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Perceptions and Experiences of Female Burn Survivors with Facial Disfigurement

Zainab Habib*

Institute of Applied Psychology, University of Punjab, Lahore, Pakistan

*Corresponding Author:
Zainab Habib
Zainab Habib, Institute of Applied Psychology
University of Punjab, Lahore, Pakistan
Tel: 923004810969
E-mail: [email protected]

Received Date: July 13, 2019 Accepted Date: July 29, 2019 Published Date: August 09, 2019

Citation: Habib Z (2019) Perceptions and Experiences of Female Burn Survivors with Facial Disfigurement. Trauma Acute Care Vol.4 No.2: 72.

Copyright: © 2019 Habib Z. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

 
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Abstract

Objective: This study aimed at exploring the perceptions and experiences of female burn survivors with facial disfigurement.

Methodology: An interview protocol was developed based on piloting. In-depth interviews of five female burn survivors with facial disfigurement were taken from Lahore, Pakistan. The transcripts were analyzed using thematic analysis and four major themes were identified; physical appearance, post-traumatic growth, relationships, and coping/adjustment.

Results: The qualitative analysis reflected differences in attributional style, perceptions and individual experiences of burn survivors with facial disfigurement. It showed the importance of physical appearance for different individuals and how their life had changed for them after the burn injury.

Conclusion: Those who had embraced their visible differences post burn injury, exhibited a positive outlook towards life had strong family support, availability of resources and gratitude was more satisfied with their QoL. On the contrary, lack of family support, low self-esteem, and non-availability of resources resulted in dissatisfaction with life.

Keywords

Burn injury; Facial disfigurement; Quality of life; Physical appearance; Psychosocial; Life orientation; Relationships; Coping; Thematic analysis

Introduction

Going through any trauma is a daunting experience of our life e.g. death of a loved one, being in or seeing a genuine auto crash, severe damage (for example burns), significant medical problem (for example heart medical procedure), sexual or physical abuse and so on and so forth. Any such trauma is debilitating both physically and psychologically but experiencing burn injury especially facial burns are devastating for the person who goes through it that can impact the survivor’s life for a long time. For them, life takes a new turn encompassing lots of issues to go through be it physical, psychological or social. Keeping in view the implications of burn injury for women and its effects, the purpose of the current study was to explore the perceptions and experiences of female burn survivors with facial disfigurement. According to McQuaid, while understanding the consequences of any injury, and to put this in perspective, factual background information regarding the medical aspects of the injury is needed. For this reason, an introduction to the physical and psychological aspects of burn injuries is provided [1].

According to McQuaid to comprehend the outcomes of any damage, and to place this in context, truthful data with respect to the restorative parts of the damage is required. Thus, a detail of the burn wounds is as follows; Burn-from hot fluid, fire/ streak, electrical, substance (corrosive), and contacting hot items, e.g. hot steel. Burn injuries tend to damage the body's most important organ i.e. the skin. As the major tactile organ, the skin has numerous unpredictable capacities, for example, temperature guideline, security against disease and guideline of body liquids. It involves two layers; the dermis and the epidermis, and the nature and degree of burn damage relies upon the harm to either or both of these. Burn severity is dictated by the sum and profundity of skin influenced. The description of burn wounds is typically Total Body Surface Area Burned (TBSA) and depth of burn (degree or thickness) [1].

Burn injury is calculated through a percentage of the Total Body Surface Area (TBSA) affected. There are different methods for ascertaining this, contingent upon the age of the burn survivor. Standard diagrams partitioning the body into discrete zones are commonly utilized, and shading is utilized to demonstrate the degree (profundity) of the copy. A supportive model is that a hand is normally viewed as I% TBSA [1]. The duration and intensity of heat impact the degree of the injury. Two different ways are used for grouping this; by the level of the burn: first, second and third; or by the profundity of the burn: superficial, partial thickness and full thickness [1]. On the basis of the extent of the burn, it has been classified into 3 type’s i.e. first degree, second degree, and third-degree burn.

Newell, portrayed facial disfigurement in patients of burns as "the physical and psychological experience of a person whose face is scarred, blemished, or deformed due to burning injury".

Appearance change, for example, has a solid potential for modified self-perception, paying little respect to age [2].

MacGregor, expressed that the stress experienced by burn patients with facial disfigurement has been depicted as one of the main reasons for major psychosocial alterations causing social incapacity [3]. Burn patients with facial disfigurement are exposed to visual and verbal assaults, invasion of privacy, pity and ridicule from others, all of which create sentiments of disgrace, barrenness, outrage, and mortification. They have practically no security, typically embrace evasion practices, and live in a condition of psychological misery. They experience significant trouble in every social communication, particularly first-time gatherings.

Their facial disfigurement due to burn injury additionally impacts the well-being of the significant ones, who might be considerably more at risk to develop psychological issues than the individual who is had gone through a burn-related injury [4].

Burn injury with a facial disfigurement can impact one ’ s psychosocial adjustment in many ways which in turn can affect their overall well-being. Self-esteem is one such aspect the role of which is extremely important in the daily functioning of burn survivors. It refers to a person’s positive or negative appreciation of the different roles and domains of life [5,6]. The sense of pride in oneself is a prime constituent of positive selfperception. Positive self-esteem gives a feeling of security and leads to good health. It helps one in many ways to cope up with healthy functioning for example success, achievements, contentment, resilience, etc. For an individual with low selfesteem, he/she might face different kinds of problems which in return may lead to psychological disorders and social issues. Such problems eventually make such individuals go through personal suffering and misery. In extreme cases like burn injury which brings forth many challenges be it physical, psychological or social; they tend to affect the course of recuperation of burn survivors with low self-esteem [7]. Also, the extent of burn injuries strongly impacts the lives of burn survivors and their mental health predominantly if it is related to facial burns. In such cases, the patient is not only coping with his/her burn injury but at the same the stigma which is attached with facial disfigurement. They cope up with trauma, pain, wounds, scarring, amputations, and quality of life which affect their emotional, functional, and social adjustment and readjustment [8]. In such situations, stress is common especially when the survivors are aware of others perceptions towards their disfigured face [9]. Resultantly, they go through different kinds of psychological symptoms from mild to severe ones, for example; stress, fear, discomfort, sadness, and lack of selfconfidence leading to severe psychological symptoms like posttraumatic stress disorder, depression, anxiety, delirium, etc. Symptoms like these get worse aggressive not only due to the severity of burns but in most of the cases related to their visible differences [10].

The most common problems faced by burn survivors with facial disfigurement is interaction with people [11]. Meeting or interacting with people triggers anxiety in them as they apprehend stigmatizing behavior and other perceptions towards their visible differences. Thereby, this change in appearance from minute to drastic is complicated in nature as the survivors are not only dealing with their own body alterations but at the same time others’ reactions as well [12].

A large number of men and women go through such injuries and cope up with their self–esteem along with so many other issues. However, females tend to suffer more from psychological issues as their adjustment of the self-image gets altered after the burn injury and takes time to regain confidence [7]. Being a female, keeping in mind the certain standards set by society, they are strongly affected by the after-effects of burn injury thus hampering the way they see themselves and this also acts as an obstruction in their day to day tasks and chores. The can develop sleep disorders, phobias, depression, post-traumatic stress disorder, nightmares, and even disrupt the personality of burn survivors with facial disfigurement which can affect their selfesteem.

As indicated by Rumsey and Harcourt, an assortment of methodologies has been utilized to clarify individuals' encounters of living with facial disfigurement. The degree to which self-perception is characterized and incorporated into these structures shifts impressively—in certain occasions the build is utilized as a forerunner, in others, it is incorporated as a procedure variable and others as a result [13].

Coasta et al. directed an examination to investigate the basic elements of patients' observations and encounters of facial disfigurement following medical procedure for disease treatment, utilizing a subjective methodology dependent on the individual inside and out meetings [14]. Information study and elucidation comprised of isolating reactions into expressions or articulations with a solitary topical angle. Consequently, various measurements and classifications were made utilizing a deductive-inductive substance study. Three principle classifications developed: Finding of the malignancy, adapting to the infection and disfigurement, and recreating another character. The underlying stage inspired sentiments of dread, forswearing, and blame as a response to shame and bias. Adapting methodologies included abdication and acknowledgment, extending religiosity, fortification of recognizable attachment, and production of an informal organization of solidarity and backing. The last stage contained fuse of the changed facial picture, recovery conceivable outcomes, remaking of identity and psychological self-portrait, and the sentiment of having beaten the illness. It was inferred that singular encounters are perplexing, testing, and effetely affect their lives. There is a critical requirement for preparing and improvement in HR to deal with these patients in a multidisciplinary approach went for their reintegration into society and diminishing the preference and shame of the ailment and disfiguration.

A few analysts have adjusted systems from different settings [15]. For instance, utilized Lazarus' model of pressure and adapting to clarify post-employable recuperation and acclimation to self-perception changes following medical procedure for head and neck malignant growth. Fruitful adjustment expected people to change their own esteem framework and to put less dependence upon appearance. Heason investigated the importance of viewpoints on disgrace and social rejection [16-18]. She presumed that they may all have a task to carry out in clarifying people's encounters of disfigurement. Different authors (Kent and Newell) have reprimanded the absence of hypothetical structures grew solely for this reason and as of late various disfigurement; explicit models are suggested by them.

Egan, et al. investigated the encounters of individuals who distinguish themselves as having balanced decidedly to an unmistakable distinction [19]. Individual and gathering interviews investigated encounters of constructive modification among 12 individuals with a scope of unmistakable contrasts. Topical examination distinguished four fund psychological subjects: the significance of appearance; self-awareness; associations with others; and adapting (factors in the adapting topic viewed as foremost to positive change were internal quality and energy, dynamic adapting strategies, descending social correlations, taking things to step by step, otherworldliness, and amusingness). The discoveries give understanding into practices and individual viewpoints that may add to versatile adapting and have suggestions for future research and intercessions went for the individuals who display the poor change in accordance with obvious distinction. The article considers the utilization of both individual and gathering interviews for research in this field.

Newell adjusted thoughts initially proposed by Lethem, Slade, Troup, and Bentley in regards to managing endless torment. Newell and Marks proposed that a large number of the psychological troubles of individuals encountering dangers to their self-perception are like those endured by individuals with social fear. Newell suggested avoidant reactions, with showdown, ventured to be progressively versatile, and evasion adding to assist in capacity and debilitation. Shirking is regarded to be provoked by dread and expectation of a negative result and prompts the individual taking part in an undeniably confined scope of exercises, with always harmless circumstances decided as undermining. Conceptualizes dread and evasion as a potential go-between in exasperates self-perception. His model offers a plausible clarification for social evasion grounded in a subjective conduct approach.

While likewise drew upon subjective social standards to build up a model of self-perception among individuals treated for malignant growth [20]. His model suggests that psychological pain, negative musings, and mal-adaptive adapting procedures are increasingly clear among patients who place more noteworthy significance on their appearance and whose malignant growth is influencing an especially esteemed piece of the body. The achievement and utility of the models created to date are restricted, as they all require further testing and refinement. New analysts to the zone may discover them supportive; be that as it may, we should not enable models to compel our reasoning, dazzle us to new thoughts and to the complexities of the connections among the different variables included.

Tebble et al. stated that when it comes to social interaction, patients with facial disfigurement tend to face a lot of difficulties and can lead to many social consequences [21]. Face holds so much important that if disfigurement makes one’s face ugly or visibly different, the same individual having many other traits and qualities are simply disregarded hence making highlighting the disfigurement and issues that come along with it [3]. The issues may include impaired social relationships, particularly intimate relationships. The difference in appearance can even negatively affect the sexual relationships however; this area needs to be implored in detail. Other than intimate relationships, day to day interactions can also be negative experiences for patients with facial disfigurement. Thereby they often avoid social interaction as they fear stigmatizing behaviors of others such as laughing, questioning, staring or rude behavior. Brown et al., found that that 53% of the participants felt their relationships were affected because of their visible differences while 35% of the participants stated that they prefer to be alone and avoid interacting with people [22]. Also, their fear of interacting with people and coming across various kinds of stigmatizing behavior affects their work lives and they end up covering their faces to avoid such stigmas. This social attitude towards patients with facial disfigurement also affects their ability to communicate for example; facial expressions, maintaining eye contact, body language and gestures.

Brown et al., found that many burn injury survivors reported feelings of sadness, particularly about their scars that they will not go away and eventually they have to live with them now [22]. The feeling of rejection is another issue which makes them extremely anxious about the meeting and interacting with people around them and causes serious emotional issues. Kent and Keohane investigated patients with skin disease and concluded that skin disease particularly of face and hands can cause serious psychological and emotional issues in the patients diagnosed with it. Kent reported that in situations like these patients tend to remember the rejection more when they are aware of their obvious visible differences. On the contrary positive experiences and acceptance by society in general and significant others, in particular, bring marked differences in their level of anxiety and self-esteem. It not only boosts their ego, level of confidence, daily functioning, social interaction, and selfimage but also helps them in coping emotionally with their facial disfigurement [23].

Rationale

Most of the studies based on burn injury tend to focus on the psycho-social factors associated with post burn injury. However, there is a need to gain an in-depth understanding of the perceptions and experiences of female burn survivors with facial disfigurement in regards to their emotions, feelings, behaviour, stigmatization, coping, resilience, support system, day to day functioning, relationships, attitude towards self, others and future life by using a qualitative approach. This can aid in exploring the most important aspects pertaining to burn injury in general and facial disfigurement in specific that lead to physical and psychological changes in burn survivors which in result define their life orientation. Thus, this can be instrumental in providing new themes mostly not focused on quantitative research towards an understanding of post-traumatic growth after burn injury [24].

Method

A semi-structured interview was conducted with five female burn survivors with severe facial disfigurement to acquire about their perceptions and experiences of burn injury (Table 1).

Participant no.AgeMarital StatusReligionEducationOccupationMonthly IncomeCause of Burn InjuryType of Burn InjuryTime since Burn Injury123MarriedChristianNilHairstylistRs. 10, 000Acid attackChemical6 yrs245WidowMuslimSchool levelNil-Acid attackChemical19 yrs325WidowMuslimFATraineeRs. 15, 000IncidentGas21 yrs419SingleMuslimSchool levelTraineeRs. 10, 000Acid attackChemical4 yrs529SingleChristianBAFront desk officer Rs.8,000IncidentFlame22 yrs

Table 1: Characteristics of the participants.

Participants: Five burn patients with severe facial disfigurement were taken as a sample from Lahore, Pakistan.

Procedure

Formal permission was obtained from the authorities of the selected organization in Lahore. The nature of the research study was thoroughly explained. In this regard, the organization was approached on different days to conduct interviews. After obtaining formal permission from the authorities, five participants were chosen on the basis of severe facial disfigurement. Participant ’ s consent was taken wherein the nature of the study was explained. Participants who fulfilled the inclusion criteria were then interviewed about their perceptions and experiences of the burn injury with facial disfigurement. The participants were additionally probed for a better understanding of their current quality of life. At the end of the interview, the patients were thanked for their cooperation.

Data Analysis

Thematic Analysis was used to identify themes which adequately reflect their textual data. The aim is to analyze informants' talk about their experiences [25,26]. Transcripts were analyzed to identify similar themes emerging in a passage of text that appeared to have a particular meaning. Across the dataset, themes were compared for similarities and differences, both within and across interviews. Common themes were divided into categories. The transcripts were re-read and checked to clarify emerging sub-themes so that the titles of the categories reflected the totality of that experience. Four key themes were identified including; physical appearance, posttraumatic growth, relationships, and coping/adjustment. The themes emerged from the transcripts are as follows:

Physical appearance

The notion of physical appearance emerged throughout the transcripts as the burn survivors described the importance of appearance in their lives and the way it has affected their quality of life after the injury. For some their whole life had turned upside down after the burn injury as it has completely changed their face so much so that they could not recognize their own face now. Even if they do, they don’t feel like seeing themselves in a mirror as they end up thinking about their face before the injury. Facial disfigurement left a strong impact on their lives thus led to feelings of worthlessness and uselessness for most of them. Almost all of them cover their face with a veil while going out for work or some other task as that protects them from any kind of stigmatization. However, those who had gone through reconstructive surgeries described that the surgery has made them look better and boosted their confidence. A few of them made reference to the over-importance attached to an appearance in Pakistani society and made specific reference to the role of media, beauty products and cosmetic surgery in setting certain standards about appearance.

The issues described by burn survivors regarding appearance included; perceived stigmatization, self-perception, and perception of others. An acid burn survivor (case no: 1) who got attacked by her husband 6 years ago and now working, said; “It makes a person look beautiful (smiling). Nobody can make fun of it. And now what my face is, they make so much fun of it, kids laugh at me, and sometimes they get scared.”

The above quote clearly shows the importance of appearance for her and indicates perceived stigmatization after facial disfigurement due to burning injury. Another acid burn survivor (case no: 4) who is single and got a burn injury 4 years ago, said; “The difference is, I was living a happy life before, I was not tensed, I mean, I am a burn survivor, my face is burnt, I don’t have one of the eyes, now the tension is, I don’t have an eye, my face is burnt, how do people see me, what do they talk about, this is the tension, that’s what is different (anxious). For this woman, there is a stigma attached to the facial disfigurement as she compares herself before and after the burn injury and said life is different now and attributes her happiness to her appearance.

The same woman expressed her perception of others when they interact with her. She doesn’t feel comfortable while they stare at her because of facial disfigurement. “When someone is sitting in front of me and looks at me as her eye is burnt, her foot is burnt, her hand is burnt, then I feel tensed that why is he/she looking at me like that. So, this is how I think that it shouldn’t happen.”

This theme is clustered around the interaction of burn survivors with different people and their perceptions towards facial disfigurement. It highlights the struggle of burn survivors with their facial disfigurement right after their injury and how they have been able to cope up with it in the long run. The stigmatizing behavior that they have come across, the curiosity of others to know about the reason behind their injury, putting the blame on the survivor for the injury, treating them differently led to feelings of social disapproval and low selfesteem which consequently influenced their overall well-being. However, day by day they become used to such perceptions and attitude of people, tend to ignore them and divert their attention to other aspects of life.

Post traumatic growth

The burn survivors also described different factors that have aided them in post-traumatic growth. Perception of others towards their facial disfigurement is one thing that acts as a hindrance for many burn survivors in their personal growth. On the other hand, they also reported they have changed in a positive way owing to their visible differences. Post-traumatic growth is very challenging for these survivors as they are not only coping with their trauma only but living with their visible differences at the same time. Becoming more productive and resourceful was found to be of utmost importance to almost all the burn survivors. All those who are working have reported the remarkable difference it has made in their lives after the burn injury. It gives them a sense of achievement and satisfaction and is closely associated with an improved QoL. Acceptance of burn injury is another major factor that strongly influences their outlook towards life. Those who have accepted their injury have shown gratitude and optimism to express their feelings and emotions and one of the ways to cope up with their trauma.

The factors that influenced these burn survivors ’ posttraumatic growth included; acceptance, gratitude and life orientation.

A woman (case no. 3) who is a widow, said; “The reason for that is when I came here, Thank God, it’s simple, I saw the attitude of Madam. She gave us so much love, like so much, and the reality is it’s her because of her, it’s her love, we don’t feel much that we are burnt. When I came here they all loved me, whoever I saw they gave us a smile.” This clearly indicates the positive influence of acceptance of others towards burn survivors with facial disfigurement. Embracing them with their burn injury, being nice to them and even a mere act of passing a smile at them leaves a positive impact on their well-being. Another woman (case no. 1) who is an acid burn survivor expressed the similar views and said; “When someone gave me courage, and say you look nice like this (smiling) then I feel I am satisfied with my life, I am very happy.”

In addition to acceptance, another important factor associated with improved QoL is gratitude as one of the burn survivors (case no. 5) said; “I thank Allah and I can never thank Allah enough. I am always praying for everyone. I never thought that I will be so happy in my life. All I would say is be patient, work with honesty, and the fruit of patience is always sweet.” Another woman (case no. 3) said; “What if the face has gotten burnt? May Allah forgive us; there are all kinds of problems in life. That doesn’t mean you cannot meet anyone, or take your own life. We are thankful to Allah for keeping us like how we are.” Gratitude was found common among those burn survivors who are more resourceful and are considered as a valued member of the society.

This theme sheds light on the various factors that are significant in post-traumatic growth. It is not easy for anyone to come out of trauma as sensitive as a burn injury but acceptance and life orientation played a key role in most of the cases and changed their attitude towards life in general. Their optimistic approach helped them in overcoming feelings of worthlessness and gratitude made them resilient.

Relationships

The notion of relationships appeared throughout the transcripts and the burn survivors talked about the significance of the relationships in their lives and how their attitude towards their burn injury has influenced their quality of life. For most of them, it ’ s the support of their families that aided them in moving on and helped them in coping and adjusting well with their trauma. In many instances even if they would feel inferior to others because of their facial disfigurement, their families had uplifted them and had made their lives meaningful and worthwhile. The types of interactions and behavior of the family members, friends, relatives, colleagues, and others appeared to be having played a significant role in the recovery of the burn survivors. Acceptance of burn injury by the family and positive interaction with them has significantly impacted their quality of life. The aspects/issues described by burn survivors regarding relationships included; family support, bonding, care, financial support, and future prospects.

A woman (case no. 1) who was an acid burn survivor, said; “My family’s attitude was good with me before the burn injury and my family supported me so much even after the burn injury and their behavior is very good towards me, my sisters, my brother, my father everyone.” This clearly indicates how all the family members had maintained their relationship with her as it had been before her injury. They did not make her feel any different rather they showed more affection towards her and took care of her which had become her strength. Another woman (case no. 5) said; “ My parents are there for me. Whenever I would feel low, they would give me strength and courage. My father would say that when you will get an education then you will earn something in your life.”It is quite evident from this quote that her parents wanted her to pursue her education and career and not to give up on life because of her burn injury. A woman (case no. 2) who was living with her brother seemed unhappy and dissatisfied with her relationships as she said; “Their attitude towards me was good before but it’s not good anymore.” She also added; “I used to earn before. Life was good and all my siblings would take care of me including my parents. Now, there is no one there for me, not even my siblings and relatives. So much so I used to live in their house but they took it back from me. I was working before so I was living on rent but I don’t have any resources now.”

This theme indicates the importance and role of relationships in various forms in the lives of burn survivors. Family support is one of the main contributing factors in their lives and most definitely leaves a positive impact on them. The acceptance of their burn injury with facial disfigurement and the presence of unconditional love and care towards them further influenced their self-image and self-esteem hence their QoL.

Coping/Adjustment

Going through any traumatic experience leaves an everlasting impact on one’s life and the most challenging aspect of going through trauma is coping and making adjustments with it. The burn survivors described various factors that played a significant role in the acceptance of their burn injury that further led to coping and adjusting well to their visible differences. The foremost coping strategy that was also found common in all the transcripts was emotional coping. Even if the burn survivors accept their differences they can always come across a situation which can end up in having them relive the trauma. Emotional coping helps them inventing out and makes them feel better. Another important coping strategy that emerged throughout the transcripts was religious coping. Religion teaches one to be patient no matter what one goes through in his/her life. Thereby, most of them believed in the same and kept going with their faith and optimistic approach towards life. Religion also teaches one to be content in any situation and most of the burn survivors did the same. Despite their facial disfigurement they exhibited a positive outlook towards life and were found to be content even after going through such pain and trauma.

The coping strategies described by burn survivors regarding appearance included; emotional coping, religious coping and social comparisons.

An acid burn survivor (participant no. 4) said; “Then I think for some time, I get upset, and when I am done of thinking like this I cry. Then I feel relaxed and say this is what life is now and that’s how I have to live. Sometimes I get very happy.”She further added; “I used to get tensed after the incident, would get unwell and I don’t like being unwell. So I thought that whatever was meant to happen has happened and if I over think about it, that would make my family upset, I will get upset too, so I should remain happy and I should be strong (motivated).”

This clearly shows that even during the toughest of times, this burn survivor kept herself motivated. An important factor here is the role of her family members who stood by her and she did not want to make them upset by crying or staying sad/ depressed.

Another woman (case no. 1) expressed a similar situation and her coping style. She said; “I start crying then. I say why did this happen to me and why not with others? I feel that this has only happened to me, and after some time I get relaxed. ” One woman (case no. 3) who got injured because of the gas explosion expressed how different people had reacted to her facial disfigurement. It wasn ’ t easy for her to tolerate such attitude but she dealt with situations in a much calmer manner and coped up well. As she reported; “I always try not to hurt someone and those who don’t treat me well then it makes me very angry that if I am nice to him/her then why she isn’t nice to me. Then sometimes I feel like taking revenge but then I think no revenge, leave it, whoever does it see the consequences.”

Religious coping is another strategy that appeared throughout the transcripts. Burn survivors accepted their injury and showed reliance on their religion.

Another burn survivor (case no. 3) who had undergone 4 surgeries said; “One should try to live life in a good manner and should pray to Allah that if he gives us pain then he gives us strength as well, Allah also helps us then. Thank God I am okay, satisfied, and I am very happy with my life.” She also added; “When I am very upset I mostly try to spend most of my time in the worship of Allah, offer prayer, or recitation of the Holy Quran. That’s how I keep myself busy, like occupying myself in any kind of work.”A burn survivor (case no. 2) expressed that she asks Allah for strength and doesn’t rely on anyone else. She expressed; “I think, I pray, and ask Allah for the courage. Allah gives me courage, He is the one who helps everyone, human beings, siblings, relatives, none of them give courage except Allah.” This quote shows that for this burn survivor who did not have support from her significant ones and only asked Allah to give her courage.

The use of coping strategies mainly emotional and religious coping was found to be dominant in the transcripts of the burn survivors. Despite their burn injury these burn survivors showed contentment and gratitude towards life and embraced the difficulties including stigmatizing behavior of others that they come across in their lives. They also tend to distance themselves from stressful situations and people and focus more on positive aspects of life which played a significant role in influencing their self-esteem and thus leading to improved QoL.

The qualitative analysis reflects differences in attributional style, perceptions and individual experiences of burn survivors with facial disfigurement. It shows the importance of physical appearance for different individuals and how their life has changed for them after the burn injury. Those who had embraced their visible differences post burn injury, exhibited a positive outlook towards life, had strong family support, had enough resources and gratitude tend to be more satisfied with their QoL. On the contrary, lack of family support, low selfesteem, and non-availability of resources tend to result in dissatisfaction with life and the only aspect that keeps them moving on is their religious coping.

Discussion

The findings of the study show that the perception of burn survivors with facial disfigurement about QoL is influenced by psychosocial factors and personal attributes. Self-perception, support system, financial stability, environmental factors, the success of surgeries, life orientation, social comparison, gratitude, and coping strategies are all those factors which strongly influence their well-being and QoL. Those with an optimistic approach towards life, in general, aspire to utilize their skills for a better tomorrow.

Research shows the manner in which the participants are treated, their own personal insecurities about their appearance, and their life-experiences growing up and living with facial disfigurements has a big influence on their self-esteem, selfworth, and overall perceptions of self [27]. The role of these factors is indeed significant for burn survivors in perceiving their life in general and further defines their quality of life. The current study highlights the same issues and aspects that play an important role in forming the perceptions of burn survivors with facial disfigurement regarding their QoL. Those who go through a trauma like a burn injury; their day to day functioning is characterized by so many aspects. A welcoming attitude towards them, an empathetic approach, and treating them like others leave a strong impact on them. This instills a new hope and optimism in them and motivates them to function like others and excel in their lives.

Previous research also shows the experiences of people who identify themselves as having adjusted positively to a visible difference [13]. Inner strength and positivity, active coping techniques, downward social comparisons, taking things day-byday, spirituality, and humor are the key factors that bring a positive difference in their lives.

All these factors have their own significance in bringing a positive change in their lives however social support turned out to be the most dominant one. Acceptance of their burn injury by their support system be it: informational, moral or tangible, leads to perceive their lives in a positive manner and better satisfaction with life. The present study supports the findings that indicate the importance of social support that positive attitude of friends and relatives are internalized by participants and used to boost their confidence and leads to better psychosocial adjustment [28-34]. The family support acts as a constant inspiration behind their willingness to progress further in their life in terms of everything. Even if at times they get depressed or anxious and are overcome by feelings of worthlessness and low self-esteem, the immense support that they get from their significant ones uplifts them.

Conclusion

I conclude that the individual experiences of these burn survivors with facial disfigurement regarding their family life, social environment, personality type, and belief system influenced their process of acceptance, post-traumatic growth, adjustment, in spite of that those who were satisfied with their life differ in their overall outlook towards self, others and life in general. Thus, there is a need to focus more on the curative plan for burn survivors to aid them in managing their injury and protocol should be developed to help them in their coping/ management skills.

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