Results of a One-Day, Descriptive Study of Quality of Life in Patients with Chronic Wounds

  Quality of life (QoL) is a vague, ethereal construct that reflects an individual’s perspective on life satisfaction regardless of the situation – a subjective phenomenon that can be measured only by the patient.¹ Patient QoL can be profoundly altered by the presence of a wound.² Despite optimum care, many wounds will not heal expediently; due to inherent alterations in their pathophysiology, wounds may become chronic and healing protracted, variable, and non-uniform.³ It may be clear from the onset that wounds in some patients are unlikely to heal or that healing is not the priority of care. In such situations, QoL becomes a particularly important part of the care plan.   Quality of life in an individual with a chronic wound incorporates such variables as pain and suffering, financial healthcare costs, strain on personal resources, and overall impact of the wound on life and activities of daily living. Observing these variables, the authors conducted a 1-day descriptive study to assess the effect of chronic wounds on various aspects of patient quality of life.

Material and Methods

  A 1-day, descriptive study was conducted among 50 consecutive patients with chronic wounds attending the wound clinic of the University Hospital in Varanasi, India. This study was a continuation of a previously published pain study⁴ and included the same study population. This study was approved by the ethics review committee of University Hospital, Banaras Hindu University, Varanasi, India. The study and questionnaire were explained to all participants. While volunteers had participated in other pain studies, the questionnaire for this study had not been administered before. In this situation, the questions were read to the participants and a volunteer recorded the answers.

  A short (six segments comprising two to six statements each), easy-to-use questionnaire was developed for implementation in a range of healthcare settings for both research and clinical practice. (Demographic information had been collected as part of a previous study.) The questions/indicators were compiled based on the authors’ observations of variables influenced by the presence of a chronic wound: physical activities, feelings (ie, overall emotional status), household duties, leisure time activities, social relations, and general activities (see Table 1). Questions related to the variables were answered using a five-point rating scale (1= completely disagree to 5 = totally agree).

  The scores for each of the 50 patients were added and the mean value for each of the six sections of the tool was obtained by statistical analysis. Scores above the mean (17±3) were classified satisfactory and those below the mean unsatisfactory. The actual mean for each of the six scores coincidentally equaled 17.

  The study group was further divided into three classes based on participant age: young (<30 years old), middle-aged (30 to 60 years old), and old (>60 years). Wound size was divided into three categories: small (<10 cm²), medium (10 to 50 cm²), and large (>50 cm²). Descriptive statistics were used for demographic variables and z-test and Fisher’s exact test were used to test differences between the proportions.

  Other QoL measurement tools are the 36-item Medical Outcomes Short Form Health Survey (SF-36); EuroQol (EQ); McGill Short Form Pain Questionnaire (SF-MPQ) and the Frenchay Activities Index (FAI).⁵ These scales were not used due to technical problems.

Results

  The study group comprised 50 patients (64% men, 36% women). Patient age ranged from 14 years to 78 years; according to the age classification, 16% were young, 50% middle-aged, and 34% old. The most common wound site was the lower limbs (78%), followed by upper limbs (12%) and head, neck, and trunk (10%). Overall, diabetes mellitus (38%) was the leading underlying cause of wounds, followed by venous disease (26%), pressure ulcers (18%), and tuberculosis (8%). Lower leg wounds most commonly were the result of diabetes; head, neck, and trunk wounds were caused by diabetes (6%) and tuberculosis (4%). Wound size was classified as small (46%), medium (34%), and large (20%).

  Overall, patients rated physical activities (54%), feelings (52%), social relations (54%), household activities (52.6%), leisure time activities (64%), and general activities (56%) unsatisfactory (see Table 2). Middle-age participants had higher proportions of satisfactory scores for physical activities, feelings, and social relations than young or old participants (P <0.05 and P <0.01, respectively). The proportion of middle-aged patients with satisfactory scores for leisure time, household duties, and general activities was higher than in old patients (P <0.05) (see Table 3). The proportion of men whose QoL score was satisfactory with regard to physical activities, leisure time activities, and general activities was higher than in women (P <0.05); whereas, the latter enjoyed an overall better quality of life (P <0.05) in terms of household duties (P <0.001) and social relations (P <0.05) (see Table 4). Compared to patients with medium or large wounds, the proportion of patients whose QoL score was satisfactory was higher in the following domains: physical activity (P <0.05), household duties (P <0.01), feelings (P <0.05) and social relations (P <0.05) (see Table 5). More patients with wounds located over the lower limbs rated physical activity, feelings, household duties, social relations, and general activities unsatisfactory than patients with wounds on their upper limbs. By contrast, the number of patients with an unsatisfactory QoL score for social relations and leisure time activities was higher when the wound was located on the head and neck than in other parts of the body (see Table 6).

Discussion

  Health-related QoL refers to the “impact of disease and treatment on disability and daily living, or as a patient-based focus on the impact of a perceived health state on the ability to lead a fulfilling life.”⁶ In 1993, Patrick and Erickson⁷ defined QoL as the “value assigned to the duration of life and modified by impairments.” In a study of patients with chronic wounds, Franks and Moffatt⁸ noted that when an individual with a chronic wound is feeling ill, he/she likely is experiencing “feelings of pain and discomfort or change in usual functioning and feeling.” This is the core consideration in health-related quality of life: the individual’s sense of well-being is the most important factor, not what a healthcare provider might determine it to be.⁹ Culture also influences the patient’s perception of QoL.⁸

  A wound is defined as a disruption in the integrity and function of body tissue; having a wound implies imperfection, which impacts physical and emotional vulnerability.¹⁰ Any visible wound leads to greater emotional or psychological trauma than a wound on location that is not typically visible because of the feelings of shame and embarrassment that might occur.

⁸   Studies have shown that patients with chronic wounds have a decreased QoL^11,12: Phillips et al¹¹ conducted a subjective/descriptive study in 73 patients with chronic leg ulcers (two groups: persons with venous ulcers and younger patients) and Franks and Moffatt¹² studied 473 patients with venous ulcerations. Various factors have been implicated in decreased QoL: frequency and regularity of dressing changes that affect daily routine; continued fatigue due to lack of adequate sleep; restricted mobility; pain; wound infections; and social isolation. The requirements and consequences of having a chronic wound also have an enormous impact on the patient’s social life. The loss of independence associated with functional decline can lead to several, sometimes subtle, changes in overall health and well-being: altered eating habits, depression, social isolation, and a gradual reduction in activity levels. These factors, along with immobility, not only increase the likelihood of additional wounds, but also exacerbate their severity and jeopardize their ability to heal.³

  In the present study, it was observed that the proportion of participants with satisfactory QoL scores for physical activities and social relations was higher in middle-aged patients than in younger or older patients. The proportion of middle-aged patients reporting satisfactory leisure time, household duties, and general activities was also higher than in older patients. Philips et al’s study¹¹ demonstrated more negative emotions related to their ulcers and mobility in middle-aged than older individuals (P <0.001). Older individuals were found to be more able to cope effectively with their limitations and disabilities than younger study participants. Similar findings were reported by Franks and Moffatt⁹ in their study. In a cross-sectional study of age- and gender-matched leg ulcer patients (n = 758) that used the Nottingham Health Profile, younger men reported poorer QoL than older men. Conversely, age was not found to be a statistically significant QoL factor in a descriptive study of 63 chronic leg ulcer patients.^6,13

  The present study showed that the proportion of men with satisfactory QoL scores was higher than in women in terms of physical activities, leisure time activities, and general activities; whereas, more women than men had satisfactory feelings, household duties, and social relations QoL scores. Reported effects of gender on QoL are inconsistent in the literature. In a retrospective study¹³ of 758 leg ulcer patients, women were found to have lower QoL scores than men. Results vary with gender in relation to specific factors. When pain and physical mobility were considered as part of a 125-person subjective study of patients with chronic leg ulcers, QoL scores were lower in men than women,¹⁴ and with regard to vitality and social and physical functioning, women had lower QoL scores than men.⁶ Overall, in the general non-wound population, average women’s QoL scores are lower than those of men, particularly in older age groups. Thus, poorer QoL scores in women with ulcers may be more closely related to gender than to the ulcers.⁹

  Wound size also influenced patient QoL. The proportion of patients with satisfactory quality-of-life scores related to physical activity, household duties, feelings, and social activities was higher in patients with small wounds than in patients with larger wounds. Compared to patients with upper limb wounds, more patients with lower limb wounds had below-average QoL scores for physical activity, feelings, household duties, social relations, and general activities’ parameters while the number of patients with unsatisfactory QoL scores for social relations and leisure time activities was higher in patients with head and neck wounds than in patients with wounds in other locations. These effects of lower limb wounds on QoL have previously been reported. Franks et al¹⁵ evaluated QoL in 118 patients with chronic venous leg ulceration using the SF-36 questionnaire and observed that patients with leg ulcers had significantly lower mean scores than age-sex adjusted normative published scores in the following domains: role-emotional, social-functioning, role-functioning, role-physical, and bodily pain. In an in-depth analysis of patients’ experience with foot ulcers, Ashford et al¹⁶ observed that the majority of patients expressed problems with footwear, working life, pain, mobility, and relationships.

  While the absence of a control group limits ability to interpret the findings of this study, results are consistent with previously published studies. The instrument will benefit from further use and assessment of its reliability to provide an accurate picture of patient QoL. Most important will be clinician utilization of the information obtained to respond to QoL issues in their patients.

Conclusion

  The results of a prospective, descriptive study of 50 outpatients with chronic wounds suggest that the presence of a chronic wound affects physical, psychological, emotional, and social QoL parameters. Although clinicians cannot change these factors, awareness of the effect of the wound should be enhanced and this knowledge used to improve approaches to care, particularly when full healing is not a realistic expectation. Studies assessing the effects of wound management on patient QoL are needed.

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