Effectiveness, acceptability and feasibility of an exercise training and healthy eating group program (ATHENA) for overweight and obese women with urinary incontinence: an effectiveness-implementation hybrid study

Introduction: Supervised pelvic floor muscle training (PFMT) is first-line treatment for women with urinary incontinence (UI); and weight loss and exercise are recommended for overweight and obese women with UI. Multi-component, interdisciplinary group interventions may result in improved clinical outcomes, however no studies have reported on the effectiveness, acceptability and feasibility of a holistic, integrated group program that incorporates PFMT, general exercise training, dietary advice and pelvic health education for obese and overweight women with UI. Objective: This study aimed to implement and evaluate the effectiveness, acceptability and feasibility of a 12-week exercise training and healthy eating group program (ATHENA) for overweight and obese women with diagnosed UI. Methods: This mixed-methods study used an effectivenessimplementation hybrid design and was conducted with patients attending a Women’s Health Physiotherapy service, at a large, tertiary, public hospital in Australia, over a 12-month period in 2019 Participants were overweight and obese women diagnosed with UI. ATHENA was co-developed by clinicians, researchers and a consumer representative and comprised of four components: 1) Supervised PFMT; 2) General exercise training; 3) Healthy eating education; and 4) Pelvic health education. Clinical effectiveness was assessed by collecting pre/post intervention data via Australian Pelvic Floor Questionnaire (APFQ), Assessment of Quality of Life-6D (AQOL-6D) questionnaire, Global Rating of Change (GROC) scale, Intuitive Eating Scale-2 (IES-2), and standardized weight/height measurements to calculate body mass index (BMI). Acceptability and feasibility was assessed using process evaluation of reach, intervention, and participant satisfaction. Process data were analyzed using descriptive statistics; outcome data were compared pre/post intervention using inferential statistics. Results: Of the 156 overweight and obese women with UI, 37 (24%) agreed to participate in ATHENA. Median (IQR) age was 53 (47-65) years and BMI was 30.8 (29.1-34.8) kg/m2 . Twentynine women (78%) completed ATHENA. Median enrollment in the program was 91 (IQR 67-102) days. Clinical effectiveness was indicated: Significant improvements were found for overall APFQ dysfunction scores (median score baseline=11.1, discharge=6.0, IQR 5.8-16.5; p=0.001), and in all AFPQ domains in both dysfunction and bother scores (p<0.05). The median AQOL-6D utility score improved from 0.81 (IQR 0.73-0.87) to 0.86 (IQR 0.83-0.92), p=0.001. QOL dimensions significantly improved for relationships, coping, pain and independent living dimensions (p<0.05). No women reported deterioration in their UI condition; one reported no change; and the remainder reported improvements ranging from 1- 2 points (n=7) and 3-5 points (n=21,72%) (GROC). Significant improvements were found for body-food choice congruence domain in the IES-2 (p<0.01), but there were no significant changes in weight or BMI. All participants were satisfied with ATHENA and would recommend it to others. Process data indicated ATHENA was feasible to implement with all aspects of the intervention delivered as intended. Conclusions: This novel study provides outcome and process data for a new integrative group-based model of care for overweight and obese women with UI. The model was highly effective, acceptable and feasible to implement into a large, tertiary, public hospital. Further research into the cost effectiveness of the group intervention is recommended.