Fourteen participants from The Ottawa Hospital were recruited for this study. Ten of 11 patients, and 4 of 8 health care providers who were approached agreed to participate. Amongst those who completed interviews, 10 participants were patients using pessaries and 4 participants were health care providers (physicians or nurses) fitting pessaries and teaching self-care. The median age of patients was 66 years (range 42 to 85). Eight patient participants had used the pessary for less than 3 months but 2 had used a pessary for more than 5 years and recently underwent re-fitting. All patients could describe their pessary, but 9 out of 10 did not know the formal name or size. All patients except one were engaged in self-care following the initial fitting.

The data were coded into basic themes within three categories: motivations, benefits, and barriers. In each category, codes were grouped into organizing themes as patterns were identified through interpretive engagement with the data [8].

The most common motivators for learning pessary self-care were ease, personal hygiene, and health care provider advice (Table 1). Patients described learning to insert and remove their pessary as a relatively simple procedure and expressed that they felt capable of performing this on their own after initial instruction.

Many patients described caring for their pessary as important for hygienic reasons. They compared learning pessary self-care to other routine hygiene activities such as changing undergarments and brushing teeth. Providers highlighted the minimization of vaginal discharge associated with regular removal and cleaning as a means of promoting patients’ perception of cleanliness. Providers felt that maintaining cleanliness was a motivator for patients.

Health care providers also played a prominent role in motivating patients to learn self-care. Health care providers described the importance of explaining the benefits of self-care, taking time to ensure patient understanding with step-by-step instructions, and providing reference pamphlets to aid in success with self-care outside of the visit. Providers described their role as normalizing self-care and strongly encouraging patients to learn self-care. Some patients also believed self-care was the standard practice and expressed that they did not feel that they were offered provider-led care. Moreover, many patients described being comfortable with the health care provider as an important facilitator for learning self-care. Patient 6 stated,

“They were very good listeners and very positive so then you feel more relaxed and confident.”

Several benefits of self-care were described by participants (Table 2). Caring for their own pessary provided patients with autonomy of care. Nine out of 10 patients felt capable of inserting and removing their device following their pessary-fitting appointment, which includes self-care education. Patient 4 explains her experience:

“When I insert it myself, it’s just more responsible–no it makes more sense, you know it’s my body, and if there is anything wrong, I’m more aware of it. I suppose that’s instead of having someone else look at it.”

Patients also felt that self-care fosters independence, which they greatly valued. They believed it was important to learn to manage their pessary rather than depending on health care providers. Health care providers held similar beliefs, stating that self-care gives patients more control over their body and ownership over the management of their condition.

Participants described self-care as being beneficial to their sexual relationships, as 4 out of 5 sexually active patients indicated that they were removing their pessary for intercourse. Four of the 9 patients who did self-care were not sexually active, but providers described desire for sexual activity to be a strong patient driver in engaging in self-care and reported discussing sexual activity as part of their counseling to promote self-care.

Both patients and health care providers described self-care as more convenient in terms of time dedicated to care. They specifically highlighted that self-care minimized the number of follow-up visits required. Some patients did not live near the clinic, and they highlighted the decreased number of follow-up visits as a major benefit because it minimized the requirement for travel. Several patients described engagement in self-care as a means of helping to reduce the burden on the health care system, with one commenting that the current 8-month wait time for a fitting appointment was long. They expressed a sense of duty to perform self-care to promote access to others and minimize their contribution to an overburdened system. Providers echoed this benefit and described that the default strategy at the clinic among providers at the time of the study was to teach self-care owing to a lack of appointment availability. Health care providers also noted an additional benefit that was not expressed by patients interviewed in the study: they described that pessary self-care reduces complications such as tissue irritation, erosion, laceration, bleeding, and discharge build up. The health care providers reported that they often mention this benefit to patients.

Patients and providers faced barriers to learning or teaching pessary self-care (Table 3). Some patients described physical limitations due to medical conditions such as arthritis or obesity or age-related physical changes such as decreased flexibility. Patients also described structural limitations related to the pessary itself, including difficulty grasping the pessary without a handle and challenges in bending the pessary during insertion. They expressed that their physical limitations were compounded by structural limitations to make self-care more challenging. Importantly, many patients described succeeding in self-care despite physical limitations and highlighted modifications such as the addition of a loop of dental floss or having a supportive partner assist them in performing self-care as a means of mitigating the impact of structural barriers.

Other patients reported facing mental barriers and these were also reported by providers when describing unsuccessful self-care teaching during pessary fittings. Some patients self-identified as lacking the mindset to learn self-care, whereas others reported believing that health care provider-led care resulted in improved health outcomes. Providers described some patients as having negative attributions toward self-care from the outset of the appointment and identified this mindset as a major barrier to consideration of self-care. Providers also described teaching self-care to patients with some medical conditions, such as dementia, as challenging and potentially futile. Finally, providers expressed that they suspected that some patients preferred frequent follow-up visits owing to the social nature of appointments, particularly in the context of limited social interactions during the COVID-19 pandemic.

Both patients and health care providers noted that negative emotions, including anxiety and fear, can pose a challenge to learning self-care. Health care providers found that it was harder to facilitate self-care in patients who did not have appropriate prior counselling or knowledge of pessaries, or who were not able to understand self-care as effectively owing to language barriers.

Time was noted as a barrier for patients and health care providers. One patient mentioned that caring for the pessary was time consuming and conflicted with her work schedule. In the clinical setting, health care providers faced time constraints when teaching self-care. Providers described the challenge of taking adequate time to counsel and coach patients to ensure capability and promote feelings of self-efficacy around self-care prior to the completion of an appointment. Providers highlighted that this was particularly challenging in clinical situations where multiple fittings were completed to find the perfect pessary fit for the patient, as these appointments often run over the scheduled time to perform the fitting alone. No patients mentioned a time limit to the appointments, but patient 8 returned twice after some vaginal irritation with her initial fitting and expressed gratitude to the nurse who found a successful pessary:

“I had an excellent nurse…This particular nurse did not give up…Now we have a pessary that works.”

Last, social taboo emerged as a barrier to self-care. Both patients and providers expressed that there is a desire among some users for secrecy around pessary use. Some patients expressed embarrassment around the requirement for pessary use. Additionally, many interviewees highlighted the lack of knowledge around the prevalence of pelvic floor disorders and pessary use as drivers of feelings of isolation and shame around pessary use. The desire for discretion was highlighted as a driver of engagement in health care provider-led care.