Correlation Between Spiritual Well-being and Quality of Life in Patients With Urinary Incontinence: A Cross-sectional Descriptive Study

Urinary incontinence (UI) is an uncontrolled leakage of urine that frequently causes medical, psychosocial, physical, and emotional problems in people of all ages.^1–3 It also reduces patient comfort and quality of life (QOL).^4–6 A decline in QOL is a critical indicator for seeking treatment of UI. The World Health Organization defines QOL as one’s perception of one’s position in life in the context of the culture and value systems in which one lives.⁷ Cross-sectional studies conducted in Turkey and Australia^2,8 have reported that people with UI are likely to have lower self-confidence as well as higher anxiety and social isolation. They consume little water, avoid using public transportation, avoid having sexual intercourse, have anxiety on trips too far away from home, and experience difficulty fulfilling their religious duties.^9–12 Spiritual well-being (SWB) is defined as a dynamic manifestation of spiritual health and maturation.¹³ Spiritual care is essential for patients with UI because it can provide spiritual comfort and promote recovery.^11,12,14,15 Spiritual care help to ensure SWB. Therefore, health care professionals should listen to and empathize with their patients, provide an appropriate setting in which patients can fulfill their religious obligations, answer their questions, and assist them in solving problems.^16,17 SWB determines the quality of one’s relationship with oneself, society, and one’s faith.^10,14  It also can make one mentally comfortable and help in overcoming illness.^10,14

SWB is an integral part of holistic nursing care and recovery.¹⁸ Nurses should have knowledge about their patients’ spiritual beliefs and rituals to provide patient-specific and  holistic care.¹⁹ SWB is a critical aspect of quality of life (QOL).²⁰ Panzini et al²¹ conducted a systematic review and detected a positive correlation between SWB and QOL. Determining QOL and SWB in patients with UI can help health care professionals plan and provide care that promotes SWB. The spiritual beliefs and needs of patients are crucial parts of holistic nursing care. However, to the best of the authors’ knowledge, there is no published research examining the relationship between SWB and QOL in patients with UI. 

The research questions of the current study were as follows: 1) What is the participants’ total mean Incontinence Quality of Life Questionnaire (I-QOL) score? 2) What is the participants’ total mean Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being 12 Item Scale (FACIT-Sp-12) score? 3) What is the correlation between QOL and SWB?

Research design. This cross-sectional descriptive study was conducted between April and November 2019 to determine the correlation between SWB and QOL in patients with UI. Patients who had UI, were older than 18 years, and did not have hearing and/or visual impairments or dementia were included in the study. Participants were recruited using convenience sampling methods (N = 383) in the urology outpatient clinic of a university hospital in Turkey.

Data were collected using a demographic information form (the FACIT-Sp-12) and the I-QOL form. The FACIT-Sp-12 form was based on a literature review conducted by the researchers.^2,7,9 The form elicited information on age, level of education, employment status, UI onset, hearing about spiritual care, believing in the necessity of spiritual care, and receiving spiritual care. Before collecting data, the researchers explained what “spiritual care” means to those who did not understand the questions about it. The researchers informed them that spiritual care was a broad concept encompassing individual values, beliefs, hope, and love and that it helped individuals to cope with despair and frustration. The researchers asked patients whether they had heard about spiritual care before, whether nurses had ever met their spiritual care needs, and whether they believed that spiritual care was necessary. 

The I-QOL (Cronbach’s alpha of 0.95) was developed by Wagner et al²² to determine QOL in patients with UI living in Washington (N = 62). Özerdoğan adapted the I-QOL to Turkish and established its validity and reliability.²³ It consists of 22 items and 3 subscales: limiting behavior (8 items), psychosocial impacts (9 items), and social embarrassment (5 items). The items are scored on a 5-point Likert-type scale (1 = very much, 5 = not at all). The total score is converted into a grade from 0 (lowest QOL) to 100 (highest QOL). Higher scores indicate higher QOL. Özerdoğan²³ reported that the Turkish version of the I-QOL had a Cronbach’s alpha of 0.96; the Cronbach’s alpha was found to be 0.94 in the current study.

The FACIT-Sp-12 was developed by Peterman et al²⁴ on 131 participants in the United States and adapted to Turkish by Aktürk et al.¹³ The FACIT-Sp-12 consists of 12 items and 3 subscales: meaning (4 items),  peace (4 items), and faith (4 items). The subscale “meaning” assesses internal harmony, “peace” assesses inner peace, and “faith” assesses the comfort and strength found in one’s religious belief. The items are scored on a scale of 0 to 4 (0 = never, 4 = always). The total score ranges from 0 to 48. Higher scores indicate better SWB. Aktürk et al¹³ reported that the Turkish version of the FACIT-Sp-12 had a Cronbach’s alpha of 0.87; Cronbach’s alpha was 0.76 in the current study. 

Data collection. Data were collected during routine visits through face-to-face interviews and using pen and paper. Patients were informed about the purpose and procedure of the study prior to participation. Written and verbal consent were obtained from those who met the inclusion criteria and agreed to participate. Afterward, they were asked to complete the data collection forms. The researcher was present to answer any questions regarding the forms and to read the items with which participants had difficulty. Data collection lasted 15 to 20 minutes. The data collection procedure was designed to protect confidentiality and anonymity. The interviews took place in a quiet and private room in the hospital. Only the researchers had access to data, and no data were shared with third parties. All identifying information was removed to ensure confidentiality and anonymity. 

Ethical considerations. The study was approved by the Non-Interventional Ethics Committee (decision no. 2019.03.24). Permission was obtained from the hospital. Patients were informed about the purpose and procedure of the study prior to participation, and informed consent was obtained from those who agreed to participate. 

Data analysis.  Data were analyzed using the Statistical Package for Social Sciences (SPSS v. 22) at a significance level of 0.05. Two (2) researchers checked the databases and analyses. A third researcher removed the forms with missing data (2 or more unanswered items). Number, percentage, mean, and standard deviation were used for descriptive statistics. Normality was tested using skewness and kurtosis values. Skewness and kurtosis values in the range of -2 to +2 suggest that data meet the normality assumption.²⁵ Neither I-QOL (skewness: 0.117; kurtosis: -0.876) nor FACIT-Sp-12 (skewness: -0.847; kurtosis: 1.704) scores were normally distributed. Therefore, an ordinal type of measurement and Spearman’s correlation were used to determine the correlation between the scale scores. The magnitudes of correlations were classified as follows: ≤ 0.25 = very low; 0.26 ≤ r ≤ 0.49 = low; 0.50 ≤ r ≤ 0.69 = moderate; 0.70 ≤ r ≤  0.89 = high; and 0.90 ≤  r  < 1 = very high.²⁵

Table 1 shows the demographic characteristics of the participants: 61.4% were women, 36.8% had a primary school education (8 years of schooling), 67.1% were unemployed, 84.3% had not heard about spiritual care previously, 47.5% believed that spiritual care was necessary, and 93.7% had not received spiritual care before. The mean age of participants was 52.76 ± 14.01 years, and they had UI for 3.54 ± 3.44 years on average.

Table 2 shows the participants’ mean I-QOL and FACIT-Sp-12 scores. Participants had a mean I-QOL score of 65.31 ± 19.71. Their mean “limiting behavior,” “psychosocial impact,” and “social embarrassment” subscale scores were 62.10 ± 20.65, 71.44 ± 19.91, and 59.69 ± 22.46, respectively. These results showed that they experienced social embarrassment the least and psychosocial impact the most. Participants had a mean FACIT-Sp-12 score of 28.00 ± 6.08. Their mean “meaning,” “peace,” and “faith” subscale scores were 8.86 ± 2.31, 7.98 ± 2.19, and 11.15 ± 3.16, respectively. 

Participants’s I-QOL and FACIT-Sp-12 scores were weakly and positively correlated (r = .235) (Table 3). FACIT-Sp-12 “meaning” subscale scores were weakly and positively correlated with I-QOL “limiting behavior” (r = .204), “psychosocial impact” (r = .258), and “social embarrassment” (r = .212) subscale scores. FACIT-Sp-12 “peace” subscale scores were weakly and positively correlated with I-QOL “limiting behavior” (r = .260), “psychosocial impact” (r = .326), and “social embarrassment” (r =.294) subscale scores. FACIT-Sp-12 “faith” subscale scores were weakly and positively correlated with I-QoL “limiting behavior” (r = .012), psychosocial impact” (r = .111), and “social embarrassment” (r =.069) subscale scores. 

To the authors’ knowledge, this is the first study to investigate SWB and I-QOL in patients with UI. Participants had a mean I-QOL score of 65.31 ± 19.71 (out of 100), which was above average in the score range (Table 2). Earlier studies, however, reported different results. Velázquez et al²⁶ conducted a descriptive study in Mexico and found that Mexican women with UI (N = 80) had an I-QOL score of 77.2 + 21.7. Melville et al²⁷ reported that for women living in Washington State,  the I-QOL score was 82.6 ± 17.6 (women without UI n = 1980, with UI n =1458). Akkus and Pinar²⁸ conducted a cross-sectional study in Turkish women with UI living in Turkey (N = 150) and determined that they had an I-QOL score of 56.7 ± 23.28. The differences in I-QOL scores may be due to differences in the type and severity of UI, sample size, sampling method, sociocultural background, religious belief, and hygiene perception. Overall, the participants of the current study had an above-average I-QOL score in the score range.

Hamid et al¹⁰ conducted a qualitative study on Iranian women with UI (N = 17) and reported that UI involved dysfunctions and impairments in emotional, spiritual, physical, and daily life. They found that Iranian women with UI were emotionally upset and spiritually exhausted about UI. van de Muijsenbergh and Lagro-Janssen²⁹ conducted semi-structured in-depth interviews with Moroccan (n = 13) and Turkish (n = 17) immigrant women with UI in the Netherlands and found that they had difficulty performing their religious duties. El-Azab et al³⁰ conducted a cross-sectional study of 1652 Egyptian women with UI in Egypt and reported that 90% had difficulty fulfilling their religious duties. The participants of the current study had a mean FACIT-Sp-12 score of 28.00 ± 6.08, which indicated average SWB in the score range (Table 2). Of the participants, 84.3% had not heard about spiritual care before, 93.7% had not received spiritual care before, and 47.5% stated that they needed spiritual care (Table 1). This shows the importance of providing information about spiritual care to patients as well as assessing their knowledge and need of spiritual care.

Eğlence and Şimşek³¹ conducted a descriptive study with 103 nurses in Turkey. They found that 59.4% of the nurses had knowledge about spiritual care and that 59.4% failed to meet their patients’ spiritual care needs because they did not have enough time (44.8%) or were understaffed (31.6%). Eğlence and Şimşek³¹ also reported that 40.6% of the nurses were able to meet their patients’ spiritual care needs by talking (53.8%) and listening to them (30.7%). McSherry and Jamieson³² conducted an online survey with 4054 nurses in the United Kingdom and found that 92.2% of nurses were able to meet the spiritual needs of their patients only occasionally. Spiritual care, which is part of holistic care, is as important as physical, emotional, and psychosocial care. However, spiritual and psychosocial needs are more abstract and complex and difficult to measure than physical needs. Therefore, it is more difficult to identify and meet patients’ spiritual needs.^31–33 These results suggest that nurses should consider the spiritual care needs of their patients when planning treatment. To that end, nurses should listen to their patients, sit quietly with them, empathize with them, answer their questions, and perform therapeutic touch.¹⁷

Participants’ I-QOL and SWB scores were weakly correlated (r = 0.235; P = .000) (Table 3), suggesting that patients with high SWB are likely to have higher QOL. UI has psychological, social, and economic effects that can lead to negative health outcomes; for example, patients with UI may feel dirty and be depressed or irritable.^34,35 It is important for Muslim women to fulfill their religious duties. However, Islam has more meticulous duties (rules of ablution and worship) than other religions, making it harder for Muslim women with UI to perform their religious practices. Nurses should take into account patients’ cultural backgrounds, beliefs, and habits when planning care and interventions.³⁶ As stated previously, the objective of care should be to help patients with IU sustain their activities of daily living despite limitations. Therefore, the focus should be on behaviors that promote QOL.^37,38 Nurses should help their patients with IU feel strong and adopt coping strategies to improve QOL.^39,40 Therefore, they would be also take SWB into account during care. The current study found a weak correlation between  QOL and SWB, suggesting that nurses should consider patient SWB as a variable to help optimize QOL for patients with UI.

The study had several limitations. First, participants were randomly selected; therefore, the results cannot be generalized. Second, participants were recruited from the urology outpatient clinic of only 1 university hospital in Turkey. Third, the study did not determine the type and severity of UI. Fourth, this was a correlational study that was not designed to examine interventions.

This cross-sectional descriptive study evaluated the correlation between QOL and SWB in patients with UI (N = 383). Patients had moderate I-QOL and SWB scores, which were weakly correlated. This study determined that “social embarrassment” subscale scores were weakly correlated with “peace” and “faith” subscale scores. The results of this study suggest that considering SWB when planning care may help optimize QOL for patients with UI. Future studies are needed to ascertain optimal methods to assess SWB, implement care, and evaluate its effects on patient QOL.

Dr. Gülnar is an assistant professor, Faculty of Health Sciences, Nursing Department, Kirikkale University, Kirikkale, Turkey. Dr. Özveren is an associate professor, Faculty of Health Sciences, Nursing Department, Kirikkale University, Kirikkale, Turkey. Dr. Yuvanç is an associate professor, Faculty of Medicine, Department of Urology, Kirikkale University, Kirikkale, Turkey. Address all correspondence to: Emel Gülnar, RN, PhD, Assistant Professor, Faculty of Health Sciences, Nursing Department, Kirikkale University, 71450 Kirikkale, Turkey; tel: 0090 3183573738; email: imel84@hotmail.com.