Community-based wound management in a rural setting of Côte d'Ivoire

Abstract

Background: Wounds are a neglected health problem in rural communities of low-income countries, mostly caused by trauma and ulcerative skin diseases including Neglected Tropical Diseases (NTDs) and associated with systemic complications and disability. Rural communities have limited access to high quality health services-based wound care.

Methods: We conducted a prospective observational study on wound management at three levels-community (C), health centre (HC), district hospital (DH)-in a rural community of Côte d'Ivoire. Patients with skin wounds actively identified in a house-to-house survey and passively in the health services in a defined area of the Taabo Health and Demographic Surveillance System were asked to participate and followed-up longitudinally. Endpoints were proportion of wounds closed, time to wound closure, wound size over time, frequency of secondary bacterial infection, need for recapturing after follow-up interruption, and duration of treatment stratified by health service level and wound aetiology.

Results: We enrolled 561 patients with 923 wounds between May 2019 and March 2020. The observation period ended in March 2021. Median age was 10 years (IQR 7-15), 63.0% of patients were male. Almost all (99.5%, 870/874) wounds closed within the observation period, 5.3% (49/923) were lost to follow-up. Wounds primarily treated in C, HC and DH closed within a median time of 10, 16 and 170 days, respectively. Median time to acute wound and chronic wound closure was 13 and 72 days, respectively. Wounds treated in C, HC and DH presented with secondary bacterial infections in 10.3% (36/350), 31.0% (133/429) and 100% (5/5) of cases, respectively. Recapturing was required in 68.3% (630/923) of wounds with participants reporting wound closure as the main reason for not attending follow-up.

Conclusions: We describe a wound management model based on national and WHO recommendations focusing on early identification and treatment in the community with potential for broad implementation in low-income countries.

Trial registration: Registration at ClinicalTrials.gov (NCT03957447).

Conflict of interest statement

The authors have declared that no competing interests exist.

Figures

Fig 1. Study flow chart: interaction between household- and health services-based surveys and wound management study.

Patients identified in the household- and health services-based surveys were offered to participate in the wound management study. The wound management study was carried out at three levels, in the community (community health workers—CHWs), health centre and district hospital according to the capability of the various levels and with the aim to identify and treat wounds as early as possible. The health staff of all three levels were trained in identifying, classifying, and treating wounds. W1 and W2: Training workshops (W) of nurses, assistant nurses, and CHWs; On-site training. IC1 and IC2: Informed consent (IC) for cross-sectional study and wound management study, respectively.

Fig 2. Enrolment of wound events into the wound management study during household- and health services-based surveys.

Wound event was defined as an injury (e.g. mechanical trauma, burn, animal bite) or a specific pathology (e.g. BU, yaws) leading to one or multiple wounds. Wounds enrolled on the same date and attributed to the same aetiology were considered as one wound event. Specific aetiologies, such as BU or yaws, that could lead to multiple wounds over time were considered a single wound event. For details see [13].

Fig 3. Representative images of the wounds treated within the study stratified by health service level.

In the large subgroups “Primarily treated in the community” (N = 387) and “Primarily treated in AHC” (N = 510) the images were randomly selected to rule out selection bias. Multiple pictures are shown for patients with complicated wounds. Abbreviations in the square boxes indicate the wound aetiology: Fu = furuncle (ulcerated), T = Mechanical trauma, BU = Buruli Ulcer, LF = Late-stage lymphatic filariasis, ChU = Chronic wound of unknown origin. AHC: Ahondo Health Centre; WMU: Wound Management Unit. * = Number of wounds.