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Health maintenance is a critical factor that contributes to the quality of life of persons with spinal cord injury (SCI). While rehabilitation professionals can do much to influence a person’s health maintenance efforts through interventions such as routine clinical monitoring, the person's own health behaviour is equally important, if not more.

Health behaviour has two essential components – risk behaviour and protective behaviour, each of which may be present to varying degrees in the same person. Under ideal circumstances in a rehabilitation setting, a person's risk behaviour is kept at a minimum while protective behaviour is maximized. However, promoting health behaviour in the context of health maintenance is challenging for everyone. Ultimately, the final responsibility for health behaviours lies with the person him-or herself.

Health behaviour is especially important in the prevention of pressure ulcers (PUs), a serious and potentially life-threatening complication of SCI. PUs offer a good example of a secondary health condition that is significantly dependent upon a person's health behaviour. Risk behaviours such as smoking can increase the chances of developing PUs. Accordingly, protective factors include leading a healthy lifestyle and proper nutrition.

Monica’s case is instructive in that it illustrates the challenges faced by rehabilitation professionals when focusing on health maintenance, including the implementation of preventative strategies and strengthening a person's own health behaviour, as an approach toward dealing with PUs.

""Risk behaviours such as smoking can increase the chances of developing PUs.""

Although Monica's surgery and the treatment of existing PUs were successful, the rehabilitation team felt that Monica was not “taking ownership” of her health condition and rehabilitation. This was apparent during the assessment phase of the Rehab-Cycle® when she indicated that her main issues lie primarily in restrictions in her body functions, and activities and participation. She did not acknowledge what her rehabilitation team had perceived as an important factor that contributed to the problems she was facing in health maintenance – her own health behaviour.

""Health maintenance...contributes to the quality of life.""

In general, progress in improving Monica's health behaviour was disappointing. Given her addiction to cigarettes, unwillingness to give up smoking and an overall limited effort in looking after her health, Monica seemed to reflect the high risk, low protective behaviour group outlined in Krause's bi-dimensional model of health behaviour.4 Her rehabilitation team felt that low levels of disease acceptance, self-responsibility and health behaviour in general were significant personal factors that put Monica at risk for developing PUs. The team had a feeling they would be seeing Monica again.

Recurring PUs could certainly be one symptom that suggests a lack of acceptance of the patient’s paralysis. Although Monica had formulated her goal as ‘going home with a completely healed ulcer’, to reach this there are certain requirements that have to be fulfilled...And I know that for someone like Monica, having to undergo psychological counseling is a difficult requirement. When I consider her biography and her overall case, I think she’ll likely return at some point with another ulcer. I really see psycho-therapeutic counseling as one important opportunity that will help her develop behaviours that promote ‘looking after herself’.

Monica's physician

In re-evaluating Monica's case, the rehabilitation team agreed that the Rehab-Cycle® might have achieved a better outcome if it proceeded slightly different. They would have placed more attention on aspects of ‘looking after one's health’, and they would have engaged Monica more in the goal-setting process. In addition, they would have considered setting ‘looking after her health’ as an overarching service-program goal rather than as a specific cycle goal. This may have lead to better preventative health behaviour.

""...low levels of disease acceptance, self-responsibility and health behaviour in general were significant personal factors that put Monica at risk for developing PUs.""

Lastly, more time and energy would have been reserved to support and strengthen Monica’s responsibility and management of her own health, that in turn, was expected to contribute greatly to preventing future PUs. In the event of an unfortunate return visit, Monica’s rehabilitation team will ensure that the Rehab-Cycle® takes a slightly different path than in the past.