Abstract Psychological distress associated with the visible changes to the body after a burn is common. This distress may be termed “appearance concern” which is estimated to occur in 1 in 3 adults after burns. Appearance concerns are known to start early post-burn (e.g., during hospitalization) and persist over time. Research suggests that appearance concerns are associated with significant psychological distress and functional impairment and can impact quality of life. Identification and management of appearance concerns at an early timepoint may significantly reduce the later psychosocial impact of injury. However, most research and practice in this area has been conducted following discharge from hospital and so there are gaps in the knowledge base and potentially missed clinical opportunities. Nevertheless, early psychosocial intervention and research poses ethical dilemmas, including: 1) Do the benefits of identifying and intervening with appearance concerns during hospitalization or early care outweigh the risks associated with doing so?; 2) Is research on appearance concerns (and interventions for this) early post-burn ethical and acceptable to patients and what can be done to optimize this?; and 3) What are psychological professionals’ views on the acceptability and feasibility of early psychological screening and interventions for appearance concerns being embedded into routine clinical practice, and what prevents this? Based on the evidence collected during studies in this area, this presentation will discuss the processes involved in carrying out this type of research to make the case that patients are likely to be willing to participate in research during hospitalization and early after discharge, and that patient advisory groups, patient and public involvement and co-development are key to conducting ethical and acceptable research. Finally, it will be argued that early screening for appearance concerns is on the balance of probabilities ethical practice, as is offering early psychological interventions (e.g., during hospitalization) as opposed to watchful waiting. Nevertheless, it is acknowledged that further research is needed.

Appearance concerns after burns start soon after injury. However, early psychological interventions to support individuals with their changed appearance are absent. This study investigated the acceptability of an early acceptance and commitment therapy (ACT) intervention delivered by a psychological therapist either in person or virtually to help individuals adjust to changes to their appearance after burns. As a secondary objective, the potential effectiveness of ProACTive was also investigated. Using mixed-methods, 13 adults (eight women, five men) participated. Acceptability was measured by uptake rates, module completion rates and interview data. Over two-thirds of participants completed all modules. Three main themes were identified from interviews: An acceptable intervention; Valuing the therapeutic relationship; and Early support is key. Data suggested that ProACTive may be acceptable, although some inconsistencies within the data were observed. Ratings of helpfulness were positive and qualitative feedback suggested that ProACTive seemed helpful by providing space to explore and reflect on appearance changes, developing psychological flexibility and self-compassion, and preparing individuals for being around other people. Positive and negative affect significantly decreased (moderate effect sizes) but no significant changes on appearance concerns, psychological flexibility or self-compassion (small effect sizes) were revealed. ProACTive may be an acceptable early psychological intervention to support the adjustment of appearance changes after burns. Acceptability may be higher in individuals with appearance concerns and those admitted to hospital. The intervention holds promise soon after burns but further research on acceptability and effectiveness is needed.

Introduction Paediatric burn prevention campaigns are common, yet little research has explored caregivers’ views of these materials. This study aimed to examine caregivers’ perspectives on UK-based paediatric burn prevention materials used in 2023. Methods Fourteen caregivers (8 female, 6 male) of children aged five or under participated in online focus groups. Participants were recruited through multiple community-based and online channels using non-probability sampling. Participants were shown six different UK burn prevention materials (two video-clips and four posters) and asked semi-structured questions about their views. Data were analysed using reflexive thematic analysis. Results Three themes were identified: 1) Campaigns shouldn’t be sugar coated; 2) Evoking differences in risk perception (caregivers’ varied perceptions around the likelihood and consequences of burn-related hazards influenced their engagement in safety behaviours); and 3) People don’t like being told what to do. Caregivers felt campaigns often "sugar coated" burns, reducing their emotional impact. Video content was seen as more engaging than written information, with personally meaningful, lived-experience-based content viewed as most effective. Risk perception varied: some caregivers felt their children were at high risk and found the materials reinforced their current behaviours, while others with lower perceived risk reported limited engagement or intention to change. Some found written guidance overly basic or overly directive. Conclusion Prevention materials may have limited impact on caregivers who engage in fewer prevention behaviours—those arguably most in need of change. Co-developing materials with at-risk caregivers and incorporating real-life burn experiences may increase emotional engagement and effectiveness. Further research is needed to explore how prevention materials can drive meaningful behaviour change across different caregiver groups.

ObjectiveAdults born with a cleft lip and/or palate (CL/P) may experience appearance-related distress and seek surgery to alter the appearance of their lip and/or nose. Little is known about the psychological experience of this decision-making process, which is often their first opportunity to make surgical choices independently. This study aimed to explore the experiences of adults with CL/P making decisions about lip and/or nose surgery to alter their appearance.DesignA qualitative study was conducted.Setting: A regional cleft service in the United Kingdom.Participants: A total of 12 adults (9 women, 3 men), ranging from 20 to 61 years, had either decided to pursue surgery, were in the process of deciding to pursue surgery, or had lip and/or nose surgery in the previous 6 months to alter their appearance.Main Outcome Measures: Semi-structured interviews were completed with all participants either via video (N = 10) or telephone (N = 2), along with a demographic questionnaire to provide contextual information for findings.ResultsThree themes were created during inductive-deductive thematic analysis: legacy of adversity (implicit and explicit shaping how participants viewed themselves), conflict driven by fear and emotional investment (related to uncertain outcomes, dual experiences, and identity erasure), and taking back control of decisions (pragmatically and by taking ownership, which was not without challenge).ConclusionsFor adults considering lip or nose surgery, psychological support may be helpful for patients to process previous aversive experiences and/or manage fear or uncertainty around decision-making.

Objectives Some children born with a craniofacial condition, and their caregivers, can experience psychological difficulties. Psychological flexibility involves responding to internal distressing experiences (eg, emotions) with openness rather than avoidance, being present-focused, and behaving in ways that align with personal values. Psychological flexibility is typically associated with greater psychological well-being. The current study aimed to investigate whether psychological flexibility in caregivers of a child with a congenital craniofacial condition was associated with caregiver and child psychological well-being, to inform the development of interventions likely to help caregivers. It was hypothesized that higher levels of both general and parenting-specific psychological flexibility would be associated with greater psychological well-being in both caregivers and children.Design A cross-sectional questionnaire study.Setting Questionnaires were completed online.Participants Caregivers (N = 89) of children aged 1-5 years with a congenital craniofacial condition.Main outcome measure(s) Questionnaires measuring psychological flexibility, parenting-specific psychological flexibility, caregiver depression and anxiety, and caregiver-reported child well-being.Results Correlational and linear regression analyses revealed that higher parenting-specific psychological flexibility in caregivers was associated with-and predictive of-lower depression and anxiety in caregivers, and greater well-being in children. Higher general psychological flexibility in caregivers was associated with-and predictive of-reduced caregiver depression and anxiety and increased child well-being.Conclusions Early identification of caregivers of children with craniofacial conditions exhibiting difficulties with parenting-specific psychological flexibility, and the provision of psychological interventions to enhance psychological flexibility (acceptance and commitment therapy), is indicated for benefiting caregiver and child well-being.

Elective surgeries to improve facial appearance are frequently offered to adolescents and adults with craniofacial conditions. While some studies point to the psychosocial benefits of surgery, others have described patient distress and disappointment. The aim of this study was to explore individuals' experiences of viewing their appearance for the first time following craniofacial surgery. An existing questionnaire was adapted for the craniofacial population and disseminated online. Retrospective, mixed methods data from 31 adults with a range of craniofacial conditions were analysed using descriptive statistics, Pearson correlations and conventional content analysis. Seventy-one percent of participants were worried about looking in the mirror for the first time. Participants reported a moderate level of distress and satisfaction with the surgical results on average, yet ratings varied considerably between participants. Almost half felt more distressed than expected and perceived their immediate postsurgical appearance to be worse than they had imagined. A range of emotions were described in response to the "first look," many of which were negatively valenced. Greater preparedness was significantly associated with feelings of relief and greater initial satisfaction with the surgical outcome, yet most participants felt that support at the time of the first look could have been improved. The findings represent a self-selected group of adults, some of whom underwent surgery several years ago. Nonetheless, patients' psychosocial experiences of the immediate postsurgical phase appear to be important. Preparing individuals for what they will look like and how they may feel after seeing themselves in the mirror for the first time is, therefore, an important consideration for craniofacial teams.

ObjectiveTo synthesize research exploring the impact of surgery on quality of life (QoL) in families of children with a cleft lip and/or palate (CL/P).DesignMedline, PsycINFO, CINAHL, and ProQuest databases were systematically searched (from database inception to July 2024) to identify studies exploring QoL in families following surgery for a child with CL/P. Studies were quality appraised using Quality Assessment for Diverse Studies criteria, and a narrative synthesis was undertaken.Main Outcome Measure: Quality of life was explored but specific measures varied across studies.Interventions: Type of surgery being investigated varied across the reviewed studies. This systematic review focussed on both functional and aesthetic surgeries throughout childhood.ResultsOf 157 identified studies, 9 were eligible for inclusion (1 mixed-methods, 1 observational, 1 qualitative, 2 cross-sectional, 4 quasi-experimental). Analysis indicated that QoL was positively impacted by surgery through reduced financial burden, increased sense of mastery/coping, and reduced social impact. However, for some families, new demands (eg, medical/dental appliances, food restrictions), intolerance of uncertainty, and adjustment to changes to their child's appearance were identified following surgery.ConclusionsThere is limited qualitative and quantitative research exploring the impact of a child's cleft surgery on family QoL. The quality of studies included in the review was variable. Supporting families accessing cleft services, especially where QoL and mental health are negatively impacted, is important. Due to the variability within and between the studies, and lack of detail relating to rationale and processes taken, the conclusions from this review are tentative. Further research is needed that addresses methodological and conceptual limitations.

ObjectivesAppearance concerns following burn injuries are common. Psychological factors are important in maintaining such concerns. However, there is a lack of longitudinal or prospective research investigating their development. This study investigated whether psychological flexibility and self-compassion at hospital admission predicted subsequent appearance concerns.DesignA multi-centre prospective cohort study across six burn services.MethodsAdults (n = 175; 67% male) in hospital following burn injuries were recruited. Questionnaires measuring appearance concerns, psychological flexibility, self-compassion, post-traumatic stress disorder symptoms and perceived noticeability were completed during hospital admission and two- and six-months later. Demographic and burn injury information was collected.ResultsCorrelational analyses showed that increased psychological flexibility and self-compassion at admission were associated with decreased appearance concerns cross-sectionally and prospectively at two- and six-month follow-up. These associations remained significant when controlling for key covariates (i.e. gender, age, ethnicity, percentage total body surface area burnt, perceived noticeability, PTSD symptoms). Multiple linear regression analyses revealed that psychological flexibility and self-compassion predicted appearance concerns during hospital admission. Although psychological flexibility significantly predicted appearance concerns over time, it became non-significant when controlling for baseline appearance concerns.ConclusionsPsychological flexibility has a protective role against appearance concerns soon after burn injuries, although this protective role is reduced when accounting for baseline appearance concerns. Early interventions targeting psychological flexibility (i.e. acceptance and commitment therapy) may be beneficial after burns if adapted to address appearance-related concerns.

INTRODUCTION:Burns can result in life-long physical and psychological difficulties. Interventions aimed at preventing burns are therefore important. Behaviour change theories propose that psychological variables (e.g., knowledge, attitudes, beliefs, self-efficacy) are associated with injury prevention behaviour. However, whether or not burn prevention interventions impact psychological variables is uncertain. This systematic review aimed to address this gap in the literature. METHODS:A systematic review was conducted according to PRISMA guidelines. Electronic databases (CINAHL, MEDLINE, PubMed and Scopus) were searched for randomized control trials (RCTs) of burn prevention interventions which measured at least one psychological construct. Studies were quality assessed using the Effective Public Health Practice Project (EPHPP) quality assessment tool. RESULTS:Eight studies met inclusion criteria. A narrative synthesis was conducted. Seven RCTs detailed interventions aimed at reducing paediatric burns (five delivered to parents/caregivers and two delivered to children). One RCT was aimed at adults. All RCTs measured burns knowledge, but findings were mixed about whether knowledge changed following interventions. Four RCTs measured self-efficacy, with all finding an increased perceived ability to engage in burn prevention behaviour following interventions. Risk perceptions (e.g., around the perceived severity and susceptibility of burns) were rarely measured. CONCLUSION:To date, burn prevention RCTs have mainly focused on paediatric burns and most often measured knowledge change. However, the impact of interventions on knowledge is variable. Future burn prevention interventions should measure a range of psychological constructs, as these are likely to be important in burn prevention behaviour.

Few qualitative studies have explored appearance concerns soon after burn injuries. This study aimed to understand the early experiences of appearance concerns after burns, through the lens of psychological flexibility and self-compassion. Template analysis informed data collection and analysis. Fifteen adults (nine female, six male) with appearance concerns were interviewed within three months of their burns. Three superordinate themes were identified: (1) Need for social connection; (2) Distress through difference; and (3) Experiential avoidance and self-criticism in response to early appearance concerns. Findings highlighted that early appearance concerns are influenced by the need for social acceptance and the desire to conform to societal ideals. Internalised gender and appearance ideals and concerns about rejection and stigma were activated by the burn, and individuals had difficulty responding to their early appearance concerns with psychological flexibility and self-compassion. Instead, attempts to avoid distress (experiential avoidance) occurred. Self-criticism in response to distress was evident which, for some, extended to the event leading to their burns. Early interventions to enhance psychological flexibility and self-compassion (e.g., acceptance and commitment therapy, mindful self-compassion), to help individuals respond to appearance concerns with less experiential avoidance and self-criticism, would likely promote adjustment to changes in appearance after burns.

Introduction: Appearance concerns are common following burns. However, there is a lack of research investigating early psychological interventions for appearance concerns. This qualitative study explored the acceptability of early psychological interventions for appearance concerns after burns. Methods: Fifteen adults (nine female; 18-56 years) with appearance concerns were interviewed within three months post-burn to explore their views about the acceptability of early psychological interventions for these concerns. Interviews were audio-recorded and transcribed. Template analysis informed data collection and analysis. Results: Three themes represented participants' views about the acceptability of early psychological interventions for appearance concerns: (1) early psychological interventions are absent; (2) early psychological interventions are acceptable within a therapeutic relationship (to manage upsetting emotions and thoughts about appearance, with therapists who are experienced in supporting burns patients); and (3) ambivalence and obstacles exist (e.g., difficulties accepting help, minimising injuries or concerns, and time restricConclusion: Early psychological interventions for appearance concerns following burns are likely to be acceptable for some patients. However, ambivalence and potential barriers remain to be addressed. Embedding early psychological interventions for appearance concerns into routine burn care could increase acceptability through normalisation. Crown Copyright (c) 2024 Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

Great disparity is observed among studies investigating the prevalence of PTSD after burns. This systematic review and meta-analysis aimed to explore the pooled prevalence of PTSD in adult burn survivors over the first two years post-burn. Five electronic databases were searched for observational studies assessing the prevalence of PTSD symptoms after burns. Meta-analysis was performed using an auto-correlation and hierarchical effects model to estimate the course of PTSD prevalence rates over time and to establish point-prevalences. The effect of different moderators over time was tested with meta-regression. Thirty-two studies were included in the meta-analysis. The overall pooled prevalence of PTSD was 20.5% (95% CI 16.4-24.6) and the prevalence significantly decreased by about 0.37% per month post-burn over time. Questionnaire-based studies, and studies published from 2000 onwards, were more likely to show a decrease in PTSD prevalence over time compared to diagnostic studies and studies before 2000. A qualitative comparison revealed that inter-continental differences are likely to be complex and multi-factorial. PTSD affects about one in five burn survivors, with moderately decreasing rates from six months post-burn onwards. Early screening and identification of burn survivors who require specialist psychological care are vital for burns services.

Ethnic inequalities exist across healthcare, including access to and experiences and outcomes of mental health services. Access to and engagement with burns clinical psychology services is essential for all patients. This study aimed to explore the ethnic diversity of adults referred to a burns clinical psychology service compared to those admitted to the burns service. It also aimed to investigate associations between ethnicity and indicators of access and engagement (receiving, declining or not attending psychological assessments, receiving psychological therapy and the number of therapy sessions completed). Routinely collected data over eight years were analysed. Analysis revealed an association between ethnicity and referral to the burns clinical psychology service. Patients from White British and Other ethnic backgrounds were less likely to be referred, whereas patients from Black and Asian ethnic groups were more likely to be referred. There were no statistically significant associations between ethnicity and receiving, declining or not attending psychological assessments or receiving psychological therapy. Furthermore, there was no statistically significant difference in the number of psychological therapy sessions received between the ethnic groups. Therefore, patients from ethnic minority groups did not appear to have significant difficulties engaging with the service but further research is recommended.

Introduction: Physical changes to appearance caused by burn injuries can have significant psychological consequences. Medical tattooing is an intervention aimed at restoring appearance but little is known about the experiences of patients or the psychological impact of medical tattooing following burns. This study aimed to explore burn patients' psychological experiences of medical tattooing.Method: In-depth interviews were conducted with eight adult women who had experienced a burn injury and subsequently undergone medical tattooing.Results: Using interpretative phenomenological analysis (IPA) to analyse the verbatim transcripts of interviews, two subordinate themes ('Management of Hope' and 'The Medical Tattooing Process') and one superordinate theme ('Impact of Medical Tattooing: 'Normal-ish is Fantastic'') emerged, which were set within a broader context of another superordinate theme: 'Inner Conflict about Acceptability of Perceived Need'. The findings suggested that medical tattooing is experienced positively, may have positive psychological consequences, and may allow women to regain a sense of normality and an improved sense of being acceptable in society following burn injuries. Findings additionally highlighted a conflicting narrative of a pressure to conform to certain expectations of appearance, alongside a sense that a desire to meet these expectations may also not be viewed as important, acceptable or legitimate.Conclusions: Medical tattooing may be a potentially valuable intervention psychologically, although support and information seem important and further research is required. CrownCopyright (c) 2021 Published by Elsevier Ltd. All rights reserved.

Within healthcare generally, patients who self-harm can experience stigma and inequitable medical care. Previous studies have suggested that patients with small self-harm burn injuries may not be treated equally in comparison to non-intentional injuries. Furthermore, there is an absence of literature related to surgical outcomes for self-harm burn injuries. A retrospective cohort study of an adult burns service’s outpatient attendances over a four-year period was completed. Self-harm burn injuries were identified and hospital medical records were used to extract demographic, burn injury, treatment and outcome information. 94 self-harm burn injuries in 58 patients presented over the study period. Of those who presented with self-harm burn injuries, 29 % (n = 17) of patients presented on more than one occasion, 54 % (n = 50) of wounds were managed surgically and 80 % (n = 36) of full thickness injuries were managed surgically. The post-operative course and healing time was similar to what would be expected after non-intentional burn injuries. In 93 % (n = 54) of all patients presenting with self-harm burn injuries, there was no reported tampering or non-compliance. There was no tampering or non-compliance in 94 % (n = 47) of those with self-harm burn injuries when wounds were treated surgically. The findings support the view that self-harm burn injuries should be treated in the same way as non-intentional burn injuries and that similar outcomes from treatment can be expected. However, further research is needed to explore this systematically.

National guidance in the UK advises that psychosocial screening is completed for all inpatients admitted to burns services for over 24 h. Acceptable methods of psychosocial screening have been nationally agreed. However, little is known about how different services conduct psychosocial screening. Moreover, data related to validity and reliability are lacking. This paper describes a tiered approach to inpatient psychosocial screening in a UK adult burns service and considers implications for services. Data collected over a seven-year period was analysed retrospectively. Of 891 patients, almost half (48%; n = 431) were screened face-to-face by a graduate level assistant psychologist. Almost one quarter (23%, n = 205) were screened face-to-face by a qualified clinical psychologist. Around a fifth (22%, n = 193) were screened indirectly through psychological discussions at multi-disciplinary team meetings with a member of the burns clinical psychology team present. A minority of patients were screened face-to-face by liaison psychiatry, or by both liaison psychiatry and a clinical psychologist. Screening and delivery of low-level psychological interventions by a graduate level assistant psychologist appeared to protect resources of qualified clinical psychologists for the most distressed patients. Results highlight the value and cost-effectiveness of a tiered approach to psychosocial screening and in guiding subsequent intervention. Future study is needed in relation to inpatient psychosocial screening and its validity and reliability. Investigating the predictive value of screening methods in identifying those with longer-term psychological difficulties would also be important clinically.

Portfolio Abstract Burns injuries can affect both adults and children. They can cause severe and enduring physical and psychological consequences, for both the individual and their family. Changes to appearance are a fundamental part of a burn injury. Medical tattooing (MT) is an intervention designed to address appearance/body dissatisfaction. Systematic Review: a systematic search was completed of five electronic databases (CINAHL, Cochrane Library, MEDLINE, EMBOSE and PsycINFO), reference lists and ‘cited by’ referencing sources to identify and evaluate all published qualitative research literature on the psychological experiences of parents of children who have experienced burn injuries. Seven studies met the selection criteria and four themes were identified: ‘the trauma of witnessing a family member’s burn injury’, ‘the ‘mixed blessing’ of hospitalisation’, ‘attempting to return to ‘normal’ life -adapting to new roles’, and ‘guilt and blame: core issues’. The results suggest parents experience three phases of recovery following a child’s burn, all impacted on by feelings of guilt and blame. Journal Article: Interpretative Phenomenological Analysis (IPA) was applied to eight in-depth interviews with burn survivors with medical tattoos. Three themes were extracted: Management of Hope, The Process and Impacts of MT: ‘Normal-ish is Fantastic’ which were set within a context of ‘Conflict about Legitimacy’. The findings suggest MT may facilitate a regained sense of normality and an improved sense of being acceptable in society. However, a potential paradox was identified between a pressure to conform to certain expectations of appearance and a sense that a desire to meet these expectations is also not viewed as important or acceptable. By understanding these experiences, healthcare professionals can increase awareness of the lived experienced of individuals with burn injuries and of those around them. It also demonstrates that MT is a potentially valuable intervention. Further research needs are highlighted.