In this secondary analysis of baseline data from three RCTs, we found that QoL was reduced in women that sought care for UI through e-health, and that the severity of leakage had the greatest impact on QoL. The type of UI also affected QoL, but not to the same extent. The absence of a university education and the presence of comorbidity both had negative impacts on the QoL, but age alone had no significant effect.
In this study, the mean ICIQ-UI SF score for all included women was 10.9, which corresponded to moderate leakage , and the mean ICIQ-LUTSqol score was 34.9. Slightly lower scores were found in a survey conducted in 2015 in the UK, France, Germany, and the USA. That study included 1203 women 45–60 years old with unspecified subtypes of UI that completed a questionnaire via the internet. Those results showed moderate leakage (overall ICIQ-UI SF score 8.7) and a mean ICIQ-LUTSqol score of 32.8 . Another RCT from urban parts of Malaysia studied women that sought care for UI through conventional avenues. Their baseline data on 120 women with SUI that received non-surgical 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 UI severity, with a slightly higher impact on QoL, compared to our study population . Another RCT, conducted in the UK, included 600 women that received new clinical diagnoses of SUI or MUI in centres that provided incontinence care. Compared to our study, they found a slightly higher mean ICIQ-UI SF score (12.4), but within the moderate severity range, and a somewhat higher mean ICIQ-LUTSqol score (42.9) . Thus, although the level of severity was moderate in all these studies, the impact on QoL in our study population was slightly higher, compared to women in the internet survey, but slightly lower, compared to women that sought care for UI through conventional avenues. These results suggested that by the use of e-health, the eContinence project might have reached a new group of women that perhaps would not have sought UI care through conventional avenues, but had UI that clearly impacted their QoL.
Overall, among the participants in our study, UI had the highest impact on the QoL domains of physical limitations, role limitations (including household tasks and daily activities), and emotions. The women with UUI/MUI had more severe leakage and experienced a higher impact on social limitations, emotions, role limitations, and sleep, than the women with SUI. We have found no previous study that compared SUI to UUI/MUI and considered the ICIQ-LUTSqol domains. However, in a study by Abrams et al. (2015), the QoL domains were compared among participants divided into severity categories. They found that women with more severe UI experienced the greatest impact on QoL in the domains of social limitations and emotions .
Our regression analysis showed that, in our population, UI severity had the greatest impact on QoL. This finding was expected, based on previous studies. A large study conducted in 2007 on women that sought UI care through avenues other than e-health showed that severity was the single most important predictor of QoL among women with UI, regardless of the type of UI . Another study conducted in 2018 explored relationships between mental health, sleep, and physical function and the UI type and severity. They showed that, among 510 women that sought help for UI symptoms, the severity, rather than the type of UI, had the greatest impact on anxiety, depression, and stress .
At first sight, our study results might appear to indicate that the UI type was the most important factor, based on the adjusted beta of 2.5; in contrast, UI severity only showed an adjusted beta of 1.5. However, it should be borne in mind that the UI type was a dichotomous variable; thus, there was only one step of comparison. In contrast, UI severity (according to ICIQ-UI SF) was a continuous variable that reflected many more steps of comparison; thus, UI severity had a much greater potential impact on the ICIQ-LUTSqol score.
To our knowledge, this study was the first to evaluate condition-specific QoL specifically in women with UI that sought care through e-health. One strength 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 thus, they represented a clinically relevant group. Moreover, the research group conducting the studies had solid clinical competence, and the diagnoses of SUI and UUI/MUI were well established. In the analyses, we were able to include many variables that could potentially affect QoL, and we worked in close collaboration with a statistician. For easier comparison with other studies, we used validated, recommended questionnaires to measure UI severity and condition-specific QoL [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 versus 373 women), and this might have affected the results. Additionally, 80.6% of participating women had a university education, compared to 47% of all Swedish women aged 25–64 years in 2015 . Thus, the results from our population might not be generalizable to all women with UI in need of treatment. However, to date, e-health is mostly used by individuals with a higher education ; therefore, our population might have been representative of women that seek care through ehealth. Another limitation was that our data were restricted to data collected in previous RCTs. Thus, other factors that we did not investigate might also have influenced the QoL of our participants. For example, psychological illness might have an impact on condition-specific QoL, but questions about anxiety and depression were only included in the baseline questionnaires in two of the three RCTs; thus, they could not be further explored. Moreover, we might have underestimated the presence of some comorbidities (e.g., endocrinological 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 wording in the questions regarding prescribed medications and concurrent diseases. RCTs one and three had comparable data on prescription drugs and corresponding diseases; therefore, we used prescribed medications as a marker of comorbidity. Finally, eight years had passed from the start of the first RCT to the start of the third RCT. During that time period, the fast-growing field of e-health had developed rapidly, and this may have affected the results.
Clinical implications and future perspectives
Our study showed that women with UUI/MUI and SUI that sought care through e-health experienced an impact on condition-specific QoL, mainly related to UI severity, rather than UI type. UI treatment can decrease symptom severity, and therefore, improve QoL; thus, it is important to provide effective, easily accessible treatments to everyone with UI, regardless of the subtype. Individual assessments of patients with UI are also needed, with careful assessments of the severity of leakage, to provide adequate help.
A considerable amount of research has been performed to investigate QoL among women with UI, in general, but not specifically among women that sought medical care for UI through e-health. Our study contributes new knowledge about this group of women, which may help to develop and improve treatments through e-health. Currently, the app, Tät® (RCT two) is freely available at the App Store and Google Play in several languages, including Swedish, English, Arabic, and Spanish. This app is intended for individuals that want to self-manage SUI, but it may also be useful as a complement to other treatments. We also aim to release the Tät ®II (RCT three) app to the public in the future. Treatments based on apps will not suit all women with UI, but they might contribute to new, cost-effective ways to help many women, and they may lead to an improvement in their QoL. Easily accessible self-management treatment programmes, through the internet or mobile applications, may facilitate access to medical care for this group of patients, and at the same time, relieve pressure on primary care.
Future research should investigate factors that separate this study population of e-health users from individuals that seek care through conventional avenues.