Health-related Quality of Life and Wound Care Practices Among Patients With Chronic Wounds in a Southwestern Nigerian Community

Introduction. Chronic wounds (CWs) are a common problem around the world. Although known to affect quality of life, patients’ perception may vary among cultures. Objective. The purpose of this article is to determine the effects of CWs on health-related quality of life (HRQoL) and identify wound care practices among a select population in southwestern Nigeria. Materials and Methods. This is a descriptive study of 60 patients with CWs receiving outpatient care. Adult patients > 18 years of age with a wound duration > 3 months were chosen by convenience nonprobability sampling at the point of care. A pretested, semistructured, interviewer-administered questionnaire and a guided interview was provided to each patient to complete; collected data were coded to ensure confidentiality and input into computer software for statistical analysis. Results. The average respondent age was 48.3 years (range, 18–80 years). Male to female ratio was 1:1.2, with 71.7% married, 96.7% of the Yoruba ethnic group, and 40% traders by occupation. The average wound duration was 23.2 months (range, 3–240 months). Trauma was the most common etiology of CWs followed by infection. There was no relationship between wound duration and patients’ gender. Most patients accessed care from more than 1 source simultaneously. The presence of CWs adversely affected the quality of life (R = -.288; P = .025). Many patients had varying degrees of abnormality in their mental health. Conclusions. Chronic wounds are associated with poorer HRQoL, and simultaneous reception of wound care from multiple sources was common. These findings also suggest a need to pay increased attention to psychological aspects of patients with CWs.

Chronic wounds (CWs) are a common problem across the world.¹ In the United Kingdom, up to 200 000 people have CWs that significantly impact their health-related quality of life (HRQoL).^2,3 Cultural beliefs and practices are known to significantly affect perceptions of diseases that may influence patients’ perceived HRQoL.⁴

The purpose of this descriptive research study is to determine the HRQoL and identify particular wound care practices of patients with CWs in the cultural settings of the Ife and Ijesa communities of southwestern Nigeria.

Participants were recruited by consecutive method of convenience nonprobability sampling at the point-of-care access from outpatient health care facilities. Four hospitals were selected for the study, 2 each from Ife and Ilesa: Obafemi Awolowo University Teaching Hospitals’ Complex, Ife Hospital Unit, Ile-Ife; State Hospital, Oke-Ogbo, Ile-Ife; Wesley Guild Hospital, Ilesa; and General Hospital, Ilaje, Ilesa. A sample size of 60 individuals was determined using PEPI Version 2 (USD Inc, Stone Mountain, GA).

Inclusion criteria consisted of adult patients between the age of 18 to 80 years with a wound > 3 months’ duration. Patients who were too sick (determined by the attending physician) to cooperate, had cognitive issues, or could not provide required information about their health were excluded from the study. All included patients provided written, informed consent prior to study.

Information on participants sociodemographic data (age, gender, marital status, number of children, ethnicity, religion, occupation, spouse’s occupation, level of education, and duration of the wound) were recorded (Table 1). Further information about patients’ well-being were obtained with a semistructured, interviewer-administered questionnaire and a question-answer interview with a key informant adapted from the World Health Organization-5 Well-being Index (WHO-5), 12-item General Health Questionnaire (GHQ-12), and Hospital Anxiety and Depression Scale (HADS). These were translated from English to Yoruba language (the indigenous language in the communities) and back to English to ensure there was no variation in content. It was validated through the face and content criteria and a pilot study was conducted at Ladoke Akintola University of Technology Teaching Hospital, Osogbo, Nigeria. The reliability of the questionnaire was ascertained with the test-retest technique and its internal consistency was validated with a Cronbach’s α coefficient of 0.7. Ethical approval was obtained from the Ethics and Research Committee of Obafemi Awolowo University Teaching Hospitals’ Complex, Ile-Ife, Nigeria.

Collected data were coded for confidentiality and input into SPSS, version 20 (IBM Corporation, Armonk, NY), for statistical analysis. P values were determined by chi-square and Pearson’s correlation. 

Average age of patients was 48.3 years (range, 18–80 years; median, 52 years; mode, 60 years) and 96.7% were of the Yoruba ethnic group. Sociodemographic information is shown in Table 1. There was no significant difference in wound duration between genders (P =.684). Wound etiology is shown in Figure 1.

Average wound duration was 23.2 months (Figure 2). The location of the wounds, sources of treatment, comorbidities, and other wound care practices are shown in Table 2. Only 18.3% (11/60) of patients strictly complied with the hospital prescription for wound care. All others (49, 81.7%) received concurrent care from more than 1 source or applied other nonprescribed agents to their wounds. 

The quality-of-life findings among the participants are shown in Table 3 and Table 4. Of the 60 participants, 35 (58.3%) were categorized as having better well-being while 25 (41.7%) were likely to have either depression or a low mood. Based on participant answers to HADS, 19 (31.7%) participants suffered from anxiety and 9 (15.0%) from depression. The other 32 (53.3%) participants were determined to have varying degrees of abnormality in their mental health. 

In addition, the results show a significant relationship between CWs and quality of life (P = .025; Table 5).

In this study, middle-aged and elderly patients constituted 60% of the participant population, as CW are most common in the third to fifth decades of life.⁴ Although there were more male participants, there was no difference in CW duration between genders. This may suggest similar attitudes to CWs among men and women. An average duration of 23 months and a maximum duration of 240 months suggests poor knowledge and attitude to CW care, perhaps aided by the inability to finance surgical interventions to aid early healing.  

Trader was the most common occupation at 40%, as compared with farmers and agricultural workers reported in a study conducted in China.⁵ More than 98% had at least a primary education, though level of education did not appear to influence the wound duration. The leg was the most common site of wounds in 66.7% and trauma the most common cause, similar to previously reported results in the literature.^4-6

In the present study, 4 of 5 patients applied other “medications” to their wounds from other sources in addition to their hospital-prescribed treatment. This habit could partly account for wound chronicity, as some of these agents from unorthodox sources could have harmful effects on wound healing; this may be the focus of further research. Sources of additional care included patient medicine stores, prayer houses, herbalists, and other outpatient hospitals. This habit may in itself be deleterious to wound care and affect objective evaluation of wound care products and outcomes. The 68.3% of patients who preferred other methods of care to their prescribed treatment suggests dissatisfaction with present care. This could adversely affect their compliance but also may imply good health-seeking behavior. 

The findings of this study reveal that CWs are associated with higher HADS scores as previously reported.⁷ These higher scores may imply increased stress in these patients. Stress is a multidimensional concept comprised of physiological, psychological, and social factors. These factors are interconnected and tend to reinforce one another in patients with CWs, potentially creating a vicious circle.^8-10 Gouin and Kiecolt-Glaser¹¹ found that individuals who experience anxiety and depression as a result of high levels of stress also may have a propensity to adopt negative behaviors such as abusing alcohol and cigarettes and making poor dietary and health choices. Although evidence¹² suggests such behaviors do not completely account for the negative effects of stress on wound healing, they may exacerbate the effects of stress and have a detrimental impact on the wound healing process.

More than 40% of study participants had impaired well-being according to the WHO-5; only 3% scored as typical health by GHQ-12 and 19% were considered normal by HADS evaluation. Therefore, the statistically significant reduction in quality of life (Table 5) calls for holistic evaluation and care of the patients because CWs may impact virtually every aspect of daily life.^13-16 These findings suggest an increased need to pay more attention to the psychological aspects of the patient with a CW. Stress and anxiety have been correlated with increased wound-related pain at dressing changes.^9,17,18 Prolonged stress can lead to raised levels of cortisol, which affect body immunity, inflammatory responses, and wound healing.¹² Nursing care of wounds should include emotional, social, and psychological assessment and intervention to ensure the desired outcomes.^19-21

There is a need for regular feedback from patients to caregivers on their level of satisfaction. This is noteworthy, as 68.3% of respondents would prefer to explore other options of wound care in this study. Patients’ assessment of quality of life may differ from that of the clinician.²²

This study was conducted in the southwestern part of Nigeria, which leaves it open to potential cultural bias. The information generated by the study was subjective, and this may affect the accuracy and precision. In addition, the adapted instruments had to be translated into the Yoruba language; due to that, slight alterations may have occurred in the course of the translation despite best attempts to preserve the originality. 

The patients with CWs studied herein demonstrated significant quality of life impairment. Many patients had wounds lasting several months. Majority of participants received care from multiple sources simultaneously and were dissatisfied with their progress with care and desired more expeditious modalities of care. The reasons for such attitudes should be explored in future research.

Authors: Helen Oladunni Oladele, MSc¹; Reuben Boluwaji Fajemilehin, BSc, MSc, PhD²; Ayodeji Olanrewaju Oladele, MBChB³; and Elizabeth Olawumi Babalola, BSc⁴

Affiliations: ¹Department of Nursing Education, Obafemi Awolowo University Teaching Hospitals’ Complex, Ile-Ife, Osun State, Nigeria; ²Department of Nursing Science, Faculty of Basic Medical Sciences, Obafemi Awolowo University, Ile-Ife, Osun State, Nigeria; ³Department of Surgery, Obafemi Awolowo University; and ⁴Obafemi Awolowo University Teaching Hospitals’ Complex

Correspondence: Helen Oladunni Oladele, MSc, School of Nursing, Obafemi Awolowo University Teaching Hospitals’ Complex, Ile-Ife, Osun State, Nigeria; helenoladele@yahoo.com

Disclosure: The authors disclose no financial or other conflicts of interest.