Using the Working Model of Adjustment to Chronic Illness to explain the burden of recurrent urinary tract infection: A survey-based study
Authors: Maxwell K , Roberts L , Kramer M , Finlay K 
Published: March 2021

Abstract

Introduction
The treatment of recurrent urinary tract infection (RUTI) with antibiotics is causing concern as patients are often prescribed an inappropriate course of antibiotics, and the recurrence rate remains at 30–44% following treatment (1). Overprescription of antibiotics can also cause antimicrobial resistance. Given the current lack of adequate clinical guidelines for RUTI treatment, it is necessary for this population to adjust to living with a chronic condition, and research suggests that RUTI may be associated with poor mental health and a lower quality of life. Thus, there is a need for a more interdisciplinary approach to understanding RUTI, to inform additional treatment options.

Aim
The current study aimed to use the Working Model of Adjustment to Chronic Illness (WMACI) (see Figure 1) to explore the personal, physical and social burden of RUTI (2).

Methods
A cross-sectional survey was employed, which was informed by existing questionnaires and reviewed by experts including pain specialists (n = 6). 5,078 participants accessed liveutifree.com to seek information regarding their condition and completed the Live UTI Free survey. Participants provided information on their experiences with RUTI (recurrence rate, symptoms, pain intensity, triggers and comorbidity) and the associated burden. Binomial logistic regressions were conducted to assess the effect of RUTI characteristics on the likelihood of experiencing personal, physical and social burden.

Results
RUTI predicted greater likelihood of personal burden (enjoyment of life; enjoyment of favourite activities; mental health) (R² = 18.8 – 20.8, p = &lt;.001), physical burden (sleep; activities of daily living; maintaining a healthy lifestyle; sexual behaviour) (R² = 21.1 – 35.9, p = &lt;.001), and social burden (normal work; finances; relationships with friends and family; relationships with partners) (R² = 17.0 - 25.8, p = &lt;.001), with the burden associated with sexual behaviour showing the largest amount of variance. Rate of recurrence, symptom burden, pain intensity, and having an additional diagnosis of Interstitial Cystitis (IC) were most predictive of participant burden.

Conclusion
RUTI was associated with all areas of burden. Some factors, including pain intensity and having an additional diagnosis of IC, affected a majority of areas. Predicted burden from having an additional diagnosis of IC may be a result of lack of clarity between the two diagnoses, which have shared symptom indicators and rely on urine culture testing, which has been demonstrated to be inaccurate. Misdiagnosis, or a dual diagnosis, may consequently contribute to burden. The WMACI was used to suggest how burden can lead to poor illness adjustment. Limitations of the study were that it did not explore the possibility of misdiagnosis and its impact, or investigate the effects of SES and country-level differences. However, the findings of the study have important clinical implications, as patients worldwide who are suffering with RUTI are required to manage significant burden that is associated with the condition, and this is an important issue which needs to be addressed in primary care settings. An interdisciplinary approach in primary care settings is recommended, which acknowledges the psychosocial burden that persists when treatment fails to resolve physical symptoms.

References
1. Gupta K, Trautner BW. Diagnosis and management of recurrent urinary tract infections in non-pregnant women. BMJ (Online). 2013; 346: f3140.
2. Moss-Morris R. Adjusting to chronic illness: Time for a unified theory. British Journal of Health Psychology. 2013; 681–686.