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Titiya Potiart, M.D.*, Kamontip Harnphadungkit, M.D.*, Phond Phunchongharn, Ph.D.**
*Department of Rehabilitation Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, ailand, **Department of
Computer Engineering, Faculty of Engineering, King Mongkut’s University of Technology onburi 10140, ailand.
Development and Effectiveness Testing of “Punsook”:
A Smartphone Application for Intermittent Urinary
Catheter Users with Spinal Cord Injury
Inclusion criteria
ABSTRACT
Objective: To develop and evaluate eectiveness of a smartphone application to assist the self-management of
intermittent urinary catheter users
Methods: is is experimental clinical research as part of a medical device trial. In phase 1, 10 intermittent urinary
catheter users were recruited from spinal cord injury (SCI) patients who had been admitted to a rehabilitation ward
at Siriraj Hospital. ey used the preliminary version of “Punsook”, a web-based application (app) for a smartphone,
alongside usual intermittent urinary catheterization (IC), and gave feedback on their experiences. eir qualitative
opinions were used to further develop a second version of the “Punsook” app. In phase 2, the new version was
used by 35 participants, who were asked to complete an eectiveness questionaire aer using the app, including
providing details on their history of urinary tract infection (UTI), urinary leakage, and catheterization-related pain.
is information was gathered at the end of rst and third months in the second phase of the study.
Results: More than half the participants agreed at the end of the rst month that every part of the app was acceptably
pleasant. ey liked the simplicity and ease of use of the app, accessibility, ease of return to use, and interest in the
program. No statistically signicant changes in urinary leakage, UTI, or pain were found.
Conclusion: e app was considered eective in terms of the positive user satisfaction with all aspects of the app.
However, despite this positive reception, the app may not have contributed to an improvement in participant
bladder control.
Keywords: Mobile application; intermittent urinary catheterization; spinal cord injuries; neurogenic bladder (Siriraj
Med J 2021; 73: 99-107)
Corresponding author: Kamontip Harnphadungkit
E-mail: kamontip.har@gmail.com
Received 25 September 2020 Revised 26 October 2020 Accepted 27 October 2020
ORCID ID: http://orcid.org/0000-0003-3101-8804
http://dx.doi.org/10.33192/Smj.2021.14
INTRODUCTION
World Health Organization (WHO) estimates
from 2013 suggest that the incidence of global spinal
cord injury (SCI) is 40 to 80 new cases per million of
population per year. is means that every year, between
250,000 and 500,000 people suer spinal cord injuries.
1
e average yearly expenses and lifetime costs for patients
with paraplegia are about USD 526,066,
2
with suerers
experiencing a 2- to 5-fold higher mortality rate than
healthy people.
1
In ailand, the incidence of SCI is
approximately 23 cases per million people per year, with
an economic loss of more than THB 2.6 million per case
where disability occurs.
3
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Potiart et al.
Constrained mobility, the reduction of self-care
performance, and limitation of the patient’s vocation and
social life can occur due to neurological dysfunction in
SCI. ese are also key determinants of various systemic
complications in SCI that increase the morbidity and
mortality rates. Urinary tract infection (UTI) is the
important source of hospital re-admission in developed
countries and can be a cause of mortality, even in developing
countries.
1
Around 62% of people with SCI will experience
an infection in their urinary tract within 1 year aer a
SCI and 95% will have suered this within 20 years of
the SCI.
4
Severe problems of the urinary tract, for instance,
infection, retention, leakage, stones, and reux, may result
from inappropriate bladder management. Prolonged
exposure to such problems can lead to fatal renal failure.
1
Accordingly, certain bladder management methods
can be applied. e individual treatment method for
a patient is selected depending on many factors, for
example, their sex, bladder, sphincter function, hand
function, mobility competence, and sitting balance.
Intermittent catheterization (IC) is one possible option.
is involves the insertion of a urinary catheter into the
bladder and its removal aer completed urination using
a clean or sterile technique. is method carries the
least risk of urinary tract complications.
1
A study in the
United States of America (USA) reported an educational
program as a treatment option, comprising nursing
observation, medical consultation, and the instruction
of basic knowledge about UTI, and follow-up. Using this
educational program coupled with regular IC was capable
to decrease the rate of UTI and antibiotics treatment in
the study cohort.
5
is indicated that IC is safe, eective,
and worth applying.
6
Currently, mobile phones (or smartphones) are
commonly used to facilitate communication among
SCI patients and whoever. Various health problems
can be widely discussed and advice provided through
internet networking for the benet of patients’ self-care,
such as for smoking cessation, diabetic care, and body
weight control. Nevertheless, there is currently little
information shared about IC. To address this, a web-
based self-management intervention was developed
in English,
7
which included an online voiding diary, a
journal, educational material, calls with a nurse, a forum,
and smartphone app. It is clear that communication and
information sharing between provider and the patient
population is purposeful and warranted. Based on the
success of that development, a web-based mobile phone
application (app) was developed in the ai language
with the purpose of supporting self-management of IC
users with SCI. Satisfaction with the app and eectiveness
were evaluated.
MATERIAL AND METHODS
is study was part of an experimental clinical
research project and medical device trial. In phase 1 of
study, we investigated the eectiveness of a new web-
based app called Punsook, on a mobile phone for IC
users. Qualitative remarks from users about the app
were collected 1 month aer the end of the rst phase.
e gathered data were sent to the Punsook application
developers to guide further development of the app in a
new updated version. However, problems arising during
use the app were solved and minor changes in the app
were done throughout the duration of the initial phase.
In phase 2, the eectiveness of the new version of the
app was evaluated (Fig 1).
Participants
SCI patients, both inpatients and outpatients, of the
Department of Rehabilitation Medicine, Siriraj Hospital,
during 2017-2019 who were IC users were invited to
participate in this study by direct contact or in a phone
call. e inclusion and exclusion criteria were outlined
to each possible participant to identify the patients who
were able to comprehend the issues and decide about
their bladder management themselves. e participants
were informed about the study rationale and their role
should they choose to join the study. Researchers asked
for written informed consent from these patients. If they
agreed to join the study and provided this consent, they
were then given access to the app.
Inclusion criteria
• At least 18 years old
• Had the ability to access the web-based smartphone
app
• Understood ai language
Exclusion criteria
• Had communication problems
• Had cognitive impairment.
Furthermore, patients who had never done
catheterization by themselves were able to participate
in the study if they met the other qualifying conditions.
At the beginning of both phases of the study, the
participants’ demographic data were collected. is
included their diagnosis, patient characteristics, daily
living function abilities, and their medication. Further
information about the catheterization procedures and
patient care was also gathered, including the frequency
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and interval of catheterizing, estimated urine output,
and catheter-related adverse events (e.g., UTI, leakage,
pain).
Sample size
Initially, 10 participants joined in phase 1 of the
study to test the initial app and to give feedback and/
or comments to aid the further development of the
app in a new updated version. e power analysis was
based on a similar study
8
that showed a condence level
of 95% for adequate bladder control, which was the
most important objective in its usability questionnaire.
However, our study inferred a slightly lower rate for the
eectiveness of the app as 90% with an allowable error
of 10%. Consequently, it was calculated that 35 patients
were needed to participate in the second part of study
(phase 2).
Intervention
In phase 1 of the study, the web-based smartphone
app “Punsook” was developed in a collaboration between
physiatrists and the Computer Engineering Department
of King Mongkut’s University of Technology onburi
(KMUTT). e app consists of four parts: an electronic
basic knowledge guidebook, frequently asked questions
(FAQ), online voiding diary, and possible contact with a
doctor. e FAQ was presented in a chatbot format. e
questions covered elementary self-care management around
urinary catheterization and other related conditions. e
online voiding diary was useful for IC users to record
their volumes of water intake and urine output. Also,
voiding sensations and any abnormality of concern
could be recorded. e application administrator was
able to check the real-time records from the app and
provide feedback to patients. The participants were
asked to use this app alongside their usual regular IC
practices. Besides, if they needed medical counsel, they
could directly contact a doctor via the app.
One month aer using the app, qualitative opinions
were obtained from the participants as feedback. Most
comments suggested improving the FAQ chatbot, e.g.,
by increasing the number of common questions and by
making the answers easier to understand. In addition,
some participants complained about the registration
methods. erefore, we reformed the homepage and
modied the chatbot in the new version and then evaluated
these updates in phase 2 of the study (Fig 2).
Fig 1. Flow chart of research process.
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Potiart et al.
Measurement
Assessing the eectiveness of the smartphone app
consisted of measuring user satisfaction and their views
on its usability, and its ability to decrease the incidence
of urinary complications. We hoped that satisfaction
with the educational materials, active interaction with
an expert, and regular diary recording might inuence
appropriate bladder management, improve bladder control,
and decrease the incidence of urinary complications. We
tried to develop the program based on the comments
from phase 1 of the study. en the eectiveness of
the new app was measured in phase 2 of the study.
Participants were asked to take part in a survey at the
end of rst month for assessing the eectiveness of the
app and additionally at the end of the third month to
evaluate their adherence to using the app.
The primary outcome was the satisfaction and
applicability of the app. We assessed the user satisfaction
toward each part of the program through a feasibility
questionnaire, which was divided into 2 parts: user
opinions on the information provided and user satisfaction
with the whole program. ere were 5 scales for the user
rating: “strongly agree”, “agree”, “neutral”, “disagree”,
“strongly disagree”. In addition, if the participants did
not use a certain part of the application, they could
answer with “did not use”. e answers “agree” and
“strongly agree” represented acceptable satisfaction. e
usability questionnaire evaluated the applicability of the
program. Usability was evaluated in 5 aspects: ease of
use, accessibility, ease upon return to use, interest, and
improved ability to control their bladder. e choices
were related to the duration of use for the participants’
condition, and the options were: “All of the time”, “most
of the time”, “a good bit of time”, which were passable
times, and “some of the time”, “a little bit of the time”,
and “none of the time”, which meant it did not meet
expectations. The users were asked to complete the
questionnaires aer they had been using the application
for 1 month and 3 months.
e secondary outcome was related to the app’s
ability to decrease the incidence of urinary complications.
Catheter-related adverse events could be reported at
the same time when the participants completed the
feasibility and usability questionnaires. Scores based
on the VAS were used to indicate the user’s pain from
catheterization. e number of UTI events and leakage
rates during the last 3 months were accumulated.
Statistical analysis
Data were analyzed by PASW (SPSS) Statistics for
Windows version 18. Descriptive statistics were used for
the subject characteristics. Qualitative data are presented
herein by the percentage and quantitative data by the
mean and standard deviation (SD). e paired t-test was
used to compare quantitative data, while the chi-square
test was used for qualitative data. A p-value of <0.05 was
considered to be statistically signicant.
Fig 2. Features of web-based application
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RESULTS
Table 1 presents the participants’ characteristics
and their urinary complications. In total, 35 patients
were recruited in the study. Everyone completed the
initial survey and no one was lost to follow-up. All of
the patients used an IC until the end of study. e study
cohort comprised 18 males (51.4%). e average age
of the participants was 41.86 ± 15.1 years. Most were
diagnosed with incomplete SCI (65.7%). Considering
the duration of SCI, 77.1% were diagnosed as having
SCI for more than one year. Most participants were
independent in terms of performing the activities of
daily living. The most commonly used medications
were baclofen (54.3%) and oxybutynin (45.7%), with
solifenacin and trospium chloride also reported in some
cases. Some participants used other methods for bladder
management along with IC; for example, some participants
used an indwelling catheter when traveling, a condom
at night, or sometimes they self-voided. Around 60%
of all participants catheterized 4-6 times per day, with
an interval of 4-6 hours between each time. However,
20–30% irregularly catheterized and did not measure
the volume of urine output.
Feasibility
In the 1-month feasibility survey, the participants
mostly commented that they were quite satised and
thought that every part of the app was useful. e evaluation
at the end of the third month found that the number of
participants who did not use the program was still the
same as in the rst month, implying a good adherence to
the app use by the users (Table 2). Also, the patients still
used most parts of the app, except for the FAQ chatbot. In
terms of the FAQ chatbot, 48% thought the information
in it was useful, and 51.4% were in favor of keeping the
FAQ chatbot (Table 2). Overall, the comparison between
the users’ opinions at the end of the rst and the third
month showed no statistically signicant dierence in
opinion (p = 0.47 concerning the information in the
app, p = 0.63 concerning the program itself) (Table 2).
Usability
By the end of the rst month, most participants could
access the dierent parts of the program and thought
the app was easy to use. Likewise, they could return to
use it quite eciently even aer leaving it for a while.
Half the participants regarded the app as interesting.
However, only 40% were able to control their bladder
better even with using the advice from the app (Table
3). Two months later at the end of month 3, they still
prociently use the app, even if they had not used it
for a while. A larger number of participants, however,
stated that using the app was dicult. Controlling their
bladder was the main issue that they had never managed
to achieve.
Catheter-related pain
e averaged catheter-related pain score was collected
by the visual analogue scale (VAS). e baseline pain
score was 1.66 ± 1.8 (Table 4); whereas at 1 month and
3 months later, the pain intensity had increased to 1.8
± 2.1 and 2 ± 2.2, respectively (Table 4). However, there
was no signicant dierence between the scores aer a
longer duration of the study (p = 0.74 at the 1-month
survey, p = 0.44 at the 3-month survey) (Table 4).
Leakage
Overall, 74% of the participants reported rarely
suering leakage (Table 4). We compared this parameter
with the baseline result. ere was no statistically signicant
dierence at either the 1-month or 3-month survey
points (p = 0.79) (Table 4).
Urinary tract infection (UTI)
Information on the history of UTI in the previous
3 months was gathered from the participants. Before
joining the study, about 30% of the participants had
previously experienced UTI (Table 4). e number of
patients who had UTI was still the same as at baseline as
reported in the rst-month and the third-month surveys.
DISCUSSION
A web-based smartphone app for IC users with
spinal cord injury (SCI) was developed for the rst
time in the ai language for ai patients. is app
was intended to aid patients’ self-management. Our
preliminary reports had indicated that the views of the
medical practitioners and the engineers who developed
the app might have been dierent from the views and
needs of the patients as end users. erefore, the present
study was carried out to assess the eectiveness of this
app from the patients’ point of view to determine their
satisfaction level with the app.
Feasibility and usability surveys were performed and
the ndings fell in the form of a bimodal distribution.
Most respondents expressed either satisfaction or rejection
of the app. ere were a number of reasons why some
participants rejected using the app. At the beginning of the
study, the knowledge guidebook and FAQ chatbot were
launched before the online voiding diary. Accordingly,
some participants in the rst phase of the study spent
too little time with this online voiding diary. At the
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TABLE 1. Demographic data. TABLE 1. Demographic data. (Continue)
Characteristics n = 35
Sex n (%)
Male 18 (51.4)
Female 17 (48.6)
Age Year, mean (SD) 41.86 (15.1)
Education level n (%)
Below high school 8 (22.9)
High school 7 (20)
Bachelor’s 16 (45.7)
Master’s / Doctor’s 4 (11.4)
Completeness of lesion n (%)
SCI Complete 8 (22.9)
SCI Incomplete 23 (65.7)
Unknown 4 (11.4)
Duration of SCI n (%)
Less than 1 year 8 (22.9)
≥1year 27(77.1)
Level of SCI n (%)
Cervical 6 (17.1)
Thoracic 9 (25.7)
Lumbar 17 (48.6)
Sacral 3 (8.6)
ADL bathing n (%)
Dependent 5 (14.3)
Independent 30 (85.7)
ADL dressing n (%)
Dependent 5 (14.3)
Independent 30 (85.7)
ADL toileting n (%)
Dependent 7 (20)
Independent 28 (80)
ADL ambulation and transfer n (%)
Dependent 8 (22.9)
Independent 27 (77.1)
ADL eating n (%)
Dependent 2 (5.7)
Independent 33 (94.3)
Characteristics n = 35
Medication n (%)
Baclofen 19 (54.3)
Oxybutynin 16 (45.7)
Antibiotics 2 (5.7)
Amitriptyline 2 (5.7)
Not use 7 (20)
Other 4 (11.4) #
Other bladder management methods n (%)
Indwelling 7 (20)
Condom 1 (2.9)
Absorbent product 1 (2.9)
Credé 1 (2.9)
Self-voiding 7 (20)
No other method 18 (51.4)
Frequency of catheterizing per day n (%)
1–3 times 4 (11.4)
4–6 times 23 (65.7)
7 times or more than 8 (22.9)
Catheterizing intervals n (%)
2-3 hours 4 (11.4)
4-6 hours 21 (60)
7-9 hours 0 (0)
10-12 hours 2 (5.7)
Varies 8 (22.9)
Urine output n (%)
Less than 100 ml 3 (8.6)
100-399 ml 19 (54.3)
400 ml or more than 4 (11.4)
Unknown 9 (25.7)
Leakage n (%)
Every day 9 (25.7)
Less than every day 26 (74.3)
UTI in last 3-month n (%)
Never 22 (62.9)
1-2 times 11 (31.4)
3-4 times 2 (5.7)
5 times or more 0 (0)
Pain mean (SD) 1.69 (1.9)
# Trospium chloride = 2, Solifenacin = 1, Gabapentin = 1 # Trospium chloride = 2, Solifenacin = 1, Gabapentin = 1
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TABLE 2. Result of feasibility questionnaire.
TABLE 3. Result of usability questionnaire.
Did not use Strongly disagree disagree Neutral Agree Strongly agree
1
st
month 3
rd
month 1
st
month 3
rd
month 1
st
month 3
rd
month 1
st
month 3
rd
month 1
st
month 3
rd
month 1
st
month 3
rd
month
Was the information useful?
Voiding diary 8 (22.9) 9 (25.7) 0 (0) 0 (0) 0 (0) 0 (0) 5 (14.3) 3 (8.6) 12 (34.3) 14 (40) 10 (28.6) 9 (25.7)
Knowledge 7 (20) 8 (22.9) 0 (0) 0 (0) 2 (5.7) 2 (5.7) 5 (14.3) 7 (20) 12 (34.3) 13 (37.1) 9 (25.7) 5 (14.3)
Contact with doctor 7 (20) 7 (20) 0 (0) 0 (0) 0 (0) 0 (0) 3 (8.6) 4 (11.4) 9 (25.7) 10 (28.6) 16 (45.7) 14 (40)
FAQ (Chatbot) 7 (20) 9 (25.7) 0 (0) 0 (0) 2 (5.7) 2 (5.7) 6 (17.1) 7 (20) 12 (34.3) 13 (37.1) 8 (22.9) 4 (11.4)
Were you satised with the parts of the program?
Voiding diary 7 (20) 9 (25.7) 0 (0) 0 (0) 0 (0) 0 (0) 6 (17.1) 8 (22.9) 12 (34.3) 10 (28.6) 10 (28.6) 8 (22.9)
Knowledge 6 (17.1) 7 (20) 1 (2.9) 0 (0) 2 (5.7) 2 (5.7) 6 (17.1) 7 (20) 13 (37.1) 14 (40) 7 (20) 5 (14.3)
Contact with doctor 7 (20) 7 (20) 0 (0) 0 (0) 0 (0) 0 (0) 3 (8.6) 5 (14.3) 10 (28.6) 11 (31.4) 15 (42.9) 12 (34.3)
FAQ (Chatbot) 7 (20) 8 (22.9) 1 (2.9) 0 (0) 3 (8.6) 3 (8.6) 4 (11.4) 6 (17.1) 13 (37.1) 14 (40) 7 (20) 4 (11.4)
None of the time A little of the time Some of the time A good bit of the time Most of the time All of the time
1
st
month 3
rd
month 1
st
month 3
rd
month 1
st
month 3
rd
month 1
st
month 3
rd
month 1
st
month 3
rd
month 1
st
month 3
rd
month
Easy to use 4 (11.4) 5 (14.3) 3 (8.6) 2 (5.7) 4 (11.4) 5 (14.3) 6 (17.1) 7 (20) 7 (20) 8 (22.9) 11 (31.4) 8 (22.9)
Able to assess all around 4 (11.4) 4 (11.4) 2 (5.7) 0 (0) 3 (8.6) 6 (17.1) 7 (20) 5 (14.3) 9 (25.7) 9 (25.7) 10 (28.6) 11 (31.4)
the part of program
Back to use program after 4 (11.4) 4 (11.4) 2 (5.7) 1 (2.9) 1 (2.9) 4 (11.4) 6 (17.1) 6 (17.1) 12 (34.3) 9 (25.7) 10 (28.6) 11 (31.4)
leave for a while
Interesting and attractive 3 (8.6) 3 (8.6) 2 (5.7) 0 (0) 2 (5.7) 6 (17.1) 10 (28.6) 8 (22.9) 10 (28.6) 8 (22.9) 8 (22.9) 10 (28.6)
to use
Can control bladder 13 (37.1) 13 (37.1) 5 (14.3) 3 (8.6) 2 (5.7) 4 (11.4) 8 (22.9) 7 (20) 3 (8.6) 3 (8.6) 4 (11.4) 5 (14.3)
p value > 0.05, comparing number of each answer at the rst month to that in the third month
p value > 0.05, comparing number of each answer at the rst month to that in the third month
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same time, half the participants used other methods for
bladder management alongside IC; for example, some
used indwelling catheterization while traveling outside
their residence. us, these users had less chance to use
and test the app. Consequently, they did not feel capable
of expressing their opinion about the app when they had
rarely used parts of the app. When some participants
commented that they did not use a certain part of the
app, this answer was not included in the satised status.
Keeping a voiding diary for persons with spinal cord
injury is very useful. By analyzing the volume and frequency
of each voiding, along with other parameters monitored
in the diary, the physician can assess the diary to form an
initial opinion about the patient’s urodynamic prole.
9
e online voiding diary is more convenient to keep up
with as it involves active interaction. e data are directly
sent to administrative sta for providing early feedback
to the patients. While a paper diary is still quite common
with many patients, electronic diaries are becoming more
common and can yield better compliance.
10
However,
ai doctors usually assign this choice of method to the
patients. If we are able to provide evidence to support the
eectiveness of an online voiding diary in the ai, this
might help popularize this method which may improve
patient compliance of a voiding diary.
e usage rates for the knowledge guidebook, online
voiding diary, and FAQ chatbot decreased at the third
month, which may have been due to the familiarity with
these aspects built up over time. As patients gain more
experience of intermittent catheterization, they need
less guidance and are able to solve most problems by
themselves. Moreover, the compliance with program use
might indicate the eectiveness of the app. Generally,
patients are more likely to persist with an intervention
if they feel it can help them avoid a more negative health
condition.
11
Consequently, we tried to nd some method
to improve those compositions in the app.
Contact with a doctor was the part of the app that
attracted the highest satisfaction level, in part because
of it being an interactive activity. Patients could freely
contact a doctor about their medical issues. Apart from
gaining knowledge or asking queries, they could obtain
specic information on primary practice and access to
the doctor appointment system. In this study, contact
with the doctor appointment system was performed
via the private doctor’s LINE® (Naver Corporation,
Tokyo, Japan) account. We plan to add this element
into our app in future updates. However, this incurred
a much higher expense in addition to the ocial contact
account. erefore, we tried to adjust the usability of the
app in other ways. e FAQs for communicating with
the doctor will be increased in the FAQ chatbot during
major changing among the two phases of this research.
Besides, we tend to continuously update the program
as we go along to save time.
Bladder control problems aect the way a person holds
or releases urine.
12
erefore, the key factor determining
bladder control is urinary leakage. However, patients
may be concerned that leakage is a problem when it
accidentally occurs and they cannot manage control.
Overall, 40% of participants thought that they could
not control their bladder at any time; although only
about 26% of participants complained about leakage
every day. is result suggested that the question of
bladder control in the usability questionnaire might not
represent the problematic leakage issue correctly. e
TABLE 4. Result of urinary complication.
Baseline 1
st
month 3
rd
month
Pain Mean (SD) 1.66 (1.8) 1.8 (2.1) P = 0.74 2 (2.2) P = 0.44
Leakage n (%)
• Daily 9 (25.7) 10 (28.6) P = 0.79 10 (28.6) P = 0.79
• Non-daily 26 (74.3) 25 (71.4) 25 (71.4)
UTI n (%)
• UTI within last 3 month 12 (34.3) 11 (31.4) P = 0.78 12 (34.3) P = 1
• No UTI within last 3 month 23 (65.7) 24 (68.6) 23 (65.7)
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eectiveness evaluation will need to be more specic for
the questionnaire to be able to reveal the actual problem.
us, clarication of this question could improve the
accuracy of the results. In addition, the applicability of
the app did not represent the real rate of app use, which
would typically not be enough to help the daily bladder
control of the participants.
Limitations
ere were some limitations of this study to mention.
Firstly, many older ai SCI patients were unable to
access the web-based app through their mobile phone.
us, many elderly could not be included in this study.
Along with the small sample size, which led to a low
power to detect small eects, non-signicant results on
the secondary outcome when comparing baseline to post-
intervention follow-up were observed. Secondly, some
participants had tetraplegia and poor hand function. eir
caregiver did the IC instead of the patients themselves,
and both the patients and their caregivers used the app
together. Most these patients used only the FAQ chatbot
and educational knowledge guidebook, while the catheter
users oen used the online voiding diary as well. us,
their opinion was summarized in just one survey. irdly,
our study lacked a control group for comparison between
the traditional educational method and this app. Finally,
we could not strictly enforce them to spend more time
with this program. erefore, the time expenditure with
the app was dierent among the participants, which
likely inuenced their satisfaction levels.
CONCLUSION
We successfully developed a web-based smartphone
app based on the requirements of SCI patients using
intermittent urinary catheterization. According to the
study participants, the eectiveness of this app was
considered satisfactory and every part of the program
was usable. e study ndings suggested, however, that
the app might not actually help to improve their bladder
control. We need to constantly modify the application
over time in order to meet the needs of the patients.
Educational videos, pop-up ratings, and urological check-
up recording might be interesting functions to add to
the app. Additional qualitative opinions and actual time
use data for using the app should be collected in a future
study.
ACKNOWLEDGEMENTS
e authors thank the computer engineering scholars
Napatsorn Amonsurnthornsiri and Prapasiri Sawetsuttipan
and their consultants from the Department of Computer
Engineering, King Mongkut’s University of Technology
onburi (KMUTT), who developed this web-based
mobile application. e authors sincerely appreciate
the eorts of all the study participants who gave their
time and opinions on the smartphone application for
this research.
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