Perceived stress, pain, and wound healing in hard-to-heal wounds: cross-national cohort study

Abstract

Aim: To identify and analyze the association between perceived stress, pain, and healing in patients with hard-to-heal wounds, comparing findings from two distinct healthcare contexts: Brazil and Canada. Methods: This secondary analysis used data from two prospective observational studies. The sample included 54 participants: 32 from Brazil and 22 from Canada.  Data were collected over 2-6 visits through interviews, wound assessments, and chart reviews. Measures included clinical and sociodemographic data, pain severity, interference and subjective experience, wound healing, and perceived stress. Between-country comparisons used parametric or non-parametric tests, and longitudinal associations were examined using linear mixed-effects models. Results: No pain or stress measure in the full sample was significantly associated with wound-healing scores longitudinally. However, associations between pain, stress, and wound healing varied between countries. In Brazil, higher BPIS and PSS scores tended to correspond to lower PUSH scores, whereas in Canada they tended to correspond to higher PUSH scores. Wound etiology also differed significantly, with vasculogenic wounds predominating in Brazil and surgical wounds in Canada. Wound duration was longer in Brazil than in Canada. Female participants reported higher stress and pain scores, while Brazilian participants reported greater pain interference in daily activities; both statistically significant. Conclusion: Perceived stress and pain were not associated with wound healing in the full sample. However, comparisons between two healthcare settings revealed clinically relevant differences in wound chronicity, etiology, and pain interference, suggesting that psychosomatic aspects of wound care may be context-dependent and should be interpreted within specific care pathways and cultural forms of expression.