Development of the Available Technology Dressing: An Evidence-Based, Sustainable Solution for Wound Management in Low-Resource Settings

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Any views and opinions expressed are those of the author(s) and/or participants and do not necessarily reflect the views, policy, or position of Wounds or HMP Global, their employees, and affiliates.

Significance

At any given time, as many as 1 in 5 adults in rural areas of tropical developing countries are at least somewhat incapacitated by a wound.^1–4 When populations are otherwise equivalent, a tropical climate is associated with 5 times more bacterial-infected skin wounds than a temperate environment.⁵ In addition, poor nutrition, poor hygiene, and lack of knowledge frequently cause delayed healing of wounds in rural areas of developing countries.⁶ In developed countries, the most common cause of a chronic wound is a chronic health condition, such as diabetes, venous insufficiency, or spinal cord injury.^7–9 In contrast, in the developing world the most common cause of a chronic wound is a poorly managed acute wound (eg, injuries, insect bites).^10,11

Most of the relatively few research studies on wounds in tropical developing countries were conducted in the 1970s and 1980s.^2,12 In 2009, however, several nonprofit organizations, including the Association for the Advancement of Wound Care Global Alliance and Handicap International, worked with the World Health Organization to form the World Alliance for Wound and Lymphedema Care (WAWLC).^13–15 WAWLC promotes wound care research and education in developing countries, representing a renewed interest in this neglected field.^13,16 Since 2009, several editorials in wound journals have highlighted the challenges of wound care in resource-limited settings.^13,17,18 However, these groups primarily educate health care professionals in urban areas, and they use tools and supplies that are rarely available in the developing world and that are completely unobtainable in typical village markets.^14,16 The work of these organizations complements the initiative described in this paper, but the focus is quite different.

Problem

Health care professionals are scarce in rural areas of developing countries, and they rarely manage wounds.^14,19 In a study of wounds due to guinea worms in Ghana, only 0.5% of those affected had gone to a clinic to receive care for their wounds.⁴ When villager family or self-care (VSC) fails, traditional health practitioners (THPs) and village health workers (VHWs) provide wound management.^12,20,21 The few published research articles about wounds in this setting have found that outcomes are poor and costs are high; none of the 3 groups of lay health care providers are able to manage wounds effectively.^6,10–12,22 The authors of the only 4 studies found in a search for interventions used to improve wound management in low-resource tropical settings all concluded that their efforts were not sustainable long-term.^4,12,23–25 Wound management education for this population should include only sustainable practices that have proved to be safe and effective in a low-resource tropical setting (ie, they must have ecological validity).²⁶

Case studies

The Benskin Research Group has been working since 1999 to develop and validate a safe, effective, affordable, available, and acceptable wound management method for lay health care providers in low-resource settings.²⁷ The initial steps included documenting how advanced wound dressings performed in a remote area of a tropical developing country,²⁸ and exploring the results of historically popular local remedies. Local remedies were not very effective, sometimes caused serious complications, and were surprisingly expensive.² In contrast, in this setting PMDs provided results far superior to those of any of the other donated advanced dressings, continuously cleansing wounds, balancing moisture, controlling inflammation, and supporting wound closure in virtually every wound situation.²⁸ Over 100 case studies were documented in detail, many of which have been presented at educational conferences.^29,30 However, it was apparent that lay health providers who live in remote and conflict areas of tropical developing countries 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.^6,27 The quest to find a solution for this formidable challenge had begun. Figure 1 shows a map of the least developed countries, with the tropics marked.

Goals

Keeping wounds clean and appropriately moist is challenging in any setting, but these 2 functions of effective wound dressings clearly facilitate wound healing.^14,31 Moist wound management is so powerful that the benefits patients experience from wound management products may at times be entirely due to the moist wound management provided by the carrier, rather than the active ingredient.^32,33 Moist wound management tends to keep wounds clean via autolytic debridement.^34–36 However, some clinicians are hesitant to trust autolytic debridement, particularly when infection risks are high, even though in temperate climates dry wounds have proved to be more likely to become infected than moist wounds.^37,38 It was necessary to confirm that moist wound management is feasible in the tropical developing world setting, and if so, to learn how it can safely be implemented where resources are scarce and infection rates are high, such as in remote and conflict areas of the tropics.⁶

Published literature reviews

An extensive review of the literature in 2013 found only 4 improvised moist dressing solutions that could be sustainable in the tropical village setting: honey, boiled potato peels, banana leaves, and thin plastic.¹² Honey from the tropics is often so watery that it ferments, and it has a higher pH value and contains up to 10 times more yeasts and molds than honey produced in temperate climates.^39,40 Further, honey melts out of commercial dressings in the tropical heat. Several research groups found that banana leaves outperform boiled potato peels (and both outperform gauze).^6,12 However, banana leaves carry such a high bioburden that they must be autoclaved, which can be done in a hospital setting, but it is untenable in the environments of the target populations.^41,42

The initial studies of thin plastic improvised dressings were conducted in a temperate climate (Japan), where perforated food-grade plastic wrap (PW) proved to be safe and effective for pressure injuries of all sizes, including dirty and heavily exudating wounds in frail elderly patients.^43–47 PW is sometimes used as a secondary dressing in the United States.⁴⁸ To verify that PW is inherently nearly completely sterile, researchers in Australia plated 10 samples from a roll of PW that had been on an open shelf in a burns unit for several months onto agar plates and found no growth after 72 hours.⁴⁹ A research team in India substituted plastic surgical drapes for PW on split-thickness skin grafts, finding thin plastic superior to banana leaves due to its complete nonadherence to the wound bed.⁵⁰

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 composed of the same nontoxic plastic as PW (low-density polyethylene) are ubiquitous in rural markets throughout the tropics and are generally exempt from plastic bag bans.^51-53 Commercial thin-film adherent dressings (Tegaderm [3M Health Care], Opsite [Smith & Nephew]) do not consistently provide an optimal moist wound environment because they have far higher moisture vapor transmission rates (MVTRs) compared with PW.^31,54,55 To ensure that this would not be a problem for the improvised dressing technique the authors developed, 12 plastic bags were collected from tropical developing countries across the globe and then tested for MVTR at body temperature. (Testing was donated after hours by staff at Illinois Instruments, Inc.) Although the bags varied in thickness and appearance, all had close to the ideal MVTR for moist wound management,³¹ confirming that plastic bags are a reasonable surrogate for PW.

The aforementioned 2013 exhaustive literature search, conducted with the assistance of a librarian specializing in complementary and alternative medicine, revealed that usual practice data, which are essential for designing a comparison study, were absent from the published literature.¹² Ethnopharmacologists rarely provide the basic information needed to replicate traditional usage of the herbal remedies they catalog, such as whether the substance is used topically, ingested raw, or made into a tea.¹² The few reports that did include such details did not include tests of safety or effectiveness, and did not describe wound bed preparation or how the substance was held in place.¹² Therefore, prior to conducting an RCT of any improvised dressing technique, the comparator (usual practice) had to be defined.

Defining usual practice

A culturally appropriate quantitative study design was needed to obtain accurate detailed descriptions of usual topical wound management practice that could be evaluated using standard statistical tools.^6,12 Barriers to obtaining accurate survey data in rural areas of tropical developing countries are formidable, and include⁶: (1) cultural differences that prevent classical pencil and paper surveys from being understood, (2) a universal reluctance to expose one's work to strangers for evaluation, (3) a strong sense of hospitality that dictates that participants provide answers they believe the investigator will find pleasing, even if these answers are not at all accurate, and (4) the possibility that the survey is focused on problems (in this case, wound scenarios) that are not relevant to the participants.

The "Story Completion" survey method. A story completion survey method was developed to address these barriers. The fourth barrier (ie, the possibility that the survey is focused on wound scenarios that are not relevant to the participants) had to be addressed first. Thirty actual wound cases (photographs and brief patient histories) from a portfolio of wounds managed in a remote clinic in northern Ghana were presented to 5 Ghanaians who are experienced in wound care and familiar with village life.^6,56 These experts each provided free-responses to 20 questions about the wound cases in a qualitative pre-study to ensure that the cases were relevant.^6,57 The researcher anticipated that this would narrow the wound cases down to 1 representative patient for each of 5 common wound types. The Ghanaian experts surprised the researcher by predicting (accurately) that osteomyelitis is also common in villages,^6,57 presumably because often bones are not set properly, resulting in malunions. In addition, they asserted that cancerous ulcers are frequently encountered in villages.^6,57 This may be because cancer tends to develop at chronic wound sites (squamous cell carcinoma) and in scars (Marjolin ulcer carcinoma).⁵⁸ Thus, the pre-study participants identified 7 representative wound types for the study, each with its own photograph and case history.^6,57

The cultures of developing countries usually have a strong oral tradition, in which important transactions are always handled face-to-face, even among literate members of society.⁶ Storytelling enhances health-related communications in these settings.⁵⁹ Data collection interviews with the THPs, VHWs, and VSCs consisted of culturally appropriate conversations centering on the stories of the 7 de-identified wound patients, with a laminated photograph representing each wound type (abscess, burn, infected acute leg ulcer, chronic ulcer, trauma, osteomyelitis, and cancer).⁵⁷ Framing the survey as a storytelling exchange, with the researcher telling the beginning of the story for each case and the participant completing the story with details about what they would do for the patient, addressed barrier 1 (ie, cultural differences that prevent classical pencil and paper surveys from being understood).^6,57 Discussing disassociated case studies is less psychologically threatening than discussing one's own behavior; this addressed barrier 2 (ie, reluctance to expose one's work to strangers for evaluation).⁶⁰ Barrier 3 (ie, a strong sense of hospitality in which participants provide answers they believe the investigator will find pleasing, even if these answers are not at all accurate) was addressed by asking only open-ended questions to elicit the chronology of the usual wound management practices of each participant for each of the 7 wound types, without prompts.^6,57Figure 2 shows the usual practice interview setup.

Usual practice study results. The University of Texas Medical Branch Internal Review Board approved the initial study, which took place in 25 villages across all 4 ecosystems of Ghana, West Africa, in 2012.^6,56 A VHW, THP, and VSC from each of these villages completed the story for each of the 7 cases.^6,56,57 The 525 response narratives were tabulated and categorized as congruent or not congruent with modern topical wound management principles within 3 domains and 6 subcategories: wound bed preparation (cleansing, debridement), wound treatments (infection/moisture control, inflammation/edema control), and wound dressings (commercial materials, indigenous materials).^6,56 The study was replicated less formally in Zambia, East Africa, in 2013, and in Cambodia, Southeast Asia, in 2014 (floating villages) and 2015 (farm communities), with similar results, confirming that the essence of the usual practice data found in this study is likely to be broadly representative.⁵⁶

Almost all the study participants stated that although they have confidence in managing many other health conditions, they felt that their wound management was inadequate.⁶ Most would clean wounds with a noncytotoxic liquid, such as clean water, an herbal decoction, or saline.⁶ Participants from all 3 provider groups described using sasa, the soft, absorbent, boiled fibers of a plantain stalk, in lieu of cotton wool.⁶Figure 3 is a graph of the study results for the debridement subcategory.⁶

By far the most common method of debridement for all 7 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.⁶ However, these interventions could not consistently retain moisture overnight.^6,56 The few participants who mentioned papaya usually volunteered that it must be carefully monitored; thus, it is unsuitable for outpatients who may not reliably return for follow-up.⁶ Papaya pulp contains papain, a nonselective enzyme used in meat tenderizer.^61–63 Researchers who used it successfully on hospitalized burn patients in The Gambia cautioned that papaya can convert partial-thickness wounds to full-thickness wounds, which is congruent with our personal experience. (Figure 4).^6,62,64

Although none of the participants mentioned using honey (likely for the reasons mentioned earlier), a few of the VHWs occasionally used sugar for debridement.⁶ Irrigation was mentioned more often for the trauma wound, while sharp debridement was mentioned most often for the abscess and burn.⁶ Maggots were universally described as harmful.⁶ This is consistent with our experience in the clinic, where patients whose wounds had inadvertently attracted maggots reported excruciating pain. Although Lucilia (Phaenicia) sericata (medical maggots) feed exclusively on necrotic tissue, nearly all other species of flies are nonselective, and many are invasive.^65–69

Although aloe grows throughout Ghana and is included in the VHW's training handbook, none of the 75 participants in the usual practice study included it in their descriptions of wound management for any of the 7 wounds.⁶ Local emollients used to keep wounds moist and uninfected included warmed shea butter and various local cooking oils, often mixed with herbal remedies.⁶ Some providers applied a cloth or gauze soaked with saline (often homemade), or a dilute antiseptic, covered with more cloth in an attempt to keep it from drying out.⁶ Ashes were used to absorb excess moisture, with the ashes from the shell of a particular snail being used to pull the fluid out of burn blisters without breaking them⁶ (Figure 5). Some participants described practices that were clearly harmful, such as applying excrement, animal parts, or products characterized as "burning like pepper."⁶

Many of the participants, including over 85% of the VHWs, described elevating the wound or applying an outer cloth bandage or gauze wrap in a way that would help control edema.⁶ Approximately half the participants, particularly the VHWs, reported that they would use purchased dressing materials such as clean cloths, gauze, or adhesive bandages over wet leaves, cloths, or gauze; however, they reported that gauze was expensive and difficult to obtain, and that dressings often had to be soaked off because they dried onto the wound bed.⁶ A small minority of VHWs would remove the dressings dry, tearing the wound, or would leave the wound open to air.⁶ Those who used indigenous dressing materials (exclusively THPs and VSCs) described using thickly applied oily concoctions, other concoctions that sealed the wound, or (rarely) dry concoctions that would adhere to the wound.⁶

The likelihood of a wound being referred to a health care professional was not affected by the remoteness or ecosystem of the village, but it was dramatically different between provider types, with THPs being far less likely to refer patients than VHWs (P < .001) or VSCs (P < .002 across all wound types.⁶ This difference was most dramatic for the cancer wound exemplar, with 2 VHWs, 4 VSCs, and 22 THPs stating they would treat this patient themselves. Many participants attributed some of the wounds (especially the osteomyelitis and chronic ulcer) to supernatural causes and would incorporate supernatural remedies in their management.⁶

Summary of findings from foundational research

A wound dressing solution to meet the needs of lay health care providers in tropical developing countries must use only materials readily available in this setting. The dressing solution 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 was safe, effective, affordable, and culturally acceptable to patients. The study site needed to have sufficient numbers of patients with fairly homogeneous wounds who live in a true tropical (not climate-controlled) setting. The study team needed to be dedicated to following a rigorous study protocol exactly.

Knowledge of the basic science of wound healing guided the development of an improvised wound dressing for resource-limited settings in the tropics. The dressing technique proven successful for Japanese patients with pressure injuries was modified significantly to accommodate the special needs of patients in a much warmer environment with fewer resources.^45,46,70 The resultant evidence-based ATD technique, which consists of (1) daily thorough wound irrigation, (2) protecting the periwound with moisture barrier, (3) protecting the wound by conforming cut-to-fit thin food-grade plastic with slits to the wound bed, (4) fluffing absorbent material over the slits, and (5) holding the dressing in place (and, if possible, applying compression) with a snug wrap, uses only materials that are affordable and easily available almost everywhere on Earth.^12,70 A Wound Healing Foundation small grant, sponsored by the Wound Reach Foundation, awarded in 2015, helped fund the proposed study.⁷¹ The trial of the ATD technique was conducted at the University Hospital of the West Indies, Kingston, Jamaica, beginning in July of 2021. The final patient visit was in Nov, 2021, and the 3-month follow-up was completed in February 2022. The research team included University of the West Indies plastic surgery residents led by Rajeev Venugopal and nursing instructors led by Antoinette Barton-Gooden, and the Benskin Research Group (the authors, Richard and Linda Benskin). Ethics approval was granted by the University of the West Indies Mona Campus Research Ethics Committee (No. ECP 97, 19/20). The study was registered at ClinicalTrials.gov prior to the first patient visit (NCT04479618); the protocol and results can be found there.⁷⁰

Sickle cell leg ulcers (SCLUs) were chosen for their relative homogeneity, relative abundance in Jamaica, and the critical need for a more effective wound dressing solution for these patients.^72–75 Standard of care for SCLUs worldwide is wet-to-dry gauze or dry gauze over an ointment, because other wound management methods have not led to superior outcomes.^76–78 These disabling wounds are somewhat similar to tropical ulcers and VLUs, with the added challenge of ischemia.^76,77 The ischemia helps explain why, in addition to healing 3 to 16 times more slowly than VLUs (if they close at all), SCLUs often recur.^74,77,79,80 SCLUs are often so painful that opioids are insufficient.^{74–76,81–84}

The vast majority of affected individuals develop their first SCLU between the ages of 10 and 19 years.^73,84 However, anticipated study participant recruitment via school nurses did not take place because schools were closed during the COVID-19 pandemic.⁷⁰ Additionally, because of the pandemic, patients with less severe ulcers were dissuaded from participating and recruitment ended prematurely, leading to a study population that was skewed toward older patients with larger, more long-standing SCLUs, all of which are predictors of poor healing.^70,79 A review of studies of VLU management demonstrated that a 12-week study period was sufficient to determine whether or not a treatment was effective.⁸⁵ However, unlike VLUs, SCLUs often enlarge during the first 4 weeks of management.⁷⁹ Due to costs, 12 weeks was chosen as the intervention period for the study. The Consort flow diagram is shown in Figure 6.

Research questions and aim of study

The primary purpose of this study was to determine if the ATD technique, using only inexpensive materials available for purchase in both rural and urban settings, is a safe, and effective, culturally and medically acceptable choice for managing SCLUs in a tropical climate. Three research questions were proposed, with all parameters carefully defined, for comparing the ATD with WTM saline-soaked gauze (negative control) and PMDs (positive control) with respect to safety and effectiveness, quality of life (including pain, costs, and time), and acceptability in the management of SCLUs in Jamaica.⁷⁰

Comparator dressings

Wet-to-dry gauze, or ointment covered with dry gauze, is the usual practice for managing SCLUs throughout Jamaica, but both choices dry and adhere to the wound bed, which is not congruent with the goals of lay health practitioners in village settings or with modern wound theory.^6,18 Based on this knowledge and available resources, the researchers chose saline-soaked WTM gauze for the usual practice arm of the study, fluffing the gauze to help keep it moist.⁶ The wound was irrigated well daily, at dressing changes. However, comparing the ATD only to saline-soaked gauze would almost certainly ensure the impending obsolescence of the study results, because saline-soaked gauze is inferior to most advanced dressings.^86–89

The Sickle Cell Unit in Mona, Kingston, Jamaica, had previously trialed many advanced dressings, including honey, Unna boots, plastic wrap (used circumferentially, as in Japan), and hydrocolloid dressings, all of which failed to produce superior results and/or were not accepted by patients, largely due to the warm climate.⁷⁰ The only advanced moist wound dressing type with a strong record of success in the tropics is PMDs (PolyMem; Ferris Mfg. Corp).^28,90 Because abundant evidence supports the use of PMDs in warm climates, they were the logical choice for a positive control.^28,91–96 PMDs do not melt, break apart, or adhere to wound beds in a warm environment, and they are well tolerated in the tropical heat.^28,96,97 The continuous cleansing system that is an integral function of these dressings mitigates the problem of increased wound infections in the tropics.^28,96 PMDs also control inflammation and decrease pain, 2 key influencers of healing in VLUs that may translate to SCLUs.^28,90,98 When used on VLUs, with or without compression, PMDs increased wound closure rates, sped healing, and decreased pain.^97,98 PMDs are among the very few advanced wound dressings mentioned favorably in the sickle cell scientific literature.^76,81

Available Technology Dressings

The improvised dressing was named the ATD technique. Technology is the application of scientific knowledge for practical purposes. The study demonstrated that careful teaching and demonstration/return demonstration is required; implementing the technique accurately is not intuitive to untrained wound patients, and it is critical to its success.^70,99 The ATD tested in the RCT consists of zinc oxide paste (moisture barrier), a cut-to-fit food-grade plastic bag (clean semipermeable membrane) with slits to facilitate the release of products of autolytic debridement into the absorbent, fluffed gauze (clean absorbent), and stretch gauze or compression socks/wraps (to hold the dressing in place).^70,99 Daily, the ATD was removed, wounds were irrigated thoroughly with a strong squeeze on a homemade device (an approximately 500-mL soda bottle with a hole made in the cap with a hot bicycle spoke) filled with homemade saline, the periwound was dried, and a new ATD was applied.^70,99–101Figure 7 shows the booklet describing the ATD technique in detail.

Methods

The 3-arm, 12-week, evaluator-blinded, noninferiority RCT compared ATDs with both the negative control (WTMs, which are equal or superior to previous usual practice) and a positive control (PMDs).⁷⁰ All 3 dressing protocols were rigorously defined.⁷⁰ Dressing changes were conducted by the patients themselves, who used WhatsApp (Meta), a free end-to-end encrypted messaging phone app, to send photographs of their study ulcer and their daily data collection sheets and weekly quality-of-life forms to the primary investigator weekly.⁷⁰ In-person clinic visits took place initially, and at weeks 1, 4, 8, and 12, unless either the wound closed before the final visit or complications arose.⁷⁰

Weekly wound photographs were evaluated for complications by the 2 blinded evaluators (Dr Elizabeth Ayello and Dr Joyce Black) and by Dr Linda Benskin, who requested a face-to-face visit if a problem was suspected.⁷⁰ Wounds were also inspected at the 4-, 8-, and 12-week visits. The only complications that arose were Pseudomonas infections.⁷⁰ These were anticipated, because they are a common problem in wounds in the tropics.⁷⁰ This diagnosis was confirmed or rejected based on an assessment of wound drainage color and odor by a blinded on-site physician (usually a dermatologist) who was not a part of the research team.⁷⁰ All 4 diagnosed Pseudomonas infections resolved quickly after irrigation with 0.5% vinegar, per the study protocol.⁷⁰ Initial and final wound tracings were measured electronically using donated software (HealthE*Pix; Healthline Information Systems, Inc.) to determine change in wound area.⁷⁰

Statistical results were obtained and evaluated by 3 statisticians to ensure accuracy of interpretation of this small, heterogeneous data set. Participants in all 3 groups saw improvement in both ulcer closure and quality of life compared with their previous practice. The only complications were easily eradicated Pseudomonas infections, all 4 of which occurred in the WTM group (25%). ASCQ-Me Pain scores improved more in participants using the ATDs than in those using WTMs, and more wounds managed with ATDs decreased in size (92% vs 50%) (Table) Wound Quality of Life and ASCQ-Me Pain scores were most improved in patients treated with PMDs. Ulcers closed completely for 1 participant in the WTM group (6%) and for 2 participants in the PMD group (17%). Overall, the ATDs were clinically superior to WTMs and were only modestly clinically inferior to PMDs. Notably, ATDs are more available and less expensive than either of the other choices. Participants in all 3 groups gave ATDs high marks for acceptability.

Limitations

This small RCT was limited to a single wound type (SCLUs). Although this is among the more challenging wound types and patient populations, the participants were all ambulatory, and none had diabetes. The quality-of-life data were confounded by the fact that the study took place during a time when the participants' lives and livelihoods were intermittently dramatically disrupted by COVID-19 pandemic restrictions. Finally, wound pain and pain medication data were influenced by comorbid pain and, for some patients, a lack of access to medications. Finally, many of the participants lived in an urban setting, and all were guided by highly trained medical professionals, rather than by VHWs.  

Summary

Story Completion surveys confirmed that moist wound management is preferred, even in a tropical environment. However, until now, cost and availability has made it difficult for lay health care providers to provide dressings that promote a moist wound environment. The ATD technique proved safe, effective, and acceptable in the management of SCLUs in Jamaica, and use of ATDs dramatically improved pain scores when compared with WTMs.

Although PMDs outperformed ATDs for both pain relief and healing, ATDs were not dramatically inferior to, are far less expensive than, and are far more available than PMDs. Study participants were able to master the ATD technique quickly, and they preferred the ATD technique over other choices. The ATD technique is the first sustainable evidence-based solution for wound management in remote and conflict areas of tropical developing countries, and it shows promise for use in other resource-limited environments as well. 

This study demonstrated that the proposed ATD concept is sound. All materials (the irrigation device, periwound protectant, primary dressing, absorbent, and wrap) should be items that are readily available and affordable in the setting of the learners, and should be chosen for their functional properties. Because the ATD technique must be rigorously followed for the dressing to provide optimal benefits while minimizing risk of complications, the reason for each aspect of the dressing technique must be taught. This will empower the learners with the basic scientific knowledge to understand which aspects of each material and which aspects of each step in the technique are critical.

Authors: Richard Benskin¹; and Linda Benskin, PhD, RN, SRN (Ghana), CWCN, CWS, DAPWCA, WOCNF^1,2

Affiliations: ¹Benskin Research Group, Austin, TX, USA; ²Ferris Mfg. Corp., Fort Worth, TX USA ORCID: L Benskin, 0000-0002-6096-3971

Acknowledgments/Disclosures: The foundational studies summarized herein could not have taken place without the encouragement, advice, and support of Sheryl Bishop, Carolyn Phillips, Laura Bolton, Niipaak Laar, Christian and Lizzie Nsoah, Peter Bombande, and numerous other individuals who provided financial support, interpreting, or expertise. In addition to our co-investigators Rajeev Venugopal and Antoinette Barton-Gooden, the study participants, Graeme Crookendale, Carlos Neblett, Peter Ho, Jacqueline Garvey-Henry, Jennifer Knight-Madden, and many others contributed their time and skills to making the Jamaican study a success. We thank all of them, as well as the University Hospital of the West Indies, who hosted us. Thanks also to Ferris Mfg. Corp., makers of the PMDs used in the Jamaican ATD study, who donated enormous quantities of dressings, as well as many hours of Linda Benskin's time, and to Laura Parnell and Barbara Bates-Jensen of the Wound Healing and Wound Reach Foundations, which jointly provided the research grant for the RCT.

Correspondence: Linda Benskin, PhD; 11304 Prairie Dog Trail, Austin, TX 78750; lindabenskin@utexas.edu

Manuscript Accepted: March 26, 2024