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Keywords:

  • Spinal cord injury;
  • bladder;
  • education;
  • urinary tract infection

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. References

Purpose

To evaluate the effectiveness of educational programs in reducing urinary tract infections (UTIs) in individuals with spinal cord injuries (SCI).

Methods

A search of all relevant literature published up to and including July 2012 was conducted using multiple databases. Methodological quality was rated using the PEDro tool for randomized control trials (RCTs) and the Downs and Black tool for non-RCTs; levels of evidence were assigned using a modified Sackett scale.

Findings

Four articles were selected for review. As a result of an education program, a level 2 prospective control trial reported a reduction in number of UTIs (p = .02), but a level 2 RCT did not. A pre–post study found a reduction in number of UTIs while a case–control study did not; however, these studies did not compute statistics.

Conclusions

There is limited positive evidence that education programs reduce the incidence of UTIs.

Clinical relevance

Optimal urinary health of individuals with SCI may be optimized via education programs that provide information and enhance skills.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. References

Approximately 12,000 individuals suffer a spinal cord injury (SCI) in the United States annually; less than 1% make a complete neurological recovery (Cameron, Rodriguez, & Schomer, 2012). The vast majority of these individuals experience voiding dysfunction, including those with incomplete injuries. Voiding dysfunction can result in upper and lower urinary tract complications (Consortium for Spinal Cord Medicine, 2006). Hence, bladder management techniques are necessary in these individuals to assist with effective emptying. These bladder management programs usually include drainage devices. However, these devices leave individuals at an increased risk for urinary tract infections (UTI), which is the leading cause of septicemia associated with an increased mortality of up to 15% post SCI (Biering-Sorensen, Bagi, & Hoiby, 2001; Fonte, 2008).

In a person without a SCI, sterility of the bladder is maintained through a number of mechanisms. The urethra and the mucosal bladder cells act as physical barriers, while antibacterial enzymes and antibodies serve to protect the urinary system from infection (Menon & Tan, 1992). In individuals with SCI with urinary incontinence, chronic catheterization may result in an increased exposure to bacterial infection and increased spreading of the infection further up the ureters infecting the kidneys. Indwelling and intermittent catheters provide bacteria direct access to the uroepithelium, thereby increasing rates of infection (Menon & Tan, 1992). In addition, indwelling catheters lead to higher infection rates because a foreign body in the bladder can harbor bacteria (or calcification of the catheter bulb leading to bladder stones), thereby making antibiotics less effective. The use of indwelling catheters increases levels of bacteria by 5% to 8% per day (Doherty, 1999). There is a three times higher mortality rate among individuals with bacteriuria than those without (Leoni & Esclarin De Ruz, 2003).

Compared to males, females are at higher risk for bacteriuria as the urethra is anatomically close to the vagina and rectum. Pannek and Bertschy (2011) reported that women using indwelling catheters had a higher rate of UTIs than men. Furthermore, the rate of UTIs was significantly increased in those women with an SCI who were pregnant. This has important implications for prevention techniques in women given an increase in the number of women with SCI becoming pregnant (Ghidini & Simonson, 2011).

An optimal bladder management program for individuals with SCI should incorporate the use of new skills to ensure effective prevention strategies. These include hand hygiene, proper cleaning of urinary care supplies, proper voiding or a technique for emptying, and balanced diet and fluid intake (Eves & Rivera, 2010). Many individuals report a high incidence of UTIs due to a lack of adequate health education and medical follow-up following their discharge from acute care or rehabilitation (Hagglund, Clark, Schopp, Sherman, & Acuff, 2005). Another key factor may be lack of compliance with techniques taught to individuals by the healthcare team. Therefore, interventions that not only provide education but also behavior change for individuals living with SCI must be encouraged.

There is evidence that other education initiatives among individuals with SCI are effective at reducing complications post SCI. A recent systematic review examined the efficacy of educational interventions on preventing pressure ulcers among individuals with spinal cord injuries (Orenczuk, Mehta, McIntyre, Regan, & Teasell, 2011). This review found that there was strong evidence that patient education through an e-learning program reduced the incidence of pressure ulcers and improved quality of life among individuals with SCI more successfully than other types of education programs (Orenczuk et al., 2011). Similarly, improved education programs may potentially reduce the number of UTIs in individuals with SCI and in turn increase the quality of life of SCI patients. However, at this point, no study has examined the effectiveness of education programs in preventing UTIs post SCI. The purpose of this study was to evaluate the effectiveness of various educational programs in reducing the incidence of UTIs in individuals with SCI.

Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. References

Literature search strategy

A systematic review of all relevant literature was conducted using multiple databases (PubMed, CINAHL, ProQuest, and PsycINFO). Keywords included: spinal cord injury, urinary tract infection, bladder, education, knowledge, prevention and intervention. All retrieved references were scanned for relevant titles and abstracts by two independent reviewers (AM, KC); discrepancies between the two authors were resolved by a third reviewer (SM).

Study selection and appraisal

Studies were included for analysis if: (a) the subjects participated in an educational or knowledge-based intervention program for the prevention of UTIs; and (b) subjects had sustained a spinal cord injury. Review papers and studies not in English were excluded.

Using the same two reviewers that selected articles, a quality assessment for each article was completed independently using the Physiotherapy Evidence Database (PEDro; Moseley, Herbert, Sherrington, & Maher, 2002; Table 1) scoring system for randomized controlled trials (RCTs) and the Downs and Black tool for non-RCTs (Downs & Black, 1998; Table 2). Discrepancies in scoring were resolved via the third reviewer. The PEDro system includes 11 questions that are answered with a “yes” or “no,” in which “yes” answers receive one point and “no” answers receive zero points. Although the first item measures external validity, there is no point awarded for this question, regardless if it is scored “yes” or “no.” The remaining 10 items measure internal validity and therefore a maximum score of 10 is possible. Three classifications of excellent, good, fair, and poor RCTs have been arbitrarily defined by Foley, Bhogal, Teasell, Bureau, and Speechley (2006) as PEDro scores of 8–10, 6–7, 4–5, and <4, respectively. The Downs and Black tool consists of 27 questions examining external and internal validity, and reporting, with a maximum score of 28 (item 5 is worth two points); higher scores indicate greater methodological quality.

Table 1. The PEDro Scale
CriterionPoints AwardedConstruct
10Eligibility criteria were specified
21Subjects were randomly allocated to groups
31Allocation was concealed
41The groups were similar at baseline regarding the most important prognostic indicators
51There was blinding of all subjects
61There was blinding of all therapists who administered the therapy
71There was blinding of all assessors who measured at least one key outcome
81Adequacy of follow-up
91Intention-to-treat analysis
101The results of between-group statistical comparisons are reported for at least one key outcome
111The study provides both point measures and measures of variability for at least one key outcome
Table 2. The Downs and Black Scale
CriterionCategoryDescription
1ReportingHypothesis/aim/objective of the study clearly described
2Main outcomes to be measured in the introduction or methods section
3Characteristics of the patients included in the study
4Interventions of interest
5Distributions of principal confounders in each group of subjects to be compared
6Main findings of the study clearly described
7Study provides estimates of the random variability in the data for the main outcomes
8All important adverse events that may be a consequence of the intervention been reported
9Characteristics of patients lost to follow-up have been described
10Actual probability values been reported for the main outcomes
11External validitySubjects asked to participate are representative of the entire population from which they were recruited
12Subjects who could participate were representative of the entire population from which they were recruited
13Staff/places/facilities where the patients were treated was representative of treatment most patients would receive
14Internal validity (bias)Attempt was made to blind study subjects to the intervention they have received
15Attempt was made to blind those measuring the main outcomes of the intervention
16Any of the results of the study that were based on “data dredging” was made clear to the reader
17Analyses adjust for different lengths of follow-up of patients
18The statistical tests used to assess the main outcomes were appropriate
19Compliance with the intervention was reliable
20Main outcome measures used were accurate (valid and reliable)
21Internal validity (confounding, selection bias)Patients in different intervention groups were recruited from the same population
22Study subjects in different intervention groups were recruited over the same period of time
23Study subjects randomized to intervention groups
24Randomization was concealed from both patients/healthcare staff until recruitment was complete and irrevocable
25Adequate adjustment for confounding in the analyses from which the main findings were drawn was present
26Losses of patients to follow-up were taken into account
27Study had sufficient power to detect a clinically important effect (probability of differences due to chance <5%)

Data synthesis

Data extraction included research design, participant characteristics (e.g., age, level of injury, etc.), the treatment the subjects received, the intervention outcomes, and the study results. The extracted data were assessed for accuracy by two independent reviewers. Studies that included similar information were gathered and arranged in a summary table. A modified Sackett scale (Straus, Richardson, Glasziou, & Haynes, 2005) was used to determine the strength of evidence for each intervention. The modified version was created to simplify the 10 existing subcategories of the Sacket scale into a system with just five levels (Table 3). After evaluating the data, a meta-analysis was deemed inappropriate as a summary of the evidence due to the heterogeneity and inconsistency of the included studies.

Table 3. Modified Sackett Scale
LevelResearch DesignDescription
1Randomized controlled trialRandomized controlled trial, PEDro score ≥6. Includes within subjects comparison with randomized conditions and cross-over designs
2Randomized controlled trialRandomized controlled trial, PEDro score <6
Prospective controlled trialProspective controlled trial (not randomized)
CohortProspective longitudinal study using at least two similar groups (concurrent control) with one exposed to a particular condition
3Case–controlA retrospective study comparing conditions, including historical controls
4CohortProspective study using at least two similar groups (historical control) with one exposed to a particular condition
Pre–postA prospective trial with a baseline measure, intervention, and a posttest using a single group of subjects
PosttestA prospective posttest with two or more groups (intervention followed by posttest and no retest or baseline measurement) using a single group of subjects.
Case seriesA retrospective study usually collecting variables from a chart review
5ObservationalStudy using cross-sectional analysis to interpret relations.
Clinical consensusExpert opinion without explicit critical appraisal, or based on physiology, biomechanics, or “first principles”
Case reportPre–post or case series involving one subject

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. References

Study design, quality, and sample size

From a total of 254 articles culled, 18 articles remained after excluding articles based on titles and abstracts. Upon review of the full length of articles, a total of four studies met inclusion criteria for this systematic review (Anderson, Newman, Dryja, & Price, 1983; Barber, Woodard, Rogers, & Able, 1999; Cardenas, Hoffman, Kelly, & Mayo, 2004; Hagglund, et al., 2005; Table 4). The randomized control trial by Cardenas et al. (2004) and prospective control trial by Hagglund et al. (2005) qualified as level 2 evidence. A pre–post study by Barber et al. (1999) and a case–control study by Anderson et al. (1983) qualified as level 4 evidence. A pooled sample of 208 subjects was examined with sample sizes ranging from 17 to 75, with an average of 52 subjects. None of the participants was blinded to the interventions nor were the assessors blinded.

Table 4. Summary of reviewed articles
Study CharacteristicsCardenas et al., 2004;Hagglund et al., 2005;Barber et al., 1999;Anderson et al., 1983;
  1. ASIA, American Spinal Injury Association severity classification; D&B, Downs and Black score; FU, follow-up; sig., significant; NR, not reported; + +, significant (p < .05); − −, not significant (p > .05).

  2. a

    clinically meaningful, no statistical analysis conducted.

  3. b

    not clinically meaningful, no statistical analysis conducted.

Evidence2244
Study typeRandomized controlled trialProspective controlled trialPre–postCase–control
Quality scoresPEDro = 5D&B = 22D&B = 9D&B = 11
Sample size56601775
Participants characteristics

Treatment; control

N = 29; N = 27

Age: 40.7 ± 13.5 years (20–77); 41.5 ± 11.0 years (26–71)

Level of injury: C1–S5

Injury severity: ASIA A-D

Injury duration: 13.2 ± 11.8 years (0.5–48); 9.7 ± 7.2 years (0.5–31)

Treated; control

N = 37; N = 23

NR

Treated; control

N = 21 (1979); N = 54 (1975)

Treatment group protocolOne 2–2.5 hour education session, which included written material, a self-administered test, patient–physician discussions; one 15–20 minute telephone call to respond to any further questionsOne 6-hour training workshop led by a physician on secondary complications of spinal cord injury, included the viewing of an 8-minute videoOne or more 15–30 minute nurse-led teaching sessions on hygiene and catheter techniqueFive 45-minute teaching sessions including reading material, written examination, skill demonstration; one take-home instruction manual
Time from education to follow-up5–6 months6 months6–12 months6–8 months
Outcome

Episodes of UTI − −

sig. urinary colony counts + +

episodes of antibiotic treatment − −

UTI symptom reports − −

Episodes of UTI + +Episodes of UTIa

Confirmed UTIsb

suspected UTIsb

asymptomatic at FUb

Participant characteristics

Information on patient characteristics, research design characteristics, evidence, and methodological quality is reported in Table 4. Inclusion criteria for the Cardenas et al. (2004) were as follows: (a) SCI duration of ≥6 months; (b) history of recurrent UTIs; c) no plan to change urinary management during the study period; and d) ≥18 years. The authors included participants using any type of urinary management (i.e., intermittent catheterization, condom catheter, indwelling catheter, and spontaneous voiding). Hagglund et al. (2005) included individuals who (a) had a diagnosis of an SCI, (b) used a wheelchair as their primary mobility, and (c) used personal assistant services. The authors did not provide information on the types of urinary drainage their participants were using during the study period. Barber et al. (1999) included only participants using clean intermittent catheterizations and who had two or more UTIs in a 6-month period. Anderson et al. (1983) did not provide any information on inclusion criteria or the urinary management of their participants. Although Anderson et al. (1983) reported that their groups were similar in terms of bladder management method, age distribution, sex, and proportion of tetraplegics to paraplegics, they provided no statistical analysis to support this statement.

Study characteristics

Cardenas et al. (2004) randomized their participants into two groups. The treatment group received a 2.0–2.5 hour educational session conducted by nurses and physicians, consisting of written information, self-administered tests of bladder management, training in catheter techniques, and education on the symptoms of UTIs. A 15–20 minute follow-up call was conducted 1 week post intervention to discuss any further questions regarding any of the education material. The control group received no intervention. A UTI was defined as significant bacteriuria plus at least one sign (e.g., white blood cells) or symptom suggestive of a UTI. The number of episodes of symptomatic UTIs, significant urinary colony counts, number of antibiotic treatments, and the presence of UTI-related symptoms was assessed. Over a 5–6 month follow-up period, Cardenas et al. (2004) reported that, compared with the control group, the treatment group had significantly fewer urinary colony counts (p = .009). However, there was no significant difference between the groups for episodes of UTIs (no p value reported), episodes of antibiotic use (p = .232), or reports of UTI symptoms (p = .097).

Hagglund et al. (2005) recruited 37 participants for the treatment group and 23 participants for the control group. The treatment group participated in a 6-hour, in-person workshop addressing the prevention of UTIs. A physician specializing in SCI medicine provided a general education session on UTI prevention and management. The workshop also included an 8-minute video and a follow-up discussion with the physician. The control group received no intervention. Participants in both groups completed phone interviews at baseline and 6 months post study enrollment. The authors did not provide a definition for a diagnosis of a UTI. The treatment group had a statistically significant reduction in UTIs between baseline (68%) and follow-up (41%; p < .03); the control showed no changed between baseline and follow-up. At baseline, there was no significant difference in number of UTIs between the control and treatment group. However, at follow-up, the treatment group had significantly fewer UTIs compared with the control group (p < .02). Sociodemographic variables (e.g., marital status, ethnicity, hours of paid personal support services, age, education, and employment) were not related to incidence of UTIs.

Barber et al. (1999) conducted a study on patients who met criteria for a care pathway, a predetermined sequence of interventions initiated by the nursing staff. Each participant received an education session conducted by a clinic nurse on proper technique and hygiene of catheters. The education session lasted approximately 15–30 minutes. Following the first session, if a participant continued to exceed the UTI threshold (2+ UTIs in 6 months), they were required to receive multiple sessions until they reduced their incidence below the threshold. Barber et al. (1999) found that 17.6% (N = 3) of participants responded to a single UTI education intervention by reducing their UTIs below the threshold. Approximately, 47% (N = 8) were able to reduce their UTI incidence below threshold after multiple (>1) education sessions. Some individuals (35%; N = 6) were unable to reduce their UTIs below threshold and were recommended for prophylactic pharmacotherapy. Beyond stating simple frequencies, statistical analysis was not conducted.

Anderson et al. (1983) performed a study in which a group of individuals admitted to the hospital in 1979 (the treatment group) received five 45-minute classes taught by staff (clinician status unknown) on urinary tract care and anatomy during inpatient rehabilitation. In addition, a take-home instruction manual was provided. A survey was conducted 6 months post rehabilitation via a telephone interview. Results from the treatment group were compared with individuals in the control group, those who were admitted to the hospital in 1975 and had not previously received the education program. The authors found that 71% of the treatment group was asymptomatic at follow-up compared with just 32% of the control group. Throughout the study period, 10% of the treatment group had positive urine cultures, but were asymptomatic (suspected UTIs), whereas 15% of the control group had a suspected UTI. Despite these improvements, approximately half (52%) of the treatment group had a confirmed UTI (positive culture and symptomatic), as did the control group (48%) during the study period. Statistical analysis was not performed to compare the groups.

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. References

Maintenance of a healthy urinary system in individuals with SCI is a major concern for both subjects and clinicians. This review suggests that using an educational program may be beneficial in decreasing UTIs among those with SCI, although current evidence is conflicting and limited. In a study of level 2 evidence, Cardenas et al. (2004) found that, although their treatment group had fewer bacterial colony counts, there was no significant difference between groups in number of UTIs, symptom reports, or antibiotic treatment episodes. However, a nonrandomized study by Hagglund et al. (2005) provided level 2 evidence that their treatment group did experience a reduction in UTIs between baseline and 6 months. Barber et al. (1999), in a study of level 4 evidence, reported that participants did respond to education and reduced their number of UTIs. However, Anderson et al. (1983), also in a study of level 4 evidence, found no difference in confirmed UTIs between their two groups.

It is important to note that only the level 2 studies statistically analyzed their results. The level 4 studies only reported simple frequencies between their control and treatment groups. Without conducting statistical tests, it is unknown whether the trends were significant or not. Another important consideration is the year in which the education intervention was provided. All four of the included studies were old (published >5 years ago). In particular, the study by Anderson et al. (1983) reportedly administered the education intervention to participants in 1979. Information on the prevention of UTIs may have improved in the last few decades, which may help to explain why the authors reported negative results.

The type of education protocols employed in each of the four studies was variable. Although each intervention involved some form of education session, several variables differed across studies including: length of the session, educator status (i.e., nurse, physician, etc.), topics reviewed (i.e., hygiene, risk factors, etc.), and education medium (i.e., discussion, video, demonstration, etc.). Furthermore, some protocols involved following up with participants who had questions, whereas other protocols did not do this. The variability among interventions may explain the improvement, or lack thereof, reported by these studies. Furthermore, the protocol may not have been an effective learning strategy for all individuals as learning is an independent process that is unique to each person. At present, there is no evidence to suggest that one education approach is more effective in reducing UTIs compared with another.

Education interventions were used to teach and promote modifiable health behaviors to ultimately reduce UTI incidence. There are many injury-related and sociodemographic risk factors, which contribute to a greater incidence of UTIs including having a complete injury (Herruzo Cabrera, Leturia Arrazola, Vizcaino Alcaide, Fernandes Arjona, & Rey Calero, 1994), decreased sensation, catheterization (Shekelle, Morton, Clark, Pathak, & Vickrey, 1999), and perceived low health status (Noreau, Proulx, Gagnon, Drolet, & Laramee, 2000). Unfortunately, the level 4 studies included for review failed to provide an acceptable amount of demographic data on their participants, which open their results to interpretation. For example, Anderson et al. (1983) reported negative results; however, these differences may be explained by differences in the percentage of individuals with tetraplegia versus paraplegia. Tetraplegia is a known risk factor for developing UTIs (Galloway, 1997). Individuals who have lived longer with their SCI may have better health preventive behaviors and therefore fewer UTIs overall compared with those with a newly acquired SCI. Interestingly, Hagglund et al. (2005) did not find that the presence of UTIs was significantly related to the presence of a spouse or family member, marital status, leaving the home frequently, race, income, education, or functional status. The authors report that although these variables may influence one's ability to prevent, detect, and report a UTI, the education intervention overrides these variables (Hagglund et al., 2005).

Education programs may have other beneficial effects besides just reducing UTI rates. It has been previously reported that individuals vary in their beliefs about responsibility for control of events and situations. A study examining the Health Locus of Control and Beliefs among SCI patients reported that the psychological aspect of educational interventions is a factor in UTI incidence (Frank & Elliot, 1989). Frank and Elliot (1989) reported that people with SCI had a greater belief that UTIs were due solely to chance than those without an SCI. This may indicate that some individuals with SCI believe that they no longer have control over whether they develop UTIs or not. Interestingly, the authors also reported that those with SCI, who believed that they were primarily responsible for their health, displayed more adaptive behavior than those with externalized beliefs. Individuals with personal responsibility for their own health are more likely to participate in health prevention behaviors and to seek out healthcare services (Frank & Elliot, 1989). Although Cardenas et al. (2004) did not report a reduction in UTI incidence among the treatment group, they did report that these individuals increased their Multidimensional Health Locus of Control scale scores. Furthermore, Anderson et al. (1983) reported that only 6.7% of the treatment group lost time (≥1 days) from their usual daily activities due to a UTI compared with 21.6% of the control group. The authors suggested that knowledge uptake may have helped individuals in the treatment group identify early signs and symptoms of a UTI (e.g., fever, spasticity, etc.) and take definitive action, thereby preventing time lost in treating the condition. These studies likely reflect the beneficial effect of an education program on improving bladder health knowledge and individuals’ perception of control over their own preventive health behaviors, even though it did not translate into a reduction in the incidence of UTIs.

Nursing implications

It is important that education programs that provide information and enhance patient skills via nursing care be provided. The overall goal is to help patients make well-informed decisions and lifestyle modifications to restore and promote their health (Denehy, 2001), and improve patients’ overall satisfaction with their care. The many roles of nurses make them excellent individuals in inpatient rehabilitation to counsel patients at risk for UTI before discharge. It is accepted that patient education is an important role of nurses and forms an important element of patient care (Oermann, Harris, & Dammeyer, 2001). The Registered Nurses Association of Ontario (2002) Nursing Best Practice Guideline (2002) on Client Centered Care includes the importance of teaching techniques according to patients’ needs and situations. According to the Bladder Management for Adults with Spinal Cord Injury, a clinical practice guideline for healthcare providers, patients should be thoroughly and effectively educated on the effects that each bladder management method will have on the patients’ lifestyle (Consortium for Spinal Cord Medicine, 2006). Thus, as stipulated in these guidelines, SCI patient education on bladder management is a necessity.

Barber et al. (1999) showed that nearly half the participants had a better learning outcome after multiple education sessions, suggesting that repetition may play an important role in learning. As a function of redundancy, methods of repetition should be considered in patient education, especially when the patient population consists of patients in a neurorehabilitation unit for SCI. Denehy (2001) reported that one-on-one teaching is an effective way to customize patient learning and has advantages in ensuring patient comprehension. In general, this method may cost more than large group education sessions; however, over the long-term, it would be more cost-effective to address prevention than treatment (Denehy, 2001). Denehy (2001) reported the importance of modeling patient education with consideration of the three domains of learning: cognitive, affective, and psychomotor. Being cognizant of these domains when delivering health teaching may help to increase patient participation in health maintenance at home.

Key Practice Points
  • Individuals with a spinal cord injury have the potential to develop a neurogenic bladder which may result in voiding dysfunction.
  • Complications of urinary dysfunction, including urinary tract infections, may have a significant effect on an individual both physically and psychologically.
  • Interventions to prevent urinary tract infections are important and should be implemented.
  • There is limited positive evidence that education programs reduce the incidence of urinary tract infections among individuals with spinal cord injury.

Limitations and future directions

There were several methodological weaknesses in the four studies included for review. Three studies (Anderson et al., 1983; Barber et al., 1999; Cardenas et al., 2004) did not indicate whether individuals who participated in the study were representative of the entire population from which they were recruited. Furthermore, the sample sizes of each study were relatively low (range 17–75 participants) and only one study (Cardenas et al., 2004) provided complete demographic information on their participants. Thus, for the prospective controlled trial (Hagglund et al., 2005), it was unknown whether the treatment and control groups were comparable from the outset. In the single RCT, Cardenas et al. (2004) did not indicate how the randomization process was conducted and therefore it could not be determined whether the assignment of participants was complete and irrevocable. Regarding specific education interventions, variability in protocol, intensity, and duration likely affected the outcomes reported. It is possible that participation in these studies may have influenced participants’ behavior as they were aware that their actions were being monitored over time. Only two studies (Barber et al., 1999; Cardenas et al., 2004) provided specific definitions for a diagnosis of a UTI. Therefore, a complete description and assessment of the condition may have varied among the health professionals. Other factors may have biased the results reported; for example, in the Hagglund et al. (2005) study, researchers relied on individuals’ memory of UTIs for reporting number of episodes. As indicated previously, two studies (Anderson et al., 1983; Barber et al., 1999) did not conduct appropriate statistical analysis to interpret their data, which made it difficult to form conclusive statements, especially when comparing individuals who received an education program with those who did not. One of the most important weaknesses in all of the studies was the lack of control for types of bladder management techniques, given that some devices pose significant risk in the development of urinary infections. Finally, two studies (Anderson et al., 1983; Hagglund et al., 2005) did not describe individuals lost to follow-up.

Future research should address the aforementioned methodological concerns. Level 1 RCTs with large sample sizes that include and describe a wide demographic of participants are needed. Interventions protocols should be standardized and all statistical analyses and outcomes should be conducted and reported. Thus, in general, researchers should focus on more rigorous research designs that include blinding to prevent bias.

Conclusion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. References

This study assessed the effectiveness of educational interventions in preventing UTIs in individuals with SCI. One level 2 and one level 4 study showed evidence that education interventions reduced UTIs, whereas another level 4 study showed that significant colony counts declined. Although there has been no level 1 study published on this topic, this review found limited positive evidence that education interventions can reduce UTIs in an SCI population. Nurses have an important role in health teaching in the inpatient neurorehabilitation setting. As there is no downside to this simple, inexpensive intervention, the data are still supportive of nurses providing education on urinary care and management with their patients. Future research in this area should focus on improving study design and research methods to allow for greater understanding and generalization.

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References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. References
  • Anderson, T.P., Newman, E., Dryja, R., & Price, M. (1983). Urinary tract care: improvement though patient education. Archives of Physical Medicine and Rehabilitation, 64(7), 314316.
  • Barber, D.B., Woodard, F.L., Rogers, S.J., & Able, A.C. (1999). The efficacy of nursing education as an intervention in the treatment of recurrent urinary tract infections in individuals with spinal cord injury. SCI Nursing, 16(2), 5456.
  • Biering-Sorensen, F., Bagi, P., & Hoiby, N. (2001). Urinary tract infections in patients with spinal cord lesions: treatment and prevention. Drugs, 61(9), 12751287.
  • Cameron, A.P., Rodriguez, G.M., & Schomer, K.G. (2012). Systematic review of urological follow-up after spinal cord injury. Journal of Urology, 187(2), 391397.
  • Cardenas, D.D., Hoffman, J.M., Kelly, E., & Mayo, M.E. (2004). Impact of a urinary tract infection educational program in persons with a spinal cord injury. Journal of Spinal Cord Medicine, 27(1), 4754.
  • Consortium for Spinal Cord Medicine. (2006). Bladder management for adults with spinal cord injury; A clinical practice guideline for health-care providers. Journal of Spinal Cord Medicine, 29(5), 527573.
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