Rev. Latino-Am.

Enfermagem
2023;31:e3945
DOI: 10.1590/1518-8345.6628.3945
www.eerp.usp.br/rlae

Review Article

Effects of educational technologies on the prevention and treatment of

diabetic ulcers: A systematic review and meta-analysis*

Jefferson Abraão Caetano Lira1

https://orcid.org/0000-0002-7582-4157

Álvaro Sepúlveda Carvalho Rocha1 Highlights: (1) Educational technologies improved foot
https://orcid.org/0000-0002-7968-9597
self-care. (2) Educational technologies contributed to
Sandra Marina Gonçalves Bezerra2 diabetic ulcer healing. (3) Educational technologies were
https://orcid.org/0000-0003-3890-5887
effective in preventing diabetic ulcers. (4) Educational
Paula Cristina Nogueira3 technologies presented a protective factor for amputation.
https://orcid.org/0000-0001-5200-1281 (5) It is recommended to use educational technologies in
Ana Maria Ribeiro dos Santos1 the prevention and treatment of diabetic ulcers.
https://orcid.org/0000-0002-5825-5335

Lídya Tolstenko Nogueira1

https://orcid.org/0000-0003-4918-6531 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.
*
Paper extracted from doctoral dissertation “Construção e The educational technologies also had a protective factor to prevent the
validação de intervenção educativa em ambiente virtual de
incidence of lower limb amputations (RR=0.53; 95% CI=0.31-0.90;
aprendizagem sobre prevenção e manejo do pé diabético
p=0.02) and certainty of the evidence was very low. Conclusion: soft-
para enfermeiros da Atenção Primária à Saúde”, presented
to Universidade Federal do Piauí, Teresina, PI, Brazil. hard educational technologies such as structured verbal guidelines,
1
Universidade Federal do Piauí, Departamento de educational games, lectures, theoretical-practical training sessions,
Enfermagem, Teresina, PI, Brazil. educational videos, folders, serial albums and playful drawings, and
2
Universidade Estadual do Piauí, Centro de Ciências da
hard technologies such as therapeutic footwear, insoles, infrared digital
Saúde, Teresina, PI, Brazil.
thermometer, foot care kits, Telemedicine app and mobile phone use,
3
Universidade de São Paulo, Escola de Enfermagem,
Departamento de Enfermagem Médico-Cirúrgica, São Paulo, were effective for the prevention and treatment of diabetic ulcers,
SP, Brazil. although more robust studies are required.

Descriptors: Diabetes Mellitus; Diabetic Foot; Diabetes Complications;

Educational Technology; Systematic Review; Meta-Analysis.

How to cite this article

Lira JAC, Rocha ASC, Bezerra SMG, Nogueira PC, Santos AMR, Nogueira LT. Effects of educational technologies on the
prevention and treatment of diabetic ulcers: A systematic review and meta-analysis. Rev. Latino-Am. Enfermagem.
2023;31:e3945 [cited ]. Available from: . https://doi.org/10.1590/1518-8345.6628.3945
year mon day URL
2 Rev. Latino-Am. Enfermagem 2023;31:e3945.

Introduction and ingrown toenails, when compared to those with

insufficient knowledge(7).
Diabetic ulcers are a health problem resulting from Diabetic foot is a complication that requires
chronic complications of diabetes mellitus, such as thorough monitoring and behavioral changes. Thus,
peripheral neuropathy and peripheral arterial disease. educational technologies can be effective in controlling
Peripheral neuropathy causes protective sensitivity diabetes mellitus, stimulating the promotion of foot care
loss, foot deformity, joint mobility limitation and and, in the long term, they can enable a reduction in
abnormal biomechanical load on the feet, leading to costs, foot complications and amputations(8). In this
the formation of calluses, subcutaneous hemorrhage perspective, an educational intervention, with a practical
and ulceration. Usually caused by atherosclerosis, skills session and foot care kit, reduced the risk factors
peripheral artery disease is a risk factor for poor healing for ulceration and improved the preventive behavior of
of diabetic ulcers and for lower limb amputation. Thus, foot self-care(6).
diabetic ulcers are classified as neuropathic, ischemic Training sessions, verbal guidelines, leaflets, apps,
or neuroischemic . (1)
videos and didactic games are educational technologies
Diabetic ulcers generate significant suffering and that can be used for the health education of professionals
financial costs for the patients, in addition to overloading and patients with diabetes mellitus. Thus, structured
family members and health professionals and services, education, callus removal, use of therapeutic footwear
emphasizing the need for strategies that include and physical exercises related to the feet and mobility
elements of prevention, patient and team education, are beneficial to improve modifiable risk factors for
multidisciplinary treatment and rigorous monitoring . (2)
foot ulcerations(9). In addition, the digital educational
Diabetic ulcer treatment should include relief of plantar technology developed for nurses allows greater
pressure, removal of calluses, protection and drainage reach due to ease of access and to time, spatial and
of blisters, treatment of fungal infections, intervention schedule flexibility, in addition to offering reduced
to accelerate healing, foot self-care guidelines and costs. This educational strategy enables professional
management of peripheral artery disease, in order updating, qualification and training, contributing to the
to reduce ulceration complications such as delays in implementation of preventive interventions to reduce
the healing process, presence of infections and lower foot complications in patients with diabetes mellitus(8).
limb amputations .(1)
Educational technologies ease care management
In Spain, 44.1% of the patients with diabetes and, according to Merhy, they can be classified into
mellitus had neuroischemic ulcers, of which 20.3% were soft, soft-hard and hard. Soft technologies consist of
neuropathic and 20.3% were ischemic, with presence relationships such as welcoming, bonding and patient
of infection as an aggravating factor in 41.4% of the autonomy, through open dialog, qualified listening and
cases(3). The cumulative incidence of diabetic ulcers in group dynamics. Soft-hard technologies correspond to
Japan was 0.2% at 12 months, 2.4% at 60 months and structured knowledge, such as serial albums, educational
5.8% at 120 months, and most of these patients did not videos, pamphlets and posters. Hard technologies
return for reevaluations , highlighting the importance
(4)
comprise material resources such as technological devices
of care continuity and of implementing health education and registration forms(10).
strategies to improve adherence to the therapy and The diverse evidence about the effects of
prevent foot complications. A Brazilian study found educational technologies to prevent the incidence of
that 1.9% of the patients with diabetes mellitus had diabetic ulcers and foot complications is indispensable
diabetic ulcers, 59% had diabetic neuropathy, 69.6% to guide the clinical practice and incorporate these
were at risk of developing diabetic foot, and 86.3% of technologies in the care of patients with diabetes
the patients reported never having undergone any clinical mellitus, in order to improve care quality, comprehensive
foot examination .(5)
assistance, foot self-care and the patients’ quality of
Diabetic ulcers can be caused by trauma, life and satisfaction levels, in addition to reducing
inappropriate shoes, mycotic infections, nail problems, costs, hospital admissions and non-traumatic lower
calluses, dry skin and cracks(2,6). In addition to that, a limb amputations.
study verified that patients with moderate knowledge In view of the above, this systematic review
about self-care practices were more likely to perform and meta-analysis aimed at analyzing the effects of
foot self-care, dry the interdigital spaces, moisturize the educational technologies in the prevention and treatment
feet with creams and observe the presence of mycosis of diabetic ulcers.

www.eerp.usp.br/rlae
 Lira JAC, Rocha ASC, Bezerra SMG, Nogueira PC, Santos AMR, Nogueira LT. 3

Method the following guiding question was formulated: Which are

the effects of educational technologies on the prevention
Type of study and treatment of diabetic ulcers in patients with diabetes
mellitus? In this perspective, the care measures in the
This is a systematic review and meta-analysis healing of ulcerations and the assistance provided to
prepared according to the recommendations set forth complications related to diabetic ulcers were considered
in the Cochrane collaboration, based on the following as treatment.
stages: 1) Elaboration and registration of the systematic
review protocol; 2) Delimitation of the guiding question; Eligibility criteria
3) Definition of the eligibility criteria; 4) Search and
selection of studies; 5) Data collection; and 6) Synthesis The materials included were randomized controlled
and presentation of the systematic review results (11)
. clinical trials that evaluated the effects of using educational
The Preferred Reporting Items for Systematic Review technologies in the prevention and treatment of diabetic
and Meta-Analysis Protocols (PRISMA) guidelines were ulcers in patients with diabetes mellitus, without any time
adopted to draft the systematic review and meta- or language restrictions. The exclusion criteria were as
analysis report (12)
. follows: course completion papers, monographs, book
The review protocol was registered in the chapters and materials that did not answer the guiding
International Prospective Register of Systematic Reviews question. It is emphasized that randomized controlled
(PROSPERO), under number CRD42021287241(13). clinical trials do not usually include the Gray Literature,
that is, the one consisting of course conclusion papers,
Locus monographs and book chapters, representing an exclusion
criterion in this study.
The systematic review and meta-analysis was
conducted in Teresina, capital city of Piauí, Brazil. Bibliographic survey and search strategy

Period For the bibliographic survey, databases, a

bibliographic index and an electronic library were
The systematic review and meta-analysis took place consulted, namely: Medical Literature Analysis and
from January to October 2022. Retrieval System on-line (MEDLINE via PubMed ®);
Cumulative Index to Nursing and Allied Health Literature
Research question (CINAHL-EBSCO); Web of ScienceTM; Scopus; Embase;
Cochrane Central Register of Controlled Trials (CENTRAL
Formulation of the research question was delimited Cochrane); Base de Dados em Enfermagem (BDENF); the
based on the PICOS acronym (P: Population or Patients; Literatura Latino-Americana e do Caribe em Ciências da
I: Intervention; C: Comparison; O: Outcomes; S: Study Saúde (LILACS) bibliographic index, via Biblioteca Virtual
design), where P=Population (patients with diabetes em Saúde (BVS); and the Scientific Electronic Library
mellitus), I=Intervention (educational technologies); Online (SciELO) library. The searches were carried out on
C=Comparison (Control Group without receiving the the Journals Portal of Coordenação de Aperfeiçoamento
intervention through educational technologies or de Pessoal de Nível Superior (CAPES), through access
receiving usual care), O=Outcomes (reduction in the to the Comunidade Acadêmica Federada (CAFe) of the
incidence of ulcerations and diabetic ulcer complications) Federal University of Piauí.
and S=Study design (randomized controlled clinical The search strategies were developed by combining
trials)(14). In the comparison group, usual care consisted controlled descriptors and keywords, using the “OR” and
of the routine assistance offered by the service, “AND” Boolean operators according to the particularities
such as consultations, verbal guidelines, clinical foot of each database, index or library. In this sense, the
examination and use of therapeutic shoes. Delays in Medical Subject Headings (MeSH) controlled vocabulary
the healing process, presence of infections and lower was consulted to select the search terms in the MEDLINE
limb amputations were considered as diabetic ulcer via PubMed®, Web of ScienceTM, Scopus and CENTRAL
complications. The expected outcomes were reduction Cochrane databases, based on the following search
of ulceration and amputation in the lower limbs, in strategy: ((((“diabetes mellitus”[MeSH Terms]) OR
addition to improvement in diabetic ulcer healing. Thus, (“diabetes”[All Fields])) AND ((((((((((“educational

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4 Rev. Latino-Am. Enfermagem 2023;31:e3945.

technology”[MeSH Terms]) OR (“instructional Subsequently, a manual search was performed in

technology”[All Fields])) OR (“multimedia”[MeSH the references of the studies included. The Rayyan app
Terms])) OR (“health education”[MeSH Terms])) OR was used to store, organize and remove duplicates and to
(“educational intervention”[All Fields])) OR (“education, blindly select the studies(15). It is noted that the Rayyan
distance”[MeSH Terms])) OR (“communications app version used was the free one. In addition to that,
media”[MeSH Terms])) OR (“instructional film and the team of reviewers underwent prior training to learn
video”[All Fields])) OR (“audiovisual aids”[MeSH how to use this tool in selection of the studies. Search
Terms])) OR (“teaching materials”[MeSH Terms]))) AND and selection of the studies were carried out from January
(((((“foot ulcer”[MeSH Terms]) OR (“plantar ulcer”[All to May 2022.
Fields])) OR (“diabetic foot”[MeSH Terms])) OR (“foot
ulceration”[All Fields])) OR (“foot ulcer diabetic”[All Data collection
Fields]))) AND ((((((“clinical trial”[Publication Type])
OR (“clinical trial”[All Fields])) OR (“controlled clinical Data extraction was by means of a form prepared by
trial”[Publication Type])) OR (“controlled clinical trial”[All the authors of this review, containing the following items:
Fields])) OR (“randomized controlled trial”[Publication authors; title of the study; year of publication; study locus;
Type])) OR (“randomized controlled trial”[All Fields])). population and sample; information about the method;
In the other databases, bibliographic index and randomization; blinding; statistical analysis; follow-up
electronic library, the search strategies used were time; type and classification of the educational technology;
similar, and the CINAHL Headings controlled vocabulary intervention group; control group; main results; and
was used in CINAHL-EBSCO, Emtree in Embase and the conclusion. Data collection was carried out independently
Descriptors in Health Sciences (Descritores em Ciências by two reviewers, from June to August 2022. In relation
da Saúde, DeCS) in BDENF, LILACS and SciELO. The to the items and/or divergent information, meetings were
keywords were selected from the suggestions of the scheduled between the reviewers to discuss and resolve
controlled vocabularies and thorough prior in-depth the discordant aspects until reaching consensus.
readings on the theme.
In order to contemplate the Gray Literature, Data treatment and analysis
secondary searches were carried out in the following
sources: clinical trial registry websites, such as To assess the risk of bias in the randomized
ClinicalTrials.gov (National Institutes of Health, NIH, controlled clinical trials, we used the Revised Cochrane
USA) and The Brazilian Clinical Trials Registry (via the risk-of-bias tool for randomized trials (RoB 2), proposed
ReBEC Platform), the CAPES theses and dissertations by the Cochrane collaboration, which has five domains:
catalog, the University of São Paulo (USP) digital theses bias arising from the randomization process; bias due
and dissertations library portal and the DART-Europe to deviations from intended intervention; bias due to
E-Theses Portal. In addition to that, the lists of final missing outcome data; bias in measurement of the
references of the randomized controlled trials included outcome; and bias in selection of the reported result(16).
were manually analyzed in order to find important studies This evaluation was performed by two independent
to be added. reviewers. The doubts were discussed at the meetings,
Selection of the studies was initially developed seeking consensus.
by two reviewers, independently and blindly, following The synthesis of the results was performed
the stages indicated in the Preferred Reporting Items descriptively and through meta-analysis. Thus, when
for Systematic Reviews and Meta-Analyses (PRISMA) performing the meta-analyses, the randomized controlled
2020 statement, namely: identification, screening and clinical trials were grouped into incidence of diabetic ulcers
inclusion(12). The first step was to read the titles and and lower limb amputations. The meta-analysis analysis
abstracts. After applying the inclusion and exclusion model used was the random effect, performed using the
criteria, the studies were eligible for the next stage, Review Manager (RevMan) software, version 5.3, from
which consisted in reading the full-texts. The inclusion the Cochrane collaboration.
and exclusion criteria were applied again to reach The quality of the evidence assessment was
the review sample. It is noted that, in the selection elaborated according to the Grading of Recommendations
stage, there was disagreement between both reviewers Assessment, Development and Evaluation Working Group
regarding the inclusion of 12 studies; therefore, a third (GRADE)(17). The evaluation was performed for each
reviewer was called upon. outcome analyzed. In the meta-analysis, the outcomes

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 Lira JAC, Rocha ASC, Bezerra SMG, Nogueira PC, Santos AMR, Nogueira LT. 5

evaluated were the incidence values of diabetic ulcers Results

and lower limb amputations regarding use of educational
technologies. Certainty of the evidence can be assessed The bibliographic survey identified 2,984 studies: 298
as high (strong confidence that the true effect is close in the databases, bibliographic index and electronic library
to the estimated one), moderate (moderate confidence and 2,686 in the Gray Literature. After removing the
in the estimated effect), low (limited confidence in duplicates and applying the eligibility criteria, the sample
the estimate of the effect) and very low (very limited resulted in 11 randomized controlled clinical trials(19-29).
confidence in the estimate of the effect). The certainty Figure 1 presents the detailed flowchart corresponding
of the evidence assessment was performed using the to the selection process of the studies included in the
GRADEpro software .
(18)
systematic literature review.

Identification of studies in databases, bibliographic index Identification of studies

and electronic library through other methods

Studies identified: n=298 Studies identified: n=2,686

LILACS: n=2 ClinicalTrials.gov: n=731
Studies removed before
BDENF: n=1 Dart-Europe: n=25
screening for being
Identification

MEDLINE via PubMed: n=54 The Brazilian Clinical Trials Registry: n=87
duplicates: n=79
Web of Science: n=5 CAPES catalog of theses and
Scopus: n=43 dissertations: n=1,819
Embase: n=162 USP digital library portal of theses and
Cochrane: n=19 dissertations: n=18
CINAHL: n=9 References of the clinical trials
SciELO: n=3 included: n=6

Studies excluded after

reading titles and abstracts:
(n=206) Studies excluded after reading titles
Studies submitted to reading
Reasons for exclusion: and abstracts: n=2,654
titles and abstracts: n=219
Did not answer the guiding Reasons for exclusion:
question: n=130 Reports not completed: n=72
Not randomized controlled Did not answer the guiding question:
clinical trials: n=76 n=1,789
Screening

Not randomized controlled clinical

trials: n=793
Studies eligible for full-text
reading: n=13
Studies excluded after full-text
reading: n=4
Reasons for exclusion: Studies eligible for full-text
Did not answer the guiding reading: n=32
question: n=2 Studies excluded after full-text
Not randomized controlled reading: n=28
Studies included in the clinical trials: n=2 Reasons for exclusion:
databases, index and library: Reports not completed: n=8
Inclusion

n=9 Did not answer the guiding

Studies included through question: n=18
other methods: n=2 Studies removed for Not randomized controlled
Sample: n=11 being duplicates: n=2 clinical trials: n=2

Figure 1 - Flowchart corresponding to the selection process of the randomized controlled clinical trials included in the
systematic review, adapted from the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA).
Teresina, PI, Brazil, 2022

The randomized controlled clinical trials included a and the United States(22-23), with two studies each. The year
total of 3,115 participants . In relation to the loci of the
(19-29)
of publication varied from 2000 to 2020 and the follow-up
studies, there was prevalence of Brazil(19,27), Norway(21,28) time, from one to 24 months. 23 soft-hard technologies,

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6 Rev. Latino-Am. Enfermagem 2023;31:e3945.

16 hard technologies and one soft technology were identified that, in five studies, the control groups did not receive any
in the intervention groups. The predominant educational intervention through any educational technology(19,21,27-29).
technologies were training sessions in six studies(21,23-24,26,28-29) The descriptive synthesis of the randomized controlled
and verbal guidelines, in five . It was evidenced
(19-20,22,25-26)
clinical trials included is presented in Figure 2.

IG*/Type of educational
Authors, year Sample/ Follow-up IG†/Type of technology
technology (technology Main results
and locus time (technology classification)
classification)

Incidence of ulcerations:
n=21/Verbal guidance through n=14/Assistance routine IG*: I‡=38.1% (8/21)
Cisneros
discussion of topics related to offered by the service (did CG†: I‡=57.1% (8/14)
(2010)(19), n=35/24 months
foot complications (soft-hard) and not use any educational Recurrence of ulcerations:
Brazil
educational games (soft-hard). technology). IG*: I‡=16.7% (1/8)
CG†: I‡=83.3% (5/8)

n=958/Usual foot care, Foot self-care:

which included a practical The attitudes toward foot care
Donohoe, n=981/Standardized leaflets
visit (soft-hard) and an increased in both groups (IG*=3%;
et al. (2000)(20), n=1,939/six months (soft-hard) and structured verbal
educational intervention p<0.001 and CG†=1.8%; p<0.001) with
England guidance (soft-hard).
on diabetic nephropathy no significant difference in the change
(soft-hard). between the groups (p=0.26).

Healing of diabetic ulcers:

82.1% of the patients had ulcer healing
n=94/Telemedicine app (hard) at 12 months in the IG*, and 76.9% in
n=88/Standard care
and mobile phone for guidance the CG†. There was no difference in
provided by the outpatient
Iversen, et al. and communication between the healing time between the groups.
service, usually scheduled
(2020)(21), n=182/12 months nurses from Primary Health Care Incidence of amputations:
to occur every two weeks
Norway and the specialized service (hard) IG*: I‡=5.1% (4/94)
(did not use any educational
and theoretical-practical training CG†: I‡=14.1% (11/88)
technology).
(soft-hard). Satisfaction:
Satisfaction was similar for the IG* and
the CG†.

Incidence of diabetic ulcers:

IG*: I‡=2.4% (1/41)
CG†: I‡=15.9% (7/44)
Incidence of amputations:
n=41/Diabetic foot education
n=44/Usual care, such as IG*: I‡=0% (0/41)
Lavery, et al. through verbal guidance (soft-
diabetic foot education CG†: I‡=4.5% (2/44)
(2004)(22), N=85/six months hard), therapeutic shoes (hard),
(soft-hard) and therapeutic Complications:
United States log book (hard) and portable
footwear (hard). There were 20% (n=9) of
infrared skin thermometer (hard).
complications in the feet of the
patients from the CG† and 2% (n=1)
of complications in those from the
IG* (p=0.01).

n=59/Enhanced therapy:
educational video (soft-hard), use
of a digital infrared thermometer
n=58/Standard therapy: Incidence of diabetic ulcers:
(hard), evaluation of the lower
evaluation of the lower limbs IG* (enhanced therapy): I‡=8.5% (5/59)
Lavery, et al. limbs (soft-hard), therapeutic
(soft-hard), educational IG* (structured foot exam): I‡=30.4%
(2007)(23), n=173/15 months insoles and shoes (hard) and
video (soft-hard), therapeutic (17/56)
United States logbook (hard).
insoles and shoes (hard) CG† (standard therapy):
n=56/Structured foot examination:
and logbook (hard). I‡=29.3% (17/58)
training for foot inspection (soft-
hard), mirror (hard) and recording
in a logbook (hard).

Incidence of ulcerations:
IG*: I‡=0% (0/31)
CG†: I‡=24.1% (7/31)
n=31/Diabetes education lecture
n=31/Usual care, which Incidence of amputations:
Liang, et al. (soft-hard), training sessions
consisted of two hours of IG*: I‡=0% (0/31)
(2012)(24), n=62/24 months through hands-on workshops
diabetes education (soft- CG†: I‡=6.9% (2/31)
China (soft-hard), skills exercises (soft-
hard). Foot self-care:
hard) and foot care kit (hard).
There was a significant difference in
knowledge and foot care in the IG*
participants (p<0.05).

(continues on the next page...)

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 Lira JAC, Rocha ASC, Bezerra SMG, Nogueira PC, Santos AMR, Nogueira LT. 7

(continuation...)

IG*/Type of educational
Authors, year Sample/ Follow-up IG†/Type of technology
technology (technology Main results
and locus time (technology classification)
classification)

Incidence of ulcerations:
IG*: I‡=41% (36/87)
n=87/Leaflets (soft-hard),
CG†: I‡=41% (35/85)
handouts (soft-hard), illustrations
Incidence of amputations:
Lincoln, (soft-hard), unstructured verbal n=85/Leaflets (soft-hard)
IG*: I‡=10% (9/87)
et al. (2008)(25), n=172/12 months guidelines in home visits (soft) and unstructured and timely
CG†: I‡=11% (9/85)
United Kingdom and structured education, education (soft).
Foot self-care:
according to demand and by
The IG* presented an apparent
telephone (hard).
improvement in some foot care
aspects.

Incidence of ulcerations:
IG*: I‡=0% (0/60)
n=60/Verbal guidelines on foot
n=60/Leaflet with some CG†: I‡=10% (6/60)
ulcer risk factors (soft-hard)
recommendations for Incidence of amputations:
Monami, et al. and training through interactive
n=120/six months the prevention of ulcers, IG*: I‡=0%
(2015)(26), Italy practice with actions to reduce
according to local guidelines CG†: I‡=0%
the foot ulcer risk factors
(soft-hard). There was an improvement in
(soft-hard).
the patients’ knowledge after the
intervention (p<0.001).

Reduced risk of foot complications:

n=55/Illustrative and didactic After 15 days of the intervention, there
folder (soft-hard), visual n=54/Usual care, which was statistical significance in relation
Moreira, demonstrations (soft-hard), consisted of routine care in to tissue injury, hairiness, hydration,
et al. (2020)(27), n=109/one month templates (hard), serial album the unit, with routine clinical perspiration, skin peeling, color after
Brazil. (soft-hard), image projections follow-up (did not use any ten seconds of elevation, tissue
(hard) and playful drawings educational technology). perfusion, pedal and tibial pulses,
(soft-hard). edema, neuropathic symptoms and
plantar pressure.

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
n=88/Outpatient 3.4 and 3.8 months in the IG* and CG†,
appointments every two respectively.
Smith-Strom, n=94/Telemedicine app (hard),
weeks and, if necessary, Incidence of amputations:
et al. (2018)(28), n=182/12 months cell phone (hard) and theoretical-
additional monitoring (did IG*: I‡=6.4% (6/94)
Western Norway practical training (soft-hard).
not use any educational CG†: I‡=14.8% (13/88)
technology). Patients’ satisfaction levels:
Most of the patients in both groups
reported high satisfaction with
treatment and monitoring, with no
differences between the groups.

n=27/Skills training and

motivational interview, which
Healing of diabetic ulcers:
consisted of 50-minute sessions
The mean ulcer size in the IG*
per week for three months and
Subrata, et al. n=29/Usual care in diabetes decreased over time when compared
addressed the following topics:
(2020)(29), n=56/three months (did not use any educational to the CG†. Although not healing
physical activity, medications,
Indonesia technology). completely, the difference in ulcer size
foot care, glycemic control,
reduction was statistically significant
strengthening responsibilities,
between both groups (p<0.001).
establishing roles and active
involvement in care (soft-hard).

*IG = Intervention Group; †CG = Control Group; ‡I = Incidence

Figure 2 – Synthesis of the randomized controlled clinical trials included (n=11). Teresina, PI, Brazil, 2022

Figure 3 describes the risk of bias assessment 11 randomized controlled clinical trials included in the
using the RoB 2 tool, performed by domains for the systematic review.

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8 Rev. Latino-Am. Enfermagem 2023;31:e3945.

Note: Figure generated in the Robvis tool app (2022)

Figure 3 – Risk of bias assessment of the randomized controlled clinical trials in each domain of the Revised Cochrane
risk-of-bias tool for randomized trials (RoB 2). Teresina, PI, Brazil, 2022

Of the 11 randomized controlled clinical trials, randomization process, as randomization was performed
27.3% (n=3) presented low risk of bias, 9.1% (n=1) had but there are no details of the process in the method.
uncertain risk of bias, and 63.6% (n=7) were categorized One study(29) presented some concern in the bias domain
as with high risk of bias. Seven studies (21-24,26,28-29)
due to deviations from the designated interventions, as it
were evaluated as with high risk in the bias domain in did not clearly specify whether there was blinding of the
measurement of the results, as there was no blinding professionals who applied the intervention.
of the outcome evaluators. Four studies(21,24,26,28) had a In the meta-analysis, only randomized controlled
high risk in the bias domain due to deviations from the clinical trials with similar characteristics were included,
designated interventions, as a result of lack of blinding with regard to the interventions employed, in which the
of the participants and the professionals who applied effects of the educational technologies were evaluated
the intervention. One study(25) was classified as having by the development of diabetic ulcers and lower limb
uncertain risk of bias, as it does not specify whether amputations in the intervention and control groups.
there was blinding of the evaluators. One study(24) has The Relative Risk (RR) was described in the last column
some concern in the domain bias resulting from the of the forest plot, as shown in Figure 4.

(A.1) Educational technologies versus usual care for the prevention of diabetic ulcers

* *

(continues on the next page...)

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 Lira JAC, Rocha ASC, Bezerra SMG, Nogueira PC, Santos AMR, Nogueira LT. 9

(continuation...)
(A.2) Educational technologies versus usual care for the prevention of lower limb amputations

* *

Note: Graphs generated in the RevMan statistical program. *CI = Confidence Interval

Figure 4 - Forest plots of the meta-analyses addressing the educational technologies versus usual care for the prevention
of diabetic ulcers and lower limb amputations. Teresina, PI, Brazil, 2022

In Figure 4 A.1, the meta-analysis, with six studies the studies as substantial (I 2=70%). In contrast,
included (19,22-26)
, which compared the educational in Figure 4 A.2, heterogeneity was indicated as not
technologies with usual care, evidenced that the use of important (I2=0%).
educational technologies presented a protective factor Table 1 presents the certainty assessment of the
for preventing the incidence of diabetic ulcers (RR=0.40; meta-analyses evidence according to the GRADE criteria.
95% CI=0.18-0.90; p=0.03). In Figure 4 A.2, the meta- The estimated effect of the educational technologies for
analysis, also with six studies(21-22,24-26,28), indicates that the preventing the incidence of diabetic ulcers was RR=0.40,
educational technologies have a protective factor to prevent when compared to usual care, with low certainty of
the incidence of lower limb amputations, when compared the evidence. The estimated effect of the educational
to usual care (RR=0.53; 95% CI=0.31-0.90; p=0.02). technologies to prevent the incidence of lower limb
In Figure 4 A.1, the Higgins inconsistency amputations was RR=0.53, when compared to usual care,
statistical test (I ) classified heterogeneity across
2
presenting very low certainty of the evidence.

Table 1 - Synthesis of the certainty of the evidence assessment, according to the Grading of Recommendations
Assessment, Development and Evaluation (GRADE). Teresina, PI, Brazil, 2022

Certainty of the evidence Number of patients Effect

Number of Type of Risk of Indirect Other Educational Usual Relative Absolute

Inconsistency Imprecision Certainty
studies study bias evidence considerations technology care (95% CI*) (95% CI*)

Incidence of diabetic ulcers/Educational technology versus usual care (follow-up: range from 6 months to 2 years)

164 less
RRǁ = 0.40 per 1,000
Not 50/299 80/292 ⨁⨁◯◯
6 RCT†† Severe‡ Severe§ Not severe None (from 0.18 (from 225
severe (16.7%) (27.4%) Low
to 0.90) less to 27
less)

Incidence of lower limb amputations/Educational technology versus usual care (follow-up: range from 6 months to 2 years)

52 less per
RRǁ = 0.53
Very Not 19/347 37/336 1,000 (from ⨁◯◯◯
5 RCT ††
Not severe Severe** None (from 0.31
severe¶ severe (5.5%) (11%) 76 less to Very low
to 0.90)
11 less)
Note: Prepared in and extracted from the GRADEpro software
*CI = Confidence Interval; †RCT = Randomized Clinical Trial; ‡The reason is that four studies present high risk of bias, with a weight of 45.4%; §The reason for
the assessment is that the Higgins inconsistency test (I²=70%) indicated substantial heterogeneity across the studies; ǁRR = Relative Risk; ¶The reason for the
assessment is that four studies present high risk of bias, with a weight of 62.9%; **The reason for the assessment is that the effect estimate varies greatly

Discussion sessions through workshops and interactive practice,

educational videos, illustrative and didactic folders, serial
This study analyzed the effects of educational albums and playful drawings, and hard technologies
technologies on the prevention and treatment of such as therapeutic footwear, insoles, digital infrared
diabetic ulcers, and the results evidenced that soft- thermometer and foot care kits, contributed to reducing
hard educational technologies such as structured both the incidence of diabetic ulcers(19,22-24,26) and the
verbal guidelines, educational games, lectures, training risk of foot complications(27). In addition to that, the

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10 Rev. Latino-Am. Enfermagem 2023;31:e3945.

theoretical-practical training sessions, which are soft-hard technologies improved diabetic ulcer healing and reduced
technologies, and the Telemedicine apps and mobile phone the number of amputations, as 82.1% of the patients in the
use, which are classified as hard technologies, improved Intervention Group presented ulcer healing in 12 months,
diabetic ulcer healing and reduced the incidence of lower with 5.1% incidence of amputations in the Intervention
limb amputations in the intervention groups(21,28). Group and 14.1% in the Control Group. In addition
Educational technologies consist of knowledge to that, this intervention increased the confidence of
enriched by human action, and are not merely about the Primary Health Care nurses, who improved their skills in
construction and use of devices; they involve a systematic treating wounds, enabling a more comprehensive care
set of diverse scientific knowledge that enables planning, for diabetic ulcers(21).
execution, control and monitoring of the educational The incidence of diabetic ulcers was estimated in
process(30). From this perspective, the particularities of the six randomized controlled clinical trials(19,22-26). Based on
educational technologies explain the prevalence of soft- the meta-analysis, it was evidenced that the educational
hard and hard technologies in the randomized controlled technologies presented a protective factor for preventing
clinical trials included in this systematic review. the incidence of diabetic ulcers, emphasizing the
It was evidenced that eight randomized controlled importance of using these resources in the assistance
clinical trials (19-20,22-27)
used soft-hard and/or hard provided to patients with diabetes mellitus. In a
educational technologies for the prevention of diabetic prospective cohort study, the cumulative incidence of
ulcers, which were effective in reducing the incidence of diabetic ulcers was 5.6% in two years, with the following
ulcerations in five studies(19,22-24,26). On the other hand, risk factors for ulcerations: previous history of ulcerations
three randomized controlled clinical trials (21,28-29)
used or amputations, insulin consumption, distal neuropathy
soft-hard and/or hard educational technologies in the and foot deformity(31). This emphasizes the need for care
treatment of diabetic ulcers, of which two (21,28)
found a continuity to control the risk factors and for educational
considerable effect and recorded a higher percentage of technologies aimed at preventing complications in patients
total diabetic ulcer healing. with diabetes mellitus.
The soft-hard educational technologies were the most In this meta-analysis, the home-based educational
used in the prevention and treatment of diabetic ulcers in session conducted in the United Kingdom with illustrations
the intervention groups. Thus, a randomized controlled of injuries on the feet and a handout, classified as soft-
clinical trial carried out in Brazil, which used soft-hard hard technologies, did not present any statistically
technology, found that the implementation of educational significant difference between the intervention and
technologies through a focus group and educational games control groups regarding the prevention of diabetic
addressing foot complications reduced the incidence of ulcer incidence; however, there was an improvement in
ulcerations and the recurrence of diabetic ulcers in the foot care behaviors in the Intervention Group in relation
Intervention Group(19). In Italy, a randomized controlled to checking the shoes before wearing them, daily foot
clinical trial, which in its Intervention Group used verbal washing and use of moisturizing creams(25). On the other
guidelines on the risk factors for foot ulcerations and hand, a randomized controlled clinical trial carried out in
interactive practice, classified as soft-hard technologies, the United States, which used enhanced therapy through
presented a significant effect in reducing the incidence of educational video (soft-hard technology) associated
diabetic ulcers, as the Intervention Group had an incidence with the use of therapeutic insoles and shoes (hard
of 0% and the Control Group, 10%. In addition, they technologies), foot reevaluation (soft-hard technology)
contributed to lowering the Body Mass Index and glycated and use of a portable infrared thermometer to measure
hemoglobin, reinforcing that brief and low-cost educational foot temperature (hard technology), identified a
technologies can reduce the incidence of foot ulcerations protective effect of this intervention for the prevention
in patients with diabetes mellitus, in addition to being of diabetic ulcers, as there was a four-fold decrease in
more likely to be applied in the routine clinical practice .
(26)
the risk of developing foot ulcers, with 29.3% incidence
Through a theoretical-practical approach, of ulcerations in the usual care group and 8.5% in the
workshops and interactive practice, classified as soft- enhanced therapy group(23).
hard technologies, the training sessions proved to be In China, through lectures, practical workshops and
effective in the prevention and treatment of diabetic ulcers skills exercises, which are soft-hard technologies, and the
and were the most prevalent educational technologies in distribution of foot care kits, which included nail clippers,
six studies . In Norway, through theoretical-
(21,23-24,26,28-29)
foot cream, mono-filament 10 g, thermometer to measure
practical training and Telemedicine, respectively classified temperature of the water to wash the feet, pieces of
as soft-hard and hard technologies, the educational cotton with alcohol and a mirror, which correspond to

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 Lira JAC, Rocha ASC, Bezerra SMG, Nogueira PC, Santos AMR, Nogueira LT. 11

the hard technologies, the educational technologies had through a 30-minute face-to-face class and a 90-minute
a significant effect in preventing the incidence of diabetic interactive practice on risk behaviors did not record
ulcers and amputations, in addition to the participants the incidence of amputations between the control and
increasing their knowledge and foot care. Furthermore, intervention groups, which can be justified due to the
the patients in the Control Group were nearly 24 times brief 6-month follow-up period(26).
more likely to develop foot ulcers. This educational Non-traumatic lower limb amputations are recurrent
program asked the patients to perform daily foot care complications in patients with diabetes mellitus,
with the help of a mirror for foot inspection and invited at generate increased costs for health services, extend the
least one family member to participate in the classes and hospitalization times, reduce quality of life, exert impacts
help the patients, which ensured more effective home- on mental health and affect the patients’ productive lives.
based foot care(24). Thus, foot care management, which includes health
Foot complications increase the likelihood of education, should value holistic care, accessibility, loyalty
ulcerations, infections and amputations in people with and care longitudinality. In this assumption, an education
diabetes mellitus. In this sense, a randomized controlled and continuous foot care treatment program in Spain
clinical trial, whose intervention consisted of verbal detected that, of the total of 33 diabetic ulcers, 17 evolved
guidelines, which are soft-hard technologies, use of to amputation and 16 were in patients who did not adhere
therapeutic shoes and an infrared thermometer, which are to the program(33).
hard technologies, found that the patients in the Control In this perspective, diabetic foot complications
Group had 10.3% more risks of developing some foot are a public health problem due to the increase in the
complication, with no statistical difference in terms of number of patients with diabetes mellitus, the increased
quality of life between the groups. In addition to that, the life expectancy of the population and the growth of
Control Group had seven ulcers and two Charcot fractures, associated comorbidities. However, the expansion of the
with two patients developing infection and requiring assistance provided, which includes both early intervention
amputation, whereas the Intervention Group had one in patients with diabetic ulcers to avoid gangrene and
ulcer and no amputations, highlighting that home-based appropriate treatments such as performing the necessary
self-monitoring of daily foot temperature, associated with vascular procedures and mandatory education on foot
health education and use of appropriate footwear, is an care, can lead to a reduction in the number of lower
adjuvant tool for the prevention of diabetic ulcers and limb amputations(34).
foot amputations(22). Three randomized controlled clinical trials addressed
In a systematic review with meta-analysis, the effect of educational technologies on diabetic ulcer
thermometry had a protective effect when compared to healing(21,28-29). Although the educational technologies
standard toe care to prevent the incidence of diabetic employed, which were soft-hard and hard, did not exert
ulcers (RR=0.53; 95% CI=0.29-0.96; p=0.03), and the any statistically significant effect on reducing the ulcer
authors encourage managers, public health services, healing times(21,28), there was a reduction in the size of
professionals, patients, family members and caregivers to the ulcers(29), with 82.1% of the patients presenting ulcer
implement this preventive technique by monitoring plantar healing in the Intervention Group and 76.9% in the Control
temperature using infrared thermometers, both in the Group at 12 months. This reinforces that educational
clinical and home contexts . In this systematic review
(32)
technologies should also be used in the diabetic ulcer
and meta-analysis, two randomized controlled clinical treatment stage(21).
trials used thermometry associated with educational The effect of educational technologies on foot self-
interventions(22-23), which may have enhanced the effect care was verified in four randomized controlled clinical
of the educational technologies for the prevention of trials(20,24-25,27). Even without significant differences in
diabetic ulcers. behavioral changes (p=0.26), the attitudes regarding
The incidence of lower limb amputations was foot self-care increased in both groups(20). In addition
estimated in six randomized controlled clinical trials and, in to that, an educational intervention for foot self-care,
the meta-analysis, the educational technologies presented through an operative group which used soft-hard and
a protection factor to prevent amputations(21-22,24-26,28). hard technologies, had a significant effect in the treatment
In a randomized controlled clinical trial, which employed group after seven days (p<0.001) and 15 days (p<0.001),
Telemedicine in the community, classified as a hard when compared to the Control Group, in relation to
technology, the incidence of amputations was 6.4% in the the reduction of the risks for foot complications, such
Intervention Group and 14.8% in the Control Group(28). as an improvement in the preservation of the skin and
However, a study that used soft-hard technologies annexes, tissue perfusion, pulses, edema and plantar

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12 Rev. Latino-Am. Enfermagem 2023;31:e3945.

pressure distribution. This evidences that systematized clinical trials on the effects of educational technologies
educational interventions with brief follow-up periods are on the treatment and incidence of diabetic ulcers stands
also effective(27). out, in addition to the number of studies with a high
Thus, to enhance the effect, health education should risk of bias, which contributed to the lower certainty of
reduce language barriers and involve the patients in their the evidence.
own care plan to raise awareness about the disease and The results of this systematic review may contribute
prevent complications, as most patients are unaware of to expanding the use of educational technologies in the
the severity of these complications and follow negligent care of patients with diabetes mellitus. In addition to that,
practices in the long term, due to low education and risky this scientific evidence will assist health professionals
cultural practices. Despite the challenges, health education in choosing the most assertive type of educational
is a responsibility of professionals, who must use every technology for the prevention and treatment of diabetic
opportunity to provide specific education, even combining ulcers in the clinical practice.
the types of educational technologies available, with the
objective of improving the skills of patients with diabetes Conclusion
mellitus in foot self-care(35).
An integrated care project, which included timely Soft-hard educational technologies such as structured
referral, weekly virtual clinic, healthy lifestyle support, verbal guidelines, educational games, lectures, training
community nurse training, app delivery and personalized through workshops and interactive practice, educational
educational support, increased engagement in education video, illustrative and didactic folders, serial albums and
from 5% to 71% of those newly diagnosed with diabetes playful drawings, and hard technologies such as therapeutic
mellitus, in addition to reducing the incidence of major footwear, insoles, digital infrared thermometer and foot
amputations from 13 to three procedures per 10,000 care kits, exerted a positive effect on the prevention
patients a year and of minor amputations from 26 to 18 of diabetic ulcers and helped reduce the incidence of
procedures per 10,000 patients a year. This care model ulcerations and the risk of foot complications, in addition
also significantly reduced the daily occupation of beds to enabling improvements in foot care. In relation to
by people with diabetes mellitus in a district general the treatment, both the soft-hard technologies through
hospital(36). In line with this systematic review, when theoretical-practical training sessions, and the soft
associated with better structuring of the care network and technologies such as Telemedicine apps and use of mobile
professional training, educational technologies are more phones, contributed to the evolution of diabetic ulcer
effective in reducing foot amputations and hospitalization healing, standing out as useful strategies in foot care
due to complications arising from diabetes mellitus. management in patients with diabetes mellitus.
Regarding the satisfaction levels provided by the The meta-analysis results indicated that the
educational technologies, both randomized controlled educational technologies presented a protective factor
clinical trials that evaluated this outcome concluded that for preventing the incidence of diabetic ulcers, with
there was no statistically significant difference between substantial heterogeneity across the studies and a low
the intervention and control groups (21,28)
. However, the certainty of the evidence assessment, highlighting that,
concern with satisfaction in the development of educational in further research studies, there may be a change in the
technologies is essential, as it influences the participants’ estimate of the effect. In addition to that, the educational
adherence to the intervention proposed. technologies had a protective factor to prevent the
The randomized controlled clinical trials included did incidence of lower limb amputations, when compared to
not measure the costs of the educational technologies for usual care. Heterogeneity was indicated as not important,
the prevention and treatment of diabetic ulcers. Thus, and certainty of the evidence was assessed as very low.
the studies pointed out the need to carry out surveys In view of this, the use of educational technologies
comparing the costs of the educational and monitoring is recommended, especially soft-hard and hard, in
programs implemented with usual care, as it is expected the prevention and treatment of diabetic ulcers to
that, in the long term, these interventions will present reduce complications such as non-traumatic lower limb
better cost-effectiveness, cost-benefit and cost-efficacy amputations, in addition to conducting more robust and
ratios in preventing foot complications and, consequently, well-designed randomized controlled clinical trials at
reduce expenditure in health services and improve the different care levels for patients with diabetes mellitus,
quality of life of patients with diabetes mellitus .
(22-23,26)
which would later allow developing systematic reviews
In relation to the limitations of this systematic in different care contexts, with a view to reducing the
review, the reduced number of randomized controlled risk of bias and inconsistencies, as well as improving

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 Lira JAC, Rocha ASC, Bezerra SMG, Nogueira PC, Santos AMR, Nogueira LT. 13

homogeneity of the studies and certainty of the evidence, 9. Netten JJ, Raspovic A, Lavery LA, Monteiro-Soares M,
in order to incorporate those educational technologies Rasmussen A, Sacco ICN. Prevention of foot ulcers in
that proved to be effective in foot care. the at-risk patient with diabetes: a systematic review.
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29. Subrata SA, Phuphaibul R, Grey M, Siripitayakunkit A, Carvalho Rocha, Sandra Marina Gonçalves Bezerra, Lídya
Piaseu N. Improving clinical outcomes of diabetic foot Tolstenko Nogueira. Data analysis and interpretation:
ulcers by the 3-month self- and family management Jefferson Abraão Caetano Lira, Álvaro Sepúlveda Carvalho
support programs in Indonesia: A randomized controlled Rocha, Sandra Marina Gonçalves Bezerra, Paula Cristina

www.eerp.usp.br/rlae
 Lira JAC, Rocha ASC, Bezerra SMG, Nogueira PC, Santos AMR, Nogueira LT. 15

Nogueira, Ana Maria Ribeiro dos Santos, Lídya Tolstenko

Nogueira. Statistical analysis: Jefferson Abraão Caetano
Lira. Drafting the manuscript: Jefferson Abraão
Caetano Lira, Álvaro Sepúlveda Carvalho Rocha, Sandra
Marina Gonçalves Bezerra, Paula Cristina Nogueira, Ana
Maria Ribeiro dos Santos, Lídya Tolstenko Nogueira.
Critical review of the manuscript as to its relevant
intellectual content: Jefferson Abraão Caetano Lira,
Sandra Marina Gonçalves Bezerra, Paula Cristina Nogueira,
Ana Maria Ribeiro dos Santos, Lídya Tolstenko Nogueira.

All authors approved the final version of the text.

Conflict of interest: the authors have declared that

there is no conflict of interest.

Received: Dec 7th 2022

Accepted: Apr 8th 2023

Associate Editor:
Maria Lúcia Zanetti

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