Birdwatching as a Nature-Based Behavioral Strategy to Improve Adherence to Pelvic Floor Muscle Training in Women With...

Background Long-term adherence remains one of the greatest barriers to successful pelvic floor muscle training (PFMT) for women with stress urinary incontinence (SUI). Although digital gamification strategies have been developed to improve adherence, they often require electronic devices and digital literacy. We evaluated whether birdwatching, as a simple nature-based behavioral strategy designed to promote motivation through environmental cueing and habit formation, was associated with improved adherence to PFMT and better clinical outcomes in women with SUI. Methods This prospective comparative observational study included women with SUI who received standardized supervised PFMT. After receiving an explanation of both management strategies, participants chose either conventional PFMT alone or PFMT combined with a birdwatching-based behavioral strategy according to their preference. The primary outcome was overall PFMT adherence during the 12-week follow-up, calculated using weather-adjusted eligible walking days. Secondary outcomes included the one-hour pad test, SUI episode frequency, Patient Global Impression of Improvement (PGI-I), and Brink scale. Clinical outcomes were evaluated after 12 weeks. Results After propensity score matching, 48 women were included in the final analysis (standard PFMT, n = 24; birdwatching, n = 24). Although overall PFMT adherence gradually declined in both groups, the birdwatching group demonstrated significantly higher overall PFMT adherence at Week 12. Compared with the standard PFMT group, participants in the birdwatching group also experienced significantly fewer SUI episodes. No significant between-group differences were observed in the one-hour pad test, PGI-I score, or Brink scale score. No intervention-related adverse events were observed. Conclusions A simple birdwatching-based behavioral strategy was associated with improved adherence to PFMT and favorable short-term clinical outcomes compared with standard PFMT alone. Unlike previously reported digital interventions, this nature-based approach requires no electronic devices or specialized technology and may represent a practical, inexpensive, and scalable behavioral strategy for improving long-term adherence to conservative treatment for women with SUI.