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Page 10 of 14 Al Onazi et al. Plast Aesthet Res 2020;7:23 I http://dx.doi.org/10.20517/2347-9264.2019.74

- “I live on a farm, and I spend a lot of time taking it on and off so it will not get wet or dirty.”
- “I need to feel the food with my fingers, so I can’t wear the glove in the kitchen.”
- “The glove gets wet with meal preparation, sleeve is uncomfortable with the glove off, so I remove both.”
- “The glove is cumbersome and interferes with cooking and hand washing.”

With respect to maintaining cleanliness of the garments, participants reported the following concerns with
managing hygiene:
- “I work as a surgical nurse and cannot wear my garment during surgery as I cannot scrub and stay sterile,
and wear the sleeve.”
- “I need to wash my hands at work, so I have to remove the glove a lot.”
- “I worry about germs. Is the glove carrying germs?”

Theme: social situations and visibility
When we explored reasons for non-use of the sleeve for social events or special occasions, participants
reported issues with appearance and with the garments drawing unwanted attention or questions.

• Appearance:
- “When I go out for a special evening event, and when wearing an evening outfit, I will go without the
sleeve.”
- “I won’t wear it for weddings or formal events, as it does not look good with my outfit”
- “I won’t wear it for a photo session, doesn’t look good.”
- “Clothes don’t fit well when I have it on.”

• Drawing unwanted attention:
- “Lady with the sleeve.”
- “I am always conscious of it because I have people asking me if I have been burned or why I wear it.”
- “It draws attention to the arm and awkward questions.”
- “I like fall and winter more because I can wear long sleeve shirts and nobody asks me anything.”

Theme: alternative management strategies
Many of the participants reported the use of alternative strategies that helped them to control their
lymphedema and allowed them to “get away” with reducing daytime compression sleeve wear. Nighttime
compression, through bandaging or a night garment, was the main strategy used as an alternative to
wearing daytime compression. Other strategies included managing body weight, exercise, and nutritional
intake (such as avoiding alcohol and salt).
- “My night system controls my lymphedema, so I don’t need to wear a daytime sleeve anymore.”
- “Even minor weight loss seems to help me control the lymphedema better.”
- “Exercise helps me a lot.”
- “Drinking alcohol makes the swelling worse, I know I will need to wear my garment more after a social
event.”
- “Salt definitely makes the swelling worse, especially if I eat out.”

Data synthesis: mapping of facilitators and key themes to the TDF
The findings of the qualitative study were combined with survey data and mapped to the TDF data to
allow for the identification of potential strategies to enhance adherence to daytime compression. We found
that the main themes could not be categorized into a single component of the COM-B model. Clearly,
relationships existed among the components of opportunity, capability, and motivation, while some barriers
influenced motivation. For example, not wearing the sleeve when attending social events was related to
visibility of the garment with dress clothes representing social influences (opportunity), while the unwanted