TECHNOLOGIES FOR HEALTH EDUCATION IN THE CARE OF PATIENTS WITH URINARY INCONTINENCE: AN INTEGRATIVE REVIEW

Objective: analyze the technologies available in the literature used for health education in the care of people with urinary incontinence. Methods: integrative review, with database searches: Índice Bibliográfico Espanhol de Ciências da Saúde (IBECS), Base de Dados em Enfermagem (BDENF) via Biblioteca Virtual em Saúde (BVS), Medical Literature Analysis and Retrieval System Online via Pubmed (MEDLINE/PubMed) from the National Library of Medicine, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Scopus, Web of Science and Embase. The collection was carried out in February 2021, with the main descriptors: Urinary Incontinence, Educational Technology and Health Education. Results: 91 articles were selected, after analyzing the inclusion and exclusion criteria, there were only 5 productions that were selected, presenting as a strategy the technologies: multimedia course, videos, mobile application and book/booklet. The articles were published between 1997 and 2020. The dimensions considered were: development of health technologies for the treatment of urinary incontinence and knowledge, adherence and the effect of using health technologies for the treatment of urinary incontinence. Conclusion: the technologies used were diversified, with the adherence and the effect being directly proportional, and it depends on how the individual understands urinary incontinence and the impact it brings on each person’s life. la incontinencia urinaria. Conclusión: las tecnologías utilizadas fueron diversas, siendo la adhesión y el efecto directamente proporcionales, dependiendo de cómo el individuo comprende la incontinencia urinaria y el impacto que esta causa en la vida de cada uno.


INTRODUCTION
Urinary incontinence (UI) has as its basic definition the involuntary loss of urine. In 1998, it became part of the International Classification of Diseases/World Health Organization (ICD/WHO), no longer considered just a symptom and becoming a disease 1 .
UI does not cause death, but it has a profound negative impact on the well-being, quality of life and aspects of daily life of people affected, including personal, work and leisure activities. It is associated with a deep feeling of humiliation and stigma, affects various age groups and the main conditioning factors that interfere with quality of life (QL) are the severity and type of incontinence 2,3 .
According to the Brazilian Society of Urology Sociedade Brasileira de Urologia (SBU), this condition affects about 400 million people worldwide, and in Brazil there is an average of 10 million people with incontinence. Among general population studies, the prevalence of UI ranged between 25% and 45% in adult women, and in adult men there were publications with variations between 1 and 39%, with the proportion in women being at least twice as high when compared to men 2 .
A study on nursing care for people with UI highlighted the importance of the professional's role at various times of performance, in order to characterize UI as a basic issue of nursing care. In the meantime, nurses can work in different areas

METHODS
This is an integrative literature review (ILR) in order to compile studies that address information on educational methods aimed at UI.
The survey took place in February 2021, following the six steps directed at ILR: elaboration of the survey question; search of primary studies in database; data extraction; analysis of included studies with interpretation of results and presentation of the review 8 .
The research question was organized according to the PICo strategy (P -population; I -intervention/interest; Cocontext), as it is an integrative review 8 . Thus, the following structure was considered: P -people with UI; I -educational technologies in health; Co -health education. Thus, the following question was elaborated: What technologies are used for health education in the care of people with UI?
The following inclusion criteria were adopted for the studies: original articles regardless of the published language, without a temporal filter. As an exclusion criterion, it was observed if the articles answered the research question and duplicate articles were counted only once. Documents such as letters to the editor, animal studies, annals of scientific events, theses, dissertations and literature reviews were not included. Subject Headings (MeSH) and CINAHL titles, as well as keywords and synonyms in English and Portuguese. The Boolean operators "OR" and "AND" were used in data collection.
The descriptors used in the research, as well as the search strategies are shown in Table 1.

RESULTS
In this study, 91 articles were retrieved, with the reading of the titles and abstract, 65 were not included because they were not related to the topic. Of the 26 included, 9 appeared in more than one database, keeping 1 of each article, with 6 being excluded, totaling 20 articles; of these, 6 were excluded due to difficult access, the abstract or the full article not Technologies for health education in the care of patients with urinary incontinence: an integrative review The selected articles aimed to create or measure an educational technology to be used in people with some type of UI and/or their caregivers, with four intervention studies and one validation study. There is a scarcity of publications on the effect of educational technologies aimed at UI.
Among the technologies that appeared as a strategy were obtained: a multimedia course, two videos, an application and a book/booklet. The studies were published between 1997 and 2020, being one American, one Brazilian, one from the Middle East, one from Sweden and one from Holland, all published in English. As for the level of evidence, 2B studies predominated10.
With regard to the target audience, two surveys targeted the general public, two for women, one specifically for postpartum women and one for the elderly. And all had favorable outcomes for the effect of the strategies used and for the awareness, prevention and/or conservative treatment of UI. The information is compiled in Table 2.

Development of health technologies for the treatment of urinary incontinence
With the selected studies, it was possible to show that in the study carried out in the Netherlands, the multimedia strategy was used through book, television and radio, seeking to reach a greater number of people, whether continent or not, however, to assess the effect of the tools, it was possible to target audience people with UI. Respondents who returned the questionnaire after 3 months counted a sample of 134 participants. These received tasks such as recording their habits and urinary losses, training exercises for the lower pelvic floor muscles, improving posture, breathing and relaxation, as well as guidance on behavior changes 11 .
As for the study carried out in Sweden, we The other study that used video lessons using a tablet as an intervention strategy was carried out in the United States of America (USA) with a sample of 207 participants, with caregivers of incontinent elderly as target audience. The feasibility of developing and implementing interventions for UI for informal caregivers through portable technologies was found 15 . It is reinforced that the technologies can be used both for people who have incontinence and for family members / caregivers of individuals with this condition.
And one study used the mobile app as a method to promote adherence to pelvic floor muscle training and UI prevention, targeting postpartum women as a target population. The study validated the instrument with an expert and target audience, obtaining a minimum of 94.3% of positive responses 14 .
Knowledge, adherence and effect of using health technologies for the treatment of urinary incontinence The results of the studies directed towards the adherence and effect of the technologies and satisfactory results were obtained in all the studies, regardless of the chosen strategy, favoring the learning and improvement of the clinical picture related to UI.
The study dealing with the use of multimedia showed satisfactory results, showing that about 50% of the participants indicated an improvement in their condition, with a decrease in the severity of urinary loss and an improvement in quality of life, and demonstrated gains in secondary prevention for UI, at least in short term 11 , since in the long term it has not been evaluated.
The use of the book/leaflet as a strategy has been shown to be effective in disseminating knowledge on the subject, encouraging self-management and can provide benefits to meet growing demands and optimize health resources. It is important to emphasize that the technology was well received by the general public and by a specific group and were considered useful and efficient in the dissemination of knowledge and to facilitate self-management, however it was shown that knowledge, by itself, does not guarantee the behavioral change that favor the prevention and treatment of UI 12 .
The technology in the video class format employed in women with and without UI has resulted in improved knowledge and awareness about UI, and can reach large and heterogeneous groups, including people with poor health care conditions.
The study also demonstrated that most women are unaware of or have inadequate knowledge about UI and its interventions and that the approach significantly increased women's short-term knowledge about the topic 13 . The video class aimed at family/informal caregivers, regarding the technology used, demonstrates the feasibility of implementing technologies in the intervention for UI. Caregivers rated the intervention as effective, with improvements in care recipient urine leakage, access to a beneficial UI specialist, and would recommend it to a friend. Although the study suggests improvements with the use of more rigorous design and a larger sample to establish efficacy, the results indicate that the use of technology can also be an important option for improving access to health insurances and clinical experts 15 .
As for the use of mobile apps, the study obtained a significant number of positive responses in the items evaluated, being considered an educational technology for the promotion and adherence to pelvic floor muscle training and prevention of UI in postpartum women, which was its target audience 14 , however, no studies have been performed to assess the effect.

Development of health technologies for the treatment of urinary incontinence
Health technologies are characterized as any interventions that can be applied to promote health, prevent, diagnose or treat diseases, for rehabilitation, long-term care or even that are intended to organize the provision of health care and have been widely used as educational strategies to assist the development of activities 16 .
Considering that UI is an alteration that presents a favorable prognosis with the use of behavioral measures, the use of technologies and self-management techniques is considered an essential component for the coverage of care for incontinent people 14 , favoring learning and behavior change.
When analyzing the studies, even with a small number of publications, it can be seen that the five articles represented in this study used one or more health technologies, in a diversified way, for specific populations in the care of people with UI [11][12][13][14][15] . It is observed that the technologies, even targeted, are likely to be used by the general public.
The multimedia course format favors the approach of the chosen audience, this strategy simultaneously uses different means of communication in the quest to encompass the diversity of the group and capture their attention 11 . This approach expands the options and can favor adherence, and at least knowledge on the topic, which can be treated very positively, since for the problem to be understood, the UI needs to be understood as something not physiological.
The study with the use of videos, as well as books/booklets also reinforce the importance of using diversified resources and solutions to be used to guide and educate the population, especially in an environment with few resources and limited number of health professionals, collaborating with access to individual health care 13 .
There are several methods used to promote health education. A study on the production of educational content corroborates the studies presented when it states that one of the biggest challenges to producing educational content does not depend on the format used, but on the definition of the use of language and communication channels and their association 16 .
Currently, several methodologies have been designed to support the treatment of UI, in particular mobile applications, and it is believed that they can increase adherence to treatment and counseling, and may, among the benefits, reduce costs 17 .
Digital technology and the internet are a reality in our days and have become increasingly accessible to all niches of the population, favoring the use of applications, making this strategy a viable and feasible option.
Thus, it is opportune to confirm the importance of using technologies and that they can be diversified to provide opportunities for the population to expand their knowledge with access to information and interventions that help in conducting care for UI.
Knowledge, adherence and effect of using health technologies for the treatment of urinary incontinence Health technologies are considered an efficient method for the dissemination of knowledge, prevention and conservative treatment of UI. A study explains that its effectiveness and adherence vary from 18% to 95%, being one of the main problems in the treatment of UI 18 . There is a high variation regarding adherence and consequent effectiveness of the treatment, and this is due to multifactorial, multidimensional and individual issues.
This reality corroborates a study on treatment adherence, which states the existence of several factors that influence treatment adherence and may be related to the patient, the disease, health beliefs, lifestyle and cultural habits, treatment, quality of life , the institution and the relationship with the health staff 19 .
Thus, the use of a certain methodology is not a guarantee of efficiency and adherence, since it depends on the particular interest, impact and representation that incontinence has on the person's life and the effect directly depends on the level of awareness for the adherence of existing guidelines in the material.
All studies showed a positive impact on the use of educational materials for the prevention and treatment of UI, however it was not possible to measure which was the most effective, not even in those with the same technology, since the target audience was different, among other aspects. . For this it would be necessary to carry out experimental and comparative studies, and no studies with this proposal were found.
However, studies have shown that the use of health technologies, in the form of educational technologies, facilitates public access to the material, helps to hold the attention of participants, expands the acquisition of knowledge and promotes treatment adherence, bringing positive effects on the participants 6,[11][12][13][14] . It also reinforces the importance of interactivity to hold the public 's attention, which increases their understanding, even in people with low education 11 .
As a limitation of the study, the difficulty of locating articles in the databases can be highlighted, specifically on technologies used to promote health in people with UI, as well as having access to some of the articles in full.

CONCLUSION
The technologies used were diversified, with four intervention studies and one methodological, with a low level of evidence. Thus, it is imperative to carry out more robust research with greater scientific impact, such as randomized clinical trials, aiming to produce strong scientific evidence to support clinical practice.
The analysis of the studies showed that the educational technologies used for the prevention and treatment of UI contribute to the decision-making process, self-management of participants in relation to care related to UI, as well as to caregivers. Adherence and effect are directly proportional and depend on how the individual understands UI and the impact it brings on each person's life.
Research can improve knowledge of educational technologies aimed at UI and favor the increment of future research with the use of different technologies in the health education process in the context of UI.
In relation to this theme and bringing it to the scope of nursing, there is an expansion of studies related to the development and application of technologies aimed at teaching-learning, however they can still be considered incipient and require investments for a greater and more diversified production.
It is important to emphasize that just the development of technologies is not enough, training and dissemination are also necessary for their use and applicability, in order to modify the experienced reality.