The data from this survey indicated significant differences in bowel and bladder related measures across Canadian and Indian participants.
Bowel Dysfunction and Management
Canadian participants reported increased levels of bowel dysfunction compared to Indian participants. Canadian participants reported less frequent bowel movements and were more likely to experience uneasiness, headache, and perspiration during defecation. More than a quarter of the Canadian sample spent more than an hour on each defecation (Table 3). The decreased frequency, increased time spent on defecation, and symptoms of autonomic dysreflexia suggest the Canadian participants were experiencing constipation. This is critical since mild constipation has been identified as an insidious cause of autonomic dysreflexia, a potentially life-threatening condition [19]. Based on the WIS, a validated measure specific to fecal incontinence, both countries had an average score of less than 8 on a scale of 0–20 wherein 0 indicates no incontinence and 20 indicates complete incontinence. There was no significant difference in the severity of incontinence across countries.
The most likely explanation for differences in bowel dysfunction in these two culturally diverse regions is diet. Prior research has demonstrated the influence of diet on the management of bowel dysfunction post-SCI [20]. A healthy diet is one affordable and non-invasive treatment strategy used to create an effective bowel care program [20]. Adequate fiber in-take, estimated at approximately 15 grams per day, and decreased saturated fat, sugar, and carbonated beverages have been recommended in individuals with SCI [20].
Cultural differences in North American and Indian dietary patterns including vegetable and fiber intake, processed foods, alcohol consumption, and spice usage could have implications for neurogenic bowel management. Adequate water intake is also critical for proper bowel movements. Traditional Indian cuisine is often inherently high in whole grains which can help relieve constipation including bajra, ragi, amaranth and barley [21]. Recent editions of the Canadian food guide have emphasized the importance of plant-based proteins and whole grains [22]. However, North American diets are notoriously high in processed carbohydrates and low in fruits, vegetables, and water intake. These differences in cultural dietary practices could impact levels of constipation in patients with SCI. Further research is required on participants daily dietary habits and NBD to understand this relationship. Additionally, differences in antibiotic usage in context of urological management could play a role in differences in bowel function via changes in the gut microbiome [23].
Unaccounted for differences in patient and caregiver education could also impact results. Providing patients with clear and ongoing education about managing their bowel is critical for minimizing complications and maintaining QOL [24]. In India, bowel and bladder management were identified as specific areas where care had been lacking [25]. Diet represents a non-invasive and less costly method for maintaining effective bowel care. Depending on the resources available, there could be variation in the emphasis care providers from different countries place on treatment methods. Further, the Canadian participants were significantly older and had experienced more time since injury than the Indian sample (Table 2). Age and years since injury have been associated with challenges in managing neurogenic bowel dysfunction, specifically constipation, in individuals with SCI [26].
Bladder Dysfunction and Management
Results from the NBSS indicated a slight significant difference between countries when answering the QOL related question, “If you had to live the rest of your life with the way your bladder (or urinary reservoir) currently works, how would you feel?” On average, the Indian sample was less pleased with their bladder function compared than the Canadian sample. One explanation for this finding could be the method of voiding. Although intermittent catheterization was the most popular option for both groups, a higher portion of the Indian sample utilized this technique compared to the Canadian sample (Table 4). Further, recent research has demonstrated that there is debate surrounding the risk of UTI depending on more specific considerations such as single vs multiple use catheters as well as potentially increased safety with specific types of catheters (i.e. hydrophilic) [27]. There could also be country variations in provider’s instruction and education surrounding catheter usage and techniques. Further, financial constraints could impact choices surrounding single vs multi use and affordability of specific types of catheters. Thus, more specific questions surrounding catheterization techniques and usage would be necessary to understand country variability in outcomes.
Further, the India sample was significantly younger than the Canadian sample and reported a significantly decreased time since injury (Table 2). Both samples were largely composed of male participants (Table 2). Research has demonstrated the impact of SCI on body image and self-esteem, particularly in young-male patients [28]. The younger Indian male participants could be much more susceptible to these influences and therefore less likely to be satisfied with their bladder function. Cultural influences and social norms surrounding masculinity could also impact reported levels of satisfaction.
Study Limitations
One limitation of the study was that these samples included large, urban treatment centers in each country where there might be higher standards of care. Using samples restricted to one major center in each country also impacts cultural and geographical representation since these influences vary even within countries.
Second, the two samples showed significant differences in age and years since the injury. These two variables could impact differences found across countries including bowel and bladder management and complications.
Third, the income status of participants was not included in the survey. Differences in income have been shown to impact access to treatment and health outcomes for individuals with SCI [29]. Therefore, unaccounted individual differences in participants level of income could impact the generalizability of results.
In conclusion our study found variations in bowel and bladder dysfunction between Canadian and Indian participants. Overall, Indian participants reported lower levels of bowel dysfunction and more frequent bowel movements. Canadian participants were more likely to experience unpleasant symptoms such as headache, perspiration, and sweating during bowel movements. Results suggest Canadian participants experienced mild constipation, which could be triggering symptoms of autonomic dysreflexia. In terms of bladder function, Canadian participants reported a small but significant increased level of satisfaction when asked if they would be okay with living with their current bladder function for the rest of their lives.
This project highlights the variability of patients with SCI and how cultural, geographical, and economical factors could impact bowel and bladder dysfunction. Bowel and bladder dysfunction are two critical determinants of QOL as determined by the SCI population; therefore, understanding the various factors influencing them is fundamental in improving care for this population. Future research could explore how culturally diverse dietary practices between SCI populations impacts bowel dysfunction. There are also gaps in understanding how intermittent catheterization practices vary between countries, including patient and caregiver education. In addition, how social norms influence level of satisfaction with treatment.
Comparing SCI patients from different countries allows for mutual learning and collaboration in understanding the range of practices that can improve patients’ lives.