SELF-CONCEPT IN ELDERLY FEMALES: THE IMPACT OF …€¦ · copyrighted materials were deleted, a...

SELF-CONCEPT IN ELDERLY FEMALES:THE IMPACT OF URINARY INCONTINENCE

Item Type text; Thesis-Reproduction (electronic)

Authors Simons, Jacquelyn

Publisher The University of Arizona.

Rights Copyright © is held by the author. Digital access to this materialis made possible by the University Libraries, University of Arizona.Further transmission, reproduction or presentation (such aspublic display or performance) of protected items is prohibitedexcept with permission of the author.

Download date 24/03/2021 02:40:53

Link to Item http://hdl.handle.net/10150/291272

http://hdl.handle.net/10150/291272

INFORMATION TO USERS

This reproduction was made from a copy of a document sent to us for microfilming. While the most advanced technology has been used to photograph and reproduce this document, the quality of the reproduction is heavily dependent upon the quality of the material submitted.

The following explanation of techniques is provided to help clarify markings or notations which may appear on this reproduction.

1.The sign or "target" for pages apparently lacking from the document photographed is "Missing Page(s)". If it was possible to obtain the missing page(s) or section, they are spliced into the film along with adjacent pages. This may have necessitated cutting through an image and duplicating adjacent pages to assure complete continuity.

2. When an image on the film is obliterated with a round black mark, it is an indication of either blurred copy because of movement during exposure, duplicate copy, or copyrighted materials that should not have been filmed. For blurred pages, a good image of the page can be found in the adjacent frame. If copyrighted materials were deleted, a target note will appear listing the pages in the adjacent frame.

3. When a map, drawing or chart, etc., is part of the material being photographed, a definite method of "sectioning" the material has been followed. It is customary to begin filming at the upper left hand corner of a large sheet and to continue from left to right in equal sections with small overlaps. If necessary, sectioning is continued again—beginning below the first row and continuing on until complete.

4. For illustrations that cannot be satisfactorily reproduced by xerographic means, photographic prints can be purchased at additional cost and inserted into your xerographic copy. These prints are available upon request from the Dissertations Customer Services Department.

5. Some pages in any document may have indistinct print. In all cases the best available copy has been filmed.

University Micrdffilms

International 300 N. Zeeb Road Ann Arbor, Ml 48106

1320514

SIMONS, JACQUELYN CARROLL

SELF-CONCEPT IN ELDERLY FEMALES: THE IMPACT OF URINARY INCONTINENCE

THE UNIVERSITY OF ARIZONA M.S. 1983

University Microfilms

International 300 N. Zeeb Road, Ann Arbor. MI 48106

SELF-CONCEPT IN ELDERLY FEMALES:

THE IMPACT OF URINARY INCONTINENCE

by

Jacquelyn Simons

A Thesis Submitted to the Faculty of the

COLLEGE OF NURSING

In Partial Fulfillment of the Requirements For the Degree of

MASTER OF SCIENCE

In the Graduate-College

THE UNIVERSITY OF ARIZONA

19 8 3

STATEMENT BY AUTHOR

This thesis has been submitted in partial fulfillment of the requirements for an advanced degree at The University of Arizona and is deposited in the University Library to be made available to borrowers under rules of the Library.

Brief quotations from this thesis are allowable without special permission, provided that accurate acknowledgment of source is made. Requests for permission for extended quotation from or reproduction of this manuscript in whole or in part may be granted by the copyright holder.

SIGNED:

APPROVAL BY THESIS DIRECTOR

This thesis has been approved on the date shown below:

V. sjl. /•!#.=, JESSIE V. PERGRIN (5 Date

Associate Professor of Nursing

This thesis is lovingly dedicated to my husband, Richard, for his patience and continued support.

i i i

ACKNOWLEDGMENTS

The author wishes to express appreciation to all

those involved in the successful completion of this project.

The author extends special thanks to the members

of her thesis committee for their time and support. My

deepest appreciation to Jessie V. Pergrin, Ph.D., R.N.,

chairperson, for her encouragement and diligent effort in

assisting me. My thanks to Evelyn M. DeWalt, R.N., M.S.N,

and Lois E. Prosser, R.N., M.S.N, for their valuable input.

A very special note of thanks goes to Donna

Browning for her assistance in the preparation of the

manuscri pt.

i v

TABLE OF CONTENTS

Page

LIST OF TABLES

ABSTRACT

CHAPTER

I. INTRODUCTION 1

Statement of the Problem 2 Significance of the Problem 3 Purpose . 5 Conceptual Framework 6 Definition of Terms 9 Limitations 9

II. REVIEW OF THE LITERATURE 10 Bladder Function and Urination 10

Aging Changes in Bladder Function 12

Urinary Incontinence 14 Description and Classification 14 Causative Factors 16 Evaluation and Management 19 Scope of the Problem 20

Self-Concept 23 Self-Concept and Aging 24

Summary 27

III. METHODOLOGY 28 Research Design 28 Population Sample 28 Protection of Human Subjects 29 Study Setting 29 Data Collection Method 29 Measurement Tool 30 Pilot Test 32 Data Analysis 32

v

v i

CHAPTER Page

IV. PRESENTATION AND ANALYSIS OF DATA 33 Characteristics of the Sample 33

Demographic Characteristics 33 Health Characteristics 37

Rosenberg Self-Esteem Scale 39 Urinary Incontinence 39 Computations using t-test Ratios 48 Pearson Correlation Coefficients 49

V. DISCUSSION OF FINDINGS, CONCLUSIONS AND RECOMMENDATIONS 51

Discussion of Findings 51 Findings Related to the

Conceptual Framework 52 Findings Related to

Previous Studies 53 Conclusions 56 Recommendations 58

APPENDIX A: HUMAN SUBJECTS COMMITTEE CONSENT FORM 59

APPENDIX B: SUBJECT CONSENT FORM 61

APPENDIX C: QUESTIONNAIRE 63

REFERENCES 71

LIST OF TABLES

TABLE Page

1. Frequency Distribution of Subjects by Age ' 34

2. Frequency Distribution of Subjects by Marital Status 35

3. Frequency Distribution of Subjects by Living Status 36

4. Frequency Distribution of Subjects by Health Status 38

5. Frequency Distribution of Subjects for Summed Scores of the Rosenberg Self-Esteem Scale , 40

6. Number and Percent of Subjects by Age Group Reporting Urinary Incontinence Compared to the Total Sample Population 42

7. Number and Percent of Pregnancies in Subjects Reporting Urinary Incontinence 43

8. Frequency Distribution by Health Status of Subjects Reporting Urinary Incontinence 44

9. The Onset and Frequency of Urinary Incontinence Among Subjects Identified as Being Incontinent 45

10. Frequency Distribution of Physicians' Responses to Subjects Incontinent of Urine 47

11. Pearson Correlation Coefficients and Significance for Marital Status and Living Status to Self-Esteem 50

vi i

ABSTRACT

A descriptive study was conducted to identify

urinary incontinence and self-concept in elderly females

living in a community setting. This study was designed

to determine the relationship between the problem of

urinary incontinence and self-esteem as a measure of the

concept of self.

Forty-three subjects, aged 60 to 83 years, partici

pated in this study by completing a questionnaire which

focused on demographic data, self-concept, and descriptive

data on urinary incontinence. The Rosenberg Self-Esteem

Scale (1965) was incorporated in the questionnaire to measure

self-concept.

The data revealed a positive correlation between

self-esteem and the variables of marital status (r = .3073)

and living status (r = .3336). Urinary incontinence was

reported by 51 percent of the sample population. No

correlation was found between the problem of urinary inconti

nence and subjects reported self-esteem.

v i i i

CHAPTER I

INTRODUCTION

Urinary incontinence is a major problem in the

elderly. According to the National Institute on Aging

(NIA), urinary incontinence affects at least one in ten

persons over the age of 65. There are more than 20 million

people over the age of 65 in the United States today and it

is estimated that more than 30 million will be over age 65

by the year 2000. These statistics indicate that increased

attention will need to be given to the problem of urinary

incontinence. Few studies are related to the prevalence and

incidence of urinary incontinence in the United States.

Most of the literature on urinary incontinence comes from

Great Britain. A review of the literature reveals that

urinary incontinence is not only reversible in many selected

cases but also implies that urinary incontinence is a

"hidden symptom."

A survey of health-related problems in the elderly

was conducted in a retirement community in Arizona in

ihe spring of 1982 which included questions regarding

urinary incontinence. One of the volunteers who was to

collect data for the study refused to participate because

of these questions. If nonprofessionals find it

1

2

difficult to discuss incontinence, then professionals need

to help them.

The subject of urinary incontinence is purported to

be a sensitive one and the sensitivity of the subject.may

be the factor that makes urinary incontinence a "hidden

symptom." That we live in a society that harbors negative

attitudes toward aging and the elderly has been discussed

in the literature and in the media. If urinary incontinence

is considered an inevitable and negative aspect of aging by

the aged, this may be the factor that makes urinary incon

tinence the "hidden symptom."

How do people feel about themselves when they are

incontinent? It is assumed that they are embarrassed and

have a low self-esteem. There is a need to determine if,

in fact, ones' self-concept is affected by urinary

incontinence. This determination can only be made by

self-reports of the incontinent individual.

Statement of the Problem

The problem of urinary incontinence is a major one

for the elderly. This study will investigate the following

questions:

1. What proportion of elderly females in a selected

population admit to having urinary incontinence?

2. What proportion of elderly females in a selected

3

population have reported urinary incontinence

to a health care provider?

3. Will elderly females who respond they have

urinary incontinence have a lower self-concept

than elderly females who respond they do not

have urinary incontinence?

Significance of the Problem

Urinary incontinence is a significant problem for the

elderly. Urinary incontinence is not only a problem for the

elderly but also for their families, friends and significant

others. Surveys have estimated the prevalence of urinary

incontinence in persons aged 60 and older to b.e between 10 and

15 percent in the elderly residing in the community and 50 to

60 percent in the elderly residing in institutions (Freed,

1982). Urinary incontinence is not a normal consequence of

aging but a distressing symptom that cart make the difference

between dependence and independence. The National Institute

on Aging (NIA, 1980) has identified urinary incontinence as

a major cause for institutionalization. There are more than

22 million aged persons living in the United States today

and approximately five percent of them live in institutions.

It is estimated that by 2030 there will be 33 million people

aged 65 and older (Neuhaus, 1982). A serious effort should be

made to assess the condition of urinary incontinence so that

4

causative factors and appropriate treatments can be

identified as soon as possible.

A study of a condition with such widespread effects

can help by defining the size of the problem. The study of

urinary incontinence in women is important because urinary

incontinence in women is more common than in men. Anatomical

differences, pregnancies and gynecologic surgeries place

women at higher risk for urinary incontinence (Freed, 1982).

This study is paramount because of the need to study

the impact of urinary incontinence on the concept of self.

The literature suggests that urinary incontinence has a

negative impact on self-esteem. Sutherland (1976, p. 62)

stated, "Urinary incontinence may have devastating effects

on the view of self."

That urinary incontinence has an impact on social

acceptability was reported by Cape (1980), Freed (1982) and

Sutherland (1976). The condition of being incontinent is

embarrassing and the shame and social rejection that results

can lead to self-neglect. The significance of this study to

nursing is because it opens up lines of communication on a

subject that is embarrassing to the elderly. Isaacs (1978,

p. 146) stated, "Opportunities must be created for the

elderly to express to a sympathetic member of the health

team any matter relating to their physical, social, or

mental well-being."

5

To summarize, this study adds to the dearth of

information on the incidence of urinary incontinence among

elderly females residing in the community. It opens lines

of communication on the subject or urinary incontinence

with health care providers. It provides further study in

the area of self-concept and aging. The concept of self has

been extensively studied in various young populations,

however, the available literature on self-concept in the

elderly is limited. Only the effect of institutionalization

on the self-concept of the elderly has been widely

researched. Lee (1976) reported the need to study the self-

concept of the non-ir.stitutional ized elderly.

Finally, Newman's (1962) statement succinctly

summarizes the significance of this problem when he said,

"A patch of urine cannot be readily explained...its treatment

has proved beyond most of us; and as to its significance, it

will make the difference between social acceptance and

rejection with all that involves in prolonged hospital care

and expense." This statement was written 21 years ago and

still summarizes the problem of urinary incontinence today.

Purpose

The purpose of this study is threefold; (1) to

identify urinary incontinence in elderly females residing

in a selected community setting, (2) to identify hidden

6

urinary incontinence in the population under study, and

(3) to identify the self-concept of these elderly females.

Conceptual Framework

The conceptual framework of this study was based on

two major concepts: (1) urinary incontinence and (2)

concept of self. The relationship between these two concepts

was investigated.

Urinary incontinence is a major health problem in

elderly women. Urinary incontinence can restrict social

activity and can lead to social isolation depending on the

severity of the problem. For the purpose of this study,

urinary incontinence was defined as any leakage of urine,

regardless of frequency, that was present during the time of

this study. Sub-categories of urinary incontinence are

(1) hidden incontinence, and (2) revealed incontinence.

These categories are in keeping with the review of the

literature which suggests that urinary incontinence is a

hidden symptom (Cape, 1980; Thomas, et al., 1980; Wells,

1981).

Self-concept depends on the way an individual sees

himself or herself. Self-esteem is fundamental to the

individual's concept of self. Several authors have

differentiated between self-concept and self-esteem by

reporting that self-esteem can be measured as positive or

7

negative self-evaluation, whereas self-concept is a broad

descriptive term which cannot be evaluated as such (Wylie,

1974; George and Bearon, 1980; Hunter, et al., 1982).

The evaluation or personal judgment of being worthy

in the concept of self is a measure of self-esteem

(Coopersmith, 1967). Self-acceptance and self-rejection are

defined as aspects of the self-concept by Bloom (1960).

Self-esteem was defined as self-acceptance or a feeling of

self-worth by Rosenberg (1965). The categories of self-

acceptance and self-rejection are used in the conceptual

framework of this study. The concept of self has been

studied extensively, however, few studies are of the elderly

(Wylie, 1974; Lee, 1976). Studies of self-concept reviewed

by Busse (1976) indicated that self-concept varies with

aging due to the fact that as people pass through life they

become increasingly different rather than similar.

Generally, self-perceptions of elderly persons are

vi ewed, in part, as responses to physiological changes which

occur with age and yet little is known about the influence

these changes have on the elderly person's concept of self

(Peters, 1971). Even now, more than a decade later, this

finding remains true for urinary incontinence. No studies

dealing with the elderly person's perception of urinary

incontinence and the impact it has on the image of self were

found in the review of the literature.

8

Self-views expressed by the elderly correspond

closely with the stereotyped views of aging by society

(Butler, 1979; Buss, 1980). Where the social stereotyping

of a group is stigmatizing, the devaluation of the self can

be manifested (Wright, 1960; Hunt, 1966; Preston, 1979).

The significance of urinary incontinence as a potential

stigma label is explained by Sutherland (1976, p. 64) in his

statement, "The first automatic reaction to incontinence is

one of disgust and revulsion."

In this study, it was hypothesized that the impact

of urinary incontinence and its potentially stigmatizing

label resuits in 1ower self-esteem in certain subjects under

study. This lowered self-esteem results in hiding the

symptom of urinary incontinence.

Demmerle and Bartol (1980) suggested that people with

clear insight are affected by decreased self-esteem and

embarrassment when they are incontinent. This concept was

supported by Brink (1980) who reported that the elderly

person suffers both embarrassment and self-reproach. Brink

(1980) also reported that many nurses consider incontinence

to be inevitable in the elderly and the reluctance of many

elderly to discuss incontinence is a reflection of that

attitude. The negative attitudes of health care providers

was reported as the major problem of urinary incontinence in

the elderly by Wells (1980).

9

How does the elderly female feel about urinary

incontinence? Does urinary incontinence have an impact on

her concept of self and lower her self-esteem? This study

was intended to identify the relationship between the

perceived problem of urinary incontinence in the elderly

female and her concept of self as measured by self-esteem.

Definition of Terms

1. Urinary incontinence - any bladder leakage regardless of

frequency that exists at the time of the study.

2. Hidden incontinence - urinary incontinence that has not

been reported to a health care provider.

3. Revealed incontinence - urinary incontinence that has

been reported to a health care provider.

4. Health care provider - a nurse, physician or other person

specified by subjects in the study.

5. Self-concept - the elderly female's view of herself as

measured by the Rosenberg Self-Esteem Scale (1965).

6. Self-esteem - self-acceptance, as measured by the

Rosenberg Self-Esteem Scale (1965).

Limitations

The sensitivity of the topic may limit the responses

of the participants in the study.

CHAPTER II

REVIEW OF THE LITERATURE

The review of the literature focused on urinary

incontinence, self-concept, and self-concept in aging. The

review includes the process of urination, bladder function

changes in aging and factors relevant to the problem of

urinary incontinence.

Bladder Function and Urination

The bladder is a hollow chamber containing thick

layers of smooth muscle called the detrusor muscle. In

addition to this smooth muscle the neck of the bladder

contains other smooth muscles. Both the body and the neck

of the bladder are innervated by sympathetic and para

sympathetic nerves. The bladder acts as a reservoir for

the urine that is conveyed from the kidney. The first desi

to void is noted with about 250 ml. of urine. An increase

in the amount of urine to 700 ml. will cause pain and

probably loss of control (Selkurt, 1982).

As the bladder distends, signals are sent to the

spinal cord and cerebral nerves via the autonomic nervous

system. The detrusor muscle is innervated by acetylcholine

mediated parasympathetic nerves which cause contraction.

1 0

At the same time, the bladder neck and the urethral

sphincters are innervated by sympathetic and somatic nerves

which relax these muscles. This simultaneous contraction

and relaxation of muscles results in urination. When the

muscles of the bladder wall contract, the walls squeeze

inward, thus creating the sensation of pressure from urine

in the bladder. Proprioceptors in the detrusor muscle

respond to the pressure and also to the muscle contraction

(Selkurt, 1982).

The emptying of the bladder is usually under

voluntary control. The basic reflexes occur at the level of

the sacral spinal cord influenced by centers of the higher

brain (mid-brain and cerebral cortex). Voluntary urination

is initiated by learning to control this complex set of

neural pathways (Vander, et al., 1980). While this is a

complex neuromuscular mechanism it can be simply stated that

urination will occur when the pressure in the bladder is

greater than the resistance of the urethra (Freed, 1982).

Urinary continence is maintained when the intra

vesical pressure remains lower than the urethral pressure

except with voluntary urination (Selkurt, 1982). Urinary

continence depends on two factors: first, the ability of

the sphincter to resist sudden increases in intraabdominal

pressure, and secondly, bladder contraction inhibition. It

is common in older aged persons for incontinence to result

from a combination of both of these factors (Warrell, 1980).

Aging Changes in Bladder Function

There is little known information regarding the

effect of aging on the smooth muscle cells of the bladder.

The connective tissue changes and cross-linkage changes

seen in elastic tissue may be contributors to bladder

function changes found in the aged (Brocklehurst, 1978).

Cystometrographic examinations show several

abnormal features of the bladder in old age. The aging

bladder has both a decrease in bladder capacity and an

increase in residual urine. A residual urine volume

greater than 25 ml. is clinically significant in adults

since the urine provides a medium for bacterial growth

(Freedman, 1975). In addition to the decrease in bladder

capacity and the increase in residual urine there may be

uninhibited bladder contractions which cause urgent

urination. The uninhibited neuropathic bladder is generally

associated with disease processes but characteristics have

been found in continent elderly females without disease

process (Brocklehurst, 1979). Elderly people with

uninhibited bladder contractions may have no warning of the

need to void. The cause of this hypertonic bladder is not

known but may be related to uninhibited detrusor muscle

contractions acting against a tense bladder outlet. The

hypertonic bladder is commonly seen in elderly women with a

weakened urethral sphincter (Freed, 1982).

1 3

Cystometrographic examinations have also revealed

that bladder outlet weakness is associated with a shortened

urethra and a low urethral closing pressure. Urethral

profi1e .measurements have demonstrated that even in normal

aging the urethral closing pressure is reduced and the

length of the urethra is shortened in females (Brocklehurst,

1979).

Major differences were found in bladder function

between younger and older adults in an early study by

Brocklehurst and Dilland (1966). Cystometrograms were

performed on 40 continent and 100 incontinent women aged 65

and older. The findings of this study revealed: (1) bladder

capacity decreased with age without any anatomical change;

(2) the volume of residual urine and the frequency of

urination both increased; and (3) the sensation of fullness

and the need to void varied in the older group. In younger

persons, the sensation to void occurs when the bladder is

half full while in the aged the bladder may fill to capacity

before the desire to void is noted. Indeed, in the aged,

there may be no sensation at all. No statistical data was

reported (Brocklehurst and Dilland, 1966).

A decrease in the efficiency of the kidney nephrons

also contributes to bladder function changes in the elderly.

This decrease in nephron efficiency results in continuous

urine output both day and night. This may result in bladder

distention during hours of sleep. The resuiting nocturia,

1 4

which is common in the elderly, may precipitate urinary

incontinence (Forbes, 1981).

Urinary Incontinence

Urinary incontinence is one of the most distressing

symptoms experienced by the elderly. It can restrict the

activities of daily living, result in social rejection,

contribute to institutionalization and place the individual

who is incontinent at risk for medical complications such as

decubitus ulcer and infections (Willington, 1976; Brockle-

hurst, 1979; NIA, 1980; Freed, 1982; and Milne, 1982).

Descript ions and Classifications

Burnside (1981, p. 521) states that "the term

incontinence is a non-specific word which does not impart

any relative descriptive information about a client's urine

problem." Descriptive information related to the subject

of urinary incontinence has long been attempted by many

authors.

Sheldon (1948) described incontinence as "dribbling"

in a random sample survey of 583 women aged 60 and older

living in the community. He concluded that 5.9 percent of

women aged 60 to.65 and 27.2 percent of women aged 85 and

older experienced "dribbling." This description was not

clear in that times and amounts were not specified.

1 5

Brocklehurst, et al. (1971) defined urinary incon

tinence as being present when "yes" was the answer to the

question, "Does urine ever come away unexpectedly and with

out you being able to stop it and you get wet?". Milne

(1982) supported this concept in declaring that all patients

with urinary incontinence regardless of degree or amount

would fit this definition.

Thomas, et al. (1980) described urinary incontinence

as "regular" and "occasional." "Regular" urinary inconti

nence was defined as leakage of urine at inappropriate times

and places two or more times a month. "Occasional"

incontinence was defined as incontinence that occurred less

than twice a month.

The major descriptions or classifications of urinary

incontinence reported at the NIA (1980) workshop were:

(1) overflow incontinence, (2) stress incontinence, (3)

functional incontinence, and (4) transient incontinence.

Overflow incontinence is associated with detrusor instability,

the bladder becomes distended and incontinence results from

overflow. Stress incontinence is associated with sphincter

insufficiency, the intravesical pressure rises above

urethral pressure and incontinence results. Functional

incontinence is incontinence due to physiological change in

the absence of physiological abnormalities. For example,

confinement to bed may impair the sensation of bladder

1 6

filling and sphincter contraction. The definition of

transient incontinence is urinary incontinence associated

with acute medical conditions (Hadley and Schneider, 1980).

Stress incontinence is the most common classification

of urinary incontinence in elderly women and accounts for

50 percent of urinary incontinence found in women aged 65

and older (Freed, 1982). Leakage of urine-with coughing,

sneezing, laughing and exercise is the symptomatology

described in stres\s incontinence (Bates, 1979 ; B rock! ehurst,

1979; Ouslander, 1981; Freed, 1982). The exact function of

the sympathetic nervous system is not known and stress

incontinence in women may be due to detrusor instability

(Lapides, 1982;.James, 1979).

Causative Factors

Loss of continence can result from neurologic and

neuromuscular dysfunction, obstructions or injury to the

urethra, urinary tract infections and many disease

processes. The diminishing physical functions in the

elderly such as impaired vision and mobility coupled with

the increased incidence of chronic illnesses such as

arthritis and diabetes places the elderly at high risk for

urinary incontinence (Freed, 1982).

Neurologic conditions are significant causative

factors for urinary incontinence. The cerebral vascular

1 7

accident (CVA) is one of the most common neurologic condi

tions in the elderly. The elderly CVA patient is often

incontinent which may be related to the dysphasia that

occurs. The inability to communicate the need to urinate

can result in urinary incontinence. Spinal cord lesions or

trauma resulting in neuromuscular dysfunction are also

common causes of urinary incontinence. Acute spinal cord

injuries often cause retention of urine. The elderly

patient does not interpret the subtle symptoms of bladder

function and overflow incontinence results. Other neuro

logical disorders resulting in urinary incontinence are

multiple sclerosis, parkinsonism, epilepsy, and head injury

(Freed, 1982; Brock!ehurst, 1979).

Bladder outlet obstructions such as fecal impactions

restrict urinary output and result in overflow urinary

incontinence. Trauma to the urethra with resultant sphincter

insufficiency has also been cited as a causative factor for

urinary incontinence (Brink, 1980; Cape, 1980; Judson, et al.

1981).

Urinary tract infections are common in the elderly

and may be associated with urinary incontinence. The

bacteriuria that results from an infection irritates the

bladder, contractions increase and urinary incontinence

may result (Judson, et al. 1980). The relationship between

bacteriuria and urinary incontinence is not clear. It was

suggested by Cape (1980) that bacteriuria may be the result

of urinary incontinence and not the causative factor. He

reported that elderly people who lie in contact with urine

soaked linens are at risk for ascending urinary tract

infections (Cape, 1980). Brocklehurst (1979) reported the

prevalence of urinary tract infections in the elderly varies

according to their environment and is more common in

institutionalized populations. Patients in institutions are

less mobile which may be the causative factor.

Cape, et al. (1973) studied urine samples of 40

women aged 60 and older at the time of admission to the

hospital. Bacteriuria was present in all of these subjects

and 78 percent stated they were incontinent of urine.

Brocklehurst (1968) found bacteriuria in the urine sample

of 337 women ranging in age from 65 to 91 years. The sample

population was obtained in a community survey and only 13

percent of these subjects stated they were incontinent of

urine.

Disease processes of any type that require confine

ment to bed deprive the elderly of control over their

environment. This deprivation may precipitate an acute

confusional state. Whether the disease be CVA or any

organic brain syndrome, diseases of the central nervous

system and the resultant confusion that occurs are listed

by many authors as a major causative factor for urinary

incontinence (Willington, 1976; Brocklehurst, 1979; Milne,

1982).

Evaluation and Management

Until recently the evaluation and management of

urinary incontinence was difficult. For years women who

complained of urinary incontinence were treated with a

surgical bladder suspension. These operations were not

always successful. Cystometrographic examinations are

changing this with comprehensive reports of the urodynamics

of the lower urinary tract (Pierson, 1981).

Urodynamic studies are now widely adopted as a

diagnostic aid for patients with urinary incontinence. To

simplify comparison of results by investigators using

urodynamic methods, a standardization of terminology was

proposed by the International Continence Society (Bates, et

al. 1979).

The differential diagnoses that are made using

urodynamic studies result in choosing proper management

methods. Stress incontinence can be treated successfully

with surgical intervention. Cardoza and Stanton (1980),

in a 24 month follow-up study of 100 women diagnosed with

stress incontinence, reported an 86 percent cure rate with

surgical treatment. Detrusor instability responds to

anticholinergic drugs. According to Hodgkinson (1982),

2 0

approximately 50 percent of the cases of detrusor instability

incontinence can be treated successfully with the use of

these drugs.

Various articles have suggested that urinary inconti

nence is reversible. Bladder retraining with fluid

restrictions and established time schedules for voiding was

suggested by Maney (1976). Surgical correction for stress

incontinence was successful as reported by Kaufman (1981)

and Witherington (1982). Cholinergic drug therapy to promote

continence was suggested by Brink (1980), Finkbeiner (1980)

and Willington (1980).

Willington (1980) reported that 70 percent of

urinary incontinence in the elderly is curable. According

to the NIA report (1980), success in treating urinary

incontinence was limited by a lack of knowledge about its

exi stence.

Scope of the Problem

The significance of the scope of the problem was

seen in Milne's (1976) review of prevalence studies of

urinary incontinence. None of these studies were conducted

in the United States. Milne reported between 13 and 43

percent of elderly persons in hospitals and between 1.6, and

42 percent of the elderly residing in the community suffer

from urinary incontinence (Milne, 1976).

2 1

Yarnell and St. Leger (1979) conducted a study to

determine the prevalence of urinary incontinence in a random

sample of 27,696 elderly living in a community in South

Wales. Three hundred and ninety six subjects were included

in the sample population and 388 subjects participated in the"

study. This represented a 98 percent response rate. The

prevalence of incontinence in women aged 65 and older was

17 percent and in men it was 11 percent. All subjects were

interviewed and a questionnaire was completed. The findings

revealed that both the prevalence and severity of incontinence

increased with age. Multiple medical problems and hospital

admissions were statistically significant to the problem of

urinary incontinence at the p-<!.001 level.

The prevalence of urinary incontinence in persons

aged 5 and older living in different areas in England was

investigated by Thomas, et al. (1980). The estimated

population of this study area was 45,000 women and 29,000

men aged 65 and older. Subjects were obtained from

physicians and social service agency lists of patients.

Questionnaires were sent to all subjects on these lists.

The findings revealed the prevalence figures of incontinence

were 16 percent in women and 6.9 percent in men aged 65 and

over. Nulliparous women had a lower prevalence than women

with one, two or three pregnancies. The prevalence increased

in women who had four or more babies. Thirty four subjects

2 2

were identified as having moderate incontinence which was

defined in the study as having some restriction of activities.

Twenty four (70.6 percent) of the thirty four subjects were

receiving no help with the problem. This group found their

incontinence to be an embarrassing problem not to be

discussed (Thomas, et al., 1980).

The concealment of incontinence has also been

suggested by other authors. Cape (1980, p. 148) stated,

"Unfortunately, the early intermittent episodes of inconti

nence are likely to be concealed or forgotten, particularly

if the patient lives alone." Wells (1981) reported that the

elderly try to disguise incontinence from health care

providers with such measures as limiting fluid intake and

using incontinence pads.

According to Brink (1980), the incontinent patient

suffers embarrassment, shame, self-reproach and as a result

becomes socially isolated. Passive acceptance of inconti

nence and being unwilling to be interviewed about the subject

was reported by Dobson (1976) and Wells (1980).

Dobson (1976) surveyed 77 people aged 65 and older,

living in the community, who were incontinent and found that

less than 50 percent had received treatment. Those who had

reported incontinence to a health care provider had received

such responses as "learn to live with it." Wells (1981, p.

520) stated that the worst aspect of having an incontinence

problem comes from seeking help for the problem and hearing

2 3

"it's normal for your age." The problem of incontinence may

then become part of one's identity or concept of self.

These studies have suggested that urinary inconti

nence has a negative impact on the self-concept and can

threaten self-esteem. The following section will explore

self-concept.

Self-Concept

Bills, Vance and McLean (1951) defined the concept

of self as both the traits and values that the individual

accepts as a definition of himself. This idea was supported

by.Mason ( 1954), who added that the definition of self would

also include sel f-sati s.facti on as a major factor in self-

judgment.

Branden (1969, p. 103) stated, "There is no value

judgment more important to man than the estimate he passes

on himself." This self-appraisal is needed as a conceptual

framework to view himself when contemplating life and

acti vi ty.

According to Rosen, et al. (1968), one's self-concept

is positively correlated with the image one has of his or

her own body. Fisher and Cleveland (1968) sought to clarify

the relationship between self-concept and body image. They

suggested body image must be included when self-concept means

identity, life role and appearance. Wylie (1974) reported

2 4

that only the conscious level of self-concept can be

measured and tools used to measure body image are subject to

responses influenced by social desirability.

Self-concept was defined as the meanings an indivi

dual has about himself in relation to the world around him

by Brownfain (1952). This concept was supported by Fitts

(1965) who defined self-concept as the frame of reference of

the individual interacting with the world around him.

Self-concept, and Aging

In his development of the Tennessee Self-Concept

Scale, Fitts (1965) studied 626 subjects aged 20 to 68 and

concluded there was an age difference in self-concept. His

findings revealed the less positive self-esteem scores

correlated with the older age group. The scores were not

statistically significant and the effect of age was

negligible.

Trimakas and Nicolay (1974) used the Tennessee Self-

Concept Scale to further study the relationship between age

and self-concept in 162 female subjects residing in a low

income senior housing project. The subjects ranged in age

from 66 to 88 years with a mean age of 73.5. While there

was a steady increase in self-concept among the age groups

from 60 to 69 up to 80 to 89 years, the increase was not

significant. In their study they found no decline of self-

concept in old age.

2 5

Bloom (1961) defined self-acceptance and sel f-

rejection as aspects of self-concept. These aspects were

assumed to relate to the aging process. He studied 83 male

surgical patients ranging in age from 20 to 60 years. Age

was curvi1inearly related to self acceptance (p < .05) but

not to self-rejection. Bloom attributed the results to the

tendency of older aged subjects to avoid negative items in

self-rating.

Similarly, a comparative study of self-concept by

Lee (1976) around the theme of what it is like to be old in

the United States showed little difference when she compared

a 20 to 40 year age group with a 60 to 80 year age group.

The number of subjects was not given. The groups of subjects

lived in the community. The author concluded the older age

group was less self-derogatory than the younger age group

and possessed a more positive self-identity. No statistical

data was reported.

Rosenberg (1965) defined self-esteem as self-

acceptance or a feeling of self-worth. Ward (1977) used the

Rosenberg Self-Esteem Scale in a study of attitudes toward

age, age identification and self-esteem in a random sample

survey of 323 non-institutionalized adults. The subjects

ranged in age from 60 to 92 years with a mean age of 74.1

years. Ward found a significant correlation between younger

aged subjects and positive self-esteem (r = .13, p = .002).

2 6

In addition, good health and positive self-esteem was

correlated significantly (r = .37) at the p < .05 level.

Kaplan and Pokorny (1969) used the Rosenberg Self-

Esteem Scale to examine the relationship between age and

self-attitude. The sample of 500 subjects was selected at

random from the total population of one county in Texas.

All the subjects were over 30 years of age with 135 subjects

being over the age of 50. Kaplan and Pokorny reported a

positive correlation between self-derogation (self-rejection)

and older age, however, the relationship was not statisti

cally significant. No statistical data were reported.

Hunter, et al. (1982) randomly selected 250 subjects

aged 65 and older living in the community to study the

characteristics of high and low self-esteem in an elderly

population group. There was a significant correlation

between perceived poor health and low self-esteem (p C.001).

Self-esteem and the impact of age identification as

a stigma label was studied by Ward (1977). Three hundred and

twenty three non-institutionalized adults aged 60 and older

were subjects of this study. The findings revealed increased

age was significantly related to self-derogation (r = .14).

This relationship was not significant at the p < .05 level

when attitudes toward aging were controlled.

Finally, critical evaluations of self-concept

studies by Wylie in 1979 resulted in her conclusion that

self-regard in an older group might be lower than other

2 7

groups if the person's self-concept is the result of

society's negative stereotyping (Wyl'ie, 1979). Many elderly

look at themselves as younger people see them. Negative

attitudes toward the elderly are seen among many younger

people. The low self-esteem of some elderly is the result of

incorporating this negative cultural view (Butler, 1979).

Summary

Considerable attention has been given to urinary

incontinence in the elderly. One nursing journal devoted

an entire issue to the scope of the problem of urinary

incontinence (Geriatric Nursing, Nov/Dec 1980). Still,

there is a paucity of research studies on urinary inconti

nence in the United States.

The literature suggested that as people get older

their self-concept changes and this change is toward a less

positive view of self. Attempts to correlate self-concept

with aging produced different conclusions by various authors

as seen in the review by Wylie (1974).

It was suggested in the literature that urinary

incontinence leads to a negative view of self. Self-

reporting of the impact of urinary incontinence by elderly

females was not found in the studies reviewed. It is the

responsibility of nurses to open the lines of communication

on this subject.

CHAPTER III

METHODOLOGY

This chapter describes the research design,

population sample, study setting, data collection method

and measurement tool. The method of data analysis is also

discussed.

Research Design

A descriptive study design was used to identify

urinary incontinence in elderly females living in a

community setting and the self-concept of these elderly

females. Data was collected through the use of a

questionnaire distributed to the subjects.

Population Sample

The population sample consisted of 43 subjects who

volunteered to participate in the study and met the following

cri teri a:

1. female and aged 60 and older

2. living in a non-institutional setting

3. able to read and write English

2 8

Protection of Human Subjects

The proposal for this study was submitted for

approval to The University of Arizona Human Subjects

Committee. This study was approved as exempt from Univer

sity review by the College of Nursing Ethical Review Sub-

Committee of the Research Committee, and the Director of

Research. The subject consent form explained the purpose

of the study and the use of the data obtained. Confiden

tiality was maintained as no signatures were required on

either the subject consent form or the questionnaire.

Study Setting

The setting for this study was a mobile home

retirement community in the northwest section of a city

in the southwestern United States. Persons residing in

this retirement community own their own mobile homes and

pay rental on the lot space and facilities provided. The

mobile home park was located in an affluent, upper middle-

class neighborhood.

Data Collection Method

The data was collected from the residents of a large

mobile home retirement community. This investigator intro

duced herself to the manager of the mobile home setting and

explained the purpose of the study. Permission to conduct

the study was obtained from the manager.

3 0

The questionnaires were placed in sealed envelopes

and delivered to the manager's office by this investigator.

A receptacle was placed in the manager's office for the

return of the completed questionnaires. Residents were

given a questionnaire in a sealed envelope when they came

to the manager's office to pay their rent. The instructions

on the subject consent form were to place the completed

questionnaire in a sealed envelope and return them to the

manager's office as soon as possible. This investigator

returned to the manager's office to receive the completed

questionnaires. The time involved in completing the

questionnaire was 20 to 30 minutes for each subject partici

pating.

Measurement Tool

A questionnaire composed of three parts was used

to investigate the problem under study. Part one consisted

of six questions prepared by this investigator to elicit

demographic data for general information. These data

included age, marital status, number of pregnancies, living

status, health care, and present health status.

Part two of the research tool was the Rosenberg

Self-Esteem Scale (1965). This scale consists of ten items

with response categories on a four point continuum from

strongly agree to strongly disagree. The scale was designed

3 1

to be scored as a Guttman Scale, however simple summing

procedures were used by Kaplan and Pokorny (1969) and Ward

(1977). Rosenberg (1965) was apparently the only person

who used the method of Guttman scaling to achieve a uni-

dimensional measure of global self-esteem. The range of

scores is 10 to 40 with the higher score indicating

positive self-esteem. The instrument is to be self-

administered and the brevity of the tool makes it desirable

for use with an older population.

The Rosenberg Self-Esteem Scale was originally

designed to measure self-esteem of high school students.

It is reported to be a valuable research tool and is

recommended as a measure for global self-esteem in all age

groups. A reproducibility coefficient of .72 was reported

by Rosenberg (1965) in his study of 5,024 students randomly

selected from public schools.

The appropriateness of use of this scale for older

subjects was demonstrated by Kaplan and Pokorny (1969) and

Ward (1977). The validity of the instrument was tested by

a factor analysis of the ten items by Kaplan and Pokorny

(1969). Seven items correlated from r = .37 to r = .77.

Ward (1977) reported an alpha measure of internal consistency

of .74 in his study of non-institutionalized adults in

Madison, Wisconsin. Further use of the scale with older

subjects is warranted (George and Bearon, 1980).

3 2

The third part of the questionnaire consisted of 14

questions developed by this investigator to identify the

problem of urinary incontinence in the population sample

under study. The questionnaire was typed using large type.

This was done to allow for greater readability as the

subjects under study were aged 60 and older.

Pilot Test

The questionnaire was first administered to five

elderly females ranging in age from 59 to 81 years to

pretest the validity of the tool. All of the subjects

reported the questionnaire was both easy to read and easy

to understand. No changes were made on any of the questions.

The average time for completing the questionnaire was 23

minutes. All of the questionnaires used in the pilot test

were destroyed immediately following completion.

Data Analysis

Frequency distributions were computed on the demo

graphic characteristics of the population sample. The

independent variables in this study were age, marital status,

number of pregnancies, living status and health status.

Pearson Correlation Coefficients of the independent

variables to.self-esteem were computed to establish the rela

tionship between urinary incontinence and self-esteem scores.

To determine the level of significance between self-esteem

and reported urinary incontinence, t-test computations were done.

CHAPTER IV

PRESENTATION AND ANALYSIS OF THE DATA

The results of the study are presented in this

chapter. Frequency distribution results for characteristics

of the sample population are discussed. Analyses of data

obtained from Pearson Correlation coefficients and t-test

computations relevant to the research questions are included.

Characteristics of the Sample

Demographic Characteristics

The sample population included 43 female subjects

ranging in age from 60 to 83 years with a mean age of 69.8

years. The frequency distribution of subjects by age are

presented in Table 1. Twenty six subjects (61 percent) were

in the 65 to 74 year age group. Eight subjects (18 percent)

were 75 years of age and older.

The frequency distribution of subjects by marital

status is presented in Table 2. Twenty six subjects (60

percent) were married, one was divorced, 15 were widowed

and one subject had never been married. None of the sub

jects reported being separated.

Table 3 presents the frequency distribution of sub

jects by living status. The data revealed that 16 subjects

3 3

3 4

Table 1. Frequency Distribution of Subjects

by Age (N = 43)

Age Groups •Number Percent

60 - 64 9 21

65 - 69 12 18

70 - 74 14 33

75 - 79 5 12

80 - 83 3 6

Total 43 100.0

x age = 69.8 yrs.

3 5

Table 2. Frequency Distribution of Subjects by

Marital Status (N = 43)

Marital Status Number Percent

Married 26 60

Divorced 1 2

Separated 0

Widowed 15. 36

Never Married 1 2

Total 43 100.0

3 6


Living Status (N = 43)

Living Status Number Percent

Live Alone 16 37

Live With Spouse 27 63

Family or Friends

Total 43 100.0

(37 percent) lived alone and 27 subjects (63 percent) lived

with spouse, family or friends.

Data was also obtained about the number of preg

nancies reported by the subjects. Ten subjects (23 percent)

reported no pregnancies, five subjects (12 percent) reported

one pregnancy, and 17 subjects (39 percent) reported two

pregnancies. The remaining twenty subjects (26 percent)

reported having had more than two pregnancies. The mean

number of pregnancies for this sample population was 1.76.

Health Characteristics

The frequency distribution of subjects by health

status is presented in Table 4. Subjects' responses to the

health status category questions revealed eight subjects

(19 percent) reported their health as excellent and 28

subjects (65 percent) reported good health. Six subjects

(14 percent) reported fair health and one subject (2 per

cent) reported her health as poor.

Data was also collected to determine if subjects

were under the care of a physician and to determine their

health problems. Thirty subjects (70 percent) reported

they were under a physician's care for health problems. A

wide diversity of responses for health problems was given.

Sixteen subjects (37 percent) reported one health problem,

3 8


Health Status (N = 43)

Health Status Number Percent

Excellent 8 19

Good 28 65

Fai r 6 14

Poor 1 2

Total 43 100.0

3 9

11 subjects (26 percent) reported two health problems and

three subjects (7 percent) reported three or more problems.

Rosenberg Self-Esteem Scale

The second part of the questionnaire contained the

ten item Rosenberg Self-Esteem Scale (1965) to measure the

subject's self-concept. The responses were scored on a

four point continuum from "strongly agree" to "strongly

disagree." Each response was given a numeric score from

one to four. The range of scores was 10 to 40 with a higher

score indicating a more positive concept of self.

The summed score and the number and percent of the

subjects for each score are presented in Table- 5. The

subjects' scores ranged from 25 to 40 with a mean score of

32.7. Seven subjects (16 percent) scored 31 and five

subjects scored 32. The frequency distribution of the

remaining scores ranged from one to four indicating a

heterogenous group.

Urinary Incontinence

Questions that described urinary incontinence in

the sample population are found in the third part of the

questionnaire. The subjects were grouped as incontinent

or not incontinent by the response to question 17 of the

questionnaire (Appendix c). Twenty two subjects (51 percent)

identified themselves as being incontinent. Seventeen (77

4 0

Table 5. Frequency Distribution of Subjects For

Summed Scores of the Rosenberg Self-Esteem

Scale (N = 43)

Summed Score Number Percent

25 1 2

28 4 9

29 4 9

30 4 9

31 7 16

32 5 12

33 3 7

34 2 5

35 1 2

36 3 7

37 2 5

38 4 9

39 2 5

40 1 2

Total 43 100.0

Range = 25-40

x =32.7

4 1

percent) of the twenty two subjects stated they were

incontinent when they coughed, laughed or sneezed. The

remaining five subjects (23 percent) reported being

incontinent when "I wait too long."

The age of the subjects with urinary incontinence

compared to the age distribution of the total sample popu

lation is presented in Table 6. Four subjects (80 percent)

in the 75 to 79 age group reported urinary incontinence.

Three subjects were aged 80 and older and in this age group

two subjects (67 percent) reported being incontinent.

The number and percent of pregnancies in subjects

reporting urinary incontinence are shown in Table 7. Six

subjects (27 percent) had no pregnancies. Seven subjects

(32 percent) had two pregnancies and six subjects (26 per

cent) reported more than two pregnancies.

The frequency distribution by health status of

subjects reporting urinary incontinence is presented in

Table 8. Three subjects (14 percent) reported their health

as excellent and fifteen subjects (68 percent) as good.

None of the subjects reported poor health.

The onset and frequency of urinary incontinence

reported by the 22 subjects identified as being incontinent

are presented in Table 9. Eighteen subjects (82 percent)

reported they had urinary incontinence for an unspecified

period of months or years. Frequency of once or twice a

4 2

Table 6. Number and Percent of Subjects by Age

Group Reporting Urinary Incontinence

Compared to the Total Sample Population

Total Subjects With Percent Age Group Subjects Incontinence Incontinent

60 • - 64 9 6 66

65 • • 69 12 5 42

70 • • 74 14 5 36

75 • • 79 5 4 80

80 • • 83 3 2 67

Total 43 22 51

4 3

Table 7. Number arid Percent of Pregnancies in

Subjects Reporting Urinary Incontinence

(N = 22)

Number of Number of Pregnancies Subjects Percent

0 6 27

1 3 14

2 7 32

3 3 14

4 2 8

5 1 4

Total 22 100.0

4 4

Table 8. Frequency Distribution by Health Status

of Subjects Reporting Urinary

Incontinence (N = 22)

Health Status Number Percent

Excel 1ent 3 14

Good 15 68

Fai r 4 18

Poor 0 0

T otal 22 100

4 5

Table 9. The Onset and Frequency of Urinary Incontinence

Among Subjects Identified as Being Incontinent ( N = 2 2 )

Onset of Incontinence Number Percent

Weeks 4 18

Years 18 82

Total 22 100.0

Frequency of Incontinence

Once or twice a month 6 27

Once or twice a week 5 22

Once or twice a day 3 14

Three to five times a day 3 14

More than five times a day 4 18

Other 1 5

Total 22 100.0

4 6

month was reported by six (27 percent) of the subjects.

Three subjects (14 percent) reported frequency of once or

twice a day. Frequency of urinary incontinence of three

to five times a day was reported by three subjects (14

percent) and four subjects (18 percent) reported frequency

of incontinence more than five times a day. One subject

(5 percent) responded "I can't even guess" to the question

on frequency.

One question (item 21) sought information on any

restriction of activities due to urinary incontinence. Only

four subjects (18 percent) reported any restriction of

activities.

Eleven subjects (50 percent) stated they had reported

being incontinent to a health care provider. All of the

subjects identified the health care provider as a physician.

Nine (82 percent) of the subjects reporting urinary inconti

nence stated they had been incontinent for years.

Physicians' responses to subjects who reported

incontinence are presented in Table 10. One subject (9 per

cent) stated her physician did not respond when she reported

she was incontinent of urine. Two subjects (18 percent) were

told "don't worry about it" and three subjects (27 percent)

were told, "it's normal for your age."

4 7

Table 10. Frequency Distributions of Physicians'

Responses to Subjects Incontinent of

Urine (N = 11)

Physicians' Response Number Percent

Nothing 1 9

Don't worry about it 2 18

It's normal for your age 3 27

Treatment given 5 56

Total 11 100.0

4 8

Only five (45 percent) of the eleven subjects who

reported the problem of incontinence to their physician were

treated. Four subjects stated the treatment helped and one

subject stated the prescribed treatment did not help her.

Nine of the eleven subjects who had not revealed the

symptom of urinary incontinence to a health care provider

gave their reasons for not having done so. Responses from,

the subjects included: "it's not inconvenient;" "not a great

problem;" "elasticity loss is due to age;" "not severe

enough" and "it's common to many people of my age." One

subject stated, "I just put it down to the aging process ...

I had no idea anything could be done about it." These

responses demonstrated a passive acceptance of the condition

of urinary incontinence.

Twenty of the twenty two subjects identified as

being incontinent responded to their feelings about answering

the questions on urinary incontinence. One subject stated she

felt embarrassed answering the questions but nineteen

subjects (95 percent) reported they were comfortable

answering the questions.

Computations Using t-Test Ratios

Comparison of the mean in self-esteem scores between

subjects identified as being incontinent of urine and those

who were not incontinent was analyzed. In addition, an

analysis of self-esteem scores between subjects who revealed

4 9

urinary incontinence to a health care provider and those who

did not were computed. No differences between any of the

subject groups were significant at the p<.05 level using

t-test computations.

Pearson Correlation Coefficients

Pearson correlation coefficients were computed to

determine the relationships between the independent variables

of age, marital status, number of pregnancies, living status

and health status with self-esteem scores. Significant

correlations were found between self-esteem and marital

status (r = .3073) and self-esteem and living status

(r = .3336) at the p < .05 level. These data are found in

Table 11.

Pearson correlation coefficients computed between

the independent variables and urinary incontinence found no

significant differences between any of the relationships.

There was a positive correlation (r = .6708) that was

significant (p = .02) between the onset of urinary inconti

nence and the time it was reported to a physician. This

finding was interpreted to mean that people who have long

term incontinence are more likely to report it to their

physi cianS,

5 0

Table 11. Pearson Correlation Coefficients and

Significance for Marital Status and Living

Status to Self-Esteem

Variable Correlation Significance*

Marital Status/ .3073 .045

Self-Esteem

LivingStatus/ .3336 .029

Self-Esteem

* p - < .05

CHAPTER V

DISCUSSION OF FINDINGS

CONCLUSIONS AND RECOMMENDATIONS

This chapter includes a discussion of the study

findings and the relationship between these findings, the

conceptual framework and previous studies. Conclusions

and recommendations for future studies are proposed.

Discussion of Findings

A 24 item questionnaire was used in this study to

identify urinary incontinence in a selected population and

to identify the relationship between urinary incontinence

and self-concept. Forty three subjects consented to parti

cipate. The mean age of the sample population was 69.8

years. Urinary incontinence was operationally defined as

any leakage of urine, regardless of the frequency that was

present at the time of the study. Twenty two subjects

(51 percent) responded to being incontinent of urine. Self-

concept was operationally defined as the elderly female's

view of herself as measured by the Rosenberg Self-Esteem

Scale (1965). The higher the score on the scale, the more

positive the concept of self with a total possible score of

40. The range of scores in this study was 25 to 40 with a

mean score of 32.45 for the total sample population. The

5 1

5 2

subjects' mean score for the categories of being incontinent

and not incontinent were 32.45 and 32.85 respectively.

Data were analyzed to determine the relationship

between the independent variables of age, marital status,

living status and health status to self-esteem. Subjects

who lived with someone had a more positive self-esteem.

This finding was statistically significant (p = .029) with

a correlation coefficient of r = .3336. Self-esteem was

higher in married subjects and correlated significantly at

r = .3073 (p = .045). This finding could be explained as

being married may be a reflection of living with someone.

Findings Related to the Conceptual Framework

The conceptual framework for this study was based on

urinary incontinence and self-concept. It was hypothesized

that a negative self-esteem would result in hiding the

symptom of being incontinent. This hypothesis was not

supported as there were no statistical differences between

the self-esteem scores in the continent and incontinent

groups. The concept of hidden incontinence was supported in

that 11 subjects (50 percent) identified as being incontinent

did not reveal the symptom to a health care provider. The

subjects responded that urinary incontinence was not a great

problem and they accepted it as part of the aging process.

5 3

Findings Related to Previous Studies

The response rate of questionnaire completion was

22 percent in this study which was lower than the response

rate of 98 percent reported by Yarnell and St. Leger (1979).

The prevalence of 51 percent for urinary incontinence was

higher than reported by Milne (1972) and Willington (1976).

A possible explanation for this finding was the small size

of the sample population. A second possible explanation for

the higher prevalence figure was that incontinence was

defined as any leakage of urine. Milne (1972) suggested

that prevalence figures seem higher in studies which record

even the mildest degree of incontinence. A third possible

explanation is that those who were not incontinent did not

bother to answer the questionnaire at a higher rate than

those who were incontinent.

Seventeen (77 percent) of the subjects identified as

being incontinent reported symptoms of stress incontinence.

Brocklehurst (1978) reported it is easier for women to admit

to stress incontinence than to say "yes" to all incontinence.

It was suggested by Willington (1976) that many women with

stress incontinence are postmenopausal. The subjects in

this study were 60 years of age and older.

Stress incontinence is generally believed to be

associated with multiparity. The findings in this study

showed the prevalence of urinary incontinence was highest

5 4

(32 percent) in subjects who had two pregnancies. This

finding differed from the study by Thomas, et al. (1980)

who found the prevalence was higher in those who had four

or more pregnancies.

This investigator found many specific medical

problems cited as causative factors for urinary incontinence

in the review of the literature (Willington, 1976;

Brocklehurst 1979; Milne, 1982). Specific medical problems

were not addressed in this study, however, the questionnaire

used did address the health status of the subjects. The

findings revealed that 18 subjects (82 percent) reported

their health as either excellent or good.

Twenty one subjects (49 percent) were in the 60 to

70 year age group. Eleven (52 percent) of these twenty one

subjects reported being incontinent of urine. Twenty two

(51 percent) of the total sample population were between the

age of 71 and 83 years. Eleven subjects (50 percent) in this

age group reported being incontinent of urine. These

findings show no increase in the prevalence of incontinence

increasing with age. This supports the findings of

Willington (1969) who reported no age difference in the

distribution of incontinence in the elderly and no increase

in prevalence with older age groups. The findings of this

study differ from the findings of Yarnell and St. Leger

(1979) who found a general tendency for the prevalence of

5 5

incontinence to increase with age. The prevalence figures

reported in this study are possibly an underestimate of the

true prevalence of incontinence in the selected community

setting since the response rate was so low.

In response to frequency of urinary incontinence,

eight subjects (37 percent) reported incontinence of more

than once or twice a day. This finding is higher than the

22 percent of moderate to severe incontinence found in the

study by Thomas, et al. (1980). This finding suggests that

regular incontinence is common.

Of particular interest to this investigator were the

findings related to physicians' responses when these sub

jects sought treatment for their incontinence. Five (45

percent) of those seeking treatment were told "don't worry

about it" and "it's normal for your age." This finding

supports the contentions of Knutson (1965), Dobson (1976),

Swaffield (1981) and Wells (1981) that the real problem in

urinary incontinence is one of attitudes of health care

providers. This is important to nursing. The lines of

communication should be opened and nurses should inform

people that urinary incontinence is not a normal process of

aging.

The positive self-esteem scores found in this study

support the findings of Lee (1976) who reported that older

age groups were less self-derogatory than younger age groups.

5 6

However, the finding differed from the study by Kaplan and

Pokorny (1969) who reported a positive correlation between

self-derogation and older age and Ward (1977) who reported

that younger age correlated with positive self-esteem

(r = .37).

It is interesting that in this study there was no

significant correlation between perceived health and

self-esteem. Both Ward (1977) and Hunter (1982) found

significant correlations between good health and positive

self-esteem in their studies.

Cone!us i ons

One hundred and ninety six questionnaires were

distributed at the setting chosen for this study. Forty

three subjects (22 percent) responded and participated in

the study. The nature of the study may be of some

importance in the low response rate. The setting chosen

had a change of management at the time of the study. To

be specific, the change in management occurred the day

after the questionnaires were delivered. The new manager

reported she had forgotten who had received questionnaires

and some of the subjects may have received more than one.

The design of the study may also have had impact on the low

return of the questionnaires. Approximately 75 subjects

residing in the community were younger than 60 years of

age, however, none of the questionnaires were returned from

5 7

the younger subjects. Refusal to participate in the study

may also have had bearing on the response rate. It was

reported by Akhtar (1972) that more women significantly

refuse to participate in surveys than men.

The self-concept of the elderly females in this

study was positive. There was no significant relationship

between low self-esteem and hidden incontinence. Urinary

incontinence was accepted as a process of aging by the women

in this study. This passive acceptance was the reason for

not seeking help.

The number of elderly females (11 who reported

incontinence to a health care provider in this study was the

same as the number of those who did not seek treatment. The

eleven women reported being incontinent to a physician and

six of these women were not treated. It is significant to

nursing to note that all of these subjects sought help from

a physician and four subjects did not receive that help.

This finding has major implications for nursing.

Nurses, as professionals, need to open the lines of

communication to prevent established incontinence. Elderly

women need to be told incontinence is not "normal for your

age" and they have the right to seek treatment. In fact,

elderly women should be informed they have the right to

demand evaluation and treatment.

5 8

These findings demonstrate that a proportion of

urinary incontinence remains undetected and the scope of

the problem may be greater than was suggested in the

literature. Prevention to forestall further decline is a

major recommendation for research. Nurses have it in their

power to help prevent incontinence from becoming a major

problem by educating women in the community. The impact of

that education can be evaluated through nursing research.

Recommendati ons

The following recommendations are made based on

the findings in this study:

1. Replicate the study using larger populations

in various settings.

2. Replicate the study of women subjects as the

literature suggests the prevalence of urinary

incontinence is higher in women than in men.

3. Include subjects 50 years of age and older.

The review of literature demonstrated inconti

nence is present in women younger than 60 years

of age.

4. Have the questionnaires returned by the postal

servi ce.

5. Clearly state all questionnaires should be

returned even if the subject does not meet the

criteria of the study.

APPENDIX A

HUMAN SUBJECTS COMMITTEE CONSENT FORM

5 9

6 0

THE UNIVERSITY OF ARIZONA COLLEGE OF NURSING

MEMORANDUM

TO: Jacquel.yn Simons, R.N. 6415 N. Placita Tranquila Tucson, Arizona 85704

FROM: Ada Sue Hinshaw, R.N., Ph.D. Jan R. Atwood, R.N., Ph.D. Director of Research Chairman, Research Committee

DATE: October 25, 1982

RE: Human Subjects Review: Self-Concept in Elderly Females: The

Impact of Urinary Incontinence

Your project has been reviewed and approved as exempt from University review by the College of Nursing Ethical Review Sub-committee of the Research Committee, and the Director of Research. A consent form with subject signature is not required for projects exempt from full University review. Please use only a disclaimer format for subjects to read before giving their oral consent to the research. The Human Subjects Project Approval Form is filed in the office of the Director of Research, if you need access to it.

We wish you a valuable and stimulating experience with your research.

ASH:des 8/82

APPENDIX B

SUBJECT CONSENT FORM

6 1

6 2

SUBJECT CONSENT FORM

You are being asked to participate in a study of women aged 60 and older. The title of this study is Self-Concept in Elderly Females: The Impact of Urinary Incontinence. This study is designed to explore your feelings about yourself and your general health status. Another purpose of this study is to identify the existence of urinary incontinence in women aged 60 and older. It is important for health care providers to recognize the scope of the problem of urinary incontinence.

You are being asked to participate in this study by completing a questionnaire. Your name will not be used on the form. Your identity will not be known. No further participation will be required. There are no known risks or discomfort to you.

The information gathered in this study will be used for statistical purposes only. Results of this study may be published in nursing journals. A summary of the results of this study will be available to you upon request. You may contact me by telephone.

Completing the questionnaire will be your consent to participate in this study. The questionnaire will take you about thirty minutes to complete. When you have finished, please place the form in the envelope, seal the envelope, and return it to the manager's office.

Please return the completed questionnaire as soon as possible. I will complete my study as soon as all the questionnaires have been received.

Thank you for your participation. I will be available if you have any questions.

Jacquelyn Simons, R.N. Graduate Student College of Nursing University of Arizona

Home telephone: 297-5636

APPENDIX C

QUESTIONNAIRE

*

6 3

6 4

QUESTIONNAIRE

PART I. GENERAL INFORMATION

THE FOLLOWING QUESTIONS SEEK GENERAL INFORMATION ABOUT YOU AND YOUR PRESENT HEALTH STATUS. PLEASE ANSWER THE FOLLOWING QUESTIONS, PLACE A CHECK (v) WHERE IT APPLIES.

1. HOW OLD ARE YOU AT THE PRESENT TIME? YEARS

2. WHAT IS YOUR MARITAL STATUS? ARE YOU NOW ...

MARRIED? DIVORCED? SEPARATED? WIDOWED? NEVER MARRIED?

3. How MANY PREGNANCIES HAVE YOU HAD?

4. WHAT IS YOUR CURRENT LIVING STATUS? DO YOU ...

LIVE ALONE? LIVE WITH SPOUSE? LIVE WITH FRIEND? LIVE WITH FAMILY?

5. ARE YOU CURRENTLY UNDER A PHYSICIAN'S CARE FOR ANY HEALTH PROBLEMS?

YES No

5A. IF YES., PLEASE LIST THE HEALTH PROBLEMS YOU ARE SEEING THE PHYSICIAN FOR IN THE SPACE BELOW:

6 5

6, Do YOU CONSIDER YOUR PRESENT HEALTH STATUS TO BE ...

EXCELLENT? GOOD? FAIR? POOR?

PART II.

THE NEXT TEN ITEMS PERTAIN TO YOUR FEELINGS ABOUT YOURSELF. PLACE A CHECK (Y) BESIDE THE RESPONSE THAT COMES CLOSEST TO EXPRESSING YOUR OPINION ABOUT EACH STATEMENT. THERE ARE NO RIGHT OR WRONG ANSWERS.

7. I FEEL THAT I'M A PERSON OF WORTH, AT LEAST ON AN EQUAL PLANE WITH OTHERS.

STRONGLY AGREE AGREE DISAGREE STRONGLY DISAGREE

8. I FEEL THAT I HAVE A NUMBER OF GOOD QUALITIES.


9. ALL IN ALL, I AM INCLINED TO FEEL THAT I AM A FAILURE,


6 6

10. I AM ABLE TO DO THINGS AS WELL AS MOST OTHER PEOPLE.


11. I FEEL I DO NOT HAVE MUCH TO BE PROUD OF.


12. I HAVE A POSITIVE ATTITUDE TOWARD MYSELF.

STRONGLY AGREE AGREE DISAGREE STRONGLY DISAGREE _

13. ON THE WHOLE, I AM SATISFIED WITH MYSELF.


m. I WISH I COULD HAVE MORE RESPECT FOR MYSELF.


6 7

15, I CERTAINLY FEEL USELESS AT TIMES. STRONGLY AGREE AGREE DISAGREE STRONGLY DISAGREE

16, AT TIMES I THINK I AM NO GOOD AT ALL.


PART III

THE NEXT SEVERAL QUESTIONS SEEK INFORMATION ABOUT WHETHER OR NOT YOU HAVE A PROBLEM WITH URINARY INCONTINENCE.

ANY LEAKAGE OF URINE THAT IS NOT UNDER YOUR CONTROL IS DEFINED AS INCONTINENCE. FOR EXAMPLE: A WETNESS WHEN YOU COUGH OR SNEEZE. PLACE A CHECK (") WHERE IT APPLIES.

17. Do YOU PRESENTLY HAVE A LEAKAGE OF URINE?

YES No SOMETIMES

18. DOES THIS LEAKAGE OF URINE OCCUR WHEN YOU ... PLEASE CHECK (*^) ALL THAT APPLY.

COUGH? SNEEZE? LAUGH? OTHER (SPECIFY)

HOW FREQUENTLY DOES THIS LEAKAGE OF URINE OCCUR? 6 8

ONCE OR TWICE A MONTH ONCE OR TWICE A WEEK ONCE OR TWICE A DAY THREE TO FIVE TIMES A DAY MORE THAN FIVE TIMES A DAY OTHER (SPECIFY)

How LONG HAVE YOU HAD THIS LEAKAGE OF URINE?

WEEKS MONTHS YEARS

HAS THIS LEAKAGE OF URINE PREVENTED YOU FROM ENGAGING IN ANY OF THE FOLLOWING ACTIVITIES? PLEASE CHECK (»") ALL THAT APPLY,

TRAVELING BY CAR WALKING SHOPPING GOING TO SOCIAL EVENTS OTHER (SPECIFY)

HAVE YOU DISCUSSED THIS PROBLEM WITH A HEALTH CARE PROVIDER?

YES (GO TO QUESTION 22A) No (GO TO QUESTION 23)

6 9

22A. IF YES, HOW LONG AGO?

DAYS WEEKS MONTHS

22B, IF YES, WAS THE HEALTH CARE PROVIDER ...

A NURSE? A PHYSICIAN? OTHER (SPECIFY)

22c. IF YES, WHAT DID THE HEALTH CARE PROVIDER TELL YOU ABOUT THIS PROBLEM?

NOTHING DON'T WORRY ABOUT IT IT'S NORMAL FOR YOUR AGE OTHER (SPECIFY)

22D, DID YOU RECEIVE TREATMENT?

YES No

22E. WHAT WAS THE TREATMENT?

22F. DID THE TREATMENT HELP?

YES No

7 0

23, IF YOU HAVE NOT DISCUSSED THIS PROBLEM WITH A HEALTH CARE PROVIDER, WOULD YOU PLEASE SHARE YOUR IDEAS AS TO WHY YOU DIDN'T THINK IT WAS NECESSARY?

24. WHAT FEELINGS DID YOU HAVE WHILE YOU WERE ANSWERING THESE QUESTIONS ABOUT URINARY INCONTINENCE? D l D YOU FEEL .,, (PLEASE CHECK (") ALL THAT APPLY).

COMFORTABLE? UNCOMFORTABLE? EMBARRASSED? OTHER? (SPECIFY)

THE QUESTIONNAIRE IS COMPLETED. THANK YOU FOR TAKING YOUR TIME TO PARTICIPATE IN THIS STUDY. PLEASE PLACE THE COMPLETED QUESTIONNAIRE IN THE ENVELOPE PROVIDED, SEAL THE ENVELOPE, AND RETURN IT TO THE MANAGER'S OFFICE. AGAIN, I THANK YOU.

REFERENCES

Akhtar, A. J. "Refusal to Participate in a Survey of the Elderly." Gerontology Clinic, 1972, p. 205-211.

P., et al. "The Standardization of Terminology of Lower Urinary Tract Infection." Journal of Urol og.y, 1979, p. 551 -554.

R. E. Vance and 0. McLean. "An Index of Adjustment and Values." Journal of Consulting Psychology, 1951, p. 257-261.

K. L. "Age and the Self Concept." American Journal of Psychiatry, 1961, p. 534-538.

Branden, Nathaniel. The Psychology of Self Esteem. Nash Publishing Corporation, Los Angeles, 1969.

Brink, Carol. "Assessing the Problem." Geriatric Nursing, Nov./Dec. 1980, p. 241-245.

Brock!ehurst, J. C. "The Urinary Tract" in Rossman, Clinical Geriatrics, Lippincott Book Co., Philadelphia, 1971.

. "The Investigation and Management of Incontinence." Chapter 2 in Isaacs, Bernard. Recent Advances in Geriatric Medicine. Churchill Livingstone, New York, 1978, p. 21-39.

. "The Urinary Tract." Chapter 16 in Rossman, Isadore. Clinical Geriatrics, 2nd Ed. J. B. Lippincott, Philadelphia, 1979, p. 317-329.

Brocklehurst, J. C. and J. B. Dillane. "Studies of the Female Bladder in Old Age." Gerontology Clinic, Vol. 8, 1966, p. 285-305.

Brocklehurst, J. C. and J. B. Dillane. "Studies of the Female Bladder in Old Age." Gerontology Clinic, Vol. 9, 1967, p. 182-191.

Brownfain, John J. "Stability of the Self-Concept as a Dimension of Personality." Journal of Abnormal and Social Psychology, Vol. 47, 1952, p. 597-606.

Bates ,

Bills,

B1oom,

7 1

7 2

Burnside, Irene Mortenson. Nursing and the Aged. McGraw-Hill, Inc., 1981.

Buss, Arnold H. Self-Consciousness and Social Anxiety. W. H. Freeman and Co., San Francisco, 1980.

Busse, Ewald W. "Old Age in the Course of Life." Adulthood and the Aging Process. Vol. III. S. I. Greenspan and G. H. Pollock (Eds.) , NIMH, 1980 , p. 519-543.

Butler, Robert N. Why Survive? Being Old in America. Harper and Row Publishers, Inc., New York, 1975.

Butler, Robert N. and Myrna I. Lewis. Aging and Mental Health. 3rd Ed. C. V. Mosby Co., St. Louis, 1982.

Cape, Arnold. Aging: Its Complex Management. Harper and Row, New York, 1980.

Cape, Arnold; M. Ehtisham; and M. H. Zirk. "Management of Bacteriuria in the Elderly Female." In Urinary Tract Infection. London, Oxford University Press, 1973, p. 223-228.

Cardoza, Linda D. and S. L. Stanton. "Genuine Stress Incontinence and Detrusor Instability." British Journal of Obstetrical Gynaecology, March, 1980, p. 184-190.

Coopersmith, S. The Antecedents of Self-Esteem. W. H. Freeman, San Francisco, 1967.

Demmerle, Barbara and MariAnne Bartol. "Nursing Care For The Incontinent Person." Geriatric Nursing. Nov./Dec., 1980, p. 246-250.

Dobson, Peter. "The Management of Incontinence in the Home." General Management of Incontinence. Disabled Living Foundation, London, 1976.

Fielding, Pauline. "An Exploratory Investigation of Self-Concept in the Institutionalized Elderly, and a Comparison With Nurses' Conceptions and Attitudes." Int. Journal of Nursing Studies. Pergamon Press Ltd., Great Britain, 1979, p. 345-354.

Finkbeiner, Alex E. "Helpful Drugs." Geriatric Nursing. Nov./Dec. 1980, p. 270-273.

7 3

Fisher, Seymour and Sidney Cleveland. Body Image and Personal it.y. 2nd Edition. Dover Publications, Inc. , New York, 1968.

Fitts, William H. Tennessee Self Concept Scale. Counsellor Recordings and Tests. Nashville, Tennessee, 1965.

. The Self Concept and Behavior Research. (Monograph No. VII) Counsellor Recordings and Tests, Nashville, Tennessee, 1972.

Forbes, Elizabeth and Virginia Fitzsimons. The Older Adult. C. V. Mosby Co., New York, 1981.

Freed, Selwyn Z. "Urinary Incontinence in the Elderly." Hospital Practice, March 1982, p. 81-94.

Freedman, L. R. "Natural History of Urinary Tract Infections." Kidney International, 1975, Vol. 8, p. 96-100.

George, Linda K. and Lucille B. Bearon. Quality of Life in Older Persons: Meaning and Measurement. Human Sciences Press, Inc., New York, 1980.

Hadley, Evan and Edward Schneider. "Urinary Incontinence in the Elderly: A Major Problem for Medical Research." Workshop Proceedings, NIA, 1980.

Hodgkinson, C. Paul. "Abnormalities of Female Bladder Functions and Urinary Control." Chapter 12 in Slate, William J. Disorders of the Female Urethra and Urinary Incontinence. 2nd Ed. Waverly Press, Inc., Baltimore, MD, 1982, p. 77-86.

Hunt, Paul. Stigma. Geoffrey Chapman, London, 1966.

Hunter, Kathleen I.; M. W. Linn; R. Harris. "Characteristics of High and Low Self-Esteem in the Elderly." International Journal of Aging and Human Development, Vol. 14 (2), 1981-82, p. 117-126.

Isaacs, Bernard. Recent Advances in Geriatric Medicine. Churchill Livingstone, New York, 1978.

James, M. H. "Disorders of Micturition in the Elderly." Age Ageing. Nov. 1979, p. 286.

7 4

Judson, Leona; T. Novotny,; J. McAninch; and J. Scott. "Genitourinary System." Chapter 12 in Elder Care; A Guide to Clinical Geriatrics. Grune and Stratton, New York, 1981, p. 169-187.

Kaplan, H. B. and A. D. Pokorny. "Self-Derogation and Psychosocial Adjustment." Journal of Nervous and Mental Disease, 1969,' 149, p. 421-434.

Kaufman, Joel M. "Operative Management of Stress Urinary Incontinence." The Journal of Urology, Vol. 126, Oct. 1981, p. 465-467.

Knutson, Andie L. The Individual, Society, and Health Behavior. Russell Sage Foundation, New York, 1965.

Lapides, Jack. "Physiology of the Bladder and Urinary Sphincter - Relationships to Stress Incontinence." Chapter two in Slate, William G. Disorders of the Female Urethra and Urinary Incontinence. 2nd Ed. Waverly Press, Inc., Baltimore, MD, 1982, p. 15-24.

Lee, Robert J. "Self-images of the Elderly." Nursing Clinics of North America, Vol. 11, No. 1. March, 1976, p. 119-124.

Maney, Janet Yost. "A Behavioral Therapy Approach to Bladder Retraining." Nursing Clinics of North Ameri ca, Vol. 11, No. 1. March 1976, p. 1 79-187.

Mason, E. P. "Some Correlates of Self-Judgment of the Aged. Journal of Gerontology, 1954, p. 324-337.

Milne, J. S. "Urinary Symptoms in Older People." Modern Geriatrics, 1972, p. 198-205.

. "Prevalence of Incontinence in the Elderly Age Groups." Chapter 2 in Willington, F. L. Inconti-nence in the Elderly. Academic Presj, New York, 1976, p. 9-20.

Monge, Rolf H. "Structure of the Self-Concept from Adolescence Through Old Age." Experimental Aging Research, 1975, p. 281-291.

Murray, Ruth L. "Body Image Development in Adulthood." Nursing Clinics of North America. December, 1973, p. 617-629.

7 5

National Institute on Aging (NIA). Workshop proceedings on "Urinary Incontinence in the Elderly: A Major Problem for Medical Research." NIA, Nov. 3 and 4, 1980.

Neuhaus, Ruby Hart and R. H. Neuhaus. Successful Aging. John Riley and Sons, New York, 1982.

Newman, J. L. "Old Folks in Wet Beds." British Medical Journal , 1962.

Ouslander, Joseph G. "Urinary Incontinence in the Elderly." Geriatric Medicine. December, 1981, p. 482-490. '

Peters, George R. "Self-Conceptions of the Aged, Age Identification, and Aging." The Gerontologist. Winter 1971, Part II, p. 69-73.

Pierson, Charon A. "Urinary Incontinence. New Methods of Diagnosis and Treatment." JOGN Nursing. Nov/Dec 1981. p. 407-413.

Preston, Ronald Philip. The Dilemmas of Care: Social and Nursing Adaptions to the Deformed, the Disabled and the Aged. Elsevier, New York, 1979.

Rosen, Gerald M. and Alan 0. Ross. "Relationship of the Body to Self Concept." Journal of Consulting Psychology. 32:100, 1968.

Rosenberg, M. "Society and the Adolescent Self-image." Princeton, New Jersey, Princeton University Press, 1965.

Selkhurt, Ewald E. Basic Physiology for the Health Sciences. 2nd Edition. Little, Brown and Company, Boston, 1982.

Sheldon, J. H. "Wolverhampton Survey of Incontinence." The Social Medicine of Old Age. London, Oxford University Press, 1948, p. 74-79.

Sutherland, S. S. "The Psychology of Incontinence." Chapter 5 in Wi11ington , F. L. Incontinence in the Elderly. Academic Press, New York, 1976, p. 52-69.

Swaffield, Laura. "Attitudes to Incontinence." Nursing Times. Feb. 1981, p. 51.

7 6

Thomas, Alma M. ; K. R. Plymat; J. Blannin; T. W. Meade. "Prevalence of Urinary Incontinence." British Medical Journal , Nov. 1980, p. 1243-1245.

Thompson, W. Correlates of the Self Concept. (Monograph No. VT) Counsellow Recordings and Tests, Nashville, Tennessee, 1972.

Trimakas, Kestutis, and Robert C. Nicolay. "Self-Concept and Altruism in Old Age." Journal of Gerontology, Vol. 29, No. 4, 1974, p. 434-439.

Vander, Arthur J.; James H. Sherman and Dorothy S. Luciano. Human Physiology: The Mechanisms of Body Function. McGraw-Hill Book Co., New York, 1980.

Ward, Russell A. "The Impact of Subjective Age and Stigma on Older Persons." Journal of Gerontoloqy, 1977, Vol. 32, No. 2, p. 227-232.

Warrell, D. W. "Incontinence of Urine in Women." Practitioner, September 1980, p. 883-885.

Wells, Thelma. "Promoting Urine Control in Older Adults." Geriatric Nursing, Nov/Dec., 1980, p. 236-240.

Wells, Thelma and Carol Brink. "Urinary Incontinence: Assessment and Management." Chapter 36 in Burnside, Irene M. Nursing and the Aged. McGraw-Hill Book Co., New York, 1981.

Willington, F. L. Incontinence in the Elderly. Academic Press, New York, 1976.

. "Urinary Incontinence: A Practical Approach." Geriatrics, Vol. 35, June 1980, p. 41-48.

Witherington , Roy. "Stress Urinary Incontinence: A Practical Protocol for DX and TX." Geri atri cs. May 1982, p. 38-47.

Wright, Beatrice A. Physical Disability - A Psychological Approach. Harper & Row, New York, 1960.

Wylie, Ruth C. The Self-Concept, Vol. 1, Lincoln, Nebraska, University of Nebraska Press, 1974.

The Self-Concept, Vol. 2. Lincoln, Nebraska, University of Nebraska Press, 1979.

7 7

Yarnel1, J. W. G. and A. S. St. Leger. "The Prevalence, Severity and Factors Associated with Urinary Incontinence in a Random Sample of the Elderly." Age and Ageing, 1979, p. 81-85.

SELF-CONCEPT IN ELDERLY FEMALES: THE IMPACT OF …€¦ · copyrighted materials were deleted, a...

Documents

Transcript of SELF-CONCEPT IN ELDERLY FEMALES: THE IMPACT OF …€¦ · copyrighted materials were deleted, a...