- Email: [email protected]
Development and Pilot Testing of a Self-management Internet-based Program for Older Adults with Overactive Bladder
Health Outcomes Research Development and Pilot Testing of a Self-management Internet-based Program for Older Adults with Overactive Bladder Jorge G. Ruiz, Renuka Tunuguntla, Pedro Cifuentes, Allen D. Andrade, Joseph G. Ouslander, and Bernard A. Roos OBJECTIVES
METHODS
RESULTS
CONCLUSIONS
To implement and pilot test our Self-Management Internet-Based Program for Older Adults with Overactive Bladder (OAB-SMIP) in a group of older adults with overactive bladder (OAB) to determine its usability and outcomes, including knowledge, self-efficacy, perception of bladder condition, and health-related quality of life. In a single-group study design with pre- and post-tests, we recruited 25 men and women age 55 or older with symptoms of OAB. The OAB-SMIP intervention consisted of 3 multimedia e-learning tutorials, social networking features, and other online resources delivered over 6 weeks. Participants enjoyed the OAB-SMIP and found it easy to use. Participants demonstrated increased knowledge (SMD ⫽ 4.17, large effect size), and their symptoms improved after the intervention (SMD ⫽ 1.20-1.30, large effect sizes). Participants improved their overall selfefficacy (SMD ⫽ 1.84, large effect size) as well as their self-efficacy in performing pelvic muscle exercises (SMD ⫽ 1.41, large effect size) and controlling urge symptoms (SMD ⫽ 1.32, large effect size), and there were significant increases in health-related quality of life (SMD ⫽ 1.13, large effect size) after exposure to the OAB-SMIP. We did not find any significant gender differences. Participants using the OAB-SMIP improved their knowledge, symptoms, self-efficacy in performing pelvic muscle exercises and overall management of OAB, as well as health-related quality-of-life scores. UROLOGY 78: 48 –53, 2011. Published by Elsevier Inc.
O
veractive bladder (OAB) is a prevalent condition that increases with age and has a clinically significant impact on health-related quality of life (QOL). However, despite its adverse effects, 40% of patients interviewed had never told a physician about their symptoms and of those who did, 73% did not receive treatment.1 Although studies comparing behavioral interventions with biofeedback, medications, or a control group have found that behavioral interventions can bring about significant improvement in symptoms and health-related QOL,2 these interventions are time-
Funding sources: Bruce W. Carter VAMC GRECC and Pfizer OABLUTS. From the Geriatric Research, Education, and Clinical Center (GRECC), Bruce W. Carter Veterans Affairs Medical Center, Miami, FL; Geriatrics Institute, University of Miami, Miller School of Medicine, Miami, FL; Stein Gerontological Institute, Miami Jewish Health Systems, Miami, FL; and Charles E. Schmidt College of Biomedical Science and Christine E. Lynn College of Nursing, Florida Atlantic University, Boca Raton, FL Reprint requests: Jorge G. Ruiz, M.D., F.A.C.P., Associate Professor of Clinical Medicine, University of Miami, Miller School of Medicine; and GRECC Associate Director for Education and Evaluation, VA Medical Center, GRECC (11 GRC), 1201 NW 16 Street, Miami, FL 33125. E-mail: [email protected] Submitted: November 4, 2010, accepted (with revisions): January 21, 2011
48
Published by Elsevier Inc.
and labor-intensive for both patients and health care providers. Self-management relates to tasks that an individual can undertake to live well with one or more chronic conditions and is based on the theory that greater patient confidence in one’s own capacity to make life-improving changes yields better clinical outcomes.3 The goal of self-management, increased self-efficacy, and improved clinical outcomes4 is achieved by increasing patients’ confidence in medical management and their skills for coping and for health and wellness. Self-management has been shown to be effective in chronic diseases, such as congestive heart failure, arthritis, and HIV/AIDS.5,6 Preliminary work supports the application of self-efficacy to urinary incontinence.7 A small trial of a nurse-driven continence efficacy intervention program for women with stress urinary incontinence found increased self-efficacy, adherence to physiotherapy, and less severity.7 There are a few studies of patient self-management behavioral interventions targeting OAB.2,8 In recent years, Internet-based interventions, offering flexible pacing and the comfort of the user’s home, have become widely available.9 Older adults may find signifi0090-4295/11/$36.00 doi:10.1016/j.urology.2011.01.043
Figure 1. Screenshot of OAB-SMIP tutorial.
cant advantages in using the Internet over having to overcome mobility or transportation problems involved in attending a clinic. Only a few studies have explored the use of Internet-based self-management training for older adults.9,10 An Internet-based intervention to improve self-management behaviors and self-efficacy in older adults with diabetes mellitus was effective in improving HbA1c levels at 6 months.9 Another trial demonstrated the effectiveness of an Internet-based arthritis self-management program for changing behaviors and improving health measures of arthritis patients unable or unwilling to attend small groups.10 We implemented and pilot-tested our Internet-based intervention, the Self-Management Internet-Based Program for Older Adults with Overactive Bladder (OABSMIP), in a group of older adults with OAB to determine its usability in this population and the outcomes in older adults, including knowledge, self-efficacy, perception of bladder condition, and health-related QOL.
MATERIAL AND METHODS
and nocturia (awakening an average ⱖ2 times at night to void). They had to be able to read and communicate in English and be cognitively intact (ie, testing normal on the Mini-Cog during the first face-to-face visit). They had to have access to a computer with Internet capability and have basic computer skills. Using these criteria, a physician research associate telephone screened 41 patients for participation. Four participants had just initiated antimuscarinic drugs and had no symptoms, and 5 were unwilling or unable to complete all phases of the study. Thirty-two potential participants who passed the telephone screening were scheduled to meet with the research team. During the first visit, the research associate obtained a brief, structured history to confirm that the subject met criteria for participation, and then administered the Mini-Cog cognitive screening. Thirteen study applicants did not meet eligibility criteria; they either had abnormal Mini-Cog results (n ⫽ 4), had just initiated antimuscarinic drugs and had no symptoms (n ⫽ 4), or were unwilling or unable to complete all phases of the study (n ⫽ 5). Twenty-eight applicants met eligibility criteria; of these, 3 declined to enroll in the study. We obtained institutional review board approval from the Stein Gerontological Institute of the Miami Jewish Health Systems and from the Bruce W. Carter VA Medical Center for a waiver of documentation of informed consent.
Participants We recruited 25 study participants (13 men and 12 women) with OAB. Flyers addressing prospective participants were placed for a period of 6 months in the offices of primary care physicians, urologists, and physicians in charge of women’s health at the Bruce W. Carter Miami VAMC and in one common clinic area in the Miami Jewish Health Systems. For inclusion in the study, participants could be either men or women age 55 or older with OAB defined as presence for at least 3 months, urgency (ⱖ3 episodes/24 hours on average) ⫾ urge urinary incontinence, urinary frequency (ⱖ8/24 hours), UROLOGY 78 (1), 2011
Components of the OAB-SMIP The study design was single-group, with pre- and post-tests. We developed the OAB-SMIP by incorporating proven behavioral interventions and social networking strategies into an Internetbased self-management program. We reworked the e-learning component to be specific for patients (Fig. 1), using as a basis the e-learning program we had earlier created for medical trainees, “Urinary Incontinence and Overactive Bladder in Older Adults.” Three geriatricians defined a set of patient competencies for the management of OAB: Older adults should 49
be able to (1) identify and modify the contributory factors for OAB; (2) describe accurately how to perform pelvic floor muscle exercises (PFME); (3) confidently perform PFME; (4) demonstrate strategies to suppress urgency; (5) gain confidence in suppressing urgency; and (6) recognize medication side effects. After developing the e-learning component, we combined it with a social networking component. The e-learning modules presented information in textual and graphic format accompanied by narration, case-based exercises, and discussion groups, where participants could post questions and receive answers from experts and from other participants. The digital text documents presented self-management principles, goal setting/ action plans, emotional management and cognitive symptom management, and problem-solving exercises in 3 e-learning modules created at the 8th-grade language level (Appendix).
Research Procedure Participants came to the research clinic a minimum of 2 times (weeks 1 and 6). During these sessions, the research coordinator was available for assistance with the computer-based program. After participants received an orientation to all 4 sections of the OAB-SMIP and were assigned logins and passwords, they logged in and completed the demographic survey and baseline measures (located in the My Tools section). During weeks 2-5, participants were able to access the OAB-SMIP program from their own computers; they could also use the computers in the clinic. During the 6-week program, participants accessed different components of the program through the portal. We instructed them to log in for 1-2 hours each of the 6 weeks and to participate in the weekly activities (Table 1), including reading the week’s content posted in the Learning Center and completing assigned tasks. At the end of each week, we moved the week’s content from the Learning Center to the Repository, where it was available for reference at any time. Besides completing the tasks assigned in the Learning Center, participants were encouraged to post an action plan on a bulletin board in the Discussion Center. They were also invited to post any problems related to OAB that they wanted to share with other participants to the Discussion Center, for the comments and responses of other participants as well as the moderators. Patients’ confidentiality and privacy in the Discussion Center were preserved through the availability of an anonymous post option. In week 6, all participants returned to complete the online post-tests.
Data Collection and Management Outcome Measures At baseline and at the end of the 6-week pilot period, participants completed (1) the knowledge of OAB 20-item standardized multiple-choice questionnaire developed by the authors (a copy of the questionnaire may be requested from the authors); (2) the Patient Perception of Bladder Condition (PPBC), a validated 6-point rating scale of perception of bladder condition; (3) a self-efficacy visual analog scale (VAS, from 1-10) measuring confidence both in doing PFME and in suppressing urgency; (4) a 16-item questionnaire measuring overall self-efficacy ability for managing OAB, adapted for OAB from the validated questionnaire “Geriatric self-efficacy index for urinary incontinence”5; self-reported adherence to PFME and bladder training using a written instrument (a copy of the questionnaire may be requested from the authors); and (6) the Overactive Bladder Questionnaire (OABq), a validated assessment of symptom bother and the health-related QOL impact of 50
Table 1. Characteristics of the 25 study participants Age (y) Female (%) Ethnic group White (%) African American (%) Hispanic (%) OAB symptoms Urinary urgency (%) Urge urinary incontinence (%) Urinary frequency (%) Nocturia (%) Education Less than high school (%) High school (%) College (%) Duration of OAB symptoms (months) Medical problems Diabetes (%) Hypertension (%) Benign prostatic hyperplasia (%) Congestive heart failure (%) Coronary artery disease (%) Hyperlipidemia (%) Surgeries Prostatectomy (%) Hysterectomy (%) Myomectomy (%) Medications Antimuscarinics (%) Alpha blockers (%) Diuretics (%) Estrogens (%) Smoking (%)
62.9 (SD 7.58; range, 55-86) 48 24 12 64 72 88 44 68 8 60 32 24.72 (range, 3-120)
20 32 4 4 4 16 8 16 4 16 8 20 0 68
OAB. In addition to these pre-post measures, at the end of the program, participants completed an 18-item standardized Likert-type usability survey with questions about the program’s multimedia and social networking features, level of engagement, ease of use, narration, readability of written materials, and overall satisfaction (a copy of the questionnaire may be requested from the authors).
Data Analysis We analyzed demographic and questionnaire data by standard descriptive techniques. The time participants spent in learning as well as in social networking and other aspects of program participation was tracked throughout the 6-week pilot test. We determined the usability of the OAB-SMIP by a standardized usability survey. Within each gender, we used two-tailed paired sample t-tests to assess the significance of the change in scores from baseline to postintervention for the following variables: knowledge test, perception of bladder control, OABq, and self-efficacy for doing PFME and suppressing urge. For each variable, we compared mean change in men vs the corresponding change in women by independent sample t-tests. For the entire group, we calculated effect sizes using the standard mean UROLOGY 78 (1), 2011
UROLOGY 78 (1), 2011
1.1 1.2 ⬍.001 ⬍.001 * There were no statistical differences between men and women in any of the measures.
51.4 (16.0) 49.8 (21.1) 57.9 (16.1) 47.7 (18.9)
65.0 (13.4) 45.4 (16.7)
76.1 (13.9) 25.1 (13.6)
70.4 (14.1) 29.8 (13.9)
82.2 (11.2) 20.0 (11.9)
18.1 (14.2) –22.60 (15.5)
1.4 ⬍.001 3.6 (2.3) 4.0 (2.1)
4.4 (1.8)
8.8 (0.8)
8.9 (0.8)
8.8 (0.8)
4.8 (2.2)
1.3 ⬍.001 5.5 (1.2) 5.7 (1.3)
5.9 (1.4)
7.7 (0.8)
7.5 (1.0)
7.9 (0.5)
2.0 (1.4)
4.2 1.8 ⬍.001 ⬍.001 73.3 (13.4) 126.8 (6.5) 66.2 (11.2) 115.3 (11.5) 69.6 (12.6) 120.8 (11.0) 20.8 (9.3) 79.5 (15.9) 22.2 (11.4) 86.4 (18.7)
23.8 (13.5) 94.0 (19.1)
2.3 (0.8) 2.8 (0.6) 2.6 (0.7) 3.5 (0.5)
3.3 (0.8)
47.4 (16.5) 34.4 (16.1)
1.3 ⬍.001
Instrument
–0.8 (0.8)
SMD Women (n ⫽ 12)* All (n ⫽ 25)
Pre Mean (SD) Men (n ⫽ 13)*
Table 2. Pre- and post-intervention results of assessment instruments
All (n ⫽ 25)
Post Mean (SD) Men (n ⫽ 13)*
Women (n ⫽ 12)*
Satisfaction and Usability All participants liked the OAB-SMIP program, and 88% agreed with the statement “I was satisfied with the program.” In terms of the multimedia features, more than 80% of the participants liked the videos, animations, and illustrations. More than 90% felt engaged while watching the e-learning modules and stated that they would like to watch them again. In regard to the social networking features of the Web site, 72% agreed with the statement “I liked posting a question and discussing with the group,” and 92% felt reassured by participating in the online social network. Ninety-two percent of our study participants agreed with the statement “I liked setting attainable goals and making an action plan.” In terms of the usability, 88% of participants agreed that the e-learning program was easy to use; 96% found the written materials easy to read. There were no significant differences between men and women or between participants younger than 60 and older.
3.4 (0.7)
The characteristics of the 25 participants, all of whom completed the study protocol, are shown in Table 1.
Patient perception of bladder condition (PPBC) OAB knowledge quiz OAB self-efficacy questionnaire Self-efficacy for suppressing urge Self-efficacy for performing PFMEs OABq health-related QOL OABq symptom bother
RESULTS
Knowledge, Symptoms of OAB, and Self-Efficacy Table 2 shows the results pre- and post-intervention for knowledge, symptoms of OAB, and self-efficacy. Participants’ knowledge of OAB improved 6 weeks after the intervention (P ⬍.001). The effect size was large (SMD ⫽ 4.1). Symptoms of OAB improved as measured by 2 validated instruments. The patient perception of bladder condition, a global patient-reported measure of bladdercondition symptoms, decreased after the intervention (P ⬍.001); the effect size was large (SMD ⫽ 1.3). The OABq symptom bother scale improved from baseline (P ⬍.001), and the effect size was again large (SMD ⫽ 1.2). The overall measure of patients’ self-efficacy for managing OAB symptoms improved significantly postintervention (P ⬍.001), with a large effect size (SMD ⫽ 1.8). In response to the question “How confident are you in doing pelvic floor muscle exercises?” participants’ answers indicated that their self-efficacy improved after the intervention (P ⬍.001), and the effect size was large (SMD ⫽ 1.4). In response to the question “How confident are you in suppressing the urge?” participants indicated improved self-efficacy for suppressing urge postintervention (P ⬍.001), and the effect size was large (SMD ⫽ 1.5). There were no significant differences between men and women in any of these variables. There was a moderate correlation between self-efficacy and per-
P Value Post–Pre Mean Difference (SD) (n ⫽ 25)
difference (SMD) or the difference between the mean baseline and mean intervention divided by the standard deviation of the baseline data.11 SMDs are defined as small (0.2), medium (0.5), and large (0.8). Also, for the entire group, we used Pearson correlations to assess the association between self-efficacy and symptoms (perception of bladder condition).12 We did not calculate sample size for this pilot study.
51
ception of bladder condition (r ⫽ .432 [P ⫽ .031]). Technical problems (corrupted data) prevented the interpretation of data regarding self-reported adherence to PFMEs. Health-Related QOL The OAB health-related QOL scores improved significantly after the intervention (P ⬍.001). The effect size was again large (SMD ⫽ 1.13). Subscales of the OABq reflecting important aspects of personal effects of OAB were also greatly improved: Coping (SMD ⫽ 1.0), Concern (SMD ⫽ 1.0), Sleep (SMD ⫽ 1.0), and Social (SMD ⫽ 1.0) scales, P ⬍.001. There were no significant differences between men and women. Usage Participants accessed the program a mean of 7.1 times (SD ⫽ 1.4) during the study. The average time on task for modules 1, 2, and 3 was 40.7 (SD ⫽ 13.9), 35.9 (SD ⫽ 13.8), and 31.2 (SD ⫽ 16.7) minutes, respectively. The mean total access time to the OAB-SMIP during the 6 weeks of the study was 225.2 minutes (SD ⫽ 87.3), representing an average of 37.5 minutes per week.
COMMENT Participants enjoyed the Internet-based self-management program and found it easy to use. They demonstrated increased knowledge of OAB, and their symptoms of OAB improved significantly after the intervention. They improved their overall self-efficacy in managing their OAB as well as their self-efficacy in performing pelvic muscle exercises and controlling urge symptoms, resulting in significant increases in their health-related QOL scores after exposure to the program. We did not find any significant differences between men and women. The acceptance and high satisfaction with the program expressed by our study participants are evidence of the increasing importance of Internet-based programs for patient self-management of chronic disease.10,13 A strength of this study was the ethnically diverse study population, most of whom had only a high school education. Enabling patients to receive self-management training online offers a viable alternative to live training by a professional. Most health care professionals have neither the time nor the skills to provide education and assist the patient in acquiring self-management skills.14 Internet-based programs can complement clinicians’ pharmacologic and nonpharmacologic approaches.14 An interesting component of our program is its social networking feature. Patients affected by chronic disease are increasingly relying on online social networks for support, and there is increasing proof of the efficacy of incorporating online peer support as a social networking feature in Internet-based programs for patients with chronic disease. Improvements have been documented in knowledge, perceived social support, health behaviors, and clinical outcomes.15 More studies must be undertaken to determine the specific contributions of social networking. 52
Although knowledge by itself is not enough to achieve behavioral changes, it is an important component and a prerequisite for patient self-management interventions.16 Although our study did not include a control group, the magnitude of the effect of our intervention on participants’ knowledge was comparable with other multimedia Internet- or computer-based interventions for patients with chronic illnesses.15,17 A specific comparison could not be made, because we found no other educational intervention studies assessing OAB patients’ knowledge. Additional studies are needed to determine the specific features of the online programs that contribute to patient learning. Internet-based self-management education programs have shown small to moderate effect sizes in clinical outcomes of diabetes and asthma but not arthritis.18 The OAB-SMIP intervention resulted in large improvements in OAB symptoms and health-related QOL. Patient improvement was almost double the 10-point, minimally important difference for the symptom bother OAB questionnaire subscale.19 Our results are comparable with those of anticholinergic drug trials for OAB, demonstrating moderate to large effect sizes in controlling OAB symptoms and health-related QOL measured with the OABq.20 Furthermore, these OAB medications require long-term administration and frequently cause dry mouth.21 PFMEs are effective and safe, but long-term adherence is poor.22 Self-management and educational interventions can complement and enhance these traditional treatment modalities. Patient education with written materials and verbal reinforcement have been shown to improve satisfaction and OAB symptoms.23 Similarly, small-group sessions reduced the number of incontinent episodes in elderly women compared with controls.24 A self-management program consisting of small-group sessions improved lower urinary tract symptoms and reduced treatment failures in patients with benign prostatic hypertrophy.25 In contrast with these face-to-face, instructor-led approaches, Internet-based interventions, such as the OAB-SMIP, without the requirement for in-person professional instruction, more efficiently deliver selfmanagement programs while expanding access. Improved self-efficacy in OAB management because of the intervention may contribute to better patient self-management for this condition.14 Such improvements in selfefficacy are consistent with the results of other Internetbased chronic disease self-management programs, one a single-group design26 and another a randomized controlled trial.10 Those studies demonstrated only modest improvements in self-efficacy, and other studies found no significant changes in self-efficacy.27 The promising results of this pilot study are demonstrated by the large effect sizes achieved by 3 different self-efficacy tools, including a global scale. These preliminary findings suggest the potential and provide impetus for exploring the greater applicability of this Webbased self-management modality. Self-efficacy in performing PFMEs and suppressing urge may correlate with actual perUROLOGY 78 (1), 2011
formance of these effective behaviors. A meta-analysis suggests a strong association of self-efficacy with performance.28 The large improvements we achieved in self-efficacy may be related to our emphasis on behavioral management, an approach that empowers patients by making them more active participants in their care.14 Limitations of our study included the lack of a control group, which in general is an important factor, but which is especially important in a condition such as OAB where the placebo response in clinical trials is substantial.21 Patients generally conceal OAB and often do not seek medical help despite suffering poor health-related QOL.29 Patients may lack basic knowledge about OAB, which is remediated when they enroll in clinical trials, unlike other more common conditions, such as cardiovascular disease or diabetes, where the public benefits from more widely available information and discussion. A related issue is the practice effect from retesting, which may account for the improvement in scores. A meta-analysis found this effect size to be small but significant.30 Another limitation was the lack of access to the patients’ medical records, which precluded us from verifying clinical information, such as medication use. A factor that may limit the generalizability of these findings to older adults with OAB is the lower level of access to computers and the Internet in this population.
CONCLUSIONS The OAB-SMIP Internet-based program was found to be easy to use, and participant satisfaction was high. Participants demonstrated increased knowledge of the symptoms of OAB after the intervention. Participants improved their overall self-efficacy in managing OAB as well as their self-efficacy in performing PFMEs and controlling urge symptoms. Health-related QOL scores improved significantly after program participation. References 1. Milsom I, Abrams P, Cardozo L, et al. How widespread are the symptoms of an overactive bladder and how are they managed? A population-based prevalence study. BJU Int. 2001;87(9):760-766. 2. Burgio KL, Goode PS, Richter HE, et al. Combined behavioral and individualized drug therapy versus individualized drug therapy alone for urge urinary incontinence in women. J Urol. 2010;184(2):598-603. 3. Barlow JH, Wright CC, Lorig K. The perils and pitfalls of comparing UK and US samples of people enrolled in an Arthritis Self-Management Program: the case of the Center for Epidemiological Studies-Depression (CES-D) Scale. Arthritis Rheum. 2001;45(1):77-80. 4. Bodenheimer T, Lorig K, Holman H, et al. Patient self-management of chronic disease in primary care. JAMA. 2002;288(19):2469-2475. 5. DeWalt DA, Malone RM, Bryant ME, et al. A heart failure self-management program for patients of all literacy levels: a randomized, controlled trial [ISRCTN11535170]. BMC Health Serv Res. 2006;6(30):1-10. 6. Lorig KR, Ritter P, Stewart AL, et al. Chronic disease self-management program: 2-year health status and health care utilization outcomes. Med Care. 2001;39(11):1217-1223. 7. Kim JI. Continence efficacy intervention program for community residing women with stress urinary incontinence in Japan. Public Health Nurs. 2001;18(1):64-72. 8. Minassian V, Stewart W, Hirsch A, et al. The role of urgency, frequency, and nocturia in defining overactive bladder adaptive behavior. Neurourol Urodyn. 2010 [E-pub ahead of print].
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9. Bond GE, Burr R, Wolf FM, et al. The effects of a web-based intervention on the physical outcomes associated with diabetes among adults age 60 and older: a randomized trial. Diabetes Technol Ther. 2007;9(1):52-59. 10. Lorig KR, Ritter PL, Laurent DD, et al. The Internet-Based Arthritis Self-Management Program: a one-year randomized trial for patients with arthritis or fibromyalgia. Arthritis Rheum. 2008;59(7):1009-1017. 11. Cohen J. Statistical Power Analysis for the Behavioral Sciences. 2nd ed. Hillsdale, NJ: Lawrence Erlbaum Associates; 1988. 12. Lorig K, Chastain RL, Ung E, et al. Development and evaluation of a scale to measure perceived self-efficacy in people with arthritis. Arthritis Rheum. 1989;32(1):37-44. 13. Lorig K, Ritter PL, Laurent DD, et al. Online diabetes self-management program: a randomized study. Diabetes Care. 2010;33(6):1275-1281. 14. Schabert VF, Bavendam T, Goldberg EL, et al. Challenges for managing overactive bladder and guidance for patient support. Am J Manag Care. 2009;15(4 Suppl):S118-S122. 15. Murray E, Burns J, See TS, et al. Interactive Health Communication Applications for people with chronic disease. Cochrane Database Syst Rev. 2005;4:CD004274:CD004274. 16. Shekelle PG, Maglione M, Chodosh J, et al. Chronic Disease Self Management for Diabetes, Osteoarthritis, Post-myocardial Infarction Care, and Hypertension. Santa Monica, CA: Rand Coporation; 2003. 17. Beranova E, Sykes C. A systematic review of computer-based softwares for educating patients with coronary heart disease. Patient Educ Couns. 2007;66(1):21-28. 18. Warsi A, Wang PS, LaValley MP, et al. Self-management education programs in chronic disease: a systematic review and methodological critique of the literature. Arch Intern Med. 2004;164(15):1641-1649. 19. Coyne KS, Matza LS, Thompson CL, et al. Determining the importance of change in the overactive bladder questionnaire. J Urol. 2006;176(2):627-632; [Discussion:632]. 20. Coyne KS, Matza LS, Thompson C, et al. The responsiveness of the OAB-q among OAB patient subgroups. Neurourol Urodyn. 2007;26(2):196-203. 21. Nabi G, Cody JD, Ellis G, et al. Anticholinergic drugs versus placebo for overactive bladder syndrome in adults. Cochrane Database Syst Rev. 2006;4:CD003781. 22. Messer KL, Hines SH, Raghunathan TE, et al. Self-efficacy as a predictor to PFMT adherence in a prevention of urinary incontinence clinical trial. Health Educ Behav. 2007;34(6):942-952. 23. Wyman JF, Harding G, Klutke C, et al. Contributors to satisfaction with combined drug and behavioral therapy for overactive bladder in subjects dissatisfied with prior drug treatment. J Wound Ostomy Continence Nurs. 2010;37(2):199-205. 24. McFall SL, Yerkes AM, Cowan LD. Outcomes of a small group educational intervention for urinary incontinence: episodes of incontinence and other urinary symptoms. J Aging Health. 2000;12(2):250-267. 25. Brown CT, Yap T, Cromwell DA, et al. Self management for men with lower urinary tract symptoms: randomised controlled trial. BMJ. 2007;334(7583):25. 26. Lorig KR, Ritter PL, Dost A, et al. The Expert Patients Programme online, a 1-year study of an Internet-based self-management programme for people with long-term conditions. Chronic Illn. 2008;4(4):247-256. 27. Lorig KR, Ritter PL, Laurent DD, et al. Internet-based chronic disease self-management: a randomized trial. Med Care. 2006;44(11):964-971. 28. Stajkovic AD, Luthans F. Self-efficacy and work-related performance: a meta-analysis. Psychol Bull. 1998;124:240-261. 29. Hunskaar S, Arnold EP, Burgio K, et al. Epidemiology and natural history of urinary incontinence. Int Urogynecol J Pelvic Floor Dysfunct. 2000;11(5):301-319. 30. Hausknecht JP, Halpert JA, Di Paolo NT, et al. Retesting in selection: a meta-analysis of coaching and practice effects for tests of cognitive ability. J Appl Psychol. 2007;92(2):373-385.
APPENDIX SUPPLEMENTARY
DATA
Supplementary data associated with this article can be found, in the online version, at doi:10.1016/j.urology.2011.01.043. 53
METHODS
RESULTS
CONCLUSIONS
To implement and pilot test our Self-Management Internet-Based Program for Older Adults with Overactive Bladder (OAB-SMIP) in a group of older adults with overactive bladder (OAB) to determine its usability and outcomes, including knowledge, self-efficacy, perception of bladder condition, and health-related quality of life. In a single-group study design with pre- and post-tests, we recruited 25 men and women age 55 or older with symptoms of OAB. The OAB-SMIP intervention consisted of 3 multimedia e-learning tutorials, social networking features, and other online resources delivered over 6 weeks. Participants enjoyed the OAB-SMIP and found it easy to use. Participants demonstrated increased knowledge (SMD ⫽ 4.17, large effect size), and their symptoms improved after the intervention (SMD ⫽ 1.20-1.30, large effect sizes). Participants improved their overall selfefficacy (SMD ⫽ 1.84, large effect size) as well as their self-efficacy in performing pelvic muscle exercises (SMD ⫽ 1.41, large effect size) and controlling urge symptoms (SMD ⫽ 1.32, large effect size), and there were significant increases in health-related quality of life (SMD ⫽ 1.13, large effect size) after exposure to the OAB-SMIP. We did not find any significant gender differences. Participants using the OAB-SMIP improved their knowledge, symptoms, self-efficacy in performing pelvic muscle exercises and overall management of OAB, as well as health-related quality-of-life scores. UROLOGY 78: 48 –53, 2011. Published by Elsevier Inc.
O
veractive bladder (OAB) is a prevalent condition that increases with age and has a clinically significant impact on health-related quality of life (QOL). However, despite its adverse effects, 40% of patients interviewed had never told a physician about their symptoms and of those who did, 73% did not receive treatment.1 Although studies comparing behavioral interventions with biofeedback, medications, or a control group have found that behavioral interventions can bring about significant improvement in symptoms and health-related QOL,2 these interventions are time-
Funding sources: Bruce W. Carter VAMC GRECC and Pfizer OABLUTS. From the Geriatric Research, Education, and Clinical Center (GRECC), Bruce W. Carter Veterans Affairs Medical Center, Miami, FL; Geriatrics Institute, University of Miami, Miller School of Medicine, Miami, FL; Stein Gerontological Institute, Miami Jewish Health Systems, Miami, FL; and Charles E. Schmidt College of Biomedical Science and Christine E. Lynn College of Nursing, Florida Atlantic University, Boca Raton, FL Reprint requests: Jorge G. Ruiz, M.D., F.A.C.P., Associate Professor of Clinical Medicine, University of Miami, Miller School of Medicine; and GRECC Associate Director for Education and Evaluation, VA Medical Center, GRECC (11 GRC), 1201 NW 16 Street, Miami, FL 33125. E-mail: [email protected] Submitted: November 4, 2010, accepted (with revisions): January 21, 2011
48
Published by Elsevier Inc.
and labor-intensive for both patients and health care providers. Self-management relates to tasks that an individual can undertake to live well with one or more chronic conditions and is based on the theory that greater patient confidence in one’s own capacity to make life-improving changes yields better clinical outcomes.3 The goal of self-management, increased self-efficacy, and improved clinical outcomes4 is achieved by increasing patients’ confidence in medical management and their skills for coping and for health and wellness. Self-management has been shown to be effective in chronic diseases, such as congestive heart failure, arthritis, and HIV/AIDS.5,6 Preliminary work supports the application of self-efficacy to urinary incontinence.7 A small trial of a nurse-driven continence efficacy intervention program for women with stress urinary incontinence found increased self-efficacy, adherence to physiotherapy, and less severity.7 There are a few studies of patient self-management behavioral interventions targeting OAB.2,8 In recent years, Internet-based interventions, offering flexible pacing and the comfort of the user’s home, have become widely available.9 Older adults may find signifi0090-4295/11/$36.00 doi:10.1016/j.urology.2011.01.043
Figure 1. Screenshot of OAB-SMIP tutorial.
cant advantages in using the Internet over having to overcome mobility or transportation problems involved in attending a clinic. Only a few studies have explored the use of Internet-based self-management training for older adults.9,10 An Internet-based intervention to improve self-management behaviors and self-efficacy in older adults with diabetes mellitus was effective in improving HbA1c levels at 6 months.9 Another trial demonstrated the effectiveness of an Internet-based arthritis self-management program for changing behaviors and improving health measures of arthritis patients unable or unwilling to attend small groups.10 We implemented and pilot-tested our Internet-based intervention, the Self-Management Internet-Based Program for Older Adults with Overactive Bladder (OABSMIP), in a group of older adults with OAB to determine its usability in this population and the outcomes in older adults, including knowledge, self-efficacy, perception of bladder condition, and health-related QOL.
MATERIAL AND METHODS
and nocturia (awakening an average ⱖ2 times at night to void). They had to be able to read and communicate in English and be cognitively intact (ie, testing normal on the Mini-Cog during the first face-to-face visit). They had to have access to a computer with Internet capability and have basic computer skills. Using these criteria, a physician research associate telephone screened 41 patients for participation. Four participants had just initiated antimuscarinic drugs and had no symptoms, and 5 were unwilling or unable to complete all phases of the study. Thirty-two potential participants who passed the telephone screening were scheduled to meet with the research team. During the first visit, the research associate obtained a brief, structured history to confirm that the subject met criteria for participation, and then administered the Mini-Cog cognitive screening. Thirteen study applicants did not meet eligibility criteria; they either had abnormal Mini-Cog results (n ⫽ 4), had just initiated antimuscarinic drugs and had no symptoms (n ⫽ 4), or were unwilling or unable to complete all phases of the study (n ⫽ 5). Twenty-eight applicants met eligibility criteria; of these, 3 declined to enroll in the study. We obtained institutional review board approval from the Stein Gerontological Institute of the Miami Jewish Health Systems and from the Bruce W. Carter VA Medical Center for a waiver of documentation of informed consent.
Participants We recruited 25 study participants (13 men and 12 women) with OAB. Flyers addressing prospective participants were placed for a period of 6 months in the offices of primary care physicians, urologists, and physicians in charge of women’s health at the Bruce W. Carter Miami VAMC and in one common clinic area in the Miami Jewish Health Systems. For inclusion in the study, participants could be either men or women age 55 or older with OAB defined as presence for at least 3 months, urgency (ⱖ3 episodes/24 hours on average) ⫾ urge urinary incontinence, urinary frequency (ⱖ8/24 hours), UROLOGY 78 (1), 2011
Components of the OAB-SMIP The study design was single-group, with pre- and post-tests. We developed the OAB-SMIP by incorporating proven behavioral interventions and social networking strategies into an Internetbased self-management program. We reworked the e-learning component to be specific for patients (Fig. 1), using as a basis the e-learning program we had earlier created for medical trainees, “Urinary Incontinence and Overactive Bladder in Older Adults.” Three geriatricians defined a set of patient competencies for the management of OAB: Older adults should 49
be able to (1) identify and modify the contributory factors for OAB; (2) describe accurately how to perform pelvic floor muscle exercises (PFME); (3) confidently perform PFME; (4) demonstrate strategies to suppress urgency; (5) gain confidence in suppressing urgency; and (6) recognize medication side effects. After developing the e-learning component, we combined it with a social networking component. The e-learning modules presented information in textual and graphic format accompanied by narration, case-based exercises, and discussion groups, where participants could post questions and receive answers from experts and from other participants. The digital text documents presented self-management principles, goal setting/ action plans, emotional management and cognitive symptom management, and problem-solving exercises in 3 e-learning modules created at the 8th-grade language level (Appendix).
Research Procedure Participants came to the research clinic a minimum of 2 times (weeks 1 and 6). During these sessions, the research coordinator was available for assistance with the computer-based program. After participants received an orientation to all 4 sections of the OAB-SMIP and were assigned logins and passwords, they logged in and completed the demographic survey and baseline measures (located in the My Tools section). During weeks 2-5, participants were able to access the OAB-SMIP program from their own computers; they could also use the computers in the clinic. During the 6-week program, participants accessed different components of the program through the portal. We instructed them to log in for 1-2 hours each of the 6 weeks and to participate in the weekly activities (Table 1), including reading the week’s content posted in the Learning Center and completing assigned tasks. At the end of each week, we moved the week’s content from the Learning Center to the Repository, where it was available for reference at any time. Besides completing the tasks assigned in the Learning Center, participants were encouraged to post an action plan on a bulletin board in the Discussion Center. They were also invited to post any problems related to OAB that they wanted to share with other participants to the Discussion Center, for the comments and responses of other participants as well as the moderators. Patients’ confidentiality and privacy in the Discussion Center were preserved through the availability of an anonymous post option. In week 6, all participants returned to complete the online post-tests.
Data Collection and Management Outcome Measures At baseline and at the end of the 6-week pilot period, participants completed (1) the knowledge of OAB 20-item standardized multiple-choice questionnaire developed by the authors (a copy of the questionnaire may be requested from the authors); (2) the Patient Perception of Bladder Condition (PPBC), a validated 6-point rating scale of perception of bladder condition; (3) a self-efficacy visual analog scale (VAS, from 1-10) measuring confidence both in doing PFME and in suppressing urgency; (4) a 16-item questionnaire measuring overall self-efficacy ability for managing OAB, adapted for OAB from the validated questionnaire “Geriatric self-efficacy index for urinary incontinence”5; self-reported adherence to PFME and bladder training using a written instrument (a copy of the questionnaire may be requested from the authors); and (6) the Overactive Bladder Questionnaire (OABq), a validated assessment of symptom bother and the health-related QOL impact of 50
Table 1. Characteristics of the 25 study participants Age (y) Female (%) Ethnic group White (%) African American (%) Hispanic (%) OAB symptoms Urinary urgency (%) Urge urinary incontinence (%) Urinary frequency (%) Nocturia (%) Education Less than high school (%) High school (%) College (%) Duration of OAB symptoms (months) Medical problems Diabetes (%) Hypertension (%) Benign prostatic hyperplasia (%) Congestive heart failure (%) Coronary artery disease (%) Hyperlipidemia (%) Surgeries Prostatectomy (%) Hysterectomy (%) Myomectomy (%) Medications Antimuscarinics (%) Alpha blockers (%) Diuretics (%) Estrogens (%) Smoking (%)
62.9 (SD 7.58; range, 55-86) 48 24 12 64 72 88 44 68 8 60 32 24.72 (range, 3-120)
20 32 4 4 4 16 8 16 4 16 8 20 0 68
OAB. In addition to these pre-post measures, at the end of the program, participants completed an 18-item standardized Likert-type usability survey with questions about the program’s multimedia and social networking features, level of engagement, ease of use, narration, readability of written materials, and overall satisfaction (a copy of the questionnaire may be requested from the authors).
Data Analysis We analyzed demographic and questionnaire data by standard descriptive techniques. The time participants spent in learning as well as in social networking and other aspects of program participation was tracked throughout the 6-week pilot test. We determined the usability of the OAB-SMIP by a standardized usability survey. Within each gender, we used two-tailed paired sample t-tests to assess the significance of the change in scores from baseline to postintervention for the following variables: knowledge test, perception of bladder control, OABq, and self-efficacy for doing PFME and suppressing urge. For each variable, we compared mean change in men vs the corresponding change in women by independent sample t-tests. For the entire group, we calculated effect sizes using the standard mean UROLOGY 78 (1), 2011
UROLOGY 78 (1), 2011
1.1 1.2 ⬍.001 ⬍.001 * There were no statistical differences between men and women in any of the measures.
51.4 (16.0) 49.8 (21.1) 57.9 (16.1) 47.7 (18.9)
65.0 (13.4) 45.4 (16.7)
76.1 (13.9) 25.1 (13.6)
70.4 (14.1) 29.8 (13.9)
82.2 (11.2) 20.0 (11.9)
18.1 (14.2) –22.60 (15.5)
1.4 ⬍.001 3.6 (2.3) 4.0 (2.1)
4.4 (1.8)
8.8 (0.8)
8.9 (0.8)
8.8 (0.8)
4.8 (2.2)
1.3 ⬍.001 5.5 (1.2) 5.7 (1.3)
5.9 (1.4)
7.7 (0.8)
7.5 (1.0)
7.9 (0.5)
2.0 (1.4)
4.2 1.8 ⬍.001 ⬍.001 73.3 (13.4) 126.8 (6.5) 66.2 (11.2) 115.3 (11.5) 69.6 (12.6) 120.8 (11.0) 20.8 (9.3) 79.5 (15.9) 22.2 (11.4) 86.4 (18.7)
23.8 (13.5) 94.0 (19.1)
2.3 (0.8) 2.8 (0.6) 2.6 (0.7) 3.5 (0.5)
3.3 (0.8)
47.4 (16.5) 34.4 (16.1)
1.3 ⬍.001
Instrument
–0.8 (0.8)
SMD Women (n ⫽ 12)* All (n ⫽ 25)
Pre Mean (SD) Men (n ⫽ 13)*
Table 2. Pre- and post-intervention results of assessment instruments
All (n ⫽ 25)
Post Mean (SD) Men (n ⫽ 13)*
Women (n ⫽ 12)*
Satisfaction and Usability All participants liked the OAB-SMIP program, and 88% agreed with the statement “I was satisfied with the program.” In terms of the multimedia features, more than 80% of the participants liked the videos, animations, and illustrations. More than 90% felt engaged while watching the e-learning modules and stated that they would like to watch them again. In regard to the social networking features of the Web site, 72% agreed with the statement “I liked posting a question and discussing with the group,” and 92% felt reassured by participating in the online social network. Ninety-two percent of our study participants agreed with the statement “I liked setting attainable goals and making an action plan.” In terms of the usability, 88% of participants agreed that the e-learning program was easy to use; 96% found the written materials easy to read. There were no significant differences between men and women or between participants younger than 60 and older.
3.4 (0.7)
The characteristics of the 25 participants, all of whom completed the study protocol, are shown in Table 1.
Patient perception of bladder condition (PPBC) OAB knowledge quiz OAB self-efficacy questionnaire Self-efficacy for suppressing urge Self-efficacy for performing PFMEs OABq health-related QOL OABq symptom bother
RESULTS
Knowledge, Symptoms of OAB, and Self-Efficacy Table 2 shows the results pre- and post-intervention for knowledge, symptoms of OAB, and self-efficacy. Participants’ knowledge of OAB improved 6 weeks after the intervention (P ⬍.001). The effect size was large (SMD ⫽ 4.1). Symptoms of OAB improved as measured by 2 validated instruments. The patient perception of bladder condition, a global patient-reported measure of bladdercondition symptoms, decreased after the intervention (P ⬍.001); the effect size was large (SMD ⫽ 1.3). The OABq symptom bother scale improved from baseline (P ⬍.001), and the effect size was again large (SMD ⫽ 1.2). The overall measure of patients’ self-efficacy for managing OAB symptoms improved significantly postintervention (P ⬍.001), with a large effect size (SMD ⫽ 1.8). In response to the question “How confident are you in doing pelvic floor muscle exercises?” participants’ answers indicated that their self-efficacy improved after the intervention (P ⬍.001), and the effect size was large (SMD ⫽ 1.4). In response to the question “How confident are you in suppressing the urge?” participants indicated improved self-efficacy for suppressing urge postintervention (P ⬍.001), and the effect size was large (SMD ⫽ 1.5). There were no significant differences between men and women in any of these variables. There was a moderate correlation between self-efficacy and per-
P Value Post–Pre Mean Difference (SD) (n ⫽ 25)
difference (SMD) or the difference between the mean baseline and mean intervention divided by the standard deviation of the baseline data.11 SMDs are defined as small (0.2), medium (0.5), and large (0.8). Also, for the entire group, we used Pearson correlations to assess the association between self-efficacy and symptoms (perception of bladder condition).12 We did not calculate sample size for this pilot study.
51
ception of bladder condition (r ⫽ .432 [P ⫽ .031]). Technical problems (corrupted data) prevented the interpretation of data regarding self-reported adherence to PFMEs. Health-Related QOL The OAB health-related QOL scores improved significantly after the intervention (P ⬍.001). The effect size was again large (SMD ⫽ 1.13). Subscales of the OABq reflecting important aspects of personal effects of OAB were also greatly improved: Coping (SMD ⫽ 1.0), Concern (SMD ⫽ 1.0), Sleep (SMD ⫽ 1.0), and Social (SMD ⫽ 1.0) scales, P ⬍.001. There were no significant differences between men and women. Usage Participants accessed the program a mean of 7.1 times (SD ⫽ 1.4) during the study. The average time on task for modules 1, 2, and 3 was 40.7 (SD ⫽ 13.9), 35.9 (SD ⫽ 13.8), and 31.2 (SD ⫽ 16.7) minutes, respectively. The mean total access time to the OAB-SMIP during the 6 weeks of the study was 225.2 minutes (SD ⫽ 87.3), representing an average of 37.5 minutes per week.
COMMENT Participants enjoyed the Internet-based self-management program and found it easy to use. They demonstrated increased knowledge of OAB, and their symptoms of OAB improved significantly after the intervention. They improved their overall self-efficacy in managing their OAB as well as their self-efficacy in performing pelvic muscle exercises and controlling urge symptoms, resulting in significant increases in their health-related QOL scores after exposure to the program. We did not find any significant differences between men and women. The acceptance and high satisfaction with the program expressed by our study participants are evidence of the increasing importance of Internet-based programs for patient self-management of chronic disease.10,13 A strength of this study was the ethnically diverse study population, most of whom had only a high school education. Enabling patients to receive self-management training online offers a viable alternative to live training by a professional. Most health care professionals have neither the time nor the skills to provide education and assist the patient in acquiring self-management skills.14 Internet-based programs can complement clinicians’ pharmacologic and nonpharmacologic approaches.14 An interesting component of our program is its social networking feature. Patients affected by chronic disease are increasingly relying on online social networks for support, and there is increasing proof of the efficacy of incorporating online peer support as a social networking feature in Internet-based programs for patients with chronic disease. Improvements have been documented in knowledge, perceived social support, health behaviors, and clinical outcomes.15 More studies must be undertaken to determine the specific contributions of social networking. 52
Although knowledge by itself is not enough to achieve behavioral changes, it is an important component and a prerequisite for patient self-management interventions.16 Although our study did not include a control group, the magnitude of the effect of our intervention on participants’ knowledge was comparable with other multimedia Internet- or computer-based interventions for patients with chronic illnesses.15,17 A specific comparison could not be made, because we found no other educational intervention studies assessing OAB patients’ knowledge. Additional studies are needed to determine the specific features of the online programs that contribute to patient learning. Internet-based self-management education programs have shown small to moderate effect sizes in clinical outcomes of diabetes and asthma but not arthritis.18 The OAB-SMIP intervention resulted in large improvements in OAB symptoms and health-related QOL. Patient improvement was almost double the 10-point, minimally important difference for the symptom bother OAB questionnaire subscale.19 Our results are comparable with those of anticholinergic drug trials for OAB, demonstrating moderate to large effect sizes in controlling OAB symptoms and health-related QOL measured with the OABq.20 Furthermore, these OAB medications require long-term administration and frequently cause dry mouth.21 PFMEs are effective and safe, but long-term adherence is poor.22 Self-management and educational interventions can complement and enhance these traditional treatment modalities. Patient education with written materials and verbal reinforcement have been shown to improve satisfaction and OAB symptoms.23 Similarly, small-group sessions reduced the number of incontinent episodes in elderly women compared with controls.24 A self-management program consisting of small-group sessions improved lower urinary tract symptoms and reduced treatment failures in patients with benign prostatic hypertrophy.25 In contrast with these face-to-face, instructor-led approaches, Internet-based interventions, such as the OAB-SMIP, without the requirement for in-person professional instruction, more efficiently deliver selfmanagement programs while expanding access. Improved self-efficacy in OAB management because of the intervention may contribute to better patient self-management for this condition.14 Such improvements in selfefficacy are consistent with the results of other Internetbased chronic disease self-management programs, one a single-group design26 and another a randomized controlled trial.10 Those studies demonstrated only modest improvements in self-efficacy, and other studies found no significant changes in self-efficacy.27 The promising results of this pilot study are demonstrated by the large effect sizes achieved by 3 different self-efficacy tools, including a global scale. These preliminary findings suggest the potential and provide impetus for exploring the greater applicability of this Webbased self-management modality. Self-efficacy in performing PFMEs and suppressing urge may correlate with actual perUROLOGY 78 (1), 2011
formance of these effective behaviors. A meta-analysis suggests a strong association of self-efficacy with performance.28 The large improvements we achieved in self-efficacy may be related to our emphasis on behavioral management, an approach that empowers patients by making them more active participants in their care.14 Limitations of our study included the lack of a control group, which in general is an important factor, but which is especially important in a condition such as OAB where the placebo response in clinical trials is substantial.21 Patients generally conceal OAB and often do not seek medical help despite suffering poor health-related QOL.29 Patients may lack basic knowledge about OAB, which is remediated when they enroll in clinical trials, unlike other more common conditions, such as cardiovascular disease or diabetes, where the public benefits from more widely available information and discussion. A related issue is the practice effect from retesting, which may account for the improvement in scores. A meta-analysis found this effect size to be small but significant.30 Another limitation was the lack of access to the patients’ medical records, which precluded us from verifying clinical information, such as medication use. A factor that may limit the generalizability of these findings to older adults with OAB is the lower level of access to computers and the Internet in this population.
CONCLUSIONS The OAB-SMIP Internet-based program was found to be easy to use, and participant satisfaction was high. Participants demonstrated increased knowledge of the symptoms of OAB after the intervention. Participants improved their overall self-efficacy in managing OAB as well as their self-efficacy in performing PFMEs and controlling urge symptoms. Health-related QOL scores improved significantly after program participation. References 1. Milsom I, Abrams P, Cardozo L, et al. How widespread are the symptoms of an overactive bladder and how are they managed? A population-based prevalence study. BJU Int. 2001;87(9):760-766. 2. Burgio KL, Goode PS, Richter HE, et al. Combined behavioral and individualized drug therapy versus individualized drug therapy alone for urge urinary incontinence in women. J Urol. 2010;184(2):598-603. 3. Barlow JH, Wright CC, Lorig K. The perils and pitfalls of comparing UK and US samples of people enrolled in an Arthritis Self-Management Program: the case of the Center for Epidemiological Studies-Depression (CES-D) Scale. Arthritis Rheum. 2001;45(1):77-80. 4. Bodenheimer T, Lorig K, Holman H, et al. Patient self-management of chronic disease in primary care. JAMA. 2002;288(19):2469-2475. 5. DeWalt DA, Malone RM, Bryant ME, et al. A heart failure self-management program for patients of all literacy levels: a randomized, controlled trial [ISRCTN11535170]. BMC Health Serv Res. 2006;6(30):1-10. 6. Lorig KR, Ritter P, Stewart AL, et al. Chronic disease self-management program: 2-year health status and health care utilization outcomes. Med Care. 2001;39(11):1217-1223. 7. Kim JI. Continence efficacy intervention program for community residing women with stress urinary incontinence in Japan. Public Health Nurs. 2001;18(1):64-72. 8. Minassian V, Stewart W, Hirsch A, et al. The role of urgency, frequency, and nocturia in defining overactive bladder adaptive behavior. Neurourol Urodyn. 2010 [E-pub ahead of print].
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9. Bond GE, Burr R, Wolf FM, et al. The effects of a web-based intervention on the physical outcomes associated with diabetes among adults age 60 and older: a randomized trial. Diabetes Technol Ther. 2007;9(1):52-59. 10. Lorig KR, Ritter PL, Laurent DD, et al. The Internet-Based Arthritis Self-Management Program: a one-year randomized trial for patients with arthritis or fibromyalgia. Arthritis Rheum. 2008;59(7):1009-1017. 11. Cohen J. Statistical Power Analysis for the Behavioral Sciences. 2nd ed. Hillsdale, NJ: Lawrence Erlbaum Associates; 1988. 12. Lorig K, Chastain RL, Ung E, et al. Development and evaluation of a scale to measure perceived self-efficacy in people with arthritis. Arthritis Rheum. 1989;32(1):37-44. 13. Lorig K, Ritter PL, Laurent DD, et al. Online diabetes self-management program: a randomized study. Diabetes Care. 2010;33(6):1275-1281. 14. Schabert VF, Bavendam T, Goldberg EL, et al. Challenges for managing overactive bladder and guidance for patient support. Am J Manag Care. 2009;15(4 Suppl):S118-S122. 15. Murray E, Burns J, See TS, et al. Interactive Health Communication Applications for people with chronic disease. Cochrane Database Syst Rev. 2005;4:CD004274:CD004274. 16. Shekelle PG, Maglione M, Chodosh J, et al. Chronic Disease Self Management for Diabetes, Osteoarthritis, Post-myocardial Infarction Care, and Hypertension. Santa Monica, CA: Rand Coporation; 2003. 17. Beranova E, Sykes C. A systematic review of computer-based softwares for educating patients with coronary heart disease. Patient Educ Couns. 2007;66(1):21-28. 18. Warsi A, Wang PS, LaValley MP, et al. Self-management education programs in chronic disease: a systematic review and methodological critique of the literature. Arch Intern Med. 2004;164(15):1641-1649. 19. Coyne KS, Matza LS, Thompson CL, et al. Determining the importance of change in the overactive bladder questionnaire. J Urol. 2006;176(2):627-632; [Discussion:632]. 20. Coyne KS, Matza LS, Thompson C, et al. The responsiveness of the OAB-q among OAB patient subgroups. Neurourol Urodyn. 2007;26(2):196-203. 21. Nabi G, Cody JD, Ellis G, et al. Anticholinergic drugs versus placebo for overactive bladder syndrome in adults. Cochrane Database Syst Rev. 2006;4:CD003781. 22. Messer KL, Hines SH, Raghunathan TE, et al. Self-efficacy as a predictor to PFMT adherence in a prevention of urinary incontinence clinical trial. Health Educ Behav. 2007;34(6):942-952. 23. Wyman JF, Harding G, Klutke C, et al. Contributors to satisfaction with combined drug and behavioral therapy for overactive bladder in subjects dissatisfied with prior drug treatment. J Wound Ostomy Continence Nurs. 2010;37(2):199-205. 24. McFall SL, Yerkes AM, Cowan LD. Outcomes of a small group educational intervention for urinary incontinence: episodes of incontinence and other urinary symptoms. J Aging Health. 2000;12(2):250-267. 25. Brown CT, Yap T, Cromwell DA, et al. Self management for men with lower urinary tract symptoms: randomised controlled trial. BMJ. 2007;334(7583):25. 26. Lorig KR, Ritter PL, Dost A, et al. The Expert Patients Programme online, a 1-year study of an Internet-based self-management programme for people with long-term conditions. Chronic Illn. 2008;4(4):247-256. 27. Lorig KR, Ritter PL, Laurent DD, et al. Internet-based chronic disease self-management: a randomized trial. Med Care. 2006;44(11):964-971. 28. Stajkovic AD, Luthans F. Self-efficacy and work-related performance: a meta-analysis. Psychol Bull. 1998;124:240-261. 29. Hunskaar S, Arnold EP, Burgio K, et al. Epidemiology and natural history of urinary incontinence. Int Urogynecol J Pelvic Floor Dysfunct. 2000;11(5):301-319. 30. Hausknecht JP, Halpert JA, Di Paolo NT, et al. Retesting in selection: a meta-analysis of coaching and practice effects for tests of cognitive ability. J Appl Psychol. 2007;92(2):373-385.
APPENDIX SUPPLEMENTARY
DATA
Supplementary data associated with this article can be found, in the online version, at doi:10.1016/j.urology.2011.01.043. 53