Abstract
Objectives
To evaluate the association between socioeconomic factors and diabetic foot ulcers (DFUs) among adults with diabetes mellitus through systematic review and meta-analysis.
Design
Systematic review and meta-analysis of observational studies conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines.
Data sources
PubMed/MEDLINE, Scopus, CINAHL and Google Scholar were systematically searched from database inception to 31 December 2024, with a final updated search performed in February 2025.
Eligibility criteria
Cross-sectional and case–control studies evaluating the association between socioeconomic factors and DFUs among adults with diabetes mellitus were included.
Data extraction and synthesis
Study selection and data extraction were performed independently by two reviewers. Methodological quality was assessed using the Joanna Briggs Institute Critical Appraisal Checklist for cross-sectional studies and the Newcastle-Ottawa Scale for case–control studies. Random-effects meta-analysis was used to pool ORs and corresponding 95% CIs. Heterogeneity was assessed using the I² statistic.
Results
Eight cross-sectional and case–control studies involving 3488 participants were included. Lower educational attainment was significantly associated with higher odds of DFUs (pooled OR=2.54, 95% CI 1.24 to 5.20; I² = 68.0%). Similarly, lack of formal employment was associated with higher odds of DFUs (pooled OR=1.71, 95% CI 1.05 to 2.77; I² = 21.2%). In contrast, although low income showed increased pooled odds of DFUs, the association did not reach statistical significance under the random-effects model (pooled OR=2.70, 95% CI 0.36 to 20.41; I² = 81.9%). Interpretation of the income analysis was limited by substantial heterogeneity and wide CIs. Sensitivity analyses excluding moderate-to-high risk studies demonstrated similar directions of association for education and occupational status.
Conclusions
Lower educational attainment and lack of formal employment were associated with higher odds of DFUs among individuals with diabetes mellitus. These findings suggest that socioeconomic factors should be considered in diabetic foot prevention and management strategies alongside conventional clinical risk factors. Further high-quality prospective studies using standardised socioeconomic measures are needed to strengthen the evidence base in this area.