36 - Importance of a “Toolbox”: A Grounded Theory of long-term self-management after pelvic floor muscle training

No research has addressed the impact of pelvic floor muscle training (PFMT) beyond symptom improvement, particularly in the long term (>1 year). This study aimed to qualitatively explore, through a grounded theory approach, what older women with urinary incontinence (UI) retain and integrate into their daily lives eight years after participating in a PFMT program. This qualitative study was conducted based on the principles of constructivist grounded theory [1] . Semi-structured interviews were conducted with a purposive sample of women 60 years and older who had participated in a PFMT RCT in 2012 [2] . Initial coding was conducted independently by three female coders. Data analysis was performed using open, axial, and selective coding, in an iterative process of constant comparison. Transcripts of interviews were imported and coded in the NVivo 13 software (QSR International). The final sample included 30 women between the ages of 67 and 84. The study findings were articulated around a theory called Importance of a “Toolbox”: A theory of long-term self-management after PFMT. This theory is composed of three main categories: 1. Toolbox This category includes the set of practical and cognitive resources acquired during the PFMT program, which participants retained and used as needed. It comprises two subcategories: 1.1 Skills, knowledge and strategies Participants continued to perform pelvic floor muscle (PFM) exercises, albeit with varying frequencies. Some maintained regular routines, while others returned to the exercises occasionally when symptoms reoccurred. Additionally, they reported continued use of bladder training techniques. Participants integrated an understanding about PFM function, bladder control, and risk factors associated with UI. Some also used reminders and notes or associated the exercises with other physical activities such as yoga or stretching. 1.2 Transformative awareness: This represents the consolidation of participants’ experiences in the program, including a comprehensive understanding of the effectiveness of the tools. This awareness emerged from their personal experiences, observations of others, and external sources of information. This paradigm shift generated a more proactive attitude towards their own pelvic health. 2. Perceived benefits This category captures the sustained positive effects of PFMT beyond symptom improvement. It includes: 2.1 Physical benefits: Most participants reported a significant reduction in UI episodes, as well as improvements in other dimensions of pelvic health, such as prolapse symptoms. 2.2 Psychological: Many women reported an increase in self-efficacy and control over their condition, as well as a reduction in UI-related anxiety and stress. 2.3 Environmental: Some participants highlighted that reducing the use of absorbent products had a positive economic and environmental impact (i.e., less landfill waste). 2.4 Social: The program enabled many participants to resume or maintain recreational, cultural, or family activities. It also improved their willingness to speak openly about UI, both with healthcare professionals and those closest to them. Several became advocates of PFMT, recommending it to others and advocating for its inclusion in public health programs. 3. Trust in the program This reflects how participants' trust is shaped by the alignment between program satisfaction and the expected PFMT benefits. This trust was based on satisfaction with the obtained results, fulfillment of their expectations, and the perception that the program was carefully designed. This confidence contributed as positive feedback loop, reinforcing their motivation to continue applying the learned tools. The long-term effect of PFMT in older women extends beyond UI symptom relief. Participation in PFMT not only allowed for the acquisition of practical tools for UI management but also generated emotional, social, and cognitive benefits. Participants developed a personalized “toolbox”, perceiving benefit from and trust in the program promoting sustained self-management. This qualitative study is the first to document long-term biopsychosocial effects of PFMT. Funding Canadian Institutes of Health Research (MSH-258993), Research Centre of the Institut Universitaire de Gériatrie de Montréal (CRIUGM) grant, Quebec Network for Research on Aging (RQRV) grant Clinical Trial Yes Registration Number NCT02039830 RCT Yes Subjects Human Ethics Committee Institut Universitaire de Gériatrie de Montréal Helsinki Yes Informed Consent Yes

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