Urinary incontinence (urine leakage) affects at least 25% of all women(1) and can occur at any age: about 10% of young women; 30% in late pregnancy or after giving birth and as many as 60% up to 26 years after giving birth.(2) The problem is associated with substantial consequences for physical, mental, and social wellbeing. Cochrane reviews clearly summarise evidence that Pelvic Floor Muscle Exercises (PFME) help for prevention, treatment, and cure of leakage. But these exercises are seldom prioritised. Research shows women want to talk about leakage but do not want to be the first to raise this topic with their health professional, women also lack knowledge about their pelvic floor and how to do these exercises. For those health professionals who are not continence specialists the lack of consistency in guidelines about PFME prescription means it is difficult to initiate, with confidence, any conversation about leakage or how these exercises can help. Yet opportunities to support women in preventing or managing this common problem is critical for improving the lives of many women, for reducing health care costs and minimising impact on the environment. Primary care clinicians are well placed to provide this support and could help women do these exercises throughout their life course.  

The introduction of a new national long-term plan to improve women’s health services includes training for all health professionals in pelvic floor health. This study was originally planned to adapt training designed for midwives, use stakeholder input with public involvement activities to identify ‘teachable moments’ in primary care, and then undertake initial research evaluation as a pilot clinical trial. However, early stakeholder work indicated the need to start again, albeit with the same evidence base for PFME and similar messages. Hence this report covers the early development work with stakeholders and members of the public with the aim to co-produce a bespoke training package suitable for teaching primary care clinicians when and how to support women to do PFME throughout their lives.

Early phase feasibility and acceptability development work with an iterative co-production approach. The underlying principle of public involvement was adopted in that the work was done with them and not to them, and opportunities for involvement were made as inclusive and early as possible using accessible locations and times for meetings, with support and feedback provided. Those involved were thanked for their time with vouchers and/or refreshments.  Activities included on-line and in-person meetings, practice run-throughs of training materials, with feedback-refinement cycles following further meetings or email exchanges. We asked women, primary care clinicians and researchers to discuss five points: (1) How do you feel about PFME being raised in GP/nursing appointments? (2) When should the topic of urine leakage and PFME be raised? (3) How should it be taught, by whom? (4) What resources would help? (e.g. leaflets, videos, logo etc) and (5) what are the likely barriers and facilitators. The updated Consolidated Framework for Implementation Research(3) was also used to structure discussion and development as this informs future national roll out and considers the outer setting (e.g., external policies, incentives), inner setting (e.g., culture, networks, and communication), and processes (e.g., planning, engaging, executing, reflecting, and evaluating). Objectives were to identify and agree: ‘teachable moments’; the scope and content of what women would want to be offered, including support resources; and what would enable clinician buy-in to do the training, including what resources they or their clinic would need.

Initial public involvement comprised two sessions with 13 women, 10 attending on-line who were nationally based with ethnic diversity, and three women attending a local in-person event held at their community centre playgroup. Initial stakeholder input occurred via two on-line sessions with seven national and international pelvic health expert clinicians and researchers. Many ‘teachable moments’ were identified and agreed. These were opportunities afforded by routine primary care appointments such as teenage contraceptive advice, cervical screens, post-natal checks, pessary fitting as well as opportunities arising from other consultations, such as for chronic cough, vomiting (morning sickness) or urine tests for infection or diabetes. A “Citizen’s Jury” approach was used to ascertain the most helpful App for supporting PFME habits. A resource logo was also jointly designed, to depict a water droplet being supported by ‘hands’ resembling the shape of a pelvis, and then professionally produced. Two sessions (one on-line and one in-person) with three primary care clinicians discussed the proposed training, and potential barriers and facilitators to implementation. The views gathered were subsequently mapped to theory and modifications were made to the training and resources. Following this, six GPs and one practice nurse attended one of five sequential presentations of the training; new iterations of the training package was presented on each occasion and comments and suggestions were incorporated into subsequent versions.

Four main messages were agreed for the training package: raising the topic and explaining why; screening for urine leakage (versus red flag conditions); teaching PFME and providing the resources; reminding, offering extra support or referral. The four messages allow for individual tailoring, one or more can used in the same appointment, but all women receive the same underlying messages from all their primary care clinicians. Refinements included using an experiential learning approach with case study scenarios, strategies for when and how to implement, and what resources were needed to support women (apps, texts, leaflets) and for use in clinics (posters, videos). Feedback meetings were then held with 10 women who were all keen to continue being involved in future work; feedback events were also held for clinician stakeholders.

The training package is ready for piloting in primary care. The strengths of using a co-production approach mean this evidence informed training package is designed to fit into routine primary care, and is likely to be acceptable to GPs, nurses, and the women they care for. By making the training brief (30minutes duration) but with supportive resources it should be feasible to implement into practices. It will also help meet the James Lind Alliance research priority that GPs are trained to promote better management of incontinence. However, the development work would benefit from more input from primary care nurses and wider public involvement including greater reach into underserved communities. A future formal research evaluation of this training package still needs to be undertaken.

Co-producing a training package specifically designed for use in routine primary care appointments creates a potential opportunity to support GPs and nurses provide a population prevention approach for women of any age. Repeated consistent messages across a woman’s life to do these exercises, from a wide range of health professionals, could mean additional benefits occur as these PFME are also a first level approach for treatment of incontinence and pelvic organ prolapse. The training package has the potential to contribute to the national long-term plan which stipulates that all health professionals are trained to support women’s pelvic health. Research is now needed to evaluate its potential for quality-of-life improvements and cost-effectiveness.

Todhunter-Brown A, Hazelton C, Campbell P, Elders A, Hagen S, McClurg D. Conservative interventions for treating urinary incontinence in women: an Overview of Cochrane systematic reviews. Cochrane Database of Systematic Reviews 2022, Issue 9. Art. No.: CD012337. DOI: 10.1002/14651858.CD012337.pub2.
Hagen S, et al. (2023). Long-term pelvic floor dysfunction after childbirth: the ProLong20+ study, Chief Scientist Office, Scotland, Final Report https://www.cso.scot.nhs.uk/wp-content/uploads/HIPS1709.pptx.pdf
Damschroder, L.J., Reardon, C.M., Widerquist, M.A.O. et al. (2022). The updated Consolidated Framework for Implementation Research based on user feedback. Implementation Sci 17, 75. https://doi.org/10.1186/s13012-022-01245-0

Continence 12S (2024) 101668
DOI: 10.1016/j.cont.2024.101668