In this secondary analysis of baseline data from three RCTs, we found that quality of life was reduced in women who sought care for UTI through e-health, and that the severity of the leaks had the greatest impact. on quality of life. The type of user interface also affected the quality of life, but not to the same extent. Lack of university education and the presence of comorbidities both had negative impacts on quality of life, but age alone did not have a significant effect.
In this study, the mean ICIQ-UI SF score for all included women was 10.9, which corresponds to moderate leakage , and the mean ICIQ-LUTSqol score was 34.9. Slightly lower scores were found in a 2015 survey in the UK, France, Germany and the US. This study included 1,203 women aged 45 to 60 with unspecified UTI subtypes who completed a questionnaire via the Internet. These results showed moderate leakage (overall ICIQ-UI SF score of 8.7) and an average ICIQ-LUTSqol score of 32.8 . Another RCT from urban areas of Malaysia studied women seeking treatment for UI through conventional routes. Their baseline data on 120 women with SUI who received nonsurgical treatment for UI showed a mean ICIQ-UI SF score of 10.0 and a mean ICIQ-LUTSqol score of 39.0. Thus, they observed a slightly lower severity of UI, with a slightly higher impact on quality of life, compared to our study population. . Another RCT, conducted in the UK, included 600 women who received new clinical diagnoses of SUI or UMI at centers that provided incontinence care. Compared to our study, they found a slightly higher mean ICIQ-UI SF score (12.4), but in the moderate severity range, and a slightly higher mean ICIQ-LUTSqol score (42.9). . Thus, although the level of severity was moderate in all of these studies, the impact on quality of life in our study population was slightly higher, compared to the women in the Internet survey, but slightly lower, compared to women who sought care for UI by conventional routes. These results suggest that through the use of eHealth, the eContinence project could have reached a new group of women who may not have sought unemployment insurance care through conventional channels, but whose insurance -Unemployment had clearly had an impact on their quality of life.
Overall, among the participants in our study, IU had the greatest impact on the quality of life domains of physical limitations, role limitations (including household chores and daily activities) and emotions. Women with UUI / MUI had more severe leaks and experienced a higher impact on social limitations, emotions, role limitations, and sleep, than women with SUI. We found no previous studies comparing SUI to UUI / MUI and taking into account the ICIQ-LUTSqol domains. However, in a study by Abrams et al. (2015), quality of life domains were compared among participants divided into severity categories. They found that women with more severe UTI had the greatest impact on quality of life in areas of social limitations and emotions. .
Our regression analysis showed that in our population, severity of UI had the greatest impact on quality of life. This result was expected, based on previous studies. A large 2007 study of women seeking UI care by means other than eHealth found that severity was the most important predictor of quality of life in women with UI, regardless of or the type of UI. . Another 2018 study explored the relationships between mental health, sleep, and physical function and the type and severity of UI. They showed that, among 510 women who sought help for symptoms of UI, the severity, rather than the type of UI, had the greatest impact on anxiety, depression, and stress. .
At first glance, the results of our study might seem to indicate that type of UI was the most important factor, based on the adjusted beta of 2.5; in contrast, the severity of UI only showed an adjusted beta of 1.5. However, keep in mind that UI type was a dichotomous variable; thus, there was only one comparison step. In contrast, the severity of UI (according to ICIQ-UI SF) was a continuous variable that reflected many stages of comparison; thus, the severity of the UI had a much greater potential impact on the ICIQ-LUTSqol score.
To our knowledge, this study was the first to assess condition-specific quality of life specifically in women with UI who sought care through eHealth. One of the strengths of this study was the relatively large number of participants and the small amount of missing data. Another strength was that the participants were actively seeking treatment and therefore represented a clinically relevant group. In addition, the research group conducting the studies had strong clinical competence and the diagnoses of SUI and SUI / MUI were well established. In the analyzes, we were able to include many variables that could potentially affect quality of life, and we worked closely with a statistician. To facilitate comparison with other studies, we used validated and recommended questionnaires to measure the severity of UI and condition-specific quality of life. [7, 22, 23]
This study also had some potential limitations. First, the UUI / MUI group had a considerably smaller number of participants than the SUI group (123 vs. 373 women), which may have affected the results. In addition, 80.6% of participating women had a university education, compared to 47% of all Swedish women aged 25 to 64 in 2015. . Thus, the results of our population may not be generalizable to all women with UI requiring treatment. However, to date, e-health is mainly used by people with a graduate degree. ; therefore, our population could have been representative of women seeking care through e-health. Another limitation was that our data was limited to data collected in previous RCTs. Thus, other factors that we have not studied could also have influenced the quality of life of our participants. For example, psychological illness might impact condition-specific quality of life, but questions about anxiety and depression were only included in the baseline questionnaires in two of the three RCTs; they could not therefore be explored further. Additionally, we might have underestimated the presence of some co-morbidities (eg, endocrinologic diseases, etc.), particularly in RCT three, due to the definition used. Our choice of definition was based on the fact that the three RCTs used different wordings in the questions about prescribed drugs and concomitant illnesses. RCTs one and three had comparable data on prescription drugs and corresponding illnesses; therefore, we used the prescribed drugs as a marker of comorbidity. Finally, eight years had passed between the start of the first RCT and the start of the third RCT. During this period, the growing field of eHealth had grown rapidly, which may have affected the results.
Clinical implications and future perspectives
Our study showed that women with UUI / MUI and SUI who sought care via e-health experienced a condition-specific impact on quality of life, primarily related to the severity of the UI, rather than to the type of UI. Treatment of UI can decrease the severity of symptoms and therefore improve quality of life; thus, it is important to provide effective and easily accessible treatments to all people with UI, regardless of the subtype. Individual assessments of UTI patients are also necessary, along with careful assessments of the severity of the leaks, to provide adequate help.
A considerable amount of research has been done to study the quality of life in women with UI, in general, but not specifically in women who have sought medical care for UI through eHealth. Our study provides new insight into this group of women, which can help develop and improve treatments through e-health. Currently, the Tät® app (RCT 2) is available for free on the App Store and Google Play in several languages, including Swedish, English, Arabic and Spanish. This application is intended for people who wish to manage SUI on their own, but it can also be useful in addition to other treatments. We also aim to release the Tät ®II app (RCT three) to the public in the future. App-based treatments will not be suitable for all women with UI, but they could contribute to new, cost-effective ways to help many women, and they may lead to an improvement in their quality of life. Easily accessible self-management treatment programs, via the Internet or mobile applications, can facilitate access to medical care for this group of patients and, at the same time, ease the pressure on primary care.
Future research should examine the factors that separate this studied population of eHealth users from those seeking care through conventional channels.