Rural adults who are living with stress urinary incontinence or urgency urinary incontinence have limited access to specialty care or support for self-management of symptoms. Community health workers, often referred to locally as promotoras, have a long history as trusted and knowledgeable community members who provide health education outreach and support along the U.S.-Mexico border. Based on our previous findings, promotoras have an overall lack of knowledge regarding different types of urinary incontinence and evidence-based, behavioral self-management strategies that may reduce symptom burden [1]. Promotoras were eager to be trained to provide urinary incontinence self-management support to their community because rural, Hispanic adults are reluctant to seek medical care for incontinence. The effectiveness of a nurse-promotora partnership to promote urinary health and reduce incontinence severity in rural communities has not been explored. The specific aims of this study were to 1) evaluate the cultural relevance and usefulness of content in educational train-the-trainer modules for promotoras to meet the needs of their community, and 2) explore format issues that may hinder access or use of the resource by promotoras in a rural, primarily Hispanic setting.

This ongoing community-based participatory research program is guided by Persily and Hildebrandt’s Theory of Community Empowerment [2]. A descriptive design was chosen to evaluate educational module content and to explore promotoras’ perspectives on accessibility and usefulness of a train-the-trainer resource. Following IRB approval, we were invited to present educational content in a conversational, workshop format at monthly meetings of promotoras. Workshops were presented in English with simultaneous voice translation in Spanish. All written materials, informed consent, evaluation surveys, and visual aids were provided in both languages for anonymous choice by participant. Following completion of a post-test, participants received 2 Continuing Education Units (CEU), approved for certification requirements if the participant’s post-test score was 70% or greater. Participants completed an open-ended evaluation survey; comments made during the workshop were noted and added to the survey responses. Qualitative data was analyzed for themes by content analysis.

Two content evaluation workshops were held midweek, during the day, in small rural community centers. Broadband access and video projection capability was unreliable, though participants were using their personal smart phones to video record and take photos. Results from qualitative content analysis of themes in evaluations and comment from the first workshop (n = 16) included the overarching theme of Lack of Desired Knowledge and two subthemes: Incontinence Self-Care is Empowering and Incontinence Self-Care is Counter-Intuitive (Table 1). Data analyzed from the first workshop informed the content for the second workshop. Results from the post-test scores following the second workshop demonstrated that all participants (n = 48) met CEU benchmark scores of 70% or greater (Table 2). Due to sample size constraints resulting in an under-powered test of differences between groups and violation of assumptions of normality on post-test scores in both groups, the non-parametric Mann-Whitney U test was used to compare groups on post-tests. No significant differences were found between English and Spanish language users on post-test scores (U = 277.5, z = -.220, p = .83).

Educational content from a continence nurse educator about incontinence self-care and prevention strategies was well received by the community health workers. Commonly held misconceptions expressed in the first developmental workshop were addressed and clarified in the second workshop, resulting in 100% of English and Spanish language users achieving benchmark scores on post-test to meet certification requirements. Promotoras requested nurse-led train-the-trainer programming in a smart phone compatible format.

Results from this study will guide development of a nurse-led, sustainable, interactive, train-the-trainer resource that is smart phone compatible in order to provide promotora outreach support to rural, Hispanic adults living with urinary incontinence.

Saiki, L. S., & Morales, M. L. (2019). Incontinence care needs in a US rural border region: Perspectives of promotoras. Online Journal of Rural Nursing and Health Care (Accepted).
Persily, C. A., & Hildebrandt, E. (2008) Theory of community empowerment. In M. J. Smith & P. R. Liehr (Eds.), Middle range theory for nursing (2nd ed., pp. 131-144). New York, NY: Springer Publishing Company.