Hyperbaric Oxygen Therapy for Diabetic Foot Ulcers in Sub-Saharan Africa: A Critical Review of Clinical Evidence, Health-System Feasibility and Public Health Implications.

Diabetic foot ulcers are an important cause of morbidity, amputation, disability, and healthcare expenditure in sub-Saharan Africa.

• Limitations in preventive foot care, referral pathways, vascular services, multidisciplinary wound care, and financial protection may contribute to poor outcomes in the region.
• The review identifies the burden of diabetic foot ulcers as a significant regional public health concern.
• The paper is a critical narrative review, not a primary data study, drawing on clinical studies, systematic reviews, clinical guidelines, economic evaluations, and regional health-system literature.

Global evidence suggests that systemic hyperbaric oxygen therapy may improve wound healing in selected diabetic foot ulcer patients whose ulcers fail to heal with best standard care.

• The review characterizes this finding as applying only to 'selected patients' whose ulcers fail to respond to best standard care.
• Findings across the global evidence base were described as 'heterogeneous,' indicating inconsistency across studies.
• Evidence was drawn from clinical studies, systematic reviews, and clinical guidelines rather than from original regional data.
• The therapy is characterized as a potential adjunct to standard diabetic foot ulcer care, not a replacement.

Evidence for hyperbaric oxygen therapy reducing amputation in diabetic foot ulcer patients is uncertain.

• The review specifically distinguishes between wound healing outcomes and amputation outcomes, noting uncertainty for the latter.
• Direct regional evidence from sub-Saharan Africa is described as 'sparse.'
• The uncertainty around amputation outcomes is identified as a key limitation of the current evidence base.

Implementation of hyperbaric oxygen therapy in sub-Saharan Africa would require substantial infrastructure and system-level prerequisites.

• Identified prerequisites include reliable oxygen supply, reliable electricity, trained staff, and safe maintenance systems.
• Additional requirements include multidisciplinary care, referral pathways, sustainable financing, and feasible treatment completion.
• These infrastructure gaps are identified as major barriers distinguishing the sub-Saharan African context from settings where existing evidence was generated.
• The review integrates clinical effectiveness evidence with health-system, economic, equity, and implementation considerations specific to the region.

Hyperbaric oxygen therapy should not be considered routine or first-line treatment for diabetic foot ulcers in sub-Saharan Africa.

• The authors state the therapy 'should therefore not be considered routine or first-line treatment' in the regional context.
• This recommendation is based on the combination of heterogeneous global evidence, uncertain amputation outcomes, sparse regional evidence, and substantial infrastructure requirements.
• The conclusion applies specifically to the sub-Saharan African health-system context.

The review recommends carefully monitored referral-centre pilot programs before any wider implementation of hyperbaric oxygen therapy in sub-Saharan Africa.

• Pilots are recommended only 'where appropriate infrastructure exists.'
• Recommended pilot outcome measures include clinical outcomes, safety, treatment completion, affordability, budget impact, and equity.
• The phased approach—pilots before wider implementation—is presented as the appropriate pathway for evaluating feasibility and effectiveness in the regional context.
• Equity is explicitly included as a key evaluation criterion alongside clinical and economic outcomes.