Mobile health (mHealth) applications (apps) provide a promising route to improve healthcare delivery and outcomes. Besides increasing adherence, health apps have the ability to reach people suffering from conditions that make them feel embarrassed or stigmatized and may lower barriers for women with urinary incontinence (UI). Recent studies show that apps for UI could be an effective and cost-effective option in the treatment of UI. Knowledge about the attitudes of stakeholders is important for successful implementation, but lacking [1].
Therefore, we aim to explore the attitudes of care providers towards the use of an app in the treatment of urinary incontinence, and to investigate the preferences and anticipated barriers for implementation of an app-based treatment for UI according to care providers.

We performed a sequential mixed methods study, consisting of focus groups followed by a quantitative questionnaire. We organized 5 focus group sessions with the main caregivers involved with UI care; general practice assistants (PA) (n=7), (resident) general practitioners (GP) (n=6), registered pelvic physiotherapists (PPT) (n=8, n=7), and (resident) uro- and gynecologists (UG) (n=6). Sessions were recorded, transcribed verbatim and coded separately by two researchers. Emerging themes were used to form a questionnaire, which was widely spread among Dutch caregivers to further investigate their attitudes towards current UI care and the possible role of eHealth applications in UI treatment. The questionnaire included 17 statements regarding the use of an app for treatment of UI in women, with 5 response categories ranging from strongly disagree to strongly agree.

Focusgroup sessions
Care providers explored and discussed the possible roles eHealth applications could play in the treatment of UI in women, like providing patients with reliable information, supporting treatment adherence and lowering barriers for women who don’t want to visit their physician for UI.
Additionally, they discussed preconditions and barriers concerning implementation of an app for the treatment of UI. Some of them felt that a reliable party should develop such an app and effectiveness should be demonstrated before they would consider it as a treatment option. Barriers for implementation according to care providers were concerns about data safety, lack of time and financial compensation for this time, a fear of decreased or increased patient contact and a lack of clear legal guidelines for usage of eHealth applications. 

Quantitative Questionnaire
In total, 741 care providers with a mean age of 45 years, completed the questionnaire (Figure 1); 87% of the participants was female, and 75% had never referred patients to treatment apps for UI.
The majority of all care providers (strongly) agreed that an app for UI can support regular treatment (68%) and that it can support treatment adherence after regular treatment (61 %)(Figure 2). 56% of all care providers and 89% of all PPTs (strongly) agreed that an app for UI should always be used with supervision of a care provider. 48% of all care providers and 15% of PPTs (strongly) agreed that an app for UI is a sound alternative for women who don’t visit a care provider.
Almost all care providers (strongly) agreed that an app for UI should be developed by a reliable organization (95%) and that it should fulfil legal obligations regarding safety and privacy (93%), before they would refer patients to a treatment app for UI. Proven effectiveness was important to 83% of all care providers. There were no evident differences in subgroups.
A lack of time to get familiar with the app, was seen as a barrier by 42%, and lack of financial compensation for this time investment by 19% of participants. The majority of participants (strongly) disagreed that fear of decreased or increased patient contact would be a barrier for using an app for UI (respectively 80% and 81%). 49% of care providers (strongly) disagreed that doubts about personal benefits would be a barrier for implementation.

Our results demonstrate that many care providers in the Netherlands see a supportive role for mhealth in the treatment for UI. This is in agreement with recent literature showing that care providers have a positive attitude towards a variety of mHealth applications [2]. In an earlier study, Dutch GPs welcomed eHealth for UI as a new tool, but reported doubts regarding eHealth as a standalone therapy. This is in line with current data showing that 56% of all care providers and 47% of GPs feel that a caregiver should always supervise an app treatment. 
Our study shows that several contextual factors like a lack of time, financial issues, protection of data and privacy could play a role when implementing an app for UI. A recent systematic review on mHealth adoption by professionals identified several barriers and facilitators of which ‘time-issues’ was the most common barrier, in n=10 out of 33 reviewed articles [3]. Reimbursement of tasks related to mHealth was mentioned as a barrier by only one publication in this review article. This might indicate a low importance, which was also seen in our study where only 19% of our participants viewed financial compensation for time investment as a barrier.

This study provides valuable insight into several contextual factors valued by professionals regarding implementation of an app based treatment for UI in women. Care providers see a supportive role for an app during and after regular treatment. Despite the evidence for effectiveness of eHealth for UI as a stand-alone treatment, care providers are divided towards app usage in absence of a health provider. These factors, along with other barriers and preconditions identified in this study, should be taken into account to promote future implementation of an app for the treatment of UI in women.

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