Improving patient adherence to wearing compression stockings in the management of venous leg ulcers

Abstract

Background: Venous leg ulcers (VLUs), often resulting from poorly managed chronic venous insufficiency, are painful wounds that can have a major impact on quality of life and healthcare systems. Prevalent among older adults with comorbidities and elevated body mass index, they affect 1.3 to 3 per 1,000 individuals globally. Compression stockings are essential in preventing recurrence, yet patient adherence remains poor (12% to 52%). Over 200 barriers to daily stocking wear have been identified, and a multidimensional approach is recommended to address this. Guided by Design Thinking, this thesis presents five studies addressing the question: How can adherence to wearing compression stockings be improved in the management of venous leg ulcers?

Methods and Results: Five related studies collectively contributed to a broad exploration of the research question. Study 1 was a scoping review, with 69 articles included after full-text screening (up till October 2019). The review highlighted a lack of high-quality trials exploring multidimensional interventions; existing randomised controlled trials (RCTs) and cohort studies were predominantly unidimensional, while small studies showed promise for multi-dimensional approaches. An updated search was conducted in December 2024 using the same search terms, identifying an additional 15 eligible articles but revealing no new findings. Informed by the initial search, Study 2 used behaviour change theory to develop a suite of clinical resources including a questionnaire to identify patient-specific barriers, information sheets, handouts and videos. To support accessibility and usability in clinical settings, these resources were integrated into an iPad-based mobile health app, as a clinical decision-aid named PAMCAI (Personalised and Multi-dimensional Compression Assessment Intervention). Study 3, a pilot RCT (n=20) evaluated the decision-aid against usual care in a tertiary occupational therapy vascular outpatient clinic. The intervention group demonstrated significantly improved adherence (p = 0.002) and cost-effectiveness, with an incremental cost-effectiveness ratio (ICER) of $3,379.36 per quality-adjusted life year (QALY) gained. Improvements in adherence were linked to the resolution of individual patient barriers. Study 4, a prospective cohort study, explored the relationship between clinician practice and patient adherence. Using the Quality Evaluation Strategy Tool (QUEST) by the World Federation of Occupational Therapists, documentation from 36 medical records revealed significantly higher documentation scores in areas targeted by the decision-aid (p < 0.001), which were strongly associated with improved adherence (p < 0.001). Study 5 used a qualitative methodology guided by the Technology Acceptance Model (TAM) to explore clinicians’ willingness to adopt the decision-aidinto future practice. Nine clinicians participated in the first phase, with four completing follow-up interviews. Thematic analysis identified overarching themes aligned with TAM constructs. Overall, the app was perceived as user-friendly and beneficial to patients, supporting its integration into routine care.

Conclusions and Implications: This thesis addresses a critical gap by detailing the theory-informed development and preliminary testing of a suite of resources incorporated into a personalised, multidimensional, clinician-delivered, clinical decision-aid to improve patient adherence to compression stockings. Findings demonstrate that the decision-aid improves adherence, positively influences clinician practice, and shows promising cost-effectiveness alongside strong clinician acceptability. If implemented at scale, the clinical decision-aid has the potential to improve health outcomes, reduce VLU recurrence rates, and ease healthcare system burdens. This research provides a foundation for future large-scale trials to validate and expand upon these findings.

Date of Award	3 Dec 2025
Original language	English
Supervisor	Susan Brandis (Supervisor) & Darryn Marks (Supervisor)