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Are washable absorbents effective at containing urinary incontinence?

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Washable absorbent products that are worn on the body are made from a variety of synthetic and natural materials - terry towelling, for example - and are laundered after each use. In the late 1960s their widespread use was superseded by disposable products, which have become the mainstay of containment (Medical Devices Agency, 2001). However, pressure on budgets for continence pads and, to a lesser extent, environmental concerns have led purchasers and prescribers to re-examine the use of washable absorbent products.

Abstract

VOL: 100, ISSUE: 12, PAGE NO: 58

Margaret Macaulay, RN, DN, is research nurse

Sinead Clarke-ONeill, MSc, BSc, RN, is project manager; Mandy Fader, PhD, PG Dip, BSc, RN, is nurse director; Lena Pettersson, MSc, BSc, RN, is project manager; and Alan Cottenden, PhD, MA, MIPEM, MIMMM, CEng, is director, Continence Technology Group, Departments of Medicine/Medical Physics and Bio-engineering, UCL, London

 

Washable absorbent products that are worn on the body are made from a variety of synthetic and natural materials - terry towelling, for example - and are laundered after each use. In the late 1960s their widespread use was superseded by disposable products, which have become the mainstay of containment (Medical Devices Agency, 2001). However, pressure on budgets for continence pads and, to a lesser extent, environmental concerns have led purchasers and prescribers to re-examine the use of washable absorbent products.

 

 

Washable products offer potential economic advantages. The recommended lifespan of 200-300 washes means washable products are economical in terms of pence per day product cost. However, there are costs associated with the laundering process and the environmental case for washable products is unclear since laundering uses additional detergents and energy (Cottenden, 1992). Washable products also require a high capital outlay, and it is imperative that purchasers, prescribers and users have up-to-date information so that they can avoid inappropriate use and costly mistakes.

 

 

There is very little research available about body-worn washable products for adults with moderate to heavy incontinence. The studies that have been conducted are now out of date and vary widely with respect to sample size and outcomes measured (Gallo and Staskin, 1997; Philp and Cottenden, 1993; Hu et al, 1989; Dolman, 1988; Haeker, 1986; Grant, 1982; Beber, 1980).

 

 

Method
The aim of this small, pilot study was to give an overall impression of product performance. The study identified 19 washable absorbent body-worn products for moderate to heavy incontinence (Table 1) that were available in the UK at that time.

 

 

The products fell into a range of designs:

 

 

- Two-piece, pad-and-pant system;

 

 

- All-in-one pad;

 

 

- Pant with integral pad;

 

 

- Pouch pants with insert pad.

 

 

A representative sample of three equivalent disposable products was also selected for comparison. Following ethics committee approval, 10 men and four women (aged 28-67 years) were recruited. The subjects visited the research department three times during the study.

 

 

Subjects selected the washable products that they wished to test from the 19 available; some products were found to be unacceptable at this point. This led to a limitation of the study as some products were tested by only a small number of people. Every subject was required to test all the disposable products.

 

 

The subjects’ chosen products were then ordered in the appropriate sizes and, once the fit had been checked, the products were laundered twice prior to first use - as recommended by manufacturers - and coded. The products were then sent to the subjects with laundry instructions (written in consultation with the manufacturers) and a complimentary box of washing powder. Two types of plastic pant and nappy pin were sent to subjects testing the Paddy T and terry towelling nappy. Five pairs of net stretch pants were also given to each subject for use with both washable and disposable waterproof-backed insert pads.

 

 

The products were tested in a random order to avoid order bias. Quantitative data were collected using a 26-point product-performance questionnaire, based on key product attributes identified by subjects at the first interview (Table 2).

 

 

Subjects rated each product’s characteristics on a three-point scale as ‘good’, ‘OK’ or ‘poor’. Subjects used a leakage diary to record each time they used a product and the amount it leaked (‘none’, a ‘little’ or a ‘lot’). Subjects were asked to test each product for a maximum of eight times. Three interviews were conducted during the study.

 

 

Interview 1: This took place before the subjects started using the products. The subjects were asked to state:

 

 

- Which product characteristics they felt were most important in product selection;

 

 

- Their views on the concept of reusability;

 

 

- Potential benefits from the use of washable products.

 

 

Interview 2: Subjects tried on their products to check the fit and researchers explained the use of the case record file and the procedures for testing the products.

 

 

Interview 3: Following the use of products, subjects were asked to:

 

 

- Expand on some of their comments in the product performance questionnaires;

 

 

- Comment on how the washable products have affected their lifestyle;

 

 

- State any preferred styles and ways in which the products could be improved;

 

 

- State if they would be prepared to continue using washable products.

 

 

Results and discussion
Interview 1: Subjects entered the study hoping to find that washable products would offer an advantage in terms of procurement, storage and transportation. They were also looking for increased comfort over the disposable products they were using.

 

 

Subjects perceived washable products to be a ‘green’ alternative. They acknowledged the potential product-cost savings of reuse. Interestingly, none of the subjects objected to having to bear additional laundry costs. Some subjects felt that washable products might prove more absorbent at night although others had tried them previously and found this not to be the case.

 

 

Table 2 shows that out of all the product characteristics identified by the subjects, leakage/absorbency, discreetness, comfort and fit were most important in product selection.

 

 

Fitting and laundering There were significant difficulties in achieving a good fit with many of the standard-sized products, particularly for the larger subjects. This included the Bullen trainer pant, which is made to measure. Several of the all-in-one products and pants with integral pads did not reach the subjects’ waists and therefore could not be fastened.

 

 

It is important to take into account the distance from crotch to waist when assessing an individual for such a product.

 

 

The insert pads were found to be too wide, narrow or short for some subjects causing discomfort. Men were not always happy with a product they perceived to be designed for women. Some reversed the insert pads thereby having the larger end situated to their front. However, this left the smaller end feeling uncomfortable under the buttocks.

 

 

All the washable products could be machine-washed and all except the Milton Contenta garment and Bullen trainer pant could be tumble dried: the two exceptions required air-drying. Some deterioration was noted in the laboratory after only two washes on the Shiloh and Vernacare products (pilling on the fabric surface and some fraying).

 

 

One subject did not have a private washing machine and not all subjects had a tumble drier. One man had to use a launderette which was unsatisfactory. Even washing products at home led to some embarrassment when they were part of family laundry, in a bucket or on a drying line.

 

 

In residential institutions, the need to personalise these products in the same way as underwear could create practical problems and it would be unacceptable to use them communally.

 

 

Interview 3: Although most subjects found at least one product that was helpful and welcomed the smaller quantities of products required, they found significant problems with the washable products. In particular they were prone to leakage, indiscreet and difficult to dry without a tumble drier. No one was prepared to continue using them in isolation.

 

 

No one style was preferred over others. The pants with integral pads were liked for their similarity to normal underwear although they were difficult to change when away from home.

 

 

The all-in-one products performed badly but felt secure; the two-piece systems were difficult to keep in place. When invited to suggest improvements, subjects said the products must be more reliable in containing leakage, more comfortable, discreet, and easier to dry.

 

 

Specific product performance The products can be compared by looking at how they performed in the four key areas identified by the subjects as important when they selected the products at the first interview (Table 2). - Absorbency/leakage Overall, the washable products were poor at holding urine and there was a high level of leakage. This was particularly true for the neater, more discreet products, for example, the pants with integral pads. However, the Paddy T (made from terry towelling) performed very well. For night use it was the most absorbent product outperforming even the large disposable all-in-one pad. For day use, the disposable all-in-one was the most absorbent product followed by the Paddy T. Unfortunately, the bulky size of the product might limit its suitability for day wear in public. It was surprising that the large disposable insert pad that was designed for heavy/night use did not perform better during the day or night.

 

 

- Discreetness The most discreet products in terms of size were the two-piece pad and pant systems and the pants with an integral pad - the latter were particularly popular as they had a similarity to normal underwear. The least discreet products were the washable and disposable all-in-one products particularly the Bullen trainer pants.

 

 

The noise caused by some of the closure mechanisms was unacceptable - the Velcro tabs were very noisy when pulled apart as were the poppers, which could ‘snap’ open.

 

 

A rustling noise from the plastic element in both washable and disposable products was a problem. A better solution for day use could be a more discreet product changed frequently, such as a shaped insert pad with pants. At night when discreetness is less of an issue a larger more absorbent product could be used.

 

 

- Comfort Most products were comfortable but only the Bullen trainer pant was comfortable when wet. This is surprising since the lining is made from terry towelling which remains ‘soggy’ when in contact with the skin. It is possible that the conformable nature of the towelling in combination with the soft plastic used in the Bullen trainer pant accounted for this. Some of the larger all-in-one products can be stiff and this may account for their poor comfort scores.

 

 

- Fit The reusable products that performed well for fit were the Shiloh super elasticated insert pad and unisex briefs, Paddy T and Vernacare briefs - as well as the all-in-one disposable product. No single product style was better than another for this characteristic. Fit is critical for product performance and it is noteworthy that the use of safety pins - a ‘low-tech’ mechanism - in conjunction with the shape of the Paddy T gave a great deal of flexibility in achieving a good fit.

 

 

- Overall opinion Of the subjects who tested Paddy T, 78 per cent rated it as ‘good’ for overall performance making it the best performing product from all the products tested. This was followed by the all-in-one disposable product (69 per cent). None of the remaining products achieved a ‘good’ rating from more than 50 per cent of the subjects who tested them.

 

 

Conclusion
This small pilot study has demonstrated that there is some way to go before washable body-worn absorbent products for heavy to moderate incontinence can hope to enjoy the popularity and widespread use of washable bed protection and products for light incontinence. The subjects in this study were very critical of the products and felt that improvement was needed in all four key areas of leakage/absorbency, discreetness, comfort and fit.

 

 

However, most of the subjects in this evaluation found a product with some characteristics that were personally useful. With careful consideration of the issues highlighted above, these products have the potential to provide a useful and appropriate adjunct to the more frequently used disposable products.

 

 

Although these products are not worthy of a more comprehensive evaluation at this stage in their development, they should be included in the range of products considered by nurses and their patients when assessing individual need.

 

 

Recommendations
Figure 1 identifies some of the important points when considering patients’ needs:

 

 

- It is important that nurses have knowledge about reusable body-worn absorbent products;

 

 

- It is useful to have an up-to-date set of literature that can be used to show products to patients;

 

 

- It is important to note that the provision of a washable product by the NHS is at the discretion of the local continence service/supplies organisation. The patient can make a private purchase;

 

 

- Think about mixing washable and disposable products. For example, use a disposable product during the day when it is imperative that the product is discreet and leak-free but try a washable product at home or at night when discretion may be of lower priority;

 

 

- Alternatively, use a washable product to enhance the function of a disposable product or vice versa. For example, add an unbacked disposable insert pad to boost the leakage performance of a washable product or wear a reusable pant or all-in-one over a disposable product to reduce leakage.

 

 

Many products are sold with a stated absorbency level but how well a product actually performs in terms of leakage is variable and depends on many factors. For example, the same product will perform differently if the patient is lying down from when she or he is walking.

 

 

It is recommended that when deciding on the absorbency required, you refer to your patients’ current product usage and discuss possible changes in requirement with your continence nurse specialist and the manufacturer.

 

 

FOOTNOTE
The full report from this study, IN11 Reusable Absorbent Body Worn Products Moderate/Heavy Urinary Incontinence: A Pilot Study Evaluation, is available from the Medicines and Healthcare products Regulatory Agency and will have been sent to chief executives and continence nurse specialists (CNS). It contains detailed information regarding individual product performance and also details of the companies that manufacture the products. Copies of the full report are available free for health and social service care professionals. If you would like to obtain a copy, contact the Medicines and Healthcare products Regulatory Agency (MHRA), Business Services, 9th Floor, Hannibal House, Elephant and Castle, London SE1 6TQ, or call 020 7972 8181. A full list of all the disability reports available from the MHRA can be seen on its website at www.medical-devices.gov.uk

 

 

The full version of this report will be published in Wound Ostomy and Continence Nursing later this year.

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