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Al Onazi et al. Plast Aesthet Res 2020;7:23 I http://dx.doi.org/10.20517/2347-9264.2019.74 Page 11 of 14

Figure 2. Survey and qualitative findings mapped to the capability, opportunity, and motivation behaviour change wheel (COM-B)

attention was related to emotion (motivation). “Discomfort” crossed components of capability (i.e., lack of
adaptive strategies) and opportunity (e.g., lack of experienced fitters and environmental factors/weather)
leading to issues with motivation (i.e., negative emotions). Interference with function appeared to primarily
involve the lack of opportunity in relation to proper fit of the garment, and the need for garments that
both facilitate functional/work activities and are hygienic. We noticed that interference with function also
appeared to be influenced by a lack of adaptive strategies (capability) [Figure 2].

DISCUSSION
A primary finding of this study was that adherence to daytime compression was less than optimal. At
[10]
present, compression garments are the mainstay of lymphedema self-management , and are generally
recommended for use during all waking hours [23,24] . Poor adherence to BCRL self-care practices has been
[12]
associated with increased arm volume and progression of BCRL to more advanced stages , supporting
the importance of good adherence. A prior research study examining adherence to self-care strategies
had similar findings, reporting that only 39% of their study participants adhered to greater than 75%
[25]
of recommended compression sleeve wear time across a one-year follow-up period . While overall
adherence was poor among participants in our study, those participants who reported daily adherence of >
9 h also reported better perceived-control of their lymphedema, suggesting a positive medium effect from
use of daytime compression. Based on our findings, however, only 9.2% of the total variation in perceived
control can be explained by adherence to use of daytime compression. Thus, 91% of the variation is related
to other potential factors including the use of other maintenance strategies identified by the participants.

Capability
The results of this study suggest that strict adherence to use > 12 h per day, while recommended, may not
be necessary to achieve control of lymphedema, especially in the case of those with mild lymphedema.
Other self-management practices reported by many participants in this study were used to replace the
need for strict adherence to daytime compression, by supplementing wear schedules with nighttime