Mixed feelings: general practitioners' attitudes towards eHealth for stress urinary incontinence - a qualitative study

Attitudes and Perceptions of eHealth Among Female Patients with Urinary Incontinence and Healthcare Providers: A Systematic Review and Thematic Synthesis

Aim

The objective of this systematic review was to synthesize qualitative evidence to explore the promoters and barriers to implementing eHealth interventions from the perspective of female patients with urinary incontinence and healthcare providers.

Background

Guiding patients to pelvic floor muscle training through eHealth can effectively improve urinary incontinence symptoms, and understanding the attitudes and perceptions of patients and healthcare providers is critical to the successful application of eHealth. However, systematic reviews that combine both views are lacking.

Design

A systematic review of qualitative research and thematic synthesis. This was reported following the Preferred Reporting Items for Systematic Reviews and Meta Analysis (PRISMA) guidelines 2020.

Date Sources

The search period was from the establishment of the database to May 2024, and eligible English literature was searched in PubMed, Web of Science, Cochrane Library, Embase, CINAHL, PsycINFO, and MEDLINE databases.

Review Methods

Two researchers independently screened and included the literature and used the Critical Appraisal Skills Program tool (CASP) to evaluate the methodological quality of the included literature. Themes were developed using thematic synthesis.

Results

A total of nine studies were included, which included 678 patients and 13 healthcare providers. Four themes were condensed into ten categories: multiple motivations for eHealth use, diverse reasons for taking action, complex reasons for preventing action, and conflict in establishing eHealth use behaviors.

Conclusion

The majority of patients are enthusiastic about utilizing eHealth to train their pelvic floor muscles, although there are occasionally issues like low desire. Although some medical practitioners are not well versed in eHealth, their engagement can aid patients in making use of eHealth. The future should focus on the difficulties and needs of women with urinary incontinence during the use of eHealth exercise and improve the understanding of eHealth among healthcare personnel.

Self-care conditioning factors in women and men with urinary incontinence and Human T-Lymphotropic Virus Type 1

OBJECTIVE

To analyze self-care conditioning factors in women and men with urinary incontinence symptoms living with the Human T-Lymphotropic Virus Type 1.

METHOD

Qualitative study, based on the pragmatic phase of Praxis Model for Technology Development. Twelve women and five adult men living with Human T-Lymphotropic Virus Type 1, residing in Bahia, Brazil, participated in the study. A structured instrument and focus group were applied to collect data. The empirical material was subjected to Thematic Content Analysis, using the software WebQDA and the Self-Care/Self-Care Deficit Theory was used.

RESULTS

Facilitating conditioning factors were used by women and men as strategies for performing self-care, and hindering conditioning factors prevented or disturbed, but opened paths to direct the nurse's performance to address self-care deficits.

CONCLUSION

Self-care requirements were impacted by the hindering conditioning factors; the facilitating ones allowed self-care, providing technology in nursing/health.

Effects of using a mobile application on pelvic floor training in women with stress urinary incontinence: A randomized controlled clinical study

INTRODUCTION

Urinary incontinence (UI) is defined as any involuntary loss of urine that causes negative impacts on women's lives. Pelvic floor muscle training (PFMT) is considered to be "level A" of scientific evidence in the treatment of UI. Despite its efficacy, it is known that the effect of PFMT may depend on continuous adherence. Therefore, healthcare professionals are looking for alternatives to improve adherence in their patients. Healthcare has been innovating through mobile device apps.

OBJECTIVE

Thus, the objective of this study was to verify the effects of PFMT with the use of a mobile device app in incontinent women.

TRIAL DESIGN

This was a controlled, randomized clinical trial that occurred remotely.

METHODS

A total of 104 women with stress UI and/or mixed incontinence, over 18 years old, literate, with preserved cognitive capacity, with internet access and a mobile device with the Android system, participated in this study. They were randomly divided into two groups: The App group and the Booklet group, which underwent a PFMT protocol guided by a mobile app and a booklet, respectively. Both groups received daily reminders to perform the exercises. Before and after 12 weeks of intervention, it was evaluated using the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) and the King's Health Questionnaire (KHQ).

RESULTS

Both groups showed improvements in the final ICIQ-SF score. However, superior results were shown for the Booklet group (App: pre: 11.5 [±3.8], post: 9.8 [±4.5]; Booklet: pre: 12.6 [±4.5], post: 7.4 [±4.3]; p = 0.03).

CONCLUSION

It was concluded that PFMT, with the use of a mobile app, is capable of reducing UI and the impact of UI, but it is not superior to training with the use of booklet instructions.

Mothers' Internet Journeys Through Social, Health Care, and Virtual Systems When Congenital Anomalies Are Diagnosed In Utero

OBJECTIVE

To examine mothers' internet usage, in conjunction with social, health care, and virtual peer support navigations, when congenital anomalies were diagnosed in utero.

DESIGN

Qualitative descriptive, consisting of semistructured interviews.

SETTING

Interview data were collected over Zoom; mothers participated from locations of their choosing.

PARTICIPANTS

Mothers of neonates discharged postoperatively from NICUs for uterine-diagnosed congenital anomalies. The sample was purposefully recruited from private Facebook groups for parents of children with congenital anomalies.

INTERVENTION/MEASUREMENTS

Analysis was done with deductive coding using concepts from the third iteration of the systems engineering initiative for patient safety theory. The a priori codes were health care, social, journey-benefit, journey-risk, task, and technology.

RESULTS

Twenty-two mothers signed up for an interview; 12 completed an interview, and 10 did not. The majority (n = 8, 66%) were White, had a bachelor's or graduate degree (n = 7, 58%) and were between 24 and 33 years of age (n = 8, 66%). Nine themes emerged: (a) Providers cautioned searching for diagnosis information but encouraged private Facebook groups for peer support, (b) Mothers' inquiries for their own care are lacking, (c) Search for information while recognizing parent-partner's coping differences, (d) Pace information from friends and family with patience and appreciation, (e) Manage inquiries from friends and family with group sharing, (f) Private Facebook groups provide a means of receiving and giving peer support, (g) Exposure to difficult stories on Facebook is a risk of stress, (h) Select a NICU, learn about their children's diagnoses, participate in virtual peer support, and (i) Device features frame search strategies.

CONCLUSION

Mothers reflected on the internet as a burden and a source of support in their health care journeys. The ubiquity of internet access calls for mothers to include in their health care journeys the complexities of managing time spent on the internet.

General practitioners' perspectives on relocating care: a Dutch interview study

BACKGROUND

Healthcare systems around the world are facing significant challenges because higher costs and an increase in demand for care has not been matched by a corresponding growth in the health workforce. Without reform, healthcare systems are unsustainable. Relocating care, such as from hospitals to general practices, is expected to make a key contribution to ensuring healthcare remains sustainable. Relocating care has a significant impact upon general practitioners (GPs). Therefore, we investigated which care, according to GPs, could be relocated and under which conditions.

METHOD

GPs were recruited through Nivel's GPs network on eHealth and innovation, located in the Netherlands. One exploratory focus group and 12 in-depth interviews were conducted. Interview transcripts were analyzed using the qualitative research principles of thematic analysis.

RESULTS

According to the participants, some diagnostic and follow-up care could be relocated from hospitals to GPs once certain prerequisites are fulfilled. An important condition of relocating care from the hospital to the GP is that GPs have sufficient time to take over these tasks. The types of care that can be relocated from the GP to other settings are those questions where the medical knowledge of the GP can offer nothing extra or where problems in navigating the health system cause patients to either turn to, or stay with, their GP.

CONCLUSION

Care should first be relocated from the GP to other settings before attempting to organize the relocation of care from the hospital to the GP. When this, and other conditions are met, some diagnostic and follow-up care can be relocated from the hospital to the GP.

Person-Generated Health Data in Women's Health: Scoping Review

BACKGROUND

The increased pervasiveness of digital health technology is producing large amounts of person-generated health data (PGHD). These data can empower people to monitor their health to promote prevention and management of disease. Women make up one of the largest groups of consumers of digital self-tracking technology.

OBJECTIVE

In this scoping review, we aimed to (1) identify the different areas of women's health monitored using PGHD from connected health devices, (2) explore personal metrics collected through these technologies, and (3) synthesize facilitators of and barriers to women's adoption and use of connected health devices.

METHODS

Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines for scoping reviews, we searched 5 databases for articles published between January 1, 2015, and February 29, 2020. Papers were included if they targeted women or female individuals and incorporated digital health tools that collected PGHD outside a clinical setting.

RESULTS

We included a total of 406 papers in this review. Articles on the use of PGHD for women steadily increased from 2015 to 2020. The health areas that the articles focused on spanned several topics, with pregnancy and the postpartum period being the most prevalent followed by cancer. Types of digital health used to collect PGHD included mobile apps, wearables, websites, the Internet of Things or smart devices, 2-way messaging, interactive voice response, and implantable devices. A thematic analysis of 41.4% (168/406) of the papers revealed 6 themes regarding facilitators of and barriers to women's use of digital health technology for collecting PGHD: (1) accessibility and connectivity, (2) design and functionality, (3) accuracy and credibility, (4) audience and adoption, (5) impact on community and health service, and (6) impact on health and behavior.

CONCLUSIONS

Leading up to the COVID-19 pandemic, the adoption of digital health tools to address women's health concerns was on a steady rise. The prominence of tools related to pregnancy and the postpartum period reflects the strong focus on reproductive health in women's health research and highlights opportunities for digital technology development in other women's health topics. Digital health technology was most acceptable when it was relevant to the target audience, was seen as user-friendly, and considered women's personalization preferences while also ensuring accuracy of measurements and credibility of information. The integration of digital technologies into clinical care will continue to evolve, and factors such as liability and health care provider workload need to be considered. While acknowledging the diversity of individual needs, the use of PGHD can positively impact the self-care management of numerous women's health journeys. The COVID-19 pandemic has ushered in increased adoption and acceptance of digital health technology. This study could serve as a baseline comparison for how this field has evolved as a result.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/26110.

The relation between usage of an eHealth intervention for stress urinary incontinence and treatment outcomes: an observational study

BACKGROUND

Stress urinary incontinence (SUI), though a prevalent condition among women, is undertreated in primary care. EHealth with pelvic floor muscle training is an evidence-based alternative to care-as-usual. It is unknown, however, how eHealth usage is related to treatment outcome, and this knowledge is required for general practitioners to implement eHealth in their practice. This study examines the relation between usage of eHealth for SUI and treatment outcomes by examining log data. Baseline factors were also explored for associations with treatment success.

METHOD

In this pre-post study, women with SUI participated in "Baasoverjeblaas.nl", a web-based intervention translated from the Swedish internet intervention "Tät®-treatment of stress urinary incontinence". Usage was based on log data and divided into three user groups (low, intermediate and high). Online questionnaires were sent before, after treatment and at six-months follow-up. The relation between usage and the primary outcome - treatment success (PGI-) - was studied with a binomial logistic regression analysis. Changes in the secondary outcomes - symptom severity (ICIQ-UI SF) and quality of life (ICIQ-LUTSqol) - were studied per user group with linear mixed model analysis.

RESULTS

Included were 515 users with a mean age of 50.5 years (12.0 SD). The majority were low users (n = 295, 57.3%). Treatment success (PGI-I) was reached by one in four women and was more likely in high and intermediate users than in low users (OR 13.2, 95% CI 6.1-28.5, p < 0.001 and OR 2.92, 95% CI 1.35-6.34, p = 0.007, respectively). Symptom severity decreased and quality of life improved significantly over time, especially among high users. The women's expected ability to train their pelvic floor muscles and the frequency of pelvic floor muscle exercises at baseline were associated with treatment success.

CONCLUSION

This study shows that usage of eHealth for SUI is related to all treatment outcomes. High users are more likely to have treatment success. Treatment success is more likely in women with higher expectations and pelvic floor muscle training at baseline. These findings indicate that general practitioners can select patients that would be more likely to benefit from eHealth treatment, and they can enhance treatment effect by stimulating eHealth usage.

TRIAL REGISTRATION

Landelijk Trial Register NL6570;  https://onderzoekmetmensen.nl/nl/trial/25463 .

Citizens' perspectives on relocating care: a scoping review

BACKGROUND

Healthcare systems around the world are facing large challenges. There are increasing demands and costs while at the same time a diminishing health workforce. Without reform, healthcare systems are unsustainable. Relocating care, for example, from hospitals to sites closer to patients' homes, is expected to make a key contribution to keeping healthcare sustainable. Given the significant impact of this initiative on citizens, we conducted a scoping review to provide insight into the factors that influence citizens' attitudes towards relocating care.

METHOD

A scoping review was conducted. The search was performed in the following databases: Pubmed, Embase, Cinahl, and Scopus. Articles had to include relocating healthcare and citizens' perspectives on this topic and the articles had to be about a European country with a strong primary care system. After applying the inclusion and exclusion criteria, 70 articles remained.

RESULTS

Factors positively influencing citizens' attitudes towards relocating care included: convenience, familiarity, accessibility, patients having more control over their disease, and privacy. Factors influencing negative attitudes included: concerns about the quality of care, familiarity, the lack of physical examination, contact with others, convenience, and privacy. Furthermore, in general, most citizens preferred to relocate care in the studies we found, especially from the hospital to care provided at home.

CONCLUSION

Several factors influencing the attitude of citizens towards relocating care were found. These factors are very important when determining citizens' preferences for the location of their healthcare. The majority of studies in this review reported that citizens are in favour of relocating care. In general citizens' perspectives on relocating care are very often missing in articles. It was significant that very few studies on relocation from the hospital to the general practitioner were identified.

Digital Technologies for Women's Pelvic Floor Muscle Training to Manage Urinary Incontinence Across Their Life Course: Scoping Review

BACKGROUND

Women with urinary incontinence (UI) may consider using digital technologies (DTs) to guide pelvic floor muscle training (PFMT) to help manage their symptoms. DTs that deliver PFMT programs are readily available, yet uncertainty exists regarding whether they are scientifically valid, appropriate, and culturally relevant and meet the needs of women at specific life stages.

OBJECTIVE

This scoping review aims to provide a narrative synthesis of DTs used for PFMT to manage UI in women across their life course.

METHODS

This scoping review was conducted in accordance with the Joanna Briggs Institute methodological framework. A systematic search of 7 electronic databases was conducted, and primary quantitative and qualitative research and gray literature publications were considered. Studies were eligible if they focused on women with or without UI who had engaged with DTs for PFMT, reported on outcomes related to the use of PFMT DTs for managing UI, or explored users' experiences of DTs for PFMT. The identified studies were screened for eligibility. Data on the evidence base for and features of PFMT DTs using the Consensus on Exercise Reporting Template for PFMT, PFMT DT outcomes (eg, UI symptoms, quality of life, adherence, and satisfaction), life stage and culture, and the experiences of women and health care providers (facilitators and barriers) were extracted and synthesized by ≥2 independent reviewers.

RESULTS

In total, 89 papers were included (n=45, 51% primary and n=44, 49% supplementary) involving studies from 14 countries. A total of 28 types of DTs were used in 41 primary studies, including mobile apps with or without a portable vaginal biofeedback or accelerometer-based device, a smartphone messaging system, internet-based programs, and videoconferencing. Approximately half (22/41, 54%) of the studies provided evidence for or testing of the DTs, and a similar proportion of PFMT programs were drawn from or adapted from a known evidence base. Although PFMT parameters and program compliance varied, most studies that reported on UI symptoms showed improved outcomes, and women were generally satisfied with this treatment approach. With respect to life stage, pregnancy and the postpartum period were the most common focus, with more evidence needed for women of various age ranges (eg, adolescent and older women), including their cultural context, which is a factor that is rarely considered. Women's perceptions and experiences are often considered in the development of DTs, with qualitative data highlighting factors that are usually both facilitators and barriers.

CONCLUSIONS

DTs are a growing mechanism for delivering PFMT, as evidenced by the recent increase in publications. This review highlighted the heterogeneity in types of DTs, PFMT protocols, the lack of cultural adaptations of most of the DTs reviewed, and a paucity in the consideration of the changing needs of women across their life course.

Barriers and enablers of pelvic floor rehabilitation behaviours in pregnant women with stress urinary incontinence: a qualitative analysis using the theoretical domains framework

BACKGROUND

Stress urinary incontinence during pregnancy is closely related to the occurrence of postpartum and long-term urinary incontinence. Early pelvic floor management is of great significance in promoting the recovery of pelvic floor tissues in pregnant women. However, effective management of urinary incontinence is far from achievable owing to the low adherence of pregnant women in partaking in pelvic floor rehabilitation. As a comprehensive framework for behavioural theory, the Theoretical Domain Framework allows for comprehensive identification of behavioural determinants. Using Theoretical Domain Framework, this study aimed to identify barriers and enablers of pelvic floor rehabilitation behaviours in pregnant women with stress urinary incontinence.

METHODS

A descriptive, qualitative design was used in this study. Face-to-face semi-structured interviews were conducted with pregnant women with stress urinary incontinence based on the Theoretical Domain Framework. The data were analysed using a combination of inductive and deductive methods.

RESULTS

Twenty pregnant women with stress urinary incontinence were interviewed. Seven themes were summarised and used to explain the pelvic floor rehabilitation behaviours of pregnant women with stress urinary incontinence. The seven themes were (1) individual knowledge and experience of pelvic floor management, (2) judgments about expected outcomes, (3) interactions of interpersonal situations, (4) environment, resources, and decision-making processes, (5) personal goal-setting and efforts towards behaviour change, (6) emotional influences on decision-making, and (7) personal characteristics. Besides the "Optimism" domain, 13 of the 14 Theoretical Domains Framework domains were found to influence pregnant patients' pelvic floor rehabilitation behaviours after deductive mapping of themes to the Theoretical Domains Framework. In addition, the inductive analysis generated a theme of personal characteristics that did not map to any of the Theoretical Domains Framework domains.

CONCLUSIONS

The pelvic floor rehabilitation behaviours of pregnant women with stress urinary incontinence are complex and are affected by many factors. The findings confirm the need for multiple interventions to support pelvic floor management in pregnant women with stress urinary incontinence, focusing on enhancing knowledge and skills in pelvic floor care and using appropriate behaviour change techniques (such as prompts) to provide a supportive environment.

Technical Update No. 433: eHealth Solutions for Urinary Incontinence Among Women

OBJECTIVE

The purpose of this technical update is to establish the state of the science regarding emerging and novel electronic health (eHealth) and mobile health (mHealth) solutions for urinary incontinence among women.

TARGET POPULATION

Women over 18 years with urinary incontinence.

OPTIONS

Websites and mobile health applications are useful in the conservative care of urinary incontinence. Relevant care providers should be familiar with such tools, particularly those that use motivational principles for behaviour change, which can be used as adjunct tools for urinary incontinence care. Telemedicine is an effect mode to provide services for the conservative care of urinary incontinence.

OUTCOMES

Use of eHealth and mHealth solutions has potentially significant health outcomes for patients, providers, and global health systems. Broader use of telemedicine, in and of itself, could improve care access and reduce costs incurred by patients and the health care system.

BENEFITS, HARMS, AND COSTS

Evidence for the efficacy of eHealth and mHealth technologies and applications for urinary incontinence ranges from weak to strong. However, the research landscape for many of these novel solutions is developing rapidly. Furthermore, these options have minimal or no harm and confer an established cost benefit and care access benefit.

EVIDENCE

The Cochrane Library, Medline, EMBASE, CENTRAL databases (from January 2014 to April 2019) were searched to find articles related to conservative care of urinary incontinence in women (over 18 years) and studies on eHealth and mHealth interventions for urinary incontinence. Articles were appraised, and the collective evidence was graded.

VALIDATION METHODS

The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations).

INTENDED AUDIENCE

Relevant primary care providers and medical specialists, including physicians, nurses, midwives, and pelvic health physiotherapists.

SUMMARY STATEMENTS

RECOMMENDATIONS.

Women's adoption of a web-based intervention for stress urinary incontinence: a qualitative study

Background

Stress urinary incontinence (SUI) is common among women and affects their quality of life. Pelvic floor muscle training is an effective conservative therapy, but only a minority of women seek help. E-health with pelvic floor muscle training is effective and increases access to care. To implement an e-Health intervention in a sustainable way, however, we need to understand what determines adoption. The aim is to investigate the barriers and facilitators to adopting an e-Health intervention among Dutch women with stress urinary incontinence.

Methods

Semi-structured telephonic interviews were carried out among participants of the Dutch e-Health intervention for women with stress urinary incontinence. Women were purposively sampled. The ‘Fit between Individuals, Task and Technology’ (FITT) framework was used for both the data collection and data analysis, to gain a more in-depth insight into the adoption of the intervention.

Results

Twenty women were interviewed, mean age 51 years and mostly highly educated. The adoption of e-Health for women with SUI mainly depends on the interaction between users and e-Health, and users and pelvic floor muscle training exercises. Facilitators for the adoption were the preference for an accessible self-management intervention, having a strong sense of self-discipline and having the ability to schedule the exercises routinely. Women needed to possess self-efficacy to do this intervention independently. Barriers to the adoption of e-Health were personal circumstances restricting time for scheduling pelvic floor muscle training and lacking skills to perform the exercises correctly. Despite guidance by technical features several women remained uncertain about their performance of the exercises and, therefore, wanted additional contact with a professional.

Conclusions

For stress urinary incontinence e-Health is an appropriate option for a target audience. Use of the FITT framework clearly demonstrates the conditions for optimal adoption. For a subgroup it was a suitable alternative for medical care in person. For others it identified the need for further support by a health care professional. This support could be provided by improvements of technical features and incorporating modes for digital communication. The additional value of integration of the e-Health intervention in primary care might be a logical next step.

Trial registration

The study was prospectively registered in the Netherlands Trial Registry (NTR) NTR6956.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06585-z.

A guide to physiotherapy in urogynecology for patient care during the COVID-19 pandemic

Introduction and aim

Physiotherapy in urogynecology faces challenges to safely continuing its work, considering the adoption of social distancing measures during the COVID-19 pandemic. Some guidelines have already been published for urogynecology; however, no specific documents have been produced on physiotherapy in urogynecology. This article aimed to offer guidance regarding physiotherapy in urogynecology during the COVID-19 pandemic.

Methods

A group of experts in physiotherapy in women’s health performed a literature search in the Pubmed, PEDro, Web of Science and Embase databases and proposed a clinical guideline for physiotherapy management of urogynecological disorders during the COVID-19 pandemic. This document was reviewed by other physiotherapists and a multidisciplinary panel, which analyzed the suggested topics and reached consensus. The recommendations were grouped according to their similarities and allocated into categories.

Results

Four categories of recommendations (ethics and regulation issues, assessment of pelvic floor muscle function and dysfunction, health education and return to in-person care) were proposed. Telephysiotherapy and situations that need in-person care were also discussed. Regionalization is another topic that was considered.

Conclusion

This study provides some guidance for continuity of the physiotherapist's work in urogynecology during the COVID-19 pandemic, considering the World Health Organization recommendations and the epidemiological public health situation of each region. Telephysiotherapy can also be used to provide continuity of the care in this area during the COVID-19 pandemic, opening new perspectives for physiotherapy in urogynecology.