Since adherence is a key predictor of the success of pelvic floor muscle (PFM) training, many attempts have been made to explain and enhance adherence. However, applying behavioral change theories in a particular exercise setting requires context-specific knowledge and an understanding of the patient’s experience [1]. While many older adults with urinary incontinence (UI) undertake PFM training, little is known about their experience in doing so individually or as a group. This study aims to describe the phenomenon of therapeutic adherence to a 12-week PFM training program for the treatment of UI, based on women’s perceptions of individual physiotherapy or group physiotherapy.

Women aged 60 years and over who had participated in a non-inferiority RCT comparing individual and group physiotherapy for stress and mixed UI were asked to be interviewed after their treatments. Both treatments consisted of a 12-week physiotherapy program including a weekly one-hour PFM training session with an experienced physiotherapist and daily home-based progressive PFM exercises. Each PFM training session comprised 10 minutes of education on UI, 30 minutes of PFM training in different static positions and 20 minutes of functional PFM training. The individual intervention consisted of one-on-one sessions between the participant and the physiotherapist, while group intervention consisted of sessions with eight participants supervised by the physiotherapist.

June 2016 to August 2017, 12 participants consented to face-to-face interviews that were facilitated by a semi-structured interview guide. Of these, half completed the individual physiotherapy program and half the group-based physiotherapy program. The interview questions were related to UI stigmatization, but the phenomenon of therapeutic adherence also emerged during the interview session. The interview data was audio-recorded and transcribed. Transcripts were then organized with ATLAS.ti software and analyzed using the interpretive phenomenological analysis method. To enhance our understanding of the data, two meetings were conducted with two experts in qualitative research, one expert in PFM rehabilitation research, the interviewer and the first author to discuss and achieve consensus regarding data interpretation.

The women’s mean age and standard deviation was as follow: individual treatment = 66.8±6.6 years and group treatment = 69.7±6.2 years. In both intervention groups, 4/6 women had lived with UI for two to five years and 2/6 for seven years or more. Their ICIQ-UI SF score varied from 9/21 to 16/21 in the individual treatment (mean = 13.0±2.3) and from 7/21 to 18/21 in the group treatment (mean = 12.3±4.9) which is indicative of moderate to severe symptoms. On the Geriatric Self-Efficacy Index questionnaire, participants in both treatments had similar scores before the intervention (individual treatment = 50.8±28.7 and group treatment = 53.5±31.2), representing moderate level of self-efficacy. 

Adherence facilitators that emerged from the data were interpersonal in nature. Two main themes arose from the women’s perceptions of adherence: (1) physiotherapist’s impact and (2) group effect. These themes, each in its own way, appeared to influence a third theme in the data: (3) self-efficacy. In the context of individual treatments, adherence seemed to be influenced mainly by verbal persuasion from the physiotherapist. In the group treatment, sharing difficulties and successes between participants seemed to facilitate therapeutic adherence. Both groups reported improved self-efficacy (i.e., the individual’s belief in her own capacity to accomplish a task) related to the physiotherapist or the group interactions, which was also a facilitator for adherence. Figure 1 presents women’s perception of adherence.

Theme 1: In both treatment contexts, physiotherapists were perceived to enhance adherence through particular characteristics such as dynamism, organization and competence. These same attributes are found to be adherence facilitators, in the literature [1]. Specific to the individual treatments, the women also reported that “forming a team” with the physiotherapist was an additional facilitator to adherence. This concept called “therapeutic alliance” provides the patient with the feeling of working in tandem with the therapist in a shared effort against the patient’s distress [2]. 

Theme 2 is related to the feeling of association between each woman taking part in a group treatment. Their opportunity to share their weaknesses with other women in the group seemed to induce positive feelings about PFM training instead of self-blame, which appears to enhance adherence. To exercise with women who have the same pathology also appeared to improve self-image, in some women. Moreover, seeing benefits and difficulties of their peers, enhanced the women’s desire to be part of the treatment and motivated them to adhere.  

Theme 3: Depending on the treatment context, the physiotherapist or the group were perceived as a source of self-efficacy enhancement for the women. In the individual treatment, women reported improved self-efficacy after receiving specific encouragement from the physiotherapist. In fact, the physiotherapist in this context could produce “verbal persuasion” and make the person believe in her own ability to perform the exercises. In the group treatment, women reported witnessing difficulties and successes among the other women of the group and this led to a higher adherence. This finding aligns well with Bandura’s Social Learning theory and “vicarious experience” [3]. Self-efficacy is very important in this type of program since women who initiate a PFM training report feeling relatively disempowered [1]. Improved self-efficacy is known to be closely related to greater long-term adherence to PFM training [1].

Our findings contribute to a better understanding of older women’s experience and perception of adherence to a PFM training program for urinary incontinence. While both groups demonstrated improved self-efficacy, positively influencing their adherence, this was due to different facilitators in their treatment context.  Additional studies are needed to further explore these underlying facilitators.

Dumoulin, C., Hay-Smith, J., Frawley, H., McClurg, D., Alewijnse, D., Bo, K., ... & Hagen, S. (2015). 2014 consensus statement on improving pelvic floor muscle training adherence: International Continence Society 2011 State-of-the-Science Seminar. Neurourology and urodynamics, 34(7), 600-605.
Ackerman SJ, Hilsenroth MJ. A review of therapist characteristics and techniques positively impacting the therapeutic alliance. Clin Psychol Rev. 2003 2003/02/01/;23(1):1-33.
Bandura A. Self-efficacy: Toward a unifying theory of behavioral change. Psychol Rev. 1977;84(2):191-215.