Study design, materials and methods
Mind Over Matter: Healthy Bowels, Healthy Bladder (Mind Over Matter) is a small-group behavior change intervention for women aged 50 or older who want to prevent or improve urinary incontinence (UI) or anal incontinence (AI). Facilitated by a trained community member, the in-person program consists of three two-hour sessions delivered over one month, and in a 2017 RCT, participants achieved a 9-fold improvement in bladder symptoms and a 4-fold improvement in bowel symptoms compared to controls . State-wide dissemination of Mind Over Matter began in 2019; in response to the COVID-19 pandemic, Mind Over Matter was transitioned to online delivery using Zoom in May 2020.
Voluntary questionnaires are completed by Mind Over Matter participants just prior to and following the program. Participants are asked about demographics, bladder and bowel symptoms, and related behaviors (pad use, pelvic floor muscle exercise frequency, care seeking). The International Consultation for Incontinence Questionnaire – Urinary Incontinence (ICIQ-UI) and St. Mark’s (Vaizey) Incontinence Score (SMIS) assess symptoms [2, 3 ]; following completion, an evaluation survey and patient global ratings of satisfaction (PSQ), global perception of improvement (GPI), and estimated percent improvement (EPI) assess the program.
For this study, descriptive analyses characterized and compared participants in Mind Over Matter when implemented in-person versus virtually. Related samples were analyzed using paired t-tests, Wilcoxon signed rank tests, and McNemar’s test; independent samples were analyzed using student’s t-tests, Mann-Whitney U tests, and Chi-square tests. A p-value less than 0.05 was considered statistically significant.
Between April 2019 and December 2021, 85 workshops were held state-wide (56 in-person, 29 online), reaching 708 women (481 in-person, 227 online). Table 1 describes the sample and compares in-person and online participants. Mean age of participants was (74.2±8.5); the majority identified as non-Hispanic white, had education beyond high school, were insured by Medicare, and perceived themselves to be in good health. Participants in the online program were significantly younger than those who participated in-person (72.9±8.3 vs. 74.6±8.5 years, p=.031). Participants in the online program were more likely to live alone (66% vs. 54%, p=.011), have a bachelor’s or graduate degree (53% vs. 44%, p=.006), and have access to someone to help around the house when needed (93% vs. 85%, p=.007). There were no significant differences between in-person and online participants as regards race, ethnicity, marital status, urban vs. rural dwelling, health insurance type, and general health status.
Table 2 describes changes from baseline to post-program symptoms and behaviors among in-person and online program participants. Urinary incontinence severity improved by one point on the ICIQ-UI for participants in both online and in-person programs. The proportion of women with mixed UI decreased from baseline to post-program among the sample overall and among in-person participants but not among online participants. There was a statistically significant improvement in AI severity by SMIS among online but not in-person participants. The amount of money spent per month on incontinence products decreased significantly from $5 to $2 among participants in both programs but there were not significant changes in types of products used. The proportion of participants who did pelvic floor muscle exercises routinely (often or always) was significantly higher at program completion than baseline among both groups of participants (16% → 77% in-person; 13% → 82% online, p<.001 for both). Plans to seek care did not differ between baseline and program completion for any group.
Regarding program evaluation, most participants heard about the program from a newsletter or friend / family member (Table 2). Those in the in-person program were significantly more likely to have heard about the program from a healthcare provider. The reasons cited for program participation did not differ between online and in-person participants; the most common reasons were to prevent or improve symptoms or because of liking the self-management approach.
Online participants were more likely than in-person participants to attend all three Mind Over Matter sessions (p=.001). The vast majority of participants in both online and in-person programs agreed that they felt comfortable in the program, thought the program was well-organized, and would recommend the program to others. Online participants were significantly more likely to agree that their voice was welcomed and less likely to agree that they learned from others through program participation. Online participants were significantly less likely than in-person ones (55 vs. 63%, p=.031) to feel completely satisfied with the program. Global perception of improvement (>85%) and estimated percent improvement (59%) did not differ between online and in-person participants.
Interpretation of results
A small-group behavior change program proven to improve incontinence in older women when administered in-person was successfully implemented virtually during the COVID-19 pandemic. The online program was more likely to reach those who live alone and have access to help around the house when they need it, and less likely to reach older women and those with a high school education or less, suggesting a role for both in-person and online programs to optimize program reach. Both in-person and online program participants saw improvements in both UI and AI symptoms following program completion, and the significantly increased rate of routine pelvic floor muscle exercise performance was similar to that seen in the RCT of the Mind Over Matter program, providing evidence of its impact when implemented in communities outside the research context. Of note, the significant decrease in money spent on incontinence products among in-person and online community program participants was not seen in the 2017 Mind Over Matter RCT participants, suggesting that real-world program implementation of Mind Over Matter may have even higher impact.