The knowledge level towards urinary incontinence among community-dwelling Hong Kong Chinese women – a crosssectional study

Minru Li 李敏如，Huali Wang 王華力，Wai-kit Ko 高煒杰，Siu-kei Kwong 鄺兆基

HK Pract 2025;47:64-71

Summary

摘要

Introduction

Urinary incontinence (UI) is defined as any leakage or involuntary loss of urine at inappropriate times. UI is not life threatening, but it can impair the physical, mental, and social aspects of health.¹ The prevalence rate of UI in women world wide ranges from 25% to 45%.2,3 Seeking medical help early can minimise dysfunction and reduce long-term morbidity. In Hong Kong, one research found that community-based nurseled continence care can effectively alleviate symptoms and improve health-related quality of life.⁴ Despite its high prevalence, the help seeking rate is low. A Chinese survey found that only 25% women with UI had consulted physicians with their symptom.⁵ The low help seeking rate is possibly due to misconception, embarrassment in talking about the subject, behaviour to minimise the problem and not knowing the existence of effective treatment³, all of which may indicate a lack of knowledge related to UI.

Our previous study found that besides the severity of UI, the other affecting factor for a patient’s seeking help behaviour was their level of knowledge.⁶ Henceforth improving population knowledge on this subject may promote a patient’s help seeking rate. Current studies addressing knowledge of UI primarily focused on women presenting to specialists⁷ or among carer providers.⁸ Little is known about the knowledge among the general female population and their predictive factors. No quantitative study on the subject of UI knowledge has been performed in our communitydwelling Hong Kong Chinese women.

The objective of this study is to determine baseline levels of UI knowledge among adult women presenting to the primary care clinic, and to further assess the predictive factor of knowledge level. Through these findings, we hope to support the planning of educational interventions and improve help seeking rates.

Methods

This is a cross-sectional study using questionnaires. The study was approved by the Institutional Review Board of the University of Hong Kong/Hospital Authority Hong Kong West Cluster (HKU/HA HKW IRB) (reference: UW 22-234).

Selection criteria

Women age ≥ 40 years attended the 4 General Outpatient Clinics (GOPC) of Hong Kong West Cluster between 1^st May to 30^th June 2022 were invited to complete the questionnaire. Exclusion criteria included (1) non-Chinese ethnicity; (2) unable to understand Chinese and (3) refusal to join this study. Information sheets about the study were consecutively distributed to patients who have met the inclusion criteria who attended the aforementioned GOPCs. Patients were interviewed by the principal investigator to complete the questionnaires after verbal consent.

Questionnaire

The questionnaire consisted of three sections: (1) demographic data, (2) knowledge of UI, (3) severity of UI and impairment of quality of life (for symptomatic women).

1. sociodemographic data such as age, education level, marital status, occupation, income and obstetric history were collected.
2. Knowledge of UI was assessed using Urinary Incontinence Quiz (UIQ) developed and validated by Branch et al.⁹ It was developed to elicit beliefs and knowledge regarding (a) treatment and effects of UI (item 4, 5, 6, 11, 13 and 14), (b) cause of UI (items 3, 8, 10 and 12), (c) physician – patient discussion about UI (items 7 and 9), (d) and relationships of aging and UI (items 1 and 2). Participants were asked to answer each item using the following options: “Agree,” “Disagree,” and “Do not know.” Items marked as “Do not know” were considered incorrect. The correct answer was “Agree” for the 3^rd ,6^th, 8^th, 11^th, 12^th and 14^th items and “Disagree” for the 1^st, 2^nd, 4^th, 5^th, 7^th, 9^th, 10^th, 13^th items. Each correct answer was assigned one point, and the total score ranged from 0 to 14, where higher scores indicated a higher level of knowledge about UI. The Chinese version of this questionnaire used in this study was validated by Ju et al.¹⁰
3. Symptom of UI and it’s effect on the patients’ quality of life were assessed using Urogenital Distress Inventory-6 (UDI-6) and Incontinence Impact Questionnaire-7 (IIQ-7). UDI-6 is a valid and reliable six points survey used particularly to investigate symptoms associated with lower urinary tract dysfunction and inquire on irritative, stress, and obstructive/discomfort complaints. IIQ-7) is a questionnaire specific to UI which reflects the impact on the patients’ quality of life. To scale the scores of UDI-6 and IIQ-7 on a range of 0-100, it is multiplied by 33 1/3. Higher scores indicate more symptom distress and more impact on daily life. The Chinese version of the questionnaire showed good internal consistency and test-retest reliability.¹¹

Statistics

Descriptive statistics were used to summarise demographic characteristics. Continuous variables were expressed as mean ± standard deviation. Categorical variables were expressed as frequency and percentage. Statistical analysis was performed using SPSS 23.0. Chi square test was used to compare the demographic parameter between our group and the female population of Hong Kong. Univariate analysis using one-way ANOVA to assess the relationship of demographic status including age, marriage status, parity, education level, occupation, income level and UI symptoms with knowledge level. Parameter with P < 0.1 were entered into multivariate linear regression to calculate the independent affecting factor of UI knowledge. P value < 0.05 was considered statistically significant.

Result:

351 patients were included in the study, with the mean age of 61.98 ± 9.99 years old. There was no significant difference in age, income and education level between our group and the 2021 Hong Kong female population census. (Table 1)

Table 1: Demographics and past training experience of the respondents

*Data from Women and Men in Hong Kong Key statistics 2022 edition and Thematic report: household income distribution in Hong Kong

187 (187/351, 53.2%) had symptoms of UI. Among them, 40.1% (75/187) had mixed UI, 46.0% (86/187) had stress UI, and 13.9% (26/187) had urge UI. UDI-6 mean score was 19.23 ± 12.21. (Table 2)

Table 2: Prevalence of urinary symptoms in the study population and the severity of symptoms (UDI-6)

*The mean score of items is multiplied by 33 1/3 to convert to a 0–100 scale.

20.9% (39/187) women reported quality of life was affected (IIQ-7 > 0). IIQ-7 mean score was 3.33 ± 9.09 (Table 3).

Table 3: Incontinence impact Questionnaire IIQ-7

*The mean score of items is multiplied by 33 1/3 to convert to a 0–100 scale.

Only 47 of women (47/187, 25.1% ) with symptoms of UI had consulted a doctor, mainly general practitioners (31/47, 66.0%), followed by gynaecologists (13/47, 27.7%) and urologists (3/47, 6.3%).

1. Participant’s UI knowledge level (Table 4)

   The UI quiz mean score was 6.82 ± 2.76. The lowest score was 1 and the highest score was 13.

   The questions about the relationship of aging and UI (Q1 and Q2) had the lowest correct rate, which were only 13.7% and 17.7% respectively; The questions about the physician-patient discussion about urinary incontinence (Q7 and 9) had the second lowest correct rate, which were both lower than 50%; Among the 4 questions about causes of urinary incontinence, the correct rate of Q3 and Q10 were only 23.9% and 31.1% respectively. The correct rate of questions (Q4,5,6,11,13 and 14) about the treatment of UI were higher, but more than 50% participants thought that “Once people start to lose control of their urine on a regular basis, they usually can never regain complete control over it again” (Q5), and 50% participants considered “The best treatment for involuntary urine loss is usually surgery” (Q13).

   Table 4: Urinary Incontinence Quiz (UIQ) on Knowledge

   

2. Affecting factors of UI knowledge level

   In univariate analysis, there was a significant difference among age, education level, income, employment, marital status, and parity with the knowledge score. Participants with age between 50-59 years had the highest knowledge level, while those with age > 70 years had the lowest level (P = 0.006). A higher education level had a significant higher knowledge level (P < 0.001). There were similar trends when we compared their incomes (P < 0.0001). Employed participants had a higher UI knowledge level compared with housewife/unemployed participants (P < 0.05).

   When marital status was compared, we found that unmarried participants had the highest UI knowledge level, followed by divorced and married participants, the lowest UI knowledge level was in the widow group (P = 0.006). We found that nulliparous participants had a significant higher UI knowledge level when compared to their multiparous counterparts (P = 0.007).

   UIQ score was higher in patients with UI symptoms, but this was not found to be statistically significant (P = 0.082) (Table 5).

   On multivariate analysis, result showed that income (B=1.116, P < 0.001), education level (B = 0.768, P = 0.002) and symptomatic UI (B = 0.651, P = 0.015) were significant independent impact factors of a patient’s knowledge of UI.

   Y (UI score) = 3.820+ 0.768 x (education) + 1.116 x income + 0.651 x continence

Table 5: univariate analysis of character association with UI quiz score

Discussion

Participants in our study were recruited from 4 GOPCs and were not recruited from the general people of Hong Kong. We compared the demographic data including age, education level and income between the 2021 census of Hong Kong female population and our group, and there was no significant difference found between them.

We used UID-6 and IIQ-7 in our study, as these are used worldwide including China and Hong Kong for evaluating urinary symptoms and quality of life with a high sensitivity and specificity.¹² Their wide use can help us compare other local studies.

There were 53.2% women who suffered from UI and only 25.1% with symptoms of UI seek any doctor consultation regarding this. This was comparable to the literature found on this subject among Chinese women in mainland China¹ and was similar to a territory-wide telephone survey done in Hong Kong in 2006.¹³ In Wong’s study, 16% reported QOL impairment, which was similar to ours (21.9%).

Our study suggested that the knowledge level of UI in Hong Kong Chinese women who attended GOPCs in HKWC was below average, with a mean score of UIQ was 6.82 ± 2.76. It was reported that the mean score of UIQ was 9.29 (66.4%) in 18–30-year-old American women¹⁴; 6.16 in white and 5.46 in minority women¹⁵; and 4.85 in community-dwelling Korean-American women above 30 years of age.¹⁶

From our questionnaire, we found that more than 80% of participants thought that urinary leakage was part of normal aging. It was even a little bit higher than the study done in 2006 in Hong Kong¹⁶, which reported 75.7%. Studies have found that this misconception was one of the barriers for women seeking help as they do not perceive UI as abnormal. Women also did not have enough knowledge of the cause of UI. The “correct rate” of Q3 (“Many common over the counter medications can cause involuntary urine loss”) and Q10 (“Involuntary urine loss is caused by only one or two conditions”) were only 23.9% and 31.1% respectively. 65% participants mistaken that physicians would proactively ask their older patients whether they had bladder control problems. This misconception also would delay patients in their report of symptoms. For the treatment option, though the questions of this domain had a higher knowledge compared to others. There was still nearly half of the participants who didn’t know UI was treatable or even curable, and thought that surgery was the best treatment. Still 45% patients thought other than pads, diapers, and catheters, little can be done to treat or cure involuntary urine loss. When women encounter urine leakage problem, selfcoping strategies are usually the first action women take to manage UI. In one study, 85% incontinence women were found to rely on the use of pads and adult diapers.¹⁷ This strategy, while seems to be a positive action and can keep their quality of life, could worsen UI by preventing them seeking medical help.

In the univariable analysis, several demographic factors (age, income, education level, employed, marital status, high parity) were significantly associated with UI knowledge level. While only education level, income and UI symptom retained statistically significance in the multivariate analysis. For Branch et al ⁹, advanced age seemed to be related to better levels of knowledge about the treatment and consequences of UI. While Chen et al¹⁸ found that the age group between 40-49 had a higher knowledge level. We found that population at age 50-59 had the highest score of UIQ and was significantly higher than the age group of 69-69 and > 70. It is similar to Branch’s research. But in multivariate analysis, age was not the significant impact factor, when other demographic factors were taken into account. When we explored the impact of marital status on knowledge level, it is not surprising to find that the lowest level is the widow group. Most of the widow women were elderly. They tended to be less educated and had a lower income. Interestingly, in the univariate study, unmarried participant had the highest knowledge score, while married participants had even lower UI knowledge level than single and divorced women. This could possibly be explained by single persons were more highly educated. In one of the population surveys of Hong Kong, among the women with education level above college, 12.6% women in the 30-40 age group never were married in 1996, while this percentage increased to 16.8% in 2004 (from http://HKCSS.ORG.HK). It is assumed that married women needed to take care of the whole family and pay less attention to their health. Further multivariate analysis showed that marital status was not significant when other demographic factors were taken into account.

Another interesting result was that nulliparous women had better knowledge than multiparous respondents in the univariate analysis, though this was not statistically significant with the multivariate analysis after balancing other demographic factors. One would expect women to gain knowledge on pelvic floor disorders from previous pregnancies. Maybe early childbearing could be associated with lower education levels and employment. Childcare commitments may also reduce these women’s attention to their own health. Hence, we can give more education led by nurses or physiotherapists on UI through prenatal class.

It is not surprising to find that higher education, high income and employed participant will have a higher UI knowledge level. They may have a better access to resources such as the internet, health magazines, articles and interact with their colleagues, all of which could result in an increase in their knowledge on this topic.¹⁹ Our multivariate analysis showed that education and income had a significant impact on UI knowledge level. These findings are consistent with several studies.^20,21 Therefore, when we face the patient with a low income or education level, we should provide more education and anticipatory care about UI when their attend for a consultation. This might empower them to take responsibility for their condition and treatments.

Symptom of UI is another significant impact factor of UI knowledge. Perera’s study²² also found that symptomatic patients had higher knowledge of UI. As for the symptomatic patient, they may pay more attention to information on UI from media or / and friends. Some of them had already sought help from specialist. Hence this all could result in having a higher level of knowledge compared to the asymptomatic patients.

Conclusion

The knowledge level among Chinese women who attended GOPCs of HKWC is below average. More than half of the participants were unaware that UI is a disease with the possibility of prevention and treatment. Community education on UI, recognition of early symptoms and creating awareness of available management options may help to encourage women to seek help early. While imparting knowledge can be time-consuming, simple strategies to communicate that UI is not a “natural part of childbirth and aging” can alter perception and knowledge. This is especially when we face those with a low income and a low education level. Community-based educational tools through health talks, pamphlets and public services advertising may help women to be familiarised with UI.

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