Abstract
Background:
Burns are a major cause of morbidity, including prolonged hospitalization, disfigurement, disability, and emotional trauma. Long-term absence from work and high healthcare costs for burn treatment have a significant socio-economic impact.
Objective:
his study aims to evaluate the level of knowledge for burn management in the adult population of Thrace in Northern Greece and to determine factors associated with a better level of knowledge.
Methods:
A questionnaire-based cross-sectional study was conducted οn a random sample of the adult population of Thrace. Data were collected using a structured pre-coded questionnaire, which included subjects’ socio-demographic characteristics and the first aid practices for burns. Multivariate logistic regression analysis was used to determine the effect of subjects’ characteristics on their knowledge of burn first aid practices.
Results:
A total of 711 subjects (49.6% males; mean age, 41.89±16.48 years) were included in the study. The incidence of a previous burn was 55.4%. Only 10.5% of the subjects would apply the optimal practice, consisting of rinsing the burn wound with cool running water for at least 10 minutes, applying only non-adhesive dressing on it and leaving the blisters intact. The optimal practice was independently associated with female gender (aOR=1.86, p=0.016), high education level (aOR=2.00, p=0.023), the presence of >3 children (aOR=2.27, p=0.009) and previous training in first aid (aOR=2.36, p=0.001). A large number of participants reported the application of toothpaste (38%), moisturizer (35.4%), aloe (31.8%) or yogurt (27.7%) to the burn surface.
Conclusion:
Only a small proportion of the participants were aware of the optimal burn first aid practices, most of them female, of high socioeconomic status. We recommend a more targeted approach in the design of health campaigns in the future, in order to reach vulnerable parts of the population.
Keywords: Burn, First aid, Attitudes, Socio-demographic characteristics
1. BACKGROUND
Burns are a major cause of morbidity, including prolonged hospitalization, disfigurement, disability, and emotional trauma. Long-term absence from work and high healthcare costs for burn treatment have a significant socio-economic impact (1). In developed countries significant progress has been made in reducing the mortality and morbidity of burns, thanks to the implementation of prevention strategies combined with the improvement of the quality of burn care. Despite this, each year 11 million people worldwide continue to suffer from burns severe enough to require medical attention. Increased awareness and access to information of vulnerable populations and optimization of community education in first aid for burns will further reduce the effects of burns (2).
The provision of appropriate first aid is a well-documented determinant of burn outcomes. Inappropriate first aid practices have been reported from developed as well as developing countries. The immediate and correct application of appropriate measures aims to limit the thermal damage, remove any chemical caustic agents, cover and protect the burn area and provide adequate analgesia, thus leading to a reduction in the number of complications, better healing and reduced need for surgical intervention (3, 4, 5).
Current burn first aid best practices include flushing the burn with cool running water for 10-20 minutes and cover with sterile gauze (6), avoiding the application of inappropriate substances on the burn area (7), and leaving the blisters intact (8).
Unfortunately, the data published in Greece regarding the level of knowledge of the population, the beliefs and the first aid practices for burns are very limited (9). According to a paper published in 2006 regarding the level of first aid knowledge of the Cretan population for a variety of emergency situations, only 25% of the participants would place the burnt area under running water (10). Accordingly, in a 2018 study conducted in several pediatric hospitals in Attica which assessed the level of knowledge of parents regarding first aid for burns in children, it was found that 43.1% of the respondents would apply cool, running water to the burn (11). In none of the above studies participants were asked about the use of traditional treatments, such as toothpaste, yogurt, aloe vera, honey, etc., nor about how they would manage the presence of blisters.
Recent massive reshuffles of populations and increase in cultural diversity in many European countries, including Greece, render assessment of population awareness difficult, though essential in re-designing and implementing effective prevention and public health promotion strategies.
1. OBJECTIVE
The aim of this study was to investigate the level of knowledge for burn management in the population of Thrace in Northern Greece and to determine the factors associated with a better level of knowledge.
2. MATERIAL AND METHODS
Study population – Sampling scheme
The study was conducted between June 2021 and October 2022 and included adults (aged ≥18 years) living in the region of Thrace, randomly selected by a telephone number generator. After the aim of the study was explained to them, the participants agreed to have field researchers visit their homes, to complete the study questionnaires in a 15-min interview. The overall response rate was 77%.
Sample size
Power analysis determined that a minimum sample size of 588 subjects was required to estimate the proportion of the general population with good knowledge of the current burn first aid best practices with precision ±3.5% and a confidence level of 95%, assuming that this proportion in the Greek population was ≈25%7 (https://www.openepi.com/Menu/OE_Menu.htm).
Ethical approval
The study was approved by the Ethics Committee of the Democritus University of Thrace (Protocol Number DUTH/EC/37239/339/02-03-2021). Participation was anonymous and voluntary. Written informed consent was obtained from all participants of the study.
The questionnaire
The first part of a structured questionnaire was used to collect the following subjects’ sociodemographic characteristics: gender, age, cultural status, place of residence, marital status, number of children, education level (low: basic education (≤nine years); medium: up to high school or technical colleges; high: university), working status, and financial status (mean monthly household income; low: ≤1000€; medium: 1001-2000€; high: >2000€). In addition, previous history of burns, treatment by a professional and first aid training was also recorded. In the second part the practices applied and material used in first aid for burns were assessed. Participants with answers that included rinsing the burn with cool running water for at least 10 minutes and not applying traditional treatments were considered to have adequate knowledge, while all others were classified as insufficiently knowledgeable about first aid for burns.
Statistical analysis
Statistical analysis of the data was performed using IBM Statistical Package for Social Sciences (SPSS), version 19.0 (IBM Corp., Armonk, NY, USA). Quantitative variables were expressed as mean±standard deviation (SD) and qualitative variables were expressed as absolute and relative (%) frequencies. The association of the knowledge of best practices in first aid for burns with subjects’ characteristics was assessed using the chi-square test. To assess the independent effect of demographic characteristics on first aid knowledge, multivariate stepwise logistic regression analysis was also performed. Odds ratios (OR) with their 95% confidence intervals (CI) were estimated as the measure of the above associations. All tests were two-tailed and statistical significance was considered for p values <0.05.
3. RESULTS
A total of 711 participants, 353 (49.6%) males and 358 (50.4%) females, with a mean age of 41.89±16.48 years (range, 18-86 years; median age, 43 years) were included in the study. Participants’ characteristics are summarized in Table 1. The majority of the participants had a previous burn history (55.4%), while only 29.8% had been trained in first aid.
Table 1. Appropriate burn management (rinsing the burn wound with cool running water for at least 10 minutes) in relation to the characteristics of the participants.
| Total sample | Appropriate burn management | p value | OR (95% CI) | |
|---|---|---|---|---|
| Number of subjects | 711 | 75 (10.5) | ||
| Gender | 0.012 | |||
| Men | 353 (50.4) | 27 (7.6) | Ref. | |
| Women | 358 (49.6) | 48 (13.4) | 1.87 (1.14-3.07) | |
| Age | 0.164 | |||
| 18-30 years old | 263 (37.0) | 12 (8.0) | 0.60 (0.35-1.03) | |
| 31-60 years old | 346 (48.7) | 44 (12.7) | Ref. | |
| ≥61 years old | 102 (14.3) | 10 (9.8) | 0.75 (0.52-1.54) | |
| Cultural status | 0.828 | |||
| Christian | 631 (88.7) | 66 (10.5) | Ref. | |
| Muslim | 80 (11.3) | 9 (11.3) | 1.09 (0.52-2.27) | |
| Place of residence | 0.931 | |||
| Urban | 490 (68.9) | 53 (10.8) | Ref. | |
| Semi-urban | 144 (20.3) | 14 (9.7) | 0.89 (0.48-1.65) | |
| Rural | 77 (10.8) | 8 (10.4) | 0.96 (0.44-2.10) | |
| Marital status | 0.343 | |||
| Married/Divorced | 406 (57.1) | 46 (11.3) | 1.29 (0.80-2.15) | |
| Single | 289 (40.6) | 26 (9.0) | Ref. | |
| Widow | 16 (2.3) | 3 (18.8) | 2.33 (0.63-8.73) | |
| Number of children | 0.021 | |||
| None | 357 (50.2) | 31 (8.7) | Ref. | |
| 1-2 children | 263 (37.0) | 27 (10.3) | 1.20 (0.70-2.07) | |
| ≥ 3 children | 91 (12.8) | 17 (18.7) | 2.42 (1.27-4.60) | |
| Education level | 0.010 | |||
| Low | 93 (13.1) | 5 (5.4) | Ref. | |
| Medium | 146 (20.5) | 10 (6.8) | 1.29 (0.43-3.91) | |
| High | 472 (66.4) | 60 (12.7) | 2.56 (1.00-6.57) | |
| Work status | 0.218 | |||
| Employed (white collar) | 328 (46.1) | 43 (13.1) | Ref. | |
| Employed (blue collar) | 107 (15.0) | 7 (6.5) | 0.46 (0.20-1.07) | |
| Unemployed | 37 (5.2) | 1 (2.7) | 0.18 (0.03-1.38) | |
| Student | 129 (18.1) | 13 (10.1) | 0.74 (0.38-1.43) | |
| Retired | 92 (12.9) | 10 (10.9) | 0.81 (0.39-1.68) | |
| Household | 18 (2.5) | 1 (5.6) | 0.39 (0.05-3.01) | |
| Financial status | 0.005 | |||
| Low | 159 (22.4) | 11 (5.9) | Ref. | |
| Middle | 226 (31.8) | 22 (9.7) | 1.71 (0.81-3.62) | |
| High | 185 (26.0) | 24 (15.1) | 2.81 (1.33-5.94) | |
| First aid training | 0.001 | |||
| No | 212 (29.8) | 40 (8.0) | Ref. | |
| Yes | 499 (70.2) | 35 (16.5) | 2.27 (1.40-3.69) | |
| Burn history | 0.382 | |||
| No | 317 (44.6) | 37 (11.7) | Ref. | |
| Yes | 394 (55.4) | 38 (9.6) | 0.81 (0.50-1.30) | |
| Treated by a professional | 0.543 | |||
| No | 246 (62.4) | 22 (8.9) | Ref. | |
| Yes | 148 (37.6) | 16 (10.8) | 1.23 (0.63-2.43) |
Regarding the first aid applied by the participants to the burn, the majority (57.2%) would apply water on the burn surface, 53.6% would use cool water and 84% of them would use running water, but only 84 participants (24.6%) would flush the burn for more than 10 minutes. A large number of participants report adopting inappropriate practices, such as applying toothpaste (38%), moisturizer (35.4%), aloe (31.8%) or yogurt (27.7%) to the burn surface. Covering the burn surface with sterile gauze was reported by only 26%, while, 69.9% would leave the blisters intact. (Table 2)
Table 2. Burn management.
| Number of subjects | Percentage (%) | |
|---|---|---|
| Do you apply water to the burn area? | ||
| No | 304 | 42.8 |
| Yes | 407 | 57.2 |
| If you apply water, do you use.… (n=407) | ||
| Cold water | 189 | 46.4 |
| Cool water | 218 | 53.6 |
| If you apply water, do you use… (n=407) | ||
| Bowl of water | 65 | 16.0 |
| Running water | 342 | 84.0 |
| How long do you apply running water? (n=342) | ||
| < 1 minute | 68 | 19.8 |
| 1-10 minutes | 190 | 55.6 |
| > 10 minutes | 84 | 24.6 |
| Substance applied to the burn | ||
| Toothpaste | 270 | 38.0 |
| Moisturizing cream | 252 | 35.4 |
| Aloe vera | 226 | 31.8 |
| Yogurt | 197 | 27.7 |
| Hypericum oil | 148 | 20.8 |
| Ice | 49 | 6.9 |
| Tomato paste | 37 | 5.2 |
| Cucumber | 35 | 4.9 |
| Butter | 29 | 4.1 |
| Olive oil | 29 | 4.1 |
| Vaseline | 20 | 2.8 |
| Honey | 18 | 2.5 |
| Tea tree oil cream | 16 | 2.3 |
| Egg white | 15 | 2.1 |
| Curcubita oil | 10 | 1.4 |
| Baking soda | 6 | 0.8 |
| I cover the burn with... | ||
| Nothing | 434 | 61.0 |
| Clean towel/kitchen paper | 68 | 9.6 |
| Adhesive bandage | 24 | 3.4 |
| Gauze | 185 | 26.0 |
| The blisters should… | ||
| Be left intact | 497 | 69.9 |
| Be broken | 26 | 3.6 |
| Be broken and the skin be removed | 19 | 2.7 |
Seventy-five participants (10.5%, 95% CI=8.4%-13.0%) reported rinsing the burn with cool running water for at least 10 minutes and not applying traditional treatments, which was considered the best practice in first aid for burns. The prevalence of knowledge of best practices in relation to participants’ characteristics is shown in Table 1; it was more frequent among females (p=0.012) and those previously trained in first aid (p=0.001), while it was increasing as the number of children in the family (p=0.021), education level (p=0.010) and financial status (p=0.005) were increasing. On the contrary, the knowledge of best practices was independent of age (p=0.164), cultural status (p=0.828), place of residence (p=0.931), marital status (p=0.343), working status (p=0.218), previous burn history (p=0.543) and treatment by a professional (p=0.543).
Multivariate logistic regression analysis demonstrated (percentage of correct prediction, 89.5%) that the knowledge of best practices was independently associated with female gender (aOR=1.86, 95% CI=1.12-3.09, p=0.016), high education level (aOR=2.00, 95% CI=1.10-3.64, p=0.023), the presence of more than 3 children (aOR=2.27, 95% CI=1.23-4.18, p=0.009) and previous training in first aid (aOR=2.36, 95% CI=1.44-3.88, p=0.001).
4. DISCUSSION
This study attempts to determine the level of knowledge, beliefs and practices applied in first aid for burns in a sample of the general adult population in Thrace. Only one in ten people knew enough about first aid for thermal burns.
It is well established that an immediate flush of the burn with cool running water is the most important practice for reducing burn morbidity. In 2006, Cuttle et al. found that when cool water at 2–15°C was applied for 20 minutes to a porcine partial-thickness wound model it significantly improved healing, accelerated the rate of re-epithelialization, and had a better aesthetic outcome (12). Although there is no consensus on the optimal water temperature and duration of flushing, the mechanisms of action have been thoroughly investigated. Running cold water stops the combustion process (13) and prevents cell necrosis in a stop zone (14) by reducing cell metabolism (15) and capillary permeability (16), increasing skin perfusion (17), and restoring blood flow (18). Cold water has also been found to reduce the inflammatory response and subsequent edema (3), by reducing histamine and lactic acid release (4), prostaglandin and thromboxane levels (5), and inhibiting kallikrein activity, and subsequent formation of quinine (19).
The use of traditional treatments used in burns is passed down from one generation to another and some of them are of ethnopharmacological interest. However, the use of inappropriate treatments in the present study was by no means limited to any particular ethnic group of participants, as toothpaste was popular among all groups “for its ability to soothe burning and reduce blistering.”
Previous studies have shown that raw egg white, oil, honey, yogurt, toothpaste, tomato paste, and ice are just some of the agents applied as first aid in countries such as Ghana, the United Kingdom, Australia and Turkey (20, 21, 22, 23). In addition to the fact that these agents are not sterile and may contaminate the wound, some of them form a film or crust, as happens with toothpaste and yogurt, making cleaning the wound even more painful. A study published in 2018 in the Journal of the International Society for Burn Injuries reports that toothpaste can actually seal in heat and slow down the cooling and healing of the burn (24). In addition, whitening agents and fragrances contained in toothpaste can have an irritating effect on the skin and cause permanent skin discoloration (25).
Hypericum perforatum has long been investigated for its antioxidant, anti-inflammatory, and healing properties and is a popular traditional remedy used topically on burns, wounds, and ulcers. Safflower oil has been found to protect hair follicles and sebaceous glands in second-degree burns in rats and significantly accelerate re-epithelialization and neo-angiogenesis compared to silver sulfadiazine, which is the main topical agent applied to burns (26). However, further clinical studies are needed to prove its effectiveness as a first-aid treatment for human burns. Similarly, several studies support the beneficial effects of honey in limiting infections and accelerating burn healing (27). For all these traditional treatments further research is needed to establish their safety and effectiveness in first aid for burns.
High level of education and first aid training significantly determined increased degree of awareness. Several similar studies from both developed and developing countries have demonstrated the importance of first aid training as a key determinant of the adequacy of knowledge in proper burn management (28). Training is provided either in school or in the workplace or even in the form of a seminar addressed to the general public in the context of prevention. Davies et al. conducted a study with participating parents and caregivers attending the first aid and antenatal care department of a University Hospital and found that first aid training was the most significant predictor of adequate first aid knowledge for burn management, regardless of how long before the assessment the participants had received the training (29). In the same study, low socioeconomic status was statistically significantly associated with insufficient burn first aid knowledge, a finding also supported by the present study. The facts that socioeconomic status reflects the educational level and most highly educated individuals had some previous first aid training while people of low socio-economic status widely use traditional treatments may explain these findings.
A history of burns in the family did not correlate with higher best practices awareness in our study. In a recent study in Saudi Arabia the majority of the participants had dealt with burn injuries in the past five years (93.3%) (30), while in our study only half of the participants (55.4%) reported previous burn history.
5. CONCLUSION
Only a small proportion of the adult population was aware of the best practices in burn management, as is demonstrated in our study. The use of traditional treatments is still quite common, while there were factors, such as female gender and high education level, that were associated with better knowledge about burn management. The increase in immigration to southern European countries dictates the need to re-design campaigns in order to better communicate burn first aid guidelines to target vulnerable parts of the population. Improved access to correct information through the media, including the internet and social media, will eliminate language barriers, may increase awareness and reduce the morbidity of burn injuries.
Informed Consent Statement:
Informed consent was obtained from all subjects involved in the study.
Authors’ contribution:
Conceptualization and design: G.T., T.C. and D.K., data acquisition: V.P., G.T. and D.K., analysis and data interpretation: V.P., G.T., T.K. and D.K., original draft preparation: V.P., G.T., T.K. and D.K., review and editing: G.T., T.K. and D.K. All authors have read and agreed to the published version of the manuscript. authors were involved in preparation this article. Final proofreading was made by the first author.
Conflict of interest:
The authors declare that they have no conflict of interest.
Financial support and sponsorship:
None.
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