Mobile applications for the assessment of paediatric burn injuries in the Pacific Islands: A Samoan perspective for global research engagement

Abstract

Burn injuries are a major public health issue, and the rate of childhood mortality from burn injuries is over seven times higher in low and middle-income countries than in high-income nations. Mobile technologies should prove useful in resource-limited clinical settings, as well as improve the quality of data available for monitoring and evaluation activities and health service research studies. This report advocates for the Polynesian nation of Samoa to engage with global research efforts on the use of mobile technologies for burn injury assessments. This includes registration with the WHO Global Burn Registry, and membership to the International Society for Burn Injuries. Our advocacy is timely as (1) the Ministry of Health of Samoa has appointed an inaugural Research Lead position to support national health research efforts in 2024 and (2) the on-going implementation of the national Health Information System ‘Tamanu’ supports the inclusion of mobile technology health applications.

Significance for Public Health

Mobile technologies should improve the clinical diagnosis and management of paediatric burn injuries in the Pacific Islands. Research is virtually non-existent on this topic in the region, and mobile technologies should also facilitate research efforts aimed at reducing childhood morbidity and mortality from this major public health issue.

Background

According to the World Health Organisation, burn injuries are a major public health issue, and a leading cause of death and disability among children worldwide.^1–3 The majority of deaths occur in Low and Middle-Income Countries (LMICs), where the rate of childhood mortality from burn injuries is over seven times higher than that of high-income nations.^1,3 The WHO reports that the main risk factors are insufficient adult supervision and child maltreatment, while socio-economic risk factors include poverty, overcrowding, alcohol abuse, and young girls in household roles of cooking and care of children. ³ From a public health perspective, the prevalence of mortality due to burn injuries may be reduced through improved awareness, effective policies, identifying key risk factors, and implementing prevention programmes acceptable to communities. ³

For survivors of childhood burn injuries, the memory of this traumatic event may continue throughout their lifetime through permanent disfigurement, visible physical scarring, disability(ies), and the associated stigma and social rejection. ³ Indeed, the public health issues associated with burn injuries in children extend well beyond the physical injury itself, and there are lifelong negative impacts for the child and their families on psychological, social and economic well-being.^1,4 A recent systematic review found that the traumatic experience of burn injuries made children particularly vulnerable to long-term mental health issues, including elevated states of depression, fear, and anxiety, as well as self-harm and suicidal behaviour. ⁴ The review found six studies from LMICs (Brazil, Iran, Mexico, Nicaragua, South Africia, Türkiye). The report from South Africa noted that all patients in their paediatric burn unit study cohort were from lower socio-economic backgrounds, and that the severity of the burn injury was a significant predictor of poor quality of life outcomes. ⁵ The studies from Türkiye, Iran and Nicaragua respectively reported the positive impact of massage therapy, art therapy, and support camps on mental health outcomes of child survivors of burn injuries.^6–8 In contrast to established literature, the Brazilian cohort of young burn victims did not present with depression or low self-esteem, and the authors attribute this to the multidisciplinary nature of their rehabilitation team at their burns unit. ⁹ Finally, the study from Mexico highlighted the important role of caregiver well-being, with results showing that the more resilient the caregiver, the better the mental health outcomes for children in the aftermath of a burn injury. ¹⁰ There is currently no research literature on paediatric bun injuries from the Pacific Islands.

While acknowledging that there are multiple components that contribute to improving the prevention, care and long-term health outcomes for children with burn injuries, the aim of this perspective is to advocate for improved clinical care for these children in our Pacific Island nation of Samoa. An internal audit from our national tertiary hospital found that paediatric burn injuries represented 3% of total admissions to the Paediatric Ward from January to December 2021. ¹¹ There were significantly more male (76.2%) than female (23.8%) cases, the majority of presentations were in the 1–5 year-old age group (52.4%), and hot liquids were overwhelmingly the main cause of injury (78.6%). This is consistent with the global literature where childhood burn injuries are more common among males (60%), are predominantly in the 1–5 year age group (62%), and are most often due to scalds/hot liquids (80%). ¹ The Samoan audit found that although the majority of paediatric burn injuries were successfully managed, the small percentage of complex cases were potentially life-threatening and required surgical intervention.

Improving the clinical care of children with burn injuries should play a central role in developing effective public health strategies in our country. Clinical records from hospital and primary health care settings are currently the main source of epidemiology data for burn injuries, and improved clinical care should provide better quality data for the accurate assessment of the burden and characteristics of burn injuries among children: this in turn should better inform health education and promotional strategies aimed at reducing the prevalence of burn injuries. Improved clinical care should also have a positive impact on long-term public health measures among burn injury survivors through improved physical health and socio-emotional well-being.

The second aim of this perspective is to advocate for mobile application technologies as an attractive option to improve both clinical care and public health initiatives regarding childhood burn injuries in Samoa. Mobile technologies should prove useful in our resource-limited clinical setting and improve the quality of data availability for clinical auditing, monitoring and evaluation activities, as well as health service research studies. Furthermore, Samoan engagement with global research efforts should facilitate international collaborations that lead towards the successful implementation of these technologies in Samoa. Our discussion may be helpful to our Pacific Island neighbours who may also wish to investigate these options.

Mobile technologies for burn injury assessments

The management of acute burn injuries may range from basic treatment in outpatient clinics through to complex emergency, critical care and surgery. ¹ Given that over- or undertreatment may lead to life-threating consequences, it is essential that early assessment is accurate to enable best clinical decision-making on whether to proceed with conservative management or surgical intervention (i.e. excision and skin grafts). ¹² No matter the severity of the burn injury, a precise and timely evaluation of burn size and burn depth is vital to ensure optimal management and outcomes. The most common assessment tools are the Lund and Browder Charts (Figures 1 and 2), which involve a visual assessment by the attending clinician. ¹³ The Lund and Browder Charts, both the original and the modified versions, are currently used in Samoa for assessing burn injuries, and the previously cited audit recommended that improvements in burn injury assessment techniques should improve clinical outcomes, as well as enable consistency in documentation and medical record-keeping.

Figure 1.

Lund and Browder chart.

Figure 2.

Modified Lund and Browder chart.

Given the inherent difficulties of accurately diagnosing burn size and depth through visual assessments alone, image-based mobile health technologies offer an attractive solution to improved clinical care, especially for low and middle-income country settings where burn specialists are rare or non-existent. Two recent papers by Boissin and Laflamme ¹⁴ and Boissin et al. ¹⁵ provide an excellent overview of the history and current state of research towards developing and implementing image-based mobile technologies for burn injury assessments. The authors outline the progression of image-based burn injury diagnosis first for telemedicine, then mHealth technology, and currently for automated diagnosis using artificial intelligence. One of the highlights of their review is the influence of skin tone on image-based assessments, and that most studies to date have been performed on populations with fair skin tones. Research is therefore needed to develop algorithms and normative data for populations across the spectrum of skin tones.

Engaging with global research on mobile technologies for burn injury assessments in Samoa

The World Health Organization (WHO) is leading efforts to address burn injuries on a global scale. Published in 2008, the WHO Plan for Burn Prevention and Care is still the guiding document for current strategies, and describes the following seven key activities: advocacy, policy, data and measurement, research, prevention, services, and capacity-building. ¹⁶ While acknowledging the importance of a holistic approach, the focus of our discussion here is on engagement with research activities. Should Samoa have the opportunity to implement mobile application technologies through research collaborations, these initiatives should include feasibility studies (i.e. cost analysis and healthcare infrastructure requirements).

Registration with the WHO Global Burn Registry

Formal registration of the national Tupua Tamasese Meaole Hospital with the Global Burn Registry offers Samoa an opportunity to submit standardised information to this global database which may then be used for research purposes. ¹ At this time, there is no Pacific Island country represented on the registry.

Membership to the International Society for Burn Injuries

Membership to this professional organisation will increase networking opportunities for Samoa, including participation in global research efforts to address burn injuries in low and middle-income country settings. This society is the partner organisation addressing burn injuries within the WHO Safety and Mobility Unit.

Inaugural research lead position at the Ministry of Health of Samoa in 2024

The WHO notes that research efforts for burn injuries in LMICs are constrained by lack of research infrastructure and capacity support. ¹⁶ The creation of a research lead position at the Samoan Ministry of Health should begin to address these concerns by creating a focal point for health research engagement between Samoa and international collaborators. The Research Lead has the potential to advocate for the integration of capacity development within the research design of any projects undertaken in collaboration with our international partners. ¹⁷ In time, the Ministry of Health may become a WHO Collaborating Centre.

Implementation of national Health Information System ‘Tamanu’ presents a well-timed opportunity to investigate mobile technology health applications

As Samoa moves towards achieving a national electronic health record database through Tamanu, introducing mobile application software for medical diagnosis should be investigated. In the case of burn injuries, practical clinical outcomes and evaluation of service delivery may be included in feasibility and development studies of image-based mobile technologies for burn injuries among children. ¹⁸

Conclusion

Engagement with global research efforts to address paediatric burn injuries is an option worth exploring for Samoa. Data is lacking from low and middle-income countries, and Samoa may be a suitable candidate for international collaborations aimed at innovative solutions for low-resourced settings. The implementation of mobile applications should not only improve clinical care of burn injuries, but also support public health initiatives aimed at reducing the mortality and morbidity associated with burn injuries in children.