Diabetic foot ulcers are among the most disabling and costly complications of diabetes mellitus. Between 19% and 34% of people with diabetes will develop a foot ulcer at some point in their lifetime, and foot ulcers precede the large majority of non-traumatic lower limb amputations.(1) The epidemiology is unevenly distributed: a systematic review and meta-analysis of the global epidemiology of diabetic foot ulceration estimated a pooled prevalence close to 6.3%, with wide variation across regions and study populations.(2) Lower and middle income countries carry a disproportionate share of the amputation burden, in part because neuropathy is detected late and because access to structured foot care is limited.(3) In Nigeria, a two-decade synthesis of diabetic foot ulcer outcomes documented persistently high amputation and mortality rates despite advances in wound care.(4) Beyond mortality and limb loss, ulcers reduce health-related quality of life, prolong hospital stays and consume substantial resources, so prevention remains a clinical and public health priority.

Foot ulceration is largely preventable because most ulcers arise from a recognizable sequence of modifiable events. Peripheral neuropathy abolishes protective sensation, minor trauma from ill-fitting footwear or incorrect nail care goes unnoticed, and delayed care-seeking allows a small lesion to progress.( 5) Daily inspection, appropriate footwear, hygienic nail care and prompt consultation after minor injury are the behaviors that interrupt this sequence, and each of them can be taught. Structured education is therefore a cornerstone of the prevention pathway recommended by the International Working Group on the Diabetic Foot, which has advised, across successive guideline updates, that all people with diabetes receive instruction in foot self-care and that those at increased risk receive integrated foot care education delivered by trained providers.(5,6) The underlying assumption is behavioral: education raises knowledge and self-efficacy, and these constructs in turn sustain the daily behaviors that separate neuropathy from ulceration. This reasoning draws on social cognitive theory, which holds that knowledge alone is rarely sufficient to change a routine behavior and that perceived self-efficacy mediates the translation of information into action. Applied to the diabetic foot, an educational program is expected to teach the person what to inspect, why it matters and when to seek help, and to build the confidence to perform those actions consistently. Whether this chain actually reaches the endpoint of preventing a clinical ulcer is an empirical question rather than a theoretical certainty, and it is the question the present review set out to answer.

The evidence supporting this assumption is less settled than the guideline language suggests. A Cochrane review of patient education for the prevention of diabetic foot ulceration concluded that the available trials were underpowered and produced inconsistent estimates of ulcer incidence.(7) Later syntheses reported improvements in knowledge, self-efficacy and self-care behavior, but they relied heavily on uncontrolled before and after designs, pooled heterogeneous instruments and rarely distinguished behavior change from hard ulcer outcomes.(8-10) A scoping review of education programs to prevent diabetic foot ulcers and an umbrella review of foot care educational interventions reached similar conclusions about the breadth of formats and the weakness of the underlying designs.(11,12) Several of these syntheses are now aging relative to the rapid growth of digital, mobile and community-based education interventions published in the last three years, which have not been incorporated into a single structured synthesis.(13) The field has also shifted in geography: recent primary studies cluster in South and Southeast Asia and in sub-Saharan Africa, where the burden of ulceration and amputation is highest, so an update centered on the current literature is more relevant to those settings than reviews built mainly on trials from high-income countries. These gaps in currency, design coverage and geographic relevance justified a new systematic review.

The present review was undertaken to update and structure this evidence. The objective was to synthesize the evidence on structured foot care education for the prevention of diabetic foot ulcers and for the improvement of foot self-care in people with diabetes, with explicit attention to the designs and settings of the underlying studies. The review addressed the following PICOS question: in people with diabetes at risk of diabetic foot, do structured foot care education interventions, compared with usual care, no education or an alternative educational format, reduce the incidence of diabetic foot ulcers or improve foot self-care?

The main finding of this review is that structured foot care education consistently improves foot care knowledge, self-efficacy and self-care behavior in people with diabetes, whereas evidence that it reduces the incidence of diabetic foot ulcers remains scarce and inconclusive. This pattern was maintained when the analysis was restricted to the five randomized trials, which indicates that the behavioral findings do not depend on the uncontrolled designs that dominate the literature, and it was unchanged when the single observational cohort was considered separately.

The improvement in knowledge and self-care behavior is consistent with earlier syntheses. A systematic review and meta-analysis of foot care education reported pooled improvements in knowledge, self-efficacy and behavior,(10) and an umbrella review reached the same conclusion across educational formats.(12) A systematic review restricted to the impact of education on self-efficacy and self-care likewise documented favorable changes,(9) and a synthesis of health education programs found consistent gains in self-care practices.(35) The present review adds studies published after those syntheses, including digital and community-based interventions, and confirms that the behavioral effect generalizes across low and middle income settings.(11,13) A scoping review of education programs to prevent diabetic foot ulcers likewise catalogued print, digital and blended formats and noted that few studies progressed to ulcer endpoints,(11) which matches the pattern observed here. The agreement across independent syntheses using different search windows and inclusion rules strengthens confidence in the behavioral conclusion, even though the underlying primary studies are individually weak. It also means that the behavioral question is substantially answered and that the unresolved question is not whether education changes what patients know and do, but whether those changes are sufficient to alter the clinical course of the foot. The consistency of the direction across randomized and non-randomized designs is notable for a field in which publication bias toward positive within-group change is plausible, although the high risk of bias in the uncontrolled studies means the magnitude of the behavioral gain is probably overstated.

The behavioral pathway that links education to ulcer prevention is longer than the guideline recommendations imply, and this may explain the divergence between the behavioral and the ulcer findings. Education is designed to raise knowledge, and knowledge is expected to raise self-efficacy, which in turn is expected to sustain daily self-care behaviors. The present review shows that the first two steps of this chain are reliably achieved: knowledge and self-efficacy improved in every study that measured them. The later steps are weaker. Self-care behavior improved in fourteen studies, and the two partial or null results show that knowledge can rise without a corresponding change in adherence and without exceeding an alternative educational format.(28,32) The final step, a reduction in ulceration, additionally requires that the person detect a pre-ulcerative sign and act on it before tissue breakdown, a requirement that education alone may not satisfy. Monitoring interventions that provide an objective feedback signal, such as home skin temperature measurement, convert education into a timed action and have shown effects on ulcer recurrence that education alone has not replicated.( 36) This distinction between teaching and feedback is the most plausible explanation for the null ulcer result and should guide how educational programs are designed. If the active ingredient for ulcer prevention is the prompt to act on an early change rather than the knowledge itself, then programs that end at instruction will predictably improve questionnaires without reducing ulcers, while programs that attach education to a scheduled check or a monitoring device will have a better chance of reaching the clinical endpoint. The evidence assembled here supports that reading, although the comparison has not yet been tested head to head in a single trial.

The null finding for ulcer incidence diverges from the assumptions embedded in clinical guidelines. The single randomized trial included here found no reduction in new ulceration with group education,(20) a result that echoes the Cochrane review, which could not demonstrate a reduction in ulceration from education alone.(7) A randomized trial conducted before this review window similarly reported no reduction in ulcer recurrence with a foot care education intervention among people at high risk.(37) By contrast, self-monitoring interventions that pair education with an objective feedback signal, such as home skin temperature monitoring, reduced ulcer recurrence in a landmark trial,(36) which suggests that education alone may be insufficient without a monitoring component that converts knowledge into a timed action. The observational cohort in this review associated prior education with lower amputation and infection,( 34) a finding that is directionally supportive but vulnerable to confounding, because people who receive education may also differ in health literacy, socioeconomic position and access to care. The successive guideline updates have nonetheless continued to place education at the center of prevention, moving from a general recommendation in the 2019 guidance to a more explicit integration of education with risk stratification in the 2023 update.(5,6) The present review does not contradict that placement, but it clarifies that the guideline rests on behavioral evidence rather than on demonstrated reductions in ulcer incidence, and that the recommendation is best understood as a component of a package rather than a stand-alone intervention.

The heterogeneity of the included studies has identifiable sources. Designs ranged from single-arm pre-post studies to randomized trials, and the risk of bias was high in the majority. Outcome instruments varied from the Modified Diabetic Foot Care Behavior questionnaire to study-specific scales, which prevented pooling. The interventions also differed in dose, format and theoretical basis, from single five-minute sessions to monthly programs sustained over several months, and this variation was rarely described in enough detail to identify the active component. The overrepresentation of studies from Indonesia, India and Pakistan limits direct transferability to other health systems, although the consistency of the behavioral effect across those settings is itself informative. Knowledge and attitude surveys in India and China show that large gaps between knowledge and practice persist even after education,(38,39) and frailty has been associated with lower foot self-efficacy in older adults,( 40) which may explain why several interventions improved knowledge without changing behavior or clinical risk. The high recurrence rates documented within the first year of ulcer remission show why behavioral maintenance, and not only initial knowledge gain, is the relevant target.( 41)

The generalizability of these findings deserves a separate comment. The concentration of studies in Indonesia, India, Pakistan and sub-Saharan Africa means the behavioral effect is best documented in settings where structured podiatry is scarce and where community-based or digital delivery may be the only scalable option.( 13) In those settings, the observed gains are encouraging because they were achieved with low-cost formats such as infographics, leaflets and short face-to-face sessions. At the same time, the evidence cannot be transferred mechanically to high-income systems with different care pathways, where the marginal contribution of education may be smaller because risk stratification and professional foot care are already embedded. The absence of dose-response information is a further barrier: no included study compared different intensities of education directly, so the minimum effective dose remains unknown, and the two studies that delivered the most intensive formats, monthly education( 19) and family-oriented education,( 18) were also among the most favorable, which hints at a dose gradient that future trials should test explicitly.

The strengths and limitations of this review should be read together. The main strengths are the explicit PRISMA 2020 methods, the use of four databases with Scopus as the primary source, a reproducible search string, and a risk of bias assessment that separates randomized from non-randomized evidence. The main limitations follow from the evidence itself. First, most studies were uncontrolled before and after designs at high risk of bias, which weakens causal inference; the recommendation is to prioritize randomized designs with objective endpoints. Second, only two studies measured ulcer incidence, and full text was unavailable for 41 otherwise eligible records because they were not open access; the recommendation is to register the review and to seek author-provided full texts in an update. Third, screening was performed by one reviewer assisted by artificial intelligence rather than two independent reviewers, which may have introduced single-reviewer error; the recommendation is to replicate the selection with a second reviewer. Fourth, the absence of a meta-analysis prevented pooled estimation, and certainty was therefore not formally graded; the recommendation is to standardize outcome instruments and report effect sizes so that quantitative synthesis becomes possible. Fifth, the restriction to publications in English and Spanish may have excluded relevant studies published in Indonesian, Arabic or Chinese, languages in which several of the source journals operate; the recommendation is to relax the language restriction in a future update. Sixth, the bibliographic window of 2018 to 2026 excluded earlier landmark trials, which were consulted only as contextual support rather than as included evidence; the recommendation is to weigh whether an unrestricted window would materially change the ulcer conclusion. None of these limitations changes the central observation that the behavioral evidence is consistent while the ulcer evidence is thin.

The implications for practice follow directly from this pattern. Clinicians and educators can expect foot care education to improve knowledge and self-care behavior, and the low-cost formats identified here, such as infographics, leaflets, short face-to-face sessions and audio-visual materials, are feasible to deliver in primary care and community settings. Clinicians should not, however, assume that education alone prevents ulcers, particularly in people at high risk, for whom education should be combined with risk stratification and structured monitoring of the foot according to the current guideline framework.(5) Health systems that rely on community health workers or mobile delivery should treat education as the entry point of a prevention pathway rather than its endpoint, and they should link it to a mechanism for detecting and responding to early foot changes.(42) For research, trials should report ulcer incidence and time to ulcer as primary outcomes, use validated instruments with published scoring, describe the theoretical basis and dose of the intervention so that effective components can be isolated, and pre-register their protocols to reduce selective reporting. Comparative designs that vary the intensity or the addition of a monitoring component would directly address the dose and feedback questions that this review could not resolve.( 41)

Structured foot care education improves foot care knowledge and self-care behavior in people with diabetes, with a consistent effect across randomized and non-randomized studies. The evidence that education reduces the incidence of diabetic foot ulcers remains limited to one null randomized trial and one observational cohort, and is of low certainty. This pattern was stable across all sensitivity analyses performed. Education should therefore be delivered as one component of a broader prevention strategy that includes risk assessment and structured monitoring, and future trials should measure ulcer incidence directly as the primary outcome.