Health-related Quality of Life and Self-esteem Among Burn Patients

Objective. The aim of this study was to assess health-related quality of life and self-esteem in adult burn survivors in Brazil. Materials and Methods. This multicenter, cross-sectional analytical study was conducted with 30 adult burn survivors (56.7% were male), 6-24 months postburn, recruited from 3 outpatient burn clinics in the city of São Paulo, Brazil. Half of the burn injuries (50%) were caused by flammable liquids. The mean burn size was 21% of total body surface area. The Short Form 36 Health Survey (SF-36) and the Rosenberg Self-Esteem Scale/Escola Paulista de Medicina at the Federal University of São Paulo were used to assess health-related quality of life and self-esteem, respectively. Statistical analysis was performed using Student’s t test, analysis of variance (ANOVA), Tukey’s test, Kruskal-Wallis test, Dunn’s multiple comparison test, and Spearman’s correlation coefficient. Results. The results showed men reported significantly higher SF-36 scores on the role of emotional (P = 0.023) and mental health (P = 0.047) domains when compared with women. Individuals who abused alcohol had lower scores on bodily pain (P = 0.025), vitality (P = 0.041), mental health (P = 0.023), and self-esteem scores (P = 0.044) compared with nondrinkers, and illicit drug users reported lower bodily pain scores (P = 0.008) compared with nonusers. Conclusion. Women, alcohol abusers, and drug users reported the lowest health-related quality of life and self-esteem among survivors of burn injuries. The assessment of health-related quality of life and self-esteem may contribute to the planning of interventions aimed to minimize the impact of burns on the daily life of this population.

Burn injury is a traumatic experience that results in deformities and disabilities; has a negative impact on the physical, emotional, and social aspects of quality of life; and affects the mental process of the patient becoming comfortable with themselves as an individual with a visible burn scar.^1-3 Burns are a public health problem, responsible for approximately 300,000 deaths each year worldwide. Burn epidemiology varies in different parts of the world; burn incidence ranges from 3%-10%, with the highest incidences occurring in low-income countries.^4,5 In Germany, 10,000 to 15,000 patients with burn-related injuries are admitted per year and about 30%-40% of cases need intensive care.⁶ In the United States, burn injuries are one of the main causes of death, accounting for 3,240 deaths per year and 40,000 annual hospitalizations.⁷

Visible burn scars may interfere with an individual’s social activities and result in social isolation. The presence of deformities or scar contractures, changes in skin color and body contour, and loss of body parts may limit the patient’s return to previous activities.¹ Post-traumatic stress symptoms begin at the time of the accident, remain during hospitalization, and may persist for years after hospital discharge.^8,9 The rehabilitation process includes difficulties in performing physical activities due to scar contractures and pain, which are inherent to the treatment of scars after hospital discharge and obstacles in returning to social activities.¹⁰

Studies on quality of life have contributed to our understanding of the challenge of having a burn injury, adaptive strategies adopted by patients, and factors affecting the quality of life of this patient population.^1,11-13 Burn sequelae have a negative impact on quality of life due to associated factors such as pain, dysphagia, sleep disturbance, and changes in mobility, body image, and sexuality.^14-19

Thus, the aim of this study was to assess health-related quality of life (HRQoL) and self-esteem in adult burn survivors in Brazil.

This multicenter, cross-sectional study was conducted between March 2012 and August 2012. The study was approved by the Research Ethics Committee of the Federal University of São Paulo (UNIFESP), Brazil, and performed in accordance with the ethical standards of the 1964 Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from all patients prior to their inclusion in the study, and anonymity was assured.

Participants were selected by simple random sampling based on a 95% confidence interval (CI). The sample size of 30 adult burn patients was calculated for a maximum sampling error of 5%, considering a 4-month data collection period using a formula where n is the sample size, N is the population size, p is the estimated proportion of the attribute, and ε is the sample error:

Patients were recruited from the outpatient burn clinic of the Division of Plastic Surgery at the São Paulo Hospital (UNIFESP-EPM) (n = 9), São Paulo Hospital for State Civil Servants (n = 9), and Tatuapé Hospital (n = 12), all located in São Paulo, Brazil,

The eligibility criteria comprised patients of both genders, 18-59 years of age, with burn scars or sequelae. The minimum and maximum time postburn was 6 months and 24 months, respectively. The period of 6-24 months postburn was chosen as an inclusion criterion because the rehabilitation period of burn injuries has a wide variation in time. There were no restrictions regarding the cause of burn, affected body region, burn size, or burn depth. Patients who had nonhealed areas at the time of assessment and those who were hospitalized were not included. Thirty patients who met inclusion criteria and agreed to participate were enrolled.

Self-esteem and HRQoL were assessed using the Brazilian versions of the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36)^20,21 and the Rosenberg Self-Esteem (RSE)/UNIFESP-EPM scale,²² respectively. Both instruments had been translated into Brazilian-Portuguese, culturally adapted, and validated for use in Brazil.²¹

 The SF-36 is a generic instrument composed of 36 items grouped into 8 domains as follows: physical functioning (10 items), physical role functioning (4 items), bodily pain (2 items), general health (5 items), vitality (4 items), social role functioning (2 items), emotional role functioning (3 items), mental health (5 items), and 1 comparative item assessing changes in health over the past year. Examples of some of the items include: “Have emotional problems interfered with your normal social activities with family, friends, neighbors, or groups?”; “How much bodily pain have you had during the past 4 weeks?”; “Did you have a lot of energy?”; and “During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities (like visiting with friends, relatives, etc.)?”

Each domain is evaluated independently; there is no single overall score for the SF-36. Scores on each domain range from 0 to 100, with 0 corresponding to the worst health status and 100 to the best health status. This questionnaire assesses the patient’s perception of his or her health during the past 4 weeks.^20,21

The RSE/UNIFESP-EPM scale is a specific measure of self-esteem, containing 10 items, such as “On the whole, I am satisfied with myself”; “At times I think I am no good at all”; “I am able to do things as well as most other people”; and “I feel I do not have much to be proud of.” The items are scored on a 4-point Likert-type scale ranging from “strongly agree” (0) to “strongly disagree” (3), and items 2, 5, 6, 8, and 9 are inversely scored. The total score ranges from 0 to 30, with higher scores indicating lower self-esteem.

The questionnaires were administered in the form of an interview because of the low education level of the patients. A low education level may negatively affect the quality of information collected using self-report questionnaires. All interviews were administered by the first author of this study and an investigator trained for data collection. The interviews took place in a private room on the hospital unit, providing for a quiet environment. Each interview lasted approximately 40 minutes.

Statistical analysis. Student’s t test was performed to compare numeric variables and Tukey’s test was used for multiple comparisons. Differences between data were tested either by analysis of variance (ANOVA) or by the Kruskal–Wallis test. Spearman’s correlation coefficient (r) was used to determine the correlation between scales. Dunn’s test was applied for multiple comparisons. All statistical tests were performed at a significance level of 5% (P < 0.05). Data are expressed as mean ± SD.

The mean age of the 30 participants was 36.1 ± 11.23 years (range, 18-59 years); 17 (56.7%) patients were men, 16 (53.4%) were married, 11 (36.7%) had incomplete elementary education, and 21 (70%) were employed. The mean time postburn that participants took the survery was 15.4 months (range, 6-24 months).

The mean burn size was 21% ± 17.10% of total body surface area (range, 1%-60%) and the mean length of hospital stay was 34.7 ± 27.27 days (range, 2-94 days). Most burn injuries were caused by accidents (76.7%, n = 23) followed by suicide attempts (13.3%, n = 4) and homicide attempts (10%, n = 3). Fifteen (50%) burns were caused by flammable liquids, with alcohol being used as the flammable agent in all suicide and homicide attempts. Alcohol abuse and use of illicit drugs were associated with the homicide and suicide attempts (Table 1). 

Mean SF-36 scores ranged from 39.1 ± 45.3 (physical role functioning domain) to 73.8 ± 20.7 (general health domain), as shown in Table 2. The mean RSE score was 9.1 ± 5.6 (range, 0-19). 

Men reported significantly higher SF-36 scores on the emotional role functioning (P = 0.023) and mental health (P = 0.047) domains compared with women.

Male and female participants who abused alcohol (n = 6) had significantly lower SF-36 scores (worse health status) on bodily pain (P = 0.025), vitality (P = 0.041), and mental health (P = 0.023), and the highest RSE scores (indicating lower self-esteem) (P = 0.044) compared with people who do not abuse alcohol, as depicted in Table 3. Illicit drug users (n = 4) reported lower SF-36 scores on the bodily pain domain compared with individuals who were not drug users (P = 0.008). 

The correlations among scores on the 2 scales used in this study are shown in Table 4. Low self-esteem (total RSE score) was correlated with poor general and mental health and low vitality (SF-36 domain scores) (Table 4). 

Advances in medicine have contributed to the rise in the number of burn survivors, which represents a challenge for long-term care and increases the interest of health professionals in the quality of life of this patient population.^1,10,23 Burn injuries have a great impact on the quality of life of patients, but only in the past 20 years has the impact over time been studied.²⁴ In the current study, patients 6-24 months postburn were assessed for HRQoL and self-esteem and participants reported good self-esteem and a moderate impact of burns in their HRQoL. Factors associated with reduced HRQoL were female gender, alcohol abuse, and use of illicit drugs.

The mean age of the participants was 36.1 ± 11.23 years; other authors have reported a mean age of 38 years,^2,25 which is similar to the participants of this study. About 57% of the included patients were men. Compared to women, men are more exposed to dangerous activities, such as work with heavy machinery, work on an electrical installation, and work with chemicals including flammable and combustible liquids, among others.^25-31 Studies have shown the young male population is at the highest risk for burn injury.^25-31

Men reported significantly higher scores indicating an overall better health status than women on the emotional role functioning (P = 0.023) and mental health (P = 0.047) domains of the SF-36. In a study on HRQoL conducted with 15 burn patients, women had significantly higher SF-36 scores on social functioning, but lower scores on physical function and bodily pain compared with men (P < 0.05).³² In another study of 265 burn patients, women reported lower scores on mental health compared with men (P < 0.05),³³ which is in agreement with the results of this study.

Flammable liquid (alcohol) was the main cause (50%) of burn injuries, followed by hot liquids (30%), and other causes (20%), which are in accordance with the findings of other Brazilian studies.^31,34,35 The careless use of flammable products results in a large number of accidents worldwide.^31,34,35 The implementation of prevention and education programs would contribute to reduce burn accidents.³⁶ Simple measures, such as the storage of alcohol in small 100-ml containers instead of 1-liter containers as observed in other countries,^30,34,37 could prevent many accidents and, therefore, could be part of changes in policy at national level, which should be encouraged and implemented by a government agency. Around the world, burn injuries are usually related to the improper use of alcohol during festivities or social events such as barbecues, or they are related to homicide and suicide attempts.^30,34,37 The mean burn size of 21% total body surface area was similar to that reported in a study on pain control conducted with 12 patients treated in a burn center in the United States³⁸ and larger than that (14.1%) reported in another study.²⁸

With regard to working status, 70% of patients in the current study were paid workers and 30% were unemployed or retired earlier than expected due to burn injury. Mason and colleagues²⁸ also observed that 74.1% of burn patients were employed. Most burn patients have little or no difficulty in returning to work 2 years postburn.²⁷

The study participants had a low education level; only 30% of them had completed high school, while 60% had incomplete or complete primary education and 7% were illiterate. Unfortunately in Brazil, burn injuries are associated with low income, poverty, unemployment, poor housing and living conditions, and low education level.²

Consumption of alcohol is an important risk factor for burn injuries.³⁹ The use of alcohol aggravates the clinical conditions of patients, including postoperative complications, and leads to prolonged length of hospital stay, increased incidence of sepsis, and increased mortality rate.⁴⁰ Davis and coauthors⁴¹ identified a relationship of alcohol intoxication with burn and smoke inhalation injuries in a study of 53 patients with burn. The authors found that patients who were intoxicated at the time of the burn accident showed higher levels of carboxyhemoglobin and worse clinical conditions compared with burn patients who had not been intoxicated at the time of their injury.⁴¹

This study was conducted in a limited number of centers; although the sample error was set at 5%, the sample size is small compared to previous studies and may prevent the generalization of the results. Also, the subgroup analyses are subject to caution in their interpretation as the numbers are small. The variables “location of the scar” and “burn severity,” which may be confounding factors, were not assessed in the study and this may be considered a limitation of the study.

The assessment of self-esteem in patients with wounds has become more and more common, because wounds may lead to changes in appearance that may deeply affect the patient’s mental well-being.²⁴ Burn sequelae, especially visible scars, may result in emotional and social distress, which may lead to reduced self-esteem, sadness, and social isolation. The RSE scale has been used extensively to assess self-esteem in children, adolescents, and young adults with burn injuries.^42-45 Social support, especially from friends, is an important factor for the psychological adjustment after burn trauma and can have a positive impact on levels of self-esteem, depression, and body image of patients with burn injuries.⁴²

Patients who were burned due to a suicide or homicide attempt usually had a history of psychiatric or psychological problems, alcohol or drug abuse, or social problems, which may play a significant causal role in the burn injury.^46-48 In this study, 13% of burns resulted from suicide and 10% resulted from homicide attempts. These patients need attention and psychological support to develop adaptation and coping skills, which may contribute to reducing suicide attempts.¹⁴ They also need constant psychiatric support, which may prevent future episodes of self-aggression. The identification of populations or groups at risk is of fundamental importance for the implementation of directed therapeutic strategies and prevention programs.^14,35

Potential reasons for low adherence to treatment include low income, psychiatric problems, and use of drugs and alcohol.^46,47 It is difficult to assess and follow-up patients with these characteristics, including burn patients. Prevention and treatment of burn injuries and patient rehabilitation are great challenges to be met.

Burn injuries have a negative impact in HRQoL and self-esteem. Female gender, alcohol abuse, and use of illicit drugs were associated with impaired HRQoL. Burn injuries commonly lead to changes in appearance, such as visible scars, which may lead to reduced self-esteem and social isolation. The assessment of HRQoL and self-esteem may contribute to the planning of interventions aimed at minimizing the impact of burns on the daily life of this patient population.

From the Federal University of São Paulo (UNIFESP), São Paulo, Brazil

Address correspondence to:
Liliane do Amaral Zorita, RN, MS 
Plastic Surgery Division, UNIFESP
Rua Napoleão de Barros 715
4o. andar
04024-002 São Paulo, SP, Brazil
lilianezorita@yahoo.com.br

Disclosure: The authors disclose no financial or other conflicts of interest.