Using Theory of Change Models to Evaluate the Implementation of Urinary Incontinence Management in Primary Care Initiatives

Theory of change (ToC) models articulate how and why implementation interventions are expected to produce specific outcomes and can guide both program design and evaluation. As part of a theory-driven evaluation for a federal initiative to improve non-surgical management of urinary incontinence among women in primary care, we co-developed ToC models for five funded projects. Each model depicted intervention approaches, hypothesized mechanisms of change, and expected outcomes. Using a six-step process which included document review, consensus-based element identification, open coding, iterative refinement, and stakeholder validation, we created and refined a separate ToC for each grantee. The Technical Expert Panel, convened for the broader initiative, provided multidisciplinary feedback to ensure methodological rigor and contextual accuracy. Sharing the models in annual meetings supported cross-grantee learning and revealed common implementation themes: reliance on technology-based patient education and clinician training, challenges with practice recruitment, tailored facilitation to reduce clinician burden, and gaps in patient-level evaluation measures. The ToC models served four primary functions: orientation for evaluators, technical assistance for grantees, monitoring and evaluation of implementation processes, and cross-site collaboration. Key lessons included the importance of early stakeholder engagement, flexibility in model development, and the value of visual tools for communication and shared understanding. Although resource requirements and retrospective development were challenges, ToC models proved to be adaptable, dynamic tools that enhance evaluation and collaboration in complex, multi-site health initiatives. Their systematic application can strengthen future national and international implementation efforts.