Self-esteem of people with venous ulcers

Objective: to verify the level of self-esteem of people with venous ulcer and its relationship with sociodemographic, care and clinical characteristics. Methods: cross-sectional study with 44 patients with venous ulcers assisted in primary health care and evaluated using the Rosenberg Self-Esteem Scale. Descriptive and inferential statistics were performed. The t-test was to compare means of the scale scores in relation to sociodemographic, care and clinical characteristics. Results: the mean self-esteem was 9.3 (± 5.1). The variables that showed association with self-esteem were: married/common-law married patients (p=0.016), with occupation (p=0.023), using compressive therapy (p=0.040), under less than six months of treatment (p=0.014), and with small ulcers (p=0.010). Conclusion: the self-esteem of patients with venous ulcers was satisfactory/high, and it was especially higher among those with partner, with occupational activity, making use of compressive therapy, at the initial phase of the treatment and who had small ulcers. Descriptors: Varicose Ulcer; Quality of Life; Delivery of Health Care; Nursing.


Introduction
Venous ulcer is defined as a leg or foot injury that occurs in an area affected by venous hypertension, in result of reflux or obstruction of venous return (1) .Its incidence has proportionally increased with the longer life expectancy of the world population and its prevalence varies from approximately 0.1 to 2.0%.It has high chronicity and causes significant morbidity due to the difficult cure, with a recurrence of around 15 to 71.0%.In addition, 40 to 70.0% of the lesions only heal after six months of treatment and, approximately 15.0%, never heal (1)(2) .
Venous lesions affect young men and women in the same way, but they are more frequent in the elderly and in people with low level of education (3)(4)(5) .Clinically, they are large, superficial, exudative and painful ulcers, and impose difficulties to locomotion and daily activities and lead to loss of employment (5)(6) .They may also bring emotional problems such as feelings of fear, shame, inferiority, anxiety, depression, low self--esteem, decreased social interaction and a tendency towards social isolation (6)(7) .Thus, self-esteem is one of the important aspects to be considered in the evaluation of patients with venous ulcers.
Self-esteem is defined as the attribution of personal value that can be expressed in attitudes of acceptance or rejection and is associated with self-image, personal achievements, success in relationships and personality traits (8)(9) .It is dynamically built upon the personal relationship with the world and undergo changes throughout life.Low self-esteem can lead to self rejection, dissatisfaction and self-loathing (8) .
In this perspective, the present study is relevant because aspects related to the self-esteem of patients with venous ulcer need to be known in order to identify the impact of this type of injury, and qualify the care provided.In this sense, the question raised is: what is the intensity of people with venous ulcer?Thus, the objective was to verify the level of self-esteem of ve-nous ulcer patients and its relation with sociodemographic, care characteristics and clinical.

Methods
A cross-sectional study was carried out based on a survey of people followed in the primary care services of Natal/RN, Brazil (15 Basic Health Units using the Family Health Strategy model).Data collection took place from February to April 2014 at the health unit or at the patient's home.Researchers were accompanied by a professional from the Family Health Strategy team, either nurse, nursing technician or community health agent.
The population was composed of people with venous ulcer and the sample corresponded to 44 patients followed by the Family Health Strategy teams during the period of data collection, who were selected for convenience, and who met the following inclusion criteria: presence of at least one venous ulcer diagnosed by the professionals of the family health team; perfect orientation and conditions to be interviewed; aged at least 18 years.Persons who presented ulcers of another etiology (arterial or mixed ulcers) were excluded.
Data were collected through an interview and physical examination of the lesion using the Self-esteem Scale (8) and a form to evaluate the sociodemographic, care characteristics and clinical.The professional who accompanied the researchers also answered the questionnaire if the information needed was unknown to the interviewee, such as the type of ulcer and the training of the caregiver who performed the dressing.
The Rosenberg Self-esteem Scale is a generic instrument for the global evaluation of self-esteem that has been applied, translated, validated and adapted to several countries, including Brazil (9)(10) .Although it has not been validated specifically for people with venous ulcers, it has already been used in this popu-lation (6) .The Cronbach's Alpha test (alpha = 0.77) was performed to verify the reliability of the Scale for the study sample.The version of the scale (10) used in this study has a total score ranging from 0 to 30, with 0 corresponding to the best state of self-esteem and 30 corresponding to the worst state (9) .
The sociodemographic variables surveyed were: sex; age group; marital status; schooling; occupation and per capita income.Regarding the care characteristics, the following factors were considered: the availability of products for the dressings, time of treatment of the ulcer in months (≥6 months and ≤6 months), training or lack of training of the professional/ caregiver who perform the dressing; guidance provided by the health professional such as the use of compressive therapy; lifting the lower limbs to an elevated position, and regular exercise, use of compressive therapy and number of consultations with the angiologist in the last year (none or ≥1).The clinical variables were: recurrences (≥1 or none); time of presence of the venous ulcer (>1 year or up to 1 year); size of the venous ulcer (mean to large >50cm 2 or small ≤50cm 2 of diameter); signs of infection (odor, purulent exudate, perilesional hyperemia or fever) and pain related to the ulcer.
The collected data were entered into a database and exported to a computerized software .Descriptive analyses were carried out with absolute and relative frequencies and inferential analysis for their crosses.The Shapiro-Wilk test was used to verify the normality of data.After checking normality, the t-test was used to check for differences between the means of the Rosenberg Self-esteem Scale in relation to sociodemographic, care characteristics and clinical, with a level of statistical significance of p ≤ 0.05.
The study complied with the formal requirements contained in the national and international regulatory standards for research involving human beings.
As for the assistance provided, the following aspects were observed: availability of adequate products to the dressing (72.7%); daily dressing performed predominantly by a trained professional or caregiver (65.9%); non-use of compressive therapy (81.8%); treatment of the lesion for more than or at least six months (77.3%); absence of guidelines for the use of compressive therapy, lifting of lower limbs to an elevated position, and regular exercises (77.3%); and no consultation with the angiologist in the last year (52.3%).
As to clinical aspects of the venous ulcer, patients with recurrence (77.3%), presence of local pain (79.5%), more than 1 year of current venous ulcer (52.3%), venous ulcer of medium to large size (54.8%) and without signs of infection (61.3%) prevailed.
The mean total self-esteem score in the sample studied was 9.3 (SD = ± 5.1), with a median of 9.0 and a mode of 7.0.The individual scores obtained from the application of the scale ranged from 0 to 22, of which 25 (56.8%) were surveyed with a total score of up to 10, 18 (41.0%)between 11 and 21, and 1 (2.2%) above of 21.
The analysis of sociodemographic variables showed an association between self-esteem and marital status (p=0.016) and self-esteem and occupation (p=0.023).Married/common-law married individuals and active/working individuals showed higher self--esteem, as Table 1 shows.The analysis of the care characteristics showed an association between self-esteem and use of compressive therapy (p=0.040) and treatment time (p=0.014).Patients who used compressive therapy and had a treatment time of less than six months had better self-esteem scores (Table 2).Table 3 shows the relationship between ulcer size and self-esteem (p=0.010).Patients with medium or large ulcers had lower self-esteem compared to patients with small ulcers (Table 3).

Discussion
The limitation was the type of study which implies reverse causality bias, which is an impossibility of clearly demonstrating the cause and effect, and the scale that has not been validated for people with venous ulcer, although the reliability test through Cronbach's alpha showed a good result.
In this study, people with venous ulcer were mostly female, aged over 60 years, with low level of education, income below one minimum wage, with partner and without occupation.This profile has been also found in analyses carried out in Brazil and Portugal (3,11) .
The literature shows a higher occurrence of venous ulcers in the elderly, indicating that prevalence increases with age and that women are more likely to develop them, due to pregnancy repercussions, neuroendocrine disorders, varicose veins and chronic venous insufficiency (12) .Furthermore, women seek health services more often than men (13) .
The low educational level and the low income of the participants are sociodemographic characteristics present in the studied sample.This may predispose patients to development of injuries, lack of access to specialized health services and the financial imbalance of the family due to the expenses implied in the treatment (3,14) .
The analysis of the relationship between self--esteem and sociodemographic variables identified positive associations with marital status and occupation.The better self-esteem in people with some sort of occupation shows that their insertion in the market is important for their adaptation and to support the family, since these activities make them feel useful, capable, part of a social cycle with a consequent better appreciation of themselves (15) .
The presence of a partner is a positive factor for people with venous ulcer because this can help overcome difficulties and activities of daily living, as well as ease the limitations and provide day-to-day support.These aspects may explain the best self-esteem among people who live with a partner (12) .
In the analysis, the treatment of the current ulcer of less than six months and the use of compressive therapy were identified as positive factors to a better self-esteem.Treatment in the initial phase leads to a greater hope of cure of the lesion; inturn, individuals who have venous ulcers for more than one year feel powerless and hopeless about their healing (16) .Therefore, these feelings can lead people to negative self--assessments, reflecting on their self-esteem.
Studies have shown that venous ulcers heal faster using compression therapy because compression reduces edema, improves venous return, facilitates ulcer healing, reduces pain and prevents recurrence (1)(2)(17)(18) . It is epected, therefore, that the use of compression influenced a better self-esteem.
The guarantee of the supply of adequate materials to carry out the dressings is the responsibility of public health services.Nevertheless, an opposite situation has been observed in almost the entire Brazilian scenario, with an absence of therapeutic continuity due to lack of products or inadequate purchase (5) .In spite of this, in this study, the service had the materials to perform the dressings at its disposal, and the majority of the professionals/caregivers had specific knowledge about the care of ulcers.These factors are important because without the material and the knowledge, a generalized care is provided for all types of lesions and the conducts are mistaken, causing relapses and, consequently, longer healing time.
It is important to note that despite the care of trained professionals, guidelines for the use of compressive therapy, lower limb lifting, and regular exercise were not mentioned as resgularly provided.In line with these data, it has been reported in other studies that, although knowing the guidelines regarding prevention against recurrences, few nurses performed actually provide them to patients (17) .
A research carried out the professional characterization of nursing workers who care for people with vascular ulcers.The study showed a lack of knowledge of specific recommendations in the care of this 574 clientele (compression therapy, exercises and lifting of the lower limbs, among others) and flaws in the training/qualification of the team because of scarce investments in this area (19) .
In this sense, it is important to emphasize the need for continuous improvement of professionals and we reiterate that care must be multiprofessional and encompass comprehensive assessments and interventions (including the self-esteem of patients) and not only clinical aspects of the injury (19) .
The findings of this study also point out the need for teams to develop strategies to avoid recurrences.Previous history of venous ulcer increases the chance of recurrence, with a rate of 69.0% after one year of healing of the lesion (1,4) .
As for the time of presence of the current ulcer greater than one year, this is related to the chronicity of the injury and the difficulties of healing.This difficulty involves a number of factors, as for example wound conditions, treatment, care with aseptic standards, dressing technique and the choice of products used, besides the presence of other concomitant chronic diseases (5) .The lack of access to specialized services, such as angiology, also hinders the provision of care; the assessment and systemic approach may occur at a late moment in which the ulcers are already in an advanced stage (14) .
A positive association was identified between self-esteem and small ulcer size.A study that compared the dimensions of the ulcers with the healing time reported that the bigger the size of the ulcer, the longer is the healing time.Thus, size represents a risk factor for delayed cicatrization (4,18) .
Although not statistically significant, the self--esteem of patients with signs of infection and pain was lower than that in patients without pain and signs of infection.It is imperative that the team pay attention to the assessment of pain, since this is a frequent symptom in this population.Besides limiting the realization of activities of daily living, pain causes trouble to work activities, leading to the establishment of distance from social contexts, which may ultimately affect the quality of life (4) .An analysis found that pain is one of the main symptoms mentioned in studies of quality of life linked to living with venous ulcers (20) .It is therefore necessary to provide emotional support and mechanisms to face this situation, because in addition to all the aforementioned changes, this population also feels powerless and hopeless regarding the healing of the wound (12) .Thus, studies that investigating the self-esteem of people with venous ulcer are important.In the present research, the patients' self-esteem proved to be good, which was somehow unexpected because the literature reports exactly the opposite: the individuals verbalize and demonstrate little or no satisfaction with their self-esteem (6)(7)10) .
A review that evaluated the impact of venous ulcers on various psychoemotional characteristics identified depression, low self-esteem, self-loathing, social isolation and low quality of life as the most frequent (20) .The result of this study suggests that, although susceptible to low self-esteem, patients are able to maintain a positive self-assessment (6) .Individuals with venous ulcers are able to cope with the chronic injury and feel as equal and important as other people.
We emphasize that venous ulcers constitute a serious public health problem and their psychological and social effects are often neglected.In this perspective, the results of the present study may contribute to the improvement of care for people with venous ulcer, since it made it possible to identify the main sociodemographic, clinical and care aspects that affected the self-esteem of this population.
The self-esteem of people with venous ulcers was satisfactory/high.However, in view of the complexity of the lesion and its consequences in the patient's life, comprehensive attention is essential to improve the individual's health (5) .We suggested deepening the investigation of the influence of these variables on self-esteem, in order to reinforce the discussion and build instruments that better evaluate the peculiar aspects of people with venous ulcers.

Conclusion
The self-esteem of patients with venous ulcers was satisfactory/high, especially among those with partner, occupational activity, making use of compressive therapy, at the initial phase of the treatment and who had small ulcers.

Collaborations
Souza AJG, Campos SMDL and Queiroz CG contributed to the conception and design, analysis and interpretation of data and writing of the article.Salvetti MG, Torres GV and Costa IKF Costa contributed to the conception and design, analysis and interpretation of data, relevant critical review of the intellectual content and final approval of the version to be published.

Table 1 -
Sociodemographic characteristics of people with venous ulcers according to self-esteem scores

Table 2 -
Distribution of care characteristics according to self-esteem scores

Table 3 -
Distribution of clinical aspects of the lesion according to self-esteem scores.