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TABLE7.3 Examples ofthe inextricable links between thesocial determinants ofhealth, leg ulceration risk
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anddelayed healing.
Obesity People with obesity are
more likely to develop
leg ulceration through
reduction in calf muscle
function and mobility, as
well as increased
intra- abdominal
pressure (Meulendijks
etal.2020).
Smoking People who smoke are
more likely to develop
leg ulceration
(Wounds UK2022).
People with lower
income (also
referred to as
lower
socioeconomic
status) are at risk
of delayed
healing (Gethin
etal.2022).
People living in the
most deprived
areas of England
are four times
more likely to
smoke than those
living in the least
deprived areas
(Oce for
National
Statistics2023a).
Lower income is adversely
associated with obesity
(Kim and Knesebeck2018).
Smoking is related to several
other co-
morbidities such as
circulatory disorders, for
example peripheral arterial
disease, chronic respiratory
disease, kidney or liver
disease and anaemia, all of
which may be a factor in
delayed healing
(Wounds UK2022).
Obesity- related
hospital
admissions for
women from the
most deprived
areas are nearly
twice as high
asfor women
fromthe least
deprivedareas
(Holmes2021).
In 2019–2020 there
were an estimated
506k smokingrelated hospital
admissions in the
UK (Oce for
Health
Improvement and
Disparities2022).
Mental
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health and
well- being
Stress is known to have an
impact on wound
healing and can
contribute to delayed
healing (Wynn and
Holloway2019; Gethin
etal.2022). Factors such
as unemployment, low
income, food and fuel
poverty are very
stressful.
People with lower
incomes are more
likely to report
their health as
‘bad’ or ‘very bad’
(Health
Foundation2022).
The body is dependent on the
right nutrition and
hydration to heal wounds
(Wounds UK 2022). People
who have less money may
not have food security. Food
security is when we know
we have enough nutritious
food to feed ourselves and
our family. Not having food
security is stressful.
If a person’s mental
health and
well- being are low
this may aect
their ability to
participate in leg
ulcer treatment.
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men to experience a leg ulcer, and choices such as smoking and
dietary intake, which are inuenced by wider determinants such as
poverty, also contribute to incidence.
WIDER DETERMINANTS OFENGAGEMENT
WITHTREATMENT
Just as they have impacts on health outcomes, the wider determinants of
health can also create or limit a person’s capacity for engagement with
leg ulcer treatment. For example, telling people who are obese that they
need to lose weight in order to expedite wound healing is likely to have
limited success if that person has limited mobility, restricted access to
aordable healthy food (for example, they do not live near a supermarket and rely on takeaway or convenience foods), works in a sedentary job
and has a low income or is not near any green spaces. Similarly, wound
healing may not appear to be as high a priority for the person with leg
ulcers as the practitioner. For the practitioner, wound management may
be the focus of their interaction with the person. For the person with leg
ulcers, the wound may be one among many issues occurring in their life
that requires their attention, and it may not be the most urgent or important by comparison. An example of this may be that if a person has fuel
poverty and is at home cold, this may be the part of their life that is
upsetting them the most, with the ulcer taking less of a priority. To navigate this and reach a concordant decision for a management plan,
understanding wound management in the context of the wider determinants of a patient’s health and life is essential. A lack of understanding
can lead to what tend to be called ‘issues with compliance’ or ‘noncompliance’; this is a harmful term that is explored later in this chapter.
It is evident, then, that there are many factors that inuence
health behaviours and outcomes for people with leg ulcers. Considering these helps us to understand the conditions people experience
and the choices they make in response. Furthermore, acknowledging
the complexity of health and its determinants demonstrates the limited impact that health practitioners alone might have on preventing
and managing wounds. A response more reective of this complexity
of need is required, one that views lower limb health as a public
health issue. Public health can be dened as ‘the science and art of
promoting health, preventing disease, and prolonging life through
the organized eorts of society’ (Acheson1988).
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When leg ulcers are considered within the context of public
health, the ‘organised eorts of society’ from a public health perspective are required to prevent and manage the problem. What this
means is that from a public health viewpoint the response extends
beyond one practitioner and one patient to the contribution of wider
stakeholders. Table 7.4 illustrates some examples of how a public
TABLE7.4
lower limb ulceration or increase healing rates.
Employers discouraging
sedentary working
practices.
Healthy food at
aordable prices.
The government
addressing fuel poverty.
Local authorities ensuring
residents have access to
green spaces for activity.
Family, friends and
colleagues supporting
patients and reducing
isolation.
Examples ofhow public help interventions could prevent
We know that sitting or standing in one
position, all day, every day causes venous
hypertension and in the long term,
chronic venous insuciency, which may
lead to venous disease and subsequent
leg ulceration.
Examples of employment groups here may
be a person employed on a production line
in a factory, who is required to stand
upright and in a limited oor space area
for long periods of time, or a person seated
and sedentary in a call centre all day.
We have explored earlier in this chapter the
links between obesity and poor lower
limb health.
A public health approach here would be
healthy food at aordable prices, and
robust, accessible education on how to
shop and prepare healthy meals.
Fuel poverty is linked to generally poorer
mental and physical health.
Particularly within the context of lower limb
ulceration, fuel poverty is linked to
increased risk of respiratory infections,
which can aect oxygenated blood supply,
which in turn is linked to delayed healing.
Being active reduces the risk of functional
venous hypertension.
This can support shared care and self- care in
lower limb management.
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TABLE7.5
Presence of a leg ulcer(s)
Presence of lymphoedema of the lower limb (excluding cancer related)
Cellulitis of the lower limb
Chronic oedema of the lower limb
Diabetic foot ulceration and foot ulceration
Source: Adapted from Sandoz and Walton (2021).
Five key areas ofpublic health practice forthe lower limb.
health approach may be achieved in leg ulcer management. Once
again, it is important to acknowledge that this is just a snapshot of the
public health interventional possibilities and that many more exist.
Leg ulcers do not feature highly on the public health agenda, and
within clinical practice there is often a lack of recognition by senior
leadership of leg ulceration as a serious and commonly occurring public health issue. In contrast, it is a highly visible issue to those whose
daily role is caring for people with leg ulcers (Sandoz and Walton2021).
Local authorities have multiple complex health issues to commission
for and cuts to funding, coupled with the Covid- 19 pandemic aftermath, mean that services are likely to be even further stretched in the
coming years. As such, leg ulcers may not be recognised in their complexity and their full eect on a person’s health, especially when competing with other equally important public health issues such as
mental health, cardiovascular disease, antimicrobial resistance and
diabetes– even though lower leg ill- health may be directly related to
these issues (Sandoz and Walton2021). Practitioners are well placed to
raise awareness of leg ulcers as a complex public health issue, and part
of their role in clinical management might also include feeding back
information about the prevalence and wider impact of leg ulcers to
senior managers or service commissioners.
Sandoz and Walton (2021) have successfully implemented and
described a public health needs assessment that supports service redesign and new pathways of management focused on six key areas of
public health practice for the lower limb. This is explained in Table7.5.
MAKING EFFECTIVE CHANGE
As has been discussed, a purely clinical response to a person who is
experiencing a leg ulcer is likely to have limited success. A health
professional’s typical response might be to oer solutions and try to
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‘x’ problems. However, it is often the case that people know what
they need to do in order to improve their health outcomes; it is actu-
ally doing it that might require support or guidance. See Box7.1 for
some reection on this.
Box 7.1 Reflection Point
Think of an issue in your own life that you need to address (this
could be anything, for example losing weight, doing 10 000 steps a
day, taking more time to relax, managing your nances better) in
relation to the following questions:
1. Do you know what you need to do to make the improve-
ments you require? (If not, do you know where to get the
information you need?)
2. Do you follow the advice and information you have been
given exactly? If not, why not?
3. What do your responses to 1 and 2 tell you about what
facilitates/prevents people from following advice and
guidance?
As explored in Box7.1, there is a signicant dierence between
knowing that change is needed and taking action to make change
happen. Understanding the process of change can be helpful to both
practitioners and the person with leg ulcers, as this can better prepare
them to plan, implement and maintain change in a manner that
takes into account the wider determinants of health for people with
leg ulcers. Prochaska and DiClemente (1983) propose a model of
change that might help both patients and practitioners to assess their
situation and plan interventions accordingly.
Prochaska and DiClemente’s (1983) model suggests that change
is a cyclical process. Table7.6 maps out how we can apply each stage
of the cycle to support people with leg ulceration.
Considering this model in alignment with healing might suggest
to practitioners that there are optimum times in the cycle for intervention, and that intervention is likely to be dierent at dierent
stages of the cycle. For example, there would be little point in
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TABLE7.6 Applying thecycle ofchange tosupport people withleg
ulceration.
The cycle may start with the person not even contemplating the need for
change, but the practitioner will recognise this.
Pre- contemplation
and contemplation
stages– both
might go on for
prolonged
periods of time
Preparation stage Practitioners might support patients to access the
Action stage The patient takes action to address their
Maintenance stage Here the practitioner has the opportunity to support
Possible relapse Relapse is included as a possible stage of the process.
Practitioners might intervene to increase
understanding around leg ulcers, compression
therapy and lifestyle to begin with.
correct equipment, resources and information in
order to make an informed decision about
taking action.
Examples: addressing some of the wider
determinants of health– smoking, income,
access to transport and others.
wound healing.
Action might be undertaken in partnership with the
practitioner in the form of a mutually agreed
management plan, or a patient may choose to
follow their own course of action (including
taking no action).
the patient to maintain the action– to continue
with the management plan.
This might involve revisiting some of the wider
determinants of health identied in the
preparation stage, assessing their impact on
maintaining the plan and making any necessary
amendments to support maintenance.
Here, the patient may nd it dicult to maintain
the plan and temporarily or permanently cease to
engage with it.
The practitioner and patient can use this as a
learning opportunity, exploring the reasons for
relapse and planning how to mitigate them when
the plan is re-
established.
Source: Authors’ elaboration based on a model from Prochaska and DiClemente (1983).
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teaching a person how to apply compression eectively if they were
currently in the pre- contemplation stage. Instead, a useful intervention might be to spend some time listening to the person in an attempt
to build a relationship with them, in order to move on to more proactive discussions later on. There are eective tools to support practitioners in assessing people to identify what stage of engagement they
are at, which will be discussed later in this chapter.
WHAT INFLUENCES PRACTITIONERS’
DECISION- MAKING INLEG ULCER MANAGEMENT?
Just as patients’ health- related decisions and behaviours are inuenced by wider determinants, so too are those of practitioners.
Unwarranted variation in wound management is well documented
and there are multiple inuencers for this; the National Wound Care
Strategy was initiated to address the issue of sub- optimal wound
care (www.nationalwoundcarestrategy.net). Internal factors such as
practitioner knowledge, skills and social inuences, and external
factors such as workload, resource and availability of services all
have impacts on decision- making in wound management (Gray
etal.2018). Concerningly, Gray etal.’s (2018) study also identied
that colleagues, patients and the pharmaceutical industry were more
likely to inuence decision- making than research and evidence.
However, there are also individual, personal and professional
inuences on practice. Many practitioners will be familiar with the
expressions ‘We’ve always done it that way’ or ‘We’ve tried that before
and it didn’t work’, both of which at times suggest a reluctance to
change or even open oneself to new evidence or a dierent way of
working. In other words, practitioners may avoid change because it
involves a lot of work (Arsenault Knudsen etal. 2021) or perhaps
because they have become weary of change. Although this is by no
means acceptable, it is perhaps understandable in the context of
today’s practice, where workload, stang and lack of resources and
time all present barriers to opportunities for learning and development. Practitioners are human beings, subject to wider determinants
of health and health beliefs just as patients are, and doing what we
have always done in order to meet the ever- increasing demands of
modern- day healthcare in stressful and challenging circumstances
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seems to make sense, in the short term at least. However, this is a
false economy– longer healing times, wound deterioration, disengagement with services and dissatised patients and clinicians may
all use more time and resource in the long term. Time taken to expose
oneself to evidence, engage in clinical peer support and challenge
practice where appropriate might well turn out to be the less labourintensive option.
It can be dicult to challenge cultural practice, particularly
when it is well established. However, practitioners are bound by their
code of conduct (Nursing and Midwifery Council 2018) to practise
safely and eectively, to prioritise people and to promote professionalism and trust. As such, we have a duty to lead and inuence
decision- making and challenge ineective practice. Evidence suggests that implementation of impactful, evidence- based practice
occurs in situations when there are a number of facilitative factors,
including:
Practitioners having a clear understanding and condence in the
eective impact of a proposed change for patients (Mathieson
etal.2019).
Managerial support (Teodorowski etal.2019).
Ongoing education (Teodorowski etal.2019).
Access to resources (Teodorowski etal.2019).
It can be agreed, then, that there are a range of intrinsic and
external factors that influence practitioners’ decision- making and
practice. Identifying these influential factors in our own practice
is integral to taking care of ourselves as well as the people we
care for.
THE INFLUENCE OF CONFIDENCE, COURAGE
ANDCOMPETENCE
Having the right levels of condence, courage and competence can
be a challenge within lower limb practices, due to the inuence of
local culture or arguably due to the myths that have developed
particularly around compression therapy (Wounds UK2022). These
myths are discussed later in the chapter. Eective practice and
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Clinical
competence
Better
outcomes
Lower limb
leadership
Sense of
cohesion
FIGURE7.2 A framework on which to base condent and competent leg
ulcer practice.
therefore better outcomes for people with leg ulceration are underpinned by three key themes, as illustrated in Figure7.2.
Clinical competence means the development of a combination of
eective technical skills and a personalised approach to care in lower
limb management. An example may be eectively applying a bandage and understanding both the scientic theory of the therapy as
well as the art of the application in sculpting the person’s limb. Clinical competence in technical skills is discussed in more details in
Chapter8. It is suggested that the basis for clinical competence comes
from a combination of theoretical knowledge development and
organic clinical experience. Being a reective practitioner is essential
for clinical competence. The Nursing and Midwifery Council (NMC)
advocates that complexities should be weighed and reviewed in the
light of actions taken; beliefs about evidence of ecacy can emerge
from this and shape clinical practice. Courage to use compression
therapy comes from this knowledge and growing competence.
The second theme is a sense of cohesion in lower limb management. Healing rates are linked to social capital and a sense of cohesion, which brings in a participatory public health approach and
personalisation. A practitioner’s knowledge must be balanced with
the lived experience of the person with leg ulcers. This sense of cohesion and appreciation of the complexity provide the courage practitioners need in order to empower citizens, not tell them what to do.
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