Hypothesis / aims of study
Assistive Technologies (ATs) are fundamental in managing intractable incontinence, addressing toilet use problems and supporting people to remain independent. Relatively inexpensive products such as absorbent pads or handheld urinals can help maintain function and independence, potentially preventing unnecessary care home admission. The World Health Organisation recognised the importance of ATs in incontinence management, listing absorbent continence products as one of its top 50 Priority Assistive Technologies.
There is a wide array of continence containment and toilet-use ATs (and many people simultaneously need options from both groups), but most people who need them do not have information on or access to the full range. In the World Health Organization (WHO) rapid Assistive Technology Assessment (rATA) survey of 35 countries, only around a quarter of people requiring continence products had access to them [1]. By contrast, many people in developed countries are provided with ATs that remain unused as they are unsuitable for their needs or lifestyle [2]. Different ATs are usually provided by different health or social care professionals with no one profession having comprehensive insight into the full range of containment and toilet-use products and no single information source available.
To help end-users access the optimal AT for their individual needs and circumstances, the first step is to map the full range of problems with the full range of potential AT solutions. This study aimed to: 1) identify and categorise all toilet use and continence containment problems, 2) identify the range of Assistive Technologies designed (or adopted) to help people living at home with these problems, and 3) map the ATs to the problems they are designed to address.
Study design, materials and methods
The purpose of the mapping review was to ‘“map out” and thematically understand’ pre-existing knowledge [3]. A preliminary list of containment and toilet use problems was compiled following wide-ranging scoping searches of grey literature including continence websites, online product catalogues, and continence or condition-specific (such as dementia or physical disability-related) discussion forums or blogs. These were reviewed and refined during a stakeholder meeting with AT end-users and healthcare professional representatives. Problems focused on the functional need or difficulty, such as directing urine into the toilet or containing urine/ faeces while travelling, as opposed to medical diagnosis.
With the support of an information scientist, the following sources were consulted to identify ATs: continence charity and not-for-profit websites, online product catalogues, commercial directories, seminal texts and research literature. Google searches were performed using specific AT terminology identified from the preceding searches to identify the broadest possible range of products. ATs designed to address one or more of the identified toilet use or containment problems, suitable for use by adults (≥18) in a domiciliary setting, and available to the European, North American or Australian markets were eligible for inclusion. Products intended to treat or cure the underlying cause of the incontinence, such as pelvic floor training devices, were excluded. Additional searches of the Scopus electronic database and a continence discussion forum were undertaken if few ATs were identified for a problem. This search process took place from August 2023 to February 2024.
Results
Continence and toilet-use problems:
Twenty-two toilet use and 11 containment problems were identified. Toilet use problems included challenges in accessing a toilet, difficulties during toilet use, using toilet alternatives, and addressing hygiene and personal care needs. Containment problems included containing leakage (during daily activities, exercise, travel or sleep), addressing environmental concerns (managing odour, protecting furniture and bedding) and using containment products (including disposing of products and washing reusable products). To support mapping to ATs, problems were subsequently categorised into 295 sub-problems in an iterative process based on key end-user characteristics, namely an individual’s physical function, cognitive function, sex, type and level of incontinence.
Assistive technology product categories:
The search strategy revealed 162 categories of AT products that addressed the problems identified in the mapping review. Some categories, such as a vaginal insert for faecal incontinence, consisted of a single product, while others, such as booster pads, included multiple products with slight design variations. These AT categories could be broadly assigned into one of seven groups, namely body-worn products, clothing & dressing, toilet and commode-related products, bathroom-related products, furniture and home, hygiene management and reminder aids and sensors.
Mapping problems to ATs:
AT product categories were mapped to each of the 295 sub-problems. The number of AT product categories mapped to each sub-problem varied widely with between 0 and 15 options identified for each of these, and over 1500 mapping links made in total.
Interpretation of results
This study employed a novel problem-based approach to comprehensively search and map AT products designed to address continence containment and toilet use issues in community settings. The search revealed a large number of AT product categories (n=162), and their suitability was contingent on specific end-user characteristics which varied among the problems considered (n=33, with each problem divided into sub-problems (n=295) based on user characteristics).
With over 1500 mapping links, this study illustrates the complexity of supporting the optimal use of continence containment and toilet-use assistive technologies. It is known that ATs are suboptimally used, in part, due to the lack of personalisation in product choice [2], but this study makes it clear that improving personalisation (and subsequent adoption of the product into regular use) will not be straightforward. Any attempts to improve decision-making on product choice should focus on the meaningful involvement of end-users.
The next stage in moving towards improved decision-making is to evaluate the effectiveness of these ATs for a range of outcomes (including cost). Following this a digital tool to support shared decision making that takes into consideration the end-user’s individual needs, circumstances and preferences can be developed.