Process Evaluation of a Digital Smartphone Intervention (URApp) to Support Adherence to Bladder Training in...

Daytime urinary incontinence is a common childhood condition that can persist into adolescence, and it is associated with psychological distress, social and educational difficulties, and an increased risk of later mental disorders. The co-designed smartphone app "URApp" was developed in partnership with young people aged 10 to 18 years to support their self-management of bladder symptoms, but it is not yet used by community pediatric continence clinics to facilitate ongoing patient bladder training.

The study aims to understand the barriers and facilitators to embedding a digital health intervention (URApp) designed to aid adherence to bladder training in children and young people with daytime urinary incontinence in community pediatric continence clinics.

We conducted a mixed methods process evaluation using the Normalization Measure Development (NoMAD) questionnaire at 4 time points to measure behavior change in nursing teams at 6, 12, and 18 weeks. Teams' responses to questionnaire items were summarized as median scores and plotted at each time point using petal plots. Qualitative data were collected through focus groups and interviews and analyzed, drawing upon thematic analysis.

Twenty pediatric continence nurses from 5 National Health Service community pediatric continence clinics in England were recruited through purposive maximum variation sampling. URApp was well-received, and nurses were positive about introducing it to patients and felt that URApp's functionality aligned with existing bladder training provided by National Health Service community clinics. Nurses reported that URApp was easy to introduce, age-appropriate for children aged 10 to 18 years, and accessible to patients with neurodivergent conditions. However, community teams found integration into existing care pathways challenging and did not fully use URApp for urotherapy and bladder diary data collection. Teams lacked confidence in changing from paper to electronic bladder diaries, and although they were positive about young people taking ownership of their bladder condition, they struggled to encourage URApp uptake and were concerned about the lack of parental oversight of bladder diary data in URApp. Successful uptake and patient engagement with URApp were also negatively impacted by barriers in the school environment, such as lack of access to toilets and smartphones.

The successful integration of URApp into community pediatric continence clinics requires cultural change in schools regarding toilet access and healthy drinking. Future implementation of URApp into existing clinical care pathways will need to consider how electronic bladder diary data from URApp can be used more effectively by clinical teams, in partnership with patients and their parents/carers to facilitate the shift from analog to a "digital-first health service."