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Diane Newman: Welcome to UroToday's Bladder Health Center of Excellence. I'm Diane Newman, the center's editor. I'm a nurse practitioner at the University of Pennsylvania. And I'm pleased to introduce to you, Madeline Moureau, who is currently, research specialist working with Dr. Heidi Brown, in the division of Female Pelvic Medicine and Reconstructive Surgery, at the University of Wisconsin School of Medicine and Public Health.

Their primary focus of research is on identifying novel approaches to disseminate and implement effective solutions to treat and prevent incontinence. So we're going to hear, in the next few minutes, some of their research that was presented at the International Continence Society, titled Zoom to scale? Real world implementation of online versus in-person community-based continence promotion.

Madeline Moureau: Thank you so much for having me, Dr. Newman. I'm thrilled to be with you today to share some of our recent findings.

As you mentioned, our work is focused around finding novel approaches to prevent and treat incontinence. And one of those approaches is a continence promotion program, known as Mind Over Matter. In this study I'll be discussing today, we are primarily interested in comparing the online versus in-person implementation of the Mind Over Matter program.

As many of us know, incontinence is a big problem, especially for older women. More than 60% of women, over the age of 65 in the US, have urinary or bowel leakage, and the majority do not seek care. Most delay seeking care, because they do not believe solutions are available, or they want to avoid medication or surgery. However, behavior changes, such as pelvic floor muscle exercises, and making modifications to one's fluid and fiber intake, can cure mild bladder and bowel leakage, and can improve moderate and severe symptoms.

Community-based health promotion programs have been around for decades now. And the idea behind them is that they're offered in a community setting, and they build skills to make healthy behavior changes to improve chronic conditions. Traditionally, these programs are in a small format, where the same group of individuals meet several times around a particular health issue.
Mind Over Matter is a community-based self-management program led by a trained facilitator, for a small group of eight to 12 women aged 50 years or older. In its RCT, the program resulted in a ninefold improvement in bladder, and a fourfold improvement in bowel incontinence.

Over three sessions, participants gain knowledge and build skills, to make behavior changes to prevent or improve symptoms. And the key components of the program include pelvic floor muscle exercises, modifications to fluid and fiber intake, bladder training, and tools for seeking care if symptoms still persist.

A community organization called the Wisconsin Institute for Healthy Aging, started a dissemination of Mind Over Matter in 2019. WIHA disseminates Mind Over Matter, and other evidence-based programs for older adults, using a train-the-trainer strategy. So Mind Over Matter facilitators become certified following a two-day training led by a Mind Over Matter master trainer.
When the COVID-19 pandemic shut down the majority of in-person programming in 2020, we have pivoted to virtual implementation of facilitator training, and allow facilitators to implement the program online, as well as in person.

Based on the evolution of Mind Over Matter implementation from in-person only, to both in-person and online formats, we recently looked at real world evaluation data to describe the impact of Mind Over Matter on symptoms, and to compare intervention reach, impact, and evaluation outcomes when implemented in-person versus virtually.

We analyzed evaluation data for Mind Over Matter participants from 2019 through 2021. Participants complete questionnaires about demographics, incontinence symptoms and related behaviors and program experience at baseline, and then immediately following program completion.

A total of 708 participants completed 85 workshops between April 2019 and December 2021. The mean age of participants was 74, and the vast majority were non-Hispanic White. 57% lived alone, and almost half had graduated college. Most lived in an urban or suburban area, were insured by Medicare, and rated their overall health as excellent or very good.

Participants had moderate urinary incontinence, based on ICIQ-UI scores at baseline, with mix and urge incontinence being more prevalent. The mean Mark's incontinence score was consistent with mild fecal incontinence. The median number of pads used per day was one. And then, 17% reported doing pelvic floor muscle exercises often or always. And 58% endorsed plan to seek care.
Immediately following the program, there were small decreases in mean ICIQ-UI and St Mark's scores. The decrease in ICIQ-UI was statistically significant. The median number of pads used per day was similar, but 39% reported spending less money on pads than they did before the program. There was a statistically significant increase in the proportion who reported doing pelvic floor muscle exercises often or always, from 17% to 78%. There were no differences in plans for seeking care.

Now, comparing the in-person versus online participants, we found that the online participants were younger, and were more likely to live alone, be college educated and have someone to help around the home. The vast majority of participants, in both in-person and online workshops, identified as non-Hispanic White.

We saw statistically significant improvements from baseline and ICIQ-UI scores in both in-person and online participants. And then interestingly, we also saw a statistically significant reduction in St Mark's incontinence scale scores among online but not in-person participants. However, these reductions do not cross a threshold for minimum clinically important differences for these measures.
 The proportion of participants who reported doing pelvic floor muscle exercises often or always increased similarly in both in-person and online participants.

There were a total of 56 in-person workshops and 29 online workshops during this timeframe. The majority of both the in-person and online workshops were hosted by aging and disability resource centers, or aging offices.

About 20% of each charge participants of fee to participate. The mean number of participants for program was similar in in-person and online programs, but online participants were more likely to attend all three sessions. In-person participants were more likely to report complete satisfaction with the program, but there were not statistically significant differences in global or estimated perception of improvement between in-person and online participants.

Based on real world evaluation data, Mind Over Matter improves urinary incontinence symptoms, decreases money spent on pads, and increases routine pelvic floor muscle exercise performance, when implemented in-person or online. Both the in-person and online implementation reach relatively well-resourced populations. In-person implementation reaches those facing more disadvantages, such as those with a high school education or less, and those without someone to help at home.
Given the potential for this program to perpetuate existing disparities, future efforts and most focus on dismantling structural barriers to better reach women, not presently reached by either the in-person or online formats.

Lastly, program satisfaction remains high among both in-person and online attendees. But participants in the online program are less likely to be completely satisfied than their peers who participate in the in-person program. And a large proportion of participants are only somewhat satisfied. So we still have a lot of work to do.

Diane Newman: Thank you so much. I just found your research very interesting, when I heard it presented at the NICS meeting. Did you look into why would the number of pads not decrease, but the cost did? Is it because they switched from a more expensive, heavier patch, or thinner? I was just wondering. I was surprised by that.

Madeline Moureau: Yeah. We didn't look too much into the pads. We just have, what type of pads the woman uses, whether it's a Depends, panty liner, and then we also asked them the cost. But we've found over the years, that those two variables are really hard to actually analyze. And so, we have resorted to asking women whether or not they improved. They spent less money on pads, or more money or the same amount of money after the program, since that seems like a better comparison, since it is really hard to differentiate and determine, okay, are they spending less on pads, or how you extrapolate that? So we've resorted to that question, but that wasn't a primary focus. But I think that's a really good question, and something that we need to explore more in the future.

Diane Newman: The other thing though too is that, what I like about your research is that you did in-person and virtual, and gave us data comparison. Per session, how many attended the in-person? Do you have an average versus the online virtual?

Madeline Moureau: Yeah, I can't remember that off the top of my head. It was around the same for both. Let me look.

Diane Newman: I mean, it was greater than 10, greater than 20, you think? Just a ballpark.

Madeline Moureau: The recommended number, or the fidelity number, for programs is eight to 12 women per session. And with the online program, the new recommendations that came out after the study took place, and after it had already been implemented online, is six to eight. Because of the technical challenges that people may experience. And being online, it takes longer some time to transition from one person to another. And so really, allowing the facilitator to help better manage the workshop, and allowing everyone some time to speak, is what really drove that decrease from the age 12, recommended for in-person, to six to eight on the online program.

Diane Newman: I'm sure you weren't surprised that there was more satisfaction with the in-person, right?

Madeline Moureau: Right.

Diane Newman: Because I'm sure it's also, there must be some effect of having women sit there and listen to other women, and freely talk. And it's just a whole different experience, we've found with some of our research. Right? That online, although because of Covid, a lot of us have gone to education online. But I do think there's some challenges with it, and some barriers to really having an effective one. So I was not surprised by that outcome.

Madeline Moureau: Exactly. However, we did find it interesting, because we conducted a study here in Wisconsin with 400 women, of which I think 240 had incontinence, and the majority actually said they would prefer to attend an online program like Mind Over Matter, due to privacy and convenience reasons. But I do agree that when women meet in person, it's such a taboo and stigmatized topic, that they love meeting other women who have incontinence. And like I mentioned earlier in the presentation, the majority of older adults do have incontinence. So I think this is a great time for them to get together and discuss their problems, and try to find solutions together. And ways to remember, and that encouragement in that community, I think, is really important.

Diane Newman: Well, and I think though, that you asked prior to doing it. So once you say, "Yes, I'd like to do online.", because right away you think about, "I don't have to travel somewhere. This is going to be easy. I can do it for my home." But then after the experience, it may be, "Well, hey, I didn't get everything I wanted.", or, "I couldn't say what I wanted." Or like you say, "I've been involved with focus groups doing online." It's like some of the time is spent figuring out the technology, and making sure everybody can talk. Right?

Yeah. I do think there's some pros and cons for each method as far as education, but I think there's no question that we can probably... For this topic, it's nice to have that privacy, in a sense, that you do have online, and you can reach more people. I mean, there's no question about that.

Madeline Moureau: Right.

Diane Newman: But to get to those underserved populations, we're learning with other research, you have to go to where they reside.

Madeline Moureau: Yeah.

Diane Newman: Where they are, right?

Madeline Moureau: Yeah.

Diane Newman: We get the better educated person who can go online, or even come in person, but you really have to have them. You did this at a couple sites though, right? Some of your original work was done, I think, in... Where else was it? It was Wisconsin, but where else did you do some of the other programs?

Madeline Moureau: Yeah. So after the RCT, and we had took over dissemination of the program, it's now in six other states, some on the west coast and some are on the east coast. But I think it's up to six states total, not including Wisconsin. So that's exciting. And then we are in the majority of the counties in Wisconsin too for the in-person, or at least have a facilitator, or organization there to support that community.

Diane Newman: Well, again, I was so excited to hear your research. I think this is one way to get out that message to women who really do not come forward and see us in clinical practice. So hopefully, you're going to be publishing this soon, right?

Madeline Moureau: Yes, I hope so.

Diane Newman: All right. Well thanks so much for your presentation.

Madeline Moureau: Thank you so much for having me today.