Whilst health
care professionals may enable people to seek help,
those who have a lack of interest in incontinence can
negatively affect health seeking behaviour in
consumers [41, 12]. Other initiatives to promote health
seeking behavior can include providing written
information [42]. Continence health promotion
information provided in a brochure [43] and in a
computer based program [44] were found to improve
health seeking behaviour.
Language, level of education and cultural factors may
also be barriers to seeking help [45]. Consideration
should be given to health literacy in target populations.
Health literacy affects the ability to read and understand
health information in written formats. Poor health
literacy results in lower rates of health seeking behavior
[46].Effects of Continence in Children Essay
One of the most supportive government sponsored
initiatives is from Australia. The National Continence
Management Strategy (NCMS) was established in
1998 by the Australian Government Department of
Health and Ageing. Funding of over $33 million AUD
has been allocated for the period from 1998 – 2010.
More than 120 projects have received funding for
research, public awareness activities, continence
education, resource development and continence
service development. The Strategy is now in its third
phase of activity. A final evaluation report on Phase
1 and 2 of the NCMS was released in September
2006 [47, 48]. In the area of continence awareness,
1649
the report noted that recognition of the barriers to
help-seeking behaviour and identification of the most
appropriate terminology and key messages would
strengthen awareness raising strategies. The provision
of an incontinence specific helpline (the National
Continence Helpline) has been an important awareness raising initiative. Table 1 reviews the specific Effects of Continence in Children Essay
programs developed and implemented by the NCMS.

  1. CONTINENCE PROMOTION PROGRAMS
    Continence promotion programs vary across countries
    and cultures, but the singular aim of creating
    awareness is similar. There is no standard model
    promotion program nor is there a standard outcome
    measure to determine the effectiveness of the program.
    While the current level of evidence for effectiveness
    of continence promotion program in raising awareness
    generally is level 4, there is a need for research to
    provide a higher level of evidence to affirm its
    effectiveness to generate higher interest and support.
    Efforts to raise awareness of continence issues need
    to consider the following:
    • Target population – Continence promotion
    programs need to consider age, gender and culture
    of target populations. It is necessary to consult
    with target groups when planning programs in
    order to meet the needs of these groups and to
    enhance help-seeking behaviour [49].
    • Target issues – A continence promotion program
    needs to address risk factors and management
    options in different target groups.
    • Promotional material – Newman [50] reported
    on a mail survey of 1,500 women, noting that most
    of the 422 respondents wanted more information
    regarding UI, and while they may not be equipped
    to fully understand the problem, they expect
    doctors, nurses, medical professionals, retail
    outlets, medical supply companies, and mail order
    houses to provide the information, including
    information through consumer advertising.
    • Channels of communication – Health care
    professionals may launch campaigns or seminars
    to increase practice revenues. Commercial
    companies often fund public campaigns in order
    to sell their products. Continence organizations
    may be driven by missionary zeal or organizational
    growth. Regardless of motivation, care should be
    taken to avoid raising public expectations beyond
    what the services or products can deliver.
    Individualised “coaching” of the affected is one key
    channel that continence nurses use in the
    promotion of continence [51].Effects of Continence in Children Essay
    a) Creating public awareness
    In the area of UI, building awareness among the
    general public is usually attempted via the media.
    Table 1. NCMS Continence Awareness Programs
    Program Description
    Bladder and Bowel Health Information and advice on the prevention and management of bladder control and
    website bowel problems for consumers, carers, health professionals, service providers and
    www.bladderbowel.gov.au researchers. It also contains information about the Continence Aids Assistance
    Scheme.
    Continence Outcomes Development and delivery of a translation program of continence outcomes meaMeasures (COMS) sures to national and international clinicians. Further work is being proposed to
    Dissemination Project conduct field trials to establish the validity, reliability and suitability of the
    continence outcome measures in Australian treatment settings and then to
    translate these for use by health care professionals. The reports are:
    • Measuring Incontinence in Australia 2006 Effects of Continence in Children Essay
    • Continence Outcomes Measurement Suite together with Review of Patient
    Satisfaction Measures 2006
    • Framework for Economic and Cost Evaluation for Continence Conditions 2006
    • Measuring Patient Satisfaction with Incontinence Treatment 2006
    • Refining Continence Measurement Tools 2006
    • Incontinence and Patient Satisfaction Tools and Instructions
    National Men’s Continence Raise the awareness of the causes of poor bladder and bowel health, specifically
    Awareness Project targeting men.
    Pharmacy Continence Delivery of a training package to educate pharmacists and pharmacy assistants to
    Care Project enable them to better inform clients about continence care and management.
    Daily Living Self Offers strategies for people with incontinence to help with their work life, family life
    Management Resources and social life.
    • Live Better – for people with urinary incontinence
    1650
    Using the media to disseminate information in the
    form of Public Service Announcements (called PSAs)
    has been practised extensively in the U.S.A. to
    promote AIDS awareness and as anti-smoking
    campaigns. The U.S.A. National Institutes of Health,
    in partnership with the American Uro-Gynecologic
    Association, American Urological Association,
    American Foundation for Urologic Disease, National
    Association For Continence, Society of Urologic
    Nurses and Associates and the Simon Foundation
    for Continence, launched a national awareness
    campaign in 1997. The Let’s Talk About Bladder
    Control for Women awareness campaign (http://kidney.
    niddk.nih.gov/ kudiseases/ pubs/bcw_ez/index.htm)
    offers easy-to-read booklets explaining the symptoms,
    types and causes of poor bladder control, as well as
    treatment options. The materials are designed to
    encourage and enhance communication between and
    among women and their health care providers. Free
    consumer and health care provider kits are available
    through a toll-free phone number. In 2001, the NAFC
    in the U.S.A. produced and disseminated continence
    awareness PSAs to 380 television media markets,
    including Hispanic outlets.Effects of Continence in Children Essay
    In many cultures, one of the best vehicles to reaching
    the public is through an informed journalist. Journalists
    often use a “media hook,” an interesting story that
    will take priority over other news on the television,
    radio or newspaper. Having a spokesperson with the
    problem or finding a celebrity who is willing to speak
    for the cause can help [27]. These individuals can act
    as “influence leaders.”
    The Japan Continence Action Society held a “Toll
    Free Telephone Clinic” and callers were asked how
    they heard about the line. The responses in 2006
    were: 30% from television, 16% from the web, 11%
    from a newspaper, 9% from a book, 6% from a friend,
    5% from a brochure, 3% from a magazine and 20%
    others and/or unknown. In a UK campaign, Norton [52]
    found that newspapers were by far the most common
    source of information, followed by radio.
    A media campaign should use multiple channels to
    ensure the broadest coverage [53]. An initial channel
    should include print media, television and radio. The
    Internet, phones, and other mobile devices are also
    effective outreach channels [54]. A second channel
    could be specialised age and health publications. A
    third channel could be the use of posters and
    brochures placed in medical offices, hospitals, senior’s
    centre, pharmacies and churches. A final channel
    could be direct presentations to the public, such as
    at senior’s centres [55].
    Roe [56] suggested that local initiatives on the
    availability of services and how to access them, as well
    as health education information on UI, may be more
    effective in raising public awareness and should
    supplement national campaigns. Awareness raising
    materials include pamphlets, self-care instructions,
    visual aids, pictographs, posters, banners, decals and
    advertisements in newspapers, magazines,Effects of Continence in Children Essay
    newsletters, CD and films. Muller [57] believed that
    the change related to increased public awareness
    and help-seeking behaviour for continence care is
    likely to fuel the demand for innovation in technology
    and products. The Simon Foundation for Continence
    developed an innovative community education initiative
    The Bladder Health Mobil. This initiative provides
    education, increase public awareness, and promote
    early diagnosis and proper treatment of UI and other
    bladder control problems. It also facilitates dialogue
    between consumers and their health care professionals [58].
    Terminology used when discussing urinary and bowel
    incontinence is important. The words “continence” or
    “incontinence”, “interstitial cystitis” or “painful bladder
    syndrome” and “pelvic organ prolapse” are poorly
    understood and simpler terms may achieve greater
    public recognition in many languages and cultures. The
    use of “overactive bladder” in advertising has increased
    reporting of the condition to primary care professionals
    in the U.S.A. In the area of bowel disorders such as
    FI, it is felt that people find it difficult to find the right
    words to discuss their symptoms [27]. The International
    Foundation for Functional Gastrointestinal Disorder
    (IFFGD) in the U.S.A. has found that people will often
    report having diarrhea to their physician. If the
    physician or nurse does not question the patient any
    further regarding the ability to control gas, liquid or solid
    stool, the incontinence may not be discovered.
    b) Program evaluation
    Evaluation methods need to be established prior to
    developing the continence promotion program.
    Evaluation should include quantitative measurements
    and qualitative measures. Open-ended questions
    may be more sensitive than “direct satisfaction”
    questions [59, 60].
    Health promotion evaluation methods include process
    evaluation, impact evaluation and outcome evaluation.
    Evaluation measures can include the number of media
    responses to a media release, or numbers of people
    who sought help.Effects of Continence in Children Essay
    In the evaluation report of the Australian NCMS, a
    total of 16 projects were undertaken for raising
    continence awareness, with focus on the development
    and distribution of information resources for use by the
    general community and specific target groups [47,
    48, 61]. As of June 2006, a market survey found that
    9 of the completed projects with measurable outcomes
    had generally shown favorable outcome.
    Evaluation of the effectiveness of leaflets or brochures
    is gathering better evidence. An Australian study found
    that provision of a continence education package,
    which included a Continence Educational Brochure
    1651
    helped to improve the health-seeking behaviours of
    participants who were bothered by UI symptoms [62].
    Within 3 months following the education, of the 111
    participants who were bothered by UI symptoms, 49
    participants (44.1%) indicated that they had discussed
    the issue of bladder or bowel problems with someone
    directly because of the study or the information
    contained in the brochure. More than 94% of participants who remembered the brochure indicated that
    they believed it would be helpful if given to other
    people. In a study of 1175 participants, Wagg et al [63]
    reported that a self-help standard treatment leaflet is
    as effective as structured help from a continence
    nurse in reducing bothersome urinary symptoms in
    women. Similarly, a Swedish population-based study
    found that the distribution of a brochure on UI to the
    general public was well received and can be an efficient
    method to spread knowledge and encourage selfmanagement [64].
    The interventions that are most effective in reaching
    the public and triggering the desired behaviour seem
    to vary between countries and cultures. Television
    and newspapers work best in Singapore, with a “cured”
    patient bearing testimony to former suffering and its
    alleviation having the most impact. In the U.S.A.,
    television advertising targeting OAB, funded primarily
    by pharmaceutical companies, has yielded a significant
    response. Nationwide television reaches more people
    than the circulation of any single newspaper or the
    distribution of a booklet through physician offices. In
    March 2008, Japanese National Television broadcast
    a program about UI during “golden time” (2000 to
    2045 hours). The audience rating was 15.6%, the
    highest in a year (usual rating 12%), and more than
    500 calls were received in one night, requesting repeat
    broadcast and more details about treatment. There are
    also cultural differences in the online health information
    is used, as well as the types of sites users prefer to
    surf [54].Effects of Continence in Children Essay
    In France, the effect of health education was evaluated
    in a randomized study in sheltered accommodations
    for the elderly [65]. Twenty centers were randomized
    to either a single one-hour health information meeting
    or control group. During a 30-minute talk, a nurse
    encouraged people to visit a physician if they had
    urinary problems. A questionnaire three months later
    found that the experimental group was much more
    likely to have had treatment if they were incontinent
    (41% vs. 13% controls) and 82% said that they had
    received some information about UI in the previous
    3 months (compared to 22% controls).
    A health promotion project called ‘Dry Expectations’
    was developed and implemented in six ethnically
    diverse, predominantly minority, and inner city senior
    centres in the U.S.A. in 1996 [55]. The program was
    designed to address an older population. The project
    consisted of three phases: orientation and training of
    key staff members/peer educators at the centres
    (train-the-trainer model); educating seniors through four
    one-hour weekly sessions involving visual aids and
    completion of bladder records and quizzes; and follow
    up sessions with senior staff/peer educators to
    reinforce the previous training. The program was very
    well received by the participants, and approximately
    80% felt they had more control over their bladder by
    the end of the last session.
    The impact and success of any continence promotion
    program must surely be its sustained effectiveness
    many years down the road, be it for primary prevention
    or treatment. A randomized controlled study of 359
    community-dwelling older women showed that group
    instruction supplemented with brief individual
    instruction as needed is an effective teaching method
    for the acquisition of knowledge and motor skill in
    bladder training (BT) and pelvic floor muscle training
    (PFMT). The 1 year adherence following a behavioural
    modification program ranged from 63 to 82% for PFMT
    and 58 to 67% for BT [66]. Adherence is reduced over
    time and the marked benefit of intensive PFMT seen
    short-term may not be maintained and the long-term
    adherence to training can be low [67].Effects of Continence in Children Essay
    c) Recommendations for Continence Awareness and Promotion
    Based on the literature reviewed in this section, the
    following recommendations can be made:
    • Continence awareness should be included in
    any national advocacy program that is working
    towards an effective health literacy system, as it
    is consistent with and requires the involvement
    of many levels of educational, health-care, and
    community service providers, namely a(n):
    – Information dissemination system providing
    materials that are readable, comprehensible, trustworthy, and culturally sensitive;
    – Coordinated health literacy learning system;
    – Measurement and assessment system;
    – Formal and informal health advice system,
    including a helpline, handbook, and online
    support; and
    – Professional health care provider learning
    system.
    (Grade D)
    • Continence awareness should be part of the
    main stream and on-going health education and
    advocacy programs with emphasis on eliminating
    stigma, promoting disclosure and help-seeking
    behaviour and improving quality of life. (Grade
    D)
    • There is a need for research to provide higher
    level of evidence on the effectiveness of
    continence promotion programs to increase
    awareness, be it for primary prevention, treatment
    or management. (Grade D)
    1652
  2. CONTINENCE ADVOCACY
    Advocacy is defined as act or process of defending
    or maintaining a cause or proposal. Advocacy, as it
    pertains to incontinence, involves assisting individuals
    in finding necessary health care and treatment.
    Organisations consisting of professional and public
    members promote continence advocacy as a core
    mission.Effects of Continence in Children Essay
    a) Service delivery
    The provision of continence care and services in each
    country will depend on the organisation and
    infrastructure of its health services. It is difficult to
    make recommendations that will apply in such a variety
    of contexts. In addition, UI is so widespread and
    affects so many different types of people that they
    can present for help to literally any health care
    professional. This means that there will seldom be
    one portal of entry to a continence service.
    When new services are created, there is a temptation
    to focus on the high technology investigation and
    medical treatment elements without considering the
    infrastructure needed to support that service [68].
    However, there has never been a comprehensive
    examination of an optimal service. It is not known
    whether academic, specialist-led centres will achieve
    better and more cost-effective results than primary
    care clinics, domiciliary services or any other model.
    However, most experts believe that female UI is initially
    most effectively diagnosed and managed by primary
    care providers compared to specialist services.
    In 2000, the UK’s Department of Health issued
    guidance on continence services that outlined a good
    practice model to achieve more responsive, equitable,
    effective continence services [69]. In the U.S.A., the
    primary sources of care for the majority of Medicare
    patients (primarily an elderly population) are family
    physicians and primary care physicians [70]. Less
    than 1 person in 1000 is admitted to an academic,
    medical centre hospital [71]. Thus, in the U.S.A.,
    elderly persons with UI and FI will probably be seen
    by primary care physicians for initial assessment. This
    is unlikely to address the needs of developing countries
    (such as the Asia Pacific area or in Africa) where
    dissemination of expertise to rural communities and
    isolated community health care workers is more logical.Effects of Continence in Children Essay
    They are being implemented in several countries
    using shared teaching and educational resources
    through co-operative arrangements of the respective
    Continence Foundations. Thus, the general practitioner
    or family physician plays an important role in the first
    line treatment of UI that may be treated successfully
    with conservative treatments in the majority of patients
    [72, 73].

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Bladder and bowel control problems are common. More than four million Australians regularly experience leakage from the bladder and bowel (incontinence). Many others have bladder and bowel control problems, such as needing to go to the toilet more frequently and an urgency to go without leakage. Together, these problems are often called continence problems.

Although incontinence and continence problems have a considerable impact on a person’s quality of life, many people do not seek help. Embarrassment often prevents people talking about their bladder and bowel problems. Some people restrict going out and have little social contact outside their home.

There is no need to become a recluse. The good news is that for most people, these problems can either be cured or at least better managed. You can lead a normal life without needing to plan your activities around the toilet.Effects of Continence in Children Essay
Incontinence and continence problems are common
Incontinence and continence problems affect people of all ages, gender, cultures and backgrounds. Despite popular beliefs, older people are not the only ones affected.

Some incontinence facts include:
One in three women who have had a baby experience loss of bladder control.
One in five children wet the bed at some time.
One in 100 adults never achieve bladder control at night.
One in 20 adults experience bladder and bowel control problems.
Bladder and bowel control problems are not an inevitable part of ageing. Visit your doctor to discuss treatment and management options.
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Continence problems and bladder or bowel issues
Incontinence and continence problems are symptoms of bladder or bowel dysfunction. They tell you that something is not quite right. Pelvic floor muscle weakness is a common cause of these symptoms. Changes to the nerves controlling the bladder, bowel or pelvic floor can also result in loss of control.

Sometimes, other health problems such as diabetes, stroke, Parkinson’s disease or multiple sclerosis can cause bladder or bowel control problems.
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Symptoms of bladder continence problems
People with bladder control problems may experience:
leaking urine with coughs, sneezes or exercise
leaking urine on the way to the toilet
passing urine frequently
rushing to the toilet (urgency)
getting up twice or more at night to pass urine
wetting the bed when asleep
feeling their bladder is not completely empty
having poor urine flow
straining to get the bladder to empty
frequently having urinary tract infections (UTIs).Effects of Continence in Children Essay
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Symptoms of bowel continence problems
People with bowel control problems may experience:
leaking from the bowel with the urge to open their bowels
rushing to the toilet and feeling the need to urgently open their bowels
leaking from the bowel without the urge to open their bowels
leaking from the bowel on passing wind
being unable to control wind
straining to empty their bowels.
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Types of bladder control problems
Urinary incontinence and continence problems may include:
stress incontinence – leakage of small amounts of urine with exertion. Causes include childbirth, being overweight and prostate surgery
urge incontinence – leakage following a sudden urge to urinate. Causes include stroke, enlarged prostate gland and Parkinson’s disease, but often the cause is unknown
overflow incontinence – leakage because the bladder does not empty well and overfills. Causes include multiple sclerosis, an enlarged prostate gland and diabetes
functional incontinence – leakage of urine because a person was unable to get to or use the toilet due to a physical disability, a barrier in their environment or because of an intellectual or memory problem. Causes include dementia and poor mobility.Effects of Continence in Children Essay
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Types of bowel control problems
Bowel problems have many causes and may result in:
diarrhoea – frequently passing loose bowel motions. Causes include infection or bowel conditions such as Crohn’s disease and ulcerative colitis.
constipation – passing hard, dry bowel motions (with difficulty or straining). Causes include not drinking enough fluid, eating a diet low in fibre and lack of exercise.
faecal incontinence – an uncontrolled loss of a bowel motion. Causes include diarrhoea and constipation. It can also result from a problem in the lower bowel or anus, making it difficult to hold onto a bowel motion. Causes include childbirth and nerve problems such as diabetes.
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Treatment for incontinence and continence problems
If you have incontinence or continence problems, you should seek help. There is a range of management options available. The treatments depend on the type of incontinence you have and what you hope to achieve.

An incontinence management plan will usually include several of:
adequate fluid intake of up to two litres (6 to 8 glasses) each day (your urine should be pale yellow in colour)
a diet rich in fibre (such as wholegrain bread, cereals, fruit and vegetables) to prevent constipation
a pelvic floor muscle exercise program Effects of Continence in Children Essay
a bladder retraining program
a toileting program
medication
incontinence aids such as pads, condom drainage or catheters.
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Prevention of incontinence and continence problems
There are things you can do to help keep your bladder and bowel healthy, and avoid incontinence and continence problems.

Suggestions for healthy lifestyle choices include:
Drink plenty of fluid – up to at least two litres (six to eight glasses) each day, unless your doctor advises you otherwise.
Eat well to prevent constipation and to maintain a healthy body weight – eat plenty of wholegrain foods (such as porridge, brown rice, wholemeal pasta, wholemeal bread, or pulses – lentils and beans) rather than highly processed or refined food and at least two pieces of fruit and five serves of vegetables every day.
Exercise regularly (at least 30 minutes every day) to keep fit and to prevent constipation.
Tone up your pelvic floor with pelvic floor exercises for good bladder and bowel control.
Practise good toilet habits to prevent bladder and bowel control problems.
Good toilet habits can help to prevent incontinence and continence problems. These include:Effects of Continence in Children Essay
going to the toilet to pass urine only when you have the urge to go – don’t go ‘just in case’
taking time to completely empty your bladder and bowel
not delaying going to the toilet when you have the urge to use your bowels
using the correct posture on the toilet to help you pass a bowel motion (place your elbows on your knees, bulge out your stomach, straighten your spine and put your feet on a footstool (if it is safe to do).Effects of Continence in Children Essay