Three studies conducted in Brazil, Morocco and Sudan (Ibrahim et al. 2004; Kyal et al. 2018; Orlandin et al. 2020) reported pain in catheter insertion among both male and female children as one of the main barriers to usage and practice. Orlandin et al. (2020) reporting findings from Brazil noticed that pain is a sensory and unpleasant emotional experience throughout the catheterisation experience in children with spina bifida (Orlandin et al. 2020). Pain inhibits the uptake of usage and practice of CIC because of discomfort (Orlandin et al. 2020). This was further suggested by Lapides et al. (1972) in a study conducted in Korea, the process of emptying the bladder 4–5 times a day was reported as painful and causing discomfort coupled with other challenges of storage, management and irrigation of the catheter.

Linked to pain was fear. Kyal et al. (2018) in their study conducted in Morocco found that the fear of the CIC technique affects long-term adherence, and often patients with spina bifida are afraid of catheters entering their bodies, causing pain and infections. Kyal et al. (2018) expounded that after conducting the first session of therapeutic education to patients and their caregivers with spina bifida, the most pronounced barrier to the uptake of the practice was fear of catheterisation. In Morocco, psychological aspects of the barriers to CIC include being scared of harming children by causing infection or mistakenly breaking their hymen. In terms of practice, there was the fear of mistaking the vagina for urinary meatus (Kyal et al. 2018).

Four studies (Ibrahim et al. 2004; Jeruto et al. 2004; Kyal et al. 2018; Page & Coetzee 2021) described the lack of quality training for children, parents and caregivers as a hindrance to the practice and management of CIC processes. In Morocco, Kyal et al. (2018) found that external factors including limited quality of teaching, and the training environment are significant barriers to the usage and practice of CIC (Ibrahim et al. 2004). In South Africa, Page et al. (2019) reported that the lack of training to accommodate both adolescents and their caregivers on the practice and use of CIC is a significant barrier (Page & Coetzee, 2021). In Sudan, Ibrahim et al. (2004) observed that a lack of proper training encompassing all major steps with hands-on local materials affects the uptake of the practice of CIC (Ibrahim et al. 2004). Reporting findings from Kenya, Jeruto et al. (2004) found that no CIC programme is complete in its follow-up after providing training, and patients are often lost for various reasons (Jeruto et al. 2004).

Three studies (Bannink et al. 2016b; Kyal et al. 2018; Page & Coetzee 2021) conducted in Morocco, South Africa and Uganda, respectively, described the challenges to self-autonomy and independence in managing toilet activity. In Morocco, Kyal et al. (2018) explored external factors including challenges in accessing public toilets, and the unavailability of appropriate catheters. Furthermore, in South Africa Page and Coetzee (2021), found that the challenges to self-autonomy and independence in managing toilet activity affect participation in CIC among children with myelomeningocele (MMC) and spina bifida. Page and Coetzee (2021) noticed that as a result of the physical disability, access to toilet facilities and other infrastructure while practicing CIC both at schools and homes is affected. In Sudan, Ibrahim et al. (2004) observed that the lack of access to public toilets inhibits the practice of CIC. In Uganda, Bannink et al. (2016b) reported that to ensure independence, parents are required to be available and to closely support children to practice CIC.

Three studies conducted in three countries (1) South Africa (Page & Coetzee 2021), (2) Kenya (Jeruto et al. 2004) and (3) Uganda (Bannink et al. 2016b) reported that limited access to medical care and financial difficulties affect the usage and practice of CIC. Bannink et al. (2016b) found that in Uganda the most stressful part of the daily life of children with spina bifida is finding social spaces and reliable areas to practice CIC. Page and Coetzee (2021) reported that in under-resourced communities in South Africa, limited finances inhibit children with spina bifida from accessing medical care making it hard to practice or use CIC. Similarly, in Kenya, Jeruto et al. (2004) posited that financial constraints hamper the processes to use and practice CIC as simple materials and supplies can be prohibitive in cost for an average family of a child with spina bifida. Jeruto et al. (2004) also observed that catheter and lubricant costs have been a problem for a majority of families in LMIC. The study in Kenya recommended simplifying CIC as much as possible so that economically challenged communities can afford it. In South Africa, Page et al. (2021) reported that the lack of transport to rehabilitation centres to access medical care denies adolescents with spina bifida an opportunity to acquire knowledge and skills in practicing CIC (Page & Coetzee 2021).

Three studies conducted in Uganda (Bannink et al. 2016b, 2016c) and Sudan (Ibrahim et al. 2004) reported a lack of facilities to practice CIC as a hindrance to the uptake of the intervention among children with spina bifida and their families. In Uganda, Bannink et al. (2016c) noticed that the majority of parents practiced catheterisation although they complained practicing it outside the home and the rehabilitation facility was challenging. Bannink et al. (2016c) also noticed that children hardly engaged in CIC and reported that the practice interferes with their daily functioning because of a lack of facilities. In the Ugandan school setting (Bannink et al. 2016b), dirty latrines and a lack of space to practice CIC or even to find water to clean up were challenging. Bannink et al.’s (2016c) findings from Uganda showed that the inability to find alternative facilities to catheterisation outside the home poses a barrier to carrying on the practice and usage in the everyday life of children with spina bifida. While homes were mentioned as better places to practice CIC because of the availability of required resources like water, schools or other places were found to be difficult places to practice CIC because of a lack of resources and privacy (Bannink et al. 2016b).

Three studies conducted in Brazil (Orlandin et al. 2020) and Uganda (Bannink et al. 2016a; Sims-Williams et al. 2018) mentioned that children expressed a concern that CIC processes take a long time and can be hard to navigate. They preferred to use this time to play instead. Sims-Williams et al.’s (2018) findings from Uganda found that children who were initiated into CIC at an older age mentioned the lack of time to practice and use CIC. Orlandin et al.’s (2020) study in Brazil, explored the perception of CIC as a time-consuming procedure. During initial training and practice, patients with spina bifida in Brazil perceived the process as time-consuming based on the time required for mastery of the procedure (Orlandin et al. 2020). Orlandin et al. (2020) observed that the routine of daily practice becomes burdensome to both patients with spina bifida and their parents/caregivers or families.

Two studies conducted in Kenya (Jeruto et al. 2004) and Morocco (Page & Coetzee 2021) mentioned that multiple internal (patient-related) and external factors are barriers to the practice of CIC including physical disabilities encompassing positioning, dexterity and visual impairment to spot the urethra before insertion of the catheter. Jeruto et al.’s (2004) findings from Kenya showed that positioning is a requirement to perform CIC either standing, lying or sitting and yet this is still a limiting factor in the usage and practice of CIC especially among females.

Ibrahim et al.’s (2004) findings from Sudan showed that the lack of supplies to facilitate adequate toileting practices especially inadequate shelves or countertops for placing supplies in preparation is a hindrance to the practice of CIC (Ibrahim et al. 2004). In Sudan, the inability to access and acquire both local and imported supplies to foster the practice and management of CIC is reported as a barrier to the uptake of the procedure (Ibrahim et al. 2004). Sims-Williams et al.’s (2018) findings from Uganda emphasised that, especially among older children with spina bifida, the practice of CIC was abandoned because of a lack of catheters and distress.

In Uganda, Bannink et al. (2016a) reported that children with spina bifida were concerned in terms of perception of self, support and care with the processes of managing CIC even when their caregivers encouraged them to perform CIC independently. While there were barriers to the usage and practice of CIC expounded in this section, there were also facilitators to the usage and practice of the procedure discussed in detail in the next section of this review.

Kyal et al.’s (2018) study from Morocco observed that initiating catheterisation in infancy has been identified by caregivers as an ease of learning and adjustment. Infants are more tolerant and technically easier to catheterise, unlike toddlers who are behaviourally more challenging because of their growth, development and self-awareness (Kyal et al. 2018). The review also reports that in Morocco, educating rehabilitation workers regarding CIC facilitates their ability to concentrate and administer care for children based on set protocols. In Morocco, it is further noticed that to facilitate adjustment to CIC, it is important to utilise teaching methods focusing on the developmental and social maturity of a particular age or age group of children at the level of their understanding of the CIC learning process (Kyal et al. 2018).

A study conducted in Uganda mentioned that sometimes when children with spina bifida in the school or community were challenged in the use of CIC, they requested assistance from teachers or parents (Bannink Mbazzi et al. 2016). Children with spina bifida are open to accessing support from individuals they trust and those who can help (Bannink Mbazzi et al. 2016). While it is considered difficult for patients to incorporate intermittent catheterisation in their daily lives in Uganda, adjustment of social life and encouragement to practice CIC at home facilitates the practice of CIC as often patients with spina bifida are reminded of bladder emptying (Bannink Mbazzi et al. 2016). Page et al. (2019) found that in South Africa family support is an instrumental facilitator to the practice of CIC among adolescents with spina bifida (Page & Coetzee 2021). The need for consistent attention from caregivers facilitates the correct usage and practice of CIC (Page & Coetzee 2021). Besides, quality family time fosters the desire to gain knowledge and share experiences of practicing CIC (Page & Coetzee 2021). According to Page et al. (2021) biological mothers are the pillars of guidance to children or adolescents practicing CIC (Page & Coetzee 2021).

Bannink et al. (2016c) in their findings from Uganda mentioned that the parent support system has a significant influence on the practice of CIC. In Uganda, the support of another adult in the household in the family to care for a child with spina bifida is instrumental in ensuring regular practice and usage of CIC (Bannink et al. 2016c). This support system has a significant contribution to improving parent–child interaction that extends to a lifelong understanding of the need to catheterise (Bannink et al. 2016c). Similarly, one of the studies also conducted in Uganda by Bannink et al. (2016) and colleagues revealed that support from siblings across a range of activities bolsters their confidence to practice CIC and learn over time. Bannink et al. (2016a) report that the peer-to-peer practice of CIC encourages participation and instils confidence in children with encouraging results in continence management. In Brazil, Orlandin et al. (2020) posited that psychological support and regular follow-up of children and their families practicing CIC are facilitators of long-term adherence.

Through findings from Uganda, Bannink et al. (2016) noticed that children who continuously practiced CIC had increased participation in daily activities both at home and in school. Bannink et al. (2016c) found that the quality of the training environment for rehabilitation workers, parents and patients is a facilitator of the usage and practice of CIC. Page and Coetzee (2021) in South Africa highlight that patients with an overactive bladder were familiar with intermittent catheterisation after a few weeks of training. In South Africa, the basis for their motivation to understand the CIC management process is anchored on the expected results of bladder emptying (Page & Coetzee 2021). In Sudan, Ibrahim et al. (2004) observed that the frequency of CIC training is determined by the patient’s ability to gain confidence in self-managing CIC. The facilitators to usage and practice include the quality of teaching, supervision and follow-up in the community (Ibrahim et al. 2004). In Uganda, Sims-Williams et al. (2018) reported that the provision of CIC training to children with spina bifida and their caregivers facilitates usage and practice (Sims-Williams et al. 2018).

Orlandin et al.’s (2020) findings from Brazil showed that with practice and increasing confidence in CIC usage, children with spina bifida may not require much more time than normal to pass urine. Orlandin et al. (2020) also noticed that spina bifida patients in Brazil were reported to be motivated to uptake CIC once they knew the process would be long-term and they were positive on prospective outcomes of improving bladder functioning. In Brazil, it is recommended that while providing training to parents and caregivers to facilitate the acquisition of knowledge and skills in managing CIC, instructors should evaluate patients’ conditions and provide customised education (Orlandin et al. 2020). Among the Brazilian children with spina bifida and their parents, the desire to achieve independence in dressing, bathing, toileting and skin care while practicing CIC facilitates autonomy and a sense of belonging (Orlandin et al. 2020).

Orlandin et al. (2020) in a study with a Brazilian population reported that lidocaine gel lubricant is widely used to lubricate the urethra and it is effective in reducing pain and sensitivity. In Brazil, to reduce the risk of urethral trauma, promoting some urethral dilation and facilitating the introduction of the urinary catheter have proven beneficial (Orlandin et al. 2020). Orlandin et al. (2020) reported that to facilitate the reuse of urinary catheters and promote hygiene, several techniques are reported in multiple literature including putting the urinary catheter in boiling water, washing it in running water, storing it in a solution with vinegar, detergent or 70% alcohol or heating it in the microwave. In Sudan, Ibrahim et al. (2004) observed that the facilitators of usage are also premised on catheter availability in the community. Similarly, Bannink et al. (2016) reporting findings from Uganda noticed that private donors funded CIC and bowel management trainings including the provision of low-cost materials and follow-up of children with spina bifida at home.

In Uganda, caregivers who received training were provided a free supply of catheters and anticholinergic oxybutynin at every visit (Sims-Williams et al. 2018) fostering their support to practice of CIC among their children in the communities. Sims-Williams et al. (2018) reported anticholinergic oxybutynin was administered intravenously, thus motivating caregivers and children with spina bifida to use and practice CIC (Sims-Williams et al. 2018).

Jeruto et al.’s (2004) research from the Kenyan population recommended starting CIC in the new-born period as it is easier to master by parents and is more acceptable to children as they grow. This study also points out that an aggressive approach with the immediate neonatal institution of CIC has evidence of reducing the need for surgical procedures later in life (Jeruto et al. 2004). Jeruto et al. (2004) affirm that overcoming significant barriers and further parental education is needed to offer infants with spina bifida a good standard of care. In terms of healthcare provision by rehabilitation workers, Bannink et al. (2016b) in their study from Uganda noticed that the distinction between routine general health visits and visits to occupational or physiotherapists enables children to understand the role rehabilitation workers have in their lives. In Uganda, Bannink et al. (2016b) also found out that rehabilitation workers foster routine usage and practice of CIC whenever they conduct home visits.

In Uganda, household income and overall parental support were reported as important key predictors to continence management (Bannink Mbazzi et al. 2016). In families with higher incomes, transport costs to rehabilitation centres is easily met to access supplies. In this case, parents are able to support their children to carry out CIC several times in a day leading to improved quality of life, earlier better motor function and sufficient continence management (Bannink Mbazzi et al. 2016).