creation of a standardized burn course for low income countries: meeting local needs

JBUR-4270; No. of Pages 8

Creation of a standardized burn course for LowIncome Countries: Meeting local needs

Rae Spiwak a, Ronald Lett b, Laurean Rwanyuma c, Sarvesh Logsetty d,*aCommunity Health Sciences and Psychiatry, University of Manitoba, CanadabMc Gill University & University of British Columbia, Founder & International Director Canadian Network for

International Surgery, CanadacMuhimbili National Hospital, Dar es Salaam, TanzaniadDepartment of Surgery, Faculty of Medicine, University of Manitoba, Director Manitoba Firefighters Burn Unit, Canada

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a r t i c l e i n f o

Article history:

Accepted 10 January 2014

Keywords:

Burn

Low income country

Standardized training

Essential Burn Management

Multidisciplinary

Education

a b s t r a c t

Introduction: Standardized courses for the care of the burn patient have historically been

developed in High Income Countries (HIC). These courses do not necessarily reflect the

challenges and needs of Low Income Countries (LIC) and some components may not be

relevant there (i.e. use of ventilators in a country that has no or very limited number of

ventilators). We are developing a Burn Management Course for East Africa. This course was

created and trialed in a LIC and subsequently a formal manual and course curriculum

created. Recently the first iteration of the course was undertaken in a major regional burn

centre in East Africa. We present participant feedback on the course content, and potential

future directions for course development.

Objective: (1) To evaluate the ability of a standardized burn course for LIC to meet the needs

of the participants. (2) To explore characteristics of burn care and needs related to delivery of

burn care in LIC.

Methods: 21 students participated in a multidisciplinary burn management course. They

were asked to complete an anonymous questionnaire at the end of the course.

Results: There were 11 nurses, 6 doctors, a physiotherapist, occupational therapist, and a

dietician. 15 worked in either the adult or pediatric burn units, the other six worked in

emergency, ICU or the operating room. The majority of respondents (56%) had less than 3

years of experience working with burn patients. Overall agreement that the course met their

objectives was rated as 4.6 out of 5. As well the students agreement that they had a better

understanding of burn injury was rated as 4.8/5.

55.6% indicated that scalds were the most commonly seen injury followed by 27.8%

responding that flames were the most common.

Some responses to the question of top difficulties facing the caregivers were similar to

HIC: staffing shortages, bed shortages, and finding useable donor site in large burns. Other

responses highlighted the challenges these care givers face: poverty stricken patients, not

enough appropriate food available, and deficiencies in infection control practices.

Conclusion: It is possible to create a course that translates knowledge from a HIC setting to

meet the needs of the end-user in a LIC setting.

# 2014 Elsevier Ltd and ISBI. All rights reserved.

* Corresponding author at: GC401-820 Sherbrook Street, WPG MB R3A 1R9, Canada. Tel.: +1 204 787 7638.E-mail address: [email protected] (S. Logsetty).

Available online at www.sciencedirect.com

ScienceDirect

journal homepage: www.elsevier.com/locate/burns

Please cite this article in press as: Spiwak R, et al. Creation of a standardized burn course for Low Income Countries: Meeting local needs. Burns(2014), http://dx.doi.org/10.1016/j.burns.2014.01.007

http://dx.doi.org/10.1016/j.burns.2014.01.0070305-4179/# 2014 Elsevier Ltd and ISBI. All rights reserved.

http://www.ameriburn.org/ablsgeneralinfo.php

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1. Background

Burn is a serious public health concern around the world. The

WHO estimates that there are over 300,000 deaths every year

from fires alone, not including other causes of burns [1].

Among pediatric populations, burns are the leading cause of

injury death in children under 5 [2]. Although burns in high-

income countries are decreasing in number, in low-income

countries (LIC) numbers are still high. Ninety-five percent of

fire-related deaths occur in low to middle-income countries,

highlighting the magnitude of burns in low-income countries

[1,3]. While countless individuals die as a result of their burn,

millions survive and live with severe disabilities and disfig-

urement [4–6]. Burn survivors in LIC may find themselves in a

health care system that may not be able to fully manage this

complex problem [6,7]. The impact of burn injury is severe and

not only felt by the individual who is coping with the

consequences of these injuries, but also the persons involved

with the care and reintegration of these individuals into

society [6,8]. As such, burn injury is an important and complex

public health problem. Due to this overrepresentation in LIC,

targeting efforts at burn prevention and care in this population

would significantly impact the global burden of illness from

burn injury [6].

One way to target efforts at burn prevention and care in

LIC is through structured education. A uniform course

designed to inform burn care and treatment could be

promulgated to centers worldwide ensuring consistent

content independent of the instructor, as is done with other

courses such as Advanced Trauma Life Support (ATLS) [9].

While Advanced Burn Life Support (ABLS) [10] exists, this

standardized course has been developed in and for High

Income Countries (HIC), and does not necessarily mirror the

challenges and needs of LIC with components not reflecting

the needs of these populations [11]. Recognizing these

limitations, the International Network for Training Educa-

tion and Research in Burns (Interburns) created a report

(2012) highlighting the importance of setting standards and

creating a framework for teaching burn care in LICs [12].

Acknowledging the importance of standardized guidelines,

the importance of needs based assessments and evaluation,

this following paper aims to address these gaps in the

literature [13]. The goal of this paper is to briefly highlight the

development and ongoing evaluation of Essential Burn

Management (EBM) [14], a burn training program created

for East Africa in 2005 in conjunction with the Canadian

Network for International Surgery. Program evaluation used

an appreciative inquiry approach to seek out information on

both the strengths and limitations of EBM. This approach

builds on the strengths of EBM in order to guide future

direction and utilized a combination of inductive, deductive

and user-focused methods. Specifically, course participants

were asked to provide their feedback regarding course

content; course facilitators; their needs; potential for

improvement; and potential future directions for course

development. Participants also rated their knowledge in a

variety of areas both prior to and following the workshop,

and provided basic demographic data and information

regarding their experience with burn care. This evaluation

Please cite this article in press as: Spiwak R, et al. Creation of a standardiz(2014), http://dx.doi.org/10.1016/j.burns.2014.01.007

is unique in that both pediatric and adult burn units

participated in the training program and evaluation.

2. Objectives

1. To evaluate the ability of a standardized burn course for LIC

to meet the needs of the participants.

2. To explore characteristics of burn care and needs related to

delivery of burn care in LIC.

2.1. Essential burn management in East Africa: studylocation and course development

Africa represents a significant proportion of global burn

injury, having the second highest rate of fatal burns

worldwide, and is responsible for 15% of global fire-related

deaths [11]. In order to address the need for standardized burn

care in East Africa, starting in 2005 the Canadian Network for

International Surgery designed and piloted EBM. Over the

next 5 years, EBM was created and piloted in Jimma, Ethiopia

and eventually a full course was implemented in Dar Es

Salaam, Tanzania. Original course content was based on

standard burn teaching for students and residents at the

University of Alberta, Canada, and modified through discus-

sion with course participants and burn surgeons in Jimma

and Dar Es Salaam. The course was built on continuous

feedback from both faculty and students at all the centers

where it was given. Course content was initially informed by

post course questionnaires and using a modified Delphi

technique. The first iteration of the complete course including

a course manual, and standardized course slides was held at

the regional burn unit at Muhimbili Hospital in Dar Es Salaam

in March 2012. Three international and one local instructor

taught the course. Dar Es Salaam is a sub-Saharan urban

centre in Tanzania. Dar Es Salaam is Tanzania’s largest urban

economic centre, having a population of 2.5 million people,

and representing almost 30% of the total urban population in

Tanzania [8].

2.2. Brief course description and evaluation methodology

EBM is a three day course comprised of 4 components: (1)

seminar instruction with slides; (2) group seminars for case

discussion; (3) skill stations using models and simulation; and

(4) intraeroperative modules on the final day to discuss blood

conservation, surgical excision, and grafting techniques. The

overall course objective of EBM is ‘‘to provide the knowledge

base, technical skills and rationale to create effective and

competent burn teams in low-resource centres’’ (more EBM

course details available from CNIS upon request). As part of

the curriculum there is a requirement for a faculty meeting the

day prior to the course to discuss the local environment and

needs, building cases scenarios for discussion around local

experience. The complete evaluation of EBM employs three

tools including; (1) the learner course evaluation question-

naire (see Appendix A); (2) the learner pre/post-course test;

and (3) the facilitator and faculty post-course evaluation

meeting. This paper will present findings from the learner

course evaluation questionnaire.

ed burn course for Low Income Countries: Meeting local needs. Burns

http://dx.doi.org/10.1016/j.burns.2014.01.007

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2.3. The learner course evaluation questionnaire

The learner course evaluation questionnaire was distributed

and completed during day 2 at the end of the classroom

components, after the course exam and prior to the

awarding of course completion certificates. This does not

include the intraoperative component as this is primarily

one on one instruction with the surgeon and not amenable

to anonymous evaluation. Questionnaires are completed

anonymously to assure truthful responses in a non-

threatening manner. Instructors emphasize the significance

of the questionnaire in planning future courses and

highlight the important role of course participants in

directing future course materials and content. All learners

provided their consent to using gathered information for

research purposes. Completed forms were collected at the

end of the course evaluation session. This anonymous

questionnaire consists of 4 components and participants

were asked to: provide demographic and burn experience

information; self rate their knowledge and comfort level in

core subject topics before and after the course; complete an

agreement scale measuring whether the course met stated

objectives and whether presentation methods and level of

information were appropriate; answer open-ended ques-

tions about course learnings.

2.4. Component 1: demographics and burn experience

In this component of the questionnaire, learners were

asked for information on their: age, role on burn team,

whether they worked in a burn unit, years of experience,

number of burns they take care of each year, and common

burns seen (see Appendix A, Section 2). Learners were also

asked a series of open ended questions about the top 3

difficulties faced in taking care of burns, suggestions for

improvement of burn care in their hospital, and various

other questions regarding the course including and sugges-

tions for translating the course into other languages (see

Appendix A, Section 3). Frequencies were calculated for

demographic questions, and responses to open ended

questions were summarized and a thematic analysis was

undertaken to identify and group responses by similar

themes.

2.5. Component 2: self-rated knowledge

Learners were asked to self-rate their level of knowledge in a

variety of areas both before and after the EBM course. Each

question targeted an EBM topic including: initial trauma

assessment, burn and wound assessment, team approach to

burn care, respiratory tract burns, parkland formula and

circulatory resuscitation, compartment syndrome, chemical

burns, wound management, sepsis and infection control,

electrical injury, pain management and nutrition, physiother-

apy and rehabilitation, and patient transfer. Response options

included: Poor (1), Fair (2), Good (3), Very Good (4), and

Excellent (5). Descriptive statistics were run to determine

frequencies and average scores, and Wilcoxon signed rank

tests were used to determine if both pre and post scores were

statistically different.


2.6. Component 3: agreement

This component of the questionnaire examined whether the

learner felt EBM met the stated objectives; that the method of

presentation was appropriate (e.g. lectures and/or demonstra-

tions); and whether the level of information was appropriate

to their needs. Each question was based on a five point

agreement scale (Strongly disagree (1), Somewhat Disagree (2),

Neutral (3), Somewhat Agree (4), Strongly Agree (5)), and

learners were asked to rate their agreement to a variety of

statements (see Appendix A, Section 2). Descriptive statistics

including frequencies and averages were conducted.

2.7. Component 4: open-ended questions

Open-ended questions allowing participants to identify

strengths and provide suggestions for improving the course

were asked. Specifically, participants had the opportunity to

provide feedback on EBM sessions and the complete course;

provide information on how sessions could be improved,

including suggestions for further knowledge or skills; and

provide feedback on the course instructors. Responses to these

questions were summarized and a thematic analysis was

undertaken to identify and group responses by similar

themes.

2.8. Statistical analysis

Ranked self-report data was analyzed using Wilcoxon Signed-

Rank test [15]. Differences between groups were significant

when p < 0.05.

3. Results

Twenty-one learners completed the course. There were 11

nurses, 6 doctors, a physiotherapist, occupational therapist,

and a dietician. The average age of respondents was 37 years.

One participant specified their profession as a caregiver.

Fifteen (71.4%) learners worked in the burn unit; the other 6

(28.6%) worked in emergency, ICU or the operating room.

Learners included participants from both the adult and the

pediatric burn care units. Ten respondents (55.6.%) had less

than 3 years of experience working with burn patients, and 8

(44.4%) respondents stated they had 4 or greater years of

experience working with burns. Three respondents did not

provide responses. The average number of burn patients

treated by participants ranged from 15 to 360 patients per year.

The types of burns treated were scalds (n = 10), flame (n = 5),

electrical (n = 3), and contact (n = 1) (see Table 1).

With respect to self-rated knowledge on subject areas

before and after the course, statistically significant ( p < 0.001)

differences were found for each area, representing an increase

in knowledge of more than 1.0 points out of 5 in all areas (see

Table 2). With respect to Component 3, Agreement, 100% of

respondents (n = 21) indicated they either somewhat or

strongly agreed with the statement they had a better

understanding of all the aspects of burn care taught, following

the course, that the method of presentation was appropriate

(n = 20), and that the level of information was appropriate



Table 1 – Participant demographics.

Demographics N (%)a

Age 18

25–30 5 (27.8)

31–34 3(16.7)

35–40 4 (22.2)

41–45 3 (16.7)

46–50 1 (5.6)

50–55 2 (1.1)

Did not provide 0 (0)

Role on burn team 21

Nurse 11(52.4)

Doctor 6(28.6)

Student nurse 0(0)

Student doctor 0(0)

Physiotherapist 1(4.8)

Other 3(14.4)

Work in burn unit 21

Yes 15(71.4)

No 6 (28.6)

Years working with burn patients 18

Less than or equal to 3 10 (55.6)

Greater than 4 8 (44.4)

Number of burns cared for per year 15–360 burns per year

Most common type of burn 18

Scald 10(55.5)

Flame 5(27.7)

Contact 1(5.55)

Electrical 3(16.7)

Chemical 2(11.1)

Other 0(0)

a Percentages may not add up to 100 due to rounding.

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(n = 20). Only one participant selected ‘neutral’ with respect to

the course meeting the stated objectives.

When examining Component 4, the open-ended responses,

two themes emerged for both question areas inquiring about

what respondents felt was the most beneficial part of the

course, and what respondents felt was the most important

thing learned in EBM. The first theme is Knowledge. Seventeen

respondents indicated that the most beneficial thing about the

course was that it filled gaps in their knowledge base. Specific

techniques including grafting, compartment syndrome, as

well as overall knowledge in burn care was cited by

respondents. The second theme is Management of the burn

patient. Eight respondents indicated that they felt more

confident in the in treatment of burns from initial presenta-

tion, management, and rehabilitation. One respondent felt

Table 2 – Before and after self rated knowledge.

Subject area N Pre scor

Primary survey 20 2.6

Inhalational injury 20 2.3

Burn resuscitation 20 2.7

Compartment syndrome 20 2.3

Wound management 20 2.9

Infection control 20 2.8

Electrical injury 20 2.3

Pain management 20 2.9

Nutrition 20 2.7

Physiotherapy and rehabilitation 20 2.5


that the course would help them save the lives of future burn

patients.

3.1. Course improvement

When asked how the course could have been improved,

several themes emerged. The most common theme was length

of workshop (n = 11). Respondents suggested that the duration

of the classroom component of the course be increased to

three days to allow for more in-depth discussion. The second

theme that emerged was patient contact and practical procedures

(n = 6). Respondents felt that more contact with burn patients,

as well as more hands on training and practice doing

procedures would be beneficial. Many respondents would

also like to see the course offered more frequently (i.e. yearly)

(n = 6), and hoped more individuals in their workplace would

attend. When asked what further knowledge or skills related

to the course that they needed to learn or review, respondents

selected topics discussed in the course, perhaps suggesting

more support for increasing the length of the workshop. When

respondents were asked to provide feedback for the facilitator,

the consensus was that the information provided was

excellent (n = 20) and well received. Out of the 21 participants

who completed the questionnaire, 17 were fluent in English.

The main recommendation was to have this course translated

into Swahili.

3.2. Burn care difficulties in Dar Es Salaam

When asked to rate the top 3 difficulties faced in taking care of

burn patients, several themes emerged. The most common

theme was shortage of dressing materials (n = 8). The second

most common theme was sterility or infection. Seven

respondents indicated that infection was a major concern

for patients as well as maintaining sterility. Five respondents

indicated that maintaining and controlling fluids was a

significant difficulty to caregivers. Other themes which

emerged included staff shortage and lack of teamwork

(n = 6), poor cooperation with patient (n = 4), food shortage

and malnourishment (n = 4). Respondents provided excellent

information on ways to improve burn care, including

improving availability of supplies, improving nutrition skills

and employing technical people in hospital kitchens, improv-

ing team work, early excision and grafting and improved

screening methods to detect infection early. Some responses

to the question of top difficulties facing the caregivers were

e mean Post score mean Significance

0 4.15 p < .001

5 4.10 p < .001

0 4.30 p < .001

0 3.95 p < .001

0 4.30 p < .001

0 4.25 p < .001

5 4.15 p < .001

0 4.55 p < .001

5 4.20 p < .001

0 4.15 p < .001



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similar to those recognized in HIC: staffing shortages, bed

shortages, and finding useable donor sites in large burns.

Other responses highlighted the challenges these care givers

face: poverty stricken patients, not enough appropriate food

available, and deficiencies in infection control practices. When

asked about the number of preventable burns seen on an

annual basis, respondents indicated that between 50% and

90% of burns were preventable.

4. Discussion

The post course evaluation demonstrated that participants of

EBM in Dar Es Salaam were overall very happy with both the

quality and content of the course. While the evaluation

examined a variety of important areas and found while

individuals were happy with the course, there were unique

characteristics about respondents and the environment that

are necessary to acknowledge and incorporate into the

development of EBM. The following discussion aims to discuss

the strengths, limitations and observations gathered.

Overall, the evaluation identified that participants had an

increase in self-rated knowledge in a variety of areas related

to burn care. While several participants indicated that they

had poor knowledge in several areas prior to EBM (Primary

Survey, Inhalation Injury, Burn Resuscitation, Compartment

Syndrome, Electrical Injury, Physiotherapy and Rehabilita-

tion), no participant indicated that their knowledge

remained poor following the course. While respondents

were happy with the knowledge gained, feedback indicated

that more hands on training be provided, as well as

increasing the length of the workshop, and the number of

times offered (should be offered annually). While knowledge

of burn care is important, it is important to incorporate

the difficulties faced by participants in Dar Es Salaam.

Incorporating care of malnourished and poverty stricken

patients, deficiencies in sterilization and infection control

practices, maintenance of IV fluids, and shortage of dressing

materials are important in the development of EBM for East

Africa.

While many strengths of EBM and the course evaluation

have been discussed it is important to mention some

potential limitations. The information gathered refers to

course participants in the 2012 EBM session, so there is a

potential for response bias. While EBM was taught in

Tanzania, there was no discussion of culture by the

facilitators or the participants. Finally, the pre-post study

design did not use a control group; instead it used self-rated

knowledge to assess knowledge gained. As a result, the ability

to detect change in knowledge was limited and may be biased

by participants’ perception of their knowledge, EBM, or other

factors.


In summary, EBM participants were satisfied with the

course, supporting the conclusion that it is possible to create a

course that translates knowledge from a HIC setting to meet

the needs of the end-user in a LIC setting. The evaluation of

EBM was effective at measuring what it intended to measure,

and findings will be incorporated into future versions of EBM

by CNIS. Specifically, nutrition and infection control sections

will be expanded to address respondent feedback. While

evaluation findings will help inform future sessions, it is

important to acknowledge that each population will bring

unique characteristics and needs, therefore evaluations will

be done after each session of EBM. Findings from these

evaluations are useful in bringing to light the unique needs of

low and middle income countries.

5. Future goals

At the time of the course a burn registry was commenced. The

data from this registry will help guide prevention strategies and

evaluation of outcomes from changes in burn care, helping

identify potential future learning objectives. Further work is

underway to create an Instructor course to ensure that future

instructors are comfortable with the course content, interactive

group learning, and assess the effectiveness of the course.

Collaboration with other agencies is currently being explored to

create opportunities for promulgation of the course.

Source of support

Preparation of this article was supported by the Canadian

Network for International Surgery (CNIS), Canadian interna-

tional development agency, and the Wild Rose Foundation

(WRF).

Conflicts of interest

None.

Applicability of research to practice

This research will help guide development of future standard-

ized burn courses for LICs.

Acknowledgment

Justin Gawaziuk for his work on preparing the article for

publication.



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Appendix A. The learner course evaluation questionnaire

Appendi x A: The learn er course evalu ati on questionn aire .

I. Demog raph ic Informatio n and Burn Experie nce

1.How old are you?

2. My role on the bur n team is: Nu rse Type of Nu rseDoctor Type of Doctor_______ ________________________Stud ent Nu rseStud ent DoctorPhysioth erapi stOther Type__ _____________ ___________________________

3. Do you wo rk in a bur n uni t? Y es No

4. How many year s have you worked wit h bur n pati ent s?

5. How many burn patients do you take care of each year?

6. What is the most comm on kind of burn you take care of?ScaldFlame

ContactElectricalChemicalOther________________________ _______________________

7. What are the top three difficulties you face in taking care of burn patients ?i)

ii)

iii)

8. How can burn care in you hospital be improved?

9. How many burn injuries you take care of are preventable?

10. What caused these burns?

11. What can be done to prevent these burn injuries?

12. Are you fluent in English? Yes No

13. Which languages should we translate this course into?______________________________

14. Who should take this course?____________

II. Self rated Knowledge

1. My knowledge of Primary survey :BEFORE the workshop WA S:

Poor Fair Good Very Good ExcellentAFTER this workshop it IS :

Poor Fair Good Very Good Excellent

2. My knowledge of Inhalational injury :BEFORE the workshop WA S:



3. My knowledge of Burn Resuscitation :BEFORE the workshop WA S:





BEFORE the workshop WAS:Poor Fair Good Very Good Excellent

AFTER this workshop it IS :Poor Fair Good Very Good Excellent

5. My knowledge of Wound Management:BEFORE the workshop WAS:



6. My knowledge of In fection Control :BEFORE the workshop WAS:



7. My knowledge of Electrical injury :BEFORE the workshop WAS:



8. My knowledge of Pain Management:BEFORE the workshop WAS:



9. My knowledge of Nutrition :BEFORE the workshop WAS:



10. My knowledge of Physiotherapy and rehabilitation :BEFORE the workshop WAS:



4. My knowledge of Compartment syndrome:

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How c ould this s ession have bee n improved?

Please su gges t further knowledge and/or skills related to this s ession that yo u nee d to learn/r evie w.

Please provide feedb ack for the facilitator.

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