INTRODUCTION:

Burns is one of the most devastating injuries in the field of medicine. According to the International Society for Burn Injuries (ISBI), a burn occurs when some or all of the different layers of cells in the skin are destroyed by a hot liquid (scald), a hot solid (contact burns), or a flame with flame burns. Skin injuries due to UV radiation, radioactivity, electricity, or chemicals, as well as respiratory damage resulting from smoke inhalation, are also considered to be burns¹.

Burn injuries are a major public health concern on a global scale, resulting in approximately 180,000 fatalities each year and ranking as the fourth most frequent traumatic injury worldwide². Low and middle-income countries are particularly affected, with India, which boasts a population of over 1.35 billion, recording an estimated 6-7 million burn cases annually³. These figures underscore the pressing need for heightened awareness, prevention, and treatment of burn injuries across the globe. Burn injuries produce the most painful experiences and may result in unpleasant physical and psychological outcomes among patients. Burn injuries can lead to enormous physical problems like pain, infections, scarring, contractures, deformities and disabilities. Psychological problems like depression, post-traumatic stress disorder, social anxiety, problems with sleep, suicidal ideations and personality changes also occur as complications after burns⁴.

Changes in appearance and scarring, leading to body image alteration and functional impairment, can cause a deterioration in quality of life. People who suffer from burns have a change in their life satisfaction after the injury⁵.

Definition of life satisfaction:

Life satisfaction is the evaluation of one's life as a whole, not simply one's current level of happiness⁶. It is the general feeling about one’s life and how pleased they are with how it's going, as Ruut Veenhoven stated in 1996.Life satisfaction is the degree to which a person positively evaluates the overall quality of his/her life as a whole. In other words, how much the person likes the life he/she leads⁷.Life Satisfaction is defined as being able to live an autonomous and self-determined life, feeling needed in everyday life, having a fulfilled employment or retirement, enjoying leisure activities, and being content with one's appearance, physical functioning, and mental well-being⁸.

Burn survivors' quality of life can be assessed using life satisfaction as a global indicator. The assessment of life satisfaction in burn survivors is influenced by physical, psychological, and social factors, and can be utilized to evaluate their well-being. If burn survivors are dissatisfied with their life, it can result in a decrease in their overall quality of life.^9,11.

Satisfaction with life score (SWLS) has proven to be a dependable tool for evaluating the life satisfaction in burn survivors¹². Social relationships, work or school, personal satisfaction with religious or spiritual life, learning and growth, and leisure activities are among the factors that contribute to life satisfaction. A systematic review of life satisfaction conducted, which included nine cross-sectional studies comprising 3352 burn patients, revealed that the mean score of life satisfaction in burn patients was as follows: 23.02 (SD = 7.86) out of 35 based on SWLS, 12.67 (SD = 4.99) out of 20 based on Life satisfaction index (LSI-A), and 4.81 (SD = 1.67) out of 7 based on the life satisfaction questionnaire⁵. It highlights that burn survivors are slightly satisfied with their life and it urges the health care professionals to plan for psychological interventions to enhance their life satisfaction.

Positive and significant relationship was found between life satisfaction in burn patients and factors such as time since burnt and religion as religion was their source of strength⁵. Whereas, factors such as single marital status, age at injury, length of hospital stay, presence of pain, larger total body surface area burn, head and neck burn, functional impairment, marital dissatisfaction, dissatisfaction with appearance, and previous psychiatric treatment had a negative and significant relationship with life satisfaction in burn patients⁵. Abouzeid et al conducted a study involving 421 adults who had suffered burns, which revealed that as time passes, life satisfaction tends to decline.¹³

A research was conducted on 379 individuals who suffered burns and the results showed that 48.5% of them were satisfied with their lives. The study identified several factors that affected life satisfaction, including educational background, marital status, post-burn, pre-burn occupation, post-burn occupation, skin graft, and insurance¹⁴.

A study was conducted to track satisfaction with life over a period of two years, and it revealed two distinct patterns. The majority of participants (60%) who had consistent levels of satisfaction with life maintained high initial scores throughout the two-year period. The remaining 40% of participants demonstrated low average scores and experienced a decline in satisfaction over time. After being discharged from the hospital, most burn survivors (60%) reported healthy levels of satisfaction with life for up to two years. The individuals in the group with consistent levels of satisfaction tended to be younger when they sustained their injuries, were employed before their injury, and had better mental health related to their quality of life at the time of their discharge. Alternatively, those in the group with lower satisfaction scores at the start tended to have lower initial scores, and their satisfaction with life got worse over time.⁹

A research conducted by Goverman and colleagues across six US centers studied 1129 burn patients at different intervals, including at discharge, 6 months, 12 months, and 24 months after discharge. The study revealed that the Satisfaction with life (SWL) scores of burn survivors was persistently less than that of non-burn patients at all follow-up stages. Moreover, the SWL scores for burn patients remained unchanged throughout the two-year period²⁴. Factors that increase the likelihood of experiencing decreased levels of satisfaction at various time period during the 2-year duration include: the duration of hospitalization, enrollment in school, magnitude of body surface area that has been burned, and the occurrence of amputation ¹⁶. A majority of burn survivors who were retrospectively assessed for life satisfaction were found to have fulfilled the domains of autonomy, fulfillment, joy, and being needed. The domain of being needed showed a negative correlation with length of stay, as those with severe burns over a large area required more support from their environment and were unable to provide as much support⁸.

In a study done to assess the physical health-related quality of life (HRQoL) after a burn injury, recovery was evaluated and categorized into three classes: class I represents recovering which forms the majority and who attain their preinjury level of health, class II represents static condition which does not move towards the better quality of life, and class III represents weakened state where they improve in their health-related quality of life but does not improve to the preinjury QOL. The study found that individuals in the static and weakened classes reported lower levels of life satisfaction¹⁸.

Survivors of head and neck burns were studied to determine how was their social functioning, physical health, and quality of life compared to survivors without such burns. The study found that those with head and neck burns had similar outcomes in community integration, physical health, and life satisfaction when compared to those without head and neck burns. Over time, these outcomes improved for both groups of survivors¹⁹.Burn survivors exhibit significantly lower SWL scores compared to non-burned individuals and their scores do not show significant improvement from 6 months to 2 years after the injury.¹⁶

Patterson and colleagues identified factors that could predict SWL at discharge and after a 6-month period following injury. It was revealed that individuals who were not married, had a history of alcohol abuse, required psychological treatment prior to the injury, and had a longer stay in the ICU had lower SWL scores at discharge. At 6 months, lower SWL scores were associated with being unmarried, requiring psychological treatment prior to the injury, having a longer stay in the ICU, and undergoing amputation as a result of the burn²⁰.

We will discuss about few factors that affect life satisfaction in burn survivors and its impact on health-related quality of life in detail.

Major Factors affecting life satisfaction after burns Pain:

Burn injuries can cause several types of pain, such as acute, chronic, breakthrough, resting, and neuropathic pain²¹. Despite receiving pharmacological treatment, the severity of the pain may persist. Non-pharmacological interventions can assist burn survivors in managing their pain²².Evidence based treatment can be implied for the burn management²³.Banana leaf dressings has helped burn survivors to reduce the pain and discomfort as reported by Jifi A et al²⁴. Chronic pain may result in dissatisfaction with life. A study done by McNamee and Mendolia has shown that chronic pain is negatively associated with life satisfaction^25.

Satisfaction with appearance:

Scarring, disfigurement, and deformities are common consequences of burn injuries, which can have significant impact on one's appearance. The effects of appearance-related concerns vary based on gender, with women experiencing greater impact. Additionally, the severity of the wound influences the extent of scarring, as the depth of the wound is directly proportional to the amount of scarring. Chapman University in the United States has conducted a large-scale study among 12,176 people which revealed that people who had better satisfaction with their physical appearance also experienced higher levels of self-esteem and further had greater satisfaction with life which can be implied for the burn survivors as well²⁶.

The desire to alter the appearance of the injury was expressed by 25% of the individuals who had suffered from burns¹⁷. Burn survivors who were less satisfied with their physical appearance before the injury also had lower overall satisfaction with life. The importance of physical appearance was greater for younger patients and female patients, who tended to have negative opinions about their scars⁸.

Functional impairment:

Functional independence is a notable predictor of life satisfaction. Burn survivors have functional impairment due to contractures, deformities, and amputations. Among 1865 burn patients who participated in a study, 33% or 620 patients developed at least one contracture during their hospital discharge. The shoulder joint (23%) was most commonly affected one followed by the elbow (19.9%), the wrist (17.3%), the ankle (13.6%), and the knee (13.4%). This condition can have an effect on the patients' functional ability²⁷.

In a study done to assess the influence of functional disability on depression and life satisfaction among middle-aged and older adults it was found that people with functional impairment experienced depression and reduced satisfaction with life²⁸. According to a study done by Kishawi, one-third of the participants expressed a desire to enhance their bodily function. Better bodily functionality was more desirable among younger patients who had experienced hand injuries, as such injuries tend to result in contracture¹⁷. Functional impairment can negatively affect the life satisfaction.

Social relationship:

Individuals who have suffered burns often experience changes in their physical appearance, which can result in a decrease in their self-confidence. This can also impact their ability to engage and interact with others in social situations. As a result, they may develop anxiety while facing the society which can negatively impact their ability to initiate and maintain effective social relationship. However, if they are able to overcome these obstacles, they may find that social relationships enhance their overall satisfaction with life.

Providing social support to burn survivors can improve their life satisfaction. A study has shown that there is a noticeable strong relationship between satisfaction with life and social support provided by important members, family, and friends which plays an inevitable role in providing such support²⁹. Burn survivors who are employed and those who are not employed were compared in their level of social participation. The results showed that burn survivors who are employed had greater scores in the areas of family and friends, social activities, and social interactions compared to those who are not employed³³.

The influence of society on the burn survivors can be assessed by measuring their social engagement in various recreational activities, including play, sports, art, culture, hobbies, and caring for pets. Survivors of burn injuries have reported that they continue to engage in activities they enjoy, even if they have to make adjustments to accommodate their injuries³⁰.

Personal Satisfaction with Religious or Spiritual Life:

Religious or spiritual life can influence a person’s overall sense of satisfaction with life and empowers individuals with the required strength to depend on a superior power, which can help them maintain their spiritual stamina and resilience. By doing so, it can greatly improve the life satisfaction of burn survivors. A study was conducted by Royse & Badger in 2017 on 92 burn survivors to analyze their level of life satisfaction, and those who expressed that religion supported them with strength and comfort had higher scores on the life satisfaction scale³¹.

Life satisfaction for burn survivors is closely linked to pain relief and being content with the management of their pain. A study conducted on 68 burn patients examined the impact of religion and spiritual care on these factors and discovered that it led to decreased pain intensity during dressing changes and an increased satisfaction with pain control³².

Family satisfaction:

Family satisfaction refers to perceptions of family quality such as solidarity and happiness and overall relational well-being as stated by Jordan Soliz & Jody Koenig Kellas³⁴. Life satisfaction and happiness are positively linked to improvements in family functioning, attachment, and changeability levels³⁵. Studies done on patients with injury which includes burn injury reveal that social integration enhances life satisfaction and family satisfaction 5 years post-injury³⁶.

Mental wellbeing:

Enormous psychological problems occur as a complication after burn injury which includes anxiety, depression, anger, sleep disturbances, phobias, post-traumatic stress disorder, personality changes, guilt, and suicidal thoughts⁴. Mental health is a vital element in the recovery journey of burn survivors. It has been found that mental well-being plays a substantial role in deciding the overall life satisfaction of burn victims. According to a study done by Wiechman SA in 2023, 18% of participants expressed a desire for improvements in their mental health. Among female participants, the need for better mental well-being was more prevalent, as they were more likely to have a psychiatric illness and suffer from third-degree burns¹⁷.

Stigma:

Burn stigma was associated with reduced satisfaction of life. Affect and body image partially accounted for the relationship between stigma and life satisfaction. With the recent advancements in the burns care, the survival rate of patients has drastically improved. But burn survivors face the challenge of experiencing stigma related to their injury leading to negative psychosocial outcomes, dysfunctional coping, pain, and decreased physical functioning.

Individuals with a burn experiences stigma, which then results in negative body image or affect. This leads to reduced life satisfaction. Watson has suggested that resilience help to reduce self-perceived stigma and suggested ways to reduce invalidating or stigmatizing verbalization and behavior from family and caregivers can improve the quality of life and life satisfaction³⁷.

Gender:

Gender plays a pivotal role in determining satisfaction with life. Amtmann et al in their study highlighted that male patient had decreased life satisfaction before burn injury⁹. But in a study done by Hutter et al (2022), females were found to have lower scores in all the domains and in particular in the domains of fulfillment and mental wellbeing⁸. Similarly, in a study conducted by Goverman et al. potrayed that female gender was linked with decreased satisfaction with life at 6 months after experiencing burns¹⁶. In general, married women and those with better economic security had better life satisfaction than unmarried women as revealed in a study done by Pratibha B³⁸.

Total body surface area affected:

Life dissatisfaction was more common among patients who had greater burn visibility and a larger affected body surface area⁸. The extent of burns on a person's body is negatively correlated with their level of life satisfaction. Burn survivors tend to have lower SWL scores compared to those who have never experienced burns. These scores also do not show significant improvement from 6 months to 2 years after the injury¹⁶. Kishawi et al conducted a study in 2020 that highlighted comparable results, indicating that the functional ability and consequently the quality of life were affected by extended hospital stay and increased TBSA.¹⁷

Employment and Return to Work:

Being employed helps burn survivors stay involved and productive, and returning to work as they did before their injury can help them reintegrate into society. However, functional impairment may sometimes make it difficult for them to resume their previous employment after a burn injury. Pre-burn unemployment can lead to dissatisfaction with life¹⁵.

Health-related Quality of Life (HRQoL), job status, and life satisfaction are impacted by burn injuries in survivors. The two strongest factors affecting the return to work after a burn injury were employment status prior to the injury and surprisingly, age. Male and female patients had significant difference in the employment status. Before the burn injury, male patients had better employment status than female patients, but a majority of both male and female patients were able to resume their pre-injury employment³⁵.

In addition, individuals with less education were able to resume employment. The fact that these patients had a job prior to the trauma could have served as a source of motivation during their recovery journey towards normalcy⁹. In the study conducted by Orwelius et al., it was discovered that the negative impact of unemployment on Health-related Quality of life (HRQoL) was the most significant among the study participants³⁹and, Dyster-Aas et al.⁴⁰ found in their study group that patients who were employed not only had higher levels of health-related quality of life (HRQoL), but also experienced better physical and psychological well-being as compared to those who were unemployed. Another aspect that should not be left out is, as Goei et al. pointed out, that absenteeism from work contributes to societal costs for burn victims⁴¹.

Community reintegration:

Reintegrating into the community is a major milestone in the life of burn survivors. Burn rehabilitation program focusses on helping them return to their pre-injury life as closely as possible. This includes resuming education or work, rebuilding relationships, pursuing interests, and restoring their lifestyle to how it was before the burn injury⁴².Community integration makes the burn survivor become active member of the society where they live in and helps them to overcome social isolation and social anxiety⁴³.

Getting integrated with society in terms of acceptance by the community is essential for better life satisfaction. But Satisfaction with life was significantly worse over time and community integration did not show significant impact on it. A study conducted by Callie Abouzeid discovered that while satisfaction with life score decreases over time, the community integration score remains relatively stable with no change in the long term⁴². Social integration is associated with greater overall life satisfaction and increased social integration is associated with greater family satisfaction.

Ways to Improve Life Satisfaction among burn survivors:

Life satisfaction in burn survivors can be improved by focusing on the factors that predict life satisfaction. These factors include relationships with loved ones, fulfillment from work, satisfaction with physical health, happiness with a romantic life, and contentment with a sense of spirituality or religion. Health managers and policymakers can improve the quality of life of burn victims by planning psychological counselling and behavioral therapy, and consequently increase their life satisfaction¹³.

It is possible to improve the life satisfaction of burn survivors by providing them with additional services that can help identify and overcome obstacles to rehabilitation. Improved life satisfaction can be achieved through access to better rehabilitation measures. Perception of social support can also play a crucial role in enhancing life satisfaction¹⁵

There is a possibility of enhancing life satisfaction through intensified focus on community integration and psychosocial support. The process of community integration encompasses areas such as education, employment, social connections, leisure activities, and diverse interests and lifestyles outside of one's immediate surroundings. Furthermore, it is imperative to conduct a more comprehensive assessment of the significance of extended psychological treatment for individuals who have experienced burn injuries¹⁶.

The adult head and neck burn population may require significantly more resources in managing appearance and psychosocial health after a burn injury. One way to improve the appearance of scarring is to increase access to secondary interventions, such as reconstructive surgery and laser treatments⁴⁴. Student nurses who are learning to care for the burn patients can be taught burn nursing through integrated learning system which is effective as studied by Kavitha S⁴⁵. Burn survivors can improve their quality of life by consistently evaluating their satisfaction with their appearance and the effectiveness of post-acute reconstructive surgical interventions¹⁹. Organizations such as Phoenix Society and other local burn support groups can greatly improve the quality of life for burn survivors. By promoting peer support, these organizations can provide motivation and assistance to help survivors overcome the challenges they face during their recovery from burns. Preventive measures must be implemented as it can help to avoid disastrous complications^46.Evidence based treatment can be incorporated in the care to bring better outcomes.⁴⁷

CONCLUSION:

Burn injuries are painstaking and take longer duration for the healing and the rehabilitative process. Burn survivors need to have a productive and fulfilling life. Life satisfaction is essential to have an improved quality of life. Identifying the factors associated with life satisfaction and enhancing the positive factors will help the burn survivors. Nurses play a key role in the care and rehabilitation of burn survivors. Let us help the burn survivors have enriched life satisfaction and ultimately a better quality of life.

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Received on 02.10.2024 Revised on 18.11.2024

Accepted on 20.12.2024 Published on 24.02.2025

Available online from March 17, 2025

Asian J. Nursing Education and Research. 2025;15(1):12-18.

DOI: 10.52711/2349-2996.2025.00003

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