Spinal cord injury (SCI) is damage to the neural connections, resulting in motor and sensory problems, and causing difficulties in performing everyday tasks.1 It changes the life of an individual, creating challenges in functional, emotional and socioeconomic areas, along with various complications,2 of which pressure injuries (PIs) are one of the most common.3 The global incidence of SCI is 8–246 per million, whereas the prevalence is 236–1298 per million people each year, and is observed to be increasing gradually.4 Moreover, people with SCI are more susceptible to secondary complications5 due to immobility and disturbed sensation.6 Approximately 30–85% of people with SCI develop PIs in the acute phase of injury, 85% experience them at some point in their lives,7 and 95.1% of PIs are preventable.8 Furthermore, PIs impose a huge medical and economic burden on the patient,9,10 and a study in northern Ethiopia reported that treatment is about 2.5-times more expensive than prevention.11 In addition, PIs are among the most common secondary health problems in low- and middle-income countries (LMICs),12 and people with SCI are at greater risk of developing PIs.13 Despite the fact that PIs are generally preventable, prevention sometimes necessitates an individual's diligent caretaking.14 Moreover, people with SCI need to be protected against secondary problems in order to continue to participate in society and in daily life. Individuals with SCI often perceive that they can avoid PIs through proper maintenance of their living environment.15 However, the identification of protective factors and factors which make them susceptible might minimise the incidence of PIs. It has been observed that the occurrence of PIs in individuals with SCI ranges from 33–40% during inpatient rehabilitation and from 31–79% among those residing in the community.16 Correspondingly, the majority of studies have reported on risk factors for PIs in hospital or rehabilitation settings.13,17,18
The lifestyle factors responsible for PIs in the community in LMICs have rarely been investigated. Similarly, it has been found that the chance of having PIs in individuals with SCI is higher in society than in hospital settings, and community-based PI-prevention measures are strongly recommended.19 In contrast, institutional-based rehabilitation services have presented promising functional outcomes for individuals with SCI, but the challenges lie in their reintegration back into the community.20 As a result, determining which parts of everyday life have the most impact on the likelihood of developing PIs would aid in formulating preventive efforts.
In Bangladesh, 28% of people with SCI admitted for rehabilitation treatment experienced PIs during the acute phase,21 but the rate of PIs in the community has been unknown. Therefore, the present research should assist healthcare providers in developing understanding of the prevalence and risk of developing PIs in individuals with SCI in the community by identifying the underlying causes. A study conducted two years after patients were discharged from the Centre for the Rehabilitation of the Paralysed (CRP), Bangladesh, revealed that one out of every five people with SCI who relied on a wheelchair died due to PIs.22
There remains a research gap and the research question focuses on which lifestyle factors in people with SCI in Bangladesh may serve as protective and which are predisposing factors for the development of PIs. The lifestyle risk factors in the context of developed countries have been studied,14,15,23 but these could vary when compared to LMICs such as Bangladesh. Therefore, our understanding remains incomplete, and the present study could provide a wider understanding of the factors responsible for developing PIs. Moreover, lifestyle might have a substantial impact on the prevention or occurrence of PIs in individuals with SCI, while the causative factors that affect their everyday lives could be modified or adjusted.15 Preventive measures could be developed and people with SCI with PIs could be educated at the time of hospital discharge to reduce the rate of recurrence.
The objective of this study was to identify the protective and predisposing lifestyle factors that influence and prevent the development of PIs in people with SCI residing in the community. Identifying lifestyle factors may help in developing PI prevention programmes for people with SCI in the community.
Methods
Statement of ethics
The Institutional Review Board (IRB) of the Bangladesh Health Professions Institute (BHPI) approved this study (reference number CRP-BHPI/IRB/09/18/1226). The study involved human volunteers, and all the required ethical regulations were followed during the course of this research.
Procedures
A quantitative cross-sectional survey was conducted among the people with SCI discharged from the CRP, Bangladesh. The CRP is one of the biggest SCI units in the world, treating an average of >400 people from all over Bangladesh each year.24 The study participants were those people with SCI residing in the community in Dhaka district, at least one-year post-discharge from the CRP. The records of people with SCI who were discharged from the CRP were reviewed, and they were contacted by telephone and their consent requested to participate in this study.
A total of 80 people with SCI were recruited into the study using a convenience sampling method—divided into two groups with 40 participants in each. The first group comprised participants with PIs at the time of study or who had developed PIs in the last year, whereas the other group was without PIs and had not developed PIs for at least one year during their stay in the community.
The data were collected through face-to-face interviews with both groups in their own community. People with paraplegia were discharged from the CRP after approximately 3–4 months. All the people with SCI with paraplegia having any duration of injury were interviewed and were categorised as: >1–10 years; 11–20 years; 21–30 years; and >30 years with regard to post-SCI duration.
The inclusion criteria were as follows:
- Patients of both sexes with SCI
- Age >18 years
- With paraplegia
- Residing in the community
- With or without PIs for the last year
- Post-discharge after rehabilitation (one year) or chronic rehospitalised cases for management of PIs.
Exclusion criteria were:
- Patients with mental disorders
- Patients with mechanical ventilation dependency
- Patients requiring assistance for wheelchair propulsion and transfers.
The outcome measures used included two sections: sociodemographic and the Spinal Cord Injury Lifestyle Scale (SCILS). The standard questionnaire was adapted, and the questionnaire was prepared in an English–Bengali version to ensure the quality of the data. Prior to data collection, the questionnaire was checked for clarity, comprehensiveness and content validity by the two researchers and clinical physical therapists with >10 years' experience in SCI rehabilitation. The SCILS questionnaire, used to measure the predisposing and the protective lifestyle factors that influence and prevent the development of PIs in individuals with SCI, served as the study's dependent variable. In addition, the independent variables included sociodemographic and injury-related information. The pilot-testing was conducted on 10 participants to determine its reliability, and after noticing challenges in understanding some of the technical terms, some sentences were simplified based on the perspective of Bangladesh (e.g., ‘contracture’ was simplified to ‘muscles get tight and joint mobility restricted’; ‘intermittent catheterisation’ to ‘urine bag’; ‘incontinence’ to ‘leakage of urine’ etc.). The sociodemographic questionnaire consisted of seven items to assess the respondent's age, sex, educational status, marital status, level of injury, duration of injury and living area. Similarly, the SCILS measured the frequency of health-related behaviour performance in individuals with SCI. It has five subscales that include:
- Cardiovascular
- Genitourinary
- Neuromusculoskeletal
- Skin
- Psychosocial.
The frequency with which each behaviour has been performed over the past three months is rated using an ordinal scale where: 4=’almost always’; 3=‘frequently’; 2=‘sometimes’; 1=‘rarely’; and 0=‘never’. The genitourinary subscale item was reverse scored. According to the validation of this outcome measure, higher scores on the SCILS indicate higher performance of behaviours that promote health in persons with SCI. However, for the genitourinary section, the scores indicate the opposite and therefore they have been reversed for this section. This follows the method described by Pruitt et al.25
The reliability of the standard SCILS questionnaire was determined as Cronbach's alpha=0.81 and for the subscales:
- Cardiovascular=0.73
- Genitourinary=0.32
- Neuromusculoskeletal=0.75
- Skin=0.86
- Psychosocial=0.32.25
Data processing and analysis
The outcome scores were entered into Excel (Microsoft Corp., US) and analysed statistically using SPSS Version 20.0 (IBM Corp., US). For the SCILS questionnaire, a score was generated for each subscale by summing the values for each item within the subscale. The overall score ranged from 0–100 and was determined by adding the five subscale values together. The SCILS is a five-point Likert scale where 4=‘almost always’, 3=‘frequently’ and 2=‘sometimes’ were combined, computed, and displayed as ‘Yes’, while the scores for 1=‘rarely’ and 0=‘never’ were combined and shown as ‘No’. Based on this observation, the statistical analysis was conducted.
The demographic section was presented as a frequency distribution. Similarly, the odds ratio (OR) was used to evaluate the associated difference of SCILS variables with both groups having PIs or with no PIs to identify them as predisposing factors or protective factors. The OR was calculated independently for each variable among individuals with PIs and without PIs. Again, a t-test was calculated to test the significance. A 95% confidence interval (CI) with a p-value of ≤0.05 was set as the level of statistical significance.
Results
The overall mean age (Table 1) of the participants was 32.63 years (standard deviation (SD)=12.20), whereas the mean age of those with PIs was 36.68 years (SD=13.33) and without PIs was 28.58 years (SD=9.5). The largest proportion of respondents (41.3%) were between the ages of 18–27 years, while the smallest age group (10.1%) was between the ages of 38–47 years. Moreover, the majority of the participants were male (65.0%), and more than half (55.0%) were married, while 37.6% were unmarried. The respondents' educational status revealed that those with less than a Secondary School Certificate (SSC) level of education made up the majority (57.7%), while 21.3% had no formal education. The greatest number of participants (42.6%) had T10–T12 level injuries, with those with >1–10 years of injury accounting for the highest percentage (68.8%), and coming mostly from rural areas (68.8%).
Table 1.
Sociodemographic characteristics of the participants and associated differences with both groups (n=80, with pressure injuries (PIs)=40, without PIs=40)
| Variables | With PIs n (%) | Without PIs n (%) | Chi-squared | p-value |
|---|---|---|---|---|
| Age, years | 8.200 | 0.240 | ||
| 18–27 | 13 (16.3) | 20 (25.0) | ||
| 28–37 | 10 (12.5) | 15 (18.8) | ||
| 38–47 | 5 (6.3) | 3 (3.8) | ||
| ≥48 | 12 (15.0) | 2 (2.5) | ||
| Sex | 5.495 | 0.019 | ||
| Female | 9 (11.25) | 19 (23.75) | ||
| Male | 31 (38.75) | 21 (26.25) | ||
| Marital status | 0.240 | 0.624 | ||
| Unmarried | 13 (16.3) | 17 (21.3) | ||
| Married | 23 (28.7) | 21 (26.3) | ||
| Separated | 3 (3.8) | 2 (2.5) | ||
| Widowed | 1 (1.3) | 0 (0.0) | ||
| Educational status | 0.198 | 0.906 | ||
| No formal education | 9 (11.3) | 8 (10.0) | ||
| Below and SSC | 24 (30.1) | 22 (27.6) | ||
| HSC | 2 (2.5) | 6 (7.5) | ||
| Bachelor and above | 5 (6.3) | 4 (5.0) | ||
| Level of injury | 1.826 | 0.198 | ||
| T2–T5 | 5 (6.3) | 3 (3.8) | ||
| T6–T9 | 12 (15.0) | 11 (13.8) | ||
| T10–T12 | 17 (21.3) | 17 (21.3) | ||
| L1–L4 | 6 (7.5) | 9 (11.3) | ||
| Duration of injury, years | 1.184 | 0.367 | ||
| >1–10 | 26 (32.5) | 29 (36.3) | ||
| 11–20 | 12 (15.0) | 7 (8.8) | ||
| ≥21 | 2 (2.5) | 4 (5.0) | ||
| Living area | 0.818 | 0.826 | ||
| Urban | 14 (17.5) | 11 (13.8) | ||
| Rural | 26 (32.5) | 29 (36.3) |
HSC—Higher Secondary Certificate; SSC—Secondary School Certificate
The sex of the participants was found to be significant (p=0.01), although none of the other sociodemographic variables were significant. This indicates that sex may be one of the factors that influence the risk of developing PIs in people with SCI.
Table 2 shows that among 80 participants, 73.5% of those with PIs were smokers, while 67.4% of those without PIs avoided smoking. Only smoking showed a statistically significant relationship (p<0.01), whereas other cardiovascular risk factors showed non-significant relationships. This indicates that those who did not avoid smoking had a greater chance of developing PIs (OR: 0.174; 95% CI: 0.065–0.464). In addition, the OR is <1 and is therefore a protective factor (1–0.17=0.83 times more protective). This means that those who avoided smoking were 0.83 times more protected against PIs.
Table 2.
Associated differences of cardiovascular, neuromusculoskeletal, skin, psychosocial and genitourinary factors with both groups (with pressure injuries (PIs) and without PIs)
| Variables | With PIs (%) | Without PIs (%) | Chi-squared | p-value | Odds ratio | 95% CI | |
|---|---|---|---|---|---|---|---|
| L/L | U/L | ||||||
| Cardiovascular factors | |||||||
| *I avoid smoking cigarettes | 13.095 | 0.000 | 0.174 | 0.065 | 0.464 | ||
| Yes | 26.5 | 67.4 | |||||
| No | 73.5 | 32.6 | |||||
| *I limit the amount of fat and cholesterol in my diet (for example, I limit red meats, dairy products) | 1.289 | 0.256 | 0.595 | 0.242 | 1.462 | ||
| Yes | 44.7 | 57.6 | |||||
| No | 55.3 | 42.4 | |||||
| *I am aware of and try to reduce my risk for heart disease | 3.647 | 0.056 | 0.393 | 0.149 | 1.038 | ||
| Yes | 34.6 | 57.4 | |||||
| No | 65.4 | 42.6 | |||||
| *I monitor my blood pressure on a regular basis | 3.516 | 0.61 | 0.407 | 0.158 | 1.052 | ||
| Yes | 42.3 | 64.3 | |||||
| No | 57.7 | 35.7 | |||||
| Neuromusculoskeletal factors | |||||||
| *I do range-of-motion exercises daily to keep my joints flexible | 21.333 | 0.000 | 0.086 | 0.028 | 0.267 | ||
| Yes | 16.7 | 70 | |||||
| No | 83.3 | 30 | |||||
| *I do exercises that enhance my muscle strength (for example, weight training) at least 3 times a week | 21.978 | 0.000 | 0.074 | 0.22 | 0.249 | ||
| Yes | 14.3 | 69.2 | |||||
| No | 85.7 | 30.8 | |||||
| *My muscle strengthening exercises are monitored by a therapist at least once a year | 26.467 | 0.000 | 0.073 | 0.025 | 0.212 | ||
| Yes | 20.5 | 78 | |||||
| No | 79.5 | 22 | |||||
| *I allow my shoulder joints to rest when I am having pain from overusing them | 1.317 | 0.251 | 0.588 | 0.237 | 1.460 | ||
| Yes | 41.9 | 55.1 | |||||
| No | 58.1 | 44.9 | |||||
| *I do activities which put weight on the bones in my legs to help increase bone density about 3 times a week (for example, use standing frame) | 28.614 | 0.000 | 0.044 | 0.03 | 0.27 | ||
| Yes | 10.3 | 72.5 | |||||
| No | 89.7 | 27.5 | |||||
| *I pay attention to the position my body is in when I am in my wheelchair | 21.587 | 0.000 | 0.635 | 0.264 | 0.506 | ||
| Yes | 0.0 | 63.5 | |||||
| No | 100.0 | 36.5 | |||||
| *I pay attention to the position my body is in when I am sleeping | 11.250 | 0.001 | 0.098 | 0.020 | 0.447 | ||
| Yes | 12.5 | 59.4 | |||||
| No | 87.5 | 40.6 | |||||
| *If I noticed beginning of a contracture (a joint that is `freezing up’), I would know exactly what to do | 14.907 | 0.000 | 0.150 | 0.055 | 0.410 | ||
| Yes | 24.2 | 68.1 | |||||
| No | 75.8 | 31.9 | |||||
| Skin factors | |||||||
| *I check my skin to look for any areas of redness or breakdown | 21.587 | 0.000 | 0.365 | 0.264 | 0.506 | ||
| Yes | 100 | 63.5 | |||||
| No | 0.0 | 36.5 | |||||
| *I do some type of pressure relief every 30 minutes any time I am in my chair or driving | 19.286 | 0.000 | 0.073 | 0.019 | 0.277 | ||
| Yes | 12.5 | 66.1 | |||||
| No | 87.5 | 33.9 | |||||
| *I am careful not to bump my legs, feet, or buttocks when doing transfers | 16.807 | 0.000 | 0.038 | 0.05 | 0.309 | ||
| Yes | 5.9 | 61.9 | |||||
| No | 94.1 | 38.1 | |||||
| *I wear something on my feet when I am out of bed (for example, shoes or foam boots) | 14.528 | 0.000 | 0.099 | 0.026 | 0.375 | ||
| Yes | 14.3 | 62.7 | |||||
| No | 85.7 | 37.3 | |||||
| *I am careful when handling hot liquids by not carrying them in my lap | 2.489 | 0.115 | 0.487 | 0.198 | 1.196 | ||
| Yes | 35.0 | 52.5 | |||||
| No | 65.0 | 47.5 | |||||
| *I am aware of the condition of my wheelchair cushion | 11.114 | 0.01 | 0.060 | 0.007 | 0.487 | ||
| Yes | 7.7 | 58.2 | |||||
| No | 92.3 | 41.8 | |||||
| *I am aware of the condition and repair needs of my wheelchair | 1.978 | 0.160 | 0.513 | 0.201 | 1.308 | ||
| Yes | 39.3 | 55.8 | |||||
| No | 60.7 | 44.2 | |||||
| Psychosocial factors | |||||||
| *I am able to get around in my house (my house is wheelchair accessible) | 18.462 | 0.000 | 0.091 | 0.027 | 0.304 | ||
| Yes | 15.4 | 66.7 | |||||
| No | 84.6 | 33.3 | |||||
| *I am with or talk to other people at least once a day | 0.827 | 0.363 | 1.750 | 0.519 | 5.903 | ||
| Yes | 61.5 | 47.8 | |||||
| No | 38.5 | 52.2 | |||||
| Genitourinary factors | |||||||
| *I use an intermittent catheterisation program and stick to the recommended schedule | 4.267 | 0.039 | 0.328 | 0.111 | 0.969 | ||
| Yes | 30 | 56.7 | |||||
| No | 70 | 43.3 | |||||
| *I change my catheters as often as I have been directed to | 5.591 | 0.018 | 0.265 | 0.085 | 0.830 | ||
| Yes | 26.3 | 57.4 | |||||
| No | 73.7 | 42.6 | |||||
| *I have episodes of bladder incontinence | 4.053 | 0.044 | 2.500 | 1.016 | 6.149 | ||
| Yes | 61.5 | 39 | |||||
| No | 38.5 | 61 | |||||
| *I use a rectal suppository as part of my regular bowel program | 13.067 | 0.000 | 1.110 | 0.029 | 0.416 | ||
| Yes | 38.3 | 85 | |||||
| No | 61.7 | 15 | |||||
CI—confidence interval; L/L—lower limit; U/L—upper limit
Approximately 57.3% of those without PIs were found to be diet-conscious, but approximately 55.3% of those with PIs did not restrict the quantity of fat and cholesterol in their diet. Similarly, 65.4% of those with PIs were unaware of the risk of heart disease, while 57.4% of those without PIs took proper precautions to reduce the risk. Regular blood pressure monitoring was only performed by 42.3% of those with PIs, whereas 35.7% of those without PIs did not measure their blood pressure regularly.
Neuromuscular factors demonstrated that 83.3% of those with PIs did not practice range-of-motion exercises to maintain joint flexibility, whereas 70% of those without PIs did so on a regular basis and this was statistically significant (p<0.01), indicating a lower chance of developing PIs (OR: 0.086; 95% CI: 0.028–0.267) (1–0.08=0.92 times more protective). This means that those who regularly exercised were 0.92-times better protected against PIs.
Despite knowing that exercise is essential for maintaining muscle strength, only 14.3% with PIs performed weight training at least three times per week, whereas only 30.8% of individuals without PIs did not follow this protocol, with a statistically significant (p<0.01) increased risk of PIs (OR: 0.074; 95% CI: 0.22–0.0249) (1–0.07=0.93 times more protective).
Moreover, the majority (78%) of those without PIs performed muscle-strengthening exercises at least once a year under the supervision of a therapist, compared with 85.7% of those with PIs who did not receive any supervision from a therapist; this was statistically significant (p<0.01) and indicated an increased predisposition to PIs (OR: 0.073; 95% CI: 0.025–0.212) (1–0.07=0.93 times more protective). In addition, 55.1% of those without PIs rested while experiencing shoulder joint pain due to overuse. However, 58.1% of those with PIs did not value rest but this demonstrated statistical insignificance with no evidence of developing PIs in those who did not rest.
People with PIs tended to avoided weight-bearing activities (89.7%) and many of those without PIs used a standing frame to put weight on their legs about three times a week (72.5%). This was statistically significant (p<0.01), indicating that participants who regularly avoided weight-bearing activities had a higher risk of PIs (OR: 0.044; 95% CI: 0.03–0.27) (1–0.04=0.9-times more protective).
All participants (100%) with PIs did not ascribe importance to body positioning while seated in a wheelchair, whereas 63.5% without PIs understood the value of positioning and this was statistically significant (p<0.01), indicating that participants who were unaware of the importance of body positioning had a greater chance of developing PIs (OR: 0.365; 95% CI: 0.264–0.506) (1–.036=0.64-times more protective).
The individuals with SCI but without PIs (59.4%) maintained their body posture during sleep, but those with PIs (87.5%) did not value their body position during sleep, and this was statistically significant (p<0.01), showing a larger risk of PIs (OR: 0.098; 95% CI: 0.020–0.447) (1–0.09=0.91-times more protective).
Similarly, 68.1% of those without PIs were confident in managing the occurrence of joint contracture, whereas 75.8% of those with PIs did not know what to do when noticing joint freezing, showing statistical significance (p<0.01) placing these participants at a greater risk of having PIs (OR: 0.150; 95% CI: 0.055–0.410) (1–0.15=0.85-times more protective).
Skin factors revealed that 63.5% of those without PIs examined their skin for redness or breakdown regularly, but 100% of those with PIs did not, and this was statistically significant (p<0.01), placing those with PIs at a greater risk for developing PIs (OR: 0.365; 95% CI: 0.264–0.506) (1–0.36=0.64 times more protective).
Approximately 87.5% of those with PIs did not perform pressure relief every 30 minutes during sitting, while 66.1% of those without PIs released pressure from their buttocks, showing statistical significance (p<0.01) with a greater likelihood of developing PIs in individuals who did not perform pressure relief (OR: 0.073; 95% CI: 0.019–0.277) (1–0.07=0.93 times more protective).
Similarly, 61.9% of those without PIs were cautious not to hit their legs or feet during transfer, but 94% of those with PIs did not take any measures, demonstrating statistical significance (p<0.01; OR: 0.038, 95% CI: 0.05–0.309) (1–0.03=0.97 times more protective).
Moreover, those without PIs (62.7%) always wore shoes or boots while leaving their beds, but those with PIs (85.7%) did not, and this was statistically significant (p<0.01; OR: 0.099; 95% CI: 0.026–0.375) (1–0.09=0.91-times more protective).
Similarly, 35% of those with PIs were careful while handling hot liquids, whereas 47.5% of those without PIs were negligent, although this did not show statistical significance.
In addition, 92.3% of those with PIs did not place much importance on the wheelchair cushion, whereas 58.2% of those without PIs were aware of the condition of the cushion, and this was statistically significant (p=0.01), indicating that those who were unaware of the condition of the cushion on the wheelchair had a greater chance of developing PIs (OR: 0.06; 95% CI: 0.07–0.487) (1–0.06=0.94-times more protective).
In addition, 39.3% of individuals with PIs were aware of the condition of their wheelchairs, while 44.2% of participants without PIs were unaware of the wheelchairs' need for repair; nevertheless, this was not statistically significant.
The psychosocial factors demonstrated that only 15.4% of participants with PIs have wheelchair-accessible homes, whereas only 33.3% of participants without PIs had difficulty entering their homes with a wheelchair. This was statistically significant (p<0.01), indicating that participants with inaccessible houses had a greater chance of developing PIs (OR: 0.091, 95% CI: 0.0270.304) (1–0.09=0.91-times more protective).
Approximately 61.5% of those with PIs met with friends or other people at least once a day whereas 38.5% did not. This showed no statistical significance, and not enough evidence has been reported to suggest that this factor could contribute to the development of PIs.
Similarly, all genitourinary factors were statistically significant, indicating that they contributed to the development of PIs. Only 30% of those with PIs strictly followed the intermittent catheterisation programme, whereas 43.3% of those without PIs had an irregular schedule, and this showed statistical significance (p=0.03) suggesting that individuals who did not follow the recommended schedule had a greater chance of developing PIs (OR: 0.328; 95% CI: 0.111–0.969) (1–0.032=0.68-times more protective). Moreover, approximately three-quarters (73.7%) of those with PIs did not change the catheter frequently, as instructed, while 57.4% of those without PIs did so, presenting statistical significance (p=0.01) and showing susceptibility for those with PIs who did not change the catheter in a timely manner (OR: 0.265; 95% CI: 0.085–0.830) (1–0.26=0.74-times more protective).
In addition, 61.5% of those with PIs experienced bladder incontinence, while 61% of those without PIs reported no episodes of incontinence. This was statistically significant (p=0.04), showing an association between bladder problems and an increased risk of PIs (OR: 2.50; 95% CI: 1.01–6.14). The odds ratio was >1 and is therefore a risk factor. This suggests that people with episodes of urinary incontinence have a 2.5-times higher risk of developing PIs.
Although the majority of people without PIs (85%) reported using suppositories for bowel evacuation, 61.7% of people with PIs did not, and there was statistical significance (p<0.01), indicating that participants who avoided rectal suppositories were more likely to develop PIs (OR: 0.110; 95% CI: 0.029–0.416) (1–0.11=0.89-times more protective).
Discussion
The present study examined the predisposing and protective lifestyle factors that influence and prevent the development of PIs in community-dwelling individuals with SCI. The findings of this study demonstrated that, among all cardiovascular factors, only avoiding smoking acted as a protective factor among people with PIs. Moreover, it has been observed that smokers develop more PIs than non-smokers, because smoking interferes with wound healing.26 This could be because the smoking rate is higher in LMICs due to a lack of strict regulations.
Simultaneously, the neuromusculoskeletal factors indicated that participants who performed irregular joint flexibility and non-weight bearing exercises <3 times per week had a higher chance of developing PIs. Inadequate exercise over the long term also influences the development of secondary complications, most often PIs, in individuals with SCI.27
In the prevention and treatment of PIs in people with SCI, the therapist plays an important role.28 This supports the notion that visiting a therapist at least once a year for exercise constitutes a protective factor. Early discharge from a rehabilitation centre, resulting in the discontinuation of treatments, may be the consequence of a lack of better health services and/or the necessity to spend more money. It could also be a possible reason for not visiting the therapist.
In addition, self-positioning in a wheelchair served as a preventive factor against the development of PIs. Similarly, it is argued that seated positioning, pressure relief manoeuvres and patient education all contribute to the prevention of PIs.29 Simultaneously, those who were aware of their sleeping posture reported a lower incidence of PIs. This statement is supported by the relationship between frequent body repositioning in bed and during sleep and the avoidance of the development of PIs.30
Again, it was reported that individuals who did not know what to do when they noticed joint contracture had a greater risk of developing PIs. A study has revealed that the incidence of contracture in people with SCI is the most common risk factor for the development of PIs.31
On the other hand, skin factors demonstrated that those who did not perform regular skin examinations reported a higher rate of PI development. A previous study showed that knowledge of skin care was negatively correlated with the occurrence of PIs.32
Regular practitioners of the pressure relief technique are less vulnerable to the PI risk. In addition, it is recommended that the pressure relief manoeuvre be included in patient education.33 Participants who were inattentive during transfer tasks had a greater risk of developing PIs. This relates to individuals with complete paraplegia who reported frequent falls and at least one complication post-discharge from rehabilitation.34
The present study revealed that wearing shoes or boots after leaving bed acted as a preventive factor against PIs. Furthermore, the condition of the wheelchair and cushion was seen to have a significant role in minimising the risk of PIs. Those with PIs who are confined to a wheelchair should be aware of this.
Regarding psychosocial factors, individuals with wheelchair-inaccessible homes reported a greater risk of PIs. The cause may be that individuals with SCI will remain bedbound for a longer period of time, and inaccessibility reduces mobility, leading to secondary complications. This relates to the finding that the majority of people with SCI in LMICs are restricted to their homes due to a lack of access to the outdoors and are susceptible to PIs.35 In contrast, home modification has a greater impact on enhancing quality of life (QoL).36 However, it is unclear how inaccessible houses contribute to the development of PIs.
Furthermore, genitourinary factors are among the most important lifestyle factors and intermittent catheterisation has been found to reduce the risk of PIs. In addition, intermittent catheterisation is an appropriate method for voiding the bladder37 and can prevent urological complications.38 Similarly, the use of rectal suppositories for bowel evacuation and the regular replacement of catheters were expected to be protective factors against the development of PIs, but bladder incontinence episodes acted as a risk factor. It was reported that urinary tract infections39 and urine incontinence are related to an increased risk of developing PIs.40 It may be expected that insufficient nursing care, inappropriate knowledge of personal hygiene, and inadequate health services could increase the risk of PIs. The people without PIs achieved greater scores than those with PIs, which may be attributable to their better lifestyle. The results may aid in the development of a PI-prevention programme for community-dwelling individuals with SCI in LMICs.
The possible explanation for these results is that a study conducted in Bangladesh revealed that a large number of people with SCI in Bangladesh are jobless, live in poverty, and have a lower QoL and level of participation in society.41 Similarly, it was also observed that the majority of people with SCI were younger and lacked formal education, which may have a role in the development of PIs that result in life-threatening illnesses or even death.41,42 In addition, they reported moderate rates of depression and a reduced QoL.43
In Bangladesh, regular follow-up with individuals with SCI after their discharge from a rehabilitation centre has proven to be challenging and inadequate.44 Moreover, those living with an SCI in countries with minimal resources, such as Bangladesh, experience difficulties due to limited access to healthcare, rehabilitation programmes, and high-quality assistive technologies.24 Furthermore, community integration and life satisfaction were observed to be lower in Bangladesh, indicating that government and non-government agencies must create strategies to better integrate people with SCI into society.45 Concurrently, research on the care of PIs in India has indicated that their understanding of bedsore treatment was insufficient and that their practices were inappropriate.46 In addition, research carried out in Nepal has demonstrated a lack of awareness about the avoidance of immobility-related problems.47 Additionally, a Pakistani study showed that education on dietary management and avoidance of PIs may be useful in reducing problems in patients with SCI.48
Limitations
The study's findings were limited by the small sample size. Because the participants came from various Bangladesh districts, outreach was limited. The shift from a 5-point Likert scale to a 2-point scale may have affected the results, despite the fact that many cells were empty during the 5-point analysis. Factors such as poor reliability (low Cronbach's alpha) of the genitourinary and psychosocial domains might have influenced the outcome, dependency or independency level, employment status or previous SCI education pertaining to prevention of PIs. The study may also have missed other possible factors, such as socioeconomic status, personal hygiene, nutrition and caregiver support, that may have influenced the development of PIs. Again, further research should be undertaken to examine the lifestyle factors of people with SCI from rural and urban areas in order to address the problem as a whole and plan the necessary interventions.
Conclusion
This study revealed that factors associated with lifestyle varied significantly between individuals with PIs and those without PIs. Smoking, exercise, weight-bearing activity, body position on a wheelchair, joint contracture, skin examination, pressure relief, wearing protective devices on the foot, accessibility, and bowel and bladder management were all strongly linked to the occurrence of PIs, with bladder incontinence appearing to be a high-risk factor for developing PIs in community-dwelling individuals with SCI. In addition, these factors were identified as protective factors for people with SCI who had adopted an active lifestyle. The findings indicate that a small proportion of people with PIs adopt an active lifestyle and have incomplete knowledge about wheelchair type, cushion, transfer method, pressure relief strategies, etc. In order to reduce the incidence of PIs, it is recommended that people with SCI be aware of and regularly review their lifestyle factors.
Reflective questions
- What lifestyle factors of people living with spinal cord injury could lead to development of pressure injuries (PIs)? Why?
- What steps might help to prevent the occurrence of PIs?