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The burden of venous leg ulcers in patients with low health literacy

22nd December 2021

Successful medical recovery often relies on a patient’s ability to independently manage and actively improve their own health condition. Being able to do this effectively relies on a patient being able to fully comprehend what is required of them and to implement it effectively; this is known as health literacy (HL).

Patient HL is defined as ‘the ability to obtain, process and understand basic health information and services needed to make appropriate health decisions and follow instructions for treatment’.[1] Someone with low patient HL might, for example, struggle to read and comprehend instructions for taking medicine, and subsequently take medication incorrectly.


Low HL is a widespread problem. Many people do not have the appropriate knowledge, understanding or confidence to navigate healthcare information and services. Approximately 80 million adults in the US are thought to have limited or low HL[1], while in England 42 percent of adults aged 16-65 years are unable to understand or act on everyday health information.[2] Low HL is particularly prominent in adults above the age of 65, who are four times more likely to have limited functional HL than other age groups[3].

Combined risks hindering patient outcomes

Older adults are also at a greater risk of developing chronic wounds, such as venous leg ulcers (VLU). VLUs are chronic skin ulcers that mainly affect the gaiter area and, in most cases, are caused by continuous venous hypertension or chronic venous insufficiency.[4] VLUs are a common health condition that impacts up to three percent of the global population.[5] The risk of developing a VLU increases with age, with prevalence doubling among those older than 65 years.[6]

Current standard of care (SoC) for VLU typically recommends compression therapy and exercise. Specific clinical recommendations for treating VLUs can be difficult for some patients to understand and act on. Patients that are required to treat their wounds independently at home – which has become increasingly common during the Covid-19 pandemic – may find self-management of VLUs particularly challenging. Patients with limited HL who must treat VLUs at home are therefore at a greater risk of wounds worsening or healing at a slower rate.

The burden of VLU

VLUs take months to heal, while some never heal at all. Even if a wound has healed, the chance of recurrence is high.[7] It is therefore essential for healthcare professionals and patients to collaborate to ensure the recommended care is fully understood and working.

Increased blood flow to the wound surface has been clinically proven to promote wound healing[8] in VLUs, enhancing venous return and preventing venous stasis4. Current SoC recommends the use of compression therapy, which is usually applied below the knee to increase blood flow to the gaiter area. Increased exercise also promotes blood flow and is recommended by healthcare professionals, but clearly this may be challenging for patients that are elderly or immobile. Patient understanding of and adherence to the VLU management recommendations can be less than optimal, due to HL issues or immobility.[9]

VLU-specific HL can impact patient outcomes by affecting the adoption of positive health behaviours. Higher HL enables patients to better understand the benefits of adhering to VLU self-management recommendations[10] and can make adopting healthy behaviours – in line with an agreed plan – more achievable. For example, patients with low HL may have a poorer comprehension of comfort when choosing compression bandaging[11] subsequently hindering the effectiveness of compression treatment.[12] Similarly, such patients may have limited bandage application skills due to difficulties understanding guidelines and instructions. [13]

Pandemic-accelerated change

Treatment of VLUs (and many other conditions) has become increasingly difficult during the pandemic; hospitals have been at full capacity and several wards deemed ‘non-essential’ have closed. This has left many patients independently managing health conditions.

As wound clinics have closed, patients living with VLUs have had to relocate treatment into the home setting, including compression therapy management, changing dressings, and exercising. This pandemic-accelerated change, derived from an overstretched primary care resource, has shifted VLU care to teleconsultation. However, this relies on patient self-management and has further increased patient isolation, negatively impacting compression adherence, concordance and patient well-being. For patients with limited HL this can lead to high levels of non-compliance and consequent slowing of healing.

The new era of telemedicine and digital care could be a lasting change. Therefore, innovative medical interventions are required to make independent care simpler, more achievable, and more accessible, particularly for those with limited HL.

Intervention of innovation

An area well equipped to address issues with HL and improve VLU care is medical technology (MedTech). Innovation in MedTech is making healthcare easier and more accessible. Increasingly, MedTech devices are designed with self-medication in mind – they are easy for patients to use and improve levels of medical compliance in the home setting, even for those with lower levels of HL.

For example, a device that is clinically proven to promote blood flow could have a role in the treatment of VLU. To enable patients to use it independently, the device needs to be safe, quick and easy to administer, and come with clear and concise instructions written in simple language with supporting illustrations. Such devices can work alongside or instead of the current SoC, and potentially offer more cost-effective treatment options.

Devices that are suitable for patients with low or limited HL enable increased adherence and concordance to VLU recommendations. This would give those patients independently managing VLUs a better chance of recovering quickly and effectively and reduce the chance of a VLU recurrence.

Making healthcare fair

Innovation is a driving force in healthcare offering patients, medical professionals and healthcare systems faster and simpler solutions to care while making it more accessible for everyone. Patients with low HL are typically at a greater risk of developing health issues. Older adults with low HL and conditions such as VLUs are therefore more likely to either develop complications during treatment, recover slower or face recurrences. This has been made more complicated by the pandemic which has shifted care to digital platforms. However, technological interventions are making treatments simpler to understand, navigate and practice independently in the home setting, creating a brighter future for healthcare globally.


  1. Health Resources & Services Administration, Health Literacy. https://www.hrsa.gov/about/organization/bureaus/ohe/health-literacy/index.html
  2. Prince LY, Schmidtke C, Beck JK, Hadden KB. Qual Manag Health Care. 2018 Apr/Jun; 27(2):93-97.
  3. Rowlands G, Protheroe J, Richardson M, et al. The health information gap: the mismatch between population health literacy and the complexity of health information. An observational study. London: British Journal of General Practice, [Forthcoming].
  4. Kobayashi LC, Wardle J, Wolf MS, et al. Aging and Functional Health Literacy: A Systematic Review and Meta-Analysis. The journals of gerontology Series B, Psychological sciences and social sciences 2014.
  5. Australian Wound Management Association Inc, New Zealand Wound Care Society Inc. Australian and New Zealand clinical practice guideline for prevention and management of venous leg ulcers. Barton, ACT: Cambridge Publishing, 2011.
  6. Graves N, Zheng H. The prevalence and incidence of chronic wounds: a literature review. Wound Practice Res 2014; 22: 4–12.
  7. Pérez MB, López‐Casanova P, Lavín RS. Recent Reports from University of Alicante Highlight Findings in Leg Ulcers [Epidemiology of venous leg ulcers in primary health care: Incidence and prevalence in a health centre-A time series study (2010-2014)] Citation metadata. Int Wound J 2018; 16: 256–65.
  8. Finlayson KJ, Parker CN, Miller C, et al. Predicting the likelihood of venous leg ulcer recurrence: the diagnostic accuracy of a newly developed risk assessment tool. Int Wound J 2018; 15: 686–94. doi:10.1111/iwj.12911 http://www.ncbi.nlm.nih.gov/pubmed/29536629
  9. Jones NJ & Harding KG et al, Neuromuscular electrostimulation on lower limb wounds. British Journal of Nursing VOL. 27, No. 20.Published Online: 12 Nov 2018. https://doi.org/10.12968/bjon.2018.27.Sup20.S16
  10. Klonizakis M, Tew GA, Gumber A, et al. Supervised exercise training as an adjunct therapy for venous leg ulcers: a randomized controlled feasibility trial. Br J Dermatol 2018; 178: 1072–82. doi:10.1111/bjd.16089 http://www.ncbi.nlm.nih.gov/pubmed/29077990
  11. Orr L, Klement KA, McCrossin L, et al. A systematic review and meta-analysis of exercise intervention for the treatment of calf muscle pump impairment in individuals with chronic venous insufficiency. Ostomy Wound Manage 2017; 63: 30–43. doi:10.25270/owm.2017.08.3043 http://www.ncbi.nlm.nih.gov/pubmed/28873064
  12. Boxall S, Carville K, Leslie G, et al. Compression bandaging: identification of factors contributing to non-concordance. Wound Practice Res 2019; 27: 6–20. doi:10.33235/wpr.27.1.6-20
  13. Muldoon J. Compression hosiery for venous conditions: a literature review. J Community Nurs 2019; 33: 29–34.
  14. O’Meara S, Cullum N, Nelson EA, et al. Compression for venous leg ulcers. Cochrane Database Syst Rev 2012; 11: CD000265. doi:10.1002/14651858.CD000265.pub3 http://www.ncbi.nlm.nih.gov/pubmed/23152202

Sue Davenport – VP Marketing Communications
22nd December 2021