An Evidence-Based, Sustainable Solution for Wound Management in Low-Resource Settings: Part 1

The Available Technology Dressing (ATD) Controlled Trial 

Linda Benskin, PhD, RN, SRN (Ghana), CWCN, CWS, DAPWCA, WOCNF and Richard Benskin

Editor’s Note: This series originally appeared on Today’s Wound Clinic and is adapted with permission. The peer-reviewed article from which this commentary originated is published with Wounds. Part 2 of this series can be found here. 

At any given time, as many as one in five adults in rural areas of tropical developing countries experience incapacitation due to a wound.^1,2 In otherwise equivalent populations, there are five times more bacterial-infected skin wounds in a tropical climate than in a temperate environment.³ In addition, poor nutrition, poor hygiene, and lack of knowledge frequently cause delayed healing of wounds in rural areas of developing countries.⁴ The most common cause of a chronic wound in the developing world is a poorly managed acute wound (eg, injuries, insect bites).^5,6 

Health care professionals are scarce in rural areas of developing countries, and they rarely manage wounds.^7,8 When villager family or self-care (VSC) fails, traditional health practitioners (THPs) and village health workers (VHWs) provide wound management.^9–11 The few published research articles about wounds in this setting have found that outcomes are poor and costs are high; none of the three groups of lay healthcare providers are able to manage wounds effectively.^4–6,9,12 

Since 1999, the Benskin Research Group has worked to develop a safe, effective, affordable, available, and acceptable wound management method to teach lay health care providers in low-resource settings.¹³This series of Clinical Insights pieces summarizes these 20+ years of research, culminating with testing Available Technology Dressings (ATDs), a very specific sustainable moist dressing technique which can be taught to patients and lay health care providers. 

A Closer Look at the Foundational Research

During five years of working in a remote clinic in northern Ghana, our team found that local wound remedies were often ineffective, sometimes caused serious complications, and were surprisingly expensive.^2,14 In contrast, in this setting, polymeric membrane dressings (PMDs) provided results far superior to those of any of the many other donated advanced dressings, continuously cleansing wounds, balancing moisture, controlling inflammation, and supporting wound closure in virtually every wound situation.¹⁴ Over 100 case studies were documented in detail, many of which have been presented at educational conferences. However, it was apparent that lay health providers who live in remote and conflict areas are best served if they can be taught to meet wound goals using only dressing materials that can be readily obtained from the local market or natural environment.^4,13 The quest to find a solution for this formidable challenge had begun. 

An extensive 2013 review of the literature found only four improvised moist dressing solutions considered sustainable in the tropical village setting, of which banana leaves and thin plastic appeared the most promising.⁹ However, banana leaves carry such a high bioburden that they necessitate autoclaving. This can be done in a hospital setting, but is untenable in the environments of our target populations.^15,16 The initial studies of thin plastic improvised dressings were conducted in a temperate climate (Japan), where perforated plastic food wrap (PW) proved to be safe and effective for even the most challenging pressure injuries.^17–21 A research team in India substituted plastic surgical drapes for PW on split thickness skin grafts, finding thin plastic superior to banana leaves.²² PW and surgical drapes are not available in most rural markets. However, thin clear food-grade plastic bags are used to carry soup, water, rice, and other prepared foods to the fields. Such bags, which are semi-permeable membranes, are ubiquitous in rural markets throughout the tropics.^23–25

Usual practice data, which is essential for designing a comparison study, was completely absent from the published literature.⁹ The “Story Completion” survey method was developed to address four identified cultural barriers to obtaining accurate descriptions of usual topical wound management practice, which were evaluated using standard quantitative statistical tools.^4,9 The initial survey took place in 25 villages across all four ecosystems of Ghana, West Africa in 2012.^4,26 A VHW, THP, and VSC from each of these villages completed the story for each of the seven cases, yielding 525 response narratives.^4,26,27 The study was replicated less formally later in East Africa and Southeast Asia with similar results, confirming that the essence of the usual practice data found in the initial study is likely to be broadly representative.²⁶ Almost all of the study participants stated that although they have confidence in managing many other health conditions, they felt that their wound management was inadequate.⁴ 

By far the most common method of debridement for all seven wound types was autolytic, described by study participants as applying occlusive dressings, crushed leaves, or moist herbal poultices in an attempt to keep the wound moist.⁴ However, these interventions could not consistently retain moisture overnight.^4,26 The few participants who mentioned papaya usually volunteered that it must be carefully monitored, making it unsuitable for outpatients who may not reliably return for follow-up.⁴ 

None of the participants mentioned using honey, which is unsurprising because the quality is often inferior in tropical environments.³⁴ Maggots were universally described as harmful.⁴ This is consistent with the authors’ experience: Patients whose wounds had attracted maggots inadvertently invariably complained of excruciating pain. Although Phaenicia (Lucilia) sericata (medical maggots) feed exclusively on necrotic tissue, virtually all other species of flies are non-selective, and many are invasive.^35–39 

Summary of findings from foundational research: A wound dressing solution to meet the needs of lay health care providers in tropical developing countries should reliably keep wounds moist, promoting healing and keeping wounds clean via autolytic debridement. Thin food-grade plastic showed promise as a primary dressing. A study was needed to ensure that the proposed improvised wound dressing technique, using only materials that are widely available, was safe, effective, affordable, and culturally acceptable to patients and providers. The study site needed to have sufficient numbers of patients with fairly homogeneous wounds, and they needed to live in a true tropical (not climate-controlled) setting to ensure ecological validity.⁴⁰ The study team needed to be dedicated to following a rigorous study protocol exactly. 

In the next installment of this topic, the authors will discuss their randomized controlled trial on the Available Technoology Dressing (ATD).

The below figures are used with permission from Linda and Richard Benskin:

Linda Benskin gained extensive wound management experience providing primary care for five years in a remote conflict-prone area of West Africa. She wrote a comprehensive handbook for the self-supporting village health worker training program she developed. The lack of sustainable wound management solutions in this challenging environment drove her to a deeper understanding of the basic principles and physiology underlying wound healing. 

Dr. Benskin emphasizes working with the body to promote healing, often with information-dense heavily-referenced articles and presentations. Topics include basic wound healing principles, managing wound infection, pain and inflammation, and the role of vitamin D. She presents at conferences, in classrooms and hospitals, via webinars and podcasts, in church foyers, and under mango trees. Her eager audiences have ranged from experienced surgeons to barely-literate villagers across six continents. 

Dr. Benskin works for Ferris Mfg. Corp. and independently with her husband, Richard. The Benskin Research Group developed the Available Technology Dressing technique for resource-limited settings, conducting a grant-supported RCT demonstrating its safety and effectiveness. Linda Benskin was inducted into the inaugural class of WOCN Fellows in 2023. 

References

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3.         Taplin D, Lansdell L, Allen AM, Rodriguez R, Cortes A. Prevalence of streptococcal pyoderma in relation to climate and hygiene. Lancet. 1973;1(7802):501-503.

4.         Benskin L 1959. Discovering the Current Wound Management Practices of Rural Africans: A Pilot Study. Dissertation. University of Texas Medical Branch; 2013. Accessed December 29, 2020. https://utmb-ir.tdl.org/handle/2152.3/538

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52.       Benskin LL. Trial of an Available Technology Dressing for Resource Limited Settings. Poster #204 presented at: NCCHC Spring 2023; May 1, 2023; New Orleans, LA, USA.

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60.       Benskin LL. Evidence for Polymeric Membrane Dressings as a Unique Dressing Subcategory, Using Pressure Ulcers as an Example. Adv Wound Care (New Rochelle). 2018;7(12):419-426. doi:10.1089/wound.2018.0822

61.       Feliciano I, Castillo R. Blast Injuries Successfully Managed with PolyMeric Membrane Dressing*. Poster presented at: Philippine Wound Care Society (PWCS); October 22, 2014; Manila, Philippines.

62.       Benskin L. Deep Ulceration Treated with Polymeric Membrane Dressings Until Complete Wound Closure. Poster #0727 presented at: 3rd Congress of the World Union of Wound Healing Societies; June 4, 2008; Toronto, Ontario Canada.

63.       Agathangelou C. How We Resolved the Problem of Poor Compliance with 20 Chronic Ulcers Patients by Using PolyMeric Membrane Dressings. Poster presented at: European Wound Management Association (EWMA); May 15, 2013; Copenhagen, Denmark.

64.       Campton-Johnston S, Wilson J, Ramundo JM. Treatment of painful lower extremity ulcers in a patient with sickle cell disease. J Wound Ostomy Continence Nurs. 1999;26(2):98-104.

65.       Benskin L. Excellent healing of pediatric wounds using polymeric membrane dressings... 41st Annual Wound, Ostomy and Continence Nurses Annual Conference, St. Louis, Missouri, June 6-10, 2009. Journal of Wound, Ostomy & Continence Nursing. 2009;36(3S):S14-S14.

66.       Benskin LL. Dissecting Hand Abcess Wound Treated with Polymeric Membrane Dressings* Until Complete Wound Closure. Poster #31 presented at: 19th Annual Symposium on Advanced Wound Care (SAWC); May 30, 2006; San Antonio, TX.

67.       Benskin L. Diabetic foot salvaged, wounds closed in only two months using polymeric membrane cavity filler* and polymeric membrane dressings. Poster presented at: 39th annual meeting of the Wound Ostomy Continence Nurses Society (WOCN); June 10, 2007; Salt Lake City, UT.

68.       Benskin L. Extensive tunneling lower leg wounds with exposed tendons closed quickly using various polymeric membrane dressing configurations. Poster #41 presented at: 23rd Annual Clinical Symposium on Advances in Skin & Wound Care; October 26, 2008; Las Vegas, NV USA.

69.       Benskin LL. Spreading the Revolutionary Message of Modern Wound Management Principles: Facilitating Change Among Surgeons. Poster # CS16-031 presented at: WOCN Society & CAET Joint Conference; June 4, 2016; Montreal, Canada.