Limited effects from limited adherence: using behavioural theory to underpin pelvic floor muscle training programs and outcomes

Abstract

Background: Pelvic floor muscle training (PFMT) is widely advocated for women with urinary incontinence (UI) but key to effectiveness is both short and longterm adherence. Adherence is defined as 'the extent to which a patient's behaviour matches agreed recommendations/ instructions from the prescriber; it is intended to be non-judgmental, a statement of fact, rather than to ascribe blame to the patient, prescriber, or treatment method'. To date little is known about the determinants of adherence in this patient group but it is thought that interventions to promote adherence should be based on theoretical models that provide explanation of that behaviour. Purpose: Our aim was therefore to identify theoretical models that have already been used in PFMT research in order to better facilitate adherence. Methods: Electronic literature searching (Medline, Cinahl, Embase; 1995 to 2012) and hand searching (reference lists of PFMT systematic reviews) was undertaken to identify English language publications reporting the use of a health behaviour theory to underpin the planning and/or delivery of a PFMT programme with the intent of promoting PFMT adherence. Results: From 13 studies that reported the use of health behaviour theory to promote or understand PFMT adherence five models were identified. These were: The Health Belief Model (4 studies); Theory of Planned Behaviour (one study); Social Cognitive Theory (SCT) (6 studies); the Transtheoretical Model and Self-regulatory model (used conjointly in two studies by the same author). Self-efficacy (a major component of SCT) was the most studied determinant of adherence and was found to be important in the prediction of adherence, and in the short and long term, behavioural changes required to undertake PFMT in peri-partum women and those with SUI (all ages). The Health Belief Model primarily focused on the person's ability to assess the benefits and disadvantages of undertaking the exercises with studies again focussing on the peri-partum period with one recruiting women from primary care. The Theory of planned Behaviour describes the intention to behave in a certain way in order to overcome a perceived threat, e.g. intention to undertake PFM exercises pre and post-delivery to prevent UI. Other authors used the Transtheoretical Model and Self-regulatory model to assess and develop a health education programme and protocol checklist for undertaking PFM exercise for women with stress and or urge UI. Conclusion(s): This is the first review on the use of Behavioural Theories to support interventions to improve adherence to PFMT. Evidence is limited, but the findings would suggest that self-efficacy (SCT) is important in long and short term effectiveness. A better theoretically-based understanding of interventions to promote PFMT adherence needs to be developed. The work to date has primarily focussed on the peri-partum period but future work should focus on variables e.g. age, type of UI. Implications: Existing health behaviour theories show some promise in planning PFMT programme content and delivery. Clinicians should be encouraged to use skills to enhance self-efficacy for PFMT. In research more attention is needed in reporting the theoretical underpinning of interventions intended to promote adherence and developing robust measures of adherence.