Burns 32 (2006) 529–537

www.elsevier.com/locate/burns

Review

Burns in low- and middle-income countries: A review of available

literature on descriptive epidemiology, risk factors,
treatment, and prevention
S.N. Forjuoh *
Department of Family & Community Medicine, Scott & White Memorial Hospital and Scott, Sherwood and Brindley Foundation,
Texas A&M University System Health Science Center, College of Medicine, Temple, TX, United States
Accepted 4 April 2006

Abstract

Burn prevention requires adequate knowledge of the epidemiological characteristics and associated risk factors. While much has been
accomplished in the areas of primary and secondary prevention of fires and burns in many developed or high-income countries (HICs), such as
the United States, due to sustained research on the descriptive epidemiology and risk factors, the same cannot be said of developing or low-
and middle-income countries (LMICs). To move from data to action and assist preventive efforts in LMICs, a review of the available literature
was conducted to assess the current status of burn preventive efforts. A MEDLINE search (1974–2003) was conducted on empirical studies
published in English on the descriptive epidemiology, risk factors, treatment, and prevention of burns in LMICs. Review of the 117 identified
studies revealed basically the same descriptive epidemiological characteristics but slightly different risk factors of burns including the
presence of pre-existing impairments in children, lapses in child supervision, storage of flammable substances in the home, low maternal
education, and overcrowding as well as several treatment modalities and preventive efforts including immediate application of cool water to a
burned area. Continuous evaluation of promising interventions and those with unknown efficacy that have been attempted in LMICs, along
with testing interventions that have proven effective in HICs in these LIMC settings, is needed to spearhead the move from data to action in
preventing burns in LMICs.
# 2006 Elsevier Ltd and ISBI. All rights reserved.

Keywords: Burns; Injury; Developing countries; Prevention; Intervention; Risk factors

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 530
2. Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 530
3. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 530
3.1. Epidemiological characteristics of burns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 530
3.1.1. Who gets burned? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 530
3.1.2. Where do burns occur? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 531
3.1.3. How do burns occur? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 531
3.1.4. Body part or anatomical region burned . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 531
3.1.5. Total body surface area burned and mortality from burns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 531
3.1.6. When do burns occur? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 532
3.1.7. Why do burns occur? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 532

* Department of Family & Community Medicine, Scott & White Santa Fe - Century Square, 1402 West Avenue H, Temple, TX 76504, United States.
Tel.: +1 254 771 7695; fax: +1 254 771 8493.
E-mail address: sforjuoh@swmail.sw.org.

0305-4179/$30.00 # 2006 Elsevier Ltd and ISBI. All rights reserved.

doi:10.1016/j.burns.2006.04.002
530 S.N. Forjuoh / Burns 32 (2006) 529–537

3.2. Risk factors for burns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 532

3.3. Treatment of burns and complications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 533
3.4. Prevention of burns. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 533
4. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 533
5. Conclusions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 534
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 535

1. Introduction treatment. Search terms and key words used included burns,
wounds, injury, burn injury, burn accident, risk factors for
Burns are among the most devastating of all injuries, with burns, burn prevention, burn treatment, burn intervention,
outcomes spanning the spectrum from physical impairments and developing countries as well as individual names of all
and disabilities to emotional and mental consequences [1,2]. LMICs. The reference lists of key papers were examined for
Most burns are caused by thermal energy including scalding other relevant papers, as were hand searches of selected
and fires, with the minority caused by exposure to chemicals, journals that focus on burns such as Burns and Journal of
electricity, ultraviolet radiation, and ionizing radiation. Burn Care and Rehabilitation for the same time frame. Only
Globally, fire-related burns are responsible for about papers based on empirical studies were included. Review
265,000 deaths annually [3]. Over 90% of fatal fire-related papers of empirical studies were excluded to avoid
burns occur in developing or low- and middle-income duplication. Also excluded were papers that duplicated
countries (LMICs) with South-East Asia alone accounting data from research in the same country and letters to the
for over half of these fire-related deaths [3]. Like other injury editor without any empirical data.
mechanisms, the prevention of burns requires adequate
knowledge of the epidemiological characteristics and
associated risk factors. However, while much has been 3. Results
accomplished in the areas of primary and secondary
prevention of fires and burns in many developed or high- The literature search identified 139 studies from 34
income countries (HICs) such as the United States due to different LMICs including Algeria, Angola, Bangladesh,
sustained research on the epidemiology and risk factors, the Brazil, China, Cote d’Ivoire, Egypt, Ethiopia, Ghana, Hong
same cannot be said of many LMICs [4–6]. Kong, India, Iran, Israel, Jordan, Kenya, Kuwait, Liberia,
The purpose of this paper was to review and summarize Libya, Malawi, Morocco, Mozambique, Nigeria, Pakistan,
available data on the descriptive epidemiology of burns in Papua New Guinea, Peru, Saudi Arabia, Singapore, South
LMICs, along with identified risk factors, treatment, and Africa, Sri Lanka, Taiwan, Turkey, Vietnam, Yemen, and
attempted preventive measures in terms of potential and Zimbabwe, of which 117 met the criteria for inclusion [8–
effectively proven interventions. LMICs or developing 124]. The vast majority of the papers focused on childhood
nations are defined in this paper according to a classification burns. In addition, all but a few of the studies [23–32,96],
used by the World Bank for the World Development Report were hospital- or clinic-based, while two others were based
1993 [7]. This classification was based on the level of on autopsy reports [44,56]. One third of the papers were
socio-economic development, epidemiological homogene- published by authors from India (n = 18) and Nigeria
ity, and geographic location [7]. The countries include all (n = 19).
those in Sub-Saharan Africa, Latin America and the
Caribbean, and the Middle East crescent, India, China as 3.1. Epidemiological characteristics of burns
well as other countries in Asia and adjoining Islands.
Countries with established market economies such as the 3.1.1. Who gets burned?
United States, United Kingdom, Canada, Australia, New Of the studies that reported data on childhood burns,
Zealand, Japan, those in Western Europe, and most of those infants and toddlers from birth through 4 years of age were
in the formerly socialist economies of Europe were, shown to have a disproportionately higher number of burns
therefore, excluded. [12,16,19,26,34,40,46,47,75,87–90,104,114]. In many set-
tings like Brazil, Cote d’Ivoire, and India, this age group was
found to account for nearly half of all childhood burns
2. Methods [12,19,47]. This high number of burns in infants and toddlers
was attributable largely to their total dependence on their
Available literature on burns in LMICs published in parents and caretakers. In studies where all age groups were
English for the 30-year period 1974–2003 was accessed studied, children from birth through 4 years still comprised
using MEDLINE (www.pubmed.gov) and reviewed. Pub- nearly one-third of the total number of cases [9].
lications from earlier years were not included since they may The number of burns was reported to then taper off for
no longer inform us about current burn epidemiology and each subsequent year until during older adolescence when
 S.N. Forjuoh / Burns 32 (2006) 529–537
burns began to increase again due to the engagement of work
and improper use of flammable substances. For adults, the
number of burns was found to be relatively low until among
the 30–39 year age group [19,114]. The preponderance of
burns seen during childhood and among the elderly in HICs
was rarely seen in LMICs probably due to lack of data on the
elderly. Nonetheless, a recent study in Egypt, where the
elderly population is gradually expanding probably due to
reduced mortality for persons between the ages of birth and
five years as well as improved living conditions and medical
care, among other things, found a high number of burns in
persons older than 60 years [21].
The gender distribution of burns was not consistently
reported. While most studies in children reported a signi-
ficantly higher number among males [10,16,34,59,106],
those based on all age groups reported conflicting results
[9,19,20,96]. In settings with all year-round warm tempera-
tures such as Angola and Cote d’Ivoire, a slight pre-
ponderance in males was reported [9,19], while in other
settings with seasonal weathers such as Egypt and Pakistan,
a higher proportion was reported for females [20,96]. In a
Ghanaian study, although no significant gender difference
was reported overall, a reversal of the gender trend was
demonstrated with increasing age. From birth until 4 years,
a higher incidence was reported for males. Thereafter, a
higher incidence was reported for females [25]. This
finding was corroborated in an Indian study where a
considerable variation was seen in the gender ratio for
differing age groups, with males predominating in the
0–5-year age group [46]. According to one earlier
investigator, the decrease in the male preponderance with
increasing age among children may be explained by the
change in the respective activities of the two genders: while
girls are brought closer to the kitchen to help their mothers
and therefore become more exposed to fire, hot liquids, and
hot substances, boys tend more and more to remain outdoors
[96]. However, among older adolescents and adults, ‘‘bride
burning’’ was blamed for the higher incidence of burns in
females in India as they are burned within 5 years of their
marriage [44].
3.1.2. Where do burns occur?
The vast majority of childhood burns was reported to
occur in the home [12,16,20,25,34,35,47,59,64,114], while
adult burns were reported to occur in the home, outdoors,
and at work places in approximately equal proportions
[19,20,46]. While burns to adult females were reported to
occur mostly at home, adult males were reportedly burned
most commonly in outdoor and work locations such as in
electrical industries [20,46]. For all age groups, the kitchen
was reported as the most common scene of burns, followed
by the backyard, house yard, or veranda for younger
children, and the living room and the home vicinity for older
children [12,19,20,25,47,56]. Among the elderly population,
the bathroom was also reported as a common scene of burns
in Egypt, next to the kitchen [21].
531
3.1.3. How do burns occur?
For all age groups, scalding from hot liquids
accounted for one-third to one-half of all burns
[9,12,19,25,34,46,47,59,60,62,64,75]. This was followed
by hot objects and flame in children [25,34,46,47,75],
and by flame in adults [9,46,98]. Burns through clothing
ignition were reported by some authors from India,
Nigeria, and Papua New Guinea and were partly attributed
to the use of loose clothes made solely of cotton, a highly
flammable fabric [45,90,92,99]. Electrical or chemical
burns were, however, found to be very rare in LMICs
[25,38,39,69,77,115,120]. Nonetheless, chemical burns in
the form of pouring acids or other corrosive substances in the
face of rivals as a means of retaliation, to assault thieves and
robbers or in domestic disputes were reported in a few
settings like Hong Kong, Nigeria and Sri Lanka
[38,77,87,113].
A few studies reported data on the intent mechanism of
burns in many of these settings. Although most burns were
reported as unintentional, a few cases of self-inflicted burns
and burns caused by assault or maltreatment were reported
in Ghana, India, Iran, Malawi, Nigeria, South Africa and Sri
Lanka [28,44,56,59,60,72,77,78,87,89,108,113]. Several
cases of self-inflicted burns were reported by Laloe and
Ganesan in eastern Sri Lanka where the victims, who were
mainly women ages 15–50 years who had had a quarrel with
their husbands or other family members, poured gasoline
over their bodies and set themselves ablaze [112]. Deliberate
self-burning or attempted suicides by burns were also
reported for children in Iran [59]. Two cases of therapeutic
burns from hot fomentation of the umbilical cord stump
were described in Nigeria by Adesunkanmi and Oyelami
[89], while an intentional burn prevalence of 5% was
reported in the extensive population-based study reported
from Ghana, perpetrated mainly by peers, with a few
therapeutic burns caused by traditional healers secondary to
childhood convulsions [28].
3.1.4. Body part or anatomical region burned
Very few studies described burns by the anatomical
region or body part affected [19,25,34,88–90]. Most of these
studies found the upper extremity as the body part most
frequently affected for all causes of burns except for flame
burns, followed by the lower extremities [19,25,34]. Flame
burns including clothing ignition were found to predomi-
nantly affect the lower extremity [25,90].
3.1.5. Total body surface area burned and mortality
from burns
The reported total body surface area (TBSA) burned for
most burns totalled less than 10%, with a low mortality
[9,19,25,35,36]. However, a few cases of burns totaling more
than 50% of the TBSA, with subsequent high mortality were
reported, particularly from flame burns [68] and studies
based on data from regional burn centers [9,19,20,47,48,75].
Approximating 9.9% for an overall mortality, rates for
532 S.N. Forjuoh / Burns 32 (2006) 529–537

hospitalized burns reaching 21.3% were reported, while that
of cases seen at the out-patient department were reported as
3.6% [9].
3.1.6. When do burns occur?
Two peak times of the day were reported for burn
events: late morning and evening around supper time
[25,46,114]. These times are also related to the etiology of
burns when food is being prepared, cooked, and served.
Besides the time of day, the distribution of burns by
season of year was also reported. In tropical climates like
most of Sub-Saharan Africa, an even distribution of burns
was seen since the need for heating does not arise [9,25].
In other areas with seasonal variations such as China,
Egypt, Hong Kong, and India, a higher incidence was
reported for the winter months [16,20,34,40,46,62]. In
addition to the time of day and season of the year, the
relationship of burn incidence and special events was
reported. An Israeli study noted a higher burn incidence
among Jewish children during the time of Passover
festivities in the month of April [62].
3.1.7. Why do burns occur?
In addition to specific environmental and behavioral
factors causing burns, certain conditions and diseases were
reported to increase people’s predisposition to burns.
Epilepsy was reported as the cause of burns in a few cases
[31,72]. In Malawi, the most common cause of unintentional
adult burns seen at one hospital was reported as secondary to
epileptic seizures [72]. A few of the burned Ghanaian
children studied also had some form of hearing loss,
impaired vision, or lameness secondary to polio [31].
Among the elderly, fall, cardiac disease (e.g., cardiovascular
accident or stroke), diabetes, and other chronic illnesses
were reported as causes of burns [21].
3.2. Risk factors for burns
While the vast majority of the studies of burns in LMICs
were descriptive using case reports, case series, or the cross-
sectional design and thereby limit our knowledge about risk
factors, few studies focused on the risk and protective factors
for burns using the case-control analytic design
[10,11,31,100]. Again, all of these studies focused on
children. Table 1 summarizes some of these identified
putative risk and protective factors by strength of associa-
tion. In a comprehensive, population-based study in Ghana,
the presence of a pre-existing impairment in a child (e.g.,
blindness, epilepsy, lameness), history of a burn in a sibling,
history of a sibling death from a burn, and storage of a
flammable substance in the home were found to be the main
risk factors for childhood burns [31]. Maternal education
was reported as being protective against childhood burns,
although its effect was not very strong [31]. In a Brazilian
study, the risk factors found for childhood burns included
overcrowding, a child not being the first-born, mother being
pregnant or recently dismissed from a job, and a recent
family relocation [11]. A history of previous injury in a child
was reported as a protective factor for burns in boys living in
a good environment [11].

Table 1
Strength of risk and protective factors found for childhood burns in LMICs using case-control analysis
Risk/protective factor Source N OR (95% CI) or P-value
1. Presence of a pre-existing impairment in a child Ghana, 1995 [31] 610 6.7 (2.8–16.2)
2. Sibling death from a burn 4.4 (1.2–16.7)
3. History of a burn in a sibling 1.8 (1.2–2.6)
4. Storage of a flammable substance in the home 1.5 (1.0–2.2)
5. Mother educated 0.8 (0.6–1.0)
6. Child’s mother recently dismissed from a job Brazil, 1997 [11] 242 7.0 (1.5–33.9)
7. Child’s mother pregnant 5.0 (1.2–21.8)
8. Family recently moved residence 4.9 (1.7–14.3)
9. Child other than a first-born 2.5 (1.2–5.2)
10. Child living in a crowded household 2.2 (1.1–4.7)
11. History of a previous injury in the child 0.3 (0.1–0.7)
12. Lack of water supply Peru, 2002 [99] 740 5.2 (2.1–12.3)
13. Low income 2.8 (2.0–3.9)
14. Crowding 2.5 (1.7–3.6)
15. Presence of a living room 0.6 (0.4–0.8)
16. Better maternal education 0.6 (0.5–0.9)
17. Lack of alertness among parents Bangladesh, 2001 [10] 105 P < .001
18. Clothing of manmade fabrics P < .001
19. Cooking equipment within reach of children P < .001
20. Illiterate mother P < .01
21. House in slums and congested area P < .01
22. Illiterate father P < .02
23. Presence of a pre-existing impairment in a child P < .05
24. History of a burn in a sibling P < .05
25. Low economic status of parents P < .05
 S.N. Forjuoh / Burns 32 (2006) 529–537
Lapses in child supervision, use of clothing with
manmade fabrics, parental illiteracy, housing location in
slums and congested areas, presence of a pre-existing
impairment in a child, prior history of a sibling burn, and low
socioeconomic status were reported as significant risk
factors for childhood burns in Bangladesh and Pakistan
[10,97]. A study in Peru also reported lack of water supply,
low income, and overcrowding as risk factors for childhood
burns, with better maternal education and the presence of a
living room being protective factors for childhood burns
[100].
Other putative factors uncovered from some of the
descriptive studies include lack of parental supervision for
children [29], lack of enclosure for open fires and flames, the
floor-level location of fires and stoves, instability of candles,
use of small kerosene stoves and lanterns, use of volatile and
highly flammable fuels, use of flammable housing materials,
and lack of exits [20,98]. Lapses in the supervision of
children by their parents were also reported to be an
important risk factor for repeat burns [29].
3.3. Treatment of burns and complications
The few population-based studies conducted in LMICs
reported data on the first-aid provided and the subsequent
healthcare-seeking for burns, along with reported methods
of burn treatment at home [23,25,27]. Overall, one-half to
two-thirds of burned persons were reported to have been
taken to a health facility for treatment [23,27]. As a first-aid,
cool water was applied to the burned area in a third of cases.
In another third of cases, a traditional preparation was
applied in the form of concoctions made of urine and mud,
cow dung, beaten eggs, or mud and leaves [23,25].
A significant relationship was found between the size of
burn sustained and subsequent healthcare-seeking in the
Ghanaian study [25,27]. Those who sought healthcare had
significantly deeper burns covering a wider TBSA or an
infected burn previously treated at home. In addition, a
significant relationship was found between the size of burn
sustained and type of home-based treatment. Superficial
burns and those covering a small body surface area were
treated with Gentian Violet, while more extensive burns
were paradoxically treated with a traditional preparation
[25].
The actual treatment and management of burns varied
and generally followed conventional methods including
early tangential excision and grafting for deep dermal burns
and escharectomy and delayed skin grafting for full
thickness skin loss [15,19,21,33]. However, this was
reported to be constrained by inadequate resources and
personnel [33,70].
A moderate proportion of burns was reported to result in
complications [30,80,81,86]. In the Ghanaian study, 18% of
the childhood burns studied were reported to result in a
physical impairment or disability [30]. The long-term
complications of childhood burns described were reported to
533
include physical impairments like hypertrophic scars and
keloids, contractures, amputations, and other cosmetic
disfigurements [21,30]. Among the short-term complica-
tions reported were infection and septicemia [19,68,74,82].
3.4. Prevention of burns
The few studies that reported data on burn prevention
suggested improvement in socio-economic status – parental
education, improved housing, provision of basic amenities
such as water, – proper regulation and design of industrial
products such as kerosene stoves, proper storage of flammable
substances, and adequate child supervision, particularly for
those with impairments [10]. Community programs to ensure
adequate child supervision and general child well-being,
particularly for those with impairments as well as parental
education about burns and advising the public against storing
flammable substances in the home were also proposed as
primary prevention strategies for burns [31].
Ghosh and Bharat also reported data on the impact of an
educational intervention on domestic burns prevention and
first aid awareness in and around Jamshedpur, India [52].
The use of kitchen sand buckets was also proposed for use to
target the young uneducated female house worker, clothed
in loose attire who is predominantly injured during the
daylight at home around a floor-level stove, unaware of fire
safety [98]. Another potential strategy to assist with burn
prevention suggested was the use of hospital statistics to plan
ahead – using the extensive knowledge of the epidemio-
logical parameters influencing the occurrence of burns
severe enough to warrant hospital admission to ensure
readiness [76].
4. Discussion
This project has revealed that many published studies
from several LMICs have contributed to our understanding
of the epidemiological characteristics, risk factors, treat-
ment, and prevention of burns in these LMIC settings.
However, most of the studies focused on childhood burns
[10–12,16,25–32,47–50,88,100,104–106,110] probably
because fires and burns are the leading cause of injury
death in the home for children ages 1 through 14 years. In
addition, the vast majority of the studies were clinic- or
hospital-based, compromising the generalizability of their
findings. Nonetheless, findings of more current research
were found to largely corroborate most of those of earlier
investigators [60,74,119].
Generally, burns were found to be caused by thermal
energy mostly from hot liquids, open flames, or hot surfaces.
In most of these settings, open flames are a common feature
of households, particularly in rural settings without
electrification. Even though conflagrations or house fires
and clothing ignition are the most severe and lethal forms of
burns [1,2], they are less frequent sources of fires and burns
534 S.N. Forjuoh / Burns 32 (2006) 529–537
in LMICs. Not surprisingly, this review did not find any
discussion on burns caused by smoke inhalation from house
fires and other conflagrations, which is the most common
cause of fire and burn deaths in HICs, but uncommon in
LMICs. The high mortality rate in conflagration victims is
largely due to the difficulty associated with escaping from
burning buildings that are often multi-story. Multi-story or
high-rise buildings are not common in most LMICs. However,
with the burgeoning economies of many LMIC cities, burns
through smoke inhalation from house fires and other
conflagrations may well be on the increase in the future.
The few instances of intentional burns reported from these
LMICs deserve some comments. Although the study of
inflicted injuries on children owes its origin to Caffey [125],
the first report on child maltreatment by burns was published
in 1970 by Stone and colleagues, who also listed 12 criteria to
assist healthcare professionals in confirming the suspicion of
inflicted burn injuries [126]. The reasons for maltreating
children through burns that have been cited in the published
literature from HICs include punishment or as a training
method for enuresis, parental psychological problems,
fussing infants, unwanted children, and parental substance
use or abuse [126], which are entirely very different from what
was reported in these LMIC settings [28,89].
Although found in a few settings, burning using acids and
other corrosive substances – such as found in car batteries,
jewelry cleansers, leather-making concoctions – appears to
be a relatively new phenomenon in the last two decades. In
most cases, young women are the victims, with the genitalia,
the face and the neck being the body parts targeted. Bride-
burning also found in settings like India [44,56] and Sri
Lanka [112] is probably linked to culture and religion.
Additionally, it explained the gender ratio disparity of burns
found in India, for example.
This review uncovered important putative risk factors
from multiple settings (Table 1). Both the Bangladeshi and
Ghanaian studies found the presence of a pre-existing
impairment in a child, history of a sibling burn, and maternal
illiteracy or low maternal education as significant risk
factors for childhood burns [10,31]. A case-control study of
childhood burns in Greece, a demographically developed or
HIC, however, found no significant socio-demographic risk
factor but rather several environmental factors [127]. The
risk and protective factors identified in this review can
generally be categorized into manipulatable (e.g., storage of
a flammable substance in the home; illiterate mother) and
non-manipulatable (e.g., presence of a pre-existing impair-
ment in a child; child other than a first-born) factors, with the
former being the majority [30]. For instance, an individual
can be educated to modify their habits about storing
flammable substances in the home, but an individual may
have little influence on whether a burn happens to child who
is or is not a first-born. Evidently, corroboration of the
uncovered risk and protective factors found in this review by
different studies in multiple settings is necessary to establish
the true causality of the risk factors.
There seems to be overwhelming evidence that childhood
burns are largely environmentally conditioned and pre-
ventable [127]. Therefore, it would seem reasonable that
preventing burns in LMICs ought to focus on a blend of
environmental modifications, parental education, and
product redesign and safety, with a special attention to
the kitchen, which is the scene of most burns. It was with
little surprise that interventions to improve socio-economic
status – parental education, improved housing, provision of
basic amenities such as water, – proper regulation and design
of industrial products such as kerosene stoves, proper
storage of flammable substances, and adequate child
supervision, particularly for those with impairments, were
all proposed as potential primary prevention strategies for
burns [10,31]. It is worth mentioning that the use of kerosene
stoves should take advantage of the re-design feature of the
Sri Lanka’s Safe Bottle Lamp Program with demonstrated
effectiveness to prevent kerosene spills when stoves tip over
(www.rolexawards.com). Community programs to ensure
adequate child supervision and general child well-being,
particularly for those with impairments as well as parental
education about burns and advising the general public
against storing flammable substances in the home were also
proposed [31].
Unfortunately, only a handful of studies evaluating burn
interventions in LMICs were reported in this review,
possibly due to lack of funding to conduct such studies
and partly due to lack of expertise in many of these LMICs.
In fact, only one Vietnamese study reported data on the
evaluation of the cooling effect on burns with some positive
findings [121]. Therefore, it would seem appropriate to
educate people about this secondary preventive measure for
burn injuries, although the use of a case series as was the
case in this Vietnamese study instead of a more rigorous
prospective randomized trial design does not convey strong
support. Nonetheless, the physiological effects of cooling a
burn ought to be the same irrespective of the setting.
Education on the immediate application of cool water to
burns has indeed been shown by others in earlier studies to
be an effective first-aid treatment [111,132,133].
5. Conclusions
It is time for researchers in LMICs to move from
generating more data on the descriptive epidemiology and
risk factors of burns to testing and evaluating proven and
promising interventions in specific settings. However, there
is no need to reinvent the wheel, although due attention
ought to be paid to cultural sensitivities, among others
[6,129–131]. For example, lowering hot water heater
temperatures, which is an intervention used in many HICs,
makes little sense in LMIC households without electricity
[131]. Proven and promising interventions developed largely
in HICs need evaluation and adaptation to LMIC settings
[129].
 S.N. Forjuoh / Burns 32 (2006) 529–537
There is indeed enough evidence to prove that fire and
burn prevention works [128]. For example, in many HICs,
fewer children are burned when their clothing catches fire
because of sleepwear flammability standards, introduction
of new and less flammable fabrics, and design of more close-
fitting dresses. In addition, fewer people die in residential
fires, partly due to widespread use of smoke alarms and
sprinkler systems. From these burn prevention success
stories, one thing that stands out is that the common element
in successful burn prevention programs is making consumer
products and the environment safer [128]. Therefore, any
burn prevention efforts ought to be tailored to the
characteristics of the specific burn risk factors as described
above. For example, it would seem that flame burns would
be reduced dramatically in LMICs if people used efficient,
safe, inexpensive kerosene lamps and stoves that are re-
designed according to the Sri Lanka’s Safe Bottle Lamp
Project and placed above the floor level in the kitchen. Also,
clothing ignition would be reduced if inexpensive flame-
resistant materials are developed and women are encouraged
to wear close-fitting dresses while cooking. In settings where
house fires may be a problem as many of these LMICs
become industrialized, the use of smoke alarms and
sprinkler systems ought to be promoted as primary burn
interventions [129]. For all settings, education on the
application of cool water to a burn should be promoted as a
secondary intervention strategy. When cool water is not
readily available or the water source appears to be
contaminated or polluted, the use of banana leaves as
sterile bandages, which has been demonstrated to be
effective anecdotally, should be considered.
Recent systematic reviews of fire and burn interventions in
HICs have found some effective interventions including burn
educational campaigns in schools and in the home focusing on
a three-pronged intervention involving regulation, education,
and technology as well as targeting flame and scald burns to
high risk groups via a media campaign [134–136]. These
interventions need to be tested and evaluated in LMICs.
Ghosh and Bharat already reported the impact of an
educational intervention on domestic burns prevention and
first aid awareness in and around Jamshedpur, India [52]. The
use of kitchen sand buckets that has also been proposed for use
to target the young uneducated female house worker, clothed
in loose attire (saris or other traditional dresses used in Muslim
populations) who is predominantly injured during the
daylight at home around a floor-level stove, unaware of fire
safety [98] has not been formally tested and evaluated.
Focusing on burn prevention in LMICs rather than treatment
cannot be over-emphasized due to lack of resources for
secondary and tertiary prevention in these settings [137–140].
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