G Model
AGG-3130; No. of Pages 6 Archives of Gerontology and Geriatrics xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
Archives of Gerontology and Geriatrics journal homepage: www.elsevier.com/locate/archger
Prevalence of fecal incontinence (FI) and associated factors in institutionalized older adults Javier Jerez-Roig a,b,*, Dyego L.B. Souza c, Fabienne L.J.S. Amaral a, Kenio C. Lima a a Graduate Program in Collective Health, Federal University of Rio Grande do Norte, Avenida Senador Salgado Filho 1787, CEP: 59010-000 Lagoa Nova, Natal-RN, Brazil b Servicio de Rehabilitacio´n, Hospital Can Misses, Calle Corona s/n, 07800 Ibiza, Illes Baleares, Spain c Department of Collective Health, Federal University of Rio Grande do Norte, Campus Universita´rio s/n, CEP: 59078-970, Lagoa Nova, Natal-RN, Brazil
A R T I C L E I N F O
A B S T R A C T
Article history: Received 12 May 2014 Received in revised form 4 February 2015 Accepted 6 February 2015 Available online xxx
The objective of this work is to determine the prevalence of FI and associated factors in institutionalized elderly. A cross-sectional study is presented herein, conducted between October and December 2013, in 10 nursing homes (NHs) of the city of Natal (Northeast Brazil). Individuals over the age of 60 were included in the study, while those hospitalized or in terminal phase were excluded. Data collection included sociodemographic information, FI characterization, as well as variables related to the institution itself and to health conditions (comorbidities, medication, pelvic floor surgery, Barthel Index for functional capacity and Pfeiffer test for cognitive status). FI was verified through the Minimum Data Set (MDS) 3.0, which was also used to assess toileting programs. The Chi-square test and the linear Chisquare test were performed for bivariate analysis, as well as logistic regression for multivariate analysis. The final sample consisted of 321 elderly, mostly females, with mean age of 81.5 years. The prevalence of FI was 42.68% (CI 95%, 37.39–48.15). Most residents presenting FI were always incontinent (83.9%) and the most frequent incontinence type was total FI (solid and liquid stools). Incontinence control measures were applied only to 9.7% of the residents. The final model revealed a statistically significant association between FI and functional and cognitive impairments. It is concluded that FI is a health issue that affects almost half of the institutionalized elderly, and is associated with functional and cognitive disability. ß 2015 Elsevier Ireland Ltd. All rights reserved.
Keywords: Aging Elderly NHs FI
1. Introduction Fecal incontinence (FI) is a common gastrointestinal complaint in elderly individuals, defined as the involuntary loss of stool or inability to control stool from expulsion, which is a social and hygienic problem (Norton, Whitehead, Bliss, Harari, & Lang, 2010; Shah, Chokhavatia, & Rose, 2012). Although it is a health issue frequently neglected, it affects between 2% and 20% of the elderly in community settings and prevalence increases considerably when an institution environment is considered (Aslan, Beji, Erkan, Yalcin, & Gungor, 2009; Leung & Rao, 2009; Leung & Schnelle, 2008; Saga, Vinsnes, Morkved, Norton, & Seim, 2013; Shah et al., 2012; Zarate, Lopez-Kostner, Vergara, Badilla, & Viviani, 2008). This problem entails a strong impact for health systems, as well as
* Corresponding author at: Graduate Program in Collective Health, Federal University of Rio Grande do Norte, Avenida Senador Salgado Filho 1787, CEP: 59010-000 Lagoa Nova, Natal-RN, Brazil. Tel.: +55 84 3215 4133; fax: +55 84 3215 4133. E-mail address: [email protected] (J. Jerez-Roig).
social impact to caregivers, family members, and on the health and life quality of the elderly (Leung & Rao, 2009; Shah et al., 2012). In Brazil, it is estimated that FI in the general population varies between 2% and 7%, however this figure may represent an underestimation of cases, due to the fact that the presence/ absence of the issue is auto-reported (Amaro et al., 2009; Santos & Santos, 2011; Santos et al., 2014). Controversy regarding the associated factors still remains for FI, and the subject has been the focus of limited research, especially in institutionalized elderly of Latin America (Santos et al., 2014; Townsend, Matthews, Whitehead, & Grodstein, 2013; Zarate et al., 2008). It is worth noting that continence control measures are not systematically applied in Brazil as in other developed countries such as USA, which could influence FI prevalence (Jerez-Roig, Souza, & Lima, 2013). Therefore the findings of this study contribute to the knowledge base on this specific health issue, frequent in older age groups and consequently, contribute to support prevention and control actions in a NH context. Thus, the objective of this study is to verify the prevalence of FI and associated factors in institutionalized elderly.
http://dx.doi.org/10.1016/j.archger.2015.02.003 0167-4943/ß 2015 Elsevier Ireland Ltd. All rights reserved.
Please cite this article in press as: Jerez-Roig, J., et al., Prevalence of fecal incontinence (FI) and associated factors in institutionalized older adults. Arch. Gerontol. Geriatr. (2015), http://dx.doi.org/10.1016/j.archger.2015.02.003
G Model
AGG-3130; No. of Pages 6 J. Jerez-Roig et al. / Archives of Gerontology and Geriatrics xxx (2015) xxx–xxx
2
2. Materials and methods 2.1. Subjects A cross-sectional study is presented herein, with data collection accomplished between the months of October and December 2013, in 10 of the 14 NH certified by the Sanitary Vigilance of the municipality of Natal (Northeast Brazil). The remaining 4 NH declined participation in the study. All elderly individuals were included in the study, i.e., over the age of 60, according to criteria from the World Health Organization (WHO) for developing countries. Exclusion criteria were: hospitalized or palliative care residents (terminal phase). The research team was constituted by the main researcher and by students from the undergraduate Physiotherapy course of the Federal University of Rio Grande do Norte (UFRN). The team met previously in two occasions, to ensure adequate comprehension of the questionnaires and calibration of examiners. A pilot study was carried out with 24 elderly from the first NH studied. The current study was approved by the Research Ethics Committee of the Federal University of Rio Grande do Norte, approval no. 308/2012. 2.2. Measures The dependent variable of the study was the presence of FI, defined as ‘the involuntary loss of liquid or solid stool’, as accepted by the International Consultation on Incontinence (Norton et al., 2010). This information was extracted from item H4 of MDS version 3.0, which considers fecal continence during the previous 5 days, according to the direct caregiver. The following categories are possible: always continent, occasionally incontinent (1 episode of bowel incontinence), frequently incontinent (2 or more episodes), always incontinent (no episodes of continent bowel movements) and not rated (ostomy or no bowel movements for the entire 5 days). Residents with FI were selected when classified as occasionally, frequently or always incontinent for bowel movements. The MDS is a complete database for standardized assessment in NH, which has also presented high levels of reliability regarding continence status and toileting programs (Saliba & Buchanan, 2012). This tool was also used to assess urinary incontinence, devices (including ostomy), constipation and if bowel toileting programs were applied. Ostomy cases were accounted for, but were excluded from bivariate analysis. The direct caregiver also answered questions regarding the use of diapers and daily amount, classification of FI according to the type of feces (solid, liquid, or both) (Johanson, Irizarry, & Doughty, 1997), as well as the daily mean of bowel movements, presence of diarrhea and use of laxatives. A period of 5 days was considered to assess all variables regarding incontinence and bowel patterns (Saliba & Buchanan, 2012). Sociodemograhic variables were also collected (age, gender, race, education level, marital status, number of children and births, reason for institutionalization, residency time, free time occupation/hobbies, retirement, finance administration, health plan and ratio number of elderly per caregiver) as well as variables related to the NH (type of NH, length of stay and ratio residents/caregiver), and related to health conditions (presence and number of comorbidities, diabetes, cancer, prostate cancer, Parkinson’s disease, Alzeimer’s disease, stroke, arterial hypertension, kidney insufficiency, cardiovascular disease, pulmonary disease, osteoporosis, rheumatic disease, mental disease, vaginal, anal–rectal and prostate surgery records, consumption of alcohol, current and past consumption of tobacco, urinary infection within the last 30 days, hip fracture within the last 60 days, daily medication and number of medicines). All these variables were collected from medical records and complemented by information given by the main caregiver and healthcare professionals.
The mobility status was also considered (walks without aid, walks with aid, wheelchair user and bedridden) along with the functional capacity for activities of daily living (ADL), through the validated Portuguese version of the Barthel Index (Cincura et al., 2009), excluding the areas corresponding to continence, as described previously (Prado-Villanueva, Bischoffberger-Valde´s, Valderrama-Gama, Verdejo-Bravo, & Damia´n, 2011). Cognitive capacity was evaluated through Pfeiffer’s test, except for those with severe hearing deficit or those who did not speak the language (Martinez-Iglesia et al., 2001). 2.3. Analyses Bivariate analysis was carried out through the Chi-square test (or Fisher’s test) and the linear Chi-square test. The magnitude of association was verified through the prevalence ratio, to a significance level of 95%. Variables with p values lower than 0.20 were analyzed by logistic regression to build the multivariate model, through the Stepwise Forward method. Permanence of the variable in the multiple analysis depended on the Likelihood Ratio Test, absence of collinearity, as well as its capacity to improve the model through the Hosmer and Lemeshow test. Following Miettinen, odds ratio was transformed into prevalence ratio (Miettinen & Cook, 1981). 3. Results Of the total number of elderly, 8 (2.4%) of the individuals were excluded from the study: 6 (1.8%) were hospitalized, 1 (0.3%) was in terminal phase, and 1 (0.3%) was under the age of 60. A total of 321 elderly were included in the study (100% response rate), mostly of the female gender (75.4%) and the mean age was 81.50 (SD: 9.0). Of the total, 49.2% did not have children, 47.4% were single and 25.2% were widows/ers. The majority (63.3%) resided in not-forprofit organizations, and was institutionalized because of the lack of caregivers (46.7%) or because lived alone (13.4%). A total of 268 (83.5%) individuals were long-term stay residents (more than 1 year) and 16.5% were new admissions (up to one year). The mean residency time was 63.2 months (SD: 62.0) and the mean ratio elderly/caregiver was 8.09 (SD: 5.2). The majority of the elderly was retired (95.3%), however did not have private health plans (62.6%). The use of diapers comprehended 66.0% of the elderly and bowel toileting programs were applied to 31 residents (9.7%), through prompted voiding or facilitation of defecation by the use of laxatives. Of the total number of elderly, 40 presented constipation (12.5%), 9 presented diarrhea (2.8%), and 31 used laxatives (11.5%). The daily mean of bowel movements was 1.2 (SD: 0.8). FI prevalence was 42.68% (CI 95%, 37.39–48.15), and there was 1 (0.3%) unclassified case (colostomy). Among the 137 elderly with FI, double (fecal and urinary) incontinence was observed in 135
Table 1 Characteristics of the residents presenting FI (n = 137).
Frequency Occasionally incontinent Frequently incontinent Always incontinent FI type Solid stool Liquid stool Total Bowel toileting program No Yes
n
%
7 15 115
5.1 10.9 83.9
42 14 81
30.7 10.2 59.1
129 8
94.2 5.8
Please cite this article in press as: Jerez-Roig, J., et al., Prevalence of fecal incontinence (FI) and associated factors in institutionalized older adults. Arch. Gerontol. Geriatr. (2015), http://dx.doi.org/10.1016/j.archger.2015.02.003
G Model
AGG-3130; No. of Pages 6 J. Jerez-Roig et al. / Archives of Gerontology and Geriatrics xxx (2015) xxx–xxx
3
Table 2 contains the variables that presented p value equal or lower than 0.20 in the bivariate analysis and were not included in the final model. Multiple analysis showed that FI was associated with functional and cognitive incapacities, assessed by the Pfeiffer scale, adjusted by the variables age, race, stroke, and reason for institutionalization ‘‘lack of caregiver’’ (Table 3). This re-categorization of the variables functional and cognitive incapacities occurred due to a low frequency of FI cases presenting functional independency and intact cognitive capacity. The Hosmer–Lemeshow value was 0.930.
(42.1%) individuals, and only 2 (0.6%) did not present urinary incontinence. The majority of the elderly with FI presented the total type (solid and liquid stool), was always incontinent (not presenting any episode of continence), and did not follow any continence control program. The characteristics of the elderly presenting FI are shown in Table 1. It is worthwhile to mention that in the FI group there were no cases of functional independency, and only one case of slight dependence. For this reason, it was decided to group the categories independency, slight and moderate dependency.
Table 2 Bivariate analysis of the FI associations with independent variables. FI No
Yes
Gender Male Female Marital status Married Other Arterial hypertension Yes No Education level Illiterate-Primary Education I Primary Education II-Superior Daily frequency of bowel movements
AGG-3130; No. of Pages 6 Archives of Gerontology and Geriatrics xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
Archives of Gerontology and Geriatrics journal homepage: www.elsevier.com/locate/archger
Prevalence of fecal incontinence (FI) and associated factors in institutionalized older adults Javier Jerez-Roig a,b,*, Dyego L.B. Souza c, Fabienne L.J.S. Amaral a, Kenio C. Lima a a Graduate Program in Collective Health, Federal University of Rio Grande do Norte, Avenida Senador Salgado Filho 1787, CEP: 59010-000 Lagoa Nova, Natal-RN, Brazil b Servicio de Rehabilitacio´n, Hospital Can Misses, Calle Corona s/n, 07800 Ibiza, Illes Baleares, Spain c Department of Collective Health, Federal University of Rio Grande do Norte, Campus Universita´rio s/n, CEP: 59078-970, Lagoa Nova, Natal-RN, Brazil
A R T I C L E I N F O
A B S T R A C T
Article history: Received 12 May 2014 Received in revised form 4 February 2015 Accepted 6 February 2015 Available online xxx
The objective of this work is to determine the prevalence of FI and associated factors in institutionalized elderly. A cross-sectional study is presented herein, conducted between October and December 2013, in 10 nursing homes (NHs) of the city of Natal (Northeast Brazil). Individuals over the age of 60 were included in the study, while those hospitalized or in terminal phase were excluded. Data collection included sociodemographic information, FI characterization, as well as variables related to the institution itself and to health conditions (comorbidities, medication, pelvic floor surgery, Barthel Index for functional capacity and Pfeiffer test for cognitive status). FI was verified through the Minimum Data Set (MDS) 3.0, which was also used to assess toileting programs. The Chi-square test and the linear Chisquare test were performed for bivariate analysis, as well as logistic regression for multivariate analysis. The final sample consisted of 321 elderly, mostly females, with mean age of 81.5 years. The prevalence of FI was 42.68% (CI 95%, 37.39–48.15). Most residents presenting FI were always incontinent (83.9%) and the most frequent incontinence type was total FI (solid and liquid stools). Incontinence control measures were applied only to 9.7% of the residents. The final model revealed a statistically significant association between FI and functional and cognitive impairments. It is concluded that FI is a health issue that affects almost half of the institutionalized elderly, and is associated with functional and cognitive disability. ß 2015 Elsevier Ireland Ltd. All rights reserved.
Keywords: Aging Elderly NHs FI
1. Introduction Fecal incontinence (FI) is a common gastrointestinal complaint in elderly individuals, defined as the involuntary loss of stool or inability to control stool from expulsion, which is a social and hygienic problem (Norton, Whitehead, Bliss, Harari, & Lang, 2010; Shah, Chokhavatia, & Rose, 2012). Although it is a health issue frequently neglected, it affects between 2% and 20% of the elderly in community settings and prevalence increases considerably when an institution environment is considered (Aslan, Beji, Erkan, Yalcin, & Gungor, 2009; Leung & Rao, 2009; Leung & Schnelle, 2008; Saga, Vinsnes, Morkved, Norton, & Seim, 2013; Shah et al., 2012; Zarate, Lopez-Kostner, Vergara, Badilla, & Viviani, 2008). This problem entails a strong impact for health systems, as well as
* Corresponding author at: Graduate Program in Collective Health, Federal University of Rio Grande do Norte, Avenida Senador Salgado Filho 1787, CEP: 59010-000 Lagoa Nova, Natal-RN, Brazil. Tel.: +55 84 3215 4133; fax: +55 84 3215 4133. E-mail address: [email protected] (J. Jerez-Roig).
social impact to caregivers, family members, and on the health and life quality of the elderly (Leung & Rao, 2009; Shah et al., 2012). In Brazil, it is estimated that FI in the general population varies between 2% and 7%, however this figure may represent an underestimation of cases, due to the fact that the presence/ absence of the issue is auto-reported (Amaro et al., 2009; Santos & Santos, 2011; Santos et al., 2014). Controversy regarding the associated factors still remains for FI, and the subject has been the focus of limited research, especially in institutionalized elderly of Latin America (Santos et al., 2014; Townsend, Matthews, Whitehead, & Grodstein, 2013; Zarate et al., 2008). It is worth noting that continence control measures are not systematically applied in Brazil as in other developed countries such as USA, which could influence FI prevalence (Jerez-Roig, Souza, & Lima, 2013). Therefore the findings of this study contribute to the knowledge base on this specific health issue, frequent in older age groups and consequently, contribute to support prevention and control actions in a NH context. Thus, the objective of this study is to verify the prevalence of FI and associated factors in institutionalized elderly.
http://dx.doi.org/10.1016/j.archger.2015.02.003 0167-4943/ß 2015 Elsevier Ireland Ltd. All rights reserved.
Please cite this article in press as: Jerez-Roig, J., et al., Prevalence of fecal incontinence (FI) and associated factors in institutionalized older adults. Arch. Gerontol. Geriatr. (2015), http://dx.doi.org/10.1016/j.archger.2015.02.003
G Model
AGG-3130; No. of Pages 6 J. Jerez-Roig et al. / Archives of Gerontology and Geriatrics xxx (2015) xxx–xxx
2
2. Materials and methods 2.1. Subjects A cross-sectional study is presented herein, with data collection accomplished between the months of October and December 2013, in 10 of the 14 NH certified by the Sanitary Vigilance of the municipality of Natal (Northeast Brazil). The remaining 4 NH declined participation in the study. All elderly individuals were included in the study, i.e., over the age of 60, according to criteria from the World Health Organization (WHO) for developing countries. Exclusion criteria were: hospitalized or palliative care residents (terminal phase). The research team was constituted by the main researcher and by students from the undergraduate Physiotherapy course of the Federal University of Rio Grande do Norte (UFRN). The team met previously in two occasions, to ensure adequate comprehension of the questionnaires and calibration of examiners. A pilot study was carried out with 24 elderly from the first NH studied. The current study was approved by the Research Ethics Committee of the Federal University of Rio Grande do Norte, approval no. 308/2012. 2.2. Measures The dependent variable of the study was the presence of FI, defined as ‘the involuntary loss of liquid or solid stool’, as accepted by the International Consultation on Incontinence (Norton et al., 2010). This information was extracted from item H4 of MDS version 3.0, which considers fecal continence during the previous 5 days, according to the direct caregiver. The following categories are possible: always continent, occasionally incontinent (1 episode of bowel incontinence), frequently incontinent (2 or more episodes), always incontinent (no episodes of continent bowel movements) and not rated (ostomy or no bowel movements for the entire 5 days). Residents with FI were selected when classified as occasionally, frequently or always incontinent for bowel movements. The MDS is a complete database for standardized assessment in NH, which has also presented high levels of reliability regarding continence status and toileting programs (Saliba & Buchanan, 2012). This tool was also used to assess urinary incontinence, devices (including ostomy), constipation and if bowel toileting programs were applied. Ostomy cases were accounted for, but were excluded from bivariate analysis. The direct caregiver also answered questions regarding the use of diapers and daily amount, classification of FI according to the type of feces (solid, liquid, or both) (Johanson, Irizarry, & Doughty, 1997), as well as the daily mean of bowel movements, presence of diarrhea and use of laxatives. A period of 5 days was considered to assess all variables regarding incontinence and bowel patterns (Saliba & Buchanan, 2012). Sociodemograhic variables were also collected (age, gender, race, education level, marital status, number of children and births, reason for institutionalization, residency time, free time occupation/hobbies, retirement, finance administration, health plan and ratio number of elderly per caregiver) as well as variables related to the NH (type of NH, length of stay and ratio residents/caregiver), and related to health conditions (presence and number of comorbidities, diabetes, cancer, prostate cancer, Parkinson’s disease, Alzeimer’s disease, stroke, arterial hypertension, kidney insufficiency, cardiovascular disease, pulmonary disease, osteoporosis, rheumatic disease, mental disease, vaginal, anal–rectal and prostate surgery records, consumption of alcohol, current and past consumption of tobacco, urinary infection within the last 30 days, hip fracture within the last 60 days, daily medication and number of medicines). All these variables were collected from medical records and complemented by information given by the main caregiver and healthcare professionals.
The mobility status was also considered (walks without aid, walks with aid, wheelchair user and bedridden) along with the functional capacity for activities of daily living (ADL), through the validated Portuguese version of the Barthel Index (Cincura et al., 2009), excluding the areas corresponding to continence, as described previously (Prado-Villanueva, Bischoffberger-Valde´s, Valderrama-Gama, Verdejo-Bravo, & Damia´n, 2011). Cognitive capacity was evaluated through Pfeiffer’s test, except for those with severe hearing deficit or those who did not speak the language (Martinez-Iglesia et al., 2001). 2.3. Analyses Bivariate analysis was carried out through the Chi-square test (or Fisher’s test) and the linear Chi-square test. The magnitude of association was verified through the prevalence ratio, to a significance level of 95%. Variables with p values lower than 0.20 were analyzed by logistic regression to build the multivariate model, through the Stepwise Forward method. Permanence of the variable in the multiple analysis depended on the Likelihood Ratio Test, absence of collinearity, as well as its capacity to improve the model through the Hosmer and Lemeshow test. Following Miettinen, odds ratio was transformed into prevalence ratio (Miettinen & Cook, 1981). 3. Results Of the total number of elderly, 8 (2.4%) of the individuals were excluded from the study: 6 (1.8%) were hospitalized, 1 (0.3%) was in terminal phase, and 1 (0.3%) was under the age of 60. A total of 321 elderly were included in the study (100% response rate), mostly of the female gender (75.4%) and the mean age was 81.50 (SD: 9.0). Of the total, 49.2% did not have children, 47.4% were single and 25.2% were widows/ers. The majority (63.3%) resided in not-forprofit organizations, and was institutionalized because of the lack of caregivers (46.7%) or because lived alone (13.4%). A total of 268 (83.5%) individuals were long-term stay residents (more than 1 year) and 16.5% were new admissions (up to one year). The mean residency time was 63.2 months (SD: 62.0) and the mean ratio elderly/caregiver was 8.09 (SD: 5.2). The majority of the elderly was retired (95.3%), however did not have private health plans (62.6%). The use of diapers comprehended 66.0% of the elderly and bowel toileting programs were applied to 31 residents (9.7%), through prompted voiding or facilitation of defecation by the use of laxatives. Of the total number of elderly, 40 presented constipation (12.5%), 9 presented diarrhea (2.8%), and 31 used laxatives (11.5%). The daily mean of bowel movements was 1.2 (SD: 0.8). FI prevalence was 42.68% (CI 95%, 37.39–48.15), and there was 1 (0.3%) unclassified case (colostomy). Among the 137 elderly with FI, double (fecal and urinary) incontinence was observed in 135
Table 1 Characteristics of the residents presenting FI (n = 137).
Frequency Occasionally incontinent Frequently incontinent Always incontinent FI type Solid stool Liquid stool Total Bowel toileting program No Yes
n
%
7 15 115
5.1 10.9 83.9
42 14 81
30.7 10.2 59.1
129 8
94.2 5.8
Please cite this article in press as: Jerez-Roig, J., et al., Prevalence of fecal incontinence (FI) and associated factors in institutionalized older adults. Arch. Gerontol. Geriatr. (2015), http://dx.doi.org/10.1016/j.archger.2015.02.003
G Model
AGG-3130; No. of Pages 6 J. Jerez-Roig et al. / Archives of Gerontology and Geriatrics xxx (2015) xxx–xxx
3
Table 2 contains the variables that presented p value equal or lower than 0.20 in the bivariate analysis and were not included in the final model. Multiple analysis showed that FI was associated with functional and cognitive incapacities, assessed by the Pfeiffer scale, adjusted by the variables age, race, stroke, and reason for institutionalization ‘‘lack of caregiver’’ (Table 3). This re-categorization of the variables functional and cognitive incapacities occurred due to a low frequency of FI cases presenting functional independency and intact cognitive capacity. The Hosmer–Lemeshow value was 0.930.
(42.1%) individuals, and only 2 (0.6%) did not present urinary incontinence. The majority of the elderly with FI presented the total type (solid and liquid stool), was always incontinent (not presenting any episode of continence), and did not follow any continence control program. The characteristics of the elderly presenting FI are shown in Table 1. It is worthwhile to mention that in the FI group there were no cases of functional independency, and only one case of slight dependence. For this reason, it was decided to group the categories independency, slight and moderate dependency.
Table 2 Bivariate analysis of the FI associations with independent variables. FI No
Yes
Gender Male Female Marital status Married Other Arterial hypertension Yes No Education level Illiterate-Primary Education I Primary Education II-Superior Daily frequency of bowel movements
