For people living with incontinence, effectively containing leakage is fundamental to maintaining health, dignity and quality of life. Absorbent products (either disposable or washable) are widely used to achieve this goal but are not accessible to all.  In a rapid Assistive Technology Assessment World Health Organisation (WHO) survey of 35 countries, only around a quarter of people requiring continence products had access [1].  Disposable, single-use absorbent products are common-place but have considerable drawbacks; plastics and super-absorbent polymers in the products are not biodegradable and for many people these products are not affordable or accessible. Washable absorbent continence products are used less widely and are not easily available in most settings (other than for infants).

As part of a project to address the provision of assistive technologies, the WHO worked with country coordinating partners in India, Papua New Guinea and Romania to explore the potential for the widescale provision of washable absorbent continence products. Country partners worked with primary healthcare providers to provide washable products (choice of all-in-one with waterproof outer lining, two-piece washable fabric with a separate waterproof layer, washable pads and cotton towelling squares) to at least 75 product. As part of this project, a qualitative study was undertaken with the aims of:

•	Understanding more about the needs and experiences of people using washable incontinence products in different settings, including the impact on daily activities and well-being.
•	Identifying barriers and facilitators to the provision and use of washable products in different settings and contributing to the product innovation agenda.

Using a qualitative exploratory design and participatory action research approach, the WHO team and country partners worked with a UK-based researcher to undertake interviews with end-users and focus groups with service providers in the three countries. Multiple online workshops were undertaken with all research partners to finalise the research objectives and methods and to discuss analysis. The WHO GATE 5P framework (People, Products, Provision, Personnel and Policy) [2] was used as a basis for developing data collection tools and undertaking analysis. The Consolidated criteria for reporting qualitative research (COREQ) checklist has aided full and transparent reporting of these findings. Data collection took place from January 2022 to January 2023. All necessary ethical approvals were sought and received. All participants provided written or verbal informed consent. All end-users who had been provided with products were invited to take part in an interview. Interviews were conducted by local teams, digitally recorded and translated/transcribed verbatim. All personnel directly involved in providing products to end-users were invited to take part in their local focus group which were conducted by the UK-based researcher via recorded video calls. A framework approach [3] was taken to identify themes based on the objectives of the research for both the interviews and focus groups

57 interviews were undertaken with product users (adults and children over the age of 7) and/or carers (19 in India, 11 in Papua New Guinea and 27 in Romania), who had used a range of products. Settings varied widely, including urban areas with reliable utilities to rural areas without access to facilities such as regular rubbish collection. Three focus groups (one with each country partner), with a total of 16 participants (eight in India, six in Papua New Guinea and two in Romania) were undertaken. Five themes were identified from the combined data:

1)	Impact of washables on people’s lives -
a.	Common washable product positives (e.g., lower long-term costs for those previously using disposables, reliable accessibility, facilitated participation in daily activities)
b.	Common washable product negatives (e.g., poor product fit causing leakage, post-washing smell, cotton towelling squares generally unpopular)

2)	Wide variation in usability/acceptability within similar contexts -
a.	Personal values affect acceptability (e.g., concern about bulkiness bother some but not others)
b.	Specific circumstances lead to variation in opinion between seemingly similar users (e.g., varying views on whether the product increased or decreased carer workload)

3)	Do no harm -
a.	Appropriate assessment needed to ensure the correct bladder management strategy
b.	Potential washable product hazards (e.g., skin irritation or tissue damage)

4)	Planned future washable use - spectrum of responses from enthusiastic ‘Yes’ (“This product is like gold”) to ‘sometimes’ (e.g., during the summer or at night) to a range of reasons for ‘no’

5)	Scalability requirements – 
a.	Product innovation (e.g., more adjustable fit around legs and waist)
b.	Provision innovation (e.g., availability of bladder assessment for urinary retention, ensuring the provision of sufficient products)
c.	Infrastructure & provider support (e.g., reliable water supplies)
d.	Tackling stigma to support case identification

This study provides the first in-depth examination of the washable absorbent continence product-related experiences of both end-users and service providers.  This work indicates that the wide-scale provision of washable absorbent continence products has the potential to improve the day-to-day lives for many people living with long-term continence problems.  However, they do not work for everyone and they have the potential to cause harm. Bladder drainage needs should be evaluated by a trained assessor where possible to ensure that an absorbent product is the most appropriate product, rather than, for example, a urinary catheter. The potential for skin or tissue damage should also be monitored. The opportunity to try out products (or a range of products) would be beneficial as different products suit different needs and people in seemingly similar circumstances have very different opinions on using washable products. Opinions on washable products are partly shaped by the level of satisfaction with the product used (if any) by an individual before the washable and personal financial considerations also play an important role.

There is considerable scope for improving the design of the products, in particular, the challenge of improving the absorbency of materials (whilst maintaining washability) and to improve the fit of products around waist and legs. For service providers, training is required to ensure that potential end-users have been adequately assessed (particularly for urinary retention) and that appropriate number and design of products are provided. The setting also needs to be considered, with reliable access to water for washing the products a prerequisite for use.

Washable continence products are currently under-utilised and have an important role to play with potential health, quality of life and sustainability benefits. To maximise their usefulness, product and service innovation is urgently required.

Global report on assistive technology. Geneva: World Health Organization and the United Nations Children’s Fund (UNICEF), 2022
Holloway, C., Austin, V., Barbareschi, G., Ramos Barajas, F., Pannell, L., Morgado Ramirez, D., Frost, R., McKinnon, I., Holmes, C., Frazer, R. and Kett, M., 2018. Scoping Research Report on Assistive Technology-On The Road For Universal Assistive Technology Coverage
Gale, N. K., Heath, G., Cameron, E., Rashid, S., & Redwood, S. (2013). Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC medical research methodology, 13, 117.

Continence 7S1 (2023) 100731
DOI: 10.1016/j.cont.2023.100731