Volume 33 Number 1

Introduction

Venous leg ulcers (VLUs) are an ongoing concern for many people around the world, as well as for healthcare systems internationally. Personally, people living with VLUs experience issues with cost impact of treatment,^1,2 physical limitations,^3-5 pain and psychological well-being.^3,5-10. Additionally, these people experience a 50% to 76% recurrence rate with the ulcer returning on average, four times in a lifetime^9,11 further impacting their general wellbeing. The health care system is also impacted as the estimated cost of VLUs for one individual is between £4787.70 to £7615.03 per ulcer annually in the United Kingdom,^12,13 depending on the health care system structure. Research reports up to US$10.73 billion on average being spent on VLU care by the global healthcare systems, being between US$5226 in Australia and US$7679 in the USA per person per year.¹⁴ There is currently very little research on the physical, emotional or financial costs of recurrence to the person, community and the health care system in the literature. However, given the high recurrence rates, it could be assumed the cost of recurrence constitutes a large proportion of costs and impacts to the system and people globally. Preventing these recurrent VLUs could make a significant impact.

There are many prevention strategies to minimise the risk of recurrence. Firstly, the application of life-long compression therapy has been demonstrated to improve venous return, hence minimising the risk of recurrent VLUs,^15-17 however, there are many issues with compression therapy concordance, such as pain/discomfort, donning/doffing garments, and cost, as well as the impact of poorly applied compression therapy causing injury.^1,6,18,19 Another factor impacting the concordance with compression, and VLU recurrence prevention strategies is patient knowledge and education. Patient education has been linked to better outcomes, in compression therapy concordance, as well as assisting with the prevention of VLU recurrence.^15,20,21 Lower limb activity and elevation are the other major interventions with evidence supporting the prevention of VLU recurrence.^15,22-26 However, even with the evidence, information and research, VLU recurrence remains an ongoing issue for wound management.

One such issue is the long duration and ongoing impact of VLUs across the person’s lifespan, as well as broader effects on communities and healthcare systems. The average duration of a VLU ranges from 13.8 to 65.5 months, highlighting the long-term nature of this condition, which is further complicated by frequent recurrences.⁹ Given the extended duration and the lifelong risk of recurrence, VLUs can be strongly argued to meet the definition of chronic diseases/conditions: Noncommunicable diseases with duration of at least one year, requiring ongoing medical attention; that may or may not be associated with functional limitations.²⁷ In fact VLUs have many common features associated with chronic diseases/conditions such as complex causality, long development periods, prolonged course of illness and associated disability/impairments.²⁷ Despite the long-term nature of VLUs, the focus of both service provision and research appears to be on the processes of healing VLUs, within acute medical models.²³ However, shifting the focus from acute medical care to sustained, community-based chronic illness management could favor alternative methods, such as integrated care and self-management.

Self-management is acknowledged as an effective way to manage long-term chronic disease/conditions. Literature discusses the positive impact of self-management interventions on both symptom management as well as general quality of life and wellbeing.^28,29 A limitation of the evidence is, however, the use and application of terminology, where self-care and self-management are used interchangeably.^30–32 Therefore, for the purposes of this paper we will define the concepts as:

• Self-care: The broad concept that encompasses all capacities, activities, and processes directed toward maintaining health, preserving life, and monitoring and managing acute and chronic conditions.³³
• Self-management: The capacities, activities and processes directed towards managing symptoms associated with a condition, including prevention of an exacerbation or activation of symptoms.³⁴
• Self-treatment: The capacities, activities and processes (cleaning wound, applying/removing dressings and applying compression) directed towards controlling active or exacerbated symptoms (wounds).³⁵

These concepts and definitions can be used when examining the chronicity of venous leg ulcers, where self-care would be the completion of overall health and well-being activities; self-management being the activities and tasks involved in managing the chronic disease and preventing the activation of a VLU, and self-treatment being the activities and tasks completed by an individual focused on healing an active VLU.

Evidence demonstrates a strong influence on the development of chronic diseases by social determinants of health.³⁶ The ability to complete self-management is influenced by many contexts and situations. Evidence indicates that social supports, geographical locations, access to health care services, social and economic situations and the built and natural environments impact the ability to self-manage chronic diseases.^36,37 These concepts can act as either a barrier or a facilitator to self-management success.

Self-management may be underutilised or inaccessible for populations without adequate financial resources, shortfalls in enabling physical environments, weak social support networks, and lacking access to a health-care team.³⁸ Although much research has focused on the healing and prevention of wounds, self-management to prevent recurrence is still evolving and remains underdeveloped. This study explored the extent and quality of evidence for self-management in preventing venous leg ulcers, the contexts in which this evidence was generated, and the characteristics of the existing literature.

Aim

To identify and describe the evidence characteristics of literature dealing with self-management (and related terms) to prevent venous leg ulcer (VLU) recurrence after healing.

Research questions

What are the evidence characteristics of the existing published literature, for self-management to prevent VLU recurrence post-healing.

What interventions are included as part of self-management in prevention of recurrence of VLUs post-healing.

Methods

A scoping review was conducted, as the area of self-management for leg ulcer recurrence prevention is a developing area of research, allowing a broader range of data to be included in the review. The Joanna Briggs Institute (JBI) Scoping Review guidelines were used as a protocol to conduct the research, with the question being first broken into the core concepts of population, concept and context.

Population: Adults (over 18 years) with healed VLUs (not diabetes-related ulcers, sickle cell anemia or acute wounds).

Concept: Self-management to prevent recurrence of venous leg ulcers after healing (not treatment or self-treatment of healing wounds)

Context: Completing self-management within the community setting (not living in acute or supported accommodation settings).

Search Strategy: The university librarian was consulted when forming the search strategy and a trial search within EBSCO (CINAHL and MEDLINE) conducted in February/March 2023. The terms were then finalised, and a systematic database search of CINAHL, MEDLINE; PubMed; and Scopus was conducted in May 2023 using the search terms: (self-management or self-care or self-monitoring) AND (“leg ulcers” or “chronic leg ulcers” or “venous leg ulcers”) AND recurrence AND prevention NOT (DFU or “diabetic foot “ or “sickle cell”) as both keywords and MESH/Heading terms. An updated database search was conducted in March 2024, to ensure the data collection was up to date.

Data Screening and extraction

Covidence and Endnote were used to assist with the collation, screening and extraction processes. Articles were imported into Endnote from each database and collated into raw data and duplicates removed. This raw data was then transferred to Covidence, and the screening of titles and abstracts to meet the inclusion criteria completed by the first researcher (Author 1). After screening, two researchers (Authors 1 and 3) reviewed the screened full text articles, and articles were removed if they did not meet the inclusion criteria.

Data extraction was completed by two researchers (Authors 1 and 3) with a third researcher to clarify any discrepancies between the researchers. The data extraction table was based on the JBI Scoping Review protocol; including authors, author background, publication year, publication type; type of article as well as the aim, subjects/participants, interventions and contexts. Consensus was reached and the third researcher (Author 2) was not utilised in the process.

Results

With the initial search in 2023, 91 articles were identified using PUBMED, CINAHL and Scopus. Duplicates were then removed, and the remaining 62 articles were entered into the Covidence program, where another four duplicates were removed. From the remaining 58 studies, title and abstract screening excluded 17 articles for not meeting the inclusion criteria and another 21 were excluded during the full text screening. Reasons for exclusion included language (n=2); including wound healing (n=12); not examining self-management (n=2); one was about sickle cell anemia and one was a conference abstract. The final 20 articles were identified as meeting the inclusion criteria to address the research question. The second updated search in March 2024 identified another five articles, of which two were excluded due to including wound healing and three were included after screening and full text review (see Figure 1).  The final number of articles rested at 23.

 

Figure 1. PRISMA diagram

 

Evidence characteristics

The articles ranged from 1996 until 2024, however, the majority of articles were clustered within the last 10 years. From a professional perspective, all journal articles were published within either nursing or wound care journals, with most authors identifying as having either nursing or nursing/academic backgrounds, with the exception of two articles, where the authors did not identify their backgrounds clearly. With regards to research location and context, the majority of studies were located in the United Kingdom (n=10), with Australia next (n=10). Two articles were from South America, and one from South East Asia (See Table 1).

 

Table 1. Study location and Study ID.

 

As seen in Table 2, data extraction highlighted the prevalence of expert opinions (n=7) when reviewing the literature on self-management to prevent VLU recurrence. Quantitative approaches were identified (n=5), however, it must be noted several articles were secondary data analysis of previously reported data, as well as a publication of prospective quantitative protocols, later reported on. The quantitative approaches included a Randomised Control Trial (RCT), as well as in-depth and extensive measures, including standardised measures (such as SF12 and the Geriatric Depression Scale), as well as bespoke surveys and questionnaires. From the qualitative perspective, as well as the mixed methods approaches, focus groups and interviews were frequently identified within the articles, with one qualitative open-ended questionnaire used.

 

Table 2. Methodology approaches and Study ID.

 

With the research that involved participants (see Table 3), large sample sizes (from  80 to 250 participants) were used in the quantitative studies and smaller sample sizes (10 to 12 participants) were used in the qualitative studies. The sample sizes were justified, and where needed, power calculations informed the sample sizes. It was noted that only one study included patients, family/carers and health care professionals. The study involved the development of a tool for readiness to self-management. Two articles included a health care provider perspective, the previously mentioned tool development article, and a literature review, which included a survey with a small sample of health care professionals. The general demographics and contexts of the healthcare professionals and family/carers were not reported in any of the studies.

 

Table 3. Participant characteristics

 

Except for two articles, the ratio of male to females was approximately equal and the ages ranged from 41 to 96 years (see Table 3). The demographics gathered for the patient populations were not consistent. It is noted that socioeconomic information, including income type, social situation and social support was gathered via a survey tool in all articles with Finlayson as the primary author. Finlayson et al 2011²⁶ and 2014¹⁰ both reported on a data set collected between 2006 and 2009 with 80 participants; their income streams included: aged pension (42%), disability pension (7%), self-funded or employed (26%). However, when these data were combined with data from a third study (led by Edwards⁶¹) to create a sample of 250 participants for secondary data analysis by Finlayson, Wu and Edwards in 2015⁶², the income breakdown changed to: aged pension (64%); disability pension (12%): employed (7%); and self-funded retired (7%). Relationship status ranged in the study by Finlayson et al 2015⁶², with 37–43% of participants married; 11–17% single (living alone) and 29–39% widowed (living alone). The majority of the participant data sets, and specifically, the data sets with more demographics, were recruited from the Australian population.

Regarding the context of the study and sampling pool, when reported, all research was based in metropolitan or urban areas, no participants identified as being from rural, regional or remote areas in the data. The research was identified as being completed in the community, either at clinics or during home nursing services. Three articles included recruitment from both a hospital and a community setting.

In Table 4, the interventions which were identified as part of the self-management or self-care to prevent recurrence are described. Compression was the most frequently identified treatment, with 22 out of 23 articles highlighting compression therapy as the main component for preventing recurrence. Exercise or activity was the next most frequent treatment (n=13) with the elevation of legs being the third most frequently identified component for self-management to prevent recurrence (n=11), then skin care (n=9). Education, nutrition and family or support were all identified at approximately the same rate, with group interventions being the least identified part of self-management in relation to preventing VLU recurrence.

 

Table 4. Study ID and interventions for self-management

 

Discussion

This scoping review aimed to explore the scope and characteristics of self-management, and related concepts, in preventing the recurrence of venous leg ulcers (VLUs) post-healing. A deliberate methodological decision was made to exclude articles addressing healing wounds, as this review specifically focused on recurrence prevention. This is critical because terminology in wound management regarding self-management is inconsistent.³⁹ In this review, self-management refers to managing symptoms associated with a condition, including prevention,³⁴ whereas self-treatment pertains to actions targeting the healing of exacerbated symptoms, such as wounds.³⁵ The key distinction is that self-management is a lifelong task, while healing has an endpoint. This differentiation is important as the psychological factors—such as lack of acceptance, resignation, and emotional exhaustion—differ between these two concepts.

The tasks associated with self-management identified in this review align with previous research in the field. Compression therapy emerged as the most frequently cited intervention for preventing recurrence, underscoring its role as the primary self-management task for VLU prevention^{15,17,23,40-42} Other commonly reported tasks include exercise, leg elevation, patient education, and, to a lesser extent, skin care.^15,40,43 Interestingly, education was rarely highlighted as a core component of self-management interventions in VLU prevention, which contrasts with chronic disease self-management, where education plays a crucial role.^44-47 However, challenges with patient education exist in both contexts. Low literacy and educational levels have been linked to poorer outcomes and increased risk factors for chronic diseases, including VLUs.^15,36,48-50

Contextual factors, such as demographic characteristics, have been shown to influence the effectiveness of self-management interventions^36,51 Social determinants of health (SDH), including socio-economic status and living conditions, have been related to both the development and management of chronic diseases.^8,52,53 This relationship extends to VLUs, where contextual factors impact not only the development and healing of ulcers but also their management.^8,53

In contrast, this review found that certain contextual factors, such as marital status, did not significantly influence VLU recurrence rates. Similarly, social support, while not directly linked to recurrence rates, was found to impact self-efficacy in self-management.^1,5 This contrasts with other studies that have identified social support as a factor in both ulcer healing and the enhancement of self-management skills. It may be that relationship status does not necessarily equate to social support. Furthermore, access to services—such as transport, urban versus rural living, and neighborhood socioeconomic status—has been associated with the risk of developing chronic diseases and delayed ulcer healing.^{8,36,51,53,54} However, in this review, income and socioeconomic status measures did not appear to influence recurrence or self-management. It is important to note that the population studied was limited, with all participants recruited from the same sources, which may have impacted the findings.

As self-management for VLU recurrence prevention is still developing as an area of research, a scoping review methodology was employed to capture a broad range of articles. This is reflected in the inclusion of numerous expert opinions and case studies. At the higher end of the evidence hierarchy, three systematic reviews were identified, one of which was a scoping review protocol. Quantitative studies (n=5) and mixed methods studies (n=3) were the next most common, though some relied on secondary data analysis, which may have limited participant diversity. Recruitment in several studies was based on previous or concurrent studies, further restricting the population sample. Qualitative research was the least utilised, and none of the studies focused on rural populations or access to community or hospital services. Future research should explore the impact of service accessibility, as both geographic location and service availability have been shown to significantly influence self-management skills in chronic disease management.^8,54,55

The findings indicate that nursing professionals currently lead the field of VLU recurrence prevention through self-management, as evidenced by the authorship and journal orientation of the studies reviewed. In contrast, self-management for chronic diseases typically involves a wider range of healthcare professionals, including those from social sciences and allied health disciplines. The benefits of a multidisciplinary team approach are well-documented and have been recommended for both clinical practice and research in wound management.

Self-management has proven effective in chronic diseases such as heart failure, asthma, arthritis, and diabetes. These interventions, often delivered by multidisciplinary team, consistently incorporate patient education, lifestyle modifications and lifelong behavioural changes such as problem-solving, and self-monitoring.^46,55-58 These strategies empower patients to take control of their conditions, leading to better clinical outcomes, fewer hospitalisations, and improved quality of life. In contrast, self-management in VLU care, particularly in preventing recurrence, is less developed. While chronic disease management focuses on addressing underlying pathophysiology and modifying risk factors, VLU care often remains centered on wound management, neglecting the broader context of chronic venous insufficiency.^43,59,60 A shift towards a more holistic approach, targeting underlying venous disease through patient education and self-care, could replicate the successes seen in heart failure and diabetes management.

Conclusions

In conclusion, self-management to prevent VLU recurrence is a crucial yet evolving concept in wound management. The current literature is characterised by a reliance on expert opinions, an underrepresentation of qualitative research, and inconsistencies in terminology and approaches. While compression therapy remains the most well-established intervention, other strategies such as exercise, education, and skin care require further development and evaluation. Core concepts of chronic disease self-management, like education and adherence to lifestyle modifications or adherence to lifelong factors that reduce recurrence risk, are generally absent in the wound self-management literature, partly due to the exclusion of articles on healing VLUs. To improve patient outcomes, it is essential to expand the understanding of VLUs as a chronic condition and integrate them within chronic disease management frameworks. A multidisciplinary approach, community integration, and a shift in language and focus are necessary for advancing VLU management.

Conflict of interest

The authors declare no conflicts of interest.

Ethics statement

An ethics statement is not applicable.

Funding

The authors received no funding for this study.

Author(s)

Yvonne Pennisi¹*, Nicole Muller¹, Claire Buckley^1,2, Siobhan Murphy¹, Irene Hartigan^1
1University College Cork (UCC), Ireland
²Public Health Medicine, Health Service Executive (HSE), Ireland

*Corresponding author email yvonne.pennisi@ucc.ie

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