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 TE
ORIGINAL RESEARCH

Health-related Quality of Life, Self-

CA
esteem, and Functional Status of
Patients With Leg Ulcers

Elaine Faria, RN, MS; Leila Blanes, RN, PhD; Bernardo

Hochman, MD, PhD; Marcos Mesquita Filho, MD, PhD;
Lydia Ferreira, MD, PhD

WOUNDS 2011;23(1):4–10
From the Federal University of São
Paulo (UNIFESP), Brazil
Address correspondence to:
Elaine C. Faria, RN, MS
DU
Federal University of São Paulo
(UNIFESP)
Rua Napoleao de Barros 715
4o andar
04023-062 São Paulo
Brazil
Phone: 55-11-5576-4118
E-mail: lavelle@uol.com.br
T
I
PL
Abstract: A study was conducted in Southern Minas Gerais, Brazil that
comprised 80 subjects with chronic venous leg ulcers (study group)
and 80 subjects without ulcers (control group). The aim of this study
was to assess the health-related quality of life (HRQoL), self-esteem,
and functional status of patients with chronic venous leg ulcers. The
Medical Outcomes Study 36-Item Short Form Health Survey ques-
tionnaire (SF-36), Rosenberg’s self-esteem (RSE) scale, and the
Stanford Health Assessment Questionnaire (HAQ-20) were adminis-
tered to all participants. There were statistically significant differences
between groups in the mean scores on the following SF-36 domains:
physical functioning, physical role, social functioning, emotional role,
bodily pain, vitality, and general health (P < 0.05). No statistically sig-
nificant differences in mean RSE scores were found between groups.
However, significant differences were found between groups in mean
scores on 7 of the 8 HAQ-20 categories (P < 0.001). The presence of
venous ulcers adversely affected quality of life (SF-36) and function-
al status (HAQ-20), but did not affect self-esteem (RSE).

KEYPOINTS
•The aim of this study was to assess the health-related quality of life
NO

(HRQoL), self-esteem, and functional status of patients with chronic

venous leg ulcers

eg ulcers have become increasingly common among patients with

L chronic diseases. Almost 70% of the ulcers that occur are a result of
chronic venous insufficiency.1 Venous insufficiency is defined as
changes in the functioning of the venous system caused by valvular incom-
petence with or without associated venous outflow obstruction, which may
affect the superficial venous system, the deep venous system, or both.2
Epidemiological studies of prevalence of leg ulcers in the United
O

Kingdom revealed that 8 per 1000 in the population have leg ulcers, corre-
sponding to approximately 1% of adults.3 It is estimated that 7 million peo-
ple in the United States have chronic venous insufficiency.2,3 In Brazil, a study
conducted in Botucatu, São Paulo, reported a 35.5% prevalence of varicose
4 WOUNDS www.woundsresearch.com

veins and 1.5% prevalence of severe chronic venous
insufficiency with an ulcer or ulcer scar.4
Quality of life (QoL) is a popular and broad term that
has been used in various contexts, and has garnered the
attention of professionals from various fields, particularly
in healthcare. Quality of life involves concepts that reach
beyond symptom control, mortality reduction, and
increase in life expectancy.5 Self-esteem is a construct
related to QoL in which a person’s feelings of self-worth,
self-value, self-image, and self-concept are also considered.6
I
Venous ulcers often take a long time to heal, which
results in physical and psychological discomfort, and
PL
negatively affects a patient’s functional status. Functional
status relates to the ability of the patient to perform nor-
mal daily activities, reflecting the impact of the disease
on his or her daily routine.7
Chronic leg ulcers have a negative impact on QoL.
Edwards et al8 tested a care model emphasizing social-
ization and peer support for the management of patients
with chronic leg ulcers that significantly improved out-
DU
comes in QoL, morale, self-esteem, healing, pain, and
functional ability.
In view of the high prevalence rates and major physi-
cal and psychological distresses venous ulcers cause, a
study was conducted to evaluate the QoL, self-esteem,
and functional status of patients with this condition.
Methods
The Research Ethics Committee of the Sapucaí Valley
University (Universidade do Vale do Sapucaí, UNIVAS)
T
approved this study. Written informed consent was
obtained from all patients prior to their inclusion in the
study.
Data were collected from October 2005–July 2006. A
NO
total of 160 patients were equally distributed into two
groups.
Study group. Eighty participants were selected from
consecutive patients with chronic venous leg ulcers who
attended either the Outpatient Clinic of the Samuel
Libânio General Hospital (Hospital das Clínicas Samuel
Libânio, HCSL), Family Health Centers, or Outpatient
Clinics of Public Health Centers in Pouso Alegre and
Minas Gerais, Brazil. Patients between 40- and 80-years-
old with clinical diagnosis of chronic venous leg ulcers
were included in the study independent of ulcer dura-
O
tion, number, and ulcer type (primary or recurrent).
Control group. Eighty persons without ulcers were
selected from a random sample of people from the com-
munity. Patients with cognitive deficits or psychiatric dis-
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Faria et al
orders were excluded from the study. All patients agreed
to participate in the study (no data were missing).
CA
The Medical Outcomes Study 36-Item Short Form
Health Survey questionnaire (SF-36) was used to assess
health-related quality of life (HRQoL). The SF-36 is a
generic tool containing 36 items of which one is a com-
parative item assessing changes in health over the past
year, and 35 items are grouped into 8 domains as follows:
physical functioning, physical role, bodily pain, general
health, vitality, social functioning, emotional role, and
mental health. Each SF-36 domain was evaluated inde-
pendently. Domain scores ranged from 0 to 100 (0 =
“worst health status” and 100 = “best health status”).
Self-esteem was assessed by the Brazilian version of
the Rosenberg Self-Esteem scale (RSE/UNIFESP-EPM),
which consists of 10 items rated on a 4-point scale.6 The
total RSE score ranges from 0 to 30 (0 = highest self-
esteem level and 30 = lowest self-esteem level).
Functional status was evaluated using the 20-item
short version of the Stanford Health Assessment
Questionnaire (HAQ-20),9,10 which had been translated
into Portuguese, culturally adapted, and validated for use
in Brazil.11 The full version of the HAQ contains 37 items
grouped into 4 dimensions: 1) disability, 2) discomfort
and pain, 3) drug side effects/toxicity, and 4) dollar
costs. Only the disability dimension was assessed in the
present study. The HAQ-20 consists of 8 categories:
dressing and grooming, arising, eating, walking, hygiene,
reach, grip, and activities. This instrument measures the
difficulty in performing activities of daily living. For each
item, there is a 4-level difficulty scale that is scored from
0 to 3. The eight category scores are averaged into an
overall score on a scale from 0 (no disability) to 3 (com-
pletely disabled).9,11
The same investigator administered the questionnaires
by way of interview after the participants provided
signed informed consent. Patients were asked to select
the statement that best reflected his or her opinion for
each questionnaire item. Any questions the participants
raised were clarified. There were no missing data.
For the analytical procedures, the homogeneity of the
study and control groups was tested using the chi-square
test. The Kolmogorov-Smirnov test was performed to
assess whether the study data followed a parametric or
non-parametric distribution. Statistical comparisons
between mean scores were made using the Mann-
Whitney test and z-test. All statistical tests were per-
formed at a significance level of 0.05. Data are presented
as mean ± standard deviation (SD).
Vol. 23, No. 1 January 2011 5
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Faria et al

Table 1. Mean SF-36 scores on each of the eight domains for the study and control groups.

CA
SF-36 domains Study Control Difference P Z
group group between
(n = 80) (n = 80) groups
Physical functioning 48.68 80.06 (31.38) <0.001* -6.7
Physical role 22.50 75.31 (52.81) <0.001* -8
Bodily pain 57.81 72.29 (14.48) 0.002* -2.9
General health 66.18 73.13 (6.95) 0.031* -2.1
Vitality 59.37 70.75 (11.38) 0.002* -2.9
Social functioning 56.25 81.60 (25.35) <0.001* -3.7

I
Emotional role 41.61 80.34 (38.73) <0.001* -4.4
Mental health 64.90 71.94 (7.04) 0.115 -1.6

PL
*Statistically significant; Mann-Whitney test

Table 2. Mean total scores on the Brazilian version of the Rosenberg Self-Esteem Scale (RSE/UNIFESP-EPM) for
the study and control groups.

Instrument Study Control Difference P* Z*

group group between
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(n = 80) (n = 80) groups
Total RSE score 7.83 6.82 (1.01) 0.123 -1.6

*Mann-Whitney test

Table 3. Mean Health Assessment Questionnaire Functional Disability Index (HAQ-DI) scores for the study and
control groups.
Instrument Study Control Difference P Z
group group between
(n = 80) (n = 80) groups
T

HAQ-20 0.700 0.175 (0.525) <0.001* -6.2

*Statistically significant; Mann-Whitney test

NO

Table 4. Mean Health Assessment Questionnaire (HAQ-20) scores for the study and control groups.

HAQ-20 Study Control Difference P Z

categories group group between
(n = 80) (n = 80) groups
Dressing and grooming 0.45 0.16 (0.29) <0.001* -3.41
Arising 0.64 0.20 (0.44) <0.001* -3.81
Eating 0.18 0.06 (0.12) 0.161 -1.40
Walking 0.86 0.15 (0.71) <0.001* -6.42
Hygiene 0.39 0.11 (0.28) <0.001* -3.20
Reach 0.91 0.30 (0.61) <0.001* -4.52
O

Grip 0.99 0.23 (0.76) <0.001* -4.85

Activities 1.19 0.34 (0.85) <0.001* -5.27

*Statistically significant; Mann-Whitney test

6 WOUNDS www.woundsresearch.com

KEYPOINTS
• The Medical Outcomes Study 36-Item Short Form
Health Survey questionnaire (SF-36) was used to
assess health-related quality of life
• Functional status was evaluated using the 20-item
short version of the Stanford Health Assessment
Questionnaire
Results
Patients in the study group were predominantly
I
women (71.25%), white (76.25%), age 46–85 years
(96.25%), married (51.25%), and with 1–4 years of edu-
PL
cation (50%). In the control group, patients were also
predominantly women (75%), white (80%), aged 46–85
years (95%), married (65%), and with 1–4 years of educa-
tion (45%).
There were significant differences between groups in
the mean scores for the SF-36 domains of physical func-
tioning, physical role, emotional role (P < 0.001), bodily
pain, general health, and vitality (P < 0.05). No statistical-
DU
ly significant differences were found (P = 0.115) in mean
mental health scores between groups (Table 1). No sig-
nificant differences between groups (P = 0.123) were
found in the mean RSE scores (Table 2). However, there
were significant differences (P < 0.001) between groups
in the functional status (overall HAQ-20 score) and mean
scores for all HAQ-20 categories (Table 3), except for the
eating category (P = 0.161), as shown in Tables 4.
Discussion
T
Quality of life is defined as a multidimensional con-
cept, a traditional theme of philosophers and poets that
today is used by researchers as a quantitative tool in clin-
ical trials and economic models. The current interest in
NO
quantifying QoL has been reinforced by the develop-
KEYPOINTS
• There were significant differences between groups
in the mean scores for the SF-36 domains of phys-
ical functioning, physical role, emotional role (P <
0.001), bodily pain, general health, and vitality (P
< 0.05)
• No significant differences between groups (P =
0.123) were found in mean RSE scores
• There were significant differences (P < 0.001)
O
between groups in functional status (overall HAQ-
20 score) and mean scores for all HAQ-20 cate-
gories (Table 3), except for the eating category (P
= 0.161)
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Faria et al
ment of quantitative methods in psychology, economy,
and other social sciences.12
CA
The multidisciplinary approach to health care has
changed in the last several years. Subjective variables that
reflect patients’ perception of their well being and QoL
have been used in quality-of-life assessments. Not only
are researchers interested in assessing QoL, but also
those professionals involved in clinical practice.5
Venous ulceration is a chronic disease, which is char-
acterized by periods of exacerbation and remission, and
restrictions imposed by treatment that result in physical
limitations and life-style changes.13 The prevalence of
venous ulcers has increased each year,5 affects the activ-
ities of daily lives of patients, and is a serious public
health problem.
Both groups in the present study were statistically
homogeneous regarding sociodemographic variables; sig-
nificance levels ranged from 0.17–0.88, demonstrating
homogeneity; therefore, the control group was consid-
ered comparable to the study group.
The mean age of all participants (n = 160) was 64.1 ±
9 years (range, 43 to 88 years), and of patients with
chronic venous leg ulcers (n = 80) was 64.0 ± 10 years.
Several studies have reported that chronic venous leg
ulcers are a severe health problem common among the
elderly, and considered aging as a risk factor, especially in
individuals older than 65 years.2,14–16
The percentage of women was 71.3% in the study
group and 75% in the control group, which is in agree-
ment with the literature. This may be attributed to the
fact that women live longer than men, and are at a high-
er risk of developing deep venous thrombosis during
pregnancy.3,5,17,18
Results also revealed that the percentage of subjects
who had 1–4 years of education was 50% in the study
group and 45% in the control group, and that 37.5% of
the patients in the study group were illiterate versus
33.8% in the control group. A low level of education may
affect a patient’s compliance with treatment.5,19,20
The percentage of patients with diabetes was 17.5%
in the study group and 15% in the control group, and of
patients with arterial hypertension was 48.8% in the
study group versus 42.5% in the control group. Studies in
the literature report that venous ulcers are associated
with diseases such as diabetes, peripheral vascular dis-
ease, and chronic venous insufficiency,4,5 and have a
recurrence rate of 70% after healing.5,21,22
Anand et al23 reviewed the concept and tools used to
assess QoL in patients suffering from chronic venous leg
Vol. 23, No. 1 January 2011 7

Faria et al
ulcers. Another study comparing four generic instru-
ments used for measuring HRQoL in patients with
venous leg ulcers recommended the SF-36 alone or in
combination with the short form McGill Pain
Questionnaire (SF-MPQ) for long-term follow-ups (12
months) in clinical studies.24 In the present study, the
mean duration of ulcer symptoms was 11.2 years, with
95% confidence interval (CI) (range, 8.8 to 13.6 years).
The SF-36 was used to assess the HRQoL, and the mean
SF-36 domain scores were evaluated. The results showed
I
that there were significant differences in the mean
scores on the SF-36 physical functioning domain (P <
PL
0.001) between the study group (mean score, 48.7) and
control group (mean score, 80.1). Patients with venous
leg ulcers had more difficulty performing activities of
daily living than control group patients. The difficulty
experienced while performing simple tasks intensifies
the dependency needs of these patients.2,4,18,25
It was also found that there were significant differ-
ences in mean scores on the physical role domain (P <
DU
0.001) between the study group (mean score, 22.5) and
control group (mean score, 75.3), indicating that physical
health affected work-related activities of patients with
venous leg ulcers.These limitations were also reported in
studies on chronic venous insufficiency and venous
ulcers.2,4,18,19,25
The mean scores on the bodily pain domain were sig-
nificantly lower (P < 0.05) in the study group (mean
score, 57.8) than in the control group (mean score, 72.3).
This indicates that bodily pain had a more negative
T
impact on the HRQoL of patients with venous ulcers
than that of controls. Note that scores on the bodily pain
dimension range from 0 to 100 (0 = very intense pain
and 100 = no pain). A number of studies on pain related
NO
to venous ulcers can be found in the literature; they
reported that pain may result in social isolation, suffer-
ing, depression, anxiety, changes in the family relation-
ship, and reduced wound healing rates.2,5,18,19,25–27 Studies
on chronic venous leg ulcers have indicated that some
types of dressings may promote pain relief and improve-
ment in QoL, which may lead to faster wound healing.27,28
Healthcare professionals caring for patients with chronic
diseases should have knowledge of pain and pain man-
agement, and also be aware that control or reduction of
pain may affect HRQoL, psychosocial functioning, and
O
wound healing.20,27
The general health domain evaluates the patient’s per-
ception of health status and opinion about the future,
independently of having or not having ulcers.There were
8 WOUNDS www.woundsresearch.com
TE
significant differences in the mean scores on the general
health domain (P < 0.05) between the study group
CA
(mean score, 66.2) and control group (mean score, 73.1).
It would be interesting to separately evaluate patients
who have had ulceration for a long time, because their
responses may reflect an accommodation to the disease
over the years or be associated with aging.18
Vitality measures the energy and spirit to perform
activities of daily living. There were significant differ-
ences in the mean scores on the vitality domain (P <
0.05) between the study group (mean score, 59.4) and
control group (mean score, 70.8). Vitality is directly relat-
ed to physical functioning and physical role domains.The
presence of venous ulcers has a negative effect in the
HRQoL of patients, resulting in feelings of frustration and
dissatisfaction due to the inability to perform work-relat-
ed activities and daily tasks.20,29,30
The social functioning domain measures the extent to
which an individual is unable to carry out social activi-
ties due to his or her physical and emotional state. There
were significant differences in mean scores on the SF-36
social functional domain (P < 0.001) between the study
group (mean score, 56.3) and control group (mean score,
70.8).This result may be attributed to the fact that chron-
ic ulcers have a high recurrence rate, causing people to
feel uncomfortable in social situations or leading to feel-
ings of inadequacy and embarrassment. The recurrence
rate of healed leg ulcers is about 30% within the first year
and this rate increases to 78% within 2 years.22 Most
venous ulcers are visible, have an unpleasant odor, cause
pain, edema, and difficulty in walking. All of these factors
negatively affect the social life of patients with a venous
leg ulcer.4,7,18,26,31–33
There were significant differences in mean scores on
the SF-36 emotional role domain (P < 0.001) between
the study group (mean score, 41.6) and control group
(mean score, 80.3). Chronic ulcers cause many discom-
forts, as mentioned in the analysis of other SF-36
domains. With regard to the emotional role domain, sta-
tistical results confirmed patients’ dissatisfaction with
their condition, which points to the importance a multi-
disciplinary approach to the treatment of venous
ulcers.17 Venous ulcers are associated with almost no
mortality, but with high morbidity, which causes suffer-
ing and impairment, and interferes with many aspects of
QoL, such as social life and work, among others.4,34
Changes in emotional functioning have also been
observed in patients with venous ulcers.26,31
The items on the mental health domain assess the

extent to which feelings of anxiety, depression, happi-
ness, and peacefulness affects the QoL of an individual.
No statistically significant differences in the mental
health scores were found between groups (P = 0.115),
revealing that both the study group and control group
had similar mental health status. One explanation for this
might be that the patients with venous ulcers shared sim-
ilar values, customs, and beliefs, favoring social interac-
tion and reducing isolation.18
Self-image can be objectively measured and evaluated
I
based on the social experiences of the individual.6
Statistically significant differences (P = 0.123) in the
PL
mean RSE scores between the study group (mean RSE
score, 7.8) and control group (mean RSE score, 6.8) were
not found. RSE scores for both groups had a close to nor-
mal distribution. In a previous study on the impact of
venous ulcers on the QoL and their financial, social, and
psychological implications, 68% of the patients reported
that the ulcer had a negative emotional impact on their
lives, causing depression and negative self-image.31 In a
DU
study on the psychosocial aspects of chronic venous
ulcers in the elderly, patients in the study group reported
low levels of self-esteem and high levels of negative
expectancy.35
With regard to functional status, there was a signifi-
cant difference (P < 0.001) in the mean overall HAQ-20
score between the study (mean overall score, 0.70) and
control (mean overall score, 0.17) groups. Patients with
venous ulcers reported difficulties in mobility and in per-
forming activities, pain, and concern/interest in health
T
matters.35 Ulcers can affect the patient’s productivity at
work resulting in an increased number of persons retir-
ing under the Social Security Disability program, and lim-
iting daily and leisure activities. For many patients,
NO
venous disease means pain, loss of physical mobility, and
impairment in QoL, which consequently has a signifi-
cantly negative impact on their overall QoL.29,32,36
KEYPOINTS
• According to the RSE scores, self-esteem was not
affected by the presence of venous ulcers
• Based on the HAQ-20 scores, it was observed that
chronic venous leg ulcers had a negative impact on
the functional status of these patients
O
Conclusion
In the present study, patients with chronic venous leg
ulcers reported low scores on all SF-36 domains (physi-
cal functioning, physical role, bodily pain, general health,
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Faria et al
vitality, social functioning, emotional role, and mental
health) reflective of their poor health status. According
CA
to the RSE scores, self-esteem was not affected by the
presence of venous ulcers. However, based on the HAQ-
20 scores, it was observed that chronic venous leg ulcers
had a negative impact on the functional status of these
patients.
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10 WOUNDS www.woundsresearch.com
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