A wound is an interruption of the continuity of a tissue structure. Different forms of injuries either caused by accident or surgery, results in tissue destruction, interference with blood vessels, extravasation of blood components and hypoxia. Wounds can, therefore, occur at any time be it at home, at work or in any other place. This requires that an immediate response is made to prevent further microbial infection and bleeding. Honey has historically been used for wound dressing in various settings. Honey is a natural substance produced from nectar collected and changed by a variety of honeybees, especially the Apis mellifera. For instance, one of the old text on surgery, Edwin Smith papyrus in the 2200 BC shows the healing of head wound using a combination of oil and honey (Pe?anac, Janji?, Komar?evi?, Paji?, Dobanova?ki, & Skeledžija-Miškovi?, 2013). Ancient records from Egypt, Greece, and Hippocrates among others report on the healing property of honey (Alves, Medeiros, Albuquerque, & Rosa, 2013). Modern studies have reported on the clinical properties of honey in the prevention of bacterial infections (Khalil, Khan, Ahmad, Khan, Khan, & Khan, 2013), and in the treatment of venous ulcers (Vandamme, Heyneman, Hoeksema, Verbelen, & Monstrey, 2013).
Additionally, studies have demonstrated the effectiveness of honey in treating fatal wounds, especially regarding the size and hygiene using bandages coated with honey (Yaghoobi & Kazerouni, 2013). Likewise, Boateng and Catanzano (2015) have shown that honey accelerates the rate of healing when applied in pressure wounds. The authors further confirm that honey is vital in minimizing the foul odors that come from injuries; as an aspect that can result in social isolation. The objective of this paper is to critically review five latest articles that address the effectiveness of honey in dressing wounds with a view of providing most recent information on the same and possible recommendations. It is expected that the review will answer the research question which is How effective is honey at treating bacterial wound infections?
Search strategy
The researcher used search engines and databases such as Google Scholar, PubMed, MEDLINE, and NCBI to search for relevant articles to be included in the study. The keywords used include wound, honey, wound healing and wound care. The keywords were searched in combination on the multiple databases under title, abstract or all fields. The search was restricted to the articles published in English only and within the last seven years. The researcher did not contact the authors for original data. The study was carried out between October and November 2018. A total of 25 articles were obtained from the databases after identification, screening and quality check. The twenty-five articles were then evaluated and ten of them excluded due to duplication. Out of the fifteen remaining studies, ten of them had no free access, and thus the researcher remained with five articles that fully met the inclusion criteria. These comprised of four systematic reviews and one randomized control trial (RCT). The articles were critiqued using the CASP checklist for systematic reviews and RCTs.
Results
Yaghoobi and Kazerouni (2013) conducted a review of both RCTs and articles to ascertain the evidence for the clinical use of honey in the healing of the wound. The adoption of a systematic review is most appropriate because it enables the researcher to bring together research and aid to ascertain commonalities and variations (Page et al., 2016). This is significant in comprehensively answering the research question and in identifying research gaps and making recommendations for future research.
The study used a comparator and the review undertaken by three reviewers. This minimized the possibility of evidence selection bias which could be as a result of missed articles by either of the reviewers (Drucker Fleming, & Chan, 2016). Additionally, the inclusion of only published articles will bias the systematic review of positive outcomes because the unpublished articles are statistically non-significant (Dwan, Gamble, Williamson, & Kirkham, 2013).
The study doesn’t have a confounding factor since only honey is reviewed concerning wound healing. The review doesn’t also highlight any possible ethical issues considered while selecting articles to be included in the study. This neglect compromises the quality of the research since it included RCTs that dealt with humans and animals. Using grade recommendations of FORM, the review can be graded to be of group C (Schünemann, Bro?ek, Guyatt, & Oxman, 2013). This is because the study provides evidence for its conclusion, however, caution has to be exercised in implementation because the authors haven’t disclosed any inclusion and exclusion criteria, ethical issues and any possibility of biases.
Stewart, McGrane, and Wedmore (2014) conducted a systematic review of the use of honey in treating wounds in wilderness settings. The design is most appropriate for the study since it is transparent in the manner in which the conclusions are made by avoiding the misrepresentation of the knowledge base because each article is assessed and its quality and application ascertained (Page et al., 2016). This ensures that the research question of determining whether honey can be an effective improvised treatment in pre-hospital settings is adequately answered.
The study has disclosed the search strategy including the databases and keywords. This ensures that source and selection biases are minimized because the selection of articles for review follows a specific protocol. Additionally, the search in a variety of databases also ensured that database bias was reduced and the yield of appropriate research is optimized (Drucker, Fleming, & Chan, 2016).
The authors do not expressly indicate any declarations for ethical considerations, but since it’s a review, it can be assumed that the studies reviewed had obtained original consent and therefore the systematic review is ethical. However, it is not always the case in the context of informed consent since it may not be valid as at the time of the systematic review (Connelly, 2014). On the other hand, the authors haven’t explicitly indicated whether there were potential conflicts of interest or funding. Based on the FORM grading protocol, the article can be graded as B because the presented evidence can be relied upon in most cases. This is because the authors have attempted to minimize bias which is prone to systematic studies.
Imran, Hussain, and Baig (2015) conducted an RCT of the effect of honey dressing as an intervention for diabetic foot ulcer in comparison with standard saline dressing. This approach was the most appropriate in ascertaining the effectiveness of honey in the treatment of diabetic foot ulcer because it enables the direct comparison of one medication with another to determine superiority. Furthermore, randomization minimizes selection and allocation bias thus improving the quality of the research (Kahan, Rehal, & Cro, 2015). The RCT design, therefore, is more effective in responding to the research question of ascertaining the efficacy of honey on diabetic foot ulcer in comparison with usual saline dressing.
The allocation of the patients to the two study groups was based on randomized numbers generated by a computer, and the researchers could only select the patients for eligibility criteria. This ensured that allocation bias was minimized (Kumar & Yale, 2016). Additionally, the baseline features of all the subjects have been displayed in a table and the treatment groups reasonably balanced.
Confounding has been presented in the study by independently separating the outcomes of the effects of honey and saline intervention on wound treatment (Mansournia, Higgins, Sterne, & Hernán, 2017). The controlling of the confounding factor (saline treatment) reduced bias in the estimated effect of honey treatment. This ensured that there was an observed difference between the study groups with actual variations.
Informed consent was obtained from the prospective participants in writing, and institutional review boards and ethical committees approved the study protocol. This improves the reliability and validity of the study because a standardized protocol was used in the study besides the willful participation of the participants which assures accuracy in the information provided and the inferences made (Noble & Smith, 2015). The research can be graded as A (excellent) using FORM approach because the body of evidence is reliable for decision making and several attempts have been made to minimize all possible potential bias in addition to the ethical approvals from two institutes and ethical committees.
Al-Waili, Salom, and Al-Ghamdi (2011) conducted a review of relevant data on the effectiveness of natural honey in treating burns, wounds, and ulcers. This approach is suitable for the study topic because it acknowledges an extensive body of present research and aims at assessing the outcomes from all the included articles. However, the study relies only on published research which is readily available thus making the findings unreliable. Furthermore, the use of published articles only to the exclusion of unpublished literature is likely to lead to misrepresentation because it doesn’t factor in the outcomes from all the existing studies. This, therefore, becomes a challenge in comprehensively answering the research question of determining the effectiveness of honey in the treatment of wounds burns and ulcers.
The authors do not disclose any specific criteria for the inclusion and exclusion of the articles included in the study. Additionally, there is no indication of the particular protocol followed in the appraisal of the reviews. This creates high chances of evidence selection bias. Furthermore, the authors have not indicated the specific data sources such as databases leading to the possibility of database bias, publication bias and source selection bias (Jansen, 2017).
The study doesn’t disclose any methodology used in carrying out the review, and therefore there is the possibility of including unethical studies in the analysis. Moreover, the study doesn’t have a note on contact and funding information and any declaration on conflict of interest as generally recommended for reviews in the Cochrane protocol (Deeks, Wisniewski, & Davenport, 2013). According to Mertz, Kahrass, and Strech (2016) reviews are likely to become unethical due to the desire to conduct an exhaustive search for literature. The investigation by Al-Waili et al. (2011) belongs to the D grade because the literature evidence is weak and since there are no specific measures to minimize bias and not protocol exists on how the review was conducted. Therefore, the recommendation has to be cautiously implemented.
A study was conducted by Minden-Birkenmaier, and Bowlin (2018) to provide current literature on the ability of honey to heal wounds based on tissue regeneration. This approach was most suitable for the review because it allows a researcher to undertake an exhaustive search to find optimal relevant literature to support the derived conclusion. This reduces bias because the findings are not likely to be overly influenced by the research that is readily available. On the other hand, the approach is expected to have a bias towards good results because it is more often the case that adverse epidemiological outcomes are suppressed and not published (Jansen, 2017). This, therefore, implies that the approach is relatively effective in responding to the research question of assessing the present state of the use of honey in the healing of wounds and tissue engineering.
The review has not shown rigor in minimizing bias which is a general characteristic of systematic reviews. For instance, the study has neither shown any inclusion or exclusion criteria nor the search strategy such as the databases from which the articles were retrieved. This leaves room for multiple biases. There is potential for bias in the review design because no protocol is stated to have been followed and this allows preconceived ideas of the researcher to determine the manner in which the review is to be carried out (Jansen, 2017).
The non-disclosure of any inclusion and exclusion criteria in the review raises the question of ethical consideration of the study. This is because it is most likely that insufficient reporting of ethical considerations in the original studies might be reflected in the current review (Mertz, Kahrass, & Strech, 2016). Additionally, there is no indication that the original authors were contacted for additional information; an aspect which could also have enabled the authors to give informed consent to the inclusion of his or her study in the systematic review. Based on the above evaluation the review is average and can be graded as C using the FORM guidance of grading evidence-based clinical studies.
There is a consensus of the effectiveness of honey in the treatment and dressing of wounds across all the reviewed studies. The reviewed articles have shown that honey has more significant effects on the treatment of acute wounds in comparison with conventional medications (Yaghoobi, & Kazerouni, 2013). Honey has wound healing properties such as triggering tissue growth, improved epithelialization, and reduced development of scars after the wound has healed (Oryan, Alemzadeh, & Moshiri, 2016). These properties have attribute to the acidity of honey, osmotic influence, the presence of hydrogen peroxide, and dietary and antioxidant contents as result honey reduces the level of prostaglandin and increase levels of nitric oxide and final products (Yaghoobi, & Kazerouni, 2013; Al-Waili, Salom, & Al-Ghamdi, 2011). All these features justify the therapeutic and biological properties of honey, more so as an antibacterial agent or wound healer. The highest quality studies amongst the five reviewed article are the RCT conducted by Imran, Hussain, and Baig (2015) and the systematic review by Stewart, McGrane, and Wedmore (2014). The RCT by Imran was of the highest quality when graded using the FORM guideline because the body of evidence is reliable for decision making and several attempts have been made to minimize all possible potential bias in addition to the ethical approvals from two institutes and ethical committees.
Furthermore, RCTs have been found to be most effective in epidemiological studies (Porzsolt et al., 2015). The systematic review by Stewart was also of high quality because the presented evidence can be relied upon in most cases. This is because the authors have attempted to minimize bias which is prone to systematic studies.
The findings in the review have the potential to be implemented in policies and practice due to several reasons. The studies are the most recent and therefore are likely to reflect the current state of wound infection and treatment in the society. Thus, the findings with regard to the effectiveness of honey in wound healing can be implemented in policy and practice because they will reflect the present condition. Secondly, the studies which include systematic reviews and RCT have considered the findings of multiple researchers carried out in diverse geographical settings and focusing on different types of wounds and the effectiveness of honey in their treatment. This increases generalizability and therefore have the potential to be implemented in designing policies and practices of wound treatment in different geographical locations. However, there is a need for further research to address the gaps identified in the literature. There is a need for more RCTs with significant statistical power comparing wound healing properties of different types of honey. However, this study is not without limitations. The RCT control reviewed did not have proper blinding, thus increasing the risk of personal bias and poor validity. Additionally, it is likely that the systematic reviews used in this study had inconsistency and personal bias, therefore the conclusions of this review must be implemented with caution.
Conclusion
There exists sufficient evidence proposing the use of hone in the management of both critical and moderate wounds. Of all the most archaic of wound treatments, honey has been re-examined about its viability to manage different forms of wounds. The properties of honey include antibacterial, antiviral, anti-inflammatory and antioxidant thus making it more effective in wound treatment and dressing more than conventional medications.
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