Psychosocial and behavioural prognostic factors for diabetic foot ulcer development and healing: a systematic review

Maggie Westby, Gill Norman, Kavita Vedhara, Fran Game, N Cullum

Research output: Contribution to journalArticlepeer-review


To investigate whether ulceration, amputation and healing of foot ulcers in people living with diabetes are associated with psychosocial and behavioural factors.

We searched MEDLINE, EMBASE, PsychINFO, CINAHL and The Cochrane Library to March 2019 for longitudinal studies with multivariable analyses investigating independent associations. Two reviewers extracted data and assessed risk of bias.

We identified 15 eligible studies involving over 12,000 participants. Clinical and
methodological heterogeneity precluded meta-analysis, so we summarise narratively. Risk of bias was moderate or high. For ulceration, we found significantly different results for people with and without an ulcer
history. For those with no ulcer history, moderate quality evidence suggests depression increases ulcer risk (three studies, e.g. HR 1.68 (1.20, 2.35) per Hospital Anxiety and Depression Scale (HADS) standard unit). Better foot self-care behaviour reduces ulcer risk (HR 0.61 (0.40, 0.93) per Summary of Diabetes Self-Care Activities scale standard unit; one study). For people with diabetes and previous ulcers, low or very low quality evidence suggests little discernable association between ulcer recurrence and depression (e.g. HR 0.88, 0.61, 1.27
per HADS standard unit), foot self-care, footwear adherence or exercise.
Low quality evidence suggests incomplete clinic attendance is strongly associated with amputation (OR 3.84 (1.54, 9.52); one study). Evidence for the effects of other psychosocial or behavioural factors on ulcer healing and amputation is very low quality and inconclusive.

Psychosocial and behavioural factors may influence the development of first ulcers. More high quality research is needed on ulcer recurrence and healing.
Original languageEnglish
JournalDiabetic medicine: a journal of the British Diabetic Association
Early online date21 Apr 2020
Publication statusE-pub ahead of print - 21 Apr 2020


  • behavior
  • diabetes mellitus
  • depression
  • diabetic foot
  • psychology (psychosocial factors)
  • self care
  • wound healing


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