This process evaluation used a mixed methods approach based on Normalization Process Theory (NPT). NPT is a framework used to guide the implementation and evaluation of complex interventions [28-30] and to understand how staff routinely incorporate a complex intervention into practice in a specific setting [31]. The Normalization Measure Development (NoMAD) questionnaire [32,33] operationalizes NPT across its 4 constructs: coherence, cognitive participation, collective action, and reflexive monitoring. Coherence refers to key stakeholders’ understanding of and opinions about an intervention. Cognitive participation involves stakeholders’ engagement with the intervention. Collective action involves putting the intervention into practice, and reflexive monitoring focuses on stakeholders’ appraisal of the intervention and its effects [28].

Pediatric continence nurses who introduced bladder training to young people aged 10 years and older in Children’s Community Continence Services were eligible to participate.

Children’s Community Continence Services are Tier 2 community specialist services comprising nurse-led, multidisciplinary teams that provide more specialized assessment and management of bladder and bowel issues in young people. They aim to reduce unnecessary referrals to secondary care. Clinical coapplicants DR and JC assisted with identifying sites in different regions of England serving young people from diverse socioeconomic and ethnic backgrounds. URApp was not routinely embedded within participating Children’s Community Continence Services before the study. As part of this process evaluation, teams were asked to familiarize themselves with URApp and were encouraged to offer it to eligible young people receiving bladder training during the 18-week study period. Decisions about whether and how URApp was used with individual patients remained at the discretion of pediatric continence nurses. Therefore, the study evaluated the implementation and integration of URApp into routine practice rather than testing a mandated implementation protocol.

We recruited Children’s Community Continence Service nurses from 5 centers to provide a purposive maximum variation sample of 20 participants. DR distributed the study advert to the lead nurse at each site via email (Multimedia Appendix 1), who provided consent to be contacted by LB if interested in finding out more about the study. LB emailed the participant information sheet to each interested site and provided further information at an online meeting. NHS staff completed consent forms via REDCap (Vanderbilt University), a secure encrypted web application for building and managing online surveys and databases [34,35]. All participating team members were asked to familiarize themselves with URApp using View the App Guide and by downloading URApp onto a mobile device [20].

Staff completed an online NoMAD questionnaire (Multimedia Appendix 2) via REDCap at baseline and 6, 12, and 18 weeks. The NoMAD questionnaire is a set of 20 questions for assessing implementation processes among participants directly involved in implementing complex interventions in health care [32,33]. Staff at each site were also invited to take part in focus groups or interviews. Focus groups and interviews (lasting around 30‐45 min) were conducted online via Teams, audio-recorded with consent from participants, and transcribed, and data were deidentified. A topic guide (Multimedia Appendix 3) was developed in consultation with the clinical coapplicants. The topic guide drew on the NPT theory and had the flexibility to explore teams’ NoMAD questionnaire responses (eg, if there was “low agreement” with NPT subconstructs at a particular site/time point).

Responses to NoMAD items were analyzed descriptively as follows: “strongly agree” and “agree” were interpreted as “high agreement” (5 and 4), “Neither agree nor disagree” as a “neutral” response (3), and “disagree” and “strongly disagree” as “low agreement” (2 and 1). NoMAD item-10 was reverse-coded so that the higher value indicated more agreement for ease of interpretation. Measures of the “normalization” of practice from the NoMAD questionnaires were summarized as median scores and plotted at each time point using petal plots. Higher agreement with NPT subconstructs and better integration of an intervention are characterized by more uniform “petals,” closer to the outer limits of each petal plot (see Multimedia Appendix 4, Figures SA-SE, petal plots). Qualitative data analysis used the NVivo software (version 14; Lumivero) to organize data and drew on reflexive thematic analysis [36] with a deductive approach to explore how data fitted with NPT constructs and subconstructs. NoMAD outputs were cross-referenced with qualitative data to gain an in-depth understanding of the optimization of URApp in community clinic settings.

The original idea for developing URApp came from our previous research with young people with UI, who told us that they needed more support to manage their symptoms [26] and felt they were not adequately supported by current services. URApp was co-designed and iteratively optimized through extensive work with young people with incontinence to ensure it is age-appropriate and meets their needs [26].

Ethical approval was granted by the University of Bristol Faculty of Health Science Research Ethics Committee (reference 17560) and by the Health Research Authority and Health and Care Research Wales (IRAS project ID 338625, protocol number 2023‐7539).

From April to October 2024, 5 Children’s Community Continence Service teams in England were recruited to take part (Table S1 in Multimedia Appendix 5), with participants at each site completing NoMAD questionnaires from June 2024 to January 2025. Most participants were band 6 or above (specialist) pediatric continence nurses (n=14) and had worked in a pediatric continence clinic setting for up to 5 years (n=12; Table S2 in Multimedia Appendix 5). At baseline, half of the participants (n=10) reported that they had “never used” URApp; 8 participants stated that since the study began, they “sometimes” use it with patients, and 1 had started to “routinely use” the app with patients (Table S3 in Multimedia Appendix 5). Only 3 participants responded “never use” when they completed their final NoMAD questionnaire.

Twelve participants completed NoMAD questionnaires at 4 time points: baseline and 6, 12, and 18 weeks (sites A-D). The remaining 7 participants (site E) completed NoMAD questionnaires at baseline and 6 and 12 weeks (Multimedia Appendix 4). Broadly speaking, sites showed collective agreement with “Coherence” NoMAD items at all time points and high levels of neutrality (score of 3, neither agree nor disagree) in relation to cognitive participation, collective action, and reflexive monitoring items. A detailed descriptive analysis of NoMAD questionnaire data, participants’ free-text response data, NoMAD median scores by sites at each time point, and raw NoMAD data is provided in Multimedia Appendix 6.

Findings from NoMAD questionnaire data were expanded upon during focus group and interview discussions to gain a more in-depth understanding of why teams struggled to integrate URApp. Five focus groups were conducted with 16 participants, and 3 participants took part in one-to-one interviews. One additional participant who did not complete a NoMAD questionnaire participated in a focus group (pediatric continence nurse or nonnurse, band 5 or below), and one participant who did complete NoMAD questionnaires did not take part in a focus group or interview (specialist pediatric continence nurse, band 6 or above). Illustrative themes, corresponding NPT constructs, and quotes can be found in Table 1 and Multimedia Appendix 7.

This is the first study to explore facilitators and barriers to embedding a digital health intervention (URApp) in Children’s Community Continence Services in England. We used a mixed methods approach combining results from the NoMAD questionnaire with qualitative data from interviews/focus groups. The main findings of this study were that URApp’s functionality, alignment with bladder training techniques, age appropriateness, and accessibility (eg, supporting young people with neurodivergent conditions) facilitated staff engagement with URApp. Although nurses found URApp engaging and easy to introduce, they reported broader challenges relating to young people’s engagement with bladder training. School toilet access policies were reported as a key barrier to successful engagement with bladder training. Nurses did not engage with the bladder diary data export function in URApp and had concerns about relying on young people to self-manage their bladder training and digital data without access being granted to parents/carers. We found that nurses acknowledged the importance of young people taking ownership of managing their bladder symptoms; however, they also stressed their belief that successful management should be part of a shared decision-making model that includes positive support from parents/carers. Although our sample was not large enough to draw firm conclusions, our findings tentatively suggest that engagement with URApp may vary by age, with younger children appearing more responsive to app-based motivational features than older teenagers. This may reflect age-related differences in motivation and preferences but could also be influenced by changing attitudes toward smartphone use among young people, including increasing awareness of screen time and digital well-being. Policies limiting mobile phone use in schools were major barriers to engagement with URApp. These factors warrant further investigation when optimizing and implementing digital bladder training interventions.

This is the first study in this area to use a process evaluation approach guided by NPT; we provide valuable insights into the challenges and facilitators of embedding a digital health intervention in community pediatric continence services. Using a mixed methods approach enabled us to capture behavior change over an 18-week period and to gain an in-depth understanding of current clinical practice. Challenges included clinical teams’ resistance to changing usual practice (eg, paper-based bladder diaries) and school-based barriers that prevented young people’s engagement with bladder training (policies relating to toilet access and mobile phone use). Our study included Children’s Community Continence Service teams in different geographical regions of England, serving rural and urban populations, but transferability of our findings is limited by the small sample size and the small number of teams involved in the study. We aimed to recruit nurses with varying levels of experience, but our sample mainly comprised nurses with up to 5 years of experience in Children’s Community Continence Services. We were only able to capture behavior change in the clinical teams over a relatively short period of time (at baseline and 6, 12, and 18 wk). Constraints included the short period of funding for the study (1 y) and the length of time taken to gain capacity and capability in the 5 participating NHS sites. Data collection time points did not align well with the time period (approximately 3 months) between the initial clinic appointment, in which URApp was introduced, and routine follow-up appointments. Some team members reported that they had not yet seen patients who had previously been introduced to URApp at a follow-up appointment. Although young people were involved throughout the development and optimization of URApp [26], patient and public involvement was not incorporated into the design, conduct, or interpretation of this process evaluation. The absence of young people and parents/carers as study participants may have limited our understanding of implementation barriers and facilitators from the perspective of end users.

Empirical evidence indicates that bladder training can be effective [13,37,38]; however, the success of bladder training depends on motivation and continued engagement [39,40]. There is evidence that digital health interventions can support pediatric bladder training [26,41,42], but barriers include individuals’ beliefs about the effectiveness of conservative interventions, clinicians’ resistance to adopting new approaches, and environmental barriers.

One of our key findings was that children and young people experienced difficulties engaging with bladder training because of concerns about standing out from their peers at school and dissatisfaction with school toilet facilities. This aligns with findings from a European focus group study of children aged 9 to 13 years, which identified fear of attracting unwanted attention and dissatisfaction with school toilets as important influences on engagement with bladder training [39]. We also found that participants described frustration with symptom relapse and a lack of long-term engagement with URApp. These findings are consistent with previous UK research in which young people reported frustration with bladder training due to treatment failure and relapse, alongside disengagement from treatment following unsuccessful symptom management [9]. Participants described how school-related barriers could limit adherence to bladder training, which may contribute to perceptions among parents and young people that medication is a more practical treatment option. Similar barriers have been reported in studies of children’s bladder health in school settings [43]. However, evidence from adult populations suggests that bladder training may be as effective as, or more effective than, anticholinergic medication for improving bladder symptoms [44]; therefore, further research is needed in pediatric populations.

Although health care professionals recognized the potential advantages of electronic bladder diaries, many remained reluctant to replace established paper-based approaches. This finding is consistent with implementation research showing that the adoption of digital innovations depends on staff confidence, organizational support, and the presence of local champions who facilitate new ways of working [45-47]. Evidence from mobile health research similarly highlights the important role of health care professionals in supporting engagement with digital interventions [48]. Our findings therefore suggest that implementation efforts should focus not only on patient engagement but also on enhancing health care professionals’ confidence and readiness to adopt digital continence technologies.

Although a recent systematic review reported that mobile apps for urological conditions can improve the quality of life and symptoms in adults through real-time data capture and self-monitoring [49], our findings suggest that the benefits of digital bladder training interventions may be limited by the school environment. Participants described school policies that limit access to toilets (only during morning/afternoon break or at lunchtime) and reported that toilet facilities were inadequate and unhygienic. These findings are consistent with previous research demonstrating that school environments can hinder healthy toileting and drinking behaviors [6,50-53] and are further supported by a recent systematic review, showing that restricted toilet access, poor toilet conditions, and privacy concerns represent significant barriers to healthy toileting behaviors in a school environment [54]. These findings highlight the need for greater awareness among school staff of the ongoing toileting requirements associated with bladder training, particularly in school environments where toilet access is closely regulated [55].

Participants also highlighted restricted access to mobile phones during the school day as a potential barrier to engagement with URApp. This challenge may become increasingly important as schools adopt stricter policies regarding phone use [56,57]. Although smartphone ownership among young people is high [58], more than half of children aged 8 to 17 years are not permitted to use their phones during school hours [59]. While UK guidance emphasizes schools’ responsibilities to support pupils with medical conditions, including access to drinking water and toilet breaks when needed, it does not address the use of digital health tools to support self-management [55,57]. Given growing evidence that mobile health interventions can improve adherence and self-management across a range of health conditions [60], further research is needed to determine how school phone policies can support equitable access to digital health interventions for young people with medical conditions.

The successful implementation of digital bladder training interventions requires action at multiple levels. Within Children’s Community Continence Services, efforts should focus on increasing NHS staff confidence in digital tools and integrating electronic bladder diary data into routine practice. Although health care professionals recognized the potential value of URApp, reluctance to replace established paper-based approaches suggests that staff training, organizational support, and local implementation champions may be important for successful adoption [45,61]. Our findings also highlight the importance of involving young people, parents/carers, and health care professionals in shared decision-making. Previous research found that young people wished to take ownership of their continence management and viewed smartphone apps as a supportive tool for self-management [26]. Future research should explore how shared decision-making influences engagement with digital interventions and adherence to bladder training.

Beyond health care settings, participants in this study consistently identified the school environment as a major barrier to bladder training adherence. Schools should be supported to develop policies that balance educational priorities with pupils’ needs for regular toilet access and hydration [6,52,54]. In addition, schools should consider how digital health technologies can be accommodated for pupils who rely on them to manage long-term health conditions [55,57]. As schools increasingly adopt restrictions on mobile phone use, alternative implementation strategies may be required, including negotiating health-related exemptions, permitting their use during school holidays, or delaying data entry outside school hours. More broadly, our findings highlight the importance of considering organizational, educational, and policy contexts when implementing digital continence interventions.

Using URApp in community clinics has the potential to align pediatric continence care with the NHS 10-year health plan [62] by focusing on early intervention in a community setting and using digital technology to capture and store data. URApp is free to download, available for both iOS and Android phones, and has the potential to empower young people to self-manage their symptoms between clinic appointments. Digitizing bladder diaries may lead to improved treatment outcomes, improved patient experience, and reduced barriers to accessing health care. Future implementation of URApp into existing clinical care pathways will need to consider how electronic bladder diary data from URApp can be used more effectively by clinical teams, in partnership with patients and their parents/carers.