Educating the future: Serbian healthcare students’ knowledge and attitudes toward urinary incontinence | BMC Medical Education

Study design and setting

The research was conducted as a descriptive, analytical, comparative, and correlational cross-sectional study at the Faculty of Medicine of the University of Novi Sad, Serbia, during the winter semester of the 2023/2024 academic year. The study adhered to Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines.

Sample and data collection

Of the 640 questionnaires distributed, 389 were collected (60.8% return rate). Furthermore, 11 incompletely filled questionnaires were considered invalid and excluded from the study; 378 were included in the analysis (59.1% response rate). Therefore, the overall convenience sample comprised N = 378 students (n = 154 medical students, n = 129 nursing students, and n = 95 physiotherapy students).

The study inclusion criteria were established on the curriculum, which implied that the students had undergone training in compulsory subjects that should include lectures on the treatment of UI, such as Fundamentals of Nursing, Family and Primary Health Care, Gynaecology and Obstetrics, Surgery, Neurology, and Medical Rehabilitation. Hence, nursing and physiotherapy students were included if they were in the second, third, or fourth year of bachelor’s or master’s studies, while medical students were included if they were in the fifth or sixth year of integrated studies. First-year nursing and physiotherapy students and medical students in the first four years of their studies were excluded.

The sample size was determined based on the total number of students from all study programs who met the inclusion criteria (n = 640). Thus, using sample size software for cross-sectional studies, a sample of 240 students is required for a 95% confidence interval with a 0.05 margin of error. In order to compensate for the potential data loss of 20%, the sample needs a minimum of 290 students.

Data were collected using a paper version of the questionnaires distributed in the classroom after regular lectures. Before filling out the questionnaire, the students were informed about the study.

Student reported measures

A general questionnaire for obtaining sociodemographic data, the Urinary Incontinence Knowledge Scale (UIKS) [4] and the Urinary Incontinence Attitude Scale (UIAS) [5] were used as students’ report measures.

The general questionnaire includes seven items for obtaining the following data: gender, study program, study year, previously completed school, whether they had or not lectures on urinary incontinence, interest in education about UI, and a family member diagnosed with UI.

The UIKS includes 30 items grouped into six domains of knowledge about UI: risk factors, symptoms, impact on quality of life, prevention, treatment, and symptom control [4]. Answers to the statements are closed-ended: true, false, and do not know. A correct answer is scored with 1, and an incorrect and do know with 0. The maximum total score is 30. A score greater than 24 (> 80%) indicates good knowledge, from 18 to 24 average knowledge, and a score less than 18 (< 60%) indicates poor knowledge. The internal consistency measure in previous research for the entire scale was 0.72.

The UIAS includes 15 items grouped into three domains of attitudes towards UI: lower urinary tract symptoms and prevention, followed by treatment and symptom control [5]. The items in the questionnaire are evaluated on a four-point Likert-type scale, where 1 = completely disagree, and 4 = completely agree. The possible cumulative score ranges from 15 to 60, with a higher score indicating more positive attitudes toward treatment in UI care. The scale contains seven positively and eight negatively worded items. In previous studies, the scale’s internal consistency measure ranged from 0.65 to 0.70.

Permission to use both questionnaires was obtained from the author.

Translation procedure

A standard translation procedure, including forward, back translation, and reconciliation, was applied to ensure the linguistic validity of the questionnaire [19]. Namely, UIKS and UIAS were translated into Serbian by two independent experts, native Serbian speakers proficient in English. Subsequently, a back-translation of the Serbian version of the questionnaires was also done by the other two independent experts, who had not anticipated previous translations. The experts (authors of this manuscript) have competencies for translation and professional knowledge in urology and nursing. After that, they verified the synonymy of the back-translation version and original instruments. All the translators and the Serbian language lector conciliated with the final versions of both questionnaires.

Face validity and reliability

A panel of experts consisting of two students and one lecturer from each study program was assembled to assess the face validity of the questionnaires. They were asked to evaluate whether the items in both questionnaires were clear, unambiguous, correctly written, and at an appropriate level of difficulty for the students. Additionally, they assessed whether the instructions on the questionnaire were adequately given. The percentage of “yes” responses was 97%, signalling that the final Serbian version of the questionnaire can be accepted [20] (Appendix 1).

To determine the reliability of UIKS, the Kuder-Richardson Coefficient (K-R 20) was used to measure the internal consistency of the dichotomous items and Cronbach’s alpha (α) coefficient was used to assess the reliability of UIAS. K-R 20 showed high reliability of the knowledge scale at 0.83, while α was 0.62 for the attitude scale.

Data analysis

Data analysis was performed using descriptive and inferential statistics. The normality of the data distribution was assessed using the Kolmogorov-Smirnov test. Numerical characteristics are presented using descriptive statistics methods, such as mean values (arithmetic mean), measures of variability (standard deviation, minimum and maximum), and attributive characteristics by absolute and relative frequency. The significance of the differences was determined using the independent sample Student’s t-test and the ANOVA with the appropriate follow-up test (post hoc test). Pearson’s linear correlation coefficient (r) was used to determine the degree of association between students’ knowledge and attitudes about UI. Statistical processing and analysis of the obtained results were performed using the software package IBM SPSS 28, and all tests were two-sided with a significance level of p < 0.05.

Ethics approval and consent to participate

The study was conducted following ethical principles for the protection of human subjects. Approval was obtained from the Faculty of Medicine Commission for the Ethics of Clinical Research, the University of Novi Sad, Serbia 01–39/239/1 of September 9, 2022. Students received a written statement explaining the purpose of the study, anonymous and voluntary participation, and a guarantee that (non)participation in the study will not affect their further education. Informed consent to participate was obtained from all students who participated in the study.