The main finding in this study was that the problems with appliances, both cooking and heating appliances, played a major role in causing the burns to happen. This includes safety problems in appliance product safety as well as appliance usage including; place of usage, process of usage and purpose of usage. Similarly with findings of this study, kitchen is stated to be the main place of domestic burns in most hospital based injuries [2, 3, 10, 17]. However, this may not be the case in minor burns . Nevertheless, unsafe heating/cooking appliances or unsafe use of them to be predictors of burns, doesn’t exclusively mean that such risks are only present in kitchens. As found in this study, using traditional pipe-less Valor and Aladdin heating devices to heat the house may increase the risk of burn injuries. The common pattern of using these appliances in Iran is such that during the winter they are placed in living room where they can be used for dual purpose of cooking and heating the air (Figure 2). This may increase the chance that people at home, especially kids, bump into them [14, 19]. The chance may be higher when these appliances are placed in the middle of the room, where is much frequented by running/playing kids, especially at the times that kids are left less supervised. Mashreky et al. have found that the vast majority of burns take place during the first half of the day, from 9 am to 1 pm, when mothers are busy with their household chores . Lack of supervision can be identified as a major determinant of childhood burns. In Bangladesh also some kerosene appliances are used for heating or cooking purposes. Consistently with our findings, a prior study in Bangladesh also revealed that using these appliances increases the likelihood of getting burned by three times .
In our study the use of electric samovars, rather than kettles and non- electric samovars, reduced the risk of burn injuries. Using flammable fuel for heating and cooking in non-industrialized countries and also the explosions related to industrial activities in developed countries are important factors that increase the risk of burns [22, 23]. Moreover, it could be noticed in our study findings that several of the unsafe appliances were not working on electricity/gas networks incorporated in the house. The question would be that if this is because of the lack of these facilities, or these households still use the same appliances for decades because they did not need to be replaced yet? In Iran, all cities have complete coverage of electricity to households. In rural areas, however, all villages with more than 20 households have access to electricity network. However, possibly due to higher cost of electricity in Iran, there are many people who continue to use kerosene burning appliances or gas-burning appliances. Gas networking, especially in rural areas, is not as wide as electricity. This is both due to national limitation in extending the networking, household financial limitations to establish a gas network, and houses lacking minimum structural standards of establishing gas networking.
In this study it was found through bivariate analysis that, the economic ability of the households was associated with the risk of burn injuries, such that, having a very poor financial expenditure ability increased the chance of burn injury. The issue of poverty and burn risk is a significant fact well discussed in literature [24–26]. However, if studies gain success in depicting the mechanisms through which the poverty increases burn risk, it will be easier and more cost-effective for the policy makers to decrease such a risk. Physical environment including the heating/cooking appliances is an example addressed in present study.
In present study it was found that using a samovar without national standard authorization mark increased the odds of getting burnt. Two notices should be taken in this regard. First is the necessity to develop or operationalize national legislations in order to prevent the production, import and sales of unsafe cooking heating appliances. A mandatory requirement in this regard will be to improve and extend available standards for heating/cooking appliances. Secondly as consistent with findings of the present study, would be to increase peoples knowledge on distinguishing standard and safe cooking/heating products available in market and also to motivate them to buy the appliances authorized by national standard organizations.
Our study results showed that the conventional oil-burning or gas-burning heaters may appear safer and less risky than other types of heating appliances. One explanation for this can be that such appliances are usually more strictly controlled by national standard organization. Also such appliances are usually larger, heavier and are placed close to the walls and out of walking area.
Our study showed that the picnic gas stove is used for cooking by some Iranian families and this was associated with nearly twice higher risk of burn injuries. This was also consistent with the Bangladeshi study indicating three times more odds of getting burned for children living in families using such types of appliances . A picnic gas stove is an appliance which is made for short term cooking in picnics and open spaces and isn’t suitable for routine use in indoor area. The higher risk of using this facility for indoor cooking purposes may be sought in following mechanisms such that; it is light and unstable so can easily be overturned especially with a cooking pot or kettle on it; it is mostly used in low income families coinciding with other risks of injuries; and as a final note that only the canister part of this facility has a national standard in Iran while the holder part is usually produced in an unsafe quality, sometimes causing connection gas leakage as well as unstable holding of dishes put on them.
Contrary to the Bangladeshi study as mentioned above, in present study the family size was not found to be a determinant of burn injuries. Several explanations can be presented in this regard such as; lower variation in household (family) size in Iran compared to Bangladesh, higher group similarity in family size due to matching done for the urbanity, the fact that family size may only be a determinant of childhood burns, and the lower role of the family size in Iran due to reasons like smaller households or different patterns of burns in Iran.
Using unsafe heating or cooking appliances, and unsafe use of them are major risk predictors of burn injuries in this population. Both active and passive approaches need to be considered to develop strategies for burn prevention. Improving product safety through legislations and standardization as well as improving customer behavior and product usage behaviors through safety education is recommended in this regard. Limitations and strengths:
A limitation of this study was that, in spite of a moderate sample size and two-year long census enrollment, the study was not large enough either to do subgroup analysis for the outcome; such as for scalds, flame, and contact burns; or to do subgroup analysis for the predictors such as for gender and age groups. Nevertheless, it doesn’t seem to jeopardize the main objective of study and provides better generalizability for the whole population and general prevention programs. The main strength of this study was that a wide range of possible burn injury predictors were measured and properly addressed with a focus on heating and cooking appliances.