Impact of patient motivation on compliance and outcomes for incontinence
Introduction
Physiotherapeutic treatment of pelvic floor dysfunction in women can be effective [1], [2] and is safe, acceptable and cost-efficient [3]. However, its outcomes can be variable [4], and identification of the predictors of success is a key objective for treatment development and service planning. To date, few studies have explored these predictors. It is known that physical dysfunction is not necessarily a primary predictor of physiotherapeutic outcomes in this context [5], [6], whereas psychological variables (e.g. depression, anxiety) do appear to play a role in the positive prognosis of physiotherapy for pelvic floor dysfunction [7], [8]. However, the full range of psychological predictors of treatment outcomes is far from established as very few relevant investigations have been undertaken.
This study aimed to explore whether a patient’s motivation to change [9] affects the results of treatment for pelvic floor dysfunction. This treatment often takes the form of pelvic floor muscle training (PFMT) programmes, which require active patient participation including attendance at classes and behavioural change to achieve the desired outcome. As patient participation and commitment are central to the success of the treatment, it stands to reason that the outcomes may be affected by the psychological characteristics of the patient [7], [8]. Given these considerations, the patient’s motivation to change may be predictive of the outcomes of physiotherapeutic treatment of the pelvic floor [8].
The Trans-theoretical Model of intentional behaviour change [9] suggests that an individual progresses through a number of ‘motivational stages’ before behaviour change is achieved. According to this model, there are four stages of the change process: the precontemplation stage is characterised by limited awareness of the problem, or, if the individual knows about the problem, a lack of intention to change; the contemplation stage involves awareness of the problem, and often consideration of the impact of that problem, but without any intention to act on these considerations; the action stage comprises the individual modifying their behaviour as intended, often using aspects learned during the contemplation stage; and the maintenance stage involves prolonged engagement with the behaviours needed to maintain any gains and/or avoid a return of the problem.
This model has been shown to have strong predictive validity in many health settings, such as those involving treatment for alcohol abuse [10], [11], illicit drug use [12], [13], [14], [15], cigarette smoking [16], [17], [18], criminal offending [19] and excessive gambling [20]. However, to the authors’ knowledge, no research has been conducted on how motivation to change may be used as a predictive tool for physiotherapeutic treatment of pelvic floor dysfunction. Having reliable outcome predictors will help to ensure that appropriate patients are offered treatment and that the benefits of that treatment are maximised.
To this end, the current study used a prospective cohort design to assess the impact of patient motivation at intake on their compliance (as assessed by attendance at sessions) with physiotherapeutic treatment for pelvic floor dysfunction. In addition, it examined the relationship between initial motivation to change and the outcomes of the intervention, as assessed by a clinician-reported outcome measure and a patient-reported outcome measure. The use of both clinician- and patient-rated outcome measures of pelvic floor function is important as, regardless of the change in function from the clinician’s perspective, the patient’s perception of that change is critical in assessing the outcome of the intervention [21]. There may not be a significant relationship between the two [22], as has been reported in other conditions [23]. If a patient has higher motivation to change, it has been suggested that they will tend to perceive smaller clinician-rated change more positively than patients lacking this motivation [24]. Theoretically, the presence of a motivational state in behavioural psychology is often termed an establishing operation for sensitivity to environmental change connected to that state [25]. Given this, there may be differences in pelvic floor outcomes when measured by clinician-rated and patient-rated assessments, with patients with higher motivation to change reporting greater patient-rated benefits with smaller clinician-rated change.
In summary, this study explored whether patient motivation affects treatment compliance and outcomes of physiotherapeutic treatment, and whether it affects patient perception of clinician-rated change in muscle strength in a cohort of patients with pelvic floor dysfunction.
Section snippets
Participants
Two hundred and two adult female patients referred consecutively to the urogynaecological physiotherapy outpatients service at a National Health Service (NHS) teaching hospital were invited to participate in this study; 141 of them agreed to participate and completed the questionnaires. The mean age of the participants was 52 (SD 13, range 21–86) years. Participants were referred with either a single symptom or a combination of symptoms: 22/141 (16%) stress incontinence; 7/141 (5%) urge
Results
Table 1 shows the mean (SD) values for the clinician-rated (Oxford) and patient-rated (Queensland) assessments of pelvic floor function for the whole sample, as well as separately for the patients who attended all of the sessions in the PFMT programme (completers) and those who did not (non-completers). Of the 141 participants, 68 (48%) were completers and 73 (52%) were non-completers. Completers had less severe clinician-rated pelvic floor muscle weakness (Oxford) at intake compared with
Discussion
This study explored whether patient motivation to change would affect attendance and outcomes in a physiotherapeutic intervention for pelvic floor dysfunction. The PFMT programme resulted in significant improvement in both clinician-rated muscle strength and patient-rated pelvic symptoms, in line with previous findings [1], [4], [7]. However, motivation to change affected attendance at the PFMT sessions and patient-rated pelvic symptoms. Patients with higher levels of readiness to change were
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