Urinary incontinence (UI) is highly prevalent among older women, with one in three experiencing UI symptoms after age 65. Despite evidence supporting the efficacy of pelvic floor muscle training (PFMT) as a first-line treatment, uptake remains low, primarily due to cost and limited accessibility to trained physiotherapists. Group-based treatments, including telerehabilitation, offer cost-effective alternatives and could improve accessibility [1]. Recent evidence supports the feasibility and clinical effectiveness of a group-based telerehabilitation PFMT program for treating UI in older women [2, 3]. This study aimed to assess the acceptability of this program from the perspectives of older women participants with UI and the physiotherapist.

This study is part of a larger research program aimed at assessing the feasibility, acceptability and clinical effects of an online group-based PFMT program. This qualitative component explored the experiences of older women and a physiotherapist involved in the program, an online adaptation of a group-based, in-person PFMT program supported by robust evidence [1]. 
Population
Program participants were women age 65 and over experiencing mixed or stress UI persisting for three months or more, with a minimum of three urine leakages on the 7-day bladder diary. They were required to be able to contract their pelvic floor muscles (PFMs) and have no known risk factors or conditions that could interfere with PFMT. The physiotherapist leading the program sessions had over 20 years of experience in PFMT and was well versed with the in-person version of program.
Intervention
Before participating in the program, each woman underwent an individual, in-person evaluation session with a pelvic floor physiotherapist to establish their eligibility. This included confirmation of their ability to contract their PFMs, during which the physiotherapist also taught them to contract their PFMs correctly through vaginal digital palpation, as needed. Eligible women then took part in a 12-week, group-based PFMT program consisting of weekly one-hour online training sessions. All participating women received an exercise booklet detailing the PFMT exercises, in which they were asked to record their progression, along with support material for the educational component of the program. An experienced pelvic floor physiotherapist delivered all treatment sessions online, via Zoom, to groups of six to 11 women. Each session began with a one-on-one, three-to-five-minute meeting with the physiotherapist in a private virtual room to discuss weekly leakages and exercise adherence, while the rest of the group socialized in the main virtual room. The remaining portion of the session was divided into a 10- to 15-minute educational component and a 30- to 45-minute PFM exercise component. The educational component covered topics relevant to the aging pelvic floor, UI pathophysiology, lifestyle interventions, and self-efficacy in completing home exercises. The exercise component included a progressive program of four PFM exercises gradually increasing in duration and repetitions, and undertaken in increasingly challenging positions (from lying down, to sitting, to standing). Participating women were expected to perform PFM exercises at home, five days per week, throughout the 12-week program.
Data collection and analysis
Women participating in the program and the physiotherapist who led the sessions were invited to discuss their experiences through individual interviews or focus groups led by physiotherapists with clinical experience in PFMT and UI, and no prior interactions with the participating women. Qualitative data were recorded, transcribed verbatim, and analyzed using thematic analysis, guided by the Theoretical Framework of Acceptability (TFA). The TFA defines ‘acceptability’ as a complex construct that reflects the appropriateness of delivering or receiving a healthcare intervention. It encompasses seven domains: self-efficacy, affective attitudes, perceived effectiveness, burden, opportunity costs, ethicality, and intervention coherence.

The study included 33 women who completed the program, along with the physiotherapist leading the sessions. The participating women had a median age of 69, with half of them (18/33, 54.5%) having completed a university degree. The majority (n=31/33, 93.9%) reported symptoms of mixed UI, with a median duration of 6.0 (3.0-17.0) years. Within the seven overarching TFA domains, 27 themes and 53 subthemes emerged from the participating women’s verbatim transcripts, while 13 of these themes and 21 of these subthemes emerged from the physiotherapist’s verbatim (Figure 1).
Program participant perspective
Overall, the participating women found the program acceptable, perceiving it as a valuable contributor to their increased self-efficacy in managing UI, in performing PFM contractions, and in maintaining exercise adherence. They emphasized the supportive role of the therapeutic alliance with the physiotherapist and the structure of the program throughout their experience. Despite some initial concerns, they reported positive affective attitudes toward the program, recognizing both its effectiveness and psychosocial benefits. Women reported minimal burden and no significant sacrifices associated with their participation in the program. The program resonated with their values and aligned coherently with their health beliefs. 
Physiotherapist perspective
Similarly, the physiotherapist found the program acceptable, highlighting how both the therapeutic alliance and the program structure facilitated her role. Despite facing time management challenges in the delivery of the sessions, the physiotherapist reported positive affective attitudes. She noted the program’s positive effects on the women’s symptoms, although they progressed at a slower pace than anticipated, and identified significant psychosocial benefits associated with the program. Time management constraints, arising from the individual meetings and the time needed for technology use, emerged as the main burden when leading the sessions. The program aligned with the physiotherapist’s professional values.
For optimal success, both the participating women and the physiotherapist recommended maintaining a limited group size of six to eight women, similar to the guidelines established for the in-person program.

The group-based structure of the program appeared to be a significant asset, particularly in fostering the psychosocial benefits reported by participating women. They described acquiring new knowledge, developing a sense of empowerment in managing UI, and feeling supported. Throughout their interviews and focus groups, participating women highlighted the high value they placed on social interactions, both with the physiotherapist and fellow participants, which they felt provided them with consistent support. This support not only enhanced their motivation and self-efficacy, but also contributed to mitigating some of the stigma associated with UI.
During the program, the therapeutic alliance with the physiotherapist emerged as particularly important. Participating women emphasized the pivotal role of this alliance in their engagement, citing the support, encouragement, and guidance it provided. The physiotherapist leading the sessions also stressed how the intimacy of the individual meetings allowed her to motivate the participating women and personalize their care experience, despite physical distance. Given that the therapeutic alliance is crucial in rehabilitation, promoting patient engagement and adherence, these findings highlight the promising potential of telerehabilitation in maintaining this important connection.
Finally, as the online program aims to replicate a comparable group effect to the original in-person version, maintaining the same group size appears relevant.

The group-based telerehabilitation PFMT program proved acceptable for both the participating women and the physiotherapist. Pragmatic randomized controlled trials are now required for further validation of the program’s clinical effects and acceptability in real-life clinical settings.

Group-based pelvic floor muscle training is a more cost-effective approach to treat urinary incontinence in older women: economic analysis of a randomised trial. Journal of Physiotherapy. 2022.
Group-Based Pelvic Floor Telerehabilitation to Treat Urinary Incontinence in Older Women: A Feasibility Study. International Journal of Environmental Research and Public Health. 2023.
Online group-based pelvic floor muscle training for urinary incontinence in older women. Continence. 2023.

Continence 12S (2024) 101554
DOI: 10.1016/j.cont.2024.101554