The unseen barrier: Why some wounds don’t heal

In the world of wound care, healing is often seen as a clinical process: debridement, dressings and documentation. But for millions of Americans living with chronic wounds, healing is far more complex. It’s not just about what’s applied to the skin, it’s about the patient’s environment. Socioeconomic factors such as housing, income, transportation, education and food security all play a critical role in whether a wound heals or worsens over time. This is the intersection where public health meets patient care, and where promoting wellness becomes as essential as treating illness.

Over 8 million people in the United States are impacted by chronic wounds. The estimated cost of healthcare is 28 billion annually. The most common diagnoses are diabetic foot ulcers, pressure ulcers, and surgical site wounds. These wounds are not only disabling and painful but are also deeply influenced by the patient’s education on wound care, access to follow-up appointments, wound dressings and environment.

Research shows that up to 80% of wound healing outcomes are determined by non-medical factors which are social and behavioral drivers. The social barriers are: 

• Housing instability: Patients without stable housing may lack clean environments to change wound dressings or store supplies. Homelessness is associated with higher infection rates and delayed healing. Unstable housing can exacerbate chronic stress and delay healing.
  
  
• Income: Assigning a code to a wound care product, treatment or device does not ensure that it will be reimbursed or covered by insurance. Patients with limited income may skip treatments or reuse dressings, increasing the risk of complications. 
  
  
• Transportation: Missed appointments due to lack of transportation are a leading cause of wound care noncompliance.
  
  
• Education: Lack of education is strongly connected to poorer health literacy, impacting a patient’s ability to follow wound care instructions. Misunderstanding how to apply wound dressings or manage care can lead to worsening conditions.
  
  
• Food insecurity: Nutrition is foundational to tissue repair. Patients without access to protein-rich, nutrient-dense foods are at higher risk for delayed healing. One report found more than 13% U.S. households are food insecure, and this lack of consistent access to nutritious food is closely linked with chronic conditions like obesity, diabetes, hypertension and other wound-risk conditions. 
  
  
• Stressors: Lifelong exposure to stress can trigger physiological changes and influence health behaviors in ways that disrupt cellular balance. These disruptions may create conditions that impair tissue health, increasing the risk of wound development and poor healing outcomes.

Wound healing is also significantly influenced by human behavior including, daily habits, personal decisions, and self-care practices are often underestimated. Several key barriers are:

• Inconsistent wound care compliance: Patients who do not follow prescribed wound care regiments, including dressing changes and cleaning routines, and skip follow-up appointments is a common behavioral barrier. Whether due to discomfort, forgetfulness or lack of understanding, inconsistent care increases the risk of infection and delays healing.
  
  
• Smoking: Smoking is one of the most detrimental behaviors affecting wound healing. Nicotine reduces oxygen and nutrient delivery to tissues. Carbon monoxide from cigarettes further impairs oxygen transport. Smoking also suppresses the immune response system, delaying inflammation resolution and tissue repair.
  
  
• Alcohol consumption: Chronic alcohol use impairs inflammatory cell function and reduces fibroblast activity, both critical in wound repair. Even acute alcohol intake can decrease the body’s ability to fight off infections and regenerate tissue.
  
  
• Physical inactivity or overactivity: Immobility can lead to pressure injuries and poor circulation, while overuse of injured area can prevent new tissue from forming. Behavioral balance, which is rest combined with physician approved movement, is key to healing.

Clinically, wound care specialists advocate for interprofessional care models that extend beyond clinical staff. These models incorporate healthcare technology alongside social workers, community health workers and case managers who can help identify and address barriers to healing. They also support providing tailored education that aligns with a patient’s literacy level and cultural background to improve adherence and clinical outcomes. Additionally, partnerships with food banks, housing agencies and transportation services can help meet patients’ basic needs, creating a more stable foundation for effective wound healing. Case management programs addressing transport, food and housing reduced hospital admissions by 11% and ER visits by 4%.

Healing a wound is not just about closing the skin; it starts with ensuring safe homes, nutritious food, income stability, education and reliable transport. As public health and wound care continue to intersect, the most effective treatments will combine clinical excellence with compassion, innovation and a deep commitment to human-centered care. When we address the social and behavioral drivers of health, we pave the way for every patient to experience holistic healing.

Joscelyn Thomas, B.S., RHIT, clinical development analyst at Solventum