Exercise intervention in the management of urinary incontinence in older women in villages in Bangladesh: a cluster randomised trial

Abstract

Background Group exercise-based programmes for urinary incontinence appear to be promising low-cost interventions for women in developing countries, but no evidence exists to support whether they could be implemented or effective in such populations. We aimed to evaluate whether a group intervention that comprised pelvic floor muscle training, mobility exercises, and bladder education would be more effective than education alone, and report changes between villages (ie, clusters) rather than between individual participants. Methods In this cluster randomised trial, we recruited women from 16 pairs of villages in Bangladesh, with each pair comprising similar villages from the same sub-district. Women aged 60-75 years were interviewed to establish eligibility. Women were eligible if they had current urinary incontinence, and were excluded if they had a third degree or higher uterine prolapse, if they were unable to walk or stand without help, or if they had insufficient intellectual capacity to understand questions and follow instructions. The villages were randomly assigned within each pair to either exercise plus education or education-only intervention by use of a random number generator from a fixed seed. Women were excluded after consenting if they lived too far from the centre of the village. The exercise intervention was a physiotherapist-led group exercise class that was held twice weekly for 12 weeks, with home exercises between classes and to 24 weeks. Both groups received bladder-health education. Participants were followed up for 24 weeks. A 3-day continence record was collected at recruitment and every 4 weeks up until 24 weeks. This record involved the participant tying a knot in ribbons worn under the clothing each time they had an episode of urinary leakage. The primary outcome was change in number of knots (recorded leakage episodes) from recruitment to 24 weeks. Safety was assessed in all participants in the exercise intervention group. The trial is registered at ClinicalTrials.gov, number NCT02453100.

Promoting and maintaining urinary continence: Follow‐up from a cluster‐randomized trial of elderly village women in Bangladesh

“…In a systematic review of PFMT in women with stress incontinence, long‐term adherence (≥1 year) was found to vary from 10% to 70% 7 . In line with recommendations for more research on long‐term effectiveness, 1,6 the present study reports on factors associated with continence 12 months after the end of a cluster‐randomized trial (CRT) of PFMT and mobility group‐based exercises, led by physiotherapists with village women aged 60 to 75 years in Bangladesh 8 . Furthermore, it describes an extension of the program using exercise groups led by village paramedics who provide front‐line health care within Gonoshasthaya Kendra (GK), the Bangladeshi nongovernmental organization in which the CTR was conducted.…”

“…Diokno et al 20 showed a modest improvement in continence with a single session of group education. As in the earlier trial, 8 the primary outcome measure for the follow‐up study entailed the participant tying a knot in a ribbon each time she leaked urine. A woman who did not comply with this and tied no knots would be classified as the continent.…”

“…This paper arises from a CRT 8 carried out in rural villages in Bangladesh, under the care of GK, an NGO providing health care to some 600 villages. In Bangladesh, villagers have access at no cost to community clinics provided by the Bangladesh government but resources are too few to meet the need.…”

“…Twenty villages were chosen for the roll‐out. Female village paramedics, recruited and trained by GK to provide health and reproductive care, were trained to lead a 6‐month group exercise intervention, using the exercise protocol developed for the CRT (see online appendix 8 ). The training was carried out over 4 days in September 2018, conducted by Bangladeshi‐trained physiotherapists who had led groups in the CRT.…”

“…The paramedic then paid a home visit to complete a screening questionnaire which included questions 2, 3, and 4 from the six‐item urinary distress questionnaire 11 : this was the procedure used in the CRT. A woman who replied positively to any of these questions was eligible to be included in the group exercise class if she did not meet the exclusion criteria for the CRT (namely she had sufficient mobility and understanding and was not known to have a third degree or greater uterine prolapse) 8 . This roll‐out was a practice implementation rather than a research study and differed importantly from the intervention in the CRT in three ways.…”