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Quality of life of patients using intermittent urinary catheterization 1

ABSTRACT Objectives: measure and compare the quality of life of neurogenic bladder patients using intermittent urinary catheterization who were going through rehabilitation in Brazil and Portugal. Method: multicenter, quantitative, cross-sectional, observational-analytic and correlational study executed in Brazil and Portugal. Two data collection tools were used, being one questionnaire with sociodemographic and clinical data and the World Health Organization Quality of Life-bref. Patients were included who were over 18 years of age, suffering from neurogenic urinary bladder and using intermittent urinary catheterization. Results: in the sample of Brazilian (n = 170) and Portuguese (n = 52) patients, respectively, most patients were single (87-51.2%; 25-48.1%), had finished primary education (47-45.3%; 31-59.6%) and were retired (70-41.2%; 21-40.4%). Spinal cord injury was the main cause of using the urinary catheter in both countries. The Brazilian patients presented higher mean quality of life scores in the psychological domain (68.9) and lower scores in the physical domain (58.9). The Portuguese patients presented higher scores in the psychological domain (68.4) and lower scores in the environment domain (59.4). The execution of intermittent urinary self-catheterization was significant for both countries. Conclusions: in the two countries, these patients’ quality of life can be determined by the improvement in the urinary symptoms, independence, self-confidence, social relationships and access to work activities.


Introduction
The advances in health care in the global context have called for studies on the Quality of Life (QoL) of patients with chronic conditions or comorbidities that make them unable to execute the activities of daily living. In that population, the QoL outcomes reflect the patients' ability to cope with and adapt to their new and actual living condition. In that phase, of rehabilitation, the health team's assistance is fundamental, as care should be understood in the holistic dimension of the being, the family and the community (1) .
Studies on QoL are one way to value individual perceptions. They permit the comparison, approval and definition of treatment methods; help to understand the therapeutic choice, the assessment of costs and benefits and identify the main aspects the proposed therapeutics affect (2) .
In the context of neurogenic bladder patientsurinary bladder dysfunction of neurological origin that alters the functioning of the bladder (3) -, the main objectives of the treatment are the preservation of the kidney function and the person's adaptation to the new living condition (4) . Nevertheless, the effects and implications of the treatment, such as medication use, urinary incontinence management, micturition diaries and, mainly, the use of intermittent urinary catheterization, a fundamental tool in the treatment, result in significant impacts in the activities of daily living (5) .
Intermittent urinary catheterization is a periodical bladder voiding method, at routine intervals, by means of the introduction of a catheter through the bladder (6) .
To be effective in the neurogenic bladder treatment, it should be executed regularly, which causes costs and significant changes in daily life (7) .
In Brazil, to date, no specific policy exists for the neurogenic bladder patients who use intermittent urinary catheterization to guarantee the resources needed for high-quality care. Patients in the country are attended like all other citizens using the Unified Health System (SUS), are entitled to the material needed to execute the procedure, but this is not always available across the country (8)(9) . When comparing this reality with that of other countries, changes in these policies are observed, which seem to more intensely support the use of the urinary catheter. Studies can be observed that describe the use of more advanced technologies to accomplish the procedures and strongly discuss the patient's autonomy (10)(11) . Among the different studies, due to the nature of the material found about the theme, the use of urinary catheters in Portugal stands out (12)(13) .
In Portugal, a National Health System characterizes the healthcare provision. In that System, the public component guarantees care to all citizens and includes all health care, ranging from promotion to disease prevention, diagnosis, treatment and medical and social rehabilitation. In the country, the so-called "Hospital referencing network of physical and rehabilitation medicine" is in force, organized by the Directorate-General for Health (DGS), which covers the country in rehabilitation centers, located within the coverage regions. Those centers integrate multiprofesional health care and attend to the patients using intermittent urinary catheterization (14) .
The sociocultural diversities and the health policies in force in those countries can modify the adaptation of the neurogenic bladder patients or not, who use the intermittent urinary catheterization daily, and can interfere directly in their QoL. Nevertheless, in view of this whole picture, studies are lacking that discuss the problem of intermittent urinary catheterization users.
The evidence produced is focused on specific groups, such as incontinent or spinal injury patients, which does not picture the global reality (2)(3)7,9,11) .
In that sense, it is fundamental to identify the changes these patients experience with a view to effective planned actions. Among the changes deriving from the daily use of the urinary catheter, the acceptance of the new routine, changes in social life, in the work environment and treatment costs can be mentioned, among others. These patients lack specific care and effective actions, which require periodical monitoring by the health team. Particularly the nurse enables professional support in the educative, management, clinical and rehabilitation spheres and in the implementation of care plans in line with the reality the patient experiences (7,9,11) .
In that context, the objective in this study was to measure and compare the QoL of neurogenic bladder patients using intermittent urinary catheterization going through rehabilitation in Brazil and Portugal.  (15) . This tool has been translated and validated for Brazil (16) as well as for
The research data were coded and double-entered obtained on a positive scale, that is, the higher the score, the better the QoL in that domain (16) .  The patients' practice of intermittent urinary catheterization in both countries has been described in Table 2.
As for the urinary catheterization inputs used, in   Table 4.     Table 5.

Discussion
According to WHO, QoL is "individuals' perceptions of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns" (15) . The QoL domains adopted by WHO (physical, psychological, social and environmental) affect the general sphere of life, that is, satisfactions, aspirations, experiences, social relationships and wellbeing of an individual and the community (s)he is inserted in (18) . In that context, year (21) . In Portugal, no recent incidence and prevalence data have been published (22) , although important recent demographic changes are known that indicate that the age at the time of the injury has strongly increased, leading to a growing number of people with spinal cord injuries.
Like in relation to the other morbidities found, in case of spinal cord injury, intermittent urinary catheterization is the main treatment form of the changes the occurrence of the neurogenic bladder brings about in the urinary system. After the start of the procedure, it is undertaken at four to six or six to eight-hour intervals, according to the diuresis volume presented in micturition diary records and after assessment by means of urodynamic, radiologic and ultrasound tests (3) . Those results were also found in most of the patients in this sample ( Table 2).
The procedure provides for bladder reeducation and favors stimuli towards safe and effective spontaneous micturition (5) . Nevertheless, it causes some inconveniences, such as the sensitivity in the introduction of the urinary catheter and urine loss in between the urinary catheterizations, as reported in both populations ( Table 2). In that sense, the professionals' support is extremely important: clear and objective therapeutic communication is needed, as well as continuing assessment of the patients' conditions with a view to the success of the therapeutics at home (7) .
For the success or failure of the technique and the patient's compliance, the quality of the material used to execute the procedure is important. In this respect, differences were observed in the sample, in the acquisition process as well as in the quality of the material. The use of the lubricated catheter is not a Brazilian reality yet (9) .
Nevertheless, the studies demonstrate that this type of material minimizes the user's sensitivity and reduces the attrition with the urethral mucosa, leading to less pain and greater treatment compliance and improving the patient's QoL by about 30.0% (4,7) .
Concerning the QoL of the patients in this study, as demonstrated in  (23) . What the Brazilian standardized data are concerned, in a study undertaken in the South, agreement was demonstrated with the results found in the physical domain (lower score) and disagreement in the psychological domain. In the study, the highest score was found in the social domain (24) .
As regards the study developed in the South of Brazil, the data obtained from participants with chronic conditions presented lower scores in all QoL domains when compared to the general population (24) . Concerning the study of urinary catheterization users' QoL, other researchers have found data similar to this study in the lower scores measured by the WHOQOL-bref (15) , as well as in the higher scores measured in the psychological domain (1,25) .
It is clear that, the greater the health team's support for the multidimensional aspects of life in patients using clean intermittent catheterization, the better the treatment compliance will be (5) . In that process, the nurse is a decisive professional for the patient's progress, as she helps the patient to gain independence, within the reality experienced through self-care, from the help to obtain a better QoL (1) .
In this study, the analysis of the relation between the independent variables and each QoL domain and the two general QoL questions in the WHOQOL-bref (15) demonstrate, in Brazil, a significant relation between  (1,4) .
In Brazil, another relevant finding was the significantly positive statistics for the occupation and the psychological and environmental domains according to QoL classifies the concept as very bad, bad, neither bad nor good, good and very good (15) . Therefore, these results confirm the impact in the psychological and physical domains and QoL classification for the selfrealization of the procedure, as it outlines the feelings of independence, self-sufficiency and better self-esteem, expressed by the patients.
Concerning the QoL in both countries, the two general QoL and health questions were statistically significant, as the Brazilian patients presented higher QoL scores. Those questions examine how a person assesses his general QoL, health and wellbeing (15) . In that sense, the importance of the health professionals' work is clear, especially of the nurse, who plays an essential role in the execution, orientation, demonstration, supervision and reassessment of these patients' conditions for selfcare or care by the caregivers.
Being a global instrument, the WHOQOL-bref made it possible to measure, in two countries with linguistic similarities but distinct environmental and cultural characteristics, the QoL. Nevertheless, more specific tools need to be developed for that population, which could complement the results obtained and can be considered as a limiting factor in this study.

Conclusion
In the research findings in both countries, it could be identified that the improvement in the urinary symptoms, as well as the independence, self-confidence, social relationships, access to work activities and social insertion can determine the QoL of neurogenic bladder patients using intermittent urinary catheterization. As the results found are limited to regional populations, this research needs to be expanded to obtain the global characteristics of the target population.
In that context, the health professionals need to understand this phenomenon, aiming for these patients' satisfaction with life and with the efficacy of the support and treatment processes for neurogenic bladder patients using intermittent urinary catheterization.