# Perceptions of a 'Pelvic-Floor Friendly' Group Exercise Class in Women with Urinary Incontinence
## 1 Introduction  
Regular physical activity (PA) can improve women's mental health and help avoid or delay the onset of osteoporosis and sarcopenia, which contribute to frailty in older age and are leading causes of women requiring social care [1, 2, 3]. Crucially for women, regular PA participation has also been shown to prevent or delay the onset of dementia, Alzheimer's, and cardiovascular disease [4, 5]. Disease risk increases significantly in women during midlife and post-menopause [6, 7] and having a regular PA routine in midlife can delay the onset of disability by up to 15 years [8]. However, despite the robust evidence illustrating the efficacy of PA for reducing disease risk, women continue to participate in less PA than men, and participation rates continue to decline with age [9]. Therefore, it is important to help support women in overcoming the barriers which prevent PA participation entirely, or the formation of PA as a habit. Many PA interventions have focused on increasing women's PA by targeting the most often reported barriers to participation, such as a lack of time due to family commitments [10]. However, few interventions consider urinary incontinence (UI) and how it impacts a woman's ability to be physically active. UI is any involuntary loss of urine from the bladder [11] and is more commonly experienced by women compared to men [12]. The prevalence rate of UI has been reported to be as high as 70% [13, 14], and a number of treatments for individuals have been developed, including, for example, pelvic floor muscletraining [15]. However, the number of women seeking help for UI symptoms remains low. For example, in the UK, studies have shown that between 17 and 33% of women have sought help associated with UI [16; 17]. [PERSON] et al. [18] attribute the low levels of UI help-seeking by women to feelings of shame and fear of public stigma. Research has calculated the average delay between symptom onset and seeking help to be almost 7 years [19]. In a qualitative study exploring help-seeking behaviour, [PERSON] et al. [20] reported that when help-seeking does occur, there is a delay from the onset of symptoms to the symptoms being raised as an issue with a healthcare professional due to women perceiving UI as a \"natural process\" and \"normal\", particularly as they age. These findings have previously been reported in the literature; for example, a 2008 study found that 43% of their participants aged 30-44 years also believed UI to be \"part of being female\" and something to put up with [21] and similar findings were reported by [PERSON], [PERSON], and [PERSON] [22] in their earlier study, where they observed that women were reluctant to discuss UI with their doctor, believing UI to be non-medical and something their doctor would, therefore, not allow them time to discuss. A recent 2024 review indicated women's perceptions of UI and their attitudes to help-seeking have changed little over time; women continue to believe UI symptoms are a normal outcome of childbirth and ageing and are, therefore, to be expected, and that primary healthcare practitioners do not take their symptoms seriously or are too busy to disturb with such a 'trivial' matter [23]. It can be deduced from the availability of these findings, that UI prevalence statistics may fail to capture data for women who have yet to seek help for their UI symptoms. While the extant research suggests some reasons why women may avoid raising concerns regarding UI in the clinical setting, it remains unknown whether this behaviour continues in the PA setting, particularly when gathering data on barriers. UI, especially stress urinary incontinence (SUI), is common in physically active women and is estimated to affect up to 50% of women who exercise regularly [24].