Effects of educational technologies on the prevention and treatment of diabetic ulcers: A systematic review and meta-analysis

Lira, Jefferson Abraão Caetano; Rocha, Álvaro Sepúlveda Carvalho; Bezerra, Sandra Marina Gonçalves; Nogueira, Paula Cristina; Santos, Ana Maria Ribeiro dos; Nogueira, Lídya Tolstenko

doi:10.1590/1518-8345.6628.3945

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Revista Latino-Americana de Enfermagem

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Review Article • Rev. Latino-Am. Enfermagem 31 • 2023 • https://doi.org/10.1590/1518-8345.6628.3945 copy

Effects of educational technologies on the prevention and treatment of diabetic ulcers: A systematic review and meta-analysis^* * Paper extracted from doctoral dissertation “Construção e validação de intervenção educativa em ambiente virtual de aprendizagem sobre prevenção e manejo do pé diabético para enfermeiros da Atenção Primária à Saúde”, presented to Universidade Federal do Piauí, Teresina, PI, Brazil.

Authorship SCIMAGO INSTITUTIONS RANKINGS

Objective:

to analyze the effects of educational technologies in the prevention and treatment of diabetic ulcers.

Method:

a systematic review conducted in seven databases, a bibliographic index, an electronic library and the Gray Literature. The sample consisted of 11 randomized controlled clinical trials. The synthesis of the results was descriptive and through meta-analysis.

Results:

the predominant educational technologies were training sessions and verbal guidelines, with soft-hard technologies standing out. When compared to usual care, the educational technologies presented a protective factor to prevent the incidence of diabetic ulcers (RR=0.40; 95% CI=0.18-0.90; p=0.03) and the certainty of the evidence assessment was low. The educational technologies also had a protective factor to prevent the incidence of lower limb amputations (RR=0.53; 95% CI=0.31-0.90; p=0.02) and certainty of the evidence was very low.

Conclusion:

soft-hard educational technologies such as structured verbal guidelines, educational games, lectures, theoretical-practical training sessions, educational videos, folders, serial albums and playful drawings, and hard technologies such as therapeutic footwear, insoles, infrared digital thermometer, foot care kits, Telemedicine app and mobile phone use, were effective for the prevention and treatment of diabetic ulcers, although more robust studies are required.

Descriptors:
Diabetes Mellitus; Diabetic Foot; Diabetes Complications; Educational Technology; Systematic Review; Meta-Analysis

Highlights:

(1) Educational technologies improved foot self-care.

(2) Educational technologies contributed to diabetic ulcer healing.

(3) Educational technologies were effective in preventing diabetic ulcers.

(4) Educational technologies presented a protective factor for amputation.

(5) It is recommended to use educational technologies in the prevention and treatment of diabetic ulcers.

Authors, year and locus	Sample/ Follow-up time	IG^*/Type of educational technology (technology classification)	IG^†/Type of technology (technology classification)	Main results
Cisneros (2010)(¹⁹19. Cisneros LL. Avaliação de um programa para prevenção de úlceras neuropáticas em portadores de diabetes. Rev Bras Fisioter. 2010;14(1):31-7. https://doi.org/10.1590/S1413-35552010000100006 https://doi.org/10.1590/S1413-3555201000... ), Brazil	n=35/24 months	n=21/Verbal guidance through discussion of topics related to foot complications (soft-hard) and educational games (soft-hard).	n=14/Assistance routine offered by the service (did not use any educational technology).	Incidence of ulcerations: IG^: I^‡=38.1% (8/21) CG^†: I^‡=57.1% (8/14) Recurrence of ulcerations: IG^: I^‡=16.7% (1/8) CG^†: I^‡=83.3% (5/8)
Donohoe, et al. (2000)(²⁸20. Donohoe ME, Fletton JA, Hook A, Powell R, Robinson I, Stead JW, et al. Improving foot care for people with diabetes mellitus - a randomized controlled trial of an integrated care approach. Diabet Med. 2000;17(8):581-7. https://doi.org/10.1046/j.1464-5491.2000.00336.x https://doi.org/10.1046/j.1464-5491.2000... ), England	n=1,939/six months	n=981/Standardized leaflets (soft-hard) and structured verbal guidance (soft-hard).	n=958/Usual foot care, which included a practical visit (soft-hard) and an educational intervention on diabetic nephropathy (soft-hard).	Foot self-care: The attitudes toward foot care increased in both groups (IG^*=3%; p<0.001 and CG^†=1.8%; p<0.001) with no significant difference in the change between the groups (p=0.26).
Iversen, et al. (2020)(²²21. Iversen MM, Igland J, Smith-Strom H, Ostbye T, Tell GS, Skeie S, et al. Effect of a telemedicine intervention for diabetes-related foot ulcers on health, well-being and quality of life: secondary outcomes from a cluster randomized controlled trial (DiaFOTo). BMC Endocr Disord. 2020;20(157): 1-8. https://doi.org/10.1186/s12902-020-00637-x https://doi.org/10.1186/s12902-020-00637... ), Norway	n=182/12 months	n=94/Telemedicine app (hard) and mobile phone for guidance and communication between nurses from Primary Health Care and the specialized service (hard) and theoretical-practical training (soft-hard).	n=88/Standard care provided by the outpatient service, usually scheduled to occur every two weeks (did not use any educational technology).	Healing of diabetic ulcers: 82.1% of the patients had ulcer healing at 12 months in the IG^, and 76.9% in the CG^†. There was no difference in the healing time between the groups. Incidence of amputations: IG^: I^‡=5.1% (4/94) CG^†: I^‡=14.1% (11/88) Satisfaction: Satisfaction was similar for the IG^* and the CG^†.
Lavery, et al. (2004)(²⁴22. Lavery LA, Higgins KR, Lanctot DR, Constantinides GP, Zamorano RG, Armstrong DG, et al. Home monitoring of foot skin temperatures to prevent ulceration. Diabetes Care. 2004;27(11):2642-7. https://doi.org/10.2337/diacare.27.11.2642 https://doi.org/10.2337/diacare.27.11.26... ), United States	N=85/six months	n=41/Diabetic foot education through verbal guidance (soft-hard), therapeutic shoes (hard), log book (hard) and portable infrared skin thermometer (hard).	n=44/Usual care, such as diabetic foot education (soft-hard) and therapeutic footwear (hard).	Incidence of diabetic ulcers: IG^: I^‡=2.4% (1/41) CG^†: I^‡=15.9% (7/44) Incidence of amputations: IG^: I^‡=0% (0/41) CG^†: I^‡=4.5% (2/44) Complications: There were 20% (n=9) of complications in the feet of the patients from the CG^† and 2% (n=1) of complications in those from the IG^* (p=0.01).
Lavery, et al. (2007)(²⁵23. Lavery LA, Higgins KR, Lanctot DR, Constantinides GP, Zamorano RG, Athanasiou KA, et al. Preventing diabetic foot ulcer recurrence in high-risk patients: use of temperature monitoring as a self-assessment tool. Diabetes Care. 2007;30(1):14-20. https://doi.org/10.2337/dc06-1600 https://doi.org/10.2337/dc06-1600... ), United States	n=173/15 months	n=59/Enhanced therapy: educational video (soft-hard), use of a digital infrared thermometer (hard), evaluation of the lower limbs (soft-hard), therapeutic insoles and shoes (hard) and logbook (hard). n=56/Structured foot examination: training for foot inspection (soft-hard), mirror (hard) and recording in a logbook (hard).	n=58/Standard therapy: evaluation of the lower limbs (soft-hard), educational video (soft-hard), therapeutic insoles and shoes (hard) and logbook (hard).	Incidence of diabetic ulcers: IG^* (enhanced therapy): I^‡=8.5% (5/59) IG^* (structured foot exam): I^‡=30.4% (17/56) CG^† (standard therapy): I^‡=29.3% (17/58)
Liang, et al. (2012)(²⁶24. Liang R, Dai X, Zuojie L, Zhow A, Meijuan C. Two-Year Foot Care Program for Minority Patients with Type 2 Diabetes Mellitus of Zhuang Tribe in Guangxi, China. Can J Diabetes. 2012;36(1):15-8. https://doi.org/10.1016/j.jcjd.2011.08.002 https://doi.org/10.1016/j.jcjd.2011.08.0... ), China	n=62/24 months	n=31/Diabetes education lecture (soft-hard), training sessions through hands-on workshops (soft-hard), skills exercises (soft-hard) and foot care kit (hard).	n=31/Usual care, which consisted of two hours of diabetes education (soft-hard).	Incidence of ulcerations: IG^: I^‡=0% (0/31) CG^†: I^‡=24.1% (7/31) Incidence of amputations: IG^: I^‡=0% (0/31) CG^†: I^‡=6.9% (2/31) Foot self-care: There was a significant difference in knowledge and foot care in the IG^* participants (p<0.05).
Lincoln, et al. (2008)(²⁹25. Lincoln NB, Radford KA, Game FL, Jeffcoate WJ. Education for secondary prevention of foot ulcers in people with diabetes: a randomised controled trial. Diabetologia. 2008;51(11):1954-61. https://doi.org/10.1007/s00125-008-1110-0 https://doi.org/10.1007/s00125-008-1110-... ), United Kingdom	n=172/12 months	n=87/Leaflets (soft-hard), handouts (soft-hard), illustrations (soft-hard), unstructured verbal guidelines in home visits (soft) and structured education, according to demand and by telephone (hard).	n=85/Leaflets (soft-hard) and unstructured and timely education (soft).	Incidence of ulcerations: IG^: I^‡=41% (36/87) CG^†: I^‡=41% (35/85) Incidence of amputations: IG^: I^‡=10% (9/87) CG^†: I^‡=11% (9/85) Foot self-care: The IG^* presented an apparent improvement in some foot care aspects.
Monami, et al. (2015)(²⁷26. Monami M, Zannoni S, Gaias M, Nreu B, Marchionni N, Mannucci E. Effects of a Short Educational Program for the Prevention of Foot Ulcers in High-Risk Patients: A Randomized Controlled Trial. Int J Endocrinol. 2015;2015(615680):1-5. https://doi.org/10.1155/2015/615680 https://doi.org/10.1155/2015/615680... ), Italy	n=120/six months	n=60/Verbal guidelines on foot ulcer risk factors (soft-hard) and training through interactive practice with actions to reduce the foot ulcer risk factors (soft-hard).	n=60/Leaflet with some recommendations for the prevention of ulcers, according to local guidelines (soft-hard).	Incidence of ulcerations: IG^: I^‡=0% (0/60) CG^†: I^‡=10% (6/60) Incidence of amputations: IG^: I^‡=0% CG^†: I^‡=0% There was an improvement in the patients’ knowledge after the intervention (p<0.001).
Moreira, et al. (2020)(²¹27. Moreira JB, Muro ES, Monteiro LA, Iunes DH, Assis BB, Chaves ECL. The effect of operative groups on diabetic foot self-care education: a randomized clinical trial. Rev Esc Enferm USP. 2020;54:e03624. https://doi.org/10.1590/S1980-220X2019005403624 https://doi.org/10.1590/S1980-220X201900... ), Brazil.	n=109/one month	n=55/Illustrative and didactic folder (soft-hard), visual demonstrations (soft-hard), templates (hard), serial album (soft-hard), image projections (hard) and playful drawings (soft-hard).	n=54/Usual care, which consisted of routine care in the unit, with routine clinical follow-up (did not use any educational technology).	Reduced risk of foot complications: After 15 days of the intervention, there was statistical significance in relation to tissue injury, hairiness, hydration, perspiration, skin peeling, color after ten seconds of elevation, tissue perfusion, pedal and tibial pulses, edema, neuropathic symptoms and plantar pressure.
Smith-Strom, et al. (2018)(²³28. Smith-Strom H, Igland J, Ostbye T, Tell GS, Hausken MF, Graue M, et al. The Effect of Telemedicine Follow-up Care on Diabetes-Related Foot Ulcers: A Cluster-Randomized Controlled Noninferiority Trial. Diabetes Care. 2018;41(1):96-103. https://doi.org/10.2337/dc17-1025 https://doi.org/10.2337/dc17-1025... ), Western Norway	n=182/12 months	n=94/Telemedicine app (hard), cell phone (hard) and theoretical-practical training (soft-hard).	n=88/Outpatient appointments every two weeks and, if necessary, additional monitoring (did not use any educational technology).	Healing of diabetic ulcers: 79.8% (n=75) had diabetic ulcer healing in the IG^* and 76.1% (n=67) in the CG^†, with mean healing times of 3.4 and 3.8 months in the IG^* and CG^†, respectively. Incidence of amputations: IG^*: I^‡=6.4% (6/94) CG^†: I^‡=14.8% (13/88) Patients’ satisfaction levels: Most of the patients in both groups reported high satisfaction with treatment and monitoring, with no differences between the groups.
Subrata, et al. (2020)(²⁰29. Subrata SA, Phuphaibul R, Grey M, Siripitayakunkit A, Piaseu N. Improving clinical outcomes of diabetic foot ulcers by the 3-month self- and family management support programs in Indonesia: A randomized controlled trial study. Diabetes Metab Syndr. 2020;14(5):857-63. https://doi.org/10.1016/j.dsx.2020.05.028. https://doi.org/10.1016/j.dsx.2020.05.02... ), Indonesia	n=56/three months	n=27/Skills training and motivational interview, which consisted of 50-minute sessions per week for three months and addressed the following topics: physical activity, medications, foot care, glycemic control, strengthening responsibilities, establishing roles and active involvement in care (soft-hard).	n=29/Usual care in diabetes (did not use any educational technology).	Healing of diabetic ulcers: The mean ulcer size in the IG^* decreased over time when compared to the CG^†. Although not healing completely, the difference in ulcer size reduction was statistically significant between both groups (p<0.001).

Certainty of the evidence							Number of patients		Effect
Number of studies	Type of study	Risk of bias	Inconsistency	Indirect evidence	Imprecision	Other considerations	Educational technology	Usual care	Relative (95% CI*)	Absolute (95% CI*)	Certainty
Incidence of diabetic ulcers/Educational technology versus usual care (follow-up: range from 6 months to 2 years)
6	RCT^††	Severe^‡	Severe^§	Not severe	Not severe	None	50/299 (16.7%)	80/292 (27.4%)	RR^ǁ = 0.40 (from 0.18 to 0.90)	164 less per 1,000 (from 225 less to 27 less)	⨁⨁◯◯ Low
Incidence of lower limb amputations/Educational technology versus usual care (follow-up: range from 6 months to 2 years)
5	RCT^††	Very severe^¶	Not severe	Not severe	Severe**	None	19/347 (5.5%)	37/336 (11%)	RR^ǁ = 0.53 (from 0.31 to 0.90)	52 less per 1,000 (from 76 less to 11 less)	⨁◯◯◯ Very low

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[1] Corresponding author:
Jefferson Abraão Caetano Lira E-mail: j.abraaolira@gmail.com https://orcid.org/0000-0002-7582-4157