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A mobile app for self-management of urinary incontinence: treatment effect and user experience
Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Allmänmedicin. Umeå University.
2020 (Engelska)Doktorsavhandling, sammanläggning (Övrigt vetenskapligt)Alternativ titel
En mobilapp för egenbehandling av urininkontinens : Effekt och upplevelse av behandling (Svenska)
Abstract [en]

Background

Urinary incontinence affects 25-45% of all women. The most common type is stress urinary incontinence, which is the leakage of urine on physical exertion. Pelvic floor muscle training is an effective first-line treatment for this condition but many women do not seek help from their ordinary health care service. There is a need to evaluate new methods to offer effective treatment, and internet-based treatment has previously been found to be effective for women with stress urinary incontinence.

Aim

To evaluate the mobile app Tät® which has a self-management program focused on pelvic floor muscle training for women with stress urinary incontinence, with respect to treatment effect, factors associated with successful treatment, user experience and use by pregnant and postnatal women.

Methods

Papers I, II and III are based on the same study population from a randomized controlled trial (RCT). We recruited adult women who had stress urinary incontinence at least weekly via our website. In total, 123 women  were randomized to the app group (n=62) or the control group (n=61). The app included information about incontinence, the pelvic floor and lifestyle factors associated with incontinence, pelvic floor muscle training exercises and functions for reminders and training statistics. Treatment outcome after three months was evaluated using validated questionnaires assessing incontinence symptoms, quality of life, subjective improvement and a leakage diary. Outcomes were compared between the two groups. Factors associated with a successful outcome in the app group were further analysed using logistic regression. We strategically selected 15 women who had used the app and interviewed them about their experiences of using the app. The interviews were analysed according to Grounded Theory. After closing the RCT we made the app freely available and continued to follow its use on a larger scale by incorporating an anonymous questionnaire that appeared within the app upon download and after three months. The data from these questionnaires is used in paper IV. 

Results

Participants in the RCT had a mean age of 44.7 years (range 27-72) and 120 of the 123 women had moderate/severe incontinence. The app group reported significant improvements in the primary outcomes, the incontinence symptom score (mean ICIQ-UI SF reduction 3.9, 95% CI 3.0-4.7) and the quality of life score (mean ICIQ LUTSqol reduction 4.8, 95% CI 3.4-6.2), and the difference between the groups was significant. The app group also reduced their number of leakages and use of incontinence aids compared to the control group. At follow-up 92% of women in the app group experienced subjective improvement and 56% had improved “much” or “very much” and were classified as having a successful treatment outcome.

Factors associated with a successful outcome were higher expectations of treatment effect (OR 11.38, 95% CI 2.02-64.19), weight control (OR 0.44 per kg gained, 95% CI 0.24-0.79), and self-assessed improvement of pelvic floor muscle strength (OR 35.54, 95% CI 4.96-254.61).

The main finding from the interviews was that women experienced that the app “enabled their independence”. They described that the app was “something new” that helped with “keeping motivation up” although they sometimes wondered whether their training efforts were “good enough”.

The freely available app was downloaded by 10,456 pregnant and postnatal women during a period of ten months (41% of all users). At inclusion 51% experienced incontinence and their mean ICIQ-UI SF score was 6.7 (SD 3.45). After three months, 1,805 women answered the follow-up. The majority of women with incontinence at inclusion experienced improvement with greater improvement in the postnatal group than in the pregnant group.

Conclusion

The mobile app Tät® offers a new, easily accessible and effective self-management program for women with stress urinary incontinence. Women appreciated that the app enabled them to manage their pelvic floor muscle training independently. Once the app was freely released it reached a large population with many pregnant and postnatal women. We believe that the app could be useful for the prevention of urinary incontinence among pregnant women. We also believe that the app could be used both as a stand-alone treatment and as a complement to other treatments provided by the ordinary health care service.

Abstract [sv]

Bakgrund

Urininkontinens är vanligt och drabbar ca 25–45% av alla kvinnor. Den vanligaste typen är ansträngningsinkontinens vilket innebär att man läcker urin i samband med fysisk aktivitet, hosta eller nysning. Bäckenbottenträning är en effektiv förstahandsbehandling, men många kvinnor söker inte hjälp för sin inkontinens inom vården. Det finns ett behov av att kunna erbjuda behandling på nya sätt för att nå fler kvinnor och ett internetbaserat behandlingsprogram har tidigare visat sig ha god effekt vid ansträngningsinkontinens.

Syfte

Att utvärdera appen Tät® som innehåller ett program för egenbehandling av ansträngningsinkontinens med fokus på bäckenbottenträning, med avseende på behandlingseffekt, framgångsfaktorer, upplevelse av behandling och användning bland gravida och nyförlösta kvinnor.

Metod        

Artiklarna I, II och III baseras på material från en randomiserad kontrollerad studie. Till studien bjöd vi in vuxna kvinnor med ansträngningsinkontinens och urinläckage åtminstone en gång per vecka via vår hemsida tät.nu. Vi randomiserade 123 kvinnor till antingen appgruppen (62 kvinnor) eller kontrollgruppen (61 kvinnor). Appen innehöll information om inkontinens och bäckenbotten, livsstilsfaktorer som kan påverka inkontinens, bäckenbottenövningar och funktioner för påminnelser och statistik. Behandlingseffekten utvärderades efter tre månader med hjälp av validerade frågeformulär avseende inkontinenssymtom, livskvalitet och upplevd förbättring samt antalet episoder av urinläckage. Resultaten jämfördes mellan grupperna. Faktorer som kunde vara associerade med ett lyckat behandlingsresultat analyserades med logistisk regression. Vi gjorde ett strategiskt urval av 15 kvinnor från appgruppen och intervjuade dem om deras upplevelse av att använda appen. Intervjuerna analyserades enligt metoden Grounded Theory. Efter att vi avslutat studien släppte vi appen fritt tillgänglig och fortsatte att följa användningen genom att lägga in ett anonymt frågeformulär som kom upp automatiskt i appen när man laddade ner den och sen igen efter tre månader. Artikel IV baseras på data från dessa frågeformulär.

Resultat

Medelåldern i den randomiserade kontrollerade studien var 44,7 år (27 till 72 år) och 120 av 123 kvinnor hade medelsvår eller svår inkontinens. Appgruppen förbättrades signifikant avseende de primära utfallsmåtten inkontinenssymtom (ICIQ-UI SF medelförbättring 3,9 poäng, 95 % KI 3,0 – 4,7) och livskvalitet (ICIQ-LUTSqol medelförbättring 4,8 poäng, 95 % KI: 3,4 – 6,2) och skillnaden mellan grupperna var signifikant. Appgruppen minskade också antalet episoder av läckage per vecka och användningen av inkontinensskydd jämfört med kontrollgruppen. Vid uppföljningen upplevde 92% i appgruppen att de var bättre och 56% upplevde att de var mycket eller väldigt mycket bättre och bedömdes ha ett lyckat behandlingsresultat. De faktorer som var associerade med ett lyckat behandlingsresultat var högre förväntningar på behandlingsresultatet, viktstabilitet och självskattad förbättring av bäckenbottenstyrkan.

Det viktigaste fyndet i intervjustudien var att kvinnorna upplevde att appen ”möjliggjorde deras självständighet”. De beskrev att appen var ”något nytt” som hjälpte dem att ”hålla motivationen uppe” trots att de ibland undrade över om bäckenbottenträningen de gjorde var ”tillräckligt bra”.

Den fritt tillgängliga appen laddades hem av 10 456 gravida och nyförlösta kvinnor under 10 månader vilket motsvarade ca 41% av alla användare under den perioden. Vid inklusion hade 51% av kvinnorna inkontinens. Uppföljningsfrågorna efter tre månader besvarades av 1805 kvinnor. Bland kvinnorna som hade inkontinens vid inklusion upplevde en majoritet att de blivit förbättrade.

Slutsats

Appen Tät® är ett nytt, lättillgängligt och effektivt alternativ för egenbehandling av ansträngningsinkontinens hos kvinnor. Kvinnorna uppskattade att appen möjliggjorde för dem att genomföra sin bäckenbottenträning självständigt. Den fritt tillgängliga appen fick stor spridning och användes av många gravida och nyförlösta kvinnor. Vi tror att appen kan vara användbar för att förebygga urininkontinens hos gravida kvinnor. Vi tror också att appen kan användas både för självständig behandling och i kombination med andra behandlingar inom vården.

Ort, förlag, år, upplaga, sidor
Umeå: Umeå universitet , 2020. , s. 68
Serie
Umeå University medical dissertations, ISSN 0346-6612 ; 2075
Nyckelord [en]
stress urinary incontinence, pelvic floor muscle training, mHealth, self-management, randomized controlled trial, qualitative research
Nyckelord [sv]
ansträngningsinkontinens, bäckenbottenträning, mHealth, egenbehandling, randomiserad kontrollerad studie, kvalitativ forskning
Nationell ämneskategori
Medicin och hälsovetenskap
Forskningsämne
allmänmedicin
Identifikatorer
URN: urn:nbn:se:umu:diva-168447ISBN: 978-91-7855-223-8 (tryckt)OAI: oai:DiVA.org:umu-168447DiVA, id: diva2:1396389
Disputation
2020-03-27, Hörsalen Snäckan, Östersunds sjukhus, Östersund, 09:00 (Svenska)
Opponent
Handledare
Tillgänglig från: 2020-03-06 Skapad: 2020-02-26 Senast uppdaterad: 2020-03-10Bibliografiskt granskad
Delarbeten
1. Mobile app for treatment of stress urinary incontinence: a randomized controlled trial
Öppna denna publikation i ny flik eller fönster >>Mobile app for treatment of stress urinary incontinence: a randomized controlled trial
Visa övriga...
2017 (Engelska)Ingår i: Neurourology and Urodynamics, ISSN 0733-2467, E-ISSN 1520-6777, Vol. 36, nr 5, s. 1369-1376Artikel i tidskrift (Refereegranskat) Published
Abstract [en]

AIMS: To evaluate the effect of a mobile app treatment for stress urinary incontinence (SUI) in women.

METHODS: Randomized controlled trial, conducted 2013-2014 in Sweden. Community-dwelling adult women with ≥1 SUI episode/week recruited through our website and randomized to app treatment (n = 62) or control group (postponed treatment, n = 61). One participant from each group was lost to follow-up. Intervention was the mobile app Tät(®) with a treatment program focused on pelvic floor muscle training (PFMT), and information about SUI and lifestyle factors. Primary outcomes, 3 months after randomization: symptom severity (International Consultation on Incontinence Modular Questionnaire Urinary Incontinence Short Form [ICIQ-UI SF]); and condition-specific quality of life (ICIQ Lower Urinary Tract Symptoms Quality of Life [ICIQ-LUTSqol]).

RESULTS: One hundred and twenty-three women were included (mean age 44.7), with moderate/severe SUI (97.5%, 120/123), mean ICIQ-UI SF score 11.1 (SD 2.8) and mean ICIQ-LUTSqol score 34.4 (SD 6.1) at baseline. At follow-up, the app group reported improvements in symptom severity (mean ICIQ-UI SF score reduction: 3.9, 95% confidence interval 3.0-4.7) and condition-specific quality of life (mean ICIQ-LUTSqol score reduction: 4.8, 3.4-6.2) and the groups were significantly different (mean ICIQ-UI SF score difference: -3.2, -4.3to -2.1; mean ICIQ-LUTSqol score difference: -4.6, -7.8 to -1.4). In the app group, 98.4% (60/61) performed PFMT at follow-up, and 41.0% (25/61) performed it daily.

CONCLUSIONS: The mobile app treatment was effective for women with SUI and yielded clinically relevant improvements. This app may increase access to first-line treatment and adherence to PFMT.

Ort, förlag, år, upplaga, sidor
John Wiley & Sons, 2017
Nyckelord
mobile applications, pelvic floor muscle training, randomized controlled trial, self-management, stress urinary incontinence
Nationell ämneskategori
Urologi och njurmedicin
Identifikatorer
urn:nbn:se:umu:diva-127492 (URN)10.1002/nau.23116 (DOI)000404361100020 ()27611958 (PubMedID)
Tillgänglig från: 2016-11-14 Skapad: 2016-11-14 Senast uppdaterad: 2020-02-26Bibliografiskt granskad
2. Treatment of stress urinary incontinence with a mobile app: factors associated with success
Öppna denna publikation i ny flik eller fönster >>Treatment of stress urinary incontinence with a mobile app: factors associated with success
Visa övriga...
2018 (Engelska)Ingår i: International Urogynecology Journal, ISSN 0937-3462, E-ISSN 1433-3023, Vol. 29, nr 9, s. 1325-1333Artikel i tidskrift (Refereegranskat) Published
Abstract [en]

Introduction and hypothesis: Stress urinary incontinence is common among women. First-line treatment includes pelvic floor muscle training (PFMT) and lifestyle advice, which can be provided via a mobile app. The efficacy of app-based treatment has been demonstrated in a randomized controlled trial (RCT). In this study, we aimed to analyze factors associated with successful treatment.

Methods: Secondary analysis of data from the RCT. At baseline and 3-month follow-up, participants (n = 61) answered questions about symptoms, quality of life, background, and PFMT. Success was defined as rating the condition as much or very much better according to the validated Patient Global Impression of Improvement questionnaire. Factors possibly associated with success were analyzed with univariate logistic regression; if p < 0.20, the factor was entered into a multivariate model that was adjusted for age. Variables were then removed stepwise.

Results: At follow-up, 34 out of 61 (56%) of participants stated that their condition was much or very much better. Three factors were significantly associated with success: higher expectations for treatment (odds ratio [OR] 11.38, 95% confidence interval [CI] 2.02-64.19), weight control (OR 0.44 per kg gained, 95% CI 0.25-0.79), and self-rated improvement of pelvic floor muscle strength (OR 35.54, 95% CI 4.96-254.61). Together, these factors accounted for 61.4% (Nagelkerke R-2) of the variability in success.

Conclusion: These results indicate that app-based treatment effects are better in women who are interested in and have high expectations of such treatment. Also, the findings underline the importance of strengthening the pelvic floor muscles and offering lifestyle advice.

Ort, förlag, år, upplaga, sidor
Springer, 2018
Nyckelord
Mobile applications, Pelvic floor muscle training, Stress urinary incontinence, Self-management
Nationell ämneskategori
Reproduktionsmedicin och gynekologi
Identifikatorer
urn:nbn:se:umu:diva-152224 (URN)10.1007/s00192-017-3514-1 (DOI)000443429400014 ()29222718 (PubMedID)
Tillgänglig från: 2018-10-16 Skapad: 2018-10-16 Senast uppdaterad: 2020-02-26Bibliografiskt granskad
3. User Experience of an App-Based Treatment for Stress Urinary Incontinence: Qualitative Interview Study
Öppna denna publikation i ny flik eller fönster >>User Experience of an App-Based Treatment for Stress Urinary Incontinence: Qualitative Interview Study
Visa övriga...
2019 (Engelska)Ingår i: Journal of Medical Internet Research, ISSN 1438-8871, E-ISSN 1438-8871, Vol. 21, nr 3, artikel-id e11296Artikel i tidskrift (Refereegranskat) Published
Abstract [en]

Background: Stress urinary incontinence (SUI) affects 10%-39% of women. Its first-line treatment consists of lifestyle interventions and pelvic floor muscle training (PFMT), which can be performed supervised or unsupervised. Health apps are increasing in number and can be used to improve adherence to treatments. We developed the Tät app, which provides a 3-month treatment program with a focus on PFMT for women with SUI. The app treatment was evaluated in a randomized controlled trial, which demonstrated efficacy for improving incontinence symptoms and quality of life. In this qualitative interview study, we investigated participant experiences of the app-based treatment.

Objective: This study aimed to explore women’s experiences of using an app-based treatment program for SUI.

Methods: This qualitative study is based on telephone interviews with 15 selected women, with a mean age of 47 years, who had used the app in the previous randomized controlled trial. A semistructured interview guide with open-ended questions was used, and the interviews were transcribed verbatim. Data were analyzed according to the grounded theory.

Results: The results were grouped into three categories: “Something new!” “Keeping motivation up!” and “Good enough?” A core category, “Enabling my independence,” was identified. The participants appreciated having a new and modern way to access a treatment program for SUI. The use of new technology seemed to make incontinence treatment feel more prioritized and less embarrassing for the subjects. The closeness to their mobile phone and app features like reminders and visual graphs helped support and motivate the women to carry through the PFMT. The participants felt confident that they could perform the treatment program on their own, even though they expressed some uncertainty about whether they were doing the pelvic floor muscle contractions correctly. They felt that the app-based treatment increased their self-confidence and enabled them to take responsibility for their treatment.

Conclusions: Use of the app-based treatment program for SUI empowered the women in this study and helped them self-manage their incontinence treatment. They appreciated the app as a new tool for supporting their motivation to carry through a slightly challenging PFMT program.

Trial Registration: ClinicalTrials.gov NCT01848938; https://clinicaltrials.gov/ct2/show/NCT01848938 (Archived by WebCite at https://clinicaltrials.gov/ct2/show/NCT01848938)

Nyckelord
mobile applications, urinary incontinence, stress, pelvic floor muscle training, self-management, qualitative research, grounded theory, women’s health
Nationell ämneskategori
Reproduktionsmedicin och gynekologi
Identifikatorer
urn:nbn:se:umu:diva-157751 (URN)10.2196/11296 (DOI)000461286800001 ()30869644 (PubMedID)2-s2.0-85062859247 (Scopus ID)
Tillgänglig från: 2019-04-09 Skapad: 2019-04-09 Senast uppdaterad: 2020-02-26Bibliografiskt granskad
4. Pregnant and postnatal women’s usage of an app with a pelvic floor muscle training program for the prevention and treatment of urinary incontinence.
Öppna denna publikation i ny flik eller fönster >>Pregnant and postnatal women’s usage of an app with a pelvic floor muscle training program for the prevention and treatment of urinary incontinence.
(Engelska)Manuskript (preprint) (Övrigt vetenskapligt)
Abstract [en]

Introduction: Pregnancy and childbirth are risk factors for developing urinary incontinence (UI). The prevalence of UI has been reported at 58% in late pregnancy and at around 30% in the three months after childbirth. Pelvic floor muscle training (PFMT) during pregnancy can prevent the onset of UI. We developed the mobile app Tät with a PFMT program for women with stress urinary incontinence. We evaluated its efficacy in a randomized controlled trial and found that the app group experienced fewer incontinence symptoms, fewer leakages, and better quality of life compared to the control group. The app is now freely available, and the aim of this study was to investigate the use of the app by pregnant and postnatal women.

Methods: We included pregnant and postnatal (childbirth in the last three months) women who had downloaded the app between January 16 and November 15 2018 and answered the inclusion questionnaire within the app. Questions included age, gender, country, place of residence, education, reason for download, pregnancy, childbirth in the last three months, and incontinence symptoms according to the ICIQ-UI SF. After three months a follow-up questionnaire appeared in the app. All answers were sent anonymously to our research database.

Results: 10 456 women were included (4 607 pregnant, 5 849 postnatal). The mean age was 31 years and 95% lived in Sweden. 47% of the pregnant women and 55% of the postnatal women reported having UI. The mean ICIQ-UI SF score of those with UI was 6.7 (SD 3.4). 1 805 women answered the follow-up and almost three quarters had used the app and performed PFMT at least weekly. Of those with incontinence, the majority experienced improvement with mean ICIQ-UI SF scores improving significantly at follow-up, except in the subgroup “pregnant both at inclusion and follow-up”.

Conclusion: The Tät app is widely used by pregnant and postnatal women in Sweden for prevention and treatment of UI. Postnatal women with incontinence experienced the largest improvements and reductions in ICIQ-UI SF score. With this study design we cannot say if this effect relates to the use of the app or is the natural improvement of UI over time.

Nationell ämneskategori
Allmänmedicin
Forskningsämne
allmänmedicin
Identifikatorer
urn:nbn:se:umu:diva-168428 (URN)
Tillgänglig från: 2020-02-25 Skapad: 2020-02-25 Senast uppdaterad: 2020-02-27

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