eHealth is emerging and potentially has advantages for the treatment of UI in women. Especially, the use of mobile health applications (apps) may increase adherence to treatment advices and therewith reduce costs for UI management (1). Although various apps aimed at supporting the treatment of UI are currently available, little is known about the expectations and preferences of users of these apps and whether their expectations correspond with their actual experiences. This lack of knowledge may result in poor implementation of a possibly effective application.
	The aim of this study is to explore experiences and preferences regarding usability of an app-based treatment for UI in women

We performed a qualitative usability study as part of an extensive process evaluation alongside a randomized controlled trial (RCT) evaluating an app-based treatment for stress, urgency and mixed UI in women. 
We invited women applying the following inclusion criteria: age ≥ 18 years, suffering from self-reported stress, urgency or mixed UI at least twice a week according to the 3 Incontinence Questions (3IQ), a wish for treatment and access to a smartphone or tablet. Exclusion criteria were: indwelling urinary catheter, urogenital malignancy, previous surgery for UI, treatment for UI in the previous year (pharmacologically or non-pharmacologically), terminal or serious illness, cognitive impairment or psychiatric disorders, urinary tract infection, overflow or continuous UI, pregnancy or recent childbirth (< 6 months ago) or the inability to complete a questionnaire in Dutch.
We recruited women who fulfilled the inclusion criteria, but who did not participate in the RCT to avoid the chance of influencing the RCT. For this, we invited women who had contacted their GP for UI in the past 10 years through an information letter. After checking for in- and exclusion criteria by the researcher and written informed consent, participants filled in a short questionnaire on patient characteristics, UI severity, comorbidity, drug use and previous experience with the internet. 
	Participants used the App during 6 weeks, after which semi-structured interviews were held to explore preferences and experiences regarding the usability of the App. Questions included in the interview guide were based on the Technology Acceptance Model (TAM). TAM is a validated instrument to use in a healthcare setting and is good at predicting the use of eHealth. Additionally, questions on experiences with specific app functions were asked. Automatically logged data on app-usage were collected and used to further guide the interviews. Interviews were conducted at the patients GP practice and recorded using a digital voice recorder after which they were transcribed verbatim. Transcriptions were coded in duplicate by two researchers, using nVivo and checked for consensus. Recruitment of participants continued until saturation was reached (i.e. no new themes emerged during the interviews). Data analysis was driven by an inductive approach, which allowed themes to emerge from the data by constant comparison.

Nine women, age 32 to 68 years, participated (saturation was reached after 9 interviews). The duration of UI complaints ranged from 1.5 to 26 years. Participants had urgency UI (3), stress UI (1), mixed UI (2), urgency-predominant mixed UI (2), and stress-predominant mixed UI (1). Four women indicated that they used incontinence pads on a daily basis. The ICIQ-SF score ranged from 2 to 13, indicating a low to moderate self-perceived severity of UI. 
Data analysis generated the following four main themes: 
Accessibility: this covers ease of use and how this relates to privacy. Most participants experienced the app as convenient; it made UI care and treatment easily accessible. Some participants stated that the app made it easier to receive treatment while keeping their UI symptoms private. These participants mentioned that they disliked discussing their symptoms with others and that fear of internal examination kept them from seeking help. In contrast, some participants also mentioned that they found it easier to talk about their symptoms after they started using app.  
Awareness: participants mentioned that the use of the app enhanced their awareness of their symptoms. Some participants realized that their symptoms were worse than they had previously thought. For some this was an unpleasant and confronting experience. Several participants also expressed that they became more aware of the treatment possibilities for UI and that the app made them more aware of their coping strategies and ways how these could be improved. 
Usefulness: this covers the perceived usefulness of the app, describing ways in which the app is serving a purpose for the user. Seven participants stated that overall they were positive about the usefulness of the app and would recommend the app to other women with UI. Furthermore, the majority of the participants stated that they would probably use the app in the future. 

Adherence: this covers the time it takes to be engaged with the app, to adhere to the treatment and factors that promote adherence. The majority of participants mentioned that they found it difficult to do the exercises on a regular basis, because they felt they were too busy with work or private life to invest time in the app treatment. In contrast, one participant mentioned that the app is especially suitable for people with busy schedules. Participants stated that the reminder function of the app promoted adherence to the treatment. Also, some women noted that symptom improvement was motivated them to continue doing the exercises. Another participant stated that the display of her progress in the graphs was motivational.

The results of this study provide insight into whether an app based treatment for UI fits the needs of its users. In general, women appreciated the increased accessibility of UI healthcare and possibility of 24/7 support. It enabled them to do the exercises at their own time and pace. These findings are in line with a previous study, which reported that a smartphone-based therapy for depression felt more accessible and present in patients’ everyday lives. In our study, some women were specifically attracted by the sense of privacy with the app-based treatment. Women were able to receive healthcare and treat their symptoms without having to consult a healthcare provider. On the other hand, some women experienced usage of the app had lowered barriers to talk about their UI complaints. Similar findings were reported in a study evaluating a treatment program for SUI without face-to-face contact, which described it breaking down some of the shame barriers.
An important challenge in long-term adherence to UI treatment is fitting the exercises into patients’ daily lives. Women in this study stated that they regularly forgot to do the exercises and mentioned that the reminder function of the app was an important feature; it supported them in reminding to do the exercises. This is in line with existing literature, which confirms the importance of reminder functions in eHealth tools. Other motivators to continued use of the app were symptom improvement and progress in exercise program. 
The greatest barrier to adherence mentioned by participants was being too busy. And even though women appreciated the fact that UI health care was accessible without health care provider consultation, several participants also mentioned the possible additional value of health care support. This is in line with studies on eHealth which show that adherence was low in the absence of face-to-face contact with a healthcare provider, possibly due to the lack reduced feelings of obligation (2). The results of this study indicate similar issues.

This is the first study exploring experiences and preferences of women regarding an app-based treatment for all three types of urinary incontinence (UI), i.e. stress, urgency and mixed, with the use of in-person interviews
Research has shown that patients may experience many barriers in the use self-care applications resulting in poor implementation of the application. Therefore, it is strongly advised to take into account the experiences and expectations of important stakeholders, like patients (3).  
In this study barriers and facilitators were explored, providing insight not only for treatment effects of a mobile application in the treatment of UI but potentially also for other future eHealth applications. By combining these results with experiences and expectation of other stakeholders like healthcare providers and with data on the (cost)effectiveness from the RCT (‘mixed methods’) we will be able to provide a complete picture of the introduction of an e-Health app for treatment of UI in women.

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