Iran Journal of Nursing

Introduction
The occurrence of burns is a potential trauma that affects an individual's life in various physical and psychological aspects. Visible deformities and scars can lead to rejection by others, social isolation, decreased self-esteem, stigma, and feelings of anxiety and depression. Stigmatization behaviors are different; they can be obvious or hidden to the individual. These behaviors may include avoiding from getting close, staring, showing confusing, unfriendly, and disrespectful behaviors, avoiding eye contact, asking annoying questions, making fun of the person, and aggressive and bullying behaviors. The studies on perceived stigma in children with burn injuries is very limited. Most of them have focused on acute burn conditions and children's problems during hospitalization. This study aims to determine the perceived stigmatization in Iranian children with deformities or visible scars caused by burns.

Methods 
In this descriptive cross-sectional study, 190 children with visible burn scars referred to reconstructive surgery and burn treatment centers in Tehran in Tehran, Iran, participated. The inclusion criteria were a the experience of burn injuries for at least 6 months, a burn scar greater than 1 cm, a visible scar or deformity caused by burns, and no use of a mask or any other things to cover the scar or deformity before and during the study. 
Data collection was done from October 20, 2021, to October 20, 2022. The children completed the questionnaire when their mothers were beside them. The questionnaires included a demographic form and the Perceived Stigmatization Questionnaire (PSQ) which has 21 items rated on a 5-point Likert scale as 1 (never), 2 (almost never), 3 (sometimes), 4 (often) and 5 (always). A higher score indicates a greater level of perceived stigmatization. The PSQ has 3 subscales: Absence of friendly behaviors (8 items), confusing/staring behaviors (8 items), and hostile behaviors (5 items). Data were analyzed in SPSS software, version 21 using independent t-test and one-way ANOVA.

Results
Among the participants, 111 (58%) were male, with a mean age of 12.3±3.43 years; 77 (40.5%) were studying in the middle school; 52 (52.6%) had burns in multiple areas (face, neck, hands). The most common causes were flames (44.7%) and boiling water (42.1%). The mean score of PSQ was 2.19±0.56. The subscale of confusing/staring behaviors had the highest score (2.51±0.82). 
Among the items of PSQ, the highest scores were for “People I don’t know say Hi to me” (3.31±1.157), “People I don’t know act surprised or startled when they see me” (3.15±1.31), “People feel sorry for me” (2.95± 1.31), and “ People I don’t know smile at me in a friendly way (2.84±1.8). 
Perceived stigmatization showed significant correlation with age (P=0.010), gender (P=0.030), educational level (P<0.001), frequency of reconstructive burn surgery (P=0.009), time since the burn accident (P<0.001), the burn site (P<0.001), and the cause of burn (P<0.001). Additionally, perceived stigmatization was significantly correlated with the mother's education level (P=0.007) and occupation (P=0.003). Girls tended to experience these behaviors more frequently than boys. Children experienced the behaviors mostly during early adolescence. Additionally, a higher number of reconstructive surgeries and a shorter time since the burn accident were linked to increased perception of stigmatization. Moreover, children of employed mothers and those whose mothers had higher educational levels reported more perceived stigmatization.

Conclusions
Based on the results, confusing/staring behaviors were the most perceived stigmatization behaviors in Iranian children with deformities or visible scars caused by burns. Paying attention to this issue is essential for maintaining the mental and social health of these children. Creating a positive attitude in children, especially in the new generation through social media or in kindergartens and schools towards interacting with people with deformities or scars, seems crucial. On the other hand, it is very important for the families of these children to receive psychological counseling and supportive social services, because the psychological effects caused by perceived stigmatization  can involve the children and their families in deeper and more complicated issues and problems. Nurses play a crucial role in addressing this issue. It is important for them to identify these issues and refer cases that need additional support to available social centers for further assistance.

Ethical Considerations
Compliance with ethical guidelines
Before the study, the study objectives were explained to the participants and they were assured of the confidentiality of their information. A written informed consent was obtained from them. This study was approved by the Ethics committee of Iran University of Medical Sciences (Code: IR.IUMS.REC.1398.1169).

Funding
This article was extracted from the master’s thesis of Fatemeh Rahimi Nasrabadi, funded by Iran University of Medical Sciences. 

Authors' contributions
Sampling, data analysis, and initial draft preparation: Fatemeh Rahimi Nasrabadi; Conceptualization, data collection, supervision, editing & review: Mahnaz Shoghi and Mahboobe Ali Akbari

Conflict of interest
The authors declared no conflict of interest.

Acknowledgments
The authors would like to thank the Deputy for Research and Technology of Iran University of Medical Sciences, the clinical research development units and the cosmetics surgery clinics of 15 Khordad. Hazrate Fatemeh Zahra, and Shahid Motahari hospitals in Tehran, and all children and their mothers participated in this study for their support and cooperation.

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