Title: Pelvic floor muscle training for female urinary incontinence: development of a programme
theory from a longitudinal qualitative case study
Version: 4 Date: 01 Jul 2024
Reviewer's report:
Congratulations to the author team in the execution and reporting of this longitudinal qualitative
study. This paper provides much-needed and valuable insights into womens’ experiences of
PFMT, focusing on self-efficacy, adherence, context and UI outcomes – both in the short,
and longer terms (through to 24 months post-randomisation). It presents a novel Programme
Theory based around robust methodology, that eloquently explains the different components that
influence women from the initial step of seeking treatment for UI, through to those that impact
on the long-term outcome. The findings are presented in an interesting manner and discussed
in light of the literature as well as providing recommendations that clinicians can incorporate
into their practice when supporting women with PFMT for UI. I have included some minor
comments below for consideration.
Pg 4, lines 77-79. Evidence from quantitative studies, seems a bit out of place here
Pg 5, line 103. Perhaps it may be worthwhile explicitly mentioning that development of a
Programme Theory is for a complex intervention (which is noted later in the methods section
Pg 7, line 145. Further clarity required in this sentence, as the contraction isn’t ‘hidden’ muscles
– the contraction is produced by “hidden” muscles
Pg 9, Data analysis. It’s not clear what programme or software was used to manage the data
when developing the codes – was this done in NVivo, for example? In terms of coding, were
there any disagreements, and how were these resolved? In this section, it would also be good to
include the initials of the authors that contributed to each of the 6 phases of data analysis – in
some phases more than one author is involved, but in others it is not clear (e.g., phases 5 and 6)
Pg 13, line 271. I wonder if it’s worth restating the four theorised self-efficacy sources here
(performance accomplishments, vicarious experience, verbal persuasion, physiological states),
as a reminder to the reader?
Pg 13, explanation of the model. I’m not sure if there is a way in which to highlight the
components of the model slightly differently This text is relatively easy to interpret while looking
at the model (as shown in Fig. 2), but in the absence of the figure is less easy to interpret. Perhaps
signposting where the emphasis lies – either with the outcomes or the factors that influence
self-efficacy and adherence? I imagine much thought has gone into this already, so this is just
a thought!
Pg 15, line 293. Reference to Fig 1. Could also clarify here what the allocated treatments were
(i.e., PFMT alone or biofeedback-assisted PFMT)
Pg 15, line 288. Suggest that the subheadings used in the text are the same as included in the
model (Fig 2). This would make it easier to match the information between the figure and
text. I also wonder if there is capacity to rearrange the subheading hieracy so to include more
subheadings in certain places, which may help break up the sections into smaller chunks as it
is quite long in places. For example in “Development of self-efficacy from PFMT treatments”
information relates to the therapist, PFMT education and contraction etc (positives) and (lack
of) belief in the treatment (negative); and in “The influence of contextual factors over time” –
the woman, feelings about UI, having routines and prompts...
Pg 31, lines 669-670. Please check the clarity/grammar of this sentence in the conclusion: The
Programme Theory developed in this longitudinal case study offers a model that demonstrates
women’s pathway from seeking treatment to long-term treatment outcome