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Year : 2021  |  Volume : 8  |  Issue : 2  |  Page : 122-124

Compliance with the use of compression stockings, experience from a tertiary center in Oman

Division of Surgery, Vascular Surgery Unit, Sultan Qaboos University Hospital, Al-Khoud, Muscat, Oman

Date of Submission26-May-2020
Date of Acceptance06-Jun-2020
Date of Web Publication13-Apr-2021

Correspondence Address:
Edwin Stephen
Division of Surgery, Vascular Surgery Unit, Sultan Qaboos University Hospital, Al-Khoud, Muscat
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijves.ijves_70_20

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Objectives: Compression stockings (CSs) are effective in the treatment of chronic venous and lymphatic diseases. Noncompliance with wearing them remains a hindrance to good results. This study aims to quantify the issue of noncompliance and to identify the reasons behind it. Methods: Over a period of 6 months, a set of questionnaire to assess the compliance to CSs was conducted on patients seen during their follow-up visits and of whom CSs were prescribed previously. Results: A total of 50 patients were recruited in this study. Females formed the majority of participants (76%), with a mean age of 42 years. The body mass index of our participants ranged between normal (18%), overweight (52%), and obese (30%). Most (78%) of our patients used CSs, while 22% did not. Duration of use ranged as follows: 40% of the patients used them for <2 weeks, 26% used them for 2–8 weeks, while 30% used them for >8 weeks. 71% of our patients encountered difficulty in finding appropriate CSs. Conclusions: Noncompliance with CSs is a true challenge. The reasons behind it start from difficulty in finding appropriate size/quality, to patient-related characteristics. These need to be frequently assessed by the prescribing doctor and addressed.

Keywords: Compliance, compression stocking, lymphedema, Oman, ulcer, varicose veins, venous

How to cite this article:
AlHarthi R, Stephen E, Abdelhedy I, AlMaawali H, AlWahaibi K. Compliance with the use of compression stockings, experience from a tertiary center in Oman. Indian J Vasc Endovasc Surg 2021;8:122-4

How to cite this URL:
AlHarthi R, Stephen E, Abdelhedy I, AlMaawali H, AlWahaibi K. Compliance with the use of compression stockings, experience from a tertiary center in Oman. Indian J Vasc Endovasc Surg [serial online] 2021 [cited 2023 Jan 29];8:122-4. Available from:

  Introduction Top

Compression stockings (CSs) are the mainstay in the management of a variety of venous and lymphatic diseases, such as varicose veins, venous ulcers, postthrombotic syndrome (PTS), and lymphedema.[1] The degree of compression required varies, depending on the indication for use.[2]

In our department of vascular surgery at a tertiary care hospital, the compliance rates to usage of CS were anecdotally low. The extent of noncompliance in our population of patients has not been studied, nor the reasons behind it. By qualifying the extent of this problem and identifying the challenges, we can address these issues before starting compression therapy.

  Methods Top

A questionnaire was answered by all patients with venous disease on their follow-up at the Vascular Clinic at Sultan Qaboos University Hospital from the period of June till November 2019. Patients lost to follow-up were contacted via telephone. Patients were categorized using the Clinical (C) of the CEAP classification.[3]

The questionnaire included variables such as demographics, indication for prescribing CSs, the use duration, and difficulties in preventing their use.

The difficulties reported by our participants were then grouped into similar categories.

Statistical analysis and grafts were formed using Epi Info is statistical software for epidemiology developed by Centers for Disease Control and Prevention in Atlanta, Georgia.

  Results Top

There were a total of 50 patients in our study. The demographics are summarized in [Table 1]. Seventy-six percent of our participants were females. The age range was 15–68 years and the mean was 42 years. The body mass index of our participants ranged between normal (18%), overweight (52%), and obese (30%).
Table 1: Demographic characteristics of our studied group

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Fifty-eight percent of our participants were prescribed CSs for C1 and C2 disease. 20% of the patients had C3 disease and 2% had phlebolymphedema. The balance 20% was a mixture of etiologies such as PTS, Parkes–Weber syndrome, venous malformation (VM), arterio-VM, Klippel–Trenaunay syndrome [Figure 1].
Figure 1: Indication for compression stockings prescription by CEAP classification

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Our center does not dispense CS. 78% of those who were prescribed CS purchased them. Of this percentage, the duration of use ranged as follows: 40% for <2 weeks, 26% for 2–8 weeks, while 30% used them for >8 weeks.

[Figure 2] depicts the challenges faced by our participants. Only one-third found it easy to comply with wearing CS. The reasons for noncompliance are discomfort (13%), forgetfulness and pain (11% each), tightness and swelling (8%), difficulty to put on (5%), and restrictiveness (5%). Challenges such as cost, improper fit, and misplacing them were the least frequent, with a percentage of 3% each. Frequent putting on and removal of CS was a common hindrance to compliance, among the majority of our participants.
Figure 2: Reasons behind noncompliance to compression stockings in our studied group

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  Discussion Top

CS forms the foundation for the management of venous disease, leading to improved venous return. They work by applying pressure that is maximum at the level of the ankle, which decreases gradually proximally. This pressure helps counteract the hydrostatic pressure within the venous lumen, thus improving venous return to the heart and prevent shunting of venous blood to lateral superficial veins.[4] Reducing the intraluminal venous pressure also helps absorption of fluid from the surrounding connective tissue. The result is a reduction of stasis, swelling, dermatitis, and pain, which in turn improves cosmetic results and activity tolerance.

For CS to be effective, it needs strict, prolonged, and maintained compliance by the user. Compliance to CS ranges from 30% to 65%, which is suboptimal.[5],[6]

Majority of our participants were middle-aged, overweight-to-obese females. These demographic characteristics are well-established risk factors for acquiring chronic venous disease.[7],[8]

Omani patients showed better initial compliance (78%) when compared to other studies where the range was 30%–33%.[9],[10] However, at follow-up, they had suboptimal compliance.

As our center does not dispense CS, patients found it difficult to find the proper size, despite measurements being given from our clinic. The options available too are limited in Oman. As a result, there is a delay in the initiation of treatment as well as difficulty in replacing worn-out stockings.

Pain and swelling were the most common reported challenges to compliance with CS, and this seems too common to other populations.[5] These can be attributed to improper fitting of the CS. Other challenges such as discomfort, restriction, and difficulty to put on can be attributed to most of the patients in the study being overweight or obese.

Remembering to wear the stocking is an issue, and stressing on the benefit of use at follow-up, in the hope that the patient would make it a habit, is the only way out. Sharing the benefits seen among other patients and patient information booklets can be helpful aides.

Our participants are of Islamic faith, and as part of the preparation for prayer-five times a day, patients find it difficult and time-consuming to put on and off their CS for ablution. Restrictive complaints, on the other hand, are more noted with the above-knee CS, which we rarely prescribe in our practice for the same reason. A solution to this practical problem in the form of newer ambulatory adjustable compression system/devices, such as the AEROWRAP, seems to be the way forward.[11]

  Conclusions Top

Noncompliance to CS is a reality every team managing venous and lymphatic disease has to face. Reasons behind it start from difficulty in finding appropriate CS to patient-related characteristics and local cultural and spiritual practices. These need to be borne in mind by the prescribing doctor and addressed accordingly.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Lim CS, Davies AH. Graduated compression stockings. CMAJ 2014;186:391-8.  Back to cited text no. 1
Palfreyman SJ, Michaels JA. A systematic review of compression hosiery for uncomplicated varicose veins. Phlebology 2009;24 Suppl 1:13-33.  Back to cited text no. 2
Gloviczki P, Comerota AJ, Dalsing MC, Eklof BG, Gillespie DL, Gloviczki ML, et al. The care of patients with varicose veins and associated chronic venous diseases: clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg 2011;53:2S-48S.  Back to cited text no. 3
Motykie GD, Caprini JA, Arcelus JI, Reyna JJ, Overom E, Mokhtee D. Evaluation of therapeutic compression stockings in the treatment of chronic venous insufficiency. Dermatol Surg 1999;25:116-20.  Back to cited text no. 4
Raju S, Hollis K, Neglen P. Use of compression stockings in chronic venous disease: Patient compliance and efficacy. Ann Vasc Surg 2007;21:790-5.  Back to cited text no. 5
Shingler S, Robertson L, Boghossian S, Stewart M. Compression stockings for the initial treatment of varicose veins in patients without venous ulceration. Cochrane Database Syst Rev 2011;11:CD008819.  Back to cited text no. 6
Hamdan A. Management of varicose veins and venous insufficiency. JAMA 2012;308:2612-21.  Back to cited text no. 7
Bergan JJ, Schmid-Schönbein GW, Smith PD, Nicolaides AN, Boisseau MR, Eklof B. Chronic venous disease. N Engl J Med 2006;355:488-98.  Back to cited text no. 8
Chant AD, Davies LJ, Pike JM, Sparks MJ. Support stockings in practical management of varicose veins. Phlebology 1989;4:167-9.  Back to cited text no. 9
Coughlin LB, Gandy R, Rosser S, de Cossart L. Pregnancy and compression tights for varicose veins: A randomised trial. Phlebology 2001;16:47.  Back to cited text no. 10
Vachharajani V, Khakhhar P. Science of Wound Healing and Dressing Materials. 1st ed.. Singapore: Springer; 2020. p. 102-7.  Back to cited text no. 11


  [Figure 1], [Figure 2]

  [Table 1]


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