Technological evidence for outpatient and home care in pediatric urology: a scoping review

Objective: to map the evidence on web-based technologies and their applicability in outpatient and home care in pediatric urology. Methods : this is a scoping review, with searches conducted in six databases, with no time limit, in Portuguese, English, and Spanish. Results: 2,200 articles were obtained, with 19 publications eligible for the final sample. The most used web-based technologies were te-lehealth and telemedicine (47.3%), online intervention programs (21.0%), and mobile apps (15.8%), with a lower rate of use of serious games, social media, and urination videos (5.3%), mostly in the home setting. Conclusion: the mapping of technological evidence in outpatient and home care in pediatric urology allowed us to identify the types of technology and their applications focused on self-management of symptoms and self-efficacy, for monitoring and follow-up of urologic care. Contributions to practice: the synthesized evidence contributes to an expanded, qualified, and in - novative professional practice with the pediatric population with urinary and bowel symptoms, characteristics related to advanced nursing practice, in addition to favoring early diagnosis and greater therapeutic adherence, particularly by supporting interventions tailored to the needs of the pediatric patient and his family. Descriptors: Ambulatory


Introduction
Currently, in the global scenario, health care has been transformed, particularly due to the incorporation of new means, methods, and processes brought about by the use of information and communication technologies (1)(2) . Such technologies have stood out, such as telemedicine and telecare services, encompassing internet-based technologies (IBT), which involve websites, e-mail, social media, mobile applications, and video calls (3)(4) .
The term digital health refers to the use of IBT in the health care system so that the user has access to information, services, and facilitated support to health services available within an integrated digital platform. In Brazil, the digital health strategy signals the protagonism of users, whether patients, professionals, or health organizations, given the development of a national network of health data (5) . Therefore, different specialties and health professionals may benefit from IBTs by facilitating the exchange of knowledge, offering personalized interventions, as well as providing autonomy and engagement in health care in a more lasting way (3,(6)(7)(8)(9) .
IBT has been a support tool in pediatric urology due to the complexity of treatment adherence, being used to involve patients and families in this process of self-management of symptoms, in a light and attractive way (10)(11)(12) . Particularly nurses, who work in Pediatric Urology and act in a multidisciplinary and collaborative manner in the diagnosis and management of urinary and/or bowel symptoms (13) , have a unique role in the regular follow-up and encouragement of the child and family in symptoms (self-) management practices, especially with the application of standard urotherapy (13)(14) .
Therefore, nurses who work in urologic care can benefit from the incorporation of these technologies, particularly when focused on standard urotherapy, that is, the first-line therapeutic approach to promote elimination habits and changes to a healthier lifestyle for both the child and the family (13)(14) . Moreover, by providing nursing care mediated by technology, nurses can plan care, directing it to autonomy in the process of seeking health knowledge, making informed clinical decisions, and providing more personalized care (15) . Thus, this study aimed to map the evidence on web-based technologies and their applicability in outpatient and home care in pediatric urology.

Methods
This is a scoping review, following the method recommended by the Joanna Briggs Institute (JBI). The Preferred Reporting Items for Systematic Reviews and the extension of the JBI's Manual for Evidence Synthesis (16)(17) were adopted to systematize the review process. The synthesis of this research protocol was registered in the Open Science Framework (https://osf.io/5s6qm/).
The study was organized following the nine established steps: 1) Define and align the objective(s) and question(s); 2) Develop and align the inclusion criteria with the objective(s) and question(s); 3) Describe the planned approach for evidence search, data selection and extraction, and evidence presentation; 4) Evidence search; 5) Evidence selection; 6) Evidence extraction; 7) Evidence analysis; 8) Results presentation; 9) Summary of the evidence about the review objective, conclusions, and observations on any implications of the findings (17) .
The scoping review was guided by the research question, based on the P-C-C strategy, in which (P) Population -Pediatric population with urinary and/ or bowel symptoms; (C) Concept-Internet-based technologies; (C) Context 1 -Outpatient; (C) Context 2 -Pediatric Urology Home Care. In this context, the following research question was defined: What are IBTs and how are they applied in the context of outpatient and home care in Pediatric Urology?
The inclusion criteria consisted of studies that described the use of IBT in outpatient care and/or home care of uropediatric patients, published in Portuguese, Spanish, and English, in indexed and peer--reviewed journals, available in full text online until the year 2022. It is important to clarify that the emergence of IBTs in health care started in the 1950s, and, specifically in the urology specialty, in the 2000s, and that in 2011, in the United States, telemedicine services focused on outpatient care were already started (2) .
Articles with incomplete texts in Portuguese, English, and Spanish were excluded; studies whose context was intensive care and surgery (intraoperative phase); and more complex procedures in the hospital environment (for example, endoscopic or imaging procedures with the use of radioisotopes such as scintigraphy), and palliative care.  The descriptors were selected, and then searches were performed in the databases. The selection of the descriptors was based on the controlled vocabulary of the Medical Subject Heading Terms (MeSH): pediatric, urology; internet-based intervention; Home care; Ambulatory/Outpatient. These were applied to the databases to identify the most used keywords in the published studies. Subsequently, the descriptors were crossed with the Boolean operators AND/OR: Pediatric urology AND Internet-based intervention AND Outpatient and/or home care. The combinations remained similar using different search keys, respecting the specificity of each database, as shown in Figure 1.

MEDLINE/ PubMed
Electronic searches were performed in the Medical Literature Analysis and Retrieval System Online (MEDLINE) via PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science (WoS), SCOPUS, Embase, Ovid Medline, MEDLINE Complete and Latin American and Caribbean Health Sciences Literature (LILACS) databases. In addition, searches were expanded to Open Grey and ProQuest, and searches were conducted in the Periodical Portal of the Coordination for the Improvement of Higher Education Personnel (CAPES), through the Federated Academic Community (CAFe). Initially, the database searches were performed on a single day, December 10, 2020, by two reviewers independently, and then performed again on October 31, 2022, to generate an updated report.
Rayyan software (18) was used, which allowed the transfer and storage of the studies from the different databases. Data extraction was performed by two reviewers and confirmed by a third reviewer. Disagreements or doubts were resolved by consensus among the three reviewers. We extracted data on the  characterization of the study (year, place, and periodical); characteristics of the target audience; methodological design, interventions using IBTs, main results, and health outcomes, which were stored in Microsoft Excel ® spreadsheets and presented descriptively with raw data (total value) and relative data (percentage), as shown in Figure 3. Since this is a scoping review, and therefore does not involve research with human beings, the protocol of this study was not submitted for review to a research ethics committee.

Results
A total of 2,200 publications were identified, and 372 duplicate articles were excluded. After reading and analyzing the titles and abstracts, 36 studies were selected to be read in full. After applying the eligibility criteria, 19 articles were eligible to compose the final sample ( Figure 2).
The characteristics of the studies that make up the review sample are described in Figure 3.

Authors
Journal, year and place Method Main Results

Online intervention programs
Home-based intervention program for pediatric encopresis was used as an informational support tool for parents with questions regarding their child's condition.

Prospective cohort
Telehealth/ telemedicine Domiciliar: use of Skype by health care professionals with young people with complex needs has been shown to be an effective intervention to support continence care at home.

Nonrandomized intervention
Telehealth/ telemedicine Domiciliar: remote consultations promote time savings and also avoid travel, and corroborate changes in the care plan in a personalized way.

Literature Review
Telehealth/ telemedicine Domiciliar: the study evidenced that telehealth is an effective means of encouraging young people to engage in activities related to their selfcare, particularly with continence care.

Literature Review
Telehealth/ telemedicine Domiciliar: telehealth practices have proven to be safe, effective, and satisfying for patients and professionals.

Transverse Telehealth/ telemedicine
Domiciliar: the survey showed that almost all the families were satisfied or very satisfied with their experience of virtual consultations, as they emphasize that these consultations are resolutive.

Mobile app
Outpatient: applicability of a mobile mictional diary was acceptable and feasible for the population of patients with lower urinary tract dysfunction, but no significant differences were shown in using a paper mictional diary and mobile app mictional diary.

Nonrandomized intervention
Telehealth/ telemedicine Domiciliar: families who attended the pediatric telemedicine clinic highlighted as main advantages: the time they saved, support in the process of diagnosing the condition, and improved access to health care in remote areas.
Gan et al (32) J Pediatr Urol 2021 EUA Retrospective Telehealth/ telemedicine Domiciliar: families reported high overall satisfaction with virtual video consultations, as they were able to adequately meet their children's medical needs. This consultation modality was also able to request and evaluate tests, as well as make diagnoses.  Among the studies included, IBTs were mostly applied in the home setting in 17 articles (89.5%), and only two studies used these technologies in the outpatient setting (10.5%), mainly to favor adherence and provide guidance to parents and their families about the care that is planned in the outpatient setting and that must be continued at home. In the home setting, (9 articles) did not specify the condition, only using the term Pediatric Urology. The lower urinary tract dysfunctions had a quantitative of 26.3%, corresponding to five articles; 15.8% of the studies (i.e., three articles) were about children with spina bifida (consequently, neurogenic bladder and bowel); and 5.3% were about children diagnosed with enuresis, representing only one article. As for bowel symptoms, only one article (5.3%) addressed constipation (1) and another article (5.3%) addressed encopresis.
Telehealth and telemedicine stood out (47.3%) as the most used technologies among pediatric urologists for communication with their patients and parents, followed by online intervention programs (21.0%), mobile apps (15.8%), and, with a lower rate of use, serious games, social media, and urination clip/ video (5.3% each). Figure 4 provides a summary of the applicability of IBTs in outpatient and/or home care in pediatric urology.
IBTs proved to be a useful tool to promote the engagement of patients and their caregivers in the process of (self-) management of urinary and bowel symptoms. They are effective in fostering some behaviors and care alternatives in the context of pediatric urology, such as: Self-management and Self-efficacy: three stu-dies have shown that the use of IBTs is an alternative that supports patients and their families in the process of self-management and self-efficacy in the management of urinary and/or bowel symptoms. One study (11) reports a self-management program composed of integrative education in the face-to-face modality and a mobile health (mHealth) intervention (11) , which provided children with spina bifida with increased contact with other children with the same condition, favoring experience-sharing, motivation, and engagement. The results of telehealth services with children under five years of age with spina bifida and their caregivers (9) showed positive aspects, demonstrating that telehealth was able to stimulate the participation of family members of these children and promote empowerment and self-efficacy. Moreover, telehealth is an effective way to encourage young people to engage in self-care activities, especially focused on continence, as remote interventions, and Skype were seen as attractive, facilitating supported self-care practices (19) . Personalized care: is exemplified by the program called Electronic Advice and Diagnosis Via Internet Following Computerized Evaluation (eADVICE) (23) , which provides personalized advice on the treatment proposed by the professional with the help of a virtual avatar named Dr. Evie. This remote program has promoted improved adherence rates, favoring the establishment of a collaborative care partnership with the user.
Health Education: IBTs, such as mobile apps and social media, are a strong ally for symptom management, health promotion, and information sharing about urologic care (14,26) .
Monitoring and Follow-up: the most common application of telehealth has been video consultation (teleconsultation) to assess or follow up with patients (28) . Similarly, telemedicine follow-up of patients with enuresis (6) showed comparable effectiveness to in--person follow-up. Regarding follow-up (20) , access to information made available on the Web during constipation treatment may promote faster and short-term recovery from constipation symptoms.
IBTs have also made it easier for patients and their families to follow the guidelines recommended by professionals, as well as assisting in providing better quality and more reliable data on urination, such as through the use of the elimination diary on mobile apps. They also expanded in response to the pandemic context, where one possibility for continuity of urological care was through video consultations (telemedicine) (27) , seen as a successful alternative to be applied in this pandemic context. Furthermore, IBTs have been innovating the care in pediatric urology where they are implemented, as in the case of the use of serious games (24) to increase the intrinsic motivation of pediatric patients in the practice of urotherapy interventions. The Bladder Sensor, named SENS-U, also sends data to a smartphone application and can monitor the natural filling of the bladder in children during activities of daily living and notify them when their bladder is full (34) . In addition, the use of the smartphone camera as a provider of data on urination in the home setting has been described, where clips or videos of urination were considered a non-invasive tool that does not require hospitalization or incur further costs and reduces the need for more invasive urological examinations such as urodynamic testing (35) .

Discussion
IBTs have shown promise as promising tools in symptom management, especially focused on supported self-care, including informational and ongoing follow-up support for urologic health in the pediatric setting. In addition, IBTs are used in other specialties, especially in patients with chronic and complex conditions. For example, in children diagnosed with osteogenesis imperfecta and their caregivers (5) and in young people affected by chronic diseases (27) (such as asthma, type 1 diabetes mellitus, and epilepsy), to support the performance of daily health care activities, promoting family and patient empowerment regarding their condition. They are also implemented in the transition care of adolescent and young adult patients to adult services by facilitating treatment adherence and promoting remote monitoring and supported self-care actions (19,35) .
Telehealth is an effective means of attracting young people to engage in self-care activities related to continence care (19) . Benefits were noted by parents, the young people themselves, and physicians who were also caring for participants in other healthcare settings. These benefits were related to advances in supported self-care skills, culminating in improved readiness for transitional care by interacting effectively with different healthcare professionals (19) .
These technologies can also be promoters of supported self-care (35) , and only one study (9) has addressed such applicability in the context of urologic care. However, they are being implemented in the management of chronic diseases (such as osteogenesis imperfecta and spina bifida), standing out for their ability to promote interaction between pairs of patients with the same condition. This functionality of interaction and sharing of experiences has been a positive reinforcement for the development of individual self-management skills and peer-supported self--care (3,9,34) .
IBTs have also stood out as innovative and complementary healthcare tools. Professionals can perform follow-up consultations, evaluate the evolution of symptoms, perform monitoring, and provide self--care guidance remotely, maximizing the efficiency of the work process and providing continuity of care (24) . Moreover, IBTs have been strong allies in times of pan-demic, since professionals can counsel patients and their families remotely (2,27) .
The Pediatric Urology specialty has embraced the use of telehealth, implementing it increasingly in different services and care centers, particularly for health education and patient and family empowerment (2,39) . The increasing level of telehealth activities in the specialty of pediatric nephrology is noteworthy (40) , due to the advantages they offer such as access to specialized care in remote locations, the convenience of staying at home while receiving specialized care, and the ability to rapid and effective communication between patients, families, and professionals (29,40) .
The technological devices used by telemedicine (41)(42) can be considered a drastic change in the traditional way of providing health care. The professional-patient-family interaction mediated by IBTs needs to go through a process of acceptance and overcome cultural, institutional, and professional barriers to have the process of dissemination and consolidation of telemedicine (42) . The changes in clinical practice with the implementation of digital technologies (43) provide a greater interaction of the professional with the patient, as well as ease and flexibility in scheduling appointments, saving time and money in seeking care. As observed in the use of telemedicine for follow-up consultations for uropediatric patients living in remote areas (2,28) , another benefit is the ability to store records, since access to them can be made from anywhere in the world, for example, through a cell phone (6,43) .
The Online Health Centre at the University of Queensland is one of the pioneering telehealth services in the world (40) . It aims to optimize professional time traveling between hospitals and clinics, maintain high patient satisfaction, and increase the opportunity for a multidisciplinary approach (2) , as well as decrease patient and family absenteeism from appointments (36) .
Further research is recommended to identify and analyze the professional practices mediated by IBTs, especially those developed and implemented in the national context by nurses for the self-management of urinary and bowel symptoms, given the absence of national publications on this theme.

Study limitations
Although an exhaustive search was carried out in different electronic databases and the gray literature, since this was a scoping review, no methodological assessment tool was applied to the studies that comprised the sample of this review.

Contributions to practice
Such synthesized evidence brings relevant contributions to an expanded, qualified, and innovative professional practice with the pediatric population affected by urinary and bowel symptoms, characteristics related to advanced nursing practice. These technologies have also been shown to facilitate self--management and self-efficacy skills, simplifying the process of monitoring and follow-up of the pediatric patient and his family in urologic care, performed by the nurse.

Conclusion
The applicability of IBTs in the context of outpatient and home care in pediatric urology allowed us to identify the types of technologies and their applications aimed at self-management of symptoms and self-efficacy, monitoring and follow-up, and providing personalized care.
It is indisputable that IBTs, particularly in the telemedicine modality, are promising in the management of urinary and bowel symptoms, as they provide significant savings in money and time, clearly reducing absences from work and school. They also favor the interaction between professionals, patients, and families, facilitating the communication process between them, which can make them allies in the sense of outlining care experiences and promoting supported self-care practices that are more engaging and meaningful.