Barriers and enablers to the use of venous leg ulcer clinical practice guidelines in Australian primary care: A qualitative study using the theoretical domains framework

Managing venous leg ulceration: variance and variety

Frameworks of care have been developed to enhance and standardise care for those with venous leg ulcers. Community nurses are faced with an array of frameworks and guidance documents on which to base their care. This article outlines and discusses variations in the information provided within the body of evidence relating to the care of venous leg ulcers. It is based on the findings of ongoing study for a PhD thesis.

'Nutrition has everything to do with wound healing'-health professionals' perceptions of assessment and management of nutrition in individuals with diabetes-related foot ulceration

Determine how healthcare professionals perceive their role in nutrition assessment and management, and explore barriers and enablers to assessment and management of nutrition in individuals with DFU. Mixed methods including a cross-sectional online survey derived from current international guidelines and theoretical domains framework, and semi-structured interviews with conventional content analysis was performed. One hundred and ninety-one participants completed the survey, with 19 participating in interviews. Many health professionals are not confident in their ability in this area of practice, are uncertain their nutrition advice or management will be effective in assisting wound healing outcomes and are uncertain their intervention would result in adequate behaviour change by the individual with DFU. Major barriers to implementation of nutrition assessment and management were: inadequate time, lack of knowledge and lack of clinical guidance and enablers were as follows: professional development, a standardised clinical pathway and screening tool and a resource addressing wound healing and diabetes management. Nutrition assessment and management in individuals with DFU is not consistently applied. Whilst health professionals believed nutrition was important for wound healing, they lacked confidence in implementing into their practice. Further dissemination of existing guidance and implementation of education programs and resources would help overcome cited barriers.

Supporting patients with venous leg ulcers in self-care monitoring: an interview study with primary health care professionals

OBJECTIVE

This study described the experiences and perceptions of how primary health care professionals (PHCPs) support patients with venous leg ulcers (VLUs) in self-care monitoring.

DESIGN

A qualitative approach with reflexive thematic analysis was used, with 24 individual qualitative open interviews.

SETTING

Primary health care clinics and community health care in four southern regions in Sweden.

SUBJECTS

Registered nurses, district nurses and nurse assistants who had experience of caring for patients with VLUs. In total, 24 interviews were conducted with PHCPs in Sweden.

RESULTS

PHCPs have a vital role in promoting patient independence and responsibility, identifying needs and adapting care strategies, while also recognising unmet needs in patients with VLUs.

CONCLUSION

PHCPs actively monitor patients' self-care and establish caring relationships. They see a need for a structured primary health care work routine for ulcer management.

Translating evidence into practice in primary care management of adolescents and women with polycystic ovary syndrome: a mixed-methods study

BACKGROUND

The international guideline on polycystic ovary syndrome (PCOS) provides evidence-based recommendations on the management of PCOS. Guideline implementation tools (GItools) were developed for general practitioner (GP) use to aid rapid translation of guidelines into practice. This mixed-methods study aimed to evaluate barriers and enablers of the uptake of PCOS GItools in general practice.

DESIGN AND SETTING

A cross-sectional survey was distributed through professional networks and social media to GPs and GPs in training in Australia. Survey respondents were invited to contribute to semi-structured interviews. Interviews were audio-recorded and transcribed verbatim. Qualitative data were thematically analysed and mapped deductively to the Theoretical Domains Framework and Capability, Opportunity, Motivation and Behaviour model.

RESULTS

The study engaged 146 GPs through surveys, supplemented by interviews with 14 participants. A key enabler to capability was reflective practice. Barriers relating to opportunity included limited awareness and difficulty locating and using GItools due to length and lack of integration into practice software, while enablers included ensuring recommendations were relevant to GP scope of practice. Enablers relevant to motivation included co-use with patients, and evidence of improved outcomes with the use of GItools.

DISCUSSION

This study highlights inherent barriers within the Australian healthcare system that hinder GPs from integrating evidence for PCOS. Findings will underpin behaviour change interventions to assist GPs in effectively utilising guidelines in clinical practice, therefore minimising variations in care. While our findings will have a direct influence on guideline translation initiatives, changes at organisational and policy levels are also needed to address identified barriers.

Defining success in adult obesity management: A systematic review and framework synthesis of clinical practice guidelines

Obesity is a chronic and complex disease affecting millions of people worldwide. Currently, there is no standard definition of success for the management of obesity. We set out to complete a synthesis of clinical practice guidelines for obesity management for adult populations, aiming to provide both a quantitative descriptive and qualitative analysis of definitions of success in clinical practice guidelines. An electronic search retrieved 4477 references. Sixteen clinical practice guidelines were included after screening and full-text review. We coded definitions of success 147 times across the included guidelines. No standard or explicit definition of success was identified in the guidelines but rather success was implicitly defined. We developed three themes describing how success was defined in the clinical practice guidelines: Knowledge-based decision making; management of expectations; and the perception of control. The review reinforced that success is an inherently subjective and complex concept. Defining success is limited by existing studies that focus on weight loss and would benefit from additional research on different outcomes. Equally, the relationship between people living with obesity and their clinicians should be further explored to understand how defining success is controlled, discussed and framed in a clinical setting.

Assessment of nurses' level of knowledge of the management of chronic wounds

BACKGROUND

Chronic wounds are a challenge and a major cause of morbidity. A wound is considered chronic if healing does not occur within the expected time frame depending on the etiology and location of the wound.

OBJECTIVE

To assess the level of knowledge about chronic wound management of postgraduate nurses in different areas of the health system and their previous satisfaction with the training received during their undergraduate studies.

DESIGN

Cross-sectional study of a health system of 95,000 inhabitants and 557 nursing professionals working in it.

PARTICIPANTS

Nurses working in the study health system and in areas with care for patients with chronic wounds in social, primary and hospital care.

RESULTS

Survey results described a low knowledge of chronic wound management in general. Data on knowledge according to area of work showed that nurses in primary care had the highest knowledge of wound etiology. Nurses working in health and social care were most knowledgeable in diagnostic knowledge. Hospital nurses showed the lowest knowledge overall. A relationship was observed when nurses had a master's degree followed by an expert with better knowledge in the test. In addition, nurses reported little training in chronic wounds during their university studies (69.73 %, n = 106).

CONCLUSIONS

Therefore, a review of this point should be considered to improve the management of chronic wounds and their correct approach among nursing students. A review of continuing and even specialised training needs in the clinical care setting should also be considered.

Understanding the use of evidence-based medical therapy in patients with peripheral artery disease: A qualitative study using the Tailored Implementation for Chronic Diseases Framework

Introduction

The global burden of peripheral artery disease (PAD) has been increasing. Guidelines for PAD recommend evidence-based medical therapy (EBMT) to reduce the risks of cardiovascular events and death but the implementation of this is highly variable. This study aimed to understand the current practices regarding EBMT prescription in PAD patients and the key barriers and facilitators for implementing PAD guidelines.

Method

A qualitative study was conducted in the largest tertiary hospital in Singapore from December 2021 to March 2023. The participants included healthcare professionals and in-patient pharmacists involved in the care of PAD patients, as well as patients with PAD who had undergone a lower limb angioplasty revascularisation procedure. Data were collected through in-depth, individual semi-structured interviews conducted face-to-face or remotely by a trained research assistant. Interviews were audio-recorded, transcribed and systematically coded using data management software NVivo 12.0. The Tailored Implementation for Chronic Diseases (TICD) framework was used to guide the interviews and analysis.

Results

Twelve healthcare professionals (4 junior consultants, 7 senior consultants, and 1 senior in-patient pharmacist) and 4 patients were recruited. Nine themes in 7 domains emerged. Only a small proportion of doctors were aware of the relevant guidelines, and the generalisability of guidelines to patients with complicated conditions was the doctors' main concern. Other barriers included cost, frequent referrals, lack of interprofessional collaboration, not being the patients' long-term care providers, short consultation time and patients' limited medication knowledge.

Conclusion

Findings from this study may inform strategies for improving healthcare professionals' adherence to guidelines and patients' medication adherence.

"How do I keep this live in my mind?" Allied Health Professionals' perspectives of barriers and enablers to implementing good clinical practice principles in research: a qualitative exploration

BACKGROUND

Allied health professionals (AHPs) engaged in research are expected to comply with Good Clinical Practice (GCP) principles to protect participant safety and wellbeing and enhance data integrity. Currently, few studies have explored health professionals' perceptions of implementing and adhering to GCP principles in research with none of these including AHPs. Such knowledge is vital to guide future interventions to increase adherence to GCP principles. This study aimed to identify the barriers and enablers AHPs experience when applying GCP principles to research conduct in a public hospital and health service, as well as their perceived support needs.

METHODS

The study used a qualitative descriptive study approach guided by behaviour change theory. AHPs currently undertaking ethically approved research within a public health service in Queensland, Australia were interviewed to explore barriers and enablers to adherence to GCP principles and support needs, with interview questions guided by the Theoretical Domains Framework (TDF). The TDF was chosen as it allows for a systematic understanding of factors influencing implementation of a specific behaviour (i.e., GCP implementation) and can be used to inform tailored interventions.

RESULTS

Ten AHPs across six professions were interviewed. Participants identified both enablers and barriers to implementing GCP across nine domains of the TDF and enablers across three additional domains. Examples of enablers included strong beliefs about the importance of GCP in increasing research rigour and participant safety (i.e. from TDF - beliefs about consequences); applying clinical skills and personal attributes when implementing GCP (i.e., skills), available training and support (i.e., environmental context and resources); and alignment with their moral sense to 'do the right thing' (i.e., professional identity). Barriers to GCP implementation were generally less commonly reported but included reduced time to implement GCP and a sense of 'red tape' (i.e., environmental context and resources), a lack of knowledge of GCP principles (i.e., knowledge) and a fear of making mistakes (i.e., emotions), and varying relevance to individual projects (i.e., knowledge). Suggestions for support were identified beyond training, such as physical resources (e.g., prescriptive checklists, templates and scripts), additional time, and regular one-on-one mentoring support.

CONCLUSION

Findings suggest that while clinicians recognise the importance of GCP and want to implement it, they report barriers to its practical implementation. GCP training alone is unlikely to address these barriers to implementing GCP in daily practice. Findings suggest that GCP training may be more useful to AHPs when it is tailored to the allied heath context and supplemented with additional supports including check-ups from experienced researchers and access to prescriptive resources. Future research however is needed to investigate the effectiveness of such strategies.

Barriers and enablers to structured care delivery in Australian rural primary care

OBJECTIVE

The primary aim of this study was to explore the barriers and enablers to structured care delivery in rural primary care, reflecting on Australian research findings.

DESIGN

CINAHL and Scopus databases were searched in August 2021. Inclusion criteria included English language, full-text studies, published since 2011, reporting on the barriers and enablers to the delivery of structured care within rural and remote primary care. Structured care was conceptualised as care that was organised, integrative and planned.

FINDINGS

A total of 435 studies were screened. Thirty-four met the inclusion criteria. Barriers to the provision of structured care related to workforce shortages, limited health care services and health care professional capacity, cultural safety and competency, limited resourcing, insufficient knowledge and education, geographical isolation, inadequate care coordination, unclear roles and responsibilities and poor health professional-patient relationships.

DISCUSSION

Health care system and geographical barriers and enablers encountered in rural areas are complex and multidimensional. Identification of the specific challenges to structured care delivery highlights the need for a focussed review of workforce supply and distribution challenges as well as the investigation of system integration, leadership, governance and funding reform that would be required to support rural primary care.

The observation of the curative effect of silver-containing dressings combined with hydrogel on healing of immunosuppression-induced skin ulcerations

BACKGROUND

Local inflammatory reaction is the basis of wound healing. Inappropriate inflammatory reaction will delay wound healing.

OBJECTIVE

This study aimed to investigate the effect of silver-containing dressings combined with hydrogel on healing of immunosuppression-induced skin ulcerations (IISU).

METHODS

A retrospective analysis was conducted on 48 cases of patients with IISU admitted to The First People's Hospital of Jiande from March 2018 to March 2019. According to the different treatment methods, the patients were divided into the observation group and the control group, with 24 cases in each group. Patients in the observation group were treated with silver-containing dressings combined with hydrogel, while patients in the control group were treated with silver-containing dressings alone. Initially, patients in the observation group and control group were treated with the same method of debridement and cleaning. Afterwards, for patients in the observation group, the wounded surface was coated with a layer of hydrogel. Both groups had the wound covered with a silver-containing dressing as the inner dressing, and gauze was used as the outer dressing to wrap and fix the wound. The dressing change frequency was the same for both groups. The effective rate, basic healing rate, and complete healing rate of the two groups were compared after one week and two weeks of treatment.

RESULTS

The effective rate of dressing application and wound healing rate in the observation group were significantly better than those in the control group, and the differences were statistically significant (P< 0.05).

CONCLUSION

A silver-containing dressing combined with hydrogel as the inner dressing can provide a better environment for wound healing, significantly shorten the course of treatment of patients with IISU, promote the early recovery of patients, and improve the quality of life of patients. Therefore, it can be applied in clinical practice.

Efficacy of photodynamic therapy in the treatment of venous trophic ulcers: results from the experiment

Introduction. Today, antimicrobial photodynamic therapy (a-PDT) becomes more and more popular, because of it pronounced bactericidal activity, anti-inflammatory effect. At the same time, no animal model studies have been conducted on morphological changes in cells after exposure to PDT on venous ulcers (VU) when using different types of photosensitizers (PS). The problem of comparing morphological changes in tissues when using a-PDT vs conventional PDT have not yet been resolved.

Aim. Evaluation of the effectiveness of PDT and APDT in a comprehensive examination of trophic ulcers in an in vivo experiment and compare them with standard methods for the treatment of VLU.

Materials and мethods. A series of experiments was conducted on 21 rabbits, separated into 3 equal groups of 7 rabbits each. Venous trophic ulcer was originally modeled for all rabbits. To obtain a VU, we performed an additional ligation of v. femoralis. The control group received standard therapy for VU. The PDT group had PDT with Photosens. The a-PDT group underwent a-PDT using Cholosens. Every 3 days, picture of local inflammation, regeneration rate and ulcer volume were determined. A morphological study of VLU was carried out on the first, 9th and 15th days.

Results. The a-PDT group, day 15: 100% wound epithelization. Control group, day 21st: The volume of wounds decreased on average by 50%. The PDT group: 100% wound epithelization. The morphological study indicated a positive trend in the a-PDT group compared with PDT and control groups, which resulted in a decrease in the total mass of necrotic detritus, a change in the quantitative and qualitative composition of inflammatory infiltrate.

Conclusion. The data obtained indicate that the use of a-PDT is recommended in treatment of VLU. Both PDT and a-PDT methods showed better results in comparison with standard therapy.

What promotes or prevents greater use of appropriate compression in people with venous leg ulcers? A qualitative interview study with nurses in the north of England using the Theoretical Domains Framework

OBJECTIVES

To investigate factors that promote and prevent the use of compression therapy in people with venous leg ulcers.

DESIGN

Qualitative interview study with nurses using the Theoretical Domains Framework (TDF).

SETTING

Three National Health Service Trusts in England.

PARTICIPANTS

Purposive sample of 15 nurses delivering wound care.

RESULTS

Nurses described factors which made provision of compression therapy challenging. Organisational barriers (TDF domains environmental context and resources/knowledge, skills/behavioural regulation) included heavy/increasing caseloads; lack of knowledge/skills and the provision of training; and prescribing issues (variations in bandaging systems/whether nurses could prescribe). Absence of specialist leg ulcer services to refer patients into was perceived as a barrier to providing optimal care by some community-based nurses. Compression use was perceived to be facilitated by clinics for timely initial assessment; continuity of staff and good liaison between vascular/leg ulcer clinics and community teams; clear local policies and care pathways; and opportunities for training such as 'shadowing' in vascular/leg ulcer clinics. Patient engagement barriers (TDF domains goals/beliefs about consequences) focused on getting patients 'on board' with compression, and supporting them in using it. Clear explanations were seen as key in promoting compression use.

CONCLUSIONS

Rising workload pressures present significant challenges to enhancing leg ulcer services. There may be opportunities to develop facilitated approaches to enable community nursing teams to make changes to practice, enhancing quality of patient care. The majority of venous leg ulcers could be managed in the community without referral to specialist community services if issues relating to workloads/skills/training are addressed. Barriers to promoting compression use could also be targeted, for example, through the development of clear patient information leaflets. While the patient engagement barriers may be easier/quicker to address than organisational barriers, unless organisational barriers are addressed it seems unlikely that all people who would benefit from compression therapy will receive it.

Patient Explanation of Adherence and Non-Adherence to Venous Leg Ulcer Treatment: A Qualitative Study

The aim of this study was to understand which factors influence patients’ adherence to venous leg ulcer treatment recommendations in primary care. We adopted a qualitative study design, conducting phone interviews with 31 people with venous leg ulcers in Melbourne, Australia. We conducted 31 semi-structured phone interviews between October and December 2019 with patients with clinically diagnosed venous leg ulcers. Participants recruited to the Aspirin in Venous Leg Ulcer Randomized Control Trial and Cohort study were invited to participate in a qualitative study, which was nested under this trial. We applied the Theoretical Domains Framework to guide the data analysis. The following factors influenced patients’ adherence to venous leg ulcer treatment: understanding the management plan and rationale behind treatment (Knowledge Domain); compression-related body image issues (Social Influences); understanding consequences of not wearing compression (Beliefs about Consequences); feeling overwhelmed because it’s not getting better (Emotions); hot weather and discomfort when wearing compression (Environmental Context and Resources); cost of compression (Environmental Context and Resources); ability to wear compression (Beliefs about Capabilities); patience and persistence (Behavioral Regulation); and remembering self-care instructions (Memory, Attention and Decision Making). The Theoretical Domains Framework was useful for identifying factors that influence patients’ adherence to treatment recommendations for venous leg ulcers management. These factors may inform development of novel interventions to optimize shared decision making and self-care to improve healing outcomes. The findings from this article will be relevant to clinicians involved in management of patients with venous leg ulcers, as their support is crucial to patients’ treatment adherence. Consultation with patients about VLU treatment adherence is an opportunity for clinical practice to be targeted and collaborative. This process may inform guideline development.

SUMAMOS EXCELENCIA® Project: Results of the Implementation of Best Practice in a Spanish National Health System (NHS)

The use of certain strategies for the implementation of a specific recommendation yields better results in clinical practice. The aim of this study was to assess the effectiveness of an evidence-based model using clinical audits (GRIP model), for the implementation of recommendations in pain and urinary incontinence management as well as fall prevention, in the Spanish National Health System during the period 2015-2018. A quasi-experimental study has been conducted. The subjects were patients treated in hospitals, primary care units and nursing home centers. There were measures related to pain, fall prevention and urinary incontinence. Measurements were taken at baseline and at months 3, 6, 9, and 12. The sample consisted of 22,114 patients. The frequency of pain assessment increased from 59.9% in the first cycle to a mean of 71.6% in the last cycle, assessments of risk of falling increased from 56.8% to 87.8% in the last cycle; and finally, the frequency of assessments of urinary incontinence increased from a 43.4% in the first cycles to a mean of 62.2% in the last cycles. The implementation of specific evidence-based recommendations on pain, fall prevention, and urinary incontinence using a model based on clinical audits improved the frequency of assessments and their documentation.

Survey of barriers to adherence to international inflammatory bowel disease guidelines: Does gastroenterologists' confidence translate to high adherence?

BACKGROUND & AIMS

Despite the availability of evidence-based inflammatory bowel disease (IBD) guidelines, suboptimal care persists. There is little published research assessing barriers to IBD guideline adherence. This study aimed to identify barriers to IBD guideline adherence including gastroenterologists' knowledge and attitudes towards guidelines.

METHODS

An online cross-sectional survey of 824 Australian gastroenterologists was conducted from April to August 2018, with 198 (24%) responses. A novel survey was developed which was informed by the theoretical domain's framework.

RESULTS

Confidence in guideline recommendations was high, however referral to them was low. The European Crohn's and Colitis Organisation (ECCO) guidelines were the most commonly referred to (43.6%). In multivariate analysis, significant predictors of frequent versus infrequent guideline referral were: high confidence in the guideline (OR 7.70, 95% CI: 2.43-24.39, p = 0.001), and low (≤10 years) clinical experience (OR 3.62, 95% CI: 1.11-11.79, p = 0.03). The most common barriers to guideline adherence were not having time (62%) followed by guideline specifics being difficult to remember (61%). Low confidence was reported in managing pregnancy and IBD (34%) and loss of response to therapy (29%). High confidence was reported in managing immunomodulators, however only 43% answered the associated knowledge question correctly.

CONCLUSION

Although gastroenterologists' have high confidence in guidelines, they use them infrequently, primarily due to specifics being difficult to remember and lack of time. Self-reported confidence in an area of IBD management does not always reflect knowledge. An intervention targeting these barriers, for example computer-based clinical decision support tools, may improve adherence and standardise care. This article is protected by copyright. All rights reserved.

Rationale for participation in venous leg ulcer clinical research: Patient interview study

Recruitment to wound care clinical trials is challenging and a better understanding of patient decisions to participate has the potential to influence recruitment success. We conducted 31 semi-structured telephone interviews of patients who participated in the Aspirin in Venous Leg Ulcer (ASPiVLU) randomised controlled trail (RCT) or ASPiVLU cohort study. Data were coded and analysed using thematic analysis. We identified four key themes: (a) "I participated to help others"; (b) "I participated in research to thank those who cared for me"; (c) "I participated to receive better care"; and (d) "I participated to have a say on what works." These themes became basic elements for the Rationale for Research Participation Framework that we have developed to improve the participant recruitment process for clinical trials in wound care.

Venous leg ulcer management in Australian primary care: Patient and clinician perspectives

BACKGROUND

Venous leg ulcers are the most common chronic wound seen in Australian primary care. Healing outcomes are protracted due to suboptimal use of clinical practice guideline recommendations. A better understanding of the differences between patients and clinicians may optimise management in primary care and improve healing and health outcomes for patients and healthcare spend in society.

OBJECTIVE

We explored venous leg ulcer management from patients' and primary care clinicians' perspective, including assessment, diagnosis, treatment, referral, and health education as outlined in the clinical practice guidelines.

DESIGN

We conducted a qualitative secondary analysis of data obtained from the qualitative face-to-face and telephone interviews with the primary care clinicians and telephone interviews with patients with venous leg ulcers.

SETTING

Clinicians were recruited from urban and rural primary health practices across Victoria, Australia. Patients were recruited from two specialist care wound clinics in Victoria.

PARTICIPANTS

We analysed data from interviews with 66 participants, including 31 patients with venous leg ulcers, 15 general practitioners and 20 practice nurses.

METHODS

Secondary analysis of qualitative data was carried out using thematic analysis. Interview transcripts were coded and analysed for common themes.

RESULTS

We found patients and clinicians reported differing perspectives related to venous leg ulcer management. Patients reported the need for earlier referral to specialist wound care clinics from primary care, emphasizing the need for vascular assessment and compression therapy. Clinicians discussed clinical judgements about when to refer rather than follow guideline recommendations. Clinicians frequently discussed managing venous leg ulcers using only topical dressing treatments, without compression therapy. Patients reported inadequate pain management for wound pain. Meanwhile, clinicians reported that they generally did not discuss wound pain management as part of overall venous leg ulcer management. Clinicians reported patients lacked an understanding about the role of compression in management of and subsequent healing outcomes. Patients stated they wanted more information about how to care for venous leg ulcers and how best to prevent recurrence, and needed more information than was already provided by clinicians. Conversely, clinicians reported less information is given to ensure patients were not overwhelmed with health information.

CONCLUSION

There are discrepancies between what patients want and what clinicians do. These data suggest that patients' preferences are aligned with venous leg ulcer clinical practice guideline recommendations. Greater awareness of the guidelines by health professional may not only reduce discrepancies they may improve health and healing outcomes. Tweetable abstract: Patients and primary care clinicians have different perspectives about venous leg ulcer management.

Understanding factors influencing venous leg ulcer guideline implementation in Australian primary care

The aim of this study was to gain a better understanding of the venous leg ulcer (VLU) management in primary health care settings located in Melbourne metropolitan and rural Victoria, Australia. We explored health professionals' perspective on the use of the Australian and New Zealand Venous Leg Ulcer Clinical Practice Guideline (VLU CPG) to identify the main challenges of VLU CPG uptake in clinical practice. We conducted semi-structured interviews with 15 general practitioners (GPs) and 20 practice nurses (PNs), including two Aboriginal health nurses. The Theoretical Domains Framework guided data collection and analysis. Data were analysed using a theory-driven analysis. We found a lack of awareness of the VLU CPGs, which resulted in suboptimal knowledge and limited adherence to evidence-based recommendations. Environmental factors, such as busy nature of clinical environment and absence of handheld Doppler ultrasound, as well as social and professional identity factors, such as reliance on previous experience and colleague's advice, influenced the uptake of the VLU CPGs in primary care. Findings of this study will inform development of interventions to increase the uptake of the VLU CPG in primary care settings and to reduce the evidence-practice gap in VLU management by health professionals.