Acceptance and the influencing factors towards intermittent self-catheterisation among patients with neurogenic lower urinary tract dysfunction in China: a multicentre cross-sectional study

Abstract

Objectives

The psychological acceptance of intermittent self-catheterisation (ISC) significantly impacts its initial adoption and long-term compliance among patients. However, our understanding of this acceptance remains limited. This study aims to investigate ISC’s psychological acceptance and identify influencing factors among neurogenic lower urinary tract dysfunction (NLUTD) patients in China.

Design

A cross-sectional study design.

Participants

A total of 394 patients with NLUTD were recruited from 15 tertiary general hospitals in China.

Outcome measure

The patients completed a comprehensive questionnaire that included demographic and clinical characteristics, along with study instruments such as the Intermittent Catheterization Acceptance Test (I-CAT), the Intermittent Catheterization Satisfaction Questionnaire (InCaSaQ), the Intermittent Catheterization Difficulty Questionnaire and the Intermittent Self-Catheterization Questionnaire (ISC-Q). Pearson’s correlation analysis explored interrelationships among questionnaire scores, while Spearman’s correlation assessed relationships between categorical independent variables and I-CAT scores. Additionally, multiple linear regression analysis identified key factors influencing psychological acceptance of ISC.

Results

Nearly half of the participants (46.2%) reported psychological challenges in accepting ISC, and more than 50% of the participants exhibited fear and low self-esteem in their I-CAT questionnaire scores. The I-CAT scores were strongly correlated with ISC training (r=0.861), ISC follow-up (r=0.766) and psychological well-being (r=−0.774). Regression analysis identified significant factors influencing ISC acceptance, including urinary tract infections, types of catheters, ISC training, ISC follow-up, province, and scores on the ISC-Q and InCaSaQ questionnaires, which collectively explained 85.5% of the variance in acceptance rates (F=161.409).

Conclusions

Psychological difficulties in accepting ISC are prevalent among NLUTD patients. Key factors that facilitate ISC acceptance include receiving ISC training, follow-up support and favourable ISC-Q scores. In contrast, barriers like the use of non-hydrophilic catheters present significant challenges. Notably, ISC acceptance varies significantly across different regions. Therefore, targeted strategies are recommended to enhance positive factors, reduce negative ones and consider regional disparities, thereby improving overall ISC acceptance.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• A multicentre design was employed, encompassing 15 tertiary hospitals across five Provinces in China, thereby increasing the diversity and representativeness of the sample.

• Validated instruments (Intermittent Catheterization Acceptance Test, Intermittent Catheterization Satisfaction Questionnaire, the Intermittent Catheterization Difficulty Questionnaire and the Intermittent Self-Catheterization Questionnaire) were used to comprehensively assess patients’ experiences and perceptions of intermittent self-catheterisation (ISC).

• The data collection process was rigorously implemented, including standardised training for investigators and strict criteria for excluding invalid or incomplete questionnaires.

• As a cross-sectional study, it identifies factors associated with ISC acceptance but is limited in establishing causality.

• The use of self-reported data introduces risks of recall bias and social desirability bias, which may affect the accuracy of the findings.

Introduction

Neurogenic lower urinary tract dysfunction (NLUTD) is a condition characterised by bladder or urethral dysfunction due to neurological disorders, commonly found in patients with spinal cord injury, stroke, Parkinson’s disease and multiple sclerosis.¹ These conditions disrupt neural transmission, leading to uncoordinated bladder and urethral function, resulting in urinary retention, incontinence, urinary tract infections (UTIs) and upper urinary tract damage.^{1 2} NLUTD not only causes severe physiological symptoms but also significantly impacts patients’ mental health and social life, while increasing the economic burden on healthcare systems.³

Since Lapides introduced intermittent self-catheterisation (ISC) in 1972, ISC has become the standard treatment for NLUTD.^{4 5} ISC enables patients to void independently, reducing the risks of UTIs and kidney damage and thereby significantly enhancing their quality of life.⁵ Despite the well-documented clinical efficacy and technical advantages of ISC, its global implementation and adherence rates remain below expectations.⁶ For instance, in China, the implementation rate is only around 20%.⁷ This indicates a substantial gap between guideline recommendations and actual clinical practice. The psychological acceptance of ISC by patients significantly influences its adoption and sustained adherence,⁸ which is crucial for successful ISC implementation.⁹ However, there is limited knowledge about the factors affecting psychological acceptance of ISC. Current qualitative studies suggest that procedural complexity, difficulty, negative emotions such as fear and embarrassment, and low satisfaction with ISC devices may impact patients’ acceptance and adherence.810,13

Therefore, this study aims to conduct a cross-sectional, multicentre survey to comprehensively quantify patients’ psychological acceptance of ISC and explore its influencing factors. Special focus will be placed on ISC satisfaction, operational difficulty and their relationship with the quality of life. This research seeks to fill existing gaps, providing scientific evidence to improve the psychological acceptance of ISC in clinical practice. It will aid in the development of more effective clinical guidelines and policies, increase ISC implementation and adherence rates, and ultimately enhance patients’ quality of life.

Methods

Study design

This study was conducted from March to September 2023 in 15 tertiary general hospitals across five provinces in China, namely Hubei, Henan, Sichuan, Anhui and Guangdong. These hospitals are acknowledged as critical centres for healthcare, education and research, each with a minimum of 500 beds.¹⁴ A convenience sampling and cross-sectional study design were employed.

Participants

Participants were included based on the following criteria: (1) aged between 18 and 65 years; (2) diagnosed with NLUTD resulting from central nervous system injuries, such as spinal cord injury, multiple sclerosis, stroke, spina bifida or Parkinson’s disease; (3) at least 6 months of current or prior practice of ISC. The exclusion criteria were: (1) cognitive impairments, visual impairments or hand function impairments and (2) other comorbidities, including urethral stricture, bladder or kidney stones, or rectal dysfunction. To improve the quality and transparency of the research, the team employed the Strengthening the Reporting of Observational Studies in Epidemiology Statement checklist (see online supplemental table 1).

Data collection procedure

The online survey was facilitated through the ‘Questionnaire Star’, a widely used online platform within the industry. After obtaining consent from specialised incontinence nurses at 15 tertiary comprehensive hospitals, the nurses received online training. On finalising the questionnaire’s design, researchers uploaded it to the Questionnaire Star software, generating a unique link. Investigators who completed the training and passed the competency test were officially authorised to conduct the survey.

The researchers distributed the survey link to the principal investigators at each participating centre, with a request for 25–30 patients to complete the survey. Specialised incontinence nurses recruited eligible patients in outpatient clinics and provided face-to-face guidance on completing the electronic questionnaire. This ensured that each patient accurately understood the questionnaire content and could complete it independently. Detailed explanations and instructions regarding the study’s purpose, methods and considerations were provided on the first page of the Questionnaire Star. Each participant had to read and agree to the participation statement before starting the questionnaire, ensuring informed consent and their right to withdraw from the study at any time without adverse consequences.

To ensure the integrity of the survey, this study required all questions to be answered, and each IP address was allowed to submit the questionnaire only once. Meanwhile, to improve data quality, invalid and incomplete questionnaires were strictly filtered. Invalid questionnaires were defined as those with identical scores across all items, linear sequential scores (eg, 1, 2, 3, 4, 5 or 5, 4, 3, 2, 1) or a completion time of less than 360 s. Incomplete questionnaires referred to those where respondents exited before completing all questions. To ensure the reliability of the analysis results, these invalid and incomplete questionnaires were removed before the analysis. On approval from the research team, participants received a compensation of 20 RMB (approximately US$ 3.0). The sample screening process is shown in online supplemental figure 1.

Sampling

The sample size was calculated by multiplying the total number of independent variables, which include demographic and clinical characteristics as well as the quantity of scales, by 15, yielding a total of 300 (n=18×15 = 270). To account for a potential 20% non-response rate, a minimum sample size of 338 is required.

Outcome measures

The Intermittent Catheterization Acceptance Test (I-CAT)

The Intermittent Catheterization Acceptance Test (I-CAT) was designed to assess individuals’ psychological acceptance of practicing ISC and was developed by Guinet-Lacoste et al in 2016.¹⁵ This scale contains 14 items and consists of three dimensions, including multiple fears, self-esteem and global question. The items are scored from 0 (strongly disagree) to 4 (strongly agree). A higher score on the I-CAT signifies a lower level of psychological acceptance of ISC. The Chinese version of I-CAT was used in this study, demonstrating good reliability and validity.¹⁶ In this study, the Cronbach’s alpha coefficient was 0.946.

Influencing factors

The questionnaire comprised two sections: demographic and clinical characteristics and study instruments, such as the Intermittent Catheterization Satisfaction Questionnaire (InCaSaQ),¹⁷ the Intermittent Catheterization Difficulty Questionnaire (ICDQ)¹⁸ and the Intermittent Self-Catheterization Questionnaire (ISC-Q).¹⁹

Demographic and clinical characteristics of patients

The participants’ demographic and clinical characteristics included information on age, gender, marital status, occupation, family residence, personal monthly income, education level, medical expenses payment method, residential living arrangements, duration of performing ISC, UTIs, types of catheters, ISC training (whether they received knowledge and skills training on ISC during hospitalisation), ISC follow-up (whether they received postdischarge hospital support for ISC) and province.

Study instrument

The Intermittent Catheterization Satisfaction Questionnaire (InCaSaQ)

The Intermittent Catheterization Satisfaction Questionnaire (InCaSaQ) for assessing patient satisfaction with ISC, developed by Guinet-Lacoste et al in 2014.¹⁷ This scale contains eight items and consists of four dimensions, including packaging, lubrication, catheter itself and after catheterisation. The items are scored from 0 (extremely dissatisfied) to 3 (extremely satisfied). A higher total score on the InCaSaQ indicates greater satisfaction of ISC. In this research, the Cronbach’s alpha coefficient registered at 0.895.

The Intermittent Catheterization Difficulty Questionnaire (ICDQ)

The ICDQ was designed to evaluate the challenges patients face when performing ISC and was developed by Guinet-Lacoste et al in 2014.¹⁸ This 13-item scale contains two categories, including frequency and intensity. The instrument explicitly describes the ease of catheter insertion and withdrawal, the presence of pain, limb spasticity, urethral sphincter spasms and local urethral bleeding during catheterisation. The ICDQ employs a 4-point Likert-type scale, with scores ranging from 0 (‘None’ for intensity or ‘Never’ for frequency) to 3 (‘Considerable’ for intensity or ‘Always’ for frequency). A higher overall score on the ICDQ indicates greater difficulty. Within this study, the Cronbach’s alpha was measured at 0.943.

The Intermittent Self-Catheterization Questionnaire (ISC-Q)

The ISC-Q was meticulously developed by Pinder and colleagues in 2012.¹⁹ Designed for completion by ISC patients, the questionnaire aims to evaluate the quality of life related to their unique needs, encompassing both physical and psychological concerns. This scale contains 24 items and consists of four dimensions, including ease of use, convenience, discreetness and psychological well-being. A 5-point Likert scale, ranging from 0 (strongly disagree) to 4 (strongly agree), is employed. After converting responses from 14 reverse-coded items, scores are calculated by averaging the items within each dimension and then multiplying by 25, yielding a universal range of 0–100. The overall ISC-Q score is derived from the mean values across the four dimensions, with a higher ISC-Q score indicating a more favourable QOL in relation to ISC. In this study, the the Cronbach’s alpha was 0.821.

Ethics statement

All participating centres in this study adhered to ethical standards, with the research conducted under the approval of the Medical Ethics Committee of the lead institution, Shenzhen Hospital, Southern Medical University (Approval No. NYSZYYEC20230031). This approval was recognised and accepted by all other participating hospitals. Each centre conducted patient recruitment and data collection in compliance with the approved ethical guidelines. All participants provided electronic informed consent and voluntarily completed the online survey. Additionally, all information obtained from the participants is strictly confidential and anonymised.

Patient and public involvement

Patients and/or the public were not involved in the design, conduct, reporting, or dissemination plans of this research.

Data analysis

Statistical Package for Social Sciences 26.0 for Windows was used to conduct data analyses. Descriptive statistics such as means, SD and frequencies were used to examine the main characteristics. The χ² test was used to evaluate the distribution differences in questionnaire completion status (including incomplete, invalid and valid responses) across different provinces. Spearman’s analysis is used to examine the relationship between categorical independent variables and continuous dependent variables, while Pearson’s analysis evaluates the relationship between continuous independent variables and continuous dependent variables. Demographic and clinical characteristics, InCaSaQ, ICDQ and ISC-Q were included in a multivariate linear analysis to identify the main factors influencing ISC psychological acceptance. These models were created using a backward selection method. Significance for all statistical tests was set at 0.05 (2-tailed). The categorical independent variables were recoded (assignment) before stepwise linear regression analysis (see online supplemental table 2). The variance inflation factor was used to assess multicollinearity among the predictors.

Results

Participant characteristics

Based on the inclusion and exclusion criteria, a total of 394 questionnaires were collected from five provinces, among which 12 were incomplete and 55 were invalid, resulting in 327 valid questionnaires with an effective rate of 83.0%. Details of incomplete and invalid questionnaires by province are shown in online supplemental figure 2. χ² test results indicated no significant differences in the distribution of incomplete and invalid questionnaires among the provinces (χ²=4.08, p=0.85). The sample distribution is presented in online supplemental table 3, and the demographic and clinical characteristics of the 327 valid respondents are detailed in table 1. A majority of the respondents (72.2%) were aged between 18 and 45 years. Over half of the participants were male (59.0%). Approximately 60.6% of the patients were married. Half of the patients were unemployed (51.4%) and hailed from rural areas (52.3%). A significant portion, exceeding half, reported a monthly income below 3000 yuan (83.8%). Approximately 55.0% of the respondents had an education level up to primary school, while a smaller proportion, 8.9%, achieved an education level beyond undergraduate. Regarding healthcare expenses, 40.7% of the patients were self-financing, whereas 52.0% were covered by medical insurance, each group representing nearly half of the total. 15.3% of patients live alone. 60.3% have been practicing ISC for no more than 1 year. Only 19.9% have not had a UTI within a year. Of the patients with NLUTD, 56.0% received ISC training during hospitalisation; however, postdischarge, only 26.6% had access to continued ISC support. The distribution of valid samples collected from each province is similar, with Sichuan having the highest proportion at 21.4%.

Table 1. Demographic and clinical characteristics of respondent (n=327).

Variables	Frequency	Percentage (%)
Age (year)
18<years≤35	122	37.3
35<years≤45	114	34.9
45<years≤65	91	27.8
Gender
Male	193	59.0
Women	134	41.0
Marital status
Unmarried	90	27.5
Married	198	60.6
Divorced	39	11.9
Occupation
Unemployed	168	51.4
Employed	159	48.6
Family residence
City	82	25.1
Town	74	22.6
Countryside	171	52.3
Personal monthly income (RMB)*
≤3000	274	83.8
>3000	53	16.2
Education level
Primary schools	180	55.0
Junior high school	74	22.6
Senior high school	44	13.5
Bachelor’s degree and above	29	8.9
Medical expenses payment method
Self-paid	133	40.7
Medical insurance	170	52.0
Work-related injury insurance	11	3.3
Others	13	4.0
Residential living arrangements
Solo living	50	15.3
Co-inhabiting with one individual	65	19.9
Living with two to three individuals	167	51.1
Living with four to six individuals	45	13.7
Duration of carrying out ISC
0.5≤years≤1	197	60.3
1<years≤5	56	17.1
5<years	74	22.6
Urinary tract infection
0 times/year	65	19.9
0<times/year≤2	174	53.2
2<times/year	88	26.9
Types of catheters
Non-hydrophilic-coated catheters	192	58.7
Single-use hydrophilic-coated catheters	72	22.0
Prelubricated single-use gel catheters	36	11.0
Reusable catheters	27	8.3
ISC training
Yes	183	56.0
No	144	44.0
ISC follow-up
Yes	87	26.6
No	240	73.4
Province
Hubei	64	19.6
Henan	66	20.2
Sichuan	70	21.4
Anhui	62	19.0
Guangdong	65	19.0

^*1 EUR=7.79 RMB.

ISC, intermittent self-catheterisation

Agree ratio and scores for each item of the Intermittent Catheterization Acceptance Test (I-CAT) among participants

The agree ratio used in this study was defined as the sum of values for very strongly agree and agree divided by the total value for all categories in percentages. Figure 1 presents the agree ratio as well as the mean scores (with SD) for each item. Approximately 46.2% of patients reported difficulty in accepting ISC. Additionally, over 50% of participants’ scores on the I-CAT questionnaire indicated the presence of fear and low self-esteem.

Figure 1. The agree ratio and the mean scores (with SD) for the 14 items are provided. Unacceptable ratio was the summated ratio of strongly agree (light red) and agree (dark red).

Additionally, we observed that the average score for each item exceeded 2, nearing 3. The item with the highest score was ‘I am afraid that I may never fully regain my health’ (2.97±0.91), with 76.3% of respondents agreeing. The second highest score was for ‘I am afraid that, over time, self-catheterization will damage my urethra’ (2.91±0.84), with 75.5% of respondents in agreement.

The relationship between the independent variables

Table 2 presents the correlation coefficients between the independent variables, including demographic and clinical characteristics, and the study instrument. It was observed that the I-CAT score had a strong positive correlation with ISC training (r=0.861, p<0.01) and ISC follow-up (r=0.766, p<0.01). Conversely, the I-CAT score had a strong negative correlation with psychological well-being scores (r=−0.774, p<0.01).

Table 2. The relationship between the independent variables and I-CAT scores (n=327).

Variables	Total score	Multiple fears	Global question
Age (year)	−0.086	−0.081	−0.047
Gender	0.052	0.018	0.048
Marital status	0.002	−0.001	−0.031
Occupation	0.012	−0.020	0.025
Family residence	0.051	0.025	0.081
Personal monthly income (RMB)†	0.076	0.079	0.009
Education level	0.024	0.020	−0.005
Medical expenses payment method	−0.015	−0.053	−0.016
Residential living arrangements	0.065	0.031	0.024
Duration of carrying out ISC	−0.087	−0.073	−0.119*
Urinary tract infection	0.032	0.046	0.014
Types of catheters	−0.0538**	−0.490**	−0.431**
ISC training	0.861**	0.754**	0.683**
ISC follow-up	0.766**	0.702**	0.620**
Province	−0.506**	−0.465**	−0.656**
InCaSaQ	0.100	0.066	0.057
Packaging	0.147**	0.102	0.089
Lubrication	0.105	0.088	0.049
Catheter itself	0.050	0.025	0.020
After catheterisation	0.012	0.004	0.027
ICDQ	0.341**	0.323**	0.296**
Intensity	0.320**	0.310**	0.284**
Frequency	0.342**	0.317**	0.290**
ISC-Q	−0.551**	−0.500**	−0.444**
Ease of use	−0.288**	−0.324**	−0.264**
Convenience	−0.574**	−0.530**	−0.438**
Privacy	0.068	0.071	0.048
Psychological well-being	−0.774**	−0.697**	−0.625**

*P<0.05; **P<0.01. For categorical independent variables, the relationship with I-CAT scores is analysed using Spearman’s rank correlation. For continuous independent variables, the relationship with I-CAT scores is determined using Pearson’s correlation analysis.

†1 EUR=7.79 RMB.

I-CAT, Intermittent Catheterization Acceptance TestICDQ, Intermittent Catheterization Difficulty Questionnaire; InCaSaQ, Intermittent Catheterization Satisfaction Questionnaire; ISC, intermittent self-catheterization; ISC-Q, Intermittent Self-Catheterization Questionnaire

Factors influencing intermittent self-catheterization (ISC) acceptance among neurogenic lower urinary tract dysfunction (NLUTD) patients

Based on the results of multiple linear regression and I-CAT scores (where higher scores indicate lower psychological acceptance of ISC), we conclude the following: compared with patients without UTIs each year, those experiencing one to two UTIs annually demonstrate a lower psychological burden in accepting ISC (β=−0.905, p<0.05). Patients using single-use hydrophilic-coated catheters and gel prelubricated single-use catheters find ISC more acceptable compared with those using non-hydrophilic-coated catheters (β=−4.409, p<0.05; β=−3.132, p<0.05). Furthermore, patients without ISC training and follow-up support face more psychological challenges in accepting ISC than those who received such support (β=6.984, p<0.05; β=6.759, p<0.05). In addition to these individual factors, regional differences also play a significant role. The acceptance of ISC was higher among patients from provinces other than the reference category, Hubei. Specifically, patients from Henan (β=−4.480), Sichuan (β=−3.885), Anhui (β=−5.611) and Guangdong (β=−6.195) showed significant differences in psychological acceptance of ISC (p<0.05).

Additionally, higher satisfaction with ISC correlates with lower psychological acceptance (β=0.417, p<0.01). Higher ISC-related quality of life is associated with higher psychological acceptance (β=−0.206, p<0.01). These factors, including UTIs, catheter type, ISC training, ISC follow-up support, province, ISC satisfaction and ISC-related quality of life, significantly influence psychological acceptance of ISC. These variables account for 85.5% of the total variance, with statistically significant results (F=161.409, p<0.001), as shown in table 3.

Table 3. Factors influencing I-CAT scores among NLUTD patients by multiple linear regressions analysis (n=327).

Variables	B	SE	β	T	P value	95% CI for B		VIF
						Lower	Upper
Constant	37.028	1.822		20.32	0.000	33.443	40.614
Education level
Primary schools	Reference category	–	–	–	–	–	–	–
Junior high school	−1.002	0.54	−0.04	−1.856	0.064	−2.065	0.06	1.035
Urinary tract infection
0 times/year	Reference category	–	–	–	–	–	–
0＜times/year≤2	−0.905	0.45	−0.043	−2.01	0.045	−1.79	−0.019	1.022
Types of catheters				0.034
Non-hydrophilic-coated catheters	Reference category	–	–	–	–	–	–
Single-use hydrophilic-coated catheters	−4.409	1.062	−0.173	−4.153	0.000	−6.498	−2.32	3.92
Prelubricated single-use gel catheters	−3.132	1.14	−0.093	−2.747	0.006	−5.375	−0.889	2.579
ISC training
Yes	Reference category	–	–	–	–	–	–	–
No	6.984	0.657	0.329	10.638	0.000	5.692	8.276	2.152
ISC follow-up support
Yes	Reference category	–	–	–	–	–	–	–
No	6.759	1.027	0.283	6.584	0.000	4.739	8.779	4.169
Province
Hubei=1	Reference category	–	–	–	–	–	–	–
Henan	−4.480	0.79	−0.171	−5.672	0.000	−6.034	−2.926	2.036
Sichuan	−3.885	0.717	−0.151	−5.417	0.000	−5.296	−2.474	1.753
Anhui	−5.611	0.757	−0.209	−7.41	0.000	−7.101	−4.121	1.785
Guangdong	−6.195	0.869	−0.235	−7.13	0.000	−7.904	−4.485	2.435
ISC-Q	−0.206	0.03	−0.192	−6.931	0.000	−0.264	−0.147	1.729
InCaSaQ	0.417	0.069	0.148	6.073	0.000	0.282	0.552	1.341

R2=0.861, adjusted R2=0.855, F=161.409, Pp<0.001. B, partial regression coefficient for the constant. SE, the standard errorSE around the coefficient for the constant. β, standard partial regression coefficient.NLUTD, . I-CAT, Intermittent catheterization acceptance test. ISC-Q, Intermittent self-catheterization questionnaire.InCaSaQ, Intermittent catheterization satisfaction questionnaire.

I-CATIntermittent Catheterization Acceptance TestInCaSaQIntermittent Catheterization Satisfaction QuestionnaireISC-QIntermittent Self-Catheterization QuestionnaireNLUTDneurogenic lower urinary tract dysfunctionVIFvariance inflation factor

Discussion

To our knowledge, this study is the first to systematically investigate the psychological acceptance of ISC among NLUTD patients. The results indicate that the psychological acceptance of ISC among NLUTD patients is not encouraging, with nearly half (46.2%) finding it difficult to accept ISC. Over 50% of participants had I-CAT scores suggesting issues with fear and low self-esteem. Our study found that I-CAT scores were positively correlated with ISC training and follow-up support while negatively correlated with ISC-related psychological health scores. Further analysis revealed that UTIs, ISC training, follow-up support, UTIs, catheter type, province, ISC-related quality of life and ISC satisfaction significantly influenced patients’ psychological acceptance of ISC.

This study revealed that NLUTD patients encountered significant psychological challenges during the process of accepting ISC. A majority of patients held a pessimistic view of their health recovery (76.3%), feared potential urethral damage (75.8%) and were afraid of discomfort during the procedure (56.6%). These results starkly contrast with previous studies, where patients exhibited confidence in ISC.²⁰ This disparity may be attributed to the fact that only 56% of patients in this study received ISC training, and 77.6% had a lower educational level.²¹ The study underscores the crucial role of healthcare providers in enhancing patient education and training,²² suggesting that targeted ISC training can significantly improve patients’ self-catheterization abilities,²³ thereby promoting ISC acceptance. The findings further confirm that ISC training is a key factor influencing psychological acceptance (β=6.984, p<0.05). Therefore, future research should focus on optimising ISC health education and training systems, developing personalised and easily understandable training programmes to improve patient knowledge and skills, reduce misconceptions and fears about ISC and enhance psychological acceptance.

This study identified significant correlations between psychological health (r=−0.774, p<0.01) and operational difficulty (r=−0.341, p<0.01) with the psychological acceptance of ISC. Patients often experience feelings of shame, embarrassment and anxiety when using ISC, which lead to avoidance behaviours and consequently lower psychological acceptance of ISC.⁸ Additionally, concerns about the complexity of the procedure and long-term risks further contribute to resistance.⁹ Encouragingly, the study found that ISC follow-up support plays a crucial role in improving acceptance among NLUTD patients (β=6.759, p<0.05), particularly in reducing operational difficulties and enhancing psychological health. Through ISC follow-up support, healthcare teams can provide continuous education, promptly address operational issues and offer necessary psychological support.²¹This approach not only boosts patients’ confidence in performing ISC but also alleviates resistance caused by operational difficulties and psychological stress. The findings suggest that clinical practice should include enhanced psychological health assessments and operational guidance, along with systematic follow-up support, to improve treatment experiences and overall quality of life for patients.

Additionally, patients who experienced UTIs 1–2 times per year were more likely to accept ISC compared with those without infections (β=−0.905, p<0.05). This finding supports self-management theory, suggesting that a moderate level of UTIs experience may stimulate patient initiative, encouraging the adoption of more effective management strategies to reduce infection risk.^{24 25} However, patients with higher UTIs frequency (more than twice per year) were excluded from the regression model, potentially due to the anxiety and helplessness induced by frequent infections, which may lead to doubts regarding the safety and efficacy of ISC.²⁶ Such attitudinal differences may stem from individual health experiences, disease perception and cultural background, which directly impact ISC acceptance. Notably, the bias introduced by provincial factors played a critical role in this context. Compared with Hubei, patients in Henan, Sichuan, Anhui and Guangdong exhibited higher acceptance of ISC (p<0.05), suggesting that regional differences influence patient decision-making. The disparities in medical resources, cultural awareness and social support across provinces directly shape attitudes towards ISC.⁷ This highlights the need for healthcare providers to sensitively recognise the influence of UTIs frequency and regional differences on patient psychology and treatment preferences.

This study demonstrates that catheter type significantly impacts the psychological acceptance of ISC among NLUTD patients. Compared with non-hydrophilic-coated catheters, single-use hydrophilic-coated catheters and gel prelubricated catheters are more psychologically acceptable due to their advantages of reducing friction, lowering pain, simplifying the procedure and decreasing infection risk.^{27 28} However, this study found that 58.7% of patients chose non-hydrophilic-coated catheters, likely due to economic factors. With the annual cost of ISC catheters and accessories reaching up to 1747 Euros,²⁹ this poses a significant financial burden on the 51.4% of unemployed patients in this study, accounting for one-third of the annual income for 83.8% of the patients, particularly the 40.7% who pay out of pocket. Therefore, healthcare providers should consider patients’ economic situations when recommending catheters. Policymakers and insurance companies should consider reimbursing the costs of catheters and accessories and explore establishing charitable funds or subsidy mechanisms to alleviate patients’ financial burden, thus enhancing the psychological acceptance and adherence to ISC.

This study underscores the pivotal role of ISC-related quality of life in influencing patients’ psychological acceptance, particularly regarding usability, convenience and mental health. Pinder et al’s research corroborates this, emphasising the importance of catheter usability across different countries.³⁰ Enhancing catheter design, particularly by reducing preparation time and improving portability,¹¹ is expected to reduce patients’ anxiety and stress during ISC, thereby promoting daily functioning and social participation.¹¹ Beyond physical challenges, patients also face psychological adaptation issues to this invasive procedure,⁵ including embarrassment, shame and anxiety, which significantly impede ISC acceptance.³¹ Poor psychological adaptation can lead to treatment discontinuation.³¹ Thus, ISC education and support strategies should adopt a holistic approach, encompassing technical training, improving catheter usability and convenience and facilitating psychological adaptation through social support.

Our study revealed a surprising phenomenon: previous research typically considered patient satisfaction with ISC as a key factor in promoting psychological acceptance.^{21 30} However, our findings indicate that higher satisfaction with ISC is associated with lower psychological acceptance (β=0.417, p<0.01). Possible reasons include: first, high expectations can lead to disappointment when actual problems arise, especially for patients expecting optimal lubrication. Second, high satisfaction does not necessarily equate to confidence in performing ISC, as a lack of self-efficacy may cause hesitation. Additionally, in the context of Chinese culture, traditional health beliefs emphasise bodily integrity and dignity, leading some patients to perceive ISC as an infringement on bodily integrity, thus increasing psychological barriers.³² Concerns about social stigma, privacy and bodily integrity may further exacerbate conflicting emotions,^{8 32} affecting psychological acceptance. Therefore, strategies to improve the psychological acceptance of ISC should consider patients’ mental state, personal beliefs and sociocultural background, adopting personalised and culturally sensitive education and support methods.

This study used a multicentre design, encompassing 15 tertiary hospitals across five provinces in China, offering a high level of sample diversity and representativeness. This approach provided valuable insights into the psychological acceptance of ISC among patients with NLUTD in China. Furthermore, the study employed validated instruments, including the I-CAT, InCaSaQ, ICDQ and ISC-Q scales, to systematically assess patients’ experiences and acceptance of ISC, ensuring a comprehensive understanding of their psychological and perceptual responses. Through multiple linear regression analysis, key factors influencing ISC acceptance were identified, offering an in-depth analysis of the psychological determinants that shape patients’ acceptance of ISC.

However, certain limitations should be acknowledged. First, the sample primarily consisted of patients from tertiary hospitals in five provinces, with no representation from secondary or primary healthcare institutions. As a result, the findings may more accurately reflect the psychological acceptance patterns of patients in tertiary care settings, limiting their applicability to those in primary healthcare facilities with fewer resources. Future research should expand the sample to include various levels of healthcare institutions to enhance the generalisability of the findings. Second, the cross-sectional design, while effective in identifying factors associated with ISC acceptance, does not establish causal relationships. Longitudinal studies that track patients over different time points are recommended to provide a more comprehensive understanding of the long-term impact of these factors on ISC acceptance. Additionally, the study relied on self-reported questionnaires, which are advantageous for capturing subjective patient experiences but may be affected by recall bias and social desirability bias, potentially impacting the accuracy of the results. Future studies could incorporate objective assessment tools, such as psychological interviews or professional evaluations, to minimise these biases.

In addition, the study did not distinguish between ambulatory patients and those who use wheelchairs, despite the fact that mobility can significantly impact quality of life and self-esteem. The lack of in-depth analysis of this group may limit the comprehensive understanding of their psychological state. Future research should focus on differences in psychological acceptance of ISC among patients with varying mobility abilities. Furthermore, the study did not examine the relationship between ‘dryness’ and both quality of life and self-esteem, which may limit the understanding of the connections between these factors. Similarly, bowel function and faecal incontinence were not assessed for their impact on self-esteem, even though these factors can significantly affect quality of life and psychological well-being, potentially influencing ISC acceptance. Future studies should explore the links between these physiological factors and mental health in greater depth. Finally, although some patients received ISC training and follow-up support, variations in the content and frequency of these interventions across different hospitals may have affected the consistency of the results. Future research should aim to establish more standardised interventions across diverse regions and healthcare settings, incorporating longitudinal designs to comprehensively evaluate the relationships between mobility, dryness, bowel function and psychological acceptance, thereby enhancing the generalisability and scientific validity of the findings.

Conclusion

This study is the first to evaluate the psychological acceptance of ISC and comprehensively explore the influencing factors among patients with NLUTD. The findings indicate that NLUTD patients often face psychological challenges when adopting ISC, with their acceptance influenced by various factors, including UTIs, ISC training, follow-up support, catheter type, province, ISC-related quality of life and ISC satisfaction. Notably, ISC acceptance varies significantly across different regions. Therefore, healthcare professionals should prioritise patients experiencing psychological difficulties with ISC and develop targeted intervention strategies, emphasising localised approaches. These efforts can improve treatment outcomes and enhance patients’ quality of life.

Data availability statement

Data are available upon reasonable request.