Patient Adherence: The Key To Success

Key Messages

  • Patient motivation and adherence is the most important predictor of treatment success  
  • Recent International Continence Society publications tell us the biggest patient-reported barrier to adherence is perception of minimal benefit of pelvic floor muscle exercises
  • Best outcomes are achieved when patients complete a full course of treatment, with good adherence, and are discharged to a maintenance program
  • We need to educate our patients about the effectiveness of pelvic floor exercises, and the importance of adherence to their pelvic floor muscle training program

Patient motivation and adherence is the most important predictor of treatment success.  The International Continence Society (ICS) acknowledges the importance of this and recently invited an expert panel to review the literature in this area and provide recommendations for research and clinical practice.

There is Level 1 evidence that pelvic floor muscle training is effective in treating stress, urgency or mixed urinary incontinence, pelvic organ prolapse, and lower bowel dysfunctions.  However, it is estimated that only 64% of patients adhere to their pelvic floor muscle training programs in the short term, and then only 23% of them continue in the long term. 

Guided By Research

Research by guru pelvic floor researcher, Professor Kari Bo, concluded that the best outcomes are achieved when patients:

  • Attend appointments
  • Are adherent to the prescribed treatment recommendations
  • Complete their management program  
  • Are discharged with a maintenance program

The International Continence Society’s expert panel published a 5-paper series investigating barriers and facilitators to treatment adherence1-5.  Included in this series was a survey conducted with health professionals and patients, investigating barriers and facilitators to adherence.  The top 4 patient-reported factors facilitating adherence were:

  1. The perception of significant benefit of a proposed treatment
  2. A high degree of motivation
  3. High self-efficacy
  4. An immediate beneficial effect of treatment

Interestingly, health professionals expected that low levels of patient motivation would be the biggest barrier to adherence.  However, patients reported that the perception of minimal benefit of pelvic floor muscle training was the greatest barrier.

This highlights the importance of educating our patients about how effective pelvic floor muscle training can be in treating their specific condition. It also demonstrates the value of education regarding realistic expectations and time frames.

How To Encourage Behavioural Change

Behavioural change is essential to patient adherence.  The ICS Consensus Statement2 identified 5 key techniques clinicians can use to encourage behavioural change in their patients: 

  1. ‘Patient knowledge’ is considered essential, developed by educating patients appropriate to their age, sex and ethnicity.
  2. Patients must have confidence in performing the ‘physical skill’ they are asked to perform, in this instance a pelvic floor muscle contraction. This can be achieved effectively by individual pelvic floor muscle examination.  
  3. Address a patients ‘feelings’ about the proposed intervention, encouraging positive rather than negative feelings.
  4. Enable ‘cognitive analysis, planning, and attention’ to address barriers to the intervention.
  5. Encourage ‘prioritisation’ of the program in a patient’s life.

Pelvic Health Plans @ WMHP

At WMHP we now provide all patients with an individualised Pelvic Health Plan.  It outlines a patient’s diagnosis, why they are experiencing their symptoms, and how we can help them. It also includes individual goals, and addresses any barriers to treatment.

We believe that the implementation of the Pelvic Health Plan will help to further motivate our patients, and enable them to get the most out of our treatment sessions.  The feedback so far has been very positive, the patients love it!

References

1. Dumoulin, C., Alewijnse, D., Bo, K., Hagen, S., Stark, D., Van Kampen, M., . . . Dean, S. (2015). Pelvic-Floor-Muscle Training Adherence: Tools, Measurements and Strategies-2011 ICS State-of-the-Science Seminar Research Paper II of IV. Neurourol Urodyn, 34(7), 615-621.

2. Dumoulin, C., Hay-Smith, J., Frawley, H., McClurg, D., Alewijnse, D., Bo, K., . . . Van Kampen, M. (2015). 2014 consensus statement on improving pelvic floor muscle training adherence: International Continence Society 2011 State-of-the-Science Seminar. Neurourol Urodyn, 34(7), 600-605.

3. Frawley, H. C., McClurg, D., Mahfooza, A., Hay-Smith, J., & Dumoulin, C. (2015). Health professionals' and patients' perspectives on pelvic floor muscle training adherence-2011 ICS State-of-the-Science Seminar research paper IV of IV. Neurourol Urodyn, 34(7), 632-639.

4. Hay-Smith, J., Dean, S., Burgio, K., McClurg, D., Frawley, H., & Dumoulin, C. (2015). Pelvic-floor-muscle-training adherence "modifiers": A review of primary qualitative studies-2011 ICS State-of-the-Science Seminar research paper III of IV. Neurourol Urodyn, 34(7), 622-631.

5. McClurg, D., Frawley, H., Hay-Smith, J., Dean, S., Chen, S. Y., Chiarelli, P., . . . Dumoulin, C. (2015). Scoping review of adherence promotion theories in pelvic floor muscle training - 2011 ICS state-of-the-science seminar research paper I of IV. Neurourol Urodyn, 34(7), 606-614.

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