Literature Review & Critique: Abstract and Commentary on a Study Regarding the Role of Personal Behavior on the Development of Pressure Ulcers in SCI
Marylou Guihan, PhD
Clark, F. A., Jackson, J. M., Scott, M. D., Carlson, M. E., Atkins, M. S., Uhles-Tanaka, D., Rubayi, S. (2006) Daily-living contexts of adults with spinal cord injury: Data-based models of how pressure ulcers develop in daily-living contexts of adults with spinal cord injury. Archives of Physical Medicine and Rehabilitation, 87(11):1516–1525.
Abstract
Clark et al. (2006) used in-depth interviewing and participant observation to examine the influences of daily routine and activity, personal choices, motivating influences, lifestyle challenges, and prevention techniques and strategies on the development of pressure ulcers in adults with spinal cord injury (SCI). They found that ulcers are most likely to develop “when a person with a relatively high-risk background profile is exposed to an equilibrium-disrupting change event that culminates in a specific pressure ulcer risk episode”. Their results highlight the complexity and individualization that characterizes the emergence of pressure ulcers. They recommend that prevention efforts focus on the unique constellation of circumstances that comprise a person’s everyday life.
Commentary
The health care literature has identified over 200 factors that are associated with development of either new or recurrent pressure ulcers. This raises the question: what role does practicing recommended behaviors have in preventing pressure ulcers in persons with SCI? Personal behavior has been promoted as extremely important factor in the prevention of pressure ulcers in persons with SCI. At first glance, it seems clear that there is a relationship between what someone does and what happens – but how clear is that relationship? It is common for those struggling with a health problem (and those around them) to look back and assess how negative outcomes could have been prevented or avoided. We have probably all observed that some individuals who take great care of their health still become ill, while others, even those with poor self-care behaviors, never seem to become sick. So while there appears to be a consensus that a correlation exists between what one does and what happens, it is also clear that r ≠1.0.
Krause et al. (2001) made a strong argument in favor of preventive behaviors as a way to avoid ulcers: “Theoretically, the presence of negative, self-destructive behaviors (e.g., risk taking, alcohol abuse) or the absence of positive, health-promoting behaviors (e.g., good diet, weight shifts) may lead to a greater risk for PU development. [The literature] suggests a relation between both positive health maintenance (responsibility in skin care) and self-destructive behaviors (substance abuse) and PUs…” Later, Krause and Broderick (2004) indicated that “Surprisingly little evidence exists to link behavioral factors to pressure ulcer development. Studies have varied substantially as to the nature of variables, particularly behavioral and psychologic, that are associated with developing pressure ulcers (p. 1257).”
Walter et al. used an interactive data management system to collect self-reported data related to secondary medical complications on 99 SCI veterans reporting to clinics or hospitals. While 38% of their sample reported current problems with pressure ulcers, the frequency of the health behavior of checking risk areas for redness was not significantly different between those with and without current pressure ulcers (97% vs. 88%). Similarly, Krause et al. (1992) failed to find a relationship between prevention strategies and recurrence among 633 SCI persons of whom 83 had a history of recurrent ulcers. Garber, et al. found that persons with SCI are less accurate in describing severe ulcers and ulcers that have progressed in severity after initial detection. They reported that those who took immediate action when an ulcer was detected had described performing more preventive actions. Yet, immediacy and appropriateness of action, knowledge and practice of preventive behaviors were unrelated to severity, progression of severity, and time from detection to clinic visit.
In summary, these studies suggest that current methods of early pressure ulcer detection and prevention are problematic at best. The pressure ulcer literature has been described as being contradictory with regard to assessing risk factors for pressure ulcer development because existing research is limited by heterogeneity in the populations studied (e.g., NH residents, acute vs. chronic SCI), inadequate sample sizes, different ways of defining the dependent measures, and poor or uncontrolled study designs.
In response to these contradictory findings, Clark, et al. adopt an alternative approach and use several different models to describe how the variables that individuals describe combine to affect ulcer development. They begin by interviewing subjects to discuss how ulcers develop in daily-life settings. Factors from the interviews are extracted and classified into five categories of either liabilities or buffering factors: 1) Physical (e.g., physical frailty vs. healthy weight), 2) Health-related (e.g., poor vs. good nutrition), 3) Psychological (e.g., lack of urgency concerning pressure ulcers vs. cautious/ conscientious) and 4) Social/Environmental (e.g., weak vs. strong social support) and 5) Other (e.g., presence or absence of religious support). Five different models are then used to assess these factors: 1) Balance of liabilities and buffers, 2) Individualized risk profile: pie chart, 3) Individualized risk profile: flowchart, 4) Pressure ulcer event sequence, and 5) Pressure ulcer event sequence with temporal comprehensiveness.
These approaches yield different information. For example, the first model (Balance of liabilities and buffers) documents the high degree of prevalence of many of the risk factors in their sample. The pie charts demonstrate that similar factors are involved but may play a different role in different individual’s lives. The unique contribution of this model is that two individuals are profiled and asked to assign weights to the various factors. For example, Robert has >50% liabilities, including substance abuse, depression, lack of education, social support, equipment problems, risk-taking, etc. In contrast, Helen has more things in her favor, including aging skin for which she takes precautions, an accessible neighborhood, availability of care attendants and social support, participation in meaningful activities and a substance abuse problem that is in remission. Models 3-5 demonstrate increasing complexity in the relationship between time and various factors involved in pressure ulcer development. Factors such as a history of previous ulcers which may have been seen as risk factors may actually act as buffers for some individuals but not for others. They also identify potential factors like family problems and decreased vigilance due to overconfidence that have not previously been described in the literature as risk factors.
Clark and colleagues conclude with a suggestion that health care and rehabilitation professionals “can foster successful prevention by helping patients identify and implement lifestyle changes that are considered to be personally feasible within their uniquely experienced set of circumstances. Thus, an optimal intervention should not only incorporate standard prevention techniques such as skin checks or pressure reliefs but also, based on a given patient’s personal profile, direct attention to additional concerns such as self-advocacy skills in accessing medical services, stress management, and the ability to identify an optimal balance between living a full life and avoiding activity-related ulcers.” They also emphasize that preventive behaviors need to be built into everyday activities.
So, at the end of this discussion, can we conclude that prevention behavior still matters? Based on my review of this article as well as my knowledge of associated research, it seems so. Clark and colleagues make a strong argument for the importance of examining the role of behavior in the prevention of pressure ulcers in SCI, suggesting that previous attempts to understand the relationship between health behaviors and the development and prevention of pressure ulcers have been contradictory because the definitions, models, and research designs have been too simplistic. This, in turn, raises methodological and measurement issues which will have to be addressed in future research.
References
Krause, J. S., Vines, C. L., Farley, T. L., Sniezek, J., & Coker, J. (2001). An exploratory study of pressure ulcers after spinal cord injury: Relationship to protective behaviors and risk factors. Physical Medicine and Rehabilitation 82(1):107–113.
Krause, J. S. & Broderick, L. (2004). Patterns of recurrent pressure ulcers after spinal cord injury: Identification of risk and protective factors 5 or more years after onset. Archives of Physical Medicine and Rehabilitation 85. 1257–1263.
Krause, J. S., & Kjorsvig, J. M. (1992) Mortality after spinal cord injury: A four-year prospective study. Archives of Physical Medicine and Rehabilitation, 73, 558–563
Garber, S. L., Rintala, D. H., Rossi, C. D., Hart, K. A., & Fuhrer, M. J. (1996). Reported pressure ulcer prevention and management techniques in persons with spinal cord injury. Archives of Physical Medicine and Rehabilitation, 77, 744–749.
Rintala, D. H. (1995). Quality-of-life considerations. Advanced Wound Care 8, 71–83.
Marylou Guihan, PhD, is a research health scientist at the Midwest Center for Health Services at Edward Hines VA Hospital, Hines, Illinois. Comments and suggestions are welcome: marylou.guihan@va.gov.