Effect of Chronic Wounds on Health-Related Quality of Life: A Cross-Sectional Study in Hail, Saudi Arabia

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Chronic or nonhealing wounds are characterized by their inability to progress through the expected phases of wound healing within a normal time frame, resulting in persistent tissue damage and delayed recovery.¹ Chronic wounds pose a significant health concern globally, with estimates of prevalence ranging from 1.51 to 2.21 per 1000 people, and prevalence is expected to increase as a result of aging populations in various countries.² In Saudi Arabia, chronic wounds are an emerging health concern, particularly due to the rising prevalence of diabetes, aging populations, and associated comorbidities.³ Studies in the Kingdom of Saudi Arabia have highlighted the rising incidence of diabetic foot ulcers (DFUs), venous leg ulcers, and pressure injuries, especially among elderly persons and individuals with chronic diabetes.⁴ 

In Saudi Arabia, the burden of chronic wounds is expected to increase further due to projected population increases and the rising number of individuals aged 65 years or older.⁵ Chronic wounds have been associated with extended hospital stays, increased health care utilization, and a substantial effect on patients’ quality of life (QoL).² Despite appropriate wound care, patients often experience significant impairments in physical functioning, emotional well-being, and social interaction.⁴

Health-related QoL(HRQoL) is a comprehensive measure of an individual’s physical, mental, and social well-being in relation to their health.⁶ Chronic wounds have a multifaceted effect on patients’ QoL, affecting physical, psychological, and social dimensions.⁷ Additionally, chronic wounds can lead to severe outcomes, such as limb amputation, further deteriorating QoL.⁸ The effect is exacerbated in elderly individuals due to slower healing and the presence of multiple comorbidities.⁵ 

Chronic wounds, such as arterial ulcers, have been shown to negatively affect HRQoL, particularly affecting mobility, self-care, pain and/or discomfort, and anxiety and/or depression.² Zhu et al² noted that factors such as age, sex, ethnicity, wound characteristics, and wound duration were associated with HRQoL outcomes. For example, arterial ulcers were found to have the greatest negative effect on HRQoL, and wounds of a longer duration were significantly associated with decreased mobility.² Similarly, sociodemographic characteristics and wound-related aspects have been identified as predictors of well-being, physical symptoms, and social life.⁹ Interestingly, although chronic wounds universally decrease HRQoL, the degree of effect varies according to the type of chronic wound and demographic factors. For example, patients with DFUs experience the greatest impairment in
everyday life-related QoL, and adult females generally report higher impairment in physical and psychological QoL than adult males.⁷

HRQoL serves as an important indicator of the effectiveness of treatment, reflecting an individual’s ability to perform daily activities despite having a chronic wound. Many instruments have been used to collect data on HRQoL, such as the Cardiff Wound Impact Schedule, the Würzburg Wound Score, and the Freiburg Life Quality Assessment.² 

Despite the growing body of literature on chronic wounds and HRQoL, there is limited knowledge regarding factors associated with HRQoL in patients with chronic wounds treated in Saudi Arabia. Therefore, the present study aimed to explore the current understanding of HRQoL in patients with chronic wounds treated in Hail, Saudi Arabia, and to identify the factors that may influence it. 

Study design and participants

A cross-sectional study was conducted from June through September 2023 of 60 patients with chronic wounds who received care at a diabetic foot center. Patient age ranged from 20 to 82 years. Participants were recruited during routine outpatient clinic appointments and were interviewed independently using the Arabic-language version of the Wound-QoL-17 questionnaire on QoL with chronic wounds.

Instruments and outcome measures

HRQoL was measured in patients with chronic wounds in the Hail Health Cluster using the aforementioned Wound-QoL-17 questionnaire. The Wound-QoL, which was developed at the Institute for Health Services Research in Dermatology and Nursing at the University Medical Center, Hamburg, Germany,¹⁰ is a well-known tool for assessing disease-specific HRQoL in patients with chronic wounds. The questionnaire consists of 17 questions covering 3 main subscales: body, psyche, and everyday life. Each item is scored on a 5-point Likert scale from 0 (“not at all”) to 4 (“very much”). Higher values indicate poorer HRQoL. The Wound-QoL-17 was tested for internal consistency, convergent validity, and responsiveness using longitudinal data from the Freiburg Life Quality Assessment for wounds, the Cardiff Wound Impact Schedule, and the Würzburg Wound Score.¹⁰ 

Ethical considerations

This study was reviewed and approved by the Research Ethics Committee at the University of Hail and the Institutional Review Board of Hail Health Cluster (Approval No. H-2023-0, H-08-L-074). Informed consent was obtained from all participants prior to their participation in the survey. The participants were informed that their participation in the study was voluntary.

Data analysis

Data were analyzed using SPSS version 27 (IBM Corporation). For descriptive statistics, continuous variables are represented by means and standard deviations (SDs), and categorical variables are represented by frequencies and proportions.

Statistical analysis

Descriptive statistics were used to elucidate the qualitative variables, including demographic characteristics. For investigating the research inquiries, the chi-square test and analysis of variance were employed using SPSS statistical software. Statistical significance was defined as a P value less than .05.

Demographic and clinical characteristics

This study aimed to analyze the attributes of the participants. A total of 60 patients participated, with 60% females (n = 36) and 40% males (n = 24). Most patients were older than age 50 years (58.3% [n = 35]), and 95% were Saudi nationals. A history of diabetes was present in 63.3% of the sample (n = 38). Age and nationality showed statistically significant differences across wound types (P < .05), while sex did not (P = .12). Detailed demographic characteristics are presented in Table 1.

Wound etiology and characteristics of chronic wounds

Table 2 presents the distribution of wound characteristics among the participants. The most frequently reported wound etiology was DFU (30% [n = 18]), followed by abrasions (26.7% [n = 16]), burns (13.3% [n = 8]), traumatic wounds and amputations (10% [n = 6] for each), surgical wounds (8.3% [n = 5]), and bite wounds (1.7% [n = 1]). There was a statistically significant difference in wound etiology across participants (P < .05). Regarding wound duration, most wounds (81.7% [n = 49]) lasted 12 months or less, with a mean (SD) duration of 10.43 (15.17) months. Wound duration differed significantly across wound types (P < .05). The most common wound location was the foot, with the right foot and left foot each accounting for 35% of cases (n = 21 each). Wounds located on the feet were particularly common among patients with DFUs. Wound location was also significantly associated with wound type (P < .05).

Wound-QoL scores

The Wound-QoL questionnaire asks patients to describe how their wound affected their life during the past 7 days. Based on the answers, patients in the present study had different experiences. Pain levels were widely distributed, with 25% of patients experiencing moderate pain (n = 15) and 18.3% experiencing high levels of pain (n = 11); however, these differences were not statistically significant (P = .67). In contrast, wound odor showed a statistically significant variation across wound types (P < .05). Specifically, 43.3% of patients reported experiencing noticeable to strong wound odor (n = 26). This is an important finding, because wound odor can lead to embarrassment, reduced self-esteem, and social isolation, which may negatively influence emotional well-being and QoL. Similarly, sleep disturbance differed significantly between patients (P < .05), whereas wound discharge did not (P = .08.) Patients who experienced moderate to high levels of discharge or disturbed sleep often reported increased emotional burden, such as frustration and distress. A full summary of symptom-level QoL effects is included in the Supplementary Table.

Wound-QoL subscale scores

The mean (SD) scores for the 3 subscales of the Wound-QoL were as follows: 8.68 (4.79) for the body subscale, which reflects physical symptoms such as pain, odor, and discharge; 5.86 (6.50) for the psyche subscale, which reflects emotional well-being; and 6.98 (7.93) for the everyday life subscale, which represents functional and social effects. These scores suggest that physical symptoms were the most burdensome overall, followed by effects on daily life and psychological health (Table 3).

Factors affecting QoL across different subscales

Different factors, such as sex, wound etiology, diabetic status, wound duration, and wound location were associated with QoL subscale (body, psyche, and everyday life) outcomes (Table 4). Wound location was significantly associated with body scale scores (F = 2.73; P = .028), with participants who had wounds on their lower extremities reporting significantly higher (worse) body scores than those with wounds on their upper extremities. Sex, age, diabetic status, wound etiology, and wound duration were not significantly associated with body scale scores (P > .05 for all). 

Wound etiology did not show a significant association with psyche scale scores. Similarly, no significant associations were found between psyche scale scores and sex, age, diabetic status, or wound duration (P > .05 for all). 

Sex, age, wound etiology, and wound location were all significantly associated with everyday life scale scores, as shown in Table 4. Males reported higher (worse) everyday life scores than females. Younger age was associated with lower everyday life scores, indicating better QoL. Participants who had wounds on their lower extremities reported significantly higher (worse) everyday life scores than those with wounds on their upper extremities. Diabetic status and wound duration were not significantly associated with everyday life scale scores (P > .05 for both), as shown in Table 4. 

Effect of wound type on QoL subscale scores

For the everyday life subscale, the Kruskal-
Wallis test revealed a statistically significant difference in scores across wound types (χ²₆ = 13.34, P = .0379), as presented in Table 5. DFU has the lowest mean rank (23.42). This suggests that, on average, patients with DFUs had the lowest total QoL scores. The Kruskal-Wallis tests for body score (χ²6 = 8.75, P = .1883) and psyche score (χ²6 = 12.37, P = .0542) did not show statistical significance across wound types.

The present study investigated the effect of chronic wounds on HRQoL in patients in Hail, Saudi Arabia, using the Arabic-language version of the Wound-QoL-17. The findings reveal a complex interplay of factors influencing HRQoL in this population, including wound location, etiology, and duration, as well as biological sex. 

The average (SD) age of the participants (50 [16.19] years) is comparable to that in some international studies conducted in Singapore (61.2 [4.6] years), China (62 [13.2] years), and Brazil (50 [12.5] years).^2,11,12 Furthermore, the present study demonstrated a significant difference in age distribution across wound types, which is consistent with findings in other studies.⁹

In the present study, DFUs were the most prevalent wound type in the sample (30%), a finding that contrasts with some studies reporting pressure injuries as the most common.^13,14 This difference may be due to the specific focus of the present study on a diabetic foot center, potentially leading to a higher concentration of DFU cases. Further research in broader health care settings is needed to determine the true distribution of chronic wound etiologies in Saudi Arabia.

The analysis in the present study revealed significant associations between wound location and several aspects of HRQoL. Specifically, wound location significantly affected the body subscale scores (F = 2.73; P = .028), with lower extremity wounds associated with worse QoL. This aligns with previous research highlighting the negative effect of lower extremity wounds on HRQoL, particularly concerning mobility and social engagement.¹⁵ The limitations on mobility and independence imposed by lower extremity wounds can understandably affect body image and self-esteem.

Wound etiology also played a significant role in the present study. A significant effect of wound etiology on fear of wound worsening and frustration was observed (F = 2.26; P = .05), as shown in the Supplementary Table. This suggests that the underlying cause of the wound can influence patients’ psychological responses. For instance, patients with DFUs, which are often linked to systemic conditions such as diabetes, peripheral neuropathy, and arterial disease, may experience increased anxiety about long-term health complications and the potential for wound recurrence.⁸ In the present study, the finding that diabetes mellitus was associated with higher levels of distress and fear (F = 9.46; P = .003) reinforces this idea. This aligns with studies showing that patients with diabetes often report lower HRQoL scores, particularly in domains such as physical functioning and general health.⁹

In the present study, wound duration also emerged as a significant factor, correlating with limitations in social activities (F = 2.61; P = .04). This finding is consistent with previous research demonstrating the negative effect of prolonged wound duration on HRQoL, especially in the mobility domain.¹⁶ Wound chronicity can lead to increasing social isolation, reduced participation in leisure activities, and feelings of dependency, all of which contribute to diminished HRQoL.

Biological sex also significantly affected HRQoL in the present study. There were significant sex differences in wound pain and perceived treatment burden (β = 0.72, P = .04 and β = 0.58, P = .04, respectively), with females reporting worse scores in these domains. This aligns with existing literature suggesting that females often report higher pain intensities than males.^9,11 Furthermore, the perception of treatment burden may be influenced by gender roles and responsibilities within the family and community. 

The present study has limitations. The relatively small sample size may limit the generalizability of the findings. The single-center design may introduce selection bias. Future research with larger, more diverse samples across multiple centers is needed. Additionally, exploring the effect of specific interventions on HRQoL would be of value.

This study provides valuable insights into the factors influencing HRQoL in patients with chronic wounds treated in Hail, Saudi Arabia. The findings highlight the need for a holistic approach to wound care that addresses not only the physical wound but also the psychological and social well-being of the patient. Targeted interventions that address specific concerns related to wound location, etiology, and duration, as well as biological sex are crucial for improving HRQoL in patients with chronic wounds.