Improving Adherence to Wearing Compression Stockings for Chronic Venous Insufficiency and Venous Leg Ulcers: A Scoping Review

Figures & data

Figure 1 Study flow diagram (PRISMA-ScR flow chart²⁴). Adapted from Tricco AC, Lillie E, Zarin W et al. PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation. Ann Intern Med. 2018;169(7):467–473.

Figure 2 Number of publications by year from inception to conclusion of the search.

Figure 3 Publication count organized by level of evidence.

Figure 4 Conceptual Framework of Adherence.

Table 1 Impact of Interventions on Adherence

Study	Type	Variable(s) Modified		Adherence
		Main	Second
Benigni, J.P., et al^Citation50	RCT	Stocking gradient (degressive versus progressive)	Nil	No measurable adherence outcome provided
Brooks, J., et al^Citation60	RCT	Education program versus usual care	Nil	No significant difference between groups
Christensen, C.R. and Yaeger, A.A.^65	Case study	Patient contract (collaboration)	Bed alarm	Improved adherence for the case studied
Clarke-Moloney, M., et al^Citation51	RCT	Class 1 versus class 2	Nil	Both groups improved equally
Dickey, J.W.^Citation66	Case series	Unna’s paste + elastic compression + pump	Education	Improved adherence for the cases studied
Franks, P.J., et al^Citation52	RCT	Stocking brand 1 versus brand 2	Nil	No significant difference between groups
Ham, S. and Padmore, J.^Citation46	Case series	Compression hosiery kits	Nurse training	Improved adherence for the cases studied
Hampton, S.^Citation47	Case study	Ready-wrap stockings	Carer training	Improved adherence for the case studied
Heal, D.^Citation67	Case series	Soft-fit addition	Nil	Improved adherence for the cases studied
Heinen, M., et al^Citation61	RCT	Education program versus usual care	Nil	No significant difference between groups
Kapp, S., et al^Citation58	RCT	Class 2 versus class 3	Nil	Adherence higher in class 2
Krijnan, R.M.A., et al^Citation62	RCT	Rubber mat versus stocking	Nil	No significant difference between groups
Lindsay, E and Hawkins, J.^Citation30	Case study	Collaboration with patient	Various compression styles	Improved adherence for the case studied
Lurie, F. and Schwatz, M.^Citation63	RCT	Pump versus stocking	Nil	No significant difference between groups
Milic, D.J., et al^Citation45	RCT	Class 2 versus class 3	Nil	Adherence higher in class 2 (not statistically significant)
Milic, D.J., et al^Citation64	RCT	Class 3 stocking versus bandaging A versus bandaging B	Nil	Adherence higher in class 3 (no significance data provided)
Mullins, M., et al^Citation48	Case series	Extremit Ease (stocking with zipper)	Collaboration	Improved adherence for the cases studied
Murdoch, V^Citation32	Case study	Prescribing pyramid (collaboration)	Various compression styles	Improved adherence for the case studied
Nelson, E.A., et al^Citation57	RCT	Class 2 versus class 3	Nil	Adherence higher in class 2
Protz, K., et al^Citation43	RCT	Education program versus usual care	Nil	Adherence higher in education group (no significance data provided)
Rees, R.^Citation49	Case study	High class to low class	Carer training	Improved adherence for the case studied
Uhl, J., et al^Citation42	RCT	Education program versus usual care	Nil	Adherence higher in the education group
Zajkowski, P.J., et al^Citation53	RCT	4 stocking brands	Nil	No significant difference between groups

Figure 5 Variables investigated in the RCTs and case studies/series.

Table 2 Adherence: Measurement, Scale, Requirement for Achieving Adherence, and Rate

Process	Measurement Scale
	Dichotomous			Interval
	Study	Requirement for Achieving Adherence	Rate %	Study	Requirement for Achieving Adherence	Rate %
Self-reported questionnaire	Al Shammeri O, et al^Citation79	Collected the CS from the store, used it regularly and noticed an effect (good, not comfortable, or neutral) and would recommend it	50	Clarke-Moloney M, et al^Citation51	All day every day - removing at night; some part of each day; some days, all day, and all night; or not at all^ Dichotomy: All day every day – removing at night versus the other alternatives	88.9
	Cataldo J.L, et al^Citation16	Daily use exceeding 6 hours	59.4
	Finlayson K, et al^Citation2	Daily use of CS	47
	Shannon M.M, et al^Citation73	Wearing every day	73
	Ziaja D, et al^Citation74	Wore stockings daily (not occasionally)	27, 20
Self-reported Journal	Benigni J.P, et al^Citation80	Worn for the minimum period (ie 6 hours), equal or greater than 80% of the time	95
Self-report Interview	Krijnen R.M.A, et al^Citation62	Wore CS almost every day at work	66.6	Ayala A, et al^Citation69	Not wearing at all/never, used intermittently (up to 50% of the time), most days (50–100%) and, as prescribed^*	31.8
				Franks P.J, et al^Citation52	All day every day; some of the day or some days; some of the time^*	84 +81
				Heinen M, et al^Citation61	Always, all day; occasionally somewhat shorter <2 hours <1 x per week; regularly somewhat shorter <2 hours shorter >1 x per week; occasionally, considerably shorter, >2 hours per week; regularly, considerably shorter >2 hours per week, > once per week; occasionally not, for one day, less than once per month; not, on a regular basis, more than once per month; not, in the last 6 months, more than one day at a time^*	45
				Heinen M, et al^Citation70	8 scales reduced to 3: Fully; moderately (2 hours less than all day); non-adherent^*	39
				Jull A. B, et al^Citation38	Wore stockings every day; most days; occasionally; never^ Dichotomy: Every day and most days versus occasionally or never	52
Professional Recorded	Brooks J, et al^Citation60	Wore compression every day	55–66	Raju S, et al^Citation72	Daily wear (regular use); less consistent (most days); infrequent use (sometimes or seasonally); not at all^*	21
	Erickson C.A, et al^Citation81	Kept 100% of their appointments, adhered completely with prescribed CS, and followed all instructions for wound and extremity care	32.3	Samson R.H et al^Citation9	Good (well-fitting worn daily and new CSs bought as necessary); poor (if loose or worn-out CSs were used or were worn irregularly); and none (CSs were not worn at all) ^*	47
	Mayberry J.C, et al^Citation78	Wore stockings all day, removed at night	79
	Milic D. J, et al^Citation45	Wore CS 80% of the time during the 1st and 2nd years and >50% of the time during 3rd, 4th and 5th years	89 and 93
	Stansal A, et al^Citation44	Wore CS to the appointment, correctly applied, and effective	89
Combination	Allaert F, et al^Citation68	>3 on Adhesig (Self-report via questionnaire + Thermosensors)	74	Bogachev V, et al^Citation82	As prescribed, most days, intermittently or not at all^*	29.1
	Hanley T.P, et al^Citation77	Wore CS on a regular basis (4–7 days) each week (Observation and self-report)	37	Manduz S, et al^Citation71	CSs: suggested but did not buy; recommended, bought but not used enough; recommended, bought, and used for a short time; recommended, bought, and used irregularly; recommended, bought, and still uses^*	Unclear
	Lurie F, et al^Citation63	Wore stockings during all wakeful hours for 30 days. At least 10 hours per day (Device meter and self-report via diary)	85
	Nelson E.A, et al^Citation57	Wore the allocated class of CS throughout the study (Self-report and observation)	58 and 72
	Uhl J, et al^Citation42	Average number of days worn (not a definition per se	48 and 71
	Van Hecke A, et al^Citation41	Wore every day except 2–3 days per month, wore 5–6 days per week, > 10 hours per day (Self-report via diary and interview)	Not provided
Not described	Arpaia G, et al^Citation76	Description not provided	91.6
	Kapp S, et al^Citation58	Wore CS for >50% or nonadherent <50%	44.1
	Motykie G.D, et al^Citation75	Description not provided	82
	Suehiro K, et al^Citation56	CS worn > 5 days per week	80

Notes: ^Interval scale converted to dichotomized scale by study authors. *No explanation provided for conversion to dichotomous score.

Abbreviation: CS, compression stockings.

Table 3 Adherence and Reference to Healing Time and Recurrence

Study	Variables Modified	Study Type	Outcome on VLU Healing/Recurrence
Brooks J, et al^Citation60	Usual care or education program	Quasi-experimental RCT	There was 4% VLU recurrence in intervention group and 36% in control (p=0.004). Outcome not related to adherence but to ankle movement, mobility level and leg elevation^#
Clarke-Moloney M, et al^Citation51	Class 1 or class 2	Pilot RCT	The lowest VLU recurrence rates were seen in patients who were adherent with CSs regardless of the compression level. 12-month recurrence rate recorded 16.3%. All patients wearing class 1 stockings developed a new ulcer^#
Dahm K.T, et al^Citation84	N/a	Systematic review	Class 2 seems to be more effective in prevention of ulcer recurrence than class 1^#
Dickey J.W^Citation66	Pre and post intervention (CS and education)	Case series	An examination of the clinical course of each patient shows that the faster healing was causally related to compliance^#
Erickson C.A, et al^Citation81	Pre and post Unna’s boot +class 3 CS	Retrospective cohort	Adherence reduced healing time and prolonged time to recurrence. At 5 months, VLU healing was 73% if adherent, and 59% if non-adherent^#
Franks P.J, et al^Citation52	Brand 1 or brand 2	RCT	Recurrence rate was 26% after 1 year and 31% at 18 months for both brands^#
Hanley T.P, et al^Citation77	Adherent or non-adherent patient	Prospective cohort	At 2 years the adherent group had no skin changes; 28% of non-adherent group had skin changes including VLU in some. At 60 months none of the adherent group had ulceration but 8.6% had stasis changes. Of non-adherent patients, 63% had chronic skin changes^#
Heinen M, et al^Citation61	Usual care or lifestyle counselling	RCT	The intervention group had fewer wound days (p<0.01), but time to recurrence did not differ significantly (p=0.07)^<
Kapp S, et al^Citation58	Moderate CS or high CS	RCT	Study wound recurrence was 11.8% within 26 weeks, and average time to recurrence was 77.91 days. Adherence to treatment significantly predicted study wound recurrence (p=0.005). Those who did not adhere to CS were 9x more likely for the wound to recur. Recurrence risk was 3 x greater for moderate compared to high compression^#
Mayberry J.C, et al^Citation78	Pre and post CS	Prospective cohort	Of 113 patients, 102 were compliant with CS: 11 were not. Only non-compliance with CS (p<0.0001) and a pre-treatment VLU duration of more than 9 months (p<-0.02) significantly decreased initial VLU healing. All noncompliant patients had recurrent ulceration by 36 months^#
Milic D.J, et al^Citation45	Class 2 or class 3	RCT	Class 3 had lower VLU recurrence rate compared to class 2: 28.98% versus 60% (P<0.001)^#
Milic D.J, et al^Citation64	Class 3 CS or 2 types of bandages	RCT	The healing rate for VLU area of 5–10cm^2 in group A (Class 3 CS) was 25%, 64% in group B (bandages) and 75% in group C (another type of bandages) ^#
Moffat C, et al^Citation85	N/a	Critically appraised	6 studies indicate that the healing rate was half and the median time to complete healing was twice as long when Pts were not concordant. Recurrence rates were 2–20 times greater if not concordant post healing^#
Nelson E.A, et al^Citation57	Class 2 or class 3	RCT	36% had recurrent VLU by 5 years. 39% of these did not comply with their randomized compression class in class 3, and 28% in class 2. No statistical difference between classes on VLU recurrence, though fewer patients had ulcers in class 3^#
Samson R.H et al^Citation9	Pre and post CS	Prospective cohort	Of the 25 pts who were compliant only one developed a recurrence. Of the 28 who were ‘poor’ or ‘none’, 22 developed at least one recurrence^<

Notes: ^<Adherence is the primary outcome measure. ^#VLU is the primary outcome measure.

Abbreviations: VLU, venous leg ulcer; CS, compression stockings.

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