Epidemiological differences of lower urinary tract symptoms among female subpopulations and group level interventions

Objectives:Objectives: 1) To study the risk factor pro (cid:222) les of lower urinary tract symptoms (LUTS) among adolescent girls, housewives and working women and its socioeconomic and quality of life losses. 2) To undertake risk factor modi (cid:222) cations using the adolescent girls. Design and Setting: Design and Setting: Cross-sectional descriptive study followed by educational intervention. Statistical Methods: Statistical Methods: Cluster sampling, Proportions, con (cid:222) dence intervals, Chi square and t-Tests and Logistic regression. Materials and Methods: Materials and Methods: House to house survey was done in two villages and one urban ward. Seventy- (cid:222) ve housewives, 75 working women and 180 adolescent girls were asked about the risk factors and losses due to LUTS. Three teams of adolescent girls were utilized to bring about behavioral modi (cid:222) cations. Impact was measured through user perspectives obtained from the participants. Results:Results: Risk factors, social, economic and quality of life losses were different among the three female populations. Overall prevalence of LUTS among the three groups is 61(18.5%). Improper anal washing technique, malnutrition, presence of vaginal discharge, use of unsanitary menstrual pads, pinworm infestation and use of bad toilets were the signi (cid:222) cant causes among girls. Presence of sexually transmitted diseases was a contributing factor among housewives and working women. Prolonged sitting the posture was also contributing to LUTS among working women. Seventy-four per cent of bene (cid:222) ciaries expressed that intervention is useful. Conclusions:Conclusions: The causes for LUTS and their consequences were differing among the three female subpopulations. Speci (cid:222) c group level using trained girls were successful.


INTRODUCTION
Several studies [1][2][3][4][5] revealed that Lower Urinary Tract Symptoms (LUTS) are common among females and more than in men. [4] The LUTS are known to cause socioeconomic as well as quality of life losses. Lowe NK in his study showed that the symptoms of vaginitis and LUTS affected military women's quality of life. [6] The importance of assessment of quality of life losses was stressed by Espuna Pons in his study on LUTS. [7] Broseta Rico observed differences in the proÞ les of LUTS between menopausal and young women. [8] In this study, an attempt has been made to Þ nd out the epidemiological proß es of LUTS among adolescent age, occupation, literacy status, LUTS, type of the toilets used, anal washing technique after defecation, unsanitary pad usage during menses, history of pinworm infestation, presence of sexually transmitted diseases (STDs), usage of intrauterine contraceptive device (IUCD), loss of family life, loss of sexual life, loss of public relationships, loss of leisure opportunities, working hours, loss of physical independence, loss of wages, loss of leaves, reprimands from superiors or teachers etc were Þ lled by the lady doctors. It was tested and retested in 10% of the study population and deÞ ciencies were rectiÞ ed. Survey was completed in 15 days.
• The following case deÞ nitions were utilized for the study. a) LUTS considered were burning during micturition; Strangury; Pain during micturition; Increased Frequency of micturition; Urgency for micturition and Dull lower abdominal pain. [9] b) Anal Washing technique: Direction from front to back (anus to behind) was considered as a right technique. Washing in the direction from anus to genitals was considered as wrong technique as there was a chance of soiling the genitals with feces and scope for urinary tract infection (UTI). c) Malnutrition was deÞ ned as body mass index less than 19. d) Syndromic approach of diagnosing STD under National AIDS Control Programme was utilized for the study. E) Prolonged sitting was continuous sitting for more than 6 hours. • Data was analyzed for all the variables of LUTS using SPSS version 16. Proportions, conÞ dence intervals and X 2 test and t-Tests were calculated. Contribution of the risk factors causing LUTS among females was analyzed using logistic regression models.
In the intervention phase, 60 adolescent school girls were selected to participate in the intervention. Girls were selected as they will have free time for follow-up. They were divided into three action teams according to their target group: adolescent girls' team, housewives team and working women's team. They were trained in the department using audiovisual aids for 10 days. This training was imparted in local vernacular using the lady doctors, faculty and health educators of the department. Teaching topics were selected based on the results of risk factors obtained through analysis. Training was conducted in two sessions: one general session for three days for all the 60 girls about the etiology, prevalence, prevention and management of LUTS in general. Later, the speciÞ c sessions for seven days, targeting each group with main emphasis on the risk factors found by analysis among each group were taken up. Topics on menstrual hygiene, sexually transmitted infections, anal washing technique, importance of sterile pad usage, good nutrition, care while using intrauterine devices etc were selected for behavioral modiÞ cation. Adolescent girls were mainly targeted for menstrual hygiene improvement. In case of housewives, the stress was given on preventing STDs and safe sex practices. Working women were told about prevention of the occupational hazards. These points were stressed during training: Why do women have LUTS more often than men? What can I do if I have frequent LUTS? How serious are the LUTS? The following advices on preventing LUTS were given: drinking plenty of water to ß ush out bacteria, not holding urine, urinating when one feels to urinate, wiping from front to back after bowel movements, urinating after having sex, using enough lubricant during sex, avoiding using diaphragm if LUTS was present etc.
Pre-testing and post-testing was done to know the effect of training imparted. Impact of training to action teams was found signiÞ cant in all the three teams (t df19 =2.09, P<0.05 for girls' motivating team, t df19 = 4.262, P< 0.05 for housewives' motivating team and t df19 =4.055, P<0.05 for working women motivating team). The trained girls were advised to motivate all the females in that group (not just the UTI sufferers) by persistent persuasive techniques. The idea was to carry out disease prevention for the whole group. They did it for a period of three months at the rate of 2 hours per week. The impact was evaluated through user perspectives of all the three groups. After three months of intervention, the adolescent girls, housewives and working women were asked to give their own opinion about the effects of intervention. They were asked to grade it as good, fair or poor according to their own impressions. Follow-up was done by the girls and the lady doctors. About 50% of them are still continuing the lifestyle modiÞ cations.

RESULTS
Overall prevalence of LUTS in the study population was 61(18.5%). It is 23(13%), 22(29%) and 16(21%) among adolescent girls, housewives and working women respectively [ Table 1]. As a whole, it is 21% in the poor, almost 79% in middle calss and rare in high-class females. LUTS proÞ le in adolescent girls: Prevalence of LUTS was found to be more (17.8%) in girls who had attained menarche than those who hadn't (1.6%) (χ2=4.09, df1, CI=95%, P<0.05). The prevalence of LUTS was signiÞ cantly more in those girls using unsanitary pads during menstruation, practicing improper anal washing technique, having vaginal discharge,  Table 3]. Family problems, loss of sexual life, loss of leisure opportunities, Þ nancial burden, and poor attention to children were the common losses experienced by housewives. LUTS proÞ le among working women: using bad toilets, poor anal wash, STDs, prolonged sitting and vaginal discharge were the main reasons [ Table 4]. Occupations with too much of sitting are more affected (42%). LUTS

DISCUSSION
Overall prevalence of LUTS of 18.5% in this study is considerable but almost equal to other Indian studies. [10][11] The reasons for this high prevalence in this study appear to be due to improper anal washing technique, using unsanitary pads during menses, malnutrition, vaginal discharge and pinworm infestation. Similar results were also revealed by other studies. [1,5,12] But the factors operating were different for the girls, housewives and working women. Unsanitary pads usage, improper anal washing and malnutrition were the main causes among girls. STDs, poor anal wash, unsanitary menstrual pads and malnutrition are the common ones among housewives. Working women were suffering due to prolonged sitting for more than 6 h, using bad toilets and IUCD insertion. Lazy bladder syndrome may be the reason among women with prolonged sitting occupations.
Lowe [6] and Espuña Pons M [7] tried to assess quality of life led by patients suffering from LUTS . These losses among the three groups were also dissimilar in this study. Girls' major losses were sickness absenteeism and reprimands from teachers while the housewives lost family life and faced family and Þ nancial problems. The working women lost leisure time enjoyment, wages and leaves. Economic losses were considerable among the sufferers here as seen in a German study by Vonberg. [13] Broseta Rico also observed similar difference in the proÞ les of LUTS , but between young women and menopausal women. [8] As different factors were operating in these three groups, group-speciÞ c strategies for each group were used in this study. Singh MM utilized health workers to prevent LUTS. [1] Su et al. conducted similar interventions successfully in a speciÞ c group of clean room workers. [9] Impact of intervention to bring changes in negative practices yielded good results. As a whole, almost 74% of the beneÞ ciaries appreciated that the interventions were beneÞ cial to them and changed their bad practices to a large extent. More than half of the beneÞ ciaries are continuing the changed lifestyles. However, the role of hormonal factors was not studied in this study. This might be the reason for the difference between the young women and menopausal women in Broseta's study. More elaborate study on costeffective analysis of LUTS is warranted.
To conclude, the three female groups were suffering from LUTS due to different reasons. An educational intervention through adolescent girls to bring about the reduction in risk factors was successful. This group-speciÞ c approach yielded better results.