Sustaining a burn injury can be a serious and life-altering event and can cause significant physical pain and varying degrees of psychological distress. Difficulties resulting from a burn injury can include: financial strain, relationship problems, inability to care for children, loss of physical functions, emotional dysfunction, disfigurement and body image concerns.1-4 A mismatch between a person’s ideal physical appearance, and their perception of what they actually look like after a burn injury, can result in body image dissatisfaction.
Studies have indicated that body image dissatisfaction can impair the capacity of burn survivors to adjust to life after a burn injury.5,6 Dissatisfaction is associated with increased levels of emotional distress, lower levels of quality of life, increased social difficulties,5 and greater depressive symptoms.6
Research has explored possible factors that mediate satisfaction with body image in burn survivors.7-9 Lawrence, Fauerbach, Heinberg and Doctor found that social support and worry about appearance were significantly important factors in determining body satisfaction.7 A study by Orr, Reznikoff and Smith showed that burn survivors with perceived higher levels of social support had higher levels of positive body image, self-esteem and lower levels of depression.8 It has been hypothesised that social support is important due to its capacity to promote the use of effective coping strategies. This includes encouraging the individual to face feared situations such as social interactions. It is believed that this encouragement facilitates an increase in the self-esteem and sense of value of the individual.10 It is important to note, however, that social supports are not always positive: negative social support has been shown to impact current and future health status.11
The importance of adequate, positive social support for burn survivors has been highlighted, with research showing that burn survivors receiving lower levels of social support demonstrate lower levels of psychosocial and psychological adjustment.12 In contrast, the literature shows that adequate social support for those who have sustained a burn injury is correlated with higher levels of self-esteem, body image, life satisfaction and quality of life.13-15 Whilst research has demonstrated that social support is important, a gap remains in the literature as to how social supports assist burn survivors with body image satisfaction. There has been no research to consider which specific features of social support contribute to the body image satisfaction of burn survivors. Qualitative research into this area, based on thematic analysis of in-depth interviews, allows for exploration into the experience of burn survivors to identify the mechanisms related to social support and the adjustment process. This research poses the question: what is the role of social support in contributing to a positive body image in those who have experienced a burn injury? This study focuses solely on the body image satisfaction of female burn survivors. While men are susceptible to body image dissatisfaction, due to the societal context where women are constantly scrutinized and judged for their physical attributes, they are considered at a greater risk for developing body image dissatisfaction than men.6,8,16
Materials and Methods
This study was conducted through an adult burns service providing inpatient and outpatient treatment for individuals in a public hospital in South Australia. Any patients who had attended the service, and thus were over 18 and had sustained a serious burn injury, were eligible for participation, provided that they were sufficiently fluent in English to be involved in an interview. Participants (n=9) were recruited through the outpatient clinic and via a peer support network for burn survivors. The burns unit Physiotherapist, Occupational Therapist or Registered Nurse approached potential participants and supplied them with an information sheet outlining the details of the study. Other prospective participants were notified of the study by newsletter through a peer support network. In both cases, interested patients contacted the researchers indicating a willingness to participate, and at that point further information was provided and in all cases participant consent was given. Two participants were recruited from the burns outpatient clinic and seven through the peer support newsletter. All participants gave informed consent, and the relevant Hospital and University Human Research Ethics Committees approved the research.
Participants were nine women whose ages ranged between 24 and 65 (mean age 44.6). The length of time since the participants’ burn injury ranged between 6 months to 8 years prior. Three participants sustained burns to both their upper and lower body, three reported burns to their lower body only and three described burn injuries to their upper body only. Six participants had undergone skin grafts and one participant reported sustaining full body burns including to the face. Two participants had amputations (leg and fingers). Three participants were working full time, two part-time and four were currently not in the workforce. Five participants were in a relationship and four were single at the time of the interview. Eight of the nine participants interviewed had children.
The first author conducted all of the open-ended interviews, providing prompts that were informed by the burns, body image and social support literature. Interviews began with an open-ended question Would you like to tell me about your burn injury experience? and prompts followed as relevant to answers provided. Each interview lasted between 20 to 60 minutes (mean duration 38.61 min) and was audio-recorded with the consent of the participant. All interviews were transcribed verbatim and re-read for accuracy. Phrases and possible themes related to the subject of the research were identified and noted in an audit trail. Data collection continued until saturation was achieved, meaning no new themes emerged from the data.
Data were analysed using thematic analysis.17 A process of constant comparison was used, meaning that each interview was analysed as it was completed, so that the point of saturation could be identified, with themes checked both within and across interviews. An audit trail was maintained for the purposes of rigour and dependability.18 The first author first identified themes, and the second author independently reanalysed the data: final themes were those agreed upon by both of these authors. Following the process described by Braun and Clarke analysis involved first becoming familiar with the data (listening to the tapes, reading and re-reading the transcripts), followed by generation of initial codes. These initial codes were then sorted into potential themes,17 which were then examined and collapsed where appropriate, until the final themes were produced.
Participants in this study identified social supports as partners, parents, children, friends, work colleagues and treating health care professionals. In all interviews the wider community was also discussed, in terms of strangers and the general public. Body image was consistently discussed in terms of physical and sexual attractiveness. The ways in which social supports impacted body image were encapsulated in the discrete but inter-related themes of: acceptance, social comparison, talking about appearance concerns, and the gaze of others.
Feeling accepted by their social support network was an important factor for participants in coming to terms with the appearance of their body post burn injury. Participants whose supports did not focus on their burn scars were central in helping them feel more comfortable with their body. Participants with partners who reassured them that they were still attractive, and who sought physical intimacy with them, reinforced the notion that they were still the same person: … he says look I don’t even see it (Participant 2, L542).
Friends and family who assured participants that physical appearance was not important also played a role in building self-esteem and confidence. However, not all social supports were accepting. Negative reactions from family, such as being referred to as a monster by a young daughter (Participant 3, L158) resulted in feelings of depression and self-loathing. In addition, reassurance that the burn was not important was not always accepted, with participants feeling ugly: this sometimes resulted in the participants’ rejection of support from family and friends.
One way in which friends, family and work colleagues conveyed to participants that they were accepting of the injuries, by recognising that this was still the same person, was by treating them the same as they had prior to the burn. Many participants perceived this to be an important factor in their recovery. However, this was also sometimes seen as a trivialisation of their injuries and the traumatic experiences they had been through. Thus, the participants’ social supports found themselves required to balance reassurance with recognition: one participant explained the pressure she placed on her partner, requiring him to say the right things (Participant 2, L388).
Participants’ acceptance of their appearance ranged from hating their body and feeling ugly, to ambivalence. Some were quite positive about their burn injury and its impact on their physical attractiveness, with one participant embracing it as a feature that makes her special; perhaps I like having it I don’t know (laughs). (Participant 9, L135). Whilst social supports were important in the facilitation of self-acceptance, pre-burn injury body image played a role in post-burn body acceptance or dissatisfaction. Participants who had previously defined their self-worth in terms of physical attractiveness were less accepting and unhappier with their burn injury than those for whom physical appearance played a less central role pre-morbidly. This was true regardless of the extent of the injury. Self-acceptance was sometimes sought through the approval of others in ways that were less adaptive than seeking support from friends and family. These avenues included seeking approval and acceptance through casual sex with strangers, and partying, which involved drug and alcohol use.
Participants consistently made comparisons with real or imagined others. Most commonly, participants with burns in less visible areas would state: at least it wasn’t my face or my hands (Participant 9, L143). Age was also discussed as an important comparator, with injuries sustained as an adult being deemed less life-changing than being burned as a child (Participant 8). However, when social supports used this same strategy, by reassuring the participant that they were lucky (Participant 2, L139), this was sometimes viewed as distressing, again seen as an invalidation of their suffering. Comparison of appearance with friendship networks was sometimes a source of considerable distress, particularly in relation to social outings and styles of dress: I don’t know if I spouse if I went out at night and wore a dress I don’t know if people would say well what’s wrong with your leg? (Participant 6, L195).
As well as comparing themselves with others, participants also compared their old self with their present self. This related to acceptance, with those participants for whom physical attractiveness was less important before the injury being more philosophical about ways in which the injuries had positive impacts on their self-concept. For others, the burn injury was viewed as an irreversible loss of the previous, more attractive self. Nevertheless, these participants did engage in efforts to improve their appearance, such as make-up, clothing and weight control, in order to increase the positive feedback received from others about their appearance and the confidence they had regarding their looks.
In addition to offering admiration and praise for their appearance, including progress in the healing of the burn and graft sites, the ability of social supports in recognising the burn survivor’s resilience and capacity to cope was important for the participants adjustment and acceptance of their altered appearance.
Talking about appearance concerns
The opportunity to express their concerns about the appearance of their burn to friends and family was an important aspect of the support participants received. Participants explained that social supports were able to help by listening to their concerns while remaining non-judgmental and providing reassurance. However, at times invitations from social supports to share their feelings and expressing anxieties over their appearance were unwelcome. Encouragement to be positive about their burn injury and the outcome of their burn scars led some to feel pressured to put on a front of positivity. Comments that the burn survivor was lucky caused some participants to feel selfish or self-indulgent (Participant 2, L375) for expressing their concerns about their appearance with their friends and family, and thus they would withdraw from such interchanges. Participants without a partner raised concerns over finding a future partner with family and friends. Whilst reassurance and encouragement: oh you know but it’s what’s on the inside… (Participant 1, L: 180) was valuable, it could also cause resentment and was viewed as a platitude which did not decrease anxieties about meeting a partner who would accept them with their burns and find them attractive.
Reassurance from health care professionals was considered helpful in building confidence about body image. Honesty and ideas about how to improve physical appearance were noted to be valuable. However, as with friends and family, positive feedback was sometimes interpreted negatively – a doctor praising the wonderful looking hand (Participant 7, L147) caused resentment for a participant who saw nothing wonderful about her burn injury’s appearance.
The gaze of others
Social supports such as family, friends, work colleagues and health care professionals were core to the experiences of participants, and their reactions and behaviour were fundamental to ways in which body image was formed and maintained after the burn. All participants also discussed, some at length, the importance of strangers in shaping their view of themselves. Participants were highly conscious of the burn area being exposed to public view. These feelings of self-consciousness were coupled with concerns around the public staring and what people would think about their burn scars. This anxiety over exposure of the burn area led to concerted efforts to conceal the burn area with clothing. Whist participants described actual experiences related to strangers staring and asking questions about the injuries, imagined reactions also caused distress. Living with the burn scars acted as a reminder for participants that they would always be different from the rest of the community. Trusted social supports were valuable in helping participants cope with the gaze of others, with one explaining that she preferred to be in the company of a friend when going out.
Social supports, in reinforcing their acceptance of the burn survivor and their appearance, counteracted the feelings of anxiety and distress experienced in feeling different from other members of the general public.
Discussion and Conclusions
This study sought to identify the mechanisms by which social supports impact the body image satisfaction of women who have sustained a burn injury, through in depth exploration of the accounts of participants. Four themes were identified in the data: acceptance, social comparisons, talking about appearance concerns, and the gaze of others. Within each of the four themes the ways in which social supports impact body image was evident.
Reassurance from social supports to participants that they were still attractive and still the same person played an important role in body image. This was often a positive relationship, as has been reported in previous research.7,8 As might be expected, negative feedback from social supports impacted body image in negative ways. However, positive, accepting comments did not always increase positivity about body image: at times these comments were rejected, as negative body image concerns outweighed them. Similarly, positive comments were sometimes reinterpreted in a negative light – as a dismissal of the burn survivor’s suffering. The ways in which social supports’ comments mediated body image was related to the individual’s pre-injury body image concerns, which was connected to self-acceptance.
The stress placed on friends, families and relatives when supporting someone who has sustained serious burns has been previously documented.19 Rejection of supportive comments regarding appearance and acceptance of the individual as attractive and fundamentally the same, and the consequences of this, has not been documented in previous published research, to the best of our knowledge, although Na has identified this issue in an unpublished doctoral dissertation.20
Whilst previous qualitative research has noted comparisons with others to be a feature of the psychological processes of burns survivors,21 to date there is no theoretically informed research on social comparison processes following burn injury. In this study, participants employed downward social comparison to real or imagined others (comparing the self to a situation deemed worse), upward social comparison (comparing the self to those without burns, deemed more fortunate), and also used both of these comparison types in relation to the pre-injury self (identifying ways in which they have changed for the better in terms of body image and ways in which they feel their positive body image has been lost). Further systematic exploration of how these styles of coping impact self-esteem and body image, and the role of social supports in social comparisons would be instructive.
Related to acceptance from supports and social comparisons, talking about appearance concerns with social supports was sometimes helpful in increasing positive views about the body. However, encouragement and empathy from friends and partners did not always serve to increase feelings of self-worth or attractiveness. Furthermore, encouragement to be optimistic, including the use of social comparators, sometimes resulted in a front of positivity, meaning that distress was not expressed or articulated. This caused resentment, and as with challenges to acceptance, shows the difficult position in which social supports are placed. For the participants in this study without an intimate partner, reassurance that they would surely meet someone despite their burn injuries was particularly upsetting. Talking about appearance concerns with health care professionals was similarly a situation in which participants found reassurances unhelpful in promoting positive feelings about their body image. Research with women with breast cancer has shown that positive thinking does not equate to feeling positive, and that expressing negative views about one’s situation, including appearance, can sometimes become a moral value judgement on the part of social supports, including health care professionals.22 This is an area for further research, as expressing unhappiness about appearance after a burn injury may result in explicit or implied disapproval from social supports, further adding to distress.
In this study the community and strangers were discussed as part of the wider society that shaped participants’ body image. Participants’ feelings of being unattractive were related to feeling self-conscious about the appearance of their burn scars, and concerted efforts were made to ensure these were concealed from the public view. Anxiety surrounded actual and anticipated questions and stares from people in the community. Participants in this study discussed the importance of being in the company of a trusted significant other when in public places. The acceptance received from social supports again highlights the demands placed upon the participants’ social support network, as well as highlighting the vulnerability of the burns survivor to the Gaze of Others.
Past quantitative research has established that social support is important for the body image satisfaction of burn survivors.8,9 The current qualitative study provides some insights into how social support contributes to the body image satisfaction of burn survivors. While this study replicates past findings on expected ways in which social supports increase and reinforce body image satisfaction, negative components of social support specific to body image satisfaction have also been identified. These have not been recognized in past research on burn survivors and social support and deserve closer investigation. Thus, it is apparent from this study that the mechanisms by which social supports influence body image are complex: acceptance, positive feedback, talking and supporting did not necessarily increase positive perceptions about appearance for the women in this research.
Previous research has reported a weak relationship between burn scar visibility and measures of body esteem such as self-satisfaction with appearance.6,8 In this study the site of the burn did not seem to be related to body image or reactions towards social supports. Further research is warranted to explore the site of the burn injury and any relationship to psychosocial outcomes.
This study reinforces the fundamental importance of social supports on body image for people who have sustained serious burns and whose appearance has consequently altered. This, in turn, demonstrates the need for support for those who live with, are friends with and work with those who have sustained a serious burn injury that has altered their appearance. A strength of this study is that findings are based on in-depth interviews with women who survived serious burns, providing rich and deep data about their perceptions of body image and social supports. One limitation of this study is that the data were not triangulated with members of the participant’s social support network: in thematic research such as this, collection of data from multiple sources is desirable.18 Future research should include the perceptions and experience of friends, spouses, family and co-workers who have supported a burn survivor through an appearance altering injury. This would provide an understanding of the difficulties faced by the social supports of burn survivors in providing assistance to a loved one who has sustained a burn injury. Furthermore, future research should explore the experiences of health care professionals involved in the care of burn survivors and the differences in body image concerns and social support received by male burn survivors. Participants in this study reported that, overwhelmingly, their social supports were positive and encouraging regarding the appearance of their burn scars. While there is research that details the negative social experiences of burn survivors,23,24 to the best of our knowledge there has been no research that specifically explores negative social support experiences specific to body image after a burn injury. Future research might explore how both male and female burn survivors have adjusted to the appearance of burn scars with negative or limited assistance from a social support network.