Volume 27 Number 1

Key messages

• This paper highlights the significant impact of psychological wellbeing on delayed wound healing, emphasising the need for a more structured approach to assess its role in patient outcomes.
• The goal of this paper is to explore the psychological dimensions of delayed wound healing, identify gaps in current research using Ryff’s model as theoretical framework to improve understanding and guide future studies.
• Current research often overlooks key aspects of psychological wellbeing (such as self-acceptance and purpose) in wound care, emphasising the need for comprehensive, large-scale studies to better understand these factors and develop effective interventions.

Introduction

Background

Chronic wounds affect 2.21 per 1000 people globally and 2.5% of the U.S. population, and pose a significant health and economic burden, costing the U.S between $28.1 to $96.8 billion annually.^1,2 In 2017/2018, the NHS managed 3.8 million patients with wounds, 30% of whom had non-healing wounds, occupying up to 40% of hospital beds.^3,4 The management of chronic wounds costs the UK’s NHS £5.6 billion annually, accounting for a significant portion of the total £8.3 billion spent on wound care.⁴ Common wound types like pressure ulcers, diabetic foot ulcers, arterial foot ulcers and venous ulcers^5,6 are often defined as chronic, if these wounds fail to heal in 12 weeks.^7–10 However, the term “hard-to-heal wound” proposes an earlier timeframe of four weeks to consider delayed wound healing (DWH) with the aim of improving outcomes.⁶

Beyond physical factors, like demographics and comorbidities,^4,6,11,12 psychological wellbeing increasingly appears central to wound healing.^13–16 Pain, exudate and odour from wounds contribute to body image issues, sleep disruption, low mood, immobility, social isolation and lost income, exacerbating psychological distress.^13,17–21 Emerging evidence reveals a vicious cycle: poor psychological states like depression, anxiety and stress may delay healing, while DWH worsens mental health.^18,22–25

However, despite the growing burden of psychological wellbeing on DWH, research in this field is limited by inconsistent tools and lack of standardised assessments.^26–28

Objectives

This scoping review aimed to systematically map existing research on factors influencing psychological wellbeing in individuals with DWH. By exploring the components of psychological wellbeing assessed and the factors affecting these outcomes, this review will inform future research and guide the development of effective interventions.

Research questions

Two primary research questions guided this study:

• What components of psychological wellbeing have been evaluated in people with DWH, and how have these been measured?
• What internal and external factors protect or threaten the likelihood of poor psychological wellbeing in people experiencing DWH?

Methods

Protocol and registration

This scoping review protocol was registered in the Open Science Framework (OSF) at https://osf.io/mexds/ in adherence to JBI guidance to enhance transparency and reproducibility.²⁹ Reference: DOI: 10.17605/OSF.IO/MEXDS. This review was reported based on the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR).³⁰

Eligibility criteria

This review included studies where individuals had an active wound lasting at least four weeks, from multiple wound aetiologies, and mentions aspects of psychological wellbeing. Active wounds were exclusively included to prevent recall bias stemming from past experiences that are no longer ongoing³¹ and wounds of four week duration represents the lower cut-off for classifying delayed wound healing.³² Studies excluded paediatric populations due to psychological concepts being influenced by their carer’s wellbeing³³ and unreliable measurement tools for this age group.³⁴ Some wound types,  such as burns, fungating or malignant wounds and patients with amputated limbs were excluded due to either the focus palliative care has on psychological wellbeing³⁵ or the psychological impact of amputation overshadowing the psychological impact of wound care and wound healing.^36,37

This included studies from any empirical research, peer-reviewed articles and grey literature written in English only and published between 2015 and 2024. Commentaries, case reports, letters, opinions, feasibility or psychometric studies, were also excluded. A full list of excluded studies can be found in the supplementary materials.

Information sources

Searches spanned Scopus, MEDLINE, CINAHL, EMBASE, ProQuest Global and PsycINFO. Grey literature was sourced from ProQuest Dissertations and Theses to counter publication bias.³⁸ Citation searching was equally employed to identify relevant studies. The date of the last search was 23 August 2024.

Search strategy

Boolean operators, truncations and keywords were used to combine terms related to wound population (FACET 1) and psychological wellbeing concept (FACET 2) as shown in Table 1. The search was limited to titles, full-texts and studies reported in English language in the last 10 years (2015–2024). A full electronic database search from MEDLINE can be found in the supplementary materials.

 

Table 1. Search strategy used for the literature review

 

Study selection

Studies were managed in COVIDENCE and duplicates were removed. A two-stage screening process (title/abstract, full-text) applied inclusion and exclusion criteria.

Data extraction and charting

One reviewer extracted data using the JBI-adapted form.³⁸ The selection was verified by a second reviewer. The agreed-upon data was then compiled into a final document.   

Data items

Extracted data included author, year of publication, country, healthcare setting, methods (such as qualitative, randomised controlled trials), wound type/s, demographics, instruments used to capture psychological wellbeing, study limitations and psychological constructs. These psychological constructs, where charted, related to specific diagnoses (such as anxiety, depression, mood disorders), patient reported psychological outcomes (such as quality of life), and dimensions of psychological wellbeing based on Ryff’s model.³⁹ Carol Ryff’s model of psychological wellbeing, encompassing dimensions like autonomy, environmental mastery, personal growth,positive relations, purpose in life and self-acceptance, offers a valid framework to explore these dynamics³⁹ and formed the basis of the data synthesis. Full quotes from the articles addressing each of Ryff’s psychological wellbeing dimensions can be found in supplementary materials.

Critical appraisal of individual sources of evidence

Scoping reviews aim to map existing literature, identify gaps and inform future research, and therefore, rigorous appraisal of study quality is unnecessary.²⁹ However, study limitations reported by authors were highlighted and discussed.

Synthesis of results

A deductive approach, grounded in Carol Ryff’s psychological wellbeing framework was used.^39,40 Ryff’s model, was chosen because it’s development was underpinned by the eudaimonic theory of psychological wellbeing which emphasises meaning and purpose,⁴⁰ compared to hedonic theory which focuses on immediate pleasure and satisfaction.⁴¹ Eudaimonic theory facilitates a thorough examination of long-term psychological resilience and coping strategies, shedding light on how individuals navigate challenges and find deeper purpose amid extended healing processes.³⁹ Contrarily, hedonic theory, fixating on short-term pleasures, might mislead researchers by overlooking the profound emotional complexities and transformative experiences that patients enduring delayed healing encounter.  The deductive approach chosen could lead to bias as it limits flexibility in the analysis by oversimplifying complex phenomena, making it difficult to accommodate unexpected data, and increasing the risk of overlooking alternative explanations.⁴²  Nonetheless, a deductive approach is recommended when a study does not aim to develop a theory or conceptual framework but uses an existing theory for content analysis.⁴² Due to the broad scope of psychological wellbeing, the deductive approach was chosen as it enables a focused exploration of existing concepts⁴³ on psychological wellbeing in patient with DWH.

Findings

Selection of sources of evidence

In total, 497 studies were included (480 from the database search and 17 from citation searching). A total 47 studies were included, as shown in Figure 1. A total of 155 duplicates were removed, 136 articles removed for irrelevance, 12 full text articles were not accessible and 147 studies were removed as they did not meet the eligibility criteria.

 

Figure 1. PRISMA flowchart for the studies included in the scoping review.

 

Characteristics of sources of evidence

Studies spanned from 2016–2023, with most studies (n=10, 21.7%) from the year 2017 and fewest in 2019 and 2023 (each n=4, 8.7%). Most studies involved patients with mixed ulcer aetiologies (n=22, 46.8%), followed by venous ulcers only (n=16, 34%) and diabetic foot ulcers only (n=7. 14.9%). Most studies were conducted in Asia (n=15, 31.9%). The single most common country where studies originated was Brazil (n=11, 23.4%). There were no studies from the African continent. Most studies used quantitative methodologies (n=40, 89.4%), cross-sectional design especially. A total of 6113 patients were evaluated in the included studies. For studies reporting gender (n=43 studies, 6040 patients), males predominated (n=3175, 52.6%). The least number of patients included was 16 and the greatest number was 618. In 18 of the 45 studies (40%) using quantitative tools, the most common tool used was the Short Form Health Survey (SF-12 and SF-36).

Results of individual sources of evidence

The results from individual studies can be found in Table 2 while the psychological dimensions reported to be affected in each study has been captured in Table 3.

 

Table 2. Summary of individual sources of evidence

Table 2. Summary of individual sources of evidence (continued)

Table 2. Summary of individual sources of evidence (continued)

Table 2. Summary of individual sources of evidence (continued)

Table 2. Summary of individual sources of evidence (continued)

Table 2. Summary of individual sources of evidence (continued)

Table 2. Summary of individual sources of evidence (continued)

Table 2. Summary of individual sources of evidence (continued)

Table 2. Summary of individual sources of evidence (continued)

Table 2. Summary of individual sources of evidence (continued)

Table 2. Summary of individual sources of evidence (continued)

Table 2. Summary of individual sources of evidence (continued)

 

Table 3. Psychological outcomes measured, and Ryff’s psychological dimensions affected

Table 3. Psychological outcomes measured, and Ryff’s psychological dimensions affected (continued)

 

Critical appraisal of studies

Study limitations were not reported in nine studies. Most studies reported small sample sizes^{50,55,60,77,79} as a limitation as this reduced statistical power, risking underestimation of psychological impact. Convenience sampling and single centre designs^45,56,70,71 limit representativeness, with exclusion of some people (such as non-English speakers⁴⁵) or homogenous groups (such as 95% white British⁴⁶) overlooking cultural influences on mental health. Cross-sectional designs^51,55,64,90 preclude causality, critical for understanding dynamics of mental health and wound chronicity, while short follow-up periods⁵⁶ miss long-term psychological trends.

Non-specific tools (such as DLQI, EQ-5D)^44,49,54,61 fail to capture wound-specific psychological burdens, with short recall periods causing an underestimation of cumulative distress.⁴⁴ Self-reporting biases, exacerbated by visual difficulties⁶⁸ or the presence of significant others,⁴⁶ distort wellbeing estimates. Missing data,^48,62 uncontrolled confounders (such as comorbidities^52,62) and secondary analyses⁴⁸ further weakens validity. Contextual factors, like specialised versus non-specialised settings,^81,91 exclusively urban settings, socioeconomic gaps,^56,71 and systemic differences (such as Germany’s low direct patient costs⁹¹), also introduce biases unaddressed in many studies.

Synthesis of results

The majority of the 45 empirical studies were conducted in hospital settings, with a minority in community settings and none reported in rural areas. Of the eight randomised controlled trials, all explored the potential of medical treatments in reducing pain or hastening healing. None evaluated a psychological intervention.  Autonomy was the most reported dimension (n=32 studies) while personal growth and self-acceptance were the least captured dimensions (n=5 studies each). The proportion of psychological dimensions addressed in literature has been mapped in Figure 2.

 

Figure 2. Tree map of the hierarchy of Ryff’s psychological dimensions addressed in patients with delayed wound healing.

 

Figure 3. Schematic representation of explanatory factors associated with psychological wellbeing in patients with delayed wound healing

 

This review analysed the literature to understand the wound’s impact on individuals’ autonomy, environmental mastery, personal growth, purpose in life, self-acceptance and positive relations with others.

AUTONOMY

Autonomy, defined as an individual’s sense of independence, self-determination and freedom of choice,³⁹ was the most addressed dimension (n=32/47, 68.7%) in the studies reviewed. Patients’ autonomy was significantly impacted by pain, mobility limitations, daily activity restrictions, fatigue and sleep disturbances.

Pain, itching and wound-related physical symptoms

Lowest scores in quality of life have been reported in patients with wound-related physical symptoms.^56,68 Pain, a pervasive symptom in delayed wound healing, was described as a constant, overwhelming, and worsened by procedures, like dressing changes and debridement.⁸⁸ It is a widely reported issue^46,50,90 with up to 34.6% of patients experiencing severe pain.⁶⁹ Pain notably disrupts quality of life (QoL),⁷⁸ with older patients with venous ulcers reporting higher pain levels than younger patients with other wound types.⁷³ Pain correlates with lower QoL scores⁹² and affects physical functioning,^64,76 explaining 12.5% of physiological QoL variance.⁷² Treatments like hyperbaric oxygen therapy⁸⁷ and nano-oligosaccharide factor⁵⁴ have shown success in pain reduction. Younger patients and those with wounds of venous origin report more pronounced physical symptoms.^58,85 Oedema (48%) and itching (20%) are also common complaints, with oedema linked to increased pain.^45,55

Mobility and activities of daily living

While some studies suggest physical symptoms and daily living are less impacted than other domains,^56,63 others identify them as the most affected QoL aspects.^50,79 Leisure activity limitations were reported by 45.7% of patients due to wounds.⁵³ Cunha et al⁴⁴ found 73.4% experienced autonomy and daily activity limitations, with nearly 50% dependent in at least one activity. Increased dependency on others rises with disability,^45,46 though independent mobility improves physical QoL scores.⁴⁹ Wound relapse and durations exceeding six months worsen daily life evaluations and heath-related QoL (HRQoL) related to mobility.^81,85 Younger patients and those with venous leg ulcers face greater physical functioning impacts,^62,81 while diabetic foot ulcers show the most severe mobility impairments.⁹¹ Depression, coping style and education level explain 51.7% of daily living variance,⁸² with depressed patients showing poorer physical functioning.⁵¹ Pain-induced stress further disrupts daily activities.⁶⁹ Hyperbaric oxygen therapy’s effects on daily functioning are inconsistent, with beneficial⁸⁷ and adverse outcomes⁵⁷ reported, with even placebo interventions demonstrating improved physical functioning.⁶⁵

Fatigue and poor sleep

Excessive fatigue, exhaustion, lack of energy are prevalent in patients with delayed wound healing.⁴⁵ Men with leg ulcers scored higher in vitality than women.⁵⁵ Sleep disturbances, driven by pain, significantly affect QoL,⁷⁸ influencing physical functioning, role limitations, pain and general health.^64,72

ENVIRONMENTAL MASTERY

Explored in 12 studies, environmental mastery involves problem-solving, a sense of control and effectiveness.³⁹ In delayed wound healing, it is shaped by financial circumstances, unemployment, unanticipated events, hygiene challenges and coping mechanisms.

Financial circumstances and unemployment

Patients have reported that the financial implications associated with delayed wound healing are massive as the wounds led to a point where borrowing from friends and family was not possible anymore, making them preoccupied about immediate and longer term financial pressures.⁴⁶ Pain control was linked to economic hardship.⁸⁸ Better financial status was correlated with improved wellbeing,⁹⁰ while lower socioeconomic status worsens QoL,⁷⁹ as higher income may enhance access to care and potentially expedite the healing process.⁹⁰

Zhu et al⁴⁵ reported that most patients with delayed wound healing are employed. However, unemployment later affects many patients,⁴⁵ with some authors reporting up to 80% of patients abandoning their work.⁴⁴ Financial strain from unemployment impacts wellbeing.⁹⁰

Unanticipated events, hygiene and coping mechanism

Events such as unpredictable visit timings and the need for unexpected surgeries, can disrupt the normal course of life for patients and their families, leading to feelings of powerlessness, as described by McCaughan et al.⁴⁶  The permanent presence of bandages and difficulty in maintaining personal hygiene causes significant distress to patients.⁴⁴

Acceptance-resignation coping styles negatively affect physical symptoms and social wellbeing.⁸² Patients who felt they had control over pain were better at reinterpreting their pain and had better physical activity levels.⁵⁸

PERSONAL GROWTH

Addressed in five studies, personal growth involves openness to new experiences, self-actualisation and a desire to keep learning.³⁹ It is influenced by positive beliefs and motivation, adaptation to change and education.

Positive beliefs and motivation

Maintaining positivity is challenging amid prolonged healing,⁴⁶ yet some patients strive to maintain a positive outlook to cope with challenges.⁴⁵ Patients who did not accept their illness were unmotivated to keep going.⁶⁴

Adapting to change

Wounds force lifestyle recalibration, altering self-perception and roles as patients need to modify their daily activities and curtail regular recreational and social activities. This requires them to find creative solutions to navigate challenges.⁴⁶

Education and health literacy

Higher educational attainment was associated with better wellbeing outcomes,⁵² however health literacy showed minimal impact on diabetic foot ulcer QoL.⁷⁷

POSITIVE RELATIONSHIPS WITH OTHERS

Covered in 16 studies, this dimension involves intimacy, empathy, trust and affection.³⁹ it is affected by social networks, family, marital status, care consistency and relationships with healthcare providers.

Social networks

Social dimensions are less affected^64,86 as 85.7% of patients with delayed wound healing report good social relationships. Yet, embarrassment from wounds causes isolation,⁹⁰ and this isolation is worsened by depression which causes 49.6% of the variance in social life dimensions.⁸² Pain has been reported to precipitate social isolation,⁸⁸ however ,social support mitigates pain’s psychological impact⁶⁹ as higher support (such as living with others) is linked to better wellbeing.^49,73

Family relationships and marital status

Family relationships are affected as patients feel they are a burden to others because of limited physical functioning and constant requests for assistance from family members.⁴⁴ For this reason, patients sometimes conceal their emotions.⁴⁶ Spouses invalidation was higher in depressed patients⁵¹ and unmarried patients showed increased depression.⁷³

Care consistency and relationship with health care providers

Patients voiced frustrations about variations in nursing approaches and unpredictable visit timings. This led to feelings of helplessness and dissatisfaction.⁴⁶ Conversely, patients expressed satisfaction when there was consistency in care as it fostered positive patient experiences.⁴⁶ Patients felt unheard when the care was rushed and they valued empathetic attention from their healthcare providers.⁴⁵

PURPOSE IN LIFE

Explored in eight studies, this dimension involves having goals, a sense of direction, and feeling like your life matters.³⁹ This dimension was affected by isolation, fear, hopelessness and uncertainty.

Sense of confinement and uncertainty around wound progress

Patients withdraw from the outside world, resulting in a sense of confinement within their own homes.⁴⁶ Treatment dissatisfaction and unmanaged pain breed hopelessness.^63,88 Patients get frustrated with prolonged healing⁴⁵ as this leads to widespread fear of wound worsening.^44,53 The uncertainty and severity of outcomes, such as limb loss, infection, hospitalisation, and even death instilled profound fear, disrupting individuals’ sense of security and purpose.⁷⁷

SELF ACCEPTANCE

Five studies explored the dimension of self-acceptance³⁹ which encompasses self-respect and self-image. Patients experience low mood and depression due to an impaired sense of self from the wound-related incapacity, alongside feelings of social isolation.⁴⁶ Exudate and odour significantly restrict social contacts, leading to adverse impacts on both their social and professional lives, fostering feelings of shame, embarrassment, and heightened anxiety and depression.^44,58 The changes in self-image and self-esteem can evoke feelings of disgust, anguish, and lifestyle constraints, with individuals potentially viewing the wound as a form of punishment from God, emphasising the influence of religiosity/spirituality on quality of life.⁹⁰ Women exhibited notably lower body image scores compared to men, with body image identified as a mediating factor between gender and QoL.⁷⁰

Discussion

This scoping review aimed to answer two questions: 1) What components of psychological wellbeing have been evaluated in wound-care research and how have these been measured? 2) What internal and external factors protect and threaten the likelihood of poor psychological wellbeing in people experiencing delayed wound healing? Most studies were cross-sectional and hospital-based, commonly assessing psychological wellbeing as a sub-dimension of an overall quality of life instrument. The psychological wellbeing dimension most reportedly affected was autonomy.

Psychometric tools predominated, reflecting a broader shift in healthcare towards holistic, person-centred care.⁹³ However, some critics argue that the current mechanical use of these tools deviate from their original intent of person-centeredness.⁹⁴ The Short Form Health Survey (SF-12 items/SF-36 items) was the most commonly used measure, offering physical and mental component summaries. Though widely adopted, its validity as a comprehensive QoL measure has been questioned.⁹⁵

A total of 14 distinct tools were employed to measure psychological wellbeing, re-emphasising the inconsistencies in measuring tools as previously reported in literature.^26,27  Despite the Hospital Anxiety and Depression Scale (HADS) being a validated and widely available tool, none of the studies in this review utilised it. The HADS is validated across diverse populations, available in over 30 languages and assesses both depression and anxiety, which is beneficial given the frequent overlap between these conditions, allowing for separate evaluation of these two disorders.⁹⁶ Moreover, HADS has been reported as a good tool for identifying risk for non-healing, as a score above 14 correctly identified 83.1% of people with non-healing ulcers and 71.2% of people without non-healing ulcers.⁶⁶ The HADS’ adequacy in assessing the full spectrum of psychological dimensions in patients with delayed wound healing remains uncertain, warranting further investigation. To address research inconsistencies and improve research quality, the adoption of core outcome sets may be essential. This has previously been used to capture wound management^97,98 and patient experiences.⁹⁹ Core outcome sets can enhance the quality and efficiency of clinical research in wound care, by standardising reporting and facilitating evidence-based decision-making, thereby limiting the heterogeneity of psychological outcomes.¹⁰⁰

Autonomy, linked to altered mobility and pain, was the most reported psychological dimension affected in patients with delayed wound healing, often diminishing the sense of independence. This prominence partly stems from HRQoL instruments prioritising physical function constructs, especially mobility.¹⁰¹ Conversely, self-acceptance and personal growth dimensions were unexplored. Personal growth is a multidimensional construct which is fully measured only by the Personal Growth Initiative Scale-II (PGIS-II),^102,103 unused in studies included in this review. More research on personal growth and self-acceptance, and the development of interventions fostering these dimensions are needed. Wound characteristics, like high amount of exudates and malodorous wounds impair positive relations, purpose in life and self-acceptance. While some patients have accepted wound odours and exudates as a normal part of their daily lives,¹⁰⁴ others have diminished self-worth, and have lost their usual social dynamics, due to feelings of shame and embarrassment.^44,76 Though multiple wound assessment tools exist, a Delphi consensus study has recommended the use of bacterial burden-based tools,¹⁰⁵ vital in African settings where wounds are significantly colonised by very resistant pathogens.¹⁰⁶ In spite of the fact that healthcare providers have been reported to lack confidence with respect to the current availability and usage of topical interventions to manage odour,¹⁰⁷ the effect of wound odour and exudate on multiple psychological dimensions suggests that efficient interventions managing wound odour and exudate may greatly improve psychological wellbeing.^108–110

Ageing brings with it, grief and isolation, potentially impacting psychological wellbeing,¹¹¹ however, younger patients reported greater alterations in psychological wellbeing,⁹¹ possibly due to differences in lifestyle and disrupted life expectations, as younger patients are generally non-sedentary and enjoy social participation, which are opposed to the older patient’s established routines.^112,113 Gender’s role in psychological wellbeing yielded conflicting evidence,^90,114 with a Spanish study suggesting self-concept traits and personality, outweigh biological sex.¹¹⁵ Arterial and venous ulcers were associated with greater alterations in psychological wellbeing possibly because these wounds are often associated with high symptom burden (such as pain, pruritus’, malodour and high exudate),¹¹⁶ with over half of patients experiencing repeated recurrence within 12 months of healing¹¹⁷ further emphasising the burden of leg ulcers on patients.

Despite evidence favouring community-based nurse-led care,^118,119 hospital-based research still dominates, prioritising accessibility to resources and expertise¹²⁰ but overlooking community and rural psychological needs.¹²¹ Rural residents exhibit poorer health outcomes, engage in less healthy behaviours, and experience higher mortality rates compared to their urban counterparts.¹²² This gap is further highlighted by the lack of studies from the African continent. Moreover, this review did not identify any psychological interventions, which may reflect current evidence but may possibly result from the search limits and focus of this review.

Limitations of this review include the search restrictions, single reviewer data extraction, and the predominance of cross-sectional designs, risking misinterpretation and limiting temporal analysis of factors influencing psychological wellbeing. Also, the capture of psychological wellbeing concepts qualitatively deviates from Ryff’s original quantitative questionnaire, possibly increasing the risk of misinterpretation. Longitudinal studies using electronic health records (EHRs)^123,124 could offer a cost-effective and expedited approach to generating accurate and reliable evidence, leveraging machine learning to analyse trends and personalise interventions.^125–127 Integrating psychological assessments into routine wound care could proactively identify at-risk patients, enabling timely interventions and ultimately improve patient outcomes.¹²⁸

Despite these constraints, this review used a systematic approach and thorough search strategy to retrieve evidence and to the best of our knowledge, is the only study using an established framework, like Ryff’s model, for analysing psychological wellbeing in patients with delayed wound healing, setting a benchmark for future studies.

Conclusion

This scoping review investigated the psychological impact of delayed wound healing, highlighting a complex interplay between physical health and psychological wellbeing. While QoL emerged as a frequently assessed concept, autonomy stood out as the most extensively reported psychological dimension, revealing a disparity in the exploration of other dimensions, like self-acceptance, personal growth and purpose in life.

Implications for clinical practice

• The identified gaps in psychological assessment protocols for delayed wound healing suggest that current practices may benefit from incorporating multidimensional wellbeing measures, particularly those capturing autonomy, self-acceptance, and purpose in life, to better align with patient-reported experiences.
• Emerging evidence on the bi-directional relationship between psychological distress and impaired healing emphasises the potential clinical value of integrating psychosocial support with standard wound care to address this interplay.

Implications for future research

• The substantial heterogeneity in measurement tools observed in this review highlights an urgent need for international consensus on psychological core outcomes, which would enable robust cross-study comparisons and meta-analyses in wound care research.
• The striking geographic disparities in available evidence present a critical opportunity for large-scale, culturally adapted cohort studies to elucidate how socioeconomic and healthcare system factors modulate psychological outcomes in delayed healing.

Acknowledgments

We acknowledge classmates and friends who helped review this work prior to submission: Mr Sylvester Odame-Amoabeng, Dr Meh Martin Geh, Dr Njedock Nelson Sontsa Venceslas.

Author contributions

EMM: Conceptualisation; data curation; writing (original and draft); reviewing and editing. VC: Conceptualisation; validation; project administration; supervision; reviewing and editing. C-DG: Conceptualisation; supervision; project administration; review and editing.

Conflict of interest

The authors declare no conflict of interest

Data availability statement

Data sharing is not applicable to this article as no new data were created or analysed in this study; all supporting data are available within manuscript.

Funding

This project was part of an MRes dissertation funded by the Commonwealth Shared Scholarship. No additional funding was received specifically for this scoping review.

Author(s)

Edgar Mandeng Ma Linwa*¹ MD, Victoria J Clemett¹ PhD, RN, Crina-Daniela Grosan¹ PhD
¹Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King’s College London, UK

*Corresponding author email macadamcity_2007@yahoo.fr

References

Sen CK. Human wound and its burden: updated 2020 Compendium of Estimates. Adv Wound Care. 2021;10:281.

Martinengo L, Olsson M, Bajpai R, Soljak M, Upton Z, Schmidtchen A, et al. Prevalence of chronic wounds in the general population: systematic review and meta-analysis of observational studies. Ann Epidemiol. 2019;29:8–15.

Posnett J, Gottrup F, Lundgren H, Saal G. The resource impact of wounds on health-care providers in Europe. J Wound Care. 2009;18:154–154.

Guest JF, Fuller GW, Vowden P. Cohort study evaluating the burden of wounds to the UK’s National Health Service in 2017/2018: update from 2012/2013. BMJ Open. 2020;10:e045253.

European Wound Management Association (EMWA). Position Document: Hard-to-heal wounds: a holistic approach. London, MEP Ltd; 2008.

Atkin L, Tettelbach W. TIMERS: expanding wound care beyond the focus of the wound. Br J Nurs. 2019;28:S34–37.

Berezo M, Budman J, Deutscher D, Hess CT, Smith K, Hayes D. Predicting chronic wound healing time using machine learning. Adv Wound Care. 2022;11:281–296.

Iqbal A, Jan A, Wajid M, Tariq S. Management of chronic non-healing wounds by hirudotherapy. World J Plast Surg. 2017;6:9–17.

Hess CT. Clinical Guide to Skin and Wound Care. 7th edition. Lippincott Williams and Wilkins; 2012.

Frykberg RG, Banks J. Challenges in the treatment of chronic wounds. Adv Wound Care. 2015;4:560–582.

Tipton CD, Wolcott RD, Sanford NE, Miller C, Pathak G, Silzer TK, et al. Patient genetics is linked to chronic wound microbiome composition and healing. PLoS Pathog. 2020;16:e1008511.

Fife CE, Horn SD, Smout RJ, Barrett RS, Thomson B. A predictive model for diabetic foot ulcer outcome: The Wound Healing Index. Adv Wound Care. 2016;5:279–287.

Woo KY. Wound-related pain: anxiety, stress and wound healing. Wounds UK. 2010;6(4):94–98.

Fino P, Di Taranto G, Pierro A, Kacjulite J, Codolini L, Onesti MG, et al. Depression risk among patients with chronic wounds. Eur Rev Med Pharmacol Sci. 2019;23:4310–4312.

Kloth L. The roles of physical therapists in wound management, part ii: Patient and wound evaluation. J Am Col Certif Wound Spec. 2009;1:49–50.

Basu S, Goswami AG, David LE, Mudge E. Psychological stress on wound healing: a silent player in a complex background. Int J Low Extrem Wounds. 2022;15347346221077571.

van Alphen TC, ter Brugge F, van Haren ELWG, Hoogbergen MM, Rakhorst H. SCI-QOL and WOUND-Q have the best patient-reported outcome measure design: a systematic literature review of PROMs used in chronic wounds. Plast Reconstr Surg Glob Open. 2023;11:e4723.

Gouin JP, Kiecolt-Glaser JK. The impact of psychological stress on wound healing: methods and mechanisms. Immunol Allergy Clin North Am. 2011;31:81–93.

Situm M, Kolić M, Spoljar S. [Quality of life and psychological aspects in patients with chronic leg ulcer]. Acta Med Croatica. 2016;70:61–63.

Henderson EA. Are theories of altered body image applicable to patients with chronic wounds? J Wound Care. 2006;15:58–60.

Klein TM, Andrees V, Kirsten N, Protz K, Augustin M, Blome C. Social participation of people with chronic wounds: A systematic review. Int Wound J. 2021;18:287.

House SL. Psychological distress and its impact on wound healing: an integrative review. J Wound Ostomy Continence Nurs. 2015;40:38–41.

Ousey K, Edward KL, Stephenson J. Exploring quality of life, physical and psychosocial morbidity for patients with non-infected wounds: a pilot study. Wounds UK. 2014;10:30–34.

Platsidaki E, Kouris A, Christodoulou C. Psychosocial aspects in patients with chronic leg ulcers. Wounds. 2017;29:306–310.

Upton D. Psychological aspects of wound care: implications for clinical practice. J Community Nurs. 2014;28:52–57.

Linton MJ, Dieppe P, Medina-Lara A. Review of 99 self-report measures for assessing well-being in adults: exploring dimensions of well-being and developments over time. BMJ Open. 2016;6:e010641.

Moore Z. Review of evidence-based wound management. J Clin Nurs. 2007;16:408.

Renner R, Erfurt-Berge C. Depression and quality of life in patients with chronic wounds: ways to measure their influence and their effect on daily life. Chronic Wound Care Manag Res. 2017;4:143–151.

Pollock D, Davies EL, Peters MDJ, Tricco AC, Alexander L, McInerney P, et al. Undertaking a scoping review: A practical guide for nursing and midwifery students, clinicians, researchers, and academics. J Adv Nurs. 2021;77:2102–2113.

Tricco AC, Lillie E, Zarin W, O’Brien KK, Colquhoun H, Levac D, et al. PRISMA Extension for Scoping Reviews (PRISMA-ScR): checklist and explanation. Ann Intern Med. 2018;169:467–473.

Althubaiti A. Information bias in health research: definition, pitfalls, and adjustment methods. J Multidiscip Healthc. 2016;9:211–217.

Atkin L, Bućko Z, Montero EC, Cutting K, Moffatt C, Probst A, et al. Implementing TIMERS: the race against hard-to-heal wounds. J Wound Care. 2019;28:S1–50.

Brown EA, De Young A, Kimble R, Kenardy J. Impact of parental acute psychological distress on young child pain-related behavior through differences in parenting behavior during pediatric burn wound care. J Clin Psych Medic Settings. 2019;26:516–529.

Liddle I, Carter GFA. Emotional and psychological well-being in children: the development and validation of the Stirling Children’s Well-being Scale. Educ Psychol Pract. 2015;31:174–185.

Starace M, Carpanese MA, Pampaloni F, Dika E, Pileri A, Rubino D, et al. Management of malignant cutaneous wounds in oncologic patients. Support Care Cancer 2022;30:7615–23.

Murray CD, Havlin H, Molyneaux V. Considering the psychological experience of amputation and rehabilitation for military veterans: a systematic review and metasynthesis of qualitative research. Disability and Rehabilitation. 2024;46:1053–1072.

Sahu A, Sagar R, Sarkar S, Sagar S. Psychological effects of amputation: A review of studies from India. Ind Psychiatry J. 2016;25:4–10.

Pollock D, Peters MDJ, Khalil H, McInerney P, Alexander L, Tricco AC, et al. Recommendations for the extraction, analysis, and presentation of results in scoping reviews. JBI Evid Synth. 2023;21:520–532.

Ryff CD, Boylan JM, Kirsch JA. Eudaimonic and hedonic well-being: an integrative perspective with linkages to sociodemographic factors and health. In: Lee MT, Kubzansky LD, VanderWeele TJ, editors. Measuring Well-Being: Interdisciplinary Perspectives from the Social Sciences and the Humanities. Oxford University Press; 2021. doi: 10.1093/oso/9780197512531.003.0005

Ryff CD, Keyes CL. The structure of psychological well-being revisited. J Pers Soc Psychol. 1995;69:719–727.

Kahneman D, Diener E, Schwarz N. Well-Being: Foundations of Hedonic Psychology. Russell Sage Foundation; 1999.

Elo S, Kyngäs H. The qualitative content analysis process. J Adv Nurs. 2008;62:107–115.

Casula M, Rangarajan N, Shields P. The potential of working hypotheses for deductive exploratory research. Qual Quant. 2021;55:1703–1725.

Cunha N, Campos S, Cabete J. Chronic leg ulcers disrupt patients’ lives: A study of leg ulcer-related life changes and quality of life. Br J Community Nurs. 2017;22:S30–37.

Woo KY, Wong J, Rice K. Coelho S, Haratsidis E, et al. Patients’ and clinicians’ experiences of wound care in Canada: a descriptive qualitative study. J Wound Care. 2017;26:S4–13.

McCaughan D, Sheard L, Cullum N, Dumville J, Chetter I. Patients’ perceptions and experiences of living with a surgical wound healing by secondary intention: a qualitative study. Int J Nurs Stud. 2018;77:29–38.

Salomé GM, de Almeida SA, de Jesus Pereira MT, Massahud MR, et al. The impact of venous leg ulcers on body image and self-esteem. Adv Skin Wound Care. 2016;29(7):316–321.

de Fátima Rodrigues Dos Santos K, da Silva PR, Ferreira VT, et al. Quality of life of people with chronic ulcers. J Vasc Nurs. 2016;34:131–136.

Hopman WM, Vandenkerkhof EG, Carley ME, Harrison MB. Health-related quality of life at healing in individuals with chronic venous or mixed-venous leg ulceration: a longitudinal assessment. J Adv Nurs. 2016;72:2869–2878.

Miertová M, Dlugošová K, Ovšonková A, Čáp J. Chosen aspects of quality of life in patients with venous leg ulcers. Cent Eu J Nurs Midwif. 2016;7:527–533.

Sehlo MG, Alzahrani OH, Alzahrani HA. Illness invalidation from spouse and family is associated with depression in diabetic patients with first superficial diabetic foot ulcers. Int J Psychiatry Med. 2016;51:16–30.

Walburn J, Weinman J, Norton S, Hankins M, Dawe K, Banjoko B, et al. Stress, illness perceptions, behaviors, and healing in venous leg ulcers: findings from a prospective observational study. Psychosom Med. 2017;79:585–592.

Deufert D, Graml R. Disease-specific, health-related quality of life (HRQoL) of people with chronic wounds—A descriptive cross-sectional study using the Wound-QoL. Wound Medicine. 2017;16:29–33.

Meaume S, Dompmartin A, Lok C, Lazareth I, Sigal M, Truchetet F, et al. Quality of life in patients with leg ulcers: results from CHALLENGE, a double-blind randomised controlled trial. J Wound Care. 2017;26:368–379.

Tavares APC, Sá SPC, Oliveira BGRBD, Sousa AI. Quality of life of elderly patients with leg ulcers. Esc. Anna Nery. 2017;21(4). doi: 10.1590/2177-9465-EAN-2017-0134

Li G, Hopkins RB, Levine MAH, Jin X, Bowen JM, Thabane L, et al. Relationship between hyperbaric oxygen therapy and quality of life in participants with chronic diabetic foot ulcers: data from a randomized controlled trial. Acta Diabetologica. 2017;54:823–831.

Mohd Yazid B, Ayesyah A, Nurhanani AB, Mohd Rohaizat H. The physiological, biochemical and quality of life changes in chronic diabetic foot ulcer after hyperbaric oxygen therapy. Med Health. 2017;12:210–219.

Cwajda-Bialasik J, Szewczyk MT, Moscicka P, Jawien A, Slusarz R. Influence of ulceration etiology on the global quality of life and its specific dimensions, including the control of pain, in patients with lower limb vascular insufficiency. Postepy Dermatologii i Alergologii. 2017;34(5):471–477.

Purcell A, Buckley T, Fethney J, King J, Moyle W, Marshall AP. The effectiveness of EMLA as a primary dressing on painful chronic leg ulcers: effects on wound healing and health-related quality of life. Int J Low Extrem Wounds. 2017;16:163–172.

Connor JL, Sclafani JA, Kato GJ, Hsieh MM, Minniti CP. Brief topical sodium nitrite and its impact on the quality of life in patients with sickle leg ulcers. Medicine (US). 2018;97(46):e12614. doi: 10.1097/MD.0000000000012614

Almeida WAD, Ferreira AM, Ivo ML, Rigotti MA, Barcelos LDS, Viera Da Silva ALN. [Factors associated with quality of life of people with chronic complex wounds] Fatores associados à qualidade de vida de pessoas com feridas complexas crônicas. R Pesq Cuid Fundam. 2018;10:9–16.

Jull A, Muchoney S, Parag V, Wadham A, Bullen C, Waters J. Impact of venous leg ulceration on health-related quality of life: A synthesis of data from randomized controlled trials compared to population norms. Wound Repair Regen. 2018;26:206–212.

Costa de Oliveira A, Gonçalves Bezerra SM, de Macêdo Rocha D, Rangel Andrade EML, Ribeiro dos Santos AM, Tolstenko Nogueira L. Quality of life of people with chronic wounds. Acta Paul Enfermagem. 2019;32:194–201.

Handayani E, Widiyanto P. Quality of life of patients with diabetic foot ulcer on recovering. Philippine J Nurs. 2019;89:57–60.

Jockenhöfer F, Knust C, Benson S, Schedlowski M, Dissemond J. Influence of placebo effects on quality of life and wound healing in patients with chronic venous leg ulcers. J Dtsch Dermatol Ges. 2020;18:103–109.

Kumar N, Huda F, Mani R, Singla T, Kundal A, Sharma J, et al. Role of hospital anxiety and depression on the healing of chronic leg ulcer: A prospective study. Int Wound J. 2020;17:1941–1947.

Zou Y, Wang S, Zhou H, Zhang L. Effect of the compression therapy guided by unna boots on the quality of life and complications in patients with lower limb venous ulcers. Indian J Pharmac Sci. 2020;82:126–129.

Vogt TN, Koller FJ, Dias Santos PN, Lenhani BE, Bittencourt Guimarães PR, Puchalski Kalinke L. Quality of life assessment in chronic wound patients using the Wound-QoL and FLQA-Wk instruments. Invest Educ Enferm. 2020;38:e11.

Ren H, Ding Y, Hu H, Gao T, Qin Z, Hu Y, et al. Relationships among economic stress, social support, age and quality of life in patients with chronic wounds: A moderated mediation model. J Adv Nurs. 2020;76:2125–2136.

Putri NMME, Yasmara D, Yen MF, Pan SC, Fang SY. Body image as a mediator between gender and quality of life among patients with diabetic foot ulcers in indonesia. J Transcult Nurs. 2021;32:655–663.

Ozkan S, Yilmaz E, Baydur H, Ertugrul MB. Factors affecting the quality of life of hospitalized persons with chronic foot and lower leg wounds. Adv Skin Wound Care. 2021;34:645–650.

Yan R, Yu F, Strandlund K, Han J, Lei N, Song Y. Analyzing factors affecting quality of life in patients hospitalized with chronic wound. Wound Repair Regen. 2021;29:70–78.

Yan R, Strandlund K, Ci H, Huang Y, Zhang Y, Zhang Y. Analysis of factors influencing anxiety and depression among hospitalized patients with chronic wounds. Adv Skin Wound Care. 2021;34:638–644.

Ren H, Ding Y, Hu H, Fu X, Hu Y, Cao R, et al. Does social support moderate wound pain and health-related quality of life in patients with chronic wounds? a multicenter descriptive cross-sectional study. J Wound Ostomy Continence Nurs. 2021;48:300–305.

Reinboldt-Jockenhöfer F, Babadagi Z, Hoppe HD, Risse A, Rammos C, Cyrek A, et al. Association of wound genesis on varying aspects of health-related quality of life in patients with different types of chronic wounds: Results of a cross-sectional multicentre study. Int Wound J. 2021;18:432–439.

Kaizer UADO, Domingues EAR, Paganelli ABDTS. Quality of life in people with venous ulcers and the characteristics and symptoms associated with the wound. ESTIMA, Braz J Enterostomal Ther. 2021;e0121.

Dias Â, Ferreira G, Vilaça M, Pereira MG. Quality of life in patients with diabetic foot ulcers: a cross-sectional study. Adv Skin Wound Care. 2022;35:661–668.

Mościcka P, Cwajda-Białasik J, Szewczyk MT, Jawień A. Healing process, pain and health-related quality of life in patients with venous leg ulcers treated with fish collagen gel: a 12-week randomized single-center study. Int J Environ Res Public Health. 2022;19(12):7108. doi: 10.3390/ijerph19127108

Shankar S, MK A, Palani T, Nagasubramanian VR. Factors associated with health-related quality of life of south indian population with chronic venous leg ulcers — A hospital based pilot study. J Vascular Nurs. 2022;40:162–166.

Soares Dantas J, Silva CCM, Nogueira WP, de Oliveira e Silva AC, de Araújo EMNF, da Silva Araújo P, et al. Health-related quality of life predictors in people with chronic wounds. J Tissue Viability. 2022;31:741–745.

Zhu X, Olsson MM, Bajpai R, Järbrink K, Tang WE, Car J. Health-related quality of life and chronic wound characteristics among patients with chronic wounds treated in primary care: A cross-sectional study in Singapore. Int Wound J. 2022;19:1121–1132.

Li S, Xie M, Luo W, Zhou Q, Li C, Liu Y, et al. Quality of life and its influencing factors in chinese patients with chronic wounds. Adv Skin Wound Care. 2022;35:1–6.

de Souza Bandeira CA, de Queiroz Lombardi CA, Pereira AT, Cunha NM, Vasconcelos SC. Depression in elderly people with chronic wounds treated at the skin commission. Revista Baiana de Enfermagem. 2022;36. e: 36. doi: 10.18471/rbe.v36.45878

Chan KS, Lo ZJ, Wang Z, Bishnoi P, Ng YZ, Chew S, et al. A prospective study on the wound healing and quality of life outcomes of patients with venous leg ulcers in Singapore—Interim analysis at 6 month follow up. Int Wound J. 2023;20:2608–2617.

Goulart De Oliveira CJ, Nascimento Vilerá A, Malaguti Toffano SE, Teixeira Moraes J, Machado Dos Santos E, Santos MA. Quality of life and associated factors in patients with venous ulcers. Rev Enferm Atual In Derme. 2023;97:e023119.

Severino A de OJ, Oliveira ACDS, Araújo MPD, Dantas BADS, Sánchez MDCG, Torres GDV. Influence of pain on the quality of life in patients with venous ulcers: Cross-sectional association and correlation study in a brazilian primary health care lesions treatment center. PLoS ONE. 2023;18(8):e0290180. doi: 10.1371/journal.pone.0290180

Pasek J, Szajkowski S, Cieślar G. Quality of life in patients with venous leg ulcers treated by means of local hyperbaric oxygen therapy or local ozone therapy–a single center study. Medicina (Kaunas). 2023;59(12):2071. doi: 10.3390/medicina59122071

Newbern S. Identifying pain and effects on quality of life from chronic wounds secondary to lower-extremity vascular disease: an integrative review. Adv Skin Wound Care. 2018;31:102–108.

Stechmiller JK, Lyon D, Schultz G, Gibson DJ, Weaver MT, Wilkie D, et al. Biobehavioral mechanisms associated with nonhealing wounds and psychoneurologic symptoms (pain, cognitive dysfunction, fatigue, depression, and anxiety) in older individuals with chronic venous leg ulcers. Biol Res Nurs. 2019;21:407–419.

Dantas JS, Augusto F da S, Agra G, Oliveira J dos S, Ferreira LM, Sawada NO, et al. Health-related quality of life in people with chronic wounds and associated factors. Texto Contexto Enferm. 2022;31. doi: 10.1590/1980-265X-TCE-2022-0010en

Reinboldt-Jockenhöfer F, Traber J, Liesch G, Bittner C, Benecke U, Dissemond J. Concurrent optical and magnetic stimulation therapy in patients with lower extremity hard-to-heal wounds. J Wound Care. 2022;31:S12–21.

Dias SP, Brouwer MC, van de Beek D. Sex and gender differences in bacterial infections. Infect Immun. 2022;90:e0028322.

Haraldstad K, Wahl A, Andenæs R, Andersen JR, Andersen MH, Beisland E, et al. A systematic review of quality of life research in medicine and health sciences. Qual Life Res. 2019;28:2641–2650.

Andersson V, Sawatzky R, Öhlén J. Relating person-centredness to quality-of-life assessments and patient-reported outcomes in healthcare: A critical theoretical discussion. Nurs Philos. 2022;23:e12391.

Lins L, Carvalho FM. SF-36 total score as a single measure of health-related quality of life: Scoping review. SAGE Open Med. 2016;4:20503121161725.

Hansson M, Chotai J, Nordstöm A, Bodlund O. Comparison of two self-rating scales to detect depression: HADS and PHQ-9. Br J Gen Pract. 2009;59:e283–288.

Raepsaet C, Alves P, Cullen B, Gefen A, Lázaro-Martínez JL, Lev-Tov H, et al. The development of a core outcome set for clinical effectiveness studies of bordered foam dressings in the treatment of complex wounds. J Tissue Viability. 2023;32:430–436.

Elliott D. Developing outcome measures assessing wound management and patient experience: a mixed methods study. BMJ Open. 2017;7:e016155.

Klassen AF, van Haren ELWG, van Alphen TC, Cano S, Cross KM, van Dishoeck AM, et al. International study to develop the WOUND-Q patient-reported outcome measure for all types of chronic wounds. Int Wound J. 2021;18:487–509.

Kirkham JJ, Williamson P. Core outcome sets in medical research. BMJ Med. 2022;1:e000284.

Hernández-Segura N, Marcos-Delgado A, Pinto-Carral A, Fernández-Villa T, Molina AJ. Health-related quality of life (HRQOL) instruments and mobility: a systematic review. Int J Environ Res Public Health. 2022;19:16493.

Robitschek C, Ashton MW, Spering CC, Geiger N, Byers D, Schotts GC, et al. Development and psychometric evaluation of the Personal Growth Initiative Scale-II. J Couns Psychol. 2012;59:274–287.

Verdoodt K, Simons M, de Hoog N, Reijnders J, Jacobs N. Personal growth initiative across the life span: a systematic review protocol of quantitative studies using the Personal Growth Initiative Scale-II. Syst Rev. 2024;13:127.

Gethin G, Murphy L, Sezgin D, Carr PJ, Mcintosh C, Probst S. Resigning oneself to a life of wound-related odour – A thematic analysis of patient experiences. J Tissue Viability. 2023;32:460–464.

Aminah S, Yusuf S, Natzir R, Mukhtar M. Identification candidate for odour assessment and evaluate validity and reliability among wound care nurses. Enfermería Clínica. 2020;30:297–299.

Monk EJM, Jones TPW, Bongomin F, Kibone W, Nsubuga Y, Ssewante N, et al. Antimicrobial resistance in bacterial wound, skin, soft tissue and surgical site infections in Central, Eastern, Southern and Western Africa: A systematic review and meta-analysis. PLoS Glob Public Health. 2024;4:e0003077.

Gethin G, Grocott P, Probst S, Clarke E. Current practice in the management of wound odour: An international survey. Int J Nurs Stud. 2014;51:865–874.

Holloway S. Recognising and treating the causes of chronic malodorous wounds. Prof Nurse. 2004;19:380–384.

Akhmetova A, Saliev T, Allan IU, Illsley MJ, Nurgozhin T, Mikhalovsky S. A comprehensive review of topical odor-controlling treatment options for chronic wounds. J Wound Ostomy Continence Nurs. 2016;43:598–609.

Gethin G, Vellinga A, McIntosh C, Sezgin D, Probst S, Murphy L, et al. Systematic review of topical interventions for the management of odour in patients with chronic or malignant fungating wounds. J Tissue Viability. 2023;32:151–157.

Donovan NJ, Blazer D. Social isolation and loneliness in older adults: review and commentary of a National Academies report. Am J Geriatr Psychiatry. 2020;28:1233–1244.

Guarnera J, Yuen E, Macpherson H. The impact of loneliness and social isolation on cognitive aging: a narrative review. J Alzheimers Dis Rep. 2023;7:699–714.

Margherita M, Joanna B, Fran H. Loneliness interventions across the life-course: 2023;

Lin H, Fang C, Hung C, Fan J. Potential predictors of quality of life in patients with venous leg ulcers: A cross-sectional study in Taiwan. Int Wound J. 2022;19:1039–1050.

Matud MP, López-Curbelo M, Fortes D. Gender and psychological well-being. Int J Environ Res Public Health. 2019;16:3531.

Herber OR, Schnepp W, Rieger MA. A systematic review on the impact of leg ulceration on patients’ quality of life. Health Qual Life Outcomes. 2007;5:44.

Finlayson KJ, Parker CN, Miller C, Gibb M, Kapp S, Ogrin R, et al. Predicting the likelihood of venous leg ulcer recurrence: The diagnostic accuracy of a newly developed risk assessment tool. Int Wound J. 2018;15:686–94.

Gethin G, Probst S, Stryja J, Christiansen N, Price P. Evidence for person-centred care in chronic wound care: A systematic review and recommendations for practice. J Wound Care. 2020;29:S1–22.

Dhar A, Needham J, Gibb M, Coyne E. The outcomes and experience of people receiving community‐based nurse‐led wound care: A systematic review. J Clin Nurs. 2020;29:2820–2833.

Paul KK, Salje H, Rahman MW, Rahman M, Gurley ES. Comparing insights from clinic-based versus community-based outbreak investigations: a case study of chikungunya in Bangladesh. Int J Infect Dis. 2020;97:306–312.

Batterham PJ, Brown K, Trias A, Poyser C, Kazan D, Calear AL. Systematic review of quantitative studies assessing the relationship between environment and mental health in rural areas. Aust J Rural Health. 2022;30:306–320.

Aubrey-Basler K, Bursey K, Pike A, Penney C, Furlong B, Howells M, et al. Interventions to improve primary healthcare in rural settings: A scoping review. PLoS One. 2024;19:e0305516.

Ehrenstein V, Kharrazi H, Lehmann H, Taylor CO. Obtaining data from electronic health records. In Tools and Technologies for Registry Interoperability, Registries for Evaluating Patient Outcomes: A User’s Guide. 3rd Edition, Addendum 2. Agency for Healthcare Research and Quality (US); 2019. Chapter 4. https://www.ncbi.nlm.nih.gov/books/NBK551878/

Miller P, Newby D, Walkom E, Schneider J, Li SC, Evans TJ. The performance and accuracy of depression screening tools capable of self-administration in primary care: A systematic review and meta-analysis. Eur J Psychiat. 2021;35:1–18.

Rippon MG, Fleming L, Chen T, Rogers AA, Ousey K. Artificial intelligence in wound care: diagnosis, assessment and treatment of hard-to-heal wounds: a narrative review. J Wound Care. 2024;33:229–240.

Nickson D, Meyer C, Walasek L, Toro C. Prediction and diagnosis of depression using machine learning with electronic health records data: a systematic review. BMC Med Inform Decis Mak. 2023;23:271.

McGloin H, Devane D, McIntosh CD, Winkley K, Gethin G. Psychological interventions for treating foot ulcers, and preventing their recurrence, in people with diabetes. Cochrane Database Syst Rev. 2021;2021:CD012835.

Nagle SM, Stevens KA, Wilbraham SC. Wound Assessment. In StatPearls. Treasure Island (FL): StatPearls Publishing; 2023. http://www.ncbi.nlm.nih.gov/books/NBK482198/

 

Supplementary information

Click here to download Full data extraction.

Click here to download the Prisma checklist

Click here to download Sample search strategy (OVID)

Click here to download the Summary table of excluded studies