Towards a more scientific approach to measuring barriers to seeking health care in women with fecal incontinence: the BCABL questionnaire

Abstract

Although barriers to seeking care in women with fecal incontinence (FI) have been identified consistently in the literature [1][2][3][4], research on this topic is inadequate for methodological reasons. Most importantly, there is currently no validated technique for reproducible measurement of these barriers. Furthermore, barriers to seeking incontinence care, whether urinary or fecal, are influenced by confounding anthropological and societal variables including ethnicity, culture, geopolitical orientation, indigenous psychology, personality and the individual's understanding of health, experience of health and illness, and health services utilization [5,6]. Hence, most of the available qualitative research data on care seeking, that is primarily based on thematic or deductive analysis of patient narratives, is not able to demonstrate the full impact of each care barrier with a significant overlap between barriers [4]. Another major problem is the assumption that care seeking is primarily dependent on the severity of FI without further critical evaluation of this observation or factor analysis to determine the contribution of other condition-specific quality of life measures [2]. In fact, mild FI is sometimes a greater problem for affected women than severe incontinence [7]. Finally, survey instruments to assess the epidemiology of FI are limited by differences in definition (incontinence to feces versus incontinence to feces and flatus, or incontinence only versus incontinence and fecal soiling), onset (over the last month or last year), severity (whether or not a social or hygienic problem) and frequency (daily or episodic) [2,7].It is obvious that we lack a validated and structured method to measure factors interfering with care seeking in women with FI and that we need a robust scientific approach to the development of a new research tool. Brown et al. elegantly review the subject in this issue of the International Urogynecology Journal [8]. The authors discuss the strengths and weaknesses of current methods evaluating barriers to seeking care in women with FI or Baccidental bowl leakage^. They test the validity of a questionnaire designed to measure 12 barriers to seeking care for FI identified by the group through previous focus group discussions with 29 women and cognitive interviews with 10 women with FI. A final questionnaire was constructed comprising 42 potential items about condition severity, patient activation (knowledge level, skills and coping), prior care seeking and demographics, and was administered via an electronic survey to a cohort of women with FI who were already enrolled as consumers in a health industry database. Based on an a priori calculation of the study power, a convenience sample of 427 women completed the questionnaire at baseline, and 182 of these women repeated the test after 2 weeks. The psychometric properties were examined using rigorous statistical methodology. Test-retest reliability and criterion validity were excellent for all items with a final questionnaire structure...