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Socioeconomic Status Does Not Predict Catheterization Adherence in Children Requiring CIC: Reassuring Evidence from a Universal-Access Healthcare System
Julie Wong, MD
1,
Samer Maher, BSc2, Abby Varghese, NP
1, Noreen Goraya, MSW
1, Armando Lorenzo, MD
1, Joana Dos Santos, MD
1, Michael Chua, MD
1, Mandy Rickard, NP
1
1Hospital for Sick Children, Toronto, ON, Canada, 2University of Toronto, Toronto, ON, Canada
BACKGROUND: Clean intermittent catheterization (CIC) is an essential part of managing patients with neurogenic bladder (NGB) and posterior urethral valves (PUV). Concerns remain that families with lower socioeconomic status (SES) may face greater barriers to adherence, particularly in insurance-based healthcare settings. In our single-payer, publicly funded system, we sought to determine whether SES influences CIC adherence among children followed in our urology clinic.
METHODS: We retrospectively reviewed patients prescribed CIC for PUV (2000-2025) or NGB (those undergoing intravesical Botox). Adherence was defined as performing ≥80% of prescribed catheterizations across all clinic visits (self-reported). SES was evaluated using postal-code-linked indices: the Ontario Marginalization Index (ON-Marg) and the Canadian Index of Multiple Deprivation (CIMD). Additional SES factors were abstracted from chart review. Associations among SES indicators, CIC adherence, and recurrent urinary tract infections (UTIs) were assessed using Fisher's exact, and t-tests as appropriate.
RESULTS: 209 children were prescribed CIC; 59 (28.2%) were non-adherent. 66 (31.6%) experienced recurrent UTIs. Residence in the highest-marginalization quintile of any ON-Marg or CIMD domain was
not associated with CIC non-adherence. Similarly, SES measures did
not predict recurrent UTIs, and CIC adherence was
not associated with differential UTI outcomes (Tables 1-2). However, single-parent household status was significantly associated with CIC non-adherence (Table 3).
CONCLUSIONS: In a universal-access healthcare system, socioeconomic marginalization was not associated with poor CIC adherence among children. These findings are reassuring and suggest that equitable access to supplies, multidisciplinary follow-up, and publicly funded care may mitigate SES-related disparities observed elsewhere. Future work should explore individualized, non-SES-related barriers to adherence to further optimize outcomes for this population.
Table 1: Patient Characteristics| Category | Subcategory | Number (percentage) |
| Disease | Neurogenic bladder | 116 (55.5%) |
| Posterior urethral valves | 93 (44.5%) |
| CIC adherence | Adherent | 150 (71.8%) |
| Non-adherent | 59 (28.2%) |
| Recurrent UTI | No | 137 (65.6%) |
| Yes | 66 (31.6%) |
| Single-parent household | No | 176 (84.2%) |
| Yes | 27 (12.9%) |
| Missing | 6 (2.9%) |
| Difficulty paying for basic needs | No | 37 (17.7%) |
| Yes | 30 (14.4%) |
| Missing | 142 (67.9%) |
| Primary care access | No | 8 (3.8%) |
| Yes | 199 (95.2%) |
| Missing | 2 (1.0%) |
Table 2: CIC adherence and recurrent UTI contingency table | No recurrent UTI, n (%) | Recurrent UTI, n (%) | Total | |
| Non-adherent | 36 (63.2%) | 21 (36.8%) | 57 | p-value = 0.4106 |
| Adherent | 101 (69.2%) | 45 (30.8%) | 146 | |
| Total | 137 | 66 | 203 | |
Table 3: CIC and socioeconomic variables| Variable | Total n used | Statistical test | p-value |
| English as primary language | 209 | Chi-square | 0.853 |
| Difficulty paying for basic needs | 67 | Chi-square | 0.433 |
| Household income (ordinal) | 64 | Fisher's exact | 0.976 |
| Parent education (ordinal) | 47 | Fisher's exact | 0.321 |
| Single-parent household | 203 | Chi-square | 0.016 |
| Primary care access | 207 | Fisher's exact | 0.228 |
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