Hypothesis / aims of study
The widespread adoption of single-use catheters is not supported by clinical research but has a clear environmental and financial burden [1]. We conducted a non-inferiority randomised controlled trial comparing mixed (multi/single-use) catheter management with single-use catheter management by 578 intermittent catheter users over 12 months. Participants randomised to the intervention arm were asked to combine re-use (reusing a catheter for up to 28 days with cleaning using soapy water and Milton – a commercial form of sodium hypochlorite - after each use) and single use (using their usual catheter). Those in the control arm continued with their usual single-use catheter.
To examine what people in the intervention arm thought about the catheter and their experience of cleaning and re-using it, a nested qualitative study aimed to
• Understand more about the needs and experiences of people mixing re-use and single use of intermittent catheters.
• Identify barriers and facilitators to the use of reusable intermittent catheters and contribute to the product innovation agenda.
Study design, materials and methods
A qualitative exploratory design was used to undertake semi-structured interviews. At the end of the Trial, participants from the intervention arm (including those who had withdrawn from the intervention) were purposively recruited for interview using a maximum variation schedule to achieve spread with respect to age, sex and Barthel score (a measure of independence with activities of daily living) [2]. All participants provided written and verbal informed consent and telephone interviews took place from January 2023 to March 2024. Interviews were audio recorded and transcribed verbatim. Deductive thematic analysis was undertaken on the first set of interviews to develop a framework for analysis of subsequent interviews, incorporating the specific goals of the study. Coding was undertaken by one researcher, with data discussed and reviewed by the research team at regular intervals. The consolidated criteria for reporting qualitative research (COREQ) checklist aided full and transparent reporting of these findings. We report on the first 32 participant interviews.
Results
Eighteen men and fourteen women, with a median age of seventy-one years, were interviewed. They were self-catheterising between one and seven times a day.
Interview findings:
Participants’ responses fell into four broad themes, within which it was possible to identify factors which contributed to successful use of the reusable catheter. All had voluntarily used the catheter for up to a year and most were initially motivated to reduce plastic waste or costs or both. The four themes were:
1. Characteristics/perspectives of the individual. Acceptability of the reusable catheter depended on:
a. Ability to adapt to managing the new catheter.
b. Confidence and trust in the catheter and the cleaning method.
c. Willingness to make it work/perseverance despite additional ‘bother.’
d. Physical ability (participants with low Barthel scores managed but needed to be more resourceful or use more single-use devices)
2. Context of catheter use. This was key to the feasibility of re-use, in particular:
a. At home: this was generally considered straightforward, particularly if there was a private bathroom separate from visitors. Space and facilities appeared not to be an issue.
b. Out and about during the day: this was probably the most demanding situation, which required forward planning, predictable facilities and greater confidence in managing the catheter.
c. Short breaks away from home: here the key issues were privacy-related, depending on the accommodation and circumstances.
d. Longer stays away from home. This provided the greatest potential benefits for the few who travelled, including security of supply and reduction in luggage space when travelling.
3. Opportunity to mix and match
a. Nearly all participants expressed a desire for a choice of catheters to be available for different situations and wished to continue mixed use of reusable and single-use catheters.
b. A few wished never to use a reusable catheter again whilst others were disappointed when they had to revert to single-use catheters at the end of the trial. Most were happy to use reusables at home if they had the option to use a disposable catheter when out – often as security backup even if not used.
c. Individuals clearly expressed a balance between the ‘feelgood’ factor of contributing to sustainability goals, and their limits of personal workload (physical, practical and psychological). Whilst some individuals experienced the workload more acutely, others accrued personal benefits which negated the desire to use any single-use catheters.
4. Characteristics of the catheter
Although most managed to use the multi-use catheter provided, some expressed the desire for alternative designs offering functional benefits to meet their individual needs e.g., more/less catheter flexibility, easier application or avoidance of lubricant, improved discreteness and portability outside the home.
Interpretation of results
We have identified factors which contribute towards successful use of a reusable catheter. Individuals have their own limits of personal tolerance to balance against the societal value of ‘doing the right thing.’ There were very few personal benefits of re-use, and it was considered particularly bothersome outside of the home for short periods. Almost all want to have the choice to mix and match single and multi-use.