Effects of Age and Causal Attribution to Aging on Health-Related Behaviors Associated With Urinary Incontinence in Older Women

The purpose of this study was to assess the effects of age and patients’ attribution of incontinence to aging on health-related behaviors associated with incontinence. Health-related behaviors include both “illness behavior” and “health behavior” (Kasl & Cobb, 1966). The focus of this study is on illness behavior. Mechanic (1995, p. 1208) describes illness behavior as “the varying ways individuals respond to bodily indications, how they monitor internal states, define and interpret symptoms, make attributions, take remedial actions and utilize various sources of informal and formal care.” Although incontinence is not an illness by definition, it is a condition that can be self-managed, self-treated, or treated by health care providers. Furthermore, incontinence is a condition that may be a symptom of a medical problem; or it may contribute to the development of a medical problem, as well as social, psychological, or financial problems (Wyman, Harkins, & Fantl, 1990). Thus, it is appropriate to view incontinence within the context of the growing social-psychological literature on illness behavior. Individuals’ beliefs about the cause and nature of their illness are a determining factor in their response to that condition. Whereas attribution theory has been most often applied to the achievement domain within social psychology, it is especially applicable to the health domain, as well. Weiner (1995) has demonstrated that “causal beliefs give rise to inferences about personal responsibility.” These beliefs ultimately serve to guide behavior. When individuals perceive an event as resulting from an impersonal, external, and/or uncontrollable cause, they are less likely to assume responsibility for doing anything about the event. Thus, if individuals perceive incontinence as resulting from the immutable process of aging, they may be less likely to engage in behaviors to ameliorate or treat the condition and more likely to engage in behaviors to manage the condition. Several investigators have demonstrated that incontinent individuals often attribute incontinence to aging (Gjorup, Hendriksen, Lund, & Stromgard, 1987; Mitteness, 1987a, 1987b, 1990b, 1992; Simons, 1985). The most common response to symptoms of illness involves the adoption of self-care behaviors (Haug, Akiyama, Tryban, Sonoda, & Wykle, 1991; Segall & Goldstein, 1989). These may include both self-management and self-treatment behaviors. Self-management strategies for incontinence include reducing fluid intake, increasing frequency of voiding, using absorbent devices (such as pads or towels), isolating oneself from others, changing nutritional intake, and not taking medications (such as diuretics). Self-treatment strategies for incontinence include performing Kegel exercises (Brink, Wells, & Diokno, 1987; Diokno, Brock, Brown, & Herzog, 1986; Engberg, McDowell, Burgio, Watson, & Belle, 1995; Herzog et al., 1989; Mitteness, 1987a; Thomas & Morse, 1991; Wells, Brink, Diokno, Wolfe, & Gillis, 1991). Additionally, “psychological strategies” are adopted in response to incontinence to manage the stigma associated with incontinence, thereby preserving one’s sense of self (Mitteness, 1987a). These include keeping the incontinence a secret by either not telling others about the problem or “through hyper-vigilance with respect to wetness or other evidence of accidents” (Mitteness, 1987a; p. 189). Another common response to illness is the seeking out and utilization of formal health care services. Mechanic (1978) has formulated a general theory of help-seeking behavior positing that individuals respond to symptoms based on what is culturally and socially appropriate as defined by both the self and others. “Factors affecting the response to illness include: 1) visibility, recognizability, or perceptual salience of deviant signs and symptoms, 2) the extent to which symptoms are perceived as serious, 3) the extent to which symptoms disrupt family, work, and other social activities, 4) the frequency of the appearance of the deviant signs or symptoms, their persistence, or their frequency of recurrence, 5) the tolerance threshold of those who are exposed to and evaluate the deviant signs and symptoms, 6) available information, knowledge, and cultural assumptions and understandings of the evaluator, 7) basic needs which lead to autistic psychological processes, 8) needs competing with illness responses, 9) competing possible interpretations that can be assigned to the symptoms once they are recognized, and 10) availability of treatment resources, physical proximity, and psychological and monetary costs of taking action” (pp. 130–131). Incontinence is a prevalent condition in older adults and is sometimes viewed erroneously as a natural process of aging (Brink et al., 1987; Jeter & Wagner, 1990; Locher & Burgio, 1996; Mitteness, 1987b, 1992). Whether or not age or the attribution of incontinence to age affects health-related behaviors associated with incontinence, including self-management, self-treatment, and formal treatment by health care providers, has received little attention in the literature. A few studies that have examined this issue report beliefs that incontinence is caused by aging are associated with not seeking treatment (Ashworth & Hagan, 1993; Gjorup et al., 1987; Goldstein, Hawthorne, Engberg, McDowell, & Burgio, 1992; Jolleys, 1988; Simons, 1985). It is well-known, however, that incontinence is a significantly underreported and undertreated problem, despite the availability, albeit limited, of formal treatments for incontinence by health care providers (Fantl et al., 1996). Studies of community-dwelling older adults have demonstrated that fewer than half of the participants experiencing incontinence reported the condition to their health care provider (Burgio et al., 1994; Roberts et al., 1998). Utilization of health care services is much higher for elderly adults compared with other age groups (Cockerham, 2001; Coulton & Frost, 1982; Galvin & Fan, 1975; Kronenfeld, 1978; Montiero, 1973; Wan & Soifer, 1974; Wolinsky et al., 1983; Wolinsky, Mosely, & Coe, 1986). Much of this increased utilization may be because older adults have poorer health and are more disabled, thus they have a greater need for formal services (Cockerham, 1997; Coulton & Frost, 1982; Wan, 1982; Wolinsky et al., 1983). Older adults are also more likely to have health insurance, compared with younger adults. Other literature, though, has found that older adults are less likely than younger adults to seek treatment for some clearly recognizable symptoms of potential medical problems (McKinley, Moser, & Dracup, 2000). The purpose of this study was to assess the effects of age and patients’ attribution of incontinence to aging on health-related behaviors associated with incontinence, specifically whether patients sought formal treatment, used self-management strategies, or attempted self-treatment.