|Year : 2013 | Volume
| Issue : 1 | Page : 25-30
Post burn avenues in rehabilitation of female burn victims
Prateek S Shrivastava, Saurabh R Shrivastava
Department of Community Medicine, Shri Sathya Sai Medical College and Research Institute, Ammapettai, Kancheepuram, Chennai, Tamil Nadu, India
|Date of Web Publication||17-Aug-2013|
Prateek S Shrivastava
3rd Floor, Department of Community Medicine, Shri Sathya Sai Medical College and Research Institute, Ammapettai Village, Thiruporur-Guduvancherry Main Road, Sembakkam Post, Kancheepuram - 603 108, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Background: Rehabilitation is now an essential and integral part of burn treatment starting right from the time of admission. Objectives: The objective of the study is to create a liaison between burn victims and rehabilitation services so as to help the patients lead a better life. Methods: A longitudinal study of one and half year duration (May 2009 to October 2010) was conducted among adult female burn victims admitted in a tertiary care hospital in Mumbai, India. Sampling technique adopted for the study was universal sampling i.e. all the female burns victims above 18 years of age who were admitted during the study period and were willing to participate in the study were included. A pre-tested questionnaire was used to obtain socio-demographic details and details about burns injury. Subsequently each of them was followed up for two months duration after their discharge from hospital to keep track of their health status / social problems and utilization of rehabilitation services depending upon their needs. Statistical analysis was done using SPSS-17 version. Results: Case fatality rate was found to be 35%. Out of 48 women who were followed up, only 3(6.2%) had undergone reconstructive surgery for contractures while 14(29.1%) women had developed contractures. Conclusion: Counseling services deserve special attention and play a vital and indispensable role in rehabilitation of burn victims not only during hospital stay but also after discharge. There is an immense need of giving emphasis on promotion of positive thinking, significance of physiotherapy and occupational therapy, measures for prevention of secondary infections & contractures and facilitating vocational guidance for earning own livelihood for an independent living.
Keywords: Burns, Contracture, Reconstructive surgery, Rehabilitation
|How to cite this article:|
Shrivastava PS, Shrivastava SR. Post burn avenues in rehabilitation of female burn victims. J Med Soc 2013;27:25-30
| Introduction|| |
Burns are considered as a global public health concern, responsible for an estimated 195000 deaths annually.  Burns have been identified as one of the leading causes of disability-adjusted life-years lost in low and middle-income countries.  In India, approximately, there are 6 million burns cases annually, of which around 0.7 million cases require hospitalization, of which approximately, 0.12 millions die annually.  Goldman describes burns as "the silent epidemic" . 
Rehabilitation is considered an integral part of burn management. , The rehabilitation of burn patients begins right from the day of injury, lasting for several years and requires multidisciplinary involvement. A comprehensive rehabilitation program is essential to decrease patient's post-traumatic effects and improve functional independence.  Severe burn survivors often undergo a prolonged course of rehabilitation that begins as an emergency care in the hospital and is concluded as an outpatient. ,,
In a study done in eastern India to compare the prevalence of domestic violence between men and women, it was reported that the overall prevalence of physical, psychological and sexual violence among women were 16%, 52%, 25% and 56% respectively while in men it was 22%, 59%, 17% and 59.5% respectively.  The WHO multi-country study on domestic violence estimated that the lifetime prevalence of physical intimate partner violence varied between 20% and 33%.  According to Indian National Family Health Survey - 3, in Maharashtra, 31% of ever-married women have experienced spousal physical or sexual violence from their current husband.  Almost one-in three ever-married women have experienced spousal physical or sexual violence in Maharashtra. 
There is not much information available about the outcome of burn among the victims and about their rehabilitation. This study was conducted to gain an insight into the socio-cultural determinants of burns patients and the physical, mental and social sequelae to burns injury. Thus, the objective of the current study was to build a liaison between the female burn victims and rehabilitation network with the help of medical social worker so as to help the patients cope up with their injury so that they are empowered to lead a better life.
| Materials and Methods|| |
A longitudinal study of one and half year duration (May 2009 to October 2010) was conducted among adult female burn victims admitted in a tertiary care hospital in Mumbai, India. Universal sampling technique was employed for selection of study participants.
Inclusion and Exclusion Criteria
All the female burns patients above 18 years of age who were admitted during the study period in the tertiary care institute and were willing to participate in the study were included. The patients or legally accepted guardians, in case of serious patients, who did not give consent were excluded from the study. Also, patients who expired prior to the interview were excluded from the study.
A pre-tested semi-structured questionnaire was designed after reviewing the literature. A pilot study was done to test the validity of the questionnaire and then it was suitably modified for data collection. The questionnaire consisted of questions to elicit socio-demographic details of the burn victims along with specific information pertaining to the present episode of burns injury.
Once the patients' vitals were stabilized, participants were interviewed after obtaining their informed consent. Support of the nursing staff and medical social workers was utilized to establish bond with burn victims and their relatives. Each of the burn patients and their relatives were simultaneously linked with the medical social worker (MSW) for guidance about financial concessions and available rehabilitation modalities. The extent of burn injury was calculated according to Wallace rule of nine based on total body surface area (TBSA) burnt which was later re-confirmed with the help of treating surgeon. 
Modified Kuppuswamy's scale for classifying socioeconomic status was used to determine social class of the respondents. 
In each of the visits made vy the investigators during the hospital stay of burn patients, special emphasis was given towards the utilization of rehabilitation services by the subjects after their discharge from the hospital. The subjects were offered rehabilitation services depending upon their needs viz. Medical rehabilitation (splints, pressure garments, skin grafting surgeries, physiotherapy and occupational therapy etc.,); Vocational rehabilitation (needy burn victims were referred to various rehabilitation centers depending on their requirements / qualifications) and Psycho-social rehabilitation for optimizing the acceptance of the victim by the family members.
Follow-up of Patients
After discharge, at weekly intervals for a period of two months, the subjects were contacted over telephone about their condition/ any complication/ any significant marital or social issue that may have arisen which she was unable to cope / acceptance at workplace, etc. In collaboration with the department physiotherapy and occupational therapy, the follow up days of the patients were fixed and then re-confirmed with the subjects so as not to miss the opportunity of personal contact and corroborate the reliability of the information obtained over telephonic conversation. Subjects who were not traceable even telephonically were declared as lost to follow up.
Ethical clearance was obtained from the Institutional Ethics committee prior to the start of the study. Written informed consent was obtained from the study participants before obtaining any information from them. Utmost care was taken to maintain privacy and confidentiality.
Data entry and statistical analysis was done using SPSS version 17. Frequency distributions were calculated for all the variables. Chi-square test was used to assess the association between socio-demographic parameters and post-burn impact.
| Results|| |
Overall 107 burns patients were admitted during the study duration of which three patients did not give consent for the study and hence were not included while one patient expired prior to the first interview and hence was excluded from the study. Thus, the total sample size was 103.
In the present study, majority of the women 63 (61.2%) were in the age group of 18-30 years. 21 (21.4%) were in the age group of 30-45 years. Mean age was 31.4 years with standard deviation of 13.3 years. 78 (75.7%) women were belonging to Hindu religion while only 23 (22.3%) women belonged to Muslim religion. As regards to education, 23 (22.3%) women were illiterate, 31 (30.1%) were educated up to primary level, 28 (27.2%) up to secondary level and 9 (8.7%) women were graduates and above. Majority 74 (71.8%) women were housewives while 5(4.9%) women were involved in skilled and professional work.
[Table 1] depicts the relevant information about burns injury in the study subjects. It shows that flame burn was the most common cause of burns accounting for 80.6% of the total burns. Kerosene stove was the most common offender in 56 (67.5%) victims. Other causes included chullah in 10 (12%) subjects, LPG gas in 9 (10.8%) cases. Accidental burns accounted for burns in 89 (86.4%) of cases while homicidal burns accounted for 9.7% cases. Limbs (upper & lower) were most commonly involved.
Case fatality rate within the hospital stay was 35% in the present study. Thus, only 67 burn victims were followed up out of which 18 women were further lost to follow up as they could not be contacted including 14 women who were from a different city other than in which the study was conducted. One woman had expired within two months of discharge from the hospital. Thus total 48 women were only followed up for the next two months after their discharge from the hospital.
[Table 2] shows the distribution of socio-demographic variables based on the post-burn impact. A statistical significant association was observed between age-group, marital status, nature of burns and post burn impact. No significant association was observed with other socio-demographic parameters like education, occupation, religion, mode of burn and type of kitchen.
[Table 3] reveals the contractures site among the study respondents. 14 (29.1%) women developed contractures out of which only 3 (21.4%) underwent reconstructive surgery. In addition, nine women were re-hospitalized for management of secondary wound infections.
Of the 46 women who were advised use of splints and pressure garments, only 21 (45.7%) women were actually using it. 25 (52.1%) women out of the 48 followed-up women underwent skin grafting.
15 (31.3%) women were regularly attending physiotherapy and occupational therapy sessions while rest 20 (41.6%) victims either attended physiotherapy irregularly or did not attend physiotherapy or occupational therapy at all. [Table 4] shows the reasons cited by followed-up victims for non usage of splints and for not attending physiotherapy / occupational therapy after discharge.
|Table 4: Reasons for non-utilization of medical rehabilitation services |
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[Table 5] shows that 12 (25%) subjects were completely accepted by their families and families were supportive of them. It was also observed that 26 (54.1%) women could carry out their daily activities normally, 17 (35.4%) women with difficulty and the remaining 5 (10.4%) women required help of family members for some of her daily activities. Out of the total 48 women, 18 (37.5%) were earning members of family and rest 30 (62.5%) were housewives. 14 (77.8%) women resumed work normally but four could not because of development of contractures. These four women along with seven other study subjects who were housewives were referred to different vocational rehabilitation centers with the help of medical social worker of the tertiary care institute. Vocational training in the form of tailoring, packing of vegetables at vendor shops and floral packaging was provided to 11 burn victims.
[Table 6] demonstrates the different problems faced by study subjects in their course of rehabilitation.
Follow-up visits revealed that 14 (29.1%) women had no motivation / low self esteem because of the disfigurement while 17 (35.4%) victims were repeatedly abused by their in-laws. The concerned spouse in-laws were given special attention and every attempt was taken to facilitate the integration of burn victim in their family. Simultaneously family meetings were conducted in which those burn victims whose family has accepted them as a member of the family, shared their experience and positively motivated family members of others to promote acceptance.
| Discussion|| |
In the present study, majority 63 (61.2%) of the women were in the age group of 18-30 years. Similar results were obtained in another study where almost 85% of burnt women were between the age group of 16-30 years. 
Also, findings of a study revealed that almost 41% of the female victims belonged to the age group of 15 to 24 years.  The probable reasons for more risk of burns in this young age were because of inadequate precautions during cooking, exposure to hazardous situations at home and also dowry deaths, etc.
Flame burn was the most common mode of burns which accounted for 80.6% of all the burns, in the present study. Similar results were obtained in various studies done in India as well as in other countries. , This was mainly because of incorrect and unguarded cooking practices. Almost 14 (29.1%) females in our study had developed contractures, especially in the neck in 11 (78.5%) women while in a study done in Indore, 18.2% of the subjects developed contractures. 
In the current study, 16 (64%) women did not feel the necessity of using splints while 9 (36%) women did not use it just because of ignorance. This clearly suggests the need for constant reinforcement and motivation of the women for facilitating utilization of medical rehabilitation services. The importance of splinting in influencing healing of soft tissues is well depicted.  A well-designed splintage program along with the active and passive mobilization is a must to prevent and convert joint contractures and deformities. 
It was also revealed that most 17 (85%) of the burn patients felt that it was not feasible for them to go for physiotherapy so frequently. On the other hand, 13 (65%) women felt such frequent visits will adversely affect their domestic dynamics while 8 (40%) women had no motivation. This shows the need of expansion of physiotherapy and occupational therapy services in order to improve their accessibility for the needy persons. In another study done in Mumbai, only five women attended for physiotherapy while remaining 69 were not even aware about the need of physiotherapy. 
In our study, 12 (25%) subjects were completely accepted by their families while 21 (43.7%) subjects were not completely accepted by their husband and in laws. Furthermore, it was observed that acceptance of the burn victims by their families was much better in nuclear families than by joint families.
A study in Mumbai reported that 23 women were totally rejected and deserted and they were considered as burden to their families.  In another study, prevalence of psychosocial disturbances among the adults was 10%. 
After follow-up the burn victims it was revealed that 14 (77.8%) women have resumed their work without any discomfort. Rest 4 (22.2%) women were unable to resume work because of contractures development. A study conducted in Sweden revealed 31% of bun victims could not resume their work.  Findings of a systematic review showed that 66% of study subjects were able to resume their work following their burn; with rates even higher in patients with lower total body surface are burns.  Major difficulties faced by women in their rehabilitation included lack of motivation / low self esteem in 14 (29.1%)and abuse by in laws in 17 (35.4%), etc.
The study had its limitations that no long term follow up of the burns victims was done. Also, no psychiatric assessment was done subsequent to their discharge from the hospital.
| Conclusion|| |
Following a burn injury most of the victims can feel isolated and alone especially in case of women. They may find it difficult to integrate back into society and take up life as they knew it prior to their injury. Counseling services deserve special attention and play a vital and indispensable role in rehabilitation of burn victims not only during hospital stay but also after discharge.
There is an immense need of giving emphasis on promotion of positive thinking, significance of physiotherapy and occupational therapy, measures for prevention of secondary infections & contractures and facilitating vocational guidance for earning own livelihood for an independent living.
| Acknowledgments|| |
We are very much thankful to the head of plastic surgery Department for permitting us and guiding us during the entire duration of the study.
| References|| |
|1.||Burns. Fact sheet N°365. World Health Organization, 2012. Available from: http://www.who.int/mediacentre/factsheets/fs365/en/. [Last Accessed 2012 Sep 25]. |
|2.||Batra AK. Burn mortality: Recent trends and sociocultural determinants in rural India. Burns 2003;29:270-5. |
|3.||Goldman AS, Larson DL, Abston S. The silent epidemic. JAMA 1972;221:403. |
|4.||Van Baar ME, Essink-Bot ML, Oen IM, Dokter J, Boxma H, van Beeck EF. Functional outcome after burns: A review. Burns 2006;32:1-9. |
|5.||Esselman PC. Burn rehabilitation: An overview. Arch Phys Med Rehabil 2007;88 12 Suppl 2:S3-6. |
|6.||Kwan MW, Ha KW. Splinting programme for patients with burnt hand. Hand Surg 2002;7:231-41. |
|7.||Esselman PC, Thombs BD, Magyar-Russell G, Fauerbach JA. Burn rehabilitation: State of the science. Am J Phys Med Rehabil 2006;85:383-413. |
|8.||Edgar D, Brereton M. Rehabilitation after burn injury. BMJ 2004; 329:343-5. |
|9.||Edgar D. Active burn rehabilitation starts at time of injury: An Australian perspective. J Burn Care Res 2009;30:367. |
|10.||Babu BV, Kar SK. Domestic violence against women in eastern India: A population-based study on prevalence and related issues. BMC Public Health 2009;9:129. |
|11.||Garcia-Moreno C, Jansen H, Ellsberg M, Heise L, Watts C. WHO Multi-country study on women′s health and domestic violence against women. Geneva: WHO; 2005. |
|12.||International institute of population sciences and macro international. National family health survey 3, India, 2005-06. Goa, Mumbai: IIPS; 2009. |
|13.||Koenig MA, Stephenson R, Ahmed S, Jejeebhoy SJ, Campbell J. Individual and contextual determinants of domestic violence in North India. Am J Public Health 2006;96:132-8. |
|14.||Parker S. Burns, 2012. Available from: http://www.surgical-tutor.org.uk/default-home.htm?core/trauma/burns.htm~right. [Last accessed 2012 Sep 16]. |
|15.||Park K. Medicine and social sciences. In: Park K, editor. Text book of preventive and social medicine. 21 st ed. Jabalpur: Banarsidas Bhanot Publishers; 2011. p. 638-40. |
|16.||Das Gupta SM, Tripathi CB. Burnt wife syndrome. Ann Acad Med Singapore 1984;13:37-42. |
|17.||Shanmugakrishnan RR, Narayanan V, Thirumalaikolundusubramanian P. Epidemiology of burns in a teaching hospital in south India. Indian J Plast Surg 2008;41:34-7. |
|18.||Kumar V, Tripathi CB, Kanth S. Burnt wives: A circumstantial approach. J Forensic Med Toxico 2001;18:14-9. |
|19.||Attia AF, Sherif AA, Mandil AM, Massoud NM, Arafa MA, Mervat W. Epidemiological and socio-cultural study of burn patients in Alexandria, Egypt. East Mediterr Health J 1997;3:452-61. |
|20.||Jaiswal AK, Aggarwal H, Solanki P, Lubana PS, Mathur RK, Odiya S. Epidemiological and socio-cultural study of burn patients in M.Y. Hospital, Indore, India. Indian J Plast Surg 2007;40:158-63. |
|21.||Fess EE, McCollum M. The influence of splinting on healing tissues. J Hand Ther 1998;11:157-61. |
|22.||Bhalerao VR, Desai VP, Pai DN. Study of socio-psychological aspects of burns in females. J Postgrad Med 1976;22:147-53. |
|23.||Browne G, Byrne C, Brown B, Pennock M, Streiner D, Roberts R, et al. Psychosocial adjustment of burn survivors. Burns Incl Therm Inj 1985;12:28-35. |
|24.||Dyster-Aas J, Kildal M, Willebrand M. Return to work and health-related quality of life after burn injury. J Rehabil Med 2007;39:49-55. |
|25.||Quinn T, Wasiak J, Cleland H. An examination of factors that affect return to work following burns: A systematic review of the literature. Burns 2010;36:1021-6. |
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]