Increased self-efficacy has been shown to promote adherence to pelvic floor muscle training and is indicated as a requirement sustained behavioural change(1). A systematic approach to examining the qualitative literature for the enablers and barriers to pelvic floor muscle training and influencers on self-efficacy has not been conducted to date. A behavioural framework was utilised to consider the interaction between behavioural factors to assist in behavioural change strategies. This novel review aimed to: 1) explore the facilitators and barriers in participation to pelvic floor muscle training; 2) identify the key influencers for self-efficacy which promote participation in pelvic floor muscle training.

A systematic review and meta-synthesis of the qualitative literature was performed. Seven databases (CINAHL, Cochrane, Embase, Emcare, Medline, PsycInfo and Web of Science) were searched from inception to August 2019.  Papers that included health care workers or institutions offering pelvic floor muscle training and people aged 18 years and over who had participated in pelvic floor muscle training were included. Other relevant articles were identified via citation tracking using Google Scholar. Three team members screened abstracts and titles using the software package Covidence, with a fourth member resolving any disagreements. Familiarisation of the data occurred by three members of the research team reading the articles in full and completing line by line coding of quotes and content within each paper. A collaborative approach was taken using inductive thematic analysis to identify key enablers and barriers to participation. Themes were applied to the Theoretical Domains Framework(2) and Capabilities, Opportunities and Motivation Behavioural Model(3) to establish behavioural influences on pelvic floor muscle training. The Theoretical Domains Framework is an integrative framework consisting of 14 domains that help to recognise cognitive, affective, social and environmental determinants of health related behaviour. The Capability, Opportunity and Motivation Behaviour Model is associated with the domains of the Theoretical Domains Framework to reflect that the behavioural domains do not operate in isolation and are often interactive with each other. The Critical Appraisal Skills Program Qualitative Research Checklist was used to assess study quality. Reporting in this review was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and the Enhancing Transparency in the Reporting of the Synthesis of Qualitative Research statement.

The search strategy yielded 20 eligible articles including data from 663 participants. Figure 1 represents study selection via the PRISMA flow diagram. Clear statement of the aims, adoption of appropriate qualitative methodologies and justification of recruitment strategies and data collection were included in all studies. Areas that were less consistent in reporting included declarations of bias with consideration to the relationship between the researcher and participants and in-depth explanations of a rigorous data analysis process. Five key themes were identified, including: Achieving and maintaining motivation; access to information and services; health care worker skill and expertise; competing demands; and acceptance and perception of symptom severity. Self-efficacy was a key construct that was found under four of the five themes. Self-efficacy and associated factors such as confidence in technique, knowledge and understanding, perceived benefit, recall and prioritisation all impacted motivation, perceived capability and opportunities for participation in pelvic floor muscle training. Factors described to optimise self-efficacy in patients include having positive interactions with their treating team, access to face-to-face treatments with health care workers, individualised care and goal setting and access to information through sharing with peers and the use of technology. Receipt of information did not necessarily translate to uptake, as understanding of purpose and technique often required facilitation through a health care worker. Modes of information that removed embarrassment and promoted autonomy, such as mobile applications, were viewed positively as they provided reminders and control for the user. Self-efficacy was found to be negatively impacted by acceptance of symptoms, low prioritisation and competing demands such as family and carer commitments. Health care workers felt that their own self-efficacy in prescribing and instructing pelvic floor muscle training was promoted by financially accessible professional development and access to mentorship. Limitations in resources such as staffing and time were described as being more evident in a public health system and seen as a barrier to self-efficacy.

Pelvic floor muscle training is more than a physical intervention, requiring the integration of cognitive and behavioural processes. Self-efficacy is an important element of pelvic floor muscle training and relies on a person’s capability to physically perform the task, their opportunity to engage and motivation to prioritise the action. Self-efficacy is influenced by multiple factors relating to the way information is received and sourced, belief that pelvic floor muscle training will provide symptomatic relief, acceptance of symptoms often shaped by societal influencers and competing demands. While this review highlights the importance of self-efficacy, the literature does not identify routine screening of self-efficacy levels and there are no definitive recommendations for optimisation of self-efficacy in pelvic floor muscle training. Knowing what to do with the identification of behavioural influences on self-efficacy also requires consideration. Clinicians should consider strategies to facilitate patient understanding of the purpose and benefits of pelvic floor muscle training and promote skill acquisition. This may include face to face delivery of teaching and monitoring where available, physical examination where appropriate, and use of technology to monitor progress, provide reminders and visual biofeedback. Understanding the role that societal influencers and social taboos place on the acceptance of symptoms, embarrassment and de-prioritisation of pelvic floor muscle training in place of family or social commitments is also vital when tailoring individualised care. This review took the novel approach of a systematic search of all populations and symptoms complexes for pelvic floor muscle training. Qualitative meta-synthesis provided an in-depth assessment of the experiences of people engaging with a behavioural intervention such as pelvic floor muscle training. Generalisation of findings is limited by a relatively homogenous pooled population.

Higher self-efficacy can optimise adherence and participation in pelvic floor muscle training and can be promoted through positive interactions with health professionals, enhancing understanding of the purpose and benefits, and the use of technology to provide autonomy and motivation.

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