Clean intermittent catheterization (CIC) is a method accepted as golden standard in individuals with bladder dysfunction and in the treatment of urinary retention [1]. CIC is considered as a safe and efficient method, which supports the maintenance of bladder functions by providing urinary excretion in individuals with neurogenic bladder, improves the body image and self-confidence of the patient, and increases his/her life quality [2]. However, inappropriate catheterization may lead to the occurrence of CIC-related complications such as pain, urethral trauma, hematuria, and lower urinary tract infection [3]. CIC application training is crucial in bringing in the patient him/herself or his/her caregiver the knowledge and skills related to the application in the right way [4].

Various methods of education are used in CIC education, including verbal education, written material/brochures, simulation, and multimedia-based education [2]. It is seen that education methods applied by utilizing technology are becoming more and more widespread. Video-assisted education, which is among these methods, and which provides ease of learning to individuals with the visual and audio materials it contains, has been frequently preferred in clinical learning environment and patient education in recent years [5]. With the development of technology, the Internet has become an important source of health information. The ease of finding information on the Internet means responding to health/disease-related questions and concerns [6]. Especially programs that present knowledge and skills audio-visually are broadcast on different websites, mainly YouTube [7]. YouTube users composed 95% of all Internet users [8]. YouTube, which is one of the most visited websites with a total of more than a billion visitors per month, includes users’ shares as well as reliable training videos [9]. YouTube has great potential to provide easy access to health-related information, but it is unknown how accurate and useful the information received [6].

Although studies report that YouTube videos are educational tools and sources of information for patients, the lack of studies examining whether patient training videos contain safe and accurate information/application skills is noteworthy, and these studies are confined to methotrexate injection, cervical cancer, rheumatoid arthritis, breast self-examination, and mammography training videos [7,10]. When national and international literature was examined, only one study was found regarding the evaluation of CIC videos published on websites as a reliable source of information [11]. Accordingly, in this study, it was aimed to examine the content, reliability, and quality of Internet videos related to CIC application training. It is thought that the results of the study will guide the creation of training videos for CIC application and will contribute to the increase of videos that will support sick individuals’ acquisition of the correct skills regarding the application.

This study was carried out in a descriptive type to evaluate the content, reliability, and quality of the YouTube videos related to the CIC application.

All the videos broadcast on YouTube (http://www.youtube.com) until August 31, 2019, were watched as a result of the search with the words “clean intermittent catheterization” and “intermittent self catheterization” in English. A total of 140 videos added to the playlist automatically were reviewed according to inclusion criteria. Inclusion criteria: (1) videos broadcast in English, (2) videos demonstrating the ease of application, (3) the last updated version was determined for repeated videos. Seventy-six videos were excluded (50 videos that did not show the CIC application and were only informative, 8 videos, which were not in English, 18 repeated videos). The study was completed with the analysis of a total of 64 English videos (Fig. 1). The evaluation of videos in terms of reliability, quality, and scope of videos was performed by 2 independent persons. One of the observers evaluating the videos is a urology specialist who is interested in functional urology, especially neurogenic bladder patients and the other is a nurse who is particularly interested in CIC training.

When the content of the 64 videos included in the study was examined by 2 independent individuals, it was seen that 41 of the videos (64.06%) were useful and 23 (35.94%) were misleading. The Kappa value among the observers was 0.96. The total duration of useful videos on YouTube was determined as 37.49±24.67 months, the total length as 325.59±271.87 seconds, the number of views as 31,867.93±90,926.32, the number of likes as 44.61±102.51, the number of dislikes as 9.10±24.54, and the number of comments as 3.05±8.71. Forty-one point forty-six percent (41.46%) of the useful videos showed application skill in female patients, 41.46% in male patients, 2.43% in both sexes, and 14.63% in children. When misleading videos were analyzed, it was seen that the total duration of finding videos on YouTube was 33.78 ±27.88 months, the total length 306.39 ±246.25 seconds, the number of views 11,371.83 ± 18,512.02, the number of likes 20.83±26.94, the number of dislikes 3.04±4.43, and the number of comments 4.26±7.54 (Table 2). Thirty-four point seventy-eight percent (34.78%) of misleading videos showed CIC skill regarding female patients, 56.52% regarding male patients, and 8.7% regarding both sexes (Table 2).

When videos are analyzed, the mean score of useful videos was found to be 6.43±1.36, DISCERN mean score 4.12±0.97, and the mean GQS 4.09±1.01. On the other hand, the comprehensiveness mean score of the misleading videos was 2.87±0.92, DISCERN mean score 1.85±0.65, and the mean GQS 1.78± 0.62 (Table 3). There was no statistically significant difference between useful videos and misleading videos in terms of video length, number of views, likes, dislikes, and the number of comments. On the other hand, the mean comprehensiveness scores, mean DISCERN scores, and mean GQS of useful videos were found to be higher than misleading videos, with a statistically significant difference (P<0.001) (Table 3). The features of the 10 most useful videos according to their quality and suitability are indicated in the Supplementary Table 1.

When the videos were analyzed according to publication sources, 78.05% of the videos (32 of 41) were found to be published by medical advertisement/for-profit companies (Table 3). It was seen that 43.48% of misleading videos consisted of videos with individual sources and that no useful videos were included in the videos with individual sources (Table 4). The mean scores of videos originating from medical advertisement/for-profit companies, their mean DISCERN scores, and mean GQS were found to be statistically significantly higher than other broadcast-originated videos (P<0.001) (Table 4). The average number of views and average video duration of the videos originating from universities/professional organizations/non-profit physician/physician groups were found to be significantly higher than the videos from other sources (P=0.017 for the number of views, P=0.003 for video duration).

Main objective is to provide low intravesical pressure and maintain upper urinary system function in the treatment of neurogenic bladder. In line with these goals, quality of life is improved [16]. In patients with neurogenic bladder, CIC is performed with an interval of 4-6 hours in order to protect the bladder and upper urinary system. Despite the ease of application, intermittent catheterization training is considered a problem by patients, families, and healthcare professionals [17,18]. Poor or inadequate “catheterization” technique can cause complications such as urinary tract infection and trauma, pain and discomfort, urethral stenosis, and false urethral canal [19]. Therefore, learning in a virtual environment allows flexibility and expansion of information and information access, cooperates with the formation of groups of common interests, overcomes physical evidence, or difficulty in accessing scientific evidence [20,21].

There is a range of information on health-related issues (professional opinions, literature information, innovations in the field of health, individual health experiences, comments of nonspecialists, etc.) on the Internet. This information is increasingly used by patients and healthcare professionals as an educational resource [22]. Founded in September 2005, YouTube is an open access, video-sharing website, which also includes information and educational videos aimed at individuals. Since being auditory and visual are important factors in accessing information and due to the ease of accessing information, YouTube’s popularity among patients has been gradually increasing [7,23]. However, that everyone can easily upload videos renders the inspection of the reliability and the accuracy, which leads to the presentation of missing or incorrect information [7]. The existence of unreliable information, especially in training videos aimed at bringing in skills can mislead patients and lead to undesired consequences due to misapplication. Inappropriate application of CIC may lead to complications such as urethral trauma, hematuria, and urinary tract infections, which may adversely affect the individual’s quality of life [2,3].

Within the scope of this study, only 6 showed the skills regarding CIC application for children (Table 2). During the lifespan of the individual, childhood is evaluated together with physiological and requires a psychological development and a CIC education that will meet their cognitive development. This finding suggests that the number of CIC training videos for children is insufficient and that effective, accurate, and comprehensive videos that can be utilized by children should be made available by health professionals.

As seen in Table 2, the majority of the total videos consisted of useful videos (64.06%) (Table 2). When the analysis results of the videos were examined, it was determined that useful videos contained comprehensive, reliable, and useful information, whereas misleading videos contained insufficient, unreliable, and low-quality information (Table 3). However, the total number of views, likes, and dislikes of useful videos were found to be higher than that of misleading videos (Table 2). This finding was found to be similar to the findings of studies examining rheumatoid arthritis, subcutaneous antitumor agent administration, and self-breast examination training videos on YouTube [7,8,14]. At the same time, this finding showed that the patients who performed CIC preferred the more comprehensive and reliable training videos.

Whereas only 5 of the useful videos (12.19%) were broadcast based on universities/professional organizations/nonprofit physician/physician groups, 32 of them (78.05%) were broadcast based on medical advertisement/for-profit companies. While this finding, which revealed that very few of the useful videos were broadcast by universities/professional organizations/nonprofit physician/physician groups, showed similarity with the results of the study in which Faleiros et al. [11] examined the CIC skill training videos in Portuguese language, it differed from the results of the study where self-breast examination and subcutaneous antitumor agent application training videos were examined [7,8]. Regarding comprehensiveness point averages, DISCERN point averages and GQS point averages, videos originating from medical advertisement/for-profit companies were found to contain safe and accurate information for CIC skill training and were of high quality (Table 4). However, it was observed that the vast majority of these videos originating from the medical advertisement/for-profit companies were published by the catheter companies, and in the vast majority of these videos, their application skills were presented together with the features that emphasized firms’ use of their own catheters. This situation suggested that it may cause anxiety in individuals using different types of catheters.

While 4 of the misleading videos (17.39%), which constitute 35.9% of the total videos were originated from universities/professional organizations/nonprofit physician/physician groups, it was found that the broadcast source of 9 of them (39.13%) was medical advertisement/for-profit companies and 10 of them (43.48%) individual. In terms of mean DISCERN score, mean GQS, and mean comprehension score, these videos were found to comprise unreliable, insufficient, or inaccurate information for CIC training and to be of poor quality. This finding was similar to the results of the study examining videos about subcutaneous antitumor agent administration and health information and self-methotrexate injection training for patients with type 2 diabetes [8,10,24]. This finding also reveals the need for the preparation of training videos regarding CIC led by state institutions/organizations and the presentation of information that will meet the needs of patients on the web.

It is a limitation of the study that the demographic characteristics of the video viewers are not known.

In this study, it was seen that the vast majority of YouTube videos aimed at CIC training consist of useful videos and published by medical advertisement/for-profit companies. When assessed against internationally recognized standards, the majority of high-quality videos are published by commercial organization, promoting the use of their product. There is a dearth of information for children. Videos produced by individuals tend to be of lower quality and are more likely to contain misleading information. In line with these results, it may be suggested that studies to increase the number of accurate, reliable, and useful videos that will bring in CIC-specific knowledge and skills are performed by healthcare professionals led by governmental institutions, universities, and professional organizations.