Burns Open xxx (2017) xxxxxx

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Burns Open

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Assessment of quality of life in post burn survivors: A cross-sectional single-

center first validation study from Pakistan
a b a,
Faiza Shahid , Mohammad Ismail , Salman Khan
aDepartment of Pharmacy, Faculty of Biological Sciences, Quaid-i-Azam University 45320, Pakistan
b Department of Pharmacy, University of Peshawar, Peshawar, Khyber Pakhtunkhwa, Pakistan

article info abstract

Article history: Background: Burns are major health problem and fourth frequent cause of trauma, following falls, road incidences and
Received 25 April 2017 interpersonal violence worldwide. The present study aimed to assess socio-demographic risk factors and quality of life (EQ-
Received in revised form 22 August 2017
5D-3L) in post burn patients presenting to the outpatient department.
Accepted 23 August 2017 Available online
xxxx
Methods: The present study was designed cross sectional study completed in a period of six months (March 2016 to August
2016). The overall subjects were selected from the outpatient department. The EQ-5D-3L score EQ-5D index and VAS
Keywords:
questionnaire were completed by interviewing face to face individ-uals. Finally, the data was analyzed by SPSS IBM 20.
Post burn
Quality of life
Burn aetiology Results: The present study revealed that demographic characteristics (age and gender), socioeconomic variables (low literacy
Outpatient department level, low economic status, occupation, urban residence and nuclear family struc-ture) are prognostic risk factors associated
with burn related injuries. The mean age of the sample was 17.08 years. The most frequent cause of burns was scald followed
by flame. Children (46%) of aged 310 years were predominant sustained scald and flame burns. Female proportion was high
(56%) and were significantly sustained scald and flame burn, whereas, male was observed by electric (84.2%) and contact
burns (78.3%). The upper limbs anatomical part was most commonly affected (1120%) TBSA burned in 36.4% patients and
71.6% sustained partial thickness and mixed deep thickness. Majority of the incidence take place at home (88.4%). Among co-
morbidities, Diabetes mellitus was observed the most common (4.4%). Post burn complications such as infection, surgeries,
hypertrophic scars and con-tractures were reported in 16%, 28.4%, 14.8% and 7.2% respectively. The majority of participants
was assessed in first year of post burn period (87.2%) and reported moderate to severe problem in each health dimension of
EQ-5D instrument. The depth and extent %TBSA burn and post burn period have negative impact on health dimensions EQ-
5D scores.

Conclusion: Our findings revealed that quality of life was compromised in majority of post burn patients. Several demographic
characteristics such as young age and female gender, low socioeconomic status and clinical parameters related burns were
important risk factors in assessment of quality of life in burn sus-tained patients.

2017 Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction
Burn patients comprise of diverse population with respect to wide
discrepancy age, burn injury mechanism, site and depth of wound, and a
different co-morbidity [1]. Therefore, their outcome significantly varies, with
different nature of impact on entire life of victim life and occasionally it may
cause permanent impairment [2]. Approximately, six million of burns victims
worldwide seek medical care annually [3]. However, most of them are treated
to
Corresponding author.
E-mail address: skhan@qau.edu.pk (S. Khan).
outpatient clinics [3]. Burns related death is the fourth primary causes of
mortalities associated with unintentional injuries in the United States [4].
Approximately, 90% of global burns incidences are reported by WHO in
underdeveloped countries and about 40% of burns related mortality occurs in
the Southeast Asia [5]. In developing countries, burn incidence are drastically
higher than developed countries [6]. Furthermore, a high risk of burns related
injuries in LMICs have been shown in children having age under 5 years
followed by victims of aged 2029 years [7].
Majority of burns patients has been reported with impaired quality of life
[8]. Health-Related Quality of Life (HRQOL) is a broad term and has
multidimensional concept included both

http://dx.doi.org/10.1016/j.burnso.2017.08.003 2468-
9122/ 2017 Published by Elsevier Ltd.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Please cite this article in press as: Shahid F et al. Assessment of quality of life in post burn survivors: A cross-sectional single-center first validation study from Pakistan. Burns Open
(2017), http://dx.doi.org/10.1016/j.burnso.2017.08.003
2 F. Shahid et al. / Burns Open xxx (2017) xxxxxx
self-reported measures of physical health and mental health [9]. After medical
treatments Health-Related Quality of life is a key parameter and a well
established measure to assess medical out-comes [10]. Similarly, there are
two types of instruments disease specific and generic to measure HRQoL
[11]. Generic instruments are used for measurement of core concepts of
HRQoL. It may apply on different populations and diseases. Generic
instrument evaluate HRQoL of disease population and its comparison with
general pop-ulation [12]. Therefore, the aim of this present study was to
assess HRQoL of post burn patients from an outpatient department of burn
care center, and to identify the impact of various risk factors associated with
poor Quality of Life (QoL) in post burn survivors.
2. Materials and methods
2.1. Study design and study setting
The present study was a cross sectional study completed in a period of six
months from March to August 2016 at the Depart-ment of Burn Care Center,
in Pakistan Institute of Medical Sciences Hospital (PIMS) Islamabad,
Pakistan. The Burn Care Centre is an only public sector referral tertiary burn
care specialty hospital in Islamabad and its adjoining areas. It is a 20-bed
facility with its own plastic surgery, Intensive care unit, outpatient department
and pharmacy services center.
2.2. Study subjects
The subjects presented with post burn to the outpatient Depart-ment
(OPD) of Burn Care Center, Pakistan Institute of Medical Sciences,
Islamabad Pakistan. The subjects consist of male and female and were
selected on the basis of the following criteria;
2.2.1. Inclusion criteria
Age 360 years
Accidental burns
%TBSA 10
Burn due to any cause (flame, electrical, scald, chemical, contact etc) and
thickness (superficial, mixed, deep).
Patient or Parents/caretaker of patient who give consent
Patient presented to outpatient department of burn care center
2.2.2. Exclusion criteria
Homicidal/ Suicidal burn
Patient presented with recent (acute <2 months) burn
Patient have end stage renal diseases, any malignancy, blind-ness, mental
disorder, drug addiction, chronic debilitating sickness.
2.3. Study tool
The interviewed questionnaires were responded by subjects consist of two
portions:
2.3.1. Tool I
Basic socio-demographic data and detail about cause and mag-nitude of
burns were collected over semi structure proforma.
2.3.2. Tool II: EQ-5D-3L and VAS
English version of European quality of life questionnaire was obtained
from Euroqol foundation through formal email. EQ-5D-3L have cover five
domains of life; Mobility, self care, usual activ-ities, pain and depression. The
EuroQol Group was established in
Please cite this article in press as: Shahid F et al. Assessment of quality of life in post burn survivors: A cross-sectional single-center first validation study from Pakistan. Burns Open
(2017), http://dx.doi.org/10.1016/j.burnso.2017.08.003
1987. The EuroQol is an international multidisciplinary Group which consists
of researchers from all over the world [13]. The EQ-5D, widely and
preferably used health status in observational studies, clinical trials and other
health surveys developed by Euro-Qol Group [13]. It has been translated in
various different lan-guages worldwide [12]. The EQ-5D is a descriptive
system defines health state of both general and disease population. It cov-ers
five dimensions of health encompassing questions about: mobility, self-care,
usual activities, pain/discomfort and depres-sion/anxiety [12]. For each health
dimension participants were selected according to the given value regarding
their health state whether they are in state of no problem = 1, Moderate
prob-lem = 2, extreme problem = 3. EQ-5D defines health state by
combining the participants responses on each five dimension (1, 2 or 3).
Therefore, the responded have best health state at 11,111 the worst health
state at 33333 and the total number of different health states are 35 = 243.
The EQ VAS is a vertical ana-logue scale has 20 cm line graded from 0 to
100 on which partic-ipants were asked to mark their current state of health.
This EQ-5D descriptive system defined the EQ-5D health states by
converting into a single summary index or index value by applying a formula
that had essentially attach values to each of the levels in each dimension [14].
The summary score ranges from 0 worst possible health state even have
negative value as minimum 0.594 for health states worse than death and at
100 best possible health state is recorded [12,15]. This weight index was
based on norm values in general population [15]. The use of EQ-5D-3L
instrument has been validated among general population of adults and disease
specific population of children over five years of age. The EQ-5D-3L instru-
ment is an appropriate instrument for assessment of HRQoL in children and
can be administered by online, telephone or paper pencil [16].
2.4. Methodology
The subjects were selected from the outpatient department. The
participants (Children and adults) were interviewed in waiting room of OPD
while keeping environment calm and insuring pri-vacy. A member of research
team (First author) was trained who administered the questionnaire to subjects
individually. The ques-tionnaire was administered by face to face interview
because majority of patients participated were preschool going and illiter-ate
[17]. The interview took 2040 min to be completed on individ-ual basis,
depending upon the response of participants and degree of understanding. All
patients were asked to response the ques-tions honestly. The parents or
caretakers were responded of the children being under the age of five years.
Parental proxy informa-tion was used in those cases in which children were
unable to respond to interviewer due to magnitude or nature of injury [16].
Socio-demographic data and clinical parameters of burns related injury were
recorded over semi-structured proforma including; age, gender, living, family
structure, causes of burn trauma, cir-cumstances of incidence, Degree of burn,
%TBSA burn, site of injury, location of burn, time since burn, complications
associated with burn (infection, hypertrophic scar, contracture at joints,
grafting and surgeries), comorbid condition, itching at site of injury, fre-
quency of previous hospital admission. The HRQoL outcomes of participants
were recorded on EQ-5D-3L index and VAS question-naire. The EQ-5D-3L
index scores was obtained by crosswalk calcu-lator methodology developed
by EuroQoL group [18].
2.5. Ethical considerations
The study proposal was presented for approval to the ethical committee of
Burn Care Center, Shaheed Zulfiqar Ali Bhutto
 F. Shahid et al. / Burns Open xxx (2017) xxxxxx 3

Medical University Pakistan Institute of Medical Sciences (PIMS) Islamabad, Table 1

Pakistan (Approval letter # PF.01-03/16-R-QUI-(BCC)-Admin). Verbal Percent distribution of patients socio-demographic characteristics.

consent was taken from all participants by explain-ing the purpose and nature Variable Frequency (N) Percent (%)
of study to them before including par-ticipant in study. In case of children Age in categories (years)
participants below seventeen years of age, consent were obtained from 310 115 46.0
parents or caregivers by providing information regarding purpose of study. 1120 49 19.6
2130 41 16.4
After obtaining data all information of participants were kept confidential and
3140 23 9.2
de-identified. 4150 12 4.8
5160 10 4.0
Gender
2.6. Statistical analysis Male 110 44.0
Female 140 56.0
Total 250 100.0
Data was analyzed by Microsoft excel and IBM SPSS Statistic Version 20.
Marital status (Aged 18)
Continuous variables were expressed in descriptive statistics (mean SD) and
categorical variables were expressed in frequency and percentages. The Married 59 56.2
Single 46 43.8
relationship between two or more categorical variables was analyzed by Chi- Occupation
square test. The value at p < 0.05 were considered statistical significant.
Employed 33 13.2
Housewife 46 18.4
Dependent/child 157 62.8
Unemployed 14 5.6
3. Results
Place of living
Urban 178 71.2
During the collection period of six months, a data sample of 250 patients
Rural 72 28.8
with post burn injury presented to outpatient department of burn care center Economic status
were included in the current study. Various fol-lowing parameters were
Poor 91 36.4
observed in the present study; Middle 83 33.2
Good 76 30.4
3.1.1. Sample characteristics Family structure
Nuclear 222 88.8
The mean age of participants were 17.08 years (Range 3 60 years, SD Extended 22 8.8
Single parent family 6 2.4
15.225). Majority of participants 115 (46%) were children in the range of 3 Educational status
10 years of age. Female were dominant and comprised 140 (56%) of sample.
Preschool/Nursery 92 36.8
The general demographic and socio-economic characteristics of study Primary School or illiterate 56 22.4
population were illus-trated in Table 1. Secondary School 54 21.6
Intermediate 27 10.8
Graduate 14 5.6
Post Graduation or above 7 2.8
3.1.2. Etiology of burn injury

Regarding etiology of burns, burn types were classified into five

categories including flame, electric, chemical burn, contact and scald burn
(Fig. 1). Scald burn were further classified into five sub categories including
hot tea, boiling water, hot oil, hot milk, and hot curry. Scald burn 112 (44.8%)
constituted most common cause of burn etiology. In subcategories of scald
burn water 55 (22%) was the commonest cause of burn injury. The
distribution of various causes of burn injury in participants by age and gender
is shown in Table 2. Flame and scald burn significantly affect the young age
survivors. Scald was the commonest cause of burn in most vulnerable age
group 310 years 67 (59.8%). A significant number of male patients 84.2%
had electric burn (p < 0.000) and contact burn 78.3% (p < 0.001). Females
showed significant num-bers of scald burn 71 (63.4%) than in male 41
(36.6%).
3.1.3. Parameters of burn injury
Table 3 illustrates the characteristics of patients according to parameters
of burn injury. The most commonly burnt anatomical body part were the
upper limbs including right arm (42.8%) and left arm (35.6%). However,
many patients had more than one part of the body were affected by burn.
Most of the patients (71.6%) had suffered from second degree burn with
partial thickness and mixed deep thickness of burns. Majority of patients
(36.4%) presented with burns of 1120% TBSA. On the basis of
circumstantial back-ground of buns, all accidental (100%) cases were
observed and occurred at home (88.4%). Most of patients (87.2%) had burns
<1 year. In relation to previous hospital admission due to bun
injury was observed about 64.8% of patients seeking medical care and
presenting to outpatient department had no history of previ-ous hospital
admission. Table 3 also demonstrates post burn injury status.
3.2. Descriptive statistics of health related quality of life in post burn patients
Quality of life of study population was assessed by using generic EQ-5D-
3L questionnaire. The EQ-5D scores were recorded from 240 participants out
of 250 study population by excluding ten patients had pre-existing co-
morbidities like epilepsy, depression and cardiovascular disorder. Pre-existing
co-morbidities might incorporate in estimated EQ-5D scores instead
reflecting solely the impact of injury. Majority of the participants responds to
mod-erate problem in each health dimension (Table 4). The total num-ber of
participants (58.3%) reported moderate problem in mobility followed by self
care (48.8%) and usual activities (47.5%). Most of the participants were
reported moderate pain/dis-comfort (73.3%) and sever pain (13.8%). A total
number of 57.9 sub-jects observed moderate anxiety/depression (57.9%)
followed by severe depression (9.6%).
3.2.1. EQ-5D-3L dimensions, EQ-VAS and EQ-5D index scores
according to age and gender
Table 5 illustrates that there is no statistical significant associa-tion
between age and gender with EQ-5D scores of patients. Major

Please cite this article in press as: Shahid F et al. Assessment of quality of life in post burn survivors: A cross-sectional single-center first validation study from Pakistan. Burns Open
(2017), http://dx.doi.org/10.1016/j.burnso.2017.08.003
4 F. Shahid et al. / Burns Open xxx (2017) xxxxxx

Fig. 1. Percent distribution of burn causes.

Table 2
Percent distribution of burn aetiology according to patients age and gender.

Burn etiology Age (years) Gender

310 1120 2130 3140 4150 5160 P-value Male Female P-value
N (%) N (%) N (%) N (%) N (%) N (%) N % N %
Flame 30(29.7) 31(30.7) 15(14.9) 14(13.9) 7(6.9) 4(4) 0.000
** 39 38.6 62 61.4 0.158
Electric 6(31.6) 8(42.1) 2(10.5) 0(0) 1(5.3) 2(10.5) 0.056 16 84.2 3 15.8 **
0.000
Chemical 1(100) 0(0) 0(0) 0(0) 0(0) 0(0) 0.947 1 100 0 0 0.440
*
Contact 15(65.2) 3(13) 4(17.4) 0(0) 0(0) 1(4.3) 0.291 18 78.3 5 21.7 0.001
Scald 67(59.8) 9(8) 19(17) 9(8) 4(3.6) 4(3.6) 0.000
** 41 36.6 71 63.4 0.023
*

Water 27(49.1) 5(9.1) 13(23.6) 5(9.1) 3(5.5) 2(3.6) 0.010 19 34.5 36 65.5 0.368
Tea 17(77.3) 2(9.1) 1(4.5) 0(0) 2(9.1) 0(0) 8 36.4 14 63.6
Oil 10(55.6) 1(5.6) 4(22.2) 0(0) 1(5.6) 2(11.1) 7 38.8 11 61.1
Milk 8(100) 0(0) 0(0) 0(0) 0(0) 0(0) 4 50 4 50
Curry 5(55.6) 1(11.1) 1(11.1) 2(22.1) 0(0) 0(0) 3 33.3 6 66.7
*
P-value < 0.05 significant.
*
P-value < 0.001 very significant.

complaint reported by participants of all age group was pain fol-lowed by
depression. The mean EQ-VAS scores of aged group 3 10 years was 59 14,
1120 years 60 14, 2130 years 62 12, 3140 years 61 13, 4150 years
61 13, 5160 years 54 7 respectively. Mean index score was 0.75 0.11,
0.75 0.11, 0.76 0.08, 0.78 0.10, 0.75 0.08, 0.71 0.11 of aged group
3 10 years, 1120 years, 2130 years, 3140 years, 4150 years, 5160
years, respectively. Mean EQ-VAS scores of female 61 (SD 13) and male
59 (SD 14) respectively. Mean index score of female were 0.75 10 and
male had 0.75 1.
3.2.2. EQ-5D-3L dimensions, EQ-VAS and EQ-5D index scores
according to extent (TBSA) and depth of burn
Table 6 illustrates that EQ-5D scores shows significant statisti-cal
difference with severity of burn injury. The EQ-5D index score of patients
with all categories of TBSA (%) burned showed signifi-cant difference in
moderate to severe problems at all five domains of life. The mean EQ-VAS
score was reported for %TBSA 10% (66
+ 12), 1120% (58 + 13), 2130% (57 14), 3140% (54 9), 41 50% (58
16) and 5160% (55), respectively. In mean index score for TBSA 10% was
0.8 0.1, 1120% (0.72 0.10), 2130% 90.74 0.10), 3140% (0.68 0.7),
4150% (0.70 0.09), 5060% (0.68), respectively. There was significant
statistical difference in EQ-5D index score reported by participants presented
with all three categories of burn injury depth. Moderate to severe problems of
EQ-5D index score were reported primarily in self-care
(p < 0.001) usual activities (p < 0.000) and depression (p < 0.004) by
participants presented with deep injuries, primarily in pain (64.6%), mobility
(49.2%) and depression (47.5%). According to the depth of burn injury mean
EQ-VAS score were observed 50, 61 13 and 58 15 respectively. The mean
index score were 0.69 0.06, 0.76 0.1 and 0.74 0.11 respectively.
4. Discussion
The present study was assessed quality of life of post burn patients at the
outpatient department and influence of various pre-dictors on clinical
outcome of their health status. Predictors include both socioeconomic as well
as burn related parameters. Clinical outcome of patients such as clinical burn
injury status (infection, pruritus, scar and contracture) and HRQoL outcomes
include mobility; self-care, usual activities, pain and depression were
recorded.
4.2. Participants characteristics and related burn parameters
4.2.1. Participants general description
The observed mean age of subjects in this study was observed 17.08
which is comparable to the findings of two different studies [19,20]. The
findings of the present study showed that majority of subjects were children
of aged 310 years (46%) and age group 11 20 years (19.6%).

Please cite this article in press as: Shahid F et al. Assessment of quality of life in post burn survivors: A cross-sectional single-center first validation study from Pakistan. Burns Open
(2017), http://dx.doi.org/10.1016/j.burnso.2017.08.003
 F. Shahid et al. / Burns Open xxx (2017) xxxxxx 5

Table 3 4.2.2. Parameters related to burn injury

Characteristics of patients according to parameters of burn. The current study observed that majority of patients (87.2%) present to
Parameters Frequency (N) Percent (%) OPD for follow up visits had 1 year from sustaining burns whereas 12.8% of
Site of injury participants had 6 years. These results indicated that burns are devastating
Head 15 6 type of trauma which needs medical care for a long period of time. Majority
Face 43 17.2 of the post burn patients were accessed during first year of the incidence. This
Neck 22 8.8
might be due to non healing wounds, infections, lack of medical care or fewer
Right arm 107 42.8
Left arm 89 35.6
follow up visits, contracture and hypertrophic scar [1,21,22]. Our findings
Anterior trunk 78 31.2 consistent with the results of Elsherbiny et al., who conducted their research
Posterior trunk 35 14 in the burn outpatient clinic and reported that majority of patients (64%) had
Buttocks 25 10 sustained burn injury for <1 year while 36% had burns for 15 years [8]. A
Right leg 71 28.4
total of one-third participants were undergone with surgical interven-tions
Left leg 69 27.6
Right foot 37 14.8 during the course of treatment including the graft cases which need more than
Left foot 28 11.2 one surgical intervention. This number indi-cates the severity and extent of
Genitalia 6 2.4 deep burns. Van Loey et al. stated in their study that number of surgeries
Degree of burn including grafts complica-tions had influence on HRQoL at initial stage as
1st degree 2 0.8 well as in latter stages of improvement [10]. The present study observed
2nd degree 179 71.6 pruritus complaint in post burn patients (58.4%). Pediatric post burn popu-
3rd degree 69 27.6
lation experienced itching the most distressing feature has been reported
TBSA burned
Schneider JC et al. [23]. A similar study conducted by in adults by Carrougher
10% 89 35.6
et al. reported that post burn pruritus remains a major problem over next two
1120% 91 36.4
2130% 43 17.2 years period of follow up [24].
3140% 17 6.8
4150% 9 3.6
5160% 1 0.4
Circumstances of incident
Accidental 250 100.0
Home 221 88.4
Kitchen 165 66
4.2.3. Clinical status of burn injury
Washroom 9 3.6 In the present study complications regarding clinical status of burn injury
Roof 14 5.6 were defined as either delayed healing (taking >2 months), post burn
Living Room 29 11.6 infections, hypertrophic scar or contracture formation at site of joint. The risk
Courtyard 3 1.2
of hypertrophic scar formation is substantially high in deep dermal burn
Outdoor 29 11.6
Workplace 16 6.4
injury [25]. Post burn con-tractures reduced joint mobility leads to functional
Road 7 2.8 impairment and lowers quality of life [26]. Contractures release needs further
Others 6 2.4 surgical interventions. The present study observed overall 55 post burn
Time since burn complications. The most common complication was hyper-trophic scar and
<1 year 218 87.2 contracture deformity observed in 37 (14.8%) and 18 (7.2%) participants
>1 year 32 12.8 respectively. Cubbit et al. reported post burn complications in pediatric
History of hospital admission
patients who observed 43 compli-cation in 32% of total patients including
No admission 162 64.8 hypertrophic scars in and contracture at joints [27]. Our findings observed
One admission 75 30
similar results shown by Gangemi et al. reported in their study that a total of
More than one admissions 13 5.2
Post burn injury status
77% patients were diagnosed with pathologic scarring in outpa-tient
department in follow up visits of out whom 44% developed hypertrophic
Infection 40 16
MRSA 5 2
scars and 5% developed contractures [22]. Infections of wounds in post burn
Itching at site of burn 146 58.4 period is a serious complication can con-tribute in delay healing, enhance
Surgeries/grafting 71 28.4 scaring and persistent infections may lead to death of the patients [28]. In our
Hypertrophic scar 37 14.8 study a total of 16% patients were presented with wound infection whereas
Contracture 18 7.2
2% patients were diagnosed with MRSA. Amongst gram-positive bacteria
Co-morbidities
MRSA is considered as nosocomial pathogen as it spread quickly leads to
Diabetes mellitus 13 5.2
serious complications in management of burn patients and may cause life
Hypertension 5 2
Epilepsy 4 1.6
threatening infection due to its resistance towards vari-ous classes of
Cardiovascular disorder 4 1.6 antibiotics [29].
Depression 2 0.8

TBSA = Total body surface area.

MRSA = Methicillin-resistant Staphylococcus aureus.
Table 4
4.3. Participants self-reported description of EQ-5D

Participants response to EQ-5D scoring.

The findings of the present study indicated that majority of sub-jects
EQ-5D Responses (N/%) experienced moderate to severe level of pain/discomfort (87.1%), difficulty in
Dimensions No Problem Moderate Problem Severe Problem mobility (68.7%), limitation in self care (60.5%), Depression/Anxiety
Mobility 75 (31.3) 140 (58.3) 24 (10.4) (67.1%), difficulty in performing usual activities (59.2%). These findings
Self-care 95 (39.6) 117 (48.8) 28 (11.7) were supported by Tirumala et al., who reported quality of life of burn
Usual activities 98 (40.8) 114 (47.5) 28 (11.7) patients in India and found that study population experienced moderate to
Pain/Discomfort 31 (12.9) 176 (73.3) 33 (13.8)
severe problem in each health dimension including pain (78.2%) followed by
Depression/Anxiety 78 (32.5) 139 (57.9) 9.6)
usual

Please cite this article in press as: Shahid F et al. Assessment of quality of life in post burn survivors: A cross-sectional single-center first validation study from Pakistan. Burns Open
(2017), http://dx.doi.org/10.1016/j.burnso.2017.08.003
6 F. Shahid et al. / Burns Open xxx (2017) xxxxxx

Table 5
Percent distribution of EQ-5D scores according to age-gender of participants.

EQ-5D Age categories (years) Gender

Dimension 310 1120 2130 3140 4150 5160 P-Value Male Female P-Value
Mobility (%)
No 44 21.3 16 14.7 2.7 1.3 0.200 42.7 57.3 0.974
Moderate 44.3 17.9 19.3 6.4 6.4 5.7 44.3 55.7
Severe 56 24 0 12 4 4 44 56
Self-care (%)
No 35.8 22.1 18.9 14.7 6.3 2.1 0.106 42.1 57.9 0.892
Moderate 52.1 15.4 17.1 6 4.3 5.1 45.3 54.7
Severe 50 28.6 13.6 7.1 3.6 7.1 42.9 57.1
Usual activities (%)
No 45.9 19.4 17.3 11.2 5.1 1 0.493 40.8 59.2 0.746
Moderate 43.9 17.5 18.4 8.8 5.3 6.1 45.6 54.4
Severe 50 28.6 3.6 7.1 3.6 7.1 46.4 53.6
Pain (%)
No 58.1 16.1 9.7 6.5 3.2 6.5 0.081 41.9 58.1 0.833
Moderate 42 19.3 19.9 10.8 5.7 2.3 43.2 56.8
Severe 51.5 24.2 3 6.1 3 12.8 48.5 51.5
Depression (%)
No 52.6 15.4 15.4 10.3 3.8 2.6 0.320 47.4 52.6 0.548
Moderate 42.4 20.1 17.3 10.8 85.8 3.6 43.2 56.8
Severe 39.1 30.4 13 0 4.3 13 34.8 65.2

Table 6

Percent distribution of EQ-5D scores according to severity of burns.

EQ-5D %TBSA Degree of burn

Dimension 10 1120 2130 3140 4150 5160 P-Value First Second Third P-Value
Mobility (%)
No 53.3 33.3 9.3 2.7 1.3 0 * 1.3 78.7 20 0.12
0.001
Moderate 28.6 38.6 20.7 7.9 3.6 0.7 0 75.7 24.3
Severe 8 36 28 16 12 0 4 48 48
Self-care (%)
No 46.3 33.7 15.8 2.1 2.1 0 * 0 71.6 28.4 *
0.002 0.001
Moderate 29.9 41 15.4 8.5 4.3 0.9 1.7 82.1 16.2
Severe 10.7 28.6 35.7 17.9 7.1 0 0 46.4 53.6
Usual activities (%)
No 48 29.6 17.3 2 3.1 0 ** 0 70.4 29.6 **
0.000 0.000
Moderate 28.9 43.9 14.9 7.9 3.5 0.9 1.8 83.3 14.9
Severe 7.1 32.1 32.1 21.4 7.1 0 0 46.4 53.6
Pain (%)
No 54.8 29 12.9 0 3.2 0 0.004* 0 71 29 0.270
Moderate 36.4 36.9 15.9 6.8 3.4 0.6 1.1 76.7 22.2
Severe 3 42.4 33.3 15.2 6.1 0 0 60.6 39.4
Depression (%)
No 57.7 30.8 10.3 1.3 0 0 0.000* 0 80.8 19.2 *
0.004
Moderate 25.9 41 18.7 9.4 4.3 0.7 0.7 74.8 24.5
Severe 4.3 30.4 39.1 13 13 0 4.3 43.5 52.2

TBSA = Total body surface area.

*
P-value < 0.05 significant.
*
P-value < 0.001 very significant.

activities (73.16%), self-care (68.29%), depression and anxiety (53.65%) and
mobility (31.79%) [2]. These findings are compatible with other studies
[12,30].
4.3.1. EQ-5D with respect to age and gender
Study population of present study did not show significant dif-ferences in
EQ-5D index and VAS score with regard to gender and age. Regarding gender
many studies contrasted with the findings of the present study which revealed
that quality of life is compro-mised in females as compare to male [2,17]. In
relation to age group, several previous studies supported results of the current
study [2,8,31,32]. However, certain previous literature reported poor quality
of life in older patients [33,34].
4.3.2. EQ-5D with respect to TBSA and burn extent
In the current study, it was also observed that the following independent
predictors TBSA, time since burn and degree of burn have impact on both
physical and psychological outcomes of EQ-5D. It was observed that patients
reported impaired quality of life with major burns in terms of burn extent
(degree of burn) and total body surface area (%TBSA). These results are
consistent with find-ings of other studies. Research conducted by Wiechman
and Pat-terson [35], reported that patients presented with massive burns took
longer time to rejoin work. Druery et al. [36], found that patients had more
than 20%TBSA burnt reported poor quality of life. Similar findings were
observed in India by Tirumala et al. [2], and Jain et al. [17]. Majority of Post
burn patients were accessed during first year of injury while rest in maximum
period

Please cite this article in press as: Shahid F et al. Assessment of quality of life in post burn survivors: A cross-sectional single-center first validation study from Pakistan. Burns Open
(2017), http://dx.doi.org/10.1016/j.burnso.2017.08.003
 F. Shahid et al. / Burns Open xxx (2017) xxxxxx
up to 6 years. Significant differences were observed in EQ-5D index and VAS
scores. Several previous studies found mixed results on quality of life of burn
patients by utilizing different generic instru-ment at different time point of
post burn injury on diverse popula-tion [30].
This study present evidence on various risk factors associated with burns
trauma, impaired QoL in burns survivors as still there is a lack of reported and
documented data about burns incidence in Pakistan. This study provides an
assessment of HRQoL in post burns survivors using EQ-5D generic quality of
life questionnaire. In our country no previous study has been reported for
assessment of Qol in burns survivors by using EQ-5D instrument and this
might be the first validated study of EQ-5D instrument in burns survivors
from Pakistan. This study provides a base for burn pre-ventive strategies and
policies in developing countries. This study highlights the burden of post burn
patients over outpatient depart-ment. A recent published report conducted in
same study setting shown that majority of burn patients were managed on an
outpa-tient basis [37].
The single center study was conducted in a short period of six months
duration which was the main limitation of the present study. The second
limitation was small sample size it might affect the conclusion. The quality of
life in burn patients were measured by EQ-5D-3L instrument was is a generic
instrument rather uses disease specific instruments. The EQ-5D question-
naires were only completed from patients who were presenting to OPD. The
quality of life was reported at once and was not compared to general
population. The majority of participants were assessed in first year of post
burn period and rest in period up to six years. Moreover, the findings of
present study may not valid to other geological regions with different cultural
back-grounds despite that EQ-5D questionnaire is widely administered
instrument for assessing quality of life worldwide. To acquire more
convenient results quality of life should be measured at baseline and
repeatedly.
In order to achieve optimal outcomes of burn sustained patients health
care system should approach a multidisciplinary team for psychical and
psychological treatment. Rehabilitation programs should be implemented in
acute care and long term follow up management to improved the functional
outcomes. The abnormal post burn hypertrophic scars should be managed
with pressure garment therapy containing silicon and physiotherapy at initial
basis then reconstructive surgeries can be performed to achieve optimal
functional outcomes and for cosmetic appearance of skin. More outpatient
clinics and rehabilitation centers should be estab-lished in different regions of
the country to make certain the man-agement of post burn survivors.
5. Conclusion
The findings of present study can be concluded that burn injury had
negative impact on several dimensions of EQ-5D. The several risk factors
such as age, gender, educational, economic and occupa-tional status,
anatomical location, etiology, depth and %TBSA burn, infection, itching, scar
and contracture significantly compressed outcomes of QoL in burn patients.
The major limitation observed in participants was persistent pain particularly
in sub acute phase may impaired long term outcomes of quality of life. The
existence of depression related to post burn trauma had significant negative
impact on quality of life and may contribute in Post traumatic stress disorder
(PTSD). The EQ-5D is an easy and short tool in administration and the EQ
VAS and EQ index can effectively describe various aspects of burn related
injury with HRQoL. The adjunct use of generic instrument and disease
specific instrument can effectively assess quality of life in burn injury.
Please cite this article in press as: Shahid F et al. Assessment of quality of life in post burn survivors: A cross-sectional single-center first validation study from Pakistan. Burns Open
(2017), http://dx.doi.org/10.1016/j.burnso.2017.08.003
7
Conflict of interest
None.
Acknowledgments
The researchers would like to extent their gratitude to Professor Dr. Traiq
Iqbal Director of Burn Care Center and Dr. Zofishan Jabeen Fatima Deputy
Director of Burn Care Center and all burn unit staff Burn Care Center PIMS,
Islamabad and for their kind cooperation and assistance. The authors would
also like to thank all study participants.
Conflict of interest
None.
References
[1] Pavoni V et al. Outcome predictors and quality of life of severe burn patients admitted to
intensive care unit. Scand J Trauma Resusc Emerg Med 2010;18
(1):1.
[2] Tirumala N et al. Severe burn injury in Europe: a systematic review of the incidence,
etiology, morbidity, and mortality. Int J Pharm Life Sci 2013;4 (12):31518.
[3] Brusselaers N et al. Severe burn injury in Europe: a systematic review of the incidence,
etiology, morbidity, and mortality. Crit Care 2010;14(5):1.
[4] Edelman LS. Social and economic factors associated with the risk of burn injury. Burns
2007;33(8):95865.
[5] Adil SO et al. Severity of burn and its related factors: a study from the developing country
Pakistan. Burns 2016;42(4):9015.
[6] Othman N, Kendric D, Windi A. Epidemiology of burns and the outcome of management
in Sulaimaniyah, Iraq: a prospective study. Bio Med Central Public Health 2010;10(1):83.
[7] Lau Y. An insight into burns in a developing country: a Sri Lankan experience. Public
Health 2006;120(10):95865.
[8] Elsherbiny OEE et al. Quality of life of adult patients with severe burns. Burns
2011;37(5):77689.
[9] Pan R et al. Health-Related Quality of Life in adolescent survivors of burns: Agreement on
self-reported and mothers and fathers perspectives. Burns 2015;41(5):110713.
[10] Van Loey NE et al. Health-related quality of life after burns: a prospective multicenter
cohort study with 18 months follow-up. J Trauma Acute Care Surg 2012;72(2):51320.
[11] Blades B, Mellis N, Munster AM. A burn specific health scale. J Trauma Acute Care Surg
1982;22(10):8725.
[12] ster C et al. Validation of the EQ-5D questionnaire in burn injured adults. Burns
2009;35(5):72332.
[13] Cheung K et al. EQ-5D user guide: basic information on how to use EQ-
5D. Rotterdam: EuroQol Group; 2009.
[14] Golicki D et al. Interim EQ-5D-5L value set for Poland: first crosswalk value set in
Central and Eastern Europe. Value Health Reg Issues 2014;4:1923.
[15] Gauffin E et al. Health-related quality of life (EQ-5D) early after injury predicts long-term
pain after burn. Burns 2016;42(8):17818.
[16] Brussoni M, Kruse S, Walker K. Validity and reliability of the EQ-5D-3LTM among a
paediatric injury population. Health Qual Life Outcomes 2013;11(1):157.
[17] Jain A et al. Assessment of the depression and the quality of life in burn patients seeking
reconstruction surgery. Ind J Burns 2015;23(1):37.
[18] Van Hout B et al. Interim scoring for the EQ-5D-5L: mapping the EQ-5D-5L to EQ-5D-
3L value sets. Value Health 2012;15(5):70815.
[19] Lee CJ et al. Pediatric burns: a single institution retrospective review of incidence,
etiology, and outcomes in 2273 burn patients (19952013). J Burn Care Res
2016;37(6):e57985.
[20] Khan N, Malik MN. Presentation of burn injuries and their management outcome. J Pak
Med Assoc 2006;56(9):394.
[21] Weedon M, Potterton J. Socio-economic and clinical factors predictive of paediatric
quality of life post burn. Burns 2011;37(4):5729.
[22] Gangemi EN et al. Epidemiology and risk factors for pathologic scarring after burn
wounds. Arch Facial Plast Surg 2008;10(2):93102.
[23] Schneider JC et al. Pruritus in pediatric burn survivors: defining the clinical course. J Burn
Care Res 2015;36(1):1518.
[24] Carrougher GJ et al. Pruritus in adult burn survivors: postburn prevalence and risk factors
associated with increased intensity. J Burn Care Res 2013;34
(1):94101.
[25] Edriss AS, Smrcka V. Therapy of keloid and hypertrophic scars: a review. Eur J Plast Surg
2011;34(6):42536.
[26] Garcia LP et al. Factors affecting burn contracture outcome in developing countries: a
review of 2506 patients. Ann Plast Surg 2016;77(3):2906.
[27] Cubitt JJ et al. Evaluating an outreach service for paediatric burns follow up. Burns
2015;41(6):11938.
8 F. Shahid et al. / Burns Open xxx (2017) xxxxxx

[28] Barajas-Nava LA et al. Antibiotic prophylaxis for preventing burn wound infection.
Cochrane Library 2013.
[29] Naqvi ZA, Hashmi K, Kharal SA. Methicillin resistant Staphylococcus aureus (MRSA) in
burn patients. Pak J Pharmacol 2007;24(2):711.
[30] Van Baar M et al. Quality of life after burns in childhood (515 years): children
experience substantial problems. Burns 2011;37(6):9308.
[31] Yue L, Jiang D, Huang X. Investigation of life quality of severe burn patients at
rehabilitation stage and analysis of the related influential factors. Chin J Burns
2008;24(3):1958.
[32] Eldin WS et al. Health-related quality of life after serious occupational injury in Egyptian
workers: a cross-sectional study. BMJ Open 2012;2(6):e000413.
[33] Sluys K, Hggmark T, Iselius L. Outcome and quality of life 5 years after major trauma. J
Trauma Acute Care Surg 2005;59(1):22332.
[34] Mata GV et al. Analysis of quality of life in polytraumatized patients two years after
discharge from an intensive care unit. J Trauma Acute Care Surg 1996;41
(2):32632.
[35] Wiechman SA, Patterson DR. Psychosocial aspects of burn injuries. BMJ
2004;329(7462):3913.
[36] Druery M, Brown TLH, Muller M. Long term functional outcomes and quality of life
following severe burn injury. Burns 2005;31(6):6925.
[37] Iqbal T, Saaiq M, Ali Z. Epidemiology and outcome of burns: early experience at the
countrys first national burns centre. Burns 2013;39(2):35862.

Please cite this article in press as: Shahid F et al. Assessment of quality of life in post burn survivors: A cross-sectional single-center first validation study from Pakistan. Burns Open
(2017), http://dx.doi.org/10.1016/j.burnso.2017.08.003