Burns in the Domestic Environment : Characteristics and Circumstances of Accidents 1

This study characterizes burn accidents in the domestic environment and identifies the circumstances of accidents affecting children, adults or elderly people who need supervision or care. Demographic data and burn characteristics of 61 domestic environment burn victims were collected. The family members of 13 children and one aged adult, who needed supervision or special care, were selected to answer a semi-structured interview. Two thematic groups were identified: social and environmental factors that might have contributed to the burn accidents and circumstances involving the accidents. Risk factors were: low socioeconomic and educational levels of mothers and those responsible for the children at the moment of the accident, small houses considering the number of occupants and unsafe kitchen equipment. Although cases of domestic violence were not identified there was neglect from caregivers. Health professionals should be attentive and investigate the circumstances of accidents involving vulnerable individuals.


Introduction
Burn is always an overwhelming trauma since it leaves one dependent to others for even the minimum requirements of survival. In a few seconds, a trauma like this makes a person experience terrible pain and become completely dependent. Burns are often associated with domestic violence when it affects children, elderly and people with little or no ability to defend themselves, which is an aspect fairly uninvestigated in Brazil.
There is, in research addressing the epidemiology of burns, a greater focus on the types, depth and extension of burns, affected areas (1)(2) , sequela (3)(4) , the accidents' circumstances and sites, and the presence or absence of a caregiver at the moment of the accident (5) .
Few studies focus on the perspective of the victims' parents or caregivers concerning the accident's possible causes (6) . Studies carried out in various countries such as France (4) , Brazil (5)(6) , Peru (7) and Switzerland (8) have shown that the majority of burn accidents occur in a domestic environment and affect children and that scalding is the main causal agent. A high prevalence of burns in elderly people with neurological impairment was observed in Canada and hot water in the bathtub was the main agent (9) . Patients with epilepsy are at a higher risk of deep burns, especially when they experience a seizure while performing daily activities at home (10) . The characteristics of burn accidents with neuropsychiatric patients in a study carried out in Japan were analyzed and these patients presented larger total body surface area burn (TBSA) and higher mortality when compared with the control group composed of healthy people suffering burn accidents (11) .
Other authors studied the risk factors for burns in children and concluded that the factors increasing the risk of these accidents are: absence of tap water, overcrowding of people in the same family environment and low income. Low risk factors are: houses with a larger number of rooms, parents' higher educational level, homeownership and other factors that indicate higher socioeconomic status (7) . One study carried out with children in England presented the characteristics of burn traumas and the assumption that burns can be considered due to the negligence of the caregiver at the moment of the accident (12) .
One study carried out in Brazil stresses the importance of collecting data from the victim's history along with a physical assessment and, in case inconsistencies are found, that a deeper investigation is warranted. This study reports the severity of the problem in Brazil (13) . According to data from a systematic literature review, the following factors might lead to the suspicion of mistreatment in burn accidents: scalding with a symmetric distribution pattern (extremities with sock-like or glove-like lesions), younger than six years old, incompatibility of the accident with the child's age, inconsistent reports, people with cognitive problems, associated lesions, previous traumas and sociodemographic and socioeconomic factors (unemployment and low family income and families headed by women) (14) . Intra-family (or domestic) violence in Brazil is not a new problem for health professionals. Professionals are in daily contact with this in outpatient clinics and emergency rooms (15) . Domestic violence can be experienced in all cultures and social classes, though, specific characteristics can be identified in families that practice mistreatment such as the absence of the father, families headed by women and low income (15) .
Children who arrive at the hospital with severe injuries such as burns, fractures, traumas or poisoning probably suffered previous, less severe, mistreatment that were unidentified or unreported (15) .
Negligence is characterized by privation of something one needs, that is, it might mean the omission of basic care such as medication and food and absence of protection against the elements (cold, heat) (15) . Abandonment is a type of abuse characterized by the absence of a caregiver, and is classified as partial, when the absence of the caregiver is temporary and exposes the victim to risk situations, and as total abandonment when the child is removed from the family and is left homeless, helpless and exposed to numerous risk situations (15) .

Material and Method
The concepts related to domestic abuse and the characteristics that identify mistreatment in the form of burns found in systematic literature reviews were used as the theoretical framework in this study (14) . in the study's first phase. Convenience sampling was used in this phase (16) .
This study was developed in two stages with distinct methodological designs. The patients who suffered domestic accidents and were admitted during the studied period were characterized in the study's first stage. In the second stage, case studies, interviews and direct observation were used to investigate each family and identify the circumstances of the accidents involving children, adults or elderly people who required some special care or supervision. Among those patients admitted during the study's timeframe, 13 children and one elderly patient participated in the second phase, whose family members or legal guardians were directly observed and answered a semi-structured interview.
One instrument was used to collect the following data: patient's identification, burn causing agent, TBSA, depth, site where the accident occurred and a brief report of the event. This instrument included questions about the victim's family composition, socioeconomic status and viewpoints of family members and legal guardians about the circumstances of the accident. The data collection instrument was submitted to the evaluation of four professionals who work in care delivery for burn patients so that they could evaluate the instrument's face validity and content with a view to refine it. After this stage, a pretest was carried out (16) .
Data from all participants concerning the characterization of the accident and sociodemographic information were collected from the patients' medical files at the BU-HCFMRP. The 14 family members and legal guardians who participated in the second phase took part in semi-structured interviews and were directly observed.
Participants were asked to describe how the accident Qualitative data were analyzed considering the following stages: reduction, data presentation and verification, and conclusion (17) . Units of meanings, groups of meanings and thematic groups emerged from this process. After the transcription of interviews, we proceeded to the identification of codes, grouping of similar codes and construction of categories. These categories portray the circumstances involving the accident; aspects reported by the participants who try to explain how and why the accident happened according to their perspectives. This analysis also aimed to identify the accident circumstances and, according to its characteristics, whether there was evidence or suspicion of abuse or negligence (15) . Demographic data and those related to the accident were analyzed using the SPSS 15.0 program.

Results
In relation to the first stage, of the 61 patients who were burned in a domestic environment, 20 were less than 12 years old, 34 were between 12 and 59 years old and seven were older than 60 years old. Thirty-six patients were male. Direct flame in which alcohol was the main agent was the most frequent cause of accidents among adult and elderly patients (16) and scalding among children (11). Most of the accidents occurred in the house's external area followed by the kitchen. In relation to the second stage, the majority of the 14 victims were female (10 patients); average age was nine years and three months (from <1 to 80 years of age), 11 patients were younger than six years of age, two were between 7 and 12 years old and only one patient was 80 years old. In relation to the TBSA, the average was 13.8% (0.5% to 34.5%). Scalding was the etiologic agent found in the majority of cases (six), followed by direct flame (five) and alcohol (three).
In this group, the kitchen was the place where most of the accidents occurred and all accidents by scalding happened in this room and did not present characteristics of an intentional event. However, family members reported they were absent at the moment of the accident or were not attentive to the child's protection in face of risk situations. All interviewed family members were women and the majority were the burn patient's mother (12). The average age of these individuals were 28.9 years old (Table 1). Eight out of the 14 interviewed women did not have a paid job.
According to Table 1

Social and environmental factors that might have contributed to the burn accidents
The reports of participants revealed that the mother or caregiver performs activities that involve risks of burn

Discussion
We observed that data of this study concerning the characteristics of the accidents that happened in domestic environments do not differ from other studies carried out in Brazil (5)(6) . The majority of accidents occur in a domestic environment and mainly affect children (4)(5)(7)(8) .
Direct flame combined with alcohol is the main cause of accidents in Brazil; it occurs in the external areas of the house and affects school-aged children and adults. This kind of accident for adults is mainly related to the common practice of lighting up charcoal barbecues with alcohol, and in children, these accidents are related to playing in the backyard and mainly affect male individuals (5) .
In relation to the participants who required special care or supervision, burns did not present characteristics of an intentional event and, even though mothers showed distrust during the reports while providing information, situations that characterized abuse such as previous history of burns, reports inconsistent with the trauma characteristics, uniformity of burn depth such as sock-like or glove-like burns on the extremities were not found in this study (14,18) . The characteristics of the observed accidents in general where those that affect children in domestic environments and are associated with low income populations with low levels of education, especially mothers (3,7) . The low level of education partially  (4,(7)(8) .
The poor condition of appliances and utensils used in the kitchen such as stoves and pots was also identified as a risk factor for domestic accidents in this study. The authors of this study found in a previous study that family members of burned people and the patients themselves rarely identify risk situations for burns in their homes (6) .
Additionally, living conditions might have facilitated the occurrence of these accidents since, as reported by the participants, the majority of the houses were small considering the number of residents, with few rooms, which approximates bedrooms, living room, kitchen and backyard. This fact was also reported in another study that identified that the overcrowding of people in the same house is a risk factor for the occurrence of domestic accidents (7) .
Although situations that could raise suspicions that burns were not accidental were not identified, there were cases that can be characterized as negligence (15) such as privation of basic care and absence of protection in a situation of risk for burns and in some cases, increased exposure to risk, as it occurred with the elderly patient who lived by himself, though he was totally dependent on people to perform basic activities.
We observed in all the reports that these accidents could have been avoided if adults were more attentive to the people who need care, protecting them in various situations that represent risk factors for accidents.
These families have some characteristics that have been reported in the literature and are related to domestic abuse, for example, the victims' age is lower than six years of age, low level of education and low family income (14)(15) .
Concerning a previous study published in this same periodical (6) , this study contributes to show that even when people need special supervision and care, caregivers are not concerned to protect them from burn risks.

Final Considerations
This study addressed burns in people who need special care and supervision, especially elderly and children, who represent vulnerable groups in society.
Although no domestic violence were identified among the studied cases, we consider important to signalize to health professionals caring for these groups the need to pay attention and investigate circumstances involving burn accidents.
In the studied group burns affected mainly children and adults in productive age. Burns affecting school age children and adults were caused by direct flame in which alcohol was the main agent and burns affecting children younger than three years of age were caused by superheated liquids.
Non-accidental burns were not found in this study but the results show that mothers with low level of schooling were more frequently responsible for children at the moment of the accident. Additionally, even though they do not recognize the risks, these individuals live in environments conducive to this type of injury and it is possible they did not heed the need to provide protection required by vulnerable individuals.
This study's results reinforce the need to implement programs to prevent burns directed to people with low level of education, mainly addressing the domestic environment. Teaching children in schools can also contribute to prevent accidents, since children are very sensitive and open to new information.