W8: Implementation of pelvic floor muscle training programs

in health services: challenges and strategies Workshop Chair: Helena Frawley, Australia

03 September 2019 10:00 - 11:00

Start End Topic Speakers

10:00 10:05 Introduction Helena Frawley

10:05 10:15 Introduction to topic:

- Implementation: leakage of evidence-into-practice

throughout the healthcare system. Barriers and enablers to

implementation of PFMT

- A vignette describing an everyday clinical scenario of a patient

referred to PFMT for POP/UI

Helena Frawley

10:15 10:25 The Behaviour Change Wheel (BCW) as it applies to PFMT

intervention. Understanding the levels that impact on

implementation of evidence into practice at different levels of

the health service.

E Jean C Hay-Smith

Sarah Dean

10:25 10:40 Group-based activity: Identification of barriers, and how to

incorporate behaviour change techniques in delivery of

interventions to facilitate uptake of new practice and services.

Helena Frawley

E Jean C Hay-Smith

Sarah Dean

10:40 11:00 Group feedback of barriers they identified and strategies for

facilitation.

Discussion of how to implement strategies in local health

services.

Helena Frawley

E Jean C Hay-Smith

Sarah Dean

Aims of Workshop

This workshop will address the barriers and enablers to implementation of pelvic floor muscle training (PFMT) in health services,

using a vignette that reflects a typical clinical scenario. While evidence for PFMT as an effective treatment for urinary

incontinence and pelvic organ prolapse is strong, and international recommendations endorse this intervention as first-line

treatment, availability of the service is variable and uptake and adherence is poor. The reasons are complex and relate to several

levels within the health service: the treatment itself, the patient, the clinician, the social and the organisational context. This

interactive workshop will provide strategies for participants to implement in their workplace to address the barriers and

enablers to effective implementation of PFMT, so that evidence can be translated into practice.

Learning Objectives

Appreciation of the complexity and challenges of implementation of PFMT into a health service, and an understanding of why it

is not always successful.

Target Audience

Urogynaecology, Conservative Management. All clinical disciplines and those interested in research translation.

Advanced/Basic

Intermediate

Suggested Learning before Workshop Attendance

• Damschroder, L. J., D. C. Aron, et al. (2009). Fostering implementation of health services research findings into practice:

a consolidated framework for advancing implementation science. Implementation Science 4: 50 DOI: 50 10.1186/1748-

5908-4-50

• Dumoulin, C., J. Hay-Smith, et al. (2015). "2014 consensus statement on improving pelvic floor muscle training

adherence: International Continence Society 2011 State-of-the-Science Seminar." Neurourology and Urodynamics

34(7): 600-605.

• Lamin E, et al (2016), Pelvic Floor Muscle Training: Underutilization in the USA, Current Urology Reports, 17(2): DOI:

10.1007/s11934-015-0572-0

• Frawley, H., P. Chiarelli, et al. (2014). Uptake of antepartum continence screening and pelvic floor muscle exercise

instruction by maternity care providers: an implementation project. Neurourology and Urodynamics 33(6): 976-977.

• Greenhalgh, T. (2014). How to Read a Paper: The Basics of Evidence-based Medicine. Ch15: Getting evidence into

practice.

• Grimshaw, J. M., M. P. Eccles, et al. (2012). "Knowledge translation of research findings." Implement Sci 7: 50.

• Grol, R., M. Wensing, et al., Eds. (2013). Improving patient care: the implementation of change in health care. Oxford,

Wiley Blackwell.

• Michie, S., M. M. van Stralen, et al. (2011). "The behaviour change wheel: A new method for characterising and

designing behaviour change interventions." Implementation Science 6(1).

• Salmon, V.E, Hay-Smith, E.J.C, Jarvie, R., Dean, S., Terry, R., Frawley, H., Oborn, E., Bayliss, S.E, Bick, D., Davenport, C.,

MacArthur, C. & Pearson, M. and on behalf of the APPEAL study group. “Implementing pelvic floor muscle exercises in

women’s childbearing years: A Critical Interpretive Synthesis of individual, professional, and service issues” (under

review)

• Salmon V E, Hay-Smith J, Jarvie R, Dean S, Oborn E, Bayliss S E, Bick D, Davenport C, Ismail K M, MacArthur C, Pearson,

“Opportunities, challenges and concerns for implementing pelvic floor muscle assessment and training during

childbearing years: a critical interpretive synthesis”, ICS 2017 abstract, Best in Category Prize – Health Services Delivery

• Salmon V E, Hay-Smith J, Jarvie R, Dean S, Oborn E, Bayliss S E, Bick D, Davenport C, Ismail K M, MacArthur C, Pearson,

and on behalf of the APPEAL study, “Opportunities, challenges and concerns for the implementation and uptake of

pelvic floor muscle assessment and exercises during the childbearing years: protocol for a critical interpretive

synthesis”, Systematic Reviews (2017) 6:18. DOI 10.1186/s13643-017-0420-z

• Willis CD et al. (2016). “Sustaining organizational culture change in health systems", Journal of Health Organization and

Management, Vol. 30 Iss 1 pp. 2 – 30 DOI: org/10.1108/JHOM-07-2014-0117.

Presentations

Helena Frawley, Physiotherapist, Australia

Introduction: Implementation: leakage of evidence-into-practice throughout the healthcare system

Implementation of evidence-into-practice into a healthcare system – with fidelity to the research – is challenging, and these

challenges are faced by many evidence-based interventions. Health services delivery of evidence-based PFMT is not immune to

these challenges. While PFMT is recommended as the first-line intervention for women with urinary incontinence (UI) or pelvic

organ prolapse (POP) (Dumoulin 2016), actual practice does not reflect these good intentions in many jurisdictions (Lamin 2016,

Ismail 2009, Chiarelli 1997). There is a known evidence-into-practice gap of up to 17 years (Morris 2011) for new interventions,

and the incorporation of evidence into policy, in order to change a healthcare system, may be an even larger gap. Even when

there is an intent to implement evidence, attrition or ‘leakage’ of adherence to the recommendations occurs along the pipeline

of research into practice (Glasziou 2005). This attrition has been documented in many aspects of healthcare (Mickan 2011),

however there are no reports of why and how this attrition occurs in the implementation of PFMT. Lack of attention to the

attrition which occurs at each of the stages of change (aware, agree, adopt, adhere) is a lost opportunity for patient benefit.

Findings from these other areas of healthcare will be used to inform our discussions of why and how the ‘leakage’ is occurring in

the health system for PFMT, and why there may be unique aspects related to PFMT. Studies are emerging which consider the

broader aspects which impact on implementation and uptake of PFMT in the childbearing year (Salmon 2017), however a

complete synthesis of factors relevant to other populations affected by pelvic floor dysfunction is lacking. Indeed, recent

research suggests local uptake of evidence is less informed by the traditional linear pipeline of ‘evidence–guidelines–practice’

and more by locally contextual issues such as budget, capacity and political influence (Atkins 2017).

Barriers and enablers to implementation of PFMT: This topic will explore examples of barriers and enablers in a health service

that may impact on successful implementation.

A vignette describing an everyday clinical scenario of a patient referred to PFMT for POP/UI

The following vignette will be presented and strategies to maximise evidence-based practice in this scenario, and how this could

be managed differently explored:

Family doctor / surgeon referred patient to physiotherapist / continence professional for POP/UI, said she could give PFMT a try.

After being on a waiting list for 4 months, the patient attended an initial visit. Because of clinical load and waiting list, the

therapist offered the patient a program of 4 visits. Patient cancelled 2nd visit but managed to attend 3rd visit. Patient was

dissatisfied, she reported she was not improved and did not want to attend again. The therapist referred the patient back to the

referring doctor. The case was labelled as patient had ‘failed’ PFMT, and the patient proceeded to surgery.

The Behaviour Change Wheel (BCW) (Michie et al 2011) as it applies to PFMT

Sarah Dean, Psychologist, UK and Jean Hay-Smith, Rehabilitation Academic, New Zealand

This topic explores the three ‘levels’ of the BCW and how they apply to implementation of PFMT. First, at the centre, the sources

of behaviour which are capability, opportunity and motivation (COM-B). Second, the middle level, the implementation functions

(such as enabling, persuading, training, education – see Hay-Smith et al 2015) we might use to facilitate behaviour change. Third,

the outer level, the policy categories (e.g. service provision, guidelines), which we acknowledge yet rarely overtly consider as

‘clinical’ sources of influence on behaviour. Drawing on previous and current research trials of the panel each of these levels is

illustrated with respect to their influence on awareness, agreement, adopting, and adhering to PFMT. Workshop participants will

then apply this learning to the vignette (see below).

Group based activity: With reference to the vignette, this session will involve a practical activity to be done in groups per table.

Participants will brainstorm the aspects they perceive to be barriers and enablers in a health service which impact on

implementation of evidence-based recommendations, using the BCW as a framework for understanding where these barriers

and facilitator lie. Each group will choose items from the policy level and brainstorm ways to support awareness, agreement,

accessibility, adoption and adherence of evidence-based recommendations.

Group feedback: Each table / break-out group will feedback to the whole group, the barriers and facilitators they thought were

at play in the vignette, with reference to their own particular health service. This may involve multiple perspectives, reflecting

the diverse geographical, cultural and health services contexts represented by individual group members. If time allows,

discussion will explore how other members of the healthcare team may support implementation of evidence-based PFMT for

women with pelvic floor dysfunction at different life-stages, and how a multi-disciplinary approach may be facilitated.

References:

• Atkins, L., M. P. Kelly, et al. (2017). "Reversing the pipeline? Implementing public health evidence-based guidance in english

local government." Implementation Science 12(63).

• Campbell M., Fitzpatrick R., Haines A., Kinmonth A.L., Sandercock P., et al. 2000. Framework for design and evaluation of

complex interventions to improve health. BMJ, 321, 694–696.

• Chiarelli, P. and E. Campbell (1997). "Incontinence during pregnancy. Prevalence and opportunities for continence

promotion." Australian and New Zealand Journal of Obstetrics and Gynaecology 37(1): 66-73.

• Craig P., Dieppe P., Macintyre S., Michie S., Nazareth I. & Petticrew M. 2008. Developing and evaluating complex

interventions: the new Medical Research Council guidance. BMJ, 337, 1655.

• Dumoulin, C., K. F. Hunter, et al. (2016). "Conservative management for female urinary incontinence and pelvic organ

prolapse review 2013: Summary of the 5th international consultation on incontinence." Neurourology and Urodynamics

35(1): 15-20.

• Dumoulin C. Dumoulin, A. Gareau, M. Morin, A. Tang, M. Jolivet, MC. Lemieux, D. Liberman, M. Jadin, V. Elliott, V. Faro-

Dussault, S. Pontbriand-Drolet, P. Plouffe. Research priorities for elderly women with UI: results of a citizen's jury Neurouro

& Urodyn.2012;31(6):776-777.

• Eccles M.P., Grimshaw J.M., MacLennan G., Bonetti D., Glidewell L., et al. 2012. Explaining clinical behaviors using multiple

theoretical models. Implement Sci, 7, 99.

• French S.D., Green S.E., O’Connor D.A., McKenzie J.E., Francis J.J., et al. 2012. Developing theory-informed behaviour change

interventions to implement evidence into practice: a systematic approach using the Theoretical Domains Framework.

Implement Sci, 7, 38.

• Glasziou, P. and R. B. Haynes (2005). "The paths from research to improved health outcomes." Evidence-Based Medicine 10:

4-7.

• Mickan S, Burls A, Glasziou P (2011) Patterns of ‘leakage’ in the utilisation of clinical guidelines: a systematic review

Postgrad Med J 2011;87:670e679. doi:10.1136/pgmj.2010.116012

• Morris Z, Wooding S, Grant J (2011). The answer is 17 years, what is the question: understanding time lags in translational

research. J R Soc Med 2011: 104: 510–520. DOI 10.1258/jrsm.2011.110180

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W8:

Implementation of pelvic floor muscle training programs in health services:

challenges and strategies

2019, Sep 3

- Helena Frawley, Australia

- Sarah Dean, UK

- Jean Hay-Smith, New Zealand

- Rohini Terry, UK

Please complete the in-app evaluation in the workshop before leaving.

Step 1, open app and select programme by day

Step 2, locate workshop

Step 3, scroll to find evaluation button

Step 4, complete survey –

• Handout for all workshops is available via the ICS app, USB stick and website.

• Please silence all mobile phones

• PDF versions of the slides (where approved) will be made available after the meeting via the ICS website so please keep taking photos and video to a minimum.

Affiliations to disclose†:

Funding for speaker to attend:

Self-funded

Institution (non-industry) funded

Sponsored by:

Helena Frawley

None

X

X

† All financial ties (over the last year) that you may have with any business organisation with respect to the subjects mentioned during your presentation

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PROGRAM

Start End Topic Speakers10:00 10:05 Introduction Helena Frawley10:05 10:15 Implementation: leakage of evidence-into-practice

throughout the healthcare system. Barriers and enablers to implementation of PFMT

Helena Frawley

10:15 10:20 The Behaviour Change Wheel (BCW) as it applies to PFMT intervention.

Jean C Hay-Smith

10:20 10:25 Behaviour Change Techniques (BCTs) as they apply to PFMT

Sarah Dean

10:25 10:40 Group-based activity: Identification of barriers, and how to incorporate behaviour change techniques in delivery of interventions to facilitate uptake of new practice and services.

Sarah DeanJean C Hay-SmithRohini TerryHelena Frawley

10:40 11:00 Group feedback of barriers they identified and strategies for facilitation.Discussion of how to implement strategies in local health services.

Sarah DeanJean C Hay-SmithRohini TerryHelena Frawley

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Implementation of pelvic floor muscle training

programs in health services:

challenges and strategies

ICS Workshop #8, 3 Sep 2019

Helena Frawley, PhD, FACP• Associate Professor, Physiotherapy, • Monash University• Melbourne, Australia

MONASH

Medicine, Nursing,

Health Sciences

What is implementation?

• Implementation: (Lomas 1993)

• Active, planned, tailored• involves identifying & assisting in overcoming the barriers to the use

of the knowledge

• It uses the message itself, plus:• Organisational & behavioural tools that are sensitive to constraints

& opportunities of health professionals in identified settings

• Implementation research:• Scientific study of methods to promote the uptake of research

findings for the purpose of improving the quality of care

Implementation

(Medical Research Council UK, Campbell 2000)

Implementation in clinical practice

17 years for 14% of original research to be integrated into

practice for patient gain (Balas & Boren 2000)

PFMT implementation (ICI 2017) PFMT implementation

Opportunities for PFM assessment, exercise instruction and supervised training for prevention and treatment

Bo et al 2017

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What do we know about effective PFMT?

▪ active ingredients:• Confirmation of correct PFM contraction

• Instruction in a dose-effective PFMT program

• Supervised practice

▪ Evidence into practice: with fidelity to the evidence

Current clinical practice:• Not part of standard (AN or PN) maternity care• May occur in private system

Relies on individual efforts outside model of standard care

Bo et al 2017

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Whole of health system approach

Macro

Meso

Micro Individual clinician and patient level

Social and organisational context

Economic and political context

Evidence for Level 1, Gr A

Change required at all levels in the system

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Implementation of PFMT:

leakage of evidence-into-practice

throughout the healthcare system

The leaky ‘pipeline’ of research to practice (Glasziou & Haynes 2005)

1.Aware 2.Accept 3.Target 4.Able 5. Acted on 6.Agreed 7. Adhere

Valid and

relevant

research

The ‘pipeline’ of research to practice (Mickan 2011)

29 guideline recommendations

The ‘pipeline’ of research to practice (Mickan 2011)

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Whole of health system approach

Macro

Meso

Micro Individual clinician and patient level

Social and organisational context

Economic and political context

Evidence for Level 1, Gr A

Which clinician?

AN / PN Woman

Midwife

Doctor

NCAM&CH Nurse

Physio-

therapist

MICRO: barriers? strategies?

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Evidence-based practice in context

Context is everything!

MESO: barriers? strategies?

Social and organisational context: health services

Problem of scale up in public health:• loss of fidelity to the research evidence

• Under-resourced, diluted, information-focused, -> ineffective

• Competing priorities

MESO: barriers? strategies?

• Research efforts at implementation• Xing 2017

• PF education and information program for nurses and women

• correct PFM contraction not confirmed; no supervision of PFMT

• Frawley 2014: • significant barriers, clinician and system levels

• Sustainability

MESO: barriers? strategies?

• Smart allocation of resources

• Linkages

• Referral pathways

• Very contextual

• Local solutions• Modelling

• Champions

• Clear messages

AN / PN Woman

Midwife

Obs / GP

NCAM&CH Nurse

Physio-

therapist

Info, screening

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MACRO: barriers? strategies?

Economic and political context• Scale up• Priorities, perceived value

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Problems at the Top End

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Results: - Previous research has focused on women’s perspectives of treatment and

management of postnatal UI with limited evidence exploring views and experiences of women during the antenatal period or healthcare professionals regarding PFME during childbearing years

- Despite evidence for the effectiveness of PFME for preventing UI, these findings suggest that PFME is not implemented effectively during pregnancy.

Manuscript under review

Implementation is difficult!

Affiliations to disclose†:

Funding for speaker to attend:

Self-funded

Institution (non-industry) funded

Sponsored by:

Jean Hay-Smith

None

X

† All financial ties (over the last year) that you may have with any business organisation with respect to the subjects mentioned during your presentation

The Behaviour Change WheelJean Hay-Smith

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The Behaviour Change Wheel

Michie S, Van Stralen MM, West R. The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implementation Science 2011; 6(1):42

Green: Sources of behaviour

Capability – includes necessary knowledge and skills Opportunity – factors outside person making behaviour possible or prompt itMotivation – brain processes that energize and direct behaviour

Hay-Smith et al. (2015)

Red: Intervention functions

Educate – ↑ knowledge, understandingPersuade – communicate to induce positive or negative feelings or actionTraining – imparting skills

Terry R. et al. Abstract #467

Grey: Policy categories

Regulation – scope of practice

Guideline - National Institute for Health and Care Excellence

Service provision – midwifery services and their funding

Terry R. et al. Abstract #467

Affiliations to disclose†:

Funding for speaker to attend:

Self-funded

Institution (non-industry) funded

Sponsored by:

Sarah Dean

Sarah Dean’s time is partly supported by the UK’s National Institute of Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care South West Peninsula at the Royal Devon and Exeter NHS Foundation Trust.

The views expressed are those of the presenter and not necessarily those of the NHS, the NIHR or the Department of Health.

X

† All financial ties (over the last year) that you may have with any business organisation with respect to the subjects mentioned during your presentation

Sarah Dean

Changing Behaviour is difficult!

Michie S, Van Stralen MM, West R. The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implementation Science 2011; 6(1):42

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Behaviour change theories or models

There are many!

No one model or theory provides a sufficient explanation of how behaviour can be changed for all people in all settings

Behaviour Change Techniques (BCTs)

BCT 66: Goal Setting (behaviour)

Description:Set or agree a goal defined in terms of the behaviour to be achieved

Example (adapted): Agree a daily exercise goal with the person and reach agreement about the goal.

Source: BCT Taxonomy (v1) Michie et al 2013

Therapeutic Exercise

Make sure patient is involved in all

and that they

Understand and

(and in writing) to all short term and long term goals.

BCT Label

Goal setting

goal setting

agree verbally Behavioural contract

Behaviour Contract & Commitment

Make sure patient is involved in all goal setting and that they understand and agree (in writing) to all short term and long term goals and verbalise their commitment.

Clinician: “please will you where I have written down ”

Ask the person to make statements indicating strong commitment to change the behaviour:

/ will do my exercises …..x times per week…”

Goal setting

Contract

Commitment

sign (initial) this sheet

the goal we have just agreed

patient says “I will attend all my appointments

Workshop activity – set up

Two groups at each table

Facilitator will give you a pack

Follow instructions in the pack

Basic idea is to ‘label’ up your case (BCTs labels & COM-B labels)

Discuss what enables PFMT and what are the barriers to PFMT

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Workshop activity – debrief

How did the labelling go?COM-B labels?BCT labels?

Deciding if it was an enabler or a barrier?

Deciding what level? – organisation – health professional – patient

Working out where the problems lie, what the solutions might be

Workshop Discussion

Any comments or questions?

Please remember to do the workshop evaluation

W8:

Thank you

Implementation of pelvic floor muscle training programs in health services:

challenges and strategies2019, Sep 3

- Helena Frawley, Australia- Sarah Dean, UK- Jean Hay-Smith, New Zealand- Rohini Terry, UK

Please complete the in-app evaluation in the workshop before leaving.

Step 1, open app and select programme by day

Step 2, locate workshop

Step 3, scroll to find evaluation button

Step 4, complete survey –

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