Hrev_master Healthcare in Low-resource Settings 2025; volume 13:13975 Depression among older people living in the community with urinary, fecal, and double incontinence in Bali, Indonesia: a secondary data analysis I Gede Putu Darma Suyasa, Ni Kadek Sutini, Ni Luh Putu Inca Buntari Agustini, Israfil Israfil Faculty of Health, Institute of Technology and Health Bali, Denpasar, Indonesia Abstract Depression and incontinence in older people living at home have become a global issue; however, the research around this area is limited in Indonesia. This study aimed to determine the prevalence of depression among older people with Urinary Incontinence (UI), Fecal Incontinence (FI), and Double Incontinence (DI) in Indonesia. This study used data from a com- munity project dataset for case management processes in older people in an urban area of Bali in 2022. The dataset used was 970 older people aged 60+. We measured six variables in our study: age, gender, depression, UI, FI, and DI. A multivariate logistic regression analysis was conducted to explore the determinants of depression in older people. Most respondents were female (55.3%). Findings showed that the prevalence of depression, uri- nary, fecal, and double incontinence were 8.0%, 4.7%, 9.1%, and 2.8%, respectively. Depression was associated with age and all types of incontinence, but not gender. Logistic regression showed that the strongest predictor of depression in older people was FI (OR 3.151), followed by age, with OR 2.243. Nurses and other health workers should conduct more active screening for depres- sion and incontinence for better management of these global health issues. Introduction One of the most prevalent mental health conditions affecting older persons globally is depression, which has a significant neg- ative impact on general well-being, functional status, and quality of life.1 Although prevalence rates vary by population and diag- nostic criteria, depression in older people living at home in Indonesia affects between 11.8% and 13.6% of those 60 years and older.2,3 Emerging research highlights incontinence as a significant yet underappreciated component of the multiple reasons for depression in older people, which range from social isolation and chronic illnesses to cognitive impairment. In older populations, psychological distress and depressive symptoms have been linked to Fecal Incontinence (FI) – defined as the involuntary loss of stool, Urinary Incontinence (UI) – defined as the involuntary loss of urine, as well as their co-occurrence, known as Double Incontinence (DI),4-7 in addition to gender (female) and advancing age. UI affects up to 27% of older adults living in the community and at much greater rates in institutionalized populations, making it a prevalent condition among older adults.8,9 Despite being less common, FI affects around 8% of older adults,10 and a significant percentage of long-term care patients experience DI, which is when FI co-occurs with UI.11 In addition to causing a physical and hygienic burden, incontinence also leads to social disengagement, humiliation, and embarrassment – all of which are closely related to the development and maintenance of depressed moods. There are multiple ways in which depression and UI in older persons are associated. First, UI can cause severe psychological problems because of its stigma and perceived loss of dignity.12 Second, because UI is chronic and frequently progressive, it may cause ongoing tension and anxiety, which can create an atmo- Correspondence: I Gede Putu Darma Suyasa, Faculty of Health, Institute of Technology and Health Bali, Jalan Tukad Balian No. 180, Denpasar, Bali, Indonesia Tel.: +62.81238433388 – Fax: +62.3618956210 E-mail: putudarma.stikesbali@gmail.com Key words: depression, double incontinence, fecal incontinence, urinary incontinence. Ethics approval: this study is a secondary data analysis, and the dataset was used with permission from the community project on case manage- ment processes for older people in an urban area of Bali in 2022. The Research Ethics Committee of the Institute of Technology and Health Bali granted ethical approval with the number 04.0466/KEPITEKES- BALI/VII/2022. Availability of data and materials: the data that support the findings of this study are available on request from the corresponding author, [IGPDS]. Conflict of interest: the authors declare there are no competing interests related to this study. Funding: the authors did not receive support from any organization for this study. Contributions: IGPDS, study conception and design, study supervision, critical revisions for important intellectual content, and manuscript writ- ing; NKS, study conception and design, critical revision for important intellectual content, and manuscript writing; NLPIBA, data collection, literature review/analysis, manuscript writing, references; II, data analy- ses, manuscript writing, and references. Acknowledgement: we thank the Institute of Technology and Health Bali for granting permission to use the data for secondary analysis. Received: 12 May 2025. Accepted: 9 September 2025. Early access: 2 October 2025. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2025 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2025; 13:13975 doi:10.4081/hls.2025.13975 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organi- zations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [Healthcare in Low-resource Settings 2025;13:13975] [page 239] sphere that is favorable for the emergence of depressive symptoms. According to studies, older persons with UI have a much higher likelihood of having depressive symptoms than their contempo- raries on the continent; odds ratios vary from 2.3 to 3.8 based on the context and the severity of symptoms.13 DI is the most severe type of incontinence-related morbidity. In addition to raising the likelihood of institutionalization and the care burden, DI also exacerbates the psychological toll, which fre- quently results in worsened mental health issues, such as elevated rates of anxiety and depression. Although DI is comparatively less common in the general population, its frequency rises with age, frailty, and the presence of neurological illnesses like dementia and stroke,14 which are linked to an increased risk of depression. Although less research has been done, FI is just as devastating as UI. Many older people with FI view the inability to control their bowels as even more stigmatizing than urine leakage, which fre- quently leads to higher psychological impact and more severe social isolation.15 Studies indicate that the shame and challenges associated with managing bowel incontinence worsen depressive symptomatology, and FI has been associated with greater depres- sion scores.5 Even though incontinence and depression are firmly linked, lit- tle is known about the precise prevalence of depression in older persons with various forms of incontinence. There are still numer- ous unanswered questions regarding the relationship between the multiple forms of incontinence and the prevalence of depression in older persons, although these correlations are becoming increas- ingly acknowledged. Most existing studies examine either UI or FI in isolation, without accounting for the nuanced differences between these conditions or their compounding effects when they co-occur. Because of this, the current study aims to determine the prevalence of depression in older persons living in the community who have UI, FI, and DI, as a secondary data analysis using data from a community project dataset for case management processes in older people in an urban area of Bali in 2022. By identifying the prevalence and correlations of depression within these subgroups, the findings are expected to inform primary care strategies and public health policies tailored to the needs of aging populations. The study also seeks to contribute to the global discourse on geri- atric mental health by providing context-specific evidence from a middle-income, Southeast Asian setting. Materials and Methods Study design This study is a type of secondary data research. It used a dataset from a community project on case management processes for older people in an urban area of Bali to determine the factors related to depression in older people. Data source and sampling procedure This study used a dataset from a community project on case management processes for older people in an urban area of Bali in 2022. This is the only urban site in Bali possessing this type of data. The data set was collected cross-sectionally by interviewing older people in the area from August to September 2022. Sampling was conducted by analyzing individual data from the target population, individuals aged 60+. The total sample was 970 older people. Variables of the study Variables of this study were derived from 2 validated question- naires: the Barthel Index and the 5-item Geriatric Depression Scale. The questions on the Barthel Index of bladder were used to measure UI,16 and the question on bowel was used to measure FI. We classified respondents as experiencing UI if the respondent answered either “incontinence” or “occasional accident in the last 7 days” to the question of “bladder”. Similarly, we classified respondents as experiencing FI if the respondent answered either “incontinence” or “occasional accident in the last 7 days” to the question of “bowel”. Meanwhile, respondents were classified as experiencing DI if, simultaneously, she or he experienced both UI and FI. These classification methods are considered acceptable in studies on incontinence and have been adopted a previous study.8 Depression was measured using the 5-item Geriatric Depression Scale.17 Scores of 2 and above were considered indicative of depression. Data analysis We conducted data cleaning to check for inconsistencies and missing data. Bivariate and multivariate analyses were performed. Bivariate analyses were performed using a chi-squared test with Fisher’s test as an alternative when appropriate (Table 1), to deter- mine the relationship of each independent variable for depression, including age, gender, UI, Fi, and DI. Effect sizes were calculated and reported as a phi coefficient. Multivariable analysis was con- ducted using a logistic regression to identify independent variables associated with depression, while identifying the most dominant variables related to depression with a confidence interval of 95% CI. Only the variable with p>0.25 from the bivariate statistic entered the multivariate model (Table 2). All statistical analyses were two-tailed, with statistical significance defined as p<0.05. Statistical analyses for this study were conducted using SPSS ver- sion 27. Ethical consideration This study is a secondary data analysis, and the dataset was used with permission from the community project on case manage- ment processes for older people in an urban area of Bali in 2022.The Research Ethics Committee of the Institute of Technology and Health Bali granted ethical approval with the number 04.0466/KEPITEKES-BALI/VII/2022. Results We found no missing data in the dataset. Most respondents were female (55.3%), and their ages ranged from 60 to 96. Only 0.9% live alone (Table 3). The prevalence of depression, urinary, fecal, and double incontinence was 8.0%, 4.7%, 9.1%, and 2.8%, respectively (Table 4). Interestingly, 42.7% of respondents pre- ferred to stay home more often, 41.3% showed dissatisfaction with their own life, 13.1% felt bored, and 5.9% felt helpless (Table 5). Based on bivariate analyses, depression was associated with age (p<0.001, φ 0.130), all types of incontinence with a small effect size (UI: p=0.002, φ 0.112; FI: p<0.001, φ 0.157; DI: p=0.004, φ 0.111). Depression was not associated with gender (Table 3). Direct logistic regression was performed to assess the impact of several factors on the likelihood that respondents had depres- sion. The model contained four independent variables (age, UI, FI, and DI). The model containing all predictors was statistically sig- nificant for ADLs, χ2 (4, N = 970) =29.45, p<0.001, indicating that Advancing Nursing Education and Practice for Future Global Health [page 240] [Healthcare in Low-resource Settings 2025;13:13975] Advancing Nursing Education and Practice for Future Global Health [Healthcare in Low-resource Settings 2025;13:13975] [page 241] Table 1. Bivariate analyses of depression among older people with urinary, fecal, and double incontinence (n=970). Variable Categories Depression p Effect size (φ) No n (%) Yes n (%) Age 60-74 722 (80.9) 48 (61.5) <0.001§ 0.130 75+ 170 (19.1) 30 (38.5) Gender Male 396 (44.4) 38 (48.7) 0.462§ 0.024 Female 496 (55.6) 40 (51.3) Urinary incontinence No 856 (96.0) 68 (87.2) 0.002¶ 0.112 Yes 36 (4.0) 10 (12.8) Fecal incontinence No 823 (92.3) 59 (75.6) <0.001§ 0.157 Yes 69 (7.7) 19 (24.4) Double incontinence No 872 (97.8) 71 (91.0) 0.004¶ 0.111 Yes 20 (2.2) 7 (9.0) §Chi square; ¶Fischer exact test. Table 2. Logistic regression of determinant factors of depression among older people (n=970). B S.E. Wald df Sig. Exp(B) 95% C.I.for EXP(B) Lower Upper Age 0.808 0.257 9.883 1 0.002 2.243 1.355 3.710 Urinary incontinence -0.751 0.655 1.313 1 0.252 0.472 0.131 1.705 Fecal incontinence 1.148 0.356 10.389 1 0.001 3.151 1.568 6.333 Double incontinence 0.514 0.855 0.361 1 0.548 1.671 0.313 8.926 Constant -2.626 0.581 20.404 1 0.000 0.072 Table 3. Demographic characteristics of older people living in an urban area of Bali (n=970). Variable Categories n % Age 60-74 770 79.4 75+ 200 20.6 Gender Male 434 44.7 Female 536 55.3 Living arrangement With family 961 99.1 Alone 9 0.9 Table 4. Prevalence of depression, urinary, fecal, and double incontinence among older people living in an urban area of Bali (n=970). Item Yes n (%) No n (%) Urinary incontinence 46 (4.7) 924 (95.3) Fecal incontinence 88 (9.1) 882 (90.9) Double incontinence 27 (2.8) 943 (97.2) Depression 78 (8.0) 892 (92.0) Table 5. Frequency of depression among older people living in an urban area in Bali (n=970).Item Yes n (%) No n (%) Item Yes n (%) No n (%) Satisfaction with own life 569 (58.7) 401 (41.3) Feel bored 127 (13.1) 843 (86.9) Feel helpless 57 (5.9) 913 (94.1) Stay home 414 (42.7) 556 (57.3) Feel worthless 33 (3.4) 937 (96.6) the model could distinguish between respondents with and without depression. The model explained between 3% (Cox and Snell R square) and 7% (Nagelkerke R squared) of the variance in depres- sion and correctly classified 92% of cases. As shown in Table 2, only two independent variables made a unique statistically signifi- cant contribution to the model (age and FI). The strongest predictor of depression in older people was FI, recording an odds ratio of 3.151. This indicated that respondents with FI were over 3.1 times more likely to experience depression, controlling all other factors in the model. The second strongest variable was age, with an odds ratio of 2.243. Discussion This study aimed to determine the prevalence of depression among older people with urinary, fecal, and double incontinence in Indonesia. In addition, this study also explored the determinant factors of depression based on age and all types of incontinence. This study provides essential insight into the intricate relationships that exist between depression, UI, FI, and DI in Indonesian older individuals. The results show a strong and statistically significant correlation between older adults’ higher levels of depressive symp- toms and incontinence, especially FI. This emphasizes how critical it is to acknowledge incontinence as a psychological and mental health problem in addition to a physical one, especially in older adults living in culturally conservative settings. In contrast to previous studies, our findings show a higher prevalence of FI among the study population, which differs from prior global and regional research that frequently identifies UI as the more common kind of incontinence in older persons.18,19 This disparity could be caused by several factors, as revealed in a pre- vious study, such as respondents misclassifying UI, stigma- induced underreporting, or different trends in health-seeking behavior.20,21 Those with UI tend to hide the symptoms because it is considered embarrassing, resulting in an underreporting of UI symptoms. Given its stronger correlation with depression, the increased prevalence of FI is very significant. This suggests that Indonesia’s public health and older people care initiatives must pay more attention to this disorder. Despite being less common than UI and FI, as also reported by previous studies,22,23 DI is associated with depression based on bivariate statistics, although not as a determinant factor in the multivariate analysis. This could be explained by the fact that statistically, in the data set, only 9% of those with DI experience depression compared to 24.4% in FI and 12.8% in UI. When all variables are simultaneously entered into logistic regression models, only UI and FI contribute significantly to depression. Further study using a bigger sample size may be required to test the relation between depression and DI. Compared to their peers on the continent, older persons with incontinence of any kind had a much greater overall prevalence of depression.24,25 The evidence that incontinence and psychological discomfort are related is further supported by this trend. Our results, however, go beyond confirmation and provide new evi- dence that FI is the most powerful predictor of depression, outper- forming UI and even DI. The greater degree of embarrassment, discomfort, and practical difficulties related to managing fecal loss may account for the very significant correlation between FI and depression. FI is viewed as highly embarrassing and spiritually filthy in many Asian communities, particularly those in Indonesia. This stigma frequently results in social disengagement, self-isola- tion, and withdrawal from communal and religious activities, essential sources of identity and purpose for older Indonesians.26 FI tends to be less publicly discussed, poorly managed, and linked to more negative self-perceptions than UI, which may be more under- stood and somewhat more accepted. Embarrassment and worry are made worse by the visibility of fecal accidents, their unpleasant odor, and the intricate care needed. Therefore, it’s possible that older adults with FI feel more control and dignity lost, which makes them more susceptible to sadness. From a biological stand- point, neurological or muscular degeneration, which is frequently linked to advanced ageing, chronic illnesses like diabetes or stroke, or long-term pharmaceutical use, may also be connected to the severity of FI.27 These disorders are also associated with depres- sion, resulting in a complex feedback loop that exacerbates psy- chological deterioration. In this study, age was found to be the second predictor of depression. Depressive symptoms were more common in older age groups, especially those 75 years of age and older. This pattern is in accordance with the trajectory of functional decline as well as the rising incidence of dependency, loneliness, and chronic illness- es in later life.28-30 The inability of older persons to preserve their independence, engage in community activities, and practice basic self-care is exacerbated by incontinence, whether it be UI, FI, or DI. Furthermore, there is a cultural component to the relationship between incontinence and ageing in Indonesia. Ageing gracefully and calmly is expected in many communities. Therefore, the devel- opment of incontinence in later life may be interpreted as a social departure as well as a medical alteration, leading to emotions of guilt, stress, or even spiritual failure. This relationship is especially noticeable for elderly women, who frequently internalize their car- ing responsibilities and experience more emotional distress when confronted with physical constraints.30 FI is a stigmatized condition.20 In line with previous stud- ies,12,15 the impact of social stigma on the connection between depression and incontinence is one of the main issues that this study has revealed. Bowel and bladder control problems are fre- quently taboo subjects in Indonesian society, particularly among senior citizens. Silence about these problems can result in poor self-care practices, a lack of medical or social support, and delays in diagnosis. Many elderly people suffer in quiet as a result, which raises their risk of depression. The findings from this study have important implications for healthcare practice for older persons in Indonesia. First and fore- most, regular screening for depression and incontinence must be incorporated into primary healthcare services for older people. Because of their accessibility and community-based methodology, community health centers (Puskesmas) and Posyandu lansia (elderly integrated service posts) make early identification and intervention venues. Second, healthcare providers, especially nurs- es, general practitioners, and community health workers, must be trained to understand the psychological effects of incontinence. Beyond treating symptoms, interventions should also involve patient education, emotional support, and counselling sensitive to cultural differences. Thirdly, national health policies should give incontinence management and elderly mental health top priority as interconnected public health issues. The public health system in Indonesia does not adequately handle adult incontinence, and senior mental health services are inadequate. Increasing insurance coverage for mental health therapies and incontinence products could significantly enhance the lives of those impacted. Programs for carer support and community-based mental health promotion could potentially lessen the impact of depression on senior citi- zens. Family carers, who frequently act as the first line of care, should be equipped with the skills and information necessary to Advancing Nursing Education and Practice for Future Global Health [page 242] [Healthcare in Low-resource Settings 2025;13:13975] manage elderly people who are incontinent or depressed in a kind and efficient manner. While this study provides novel insights, sev- eral limitations must be acknowledged. First, this secondary anal- ysis from a cross-sectional design limits causal inference. While incontinence appears to be associated with higher depression lev- els, the reverse may also be true; depression may contribute to reduced self-care and worsening incontinence. Longitudinal stud- ies are needed to better understand directionality. Second, self- reported measures of incontinence and depression may be subject to recall and social desirability bias, especially given cultural sen- sitivities. Future research should incorporate objective clinical assessments and qualitative interviews to triangulate findings. Third, other potentially significant factors that could influence the link between incontinence and depression, such as socioeconomic status, carer burden, comorbidities, and health literacy, were not taken into consideration in this study. A more thorough, multi- faceted framework should be used in future studies to investigate these intersections. Fourth, this study was conducted based on a data set collected from one village in Bali. Generalization for a broader population may be limited. Conclusions This study emphasizes how critical it is to treat the psychoso- cial aspects of incontinence in older Indonesian individuals. 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