Study of socio-psychological aspects of burns in femalesVijaya R Bhalerao, Vinodini P Desai, DN Pai
Department of Preventive and Social Medicine, Seth. G. S. Medical College, Parel, Bombay-400012., India
Two hundred and fifteen women admitted with burns into the female surgical ward of the K.E.M. Hospital between July 1974 and February 1975 were studied.
About 350 women are admitted into K E.M. Hospital every year with burns. After these unfortunate, disfigured women are discharged, they need to attend the hospital regularly for dressings, physiotherapy etc. Unfortunately, most of them do not come back for follow-up and their further course remains unknown. It was, therefore decided to plan a study of such patients after they go home. It was thought that it would help in their rehabilitation.
The aims and objects of this study were to analyse
(a) the physical, mental and social sequele of burns and their impact on these young women during their reproductive years of life.
(b) the effects of burns on their personal life and on the interaction in the family unit and the community at large.
(c) the extent of their rehabilitation that was possible.
Two hundred and fifteen women admitted with burns into the Female Surgical ward of the K.E.M. Hospital between July 1974 and February 1975 were studied.
While they were in the hospital, their medical and social history was recorded in detail with the help of their relatives. They were requested to report to the Department of Preventive and Social Medicine at monthly intervals after being discharged. Those who failed to report were contacted by letters and/or home visits.
Out of these 215 admitted cases, 75 died in the hospital. Remaining one hundred and thirty-seven women were discharged, out of which only 79 women could be followed up and this paper is based on data obtained from them about their socio-psychological rehabilitation.
During the follow-up careful attention was paid to the age, religion, marital status, education, income, type of dwelling and cooking facilities.
Age: Their age ranged from 16 to 60 years. The mean age was 24.8 years and the median age was 25.0 year.
Marital Status: Sixty-four women were married, 6 unmarried and 4 were widowed. Information about the marital statue of 5 was not available; of these patients 29, 2 and 3 respectively were considered as poorly adjusted in their social life.
Out of these 79 women, 40 percent were illiterate, 28 percent had received primary education, 20 percent had completed secondary education and 9.00 percent had passed S.S.C. The educational status of 3 percent of patients could not be ascertained. Thus less than one-third of the patients had gone beyond the stage of primary education.
This suggests that the frequency of burns is higher among those with lower educational levels.
Economic Status: Family income was less than Rs. 250/- per month in 40 percent of these patients, Rs. 250 to Rs. 300 in 44 percent and more than Rs. 500/- in 8 percent. It could not be ascertained in 8 percent of patients. Thus majority of the patients belonged to socio-economic class III and IV. It is possible that rich patients do not come to free general hospitals. Still this data suggests an inverse correlation between the economic status and the liability to sustain burns in the group of women studied.
Living Accommodation : Sixty-eight percent of the patients lived in one room tenaments in chawls, 24 per -cent in single room zopadas whereas only 8 percent lived in flats.
Cooking facilities: Seventy-six women cooked at sigris on the floor. Only three had cooking platforms at the home. In 98% of cases the cause of burns was an exploded pressure stove.
Site of burns:
[Table 1] shows the sites of burns in these patients. 17.71% of the women had burnt their faces. 25.2% suffered from burns only of extremities. Some were of mixed type. Those who had face involvement suffered from social and emotional problems. Some women who had limb deformities had problems in daily routine work. The family acceptance was dependant upon their usefullness in day to day life and hence they became a burden to their families.
Degree of Burns: [Table 2] shows the extent of burns in terms of percent of the body surface involved. Majority of the patients had less than 40% burns.
Only 5 women attended for physiotherapy and out of them only one was regular. In addition, other four women who were asked to come for physiotherapy had not come at all. The remaining 69 were not aware of the need for physiotherapy. Thus there was very poor awareness of the need for physiotherapy among these patients.
16 women complained of intense itching, though all women had similar problem to lesser or greater extent.
Gross contractures and deformities were present amongst 19 women. Only 2 women underwent plastic surgery. One was given appointment for plastic surgery. Four were anxiously waiting for an appointment
Family Acceptance and Attitude-25 women were fully accepted by their families. It is interesting to note that 23 women from among these did not have face involvement. 25 women were accepted physically by the family but not emotionally. 23 women were totally rejected and deserted. 4 women were of uncertain acceptance and data was not available in cases of 2 women (homicidal cases).
Analysis of our data showed that contrary to expectation adjustment was not better in nuclear families than in joint families. These patients became a burden to their families. The husbands lost interest in them and this made these women feel helpless. Friends were generally sympathetic but the neighbours and relatives only pitied these poor women. See [Table 3] & [Table 4].
Only the prominent reactions are recorded here, actually some women complained of more than one of the above psychological reactions.
Husbands of 7 well adjusted women were present during the interview, hence their reactions could have been biased. All other women were interviewed in camera.
Problems faced: We faced the following major problems during this study:
(1) Since the contact was initially attempted by post, it was found that a number of letters were returned stating "addressee not known"; obviously the patients had either not given correct address or had moved without proper forwarding address.
(2) Even those who received the letters had no particular incentive to report in person and hence a number of them did not respond to even a second or third reminder.
(3) Social workers then contacted the subjects who did not respond to the third reminder, and faced considerable opposition from the household which treated this as unwarranted intrusion.
(1) Most of the subjects who turned up for follow-up came either with their husband or mother and therefore the answers to questions could have been biased due to presence of these relatives. Attempts to request the husband or mother to wait outside were frustrated as the relatives were worried about the consequences.
(2) The interviews had to be carried out over prolonged periods and since the subjects were extremely sensitive, high confidence level and a degree of rapport had to be developed between the interviewer and interviewee.
The cases followed up are divided broadly into three main categories:
(a) Those that dial not get adjusted to society,
(b) Those that apparently got adjusted,
(c) Those that were well adjusted.
(a) Non-adjusted cases:
Case I-Mrs. A. suffered burns due to a primus stove. As a result she was disfigured and hence her husband deserted her. She and her mother were keen on rehabilitation and used to frequently visit the hospital for an appointment for plastic surgery. Their main hope was that after the plastic surgery it would be easier for her to remarry. She could not however, get any appointment; as a result she became desperate and neurotic. In the end she had to be given psychiatric treatment. It is hoped that in future, such patients who show keenness to be treated will get more prompt appointments.
Case II-Mrs. B. confessed during the interview that though she had stated that her burns were accidental actually she had tried to commit suicide. She confessed that it was her third attempt, the reason being that her husband was a drunkard.
After she got discharged from the hospital she found to her horror that her husband had taken up another woman and he drove her out of the house.
She and her two children have now to stay on the footpath, where she tried to scrape a livelihood by selling vegetables
This case illustrates how medical treatment without subsequent rehabilitation of the patient actually aggravates the original problems which led to the burns.
Cace III: Mrs. C. was discharged from the hospital and presumably returnee home in a fit condition. When the Social Worker visited her home she was informed that the lady had died after one month of discharge from the hospital. Further enquiries did not elicit any information The members of the household were reluctant to talk about the matter. This case further illustrates the urgent need for psycho-social rehabilitation of such patients after their medical treatment is over.
Case IV: Mrs. D. confessed during her interview that she had tried to commit suicide twice after her discharge from the hospital. The main reason was that the father-in-law was making her life miserable and was insisting that she should return to her parents. She was not in position to do so.
Case V: Mrs. E. had been staying with her mother to avail of physiotherapy treatment and did not feel any problem: would arise, when she would return to her husband's home later. However, month later she came on her own to inform us that her husband was demanding that she should hand over all her ornaments to the mother-in-law if she wanted to return to her husband's home.
Case VI: In this the patient's husband told the social worker that the brother of his wife was trying to instigate her to file a suite to claim that her burns were inflicted by him.
(b) Apparently adjusted cases:
Case VII (Mrs. G.) : Though the family has accepted this woman, she was unable to adjust herself to the new conditions. She was short-tempered and treated even her children badly.
Case VIII: Mrs. H. was fortunate, when her husband had all sympathy for her, when she was in hospital and thereafter. However, when the burns started healing, they looked like leukoderma patches. Due to the social implications her husband's attitude now underwent complete change to that of indifference.
Case IX: Mrs. I was well accepted in the family, till she complained of pruritis, followed by repeated infection leading to ulcer formation.
From cases no. 8 & 9 it will be seen that, although some times the patients have been able to adjust socially, the adjustment process starts breaking down when secondary complications develop and aggravate the situation.
(c) Well adjusted cases:
Case X: Mrs. J.'s case is quite out of the ordinary. The family consisted of husband, wife and a grown up son and three daughters. When Mrs. J's clothes caught fire both the son and husband went to save her and got burnt in the process. The son was more affected than the father. The son succumbed to the injuries but the mother was saved. Both husband and wife have taken a realistic attitude to the accident and have no bitterness. They are still very understanding and love each other deeply.
Case XI: Mrs. K's case is also a happy one. She is bedridden, yet her husband takes all the possible care of her. He dresses her wounds, feeds her and nurses her tenderly.
It is likely that the patients who were well adjusted belonged to families which took a view that this misfortune was either due to supernatural powers (fate) or that they were repaying for their past sins; both these beliefs are common in this country.
The following cases did not fit into any of the three categories. However, they have certain interesting features and are hence listed below:
Case XII: Mrs. L.'s only major worry seemed to be that since the accident had occurred at her parents' place, her husband would not permit her to go to her parents' place again. But later he relented and allowed her to go to her parents' home. She is now grateful to him and worships him as a god.
Case XIII: Mrs. M.'s husband was quite considerate and he destroyed the primus stove which was the cause of all the trouble and bought a new one. He also built a cooking platform so that the accident should not repeat itself.
Case XIV: Mrs. N. got burnt while trying to save her two children. She therefore feels that her misfortune was well worth as she has been able to save her two children and god had also kept her alive to look after the children.
These three cases show the resilience of human mind which can successfully divert attention from one's calamity into minor side issues and thereby help in adjustment.
Prevention seems to be the main solution though it is beyond the scope of this study. It is strongly recommended that legislation should be brought in to ban the pressure stove which causes a majority of these accidents. It is interesting to note that last year, when kerosene was in short supply, burns cases dropped to an almost insignificant level.
(a) Administrative Reforms:
(i) The patients should be given full information of post operative facilities of plastic surgery which would minimise physical disfigurement.
(ii) Preferably, the close relatives should also be educated either by slides or real life cases to inform them of the degree of improvement that is possible.
(iii) Social workers with special training should follow up these cases and offer advice.
(iv) Speedy plastic surgery would alleviate most of the problems.
(v) To facilitate uniform follow-up of discharged patients, all burn cases should be admitted under one unit preferably under Plastic Surgery Unit in a separate ward.
(b) Legal Reforms :
(i) In case of homicidal cases punishment for this method should be particularly enhanced and well published.
(ii) Attempted homicide due to burns are unique in that in other methods, e.g. poisoning, strangulation etc. an
(iii) Ban on manufacture and sale of pressure stoves should be implemented.
(iv) Government aided research should be carried out to develop a safe stove at subsidised prices.
(v) Where the women and children have been deserted a special cell should be set up to insure that the husband provides for financial assistance for the family.
(c) Social Reforms :
(i) Adequate publicity is necessary to change the attitude of society to the unfortunate burn victims. They do not need pity but need understanding and social acceptance.
(ii) Certain percentage of jobs in suitable industries should be kept reserved for the unfortunate burns victim.
(iii) Special clubs should be created and subsidised by Government to provide care, rehabilitation and training to such burns cases.
We are thankful to Dr. C. K. Deshpande, Dean, Seth G. S. Medical College and K.E.M. Hospital for rendering all the help in carrying out this project and allowing us to publish the same.
We are also thankful to N.S.S. Volunteers for rendering the help in collecting the data in the wards.[Table 1]
[Table 1], [Table 2], [Table 3], [Table 4]