Physical Injuries and Burns among Refugees in Lebanon: Implications for Programs and Policies

doi:10.21203/rs.3.rs-2062219/v1

Background: Refugees are prone to injury due to often austere living conditions, social and economic disadvantages, and limited access to health care services in host countries. This study aims to systematically quantify the prevalence of physical injuries and burns among the refugee community in Western Lebanon and examine injury characteristics, risk factors, and outcomes.

Methods: We conducted a cluster-based population survey across 21 camps in the Beqaa region of Lebanon from February to April 2019. A modified version of the ‘Surgeons Overseas Assessment of Surgical Need (SOSAS)’ tool (Version 3.0) was administered to the head of the refugee households and documented all injuries sustained by family members over the last 12 months. Descriptive and univariate regression analyses were performed to understand the association between variables.

Results: 750 heads of households were surveyed. 112 (14.9%) households sustained injuries in the past 12 months, 39 of which (34.9%) reported disabling injuries that affected their work and daily living. Injuries primarily occurred inside the tent (29.9%). Burns were sustained by at least one household member in 136 (18.1%) households in total. The majority (63.7%) of burns affected children under 5 years and were mainly due to boiling liquid (50%). Significantly more burns were reported in households where caregivers cannot lock children outside the kitchen while cooking (25.6% vs 14.9%, p-value=0.001). Similarly, households with unemployed heads had significantly more reported burns (19.7% vs 13.3%, p-value=0.05). Nearly 16.1% of the injured refugees were unable to seek health care due to the lack of health insurance coverage and financial liability.

Conclusions: Refugees severely suffer from injuries and burns, causing substantial human and economic repercussions on the affected individuals, their families, and the host healthcare system. Resources should be allocated toward designing safe camps as well as implementing educational awareness campaigns specifically focusing on teaching heating and cooking safety practices.

Refugee

Injury

Burn

Prevention

Lebanon

Injury is the leading cause of death and disability in people under the age of 44 (1, 2). While high-income countries (HICs) demonstrated a steady decrease in the rate of injuries with time, low- and middle-income countries (LMICs) showed an increasing trend (3). This can be attributed to multiple reasons, particularly due to the absence of safety regulations and injury prevention strategies in many LMICs (4).

The Eastern Mediterranean Region (EMR) has the highest rate of injuries related to deaths and disability-adjusted life years (DALYs) among LMICs, particularly injuries related to road traffic crashes and violence (5–7). According to the Global Burden of Disease (GBD 2019), injury-related deaths in the EMR were estimated at 56.2 per 100,000, ranking 4th compared to global rates (8). Wars and regional conflicts have exacerbated injury prevalence in many EMR countries and rendered the provision of healthcare services limited, if not, scarce, particularly in war-affected regions (9). The recent Syrian conflict has resulted in what has been classified as the worst humanitarian crisis in history (10), with millions of individuals displaced internally or seeking refuge in bordering countries (11).

Lebanon has taken in the highest number of Syrian refugees relative to its population, estimated at nearly 30% of its current population (12). The refugee crisis has strained the already fragile Lebanese healthcare system. Several studies have demonstrated a high prevalence of communicable disease (10, 13–15), and injuries of varying etiologies among the refugee community (i.e. camp burns secondary to open-flame cooking) (16, 17).

Few studies have examined the physical trauma and injury burden sustained by refugee communities, particularly in the EMR (15, 18). Global health has traditionally focused on communicable diseases with limited attention dedicated to injuries (19). The main objective of this study is to quantify and describe the injury burden among a refugee community in the Northern Beqaa region of Lebanon and offer insights into the injuries' characteristics, extent, risk factors, and outcomes. Understanding the frequency and severity of refugees’ injuries is vital to the planning of injury prevention programs, mitigation of injury impact on the refugee community, and for reducing the strain on the Lebanese healthcare system.

Study Design and Tool adopted

The study was designed as a cross-sectional cluster-based population survey. The Surgeons Overseas Assessment of Surgical Need (SOSAS) tool (Version 3.0) (www.surgeonsoverseas.org) was used to collect data from 21 refugee camps across the Beqaa Valley in Lebanon. This survey is a validated, cluster-based, cross-sectional tool designed based on the Demographic and Health Surveys (DHS) guidelines and the World Health Organization (WHO) guidelines for conducting community surveys for injuries and violence to determine the burden of surgical conditions within a community (20–24). Minor modifications were applied to contextualize the tool, tailor it to the Syrian refugee population and expand it to collect specific data on physical injuries and burns. For this study, a burn injury was captured independently and not considered under the umbrella of physical injuries.

Data Collection

The survey was administered to the head of the refugee household here all injuries sustained by family members over the last 12 months were recorded. A total of 750 households were conveniently sampled by selecting the 4th residence along the most accessible major routes. If the tent was vacant or absent of adults, the next residence along the route was selected. Participants provided verbal informed consent prior to their participation.

Four bilingual research assistants familiar with the local geography, culture, and Arabic language were recruited and trained to administer the SOSAS questionnaire. The training of data collectors was conducted over a period of two weeks and included simulated practice sessions with role-playing followed by a supervised data collection process at campsites for the initial phases of the study. Data collection took place over three months between February - April 2019.

The study was approved by the American University of Beirut Institutional Review Board (SBS-2018-0561).

Statistical Analysis

The Statistical Package for Social Sciences (SPSS) (version 24) (IBM Corp., Armonk NY, USA) was used for data management and analyses. A descriptive analysis was performed. Continuous data were reported as means with standard deviations, and comparisons were made using the independent t-test. Categorical data were reported as counts with proportions and comparisons reported using the Chi-Square test, or the Fisher's exact test, as appropriate. A two-sided p-value < 0.05 was used to indicate statistical significance.

Missing data was encountered secondary to an incomplete response rate for all questions. Only collected data were analyzed, and no imputation techniques were used for any missing responses. The percentage of missing data for each variable is underlined in the footnote of its respective table.

Demographics

A total of 750 heads of households were surveyed. The mean number of individuals per household/informal tented settlement (ITS) was 6.4. The mean age of individuals in each household was 20.4 years (Fig. 1). Syrian governorates of origin were diverse with Aleppo (31.7%) and Raqqa (30.0%) being the most highly represented region, followed by Homs (12.2%), Idleb (11.3%), and Hama (7.5%). The average length of stay in Lebanon was 5 years (+/- 2.5). The majority of refugees were illiterate (59.0%) and nearly (72.2%) were unemployed.

Prevalence of Physical Injury

A total of 112 households (14.9%) reported sustaining an injury within the past year. Of these, 18 (16.1%) reported being unable to seek healthcare services due to a lack of financial means.

Injuries were sustained at multiple locations with the highest being inside the tent (29.9%) and on the road (28.6%) (Table 1). Twenty-two (19.6%) injuries were classified as occupational. Road traffic injuries (RTI) were sustained in 19 households (17%), as mostly (73.7%) were due to a motorcycle crash. None of the injured refugees were adopting any safety measures while driving.

Table 1

Injury distribution in distinct locations.
Location	Number (%)
On camp (Inside Tent)	23 (29.9)
On camp (Outside Tent)	10 (13)
Road	22 (28.6)
Field	3 (3.9)
Other	19 (24.7)

The long-term effect of injuries varied, with 70 (62.5%) injuries reported as non-disabling, 39 (34.9%) injuries affected individuals’ work and daily living, and 3 (2.7%) injuries were reported as having a psychological impact (i.e. feeling ashamed) (Fig. 2).

Prevalence of Burns

A total of 136 households (18.1%) reported a burn to one of the household/tent members. Of those suffering from burns, 67 (53.6%) were males and 58 (46.4%) were females. The mean age of the injured individual was 8.2 years (± 12.4) and the majority (63.7%) of burns were incurred by children less than 5 years. Burns affected different body parts, with the highest rate affecting the hand/arm (50%), leg (19.4%), and face (11.3%) (Table 2).

Table 2

Burns distribution on body parts.
Body Part	Number (%)
Hand	36 (29)
Face	14 (11.3)
Arm	26 (21)
Leg	24 (19.4)
Foot	13 (10.5)
Multiple	11 (8.9)
*12 burns unknown

Half of the burns (49.6%) were caused by direct contact with a boiling liquid, 30.9% by contact with hot objects, and 13.8% by contact with an open flame. The mode and location of cooking varied amongst households. While 78.4% of households use propane for cooking, 21.6% use an open flame. Most cooking occurred inside tents (77%). The chi-squared test showed significance when examining ‘Burn’ and ‘No Burn’ among refugees’ households. There was no significant association between the mode or location of cooking and sustaining a burn injury (Table 3). Of the 750 households, 227 (30.3%) reported the inability of child lockout while cooking. Those tents had significantly higher reported burn cases (25.6% vs 14.9%, p = 0.001). Households with an unemployed head member were more likely to sustain more burns (19.7% vs 13.3%, p-value = 0.05), compared to employed households (Table 3).

Table 3

Incidence of burns in association with different tent-related variables.
Variable		Number (%)		p-value
Variable		Burn	No Burn
Tents		136	614
Mode of Cooking	Propane	79 (18.2)	356 (81.8)	0.204
Mode of Cooking	Open Flame	28 (23.3)	92 (76.7)	0.204
Location of Cooking	Indoor	78 (18.2)	351 (81.8)	0.187
Location of Cooking	Outdoor	30 (23.4)	98 (76.6)	0.187
Child Locked	Yes	78 (14.9)	445 (85.1)	0.001
Child Locked	No	58 (25.6)	169 (74.4)	0.001
Employed Household	Yes	24 (13.3)	147 (86.7)	0.05
Employed Household	No	112 (19.7)	457 (80.3)	0.05
Literate Household	Yes	36 (14.8)	207 (85.2)	0.102
Literate Household	No	100 (19.7)	407 (80.3)	0.102
195 tents have an unknown mode of cooking 193 tents have an unknown location for cooking

This study examined the characteristics, risk factors, and outcomes of injuries affecting the refugee community in Lebanon. Refugee status increases individuals’ risk of sustaining various injuries, particularly those associated with overcrowded living conditions and hazardous work environments. This study provides evidence on the prevalence of injuries and burns among refugees, which in turn helps to tailor data-driven injury prevention programs and strategies applicable to the context of refugees. These preventive measures attempt to mitigate the injury burden on the refugee community and reduce the demand for health and rehabilitation services in host healthcare systems (16, 25, 26).

This study aligns with existing literature and confirms the high prevalence of injuries among the refugee population in Lebanon (18, 27, 28). A recent local study indicated that a high proportion of medical care services provided to adult Syrian refugees are related to injuries, compared to those provided to local residents in Lebanon (18, 27, 28). Moreover, injuries were the leading cause of hospitalization among refugees, accounting for nearly 19.8% of hospitalizations compared to 14.9% among the host community (29). This discrepancy in injury rates has been documented in various countries; a Canadian study reported an increased rate of motor vehicle injuries, poisoning, suffocation, and overall injury-related hospitalization and mortality among refugees (27). A similar study conducted in Denmark revealed high rates of fatal injuries among refugees (30).

Household injuries were mostly reported in this study. Most refugee injuries occurred in tents (29.9%), further highlighting the refugees’ suboptimal housing conditions, overcrowded households, and adjacently installed tents. Diminished housing conditions and the absence of safety measures in camps are major contributors to the high prevalence of injuries among refugees (17). RTI (17%) represented another major contributor to the refugee injury burden. A similar estimate (19%) of RTI was reported among Afghan refugees in Pakistan (31). The adoption of safety measures (e.g., wearing helmets, and safety gear) were nearly absent among injured individuals.

Limited access to healthcare services hinders refugees’ ability to obtain timely care following an injury. 16% of the refugees who reported an inability to afford injury-related treatment underscore refugees’ social and economic disadvantages and their impact on health. Refugees often suffer from a lack of knowledge on how to navigate the healthcare system in host countries, and how to benefit from available health services, which ultimately adds yet another barrier to healthcare access (32, 33).

With the fragile, highly privatized, and under-resourced healthcare system available in Lebanon, providing care to the local population is already a challenge that is exacerbated by the refugee crisis (34). This under-resourced healthcare system, particularly in refugee areas, coupled with refugees’ increased need for healthcare services beyond that of the local population, worsens the economic burden of refugee communities on the host healthcare system (35, 36). Refugees are forced to cover their health expenses, and often resort to borrowing money to cover their out-of-pocket expenditures for injury treatment.

Findings from this study confirm the high prevalence of serious injuries leading to varying levels of physical impairment that affect refugees’ daily living activities. Many of the reported injuries result in severe prognoses, which may lead to permanent disabilities. This would limit the integration of refugees into the workforce and accordingly limit their financial capabilities, further increasing refugees’ burden on host countries. A study in war-torn Baghdad found the rates of permanent disabilities following unintentional injuries were as high as 56% (28). A similar trend was found in the United Kingdom among a population of refugees and migrants with 38% of head injuries causing persisting disability (37).

Similar to physical injury, burns were also a common health problem among refugees with a prevalence of over 18%. This rate is comparable to other refugee populations: 11% among Afghan refugees in Pakistan, 17% among Syrian refugees in Turkey, and 7% among Syrian refugees in Belgium (18, 31, 38). Refugees’ parental education levels (e.g., illiteracy), cultural practices (e.g., child supervision, cooking traditions), and housing conditions (e.g. overcrowded, unsafe heating techniques) are known to be risk factors that increase the risk of sustaining injuries among refugees (39, 40). Camps are often used long beyond their temporary design intention leading to structural failures that often compromise safety. Results of this study show that unemployment and the inability to keep children away from cooking areas are associated with a higher prevalence of burns. Notably, the number of burn injuries was higher in households adopting unsafe cooking practices using open flames instead of propane, however, this association was not statistically significant. Similarly, burn case numbers were higher among households where the head of household claimed illiteracy, but again, this was not statistically significant.

Based on the study findings, a series of recommendations to help reduce and control injuries among refugees can be proposed. First, refugee camps should be designed with high safety standards focused on avoiding injuries and burns (e.g., a larger lot for each tent to reduce family overcrowding and build camps away from major highways to reduce RTI). Second, a special focus should be given to the safe placement of heating and cooking appliances within camps. Tailored training on safe cooking practices should be considered.

Third, adequate Occupational Health and Safety (OHS) training should be provided, focusing on industrial and other high-risk work environments. Finally, refugees should be educated on how to access the local healthcare system and informed of methods for obtaining financial support for health-related needs.

To our knowledge, this is the first study to quantify physical injuries and burns among Syrian refugees in Lebanon which has the highest Syrian refugee per capita density. The results of our study can be generalizable to other refugee populations in the Middle East and Northern African (MENA) region, which share many cultural practices and living conditions. This study has several notable limitations. First, data is largely self-reported by household members. Recall bias must be considered as the collected information spans over twelve months. Second, data underreporting is considered another possible limitation of this study. This, however, might be mitigated by social concerns and fear of the stigma that may lead to underreporting of injury-related disabilities, particularly those affecting women and children.

Refugees suffer from a high burden of injuries and burns in Lebanon, with substantial human and economic repercussions on families and the host healthcare system. This study provides ground evidence for the development injury prevention programs targeting refugees. Education on safety guidelines and preventive measures should be introduced as standard protocols among the refugee community. Resources should be allocated for safe camp design, with a special focus on heat appliances and cooking methods. Further research is needed to understand the circumstances surrounding distinct types of injuries among refugees.

DALYs: Disability-Adjusted Life Years

DHS: Demographic and Health Surveys

EMR: Eastern Mediterranean Region

GBD: Global Burden of Disease

HICs: High-Income Countries

ITS: Informal Tented Settlement

LMICs: Low- and Middle-Income Countries

MENA: Middle East and Northern African

OHS: Occupational Health and Safety

RTI: Road traffic injuries

SOSAS: Surgeons Overseas Assessment of Surgical Need

SPSS: Statistical Package for Social Sciences

WHO: World Health Organization

Ethics Approval and Consent to Participate

The American University of Beirut Institutional Review Board approved the study (SBS-2018-0561). Consent was deemed applicable by the committee. All participants were above 18 and were carefully briefed about this study. Written informed consent was obtained from all participants. All methods were performed in accordance with the ethical standards as laid down in the Declaration of Helsinki and its later amendments or comparable ethical standards.

Consent for Publication

Not applicable.

Availability of Data and Material

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

Competing Interests

The authors declare that they have no competing interests.

Funding

This study did not receive funds.

Authors' Contributions

S.A. drafted the manuscript. M.EH., M.C., and A.N. conducted the data analysis and contributed to the drafting of the manuscript. M.M. and H.K. conceptualized and designed the study, and reviewed and edited the manuscript. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

Acknowledgements

Not applicable.

Krug EG, Sharma GK, Lozano R. The global burden of injuries. Am J Public Health. 2000;90(4):523.
Peden M, Oyegbite K, Ozanne-Smith J, Hyder AA, Branche C, Rahman A, et al. World report on child injury prevention. World Health Organization Geneva; 2009.
Curry P, Ramaiah R, Vavilala MS. Current trends and update on injury prevention. Int J Crit Illn Inj Sci. 2011;1(1):57–65.
Norton R, Kobusingye O. Injuries. N Engl J Med. 2013;368(18):1723–30.
Mokdad AH, Moradi-Lakeh M, Charara R, El Bcheraoui C, Khalil I, Afshin A, et al. Intentional injuries in the Eastern Mediterranean Region, 1990â 2015: findings from the Global Burden of Disease 2015 study. Int J public health. 2018;63:39–46.
Transport injuries and deaths in the Eastern Mediterranean Region. : findings from the Global Burden of Disease 2015 Study. Int J Public Health. 2018;63(Suppl 1):187–98.
Al-Hajj S, El Bcheraoui C, Daoud F, Khalil I, Moradi-Lakeh M, Abu-Raddad LJ, et al. Child and adolescent injury burden in the eastern mediterranean region: Findings from the Global Burden of Disease 1990–2017. BMC Public Health. 2020;20(1):433.
Collaborators GDaI. Global burden of 369 diseases and injuries in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet. 2020;396(10258):1204–22.
Watts S, Siddiqi S, Shukrullah A, Karim K, Serag H. Social Determinants of Health in Countries in Conflict: The Eastern Mediterranean Perspective. Cairo, Egypt: Commission on Social Determinants of Health, Health Policy and &#8230.
Hermans MP, Kooistra J, Cannegieter SC, Rosendaal FR, Mook-Kanamori DO, Nemeth B. Healthcare and disease burden among refugees in long-stay refugee camps at Lesbos, Greece. Eur J Epidemiol. 2017;32(9):851–4.
Khalid I, Abbassi MR. United Kingdom's Foreign Policy towards Syrian Refugees. Journal of Political Studies. 2017;24(1).
Ammar W, Kdouh O, Hammoud R, Hamadeh R, Harb H, Ammar Z, et al. Health system resilience: Lebanon and the Syrian refugee crisis. J Glob Health. 2016;6(2):020704.
Wilhelm T, Post S. Globalization: challenges in abdominal surgery for migrants and refugees. Der Chirurg; Zeitschrift fur alle Gebiete der operativen Medizen. 2018;89(3):197–204.
Fouad FM, Sparrow A, Tarakji A, Alameddine M, El-Jardali F, Coutts AP, et al. Health workers and the weaponisation of health care in Syria: a preliminary inquiry for The Lancet-American University of Beirut Commission on Syria. Lancet. 2017;390(10111):2516–26.
Al-Hajj S, Pike I, Oneissi A, Zheng A, Abu-Sittah G. Pediatric Burns Among Refugee Communities in Lebanon: Evidence to Inform Policies and Programs. J Burn Care Res. 2019;40(6):769–75.
Yanar B, Kosny A, Smith PM. Occupational health and safety vulnerability of recent immigrants and refugees. Int J Environ Res Public Health. 2018;15(9):2004.
Atiyeh BS, Gunn SWA. Refugee camps, fire disasters and burn injuries. Ann Burns Fire Disasters. 2017;30(3):214–7.
Duzkoylu Y, Basceken SI, Kesilmez EC. Physical Trauma among Refugees: Comparison between Refugees and Local Population Who Were Admitted to Emergency Department-Experience of a State Hospital in Syrian Border District. J Environ Public Health. 2017;2017:8626275.
De Cock KM, Simone PM, Davison V, Slutsker L. The new global health. Emerg Infect Dis. 2013;19(8):1192–7.
Groen RS, Samai M, Stewart KA, Cassidy LD, Kamara TB, Yambasu SE, et al. Untreated surgical conditions in Sierra Leone: a cluster randomised, cross-sectional, countrywide survey. Lancet. 2012;380(9847):1082–7.
Petroze RT, Groen RS, Niyonkuru F, Mallory M, Ntaganda E, Joharifard S, et al. Estimating operative disease prevalence in a low-income country: results of a nationwide population survey in Rwanda. Surgery. 2013;153(4):457–64.
Petroze RT, Calland JF, Niyonkuru F, Groen RS, Kyamanywa P, Li Y, et al. Estimating pediatric surgical need in developing countries: a household survey in Rwanda. J Pediatr Surg. 2014;49(7):1092–8.
Gupta S, Shrestha S, Ranjit A, Nagarajan N, Groen RS, Kushner AL, et al. Conditions, preventable deaths, procedures and validation of a countrywide survey of surgical care in Nepal. Br J Surg. 2015;102(6):700–7.
Grimes CE, Henry JA, Maraka J, Mkandawire NC, Cotton M. Cost-effectiveness of Surgery in Low- and Middle-income Countries: A Systematic Review. World J Surg. 2014;38(1):252–63.
Yalçın S. Syrian child workers in Turkey. Turkish Policy Quarterly. 2016;15(3):89–98.
Khater LB. Labour policy and practice. The Peace Building in Lebanon. 2017;16(4).
Saunders NR, Macpherson A, Guan J, Guttmann A. Unintentional injuries among refugee and immigrant children and youth in Ontario, Canada: a population-based cross-sectional study. Inj Prev. 2018;24(5):337–43.
Lafta R, Al-Shatari S, Cherewick M, Galway L, Mock C, Hagopian A, et al. Injuries, Death, and Disability Associated with 11 Years of Conflict in Baghdad, Iraq: A Randomized Household Cluster Survey. PLoS ONE. 2015;10(8):e0131834.
Monde JhUBSoPhMD. Syrian refugee and Affected Host Population Health Access Survey in Lebanon. Report; 2015.
Norredam M, Olsbjerg M, Petersen JH, Laursen B, Krasnik A. Are there differences in injury mortality among refugees and immigrants compared with native-born? Inj Prev. 2013;19(2):100–5.
Hyder AA, Ghaffar A, Masud TI, Bachani AM, Nasir K. Injury patterns in long-term refugee populations: a survey of Afghan refugees. J Trauma Acute Care Surg. 2009;66(3):888–94.
Cherri Z, Arcos González P, Castro Delgado R. The Lebanese-Syrian crisis: impact of influx of Syrian refugees to an already weak state. Risk Manag Healthc Policy. 2016;9:165–72.
Blanchet K, Fouad FM, Pherali T. Syrian refugees in Lebanon: the search for universal health coverage. Confl health. 2016;10(1):1–5.
Kronfol NM. Rebuilding of the Lebanese health care system: health sector reforms. East Mediterr Health J. 2006;12(3–4):459–73.
Kaafarani HMA, Khalifeh JM, Ramly EP, Simon D, Safa R, Khalil L, et al. A Nationwide, Systematic, and Comprehensive Assessment of Surgical Capacity in Lebanon: Results of the Surgical Capacity in Areas With Refugees (SCAR) Study. Ann Surg. 2019;269(6):1206–14.
Burnett A, Peel M. Health needs of asylum seekers and refugees. BMJ. 2001;322(7285):544–7.
Doherty SM, Craig R, Gardani M, McMillan TM. Head injury in asylum seekers and refugees referred with psychological trauma. Glob Ment Health (Camb). 2016;3:e28.
van Berlaer G, Bohle Carbonell F, Manantsoa S, de Béthune X, Buyl R, Debacker M, et al. A refugee camp in the centre of Europe: clinical characteristics of asylum seekers arriving in Brussels. BMJ Open. 2016;6(11):e013963.
Mayes S, Roberts MC, Stough CO. Risk for household safety hazards: Socioeconomic and sociodemographic factors. J Saf Res. 2014;51:87–92.
Beiki O, Karimi N, Mohammadi R. Parental educational level and injury incidence and mortality among foreign-born children: a cohort study with 46 years follow-up. J Inj Violence Res. 2014;6(1):37–43.

No competing interests reported.

Physical Injuries and Burns among Refugees in Lebanon: Implications for Programs and Policies

Status:

Journal Publication

Version 1

Abstract

Figures

Background

Methods

Study Design and Tool adopted

Data Collection

Statistical Analysis

Results

Demographics

Prevalence of Physical Injury

Prevalence of Burns

Discussion

Conclusions

Abbreviations

Declarations

References

Additional Declarations

Status:

Journal Publication

Version 1