JBUR-4324; No. of Pages 6 burns xxx (2014) xxx–xxx
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/burns
Burns in Sierra Leone: A population-based assessment Evan G. Wong a,b,c,1, Reinou S. Groen c,d, Thaim B. Kamara e,f, Kerry-Ann Stewart g, Laura D. Cassidy h, Mohamed Samai h, Adam L. Kushner b,c,i, Sherry M. Wren j,* a Centre for Global Surgery, McGill University Health Centre, 1650 Cedar Avenue, L9 411, Montreal, QC, Canada H3G 1A4 b Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA c Surgeons OverSeas (SOS), New York, NY, USA d Department of Gynecology and Obstetrics, Johns Hopkins Hospital, Baltimore, MD, USA e Department of Surgery, Connaught Hospital, Freetown, Sierra Leone f College of Medicine and Allied Health Science (COMAHS), Freetown, Sierra Leone g Department of Surgery, University of Southern California Keck School of Medicine, Los Angeles, CA, USA h Institute for Health and Society, and Epidemiology Division, Medical College of Wisconsin, Milwaukee, WI, USA i Department of Surgery, Columbia University, New York, NY, USA j Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
article info
abstract
Article history:
Purpose: Burns remain disproportionately prevalent in developing countries. This study
Accepted 8 March 2014
aims to describe the epidemiology of burns in Sierra Leone to serve as a baseline for future programs. Methods: A cluster randomized, cross-sectional, countrywide survey was conducted in 2012 in Sierra Leone. With a standardized questionnaire demographics and deaths during the previous 12 months of household members were assessed with the household representative. Thereafter, 2 randomly selected household members were interviewed, elucidating whether participants had ever had a burn in six body regions and determining burn mechanisms and patterns of health care seeking behavior. Results: This study included 1843 households and 3645 individuals. 3.98% (145/3645) of individuals reported at least one burn-injury. The highest proportions of burns were reported in the age groups 0–4 years old (23/426, 5.4%) and 5–14 years old (37/887, 4.17%). The majority of burns (129/145, 89.0%) were caused by a hot liquid/object and the upper, extremities were the most commonly burned body regions, with 36% (53/145) of cases. 21% (30/145) of individuals with burns sought care from a traditional healer. Conclusions: Burns are highly prevalent in Sierra Leone. Further research and resources should be allocated to the care and prevention of thermal injuries. Published by Elsevier Ltd and ISBI
* Corresponding author at: Department of Surgery, Stanford University School of Medicine, PAVAHCS G112, 3801 Miranda Ave, Palo Alto, CA 94304, USA. Tel.: +1 6508523461. E-mail addresses: [email protected] (E.G. Wong), [email protected] (S.M. Wren). 1
Tel.: +1 514 934 1934; fax: +1 514 843 1503. http://dx.doi.org/10.1016/j.burns.2014.03.007 0305-4179/Published by Elsevier Ltd and ISBI
Please cite this article in press as: Wong EG, et al. Burns in Sierra Leone: A population-based assessment. Burns (2014), http://dx.doi.org/10.1016/ j.burns.2014.03.007
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1.
Introduction
Burns are well recognized as a major cause of morbidity and mortality worldwide, particularly in low- and middle-income countries (LMICs) [1,2]. They often require long hospitalizations and lead to devastating physical and psychological sequelae [3]. For survivors of the initial injury, especially those in developing countries, inadequate treatment and/or lack of rehabilitation further compound the challenges of functional recovery [4]. Sierra Leone is a small West African country with a population of approximately 5.4 million people, living in a land area of 72,000 km2 (28,000 sq mi). It is one of the poorest countries in the world, ranking 180 of 187 nations in the United Nations Human Development Index [5]. In addition to the economic barriers, Sierra Leone presents several challenges to the delivery of surgical care. The country emerged from a brutal decade-long civil war in the beginning of this century. The civil war, resulted in immense disruption of the health care system, as well as systems to ensure access to food supplies, clean water, and basic sanitation [6]. The scarcity of human and material resources compounds the challenges of burn management in Sierra Leone. The Surgeons OverSeas Assessment of Surgical Need population based survey was developed to assess the surgical need in the community and was conducted in Sierra Leone in February of 2012 [7]. A report of injury patterns in Sierra Leone using this survey revealed that burns were the third most common cause of injury, following falls and wounds due to lacerations or crush injuries [8]. Based on this survey, this study aimed to provide detailed information on the epidemiology of burns in Sierra Leone in order to guide the development of programs to address the unmet need for burn prevention, treatment and rehabilitation in developing countries.
interview, similar to the definition used by Statistics Sierra Leone for the Demographic Health Survey [10].
2.3.
Data collection
The survey consists of two sections; the first section was administered to the household representative to determine the number of household members, household demographics, and occurrence of deaths within the household during the previous 12 months. The second section consists of structured interviews of 2 randomly selected household members. Each interview entails a head to toe verbal examination elucidating information on overall surgical needs, including whether participants had ever had a burn in any of six body regions: face/head/neck, chest/breast, abdomen, groin/genitals/buttocks, back and extremities. Responses were probed in order to determine the mechanism of the burns and the patterns of health care seeking behavior related to burns. Data was entered real-time using software programmed onto electronic tablets. Enumerators were Nursing and Medical students and professional enumerators from Statistics Sierra Leone who underwent a week long training in survey specifics, interview techniques and tablet use.
2.4.
Data analysis
The data were transferred from the tablets to an electronic database, and analyzed using SAS 9.3 statistical software (SAS Institute Inc., Cary, NC). The Proc Survey procedures including proc surveyfreq and procsurvey logistic were used to analyze the survey data. The estimated proportions of burns are reported with 95% confidence intervals and were compared by sex, age, residency, literacy, timing of burn and healthcare sought using a Chi-square test of proportions. Odds ratios for probability of sustaining a burn were reported by these characteristics and confidence intervals that did not include 1.0 were considered statistically significant.
2.
Methods
2.5.
2.1.
Study design
Informed consent was obtained from community leaders, from the head of the household, and from all participants individually. The study was approved by the Sierra Leone Ministry of Health and Sanitation. Ethical approval was obtained from the Ethical and Scientific Review Committee of Sierra Leone, the Research Ethics Committee of the Royal Tropical Institute in Amsterdam, and from the Institutional Review Board of Stanford University.
Cluster randomized cross sectional study.
2.2.
Study population
Detailed study methods were previously described [7]. Briefly, this study was a component of the SOSAS survey of surgical need in Sierra Leone, which was conducted in January to February 2012 [7]. Based on the surgical need prevalence of 7.3% as previously demonstrated in a pilot study [9], the required sample size was 3745 individual responses. A stratified randomized cluster sampling approach was used to select participants. Seventy-five of 9671 enumeration areas, the smallest administrative units in Sierra Leone, were randomly selected for the study clusters. Within each cluster, 25 households were randomly chosen, and two members of each household were randomly selected for a full interview. Household members were defined as those who ate from the same pot and slept in the same structure the night before the
3.
Ethical considerations
Results
Of the 1875 households selected, two declined to participate (98.3% response rate) and 30 were excluded from analyses based on multiple missing key responses. The final sample consisted of 1843 households and 3645 individuals. There were slightly more females (n = 1976, 54.2%) than males, and 1831 (50.2%) were children less than 15 years of age. The majority lived in rural areas (61.2%), consistent with the population census in Sierra Leone [10].
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Data were assessed based on a subject reporting one or more burns over their lifetime. Of the 3645 respondents, 145 (3.98%) reported at least one burn-injury. Table 1 shows the demographic distribution of participants who sustained burns. Females reported slightly more burns overall than males, although this was not statistically significant (87 [4.4%] versus 58 [3.5%], OR 1.27 95% CI 0.95–1.71). The highest proportions of burns were reported in the following age groups: 0–4 years old (n = 23, 5.4%) and 5–14 years old (n = 37, 4.17%). Compared to the youngest age group (i.e. individuals 4 years and younger), respondents 25–46 years old had a statistically significantly lower percentage of burns (OR = 0.64, 95% CI 0.43–0.97). With regards to occupation, homemakers reported the highest percentage of burns (n = 9, 8.3%), compared to other occupations where an average of approximately 4% reported burns. Nongovernment employees and farmers reported the least number of burns (n = 0 and n = 24 [2.8%] respectively). Literacy level, education and residency (i.e. urban versus rural) did not significantly affect the odds of sustaining burns in this study population. The mechanisms of burns, categorized as open fire/ explosion or hot liquid/object, are shown in Table 2. Different mechanisms could be reported for burns on multiple body sites, explaining the 147 reported mechanisms for 145 burns. The majority of burns (n = 129, 89.0%) were caused by a hot liquid/object, regardless of age, sex, residency, or literacy level. Interestingly, open fire/explosion caused 17.1% (n = 6) of burns in respondents who could not read or write, compared to only 5.7% (n = 2) in literate respondents. As shown in Table 3, the upper extremities were the most commonly burned body regions, with 36% (n = 53) of reported burns occurring in this area. The lower extremities were the second most commonly involved (22%, n = 32), followed by the face/head/neck (12%, n = 17). The groin/genitalia/buttocks region was the least commonly involved (4%, n = 6). Gender did not significantly affect the odds of seeking or receiving healthcare, or of seeking care from a traditional healer. Eighty-two percent of respondents (n = 119) with burns sought healthcare at a healthcare facility. Of those, 84% (n = 100) received a minor procedure (dressings, wound care, puncture, suturing, and/or incision and drainage), 4% (n = 5) received a major procedure (a procedure requiring regional or general anesthesia), and 12% (n = 14) did not receive surgical care. Twenty one percent (n = 30) of individuals with burns sought care from a traditional healer (Table 4).
4.
Discussion
The lack of surgical resources in LMICs has been well documented [11–20]. Indeed, the lack of access to material and human medical resources has been cited as a major barrier to definite burn care [21]. Concurrently, previous household surveys have estimated a cumulative incidence of burns to be between 5 and 11% in rural Ethiopia [22] and a prevalence of 6% amongst Ghanaian children [23]. Indeed, burns account for disabilities that cost more than 80.2 billion dollars a year in lost productivity, with almost 95% of that economic impact occurring in LMICs [24].
Table 1 – Demographic characteristics of participants sustaining burns. Total
Burns % (n)
Odds Ratio (95% CI)
Sex Male Female
1669 1976
3.48 (58) 4.40 (87)
Referent 1.27 (0.95–1.71)
Age 0–4 years 5–14 years 15–24 years 25–46 years >46 years Missing
426 887 728 1019 563 22
5.40 4.17 3.98 3.53 3.55 0
(23) (37) (29) (36) (20)
Referent 0.76 (0.44–1.31) 0.72 (0.43–1.20) 0.64 (0.42–0.96)* 0.64 (0.37–1.10)
Residency Rural Urban
2231 1414
79 (3.54) 66 (4.67)
Referent 1.33 (0.73–2.40)
1776 108 264 846 449 124
74 (4.17) 9 (8.33) 13 (4.92) 24 (2.84) 18 (4.01) 6 (4.84)
Referent 2.09 (1.07–4.09)* 1.19 (0.70–2.02) 0.67 (0.40–1.13) 0.96 (0.63–1.47) 1.17 (0.54–2.51)
62
0
–
16
6.25 (1)
Education None Primary Secondary Tertiary or Higher Missing
1891 809 810 125 10
4.02 (76) 4.08 (33) 3.33 (27) 6.40 (8) 10.00 (1)
Literacy (only for those Cannot read or write Can read or write Missing
15–49 years) 874 3.89 (34) 927 3.78 (35) 13 0
Total
3645
Occupation Unemployed Homemaker Domestic helper Farmer Self-employed Government employee Non-Government employee Missing
*
Referent 1.02 (0.71–1.40) 0.82 (0.50–1.33) 1.63 (0.83–3.20)
Referent 0.97 (0.60–1.56)
3.98 (145)
Statistically significant at the 0.05 level.
In this context, in addition to efforts to build surgical capacity, multiple studies have investigated the most prevalent etiologies and risk factors associated with thermal injuries in order to guide prevention strategies. The epidemiology of burns varies based on a number of factors, including economic, geographic and socio-cultural determinants. In developing countries, poverty, illiteracy, and crowded living conditions are universal risk factors [25,26]. In fact, open fire/explosion was over three times more likely to be the cause of burns in the illiterate group as compared to the literate group in the present study, which may underline areas of potential prevention. For example, graphic safety instructions may be beneficial. Age also plays an important role, with the pediatric age group comprising at least 50% of burn patients in various reported series [1,27–29], similar to the results of this study. Women are also at increased risk of severe burns and death in many countries, including Iran [27,30] India [31] and Iraq [32]. However, in sub-Saharan Africa, it appears that males are at an increased risk compared to females, particularly when
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Table 2 – Mechanism of burn according to demographic characteristics.
have reported scalding fluids as the most common cause of burns in African countries [33] although flame burns now appear to be on the increase [34]. The present study also reports a hot liquid/object as the leading cause of burns, as opposed to an open fire/explosion possibly caused by hot cooking pots in the open living spaces. However, the current survey did not further specify this. Based on the epidemiology of burns in developing countries, a number of preventive strategies have been suggested specifically for this context. Several interventions aiming to improve socioeconomic status have been brought forward, including higher parental education and increased access to basic resources, such as water [35]. At the community level, safety policies regulating the design and storage of hazardous material (e.g. kerosene stoves and lamps) and housing and kitchen construction have been recommended [1,36]. Overall, the creation of a national body of burn professionals would not only ensure adequate funds and help coordinate efforts, it would also facilitate education regarding burn prevention and management [1]. Radio announcements, school lessons and market day presentations have been advocated as key educational strategies in burn prevention [37]. Given this study’s finding that more than one in five burn patients sought care from a traditional healer, these communication strategies provide unique opportunities to provide guidance for proper medical care. Finally, efforts to build surgical capacity should not be forgotten and the implementation of cost effective burn treatments should be prioritized [1]. This study does present several limitations. First, the assessment relied solely on verbal interviews with household members. Although a physical exam would have been a beneficial addition to this study, it was not performed secondary to important ethical, logistical and economical reasons. Therefore, reporting of burns relied solely on the information provided by the interviewee. This also presents an important potential for recall bias. However, we believe this study does present an accurate snapshot of the burden of burns in the community as opposed to hospital-based studies, which may underestimate the prevalence. Indeed, our finding that only 82% of respondents sought healthcare corroborates this statement.
Open fire/ Hot liquid/hot Total explosion % (n) object % (n) Sex Male Female
11.9 (7) 12.5 (11)
Age 0–4 years 5–14 years 15–24 years 25–46 years >46 years
0 13.5 20.7 5.4 23.8
Residency Rural Urban
88.1 (52) 87.5 (77)
59 88
(5) (6) (2) (5)
100 (23) 86.5 (32) 79.3 (23) 94.6 (35) 76.2 (16)
23 37 29 37 21
11.2 (9) 13.4 (9)
88.8 (71) 86.6 (58)
80 67
82.9 (29) 94.3 (33) 87.8 (129)
35 35 147
Literacy (age 15–49 years) Cannot read or write 17.1 (6) 5.7 (2) Can read or write 12.2 (18) Total
Note: Respondents could report a different mechanism for burns on multiple body sites, hence the total of 147 mechanisms for 145 burns.
Table 3 – Body region affected by burn. Body region Face/head/neck Chest/breast Back Abdomen Groin/genitalia/buttocks Upper extremity Lower extremity Total number of burn regions
n
% of total number of burn regions
17 13 12 13 6 53 32 146
12 9 8 9 4 36 22
adjusted for self-inflicted burns [25]. However, the sex difference was not statistically significant in the present study. Moreover, flames constitute the major etiology of burns in many developing countries, particularly in the Indian subcontinent [1,26,31] and the Middle-East [27]. A number of studies
Table 4 – Burn related health care seeking behavior. Male (n = 58)
Female (n = 87)
Total (n = 145)
OR (male/female) of Receiving Care (95% CI)
%
n
%
n
n
%
Health care sought Yes No
82.76 17.24
48 10
81.61 18.39
71 16
119 26
82.07 17.93
0.92 (0.30–2.80)
Traditional healer Yes No
24.14 75.86
14 44
18.39 81.61
16 71
30 115
20.69 79.31
0.71 (0.28–1.82)
12.50 8.33 79.17
6 4 38 10
11.27 1.41 87.32
8 1 62 16
14 5 100 26
11.76 4.20 84.03
1.00 (0.48–2.08)
Health care received No surgical care Major procedure Minor procedure Missing
Burns in Sierra Leone: a population-based assessment.
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Moreover, this study is limited by the fact that it does not address mortality or disability. As previously stated, burns are associated with significant mortality and long-term consequences that extend beyond the individual. Further studies regarding these important issues are currently under way. Finally, this study was intended to provide a snapshot of the prevalence of burns in the community. The depth of the assessment did not provide adequate information to address further risk factors such as literacy or education, exact etiologies such as flame versus scalding fluids or specific contexts such as intentional or unintentional injury. More indepth studies in the future should address these issues to further guide prevention strategies. In conclusion, this nationwide community survey provides valuable insight into the burden of burns in the population of Sierra Leone. This study should serve as a stimulus for future studies regarding prevention strategies to address modifiable risk factors and cost-effective strategies to improve surgical capacity.
[9]
[10] [11]
[12]
[13]
[14]
[15]
Conflict of interest statement The authors do not have any conflicts of interest to declare.
Acknowledgements Surgeons OverSeas (SOS) with funding from Thompson Family Foundation provided logistical support. We would like to thank the Sierra Leone Ministry of Health & Sanitation, College of Medicine and Allied Health Sciences and Connaught Hospital for assistance with local transportation and administrative support.
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Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/burns
Burns in Sierra Leone: A population-based assessment Evan G. Wong a,b,c,1, Reinou S. Groen c,d, Thaim B. Kamara e,f, Kerry-Ann Stewart g, Laura D. Cassidy h, Mohamed Samai h, Adam L. Kushner b,c,i, Sherry M. Wren j,* a Centre for Global Surgery, McGill University Health Centre, 1650 Cedar Avenue, L9 411, Montreal, QC, Canada H3G 1A4 b Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA c Surgeons OverSeas (SOS), New York, NY, USA d Department of Gynecology and Obstetrics, Johns Hopkins Hospital, Baltimore, MD, USA e Department of Surgery, Connaught Hospital, Freetown, Sierra Leone f College of Medicine and Allied Health Science (COMAHS), Freetown, Sierra Leone g Department of Surgery, University of Southern California Keck School of Medicine, Los Angeles, CA, USA h Institute for Health and Society, and Epidemiology Division, Medical College of Wisconsin, Milwaukee, WI, USA i Department of Surgery, Columbia University, New York, NY, USA j Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
article info
abstract
Article history:
Purpose: Burns remain disproportionately prevalent in developing countries. This study
Accepted 8 March 2014
aims to describe the epidemiology of burns in Sierra Leone to serve as a baseline for future programs. Methods: A cluster randomized, cross-sectional, countrywide survey was conducted in 2012 in Sierra Leone. With a standardized questionnaire demographics and deaths during the previous 12 months of household members were assessed with the household representative. Thereafter, 2 randomly selected household members were interviewed, elucidating whether participants had ever had a burn in six body regions and determining burn mechanisms and patterns of health care seeking behavior. Results: This study included 1843 households and 3645 individuals. 3.98% (145/3645) of individuals reported at least one burn-injury. The highest proportions of burns were reported in the age groups 0–4 years old (23/426, 5.4%) and 5–14 years old (37/887, 4.17%). The majority of burns (129/145, 89.0%) were caused by a hot liquid/object and the upper, extremities were the most commonly burned body regions, with 36% (53/145) of cases. 21% (30/145) of individuals with burns sought care from a traditional healer. Conclusions: Burns are highly prevalent in Sierra Leone. Further research and resources should be allocated to the care and prevention of thermal injuries. Published by Elsevier Ltd and ISBI
* Corresponding author at: Department of Surgery, Stanford University School of Medicine, PAVAHCS G112, 3801 Miranda Ave, Palo Alto, CA 94304, USA. Tel.: +1 6508523461. E-mail addresses: [email protected] (E.G. Wong), [email protected] (S.M. Wren). 1
Tel.: +1 514 934 1934; fax: +1 514 843 1503. http://dx.doi.org/10.1016/j.burns.2014.03.007 0305-4179/Published by Elsevier Ltd and ISBI
Please cite this article in press as: Wong EG, et al. Burns in Sierra Leone: A population-based assessment. Burns (2014), http://dx.doi.org/10.1016/ j.burns.2014.03.007
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1.
Introduction
Burns are well recognized as a major cause of morbidity and mortality worldwide, particularly in low- and middle-income countries (LMICs) [1,2]. They often require long hospitalizations and lead to devastating physical and psychological sequelae [3]. For survivors of the initial injury, especially those in developing countries, inadequate treatment and/or lack of rehabilitation further compound the challenges of functional recovery [4]. Sierra Leone is a small West African country with a population of approximately 5.4 million people, living in a land area of 72,000 km2 (28,000 sq mi). It is one of the poorest countries in the world, ranking 180 of 187 nations in the United Nations Human Development Index [5]. In addition to the economic barriers, Sierra Leone presents several challenges to the delivery of surgical care. The country emerged from a brutal decade-long civil war in the beginning of this century. The civil war, resulted in immense disruption of the health care system, as well as systems to ensure access to food supplies, clean water, and basic sanitation [6]. The scarcity of human and material resources compounds the challenges of burn management in Sierra Leone. The Surgeons OverSeas Assessment of Surgical Need population based survey was developed to assess the surgical need in the community and was conducted in Sierra Leone in February of 2012 [7]. A report of injury patterns in Sierra Leone using this survey revealed that burns were the third most common cause of injury, following falls and wounds due to lacerations or crush injuries [8]. Based on this survey, this study aimed to provide detailed information on the epidemiology of burns in Sierra Leone in order to guide the development of programs to address the unmet need for burn prevention, treatment and rehabilitation in developing countries.
interview, similar to the definition used by Statistics Sierra Leone for the Demographic Health Survey [10].
2.3.
Data collection
The survey consists of two sections; the first section was administered to the household representative to determine the number of household members, household demographics, and occurrence of deaths within the household during the previous 12 months. The second section consists of structured interviews of 2 randomly selected household members. Each interview entails a head to toe verbal examination elucidating information on overall surgical needs, including whether participants had ever had a burn in any of six body regions: face/head/neck, chest/breast, abdomen, groin/genitals/buttocks, back and extremities. Responses were probed in order to determine the mechanism of the burns and the patterns of health care seeking behavior related to burns. Data was entered real-time using software programmed onto electronic tablets. Enumerators were Nursing and Medical students and professional enumerators from Statistics Sierra Leone who underwent a week long training in survey specifics, interview techniques and tablet use.
2.4.
Data analysis
The data were transferred from the tablets to an electronic database, and analyzed using SAS 9.3 statistical software (SAS Institute Inc., Cary, NC). The Proc Survey procedures including proc surveyfreq and procsurvey logistic were used to analyze the survey data. The estimated proportions of burns are reported with 95% confidence intervals and were compared by sex, age, residency, literacy, timing of burn and healthcare sought using a Chi-square test of proportions. Odds ratios for probability of sustaining a burn were reported by these characteristics and confidence intervals that did not include 1.0 were considered statistically significant.
2.
Methods
2.5.
2.1.
Study design
Informed consent was obtained from community leaders, from the head of the household, and from all participants individually. The study was approved by the Sierra Leone Ministry of Health and Sanitation. Ethical approval was obtained from the Ethical and Scientific Review Committee of Sierra Leone, the Research Ethics Committee of the Royal Tropical Institute in Amsterdam, and from the Institutional Review Board of Stanford University.
Cluster randomized cross sectional study.
2.2.
Study population
Detailed study methods were previously described [7]. Briefly, this study was a component of the SOSAS survey of surgical need in Sierra Leone, which was conducted in January to February 2012 [7]. Based on the surgical need prevalence of 7.3% as previously demonstrated in a pilot study [9], the required sample size was 3745 individual responses. A stratified randomized cluster sampling approach was used to select participants. Seventy-five of 9671 enumeration areas, the smallest administrative units in Sierra Leone, were randomly selected for the study clusters. Within each cluster, 25 households were randomly chosen, and two members of each household were randomly selected for a full interview. Household members were defined as those who ate from the same pot and slept in the same structure the night before the
3.
Ethical considerations
Results
Of the 1875 households selected, two declined to participate (98.3% response rate) and 30 were excluded from analyses based on multiple missing key responses. The final sample consisted of 1843 households and 3645 individuals. There were slightly more females (n = 1976, 54.2%) than males, and 1831 (50.2%) were children less than 15 years of age. The majority lived in rural areas (61.2%), consistent with the population census in Sierra Leone [10].
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Data were assessed based on a subject reporting one or more burns over their lifetime. Of the 3645 respondents, 145 (3.98%) reported at least one burn-injury. Table 1 shows the demographic distribution of participants who sustained burns. Females reported slightly more burns overall than males, although this was not statistically significant (87 [4.4%] versus 58 [3.5%], OR 1.27 95% CI 0.95–1.71). The highest proportions of burns were reported in the following age groups: 0–4 years old (n = 23, 5.4%) and 5–14 years old (n = 37, 4.17%). Compared to the youngest age group (i.e. individuals 4 years and younger), respondents 25–46 years old had a statistically significantly lower percentage of burns (OR = 0.64, 95% CI 0.43–0.97). With regards to occupation, homemakers reported the highest percentage of burns (n = 9, 8.3%), compared to other occupations where an average of approximately 4% reported burns. Nongovernment employees and farmers reported the least number of burns (n = 0 and n = 24 [2.8%] respectively). Literacy level, education and residency (i.e. urban versus rural) did not significantly affect the odds of sustaining burns in this study population. The mechanisms of burns, categorized as open fire/ explosion or hot liquid/object, are shown in Table 2. Different mechanisms could be reported for burns on multiple body sites, explaining the 147 reported mechanisms for 145 burns. The majority of burns (n = 129, 89.0%) were caused by a hot liquid/object, regardless of age, sex, residency, or literacy level. Interestingly, open fire/explosion caused 17.1% (n = 6) of burns in respondents who could not read or write, compared to only 5.7% (n = 2) in literate respondents. As shown in Table 3, the upper extremities were the most commonly burned body regions, with 36% (n = 53) of reported burns occurring in this area. The lower extremities were the second most commonly involved (22%, n = 32), followed by the face/head/neck (12%, n = 17). The groin/genitalia/buttocks region was the least commonly involved (4%, n = 6). Gender did not significantly affect the odds of seeking or receiving healthcare, or of seeking care from a traditional healer. Eighty-two percent of respondents (n = 119) with burns sought healthcare at a healthcare facility. Of those, 84% (n = 100) received a minor procedure (dressings, wound care, puncture, suturing, and/or incision and drainage), 4% (n = 5) received a major procedure (a procedure requiring regional or general anesthesia), and 12% (n = 14) did not receive surgical care. Twenty one percent (n = 30) of individuals with burns sought care from a traditional healer (Table 4).
4.
Discussion
The lack of surgical resources in LMICs has been well documented [11–20]. Indeed, the lack of access to material and human medical resources has been cited as a major barrier to definite burn care [21]. Concurrently, previous household surveys have estimated a cumulative incidence of burns to be between 5 and 11% in rural Ethiopia [22] and a prevalence of 6% amongst Ghanaian children [23]. Indeed, burns account for disabilities that cost more than 80.2 billion dollars a year in lost productivity, with almost 95% of that economic impact occurring in LMICs [24].
Table 1 – Demographic characteristics of participants sustaining burns. Total
Burns % (n)
Odds Ratio (95% CI)
Sex Male Female
1669 1976
3.48 (58) 4.40 (87)
Referent 1.27 (0.95–1.71)
Age 0–4 years 5–14 years 15–24 years 25–46 years >46 years Missing
426 887 728 1019 563 22
5.40 4.17 3.98 3.53 3.55 0
(23) (37) (29) (36) (20)
Referent 0.76 (0.44–1.31) 0.72 (0.43–1.20) 0.64 (0.42–0.96)* 0.64 (0.37–1.10)
Residency Rural Urban
2231 1414
79 (3.54) 66 (4.67)
Referent 1.33 (0.73–2.40)
1776 108 264 846 449 124
74 (4.17) 9 (8.33) 13 (4.92) 24 (2.84) 18 (4.01) 6 (4.84)
Referent 2.09 (1.07–4.09)* 1.19 (0.70–2.02) 0.67 (0.40–1.13) 0.96 (0.63–1.47) 1.17 (0.54–2.51)
62
0
–
16
6.25 (1)
Education None Primary Secondary Tertiary or Higher Missing
1891 809 810 125 10
4.02 (76) 4.08 (33) 3.33 (27) 6.40 (8) 10.00 (1)
Literacy (only for those Cannot read or write Can read or write Missing
15–49 years) 874 3.89 (34) 927 3.78 (35) 13 0
Total
3645
Occupation Unemployed Homemaker Domestic helper Farmer Self-employed Government employee Non-Government employee Missing
*
Referent 1.02 (0.71–1.40) 0.82 (0.50–1.33) 1.63 (0.83–3.20)
Referent 0.97 (0.60–1.56)
3.98 (145)
Statistically significant at the 0.05 level.
In this context, in addition to efforts to build surgical capacity, multiple studies have investigated the most prevalent etiologies and risk factors associated with thermal injuries in order to guide prevention strategies. The epidemiology of burns varies based on a number of factors, including economic, geographic and socio-cultural determinants. In developing countries, poverty, illiteracy, and crowded living conditions are universal risk factors [25,26]. In fact, open fire/explosion was over three times more likely to be the cause of burns in the illiterate group as compared to the literate group in the present study, which may underline areas of potential prevention. For example, graphic safety instructions may be beneficial. Age also plays an important role, with the pediatric age group comprising at least 50% of burn patients in various reported series [1,27–29], similar to the results of this study. Women are also at increased risk of severe burns and death in many countries, including Iran [27,30] India [31] and Iraq [32]. However, in sub-Saharan Africa, it appears that males are at an increased risk compared to females, particularly when
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Table 2 – Mechanism of burn according to demographic characteristics.
have reported scalding fluids as the most common cause of burns in African countries [33] although flame burns now appear to be on the increase [34]. The present study also reports a hot liquid/object as the leading cause of burns, as opposed to an open fire/explosion possibly caused by hot cooking pots in the open living spaces. However, the current survey did not further specify this. Based on the epidemiology of burns in developing countries, a number of preventive strategies have been suggested specifically for this context. Several interventions aiming to improve socioeconomic status have been brought forward, including higher parental education and increased access to basic resources, such as water [35]. At the community level, safety policies regulating the design and storage of hazardous material (e.g. kerosene stoves and lamps) and housing and kitchen construction have been recommended [1,36]. Overall, the creation of a national body of burn professionals would not only ensure adequate funds and help coordinate efforts, it would also facilitate education regarding burn prevention and management [1]. Radio announcements, school lessons and market day presentations have been advocated as key educational strategies in burn prevention [37]. Given this study’s finding that more than one in five burn patients sought care from a traditional healer, these communication strategies provide unique opportunities to provide guidance for proper medical care. Finally, efforts to build surgical capacity should not be forgotten and the implementation of cost effective burn treatments should be prioritized [1]. This study does present several limitations. First, the assessment relied solely on verbal interviews with household members. Although a physical exam would have been a beneficial addition to this study, it was not performed secondary to important ethical, logistical and economical reasons. Therefore, reporting of burns relied solely on the information provided by the interviewee. This also presents an important potential for recall bias. However, we believe this study does present an accurate snapshot of the burden of burns in the community as opposed to hospital-based studies, which may underestimate the prevalence. Indeed, our finding that only 82% of respondents sought healthcare corroborates this statement.
Open fire/ Hot liquid/hot Total explosion % (n) object % (n) Sex Male Female
11.9 (7) 12.5 (11)
Age 0–4 years 5–14 years 15–24 years 25–46 years >46 years
0 13.5 20.7 5.4 23.8
Residency Rural Urban
88.1 (52) 87.5 (77)
59 88
(5) (6) (2) (5)
100 (23) 86.5 (32) 79.3 (23) 94.6 (35) 76.2 (16)
23 37 29 37 21
11.2 (9) 13.4 (9)
88.8 (71) 86.6 (58)
80 67
82.9 (29) 94.3 (33) 87.8 (129)
35 35 147
Literacy (age 15–49 years) Cannot read or write 17.1 (6) 5.7 (2) Can read or write 12.2 (18) Total
Note: Respondents could report a different mechanism for burns on multiple body sites, hence the total of 147 mechanisms for 145 burns.
Table 3 – Body region affected by burn. Body region Face/head/neck Chest/breast Back Abdomen Groin/genitalia/buttocks Upper extremity Lower extremity Total number of burn regions
n
% of total number of burn regions
17 13 12 13 6 53 32 146
12 9 8 9 4 36 22
adjusted for self-inflicted burns [25]. However, the sex difference was not statistically significant in the present study. Moreover, flames constitute the major etiology of burns in many developing countries, particularly in the Indian subcontinent [1,26,31] and the Middle-East [27]. A number of studies
Table 4 – Burn related health care seeking behavior. Male (n = 58)
Female (n = 87)
Total (n = 145)
OR (male/female) of Receiving Care (95% CI)
%
n
%
n
n
%
Health care sought Yes No
82.76 17.24
48 10
81.61 18.39
71 16
119 26
82.07 17.93
0.92 (0.30–2.80)
Traditional healer Yes No
24.14 75.86
14 44
18.39 81.61
16 71
30 115
20.69 79.31
0.71 (0.28–1.82)
12.50 8.33 79.17
6 4 38 10
11.27 1.41 87.32
8 1 62 16
14 5 100 26
11.76 4.20 84.03
1.00 (0.48–2.08)
Health care received No surgical care Major procedure Minor procedure Missing
Burns in Sierra Leone: a population-based assessment.
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Moreover, this study is limited by the fact that it does not address mortality or disability. As previously stated, burns are associated with significant mortality and long-term consequences that extend beyond the individual. Further studies regarding these important issues are currently under way. Finally, this study was intended to provide a snapshot of the prevalence of burns in the community. The depth of the assessment did not provide adequate information to address further risk factors such as literacy or education, exact etiologies such as flame versus scalding fluids or specific contexts such as intentional or unintentional injury. More indepth studies in the future should address these issues to further guide prevention strategies. In conclusion, this nationwide community survey provides valuable insight into the burden of burns in the population of Sierra Leone. This study should serve as a stimulus for future studies regarding prevention strategies to address modifiable risk factors and cost-effective strategies to improve surgical capacity.
[9]
[10] [11]
[12]
[13]
[14]
[15]
Conflict of interest statement The authors do not have any conflicts of interest to declare.
Acknowledgements Surgeons OverSeas (SOS) with funding from Thompson Family Foundation provided logistical support. We would like to thank the Sierra Leone Ministry of Health & Sanitation, College of Medicine and Allied Health Sciences and Connaught Hospital for assistance with local transportation and administrative support.
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