University of Ghana http://ugspace.ug.edu.gh SCHOOL OF PUBLIC HEALTH COLLEGE OF HEALTH SCIENCES UNIVERSITY OF GHANA QUALITY OF LIFE OF POST SEVERE BURNS PATIENTS AT THE BURNS CENTER OF KORLE-BU TEACHING HOSPITAL BY SANDRA OFORI-ATTA (10263326) A DISSERTATION SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILMENT OF THE REQUIREMENT FOR THE AWARD OF THE MASTER OF PUBLIC HEALTH (MPH) DEGREE. JULY, 2019 University of Ghana http://ugspace.ug.edu.gh DECLARATION I, Sandra Ofori-Atta hereby declare that this dissertation is a result of my independent work carried out under the supervision of Prof Justice Nonvignon. References to other works have been duly acknowledged. I further declare that this dissertation has not been submitted for the award of any degree in this institution and other University elsewhere. ……………………… …………………….. .......................................... SANDRA OFORI-ATTA Date (STUDENT) …………………………………………… .......................................... PROF. JUSTICE NONVIGNON Date (ACADEMIC SUPERVISOR) ii University of Ghana http://ugspace.ug.edu.gh DEDICATION I dedicate this thesis to God and my loving husband, Mr Bright Antwi Owusu. iii University of Ghana http://ugspace.ug.edu.gh ACKNOWLEDGEMENT Without the relevant efforts of the following individuals, this accomplishment would have not been made. I appreciate God for seeing me to a successful end of my Master Degree. His grace was sufficient. A very much grateful to my academic supervisor, Prof. Justice Nonvignon of the Health Planning Policy and Management Department of the School of Public Health, University of Ghana for his guidance and helping me to develop my ideas. I am also thankful to my other lecturers and colleagues from whom I learnt a lot. Much appreciation to my loving husband, Mr Bright Antwi Owusu for his support, encouragement and willingness to enthusiastically help me bring my dream to fruition. I would also like to thank Dr. Opoku Ware Ampomah, head of National Reconstructive Plastic Surgery and Burns Centre, Korle-Bu Teaching Hospital for permitting me to conduct my research in the unit. To all the participants whose responds revealed the hidden facts, God bless you immensely. To my research assistants, Richard Oppong, Veronica Aborbi and Mary Asare of the Burns Ward, Public Health Unit and the Out Patient Department respectively, I could not have made any significant progress without your contributions, the diligence in the execution of your respective mandates, thank you. Finally, my sincere and loving appreciation goes to my family including Barrister Asante Bediatuo of the Jubilee House for all their support and encouragement. ―Determination is nothing without dedication and hard work‖ Eshraq Jiah iv University of Ghana http://ugspace.ug.edu.gh ABSTRACT Introduction: Burns is a global public health problem and the eighth commonest cause of death in the world (Stokes, 2017). Severe burns mostly have long lasting effect on the quality of life of people with persisting problems associated with weakness, scarring, itching, and pain (Moi et al., 2016). Objective: The main objective of the study was to examine the quality of life and associated factors among post-severe burns patients at the Burns Center of the Korle- Bu Teaching Hospital, Accra, Ghana. Methods: A descriptive cross-sectional study involving a complete enumeration sampling technique was used to select 147 post severe burn injured patients at the Burns Center of the Korle-Bu Teaching Hospital, Accra, Ghana. The data collected using questionnaires were analysed using statistical tests such as chi-square test and multiple logistic regressions. Results: The overall proportion of severe burn injured patients at Korle-Bu Teaching Hospital, Accra, Ghana was 78%. The overall quality of life of post severe burn injured patients at Korle-Bu Teaching Hospital, Accra, Ghana had mean 3.195 (SD± 0.84). Major factors identified to have influenced quality of life of post severe burn injured patients are adults who are females ( ), adults aged more than 60 years ( ), and adults with total burn surface area between 21-25% ( ). Conclusion and Recommendation: The study concludes that female patients, older patients, and patients with a higher percentage of full thickness surface area burns are of greater risk for quality of life after severe burn injury. The study recommends that adequate monitoring after discharge should be enforced due to the complexity of burn care outcome, at the Burns Center at Korle-bu Teaching Hospital, Accra. v University of Ghana http://ugspace.ug.edu.gh TABLE OF CONTENTS DECLARATION ....................................................................................................... ii DEDICATION ......................................................................................................... iii ACKNOWLEDGEMENT ........................................................................................ iv ABSTRACT .............................................................................................................. v LIST OF TABLES ................................................................................................... ix LIST OF FIGURES ................................................................................................... x LIST OF ABBREVIATIONS ................................................................................... xi CHAPTER ONE........................................................................................................ 1 INTRODUCTION ..................................................................................................... 1 1.1 Background of the Study .................................................................................. 1 1.2 Problem Statement ........................................................................................... 3 1.3 Research Questions .......................................................................................... 5 1.4 Study Objectives .............................................................................................. 5 1.4.1 General Objective ......................................................................................... 5 1.5 Justification...................................................................................................... 6 1.6 Conceptual Framework .................................................................................... 6 CHAPTER TWO ....................................................................................................... 9 LITERATURE REVIEW .......................................................................................... 9 2.0 Introduction ..................................................................................................... 9 2.1 Concept of burns .............................................................................................. 9 2.2 Proportion of adult burn injury ....................................................................... 10 2.3 Classification of burn injury ........................................................................... 11 2.4 Health Related Quality of Life (HRQoL) in burns .......................................... 13 2.5 Measures of Health Related Quality of Life in burns ...................................... 13 2.6 Health related Quality of life of Post burns adult patients ............................... 14 2.7. Demographic and Socio-economic Factors and Quality of Life of Post burn injured Persons .................................................................................................... 15 2.7.1 Age ......................................................................................................... 15 2.7.2 Gender .................................................................................................... 16 2.7.3 Occupation .............................................................................................. 16 2.8 Burn Injured Related Factors.......................................................................... 17 2.8.1 Time since Injury .................................................................................... 17 2.8.2 Site of burn ............................................................................................. 17 2.8.3 Total Body Surface Area ......................................................................... 17 vi University of Ghana http://ugspace.ug.edu.gh 2.9 Conclusions and Research Gaps ..................................................................... 18 CHAPTER THREE ................................................................................................. 19 METHODOLOGY .................................................................................................. 19 3.1 Study Design ................................................................................................. 19 3.2 Study Area ..................................................................................................... 19 3.3 Study population ............................................................................................ 20 3.3.1 Inclusive Criteria ..................................................................................... 20 3.4 Study variables .............................................................................................. 21 3.5 Sampling Method and Sample Size ................................................................ 22 3.6 Data and Data Collection ............................................................................... 23 3.7 Quality Control Measure ................................................................................ 25 3.8 Data Analysis ................................................................................................. 25 3.9 Ethical Consideration ..................................................................................... 25 3.9.1 Ethical Approval ..................................................................................... 25 3.9.2 Privacy and Confidentiality ..................................................................... 26 3.9.3 Possible Risk and Discomfort .................................................................. 26 3.9.4 Voluntary participation and Right to Withdraw ....................................... 27 3.9.5 Compensation ......................................................................................... 27 3.9.6 Data Storage and Management ................................................................ 27 3.9.7 Dissemination of Findings ....................................................................... 28 3.9.8 Conflict of Interest .................................................................................. 28 CHAPTER FOUR ................................................................................................... 29 RESULTS ............................................................................................................... 29 4.0 Introduction ................................................................................................... 29 4.1 Demographic and Socioeconomic Characteristics of study participants .......... 29 4.2 Proportion of Post Severe Burns Injured Adults ............................................. 31 4.3 Burn injury-related factors ............................................................................. 31 4.4 Quality of Life ............................................................................................... 34 Table 4: Domain scores of quality of life ............................................................. 35 4.5 Regression Analysis Results........................................................................... 35 CHAPTER FIVE ..................................................................................................... 40 DISCUSSION ......................................................................................................... 40 5.0 Introduction ................................................................................................... 40 5.1 Proportion of severe burn injury patients ........................................................ 40 5.2 Quality of Life ............................................................................................... 41 vii University of Ghana http://ugspace.ug.edu.gh 5.3 Association between demographic and socio-economic characteristics and Quality of Life ..................................................................................................... 42 5.4 Association between burn injury-related factors and quality of life ................. 42 5.5 Limitation of the study ................................................................................... 43 CHAPTER SIX ....................................................................................................... 44 CONCLUSIONS AND RECOMMENDATIONS .................................................... 44 6.0 Introduction ................................................................................................... 44 6.1 Conclusion of the study .................................................................................. 44 6.2 Recommendation ........................................................................................... 45 References ............................................................................................................... 46 APPENDICES ......................................................................................................... 53 viii University of Ghana http://ugspace.ug.edu.gh LIST OF TABLES Table 1: Summary of Variables used in the Study .................................................... 21 Table 2: Demographics and socio-economic characteristics of study participants ..... 30 Table 3: Burn injury related factors of study participants ......................................... 32 Table 4: Domain scores of quality of life ................................................................. 35 Table 5: Model Summary ........................................................................................ 36 Table 6: Analysis of Variance .................................................................................. 36 Table 7: Multiple Linear Regression Analysis Results ............................................. 38 ix University of Ghana http://ugspace.ug.edu.gh LIST OF FIGURES Figure 1: Conceptual Framework of the study. ........................................................... 8 Figure 2: Proportion of Post Severe Burns Injured Adults ........................................ 31 x University of Ghana http://ugspace.ug.edu.gh LIST OF ABBREVIATIONS BSI Brief Symptoms Inventory BSHS-A Burn Specific Health Scale-Abbreviated BSHS-B , Burn Specific Health Scale-Brief BSHS-R Burn Specific Health Scale-Revised D-W Durbin Watson GDHS Ghana Demographic and Health Survey GHS Ghana Health Service GSS Ghana Statistical Service HDU High Dependency Unit ICF International Classification of Functioning disabilities and health KATH Komfo Anokye Teaching Hospital KBTH Korle-Bu Teaching Hospital LOS Length of Stay HROoL Health Related Quality of Life QOL quality of life QoL Quality of Life TBSA Total Body Surface Area UN United Nations VIF Variance Inflation Factor WHO World Health Organization xi University of Ghana http://ugspace.ug.edu.gh CHAPTER ONE INTRODUCTION 1.1 Background of the Study The World Health Organization (WHO) estimates that about 90% of global burns occurrences are reported in underdeveloped countries and more than one-third of the burns that result in mortality occur in the Southeast Asia (Adil et al., 2016). Globally, a yearly report of six million patients seeks medical assistance for burns but the majority are catered for in outpatient health centers. In England and Wales, approximately 88.1% severe burn injuries were referred for assessment and admission st st to burn service centers from 1 January, 2003 to 31 December, 2011 (Stylianou, Buchan, & Dunn, 2015). Harats et al. (2016) identified that 41.2% of adult burn injured patients were admitted at burns units in five main hospitals in Israel from 2004 to 2010. The proportion of adult burns was reported in 2016 as 48.0% in Iraq (Stewart et al., 2016). In Africa, the proportion of adult burns was reported in 2017 as 43% in Kenya (Botchey et al., 2017). The proportion of adult burns injury reported in Korle-Bu Teaching Hospital (KBTH) in Ghana in 2018 was 68% (Burns Center of Korle-Bu Teaching Hospital, 2018) and in Komfo Anokye Teaching Hospital (KATH) in 2016 was 56.5% (Agbenorku et al., 2017). An in-patient treatment of burn injury is needed in a unit specialized in severe burns (Chipp, Walton, Gorman, & Moiemen, 2008; Anwar, Majumder, Austin, & Phipps, 2007; Brusselaers, Lafaire, Ortiz, Jacquemin, & Monstrey, 2008). This is because severe burns have been found to impair quality of life (Tagkalakis & Demiri, 2009), 1 University of Ghana http://ugspace.ug.edu.gh results in low chances of returning to previous workplace, and an overall poor prediction of quality of life (Pavoni, 2010). Burns constitute physical and psychological disturbance for the injured individual (Stavrou et al., 2014; Tagkalakis & Demiri, 2009). It is identified to influence health, normal social functioning and appearance and therefore makes it difficult for the injured person to be part of the society. Stylianou, Buchan, & Dunn (2015) stated that burns are a constant disturbance which begins with a traumatic occurrence of the injury, continues during hospitalization with severe pain, and ends with a post- discharge of emotional trauma (Stylianou, Buchan, & Dunn, 2015). Burn is a kind of injury that affects the body as a result of likely agents such as chemical, thermal, electric, mechanical, and radiation. Usually, a burn comprises of several skin layers but in some circumstances, it affects deeper tissues such as muscle and bone. According to Edgar et al. (2013), the primary examination of the health conditions depends on the proportion of the Total Body Surface area (TBSA) that has been affected by the burns and deepness of the burn. Nevertheless, depending on the affected area, the TBSA and deepness of the burn, the suffering patient experiences several crucial lethal problems such as infection, multiple organ failure, shock, and respiratory distress. These problems occur during severe stage of the disturbance with a challenging task of rehabilitation. Also, being accepted back into the society may have a disturbing psychological influence on the post burn injured person as well as the family (Herndon, 2007). Additionally, the monetary resources required to manage the burns are extensively high due to long hospitalization and rehabilitation (Sanchez, Pereperez, Bastida, & Martinez, 2007). These expenses due to severe burns affect the 2 University of Ghana http://ugspace.ug.edu.gh patients‘ Quality of Life (QoL) and the Health-Related Quality of Life (HRQoL) of the burn injured person (Weedon & Potterton, 2011). Brown (2003) stated that the fundamental purpose of quality of life is to ensure that the well-being of individuals. According to Brown (2003), QoL operates to certify that continues to be high irrespective of the possible rise in proportion of disabled individuals or diminishing abilities. Therefore, the main goal is to sustain enough levels of functioning and greater satisfaction of life in areas that individuals think are vital. Even though it is identified that post burn injured patients are confronted with all kinds of issues associated with the psychological, physical, and social effects of their injury, the impact of the burn injury on the quality of life of post burn injured patients is not fully identified (Moi, Haugsmyr, & Heisterkamp, 2016). Research into quality of life of post burn injured persons still remains a grey area in the world, specifically Ghana; hence the need to study the quality of life of post burn injured patients in Ghana. 1.2 Problem Statement Globally, the improved quality of post burn care has helped tremendously in increasing the rate of survival of afflicted patients (Stylianou, Buchan, & Dunn, 2015). But the quality and timely management of post burn injury has delayed total recovery and affected the quality of life of people in developing countries such as Ghana. This is so because of the health expenditure on resource intensive burn care (Agbenorku, Akpaloo, Yalley, & Appiah, 2010). According to Othman, Kendric, & Windi (2010), burn incidences are extremely higher in developing countries than developed countries. Severe burns mostly have long lasting effect on the quality of 3 University of Ghana http://ugspace.ug.edu.gh life of people with persisting problems associated with weakness, scarring, itching, contractures, psychological wellbeing, thermoregulations, body image, and pain (Esselman et al., 2006; Moi et al., 2016). In addition to the effect of the burn, the intensive care treatment may result in cognitive, affective or behavioural issues (McGarry et al., 2014). Burn injured people worldwide have reported limitations in health-related quality of life compared to the standards of living of people (Oster et al., 2011; Xie et al., 2012). According to Moi et al. (2016), after hospital discharge, many burn afflicted people report changes in social responsibilities and interpersonal relationships especially in the first year. These changes are obvious in absenteeism from work and changes in the perception of families and friends due to scars and bodily changes caused by burns (Connell et al., 2015). This physical, psychological, emotional, and severity of burn are significant factors that can impair the quality of life of burned injured people over time. In Ghana, the declining quality of life of people afflicted with burn in recent times has increased mortality in Ghana and has also rendered many afflicted patients disable, increasing the economic burden on the government of Ghana. Ghana in recent times has experienced massive burn incidence in Accra (circle fire, atomic junction fire etc.) and elsewhere involving 100s of people with various degrees of burn injuries but there is very little information about their post-burn quality of life. For instance, the atomic junction gas explosion in 2017 and Goil filling station fire explosion at Kwame Nkrumah circle in 2015 in Ghana accounted for 6 deaths and 45 injuries and 152 deaths respectively (www.ghanaweb.com). 4 University of Ghana http://ugspace.ug.edu.gh A critical assessment of quality of life of post burns injured people in Ghana by studying the rehabilitation process and the outcome is lacking. This study employs Burn Specific Health Scale to evaluate the quality of life of post-severe burns patients at the Burns Center of the Korle-Bu Teaching Hospital, Accra, Ghana. This aids in information reliability for clinical practice. 1.3 Research Questions 1. What is the proportion of post severe burn injured patients at Korle-Bu Teaching Hospital, Accra, Ghana? 2. What is the quality of life of severe burn injured patients at Korle-Bu Teaching Hospital, Accra, Ghana? 3. What is the association between socio-demographic factors, burn injury related factors and the quality of life of post burn injured patients at Korle-Bu Teaching Hospital, Accra, Ghana? 1.4 Study Objectives 1.4.1 General Objective To main objective of the study was to examine the quality of life and associated factors among post-severe burns patients at the Burns Center of the Korle-Bu Teaching Hospital, Accra, Ghana. 1.4.2 Specific Objectives The specific objectives of the study were to; 1. Determine the proportion of severe burn injured patients at Korle-Bu Teaching Hospital in Accra, Ghana. 2. Determine the quality of life of severe burn injured patients at Korle-Bu Teaching Hospital in Accra, Ghana. 5 University of Ghana http://ugspace.ug.edu.gh 3. Examine the association between demographic and socio-economic characteristics, burn injury related factors and the quality of life of post severe burn injured patients at Korle-Bu Teaching Hospital in Accra, Ghana 1.5 Justification Studies have indicated that many severe burns injuries are found in the low- and middle-income countries such as Ghana with high mortality rates (Barlett, 2002). According to Othman, Kendric, & Windi (2010), burn incidences are extremely higher in developing countries than developed countries with long lasting effect on the quality of life of people (Esselman et al., 2006; Moi et al., 2016). Nevertheless, an improved quality of post burn care increases the rate of survival of afflicted patients (Barret et al., 2002). Several studies have identified total burn surface area, site of burn, circumstances of burn, and etiology of burn to affect the quality of life among post burn injured persons (Öster, Willebrand, & Ekselius, 2013; Ahuja, Mulay, & Ahuja, 2016; Edgar et al., 2013). This study would help the government and stakeholders in the health sector in formulating measures to decrease the risk of post burns injury related morbidity and mortality in Sub-Saharan African and Ghana to be precise. Finally, the findings will aid the community, health sector, non-governmental organizations, and the government as a whole to formulate strategic measures to ensure quality of life of post burn injured people. 1.6 Conceptual Framework The graphical representation of demographic and socio-economic factors and burn injury related factors and its association with quality of life of post burn injured persons can be seen in Figure 1. The conceptual framework comprises of 6 University of Ghana http://ugspace.ug.edu.gh demographic and socio-economic factors and burn injury related factors and its association with quality of life. Demographic and socio-economic factors identified include age, sex, marital status, educational level, employment status, wealth status, and means of transportation. The burn injury related factors are age at burn, total body surface area burns, circumstances of burn, site of burn, etiology of burn, and care giving support. As highlighted by Wasiak et al. (2014), Ahuja, Mulay, & Ahuja (2016) and Edgar et al. (2013), demographic and socio-economic characteristics is significantly associated with quality of life among post burn injured persons. Ahuja, Mulay, & Ahuja (2016) found that gender has an association with quality of life of post severe burns. That are female patients have poor quality of life among post burn injured persons. Also, burn injury related factors have been identified to have an association with quality of life among post burn injured persons (Öster, Willebrand, & Ekselius, 2013; Ahuja, Mulay, & Ahuja, 2016; Edgar et al., 2013). Öster, Willebrand, & Ekselius (2013) found that time since injury has an association with the quality of life after burn injury. The conceptual framework therefore shows how the above-mentioned factors (demographic and socio-economic factors and burn injury related factors) influence quality of life of post burn injured patients of Burns Center of Korle-bu Teaching Hospital. 7 University of Ghana http://ugspace.ug.edu.gh Demographic and Scio-economic Burn Injury Related Factors Factors  Age at burn  Age  Total body surface area  Sex burns  marital status  Circumstances of burn  educational level  Site of burn,  employment status  Etiology of burn  wealth status  Care giving support  means of transportation Post-Severe Burn Quality of Life Figure 1: Conceptual Framework of the study. Source: Author‘s own work, 2019. 8 University of Ghana http://ugspace.ug.edu.gh CHAPTER TWO LITERATURE REVIEW 2.0 Introduction This section presents the theoretical framework and the view of some literature relating to the topic under consideration. Burn is a type of injury affects the skin due to thermal, chemicals, electric, or radiation. It remains a significant concern and an increasing public health problem. The burden of rehabilitation due to complications falls on the post burn injured person and family (Herndon, 2007) affecting the Quality of Life (QoL] in general, and the Health-Related Quality of Life (HRQoL) of the patient in specific (Weedon & Potterton, 2011). 2.1 Concept of burns In clinical practice, Schaefer & Tannan (2019:1) defined burns as ―dynamic injuries that may progress over hours to days, making it difficult to accurately determine the various zones during the early course of the injury‖. According to Hernon (2012) a burn is a kind of injury that happens to the skin and other deeper structures as a result of heat, electricity, chemicals or radiation. WHO also defined burn as an injury to the tissues of the skin including scalds, thermal, chemical or electrical injuries (www.who.int.org). According to Peck (2011) burns are injuries caused by heat, electricity, radiation or corrosive substances to the skin. Burns are highly variable in terms of the tissue affected, severity, and resultant complications with subsequent pain due to profound injury to nerves. 9 University of Ghana http://ugspace.ug.edu.gh Structures such as muscle, bone, blood vessels, dermal and epidermal tissue can also be damaged. Depending on the degree and/or the location of the body affected, `a burn victim may experience a wide number of potentially fatal complications including shock, infection, electrolyte imbalance, and respiratory distress (Agbenorku et al., 2010). A burn occurs when some or all of the cells in the skin or other tissues are destroyed by hot liquids (scalds), hot solids (contact burns), or flames (flame burns). Injuries to the skin or other organic tissues due to radiation, radioactivity, electricity, friction or contact with chemicals are also identified as burns. Burns can occasionally affect muscles, bones and other internal organs (Stylianou, Buchan, & Dunn, 2015). Burn injuries usually result in breakdown of the skin. It ranges from minor to severe based on the extent of skin affected, anatomical site, depth of the injury, the age of the patient, and the presence of co-existing disorders (Stylianou, Buchan, & Dunn, 2015). Burns are associated with relatively high mortality and morbidity worldwide, especially in the developing countries (Lau, 2006; Kalayi, 2006). According to WHO (2008), burns injuries may come with prolonged or even permanent trauma. They constitute one of the most common household injuries and thus, a major cause of morbidity and mortality. A major percentage of the workload for the Plastic Surgery and Burns Units are burns cases and children make up about 45% of these burns‘ cases recorded (Thompson, 2011). 2.2 Proportion of adult burn injury The World Health Organization (WHO) estimates that approximately 90% of global burns incidences are reported in underdeveloped countries and about 40% of the burns 10 University of Ghana http://ugspace.ug.edu.gh associated with mortality take place in the Southeast Asia (Adil et al., 2016). Worldwide, an estimated six million patients seek medical assistance for burns annually, but the majority are treated in outpatient health centers. 88.1% acute injuries were referred for assessment and admission to burn service in England and Wales st st from 1 January, 2003 to 31 December, 2011 (Stylianou, Buchan, & Dunn, 2015). Harats et al. (2016) found that 41.2% of adult patients with burns were admitted at five major hospitals with burn units in Israel from 2004 to 2010. The proportion of adult burns was reported in 2016 as 48.0% in Iraq (Stewart et al., 2016). In Africa, the proportion of adult burns was reported in 2017 as 51.1% in Egypt (Ahmed et al., 2018) and 43% in Kenya (Botchey et al., 2017). The proportion of adult burns injury reported in Ghana in Korle-Bu Teaching Hospital (KBTH) in 2018 was 68% (Burns Center of Korle-Bu Teaching Hospital, 2018) and in Komfo Anokye Teaching Hospital (KATH) in 2016 was 56.5% (Agbenorku et al., 2017). 2.3 Classification of burn injury The World Health Organization International Classification of Diseases version 10 classified burns by site of injury. In terms of etiology, they are classified as those caused by exposure to smoke, fire and flames, contact with heat and hot substances, exposure to electric current, lightning, and exposure to corrosive substances (Othman & Kendrick, 2010). That is, there are various types of burns dependent on what caused the burn injury. They may include thermal burn (Reid, 2018), chemical burn (Struck, 2016), electrical burn (Gentges & Schieche, 2018), and radiation burn (Herndon, 2012; Temu-Justin, Rimoy, Premji, & Matemu, 2008). 11 University of Ghana http://ugspace.ug.edu.gh A thermal burn is any damage that occur when the skin comes into contact with hot items such as boiling water, steam or hot liquids (Schaefer & Tannan, 2019). According to Schaefer & Tannan, (2019), among all the classifications of burns, thermal burns are the most popular. They constitute approximately 86% of all the burned injured people demanding admission at burn center. Electrical injuries are relatively common form of mechanical trauma, which occur as a result of lightning, low-voltage or high-voltage injury, and are often associated with a high morbidity and mortality (Zemaitis et al., 2019). Almost all electrical injuries are accidental and often, preventable. If not instantly fatal and the damage associated with electrical injuries can result in dysfunction of multiple tissues or organs (Trivedi et al., 2019; Daskal et al., 2019). Radiation burn is damage to the skin or other biological tissue caused by exposure to radio frequency energy or ionizing radiation (Waghmare, 2013). Radiation injury involves morphological and functional changes that occur in noncancerous or ―normal‖ tissue as a direct result of ionizing radiation (Mendelsohn et al., 2002). The most common type of radiation burn is sunburn caused by an ultra violet radiation. A caustic burn (chemical burn) is an acute, severe irritant reaction by which the cells have been damaged to a point where there is no return to viability; in other words, a necrosis develops (Hardwicke et al., 2012). One single skin exposure to certain chemicals can result in a chemical burn. Burns can result in minor damages or can lead to a dangerous emergency, depending on the concentration of the heat, the expanse of tissues burned, and how long the skin had been exposed to the heat. A lot of individuals suffer from infirmities and 12 University of Ghana http://ugspace.ug.edu.gh deformities as a result of burns (Hasselt, 2008). When categorizing the thickness of a burn, a system of classification that is mostly adapted involves assigning a degree to the injury, from first degree through fourth degree (Reed & Pomerantz, 2005). 2.4 Health Related Quality of Life (HRQoL) in burns Health Related Quality of Life (HRQoL) reveals the opinion of a post severe burn injured person relating to his or her physical, psychological, and social wellbeing (Guyatt, Jaeschke, Feeny, & Patrick, 1996). Tools employed to measure HRQoL are either generic or specific. Generic tools which are applied to any kind of disease assist comparison between several illnesses while specific tools for burns are only used for burn related issues (Coons, Keininger, & Hays, 2000). HRQoL concentrate on the effects of the disease and not on problems associated with life in general and factors outside the range of the individual (Fitzpatrick et al., 1998). The distinctive features of a burn make it quite complex to assess HRQoL results in post burn injured persons (Moi et al., 2006). The fact that rehabilitation of the burn injured person comprises of the social, physical, and psychological interventions make assessment of HRQoL more important (Palmieri & Klein, 2007). 2.5 Measures of Health-Related Quality of Life in burns Several standard measurements for healthcare quality of life in burns have been developed. They are Short Form 36 (SF-36), Brief Symptoms Inventory (BSI), Burn Specific Health Scale-Abbreviated (BSHS-A), Burn Specific Health Scale-Brief (BSHS-B), and Burn Specific Health Scale-Revised (BSHS-R). This study used Burn Specific Health Scale (BSHS-B) to evaluate the health-related quality of life in post severe burn injured persons. 13 University of Ghana http://ugspace.ug.edu.gh 2.5.1 Burn specific health measurement tool: BSHS-B The standardized and valid Brief Version of the Burn Specific Health Scale (BSHS-B) was adapted in this study to assess HRQOL of severe burns injured patients in 40 items among nine domains: heat sensitivity, affect, hand function, treatment regimens, work, sexuality, interpersonal relationships, simple abilities, and body image (Kildal et al., 2001). The BSHS-B consists of the 31 items from BSHS-R to which 9 items were added to cover sexuality and hand function (Kildal et al., 2001). The items were scored using a five-point Likert scale with 0, extremely; 1, quite a bit; 2, moderately; 3, a little bit; and 4, none (not at all). Higher scores indicate greater HRQOL. BSHS-B has been widely used to quantify the recovery of QoL after a burn (Edgar, 2007). That is, to study the physical and psychosocial functioning of burn patients (Xie et al., 2012; Wasiak et al., 2014). 2.6 Health related Quality of life of Post burns adult patients The domains ‗simple abilities‘ measure activity limitations. It shows that activities of individuals are limited after post burns. This is consistent with the course of recovery of burns as shortly after burns wounds are healing and physical capability is impaired. According to Spronk et al. (2018), when wounds are healed, activity improves. That is, simple activities such as walking and dressing are identified to improve, which increase the quality of life of post burn injured patients. The domains ―work‖ measure physical functioning. Physical functioning such as working is more affected by burns which also affect the quality of life of post burn injured patients. This is consistent with a study by Goei et al. (2016) who stated that advanced functioning such as working is influenced by the burns, thus affecting their quality of life. 14 University of Ghana http://ugspace.ug.edu.gh The domain interpersonal relationships measure emotional and mental wellbeing. The studies found that post severe burn injured persons were restricted due to interpersonal relations. Restrictions of regular daily activities such as work due to emotional issues would develop. Spronk et al. (2018) stated that, patients who are employed accomplish less than they would like and work not as carefully as usual. The domain affects measure mental function. A study by Spronk et al. (2018) found that the score of affects did not reach the highest score indicating that severe burn injured patients are on average affected by mental functions such as depression or anxiety. 2.7. Demographic and Socio-economic Factors and Quality of Life of Post burn injured Persons Several studies have identified socio-demographic characteristics to be an important contribution to quality of life among post burn injured persons (Wasiak et al., 2014; Ahuja, Mulay, & Ahuja, 2016; Edgar et al., 2013). 2.7.1 Age Age of post burn injured person has been identified to have a significant association with quality of life of post burn injured person (Wasiak et al., 2014). Wasiak et al. (2014) recruited 125 burn injured patients over the study period to identify clinical and patient characteristics which predict health related quality of life of burn injured people 12 months after injury. They used Burn Specific Health Scale-Brief (BSHS-B) to measure quality of life and employed multiple linear regression model to analyse the data. They found that age has a negative association with quality of life of post burn injured persons. That is, older age had lower quality of life after post burn injury. 15 University of Ghana http://ugspace.ug.edu.gh 2.7.2 Gender Ahuja, Mulay, & Ahuja (2016) assessed 60 post burn injured patients in India using Burn Specific Health Scale-Brief (BSHS-B). They found that gender has an association with quality of life of post severe burns. That are female patients have poor quality of life among post burn injured persons. This is consistent with a study conducted by Wasiak et al. (2014) who found that gender has an association with quality of life of post severe burn injured persons. According to Wasiak et al. (2014), female patients have poor quality of life after 12 months post burn injury. Also, studies in Brazil by Cabulon et al. (2015), in China by Zhang et al. (2014), and in Australia by Knight et al. (2016) found that female burn injured patients have poor quality of life compared to males. The willingness of females to report impaired health related quality of life is greater or women find it difficult to live with a mutilated body 2.7.3 Occupation Cabulon et al. (2015) assessed the quality of life of individuals from an outpatient burn treatment center in Southern Brazil using the Burn Specific Health Scale- Revised (BSHS-R), and to determine the relationship between socio-demographic variables, burn history and the mean domains of BSHS-R. They used the multiple linear regression and found that occupation has a significant association with quality of life of burn injured people. That is, those who are employed have a higher quality of life as compared to those who are unemployed. 16 University of Ghana http://ugspace.ug.edu.gh 2.8 Burn Injured Related Factors Several studies have identified burn injury related factors to be an important contribution to quality of life among post burn injured persons (Öster, Willebrand, & Ekselius, 2013; Ahuja, Mulay, & Ahuja, 2016; Edgar et al., 2013). 2.8.1 Time since Injury Öster, Willebrand, & Ekselius (2013) assessed the predictors of burn-specific health years after burn injury using BSHS-B in Sweden and found that time since injury has an association with the quality of life after burn injury. 2.8.2 Site of burn A study conducted by Ahuja, Mulay, & Ahuja (2016) who found that site of burn has an association with quality of life of post severe burn injured persons. According to Ahuja, Mulay, & Ahuja (2016), presence of hand and face burns have an association with poor quality of life after 12 months post burn injury. 2.8.3 Total Body Surface Area Edgar et al. (2013) studied the factors affecting quality of life measured using BSHS- B of post burn injured patients at Royal Perth Hospital Burn Service in Australia and found that burn injured factors such as total body surface area has an association with quality of life of post burn injured patients. This is consistent with studies by Zhang et al. (2014) who evaluated the quality of life in burn patients in China and found that total body surface area has an association with quality of life of burn injured person. 17 University of Ghana http://ugspace.ug.edu.gh 2.9 Conclusions and Research Gaps  Dearth of research on quality of life of post burn adult patients in developing countries using standard scale such as BSHS-B, with only 2% of low- and middle-income countries covered (no study in Ghana).  Few studies in low- and middle-income countries conducted among adult injured patients, for example only three of the eight studies of the proportion of post burn injured adults are from SSA.  Little to non-existent research in quality of life and burn injured factors among post burn injured adult patients in low income countries and none in SSA.  Knowledge gap in factors pertaining to quality of life among post burn injured adult patients worldwide.  Few researches in identifying the association between demographic and socio- economic factors, injured related factors and quality of life in high income countries with almost non-existence in SSA. 18 University of Ghana http://ugspace.ug.edu.gh CHAPTER THREE METHODOLOGY 3.0 Introduction This chapter presents the various techniques and tools that were used for the research. It discusses the study design, study area, study population, sample size, variables that were measured, sampling technique, data collection instrument, and data analysis. Structured questionnaires were used to collect data on demographic and socio- economic and burn injury related factors among post burn injured patients. Furthermore, this chapter presented ethical considerations of the study. 3.1 Study Design The study used a descriptive cross-sectional research design. Quantitative method of data collection and analysis was employed. 3.2 Study Area The study was carried out in Korle-Bu Teaching Hospital (KBTH) in Accra, Ghana. KBTH is the premier health care facility in the country serving both local and international patients. It is bounded to the south by the Korle Gono Township to the east by the Korle lagoon, the west by the Mamprobi Township and north by the Lartebiokorshie Township. The Burns Center is a unit in the National Reconstructive Plastic Surgery and Burns center of the KBTH. The unit was chosen for this study because it is one of the center of excellence in the hospital. It receives patients from all over the country and internationally. The centre has a bed capacity of 68 beds and sees an average of 250 patients a week on OPD basis of which about 35% are burns, others cases includes cosmetic surgeries, all forms of trauma and chronic ulcers, congenital deformities etc. 19 University of Ghana http://ugspace.ug.edu.gh It also admits emergency and referral cases through the hospital Accident and Emergency unit. The centre is near completion and opening of a High Dependency Unit (HDU) which will cater for burnt patient with intensive care need. This is going to add up to the current bed state of the centre. 3.3 Study population The study included all post burn patients aged 20 years or older who were managed at the Burns Center at the KBTH in Accra, Ghana from 2016 to 2018. The total number of burns patients admitted from 2016 to 2018 was 632 (Burns Center of KBTH, 2019). 3.3.1 Inclusive Criteria The study considered adults aged 20 years and above who have signed an informed written consent to be part of the study. The targeted population for this study were burn patients who were managed at the Burns Centre in the last 3 years (2016-2018). Admission and discharged record books were used to analyze demographic data of the patients who were seen at the unit for the past 3 years. Post burn patients age 20 years and above currently receiving other form of care at the unit were included. 3.3.2 Exclusion Criteria The study excluded burns injury patients below 20 years of age or patients aged 20 years and over who did not give their consent. Burn patients whose injury are minor or moderate as stated above were not included as well and lastly burn patients whose injury were severe but are still on admission were not enrolled. 20 University of Ghana http://ugspace.ug.edu.gh 3.4 Study variables The variables used in this study comprised of dependent variable and explanatory variables. The dependent variable was quality of life of patients. Quality of life used in this study refers to post severe burn injured person‘s wellbeing relating to his or her physical, psychological, and social wellbeing. The quality of life of post severe burn- injured patient is measured using the overall average score of the nine domains. The nine domains are Affect, Health Sensitivity, Hand Function, Treatment Regimens, Work, Sexuality, Interpersonal Relationship, Simple Abilities, and Body Image. The independent variable was demographic and socio-economic factors of the patient such as sex of patient, age of patient, educational level, religion, wealth status, and employment status. Table 1 shows a summary of the independent and dependent variables that will be used in the study. Table 1: Summary of Variables used in the Study Variable Measures Scale of Name of Variable Measurement Dependent Variable Quality of Life Average of Domains Continuous Domains Average of seven sub-domains of Affect Continuous affect Average of five sub-domains of Hand Function Continuous hand function Average of five sub-domains of Health Sensitivity Continuous health sensitivity Average of five sub-domains of Treatment Regimens Continuous treatment regimens Average of four sub-domains of Work Continuous work Average of three sub-domains of Sexuality Continuous sexuality 21 University of Ghana http://ugspace.ug.edu.gh Average of four sub-domains of Interpersonal Relationship Continuous interpersonal relationship Average of three sub-domains of Simple Abilities Continuous simple abilities Average of four sub-domains of Body Image Continuous body image Demographic and Socio- economic Factors Survey Age Years Continuous Sex Male, Female Binary Marital Status Single, Married Nominal/Categorical Unemployed, Student, Employment Status Nominal/Categorical Employed, Retired Religion Christianity, Muslim, Traditional Nominal/Categorical No education, Primary, JHS, Educational Level Nominal/Categorical Secondary, Tertiary Wealth Status Poor, Medium, Rich Categorical/Nominal Burn Injury Related Factors Time since burns Years Continuous Age during burn injury Years Continuous Total Burn Surface Area Percentage Continuous 3.5 Sample Size Determination This is a cross sectional study in which total enumeration method was used. No sampling was done. During the process all adult with post burn injury was enrolled, from which those with severe post burn were selected. This method was necessary due to the real nature of the participant under study. Gathering information from the total population often gives deeper insights into a target population than partial samples would be capable of. It has the potential to allow a researcher to paint a much more complete picture, and greatly reduces guesswork. It also eliminates the risk of biased sample selection that is often encountered in would-be random study samples (Crossman, 2018). 22 University of Ghana http://ugspace.ug.edu.gh The chosen method was used to select post burn injured patients that reports at the Centre for review to answer the questionnaires after their concern have been sought. Records have indicated that between twenty to thirty burns patients on the average report at the Reconstructive Plastic Surgery and Burns Centre at Korle-bu Teaching Hospital weekly for review. With this in mind, data was gathered on daily bases from Mondays to Fridays for ten weeks within the month April to June, 2019 and 163 participants were obtained. 3.6 Data and Data Collection The study used primary data. Primary data was collected from adults aged 20 years and above who have suffered burn injuries from 2016 to 2018 through the administration of questionnaires. The closed ended questionnaire was used to solicit for information on demographic background and the quality of life of burn injury adults aged 20 years and above managed at the Burns unit at KBTH. The principal investigator was assisted by two nurses to collect the primary data with a closed-ended structured questionnaire made up of three (3) sections, namely, Section A, B, and C. Section A sought to get information on the demographic and socio-economic characteristics of participants. This demographic and socio-economic characteristic comprises of age, sex, level of education, employment status, and wealth class. These variables have been reported in the literature to be the basis of assessment of quality of life. The Section B sought to get information on burn injury related factors such as severity of burns, degree of burns and age of participant during burn injury. 23 University of Ghana http://ugspace.ug.edu.gh The section C gathers information on quality of life of post severe burn injury adults. Quality of life has nine domains, namely Affect, Health Sensitivity, Hand Function, Treatment Regimens, Work, Sexuality, Interpersonal Relationship, Simple Abilities, and Body Image. The study adapted the Burns Specific Health Survey Brief questionnaire (BSHS-B) which has been reported in literature to measure quality of life of burns injury patients. The BSHS-B is a widely used measure of Quality of life after a burn injury (Kadal et al., 2001; Yoder Nayback, & Gaylord, 2010). It consists of nine domain which make up four modalities, namely, physical, social, mental functioning, and general well-being (Pfitzer et al., 2016). The BSHS-B asks patients to rate their degree of difficulty concerning the 40 burn specific items. The items are scored using a five-point Likert scale with ‗‗0‘‘, extreme; ‗‗1‘‘, a little bit; ‗‗2‘, moderate, ―3‖, quite a bit, and ‗‗4‘‘, none at all (Kadal et al., 2001; Yoder Nayback, & Gaylord, 2010). The quality of life of post severe burn-injured patient is measured using the overall average score of the nine domains. A minimum total score is 0 and a maximum total score is 160. An average total score is derived by dividing the total score for the nine domains by the total number of sub-domains (40). Overall average score ranges from 0.00 to 4.00. Higher scores indicate higher QoL and fewer problems. Table 2 shows the dimensions of quality of life using total quality of life and average quality of life Table 2: The dimensions of quality of life Quality of Life Total QoL Score Overall Average QoL Score Low <80 <2 Moderate 80-120 2-3 High >120 >3 24 University of Ghana http://ugspace.ug.edu.gh 3.7 Quality Control Measure Questionnaires were administered for both pre-testing and the actual research study. Information derived from participants was kept in a cabinet under lock and key, accessible to principal investigator only. The principal investigator was assisted by three nurses to collect the primary data. 3.8 Data Analysis Data gathered from the study was screened, edited, coded, and analyzed using STATA version 15. Graphs and frequency distribution tables were used to present the descriptive analysis of the data. The pie chart was used to show the proportion of post severe burns injured adults and the frequency table was used to show the proportion of quality of life of post severe burns based on the dimensions of quality of life. The Multiple Linear Regression was used to assess the association between demographic and socio-economic factors, burn history related factors, and quality of life of post burn injury adults. Statistical relationship between the quality of life and the demographic characteristics and the injury related factors was declared significant at p-value of ≤ 0.05. 3.9 Ethical Consideration 3.9.1 Ethical Approval Ethical approval for the study was obtained from the Institutional Review Board of the KBTH before the start of the study. A letter of introduction and request for permission for the study was obtained from the School of Public Health to the Director of the Reconstructive Plastic Surgery and Burns Centre of the Korle-Bu Teaching Hospital. Respondents were also accorded 25 University of Ghana http://ugspace.ug.edu.gh the due confidentiality and anonymity. Participation in the study was absolutely voluntary to the respondents after the purpose of the study explained comprehensively to them. Verbal and written consent were obtained from each study participant before information was gathered. All potential participants received information about the study in their language of choice, which enhanced free and easy understanding of technical jargon. Participants were given sufficient time to reflect on the information and questions asked. Participants were allowed to give their consent by signing an informed consent form. The consent form contained information regarding possible risk or discomfort, possible benefits, data storage and management, contact person for additional information, voluntary participation and the right to withdraw from the study at any given time without penalty attached. Consent forms was given to post burns injury patients only who are 18 years and above. 3.9.2 Privacy and Confidentiality The information to be shared by participants during the study was confidential to the principal investigator of the study. In view of this, participants were given codes for identification instead of using their names. Under no circumstance was information received shared with others. The names of participants were not disclosed to any other person before, during, and after the study is conducted successfully. 3.9.3 Possible Risk and Discomfort There were expected minimal risks for the study to be conducted. This occurred when soliciting information from the post burns injury patients which to an extent caused them to be a bit emotional. Nevertheless, any risk recognized during the study was 26 University of Ghana http://ugspace.ug.edu.gh duly addressed. A minimal discomfort was participants answering questions about their burn‘s status. 3.9.4 Voluntary participation and Right to Withdraw Participation in this study was voluntary which makes them free to answer part or the entire questionnaire. A participant can choose to withdraw from the study at any point in time. A participant can also choose not to answer any question(s) they find uncomfortable about. Their decision not to participate would not affect them or the hospital in any way. However, they are encouraged to participate fully in this study to educate us. 3.9.5 Compensation Participants sampled for the study did not receive any form of payment but were refreshed for the services rendered during the study with soft drinks and biscuits. 3.9.6 Data Storage and Management Data collected for the study was stored electronically on pen drives, compact disc, external hard disk drive, google drive and dropbox respectively. In addition, a soft copy was sent to the library of School of Public Health, University of Ghana. The password to all account of the electronic medium is exclusive to the principal investigator. The information stored was destroyed approximately a year after the dissertation is submitted and approved by the external examiner. 27 University of Ghana http://ugspace.ug.edu.gh 3.9.7 Dissemination of Findings The results of this research were submitted to the School of Public Health in partial fulfilment of the requirements for the award of a Master of Public Health Degree. The findings were written for publication in a reputable journal. 3.9.8 Conflict of Interest The principal investigator and supervisor have no conflict of interest 28 University of Ghana http://ugspace.ug.edu.gh CHAPTER FOUR RESULTS 4.0 Introduction This chapter presents the findings of the study. This study used primary data collected from post-severe burns patients at the Burns Center of the Korle-Bu Teaching Hospital, Accra, Ghana to assess the determinants of quality of life. 4.1 Demographic and Socioeconomic Characteristics of study participants A total of 147 post severe burns patients were recruited and they all completed the questionnaire making a response rate of 100%. Table 2 shows the demographic and socio-economic characteristics of post-severe burns injured persons. The mean age of the participants was 42.3 (SD ± 1.2) years, with a minimum of 24 years and a maximum of 72 years. More than one-third 52 (35.4%) of the participants belonged to the age group 21-30 years. Out of the total participants, more than half 97(66.0%) were married and 52 (35.4%) were in Middle/JHS/JSS. Also, 51 (34.6%) of the participants were unemployed. Out of the 32 participants employed 14 (43.8%) were either professional, technical, or managerial. Also, out of the participants employed, 30 (93.8%) reported that the injury affected their ability to work and 21 (65.6%) reported that the injury has made them unable to work. More than two-fifth 68(46.2%) of the participants belonged to a family with medium wealth status. Furthermore, approximately half 73 (49.7%) of the participants visited the burns injury center via public transport. 29 University of Ghana http://ugspace.ug.edu.gh Table 2: Demographics and socio-economic characteristics of study participants Characteristics Frequency Percentage (%) N=147 Socio-demographics characteristics Sex 95 64.6 Male 52 35.4 Female Age Mean (± SD) 42.3 (± 1.2) 21-30years 52 35.4 31-40years 27 18.4 41-50years 20 13.6 51-60years 28 19.0 >60 years 20 13.6 Marital Status Single (Widow/Separated/Not Married) 50 34.0 Married 97 66.0 Educational level No Formal Education 42 28.6 Primary 15 10.2 Middle/JHS/JSS 52 35.4 Secondary (SSS/SHS/Technical/Vocational) 26 17.6 Tertiary 12 8.2 Employment Status Unemployed 51 34.6 Student/Apprenticeship 42 28.6 Employed 32 21.8 Retired 22 15.0 Type of occupation employed (N=32) Professional/Technical/Managerial 14 43.8 Clerical 4 12.4 Sales and Services 2 6.2 Skilled Manual 6 18.8 Unskilled Manual 4 12.5 Agriculture 2 6.3 Injury affected ability to work (N=32) No 2 6.3 Yes 30 93.8 Effect of injury to ability to work (N=32) Work part-time 11 34.4 Unable to work 21 65.6 Socio-economic characteristics Wealth Index Poor 43 29.3 Medium 68 46.2 Rich 36 24.5 Means of transportation to burns center Walking 42 28.6 Taxi or bus 73 49.7 Own car 32 21.7 30 University of Ghana http://ugspace.ug.edu.gh 4.2 Proportion of Post Severe Burns Injured Adults The proportion of post severe burns injured adults was shown in Figure 2. Out of 163 study participants who had burns, 147(90.2%) of the participants had severe burns. 9.8% 90.2% Yes No Figure 2: Proportion of Post Severe Burns Injured Adults 4.3 Burn injury-related factors Table 3 shows the burns injury-related factors of study participants. About 41 (27.9%) of the participants were between 31-40 years at burn injury. The mean age at burn was 41.0 (SD ± 14.7) years. More than three-fourth 121 (82.3%) of the participants had burns less than a year with meantime since burn being 0.7 (± 0.4) years. This means that the average time since burn was approximately eight months ago. Fifty-two (35.4%) of the participants had an overall total body surface area burn of between 21% and 25% with a mean percentage of burn to be 0.15 (± 0.4). Majority 32 (21.8%) had the burn injury on their head and more than half 88 (59.9 %) had burns at home with 65 (44.2%) being hot objects and substance. 31 University of Ghana http://ugspace.ug.edu.gh More than three-quarters 122 (83.0%) reported that the severity of burn injury requires caregiving support for activities of daily living such as bathing, washing clothes, etc. Out of the participants who reported that caregiving support was needed for daily activities, more than three-quarters 101 (82.8%) received needed caregiving support. Out of the participants who received caregiving support 71 (70.3%) had their caregiving support paid and more than half 41 (57.8%) had their paid support from the family. Majority 14 (34.2%) of the support from the family was from the parent. Also, 83 (56.5%) of the participants had complications as a result of the burns injury and 46 (55.4%) suffered from Hypertrophic Scars. Out of those who had complications as a result of burn injury, 60 (72.3%) visited a health facility for other forms of treatment. Table 3: Burn injury related factors of study participants Characteristics Frequency Percentage (%) Age at burn Mean (± SD) 41.0 (± 14.7) 21-30years 39 26.5 31-40years 41 27.9 41-50years 19 12.9 51-60years 26 17.7 >60 years 22 15.0 Time since burn Mean (± SD) 0.7 (± 0.4) ≤ 1 year 121 82.3 >1 year 26 17.7 Total body surface area burns Mean (± SD) 0.15 (± 0.1) 5-10% 9 6.0 11-15% 48 32.7 16-20% 21 14.3 21-25% 52 35.4 >25% 17 11.6 Site of injury Head 32 21.8 Face 30 20.4 Neck 12 8.2 Arm 25 17.0 Leg 22 15.0 Foot 6 4.1 Trunk 9 6.0 Genitals 11 7.5 32 University of Ghana http://ugspace.ug.edu.gh Table 3: Burn injury related factors of study participants (Continued) Characteristics Frequency Percent (%) Circumstances of injury Home 88 59.9 Workplace 33 22.4 Roadside 26 17.7 Etiology of burns Electric 43 29.3 Hot objects or Substance 65 44.2 Open flame 39 26.5 Severity of burn injury requires care giving support for activities of daily living (e.g. bathing, washing clothes, etc.) 25 17.0 No Yes 122 83.0 Received needed caregiving support (N=122) No 21 17.2 Yes 101 82.8 The caregiving support was paid (N=101) No 30 29.7 Yes 71 70.3 People or organizations responsible for payment of support (N=70) Family 41 57.8 Government 12 16.9 NGO 6 8.5 Workplace 8 11.2 Religious organization 4 5.6 Family responsible for caregiving support (N=41) Siblings 9 22.0 Spouse 10 24.4 Children 8 19.5 Parent 14 34.2 Had complications as a result of the burns injury (N=147) No 64 43.5 Yes 83 56.5 Kind of complications as a result of burn injury (N=83) Hypertrophic Scars 46 55.4 Contractures 11 13.3 Loss of a part 10 12.1 Ectropion 6 7.2 Majorine Ulcers 7 8.4 Syndactyly 3 3.6 Visited health facility for other treatments as a result of the complications (N=83) No 23 27.7 Yes 60 72.3 33 University of Ghana http://ugspace.ug.edu.gh 4.4 Quality of Life The BSHS-B is a reliable and valid tool which can give valuable insight into a breadth and depth of burn patient experience assessing nine main domains describing Physical Function, Work, Interpersonal Relationships and Treatment Regimens. Each question is answered on a Likert scale of 0–4 with a maximum total score of 160 points and a high score indicative of the high quality of life. Table 4 shows the proportion of quality of life of study participants. From Table 4, Out of 147 participants, 4 (2.7%) of the participants had low quality of life, 138 (93.9%) of the participants had moderate quality of life, and 5 (3.4%) of the participants had high quality of life. Table 4: The proportion of quality of life of Participants Quality of Life Frequency Percent (%) Low 4 2.7 Moderate 138 93.9 High 5 3.4 Table 5 shows the domain scores of the quality of life of participants. The highest scoring domain for quality of life was "simple abilities" with mean 3.531 (SD± 0.50) while the lowest scoring domain was observed to be "work" with mean 2.325 (SD± 1.375). The overall quality of life of post severe burn-injured patients at Korle-Bu Teaching Hospital had mean 3.195 (SD±0.48). This means that, generally, post-burn- injured patients have moderate quality of life score indicating fewer problems. 34 University of Ghana http://ugspace.ug.edu.gh Table 5: Domain scores of qualities of life Construct Mean Standard Deviation Affect 2.551 1.405 Health Sensitivity 2.460 1.102 Hand Function 2.352 1.346 Treatment Regimens 2.651 1.193 Work 2.325 1.375 Sexuality 2.451 1.226 Interpersonal Relationship 2.847 1.114 Simple Abilities 3.531 0.500 Body Image 3.293 0.717 Total 3.195 0.84 4.5 Regression Analysis Results Before examining the association between the independent variables and outcome variable, the assumptions of multiple linear regression were tested. The response variable is quality of life among post-severe burns patients at the Burns Center of the Korle-Bu Teaching Hospital, Accra, Ghana. The Durbin Watson (D-W) and Variance Inflation Factor (VIF) statistics were used to check the presence of autocorrelation and multicollinearity respectively in the data. Table 6 shows the overall fit statistics. From Table 6, the adjusted coefficient of determination which is adjusted R-square was identified to be 0.8389. This shows that 83.89% of the variance in the quality of life of post-severe burns patients was explained by the independent variables (socio- demographic factors and injury-related factors). The Durbin-Watson, d = 1.726 indicates that there is no collinearity since the value is between the two critical values of 1.5 < d < 2.5, suggested by Makridakis and Wheelwright (1978). 35 University of Ghana http://ugspace.ug.edu.gh Table 6: Model Summary R R Square Adjusted R Square Std Error of Estimate Durbin-Watson 0.901 0.812 0.8389 1.214 1.726 Table 7 shows the Analysis of Variance results which are employed to assess the significance of R square. The F-ratio in Table 7 tests whether the overall regression model is a good fit for the data. The null hypothesis of the F-test is that there is no linear association between socio-demographic factors, injury-related factors, and quality of life among post-severe burns patients. That is, testing the null hypothesis of R²=0. The independent variables statistically and significantly influence the dependent variable, F (35,88) = 1.33, p<0.000. Hence, the F test endorses the strength of the contribution of demographic and socio-economic factors and injury-related factors to the quality of life among post-severe burns patients. Table 7: Analysis of Variance Model Sum of Df Mean Square F Significance Squares Regression 0.8877 33 0.0269 1.33 0.000 Residual 1.7759 88 0.0202 Total 175.592 121 From Table 8, it is observed that the VIF for socio-demographic factors and injury- related factors were within the boundary, suggesting no multicollinearity in the data. The highest VIF statistics detected in the study was 1.452 for Middle/JHS/SSS and the lowest VIF statistics detected was 1.25 for the foot. The study found that sex, educational level, wealth index, means of transportation, employment status, age at burning, total body surface area burns, and etiology have an association with quality of life of post-burn-injured persons. 36 University of Ghana http://ugspace.ug.edu.gh Participants who are females have a lower quality of life after burn injury compared to participants who are males, which was statistically significant ( ). Participants who had attained secondary education have a higher quality of life after burn injury compared to participants who have no formal education, which was statistically significant ( . Also, participants who are retired had a higher quality of life after burn injury compared to unemployed participants, which are statistically significant ( ). Furthermore, participants who are classified as rich had a higher quality of life after burn injury compared to participants who are classified as poor, which are statistically significant ( ). Participants whose age at burns was more than 60 years had a higher quality of life after burn injury compared to participants who belong to the age group 20-30 years, which are statistically significant ( ). Participants whose total burn surface area is between 21-25% had a lower quality of life after burn injury compared to participants whose total burn surface area was 5- 10%, which are statistically significant ( ). Participants whose cause of burn was electric had a lower quality of life after burn injury compared to participants whose cause of burn was chemical, which are statistically significant ( ). 37 University of Ghana http://ugspace.ug.edu.gh Table 8: Multiple Linear Regression Analysis Results Variables Coefficient 95% CI P>z VIF Sex Male Ref Female -0.056 -0.34, 0.023 0.008** 1.45 Educational level No Formal Education Ref Primary -0.085 -0.15, -0.003 0.197 1.32 Middle/JHS/JSS -0.055 -0.062, -0.015 0.200 2.32 Secondary 0.149 0.043, 0.218 0.001** 1.72 (SSS/SHS/Technical/Vocational) Tertiary -0.053 -0.133, 0.011 0.327 2.00 Employment Status Unemployed Ref Student/Apprenticeship 0.0243 0.007, 0.059 0.607 2.25 Employed -0.0008 -0.045, 0.013 0.986 1.49 Retired 0.097 0.057, 0.192 0.004** 2.19 Wealth Index Poor Ref Medium 0.027 0.008, 0.625 0.579 1.70 Rich 0.018 0.001, 0.263 0.021** 1.61 Means of transportation Walking Ref Taxi or bus 0.019 0.004, 0.117 0.617 1.62 Own car 0.070 0.002, 0.169 0.065 1.9 Age at burn 21-30years Ref 31-40years 0.017 0.012, 0.413 0.682 1.63 41-50years 0.089 0.049, 0.201 0.071 1.35 51-60years -0.012 -0.052, 0.001 0.813 1.93 >60 years 0.111 0.049, 0.362 0.026** 1.26 Time since burn Mean ≤ 1 year Ref >1 year 0.053 0.036, 0.285 0.145 1.48 Total body surface area burns 5-10% Ref 11-15% -0.118 -0.205, -0.004 0.263 1.65 16-20% -0.0655 -0.132, -0.002 0.620 1.39 21-25% -0.057 -0.096, -0.001 0.002** 1.71 >25% -0.136 -0.193, -0.002 0.155 1.43 Site of injury Head Ref Face -0.056 -0.095, -0001 0.308 1.72 Neck 0.013 0.006, 0.027 0.812 1.33 Arm 0.026 0.017, 0.093 0.604 1.61 Leg 0.023 0.012, 0.087 0.661 1.57 Foot -0.061 -0.089, -0.013 0.495 1.23 Trunk -0.061 -0.097,-0.009 0.290 1.45 Genitals 0.006 0.003, 0021 0.920 1.82 38 University of Ghana http://ugspace.ug.edu.gh Table 8: Multiple Linear Regression Analysis Results (Continued) Variables Coefficient 95% CI P>z VIF Circumstances of injury Home Ref Workplace -0.028 -0.035, -0.005 0.465 1.39 Roadside -0.004 -0.016, 0.018 0.910 1.25 Etiology of burns Chemical Ref Electric -0.103 -0.139, -0.019 0.009** 1.63 Open flame -0.063 -0.088, -0.016 0.101 1.92 Care giving support required for daily activities due to severity of burn injury No Yes 0.0040 0.001, 0.012 0.465 1.37 0.05