ABSTRACT

KEY WORDS:

KEY WORDS: Burn prevention, Cooling, Wound closure

INTRODUCTION
Burn injuries are a global public health problem with an estimated 180,000 deaths annually. Most burn injuries occur in low- and middle-income countries (LMIC), with nearly 75% in South-East Asia and Africa. Burn injuries are associated with substantial morbidity and mortality. Survivors of severe burns often experience significant long-term consequences because of the development of burn scar contractures. Contractures occur when excessive scar tissue forms and contracts, leading to a loss of flexibility. This can result in limited range of motion, which has a significant effect on the well-being and quality of life. Factors that influence burn scar deformities, such as contractures, can be minimized through prompt cooling, adequate wound closure, correction of tissue deficiencies, and diligent postoperative splinting and compression therapy. To provide such advanced burn management, a certain level of basic health care is required.

Research is scarce on burn contractures in LMIC. Most studies focused on the prevalence and consequences of burn injuries in Bangladesh are derived from limited-scale surveys at the community level or from records of hospital admissions. In Bangladesh, people living in the northern river areas and southern coastal belt have little or no access to health care. Friendship NGO aims to diminish life in extreme poverty in these areas by providing basic health care services. One of their initiatives is the Floating Hospital, a boat platform that mobilizes health care provision by being able to relocate throughout the area. Effective primary and secondary prevention strategies are crucial to reduce both the incidence of burn injuries and the long-term complications, such as burn scar contractures.

In this study, we aimed to provide comprehensive data to inform the development of effective burn prevention campaigns tailored to rural areas in northern Bangladesh. Specifically, we aimed to understand the circumstances leading to burn injuries, assess care-seeking behaviors and barriers to medical care, and evaluate current preventive measures and safety practices. These findings will guide the creation of targeted strategies to reduce the incidence of burn injuries and resulting contractures.

MATERIALS AND METHODS
Study population: This study included children requiring reconstructive surgery for burn contractures who were screened in November 2022 at the Friendship Emirates Floating Hospital. The recruitment of patients at the Emirates Floating Hospital was conducted through a multifaceted outreach initiative. Announcements were broadcast via speakers at local markets, serving as a direct call to action for those affected. All patients were from the remote northern islands, a region where access to medical facilities is substantially limited.

Study design: This study was designed as a retrospective study with mixed methods (quantitative and qualitative). We gathered data on the causes of burn injuries, first aid practices, barriers to accessing care, and preventive measures for child burn injuries in these areas. We then sought parental input on spreading this knowledge. Before inclusion of the study, written informed consent was obtained from the parents, grandparents, or guardians of all participants. If participants were illiterate, the informed consent was read aloud to them in Bengali, and they were able to provide their informed consent with a fingerprint.

Quantitative study: A questionnaire was developed to collect data on causes of burns in children with burn contractures, the first aid provided, and the barriers to accessing care in rural char areas in northern Bangladesh. We also asked every parent or grandparent about potential measures to prevent burn injuries in children, as well as their suggestions on spreading such knowledge. If the parent or grandparent of the child was illiterate, the questionnaire was conducted orally with 2 of the authors (A.A. and M.S.).

Qualitative study: To explain and elaborate on the quantitative findings, we conducted 7 qualitative face-to-face in-depth interviews, focusing specifically on children with hand burn contractures, as they represent the most severe and homogenous group within the study population. Although the quantitative questionnaire was designed to provide a broad overview of the causes of burns, first-aid practices, and barriers to care, we conducted interviews to explore in greater depth the cultural and contextual factors influencing burn injuries, the barriers to accessing adequate care, and caregivers’ perspectives on burn prevention and management. Interviews were also aimed to gather practical, experience-based recommendations from caregivers, taking into account cultural practices and norms, to inform future prevention strategies. The interviews were done at the Emirates Floating Hospital by 2 of the authors (M.U. and M.S.). Whenever possible, the interview was conducted in English. If not, one of the authors provided a Bengali translation. All interviews were audio-recorded, transcribed verbatim, and subjected to a meticulous content analysis conducted manually to ensure a comprehensive understanding of the data collected.

RESULTS
Results of quantitative questionnaire: Our study included 22 children with burn scar contractures who underwent surgical reconstruction and their parent(s) or guardian(s). Among the 22 children, 14 were girls and 8 were boys, with median age of 18 months (range, 0.5-7 y). Questionnaires showed that mean postburn period was 4.19 years (range, 0.5-12 y). Parents or guardians fully completed the questionnaire. Table 2 shows the sociodemographic characteristics at the time of injury.

Location of burn contracture: Among study patients, 63.6% (14 children) had hand contractures, 13.6% (3 children) had foot contractures, 13.6% (3 children) had axillary contractures, and 4.5% (1 child) had a neck contracture. In addition, 1 child (4.5%) presented with combined elbow, wrist, and hand contracture (Table 2).

Burn injuries, causes and treatment: At the time of the burn injury, average age of children was 2 years (24.9 mo). The most common causes of burn injuries were hot fluids, ashes, and open fires. Most burns occurred during or just after cooking (63.6%). Table 3 shows the circumstances during the burn injury.

After the burn injury, 3 patients (13.6%) did not undergo cooling of the injured area with water. The remaining 19 patients (86.3%) had water applied to cool their burns. Of these, 6 patients underwent cooling for <5 minutes, 7 patients for between 5 and 10 minutes, and 6 for >10 minutes. In most patients, nothing was applied to the affected area (40.9%). For most patients, either nothing or egg yolk was applied to the affected areas. Table 3 displays the acute management following the injury.

Most wounds (95.5%) took longer than 1 month to close. Table 3 provides an overview of wound closure durations after burn injury as reported by parents, grandparents, or guardians. Only 1 patient received a split skin graft.

All parents, grandparents, or guardians sought medical care for their children. Most consulted a village doctor or local healer (59.1%) or visited the hospital (31.8%). It should be noted that village doctors and traditional healers in this context are individuals without formal medical training. Table 3 shows the medical care-seeking patterns for parents, grandparents, or guardians of children with burn injuries.

Barriers to seeking more qualified health care providers are shown in Table 3. Almost half of parents, grandparents, or guardians mentioned that the initial health care provider they consulted did not suggest referrals to other health care providers. Furthermore, 25% mentioned that there was a financial barrier to seeking medical care.

DISCUSSION
Two-thirds of the children with contractures requiring surgical intervention in our study had sustained burn injuries in cooking-related situations and had an average age of 24.9 months at time of the burn injury. Moreover, almost half of the burn wounds were not cooled properly after the burn injury. More than half of the patients were treated by the village doctor or local healer only. This striking finding emphasizes the need for targeted burn prevention, both primary and secondary. To design these prevention campaigns, parents, guardians, and grandparents of children in our study provided valuable recommendations.

Among the 22 pediatric patients with burn contracture included in our study, the most common causes of burn injuries were hot liquids followed by ashes and open fire. Three patients (13.6%) did not receive cooling with water to the affected area at all, and 6 (27.3%) were rinsed with water for <5 minutes. Immediate cooling of a burned area is a critical first aid measure that has been extensively studied for its benefits in reducing burn severity and improving clinical outcomes. Effective acute burn management can minimize the depth of the burn injury, reduce postburn hyperthermia, minimalize pain, and reduce overall morbidity. Guidelines from the Emergency Management of Severe Burns have recommended cooling the affected area with lukewarm running water for at least 20 minutes. Similarly, the International Society for Burn Injuries (ISBI) Practice Guidelines for Burn Care has emphasized the importance of proper first aid, including the use of clean, running water, as a foundational step in acute burn care. The ISBI Guidelines provide a framework for acute burn management, highlighting 5 key components: immediate first aid, wound care, pain management, referral and transport, and public education.

Our findings revealed large gaps in burn care practices compared with these recommendations. For example, only 59% of patients received any form of cooling, and many did not meet the ISBI-recommended 15 to 20 minutes of cooling. Moreover, over half of the caregivers to patients resorted to harmful practices, such as applying raw eggs, oil, or cow dung to patients’ burns, which are strongly discouraged because of their potential to cause infection and delay healing. These results highlight a pressing need to educate communities on evidence-based first aid practices. In more than half of the patients, raw eggs or eggs with salt, leaves with oil or water, and stool of a cow were used on the wound after the burn injury. These common practices were also found in other studies in rural areas of Bangladesh and other LMICs. Although some research has suggested that egg white formulations or egg membranes may have positive effects on wound healing, of note, these were tested in controlled settings or later stages of care and are not appropriate for immediate first aid. The continued use of these substances as first aid highlights the urgent need to provide culturally relevant education to communities about safe and effective practices for acute burn care.

For patients in our study, most parents, grandparents, or guardians sought medical care at a village doctor or local healer. Only one-third went to a hospital. The most commonly mentioned barriers to seeking medical care were the lack of referrals from the initial health care provider and financial barriers. Another study in Bangladesh indicated that factors such as education, economic status, and place of residence play a significant role in determining health care provider selection. Parents with higher incomes and greater levels of education choose more qualified health care providers over other options. Enhancing the health-seeking behavior of parents or guardians could play a critical role in diminishing the incidence of permanent disabilities from burns. Education of parents or guardians on effective health care-seeking behavior has been effective. Therefore, education of caregivers is essential. In addition, in this area, the Friendship Community Medic-aides could play a vital role in improving early burn care and prevention. These women, trained by the Friendship NGO, provide primary health care, health education, and counseling within their communities. Furthermore, it would be beneficial to pursue collaborative efforts with village doctors and traditional healers to enrich referral practices. The forging of partnerships and respecting the valuable role that they play in community health can work toward a more integrated approach to burn care and prevention.

The findings of our survey provided insights to inform potential solutions for reducing the burden of burn injuries and their long-term consequences in these communities. We identified primary causes of burn injuries, such as cooking-related incidents and inadequate first aid practices. With these insights, we can tailor burn prevention campaigns to address specific risks, such as improving kitchen safety measures and emphasizing the importance of immediate cooling. Furthermore, the survey showed gaps in health care-seeking behavior, including reliance on unqualified health care providers and financial barriers, highlighting the need for educational interventions and strengthened referral systems. The practical recommendations shared by parents, grandparents, or guardians during the qualitative components of this study offer culturally relevant, actionable strategies for reducing risk of burns and improving early management. These findings lay a foundation for developing targeted interventions, such as community education programs and collaboration with local health care providers, to promote timely and effective burn care.

CONCLUSIONS
To minimize the incidence of burns in the northern rural part of Bangladesh, a crucial aspect is to restrict a child’s access to the cooking area during or after cooking (primary prevention). Furthermore, improvements in acute burn care are needed, including providing information on proper cooling after burn injuries and having an adequate referral strategy. It would be helpful to encourage cooperative initiatives with village doctors and traditional healers. By building partnerships and acknowledging their important contributions to community health, we can collectively enhance primary and secondary prevention of burns scar contractures. There is room to improve the health-seeking behavior of caregivers after burn injuries. Parents, grandparents, and guardians of children with burn injuries shared valuable recommendations, which, along with our findings, could inform burn prevention campaigns in these areas. These insights may also enhance primary care practices, leading to better burn management and potentially reducing the risk of complications like burn contractures.

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