Domestic burns that occurred during the COVID-19 pandemic in Brazil: a descriptive cross-sectional study

Abstract BACKGROUND: Due to “stay at home” restrictions during the coronavirus disease 2019 (COVID-19) pandemic, people spent more time at home leading to an increase in home accidents, including burns. OBJECTIVE: To investigate the epidemiology of burns that occurred within homes during the COVID-19 pandemic in Brazil. DESIGN AND SETTINGS: This was a quantitative, descriptive, and cross-sectional study with a non-probabilistic sample. METHODS: Data were collected through the distribution of survey links on social networking sites and websites, and through email between December 2020 and February 2021. Participants were over 18 years of age, living in Brazil. Data analysis was performed using descriptive and dispersion statistics. RESULTS: A total of 939 adults (aged > 18 years) participated in this study. The mean age was 37.2 years (standard deviation [SD] = 12.5), 75.6% were female, 70.0% self-reported white skin color, 74% had completed higher education, and 28.1% had an income of 3 to 6 times the monthly minimum wage. A total of 21.6% suffered burns during the pandemic, 44.3% from a hot object. Approximately 49.3% never had access to a burn prevention campaign. CONCLUSION: It is necessary to develop burn prevention strategies that reach a wider population and to strengthen public policies to reduce the prevalence of domestic burns, especially during the pandemic.


INTRODUCTION
Burns injuries are a universal health hazard, which carry high morbidity and mortality, especially in low-and middle-income countries. 1 The etiology, time of exposure to the thermal agent, and depth of the burn wounds influence the severity of the injury. 2 In addition to physical injuries, burns have psychological, economic, and social implications of great impact and are considered a global public health problem. Among the causes of burns, the most frequent are exposure to flames, scalding, and electrical and chemical burns. 3 It is estimated that burns are responsible for about 180,000 deaths annually, with the highest incidence in low-and middle-income countries, with approximately two-thirds occurring on the African and Asian continents. 1 In the United States of America, there were more than 410,000 cases of burns in 2008 and around 40,000 incidents required care at the hospital level. 1 In Brazil, the annual estimates of burn injuries can be as high as 1,000,000 incidents. 4 Several factors influence the occurrence of burns, such as socioeconomic level, geographic distribution, age, and gender. 5 To reduce the burden on healthcare during the coronavirus disease 2019 (COVID-19) pandemic, "stay at home" orders and "lockdowns" were implemented at different stages worldwide with varying lengths of time and severity. This raised the concern that domestic accidents, mainly burns, might increase during this period. 6 The need to adopt social distancing and lockdowns affected family routines and had a negative impact on individuals from a social and psychological point of view. 7 To adhere to the World Health Organization (WHO) measures related to in March 2020, the over-the-counter sale of hand sanitizers with 70% alcohol in liquid or gel form was approved in Brazil. 8 This public health measure was necessary to prevent the spread of disease in cases where it would be impossible to sanitize hands with soap and water. However, its sale and use were not accompanied by educational campaigns on safety for the use of products

OBJECTIVE
The aim of this study was to investigate burns that occurred within homes during the COVID-19 pandemic in Brazil.

Study design
This study adopts a quantitative, descriptive, and cross-sectional design with a non-probabilistic sampling method that aims to survey patterns of burn injuries occurring at home throughout Brazil.
Data were collected using the questionnaire-based survey method. 12 This paper was written in accordance with the guidelines for reporting observational epidemiological studies (STrengthening the Reporting of OBservational studies in Epidemiology, STROBE).

Procedure for data collection
In the first phase of the study, a 25-item questionnaire (entitled In the second phase, an expert committee was constituted of four healthcare professionals (two physical therapists, one doctor, and one nurse; a fifth was invited but did not respond) with expertise in the area of burn injuries, to validate the instrument.
An email invitation was sent to each member of the expert committee with the study objectives, study protocol, their role, and the link to evaluate the instrument built using the SurveyMonkey software (San Mateo, California, United States). The committee assessed the questions for content and apparent validation. The evaluation was based on the theory of elaboration of psychological scales. 15 The total instrument Content Validity Index (CVI) value was 0.98 and only one item had a value of 0.75 ("If you were hospitalized more than once due to burns, please specify"). In some questions, changes suggested by the experts were incorporated, such as living in urban or rural areas, type of housing, parts of the body that were burnt, difference between barbecue area and leisure area, treatment performed at home, and in the health service. In the third phase, the survey link was sent through social networking sites, websites, and email, with the aim of reaching the largest possible number of participants in the national territory. A database was created containing the emails of federal and private institutions, including hospitals, found using Google search tools.
A designated email account for the research study was created, and invitations to participate were sent from this address. To expand the sample size, the first guests to participate in the survey were invited to forward the link to their personal contacts, generating a snowball sample. The survey was available online for the period of December 2, 2020, to February 15, 2021.

Inclusion and exclusion criteria
The study selected participants who were aged 18 years and older, residing in Brazil during the period under study, spoke Portuguese, had Internet access, and were Internet literate.
Instruments answered by participants under the age of 18, duplicates, or responses with a coherence error that invalidated the instrument were excluded from the study.

Data analysis
For the analysis of the apparent and content validation data of the instrument, the CVI was calculated. 16,17 To calculate the CVI, a Likert-type scale with scores from one to four was used, which assessed the relevance/representativeness of the responses identified as follows: 1 = not relevant or not representative (strongly disagree), 2 = item needs major review to be representative (disagree), 3 = item needs minor revision to be representative (agree), and 4 = relevant or representative item (strongly agree). The answer "I don't know" was assigned a value of 0. The following formula was used: the number of responses with scores of 3 or 4 divided by the total number of responses in the script. Items that received a score of "1" or "2" were revised and responses marked as "I don't know" were eliminated. 16,17 To calculate the instrument's total CVI, the average of the values of the items calculated separately was considered, that is, the sum of all the CVI calculated separately and the division by the number of items considered in the evaluation. 18 A CVI value above 0.80 was considered the minimum. 19,20 Data collected in the third phase of the study through SurveyMonkey were exported to IBM SPSS Statistics for Windows, version 23 (IBM Corp., Armonk, New York, United States).
Descriptive and dispersion analyses were performed for all variables.

Ethical considerations
The research protocol was registered and approved by the Human The month with the highest incidence of burn-related accidents was November, followed by December and May 2020. Among the participants, 23 (11.4%) had more than one burn during the pandemic period, with a minimum interval of 7 days and maximum interval of 10 months between injuries.
Regarding the management of burn injuries, 168 participants (83.6%) did not seek care after the accident, and 171 (85.1%) did not require hospitalization ( Table 4). The use of two products in the treatment of burns stands out: medicinal plants (9, 4.4%) and running water (9, 4.4%).
Of the participants who had sustained a burn injury, 99 (49.3%) reported that they were unaware of any burn prevention campaigns.
Regarding the means of accessing information on burn prevention, 19 (26.4%) reported being healthcare professionals themselves and thus knowing how to prevent burn accidents, while articles in the media (TV programs and radio) represented the other substantial source of awareness ( Table 5).
In relation to other means used to obtain information about burns, the word "prevention" appeared 16 times in phrases such as the following: normal preventive measures linked to attention and care, equipment installed by trained professionals; prevention strategies given by older family members, and previous knowledge about preventive measures.  In this study, 40.3% of the participants who suffered from burns during the pandemic were of a high socioeconomic status. This differs from another survey conducted over a 10-year period at the Burn Care  Center of the Institute of Medical Sciences in Pakistan, where a total of 94,664 people were assessed and the majority of patients who suffered burn injuries were of low socioeconomic status. 27 It is believed that low-income people are more vulnerable to burns because of the lack of guidance on care and prevention of burns and low access to sources of media. Thus, this study suggests a need for reflection on the prevention strategies against burns and the means of dissemination, as even though the participants in this research belonged to the highest socioeconomic status, this did not prevent them from having burn accidents.
The hands were the most affected body part, followed by the arms.
In a previous study, it was highlighted that the upper limbs and trunk were the most affected in the profile of burn victims. 28  The most prevalent causal agents were burns caused by hot objects (44.3%) and liquids (29.9%). A study conducted with data from Uruguay 30 found direct fire (71%), followed by hot liquids (9%) and electricity (5%) to be the primary causes of burn injuries, and another study conducted at a regional adult burn center in the United Kingdom from March 23 to May 6, 2020, determined a prevalence of flame and scalding in burn accidents. 31

CONCLUSION
This study identified that during the COVID-19 pandemic in Brazil, a majority of the people who sustained burn injuries were female, had brown skin color, and had incomplete higher education. Almost half of the participants suffered burns from hot objects or hot liquids, and most accidents occurred in the kitchen. Almost half of the participants reported that they had never accessed a burn prevention campaign. Thus, this study proposes improving the methods of disseminating educational campaigns and guidance on burn prevention, in addition to supporting public health policies to guide the population in an attempt to reduce the incidence of domestic burns. Future studies should identify risk factors associated with burns at home to inform future burn prevention initiatives.