Effect of educational interventions on wound healing in patients with venous leg ulceration: A systematic review and meta‐analysis

Abstract

Educational interventions for patients with venous leg ulceration (VLU) may promote adherence and self‐management, however, their effect on wound healing is unclear. A systematic literature search was performed and randomised controlled trials with a focus on educational interventions were included. Wound healing was analysed by assessing wound healing rate, ulcer size, and the PUSH Score. Additional outcomes comprised pain, quality of life, and functional ability. The study protocol for this work is registered at PROSPERO 2020 (ID: CRD42021286152). Nine studies were included in this meta‐analysis. The odds ratio for wound healing was 1.91 (95% CI, 0.99–3.67, P = .053) in favour of educational interventions compared to usual care. Ulcer size reduction was higher (MD: ‐7.22; 95% CI, −11.91 to −2.53, P = .003) in patients following educational interventions. Included studies also showed significant effects on pain, quality of life, and functional analysis, though no quantitative synthesis was feasible. The overall risk of bias showed some concerns. Educational interventions aim to actively involve patients in their treatment, thereby appearing to be able to have a positive impact on wound healing within 12 weeks. Consequently, integrating educational approaches to routine wound care may be a promising strategy to improve treatment of VLU.

1. INTRODUCTION

Venous leg ulcers (VLU) affect about 1% of the population in western countries and about 3% of those over 80 years of age. ¹ In Germany, approximately 0.6%–1% of the adult population is diagnosed with a VLU, with a higher prevalence in people over 60 years of age (3.9%). ² , ³ Due to the ageing population, an increasing incidence of VLU and chronic wounds is predicted. ²

Treatment of chronic wounds is a major challenge in medical as well as economic terms. Due to wound‐, comorbidity‐, pathophysiological‐ and care‐related factors, chronic wounds usually require a long‐term care process, and high costs. ⁴ Only about half of VLUs heal within 4 months and healed ulcers have a high recurrence rate of 30%–57% within the first year. ⁵

One possible reason for that is seen in the fact that outpatient care of affected patients is often not in accordance with current evidence. ⁶ For example, care analyses show that only 30%–40% of patients receive compression therapy, which is a cornerstone in the treatment of VLU along with invasive interventions. ⁷ , ⁸ , ⁹ Best evidence for effective treatment measures is useless without patient acceptance, which is an important but often neglected key to successful therapy. ⁵ , ¹⁰ Interventions that may promote adherence include educational interventions, support groups, nursing and medical interventions, multidisciplinary interventions, and health system interventions. ¹¹

Educational interventions help patients to take an active role and foster self‐management as an important resource. ¹² , ¹³ Enhancing the understanding of the beneficial effects of VLU treatment measures among patients may increase adherence to therapy. ¹⁴ , ¹⁵ This systematic review and meta‐analysis aim to summarise educational interventions for patients with VLU and to assess their potential effect on wound healing and additional outcomes, such as pain, quality of life, and functional ability. Accordingly, it was of interest to present subsequent evidence on this topic to comprehensively present the body of evidence.

2. METHODS

This meta‐analysis was conducted in accordance with the Cochrane Handbook for systematic reviews of intervention guidelines, the Preferred Reporting Items for Systematic Review and Meta‐Analysis (PRISMA) statement (S1), and the Cochrane statistical methods guidelines. ¹⁶ , ¹⁷ The study protocol for this work is registered at PROSPERO 2020 (ID: CRD42021286152).

2.1. Criteria for considering studies for this meta‐analysis

2.1.1. Types of studies

Randomised controlled trials (RCTs) or cluster‐randomised controlled trials (cluster‐RCTs) that described educational interventions designed to improve VLU wound healing and adherence to compression therapies were included in this meta‐analysis.

2.1.2. Types of participants

Participants were adult patients receiving treatment for VLU.

2.1.3. Types of intervention

We included studies that evaluated educational interventions aiming at improving wound healing in patients with a VLU. For interventions, any type of educational training was considered eligible including support group interventions, training delivered by nurses or medical staff, as well as multidisciplinary interventions, either alone or in combination. Training could also have been delivered either face‐to‐face or digitally.

2.1.4. Types of outcome measures

The main outcome of this meta‐analysis was wound healing of VLU within the defined time period of 12 weeks. Additional outcomes related to pain, quality of life, and functional ability within 12 weeks.

2.2. Search strategy

A systematic search strategy was developed by the research team and was also guided by the Cochrane meta‐analysis from 2016 by Weller CT. ¹¹ Studies were identified by two authors (JB and LP) in the databases EBSCO CINAHL, Medline (Ovid), and The Cochrane Central Register of Controlled Trials (CENTRAL) up to November 2021. In addition, an open search on PubMed was performed to capture potentially matching studies in their entirety. The search strategy included terms relating to VLU and wound healing as well as different types of educational interventions. The detailed search key was adapted to each database. Details of the search strategy are presented in the supporting information (S2). The developed search key was applied within the systematic search and included literature until November 2021.

2.3. Data collection

Two authors (JB, LP) independently assessed the titles and available abstracts of all studies identified through the initial search using the Rayyan tool for systematic reviews. ¹⁸ Records appearing to meet the inclusion criteria and those with insufficient abstract details were included for the full‐text screening and evaluated on the basis of the defined inclusion criteria. Inclusion and exclusion criteria are presented in Table 1. Any disagreements were resolved by consensus. Furthermore, the risk of bias 2 (RoB 2) ¹⁶ , ¹⁹ tool was used for assessing the risk of bias in all included studies.

TABLE 1.

Inclusion and exclusion criteria of the full‐text screening

Inclusion criteria	Exclusion criteria
Disease: Venous leg ulcers	Disease: Diabetic foot ulcers Arterial ulcers Diseases in infants/children
Study design: Randomised controlled trials	Study design: Case reports, commentaries, laboratory research, secondary research (systematic reviews, scoping reviews, meta‐analyses)
Interventions: All training interventions for patients

2.4. Data extraction and management

The first author (JB) summarised the study characteristics and wound healing findings in a table, and a second author (TF) verified this extracted data. The extracted data included information on author(s), year of publication, country, sample characteristics (total sample size, sample size IG, sample size CG), interventions, wound healing characteristics (healing rate, PUSH score, changes in ulcer area), and comments on data collection methods. Any disagreements regarding data extraction were resolved by discussion between the two.

2.5. Statistical methods

For the comparison of healing rates between standard therapy and intervention, the odds ratio (OR) with its 95% confidence interval (CI) was pooled, whereas for the PUSH score and ulcer size reduction the mean difference (MD) with its 95% CI was used as the effect measure. Since the desired intervention effect is an increased ulcer healing, OR > 1 or MD < 0 expressed a better chance of ulcer healing and, therefore, indicated a benefit of the intervention over the standard therapy alone. For continuous outcomes, missing reported means, and standard deviations (SD) were estimated by median, minimum, maximum, and sample size according to Wan et al. ²⁰

Since only one study reported the mean and SD of the PUSH score in both groups, no meta‐analysis was performed for this outcome. Random‐effect models were used to account for the expected between‐studies variation. The Mantel Haenszel method ²⁰ was applied for estimating the overall healing rate and the overall ulcer size was estimated using the generic inverse variance method. Further, the between‐study heterogeneity was assessed using the between‐study variance τ ² along with the I ² statistic. The restricted maximum‐likelihood (REML) method was used to estimate the between‐studies variance τ ². Values of I ² on the order of 25%, 50%, and 75% indicated low, moderate and considerable unexplained heterogeneity, respectively. ³² Results of the meta‐analyses are visualised as forest plots.

In addition to the main meta‐analysis, a sensitivity analysis was performed to investigate whether the drop‐out patients had an impact on the individual or overall intervention effect in terms of wound healing rate. In total, two scenarios were investigated. In both sensitivity analyses, the applied methods were the same as for the main analysis.

The measurements of the additional outcomes could not be compared; therefore, no meta‐analysis could be performed.

All statistical analyses were performed using R version 4.1.2 ²¹ and the package meta. ²²

3. RESULTS

The result of the study selection is shown in the PRISMA Flowchart (Figure 1). The search yielded 762 unique references, while 51 references were retrieved and reviewed in full text. Finally, a total of 10 studies met the defined inclusion criteria, of which nine studies could be included in the meta‐analysis. ¹⁴ , ²³ , ²⁴ , ²⁵ , ²⁶ , ²⁷ , ²⁸ , ²⁹ , ³⁰ One study could not be included in the quantitative analysis ³¹ since the description of the methods and the results did not provide the necessary outcome parameters. Included studies were published between 2005 and 2018 and comprised a total patient sample of 631 with chronic venous insufficiency. Three studies were from Australia, ²³ , ²⁴ , ²⁷ two studies from New Zealand, ²⁵ , ²⁸ one from Brazil, ²⁹ one from Canada, ²⁶ one study from the United Kingdom, ³⁰ one from the Netherlands, ¹⁴ and one from the United States. ³¹

FIGURE 1.

PRISMA flowchart

3.1. Description of the studies

An overview of included studies can be found in Table 2. All included studies used an educational program for patients as the intervention. In total, four different education programs were employed:

TABLE 2.

Overview of the included studies—presentation of wound healing

Study, setting, and country	Population	Intervention	Comparison	Ulcer healed—Yes/no	Healing PUSH	Ulcer healed Cm2 (area)
Edwards 2005 a Australia	N total = 33 N IG = 16 N CG = 17	Leg club	Home‐care	✓	✓	✓
Edwards 2008 Australia	N total = 67 N IG = 34 N CG = 33	Leg club	Home‐care	X	X	✓
Edwards 2005 b New Zealand	N total = 56 N IG = 28 N CG = 28	Leg club	Home‐care	✓	✓	✓
Harrison 2008 Canada	N total = 126 N IG = 61 N CG = 65	Leg club	Home care by specially trained nurses,	✓	X	(✓)
Heinen 2012 Netherlands	N total = 136 N IG = 92 N CG = 72	Leg club	Usual care	X	X	(✓)
0'Brien 2017 Australia	N total = 63 N IG = 31 N CG = 32	Home‐based progressive exercises	Usual care	✓	(✓)	(✓)
Jull 2009 New Zealand	N total = 40 N IG = 21 N CG = 19	Home‐based progressive exercises	Usual care	✓	X	(✓)
Domingues 2018 Brazil	N total = 71 N IG = 49 N CG = 53	Lifestyle orientation program	Usual care	X	✓	✓
Klonizakis 2018 United Kingdom	N = 39 N IG = 18 N CG = 21	Supervised exercise program intervention	Usual care	✓	X	✓
Baquerizo 2015 United States	N = 20 N IG = 10 N CG = 10	Video	Pamphlet	X	X	X

Note: Healed (yes/no): Number (or proportion) of patients with healed ulcer after 12 weeks in intervention and control group, Healing PUSH: PUSH score at 12 weeks (and at baseline) in intervention and control groups (location and dispersion measure), Healed cm²: Reduction of ulcer area (in cm²) after 12 weeks (and to baseline) in intervention and control groups (location and dispersion measure) ✓ = Outcome is reported according to definition, (✓) = Outcome is reported, but not exactly as defined, X = Outcome is not reported; PUSH: Pressure Ulcer Scale of Healing.

Five of the included studies assessed the Leg Club and its effect on wound healing and various secondary outcomes such as pain, quality of life, and functional ability. ¹⁴ , ²³ , ²⁴ , ²⁵ , ²⁶ The Leg Club is a model of community‐based leg ulcer care, which promotes patient education and social interaction. Education in VLU management is provided by specifically trained nurses at “dressing stations” alongside routine wound care. The Leg Club aims to improve understanding of disease, wound care, and use of compression therapy in combination with physical activity (walking and leg exercises). ¹¹ Furthermore, it promotes encounters and exchanges between patients and integration into a community. ³²

O'Brien et al. and Jull et al. evaluated an educational intervention for home‐based progressive resistant exercises (HBPE) ²⁷ , ²⁸ in addition to guideline‐based compression therapy and wound care. The HBPE is intended to improve calf muscle function and wound healing alongside standard treatment. Patients received education on the use and exertion of calf exercises by research nurses. In the study by O'Brien et al., patients additionally received an author‐developed exercise booklet. HBPE could be performed in the patients' own homes without equipment. ²⁷

Klonizakis et al. implemented a supervised exercise program (SEP) to promote mobility and shorten the healing time of ulcers. The intervention was held weekly in groups of a maximum of four participants and was supervised by physiotherapists who had several years of experience. Training comprised education about the effect of mobility on ulcer healing and practical exertion of exercises in addition to standard compression therapy and regular wound care. ³⁰

Domingues et al. ²⁹ described a lifestyle orientation program (LO) as an intervention for VLU patients in addition to regular treatment. ²⁹ The LO is based on guidelines for VLU management comprising education about the importance of compression therapy and specific exercises for lower extremities. The educational intervention was carried out in person by the lead researcher and lasted an average of 40 min alongside the distribution of information brochures. Four sessions were held every 4 weeks (30 days) for reinforcement and clarification of individual problems and questions. Between the personal meetings, contact was maintained by telephone.

3.2. Main outcome

3.2.1. Wound healing rate

Of the nine studies considered for further quantitative synthesis, six studies consisting of in total 343 patients investigated and reported the wound healing rate in a way allowing them to be combined in a meta‐analysis. The forest plot (Figure 2) shows the treatment effects of the individual studies in terms of ORs and the estimated pooled treatment effect of educational interventions. The random effects model (diamond shape) shows an effect, even if not significant, in favour of educational interventions (OR:1.91; 95%‐CI 0.99–3.67, P = .053). Since it has the biggest sample size (n = 60) and the most precise estimated treatment effect of all included studies, the study by Harrison 2009 ²⁶ received the highest weight (25,7%) in the meta‐analysis model. The heterogeneity was estimated to be moderate with I ² = 46% and τ ² = 0.299. When looking at the effect estimates (OR) of the individual studies within the forest plot on wound healing rates, the Leg Club intervention in one study ²⁷ had a significant effect on wound healing rates within 12 weeks (OR:3.67; 95%‐CI 1.10–12.24). The same applies for the supervised exercise program intervention ²⁸ (OR:6.75; 95%‐CI 1.43–31.79).

FIGURE 2.

Forest plot summarising the meta‐analysis of wound healing rate

3.2.2. Ulcer size

Three studies ²³ , ²⁴ , ³⁰ consisting of in total of 128 patients were included in the meta‐analysis focusing on the change in ulcer size. Although Edwards et al. ²³ and Domingues et al. ²⁹ investigated the ulcer size, results could not be included in the quantitative analysis because no measure of dispersion was reported and information from the authors could not be obtained. The random effects (Figure 3) model shows a significant effect in favour of the LC intervention and the SEP intervention (MD: −7.22 cm²; 95%‐CI‐11.91–2.53) with the greatest weighting being assigned to the study by Edwards 2008 (49.9%) (Figure 2). Unlike the study by Edwards 2005 and Klonizakis 2018, the study by Edwards 2008 measured ulcer size at baseline and after 24 weeks rather than after 12 weeks. The heterogeneity statistics were estimated as I ² = 38% and τ ² = 5.82.

FIGURE 3.

Forest plot summarising the meta‐analysis of ulcer size

3.2.3. PUSH‐score

Four studies included the presentation of the PUSH score. Since only one study reported the mean and standard deviation of the PUSH score in both groups, no meta‐analysis could be performed for this outcome measurement since missing information could not be located even by the authors. Nevertheless, one study by Edwards et al. showed a significant improvement in the PUSH score by the LC intervention. ²⁵ Two other studies showed a tendency for educational interventions (LC, LO) to have a positive impact on the PUSH score. ²³ , ²⁹

3.2.4. Sensitivity analysis

In both the best‐case (Figure 4) and worst‐case (Figure 5) analyses, none to only slight differences in the ORs of the studies as well as the pooled OR were observed. When assuming that all 14 patients lost to follow‐up after 12 weeks achieved healed ulcer wound, the 95% CI of the pooled OR gets narrower showing a slightly significant effect (Figure 5).

FIGURE 4.

Best case analysis—forest plot summarising the meta‐analysis of wound healing rate

FIGURE 5.

Worst case analysis—forest plot summarising the meta‐analysis of wound healing rate

3.3. Additional outcomes

3.3.1. Pain

In total, the secondary outcome of pain was presented in seven studies. Due to heterogenous outcome measures, a quantitative evaluation was not possible. Scales used to assess pain were the McGill Short Form Pain Questionnaire (SF‐MPQ), the Medical Outcomes Study Short‐Form Health Survey (SF‐36), including pain as a component, ²⁶ Medical Outcomes Study (MOS) Pain Measures, ²⁴ the numeric rating scale (NRS), ²⁹ and the EQ‐5D pain score. ³⁰ Only the Edwards et al. 2008 study ²³ showed a significant reduction in pain. In this study, the intervention group's mean scores had significantly greater decreases in the severity of the pain subscale, the effect of pain subscale, and the overall total pain score when compared with the control group. Other studies also showed an improvement in pain, but without significant results. ²⁵ , ²⁹ , ³⁰ The Jull et al. study ²⁸ and the Edwards et al. pilot study ²³ did not provide a detailed description of pain in the outcome section. Jull describes pain as an adverse event that occurred more frequently in the IG.

3.3.2. (Health‐related) quality of life

The secondary outcome quality of life was presented in a heterogenous manner in a total of five studies. Scales used to assess quality of life were the Medical Outcomes Survey Short Form‐8 questionnaire (SF‐8), ²⁷ the Spitzer Quality of Life Index, the Geriatric Depression Scale, and the Philadelphia Geriatric Centre Morale Scale, ²⁵ the Freiburg Life Quality Assessment for Wounds (FLQAw), ²⁹ the EQ‐5D‐5L, and VEINES‐QOL, ³⁰ and the Short‐form Health Survey. ²⁶ In the RCT by Edwards 2008, ²³ participants who received care under the Leg Club model demonstrated significantly improved outcomes in quality of life. In the study of Klonizakis et al., participants of the intervention group had a higher baseline quality of life score, and the difference between the groups increased over time. ³⁰ In the studies by O'Brien 2016, ²⁷ Harrison et al. ²⁶ and Domingues et al. ²⁹ the interventions of HBPE, ²⁷ LC, ²⁶ and LO ²⁹ failed to demonstrate a significant difference in health‐related quality of life between the groups.

3.3.3. Functional ability

Three of the nine included studies reported the outcome of functional ability. ²⁴ , ²⁷ , ³⁰ Scales used to assess functional ability were the Gait and Balance measure and Range of Ankle Motion (ROAM) as well as different self‐reported questionnaires. The RCT by Edwards 2008 indicated that the Leg Club intervention resulted in a significant improvement in functional ability (P = .044). ²⁴ The study by Klonizakis et al. showed that in terms of physical functioning ‐ all participants in the exercise group (supervised exercise program) had higher mean scores on all tests. ³⁰ In the study by O'Brien 2016, ²⁷ the per protocol analysis indicated that among participants who adhered more than 75% of the time (n = 19), a significant improvement in ankle range of motion resulted from the self‐management exercise program.

4. RISK OF BIAS

The overall risk of bias (Figure 6) of included studies shows some concerns. One reason for this is the small sample sizes of the included studies. Another reason for this is that in some studies it was not possible to blind the patients and the persons delivering the intervention. All trials had comparable baseline clinical characteristics. None of the included studies had an incomplete report or selective reporting.

FIGURE 6.

Risk of bias

5. DISCUSSION

This systematic review and meta‐analysis aimed to assess the potential of educational interventions for patients with VLU to improve wound healing and secondary outcomes, such as pain, quality of life, and functional ability compared to treatment as usual. The random effects model showed a significant effect on the reduction of ulcer size in favour of educational interventions. With regard to wound healing rate at 12 weeks, the intervention revealed a treatment effect, although it could not be detected at the nominal significance level on the basis of the available studies. Further positive effects due to educational interventions could be proven by several RCTs for pain, ²³ quality of life, ²³ , ³⁰ and functional ability, ²⁴ , ²⁷ unless a quantitative analysis was not feasible for these outcomes. However, it seems reasonable that improved wound healing may influence these outcomes. Thus, educational interventions not only have the potential to improve wound healing, but also affect other outcomes that are highly relevant for affected patients.

Educational interventions aim to enlighten patients about their disease and actively involve them in the treatment process. This means that patient education can be understood as a planned interactive process to support and encourage patients to manage their lives with disease and to improve besides wound healing their health and overall well‐being. ³³ As a result, responsibility can transfer to them, which can have a positive impact on adherence to treatment since a higher self‐efficacy expectation may encourage patients to take a more active part in treatment.

The aspect of adherence to therapy seems particularly important in VLU treatment. Non‐adherence to compression therapy has been shown to be associated with delayed wound healing and a 2‐20‐fold increase in the recurrence rate. Lacking patient education by healthcare professionals during the treatment process and consecutive knowledge deficits regarding effectiveness and practical use of compression devices may be driving forces for non‐adherence. ³⁴ , ³⁵ As shown by this analysis, the Leg Club intervention appears to have a positive effect on wound healing. A key part of this intervention poses social interaction in combination with teaching lessons. ³² It seems to be vital that nurses collaborate with patients and transfer knowledge in order to achieve concordance with the treatment and prevent recurrences. The relevance of education in relation to adherence to VLU therapy was also demonstrated in the study by Protz et al. These results showed that education helps the patients to understand how compression therapy is related to the therapy goals. If patients recognise such relationships, adherence to interventions may increase. ¹⁰ Positive effects on adherence to compression therapy were also demonstrated in a study by Bogachev et al. In this study, a vein program consisting of lifestyle counselling and compression therapy showed that patients who received the interventions had higher treatment adherence and satisfaction with compression therapy.

The relevance of knowledge transfer within the context of social interaction is also reflected in the HBEP, LO, and SEP interventions, which, however, have mainly focussed on education and training for exercises. The beneficial effect of exercises on wound healing in VLU has already been demonstrated by a meta‐analysis by Jull et al. ³⁶ Wound healing disorder in VLU is primarily caused by venous stasis. Consequently, the effect of lower extremity exercises on wound healing seems intuitive, since they support venous reflux and counteract venous hypertension. This is most effective in combination with compression therapy, as exercises activating the calf muscle complex support its working pressure. Therefore, exercise programs for VLU treatment should focus on progressive resistance calf exercises such as heel raises. Combining calf muscle training with aerobic activities like ambulation or treadmill training may increase the effectiveness of physical training. ³⁶ Consequently, this simple general measure should be part of standard treatment. Since it is not intuitively conclusive for affected patients, knowledge about the efficacy, and safe conduction of exercises must be transferred adequately and individual limitations must be integrated into recommendations. In addition, regular exercise in the community could help to overcome social isolation, which may be helpful since most VLU patients are elderly with comorbidities and lack social support. ³⁷

The results of this meta‐analysis suggest that educational interventions may be an efficient strategy to improve the treatment of VLU. The interventions included in this analysis may serve as a role model, however, some of them are complex and may have to be implemented on a structural level. On the other hand, on the level of caregivers, a shift from simple wound treatment, which in modern wound management is strongly focused on local treatment and wound dressings, to a more interpersonal approach integrating regular interaction and education may be promising to improve the treatment of VLU patients. It could help patients to take an active role and may strengthen adherence to the main elements of VLU therapy. For example, education regarding the effectiveness of compression therapy on wound healing, as well as strengthening of self‐management in handling compression devices may help to promote its acceptance. Peer‐to‐peer exchange as implemented in the Leg Club model and cooperation with self‐help groups may integrate helpful social components within the treatment process. ³⁸ , ³⁹ , ⁴⁰ Finally, outpatient care should aim to educate patients about the effects and conduction of exercises as shown by the success of the HBEP, LO, and SEP interventions. Lower extremity exercises seem to be a simple and effective measure of improving wound healing in combination with compression therapy. Consequently, patients should be instructed on how to perform physical activity on an individual level.

5.1. Limitations and strengths of the study

A major strength of this systematic review and meta‐analysis is the comprehensive systematic literature search. Nevertheless, this work has some limitations. First, we did not examine for publication bias since the low power of such tests in a small number of studies does not indicate the presence or absence of publication bias. A further limitation is given with regard to the heterogeneity of the educational interventions assessed in the included RCTs. While most interventions sought a comprehensive educational approach for the management of VLUs, its focus is set individually, for example, on general wound management, compression therapy or exercises to promote wound healing. Due to the small number of included studies in the respective meta‐analysis, the heterogeneity might be underestimated. This should be considered with regard to the interpretation of the results.

6. CONCLUSION

According to best available evidence, educational interventions have the potential to promote wound healing in patients with VLU and have a positive impact on pain, quality of life, and functional ability. Consequently, integrating educational interventions into routine outpatient care may be a promising strategy to improve the treatment of VLU patients. Educational approaches should address the active and participatory role of patients, promote knowledge about main treatment elements such as compression therapy and integrate specific exercise recommendations.

FUNDING INFORMATION

The performance of the meta‐analysis is part of the project Ulcus Cruris Care, which is funded by the innovation fund of the federal joint committee of public health agencies in Germany (German: Innovationsfonds des Gemeinsamen Bundesausschusses) under the reference 01VSF19043. The funder has no role in the design of the study or the writing of the manuscript, nor do they have a role in the collection, analysis, or interpretation of the data.

CONFLICT OF INTEREST

The authors declare no potential conflict of interest.

Bossert J, Vey JA, Piskorski L, et al. Effect of educational interventions on wound healing in patients with venous leg ulceration: A systematic review and meta‐analysis. Int Wound J. 2023;20(5):1784‐1795. doi: 10.1111/iwj.14021

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available from the corresponding author upon reasonable request.