{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,14]],"date-time":"2026-10-14T06:53:53Z","timestamp":1791960833183,"version":"4.3.4"},"reference-count":34,"publisher":"MDPI AG","issue":"9","license":[{"start":{"date-parts":[[2025,9,13]],"date-time":"2025-09-13T00:00:00Z","timestamp":1757721600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["IJERPH"],"abstract":"<jats:p>Diabetic foot ulcers are among the most severe complications of diabetes mellitus, disproportionately affecting populations in low- and middle-income countries. Digital health technologies have emerged as promising tools for prevention, diagnosis, and management; however, their effectiveness, usability, and applicability within public health systems remain insufficiently defined. This systematic review aimed to critically synthesize the clinical effectiveness, perceived usability, and methodological quality of digital interventions for the care of individuals with diabetes-related foot ulcers. A comprehensive search was performed in PubMed, Scopus, Web of Science, Embase, and Google Scholar for studies published between 2012 and 2024. Eighteen studies met the inclusion criteria, encompassing mobile health applications, wearable sensor devices, artificial intelligence-based tools, and telehealth platforms. Methodological quality was assessed using the Mixed Methods Appraisal Tool. Artificial intelligence-driven approaches demonstrated high diagnostic accuracy, with sensitivity and specificity above 90% for ulcer detection and classification. Mobile applications showed positive effects on self-efficacy, glycemic control, and adherence to preventive foot care, while usability scores were consistently high. Wearable sensor devices demonstrated potential for reducing ulcer recurrence, though supporting evidence remains limited. Across studies, recurrent methodological limitations included small sample sizes, absence of control groups, lack of economic evaluations, and barriers related to digital literacy and interoperability between systems. Most investigations were conducted in high-income countries, with limited consideration of public health contexts such as the Brazilian Unified Health System. In conclusion, digital health technologies show promise in improving the care of individuals with diabetes-related foot complications but face significant challenges regarding scalability, equity of access, and integration into public healthcare systems. Future research should prioritize context-adapted designs, robust clinical trials, and economic evaluations to inform health policies and support the rational adoption of these tools within universal health coverage frameworks. PROSPERO registration number: CRD420251023152.<\/jats:p>","DOI":"10.3390\/ijerph22091430","type":"journal-article","created":{"date-parts":[[2025,9,15]],"date-time":"2025-09-15T07:56:51Z","timestamp":1757923011000},"page":"1430","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":9,"title":["Digital Health Technologies for Diabetic Foot Ulcers: A Systematic Review of Clinical Evidence, Access Inequities, and Public Health Integration"],"prefix":"10.3390","volume":"22","author":[{"given":"Tatiana Cristina","family":"Dias de Oliveira","sequence":"first","affiliation":[{"name":"Graduate Program in Family Health, Federal University of the South and Southeast of Par\u00e1, Maraba 68507-590, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alana Ferreira","family":"de Oliveira","sequence":"additional","affiliation":[{"name":"Graduate Program in Family Health, Federal University of the South and Southeast of Par\u00e1, Maraba 68507-590, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Laila de Castro","family":"Ara\u00fajo","sequence":"additional","affiliation":[{"name":"Graduate Program in Family Health, Federal University of the South and Southeast of Par\u00e1, Maraba 68507-590, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Maria Pantoja","family":"Moreira de Sena","sequence":"additional","affiliation":[{"name":"Postgraduate Program in Tropical Diseases, Federal University of Par\u00e1, Belem 66075-110, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Val\u00e9ria de Castro","family":"Fagundes","sequence":"additional","affiliation":[{"name":"Faculty of Medical Sciences of Par\u00e1, Para 38405-320, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Phelipe Augusto","family":"Rabelo Paix\u00e3o","sequence":"additional","affiliation":[{"name":"Graduate Program in Family Health, Federal University of the South and Southeast of Par\u00e1, Maraba 68507-590, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Stefani Gisele","family":"Bastos Dornas","sequence":"additional","affiliation":[{"name":"Graduate Program in Family Health, Federal University of the South and Southeast of Par\u00e1, Maraba 68507-590, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Clarisse Andrade","family":"Sales","sequence":"additional","affiliation":[{"name":"Postgraduate Program in Biodiversity and Biotechnology, Federal University of the South and Southeast of Par\u00e1, Maraba 68507-590, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ana Paula","family":"Sim\u00f5es Castro","sequence":"additional","affiliation":[{"name":"Postgraduate Program in Biodiversity and Biotechnology, Federal University of the South and Southeast of Par\u00e1, Maraba 68507-590, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Patricia Alves","family":"de Mendon\u00e7a Cavalcante","sequence":"additional","affiliation":[{"name":"Postgraduate Program in Biodiversity and Biotechnology, Federal University of the South and Southeast of Par\u00e1, Maraba 68507-590, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9363-5766","authenticated-orcid":false,"given":"Luann Wendel","family":"Pereira de Sena","sequence":"additional","affiliation":[{"name":"Graduate Program in Family Health, Federal University of the South and Southeast of Par\u00e1, Maraba 68507-590, Brazil"},{"name":"Postgraduate Program in Biodiversity and Biotechnology, Federal University of the South and Southeast of Par\u00e1, Maraba 68507-590, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2025,9,13]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","unstructured":"Lee, S.H., Kim, S.H., Kim, K.B., Kim, H.S., and Lee, Y.K. (2024). Factors Influencing Wound Healing in Diabetic Foot Patients. Medicina, 60.","DOI":"10.3390\/medicina60050723"},{"key":"ref_2","doi-asserted-by":"crossref","unstructured":"Ferreira, A.C.B.H., Ferreira, D.D., Barbosa, B.H.G., de Oliveira, U.A., Padua, E.A., Chiarini, F.O., Lopes, M.H.B.d.M., and Premaor, M.O. (2023). Neural network-based method to stratify people at risk for developing diabetic foot: A support system for health professionals. PLoS ONE, 18.","DOI":"10.1371\/journal.pone.0288466"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"62","DOI":"10.1001\/jama.2023.10578","article-title":"Diabetic Foot Ulcers: A Review","volume":"330","author":"Armstrong","year":"2023","journal-title":"JAMA"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"2367","DOI":"10.1056\/NEJMra1615439","article-title":"Diabetic Foot Ulcers and Their Recurrence","volume":"376","author":"Armstrong","year":"2017","journal-title":"N. Engl. J. Med."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"61","DOI":"10.1016\/j.jtv.2020.03.003","article-title":"Emerging technologies for the prevention and management of diabetic foot ulcers","volume":"29","author":"Lung","year":"2020","journal-title":"J. Tissue Viability"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"106219","DOI":"10.1016\/j.cct.2020.106219","article-title":"Using digital technologies in clinical trials: Current and future applications","volume":"100","author":"Rosa","year":"2021","journal-title":"Contemp. Clin. Trials"},{"key":"ref_7","unstructured":"Kumar Pendyala, S. (2025, July 10). Real-Time Analytics and Clinical Decision Support Systems: Transforming Emergency Care [Internet]. Available online: www.ijfmr.com."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"e44030","DOI":"10.2196\/44030","article-title":"Quality, Usability, and Effectiveness of mHealth Apps and the Role of Artificial Intelligence: Current Scenario and Challenges","volume":"25","author":"Fabelo","year":"2023","journal-title":"J. Med. Internet Res."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"740","DOI":"10.3390\/digital4030038","article-title":"Methodological Quality of User-Centered Usability Evaluation of Digital Applications to Promote Citizens\u2019 Engagement and Participation in Public Governance: A Systematic Literature Review","volume":"4","author":"Bastardo","year":"2024","journal-title":"Digital"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"71","DOI":"10.1136\/bmj.n71","article-title":"The PRISMA 2020 statement: An updated guideline for reporting systematic reviews","volume":"372","author":"Page","year":"2021","journal-title":"BMJ"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"210","DOI":"10.1186\/s13643-016-0384-4","article-title":"Rayyan-a web and mobile app for systematic reviews","volume":"5","author":"Ouzzani","year":"2016","journal-title":"Syst. Rev."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"32","DOI":"10.1258\/jtt.2011.110504","article-title":"Telemedical home-monitoring of diabetic foot disease using photographic foot imaging\u2014A feasibility study","volume":"18","author":"Hazenberg","year":"2012","journal-title":"J. Telemed. Telecare"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"477","DOI":"10.1109\/TBME.2014.2358632","article-title":"Smartphone-based wound assessment system for patients with diabetes","volume":"62","author":"Wang","year":"2015","journal-title":"IEEE Trans. Biomed. Eng."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"206","DOI":"10.1186\/s13063-016-1333-1","article-title":"Implementation of foot thermometry plus mHealth to prevent diabetic foot ulcers: Study protocol for a randomized controlled trial","volume":"17","author":"Sacksteder","year":"2016","journal-title":"Trials"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"2098","DOI":"10.1109\/TBME.2016.2632522","article-title":"Area Determination of Diabetic Foot Ulcer Images Using a Cascaded Two-Stage SVM-Based Classification","volume":"64","author":"Wang","year":"2017","journal-title":"IEEE Trans. Biomed. Eng."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"1730","DOI":"10.1109\/JBHI.2018.2868656","article-title":"Robust Methods for Real-Time Diabetic Foot Ulcer Detection and Localization on Mobile Devices","volume":"23","author":"Goyal","year":"2019","journal-title":"IEEE J. Biomed. Health Inform."},{"key":"ref_17","doi-asserted-by":"crossref","unstructured":"Wijesinghe, I., Gamage, C., Perera, I., and Chitraranjan, C. (2019). A Smart Telemedicine System with Deep Learning to Manage Diabetic Retinopathy and Foot Ulcers. MERCon 2019\u2014Proceedings, 5th International Multidisciplinary Moratuwa Engineering Research Conference, Institute of Electrical and Electronics Engineers Inc.","DOI":"10.1109\/MERCon.2019.8818682"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"692","DOI":"10.12968\/jowc.2020.29.12.692","article-title":"AI technology for remote clinical assessment and monitoring","volume":"29","author":"Zoppo","year":"2020","journal-title":"J. Wound Care"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"e933879-1","DOI":"10.12659\/AJCR.933879","article-title":"A 57-year-old man with type 1 diabetes mellitus and a chronic foot ulcer successfully managed with a remote patient-facing wound care smartphone application","volume":"22","author":"Kong","year":"2021","journal-title":"Am. J. Case Rep."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"77","DOI":"10.4258\/hir.2022.28.1.77","article-title":"Development and Usability Evaluation of a Telemedicine System for Management and Monitoring of Patients with Diabetic Foot","volume":"28","author":"Bahaadinbeigy","year":"2022","journal-title":"Health Inf. Res."},{"key":"ref_21","first-page":"20552076221142103","article-title":"Implementation of a novel mHealth application for the management of people with diabetes and recently healed foot ulceration: A feasibility study","volume":"8","author":"Haycocks","year":"2022","journal-title":"Digit. Health"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"110951","DOI":"10.1016\/j.diabres.2023.110951","article-title":"Artificial intelligence for automated detection of diabetic foot ulcers: A real-world proof-of-concept clinical evaluation","volume":"205","author":"Cassidy","year":"2023","journal-title":"Diabetes Res. Clin. Pract."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"20552076231220791","DOI":"10.1177\/20552076231220791","article-title":"Investigating the effects of digital foot self-management program on enhancing self-efficacy and self-care behavior among community-dwelling older adults with type 2 diabetes: A randomized controlled trial","volume":"9","author":"Chen","year":"2023","journal-title":"Digit Health"},{"key":"ref_24","doi-asserted-by":"crossref","unstructured":"Keegan, A.C., Bose, S., McDermott, K.M., Starks White, M.P., Stonko, D.P., Jeddah, D., Lev-Ari, E., Rutkowski, J., Sherman, R., and Abularrage, C.J. (2023). Implementation of a patient-centered remote wound monitoring system for management of diabetic foot ulcers. Front. Endocrinol., 14.","DOI":"10.3389\/fendo.2023.1235970"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"42","DOI":"10.1177\/19322968211070850","article-title":"Smart Offloading Boot System for Remote Patient Monitoring: Toward Adherence Reinforcement and Proper Physical Activity Prescription for Diabetic Foot Ulcer Patients","volume":"17","author":"Park","year":"2023","journal-title":"J. Diabetes Sci. Technol."},{"key":"ref_26","doi-asserted-by":"crossref","unstructured":"Ploderer, B., Clark, D., Brown, R., Harman, J., Lazzarini, P.A., and Van Netten, J.J. (2023). Self-Monitoring Diabetes-Related Foot Ulcers with the MyFootCare App: A Mixed Methods Study. Sensors, 23.","DOI":"10.3390\/s23052547"},{"key":"ref_27","doi-asserted-by":"crossref","unstructured":"Hellstrand Tang, U., Tranberg, R., Sundberg, L., and Scandurra, I. (2024). How do patients and healthcare professionals experience foot examinations in diabetes care?\u2014A randomised controlled study of digital foot examinations versus traditional foot examinations. BMC Health Serv. Res., 24.","DOI":"10.1186\/s12913-024-11674-w"},{"key":"ref_28","doi-asserted-by":"crossref","unstructured":"Matijevich, E., Minty, E., Bray, E., Bachus, C., Hajizadeh, M., and Liden, B. (2024). A Multi-Faceted Digital Health Solution for Monitoring and Managing Diabetic Foot Ulcer Risk: A Case Series. Sensors, 24.","DOI":"10.3390\/s24092675"},{"key":"ref_29","doi-asserted-by":"crossref","unstructured":"Zhou, G.X., Tao, Y.K., Hou, J.Z., Zhu, H.J., Xiao, L., Zhao, N., Wang, X.-W., Du, B.-L., and Zhang, D. (2025). Construction and validation of a deep learning-based diagnostic model for segmentation and classification of diabetic foot. Front. Endocrinol., 16.","DOI":"10.3389\/fendo.2025.1543192"},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"e13122","DOI":"10.54033\/cadpedv22n1-025","article-title":"Letramento digital em sa\u00fade: Capacidades, desafios e impactos na autonomia do indiv\u00edduo","volume":"22","author":"Mendes","year":"2025","journal-title":"Cad. Pedag\u00f3gico"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"e47105","DOI":"10.2196\/47105","article-title":"Guidelines and Standard Frameworks for AI in Medicine: Protocol for a Systematic Literature Review","volume":"12","author":"Shiferaw","year":"2023","journal-title":"JMIR Res. Protoc."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"13","DOI":"10.1038\/s44401-025-00017-4","article-title":"A systematic review of strategies in digital technologies for motivating adherence to chronic illness self-care","volume":"2","author":"Lu","year":"2025","journal-title":"npj Health Syst."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"2701","DOI":"10.2147\/JMDH.S419714","article-title":"Translation, Cross-Cultural Adaptation, and Validation of Measurement Instruments: A Practical Guideline for Novice Researchers","volume":"17","author":"Cruchinho","year":"2024","journal-title":"J. Multidiscip. Healthc."},{"key":"ref_34","doi-asserted-by":"crossref","unstructured":"Montgomery, R.M. (2025, July 15). Evaluating Health Technologies in the Brazilian Public and Supplementary Health Systems: Policy, Economic, and Public Health Implications [Internet]. Available online: https:\/\/www.preprints.org\/manuscript\/202502.0657\/v1.","DOI":"10.20944\/preprints202502.0657.v1"}],"container-title":["International Journal of Environmental Research and Public Health"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1660-4601\/22\/9\/1430\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,9]],"date-time":"2025-10-09T18:45:06Z","timestamp":1760035506000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1660-4601\/22\/9\/1430"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,9,13]]},"references-count":34,"journal-issue":{"issue":"9","published-online":{"date-parts":[[2025,9]]}},"alternative-id":["ijerph22091430"],"URL":"https:\/\/doi.org\/10.3390\/ijerph22091430","relation":{},"ISSN":["1660-4601"],"issn-type":[{"value":"1660-4601","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,9,13]]}}}