Volume 25 Number 3

Introduction

Injuries such as wounds and lacerations accounted for 11% of the global burden of disease in 2010¹, and are associated with a substantial, growing burden of disability^1,2. They can be especially challenging to manage in low-resource settings (LRS), defined as settings where local “health care resources (financial and human) are scarce”³, whether they occur in rich or under-resourced countries. To address these challenges, the World Health Organization (WHO) has encouraged governments and non-government organisations to integrate their knowledge, resources and initiatives across settings to improve wound and related lymphoedema outcomes around the world. According to the US Bureau of Labor Statistics, 3% of all volunteers are involved with medical care⁴, despite increasing needs for volunteers to meet medical care needs due to economic challenges. Volunteers are in demand in LRS whether they occur in distant countries or without leaving home in economically stressed areas.

Purpose

The purpose of this work is to introduce readers planning to provide innovative wound care in an LRS to techniques for successful volunteering recommended by the WHO, volunteering resources and wound care evidence that can prepare them for an interval of mutually enriching service that offers both those served and those serving sustainable benefit.

World Health Organization Paradigm for Success

For those facing the challenge of managing wounds in an LRS, two important resources summarised below for wound care can help optimise services provided. First, consistently practising the five World Alliance for Wound and Lymphedema (WAWLC) basic wound care principles favours improved wound care

— protect the wound from trauma

— promote a clean wound base and control infection

— maintain a moist wound environment

— enhance systemic conditions

— control periwound lymphoedema/oedema.

A second way to optimise enduring value of LRS service is to use the WHO time-tested paradigm for improving outcomes for wounds and chronic conditions³. It can serve as a primer for what to learn and prepare before one serves in an LRS, what to do while there, and what to leave behind in the LRS that will sustain improved wound outcomes long after one returns home:

(1) Learn in advance about special wound challenges and opportunities in the planned LRS setting. In addition to communicating with the setting host, learn all you can from online searches focused on the planned LRS setting. Volunteers can discover opportunities online (for example, http://createthegood.org/volunteer-search) or receive valuable orientation and learn more about their destination’s health care system challenges, opportunities, requirements and customs from organisations such as:

a. Health Volunteers Overseas (website)

b. Health Care Volunteer (http://www.healthcarevolunteer.com/home),

c. Doctors Without Borders (Medicines Sans Frontiers: website),

d. Red Cross (http://www.redcross.org/volunteer/become-a-volunteer#step1)

(2) Gain familiarity with the decision making process in the planned LRS, as well as current practice preferences and taboos. Knowing who makes wound care decisions and how they are made can contribute greatly to an inspiring interval of practice and mutual education that makes a sustainable difference to patients, to the LRS community and all involved. The old adage “listen first, then be listened to” applies in all endeavours. Appreciating cultural beliefs and attitudes⁵ can help one understand and harmonise with reasons why patients, families and local health care workers do what they do or don’t do. For example those who, believe that the “badness of the disease” is excreted through the wound may wonder where the badness goes if the wound is closed. Preparing a consistent explanation that nature will allow the wound to close only after the wound’s “bad” cause is resolved may mesh with local beliefs. Identify and build relationships with local caregivers, opinion leaders and community leaders. Approaching the experience with a mind open to discover practice pearls within the LRS while sharing pearls from one’s own experience may surprise those who serve and those served.

(3) Prepare a registry to monitor outcomes across settings to the extent possible by identifying local structures in place that foster consistency of care. Even paper and pencil registries can help assure that important patient wound-related hygiene, preventive and treatment care and outcomes are consistently practised and monitored across all patient settings. Monitoring clinical wound healing and infection rates and patient-centred outcomes, such as pain, limited mobility or quality of life can inform those who serve in an LRS, whether wound outcomes are improving or not as a result of practised interventions. Integrating care across settings helps resolve local hygiene wound causes and challenges^6,7. Consistently documenting outcomes like healing progress, incidence of infection, patient-reported pain, mobility or other outcomes that affect quality of life can provide feedback for caregivers and patients. Feedback about patient and wound progress can hearten patients and encourage caregivers and local health care opinion leaders and administrators to support effective practices. For example, feedback about lack of chronic wound progress after four weeks alerted those involved in care to improve care and outcomes⁸. Examples of simple, low-cost, reliable, valid patient and wound measures that can inform clinical decisions and assess outcomes important to patients are listed in Table 1.

 

Table 1: Example simple reliable, valid important measures of wound-related patient-centred or clinical practice outcomes¹⁰ 

 

(4) Align health care sectors that may influence wound prevention, such as private village health workers and traditional healers, so that all reinforce each other’s wound prevention and treatment practices. Engaging population-based activities in collaboration with other government sectors to encourage simple practices such as consistent use of footwear, preventive hygiene practices and early diagnosis can reduce morbidity, disability and socio-economic burden of Buruli ulcers⁹.

(5) Promote basic skills training for health care workers⁷ to help patients manage wounds with clean moisture-retentive dressings that minimise dressing frequency, pain, healing time and likelihood of infection, without the hazards of cross contamination associated with hand washing and reusing bandages. Document progress, outcomes and consistency of these wound management processes for patients across settings and multiple care givers. Assure that all know cues to look for and how, when and to whom to refer the patient for specialist care in time to avoid serious complications. For example, when pain can no longer be managed with a patient-appropriate dose of acetaminophen alternated with meal-time ibuprofen, consider consulting a specialist to manage the pain and its underlying cause.

(6) Engage patients and families in wound self-management with appropriate instruction during health care interactions, so they help maintain consistency and quality of wound care.

(7) Work with community institutions and non-governmental organisations to ensure that patients with wounds and their families have adequate community support with needed services, such as dependable, adequately trained local health care workers and/or wound self-care training or similar training for family care-giver(s). Social services may be needed to provide transportation, time off work or child support during treatment. Successful wound care also requires an adequate supply of clean water, easy, nearby, low-cost access to supplies and materials for managing oedema, protecting feet and changing dressings. Arrange for institutions to exchange information needed for consistent support of patient and family wound care needs and support their role in planning wound care services and making policies.

(8) Emphasise prevention (for example, good nutrition, hygiene, appropriate physical activity, reduced tobacco and alcohol use) and a healthy lifestyle as key components of wound care. This can occur in primary health care visits, in training health workers and as community organisations engage the local population.

What to know before you go

Before engaging in practice in any LRS, it is wise to learn what kinds of wounds one will be expected to manage and what resources are available that work safely to manage those wounds. The World Health Organization²⁵ and other sources²⁶ provide rich sources of information about managing wounds and lymphoedema. In addition, the Joanna Briggs Institute has in-depth Evidence Summaries²⁷ describing the safety and efficacy of low-resource interventions including the following topical interventions:

• wound dressings (banana leaves or potato peels)
• wound cleansing (clean tap water)
• topical antiseptics (iodophors, hydrogen peroxide, chlorhexidine compounds, citric or acetic acid or tea tree oil)
• odour management (green tea bags).

These peer-reviewed Evidence Summaries, each based on a comprehensive systematic literature search, can be accessed at the Low-Resource Section of the Wound Healing and Management (WHAM) website node hosted by the Joanna Briggs Institute (JBI) in collaboration with the Western Australia Centre for Evidence-Informed Health Care Practice, Wounds Australia (formerly the Australian Wound Management Association) and Wound Management Innovation CRC.

JBI evidence summaries on boiled potato peels²⁸, or banana leaves²⁹ offer sustainable, low-cost, safe, effective moisture retentive wound dressings that allow faster healing with less pain compared to traditional gauze. Clean/unused plastic food wrap, perforated if needed, with a diaper or sanitary pad secondary dressing to manage excess exudate, can serve as a low-cost alternative affording faster healing than ointment-impregnated gauze³⁰ or similar healing to that achieved using hydrocolloid, hydrogel or foam dressings³¹. Those who encourage use of such locally available, effective, low cost “practice pearls” will establish sustainable, economical practices that continue to improve wound care outcomes long after their interval of LRS service.

Literature Review Methods

The National Institutes of Health Library of Medicine MEDLINE reference database was searched from inception to 15 April 2017, for terms and synonyms for combined words “clinical AND wound AND randomised” in combination with each of the terms: “aloe vera” or “honey”. These were supplemented with accessible derivative studies and studies learned from proceedings of major wound organisation meetings. Studies were included if they described a randomised clinical trial of burns including radiation burns, traumatic injuries, surgical wounds, diabetic foot ulcers, pressure ulcers or venous leg ulcers. Studies were excluded if they were quasi-randomised or non-randomised or on non-clinical wounds or wounds not listed in Table 2 or if they were redundant to a more recent report on the same subjects.

 

Table 2: RCT significant (p< 0.05) clinical evidence supporting efficacy for using aloe vera or honey on common clinical wounds

All included studies were tabulated according to the type of wound studied and all statistically significant (p< 0.05) effects on wound care outcomes are listed in Table 2, in order to address wound care professional and patient needs efficiently.

Literature Review Results

There is modest acute and chronic wound RCT support for using aloe vera or honey to reduce healing time, pain, oedema or inflammation, necrotic tissue, antibiotic use and length of hospital stays. (Table 2). These results should be interpreted with caution, as Table 2 contains only RCTs with significant clinical evidence supporting these two interventions. Both clearly supported faster healing compared to gauze dressings for healing acute or chronic wounds, with no RCT suggesting otherwise.

Discussion

Benjamin Franklin once said, “By failing to prepare, you are preparing to fail”. Turning this maxim to advantage, the more one prepares for practice in LRS, the more one sets the stage for success in improving patient and wound outcomes. Whether one is engaged in LRS wound care by necessity or as a volunteer, using the WHO principles and path to planning and preparing for LRS challenges can add valuable perspective and enhance the experiences of those who serve and outcomes of the patients and wounds served. Keys to success include appreciating and documenting patient, wound and environmental challenges to be faced and monitoring progress toward each wound care goal.

Recognising the environmental barriers and opportunities to engage in evidence-based practice using interventions at hand may not be easy, but can be inspiring and highly rewarding to patients, caregivers and all who serve them. Measuring important outcomes like those in Table 1 can motivate caregivers and patients or provide valuable feedback about delayed healing while there is still time to improve care and outcomes or refer to a specialist, if needed. Documented outcomes also tell LRS practitioners if they are making a difference to their patients. What reward could be greater?

Sound evidence^61,62 supports using moisture-retentive dressings which favour healing and avoiding gauze dressings, which foster wound infection. The JBI WHAM Node LRS section provides valuable insight about moisture-retentive banana leaf or potato peel dressings and other wound care interventions at hand that may improve outcomes in many LRS. Table 2 informs readers of possible benefits from the use of honey and aloe vera often available in LRS. A limitation is that Table 2 summarises only significantly positive effects of honey or aloe vera demonstrated in an RCT. For perspective, using different topical treatment or radiation schedules or delivery formulations, several RCTs reported no effect of aloe vera on irradiated skin inflammation. One unreported RCT reported less inflammation using an alternative in a cream formulation⁶³ compared to aloe vera gel, but it was unclear whether the difference was due to the cream as compared to the gel formulation or to lack of aloe vera gel effect. Cumulative radiation dose is an important source of variation that may also obscure aloe vera effects. Among patients receiving higher cumulative doses of radiation (> 2,700 cGy), Olsen et al.⁵⁷ reported that the median time to radiation-induced skin changes was extended to five weeks by adding aloe vera topical treatment to a mild soap wash, compared to 3 weeks in subjects receiving soap alone. Similarly, honey may improve healing of more severe venous ulcers, without having consistent effects on less challenging ones⁵². Until sources of variability in wound outcomes are appropriately sorted out, a general conclusion from Table 2 is that honey and aloe vera can, under some circumstances, enhance the wound outcomes tabulated. Readers are encouraged to learn more in depth practical information about these and other LRS wound care interventions directly from the evidence summaries as they become available on the JBI LRS website.

Acknowledgements

The author gratefully acknowledges the works of Joanna Briggs Institute pioneers Keryln Carville RN, STN(Cred) PhD, Professor, Domiciliary Nursing Silver Chain Nursing Association and Curtin University of Technology, and Robin Watts AM, RN, BA, MHSc, PhD, FRCNA, Emeritus Professor, School of Nursing and Midwifery — WACEIHP, Curtin University, and neglected tropical disease leaders Linda F Lehman, OTR/L, MPH, C.Ped, Technical Consultant, American Leprosy Missions and Mary Jo Geyer, PhD, PT, C.Ped. This work and the field of LRS practice have been enriched by their passion and dedication to empowering professionals to practise safe wound care that works.

Author(s)

Laura L Bolton
PhD
Adjunct Assoc Professor of Surgery, Rutgers Robert Wood Johnson University Medical School,
New Brunswick, New Jersey, USA
Email llbolton@gmail.com

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