https://doi.org/10.31011/reaid-2023-v.97-n.3-art.1743

¹Jaqueline Goulart de Oliveira Constanci

²Aline Nascimento Vilerá

³Silmara Elaine Malaguti Toffano

⁴Juliano Teixeira Moraes

⁵Edirlei Machado dos Santos

⁶Mariana Alvina Santos

¹Universidade Federal de Mato Grosso do Sul. Três Lagoas, Mato Grosso do Sul, Brazil. Orcid: https://orcid.org/0000-0003-4065-0668

²Universidade Federal de Mato Grosso do Sul. Três Lagoas, Mato Grosso do Sul, Brazil. Orcid: https://orcid.org/0000.0001.8216.4479

³Universidade Federal do Triângulo Mineiro. Uberaba, Minas Gerais, Brazil. Orcid: https://orcid.org/: 0000-0002-9080-9123

⁴Universidade Federal de São João del-Rei Divinópolis, Minas Gerais, Brazil. Orcid: https://orcid.org/: 0000-0002-1109-962X

⁵Universidade Federal de Mato Grosso do Sul. Três Lagoas, Mato Grosso do Sul, Brazil. Orcid: https://orcid.org/:0000-0002-1221-0377

⁶Universidade Federal de Mato Grosso do Sul. Três Lagoas, Mato Grosso do Sul, Brazil. Orcid: https://orcid.org/: 0000-0002-7940-667

Corresponding author

Jaqueline Goulart de Oliveira Constanci

Bernadino Antonio Leite, 1114, Vila Nova. MS – Brazil. Zip cod: 79604-060

contact: +55(67) 99262 2752 E-mail: jaque_gou@yahoo.com.br

Submission: 01-03-2023

Approval: 21-06-2023

ABSTRACT

Objective: To evaluate the quality of life and associated factors in patients with venous ulcers. Method: Cross-sectional study carried out with adults with venous injuries treated by the public health system. Data were collected through interviews. An instrument with socio-demographic variables and the Freiburg Life Quality Assessment – Wound scale was used. Data were analyzed using descriptive and inferential statistics, with Mann Whitney Tests and Spearman correlation. A value of p<0.05 was considered significant. Results: There was a predominance of women (52.6%), with up to one year of injury (68.4%), who performed the dressing at home without help (77.2%). Regarding quality of life, the domains satisfaction, physical symptoms and daily life had lower scores. Significant results were obtained when comparing gender and treatment (p=0.017), partner and satisfaction (p=0.049), help with dressing at home and treatment (p=0.007), compressive therapy with treatment (p=0.012) and satisfaction (p = 0.013). Conclusions: Venous ulcers have a negative impact on people's quality of life and are associated with gender, age, presence of a partner, having help with dressing at home, use of compressive treatment, recurrence and duration of injury.

Keywords: Varicose ulcer; Quality of life; Nursing care; Stomatherapy.

RESUMEN

Objetivo: Evaluar la calidad de vida y factores asociados en pacientes con úlceras venosas. Método: Estudio transversal realizado con adultos con lesiones venosas atendidos por el sistema público de salud. Los datos fueron recolectados a través de entrevistas. Se utilizó un instrumento con variables sociodemográficas y la escala Freiburg Life Quality Assessment – Wound. Los datos fueron analizados mediante estadística descriptiva e inferencial, con Pruebas de Mann Whitney y correlación de Spearman. Se consideró significativo un valor de p<0,05. Resultados: Predominó el sexo femenino (52,6%), con hasta un año de lesión (68,4%), que realizaban el curado en casa sin ayuda (77,2%). En cuanto a la calidad de vida, los dominios satisfacción, síntomas físicos y vida diaria presentaron puntajes más bajos. Se obtuvieron resultados significativos al comparar sexo y tratamiento (p=0,017), pareja y satisfacción (p=0,049), ayuda para vestirse en casa y tratamiento (p=0,007), terapia compresiva con tratamiento (p=0,012) y satisfacción (p = 0,013). Conclusiones: Las úlceras venosas tienen un impacto negativo en la calidad de vida de las personas y se asocian con el sexo, la edad, la presencia de pareja, tener ayuda para vestirse en casa, uso de tratamiento compresivo, recurrencia y duración de la lesión.
Palabras clave: Úlcera varicosa; Calidad de Vida; Enfermería; Estomaterapia.

RESUMO

Objetivo: Avaliar a qualidade de vida e fatores associados em pacientes com úlcera venosa. Método: Estudo transversal realizado com adultos com lesões venosas atendidos pelo sistema de saúde público. Os dados foram coletados por meio de entrevista. Foi utilizado um instrumento com variáveis sociodemográficas e a escala Freiburg Life Quality Assessment – Wound. Os dados foram analisados por estatística descritiva e inferencial, com Testes de Mann Whitney e correlação de Spearman. Foi considerado um valor p<0,05 como significativo. Resultados: Houve predominância de mulheres (52,6%), com até um ano de lesão (68,4%), que realizavam o curativo no domicílio sem ajuda (77,2%). Em relação à qualidade de vida, os domínios satisfação, sintomas físicos e vida diária tiveram menor pontuação. Obteve-se resultados significativos ao comparar gênero e tratamento (p=0,017), companheiro e satisfação (p=0,049), auxílio no curativo em casa e tratamento (p=0,007), terapia compressiva com tratamento (p=0,012) e satisfação (p = 0,013). Conclusões: A úlcera venosa repercute negativamente na qualidade de vida das pessoas e está associada ao gênero, idade, presença do companheiro, ter auxílio no curativo em casa, uso de tratamento compressivo, recidiva e tempo de lesão.

Palavras-chave: Úlcera varicosa; Qualidade de vida; Enfermagem; Estomaterapia.

INTRODUCTION

Venous ulcers (VU) have affected a considerable portion of the adult population worldwide, with an incidence of 3 to 5 cases per 1,000 inhabitants per year⁽¹⁾, reaching 1% to 2%^(2-3). This condition is more common in women and in individuals over 65 years of age^(1-2). Furthermore, venous ulcers account for 70% to 80% of cases of lower limb injuries^(2,4).

VU develops as a loss of skin continuity, resulting from chronic venous insufficiency (CVI), affecting the microcirculation, especially in the region of the distal portion of the legs, around the medial malleolus, being less common in the calves and feet⁽⁵⁾. Generally, it is a consequence of an unhealed trauma to the leg⁽⁶⁾ and is characterized by difficult healing⁽⁷⁾, in addition to high recurrence rates, which may never heal⁽⁸⁾.

Caring for people affected by venous injuries has become a challenge for professionals and health systems around the world, both because of the high costs⁽⁷⁾ and mainly because it interferes in areas that go beyond the injury, such as social, mental⁽⁹⁾, everyday life⁽¹⁰⁾ and the individual's self-image⁽¹¹⁾, which may impact their quality of life (QoL). For the World Health Organization (WHO), QoL is “the individual's perception of their insertion in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns”. When referring to health issues, the term health-related quality of life (HRQoL) is used, which reflects the position of the individual affected by the pathology, the resulting damages and the experience of the treatment, portraying their useful life condition, within of this context⁽¹²⁾.

QoL is essential data for health systems, as it allows revealing changes in the health of the population, when investigating the domains or aspects of the individual's life that may be affected when they experience a health problem⁽¹²⁾. Although research has already been produced that evaluated the QoL of people with VU in Brazil⁽¹³⁾, we still lack information about its associated factors in this country.

In this sense, the present study aimed to evaluate the quality of life and identify associated factors in patients with venous ulcers. Understanding the quality of life and the elements that are related to it in this group of patients can provide important guidelines for a comprehensive and effective treatment that takes into account the specific needs of people who suffer from chronic wounds.

METHODS

This is a cross-sectional study carried out from August to December 2020 in the public health network in a municipality in the State of Mato Grosso do Sul, Brazil.

The population consisted of all 249 users with VU, with a history of medical consultations in primary care or medium complexity of the municipal public health network, from January 2018 to July 2020, and who received the diagnosis of varicose veins of lower limbs with ulcer or varicose veins of lower limbs with ulcer and inflammation.

The convenience sample consisted of 57 participants, who met the inclusion criteria: having active VU for a minimum of one month, being over 18 years of age, having an updated telephone number in the patient's medical record, being able to understand and answer questions questions, and residing in the municipality where the survey was conducted. Those people with partial or total amputation of at least one lower limb were excluded.

Initially, a first telephone contact was made with patients considered eligible for the research, excluding, at this stage, 169 patients who did not meet the inclusion criteria. There were 80 individuals left, who were invited to participate in the study and when they accepted, a home visit was scheduled according to the participant's availability for the interview. At this stage, 23 patients were excluded, and the sample considered for this study was 57 patients (figure 1).

Table 1 - Median and quartiles of domains and Freiburg visual analogue scales, of study participants, Mato Grosso do Sul, Brazil, 2020, (n = 57)

Score/Itens	Minimum	Maximum	Average	(Q1 - Q3)*
Physical symptoms	1	5	2,8	(2,2-3,4)
Pain in the wound	1	5	4	(2-5)
Insomnia	1	5	1	(1-3,5)
Itch in the wound	1	5	2	(1-5)
Secretion in the wound	1	5	5	(3-5)
Bad smell in the wound	1	5	1	(1-1)
Daily life	1	5	2,8	(2-3,5)
Sometimes has difficulty doing tasks at work/home	1	5	3	(1-4)
Difficulty in physical exertion	1	5	1	(1-4)
Reduction in leisure and fun activities	1	5	2	(1-5)
Difficulty climbing stairs	1	5	3	(1-5)
Financial difficulty due to the wound	1	5	3	(2-5)
Social life	1	5	2,33	(1,33 -3,33)
Decreased activities with other people	1	5	1	(1-4)
Felt dependent on other people	1	5	2	(1-4)
Withdrew from other people	1	5	1	(1-4)
Psychological well-being	1	4	1,5	(1 - 2)
Feelings of hate and rage	1	5	2	(1-3,5)
Depression	1	5	1	(1-1)
Exhaustion or tiredness	1	5	1	(1-3)
helplessness/abandonment	1	5	1	(1-1)
Treatment	1,5	5	2,5	(2 - 3,25)
The treatment is a burden for me	1	5	2	(2-4)
Treatment is time consuming	1	5	2	(2-3)
Need help from others for treatment	1	5	1	(1-3,5)
Total daily time for wound care	2	5	3	(3-3)
Satisfaction	1	4,7	3	(2,17-3,67)
General health	1	5	3	(1-4)
Satisfaction with treatment	1	5	4	(3-5)
Satisfaction with wound appearance	1	5	2	(1-3,5)
Total Score	1,7	3,8	2,5	(2,07-2,88)
Total Visual Analog Scales Score	0	9,3	5,7	(4,17-7,67)
General state of health	0	10	7	(5-9)
Status of wounds	0	10	5	(0-7)
Quality of life in general	0	10	6	(5-8)

*Q1 - Q3: quartis de 1 a 3.

A comparison was made between QoL and sociodemographic and treatment variables: gender, presence of a partner, having help with dressing at home and compressive treatment. A significant difference was observed between: men in the Treatment domain (p = 0.017), suggesting worse evaluation in this domain; among those who had a partner, revealing greater impairment in the Satisfaction domain (p = 0.049); among those who had family members to help with the dressings at home, suggesting greater commitment in the Treatment domain (p = 0.007), and finally, among those who applied compressive treatment, identifying worse evaluation in the Treatment domain (p = 0.012) and Satisfaction (p = 0.013) (Table 2).

Table 2 - Comparison between quality of life with sociodemographic data and treatment in people with venous ulcers, Mato Grosso do Sul, Brazil, 2020

Domains
Variables	Physical Symptoms	Daily life	Social life	Psichological weel-being	Treatment	Satisfaction	Total score	Total score Analog Visual Scales
Gender
Female (n=30)	2,9 (1,8 - 3,4)	2,9 (2 - 3,6)	2,3 (1,3 - 3,7)	1,8 (1,2 - 2,3)	2,3 (1,8 - 2,8)	3 (2,3 - 3,4)	2,6 (2 - 3)	6 (4,3 - 7,7)
Male (n=27)	2,8 (2,2 - 3,4)	2,6 (2 - 3,4)	2 (1,3 - 2,3)	1,5 (1 - 2)	2,8 (2,5 - 3,3)	3 (2 - 4)	2,5 (2,1 -2,8)	5,7 (4 - 8,3)
p*	0,955	0,378	0,065	0,239	0,017*	0,343	0,743	0,779
Partner
Yes (n = 28)	2,4 (2,1 - 3,2)	2,5 (2-3,4)	2,3 (1,3 - 3)	1,5 (1,1 - 2)	2,8 (2,3 - 3,2)	3,3 (2,3 - 4)	2,5 (2,1 - 2,8)	5,8 (4,4 - 7,8)
No (n = 29)	2,8 (2,2 - 3,8)	3 (2,1 - 3,6)	2 (1,5 - 3,7)	1,8 (1 - 2,1)	2,5 (1,9 - 3,3)	2,7 (2 - 3,3)	2,5 (2 - 3)	5,7 (3,8 - 7,7)
p*	0,203	0,554	0,63	0,604	0,254	0,049*	0,962	0,786
Having help with dressing at home
Yes (n = 15)	3 (2,6 - 3,4)	2,8 (2 - 4,2)	2 (1,7 - 3)	1,5 (1 - 2)	3 (2,8 - 3,5)	3,3 (2,7 - 3,7)	2,6 (2,3 - 2,9)	6,3 (4,3 - 8,3)
No (n = 42)	2,4 (1,8 - 3,4)	2,7 (2 - 3,5)	2,3 (1,3 - 3,7)	1,8 (1 - 2)	2,4 (1,9 - 3)	2,7 (2 - 3,7)	2,5 (2 - 2,8)	5,7 (3,9 - 7,7)
p*	0,072	0,82	0,978	0,883	0,007*	0,133	0,163	0,388
Compressive treatment
Yes	2,8 (2,2 – 3,4)	2,6 (2 – 3,3)	2 (1,3 – 3,7)	2 (1,3 – 3,7)	3,3 (2,4 – 4,1)	3,3 (3,2 – 3,8)	2,5 (2,2 – 3,3)	6 (5,7 – 8,5)
No	2,7 (2,1 – 3,4)	2,9 (2 – 3,6)	2,3 (1,3 – 3,3)	1,5 (1 – 2,2)	2,5 (2 – 2,9)	2,7 (2 – 3,7)	2,5 (2 – 2,8)	5,5 (3,7 – 7,5)
p*	0,498	0,580	0,893	0,589	0,012*	0,013*	0,227	0,070

Mann Whitney comparison test: if p value > 0.05, there is no difference between groups regarding the scale items; in the quantification of data, median (quartiles) was used; *P ≤ 0.05 significant value.

DISCUSSION

The QoL of patients with VU was impaired. Among the evaluated domains, Satisfaction presented the worst indicator, especially in the item Satisfaction with the treatment, a result equivalent to a similar investigation⁽¹⁰⁾. Dissatisfaction with the treatment comes from the long stay with the lesion, since it is reflected in hopelessness in its closure and a feeling of impotence⁽¹⁶⁾; it also emphasizes the lack of adequate assistance by the health services, reaffirmed by the report of the use of improper covers, which require frequent changes, causing trauma and pain⁽¹⁷⁾.

In the domain Physical symptoms, the items exudate and pain in the wound, it was similar to the finding in a research that addressed women with VU⁽¹⁸⁾; as well as studies that identified a relationship between lower QoL and exudate level⁽¹¹⁾ and pain^(4,10) in VU. Therefore, there is a lack of qualified professional care that addresses the characteristics of the lesion, using products that minimize the discomfort caused by it. Exudate in lesions of this nature is a common symptom.

When excelling in daily life, the items difficulties in: climbing stairs; financial due to the wound; and performing tasks at work/home, is in line with the result of a similar research, whose domain presented the same loss⁽¹⁰⁾. This outcome is linked to the functional limitation imposed by the existence of VU^(19,9), as well as by pain, scored by a large part of the sample in this research; thus reducing physical performance in activities of daily living (ADL)⁽¹⁶⁾. The low-income characteristic elucidates the financial difficulty mentioned, which interferes with the treatment, because, with a lack of products in the public network, the patient has to bear the costs⁽¹⁶⁾; it also includes the extra expenses with compression therapy and meeting nutritional needs, required in an adequate treatment⁽¹⁹⁾. Therefore, offering social support to these individuals, and providing the necessary products for the treatment, are essential factors to be carried out by the health services, with a view to minimizing the impact on their QoL.

Psychological well-being was the domain with the best evaluation in this research, a finding that corroborates with some studies^(10,19), and differs from others^(9,18), with the same theme. This domain is composed of items, feelings of hate and fury, depression, exhaustion or tiredness and helplessness/abandonment; it is noted that the study sample, due to the long stay with the injury, found ways to better adapt and live with the disease.

The population mostly composed of women shows a group vulnerable to health conditions, where some studies correlate with hormonal changes and consequences of pregnancy⁽²⁾ as well as increased female longevity⁽²⁰⁾. However, this study draws attention to the presence of productive young people, who at the time did not have a paid job. This factor can even compromise the treatment, both due to financial difficulties and because it is associated with a feeling of incapacity⁽²¹⁾. It is known that the presence of venous injury causes absence from work, and consequently leads to unemployment and early retirement^(22-23). Attention is drawn to the social role of health services to provide appropriate treatment favoring the injury in the shortest possible time, allowing the person to return to their work activities as soon as possible.

The results showed a worse evaluation in the Treatment domain, by men, emphasizing the difficulty they have in seeking help from health professionals, and their lower attendance at PHC services⁽²⁴⁾, thus leading to less clarification about the pathology, therefore, a inefficient self-care, as well as self-medication, as shown in the results; factors that lead to the worsening or chronicity of the lesion. Likewise, there is a lack of professional assistance, as previously mentioned. The need for better reception of the male public with VU by health services is evident, encouraging them to participate in health education actions, as well as making them aware of the importance of periodic follow-ups.

The correlation shown between the presence of a partner and impairment in the Satisfaction domain exposes dissatisfaction with body image^(4,19), which, due to VU characteristics such as odor, high exudation and exposure of bandages, produces a feeling of fear of being abandoned^(23,25), by the partner. There is also reference to the lack of family support, faced by people with VU⁽²³⁾, reported by most of the sample as lack of help with dressing at home. In this way, offering continuous care, which alleviates, in the shortest possible time, the disorders caused by the severity of the wound, in addition to reducing the need for care on the part of family members, can contribute to a more harmonious coexistence with the partner, in addition to increasing the person's self-confidence, providing improvement in their QoL.

People who had the help of family members with the dressing at home had the worst score in the Treatment domain. It is fundamental to educate not only the patient, but also family members about the condition they present, and the necessary care for the injury, since better treatment results are obtained(26). This outcome reveals the importance of health education that should be offered by health professionals, aiming to achieve better adherence, greater confidence in treatment and resolution.

Individuals who used compression had a poor evaluation in the Treatment and Satisfaction domains. It is noteworthy in this context, the difficulty in placing the compressive materials⁽²⁸⁾, requiring the help of other people, an issue that, for the sample of the present research is a disorder, since most carry out their care alone; there is also the fact of intolerance to the use of high-elastic bandages⁽²⁹⁾. Therefore, raising awareness about the need for compression and improving adherence to the care plan is a fundamental mission for health professionals, to be carried out together with family members and patients with VU, considering that the degree of therapeutic adherence is related to the healthcare service. health and team⁽³⁰⁾.

The correlation between relapse and quality of life revealed a significant impact on daily life, while obtaining a more positive assessment in relation to treatment, contrary to the results of other previous studies^(7,11).

Living with a VU requires changes in lifestyle⁽²⁵⁾, especially when periods of time are alternated in which it heals and then reappears, that is, leading to new adaptations to daily activities. In addition, the presence of venous ulcers entails additional expenses, as mentioned earlier, and financial difficulty is an aspect that directly impacts daily life.

The positive assessment in the treatment domain reflects greater confidence in the complete healing of the lesion, as it has already been achieved previously. This conclusion is reaffirmed by the result found in the correlation between a longer duration of the lesion and a negative evaluation of the treatment.

A slow healing process, as evidenced in similar studies, is associated with reduced quality of life⁽³¹⁾. Thus, long-standing injuries reduce the hope of cure and can be more severe⁽¹⁶⁾, imposing dressings that can be painful and more frequent. Therefore, such findings reinforce the need to offer people with VU prevention and rehabilitation treatment for physical limitations, enabling better adaptation to daily activities.

In addition, it is important to integrate them into a social support network in order to reduce the financial impact of treatment. It is also crucial to provide high-tech products that allow for less frequent changes, resulting in less pain and a lower risk of infections⁽¹⁷⁾, thus avoiding the worsening of the condition.

The findings of this research, when identifying the factors associated with the QoL of people with VU, allow contributing to the dissemination of scientific technical knowledge, in addition to serving as a basis for implementing changes in work processes in public health institutions, with a view to enabling better QOL for people with UV.

It is also noteworthy that the dressings were performed by the person, the use of inappropriate products and the absence of compression therapy, data that reveal a deficiency in PHC care. The use of absorbent dressings⁽⁵⁾, dressing procedures appropriate to the condition of the lesion⁽¹⁷⁾ and compressive therapy⁽⁷⁾ are essential for the effective treatment of a VU. It is essential that the health services can provide them, since the absence of adequate treatment can lead to the extension of the existence of the lesion, and even lead to the emergence of infections and complications, in addition to negatively interfering in the QoL of these people⁽⁴⁾.

In this study, it was not possible to compare populations with adequate versus inadequate treatment. However, it was found that the absence of a protocol to ensure effective treatment has been interfering with the QoL of these patients.

A limitation of the present study is its limited sample size, performed in only one location, which limits the generalizability of the results. Furthermore, it is important to highlight that a non-specific scale for venous ulcers was used, which may have impacted the accurate assessment of this specific condition.

Also, the lack of qualified care for people with VU in the municipality ends up making it possible for care to be carried out without professional guidance, which can then relegate evidence-based treatment, an essential tool for qualified, resolute care that takes into account the cost/benefit, therefore, more expenses can be generated and little or no result obtained.

The findings mentioned in the present study, in addition to indicating the quality of health care provided to the user, may enable the construction of parameters that will contribute both to the effectiveness of treatment for this population, as well as an efficient health service.

CONCLUSIONS

The presence of a VU had a negative impact on the QoL of people assisted in the public health network of this municipality, which does not have qualified assistance for the treatment of VU.

The domains Satisfaction, Physical symptoms and Daily life had the worst QoL assessment and the variables gender, presence of a partner, having help with dressing at home, using compressive treatment, age, recurrence and duration of injury, are associated with the QoL of people with VU.

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Contributor author

Conception and/or planning of the study: Constanci JGO, Santos MA

Data collection/analysis and/or interpretation: Constanci JGO, Vilerá AN

Writing and/or critical review of the content and final approval of the final version: Constanci JGO, Toffano SEM, Moraes JT, Santos MA

Promotion

This study was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - Brasil (CAPES) - Finance Code 001.

Support

Universidade Federal de Mato Grosso do Sul. Três Lagoas, Mato Grosso do Sul, Brazil.

Scientific Editor: Francisco Mayron Morais Soares. Orcid: https://orcid.org/0000-0001-7316-2519

Rev Enferm Atual In Derme 2023;97(3):e023119

Atribuição CC BY

Domains	Variables
	Age	Years of study	Relapse	Injury time
Physical symptoms	-0,402†	0,086	0,095	0,038
Daily life	-0,209	-0,012	278*	0,082
Psychological well-being	-0,380†	-0,036	0,089	0,18
Treatment	-0,113	0,034	-263*	374†
Satisfaction	-0,072	-0,039	-0,102	0,16
Total Score	-0,373†	0,056	0,139	0,296*