Skip to main content

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


June 18, 2024
Keywords
Categories

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:

ATD

ATD

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

1.         Gibbs S. Skin disease and socioeconomic conditions in rural Africa: Tanzania. Int J Dermatol. 1996;35(9):633-639.

2.         Mahe A, Hay RJ. Epidemiology and Management of Common Skin Diseases in Children in Developing Countries. World Health Organization; 2005. Accessed February 5, 2015. http://www.who.int/maternal_child_adolescent/documents/fch_cah_05_12/en/

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

5.         Gupta N, Gupta SK, Shukla VK, Singh SP. An Indian community-based epidemiological study of wounds. J Wound Care. 2004;13(8):323-325. doi:10.12968/jowc.2004.13.8.26657

6.         Oluwatosin OM. Wound Care Practices and Challenges in Nigeria: Advances in Skin & Wound Care. 2007;20(7):375-378. doi:10.1097/01.ASW.0000280208.98163.1b

7.         Ryan TJ. Public health dermatology: regeneration and repair of the skin in the developed transitional and developing world. Int J Dermatol. 2006;45(10):1233-1237. doi:10.1111/j.1365-4632.2006.02671.x

8.         Keast DH, ed. Wound and Lymphoedema Management - Focus on Resource-Limited Settings. 2nd ed. World Alliance for Wound and Lymphedema Care; 2020.

9.         Benskin LLL. A review of the literature informing affordable, available wound management choices for rural areas of tropical developing countries. Ostomy Wound Manage. 2013;59(10):20-41.

10.       Bender DE, Pitkin K. Bridging the gap: The village health worker as the cornerstone of the primary health care model. Social Science & Medicine. 1987;24(6):515-528. doi:10.1016/0277-9536(87)90341-8

11.       Benskin LLL. A Concept Development of the Village Health Worker. Nursing Forum. 2012;47(3):173-182. doi:10.1111/j.1744-6198.2012.00270.x

12.       Belcher DW, Afoakwa SN, Osei-Tutu E, Wurapa FK, Osei L. Endemic pyoderma in Ghana: a survey in rural villages. Trans R Soc Trop Med Hyg. 1977;71(3):204-209.

13.       Benskin L. Incorporating Wound Care in a Christian Village Health Worker Training Program. Poster #2 presented at: 8th Annual American Professional Wound Care Association; April 2, 2009; Philadelphia, PA USA. https://www.researchgate.net/publication/268106196_Incorporating_Wound_…

14.       Benskin LL. Polymeric Membrane Dressings for Topical Wound Management of Patients With Infected Wounds in a Challenging Environment: A Protocol With 3 Case Examples. Ostomy Wound Manage. 2016;62(6):42-50.

15.       Guenova E, Hoetzenecker W, Kisuze G, et al. Banana Leaves As an Alternative Wound Dressing. Dermatologic Surgery. 2013;39(2):290-297. doi:10.1111/dsu.12067

16.       Hoetzenecker W, Guenova E, Moehrle M. Banana leaves: an alternative wound dressing material? Expert Review of Dermatology. 2013;8(5):439-440. doi:10.1586/17469872.2013.835925

17.       Toriyabe S, Saito H, Sakurai K. Use of a Food Wrap as a Dressing Material. Advances in Skin and Wound Care. 1999;12(8):405-406.

18.       Takahashi J, Yokota O, Fujisawa Y, et al. An evaluation of polyvinylidene film dressing for treatment of pressure ulcers in older people. J Wound Care. 2006;15(10):449-450, 452-454. doi:10.12968/jowc.2006.15.10.26971

19.       Takahashi J, Nakae K, Miyagawa M, et al. Plastic wrap as a dressing material to treat stage III/IV pressure ulcers in the inflammatory phase: a randomized controlled trial. Int J Clin Exp Med. 2017;10(3):5586-5594.

20.       Bito S, Mizuhara A, Oonishi S, et al. Randomised controlled trial evaluating the efficacy of wrap therapy for wound healing acceleration in patients with NPUAP stage II and III pressure ulcer. BMJ Open. 2012;2(1):e000371. doi:10.1136/bmjopen-2011-000371

21.       Takafumi K, Katsunori F, Yayoi N, et al. JSPU Guidelines for the Prevention and Management of Pressure Ulcers (4th Ed.) | Article Information | J-GLOBAL. 日本褥瘡学会誌. 2016;18(4):455-544.

22.       Gore MA, Umakumar K, Iyer SP. Polyethylene Surgical Drape Dressing for Split Thickness Skin Graft Donor Areas. In: Gore MA, ed. Skin Grafts. InTech; 2013. doi:10.5772/54195

23.       Plastic Bags, Straw and Polystyrene Ban. Jamaica Information Service. Accessed May 31, 2019. https://jis.gov.jm/information/get-the-facts/plastic-bags-straw-and-pol…

24.       ruth. Jamaica’s Scandal Bag Ban Explained —. diG Jamaica. Published September 17, 2018. Accessed May 31, 2019. http://digjamaica.com/m/blog/jamaicas-scandal-bag-ban-explained/

25.       Parker L. Plastic bag bans are spreading. But are they truly effective? National Geographic. Published April 2019. Accessed May 31, 2019. https://www.nationalgeographic.com/environment/2019/04/plastic-bag-bans…

26.       Benskin LLL. The Quest for a Sustainable Wound Management Solution for Rural Areas of Tropical Developing Countries: What We Have Learned So Far. Poster #18 presented at: 29th Annual Nursing & Midwifery Research Conference and 30th Mary J. Seivwright Day; May 30, 2019; Kingston, Jamaica. doi:10.13140/RG.2.2.28503.14247

27.       Benskin LLL. A Unique “Story Completion” Research Method For Obtaining Accurate Survey Data. Poster #32 presented at: 29th Annual Nursing & Midwifery Research Conference and 30th Mary J. Seivwright Day; May 30, 2019; Kingston, Jamaica.

28.       Asuquo M, Ugare G, Ebughe G, Jibril P. Marjolin’s ulcer: the importance of surgical management of chronic cutaneous ulcers. Int J Dermatol. 2007;46 Suppl 2:29-32. doi:10.1111/j.1365-4632.2007.03382.x

29.       Rollnick S, Miller WR, Butler CC. Motivational Interviewing in Health Care: Helping Patients Change Behavior. 1 edition. The Guilford Press; 2007.

30.       Langer V, Bhandari PS, Rajagopalan S, Mukherjee MK. Enzymatic debridement of large burn wounds with papain–urea: Is it safe? Med J Armed Forces India. 2013;69(2):144-150. doi:10.1016/j.mjafi.2012.09.001

31.       Starley I, Mohammed P, Schneider G, Bickler S. The treatment of paediatric burns using topical papaya. Burns (03054179). 1999;25(7):636-639.

32.       Research C for DE and. Questions and Answers about FDA’s Enforcement Action Regarding Unapproved Topical Drug Products Containing Papain. FDA. Published online November 3, 2018. Accessed November 29, 2023. https://www.fda.gov/drugs/unapproved-drugs/questions-and-answers-about-…

33.       Benskin L, Bombande P. Complete healing of extensive third-degree burn wound using polymeric membrane dressings. Poster #7 presented at: 7th Annual Australian Wound Management Association Conference 2008; May 7, 2008; Darwin, Australia. https://www.researchgate.net/publication/295741629_Complete_healing_of_…

34.       Rosiak E, Madras-Majewska B, Teper D, Łepecka A, Zielińska D. Cluster Analysis Classification of Honey from Two Different Climatic Zones Based on Selected Physicochemical and of Microbiological Parameters. Molecules. 2021;26(8):2361. doi:10.3390/molecules26082361

35.       Sunny B, Sulthana L, James A, Sivakumar T. Maggot Infestation: Various Treatment Modalities. The Journal of the American College of Clinical Wound Specialists. 2016;8(1-3):51. doi:10.1016/j.jccw.2018.03.002

36.       Whitaker IS, Twine C, Whitaker MJ, Welck M, Brown CS, Shandall A. Larval therapy from antiquity to the present day: mechanisms of action, clinical applications and future potential. Postgrad Med J. 2007;83(980):409-413. doi:10.1136/pgmj.2006.055905

37.       Patel BC, Ostwal S, Sanghavi PR, Joshi G, Singh R. Management of Malignant Wound Myiasis with Ivermectin, Albendazole, and Clindamycin (Triple Therapy) in Advanced Head-and-Neck Cancer Patients: A Prospective Observational Study. Indian Journal of Palliative Care. 2018;24(4):459-464. doi:10.4103/IJPC.IJPC_112_18

38.       Blechman AB, Wilson BB, Norris R. Myiasis. Medscape Emergency Medicine. Published online February 8, 2019. Accessed November 29, 2023. https://emedicine.medscape.com/article/1491170-overview#a5

39.       Deluca G. Wound Myiasis Management: What Works, What Doesn’t. BROWN EMERGENCY MEDICINE. Published October 28, 2022. Accessed November 29, 2023. http://brownemblog.com/blogposts/2022/10/5/wound-myiasis-management-wha…

40.       Gliner JA, Morgan GA, Leech NL. Research Methods in Applied Settings: An Integrated Approach to Design and Analysis, 2nd Ed. Routledge/Taylor & Francis Group; 2009:xvii, 469.

41.       Benskin L. A Test of the Safety, Effectiveness, and Acceptability of an Improvised Dressing for Sickle Cell Leg Ulcers in a Tropical Climate. clinicaltrials.gov; 2021. Accessed November 29, 2021. https://clinicaltrials.gov/ct2/show/NCT04479618

42.       Grants | Wound Healing Foundation. Wound Healing Foundation. Published 2023. Accessed December 2, 2023. https://www.woundhealingfoundation.org/grants/

43.       Cumming V, King L, Fraser R, Serjeant G, Reid M. Venous incompetence, poverty and lactate dehydrogenase in Jamaica are important predictors of leg ulceration in sickle cell anaemia. Br J Haematol. 2008;142(1):119-125. doi:10.1111/j.1365-2141.2008.07115.x

44.       Serjeant GR. The Natural History of Sickle Cell Disease. Cold Spring Harb Perspect Med. 2013;3(10). doi:10.1101/cshperspect.a011783

45.       Singh AP, Minniti CP. Leg Ulceration in Sickle Cell Disease: An Early and Visible Sign of End‐Organ Disease. In: Inusa BPD, ed. Sickle Cell Disease - Pain and Common Chronic Complications. InTech; 2016. doi:10.5772/64234

46.       Serjeant GR, Serjeant BE, Mohan JS, Clare A. Leg Ulceration in Sickle Cell Disease: Medieval Medicine in a Modern World. Hematology/Oncology Clinics of North America. 2005;19(5):943-956. doi:10.1016/j.hoc.2005.08.005

47.       Minniti CP, Eckman J, Sebastiani P, Steinberg MH, Ballas SK. Leg Ulcers in Sickle Cell Disease. Am J Hematol. 2010;85(10):831-833. doi:10.1002/ajh.21838

48.       Flattau A, Gordon H, Vinces G, Ennis WJ, Minniti CP. Use of a National Electronic Health Record Network to Describe Characteristics and Healing Patterns of Sickle Cell Ulcers. Adv Wound Care (New Rochelle). 2018;7(8):276-282. doi:10.1089/wound.2018.0788

49.       Britannica.com. Technology. Published October 16, 2023. Accessed December 1, 2023. https://www.britannica.com/technology/technology

50.       CODATA, The Committee on Data for Science and Technology. Technology. CODATA, The Committee on Data for Science and Technology. Accessed December 1, 2023. https://codata.org/rdm-terminology/technology/

51.       Benskin L. Trial of an Improvised Dressing for Remote and Conflict Areas of Tropical Developing Countries. Presented at: Technology in Wound Care Conference: AAWC 2022; 2022; Salt Lake City, Utah USA. Accessed February 27, 2023. https://rgdoi.net/10.13140/RG.2.2.10887.06565

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.

53.       Venugopal R, Benskin L, Barton-Gooden A. Trial of an Available Technology Dressing for Resource Limited Settings. e-Poster presented at: Wild On Wounds 2023; September 14, 2023; Hollywood, FL, USA. https://www.researchgate.net/publication/374083790_Trial_of_an_Availabl…

54.       Martí-Carvajal AJ, Knight-Madden JM, Martinez-Zapata MJ. Interventions for treating leg ulcers in people with sickle cell disease. Cochrane Database Syst Rev. 2021;2021(1):CD008394. doi:10.1002/14651858.CD008394.pub4

55.       Bolton LL. Common Nonsense: Rediscovering Moist Wound Healing | Wound Management & Prevention. Wound Management & Prevention Journal. Published 2012. Accessed May 26, 2019. https://www.o-wm.com/blog/common-nonsense-rediscovering-moist-wound-hea…

56.       Flint L. Invited commentary on “Modern wound care for the poor: a randomized clinical trial comparing the vacuum system with conventional saline-soaked gauze dressings” by Perez et al. The American Journal of Surgery. 2010;199(1):21. doi:10.1016/j.amjsurg.2009.01.030

57.       Jones AM, San Miguel L. Are modern wound dressings a clinical and cost-effective alternative to the use of gauze? Journal of Wound Care. 2006;15(2):65-69. doi:10.12968/jowc.2006.15.2.26886

58.       Sadati L, Froozesh R, Beyrami A, et al. A Comparison of Three Dressing Methods for Pilonidal Sinus Surgery Wound Healing. Adv Skin Wound Care. 2019;32(7):1-5. doi:10.1097/01.ASW.0000558268.59745.d2

59.       Yastrub DJ. Relationship between type of treatment and degree of wound healing among institutionalized geriatric patients with stage II pressure ulcers. Care Manag J. 2004;5(4):213-218.

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.

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, HMP Global, its affiliates, or subsidiary companies.