UNIVERSIDADE FEDERAL DO RIO GRANDE DO NORTE … · A CIF, publicada em 2001, visa estabelecer uma...
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UNIVERSIDADE FEDERAL DO RIO GRANDE DO NORTE FACULDADE DE CIÊNCIAS DA SAÚDE DO TRAIRI PROGRAMA DE PÓS-GRADUAÇÃO EM CIÊNCIAS DA REABILITAÇÃO THAISSA HAMANA DE MACEDO DANTAS AVALIAÇÃO DA FUNCIONALIDADE EM MULHERES COM INCONTINÊNCIA URINÁRIA SANTA CRUZ 2018
Transcript of UNIVERSIDADE FEDERAL DO RIO GRANDE DO NORTE … · A CIF, publicada em 2001, visa estabelecer uma...
UNIVERSIDADE FEDERAL DO RIO GRANDE DO NORTE
FACULDADE DE CIÊNCIAS DA SAÚDE DO TRAIRI
PROGRAMA DE PÓS-GRADUAÇÃO EM CIÊNCIAS DA REABILITAÇÃO
THAISSA HAMANA DE MACEDO DANTAS
AVALIAÇÃO DA FUNCIONALIDADE EM MULHERES COM INCONTINÊNCIA
URINÁRIA
SANTA CRUZ
2018
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THAISSA HAMANA DE MACEDO DANTAS
AVALIAÇÃO DA FUNCIONALIDADE EM MULHERES COM INCONTINÊNCIA
URINÁRIA
Dissertação apresentada ao Programa de Pós-
Graduação em Ciências da Reabilitação da
Faculdade de Ciências da Saúde do Trairi da
Universidade Federal do Rio Grande do Norte,
como requisito para obtenção do título de mestre.
Área de concentração: Saúde funcional nos
diferentes ciclos da vida.
Linha de Pesquisa: Intervenção no sistema
músculo-esquelético e cardio-respiratório.
Orientador: Prof. Dr. Diego de Sousa Dantas
Co-orientadora: Profª Drª Luciana Castaneda
SANTA CRUZ
2018
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Dantas, Thaissa Hamana de Macedo.
Avaliação da funcionalidade em mulheres com incontinência
urinária / Thaissa Hamana de Macedo Dantas. - 2018.
69f.: il.
Dissertação (Mestrado em Ciências da Reabilitação) -
Universidade Federal do Rio Grande do Norte, Faculdade de
Ciências da Saúde do Trairi, Programa de Pós-Graduação em
Ciências da Reabilitação, Santa Cruz, RN, 2018.
Orientador: Diego de Sousa Dantas.
1. Incontinência urinária - Mulheres - Dissertação. 2.
Classificação Internacional de Funcionalidade, Incapacidade e
Saúde - Dissertação. 3. Qualidade de vida - Dissertação. 4.
Funcionalidade - Dissertação. 5. Percepção de saúde - Dissertação.
I. Dantas, Diego de Sousa. II. Título.
RN/UF/FACISA CDU 616.62-055.2
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THAISSA HAMANA DE MACEDO DANTAS
AVALIAÇÃO DA FUNCIONALIDADE EM MULHERES COM INCONTINÊNCIA
URINÁRIA
Dissertação apresentada ao Programa de Pós-
Graduação em Ciências da Reabilitação da
Faculdade de Ciências da Saúde do Trairi da
Universidade Federal do Rio Grande do Norte,
como requisito para obtenção do título de mestre.
Área de concentração: Saúde funcional nos
diferentes ciclos da vida.
Linha de Pesquisa: Intervenção no sistema
músculo-esquelético e cardio-respiratório.
BANCA EXAMINADORA
______________________________________________________
Presidente da banca: Prof. Dr. Diego de Sousa Dantas
Universidade Federal do Rio Grande do Norte
_______________________________________________________
Profª Drª Grasiéla Nascimento Correia
Examinador interno – Universidade Federal do Rio Grande do Norte
_____________________________________________________
Profª Drª Clarissa Loureiro Campêlo Bezerra
Examinador externo – Universidade Estadual da Paraíba
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AGRADECIMENTOS
Com um grande sentimento de gratidão encerro essa jornada, ciente de que não teria
chegado à metade dela sem todo o apoio que recebi. A Deus oferto meus primeiros
agradecimentos, por ter permitido essa vivência e por ter me sustentado em todos os momentos,
mostrando Sua infinita bondade por meio das pessoas que cruzaram meu caminho até aqui.
À minha família e ao meu noivo Henrique, por todo o amor e compreensão, por terem
me apoiado em todos os dias em que achei que não seria capaz de ir em frente. Vocês são meu
porto seguro e me mostram dia a dia o quão edificante é o amor.
A meu orientador Diego, por ter acreditado no meu potencial e ter investido seu tempo
e disposição me preparando durante todo o caminho. A relação de cooperação e amizade que
foi desenvolvida durante esses 19 meses só fortaleceu a admiração que tenho por você, como
profissional e ser humano. Espero trabalhar muito ainda com você.
À minha co-orientadora Luciana Castaneda, pela preciosa colaboração e pela solicitude
de me co-orientar, mesmo estando tão distante.
À minha turma de mestrado, em especial a Danielle, Sabrina, Gabrielle, Élida,
Gabrielly, Karime e Camila, por partilharem tantos momentos bons e ruins comigo e tornar
tudo mais leve, pela força que sempre passam, pelos conhecimentos partilhados, pelas idas à
doceria e até pelos dramas coletivos. Tenho certeza de que a amizade e cumplicidade
desenvolvidas irão perdurar, nada acaba aqui.
Às minhas amigas Monise e Danielle, para as quais me faltam palavras. Serei
eternamente grata a Deus pela oportunidade que tive de conhecer pessoas tão maravilhosas, que
sempre têm uma mão amiga a ofertar, um conselho, uma palavra de ânimo; que vibraram, riram
e choraram comigo em todos os momentos desde a residência.
À família HUAB, por ter me dado todo o apoio para que os meses de conciliação entre
residência e mestrados fossem “compatíveis com a vida”, por toda a torcida, suporte e,
principalmente, por terem feito tanta diferença em minha vida profissional.
E, por fim, à “equipe da iniciação científica de Diego”: Luana, Carol, Jardelina e
Vanessa, pelo companheirismo de todos os dias, pela relação de confiança que estabelecemos,
pela solicitude de sempre e por terem me acolhido tão bem.
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RESUMO
Objetivo: Compreender a relação entre a incontinência urinária nas mulheres e a
funcionalidade, por meio da análise do conteúdo dos questionários específicos para avaliação
da qualidade de vida com essa condição de saúde e sua relação com a Classificação
Internacional de Funcionalidade, Incapacidade e Saúde (CIF); assim como pela avaliação da
funcionalidade e incapacidade de mulheres com incontinência urinária por meio de um
instrumento baseado na Classificação. Métodos: A análise dos conteúdos dos questionários de
qualidade de vida e a CIF foi realizada utilizando a metodologia proposta por Cieza e
colaboradores. Para a avaliação da incapacidade das mulheres com incontinência urinária foi
realizado um estudo transversal, utilizando a versão de 36 itens do World Health Organization
Disability Assessment Schedule 2.0 (WHODAS 2.0). Resultados: O produto dos estudos está
apresentado em dois artigos científicos. A ligação do conteúdo das escalas de qualidade de vida
e a CIF evidenciou que os instrumentos possuem, em sua maioria, uma estrutura ainda baseada
no modelo biomédico, com grande enfoque em aspectos clínicos. O estudo transversal revelou,
por meio da análise das médias do WHODAS 2.0, que mulheres com incontinência urinária
possuem maior incapacidade no concernente aos domínios cognição e mobilidade, além do
escore total. A análise qualitativa da incapacidade revelou 42,5% dessas mulheres apresenta
incapacidade moderada a severa. Conclusão: Os resultados expostos servem como ponto e
partida para a discussão da incontinência urinária sob a luz da funcionalidade, auxiliando os
profissionais que prestam assistência às mulheres incontinentes a rever suas práticas e delinear
novas estratégias de atenção a esse público, transpondo o modelo biomédico de abordagem do
processo saúde-doença e utilizando a abordagem biopsicossocial, conforme recomendado pela
Organização Mundial de Saúde.
Palavras-chave: Incontinência urinária; Classificação Internacional de Funcionalidade,
Incapacidade e Saúde; Qualidade de vida; Funcionalidade; percepção de saúde.
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ABSTRACT
Purpose: To understand the relationship between urinary incontinence in women and
functioning by analyzing the content of specific questionnaires to assess the quality of life of
women with this health condition and its relation to the International Classification of
Functioning, Disability and Health (ICF); as well as evaluating the functioning and disability
of women with urinary incontinence through an instrument based on Classification. Methods:
The analysis of the contents of the quality of life questionnaires and the ICF was performed
using the methodology proposed by Cieza et al. To assess the disability of women with urinary
incontinence, a cross-sectional study was conducted using the 36-item version of the World
Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0). Results: The
product of the studies is presented in two scientific articles. The link between the content of the
quality of life scales and the ICF showed that the instruments have, mostly, a structure still
based on the biomedical model, with a great focus on clinical aspects. The cross-sectional study
revealed, through the analysis of the means of WHODAS 2.0, that women with urinary
incontinence have greater disability regarding the domains of cognition and mobility, in
addition to the total score. Qualitative analysis of disability revealed 42.5% of these women had
moderate to severe disability. Conclusion: The results presented serve as a starting point for
the discussion of urinary incontinence in the light of functioning, assisting clinicians that assists
incontinent women to review their practices and outline new strategies for attention to this
public, transposing the biomedical model of approach to the health-disease process and using
the biopsychosocial approach, as recommended by the World Health Organization.
Keywords: Urinary incontinence; International Classification of Functioning, Disability and
Health, quality of life; functioning; health status.
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SUMÁRIO
1 INTRODUÇÃO ..................................................................................................................... 8
1.1 FUNCIONALIDADE ........................................................................................................... 8
1.1.1 Checklist ........................................................................................................................... 9
1.1.2 Core Sets ......................................................................................................................... 10
1.1.3 World Health Organization Assessment Schedule 2.0 .................................................... 11
1.1.4 Model Disability Survey .................................................................................................. 11
1.2 INCONTINÊNCIA URINÁRIA ........................................................................................ 12
1.3 JUSTIFICATIVA ............................................................................................................... 13
1.4 OBJETIVOS ....................................................................................................................... 14
REFERÊNCIAS .................................................................................................................... 15
2. ARTIGOS
2.1 Linking of assessment scales for women with urinary incontinence and the International
Classification of Functioning, Disability and Health (ICF) ..................................................... 18
2.2 Urinary incontinence and functioning in women of reproductive age: assessment by using
World Health Organization Assessment Schedule 2.0 ............................................................. 35
3. CONSIDERAÇÕES FINAIS ............................................................................................. 49
ANEXOS ................................................................................................................................. 50
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1 INTRODUÇÃO
1.1 FUNCIONALIDADE
Funcionalidade é um termo complexo utilizado para definir a capacidade de um
indivíduo de atuar de forma independente em sua vida (FIEDLER E PERES, 2008; TENORIO-
MARTÍNEZ et al., 2009). Tanto a funcionalidade quanto a incapacidade são frutos das
complexas interações entre a condição de saúde de um indivíduo e seu contexto (fatores
ambientais e pessoais). Assim, os aspectos neutros ou positivos resultantes de tais interações
são denominados funcionalidade, enquanto incapacidade, por sua vez, descreve as deficiências,
limitações da atividade e/ou restrição à participação (OMS, 2015).
A abordagem baseada na funcionalidade humana surgiu a partir da necessidade de se
desconstruir o modelo biomédico dominante, centrado na doença e adotar um modelo no qual
os fatores ambientais e o contexto são também considerados no processo de determinação da
saúde, o modelo biopsicossocial (HEERKENS et al., 2018). Buscando uma representação
biopsicossocial da saúde, a Organização Mundial de Saúde apresentou em 1980 a Classificação
Internacional de Deficiências, Incapacidades e Desvantagens (CIDID), a qual era composta por
três dimensões: deficiências, incapacidade e desvantagem. Este modelo, no entanto, estabelecia
uma relação causal baseada em eventos clínicos, no qual um dano a uma estrutura ou função
corporal resultava em uma desvantagem para o indivíduo em exercer seus papéis sociais. O
processo de revisão e adequação do modelo da CIDID culminou com a criação da Classificação
Internacional de Funcionalidade, Incapacidade e Saúde (CIF) (CASTANEDA et al., 2014).
A CIF, publicada em 2001, visa estabelecer uma linguagem unificada e padronizada
acerca da funcionalidade, bem como apresentar uma estrutura que descreva a saúde e os estados
relacionados a ela. É composta por domínios descritos com base na perspectiva do corpo, do
indivíduo e da sociedade e as informações são dispostas em duas seções, a primeira referente à
Funcionalidade e Incapacidade, composta pelos itens Corpo (estrutura e função) e Atividades e
Participação; e a segunda referente aos Fatores Contextuais: Fatores Ambientais e Pessoais
(OMS, 2015).
Diversas perspectivas de abordagem na classificação da funcionalidade e incapacidade
como um processo interativo e evolutivo são propostas pela CIF. Para ilustrar esse propósito,
utiliza-se um diagrama que representa a funcionalidade do indivíduo em um determinado
domínio como resultado da interação complexa entre estado ou condição de saúde e os fatores
contextuais. A dinamicidade entre os elementos reflete o potencial de modificação que a
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intervenção sobre um componente tem sobre os demais. Todos os componentes devem ser
investigados para que se consiga descrever a experiência de saúde em sua totalidade (OMS,
2015).
Para classificar funcionalidade e incapacidade a CIF utiliza um sistema alfanumérico,
composto por uma letra que simboliza o componente (b – função do corpo; s – estrutura do
corpo; d- atividade e participação; e – fatores ambientais) e um código numérico que irá iniciar
com o número do capítulo a que se refere. Cada código estará completo após a inserção de um
qualificador, o qual indicará a magnitude do nível de saúde (OMS, 2015), conforme o descrito
abaixo:
0 = não há problema (nenhum, ausente) 0-4%
1 = problema ligeiro (leve, pequeno) 5-24%
2 = problema moderado (médio, regular) 25-49%
3 = problema grave (grande, extremo) 50-95%
4 = problema completo (total) 96-100%
8 = não especificado (a informação não é suficiente para quantificar a severidade do
problema)
9 = não aplicável (a categoria não é aplicável a um determinado indivíduo)
Existem mais de 1400 categorias descritas na CIF, o que torna sua aplicabilidade na
prática clínica um desafio (GRANBERG et al., 2014; SELB et al., 2015). Entendendo essa
dificuldade e buscando meios de contorná-la, foram desenvolvidos instrumentos que, à luz da
Classificação, viabilizam a avaliação da funcionalidade em diferentes contextos: o Checklist e
os core sets da CIF, o World Health Organization Disability Assessment Schedule 2.0
(WHODAS 2.0) e o Model Disability Survey (MDS) (CASTANEDA et al, 2014).
1.1.1 Checklist
Desenvolvido por um grupo de especialistas da OMS, o checklist é composto por 125
categorias extraídas da CIF, as quais possibilitam ao profissional obter uma visão geral dos
problemas experienciados pelo indivíduo avaliado. As categorias que o compõe estão divididas
em três diferentes domínios: estruturas e funções do corpo, atividade e participação, fatores
ambientais. Assim como na CIF, as categorias desse instrumento só se tornam códigos
completos após a inserção dos qualificadores, os quais seguem a mesma escala de graduação
da Classificação (CIEZA et al., 2006; TENORIO-MARTÍNEZ et al., 2009).
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Apesar de ser um instrumento baseado na CIF, o checklist pode se mostrar limitado em
alguns momentos, por possuir uma lista restrita de categorias a serem utilizadas na avaliação
do indivíduo. Apesar disto, o instrumento representa uma alternativa mais rápida e prática para
avaliação da funcionalidade, sendo sua utilização prática mais viável que a Classificação
completa. O checklist possui ainda a vantagem de ser genérico, podendo ser utilizado na
avaliação de qualquer pessoa ou grupo, na presença ou não de uma condição de saúde específica
(CASTRO et al., 2016).
1.1.2 Core Sets
Compostos por uma quantidade reduzida de categorias da CIF e voltados à avaliação da
funcionalidade de indivíduos com condições de saúde específicas, os core sets são listas
resumidas que visam aproximar a CIF do uso habitual (KOHLER et al., 2009; BÖLTE et al.,
2014). Propostos por um grupo de pesquisadores ligados à OMS – ICF Research Branch – e
publicados a partir de 2005 (GRILL et al., 2005), os core sets estão disponíveis em duas
versões: abrangente (com o mínimo possível de categorias para ser prático, porém com o
número suficiente destas para viabilizar uma avaliação abrangente da funcionalidade) e breve
(com um número ainda mais restrito de categorias que a abrangente, podendo ser utilizado em
situações onde apenas uma breve avaliação é necessária, bem como em pesquisas clínicas e
epidemológicas) (CIEZA et al., 2004; SCHIARITI et al., 2015). Atualmente existem core sets
para 35 condições de saúde distintas, divididas em quatro grandes áreas: musculoesquelética,
cardiopulmonar, neurológica e outras. A paralisia cerebral é a única condição de saúde com
mais de 2 listas disponíveis, pois há três listas breves adicionais, divididas por faixa etária
(menor que 6 anos de idade, 6-13 anos de idade e 14-18 anos de idade) (SCHIARITI et al.,
2015).
A especificidade dos core sets é, ao mesmo tempo, seu ponto mais forte e o mais fraco.
Por tornar viável a avaliação detalhada da funcionalidade de grupos de pessoas com condições
de saúde particulares, mediante a utilização de uma ferramenta elaborada e designada
diretamente para isso, os core sets podem ser muito úteis, por exemplo, em pesquisas com
grupos específicos. No entanto, tamanha especificidade impede a utilização das listas em
pesquisas que envolvam indivíduos saudáveis ou que apresentem condições de saúde ou
doenças para as quais ainda não existam core sets publicados (CASTRO et al., 2016).
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1.1.3 World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0)
Publicado em 2010, o WHODAS 2.0 é um instrumento genérico, voltado para a
avaliação da funcionalidade e incapacidade, e que possui boa performance na utilização em
populações de diferentes culturas, podendo ser utilizado na avaliação da população geral, bem
como em subgrupos desta, tais como pessoas com deficiências, com problemas de saúde mental
ou vícios (USTÜN et al., 2010).
O instrumento avalia seis áreas principais da vida (cognição, mobilidade, autocuidado,
relações interpessoais, atividades de vida e participação) e está disponível em três versões com
36, 12 e 12+24 questões. A versão mais curta do WHODAS 2.0 explica 81% da variância do
questionário com 36 questões, enquanto a versão 12+24 disponibiliza perguntas adicionais
quando há uma resposta positiva entre as 12 principais, visando adquirir mais informações
acerca do domínio acometido. O instrumento pode ser autoaplicado, aplicado por meio de um
entrevistador ou a um proxy (USTÜN et al., 2010; FEDERICI et al., 2017).
O WHODAS 2.0 gera uma pontuação que permite a quantificação da incapacidade, a
qual varia de 0 a 100 e pode ser calculada de forma geral ou para cada domínio. O indivíduo
deve responder às perguntas levando em consideração o grau de dificuldade que encontrou em
realizar a tarefa indicada nos últimos 30 dias, utilizando para isso uma escala que varia de 1
(nenhuma dificuldade) a 5 (incapacidade ou dificuldade extrema em realizar a atividade).
Devem ser consideradas condições de saúde e a forma como normalmente é realizada a
atividade, sendo ponderada uma média entre dias bons e ruins. Aquelas perguntas que se
referirem a atividades não vivenciadas nos últimos 30 dias não devem ser avaliadas (FEDERICI
et al., 2017).
Apesar de possuir apenas 36 itens, denotando um caráter reducionista da CIF, o
instrumento possui as vantagens da aplicação rápida e do caráter generalista, o que possibilita
sua aplicação em populações saudáveis ou com alguma condição de saúde em específico,
permitindo a comparação dos grupos entre si, por meio dos escores gerados (CASTRO et al.,
2016).
1.1.4 Model Disability Survey (MDS)
O MDS é um instrumento baseado na CIF, criado por meio de uma cooperação entre a
OMS e o Banco Mundial para viabilizar a coleta de informações acerca da deficiência, como
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postulado pelo artigo 31 da Convenção dos Direitos das Pessoas com Deficiência das Nações
Unidas. Visando fornecer estimativas de prevalência de deficiências passíveis de comparação
entre os países; aprovisionar informações necessárias à elaboração das diversas políticas,
intervenções e programas voltados à população com deficiência e fornecer indicadores para
monitoramento da implementação das recomendações da Convenção; o instrumento foi
elaborado com a divisão dos seus itens em 7 seções (características sociodemográficas;
histórico do trabalho e benefícios; fatores ambientais; funcionalidade; condições de saúde e
capacidade; utilização de serviços de saúde; e satisfação, personalidade e bem-estar) e possui
um tempo total de aplicação de 60 a 120 minutos (SABARIEGO et al., 2015; CASTRO et al.,
2016).
Por se tratar de um instrumento não reducionista, o MDS mensura o comprometimento
funcional das pessoas com deficiência em um contexto mais aproximado à sua realidade,
permitindo também uma diferenciação entre as necessidades de pessoas com diferentes níveis
de incapacidade e a comparação entre esses grupos e a população de pessoas sem deficiência
(SABARIEGO et al., 2015). Esses pontos positivos se sobrepõem à desvantagem do
instrumento, que é seu tempo extenso de aplicação (CASTRO et al., 2016).
1.2 INCONTINÊNCIA URINÁRIA
Incontinência urinária (IU), descrita como a queixa de qualquer perda involuntária de
urina, é uma condição de saúde que pode ser classificada em três tipos distintos: incontinência
urinária de esforço, caracterizada pela perda involuntária de urina durante esforços (tosse,
espirro), quando a pressão de fechamento uretral é inferior à pressão intra-abdominal;
incontinência urinária de urgência, quando o súbito e intenso desejo miccional culmina em
perda de urina antes de o indivíduo chegar ao banheiro; e incontinência urinária mista, que
apresenta sintomas dos outros dois tipos (ABRAMS et al., 2012).
Considerada um problema de saúde pública (MENEZES et al., 2012), a incontinência
urinária atinge indivíduos de ambos os sexos (MENDEZ et al., 2017), porém é mais comum
entre as mulheres (CERRUTO et al., 2013; SCHREIBER PEDERSEN et al., 2017). Em um
estudo longitudinal realizado nos Estados Unidos, foi observado que a prevalência de IU era 3
vezes maior entre as mulheres (MARKLAND et al., 2011). Apesar disso, a prevalência da IU
feminina possui grande variação entre os estudos, indo de 11,4% (IRWIN et al., 2006) a 48,3%
(SCHREIBER PEDERSEN et al., 2017), com tendência ao aumento com o avançar da idade
(IMAMURA et al., 2015; GIBSON; WAGG, 2017). Outros fatores, como a obesidade,
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multiparidade, diabetes mellitus, doença pulmonar obstrutiva crônica e presença de pelo menos
uma outra comorbidade estão associados à ocorrência de IU (SCHREIBER PEDERSEN et al.,
2017).
Nesta condição de saúde se observa prejuízo de determinadas funções do corpo, tais
como a continência urinária, a frequência miccional e as funções emocionais (LAI et al., 2017).
Podem ser observadas também alterações nas estruturas do corpo, como danos à fáscia
endopélvica e aos músculos do assoalho pélvico (MAP), que fornecem suporte à uretra (AOKI
et al., 2017). Além disto, podem ocorrer prejuízos à função do esfíncter urinário (PARK et al.,
2017) e alterações na conformidade e inervação do músculo detrusor (AOKI et al., 2017).
A IU pode ocasionar também limitação das atividades e restrição à participação,
exercendo influência negativa sobre a participação social das mulheres, o autocuidado, os
relacionamentos interpessoais, a vida sexual, prática de exercícios físicos e as atividades
laborais (FIRDOLAS et al., 2012; FARIA et al., 2015; XU et al., 2016). Em relação aos fatores
contextuais, o ambiente atitudinal pode ser uma barreira, quando há estigma em relação à perda
urinária involuntária, influenciando negativamente os relacionamentos interpessoais (WAN et
al., 2014; LAI et al., 2017).
Referente à busca por cuidados profissionais para o manejo da IU, dados demonstram
que ela está relacionada aos fatores socioeconômicos. Mulheres com menor renda familiar
tendem a reportar menos os sintomas de perda urinária para profissionais de saúde, enquanto
aquelas com menor nível educacional possuem mais chances de reportá-los apenas após o
primeiro ano do início dos sintomas. Na presença de incontinência de grau moderado, as
mulheres negras e com menor renda são menos propensas a discutir o problema com um
profissional qualificado. A menor procura por cuidados em saúde por essa população pode
justificar-se pela dificuldade que a mesma possui no acesso à saúde e pela sobrecarga nas
atribuições familiares e laborais, que levam à necessidade de pôr determinadas situações de
saúde em segundo plano (DURALDE et al., 2016).
1.3 JUSTIFICATIVA
Diante da necessidade de se abordar as condições de saúde à luz do modelo
biopsicossocial, no qual os fatores contextuais e suas influências estão associados ao processo
saúde-doença, o conceito de funcionalidade e o modelo teórico proposto pela Classificação
Internacional de Funcionalidade, Incapacidade e Saúde têm sido cada vez mais utilizados para
14
a compreensão da complexa interação entre as condições de saúde e os elementos e a ela
relacionados.
A incontinência urinária feminina tem sido tema de diversos estudos no mundo todo.
Apesar disso, as pesquisas ainda se detêm majoritariamente à avaliação de aspectos ligados às
estruturas e funções corporais, bem como à intensidade dos sintomas e os fatores a ela
associados, não contemplando aspectos ambientais e pessoais, por exemplo, relacionados a essa
condição de saúde e seus impactos sobre a vida da mulher.
Diante desses pressupostos, o presente estudo se propõe a analisar os aspectos relativos
à funcionalidade de mulheres com incontinência urinária, lançando também um olhar sobre os
instrumentos utilizados na avaliação da qualidade de vida das mesmas.
1.4 OBJETIVOS
1.4.1 Objetivo 01:
Analisar o conteúdo dos principais questionários utilizados na avaliação da qualidade
de vida de mulheres com IU, realizando a ligação de seus conceitos principais com a CIF,
viabilizando a visualização geral do enfoque desses instrumentos.
1.4.2 Objetivo 02:
Avaliar a incapacidade de mulheres em idade fértil com incontinência urinária.
15
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17
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18
Linking of assessment scales for women with urinary incontinence and the International
Classification of Functioning, Disability and Health
Thaissa Hamana de Macedo Dantas¹, Luciana Castaneda², Diego de Sousa Dantas¹
¹ Faculdade de Ciências da Saúde do Trairi, Universidade Federal do Rio Grande do Norte,
Brazil
² Instituto Federal de Educação, Ciência e Tecnologia do Rio de Janeiro, Brazil
Adress for correspondence: Diego de Sousa Dantas. Faculdade de Ciências da Saúde do
Trairi, Rio Branco Avenue, Santa Cruz, Rio Grande do Norte, Brazil. Tel: + 55 email:
19
Linking of assessment scales for women with urinary incontinence and the International
Classification of Functioning, Disability and Health
Abstract
Purpose: This study aimed to link the content of four most used questionnaires to assess the
quality of life of women with urinary incontinence (International Consultation on Incontinence
Questionnaire; King's Health Questionnaire; Incontinence Quality of Life Questionnaire and
Bristol Female Urinary Tract Symptoms Questionnaire) with the International Classification of
Functioning, Disability and Health (ICF). Methods: Linking the questionnaires content and the
ICF was performed by two independent reviewers, with an excellent concordance level (k =
0.941), using the method described by Cieza et al. Results: A total of 93 items were analyzed,
in which 154 meaningful concepts were identified and linked to 48 International Classification
of Functioning, Disability and Health categories, of which 49% were from activities and
participation component (d) and 36.8% from body functions (b). Conclusion: The scales are
linked with the Classification at different levels. The International Consultation on Incontinence
Questionnaire was the most limited instrument. Bristol Female Urinary Tract Symptoms
Questionnaire and Incontinence Quality of Life Questionnaire presented greater agreement with
the ICF, but the concepts in their items are mostly linked to body function, denoting a
biomedical vision. The King’s Health Questionnaire demonstrated greater affinity with the ICF,
and most concepts were related to the activities and participation categories, approaching more
effectively the biopsychosocial model.
Keywords: Urinary incontinence; International Classification of Functioning, Disability
and Health, quality of life; functioning; health status
Introduction
Urinary incontinence is defined as the complaint of any involuntary loss of urine and
can be classified into stress incontinence, urge incontinence and mixed incontinence (1). This
condition is a costly public health problem (2, 3) and its prevalence increases with advancing
age (4). Although it affects individuals of both sexes, urinary incontinence affects mostly
women (5-7). It is a condition that interferes with well-being and may cause harm to women's
social relationships, work activities, sexual life and hygiene (8), impairing to functioning (9).
According to the World Health Organization, Human Functioning is a term that encompasses
20
experiences related to Body Function, Body Structure, Activities and Participation (10) and
results from the dynamic interaction between health conditions and contextual factors
(Environmental Factors and Personal Factors) (11, 12).
The International Classification of Functioning, Disability and Health (ICF) was created
by the World Health Organization to be used as an instrument for language unification and a
classification system for health status (13). The ICF has over 1400 categories, which may make
it difficult to apply in clinical practice. To overcome this difficulty, the World Health
Organization created the Core Sets, which are summarized lists composed of a selection of
categories considered relevant to some specific health conditions (14).
Although evaluation of human functioning is recommended by the World Health
Organization to date, there is no specific evaluation tool for describing functioning in women
with urinary incontinence. Thus, the objective of the present study is to link the ICF with quality
of life questionnaires related to the health of women with urinary incontinence.
Materials and methods
This study was carried out in three steps. In the first step, for instruments selection, an
integrative review of the literature was carried out. Questionnaires cited in randomized clinical
trials and clinical protocols with versions in at least two languages were considered for this
study. The results were compared to a previous review, which lists specific questionnaires to
assess quality of life of women with urinary incontinence (15).
The following quality of life questionnaires were selected: International Consultation
on Incontinence Questionnaire – Short Form, King's Health Questionnaire, Incontinence
Quality of Life questionnaire and Bristol Female Urinary Tract Symptoms Questionnaire. The
International Consultation on Incontinence Questionnaire – Short Form consists of 6 questions
and, in addition to the original English version (16), it has been translated into several
languages, such as Portuguese (17), Spanish (18), Turkish (19) and Arabic (20). King's Health
Questionnaire is composed of 30 questions and it is available, among other languages, in
English (21), Portuguese (22), Turkish (23), Spanish (24) and German (25). Incontinence
Quality of Life questionnaire, consisting of 22 items and Bristol Female Urinary Tract
Symptoms Questionnaire, with 35 questions, are available in languages such as English (26,
27) and Persian (28, 29).
In the second step of the study, the method of linking the questionnaires with the ICF
was performed. Rules proposed by Cieza et al. (30) were used as theoretical reference. This
21
methodology has two updates (31, 32) and it is widely disseminated in the literature (33-37). In
the most recent version (32), are proposed ten rules for linking outcome measures to ICF and
five additional rules. The specific rules determine that all significant concepts of the instruments
should be considered before linking to ICF categories and those response options, when they
have relevant concepts, should also be included. In case the concept of a particular item contains
examples, they should also be linked (30-32). Such rules were developed based on the
accumulated experience during the process of linking hundreds of clinical measurement
documents and health status since the ICF publication in 2001 (38). Since all questionnaires
analyzed had response options, the perspectives were categorized in Intensity (how much?),
Frequency (how many times?), Duration (for how long?), Confirmation or Concordance (yes
or no) and Qualitative Attributes.
The linking of the instruments contents with the ICF was performed by two independent
reviewers, with an excellent concordance level (k = 0.941), calculated using the Kappa
Coefficient. In the event of disagreement between the two reviewers, a third reviewer was
consulted to reach consensus.
In the third step of the study, a descriptive statistical analysis was performed. Data were
expressed in absolute and relative frequencies for the domains of structure (b), body functions
(s), activities and participation (d) and environmental factors (e), in addition to personal factors
(pf). A flowchart was built from the relative frequency of the ICF categories, respecting
proportionality and the relative frequencies of the categories used.
Results
The included questionnaires had total of 93 questions to be analyzed, in which 154 significant
concepts were identified to be linked to ICF categories. Out of this total, 20 concepts (13%)
were not linked, because they were personal factors (pf), health condition (hc) or item not
definable (nd) (activities and participation – a&d; general health – gh; mental health – mh).
Forty-eight ICF categories were found, and most of them were in the activities and participation
(d) component (49%) and body functions (b) (36.8%). Categories linked to the main concepts
of questionnaires items, as well as the absolute and relative frequency of their use are described
in table 1.
[TABLE 1]
Among the four questionnaires evaluated, International Consultation on Incontinence
Questionnaire – Short Form is the shortest, with only 6 items. Of 12 main concepts identified
22
in this instrument, 2 were personal factors (pf), 6 were related to body functions (b), 3 related
to activities and participation (d) and 1 concept was not covered by the ICF (nc). Because it
does not encompass the environmental factors (e) domain in any questions, it was also the most
limited regarding ICF coverage. With a total of 30 questions and 48 identified concepts, King’s
Health Questionnaire was the only instrument that encompassed all ICF domains in its items.
Figure 1 shows the questionnaires content compared to ICF domains.
Figure 1: Questionnaires content compared to ICF domains. pf – personal factors; e – environmental
factors; d – activities and participation; s – body structures; b – body functions
As recommended by Cieza et al. (32), the questions with response options were
submitted to the qualitative analysis of the alternatives perspective, and it was observed that
more than half (58.9%) of the response options presented a perspective of intensity. These items
addressed, mostly, the extent of the impact of urinary incontinence on several aspects of
women's lives or the intensity of urine leakage. The other response options had perspective of
frequency (33.3%), qualitative attributes (5.6%), confirmation or agreement (1.1%) and
duration (1.1%).
As previously described, the activities and participation component (d) presented the
largest number of categories used in the linking process, representing 49% of total. The 24
found categories belonged to 8 of the 9 chapters of this component, chapter d1 (Learning and
applying knowledge) being the only unrelated category. Body functions (b) domain comprised
36.8% of the total categories, and it was the second most represented one. Out of 8 chapters,
however, only 4 were contemplated: b1 - Mental functions; b2 - Sensory functions and pain; b4
23
- Functions of the cardiovascular, hematological, immunological and respiratory systems; and
b6 - Genitourinary and reproductive functions, which is the category most often linked to
questionnaire items: b6202 (urinary continence), used 29 times.
In order to allow global visualization of the study results, a graphic scheme (figure 2)
was developed in which all identified categories are represented in the first level (chapter). The
circles sizes are directly proportional to the frequencies of the categories used. For this analysis
are removed the frequencies of not linked concepts, as example, health condition, not covered
and not definable items (Figure 2).
Figure 2: Representation of the relative frequency of ICF chapters identified during the linking process of
questionnaire items. For this flowchart, the relative frequencies were calculated based on the items who compose
the ICF. Items like "not covered", "health condition" and "not definable" were excluded on this analysis.
Discussion
Urinary incontinence affects several aspects of women's life (8, 9), which implies the
need to use assessment instruments that address this health condition from a holistic
perspective, avoiding the logic focused on the biomedical model (39). This study linked the
items of the four questionnaires most used and recommended for assessing quality of life of
incontinent women and the ICF, and it was observed that only the King's Health Questionnaire
contemplates all components of the ICF.
24
All investigated questionnaires had response options on most of their items. Analyzing
these options, it was observed that 58.9% of them presented a perspective of intensity,
sometimes related to the symptoms intensity, sometimes to the impact of symptoms intensity
on the woman's life. This is an important issue, since the symptoms severity/intensity in urinary
incontinence influences functioning (40, 41). Women with mixed urinary incontinence, when
compared to those with stress or urgency incontinence, present more intense symptoms and,
therefore, greater disability regarding body functions and structures, activities and participation
(42). Incontinence Quality of Life questionnaire and King’s Health Questionnaire stand out as
the questionnaires with the greatest number of response options with this perspective.
Except for King’s Health Questionnaire, all instruments had more than 50% of their
concepts related to categories of body function (b). In this sense, attention is drawn to Bristol
Female Urinary Tract Symptoms Questionnaire, where percentage of concepts related to this
component was 66.7%; and International Consultation on Incontinence Questionnaire – Short
Form, that, as the shortest questionnaire, it is also the most limited, since concepts related to
body functions component are present in 4 of 6 items of the scale, whereas concepts related to
activities and participation (d) are only present in the response options of the last item. The
category b6202 (urinary continence) was the most used, linked to 29 concepts. Although such
frequency is justified by the fact that these are specific questionnaires to evaluate women with
urinary incontinence, the main focus on symptoms, pathology and changes in body organs and
systems reflects the persistence of the biomedical and reductionist model (37). The instruments
that are proposed to evaluate quality of life of individuals should consider that the psychological
and social aspects influence on how the individual feels about their health condition and the
outcomes related to it (43).
Although many concepts related to body function are identified in the four instruments
evaluated, only King's Health Questionnaire is linked to a category of body structures domain
(s) (s6102 - urinary bladder), that may be explained by the fact that scales are specific for quality
of life assessment, and they are not sensitive to aspects related to this component. Similarly,
personal factors (pf) were contemplated only by two instruments (International Consultation on
Incontinence Questionnaire – Short Form and Incontinence Quality of Life Questionnaire).
Since personal factors such as age and lifestyle are closely related to urinary incontinence and
its outcomes (4) and considering that the components interact and influence each other (44), it
is necessary for the professional to adopt other instruments and evaluation measures that
contemplate the other components of human functioning (body structures, activities and
participation and contextual factors).
25
The activities and participation (d) component was the one with the highest number of
categories related to the scales items, which assess urinary incontinence impact on carrying out
daily routine (d230), doing housework (d640), sports (d9201), socializing (d9205), spousal and
sexual relationships (d7701 and d7702, respectively), among others. The assessment pertinence
of these aspects is that urinary incontinence causes activity limitation and participation
restriction, since women adopt coping strategies that involve avoiding sports and leisure
activities and restriction of social contact and interaction. Incontinent women also present lower
performance in daily routine management and housework tasks (41, 45). In the sexual sphere,
women face reduced desire, lubrication and the ability to reach orgasm, resulting in less
frequent sexual intercourse and greater dissatisfaction (45, 46). Despite the important influence
of urinary incontinence on activities and participation, the International Consultation on
Incontinence Questionnaire – Short Form has few concepts related to this domain, and there are
no concepts related to socializing and sexual relationships.
King's Health Questionnaire had greater prevalence (52.5%) and a variety of concepts
related to the activities and participation component. Only this questionnaire had an item linked
to category d850 (remunerative employment) (Does your bladder problem affect your job, or
your normal daily activities outside the home?).
Employment is an important component in individuals' lives and health conditions such
as urinary incontinence negatively affects the capacity, productivity, and development related
to it (47, 48).
Only five categories related to environmental factors (e) were linked to questionnaire
items. King's Health Questionnaire had 3 concepts related to the categories of this component,
Incontinence Quality of Life Questionnaire and Bristol Female Urinary Tract Symptoms
Questionnaire had 2 concepts linked and International Consultation on Incontinence
Questionnaire – Short Form does not contemplate this domain in any of its items. From total,
three concepts were linked to categories in chapter e3 - Support and relationships, addressing
the impact of UI on the relationship with immediate and extended family, and the feeling of
helplessness associated with urinary leakage. Evaluation of aspects related to these categories
is extremely relevant, since greater disability is observed among incontinent women inserted in
an unfavorable attitudinal environment, where hostile reactions are observed (49). The reduced
number of categories related to environmental factors shows instruments weakness regarding
the evaluation of functioning from a Biopsychosocial perspective (50), because it excludes
important information about factors that can be a barrier or a facilitator in the investigated
context (37).
26
Following Cieza et al (31) guidelines, when the linking of a concept to specific
categories is not possible, because the information provided is not sufficient, they were marked
as nd (not definable). Those classified as nd – mh (not definable – mental health) were a special
issue discussed among the reviewers, since the items where they were contemplated were
confusing in their construction, not allowing to define whether they were emotional status or a
specific psychological pathology, preventing the concept linking to an ICF specific category.
Although there is no ICF specific instrument for evaluating functioning in people with
urinary incontinence, it was observed that the concepts in the instruments are pertinent. Based
on the literature available on factors involved in the health-disease process of urinary
incontinence, other categories could be included in the assessment of incontinent women, such
as d2401 (handling stress), e580 (health services, systems and policies), e1101 (drugs) and e430
(individual attitudes of people in positions of authority) (39), which are relevant to the
understanding of the health status of these women, but they were not included in the analyzed
instruments.
There are various questionnaires available to assessment of several aspects of urinary
incontinence in different contexts and specific populations (51). Nevertheless, is important
highlights that the questionnaires here analyzed are most strongly recommended by the
appropriate literature for clinical practice and have good psychometric properties (25, 52, 53).
The International Consultation on Incontinence Questionnaire – Short Form has a few-
items structure that provides greater agility during application, however, makes the instrument
limited, covering only three of the five ICF components. The International Consultation on
Incontinence Questionnaire is a modular instrument and, if necessary, the professionals can use
its other modules to complement the assessment– as International Consultation on Incontinence
Questionnaire-Female Lower Urinary Tract Symptoms and International Consultation on
Incontinence Questionnaire-Lower Urinary Tract Symptoms Quality of Life. However, as these
modules are not commonly cited in the literature, they were not analyzed.
On the other hand, the Bristol Female Urinary Tract Symptoms Questionnaire presents
greater coverage of the ICF, but the concepts in its items are mostly related to body functions,
similar to Incontinence Quality of Life Questionnaire, denoting a vision based on the
biomedical model, in which aspects related to physiology overlaps the others. On King’s Health
Questionnaire, the aspects related to activities and participation, as well as environmental
factors constitute the majority of concepts.
27
Conclusion
It was possible to identify that all the scales have a connection with the ICF at different
levels, as well as characteristics that help in choosing the most suitable instrument for the
proposed objectives. In this sense, it was observed that, among the four instruments evaluated,
the King's Health Questionnaire has greater affinity with the ICF. This instrument has most of
its concepts related to the categories of activities and participation domain, more effectively
approaching the biopsychosocial model on which the ICF is based.
Thus, King's Health Questionnaire allows the collection and integration of much of
information, allowing an extended view of the health status and functioning of incontinent
women. The results presented here indicate the importance of further studies focused on the
development and validation of an ICF core set for the urinary incontinence condition, in order
to converge information obtained from the ICF and the quality of life questionnaires, unifying
the language in the education, research and clinical practice fields.
Acknowledgement
Not applicable
Declaration of interests
The authors report no conflicts of interest.
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Table 1: Absolute and relative frequency of linking categories to main concepts of the
questionnaire items
ICF category ICF category description Relative and absolute
frequency
s6102 Urinary bladder 1 (1.1%)
b1300 Energy level 1 (1.1%)
b134 Sleep functions 3 (3.2%)
b1411 Orientation to place 1 (1.1%)
b152 Emotional functions 5 (5.4%)
34
b1520 Appropriateness of emotion 7 (7.5%)
b1522 Range of emotion 3 (3.2%)
b1602 Content of thought 1 (1.1%)
b280 Sensation of pain 2 (2.2%)
b2801 Pain in body part 1(1.1%)
b435 Immunological system functions 1 (1.1%)
b450 Additional respiratory functions 2 (2.2%)
b620 Urination functions 10 (10.8%)
b6200 Urination 4 (4.3%)
b6201 Frequency of urination 2 (2.2%)
b6202 Urinary continence 29 (31.2%)
b630 Sensations associated with urinary functions 4 (4.3%)
b640 Sexual functions 2 (2.2%)
b6700 Discomfort associated with sexual
intercourse
1 (1.1%)
d230 Carrying out daily routine 4 (4.3%)
d4101 Squatting 2 (2.2%)
d430 Lifting and carrying objects 1 (1.1%)
d450 Walking 1 (1.1%)
d4552 Running 2 (2.2%)
d530 Toileting 1 (1.1%)
d5300 Regulating urination 7 (7.5%)
d5404 Choosing appropriate clothing 1 (1.1%)
d540 Dressing 1 (1.1%)
d560 Drinking 2 (2.2%)
d630 Preparing meals 1 (1.1%)
d640 Doing housework 1 (1.1%)
d6402 Cleaning living area 2 (2.2%)
d6601 Assisting others in movement 1 (1.1%)
d6200 Shopping 1 (1.1%)
d7701 Spousal relationships 1 (1.1%)
d7702 Sexual relationships 4 (4.3%)
d850 Remunerative employment 1 (1.1%)
d9 Community, social and civic life 1 (1.1%)
d920 Recreation and leisure 3 (3.2%)
d9201 Sports 4 (4.3%)
d9205 Socializing 3 (3.2%)
d9208 Recreation and leisure, other specified 1 (1.1%)
d9300 Organized religion 1 (1.1%)
e1100 Food 1 (1.1%)
e1150 General products and technology for
personal use in daily living
3 (3.2%)
e3 Support and relationships 1 (1.1%)
e310 Immediate family 1 (1.1%)
e315 Extended family 1 (1.1%)
hc Health condition 1 (1.1%)
nc Not covered 3 (3.2%)
nd-a&d Not definable - Activities and Participation 5 (5.4%)
nd-gh Not definable – general health 2 (2.2%)
nd-mh Not definable – mental health 5 (5.4%)
pf Personal factors 4 (4.3%)
35
Urinary incontinence and functioning in women of reproductive age: assessment by
using World Health Organization Assessment Schedule 2.0
Thaissa Hamana de Macedo Dantas¹, Luciana Castaneda², Diego de Sousa Dantas¹
¹ Faculdade de Ciências da Saúde do Trairi, Universidade Federal do Rio Grande do Norte,
Brazil
² Instituto Federal de Educação, Ciência e Tecnologia do Rio de Janeiro, Brazil
Adress for correspondence: Diego de Sousa Dantas. Faculdade de Ciências da Saúde do
Trairi, Rio Branco Avenue, Santa Cruz, Rio Grande do Norte, Brazil. Tel: + 55 email:
36
Urinary incontinence and functioning in women of reproductive age: assessment by
using World Health Organization Assessment Schedule 2.0
Abstract
Purpose: To analyse the disability status of women with urinary incontinence and compare
results with non-incontinent women. Methods: Forty incontinent and eighty continent women
were recruited from six Family’s Health Basic Units. Sociodemographic, gynecological and
obstetric data were assessed by using questionnaires developed for this study. To collect data
about presence and type of incontinence were used the International Continence Society’s
guidelines as reference. Disability was assessed by using the 36-items World Health
Organization Disability Assessment Schedule 2.0. Mann-Whitney, ANOVA and Kruskall
Wallis test were used for comparing WHODAS 2.0 scores between groups and Chi-square test
was used to compare degrees of disability between incontinent and non-incontinent women.
Results: The WHODAS scores showed that women with urinary incontinence had greater
disability in cognition (p=0.023) and mobility (p=0.020) domains, in addition to the total score
(p=0.23). Women with mixed urinary incontinence had greater disability in mobility domain
(p=0.039) than those with stress or urgency incontinence. Qualitative analyses of disability
showed significant difference between women with and without urinary incontinence
(p=0.033), with higher percentages of incontinent women with moderate and severe
incontinence. Conclusion: Women of reproductive age with urinary incontinence have greater
and more severe disability than those without incontinence. Results presented can be useful for
designing and adapting strategies for intervention directed to the negative effects of urinary
incontinence, developing rehabilitation programs based on ICF guidelines.
Keywords: Urinary incontinence; International Classification of Functioning, Disability and
Health; Disability evaluation.
37
Introduction
Urinary incontinence, defined as a complaint of any involuntary urine loss (1), is a
public health’s problem (2) that affect individuals of both sexes (3), but has major prevalence
among women (4, 5), affecting them up to three times more than men (6). Risk factors for
female urinary incontinence include getting older (7, 8), obesity, multiparity, diabetes mellitus,
chronic obstructive pulmonary disease and presence of at least one other comorbidity (5).
Urinary incontinence affects many areas of women’s lives, as social life, work, self-care,
relationships, sports practice (9-11) and negatively impacts on their well-being (9) and
functioning (12).
Seeking to establish a biopsychosocial approach of health, considering the
environmental factors and the context in which the individual is inserted as determinants of
health (13), in 2001 the World Health Organization published the International Classification
of Functioning, Disability and Health (ICF) (14). ICF It is composed of domains described
based on the perspective of the body, the individual and the society, arranging information in
two sections, the first one referring to Functioning and Disability, composed by the items Body
(structure and function) and Activities and Participation; and the second on the Contextual
Factors: Environmental and Personal Factors (15). To illustrate the dynamic interactions among
the components and the modification potential that interventions in a component have on others,
ICF proposes a diagram (14). On Figure 1, aspects related to urinary incontinence are shown in
this diagram.
In consequence of the extension of ICF, implementation in clinical practice has to be a
challenge (16, 17). To work around this problem, some instruments were developed based on
ICF to facilitate functioning assessment in different contexts (18). The World Health
Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) is a generic instrument that
evaluates the difficulties that a person experienced in social participation and daily activities in
the last 30 days and can be used in general population or in groups with specific health
conditions (19).
The WHODAS has been used in the evaluation of disability caused by many conditions,
such stroke (20), hand conditions (21), dementia (22), maternal complications (23), multiple
sclerosis and psychiatric disorders (24). However, are not found studies using this instrument
for functioning assessment of people with urinary incontinence. In this sense, and recognizing
the importance of the biopsychosocial approach to health conditions, the purpose of this study
is evaluating the impact of urinary incontinence on functioning of women in reproductive age.
38
Figure 1: Urinary incontinence and factors related according to ICF diagram
Materials and methods
This was a quantitative, cross-sectional study conducted in six Family’s Health Basic
Units in Santa Cruz – Rio Grande do Norte – Brazil, from August 2015 to July 2016. The local
ethical committee approved the protocol by the opinion number 49237315.9.0000.5568 and all
the participants gave informed consent before starting the interview.
Initially, were proportionally recruited 210 women aged 19 to 49 years and with
preserved cognition among the six Family’s Health Basic Units. Of this total, 15 women were
excluded because they were pregnant. Of the 195 remaining participants, 120 women who
provided information about urinary incontinence were selected to compose the final sample.
The research protocol was composed of sociodemographic, obstetrical and
gynecological questionnaires, developed specifically for this study to extract information about
age, educational level, family income, age of menarche, lifestyle (sedentary or active) number
of pregnancies and information about deliveries: number of cesarean sections and vaginal
deliveries.
39
Two questions were used to determine if the woman had or not had urinary incontinence
and the type of incontinence. Question 1: “during last month do you had involuntary urine
leakage during physical efforts, like coughing, lifting, sneezing or laughing?” question 2:
“during last month do you had a strong urge to urinate that it was impossible to get to the
bathroom in time?”. These questions are sensitive and specific to assessing urinary
incontinence. (25). Women that answered “yes” to any or both questions were considered
incontinent. The type of incontinence was defined following the definitions of International
Continence Society (1): stress urinary incontinence, when the urine loss occurred during
physical efforts; urgency urinary incontinence, when the sudden and intense voiding desire
culminates with the urinary loss before reaching the bathroom; and mixed urinary incontinence,
when characteristics of stress and urgency incontinence are present.
To evaluate functioning and disability, the World Health Assessment Schedule 2.0
(WHODAS 2.0) was used. This instrument was published in 2010 (19) and has good
performance in use in populations of different cultures and can be used in the evaluation of
healthy individuals (19, 26). WHODAS 2.0 evaluate six main areas of life (Cognition, Mobility,
Self-care, Getting along, Life activities (housework and school/work) and Participation). The
items are scored according to a Likert scale ranging from 1 to 5, where 1 means no difficulty
and 5 means extreme difficulty. The final score can be calculated total or for each domain and
vary from 0 to 100, and high scores indicate high levels of disability (19, 26). For this study,
the 36-item version administered by an interviewer, translated and validated to Brazilian
population (27) was elected.
The variables of sample characterization (sociodemographic, gynecological and
obstetrics) are presented in two groups: incontinent and non-incontinent women. Age and age
of menarche are presented by mean and standard deviation, while educational level, family
income, lifestyle, number of cesarean sections and vaginal deliveries are presented by relative
and absolute frequencies. The WHODAS 2.0 scores are presented by mean/ standard deviation
and median, for incontinent and non-incontinent women and for each type of incontinence. The
qualitative analyses of disability is presented by absolute and relative frequencies, by groups
(incontinent and non-incontinent).
Data management and statistical analyses was conducted by the Statistical Package for
Social Science (SPSS™) version 20.0. Kolmogorov-Smirnov test was used for verification of
data normality. Quantitative data are expressed in mean and standard deviation; qualitative data
are expressed in relative and absolute frequencies. For comparison of scores of WHODAS 2.0
between women with and without urinary incontinence, Mann-Whitney test was realized. Chi-
40
square test was used to evaluate the homogeneity of the sample and to compare degrees of
disability between incontinent and non-incontinent women. To compare scores of WHODAS
2.0 by the type of urinary incontinence was used ANOVA and Kruskal Wallis tests (for data
with normal and non-normal distribution, respectively).
Results
A total of 120 women were assessed for this study. Of these, 40 (33.33%) reported
involuntary urine loss, of which 19 (47.5%) were characterized as stress urinary incontinence,
12 (30%) as mixed urinary incontinence and 9 (22.5%) as urgency urinary incontinence.
The groups of urinary incontinence and non-incontinent were homogeneous in terms of
socioeconomic status, represented by age, educational level, family income, and in terms of
gynecological and obstetric characteristics, as the age of menarche, vaginal deliveries and
cesarean sections. Only number of pregnancies presented a statistically significant difference,
with a higher percentage of multiparous among incontinent (40%) compared to non-incontinent
(23.75%) women. The complete characterization of sample is presented in Table 1.
[Table 1]
Concerning to WHODAS 2.0 scores in all domains, in a comparison between women
incontinent and women without urinary incontinence (Table 2), incontinent women had higher
scores (denoting higher disability) in cognition (p=0.023), mobility (p=0.020) and the total
score (p=0.023). In participation domain, was revealed a trend to a difference (p=0.057).
Comparing disability among groups by types of incontinence (Table 3), it was observed that
women with mixed urinary incontinence had greater disability than those with stress or urgency
incontinence in mobility domain (p=0.039). Nevertheless, in other domains and total score,
there are no significant differences among the three groups.
[Tables 2 and 3]
To provide a qualitative analysis of disability, the total score was categorized in four
levels of disability, according to the International Classification of Functioning, Disability and
Health (14) (0-4% no disability; 5-24% mild disability; 25-49% moderate disability; 50-95%
severe disability). Establishing comparison between incontinent and non-incontinent women, it
was observed that, while “no disability” and “mild disability” degrees had higher percentages
41
of non-incontinent women, those with urinary incontinence composed the higher percentages
of women with moderate and severe disability (Table 4).
[Table 4]
Discussion
This study revealed that urinary incontinence-induced disability significantly affected
women’s scores in cognition and mobility domains of WHODAS 2.0, in addition to the total
score. Between the types of incontinence, mixed urinary incontinence was most disabling on
cognition domain than stress and urgency incontinence. Qualitative analysis revealed that
incontinent women compose the higher percentages of disability’s greater levels.
On women’s health, publications by using ICF as a reference for functioning and
disability assessment are concentrated on oncology and maternal areas. This study used a CIF-
based, strong and validated instrument to assess disability in incontinent women, transposing
the classic clinical events-based evaluation and approaching this health condition in a
biopsychosocial vision.
The relation between urinary incontinence and cognitive functions is described in
studies with elderly. In a study (28) assessing cognitive abilities of 51 incontinent middle-aged
and elderly of both sexes, authors observed that the verbal ability and information processing
speed were significantly reduced, compared to control group. Another research (29) revealed
that higher cognitive impairment and lower cognitive performance are associated with higher
prevalence of urinary incontinence in elderly. Both studies related the lower function of the
frontal lobe of brain in incontinent individuals. Once studies assessing cognitive functions are
concentrated in the elderly population, we not found studies with this perspective with
incontinent women of reproductive age.
Concerning to mobility, in our sample, incontinent women had a higher disability on
this domain than continent women. In a study with incontinent women from the United
Kingdom, authors found that urinary incontinence is associated to decrease in gait performance,
with a significant decrease of gait velocity and stride length. Even in presence of strong void
desire, a slow gait denotes that in a dual task of reaching appropriated place to voiding and
maintenance of continence, women are more focused on avoiding urine leakage, moving slowly
(30). In another research (31), 453 of 745 incontinent women reported difficulty to walk
distances longer than one block; with a increasing disability with higher frequency of urinary
42
incontinence (women with daily urine leakages had a higher disability). The relationship
urinary incontinence - mobility is bidirectional and complex (32) and, while some women may
reduce physical activities to reduce the risk of leakages, this reduction can increase functional
impairments that can impede them to getting on a toilet on time (31).
Comparing the three types of urinary incontinence, our findings suggest that women
with mixed urinary incontinence have a higher disability on mobility domain. Although
literature (33) report higher impairment on mobility in women with urgency incontinence, this
finding corroborates with our study, once mixed incontinence has components of urgency too.
Other studies report differences on the impact of type of incontinence about women’s lives.
Mixed incontinence is related to more severe symptoms and is related as more bothered than
stress and urgency incontinence (34) and is associated with poorer quality of life of individuals
(9, 34-36). Mixed and urgency incontinence are also more limiting to physical activity than
stress incontinence (34).
In spite of the literature points out that urinary incontinence leads to a social
participation restriction (10, 11, 37, 38), in our study, participation was not a domain that
disability scores were significantly different between incontinent and non-incontinent women.
In a study with older Australian incontinent women (39), authors found an association between
urinary incontinence and social dysfunction, but this association is not casual it is a reflection
of general health and overall level of function of women, exploring a new axis of discussion
about this domain and approaching the influence of environmental aspects on it.
To the best of our knowledge, there are no other studies assessing the disability among
incontinent women using the ICF perspective, so we did not found data to compare the
prevalence and levels of disability here presented. This study used an ICF-based instrument,
which provides a holistic evaluation of incontinent women, subscribing to the integrative
biopsychosocial approach of disability in accordance with the World Health Organization
recommendations. In our sample, 42.5% of incontinent women had a moderate or severe
disability, while this percentage among non-incontinent women was 23.75%, demonstrating
that incontinent women have bigger and more severe disability in specific domains and in
general perspective.
Although ICF is published since 2001, its model and reference are poorer used, and
publications are concentrated on clinical protocols or evaluation of quality of life, making it
difficult the holistic visualization of this health condition. Even the incontinence-specific
instruments for evaluation of the quality of life are mostly focused on biological aspects of
incontinence, to the detriment of contextual factors (40). This is a pioneer study that allows an
43
initial view of the disability panorama of female urinary incontinence, providing an
approximation to the universal language of functioning established by the World Health
Organization.
This study has a limitation to the measurement of the outcome and independent variables
at the same time. This limitation is common in cross-sectional design and to better investigation
of these associations, it is recommended to carry out longitudinal studies.
Conclusion
This pioneering study examined WHODAS 2.0 scores and found that women of
reproductive age with urinary incontinence have greater disability than those without
incontinence. Our findings show that, although continent women also present disability,
incontinent women have higher degrees of it. Results presented can be useful for designing and
adapting strategies for intervention directed to the negative effects of urinary incontinence,
developing rehabilitation programs based on ICF guidelines.
Acknowledgement
Not applicable
Declaration of interests
The authors report no conflicts of interest.
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47
Table 1:
Table 1: Sociodemographic, gynecological and obstetric characterization of sample. T = Measured by
Independent Student’s T-test. C = Measured by Chi-Square test.
Table 2
Table 2: Comparison of WHODAS 2.0 scores between incontinent and non-incontinent women.
Measured by Mann-Whitney test.
Urinary incontinence p
Yes (n=40)
Mean ± SD or n(%)
No (n=80)
Mean ± SD or
n(%)
AgeT 35.7±9.5 32.4±8.9 0.73
Educational
levelC
Primary education 23 (57.5%) 31 (38.75%) 0.139
Secondary education 12 (30%) 38 (47.5%)
Tertiary+ education 5 (12.5%) 11 (13.75%)
Family
income C
< than a minimum
wage
14 (35%) 30 (37.5%) 0.926
1 minimum wage 21 (52.5%) 29 (36.25%)
2-3 minimum wages 5 (12.5%) 18 (22.5%)
≥ 4 minimum wages 0 (0%) 3 (3.5%)
Sedentary
lifestyle C
Yes 12 (30%) 16 (20%) 0.222
No 28 (70%) 64 (80%)
Menarche AgeT 13±1.3 12.6±1.5 0.145
Pregnancies C No pregnancies 5 (12.5%) 22 (27.5%) 0.025*
1-2 pregnancies 19 (47.5%) 39 (48.75%)
≥3 pregnancies 16 (40%) 19 (23.75%)
Vaginal
deliveries C
Yes 25 (37.5%) 21 (26.25%) 0.205
No 15 (52.5%) 29 (36.25%)
Cesarean
sections C
Yes 25 (37.5%) 45 (56.25%) 0.513
No 15 (52.5%) 35 (43.75%)
WHODAS 2.0 domain Urinary
incontinence
Mean ± SD Median p
Cognition Yes 27,6±22,6 25 0,023*
No 17,6±15,1 15
Mobility Yes 28,4±26,4 25 0,020*
No 16,2±17,8 12,5
Self-care Yes 9,5±18,2 0 0,404
No 5,4±11,9 0
Getting along Yes 13,7±11,9 8,3 0,159
No 12,2±15,6 8,3
Life activities Yes 22,2±29,1 10 0,491
No 17,2±23,3 10
Participation Yes 29,4±25,1 25 0,057
No 20,4±20,4 16,7
Total Score Yes 23,9±18 20,6 0,023*
No 16±13,6 14,1
48
Table 3:
WHODAS 2.0 domain Mean ± SD p
SUI (n=19) MUI (n=12) UUI (n=9)
Cognition A 23.95 ±18.75 35.42 ±25.88 25.0 (25.49) 0.369
Mobility A 29.28 ±24.74 40.10 ±30.43 11.11 ±13.89 0.039*
Self-care k 11.57 ±22.17 12.5 ±17.12 1.11 ±3.33 0.234
Getting along A 14.47 ±13.56 10.42 ±9.48 16.67 ±11.02 0.470
Life activities k 18.94 ±29.6 31.66 ±34.33 16.66 ±18.7 0.527
Participation A 31.36 ±26.4 29.17 ±28.31 25.46 ±19.48 0.851
Total Score A 23.68 ±18.28 28.44 ±20.38 18.11 ±13.87 0.441
Table 3: Comparison of WHODAS 2.0 scores between the three types of urinary incontinence. A –
Measured by ANOVA test. K – Measured by Kruskal Wallis Test.
Table 4:
Table 4: Qualitative analyses of disability. The disability degrees were defined according to ICF.
Measured by Chi-Square test.
Urinary incontinence p
Yes (n=40) No (n=80)
Disability No disability 7/40 (17.5%) 18/80 (22.5%) 0.033*
Mild disability 16/40 (40%) 43/80 (53.75%)
Moderate disability 12/40 (30%) 17/80 (21.25%)
Severe disability 5/40 (12.5%) 2/80 (2.5%)
49
3 CONSIDERAÇÕES FINAIS
O conceito de funcionalidade e o modelo teórico apresentado pela CIF têm sido
utilizados mundialmente para abordar as diferentes condições de saúde e os estados a ela
relacionados sob a ótica biopsicossocial. O emprego cotidiano da CIF, no entanto, tem sido
dificultado pela extensão da Classificação, que possui mais de 1400 categorias, o que tem sido
contornado pela crescente utilização dos instrumentos de avaliação da funcionalidade nela
baseados. Apesar da crescente utilização da CIF a nível mundial, no que diz respeito à
incontinência urinária entre mulheres, ainda se observa uma lacuna significativa na abordagem
biopsicossocial e da funcionalidade.
O presente estudo permitiu a observação de que, entre os quatro instrumentos mais
utilizados na avaliação da qualidade de vida de mulheres incontinentes, apenas o King’s Health
Questionnaire possui conceitos que abrangem todos os componentes da CIF. O International
Consultation on Incontinence Questionnaire, o Incontinence Quality of Life Questionnaire e o
Bristol Female Urinary Tract Symptoms Questionnaire possuem mais da metade de seus
conceitos referentes às funções do corpo, revelando a persistência do modelo biomédico na
avaliação das mulheres com incontinência urinária. Observou-se ainda que aspectos
importantes da vida, como emprego, são pouco ou nada explorados pelos instrumentos. A
utilização de um instrumento baseado na CIF (WHODAS 2.0) na avaliação de mulheres com
incontinência urinária revelou que 82,5% das mesmas apresenta algum grau de incapacidade e
que 42,5% apresenta incapacidade moderada ou severa. A incontinência urinária afetou
negativamente a funcionalidade nos domínios cognição e mobilidade do WHODAS 2.0, além
de as mulheres incontinentes apresentarem escore total significativamente mais elevado que as
mulheres com continência preservada, denotando maior nível de incapacidade.
Os resultados aqui expostos apontam para a necessidade de abordar a incontinência
urinária em mulheres sob a ótica da funcionalidade, com a elaboração e validação de um core
set da CIF específico para essa condição de saúde, bem como com a reestruturação dos
protocolos e modelos de intervenção para este público, atentando para aspectos que se estendem
para além das funções e estruturas do corpo, de forma a alinhar a atenção à mulher incontinente
com o modelo biopsicossocial de atenção à saúde.
50
ANEXOS
51
ANEXO A: Comprovante de publicação do Artigo 1.
52
ANEXO B: Parecer do Comitê de Ética em Pesquisa
53
54
55
ANEXO C - International Consultation on Incontinence Questionnaire – Short Form
TAMANINI, J. T. M.; DAMBROS, M.; D’ANCONA, C. A. L. et al. Validação para o português do
“International Consultation on Incontinence Questionnaire – Short Form” (ICIQ-SF). Revista de Saúde
Pública, n.38, v. 3, p. 438–44, 2004.
56
ANEXO D - King’s Health Questionnaire
FONSECA, E. S. M.; CAMARGO, AL. L. M.; CASTRO, R. A.. et al. Validação do questionário de qualidade
de vida (King’s Health Questionnaire) em mulheres brasileiras com incontinência urinária. Revista Brasileira
de Ginecologia e Obstetrícia, n.27, v. 5, p. 235–42, 2005.
57
ANEXO E – Incontinence Quality of Life Questionnaire
58
59
60
61
CUNHA E SOUZA, C. C. Tradução e validação para a língua portuguesa do questionário de qualidade de
vida IQoL (Incontinence Quality of Life Questionnaire), em mulheres brasileiras com incontinência
urinária Dissertação (Mestrado em Ciências). Universidade Federal de São Paulo. São Paulo: 2010.
Journrology, n.77, p. 805–12, 1996.
62
ANEXO F – Bristol Female Urinary Tract Symptoms
JACKSON, S.; DONOVAN, J.; BROOKES, S. et al. The Bristol Female Lower Urinary Tract Symptoms
questionnaire: development and psychometric testing. British Journal of Urology, n.77, p. 805–12, 1996.
63
ANEXO G – World Health Organization Disability Assessment Schedule 2.0
64
65
66
67
68
69
CASTRO, S. S.; LEITE, C. F.; OSTERBROCK, C. et al. Avaliação de Saúde e Deficiência: manual
do WHO Disability Asssessment Schedule (WHODAS 2.0). Uberaba: Universidade Federal do
Triângulo Mineiro; 2015.
