Hrev_master Healthcare in Low-resource Settings 2024; volume 12:12187 Epidemiologic and clinical characteristics and outcomes of burn patients in Kurdistan Region: a one-decade large retrospective cross-sectional study Khalid Ibrahim Mohammed Saber,1 Deldar Morad Abdulah,2 Nawzad Sulaiman Murad,1 Zuhair Rushdi Mustafa1 1Fundamental and Adult Nursing Unit, College of Nursing, University of Duhok, Kurdistan Region; 2Community and Maternity Health Nursing Unit, College of Nursing, University of Duhok, Kurdistan Region, Iraq Abstract Globally, burns are the most devastating injuries, causing more than 120,000 deaths annually, particularly in low- and mid- dle-income countries. This study investigated the epidemiologic and clinical characteristics and outcomes of burn patients. This retrospective study was conducted at the Duhok Burn and Plastic Surgery Hospital between 2014 and 2023. The data collected included demographic characteristics of the patients, burn etiolo- gy, location of burn, degree of burn, and hospitalization duration. The study included 713 cases, with the majority (41.37%) in the 0-17 age group. Mortality increased with age, and housewives had the highest mortality rate (54.91%). Urban residents had a higher mortality rate (40.81%) than rural residents (28.80%). Winter and spring had higher rates of burn patients (31.84% and 29.17%). Most burns occurred at home (90.88%), with flame (70.97%) and scald (25.11%) as the primary causes. Hospitalizations were most- ly 1-14 days (83.73%), and second and third-degree burns were common (47.27% and 50.07%). About 75.74% of patients suf- fered upper limb injuries. In 2023, there was a slightly higher burn rate (16.27%) compared to previous years. Burns were most fre- quently suffered by children, particularly during winter and spring at home. The primary causes were flame and scald injuries. Females were more prone to flame injuries, while males experi- enced a higher incidence of scald injuries. Among the affected groups, housewives had the highest mortality rate, and this elevat- ed risk was linked to their advancing age. Introduction Globally, burns are devastating traumas that affect a victim’s quality of life, emotional well-being, and ability to support their family and community.1 Worldwide, burn injuries are one of the leading causes of death, and over 95% of fire-related burns occur, causing more than 120,000 deaths annually, particularly in low- and middle-income countries.2 This is perhaps due to burn injuries, which are usually associated with different types of com- plications such as infections, toxic shock syndrome, pulmonary complications, cardiac complications, electrolyte imbalance, and eventually multiple organ failure.3 Undoubtedly, the costs of man- aging burns are high and impose remarkable economic and social consequences.4,5 Burn mortality remains high, particularly in underdeveloped nations, despite advancements in clinical thera- pies such as aggressive surgery, early enteral feeding, and fluid resuscitation.6 Despite a lack of epidemiological studies, according to reports, burn injuries rank second in Iraq’s emergency room visits, after gunfire. This is because of using domestic appliances, inflammable agents at home, and clothing burns. Even though the majority of these injuries are avoidable.7 Moreover, published data on the extent of burn injuries and their epidemiology in the Kurdistan Region (north of Iraq) are scarce, and there is not enough data to direct and carry out efficient preventive measures against burns.8,9 Therefore, investigating the epidemiologic and Correspondence: Zuhair Rushdi Mustafa, Fundamental and Adult Nursing Unit, College of Nursing, University of Duhok, Duhok, Iraqi Kurdistan, Iraq. Tel.: +964.7504729354. E-mail: zuhairmustafs@gmail.com Key words: burns, epidemiology, mortality, outcome, wounds, injuries. Funding: none. Conflict of interest: the authors declare no potential conflict of interest, and all authors confirm accuracy. Ethics approval: the Ethics Committee of Duhok General Directorate of Health approved this study (reference number 26072023-6-5). The study conforms with the Helsinki Declaration of 1964, as revised in 2013, con- cerning human and animal rights. Informed consent: This study was conducted retrospectively, therefore, the written consents were not taken for the study purpose. Instead, the administrative consent of the hospital was obtained in this study. Patient consent for publication: this study was performed retrospectively, therefore, it was not possible to obtain the patient consent for publication. We obtained the required information from the medical records of the patients. In this regard, we obtained the consent of the hospital for data collection and publication. Availability of data and materials: the data of the study are available for the justified reasons. Acknowledgments: the authors would like to thank the Archive Unit of the Duhok Burn and Plastic Surgery Hospital for their kind contributions to data collection. Received: 13 December 2023. Accepted: 12 January 2024. Early access: 8 February 2024 This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2024 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2024; 12187 doi:10.4081/hls.2024.12187 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organi- zations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 276] [Healthcare in Low-resource Settings 2024;12:12187] Non -co mmerc ial us e o nly clinical characteristics and outcomes of burn patients is crucial to creating a consistent collection of national burn data, as well as to better understand the issue and develop preventive measures. Therefore, we aimed to explore the epidemiologic and clinical characteristics and outcomes of burn patients for one decade in the Kurdistan Region. Materials and Methods Research design In this retrospective cross-sectional study, patients who were either admitted or not admitted to Duhok Burn and Plastic Surgery Hospital were eligible for inclusion. Accordingly, the medical records of patients treated at the hospital were screened for this purpose. The necessary characteristics for this study were extract- ed from the medical records of the patients. Population, setting, and sampling The patients included in this study were from Duhok Burn and Plastic Surgery Hospital located in Duhok City. This hospital is the sole facility for the diagnosis and management of burn injuries and plastic surgeries in Duhok Governorate. Consequently, all burn patients from across Duhok Governorate seek treatment at this facility for their injuries. The patients included in this study attend- ed the facility between 2014 and 2023. The hospital was estab- lished in 2008. However, medical records from the years 2008 to 2013 were no longer available in the hospital’s archives, except for names, outcomes, and a few pieces of information. Therefore, we opted to include medical records from the decade spanning 2014 to 2023. Nonetheless, due to the high population, it was not feasible to include all patients in this study. Consequently, we decided to sample a fraction of the population. Sampling technique We employed a systematic technique for sampling in this study. The required sample size for a large population, based on the Cochran Formula, is 385. Since we utilized a non-random approach, we aimed to incorporate more cases in this study to account for missing information and the sampling technique. We resolved to include one case from every five medical records stored in the Archive Unit of the hospital. If the fifth case had excessive missing information or was empty for an unknown rea- son, the sixth case was included in the study. Ultimately, we included 717 cases were selected in this study. Out of 717 cases, four cases had too many missing information, therefore, we includ- ed 713 cases in the final analysis. The Syrian refugees and inter- nally displaced persons were not included in this study as they did not give us a clear picture of the socio-demographic and cultural perspectives of Duhok Governorate. Study measures The following information was gathered from the medical records of the burn patients: age, gender, employment status, edu- cation level, residency status, marital status, reason of burn injuries, location of the burn incident, etiology of the burn, dura- tion of hospitalization, degree of burn, sites of injury, and outcome. The patients who had two degrees of burn were located in the higher burn degree. The patients who had first and second, second and third, and third and fourth were located in the second, third, and fourth degrees, respectively. Statistical analyses The prevalence of burn-related information such as site and etiology of burn and outcome of the disease was identified in num- ber and percentage. The association of the etiology of the burn and demographic characteristics and burn seasons was examined in a Pearson chi-squared test. The mortality rates of burn injuries over a time period were examined in number and percentage and its associated factors were examined in a Pearson chi-squared test. The statistical calculations were performed using JMP Pro 14.3.0. (JMP®, Version 14.3.0. SAS Institute Inc., Cary, NC, 1989–2023). Ethical considerations The ethical and administrative approval was taken from the Duhok General Directorate of Health and Duhok Burn and Plastic Surgery Hospital. The protocol of this study was registered in 26 July 2023 as reference number 26072023-6-5. The confidentiality of the personal information of the patients was protected and not included in the collection data file. Results The burn patients admitted to the burn hospital in Duhok Governorate between 2014 and 2023 were predominantly children aged 0-5 years old (24.54%) and middle-aged individuals (18-59 years old: 55.82%). The majority of patients fell into the age group of 0-17 years old (41.37%), followed by unemployed individuals (22.44%). The patients comprised both males and females from various geographic areas. They ranged from preschoolers to high school students, with diverse marital statuses, and 3.46% were pregnant. The study revealed a significant increase in the mortality rate with advancing age. Housewives exhibited the highest mortal- ity rate (54.91%), followed by unemployed patients (33.75%), females (44.39%), singles (45.45%), and married patients (41.99%), compared to children (25.42%), illiterate individuals (45.05%), and high school graduates (40.0%) compared to preschoolers and those under high school. Additionally, urban res- idents showed a higher mortality rate (40.81%) compared to their rural counterparts (28.80%; p<0.0001; see Table 1). The study revealed that winter and spring had higher percent- ages of burn patients (31.84% and 29.17%, respectively) compared to summer (19.35%) and autumn (19.64%). The majority of burn injuries occurred at home (90.88%), followed by work (8.70%). Flame (70.97%) and scald (25.11%) were the most prevalent caus- es of burns, while a small percentage resulted from chemical mate- rials (1.54%), electricity (1.26%), or explosions (1.12%). Most patients were hospitalized for a duration of 1 to 14 days (83.73%), and the majority had second and third-degree burns (47.27% and 50.07%, respectively). About 23.84% of patients experienced burn injuries covering their entire bodies. Additionally, 52.03% had burns on the head and neck, 62.69% on the trunk, 75.74% on the upper limbs, and 67.74% on the lower limbs. In 2023, there was a slightly higher burn rate (16.27%) compared to other years (Table 2). Mortality rates did not show significant differences based on the season and location of the burn. Patients burned by flame exhibited a significantly higher mortality rate (42.89%), especially those with shorter hospital stays. Mortality rates increased with the severity of burn degrees. Patients with burns covering the entire body (92.35%), head and neck (56.60%), or trunk (52.57%) were more likely to die compared to those with burns on the upper and lower limbs. Patients admitted in 2020 had the highest mortality rate (65.91%), followed by 2017 (46.06%), 2016 (41.38%), 2014 Article [Healthcare in Low-resource Settings 2024;12:12187] [page 277] Non -co mmerc ial us e o nly (42.86%), and 2015 (40.00%; see Table 2, Figure 1). The study revealed that flame injuries were more common among females (79.30%) and males (60.26%), whereas scald injuries were more prevalent in males (31.73%) compared to females (19.95%; p<0.0001). The etiology of burns did not differ based on the season of occurrence and the residency of patients. The findings indicated that flame injuries were more common in adults (88.94%), while scald injuries were predominant in children (62.14%; p<0.0001). Third and fourth-degree burns were more likely to be associated with flame and scald injuries across all sites (Table 3). The study showed that most of the patients had TBSA of 10- 19% (22%) followed by 20-29% (17%), and 90-100 (15%) as shown in Figure 2. The adult patients, females, and those who were burnt by flame, and died had higher TBSA as shown in Table 4. Discussion A glance at the present data shows that the majority of patients who fell into the preschool and high school age groups occurred at home in the winter and spring and were mostly caused by flames and scalds. Flame injuries were more common among females and males, whereas scald injuries were more prevalent in males. Housewives exhibited the highest mortality rate and a higher mor- tality rate was associated with advancing age. Age and gender This study showed that the majority of patients were children under the age of 5. This may be because children receive less atten- tion from their parents as they grow up; furthermore, they do not have adequate self-protection abilities.10 In the majority of studies, an overall predominance of children among burn injuries has been observed.10,11 A systematic review revealed that nearly half of the population with severe burn injuries are children.12 In this study, women, especially housewives, exhibited the highest burn injuries and mortality rates. These results are contrary to what has been documented in the literature. A systematic review of 76 studies and more than 186,500 patients by Brusselaers et al.12 found in most studies, an overall male predominance among burn injuries, because these injuries in adults are often work-related. It could be argued that almost all included studies were conducted in Europe; hence, the situation might differ in low- and middle-income coun- tries. A study by Peck et al.13 investigated the source of burn injuries in low- and middle-income countries. They found that the Article [page 278] [Healthcare in Low-resource Settings 2024;12:12187] Table 1. General characteristics of burn patients in Duhok Governorate between 2014 and 2023. General characteristics (n=713) Statistics Outcomes no (%) No (%) Dead Recovered with Recovered with p disability minor effects 253 (35.48%) 44 (6.17%) 416 (58.35%) Age groups <0.0001 0-5 175 (24.54) 34 (19.43) 3 (1.71) 138 (78.86) 6-14 68 (9.54) 13 (19.12) 2 (2.94) 53 (77.94) 15-17 52 (7.29) 28 (53.85) 1 (1.92) 23 (44.23) 18-29 229 (32.12) 106 (46.29) 21 (9.17) 102 (44.54) 30-59 169 (23.70) 58 (34.32) 17 (10.06) 94 (55.62) 60 and over 20 (2.81) 14 (70.00) 0 (0.00) 6 (30.00) Employment <0.0001 Child 295 (41.37) 75 (25.42) 6 (2.03) 214 (72.54) Unemployed 160 (22.44) 54 (33.75) 13 (8.13) 93 (58.13) Housewife 173 (24.26) 95 (54.91) 15 (8.67) 63 (36.42) Employee 21 (2.95) 5 (23.81) 4 (19.05) 12 (57.14) Free busyness 64 (8.98) 24 (37.50) 6 (9.38) 34 (53.13) Gender <0.0001 Male 312 (43.76) 75 (24.04) 17 (5.45) 220 (70.51) Female 401 (56.24) 178 (44.39) 27 (6.73) 196 (48.88) Pregnancy 0.9386 No 223 (96.54) 112 (50.22) 20 (8.97) 91 (40.81) Pregnant 8 (3.46) 4 (50.00) 1 (12.50) 3 (37.50) Marital status <0.0001 Child 295 (41.37) 75 (25.42) 6 (2.03) 214 (72.54) Single 55 (7.71) 25 (45.45) 4 (7.27) 26 (47.27) Divorced/separated 1 (0.14) 1 (100) 0 (0.00) 0 (0.00) Married 362 (50.77) 152 (41.99) 34 (9.39) 176 (48.62) Education <0.0001 Preschooler 175 (24.54) 34 (19.43) 3 (1.71) 138 (78.86) Illiterate 364 (51.05) 164 (45.05) 31 (8.52) 169 (46.43) Under-high school 144 (20.20) 43 (29.86) 8 (5.56) 93 (64.58) High school 30 (4.21) 12 (40.00) 2 (6.67) 16 (53.33) Residency 0.0008 Rural 316 (44.32) 91 (28.80) 16 (5.06) 209 (66.14) Urban 397 (55.68) 162 (40.81) 28 (7.05) 207 (52.14) Chi-squared test was performed for statistical analyses. Non -co mmerc ial us e o nly majority of the patients were adult women, as they use non-electric domestic appliances, mainly kerosene, for cooking, lighting, heat- ing, or all three. On the contrary, although Iran is a neighboring country of the Kurdistan Region, most studies showed that the highest percentage of burns occurred in men; women are more likely to burn at home and in the kitchen, while men are more like- ly to be burned in the workplace, despite a high mortality rate among women.14-16 Similarly, a Saudi Arabian systematic review found that in terms of burn injuries, men outweighed women.17 This could be because data about the prevalence of occupational burn injuries varies significantly between nations; here, for exam- ple, we believe that a lack of occupational hazards might be related to shortages in factories and industry in the Kurdistan Region. Season of injury and location of burn The present study revealed that winter and spring had higher percentages of burn patients compared to summer and autumn. The majority of burn injuries occurred at home, followed by work. Flame and scald were the most prevalent causes of burns. Kurdistan Region has a cold winter climate, and the main heat Article Table 2. Burn related information of burn patients in Duhok Governorate during 2014-2023. Burn-related information (n=713) Statistics Outcomes no (%) No (%) Dead Recovered with Recovered with p disability minor effects 253 (35.48%) 44 (6.17%) 416 (58.35%) Season 0.6508 Spring 208 (29.17) 81 (38.94) 11 (5.29) 116 (55.77) Summer 138 (19.35) 47 (34.06) 12 (8.70) 79 (57.25) Autumn 140 (19.64) 51 (36.43) 9 (6.43) 80 (57.14) Winter 227 (31.84) 74 (32.60) 12 (5.29) 141 (62.11) Location of burn 0.6274 Home 648 (90.88) 229 (35.34) 40 (6.17) 379 (58.49) Industry 2 (0.28) 2 (100) 0 (0.00) 0 (0.00) Public building 1 (0.14) 0 (0.00) 0 (0.00) 1 (100) Work 62 (8.70) 22 (35.48) 4 (6.45) 36 (58.06) Etiology of burn <0.0001 Chemical 11 (1.54) 2 (18.18) 0 (0.00) 9 (81.82) Electricity 9 (1.26) 3 (33.33) 2 (22.22) 4 (44.44) Explosion 8 (1.12) 3 (37.50) 1 (12.50) 4 (50.00) Flame 506 (70.97) 217 (42.89) 36 (7.11) 253 (50.00) Scald 179 (25.11) 28 (15.64) 5 (2.79) 146 (81.56) Hospitalization (days) <0.0001 1-3 234 (32.82) 93 (39.74) 6 (2.56) 135 (57.69) 4-7 216 (30.29) 98 (45.37) 7 (3.24) 111 (51.39) 8-14 147 (20.62) 36 (24.49) 7 (4.76) 104 (70.75) 15-21 54 (7.57) 12 (22.22) 5 (9.26) 37 (68.52) 22-29 17 (2.38) 5 (29.41) 1 (5.88) 11 (64.71) 30 and longer 45 (6.31) 9 (20.00) 18 (40.00) 18 (40.00) Degree category <0.0001 First 4 (0.56) 0 (0.00) 0 (0.00) 4 (100) Second 337 (47.27) 40 (11.87) 8 (2.37) 289 (85.76) Third 357 (50.07) 199 (55.74) 35 (9.80) 123 (34.45) Fourth 15 (2.10) 14 (93.33) 1 (6.67) 0 (0.00) Body location All body 170 (23.84) 157 (92.35) 10 (5.88) 3 (1.76) <0.0001 Head & neck 371 (52.03) 210 (56.60) 26 (7.01) 135 (36.39) <0.0001 Trunk 447 (62.69) 235 (52.57) 28 (6.26) 184 (41.16) <0.0001 Upper limbs 540 (75.74) 236 (43.70) 37 (6.85) 267 (49.44) <0.0001 Lower limbs 483 (67.74) 228 (47.20) 32 (6.63) 223 (46.17) <0.0001 Year <0.0001 2014 77 (10.80) 33 (42.86) 8 (10.39) 36 (46.75) 2015 55 (7.71) 22 (40.00) 0 (0.00) 33 (60.00) 2016 58 (8.13) 24 (41.38) 5 (8.62) 29 (50.00) 2017 89 (12.48) 41 (46.07) 6 (6.74) 42 (47.19) 2018 83 (11.64) 31 (37.35) 0 (0.00) 52 (62.65) 2019 75 (10.52) 28 (37.33) 1 (1.33) 46 (61.33) 2020 44 (6.17) 29 (65.91) 2 (4.55) 13 (29.55) 2021 45 (6.31) 4 (8.89) 6 (13.33) 35 (77.78) 2022 71 (9.96) 18 (25.35) 9 (12.68) 44 (61.97) 2023 116 (16.27) 23 (19.83) 7 (6.03) 86 (74.14) Chi-squared test was performed for statistical analyses. [Healthcare in Low-resource Settings 2024;12:12187] [page 279] Non -co mmerc ial us e o nly Article [page 280] [Healthcare in Low-resource Settings 2024;12:12187] Table 3. Etiology of burn by season in burn patients in Duhok Governorate (Kurdistan Region) between 2014 and 2023. Etiology of burn Chemical (n=11) Electricity (n=9) Explosion (n=8) Flame (n=506) Scald (n=179) p Gender <0.0001 Male 8 (2.56) 9 (2.88) 8 (2.56) 188 (60.26) 99 (31.73) Female 3 (0.75) 0 (0.00) 0 (0.00) 318 (79.30) 80 (19.95) Season 0.2448 Autumn 2 (1.43) 2 (1.43) 1 (0.71) 101 (72.14) 34 (24.29) Spring 7 (3.37) 2 (0.96) 3 (1.44) 152 (73.08) 44 (21.15) Summer 1 (0.72) 4 (2.90) 2 (1.45) 91 (65.94) 40 (28.99) Winter 1 (0.44) 1 (0.44) 2 (0.88) 162 (71.37) 61 (26.87) Age group <0.0001 0-14 yr 3 (1.23) 1 (0.41) 0 (0.00) 88 (36.21) 151 (62.14) 15 yr or older 8 (1.70) 8 (1.70) 8 (1.70) 418 (88.94) 28 (5.96) Residency 0.1195 Rural 8 (2.53) 4 (1.27) 1 (0.32) 220 (69.62) 83 (26.27) Urban 3 (0.76) 5 (1.26) 7 (1.76) 286 (72.04) 96 (24.18) Burn degree <0.0001 First 0 (0.00) 1 (25.00) 0 (0.00) 2 (50.00) 1 (25.00) Second 9 (2.67) 3 (0.89) 4 (1.19) 196 (58.16) 125 (37.09) Third 1 (0.28) 5 (1.40) 2 (0.56) 296 (82.91) 53 (14.85) Fourth 1 (6.67) 0 (0.00) 2 (13.33) 12 (80.00) 0 (0.00) Body location All body 0 (0.00) 2 (1.18) 1 (0.59) 155 (91.18) 12 (7.06) <0.0001 Head & neck 8 (2.16) 5 (1.35) 6 (1.62) 308 (83.02) 44 (11.86) <0.0001 Trunk 3 (0.67) 2 (0.45) 3 (0.67) 351 (78.52) 88 (19.69) <0.0001 Upper limbs 7 (1.30) 7 (1.30) 6 (1.11) 420 (77.78) 100 (18.52) <0.0001 Lower limbs 8 (1.66) 4 (0.83) 5 (1.04) 356 (73.71) 110 (22.77) 0.1216 Chi-squared test was performed for statistical analyses. Figure 1. Mortality rate of patients over time, season, etiology of burn, and burn degree. Non -co mmerc ial us e o nly sources in this area are flammable fuels and electric heating. In addition, cooking at home with a gas cylinder is a common acci- dental indoor cause of burns among residents in daily life. These results are consistent with studies conducted in China, in which most cases of burns were flame burns and occurred in the win- ter.10,18,19 The length of hospitalization Most of the patients in this study were typically kept in hospi- tals until their wounds had nearly healed. The majority of patients were hospitalized for a duration of 1 to 14 days. While the mean duration of hospitalization worldwide is between 7 and 33 days.12 In this study was shorter because of the high mortality rate. A sim- ilar study10 stated that the declining trend of the mean length of hospitalization was linked to increasing age and total body surface area (TBSA), which led to increased mortality. Degree of burns and burn size The majority of patients had second and third-degree burns, and nearly one-third of patients experienced burn injuries covering their entire bodies. This might be a strong reason for the high mor- tality rate among patients. A study conducted in Iraq showed that nearly two-thirds of patients died as a complication of second-and third-degree burns.7 According to the literature, deaths from burns are 7 to 11 times higher in low-income countries than in high- income countries.20 In our opinion, this is a serious issue that has to be carefully considered to decrease the mortality rate among burn survivors. It has been reported that large-area burns mainly occur in working-age adults,10 In this study, most of the patients had a TBSA of 22%, and burns mostly occurred at home due to the daily use of flammable materials such as liquefied petroleum gas. These results are consistent with the study of Lami and Al Naser7 conducted in Iraq, in which two-thirds of the burn patients had 20% TBSA. Burns of less than 20% of TBSA may not repre- sent a large proportion of severe burns.10 On the other hand, it has been stated that a burn injury involving more than 20% of the TBSA might result in hypermetabolic, inflammatory, and stress reactions that are in some aspects as profound as in patients with over 40% TBSA burns.21 This might correlate with a high mortality rate, despite the low involvement of TBSA. Burn sites and etiology Data from 2023 records showed a slightly higher burn rate compared to other years. The majority of patients experienced burn injuries on the trunk, upper limbs, lower limbs, head, and neck, respectively. A possible explanation for that is that when individu- als suddenly face burns, they may subconsciously protect the important parts of their body, such as their heads. Moreover, burn injuries to the extremities are paramount and should be taken into consideration. This is because they can lead to not only deformities and cicatrix but also functional losses, which decrease the quality of life for the patients.22,23 Nearly one-quarter of patients experienced burn injuries cover- ing their entire bodies. Since the majority of them had burns on the trunk and upper limbs, this might explain the high mortality rate among patients. These findings are comparable with the findings of a study done in Sulaymaniyah Province, Iraq,9 and a study in China.10 Contrary to previously reported epidemiologic findings, this study showed that flame burns, rather than scald burns, were the most common cause of burn injuries.10 However, findings from the current study are inconsistent with those conducted in Saudi Arabia, China, Iran, and Turkey, where scalding was the most fre- quent etiology of all burns.15,17,24,25 The flame injuries in our study were more common among females, whereas scald injuries were more prevalent in males. Scald injuries, on the other hand, were predominant in children. Our findings are comparable with the published studies in which the majority of burn injuries were in the under-fives and were scalds.26,27 It is estimated that scald burns in pediatric populations account for 81% of all burns that need hospitalization. Burning by boiling water, accidental spillage, or falling into hot gravy is more likely to occur in young children.10,28 This could be because, as children grow up, parents give them less attention, and they also lack self-protection abilities. It should not be forgotten that in the Kurdistan Region, there are still thousands of families living in camps and tents as refugees and displaced. They suffer from a lack of safety measures concerning fire accidents, including scaled injuries. Many of these families use kerosene for cooking and boil- ing water, which may create a great risk of scale injuries among children. Thus, to lower the number of scalds, education and home Article Table 4. TBSA by age, gender, etiology of burn, and outcomes. Burn (%) Median Interquartile range p Age group <0.001 0-14 yr. 15 20 15 yr. or older 40 65 Gender <0.001 Male 20 26 Female 40 65 Etiology of burn <0.001 Chemical 35 30 Electricity 25 64 Explosion 22.5 77.75 Flame 40 60 Scald 15 15 Outcome <0.001 Recovered with minor effects17.5 15 Recovered with disability 42.5 35 Dead 85 40 Wilcoxon / Kruskal-Wallis Tests (Rank Sums) was performed for statistical analyses. Figure 2. Distribution of TBSA in burn patients in Duhok Governorate between 2014 and 2023 (the values are in number, percentage. The bars are Std. Errors). [Healthcare in Low-resource Settings 2024;12:12187] [page 281] Non -co mmerc ial us e o nly safety checks, along with thermometers or thermostatic mixing valves, should be promoted to reduce tap water scalds.29 Mortality The mortality rate was closely related to the TBSA, severity of burn degrees, advancing in age, and burning by flame. Patients with burns covering the entire body were more likely to die espe- cially those with shorter hospital stays. These findings are consis- tent with other published epidemiological studies. They demon- strated that advancing in age, increasing TBSA, and flame burns are the major risk factors for mortality among burn patients.10,12,30- 32 Moreover, our findings were also consistent with the literature, in which the mortality rate is high among high-risk groups, includ- ing the elderly and females. The age-related declines in motor function, cognitive function, and judgment make the elderly more vulnerable to burns. In the present study, female patients who were burned by flame and died had a higher TBSA. Due to the lacunae in the data, it was difficult to obtain the true cause of flame injuries among females because patients’ relatives usually conceal and pro- vide misleading information under the term ashamed of society; nevertheless, we believe that it might be related to self-immola- tion. Many studies have been published on this concern and found that self-inflicted burns were noted, especially among young women. Although this type of burn is rare in developed countries,33 conversely is common among women of Iraqi Kurdistan.34 This may be due to many factors, such as social pressures and social interactions in their own right.35 Moreover, it has been reported that numerous Kurdish women and girls resort to different methods of suicide, primarily self-immolation, as a means of escaping the discrimination they face due to their gender, social status, or tribe.34 Therefore, women who have made suicide attempts should be given special interventions and support by providing them with educational programs about the harmful nature of burns. In this study, we found that patients admitted in 2020 had the highest mortality rate of burn injuries compared to other years of the last decade. This might be related to staying at home during the COVID-19 pandemic, which increases indoor accidents. These results are similar to those of several studies conducted in this regard.36,37 Overall, burn injuries are critical and fatal; they impose a bur- den not only on the government but also on families. Surprisingly, while we were writing this piece of work, a big fire broke out in a building in one of the cities of the Kurdistan Region, killing 14 people by suffocation and wounding five others. This was a result of a lack of safety regulations for burning, including a lack of a fire extinguisher bottle and a lock on the door of the fire exit.38 Thus, every effort should be made in collaboration with the community to adopt preventive measures. Furthermore, providing public edu- cation related to the prevention of burn injuries is crucial to mini- mizing the risk of burns and their consequences. To the best of our knowledge, this study is one of the more recent epidemiologic studies to study the characteristics of burn injuries in the Kurdistan Region. 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