Introduction

Diabetic foot disease is a leading cause of preventable disability, hospitalization, and lower-extremity amputation among people with diabetes. In high-income settings, earlier risk identification, multidisciplinary foot services, and structured referral pathways have improved limb preservation.1–3 In many resource-limited settings, however, diabetic foot complications still present late and are managed within health systems constrained by limited specialist capacity, weak continuity of care, and poor financial protection.4 These gaps contribute to avoidable ulcer progression, infection, and amputation, with the greatest burden falling on already disadvantaged populations.1,2

Sub-Saharan Africa (SSA) illustrates how these inequities are manifested in resource-limited settings.2,4 In SSA, rising diabetes prevalence is occurring alongside shortages of trained personnel, limited access to podiatry and vascular care, delayed presentation, and substantial barriers to affordable long-term management; comparable constraints have also been described in other resource-limited settings where specialist diabetic foot services remain scarce. Sociocultural and structural factors, including poverty, low health literacy, transport costs, and reliance on nonformal care, further reduce opportunities for prevention and early treatment.5,6 In this context, digital health and community-based care have gained attention as practical strategies to improve patient education, continuity of care, early detection, and referral.

Yet these approaches are not stand-alone solutions. Their effectiveness depends on integration with functional primary care, referral systems, workforce support, and essential service delivery.7,8 Current evidence on digital health interventions and community-based models specifically for diabetic foot prevention and management remains limited, particularly with respect to long-term clinical effectiveness, implementation in routine care, scalability, sustainability, cost, and equity in sub-Saharan Africa and other resource-limited settings.4,9,10 Accordingly, this narrative review focuses on digital health and community-based care not as separate topics, but as interdependent and implementation-oriented strategies for advancing more equitable diabetic foot prevention and management in resource-limited settings, with particular attention to SSA.

Methods

This narrative review used a structured literature search to improve transparency and reduce the risk of selection bias. A narrative review approach was selected because the topic spans multiple interconnected domains-digital health, telemedicine, remote monitoring, community-based care, referral systems, self-management support, and health inequities, and draws on heterogeneous forms of evidence, including clinical studies, implementation reports, health-systems analyses, and policy or guideline documents. The review was informed by SANRA principles (Supplementary File 1), and a PRISMA-style flow diagram was used to document study selection.

PubMed/MEDLINE, Web of Science, and Scopus were searched for English-language literature published from 2005 to 2025. Search terms combined concepts related to diabetic foot disease, digital and community-based interventions, and resource-limited settings. Manual searches were also undertaken for relevant documents from World Health Organization (WHO), International Diabetes Federation (IDF), and International Working Group on the Diabetic Foot (IWGDF). The core database search strategies are provided in Supplementary Table S1.

Eligibility criteria were defined a priori. We included peer-reviewed articles, reviews, implementation reports, and key policy or guideline documents relevant to diabetic foot prevention or management in resource-limited settings, including studies on digital health, community-based care, self-management education, community health workers (CHWs), referral pathways, continuity of care, health-system delivery, and equity-related barriers. Studies from high-income settings were included when they offered transferable lessons. Records were de-duplicated before screening, and titles/abstracts and full texts were independently reviewed by two reviewers, with disagreements resolved by discussion and, where needed, consultation with a third reviewer.

The database search identified 472 records (PubMed/MEDLINE, n = 203; Web of Science, n = 115; Scopus, n = 154). After removal of 130 duplicates, 342 records remained. Before formal screening, 83 records were excluded because they were non-English publications, ineligible publication types (eg, editorials, news items, or conference notices without sufficient detail), or clearly outside the scope of the review. The remaining 259 records underwent title and abstract screening, after which 66 were excluded because they did not appear sufficiently relevant to the review objectives. This left 193 articles for full-text assessment. Following full-text review, 122 articles were excluded. Most were excluded because, on detailed assessment, they did not focus on digital health, community-based care, referral pathways, or health-system organization relevant to diabetic foot care (n = 94). Others showed partial thematic overlap but did not provide sufficiently relevant evidence for diabetic foot prevention or management in resource-limited settings (n = 28). Seventy-one studies were included from the database search. Six additional guideline or policy documents identified through manual searches were also included, yielding 77 items in the final narrative synthesis (Figure 1).

Figure 1 Study selection flow diagram. Flow diagram summarizing identification, screening, eligibility assessment, and final inclusion of the literature used in this narrative review.

Because of feasibility constraints, the review was limited to English-language sources and selected databases. Given the heterogeneity of study designs, interventions, and outcomes, findings were synthesized narratively rather than quantitatively. To improve transparency in the interpretation of the included literature, Supplementary Table S2 provides a representative classification of included records by evidence type.

ResultsLessons from High-Income Settings: Structured Multidisciplinary Care and Selective Digital SupportMultidisciplinary Foot Care Services and Organized Referral Pathways

In high-income countries, improvements in diabetic foot outcomes are most consistently associated with structured multidisciplinary care rather than any single intervention.11 Systematic reviews and international guidelines indicate that multidisciplinary team (MDT) models are associated with lower rates of major amputation, earlier treatment of infection and ischemia, and more consistent wound management.12 These benefits appear greatest when multidisciplinary care is embedded in organized service pathways with standardized referral criteria, rapid access to specialist assessment, and regular follow-up.13

A typical diabetic foot MDT includes endocrinologists or diabetologists, vascular surgeons, orthopedic surgeons and/or foot and ankle surgeons, infectious disease specialists, podiatrists, wound-care specialist nurses, diabetes educators, rehabilitation therapists, dietitians, and social workers; in some settings, psychologists or other mental health professionals also contribute.3,11,12 However, the value of MDT care lies less in the number of disciplines involved than in how effectively expertise is coordinated across the care pathway. Its effectiveness depends on timely integration of metabolic management, vascular assessment, infection control, wound care, offloading, rehabilitation, and psychosocial support within a functional referral system.11,14

Across these studies, there is broad agreement that multidisciplinary care improves diabetic foot outcomes, but different research groups emphasize different mechanisms. Guideline-oriented and systematic review teams most consistently highlight integrated specialty input and standardized referral criteria as central features of effective care.11,12 By contrast, regional implementation studies place greater emphasis on coordination across levels of care and the operational value of fast-track pathways linking community providers with specialist diabetic foot services.14–16 Evidence from settings such as Italy and Iran further illustrates that clear referral protocols can reduce delays in assessment and treatment and improve access to limb-preserving care.15,16 Taken together, these findings suggest that MDT effectiveness depends not only on specialist availability, but also on how well multidisciplinary expertise is translated into timely access and coordinated service delivery.

Selective Use of Digital Tools for Monitoring and Continuity of Care

Within these organized systems, digital technologies are generally used as supportive tools rather than stand-alone solutions. In high-income settings, telemedicine, remote wound monitoring, and pressure-sensing smart insoles have been explored to support early detection, recurrence prevention, follow-up, and patient self-management.9,17–19

However, the evidence varies by intervention type and by the part of the care pathway being targeted. Studies of smart insoles and plantar pressure- or temperature-monitoring systems have focused mainly on ulcer prevention and recurrence in selected high-risk populations.20,21 A systematic review identified randomized and controlled studies in this area,20 and one randomized controlled trial reported reduced ulcer recurrence and lower healthcare utilization.21 More recently, the randomized Smart Prevent Diabetic Feet trial found no incident ulcers in the intervention group compared with five in the control group over 24 months, although the adjusted hazard ratio did not reach statistical significance because of the unexpectedly low event rate.22 These findings suggest potential preventive benefit, but also highlight how difficult it is to demonstrate clear clinical effects when both study arms receive intensive education and follow-up.

By contrast, studies of telemedicine and wound imaging have more often emphasized continuity of care, communication, and access to remote specialist input rather than direct reductions in hard clinical endpoints such as amputation.18,23 When linked to primary care and specialist services, these tools may extend follow-up beyond clinic visits and facilitate earlier review of concerning changes.18,23 Emerging AI-assisted approaches, including wound image analysis and prognostic modeling, have shown promise for screening, monitoring, and risk assessment under standardized imaging and data conditions.24–26 However, this literature remains weighted toward technical performance and diagnostic accuracy under controlled conditions. A recent systematic review of machine learning-based prognostic models found that although many models showed good discrimination, most had high risk of bias, relied on internal validation, and had limited immediate applicability to routine care.27

Digital technologies are therefore not interchangeable; rather, they support different parts of the diabetic foot pathway, including prevention, monitoring, triage, and specialist review. Moreover, their real-world effectiveness depends heavily on data quality, patient adherence, clinical oversight, and the availability of timely in-person assessment when ulcer deterioration, ischemia, or infection is suspected. Overall, experience from high-income countries suggests that digital technologies are most useful when they reinforce established pathways for prevention, triage, and continuity of care, rather than attempt to replace specialist services or coordinated clinical follow-up (Figure 2).18,23

Figure 2 Conceptual model of digitally enabled diabetic foot management. This schematic shows how digital data inputs may support risk assessment and triage, clinical communication and response, and expected contributions to diabetic foot prevention and follow-up. Colours are used only to distinguish conceptual components.

Structural Barriers and Drivers of Inequity in Sub-Saharan AfricaResource Scarcity, Delayed Presentation, and High Amputation Risk

SSA carries a high and growing burden of diabetes-related foot complications, yet care is often delivered within fragile and highly unequal health systems, contributing to poor limb outcomes once ulceration occurs.5 Global estimates suggest that the lifetime risk of diabetic foot ulceration among people with diabetes is high, and available reviews indicate a substantial burden in SSA as well.2,3,5 Among patients hospitalized for diabetic foot conditions, the risks of amputation and death can be considerable in some settings.28 These outcomes reflect both advanced disease at presentation and missed opportunities for earlier detection and limb-preserving care. A major proximal driver of poor outcomes is the limited availability of diagnostic capacity, trained personnel, and specialist services. In many settings, patients present only after prolonged delays, by which time infection, ischemia, and tissue loss are already advanced. Hospital-based reports show that many admitted patients already have severe infected ulcers, indicating that opportunities for limb-preserving intervention are often missed before formal care is reached.29,30 Long-standing evidence indicates that many ulcers are preventable when risk-based foot care, patient education, and early treatment are available.28 Clinical severity at first presentation is also influenced by behavioral and contextual factors. In some settings, low awareness of foot care, barefoot walking, self-treatment, and reliance on traditional healers contribute to delayed care-seeking and disease progression.5,31 Hazardous living conditions may further increase risk among people with sensory neuropathy. For example, environmental exposures associated with inadequate housing, including domestic injuries such as rodent bites, have been reported in some settings.32 Together, these findings suggest that high amputation and mortality rates in SSA are driven not only by disease severity, but also by late presentation within under-resourced systems with limited capacity for early intervention and limb preservation.

Economic, Policy, and Health-System Determinants of Inequity

Poor diabetic foot outcomes in SSA are shaped not only by immediate clinical and behavioral factors, but also by broader economic, policy, health-system, and sociocultural determinants that influence care accessibility and treatment continuity. Together, these determinants shape affordability, geographic access, care navigation, and the ability to sustain treatment over time. Economic vulnerability is a major contributor to inequity. Many patients face substantial out-of-pocket costs for transport, consultations, dressings, medications, and protective footwear, while weak financial protection undermines repeated follow-up and prolonged outpatient management.33,34 In Tanzania, for example, the cost of diabetic foot care has been estimated to equal two years of household income.4 Poverty also interacts with service organization: poorer patients are more likely to live far from specialist services, rely on fragmented care pathways, and face competing household demands and indirect costs that delay follow-up.

Health-system and policy constraints further reinforce these disparities. Uneven distribution of trained providers, weak referral networks, poor geographic access to specialist care, and limited inclusion of preventive foot care in financing arrangements all contribute to delayed diagnosis and interrupted treatment.35,36 These barriers disproportionately affect rural and underserved populations, who are less likely to receive routine screening, risk stratification, and coordinated referral when problems emerge.37,38

Sociocultural factors, including low health literacy, language barriers, stigma, and social marginalization, may further reduce patients’ ability to recognize risk, navigate services, and adhere to treatment.31,35 In practice, these factors often compound the effects of poverty and weak health systems. Overall, the evidence suggests that diabetic foot inequities in SSA arise from interacting disadvantages across the pathway from prevention to treatment, resulting in poorer access to preventive care, weaker continuity of management, and ultimately higher risks of amputation and premature death.

Digital Health in Resource-Limited Settings: Opportunities and Implementation ChallengesMobile Wound Monitoring and Artificial Intelligence-Assisted Assessment

In resource-limited settings, digital health has increasingly been explored as a means of strengthening diabetic foot care, particularly where shortages of specialists, weak referral systems, and long travel distances delay diagnosis and treatment.7,9 Smartphone-based wound photography, mobile wound monitoring applications, and image-sharing platforms have been used to document diabetic foot lesions and facilitate remote review when specialist access is limited.26,39,40 These approaches have mainly been described as tools to support triage and communication between frontline providers and referral services.

Recent feasibility studies have extended this approach beyond single-image sharing toward more structured home-based monitoring. For example, a 2025 pilot study involving patients with previous diabetic foot ulceration found that daily remote thermal and visual foot scanning was associated with high adherence and enabled early identification of skin integrity problems; notably, visual images correctly identified all incident ulcers observed in the study cohort.41 Podiatrists in that study also rated visual data as more clinically useful than thermal data for most remote assessments, suggesting that image-based review may currently be more actionable than temperature signals alone in routine practice.41

However, reported performance depends heavily on image quality, training datasets, and workflow standardization, and evidence from routine use in SSA remains limited.10 Comparison across research teams suggests a clear divergence in emphasis. Technical and engineering-oriented studies mainly report algorithm performance, image-classification accuracy, and feasibility under standardized conditions.24–26,40,42 By contrast, implementation-oriented studies focus more on whether mobile imaging and communication tools can shorten referral delays or improve continuity of care in routine practice.26,39,40 As a result, the current evidence base is stronger for technical validity than for real-world effectiveness, particularly in SSA and other resource-limited settings.

Remote Monitoring, Smart Insoles and Other Emerging Technologies

Telemedicine and remote monitoring have also been explored to support follow-up and continuity of care where repeated in-person visits are difficult.18 Reported uses include remote review of wound progress, symptom reporting, and communication among patients, primary care providers, and specialist teams.43 Beyond ulcer follow-up, telehealth has also been used for preventive foot-care education. In a 2023 nurse-led feasibility study, monthly synchronous telehealth sessions were associated with high usability and improvements in diabetes knowledge, foot-care practices, and self-reported self-management behaviors, although the study was small, nonrandomized, and not designed to assess ulcer or amputation outcomes.44

Other emerging technologies include pressure-sensing smart insoles and related wearable or sensor-based tools for recurrence prevention and early risk detection.21,45 In selected populations, smart insoles have been associated with reduced ulcer recurrence and lower subsequent healthcare utilization.21 However, most evidence for these technologies comes from high-income settings, and their feasibility and affordability in resource-limited settings are less well established.

Implementation Barriers, Local Adaptation and Sustainability in Sub-Saharan Africa

In SSA, digital health is most useful when it supports communication, triage, follow-up, and referral rather than replacing in-person care. Expanding mobile phone access creates new opportunities for lower-cost communication and follow-up, but implementation still depends on infrastructure that is often weak in resource-limited settings.46,47 These include reliable electricity, internet connectivity, device availability, technical support, user training, and data governance.47 Such constraints are especially relevant in rural and underserved areas and may limit both uptake and sustained use.

Affordability and equity are additional concerns. Costs related to devices, maintenance, replacement, and connectivity may restrict access if interventions are introduced without attention to local economic conditions.9 Environmental considerations, including electronic waste in settings with limited regulatory and recycling capacity, have also been noted.48,49 Across the reviewed literature, digital interventions were most commonly described as tools for communication, triage support, and follow-up rather than as substitutes for in-person care.50 Feasibility and usefulness were consistently shaped by infrastructure, workforce capacity, and integration with referral pathways, yet evidence from routine implementation in SSA remained limited.7,8

Community-Based Prevention, Self-Management Education and Early ReferralDiabetes Self-Management Education in Resource-Limited Settings

In resource-limited settings, diabetes self-management education (DSME) is a core component of diabetic foot prevention, particularly where delayed presentation and limited specialist access increase the importance of early self-recognition and preventive care.28,51 Available evidence suggests that educational, behavioral, and diabetes-management interventions may improve diabetes-related knowledge, self-management behaviors, and glycaemic control, which are important components of broader strategies to prevent diabetes-related complications, including diabetic foot disease.52–54 This implementation gap is also illustrated by a large cross-sectional study from rural North China, in which knowledge and attitudes were positively associated with preventive foot-care practices, yet 71.4% of adults with diabetes still had poor foot-care practices overall, especially for routine foot examination and timely care-seeking for foot problems.55 These findings suggest that DSME effectiveness depends not only on content, but also on reinforcement over time, the type of educator, cultural and linguistic adaptation, and linkage to follow-up and care access.56,57

In SSA, self-management is often further constrained by low health literacy, limited risk awareness, restricted access to protective footwear and hygiene supplies, transport costs, and weak continuity of primary care.50,51 In this context, educational deficits are closely linked to broader structural barriers rather than knowledge gaps alone. Available studies suggest that culturally adapted group education and lifestyle-oriented interventions may improve adherence to foot care and other self-management practices.53,54,58 Lower-cost delivery models involving primary care providers, peer educators, or CHWs have also been explored in resource-limited settings.59

Community-Based Early Identification and Referral Pathways

Education alone is unlikely to reduce severe diabetic foot complications if high-risk patients are not identified early and linked to appropriate care. This is particularly relevant in SSA, where many patients first enter formal services only after ulcers have progressed to infection, ischemia, or tissue loss. Primary care plays an important role in glycemic management, routine foot screening, recognition of warning signs, and timely referral.35 Delayed referral resulting from weak primary care systems is a major contributor to ulcer progression, amputation, and mortality.29 Reports from specialist services indicate that many patients present only after infection, ischemia, or both are already established.14

In response, community-based models have increasingly focused on simplified screening, basic triage, and earlier referral of high-risk feet. Their main strength lies in standardized processes that can be implemented in primary care and community settings without reliance on advanced equipment. Evidence from fast-track referral programs in Europe and the Middle East suggests that structured pathways linking community or primary care services with specialist diabetic foot management can shorten delays and improve outcomes.15,16 In resource-limited settings, similar approaches may be adapted through existing primary healthcare and community networks, sometimes with telemedicine support for communication with higher-level facilities. Across studies, the reported benefit of community-level screening was closely linked to the availability of responsive referral pathways, follow-up systems, and access to treatment after identification of high-risk feet. However, most supporting evidence comes from organized service models outside SSA, and direct transferability to low-capacity settings should be interpreted cautiously. Reported benefits are likely to depend on whether referral destinations are accessible, responsive, and adequately resourced after high-risk patients are identified.

The Role of Community Health Workers in Diabetic Foot Prevention and Continuity of Care

CHWs are increasingly recognized as potential contributors to diabetic foot prevention and continuity of care in settings where specialist services are scarce and primary care systems are overstretched.60 Across chronic disease programs, CHWs have supported health education, behavioral reinforcement, early identification of complications, referral coordination, and follow-up.61 Although diabetic foot-specific evidence remains limited, available studies suggest that CHW-led or CHW-supported interventions may extend the reach of preventive services and, in some settings, improve continuity of care.58,62,63 Reported roles include culturally appropriate foot self-care education, community-level support for early identification and referral, and facilitation of follow-up adherence within more integrated, people-centred models of care.60,64,65

In most resource-limited settings, CHWs are best positioned to reinforce self-care, identify warning signs, support timely care-seeking, and facilitate referral and follow-up. They are not well positioned to make independent decisions about ulcer severity, infection, ischemia, offloading, or surgical care.58,59,61–63,65 Assessment and management of active ulceration, suspected deep infection, tissue necrosis, progressive ischemia, or structural foot complications should remain the responsibility of trained clinicians, including physicians, nurses, podiatrists where available, and specialist diabetic foot teams.12,35,59 CHW involvement should therefore be supported by standardized training, simple risk-recognition tools, explicit escalation criteria, and supportive supervision from nurses, physicians, or podiatrists.6,59,61

Clear communication workflows are equally important. Community-level screening is most likely to improve outcomes when CHWs use standardized reporting tools and can rapidly communicate concerns to primary care clinicians, who can then decide whether escalation to podiatry, wound care, vascular, surgical, or specialist diabetic foot services is required.15,16,35 Mobile phones or other digital tools may support reminders, referral alerts, remote discussion of suspected lesions, and follow-up tracking where feasible, although their effectiveness depends on infrastructure, supervision, and service responsiveness.7,9,46 Overall, CHWs are most effective when integrated as supervised extensions of primary care and referral systems rather than as stand-alone community actors; in settings with weak referral pathways or limited treatment access, their impact on continuity of care is likely to remain constrained (Figure 3).59,61 Equity considerations also deserve greater attention. Access to digital tools, health information, transport, and referral services may be shaped by gender, age, literacy, mobility limitations, and decision-making autonomy within households. As a result, digital and community-linked diabetic foot interventions may not benefit all patient groups equally unless implementation strategies explicitly address these barriers.

Figure 3 Community-based model for diabetic foot prevention, referral, and continuity of care. This schematic shows a community-to-specialist pathway for diabetic foot prevention and management, highlighting the roles of primary care, referral coordination, community health workers, and urgent escalation for red flags. Colours are used only to distinguish conceptual components.

System Integration, Financing and Cross-Sector CollaborationGovernment-Nongovernmental Organizations Collaboration in Strengthening Diabetic Foot-Related Services

In resource-limited settings, the effectiveness of diabetic foot care depends not only on clinical interventions but also on the capacity of health systems to support prevention, referral, treatment, and follow-up. Collaboration between governments and nongovernmental organizations (NGOs) has therefore been proposed as a pragmatic strategy for addressing service gaps where public-sector capacity for chronic disease management remains limited.65–68 In diabetic foot care, such partnerships may support frontline training, patient education, access to medicines and basic supplies, and the development of referral pathways.6,67–69

In practice, diabetic foot service delivery in resource-limited settings often depends on collaboration among multiple stakeholders beyond bilateral government-NGO partnerships. Governments provide stewardship, financing, and integration within essential health-service systems, whereas NGOs often support implementation, outreach, and frontline training.65–70 Professional associations, academic institutions, patient organizations, community groups, and appropriately regulated private-sector actors may also contribute to guideline dissemination, workforce development, patient empowerment, service responsiveness, and access to supplies or communication tools.6–10,12,34,71 Such collaboration is most likely to be effective when roles are clearly defined and aligned with national health priorities.

Direct empirical evidence on government-NGO collaboration specifically targeting diabetic foot care remains limited, and much of the available literature comes from broader diabetes programs. However, recent evidence from Latin America suggests that regionally coordinated training and service-strengthening initiatives can still play an important role: programs such as Step by Step and Train the Foot Trainer have reportedly trained more than 4000 healthcare professionals and supported the establishment of over 125 diabetic foot care units across the region.72 For example, integrated models developed by Santé Diabète in Mali and later extended to Burkina Faso and the Comoros combined prevention, treatment, workforce training, improved access to medicines, patient empowerment, and policy advocacy.66,67 In Laos, a government partnership with Action4Diabetes improved survival among children and young people with type 1 diabetes and contributed to more sustainable local systems for diabetes and complication care.68 Although these initiatives were not designed specifically for diabetic foot disease, they suggest that government-NGO collaboration may indirectly strengthen diabetic foot prevention and management by improving primary-level diabetes care, service delivery capacity, and policy implementation.

However, these models should be interpreted cautiously. Many rely on external funding, time-limited implementation teams, or NGO-led operational support, raising concerns about sustainability once donor funding ends. Where coordination with national systems is weak, partnerships may create parallel structures with limited coverage, unclear accountability, and poor long-term integration.69 Overall, government-NGO collaboration may offer a pragmatic mechanism for strengthening diabetic foot care in underserved settings, but its long-term impact and cost-effectiveness remain insufficiently evaluated and are likely to depend on sustained integration with national health systems (Figure 4).

Figure 4 Conceptual framework for government–NGO collaboration in diabetic foot care strengthening. This schematic shows how government and NGO roles may interact through shared implementation functions to improve access, continuity of care, referral, and service equity in diabetic foot care. Colours are used only to distinguish conceptual components.

Global Health Initiatives, Policy Momentum and Institutionalization

Global health initiatives have contributed to policy momentum for improving diabetes care and reducing inequalities in complication prevention and treatment. The WHO Global Diabetes Compact emphasizes strengthening primary health care, improving access to essential medicines and technologies, and promoting integrated service delivery.73 These priorities are directly relevant to diabetic foot care, particularly for risk screening, patient education, follow-up, and timely referral. Recommendations from the IWGDF have also influenced service models across diverse settings.12

Several initiatives originating in resource-limited settings also illustrate the value of context-adapted training and task-sharing approaches. A notable example is the Step by Step program, which originated in Dar es Salaam, Tanzania, and was later implemented across multiple regions. The model emphasizes practical training, task-sharing, and low-cost approaches adapted to resource-limited settings, and it has often been cited as an example of reverse innovation in diabetic foot care.70,72 Such programs suggest that training models developed in resource-limited settings can be scalable and transferable when they are simple, context-sensitive, and aligned with frontline service realities.

At the same time, the long-term effect of global initiatives depends on whether they become institutionalized within national service systems. Available literature suggests that preventive activities are more likely to be sustained when incorporated into essential service packages and supported by stable public financing, procurement mechanisms, and accountability structures.71 In diabetic foot care, this includes routine foot screening, self-management education, and follow-up of high-risk patients as part of ongoing chronic care rather than stand-alone projects.

Financing, System Embedding and Multisectoral Collaboration

Sustainable diabetic foot care requires more than isolated projects or vertical interventions. It depends on whether essential preventive and management functions can be financed, embedded in primary care and referral systems, and adapted to local delivery conditions.6,10 In many resource-limited settings, out-of-pocket payment remains a major barrier to accessing preventive foot care, wound supplies, offloading materials, follow-up visits, and transport to referral centers. These barriers contribute to delayed presentation, interrupted treatment, and loss to follow-up, particularly among rural and low-income populations.34,74

From a health systems perspective, financing arrangements are central to the success of diabetic foot programs. Without stable support for workforce training, basic supplies, referral transport, and continuity of outpatient care, even well-designed prevention strategies may not produce sustained clinical benefit.6,7 Inclusion of core diabetic foot services within broader essential service packages may help improve equity and continuity.38 However, evidence on feasible financing models in SSA remains limited.6 More research is needed on how diabetic foot prevention and management can be incorporated into broader chronic care and universal health coverage strategies in resource-limited settings.9

Multisectoral collaboration among governments, NGOs, professional associations, and international partners may help address implementation gaps by supporting capacity building, contextual adaptation, and scale-up.66,67 However, reported benefits appear greatest when such collaboration is aligned with national health priorities, embedded in existing service structures, and supported by long-term institutional commitment.68,69 Overall, the available evidence indicates that system integration, financing, and cross-sector collaboration are central to whether preventive and referral strategies can be delivered equitably, continuously, and at scale in resource-limited settings.73

Discussion

Three main messages emerge from this review. First, major inequalities in diabetic foot outcomes reflect both structural health-system constraints and gaps in the evidence base—a challenge that is widely shared across resource-limited settings. While sub-Saharan Africa remains an important focus, evidence from rural China, CHW-led programs in medically underserved communities, and regional initiatives in Latin America demonstrates that these inequities manifest through different combinations of health literacy gaps, workforce shortages, service fragmentation, and social disadvantage.55,62,63,72 Moreover, although international guidelines and clinical studies describe potentially useful strategies, the underlying evidence is often heterogeneous, focused on surrogate or short‑term outcomes, and limited in cost‑effectiveness data.11,12,53 In many resource‑limited settings, therefore, the central question is not simply whether an intervention can work, but whether it can work within existing infrastructure, financing, and workforce constraints.

Second, digital health should therefore be viewed as a complementary, system-dependent strategy. Telemedicine, mobile wound imaging, and remote monitoring may extend clinical reach, standardize follow-up, and support referral decisions, especially where geographic barriers are substantial.9,23,39,75 Yet the promise of digital innovation can be overstated. In settings with poor connectivity, weak referral capacity, or unstable financing, even technically feasible tools may fail to improve clinical outcomes. This is particularly important for patients with infection, ischemia, or rapidly deteriorating ulcers, for whom timely in-person assessment remains essential.47,76,77

A further insight from this review is that different research traditions have generated complementary but sometimes contrasting findings. Teams working from guideline, specialist-center, and multidisciplinary care perspectives tend to emphasize organized referral pathways, early access to vascular and surgical expertise, and coordinated service delivery as the core determinants of better limb outcomes.11–16 By contrast, digital health and engineering-oriented groups more often report technical feasibility, diagnostic performance, or usability of tools such as mobile imaging platforms, AI-assisted assessment, and wearable sensors.21–26,40,42 Recent work from India and Peru also illustrates how these innovations are increasingly being adapted in resource-limited settings through image-based AI models, co-created mobile applications, and patient-centered usability design. Meanwhile, implementation and public health researchers more consistently focus on affordability, delayed presentation, fragmented care, and the structural barriers that constrain real-world uptake in SSA and other resource-limited settings, including Latin America.5–8,33–38,46,47 These findings are not contradictory, but rather operate at different levels of analysis. Taken together, they suggest that technological innovation, community-based prevention, and specialist diabetic foot services should be viewed as interdependent rather than competing strategies.

Third, community-based prevention and task-sharing remain practical entry points in resource-limited settings. Education, CHW engagement, and simplified referral algorithms may shift care earlier in the disease course,51,59 but their impact depends on access to diagnostic and treatment services. Prevention is therefore not only an educational issue, but also one of service organization and financing. Community strategies are therefore most likely to be effective when embedded within functional referral and treatment systems rather than delivered in isolation.

Health financing deserves more attention than it typically receives in the diabetic foot literature. In many resource-limited settings, preventive services such as screening, therapeutic footwear, dressings, and regular follow-up are poorly funded, while late-stage admissions, surgery, and amputation consume disproportionate resources.35,36 Sustainable progress will require payment and procurement mechanisms that support early detection and limb preservation, rather than primarily financing end-stage rescue care. Cross-sector collaboration may catalyze innovation, but lasting gains depend on integration into routine services rather than short-term projects.66,69

This review has several limitations. It included only English-language literature and may therefore underrepresent evidence from francophone, lusophone, or locally indexed sources in Africa and other resource-limited settings. Because this was a narrative review, no formal risk-of-bias assessment or quantitative pooling was performed. The evidence base itself is also uneven: many digital health studies emphasize technical feasibility rather than long-term outcomes, implementation costs, or cost-effectiveness, and much of the strongest evidence still comes from high-income settings.10,47 These limitations reinforce the need for pragmatic, locally led implementation studies in SSA and other resource-limited settings.

Conclusion

Diabetic foot care in resource-limited settings cannot be improved by technology alone. The most plausible path forward is an integrated model that combines earlier risk identification, community-based education, task-sharing, structured referral, and selective digital support within strengthened primary and specialist services. Digital tools can improve continuity, triage, and communication, but only when they are adapted to local infrastructure, workforce capacity, and financing arrangements and embedded within responsive care pathways.

Future research should focus less on isolated proof-of-concept interventions and more on real-world implementation: which combinations of community-based care, referral redesign, and affordable digital support reduce delays, lower amputation rates, improve equity, and remain financially sustainable over time. For policymakers and health-system planners, the priority is clear: strengthen routine foot screening, referral capacity, access to essential supplies, and continuity of care so that prevention, early treatment, and limb preservation become realistic options long before amputation becomes the default outcome.

This review contributes to the field by integrating digital health, community-based care, and equity-oriented health-system considerations within a single implementation-focused framework. Its findings are intended to inform policymakers, clinicians, and program implementers working to strengthen diabetic foot care in resource-limited settings.

Author Contributions

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Funding

This work was supported by National Natural Science Foundation of China (No. 81700695), Yantai City Science and Technology Innovation Development Plan (No. 2024JCYJ053), Policy-Guided Projects of Yantai Science and Technology Innovation Development Program (No. 2025YT06000244) and Yantai Natural Science Foundation Biomedical Innovation Joint Fund (No. ZR2025LZ047).

Disclosure

The authors declare no conflicts of interest in this work.

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