Case Study

How a health app became a ‘gamechanger’ in continence services

Professor Nikki Cotterill and Knut Schroeder developed CONfidence, a discreet, informative health app for those experiencing continence issues.


Throughout her career, Professor Nikki Cotterill, an associate professor in continence care at the University of the West of England, had noticed that people experiencing continence issues could be reticent about getting help.

Embarrassment could be a factor but, often, people simply didn’t know that symptoms could be improved.  Nikki said: “There’s usually a tipping point – people find out that a continence service exists and are given lifestyle advice and exercises.  It’s common for people to say they wish they’d known about this ten years ago’.

“I was on a Florence Nightingale leadership scholarship and when I spoke to my group about this, we realised there was a gap in advancing the policy area. We thought an app was a good way forward. It wouldn’t solve all the issues but would be a useful starting point for a campaign.”

The challenge was, how to bring the app to life.

Nikki approached Knut Schroeder, founder of Expert Self Care, an organisation which co-creates health apps for universities, NHS organisations and local authorities. The two colleagues then identified a number of other key stakeholders to involve in their project:  people who have lived experience of bladder and bowel leakage, national experts and organisations specialising in bladder and bowel care.


Working with ORCHA

The development of high-quality content for the app was just one of the challenges faced by the team. Based on his experience of co-creating a number of other apps, Knut knew that accessibility was an issue.  He said: “The key is to have simple information – but links if people want to find out more.  It’s a bit like a TV remote control. I don’t know what 80% of the buttons do!  So, we strip out things that people never use and don’t understand.

“We do tech updates as we go along and our editorial updates are ongoing. In fact, every page has a review date on it. We are required to update certification of the overall app every two years but we voluntarily state the next review will be within 12 months.”

As he had with other Expert Self Care apps, Knut opted to have CONfidence assessed by ORCHA’s baseline review, which would measure it against 350 tough standards and assess it for clinical efficacy, data privacy plus usability. He said: “In the past, I’d had really great interactions with ORCHA and this review helped, too.  We knew where to improve, what to work on, where we could do better. All our apps have scored above the ORCHA quality threshold, which means they are distributed to healthcare professionals via app libraries. This is a great way to get them used and get the work out.

“Our app is generic for a UK audience but local areas can subscribe to optional local pages. Some areas have great information already but others are struggling and are not as coordinated.

“We have found that having an ORCHA score is really helpful for getting the trust of those organisations. Once they see the ORCHA badge they find it easier to trust the product. I hear that quite often commissioners don’t know which digital tools to recommend or use – they don’t have the time and skills to assess them. So having this independent ORCHA verification is really useful.”

It was Nikki’s first experience of working with ORCHA. She said:

“From my personal experience, given that I’m a nurse and researcher and have never done any app development, all my engagement with ORCHA has been really supportive, helpful and understanding.”


An award-winning app

CONfidence is now available on the ORCHA app library, with a score of 74%, reflecting its high standards. It’s a free-to-use national information hub with over 70 quality-assured articles on key topics about bladder and bowel leakage.

It enables health, care and education providers to offer the very best health and wellbeing information – instantly available in one convenient place, covering topics such as the causes of incontinence, treatments, and products which may help.  It even supports families coping with the challenges associated with young children: potty training, bed wetting and continence at school.

Knut said:

“The app is regarded as a complex public health intervention. Even though it’s not classed as a medical device, we are giving out a lot of information. We are currently working on pathway development within clinical pathways, focusing on GP, bladder and bowel and maternity services in local areas.”

Many services are using CONfidence as a first-line intervention and it’s been referred to as a ‘gamechanger’ in continence services. This year it won a Nursing Times award for continence promotion and care.