How effective are honey dressing in wound healing compared to conventional dressing in diabetic foot ulcer?

Background       

Among the different treatment methods that have been conventionally recognised for foot ulcer treatment, the effectiveness of wound dressings has been widely recognized by clinical scholars. However, there has been little consensus on the most useful dressing methods for dealing with different kinds of wounds. The dressing methods that have been popularly used for treating different conditions, including diabetic foot ulcers, burns or pressure ulcers, a distinction between traditional and modern dressing methods are often made. Traditional dressings are those that mainly use cotton pads, gauze or bandages, which are usually selected for their ease of usage and costeffectiveness. In contrast, modern dressings are usually defined by better degradability, biocompatibility and the ability to retain moisture, useful for effective pain relief (Shi et al. 2020). Honey consists of a number of antimicrobial properties and has been effectively used for the treatment of infected wounds.

A foot ulcer is one of the most common symptoms of Diabetes and if left untreated, can result in more severe consequences like leg amputation. In comparison to conventional methods, topical honey can be considered a useful treatment for this condition because of its costeffectiveness and the presence of healing properties. Systematic reviews dealing with the usefulness of this treatment method have not been conducted, underlining the need for the present study (Kateelet al. 2016). According to recent NHS Data, the problem of foot ulcers is noted among nearly 57% of the people suffering from diabetes and requires early intervention efforts. However, only about 54% of health commissioners have sufficient information regarding the present condition of food care services, indicating the need to research the benefits of wound dressing methods (NHS, 2017).

Pico and Clinical question

The Patient, Intervention, Comparison, Outcome or PICO model can be considered a strategic tool for defining the clinical question and conducting the literature search. The framework can be used effectively for formulating therapy questions, involving elements of prognosis and diagnosis (Eriksen and Frandsen, 2018). The main elements within the research question, as formulated by the PICO Model include:

Patient Adults possessing diabetic foot ulcers

Intervention Honey dressing method

Comparison Conventional dressing method using hydrocolloids hydrogels foam dressing

Outcome Better healing of wounds and patient recovery

Research Question:

How effective honey dressing is in would heal as compared to hydrocolloids hydrogels foam dressings for diabetic foot ulcers?

This method has therefore been useful for defining the clinical research question which evaluates the effectiveness of wound dressing using honey in comparison to conventional dressing for treating patients diagnosed with diabetic foot ulcers.

Methods used for finding evidence

A specific criterion for inclusion and exclusion has been used for sorting the evidence in this study. This is an important criterion in a systematic literature review as it is useful for judging the validity and reliability of the collected findings. The need to acquire updated information in this research has been maintained with the inclusion of journals, which have been published after 2015 and until 2021. Further, works that are associated with the research subject, including the benefits of wound dressing for foot ulcer treatment have been considered. On the contrary, studies that are not related to this subject area have been excluded. Only peerreviewed literature written in English has been included while those that are in other languages have not been used. Further, only the works of authors that have conducted a systematic review have been included in this research.

Search Strategy of the Database

The use of the Cochrane Database has been beneficial in searching for the necessary information and evidence for this study. In this database, there is a limiter that can be used for putting different words together and therefore finding the articles with the best possible information. As observed by Starr et al. (2009), the Cochrane Database can be constantly updated with the addition of new information and is not constrained by improper space. At the same time, there is a possibility of crosslinking the acquired sources with other relevant sources of information. According to Cumpston et al. (2019), the importance of Cochrane Reviews lies in evaluating relevant questions that is useful for decisionmaking purposes, along with the different challenges of clinical trials. This is therefore useful for funding works that deal with the practical questions concerning the usefulness of different dressing methods.

The keywords that were used for searching for the necessary information have been developed after applying the PICO Model. The search tools were present within the available search field and were used for selecting the titles and keywords.

As the search strategy, keywords such as honey dressing, Diabetic wound healing, and hydrocolloids hydrogels foam dressing, advantages of honey dressing, diabetic food ulcers are used. Cochrane database is used to search for the related keywords related to diabetic foot ulcers. Later, among the articles, only the journals which have detailed information related to advantages of honey dressing in diabetic wound healing are found, were selected for this study. Evidence based intervention related to diabetic food ulcers using Honey dressing method was used in this study.

SR Evidence and Quality Appraisal

The value of a systemic review lies in accumulating the best possible evidence and involves a summarization of the collected evidence.  The position of systemic reviews therefore lies at the top within the hierarchy of evidence. Among the important steps for conducting a review, the formulation of a question, identification of useful research works, quality assessment, summarization and findings are important (Khan et al. 2003). The CASP tool has been used for appraising the systemic review and top assess the quality of evidence provided.

In the review, the Cochrane, PUBMED and Google databases for used for gathering evidence for the research by using keywords like chronic wounds, diabetic foot ulcer and topical honey. The review also used a specific inclusion and exclusion criteria in which studies that dealt with patients diagnosed with ulcer and receiving honey dressing treatment across different contexts. Further, only the articles that were written in English and those dealing with case reports, case series and observational reports were included. This includes that the studies collected in the work are largely heterogeneous and cater to diabetic patients with different kinds of conditions.

The results can be regarded as valid because of the inclusion of reports from a diverse range of research articles. Proper exclusion and inclusion criteria are followed in this study. Primarily, 130 articles are selected from Cochrane database. In the next step, 50 articles are excluded by the researcher which is not in English language. In the next step, 50 articles were excluded which were not included detailed information related to effectiveness of honey dressing. In the next step, journals which only contained systematic literature reviews are selected. Finally, 6 articles, which contained recent information, are included in this study.

The results reveal that there is insufficient evidence regarding the practical use of honey for treating ulcers, but it could be regarded as a safer treatment method. There are little practical benefits of this work are not considerable unless the usefulness of honey can be proved more effectively (Kateelet al. 2016). These practical considerations inly that the Knowledge Translation to Action framework has been implemented. The article is therefore of good quality and answers all the questions that are outlined in the PICO Model.

Summary of evidence acquired from SR

The Cochrane database has been used for looking for the relevant research articles, and was useful in looking for all the necessary information that can be utilised in this research. Among the three articles identified in this work, that of Kateel et al. (2016) was the most relevant as it provided information that was directly related to the research question. This work provided information regarding the usefulness of honey in treating wounds and an evaluation of its use against other conventional methods. Other works, like that of Seckam and Mercer (2018) deal only with a specific section of the adult population, including aged patients.

Framework of Evidence

The Knowledge Translation to Action framework, which originated in Canada, involves the application of a systematic method to change and the transition from knowledge to practice. The process of translation involves four main components, including synthesis, dissemination, exchange and application, all of which are crucial for managing the process of transitioning from knowledge to actual practice. This is crucial for maintaining a structured approach in using a structured and actionoriented approach for applying and evaluating knowledge practice in research (Graham et al. 2018).

Appraisal of evidence Translation Framework

The evidence of framework has been followed by Knowledge Translation to Action that includes a transformation of knowledge to practical action. This is important to acquire the appraisal for accumulating the information based on different key words. There is a CASP tool has been used for appraising the systematic review with the quality of provided evidence. The appraisal for the evidence framework has been followed by:

Table 1: Appraisal for evidence translation framework

(Source: Selfdeveloped)

Tool for appraising evidence dissemination     

The CPG (Clinical practice guidelines) has been used in this assessment as it provides a framework for providing evidencebased guidelines that summarize the available evidence for addressing questions concerning specific medical conditions. CPG tool is used to analyse the methodological quality of reporting and development of guidelines in medical literature articles (Ferrell et al. 2018). Among the CPG tools, Randomised Controlled Trial (RCT) is used in this study as the appropriate appraisal tool. Critical Appraisal Skills Program is used in this study to assess the quality of the selected articles.

Tools for disseminating the translated evidence

The process of dissemination in clinical practice involves targeted information distribution and the use of effective intervention methods for dealing with health outcomes and guiding a practice audience. This can occur through different channels and settings and can be useful in spreading practical knowledge and associated interventions. This is also important for evaluating the gaps between existing research and useful implementation methods (Chambers, 2018). The dissemination tool that has been utilised in this study is the Clinical Practice Guidelines.  These guidelines, containing information for improving patient treatment, can be defined with the help of systematic reviews of the provided evidence. These reviews have been conducted for assessing alternate treatment options and are similar to the framework of this study.

Barriers to evidence dissemination 

A few of the most important barriers in the process of disseminating evidence can be traced to both individual as well as organisational aspects. Among the organisational barriers, insufficient time, lack of proper and specialized personnel, absence of effective management support and financial issues can be particularly identified. The absence of ethical conduct, including the effective protection of patient information, can also be regarded as a substantial barrier. The individual aspects include the absence of positive attitudes, leadership support and awareness regarding separate trial programs (Correa et al. 2020). This implies that adequate staff support is crucial for addressing these available barriers.

Reference list

Journals

Chambers, C.T., (2018). From evidence to influence: dissemination and implementation of scientific knowledge for improved pain research and management. Pain, 159, pp.S56S64.

Correa, V.C., LugoAgudelo, L.H., AguirreAcevedo, D.C., Contreras, J.A.P., Borrero, A.M.P., PatiñoLugo, D.F. and Valencia, D.A.C., (2020). Individual, health system, and contextual barriers and facilitators for the implementation of clinical practice guidelines: a systematic metareview. Health research policy and systems, 18(1), pp.111.

Cumpston, M., Li, T., Page, M.J., Chandler, J., Welch, V.A., Higgins, J.P. and Thomas, J., (2019). Updated guidance for trusted systematic reviews: a new edition of the Cochrane Handbook for Systematic Reviews of Interventions. Cochrane Database Syst Rev, 10(10.1002), p.14651858.

Eriksen, M.B. and Frandsen, T.F., (2018). The impact of patient, intervention, comparison, outcome (PICO) as a search strategy tool on literature search quality: a systematic review. Journal of the Medical Library Association: JMLA, 106(4), p.420. (Provided)

Ferrell, B.R., Twaddle, M.L., Melnick, A. and Meier, D.E., (2018). National consensus project clinical practice guidelines for quality palliative care guidelines. Journal of palliative medicine, 21(12), pp.16841689.

Graham, I.D., Kothari, A. and McCutcheon, C., (2018). Moving knowledge into action for more effective practice, programmes and policy: protocol for a research programme on integrated knowledge translation. Implementation Science, 13(1), pp.115.

Kateel, R., Adhikari, P., Augustine, A.J. and Ullal, S., (2016). Topical honey for the treatment of diabetic foot ulcer: a systematic review. Complementary Therapies in Clinical Practice, 24, pp.130133. (Provided)

Khan, K.S., Kunz, R., Kleijnen, J. and Antes, G., (2003). Five steps to conducting a systematic review. Journal of the royal society of medicine, 96(3), pp.118121. (Provided)

Seckam, A.M. and Mercer, J., (2018). Older patients experiences and perceptions of having their wounds treated with medicalgrade honey. British Journal of Nursing, 27(15), pp.S22S29. (Provided)

Shi, C., Wang, C., Liu, H., Li, Q., Li, R., Zhang, Y., Liu, Y., Shao, Y. and Wang, J., (2020). Selection of appropriate wound dressing for various wounds. Frontiers in bioengineering and biotechnology, 8, p.182.

Starr, M., Chalmers, I., Clarke, M. and Oxman, A.D., (2009). The origins, evolution, and future of The Cochrane Database of Systematic Reviews. International journal of technology assessment in health care, 25(S1), pp.182195 (Provided)

Websites

National Health Service Digital, NHS (2017). Report Highlights Need for Early Intervention for Diabetic Foot Ulcers. [Online], Available at: https://digital.nhs.uk/news/newsarchive/2017newsarchive/reporthighlightsneedforearlyinterventionfordiabeticfootulcers [Assessed 17th March 2022] (Provided)