NeuroRehabilitation 24 (2009) 5766 DOI 10.

3233/NRE-2009-0454 IOS Press

57

Pressure ulcer prevalence and barriers to treatment after spinal cord injury: Comparisons of four groups based on race-ethnicity
Lisa K. Saladin and James S. Krause
College of Health Professions, Medical University of South Carolina, Charleston, SC, USA

Abstract. Objective: To compare the prevalence of pressure ulcer (PU) and barriers to treatment in the event of PU development as a function of race-ethnicity in persons with spinal cord injury (SCI). Methods: Interview data were collected from three rehabilitation hospitals each of which was designated as a model SCI system of care by the United States Department of Education. There were 475 participants with similar portions of each racial-ethnic group (African-American n = 121, American-Indian n = 105, Caucasians n = 127, Hispanics n = 122). Results: The lowest prevalence rates for pressure ulcers were reported by Hispanics followed by Caucasians. Logistic regression revealed racial-ethnic differences in the odds of developing a PU within the past 12 months. Social support and injury severity were also associated with risk of PU while age, gender, years since injury, and education were not. Signicant racial-ethnic differences were also observed in 5 of 9 barriers to the treatment of PUs. Conclusion: Results suggest that variability in social support and barriers to treatment may contribute to the racial-ethnic differences in prevalence rates for PU that were observed. Future research in this area could lead to the development of strategies to enhance prevention and treatment targeted at the elimination of any racial-ethnic disparities. Keywords: Spinal cord injury, disparities, pressure ulcers, health, quality of life

1. Introduction 1.1. Background and signicance There is clear and convincing evidence that racial and ethnic differences both in access to health care and health care outcomes are consistently present across a wide range of illnesses [4,69,15,17,30,33,3739]. Furthermore, these differences have been documented even after statistically correcting for variables such as
Address for correspondence: James S. Krause, PhD, Department of Rehabilitation Sciences, College of Health Professions, Medical University of South Carolina, 77 President St, Suite 117, PO Box 250700, Charleston, SC 29425, USA. Tel.: +1 843 792 1337; Fax: +1 843 792 5649; E-mail: krause@musc.edu.

insurance status, income, age, co-morbid conditions, and clinical presentation. An excellent example is the study by Gornick and colleagues examining racial disparities in access to services for Medicare patients [14]. Minority patients had lower utilization rates for effective diagnostic and intervention procedures across multiple disorders and higher utilization rates for less desirable procedures such as amputations. While the evidence documenting racial and ethnic disparities in health care access and outcomes continues to expand, this issue has not been fully explored. Currently, there is a signicant gap in the existing literature related to racial and ethnic differences in outcomes following traumatic spinal cord injury (SCI), and minorities have consistently been underrepresented in SCI outcomes research. While the majority of individ-

ISSN 1053-8135/09/$17.00 2009 IOS Press and the authors. All rights reserved

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L.K. Saladin and J.S. Krause / Pressure ulcer prevalence and barriers to treatment after spinal cord injury

uals with SCI are Caucasian (67%) [29], a signicant number of minorities experience SCI (43%) [29], and recent studies have demonstrated that there has been a very signicant trend over time in race-specic incidence rates [18,31]. Over a 30 year period from 1973 2003, the percentage of SCI individuals in all minority categories increased while the percentage of whites experiencing a SCI decreased [18]. The increasing incidence of SCI in the minority population combined with the recent focus on racial and ethnic disparities in health care, indicate the need for investigations focusing on potential racial-ethnic differences in SCI outcomes. Pressure ulcers (PU) represent the most frequent secondary complication associated with SCI, occurring in approximately 34% of individuals during the acute care/rehabilitation phase [26,29] with prevalence rates in subsequent years post-injury ranging from 14 46% [11,12,21,2426,29,32]. It is also disturbing to note that despite research efforts targeted at identifying risk factors [12,25] and the development of prevention strategies [13,16,20], a recent report documented a signicant increase in the prevalence of PUs in recent years [5]. The impact of PUs on individuals with SCI is signicant as they have been associated with longer length of hospital stays [19,28,36], signicant health care costs [19,28,36], infections, decreased employment rates [24] and lower quality of life [24]. Pressure ulcers are also among the leading causes of unplanned hospitalizations post-SCI [2,19,21,28,32], and closure of PUs was the procedure most frequently performed during follow-up [29]. Finally, a 25-year morbidity and mortality study of veterans demonstrated that the majority of morbidity and the most frequent cause of death was sepsis associated with either urinary tract infections or PUs [35]. While the prevalence of PUs associated with SCI and the serious consequences associated with them are well documented, there have been few studies examining racial-ethnic differences in prevalence rates, and the few studies that have been conducted have reported conicting results. In earlier studies, there were no reported racial-ethnic differences in the incidence of PUs in small samples (n < 200) of individuals hospitalized during the post-SCI acute/rehabilitation phase [3] or in community residents with SCI [10]. However, it was noted that African-Americans had more severe ulcers (Stage III or IV) than their Caucasian counterparts [10]. Further analysis demonstrated that this difference in severity may have been due to other factors such as lower mobility scores and indicates the need for additional study to determine the impact of race on

ulcer severity. Contrary to the results demonstrating no racial-ethnic differences in the incidence of PUs, a recent study of 3,361 individuals with SCI followed from 19862002 demonstrated that African-Americans were 1.7 times more likely to develop a pressure sore than Caucasians [5]. While this is an important nding, this latter study did not contain a signicant proportion of Hispanics and did not report on American-Indians. It is clear that further research is required to investigate racial-ethnic differences in prevalence rates for PUs post-SCI and to examine the factors contributing to reported differences. With the recent focus on racial and ethnic disparities in health care, increased emphasis needs to be placed on collecting SCI data from minority populations in order to investigate potential racial disparities especially as they pertain to outcomes. 1.2. Purpose The primary purpose of this study was to identify racial-ethnic differences in PU prevalence after SCI and to identify the differential odds of developing PUs by race and ethnicity both at the time of the study and over the 12 months prior to the study. Finally, we identied other risk factors that may inuence the likelihood of PU occurrence and examined racial-ethnic differences in reported barriers to the treatment of PUs.

2. Methods 2.1. Participants Participants were adults identied from one of three collaborating model SCI systems centers and had traumatic SCI of at least one year duration at the time of enrollment into the study. Each center was designated as a model for SCI care in research by the United States Department of Education, and they are located in the Western, Mountain, and Southeastern United States. There were a total of 475 participants. 1 No data was collected on non-respondents. As this study was specically designed to identify similar portions of participants from a diverse range of characteristics, a stratied sampling procedure was used to oversample racial- ethnic minorities and wom1 There initially

were four centers that participated, with the fourth center contributing Asian-American cases, but there were too few cases to perform meaningful analyses (n = 37), and the data from the center were dropped from the current report.

L.K. Saladin and J.S. Krause / Pressure ulcer prevalence and barriers to treatment after spinal cord injury Table 1 Participant characteristics by race and ethnicity N of cases Age Years since injury onset Level of injury C1C4, non-ambulatory C5C8, non-ambulatory Non-cervical, non-ambulatory Ambulatory Cause of injury Motor vehicle Sporting injury Falls/ying objects Violence Medical complications Other Years of education completed Caucasian 127 46.1 12.4 % 13.1 27.9 32.8 26.2 % 52.0 12.0 18.4 5.6 0.8 1.2 13.8 African-American 121 44.2 13.6 % 11.4 30.7 41.2 16.7 % 50.0 3.3 8.3 31.7 1.7 5.0 12.4 American-Indian 105 39.5 11.8 % 11.5 35.6 40.4 12.5 % 81.9 1.0 4.8 5.7 0 6.7 11.8 Hispanic 122 38.7 12.8 % 11.1 27.4 44.4 17.1 % 35.2 2.5 11.5 48.4 0 2.5 10.4

59

en. Table 1 summarizes the participant characteristics as a function of race-ethnicity. The sampling strategy was successful in producing a nearly equal distribution of Caucasians, African-Americans, Hispanics, and American-Indians, as the percentage of participants across the four groups ranged from a low of 22.1% (American-Indians) to a high of 26.7% (Caucasians). Women comprised 40% of the sample. Other than for American-Indians, where the percentage of women was only 20%, the percentage of women among other groups exceeded that generally served in the SCI population and ranged from 35.5% (Hispanic) to 52% (Caucasian). Just over half of the participants were injured as a result of a motor vehicle crash (54%), followed by acts of violence (23%) and falls/ying objects (11%). When using a combination of injury level and ambulatory status (a proxy variable for an ASIA D classication), 11.6% were C1C4, non-ambulatory; 29.1% were C5C8 non-ambulatory; 39.7% were non-cervical, nonambulatory, and 19.6% were ambulatory. The average age at the time of injury was 29.3 years, with an average of 12.8 years having passed since onset. The average number of years of education was 12.1 years. 2.2. Procedures Participants were identied from one of three specialty hospitals from different geographic regions of the United States. The lead center was in the Southeastern United States where all data were compiled and stored. Each collaborating center focused their data collection on a specic racial-ethnic population which was available in their area and also identied a cross section of

cases from other racial-ethnic groups. The majority of African-American participants were from the lead center in the Southeastern United States, whereas the majority of Hispanic participants were from the Western United States, and the majority of American-Indian participants from the Mountain region of the United States. All data were collected by phone interview, except in rare cases (i.e. due to lack of a phone), where surveys were completed and returned by mail. Participants at each center were offered $50 remuneration. 2.3. Instruments The primary variable of interest in this study was PUs. A number of questions were developed to ask about PU history as well as the practices used to prevent or treat PUs. The section of the Life Situation Questionnaire Revised [22,23] regarding PUs was used, including questions identifying the presence of a current PU and the number of PUs within the past year. This last variable was dichotomized based on the presence of at least one PU in the past year. The LSQ-R consists of several sets of items that were designed to measure objectively veriable information, such as the PU outcomes in the study, rather than psychometric scales of underlying theoretical constructs (e.g., efcacy). Each set of items was designed to be measured independent of other sets of items without compromising validity (i.e, each set of items in essence could be considered a separate instrument). Two additional item sets were also included, the rst of which included ve items which identied barriers to maintaining bed rest after getting an open sore, and the second set of items identied barriers to seeing a physi-

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L.K. Saladin and J.S. Krause / Pressure ulcer prevalence and barriers to treatment after spinal cord injury

cian in the event of an open sore. Each item set was developed using a combination of consumer input and experts judgment and, as with the LSQ-R PU items, were developed to independently measure specic barriers, rather than the underlying construct. Therefore, there are no scale scores, but rather, independent sets of items. Specic wording was as follows: If you were to get an open pressure sore that you felt or were told may be bad enough to stay in bed, would (a) needing to go to work, (b) needing somebody to stay with you, (c) not having enough money to pay for extra attendant help, (d) boredom, or (e) placing a strain on your relationship with a spouse or signicant other make it more difcult for you to spend time in bed while the sore healed?. The second set of items was worded as follows: If you were to get an open pressure sore that you felt or were told may be bad enough to see a doctor, would (a) not having enough money or insurance, (b) not having transportation, (c) not trusting a physician, and (d) not having a good doctor you can see close to where you are make it more difcult for you to go see a doctor?. Social support was measured by the Reciprocal Social Support Scale (RSS) [1]. It was developed to measure support given and received, although only the support received was utilized in the current study. Individuals rated the frequency with which they received four types of support on a 7 point scale (1 = never and 7 = always): social interaction, material assistance, emotional support, and nonpaid personal assistance. Five subscales were developed, one for each type of support (social interaction, material assistance, emotional support, and nonpaid personal assistance) and one for the total score on all subscales (each scale had a range of scores from 321). In the current study, we use only the total social support score. 2.4. Data analysis Several sets of data analyses were conducted. First, the Chi Square statistic and ANOVA were used to identify any signicant differences in baseline characteristics between the various racial-ethnic groups. The Chi Square statistic was then used to identify the association of gender and race-ethnicity on the probability of having at least one PU within the previous year and having a PU at the time of the study. Two separate logistic regressions were performed to further examine the impact of race-ethnicity on the development of PUs when combined with other potential predictors. The rst analysis examined factors associated with the de-

velopment of a PU in the last year, and the second regression examined the association of these same variables with the presence of a current PU. The rst step of each analysis included the following variables; raceethnicity, gender, injury severity, etiology, age, years since injury, and years of education. The total social support score was added in the second step of each analysis. Two nal sets of analyses were conducted in order to help identify some of the barriers to PU management and how they vary as a function of race-ethnicity. The Chi Square statistic was used to determine the significance of the relationship between race-ethnicity with each of the 5 items representing barriers to maintaining bed rest in order to heal a sore (e.g., needing someone to stay with you, boredom) and 4 barriers to seeing a physician for the treatment of a pressure sore (e.g., not having enough money or insurance, not having transportation). We then ran logistic equations on each of the signicant barriers controlling for all factors in the rst two general regression analyses with the exception of social support. Social support was excluded due to the overlap between social support and the barriers themselves.

3. Results 3.1. Racial-ethnic differences in patient characteristics There were no signicant racial-ethnic differences observed in injury severity level, age since injury, or years of education. There was a signicant difference in the etiology of injury (p < 0.001) and age at the time of the survey (p < 0.001).

3.2. Prevalence of PU At the time of the study, 15.5% of the participants reported a current PU, and 32% reported a PU within the last 12 months. Of the 32% that reported PUs in the last year, approximately half, 16%, reported only one PU, and 8% reported two PUs. Only 3.4% of the participants reported three or more PU within the last year.

L.K. Saladin and J.S. Krause / Pressure ulcer prevalence and barriers to treatment after spinal cord injury Table 2 Logistic regression analysis of a pressure ulcer within the past year Exp(B) 0.983 1.019 3.041 2.142 2.783 1.120 1.700 3.652 0.978 1.022 1.631 1.842 0.124 Step 1 95% CI [0.97, 1.00] [0.99, 1.05] [1.32, 7.00] [1.05, 4.37] [1.41, 5.50] [0.55, 2.29] [0.90, 3.21] [1.86, 7.18] [0.62, 1.55] [0.96, 1.09] [0.90, 2.95] [1.04, 3.28] Sig. 0.086 0.209 0.020 0.009 0.036 0.003 0.000 0.757 0.102 0.000 0.926 0.520 0.066 0.105 0.038 0.001 Exp(B) 0.983 1.016 3.065 2.168 2.846 1.200 1.804 3.630 0.987 1.024 1.621 1.828 0.988 0.239 Step 2 95% CI [0.96, 1.00] [0.99, 1.05] [1.33, 7.08] [1.06, 4.45] [1.43, 5.65] [0.58, 2.48] [0.95, 3.43] [1.84, 7.17] [0.62, 1.57] [0.96, 1.10] [0.89, 2.94] [1.03, 3.26] [0.98, 1.00] Sig. 0.075 0.274 0.018 0.009 0.035 0.003 0.001 0.622 0.072 0.000 0.954 0.485 0.072 0.112 0.041 0.051 0.051

61

Age Years Since Injury Injury Severity* C1C4, non-ambulatory C5C8, non-ambulatory TLS, non-ambulatory Race** Caucasian African-American American-Indian Gender (Female) Years of education Etiology*** Etiology violence Etiology other Total Support Constant

*Ambulatory, all neurologic levels, was used as reference category. **Hispanic was used as reference category. ***Motor vehicle accident was used as reference category.

3.3. Race-ethnicity and gender differences in PU prevalence Simple chi-square comparisons demonstrated a signicant relationship between race-ethnicity and having at least one PU within the past year, Chi (3, n = 472) = 22.84, p < 0.001, and having a PU at the time of the study Chi (3, n = 472) = 18.91, p < 0.001. Gender was unrelated to either of these two variables when tested individually across race-ethnicity and after stratifying by race-ethnicity (i.e., there were no gender differences within any single racial group). American-Indian participants had the highest percentage of PUs within the past year (49.5%), followed by African-Americans (35.8%), Caucasians (24.6%), and Hispanics (23.1%). African-Americans were most likely to report a current PU (23.3%), followed by American-Indians (21.9%), Caucasians (11.9%), and Hispanics (5.8%). 3.4. Factors associated with reporting PU within the last year Table 2 summarizes the results of logistic regression analysis examining the odds of reporting at least one PU within the past year (Nagelkerke R 2 stage 1 = 0.12, stage 2 = 0.13). Race-ethnicity was signicantly associated with the presence of at least one PU in the past year. Since Hispanics had the lowest PU incidence, they were utilized as the base group for com-

parisons. American-Indians were 3.7 times more likely to develop a PU within the last year than Hispanics (CI = 1.86, 7.18, p < 0.001). There were no signicant differences between Hispanics and Caucasians or African-Americans when other covariates were considered. Those who were ambulatory were signicantly less likely to develop a PU within the last year than each of the other three groups that were non-ambulatory and those with an etiology of injury classied as other were signicantly more likely to report PUs than those with injuries due to motor vehicle accidents or violence. Age, gender, years lived post-injury, and years of education were all unrelated to a PU within the past year. During the second step of the analysis, social support approached signicance (OR = 0.99, CI = 0.98, 1.00, p = 0.051), with higher social support scores associated with a trend towards a decreased likelihood of reporting a PU in the last year. The addition of social support in the second step did not change any other relationships. 3.5. Factors associated with reporting PU at the time of the study Table 3 summarizes the results of the logistic regression examining the odds of reporting a PU at the time of the study (Nagelkerke R 2 stage 1 = 0.15; stage 2 = 0.17). These results are highly similar to the results of the rst regression analysis with both raceethnicity and injury severity associated with the pres-

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L.K. Saladin and J.S. Krause / Pressure ulcer prevalence and barriers to treatment after spinal cord injury Table 3 Logistic regression analysis of a current pressure ulcer Exp(B) 0.982 1.012 11.971 7.037 9.703 2.457 4.594 4.540 0.902 1.026 1.311 1.414 0.010 Step 1 95% CI [0.96, 1.01] [0.98, 1.05] [2.50, 57.43] [1.57, 31.64] [2.22, 42.41] [0.84, 7.20] [1.79, 11.83] [1.68, 12.30] [0.50, 1.64] [0.94, 1.12] [0.61, 2.80] [0.68, 2.96] Sig. 0.150 0.515 0.013 0.002 0.011 0.003 0.005 0.101 0.002 0.003 0.734 0.579 0.586 0.485 0.358 0.000 Exp(B) 0.981 1.008 12.762 7.297 10.319 2.782 5.139 4.625 0.907 1.029 1.320 1.384 0.982 0.025 Step 2 95% CI [0.96, 1.01] [0.97, 1.05] [2.64, 61.73] [1.61, 33.0] [2.35, 45.42] [0.93, 8.32] [1.97, 13.43] [1.69, 12.64] [0.50, 1.65] [0.94, 1.13] [0.62, 2.84] [0.66, 2.91] [0.97, 1.00] Sig. 0.132 0.690 0.010 0.002 0.010 0.002 0.004 0.067 0.001 0.003 0.750 0.543 0.610 0.476 0.392 0.033 0.001

Age Years Since Injury Injury Severity* C1C4, non-ambulatory C5C8, non-ambulatory TLS, non-ambulatory Race** Caucasian African-American American-Indian Gender (Female) Years of education Etiology*** Etiology violence Etiology other Total support Constant

Logistic regression analysis of a current pressure ulcer *Ambulatory, all neurologic levels, was used as reference category. **Hispanic was used as reference category. ***Motor vehicle accident was used as reference category. Table 4 Percentage of participants endorsing each barrier to treatment as a function of race-ethnicity Caucasian Barriers to Staying in Bed to Heal a Pressure Ulcer Needing to go to work Needing somebody to stay with you Not having enough $ to pay for extra attendant help Boredom Placing a strain on your relationship with a spouse or signicant other Barriers to Seeing a Physician to Heal a Pressure Ulcer Not having enough money or insurance Not having transportation Not trusting a physician Not having a good doctor you can see close to where you live AfricanAmerican 33.0 25.5 59.4 41.6 38.8 American-Indian Hispanic 2 df Sig.

42.7 43.5 50.5 65.4 30.3

44.2 33.0 49.0 58.2 41.9

30.5 28.1 35.1 40.0 25.5

5.74 9.29 13.17 20.07 6.74

3 3 3 3 3

0.125 p < 0.05 p < 0.01 p < 0.001 0.081 p < 0.01 p < 0.001 0.648 0.2

23.1 23.1 30.6 38.0

39.6 45.5 26.7 37.6

40.4 43.6 23.4 44.8

24.3 27.0 24.3 30.4

12.79 18.02 1.65 4.64

3 3 3 3

ence of a PU at the time of the study. However, the odds for both were accentuated. In this analysis, both American-Indians and African-Americans were significantly more likely to report a current PU than Hispanic participants (American-Indians, OR = 4.54, CI = 1.68, 12.30, p < 0.003; African-Americans, OR = 4.59, CI = 1.79, 11.83, p < 0.002). Once again, there were no differences between Hispanics and Caucasians, and the variables of age, years lived post-injury, and years of education were all unrelated to having a PU at the time of the study. In this analysis, social support was signicantly associated with the presence of a current PU. Individuals with higher social support scores were less likely to report a current PU (OR = 0.98, CI =

0.97, 1.00, p = 0.033). 3.6. Racial-ethnic and gender differences in barriers to treatment of PUs Chi-Square analysis revealed signicant racialethnic differences in 5 of the 9 barriers to treatment (Table 4). Racial-ethnic differences were present in 3 barriers which prevented individuals from maintaining bed rest to heal a PU and included: (a) needing someone to stay with them, (b) not having enough money to pay an assistant for the help that is needed, and (c) boredom. Hispanic subjects reported the lowest or second lowest endorsement rates for all three of these barriers while

L.K. Saladin and J.S. Krause / Pressure ulcer prevalence and barriers to treatment after spinal cord injury Table 5 Logistic regression analysis of barriers to treatment for each item as a function of race ethnicity and gender Caucasian Needing somebody to stay with you Exp (B) 95% CI Sig. Not having enough $ to pay for extra attendant help Exp (B) 95% CI Sig. Boredom Exp (B) 95% CI Sig. Not having enough money or insurance Exp (B) 95% CI Sig. Not having transportation Exp (B) 95% CI Sig. AfricanAmerican 1.00 American-Indian Hispanic Gender (Female)

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1.81 [0.98. 3.32] 0.057

1.62 [0.84, 3.32] 0.152

1.32 [0.70, 2.51] 0.392

1.54 [0.99, 2.40] 0.057

2.22 [1.16, 4.26] 0.016 2.52 [1.36, 4.67] 0.003

3.50 [1.91, 6.42] 0.000 1.09 [0.62, 1.92] 0.768

1.94 [1.03, 3.69] 0.042 1.94 [1.06, 3.55] 0.032

1.00

1.00 [0.64, 1.56] 0.989 1.00 [0.66, 1.50] 0.982

1.00

2.11 [1.10, 4.02] 0.024 2.67 [1.43, 4.97] 0.002

1.81 [0.91, 3.61] 0.091 2.23 [1.14, 4.36] 0.020

1.05 [0.50, 2.19] 0.908 1.20 [0.59, 2.45] 0.616

0.48 [0.30, 0.79] 0.003 0.67 [0.43, 1.06] 0.089*

*Each regression analysis used the same set of predictor variables as the other analyses, with the exception of social support. These variables include: age, years since injury, injury severity, yeas of education, and cause of injury.

Caucasians reported the highest or second highest endorsement rates for all three of these barriers. Signicant racial-ethnic differences were also present in 2 barriers that interfered with an individuals ability to see a physician for treatment of a PU: (a) lack of insurance and (b) lack of transportation. Both Caucasians and Hispanics did not endorse these barriers as frequently as African-Americans and American-Indians. Follow-up logistic regression analysis conrmed that race-ethnicity was associated with the probability of reporting 4 of the 9 barriers to the treatment of PUs (Table 5). Within the category of barriers to staying in bed to heal a PU, the logistic regression did not reveal any signicant race-ethnic differences in the probability of reporting needing someone to stay as a barrier. However, there were differences in the probability of reporting the remaining two barriers to staying in bed. Since Hispanics were least likely to endorse both not having enough money for attendant help and boredom as barriers to bed rest, they were used as the reference category in the logistic regression for both variables. Compared with Hispanics, the odds of endorsing not having enough money to pay for an attendant were 3.5 times higher for African-Americans, 2.22 times higher for Caucasians, and 1.94 times higher for American-Indians. A somewhat similar pattern was observed for boredom. Hispanics were least like-

ly to endorsement this as a barrier. Caucasians were 2.52 times and American-Indians 1.94 times more likely to endorse the item than Hispanics (There were no signicant differences with African-Americans). Within the category of barriers to see a physician to treat a PU, Caucasians were least likely to endorse the barriers of lack of insurance and lack of transportation, so they were set as the reference group in both analyses. Only African-Americans were signicantly different than Caucasians with respect to reporting lack of insurance as a barrier to seeing a physician for treatment of a PU, with a 2.11 times greater odds of endorsing this item. On the nal barrier, both African-Americans and American-Indians were more likely than Caucasians to report lack of transportation as an obstacle to seeing a physician for the treatment of a PU. In each case, the odds of endorsing the item are over twice that of Caucasians (African-Americans, OR = 2.67; AmericanIndians OR = 2.23).

4. Discussion The current study was designed to identify racialethnic differences in PU prevalence after SCI. Our results demonstrated that there is a signicant relationship between race-ethnicity and the presence of PUs

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L.K. Saladin and J.S. Krause / Pressure ulcer prevalence and barriers to treatment after spinal cord injury

both at the time of the study and within the last year. The prevalence rates for both American-Indians and African-Americans were higher than those for Caucasians and Hispanics with Hispanics reporting the lowest rates. Furthermore, race-ethnicity was identied as a risk factor for both a current PU and the presence of a PU within the last year even when considered with other covariates such as age, injury severity, gender, social support, years of education, and etiology of injury. These results are in contrast to four earlier studies that did not demonstrate a signicant relationship between racial-ethnic group and the presence of PUs [10,12,24, 25]. However, two of these were small studies of less than 150 participants [10,12], and none of these studies specically oversampled minority populations to obtain an adequate and equal representation of the major racial-ethnic groups including American-Indians. The results from the current study are consistent with the most recent report from a large sample of individuals post-SCI demonstrating that African-Americans were signicantly more likely to report a PU [5]. Factors that may contribute to the racial-ethnic differences observed in this study will be addressed in the following discussion. The only other factor that was signicantly associated with the likelihood of reporting both a current PU and at least one PU within the last year was injury severity as dened by ambulatory versus non-ambulatory. This is also consistent with previous studies demonstrating that injury severity dened as a complete injury [5, 21,24,26] or by the extent of motor impairment [3,10, 12], is a signicant risk factor for the development of PUs. However, it is important to note that there were no signicant racial-ethnic differences between groups in injury severity in the present study. Therefore, it is unlikely that this risk factor contributed to the racialethnic differences in PU prevalence. It was not surprising that other risk factors with the potential to contribute to the presence of a PU, including age, years since injury, gender, and years of education, were not signicant in the present study. Previous studies have reported inconsistent and often conicting results with respect to the effect of these same variables on the development of PUs [5,12,21,24,25,27] and this variability is likely due to differences in study design and the number and variety of factors used for analysis. Two additional factors were signicantly associated with PUs post-SCI. The rst was social support with increased total social support scores associated with a signicantly decreased likelihood of reporting a current pressure sore and a trend towards a decreased likeli-

hood of reporting a PU in the last 12 months. It is difcult to compare this nding to those from other studies examining the effects of social factors on PU development because of the variability of measures used. For example, previous studies have demonstrated that poor life adjustment [24] and marital status [5,12] were related to the presence of pressure sores but social integration [10] and satisfaction with social support [34] were not. To our knowledge, the present study is the rst to attempt to quantify the amount of social support received post-SCI and to examine the relationship between social support received and PUs as a function of race-ethnicity. It is tempting to consider that one of the primary reasons that Hispanics reported the lowest prevalence of pressure sores in this study is that, as a general rule, they may have a more extensive and reliable social support system. Further investigation into the relationship between social support and PUs is warranted. The other factor that was signicantly associated with the presence of at least one PU in the last year was etiology. Our results indicated that individuals with SCI due to non-violent, non-motor vehicle related causes were more likely to report a PU. We are unsure of the relevance of this result. Only one other study has identied etiology as a risk factor for PU development and, in that study, individuals with SCI due to violence were more likely to develop PUs. The present study is also one of the rst to explore two categories of barriers to the treatment of PUs and to examine racial-ethnic differences in relation to these barriers. The rst category contained 5 barriers to staying in bed as needed in order to heal a PU. Racial-ethnic differences in endorsement rates were present for 3 of the 5 barriers including needing someone to stay with them, not having enough money to pay for extra attendant help, and boredom. Overall, Hispanic subjects reported the lowest or second lowest endorsement rates for all three of these barriers while Caucasians reported the highest or second highest endorsement rates for all three of these barriers. These barriers can be interpreted as barriers associated with a lack of social support and Hispanics were least likely to cite these as obstacles to treatment. Therefore, these data provide additional support to our hypothesis that the low prevalence of PUs in Hispanics may be partially due to signicant differences in social support. The second category of barriers examined in this study included 4 potential barriers to seeing a physician for treatment of a PU. Racial-ethnic differences were observed in 2 of these; not having enough money or

L.K. Saladin and J.S. Krause / Pressure ulcer prevalence and barriers to treatment after spinal cord injury

65

insurance and not having transportation. In contrast to the social support barriers above where Caucasians had the highest or second highest rates of endorsement, Caucasians were the least likely to endorse these barriers with low rates also reported by Hispanics. Findings from a recent study suggested that immediate physician visits when a PU is rst detected may result in the reduction of PU severity and possibly enhanced prevention behaviors to prevent recurrence [12]. Therefore, the decreased likelihood of barriers to physician access reported in this study by Hispanics and Caucasians may contribute to the lower prevalence rates for PUs for these two groups when compared to AfricanAmericans and American-Indians. In summary, this study, which was the rst to specifically recruit adequate and equal samples of minorities with SCI including American-Indians, provides initial data suggesting the presence of racial-ethnic differences in the prevalence of PUs. In addition, we identied several factors that may potentially contribute to these differences including the level of social support available and barriers to treatment for PUs that also varied by race-ethnicity. 4.1. Implications Pressure ulcers represent potentially preventable secondary complications post- SCI that are associated with increased medical costs, rehospitalizations, infections, and even increased mortality. Racial-ethnic differences in the prevalence of PUs may contribute to racial-ethnic differences in the overall mortality and morbidity rates post-SCI and should be further examined in order to enhance prevention and treatment targeted at reducing these differences. 4.2. Limitations

4.3. Future research Future research would be enhanced with larger samples of minorities that include Asians. In addition, comprehensive studies identifying all major risk factors for the development of PUs are critical to the development of treatment strategies to reduce the number and impact of PUs. This line of research could lead to the elimination of racial-ethnic differences in both prevalence and outcomes associated with PUs and to a signicant reduction in health care costs associated with PUs for all individuals with SCI.

Acknowledgements This research was supported by eld initiated grants #H133G20200-93 and #H133G050165 from the National Institute for Disability and Rehabilitation Research (NIDRR) of the Ofce of Special Education and Rehabilitative Services (OSERS), the United States Department of Education. The author would like to thank the following people, without whose contributions completion of this article would not have been possible: Rodney Adkins, Lynne Broderick, Susan Charlifue, Jennifer Coker, Sarah Lottes, Karla Reed, and Zachary Sutton.

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There were four primary limitations of the current study. First, this study is somewhat limited in power which is an inherent problem in doing investigations with underserved populations. Second, although we investigated four different racial-ethnic groups, we were unable to obtain a sufcient number of Asian Americans for comparative analyses. Third, race-ethnicity was confounded with geographic region (i.e., AfricanAmericans from the southeast; American-Indians from the mountain regions; and Hispanics from the Western United States). This trend is also seen in the general population.

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