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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.
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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.
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.