Prevention and Care of Pressure Ulcers in Long-Term Bedridden Adult and Older Adult Patients in the Community: A Systematic Review

Introduction

The European Pressure Ulcer Advisory Panel defined pressure ulcers (PUs) as localized damage to the skin and/or underlying tissue, typically occurring over bony prominences, resulting from prolonged pressure or a combination of pressure and shear forces.¹ The complexity of managing pressure ulcers is compounded by various internal and external risk factors—including advanced age, malnutrition, chronic illnesses, circulatory insufficiency, immunosuppression, trauma, infection, medication effects, and hypoxia—which significantly hinder the healing process.² Consequently, maintaining skin integrity and effectively managing pressure ulcers remain significant challenges for healthcare providers.³ In this context, the acquisition and application of robust, evidence-based knowledge by healthcare professionals and caregivers are essential for the accurate and comprehensive implementation of pressure ulcer prevention and management strategies, especially within community care settings.^4,5

In the last few decades, pressure injury studies have mainly focused on hospital-acquired pressure injuries-HAPI,⁶ systematic review studies show a wide range of PU prevalence rates among hospitalized patients as 3.1% to 30.0% in the United States, 1% to 54% in Europe, 6% in Australia, and 2.7% to 16.8% in Asia.⁷ Various preventive measures and treatments have been implemented in hospitals worldwide to reduce the prevalence of PU.^8–10 However, insufficient attention has been paid to community-acquired pressure injuries (CAPI) or pressure ulcers that occur at home or in nursing homes.¹¹ In many cases, PU has already been developed prior to hospital admission. A study conducted in New England (n = 1022) found that 70.6% of the patients who already had PU before hospital admission were living at home before entering an acute care hospital, and only 21.4% were receiving home care services prior to admission.¹² Other studies have shown that the prevalence of community-acquired PU ranges from 3.3% to 11.1%.¹³ Community-acquired pressure injuries have been reported.¹⁴ Recent review evidence suggests substantial variation in community-acquired pressure injury burden across settings, with reported point prevalence ranging from 0.02% to 10.8% and period prevalence from 2.7% to 86.4%¹⁵ This issue may be particularly important in low- and middle-income settings, where community resources, equipment, and access to preventive care are often limited; for example, two systematic review in Africa reported a pooled pressure ulcer prevalence of approximately 11%.^16,17 People who have medical conditions that limit movement or who spend most of their time in bed or a chair are at high risk of developing pressure ulcers. This risk is not uniform across patient groups; for example, stroke-related immobility, spinal cord injury, and comorbidities such as diabetes are all associated with elevated PU risk, which may partly explain heterogeneity in prevention needs across studies.^18–20 However, prevention and care for pressure ulcers in these high-risk groups living in the community have rarely been studied and have not yet been reviewed systematically.

PU is associated with significant adverse outcomes, including severe pain, increased risk of infection, extended hospital stays, and even heightened mortality rates.²¹ In community care, these consequences are often compounded by factors such as reduced access to specialized care, limited mobility, and the long-term use of medical devices like catheters and feeding tubes, which can exacerbate the risk of injury.²² To address the high risk of PU among bedridden patients, a range of preventive and care strategies has been implemented in various settings. These include pressure-redistributing support surfaces, scheduled repositioning protocols, nutritional supplementation, and structured skin inspections.²³ The use of digital technologies, such as sensor-based monitoring systems, has also been explored to enhance early detection and promote adherence to repositioning schedules.²⁴ Nurse-led education programs and risk assessment tools, such as the updated Braden Quality Device Scale (Braden QD), are increasingly integrated into daily care routines.²⁵ However, despite these advancements, gaps remain in implementation fidelity, especially in community or home care settings where informal caregivers may lack training or resources.²⁶ In addition, existing digital and multidisciplinary community-based PU interventions remain limited by barriers such as digital literacy, unequal access to technology, and inconsistent care coordination across services.^27,28 Furthermore, evidence on which specific interventions are most effective under different care conditions remains fragmented. These limitations underscore the need for a comprehensive systematic review to synthesize recent evidence and inform best practices in pressure ulcer prevention and care for bedridden individuals. Thus, preventing and managing PU in this population necessitates a multifaceted approach.

In recent years, numerous studies and international guidelines have aimed to establish best practices for preventing and caring for pressure ulcers. International guidelines outline several interventions and practice recommendations for preventing PU.¹ Based on the five levels of evidence in the guidelines, from A (more than one high-quality study) to good practice statement (GPS), no studies have been reported on the evidence of nursing interventions related to the prevention of PU in long-term bedridden patients in the community. This gap highlights the urgent need for definitive, robust, and consistent evidence.²⁹ Despite widespread recognition of the problem, community care settings, where patients often experience prolonged periods of immobility, face additional challenges in consistently implementing these interventions.

In addition, research has demonstrated that the mere presence of clinical guidelines does not ensure adherence to best practices, as barriers such as insufficient training, lack of resources, and varying levels of staff compliance often impede implementation.^4,30,31 Therefore, a more structured and evidence-based approach is required to optimize care and minimize the occurrence of PUs in bedridden patients. The limited evidence for community-based PU prevention and care interventions, as highlighted in the EPUAP/NPIAP/PPPIA international clinical practice guideline,³² was a key driver for the present review.

Review Aims

This systematic review aims to synthesize existing evidence on the prevention and care strategies of pressure ulcers.

Review Questions

What interventions and strategies are available for managing and treating pressure ulcers in long-term bedridden adult and older adult patients within the community, and how can these interventions and strategies be implemented?

Materials and Methods

Design

This study was conducted as a systematic review with narrative synthesis. The final review was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA 2020) statement, and the review protocol was developed with reference to the PRISMA-P guidelines. Our processes started with formulating the review question and aim, defining the inclusion and exclusion criteria, developing the search strategy, locating and selecting relevant articles, assessing their quality, extracting data, and analyzing and interpreting the results (JBI, 2024).³³ Standardized critical appraisal instruments from the Joanna Briggs Institute (JBI), tailored to the research designs of the selected studies, were employed. Finally, the protocol to conduct the systematic review was published and prospectively registered with PROSPERO (CRD42024524789).

Search Strategy

To guide the systematic review, the PICO framework was utilized: the Population consists of long-term bedridden adult and older adult patients in community care; the Intervention focuses on nursing interventions for the prevention and care of pressure ulcers; the Comparison involves standard care practices where applicable; and the Outcome pertains to the effectiveness of strategies for preventing and treating pressure ulcers. The relevant keywords used in the search included “pressure ulcers”, “pressure injury”, “pressure sore”, “nursing interventions”, “program”, “long-term bedridden patients”, “aged”, “adult”, “older adult”, “elderly” “community care”, “prevention strategies”, and “management strategies”. To identify relevant studies, a comprehensive search was conducted across 14 databases, encompassing international, national, and grey literature sources to ensure balanced and comprehensive evidence. The databases included CINAHL, PubMed, MEDLINE, Cochrane Library, PsycINFO, SocINDEX, ERIC, IEEE Xplore, ScienceDirect, Scopus, ProQuest, CNKI, Wanfang, and Sinomed. The search focused on research publications related to nursing interventions or strategies for pressure ulcers, covering the period from March 2013 to March 2024. The following example search terms were used to access all possible and matched studies: (((((((((((“Pressure Ulcer”[Mesh]) OR (Pressure Ulcer*[Title/Abstract])) OR (Bedsore[Title/Abstract])) OR (Pressure Injur*[Title/Abstract])) OR (Pressure Sore[Title/Abstract])) OR (Decubitus Sore[Title/Abstract])) OR (Decubitus Ulcer[Title/Abstract])) OR (Skin Ulcer[Title/Abstract])) AND (((Bedridden Person OR Non-Mobile Person OR Bedridden Patients OR Bedridden Patient OR immobilized patients) OR (“Bedridden Persons”[Mesh])) OR (“Long-Term Care”[Mesh])))) AND (((Community Health Services OR Community Health Nursing OR Parish Nursing) OR (“Community Health Nursing”[Mesh])) OR (“Home Care Services”[Mesh] OR Home CareService OR Service, Home Care OR Care Services, Home OR Domiciliary Care OR Home Health Care OR Home Care))) OR (“prevent*” OR “treatment” OR “manage*”). Additionally, an ancestry search of the references of identified studies was also conducted, including a manual search of journals. Filters were articles published in the last 10 years.

Inclusion and Exclusion Criteria

The Inclusion criteria included 1) studies published in peer-reviewed journals, 2) studies conducted on long-term bedridden adult and older adult patients living in community settings, 3) studies evaluating prevention or care interventions for pressure ulcers, 4) randomized and non-randomized, controlled and non-controlled trials, quasi-experimental studies, or the studies that have an intervention study at a part of it 5) studies published in English or Chinese language and 6) studies with available full-text access. However, the studies with following characteristics including 1) studies conducted on pediatric populations or non-community settings (eg, acute care hospitals, institutionalized settings), 2) studies focusing solely on surgical interventions or pharmacological treatments for pressure ulcers, 3) animal studies, review articles, editorials, letters, and conference abstracts, 4) studies with incomplete or unavailable full-text access and 5) studies with insufficient data for analysis, were excluded from this review. All articles required for this systematic review were retrieved in full text and included in the study.

Data Extraction

On the JBI data extraction form, we recorded the authors, study design, study setting, population and sample size, outcome/measurement, significant results/conclusions, and research notes for comments. Prior to starting the review, we practiced screening articles, extracting data, and assessing quality together to ensure that the processes and results we undertook were accurate. Two reviewers (LM & JT) independently assessed the full texts of the articles and applied the inclusion criteria for filtering by Rayyan, the reference management program. If a group’s two reviewers could not agree with each other, a third independent reviewer (SB) met with the group to reach consensus. The appraisal process was employed to prevent errors and misinterpretations of research findings, thereby enhancing the quality of the systematic review. Moreover, we extracted data independently. The selected articles were divided into two groups, and each article was reviewed by two independent reviewers (Group 1: LM and WC, Group 2: CS and KR).

Quality Appraisal

The selected articles were reviewed using the Joanna Briggs Institute (JBI) standardized critical appraisal checklists to evaluate methodological quality. The checklist for randomized controlled trials (RCTs) comprised 13 items, while that for quasi-experimental studies included nine items. We developed a table to collect all relevant data from the studies, minimize the risk of errors in transcription, guarantee precision when checking information, and serve as a record for the review. The table was also used to identify themes across the studies. Reviewers’ comments and data recording were collected and organized using Rayyan reference manager software. Each study was appraised against multiple criteria, including study design, risk of bias, and reliability of outcome measures. A scoring system was applied, with each criterion rated as 1 for “yes” and 0 for “no” or “unclear”, and total score was provided at last column of the table.

Synthesis

The results from the studies were reported in a tabular form, providing a comprehensive overview that included a description of each study, its year, setting, design, sample size, interventions, duration of intervention, methods of distributing interventions, measurement techniques, and significant results or conclusions. We added a comments column to facilitate discussion and recommendations. Unfortunately, the extraction of quantitative data for meta-analysis was not possible due to the heterogeneity of study populations, variations in research designs, outcome measures, timing of measurements, and data analysis methods across the studies. We summarized the prevention and care strategies for long-term bedridden patients in older adults, incorporating additional discussion and suggestions.

Results

From the initial search results of 1976 articles, 295 duplicate records were removed. The titles and abstracts of the remaining 1681 records were then screened. During this stage, 1647 records were excluded based on title/abstract screening. As a result, 34 full-text articles were assessed for eligibility, of which 18 were excluded with reasons. Finally, 16 studies were included in the review for data extraction, critical appraisal, and synthesis (Figure 1).

Figure 1 PRISMA Flow chart of the review process and results.

Characteristics of the Articles

A total of 16 studies were included in this review, encompassing various designs that evaluated pressure ulcer prevention interventions in long-term bedridden patients within community and home settings. The study designs included four quasi-experimental studies and 12 randomized controlled trials (RCTs). These studies were conducted across three countries—China, Finland, and India—but the geographical distribution of the evidence was limited. Specifically, 14 of the 16 included studies were conducted in China,^34–47 with only one study from Finland⁴⁸ and one from India.⁴⁹

A total of 1821 patients across these 16 studies were included in this review, all of whom were long-term bedridden individuals, predominantly older adults receiving care in community and home-based environments.^34–49 The largest sample size was reported, comprising 232 patients,⁴⁸ while the smallest sample size was observed, which included 33 patients.⁴⁴ Most studies targeted older adults, with ages ranging from the adult to older bedridden patients; however, exact age ranges were not consistently reported across all studies.

The studies included a range of populations, including caregivers,^{34,37–40,42–44,46,47,49} long-term bedridden patients,^{35,37,39,40,45,46} and healthcare professionals such as nurses, doctors, and wound care specialists.^34,35,48 Caregivers were a key focus in many studies, particularly those involving older bedridden patients, especially those with chronic conditions or multiple comorbidities^37–39,41. The majority of the studies took place in home care or community settings,^35,37,45,49 while some also involved mixed settings that included hospitals.^{34,36,37,40,45}

Some studies did not report on the length of patient follow-up; however, several studies, such as Ye et al (2018)^39, provided data on the length of interventions, which typically ranged from several months to a year. Zhang et al (2014)^34, for example, followed patients for one-month post-intervention to assess changes in knowledge, attitudes, and behavior, while Xu et al (2015)³⁷ extended their follow-up for over a year to evaluate the incidence of pressure ulcers and other complications.

The studies employed a variety of intervention delivery methods, ranging from face-to-face education and home visits to technological support like smartphone apps and WeChat. Detailed descriptions of the interventions and their delivery methods are presented (Table 1).

Table 1 Data Extraction for the Included Studies

Methodological Appraisal of the Included Studies

The methodological appraisal showed that the included studies were generally of acceptable methodological quality (Tables 2 and 3). No study was rated as low quality. Nevertheless, several methodological limitations were identified. These included lack of a control group^34,36, unclear intervention duration or outcome assessment timing,^35,36,41,42 short follow-up,^34,43,46 small sample sizes,^40,43,46 limited use of validated outcome measures,^42,43 and insufficient reporting of intervention fidelity or adherence.⁴⁵ These limitations may have increased the risk of bias in some studies. They should be taken into account when interpreting the review’s findings—specifically, the certainty of the evidence across outcomes.

Table 2 JBI Critical Appraisal Checklists for Randomized Controlled Trials

Table 3 JBI Critical Appraisal Checklists for Quasi-Experimental Studies

Certainty of Evidence Across Outcomes

The certainty of evidence was assessed using the GRADE approach⁵⁰ at the outcome level across the body of evidence, rather than at the level of individual studies (Table 4). Moderate-certainty evidence suggested that the interventions may reduce the incidence of pressure ulcers and improve Braden scores and caregivers’ knowledge, attitudes, and practices. Low-certainty evidence suggested that the interventions may improve quality of life and satisfaction, and may also improve economic outcomes, including reduced PU-related medical expenses and hospitalization rates. However, the evidence regarding pressure ulcer severity or healing was of very low certainty, suggesting that the interventions’ effects remain unclear. The main reasons for downgrading the certainty of evidence were risk of bias, inconsistency, and imprecision.

Table 4 GRADE Assessment of the Certainty of Evidence for Each Review Outcome

Measurement

The 16 studies in this review used nine main tools to evaluate the effectiveness of pressure ulcer prevention and care. The incidence of pressure ulcers was the most reported measure, used in all studies to assess whether interventions reduced the number of new cases. The Braden Pressure Ulcer Risk Assessment Scale was reported in six studies,^{35,36,38,39,45,49} to evaluate patients’ risk levels before and after interventions. The Katz Index was used to measure improvements in patients’ daily living abilities.⁴⁹ Knowledge-Attitude-Practice (KAP) questionnaires were used to assess changes in caregivers’ and patients’ knowledge and behaviors related to pressure ulcer prevention in three studies.^34,44,45

Nursing satisfaction and patient satisfaction scales were reported in studies evaluating care quality after interventions.^38,41,46 The quality of life was measured using the SF-36 in studies to assess overall patient well-being.^38,42,43 Additionally, economic cost tracking was used to evaluate changes in care and hospitalization expenses.^40,46

Heterogeneity and Rationale for Narrative Synthesis

Significant clinical and methodological heterogeneity across the 16 included studies supported the use of a narrative synthesis. First, the included studies differed substantially in outcome measures and observation periods. Although some studies^39,45,49 used the Braden Scale to assess pressure ulcer (PU) risk, these findings were not pooled because follow-up durations varied considerably. For example, Kaur et al (2018)⁴⁹ followed patients for 12 months, whereas Ye (2018)³⁹ and Zhang et al (2020)⁴⁵ reported outcomes at shorter or less clearly comparable time points. Because PU risk is dynamic and may change over time with changes in immobility status and care exposure, combining results from such different follow-up periods could yield clinically misleading estimates. In addition, other studies used different outcome indicators, including PU incidence,^35,36,47 caregivers’ knowledge, attitude, and practice (KAP) scores^34,43,44 and wound healing outcomes,⁴² which further limited direct comparison of effect magnitude across studies.

Intervention content and intensity also varied widely, ranging from traditional manual-based guidance⁴⁰ to more intensive system-level models such as the Tight Medical Alliance³⁶ and digital health approaches using WeChat platforms or smartphone applications.^40,42 Finally, contextual heterogeneity was evident across study settings, from rural community home care³⁶ to international long-term care facilities⁴⁸ reflecting differences in baseline nursing resources, care structures, and patient characteristics. Taken together, these sources of heterogeneity made meta-analysis inappropriate and supported a narrative synthesis approach.

Prevention and Care for Pressure Ulcers in Long-Term Bedridden Patients

Pathways

The intervention pathways for pressure ulcer prevention and care in community-dwelling long-term bedridden adults and older adults form a multi-dimensional integrated system, mainly including face-to-face intervention including education and training^34–49 and Model Demonstration^34,43 as the foundational on-site guidance methods—through structured training, individualized guidance, educational materials, visual videos, and interactive workshops to improve patient and caregiver KAP, with enhanced retention and recall for different literacy groups; Home Visit^{34–39,41–47} as the core follow-up measure, with frequency adjusted based on Braden Scale scores (weekly for ≤12, biweekly for 13–14, monthly for 15–16); WeChat/Smartphone App^{36,39,40,43,45–47} as the technology-assisted tools breaking time and space limitations—featuring functions like education push, skin photo submission, Braden calculator, reminders, and teleconsultation to reduce incidence, hospitalization rates, and specialist response time; Group Intervention^37,46 for interactive experience sharing; Individual Intervention^40–42,46 tailored to personalized needs; Telephone Follow-up/Telephone Contact/Telephone Consultation^{35–37,39,40,43–45,47} as the convenient remote supplementary method; Family Doctor Contract Service³⁶ for collaborative support; and multidisciplinary collaboration integrating hospital, community, and family resources^{36,39–42,45–48} —via case conferences, 24-hour hotlines, shared electronic health records, and standardized care pathways to improve coordination and reduce unnecessary hospital visits, jointly ensuring the continuity, pertinence and effectiveness of interventions.

Intervention Details

Position Management and Pressure-Relief Techniques

Seven studies^{35,38,40,42,45,47,48} explored position optimization and pressure redistribution to reduce tissue ischemia. A study by Zhang et al (2023)³⁵ randomized 160 elderly patients into an experimental group (2-hour alternating supine-lateral positioning and alternating-pressure air mattresses) and a control group. The experimental group showed a lower pressure ulcer incidence (9.72% vs. 31.34%) and delayed initial ulcer onset (6.25±2.76 vs. 3.63±0.85 months). For pain-limited patients, pre-repositioning analgesia³⁸ increased cooperation from 32% to 78%. A rural-focused study⁴⁷ distributed low-cost foam pads, reducing sacral ulcer incidence by 52%. High-risk patients (Braden ≤12) who received 30° lateral tilt guidance³⁶ had a 6-month ulcer incidence of 1.7%, compared to 11.7% in controls. Mäki-Turja-Rostedt et al’s (2023)⁴⁷ introduced smart pressure sensor mats for high-risk patients, triggering alerts when interface pressure exceeded 32 mmHg, which improved adherence to turning schedules from 58% to 89%. Digital posture correction tools^40,42 enhanced positioning accuracy by 27% (Supplement Table 1).

Skin Integrity Maintenance

Six studies^{34,36,39,44,45,48} focused on skin care, including cleaning, incontinence management, early ulcer detection, and wound care. One Study³⁴ recommended cleaning with water (37–40°C) and neutral soap, and zinc oxide for incontinent patients, resulting in a 52% reduction in skin redness. A study by Zheng et al (2018)³⁶ trained caregivers to use the “press-test” (15-minute erythema fade test) for early detection and applied hydrocolloid/foam dressings for Stage I–II ulcers, achieving a 68% healing rate within 4 weeks. Hypoallergenic lotions³⁹ reduced skin cracking by 45% in xerotic patients, while draw sheets³⁵ minimized abrasions by 38%. A skin assessment checklist⁴⁵ improved the detection of ulcers in dark-skinned patients by 35%. Mäki-Turja-Rostedt et al’s (2023)⁴⁸ validated a digital skin imaging system for early ischemia detection, which increased Stage I ulcer identification by 29% compared to visual inspection. Additionally, their standardized saline irrigation protocol reduced Stage II ulcer infection by 22% (Supplement Table 1).

Nutrition and Fluid Support

Five studies^{35,38,40,42,48} linked nutrition to skin integrity and tissue repair. Study²⁶ recommended a daily protein intake of 1.2–1.5g/kg (eg, eggs, lean meat) and high-vitamin diets. Enteral supplements for patients with poor appetite³⁸ increased serum albumin levels (38.5±2.1 vs. 32.3±1.8g/L) and reduced ulcer incidence (10% vs. 28.33%). Weekly dietary counseling for malnourished patients (MNA <17)³¹ shortened healing time by 30%. Low-cost rural meal plans⁴² (eg, bean curd-egg stir-fry) improved dietary adherence from 32% to 68%. The Finnish study³⁸ emphasized omega-3 fatty acid supplementation (1g/day) for patients with chronic inflammation, improving skin barrier function by 24% and reducing ulcer recurrence by 18%. Their fluid intake protocol (1500–2000 mL daily) also reduced dry skin damage by 29% (Supplement Table 1).

Significant Outcomes

This systematic review identified nine primary instruments used across 16 included studies to measure significant key outcomes related to the prevention and care of pressure ulcers among long-term bedridden patients in community settings. These instruments included pressure ulcer incidence rates in all included studies, the Braden Pressure Ulcer Risk Assessment Scale,^{34,36,38,39,45,49} the Katz Index of Independence in Activities of Daily Living,⁴⁹ Knowledge-Attitude-Practice (KAP) questionnaires,^34,44,45 nursing satisfaction scales,^38,43,46 patient satisfaction questionnaires,^41,46 the Quality-of-Life measures,^38,42,43 and economic cost tracking tools for care and hospitalization expenses.^40,46

A reduction in the incidence of pressure ulcers was reported following interventions across the included studies, suggesting potential benefits of community and family-based care models. For example, Zhang et al (2023)³⁵ reported a reduction in pressure ulcer incidence from 31.34% to 9.72% following community-based family nursing interventions, while Xu et al (2015)³⁷ found a reduction from 25% to 6.25% after individualized health guidance interventions. Similarly, Kaur et al (2018)⁴⁹ reported a reduction in stage I pressure ulcers in an Indian community intervention, and Dong et al (2019)⁴⁰ reported a decrease in incidence from 22% to 6% through smartphone-based follow-up care.

Improvements in Braden Pressure Ulcer Risk Assessment scores were also observed. Yang et al (2016)³⁸ reported an improvement in Braden scores following intervention using a WeChat-assisted home visitation model, while Zhang et al (2023)³⁵ also reported better Braden scores, indicating a lower risk of pressure ulcers after family-centered community nursing care.

In addition to reducing the risk of pressure ulcers, improvements in patient mobility were reported as an outcome of the interventions. Kaur et al (2018)⁴⁹ reported that 87% of moderately dependent patients in the intervention group showed improved mobility post-intervention, as assessed using the Katz Index.

Educational interventions targeting caregivers appeared to improve caregiving efficiency and reduce caregiver burden as Zhang et al (2014)³⁴ and Wang et al (2020)⁴⁴ reported improvements in caregiver knowledge, attitudes, and practices, reflecting enhanced caregiving abilities.

Improvements in nursing and patient satisfaction were also observed in several studies,^38,41,46 suggesting enhanced care experiences in intervention groups. Yang et al (2016)³⁷ documented an increase in nursing satisfaction from 75% to 92.5% following interventions using WeChat in conjunction with home visits. Similarly, Bu et al (2020)⁴⁵ found that integrated hospital-community-family care models were associated with higher nursing satisfaction and overall care quality. Additionally, Fan (2019)⁴⁰ reported marked increases in patient satisfaction following comprehensive community nursing interventions.

Quality-of-life improvements were also reported as significant outcomes. Yang et al (2016)³⁸ and Liu (2018)³³ observed significant improvements in SF-36 Quality of Life scores among patients in the intervention groups, indicating possible enhancements in physical, social, and psychological well-being.

Economic cost reductions emerged as a notable outcome in studies that evaluated healthcare resource utilization. Dong et al (2019)⁴⁰ reported lower care-related expenses and hospitalization costs in groups using smartphone app-based interventions for pressure ulcer prevention. Similarly, Bu et al (2020)⁴⁶ highlighted reductions in overall care costs associated with fewer hospital admissions and more efficient community follow-up systems (Table 1).

Discussion

The primary aim of this systematic review was to synthesize current evidence of interventions or strategies for the prevention and management of pressure ulcers (PUs) in long-term bedridden adult and older adult patients within community care settings. While numerous studies have examined PU prevention in acute or institutional settings^9,25,51 research specific to community and home environments remains fragmented and underrepresented. To address this research gap, the present review summarized evidence regarding two interconnected core components of PU prevention and care in community settings: multi-dimensional intervention pathways and three targeted preventive measures. The latter encompasses position management with pressure-relief techniques, skin integrity maintenance, and nutritional and fluid support. This synthesis helps to reduce the fragmentation inherent in prior community-focused PU research and suggests a range of potentially adaptable strategies for use in diverse community care environments.

First, the multidimensional intervention pathway—integrating face-to-face education, home visits, digital tools (eg, WeChat/Smartphone Apps), multidisciplinary collaboration, and remote follow-up—aligns with the “person-centered continuity of care” model recommended by the European Pressure Ulcer Advisory Panel (EPUAP, 2019).³² This comprehensive pathway addresses the well-recognized fragmentation in traditional community-based care. Evidence from the included studies suggests that structured face-to-face interventions, supplemented by model demonstrations and low-literacy-oriented visual materials, can improve caregivers’ knowledge, attitudes, and practices (KAP) across various settings.^2,9,39,48 Meanwhile, the integration of digital support may help to remove temporal and geographical barriers: WeChat-based photo feedback⁴⁶ and smartphone wound-care applications⁴¹ have been associated with reductions in pressure ulcer incidence from 22–30% to 6–12% in community-dwelling older adults. These findings align with telehealth evidence showing improved adherence to pressure-ulcer-preventive behaviors among community care recipients.⁵² Furthermore, embedding multidisciplinary coordination—typically involving specialists, community nurses, and dietitians—may help strengthen care continuity. Mäki-Turja-Rostedt et al’s (2023)⁴⁸ reported that shared electronic health records and team-based monitoring were associated with fewer preventable hospital visits, although this finding should be interpreted cautiously given the limited evidence base, an advantage not commonly achieved by single-pathway interventions highlighted in earlier reviews.

However, this multidimensional pathway is not without limitations that warrant targeted improvements. Disparities in digital accessibility and literacy remain a critical barrier: while digital tools may be more feasible in urban settings, rural or elderly caregivers with limited digital skills (eg, inability to upload skin photos or navigate apps) may be less able to benefit from such interventions, potentially widening health inequities.⁵³ Second, inconsistent intervention fidelity across components may limit potential benefits: face-to-face training may be standardized, but home visits and remote follow-up are prone to variability in frequency and quality due to community nurse workloads or inadequate monitoring^36,45. Third, insufficient integration of caregiver burden is a notable gap—long-term caregiving stress can erode adherence to KAP gains, yet current pathways rarely include tailored psychological support or respite care referrals for caregivers.^41,44 Fourth, limited adaptability to resource-constrained settings may hinder broader implementation: multidisciplinary collaboration relies on well-coordinated healthcare systems, which are often lacking in low- and middle-income countries, while digital tools require reliable internet access that may not be universally available.⁴⁸

Regarding position management, the combination of repositioning and pressure-relief devices (eg, 9.72% vs. 31.34% incidence) is consistent with biomechanical evidence that maintaining interface pressure below 32 mmHg can help mitigate tissue ischemia.⁵⁴ Innovations like Mäki-Turja-Rostedt et al’s (2023)⁴⁸ smart pressure sensor mats, which were associated with adherence rates of up to 89%, demonstrate how technology can potentially reduce human error in turning schedules.⁵⁵ Yet, the lack of individualized protocols—especially for patients with pain or diabetes—remains a key challenge. This is evidenced by 28% refusal rates, highlighting a disconnect between standardized approaches and patient-centered needs.^56,57 Furthermore, rural disparities (device access <30%) emphasize that interventions must be contextually adaptive, and World Health Organization (WHO) has also highlighted the low-cost alternatives like foam pads to reduce sacral ulcers in resource-limited settings. A meta-analysis also supports the use of silicone foam dressings as a potentially effective strategy to reduce the incidence of stage II or higher pressure injuries, including sacral ulcers, by 52% compared to standard care.⁵⁸

In terms of skin integrity maintenance, Zhang et al (2014)³⁴ found support for a reduction in skin redness associated with temperature-controlled cleaning and zinc oxide use, reinforcing the importance of preventive skin care in interrupting the progression of pressure ulcer development (NPIAP, 2022; Tan & Hu, 2023).^59,60 Moreover, the Mäki-Turja-Rostedt et al’s (2023)⁴⁸ digital imaging system’s reported 29% improvement in early detection addresses a longstanding limitation in visual assessments, particularly for patients with darker skin tones, where erythema-based diagnoses may miss 35% of cases (Miller et al, 2020).⁶¹ However, caregiver difficulties in dressing management were also reported, which reflects a lack of standardized care pathways. This is consistent with international studies showing that inconsistent wound care can prolong healing by 30–40%, further underscoring the need for algorithm-driven guidance, such as determining dressing change frequency based on ulcer stage.⁶²

Nutritional support continues to be a critical modifiable determinant of skin resilience, as evidenced by high-protein diets and enteral supplements that were associated with higher serum albumin levels (38.5 ± 2.1 g/L),³⁸ which may contribute to improved skin health and reducing pressure ulcer risk (Smith et al, 2020).⁵⁴ The Mäki-Turja-Rostedt et al’s (2023)⁴⁸ study’s finding that omega-3 supplementation was associated with improved skin barrier function by 24% provides new insights into the role of anti-inflammatory nutrition in preventing PU recurrence, expanding beyond traditional protein-focused strategies.^63,64 Nevertheless, key gaps remain, such as the absence of validated screening tools like the Mini Nutritional Assessment (MNA) in most studies (only four of the 16 studies^35,38,40,48 used it), as well as unclear protein doses for patients with renal insufficiency. These gaps reflect the broader issue of imprecision in nutritional care, aligning with the ESPEN guidelines, which caution against “one-size-fits-all” protocols, as malnutrition undertreatment or overtreatment can increase PU risk by 25–35%.⁶⁵

One of the most compelling findings of this review is that integrated protocols may improve care efficiency, such as combining Braden-stratified repositioning, high-protein diets, and app monitoring.⁴⁰ These integrated approaches may provide benefits beyond individual interventions. Education enhances the utility of technology, as evidenced by WeChat videos improving repositioning accuracy to 89%, while multidisciplinary teleconsultations have been associated with shorter Stage II+ ulcer healing time by 35% (Miller et al, 2020).⁶¹ The Finnish model,⁴⁸ which combines cross-sectoral teams, digital imaging, and omega-3 supplementation, was associated with a lower recurrence rate compared to single-modal care, emphasizing that PU prevention is likely to require coordinated rather than isolated interventions.⁶⁶

Strengths and Limitations

This review reveals several strengths and limitations. A major strength lies in its focused attention on the under-researched population of community-dwelling, long-term bedridden adults and elderly individuals. By synthesizing studies from diverse regions, the review captures cross-cultural variations in care and addresses a critical evidence gap between institutional and community settings. Additionally, the systematic review benefited from the initial draft being thoroughly reviewed by the entire research team, including clinicians and methodological experts, ensuring both clinical relevance and methodological rigor. The involvement of library staff in the database searching process further strengthened the review by ensuring a comprehensive and precise literature search across multiple English databases.

This review also has several limitations. Heterogeneity in study designs, measurement tools, outcomes, and intervention methods limited the comparability of findings and hindered the ability to draw firm conclusions regarding the superiority of specific interventions or technologies. For example, different studies used different scales or indicators to assess outcomes such as pressure ulcer risk, caregiver competence, satisfaction, and quality of life, making it difficult to compare the magnitude of effect across studies. Furthermore, because community care is not a prominent component of healthcare services in many European and American countries, only one eligible study from these regions, conducted in Finland, was identified. In addition, 14 of the 16 included studies were conducted in China, with only one study from India, indicating limited geographical diversity in the evidence base and restricting the generalizability of the findings. In addition, many studies did not provide detailed implementation guidance—for example, the recommended frequency of repositioning or the precise use of pressure-relieving devices—thereby constraining the practical applicability of the findings. These limitations are also consistent with the moderate- to very low-certainty evidence identified across outcomes, particularly where risk of bias, inconsistency, and imprecision reduced confidence in the findings. Most studies had short follow-up periods (<1 year), with limited data on intervention sustainability and long-term PU recurrence (2–3 years). In addition, few studies reported cost-effectiveness, which is important for scaling interventions in resource-constrained settings.

Conclusions and Recommendations

This systematic review (16 studies) identifies two interdependent core elements for community-based pressure ulcer (PU) care in long-term bedridden/older adults: multi-dimensional intervention pathways (face-to-face education, home visits, digital tools, multidisciplinary collaboration, remote follow-up) and targeted preventive measures (position management with pressure relief, skin integrity maintenance, and nutritional/fluid support). Together, may be associated with improvements in PU-related outcomes: single-component interventions reduced PU incidence by approximately 3%–22%, whereas multidimensional composite interventions were generally associated with larger reductions of about 15%–25%, along with about 2–3 point improvement in pressure ulcer risk scores and more sustained long-term effects. However, these findings should be interpreted cautiously because the certainty of evidence ranged from very low to moderate across outcomes. Limitations include heterogeneous study designs, limited representation of Western populations, incomplete reporting of implementation details, gaps in digital accessibility, and insufficient caregiver support, all of which may affect generalizability and translation into practice.

Based on the available evidence, several practical recommendations can be drawn. For clinical practice, healthcare providers may consider prioritizing prioritize multicomponent care models that combine multidimensional delivery pathways with targeted preventive measures. In community and home-based settings, bundled interventions supported by remote follow-up or digital tools may be particularly useful, whereas in institutional or centralized care settings, standardized nursing protocols combined with regular risk assessment may be more appropriate. In resource-limited areas, a basic model incorporating pressure-relief devices and essential caregiver skills training may represent a feasible first-line approach. Comprehensive caregiver support, including psychological counseling and respite care referral, may also be considered to improve implementation and sustainability. For health policy, efforts may be directed toward strengthening community healthcare infrastructure, expanding access to telehealth and pressure-relief devices, developing standardized national PU prevention and care guidelines, and enhancing workforce capacity through targeted professional training. Future research is needed to examine large-scale, multicenter randomized controlled trials with longer follow-up, greater standardization of outcome measures and intervention protocols, broader inclusion of diverse care settings and populations, and formal evaluation of the cost-effectiveness of integrated versus single-component interventions. In addition, studies should further develop and validate tailored intervention protocols for populations with distinct care needs.