Ethnophytotherapy Practices for Wound Healing among Populations of District Haripur, KPK, Pakistan

Wounds, burns, cuts, and scarring may cause a serious problem for human health if left untreated, and medicinal plants are identified as potentially useful for wound healing. Therefore, the study focused on ethnophytotherapy practices for wound healing from an unexplored area, Pakistan. Ethnophytotherapeutic information was collected through well-planned questionnaire and interview methods by targeting 80 informants (70 males and 10 females), in the study area. Data was analyzed through quantitative tools like use value (UV) and credibility level (CL). A total of forty wound healing plant species, belonging to twenty-nine families, were being used in forty-six recipes. Herbs constitute (35%), shrubs (30%), trees (30%), and climbers (5%) in the treatment of multiple human injuries. For remedies preparations, leaves were most frequently utilized (52%) followed by whole plant, flowers, twigs, roots, bulb, bark, rhizome, resin, oil, leaf gel, latex, gum, and creeper. The most form of herbal preparation was powder (34.7%) and poultice (32.6%), followed by decoction, bandaged and crushed, in which 40% internally and 60 % externally applied. The drugs from these plants seem to be widely used to cure wounds: Acacia modesta, Aloe barbadensis, Azadirachta indica, Ficus benghalensis, Nerium oleander, and Olea ferruginea with higher use values (0.75). Local people are still connected with ethnophytotherapies practices for curing wounds for several reasons. This ethnomedicine and the wound healing plants are under severe threats; thus conservation must be considered. Further research should be directed towards implementing pharmacological activity on these invaluable botanical drugs.


Introduction
Plants as medicine play an important role in the public health sector across the world. Patients have been utilizing medicinal plants for a long time to fulfill different daily needs and to maintain well-being [1]. Plants provide people with food, medicines, and fodder for livestock, as well as materials for construction of houses [2]. The history of discovery and use of different medicinal plants is as old as the history of discovery and use of plants for food [3]. From the history, it was revealed that the ancient people used herbal medicine for treatment of various diseases including burn injury, due to its simplicity, low cost, and affordable basis [4]. Today, the injury is a serious health problem across the world, often associated with high-costs and inefficient therapies [5] and affect people both physically and psychologically [6]. It is estimated that several million patients suffer from wounds, burns, and cuts every year, which may result in death when they did not get treated properly [7,8]. Wound infections and related diseases are very common in developing and some developed countries due to unhygienic conditions [9,10]. Wounds can be referred to as physical disabilities [11] and are marked as injury to normal skin structural, anatomical, physiological, and functional variation [12]. World Health Organization (WHO) 2018 data estimated that 180 000 people died every year due to burn injuries, and the vast majority of these deaths occur in low-and middle-income countries. Many medical plants support natural repairing process of skin [13,14]. As described in the different literature, 70% of the wound healing drugs are of plant origin, 20% of mineral origin, and the remaining 10% consisting of animal products [15]. So, by keeping in view the importance of phytotherapies for wound healing, our study was conducted with the aims (i) to unveil the valuable wounds healing plants from District Haripur, KPK, Pakistan, as previously this area was unexplored in this regard, (ii) to record traditional folk knowledge and phytotherapies being used in wound healing practices, (iii) to record wound healing medicinal plants with highest use value (UV) and credibility level (CL) for further in vitro investigations, (iv) to identify potential threats, and (v) to provide baseline data for phytochemists, pharmacologists, and conservationists for further future study.

Methods
. . Study Area. Haripur district is situated in Hazara division of Khyber Pakhtunkhwa province of Pakistan ( Figure 1)  . . Field Survey. The whole study area was frequently visited and the main target sites in the study area were Khanpur, Garmthun, Najafpur, Dartian, Babotri, Baghpur dehri, Kohala, Nilan Bhoto, Jabri, Hattar, Kotnajibullah, Khalabat, Beer, Ghazi, Nara Amazai, etc. A field survey was aimed to collect field data and activities like (i) recording folk knowledge and phytotherapies being used in wound healing practices, (ii) plant's collection, (iii) local information about plants, (iv) identification of potential threats, (v) photography, etc. This survey was completed through well-planned questionnaires, interviews, and keen observations. Questionnaire method was also helpful in the documentation of folk indigenous knowledge. The interviews were helpful in investigation of local people and knowledgeable persons (farmers and herdsmen), who are mainly connected with plants and involved in traditional health care. During the field visits, total of 80 informants were approached randomly for questionnaires and interviews. Their description with respect to age, education, profession, etc. is given in (Table 1).
. . Plant Collection and Identification. The plant specimens collected were authenticated using the international plant name index (http://www.ipni.org), the plant list (www.theplantlist.org), and GRIN taxonomy site (http://www.ars-grin .gov/cgi-bin/npgs/html/queries.pl). The life form of investigated plants was categorized into herbs, shrubs, grasses, and trees (annual, biennial, or perennial), according to the system Evidence-Based Complementary and Alternative Medicine 3  [17]. The collected plant specimens were identified by Prof. Dr. Ghulam Mujtaba Shah (Plant Taxonomist), Hazara University Mansehra (Pakistan), and by using Flora of West Pakistan [18] and Flora of Punjab [19]. The voucher specimens were deposited in the Herbarium, Department of Botany, Hazara University, Mansehra (Pakistan).
. . Identification of Potential reats. During field survey, potential threats were identified through well-planned questionnaires, interviews, and keen observations. Therefore, the data obtained were tabulated and supported by photography. The main aim of the photography was to support field data with evidence. Photography of study area, as well as important plants and potential threats, was taken.
. . Statistical Analysis. The ethnophytotherapeutic data was statistically analyzed using Microsoft Office Excel software (2010). The use value (UV) of plant species were also determined [1,20].
Use value (UV) determines the relative importance of uses of plant species. It is calculated using the following formula: where "UV" indicates use value of individual species, "U" is the number of uses recoded for that species, and "N" represents the number of informants who reported that species. Credibility level (CL) of plant species: to determine credibility level of plants, a simple statistical tool was developed given name "credibility level" (CL). First of all, those plants are chosen which were reported by more than five informants with the same use. Then each plant was evaluated under the following formula: where "CL" indicates credibility level of plant species, "N" is the number of informants recorded for this plant, and "úN" represents the total number of informants for all plant species. CL value of each plant was tabulated in ascending series. The higher CL value is the most credibility of the medical plant used as ethnomedicine among communities in the study area.

Results
During the present study, data on 40 medicinal plant species belonging to 29 families that are being used in wound healing phytotherapies were collected from the study area. From those, herbs (35%) were the most widely used by local patients to treat various injury problems in the study areas of Haripur, followed by shrubs (30%), trees (30%), and climber species (5%) in which there were (22.5%) annual and (77.5%) perennial plant species as shown in Figure 2(a). Detailed information about each plant pertaining to the botanical name, voucher number, local name, family, habit, lifespan, locality, plant parts used, ethnophytotherapies, number of informants, etc. is listed in Table 2. People of District Haripur use different parts of the plants for wound healing phytotherapies as shown in Figure 2(b). Among those plant parts, leaves were the most frequently used (52%) followed by whole plant (10%), flowers (8%), twigs, roots, bulb and bark (4% each) and rhizome, resin, oil, leaf gel, latex, gum, and creeper (2% each). The methods of preparation for 46 recorded recipes fall into 5 categories, viz., plant parts used as decoction/extract (21.7%), Grinded/powdered form (34.7%), paste/poultice (32.6%), crushed (4.3%), and bandaged (6.5%) as shown in Figure 2(c).
Study also revealed that local people use wound healing phytotherapies both internally and externally. These treatments involve 40% internal and 60 % external use. Use value (UV) of plant species was also calculated in order to determine the relative importance of plant in study area with respect to usage. Results showed that Acacia modesta, Aloe barbadensis, Azadirachta indica, Ficus benghalensis, Nerium oleander, and Olea ferruginea have higher use values (UVs), i.e., 0.75, while species Solanum surattense, Punica granatum, Mentha arvensis, and Allium sativum have lower use values (UVs), i.e., 0.07, 0.11, 0.12, and 0.12, respectively, as shown in Table 2. CL value was also calculated to check the credibility of plants used in study area. CL values obtained are given in

Discussion
Since time immemorial, people have been used various parts of plants and its extracts in the treatment and prevention of many ailments [21]. This knowledge varies from region to region and from the community to community according to the presence of herbs and their historical uses [22]. In similar investigates, many other researchers [23][24][25][26] have significantly explored wound healing medicinal plants from other parts of the world. This is also confirmed by several other studies showing that herbs and plant organ leaves could be a major herbal remedy considered for many human ailments around the world including wounds and burns [27]. Many of these herbal medicines are used for wound   [28]. Comparative analysis shows that ethnophytotherapies for wound healings in District Haripur may or may not be similar in use with the other published literature reported from various other parts of the world. For example, present use of leaf juice of Melia azedarach is used to cure pimples and burns, while Ahmad [29] reported that this plant is beneficial against scabies, carbuncles, and abscess in district Attock. In Indian traditional medicine, species of the following genera are commonly used to treat wound and related injuries;  [30]. Pistacia atlantica subsp. kurdica Zohary can be used externally to treat skin injury as well as internally for abdominal pain [31]. A review of the previously published literature shows that the most species display a range of pharmacological activities that are suggested to have wound healing potential. For example, Acacia modesta has anti-inflammatory properties [32]. Ocimum basilicum holds antibacterial activity [33,34]. Berberis lyceum retains antifungal properties [35,36]. In rats, methanolic extract ointment from leaves of Adhatoda vasica had significant wound healing activity compared to standard drug [37]. A study by Ahmed [1] showed the importance of Allium sativum for antidandruff, intestinal worms, blood circulation, rheumatism, stimulant, cancer, cholera, alopecia areata, tuberculosis, and plague in Kurdistan region of Iraq, while in our study the same species was used to treat wounds by insect. The same author reported Althaea officinalis to treat burns in the form of poultice, which is exactly similar to our results. This is due to that fact that there may be several factors playing a role in establishing knowledge of ethnobotany and ethnomedicine particularly in rural areas, such as phytogeographical and ecological characteristics, demographic and ethnic structure as well [28]. This comparative analysis strengthens the value of the wound healing knowledge from our study location for further future studies.

Conclusion
Plant extracts have been demonstrated as important potential herbal remedies in many traditional medicinal systems around the world for wound repair and tissue regeneration. People of District Haripur (study area) rely mainly on ethnophytotherapies for wound healing. This is because of traditional culture, easy availability, and cheaper source of herbal medicines. Local people have sufficient knowledge about wound healing practices and saved mostly by older informants. In the study area both the wound healing, medicinal plants, and folk traditional knowledge are getting depleted thus conservation is required to maintain this valuable natural resource. Further pharmacological studies are recommended to validate the current herbal traditional knowledge.

Data Availability
The data used to support the findings of this study are included within the article.