Background: Diabetic foot ulcer remains the leading cause of non-traumatic amputations globally. Informal caregivers (persons providing unpaid services at home) can play significant role in patients’ disease management and involving them in self-care interventions could lead to improved diabetic foot outcomes.
Aim: (1) To determine the effects of interventions involving informal caregivers in the prevention and/or management of diabetic foot ulcers in adults and (2) To understand if combinations of intervention components were associated with particular foot ulcer clinical outcomes.
Method: A systematic review based on Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) and Synthesis Without Meta-analysis (SWiM) guidelines was conducted. The protocol was duly registered with the International Prospective Register of Systematic Reviews, PROSPERO, with registration number CRD4202123176. MEDLINE (Ovid), Embase (Ovid), PsycINFO, Cumulative Index of Nursing and Allied Health Literature (CINAHL) and Cochrane Central Register of Controlled Trial of the Cochrane Library databases were searched from inception to 28 February 2021. In addition to keywords optimised for each database, the following MESH terms were used, diabetic foot, foot ulcer, foot disease, diabetes mellitus, caregiver, family caregiver and family. Experimental studies involving persons with diabetes, with or at risk of foot ulcers and their caregivers (dyad) were included. Data was extracted from included studies and narrative synthesis of findings undertaken.
Results: Following the search of databases, 9275 articles were screened and 10 met the inclusion criteria. The review identified that the involvement of informal caregivers in interventions resulted in improved foot care practices, decrease foot ulcer incidence, improved wound healing and decrease HbA1c. Even though not all studies were with controlled groups, the included five Randomised Controlled Trials all indicated that these outcomes were better in the caregiver involved groups compared to no caregiver involvement. Informal caregivers were involved in the programmes as supportive persons, assisting in wound care, daily inspection of feet, using monofilament to check feet sensation and diet/meal planning.
Engaging both caregivers and the person with diabetes in hands-on skills training on wound and/or foot care combined with education were peculiar components of interventions that consistently produced clinically and statistically significant improvement in wound healing and reduction in incidence of foot ulcers. Other key elements of these interventions were follow up telephone calls reminding participants and caregivers to perform foot care and report any foot problems to the clinic after the face-to-face interactions. However, addressing negative and inaccurate beliefs about diabetes through only education over the telephone did not result in significant improvement in foot care and HbA1c.
Discussion: The involvement of informal caregivers strengthened the interventions and resulted in improved foot care practices and favourable diabetic foot clinical outcomes. However, the effects of these interventions differed based on the combination of different intervention elements, and these may need to be considered by researchers and practitioners when planning foot care programmes. Future research may need to assess the characteristics of caregivers and how their involvement may impact on their own health.