Resilience and Posttraumatic Growth after Burn: A Review of Barriers, Enablers, and Interventions to Improve Psychological Recovery

Burn injuries are traumatic experiences that can detrimentally impact an individual’s psychological and emotional wellbeing. Despite this, some survivors adapt to psychosocial challenges better than others despite similar characteristics relating to the burn. Positive adaptation is known as resilience or posttraumatic growth, depending on the trajectory and process. This review aimed to describe the constructs of resiliency and growth within the burn injury context, examine the risk factors that inhibit resilience or growth after burn (barriers), the factors that promote resilience or growth after burn (enablers), and finally to assess the impact of interventions that have been tested that may facilitate resilience or growth after burn. This review was performed according to the recently updated Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Guidelines. An electronic search was conducted in November 2021 on the databases PubMed, Medline (1966-present), Embase (1974-present), PsycINFO for English-language peer-reviewed academic articles. There were 33 studies included in the review. Findings were mixed for most studies; however, there were factors related to demographic information (age, gender), burn-specific characteristics (TBSA, time since burn), person-specific factors (personality, coping style), psychopathology (depression, PTSD), and psychosocial factors (social support, spirituality/religion, life purpose) that were evidenced to be related to resilience and growth. One qualitative study evaluated an intervention, and this study showed that a social camp for burn patients can promote resilience. This study has presented a variety of factors that inhibit or encourage resilience and growth, such as demographic, individual, and social factors. We also present suggestions on interventions that may be used to promote growth following this adverse event, such as improving social support, coping styles and deliberate positive introspection.


Introduction
Improved care and treatments for burn injury have increased survival rates, but have led burn survivors to contend with greater long-term psychosocial and physical consequences [1]. It is recognized that burn injuries are traumatic experiences that can detrimentally impact an individual's psychological and emotional wellbeing. Posttraumatic stress disorder occurs in 8 to 30% of the adult burn population [2], and 11 to 13% of child burn populations [3], and routine clinical practice accepts the absence of a mental health reviewed academic articles. No time restrictions were placed. Medical Subject Headings (MeSH terms) or equivalent terms were used for searching in Title, Abstract, and Keywords according to the requirements of the database. The search terms were broad to capture all relevant articles. MeSH or Indexed terms related to burn injury were combined using the Boolean operator "OR". Separately, MeSH or Indexed terms related to burn survivorship, resilience, and posttraumatic growth were also combined using the Boolean operator "OR". These two searches were combined with the Boolean operator "AND".
MeSH terms: (Burns) AND (Survivors/psychology) OR (Trauma and Stressor Related Disorders/psychology OR Trauma and Stressor Related Disorders/rehabilitation) AND (Resilience, Psychological OR Posttraumatic Growth, Psychological).

Inclusion and Exclusion Criteria
For question one (the investigation of barriers and enablers on resilience or PTG), qualitative or quantitative articles were included if they described factors that negatively or positively influenced resilience or growth. Participants could be adult or pediatric. Reviews were handled by extracting the relevant reference articles for inclusion in this review.
For question two, inclusion criteria were (1) adults and children with burn injury, (2) a psychosocial or physical intervention aimed at improving resilience or posttraumatic growth (this could be a psychotherapy (e.g., cognitive behavioral therapy), counselling, a psychoeducational strategy, peer support, or a physical or social activity, (3) any comparators, (4) outcomes involving resilience or posttraumatic growth, (5) all RCTs, and quasi-experimental intervention research studies. No time limits were set. Case reports, letters to the editor, conference abstracts, and grey literature were excluded. Articles published in languages other than English were excluded.
Titles and abstracts identified through the electronic search were reviewed independently by two authors (AW and LM) for inclusion. Each full-text review was completed by two authors to decide on eligibility for inclusion in the review. Any discrepancies in opinion were discussed between the authors. See the PRISMA diagram in Figure 1 for details.

Critical Appraisal
Quality assessment and risk of bias was assessed with the Joanna Briggs Institute critical appraisal tools [16]. The appropriate tool was selected depending on study design (see Table 1). Each study was assessed using these tools, the results were reviewed by the authors, and any discrepancies discussed. Two studies were excluded after quality assessment.

Data Extraction and Synthesis
The following information was extracted from the articles: authors, year and country, aim, study design, sample size, participant characteristics, clinical characteristics, outcome measures, statistical analyses, and findings.

Study Selection and Characteristics
This review included 33 studies. Study characteristics are outlined in Tables 2 and 3. The  studies comprised of two cohort studies, 15 analytical cross-sectional studies, 15 qualitative studies, and one qualitative intervention study. The settings of the studies included Australia (n = 8), China (n = 5), United States (n = 4), Pakistan (n = 3), Germany (n = 2), Korea (n = 2), United Kingdom (n = 2), Canada (n = 1), Iran (n = 1), Mexico (n = 1), Norway (n = 1), Saudi Arabia (n = 1), South Africa (n = 1), and Taiwan (n = 1). Thirty studies investigated adult populations, while only three investigated children or young people. In total, there were 1972 participants in the quantitative studies, and 205 participants in the qualitative studies. Of the quantitative studies, nine investigated resilience and eight investigated PTG. Four evaluated resilience with the Connor Davidson Resilience Scale, two used the Resilience Scale developed by Wagnild and Young [52], one used the Ego Resilience Scale developed by Block and Kremen [53], one used the State-Trait Resiliency Scale [54] and one used resilience scales developed for Mexican populations. Seven studies evaluated PTG with the Posttraumatic Growth Inventory [55,56], and one used the Perceived Benefit Scale [57]. For resilience, as measured by the CD-RISC, mean scores varied from 49.89 to 67.34 (Table 2). For PTG, as measured by the PTGI, mean scores (out of 5) varied from 1.26 to 3.18 [30], with mean scores over 2.5 recommended to represent a useful level of PTG [44]. Forty different outcome measures were used in the analyses, and this prevented the ability to quantitatively synthesize the data ( Table 2). The qualitative studies were mixed, those that evaluated resilience stated this outcome, and those that evaluated growth reported the positive changes described by burn survivors.

Question One: Barriers and Enablers to Resilience or PTG
The results of the quantitative studies suggested that there are several barriers and enablers to resilience or PTG following a burn (see Table 2). Total body surface area of the burn was reported to be positively associated with PTG in four studies [18][19][20]31], although another study reported no association [30]. The relationship with stress differed between resilience and PTG, and was reported to differ between males and females. In terms of resilience, three studies reported that increased stress [22,28] or subclinical symptoms of post-traumatic stress disorder [21] hindered resilience following a burn. Bibi et al., [21] reported that this barrier to resilience was further associated with gender, as females reported higher traumatic stress and lower resilience. Masood et al. also reported similar findings about gender, resilience, and distress [28]. However, Yang et al. [34] reported resilience to be higher in females. For PTG, stress and PTG co-exist, stress is reported to precede growth, and has a positive association with growth [18,20,30], with females reporting more growth than males [30]. In terms of barriers to PTG, time postburn was identified as a factor, with higher risk for poor PTG occurring in the year following a burn [32]. Younger age was associated with resilience [29], but not PTG [30], and other studies found no association between age and either construct [23].
The process of growth emerges from distress, aided by coping styles and social support.
Burns involving the face and hands reported more growth The more severe the burn the more growth experienced. More PTG with more time postburn.
Facilitating growth through narrative may be beneficial. Patients could also be assisted to establish or renew meaningful social support networks.
Females had generally lower resilience than males.
Low levels of resilience are associated with higher symptoms of PTSD.
Females had more severe PTSD symptoms and lower resilience than males; likely due to cultural factors and differing peer supports for men and women in Pakistan.

Question Two: Interventions Targeting Resilience or PTG after Burns
There was only one qualitative study that investigated the impact of a burn camp for children on psychosocial outcomes and found that the social environment of a burn camp greatly enhanced resilience [49]. In particular, the camp improved the children's confidence, psychological recovery, it normalized their experiences, and provided social support.

Discussion
This study aimed to describe the constructs of resilience and growth within the burn injury context, examine the risk factors that inhibit resilience or growth after burn (barriers), the factors that promote resilience or PTG after burn (enablers), and to assess the impact of interventions that have been tested that may facilitate resilience or growth after burn. Findings were mixed for most studies; however, there were factors related to demographic information, burn-specific characteristics, person-specific factors, psychopathology, and psychosocial and social factors that were evidenced to be related to resilience and PTG. It is important to remember the differences in the construct of resilience and growth.
For age, one study found that being younger promoted resilience [29], another that showed older participants demonstrated more PTG [30], and another that contradicted this finding of no significant association between age and PTG [23]. In other populations, PTG is typically associated with younger age [59,60], and thus these results should be interpreted with caution given the variability in findings. For gender, associations with resilience were reported to be higher in women in one study [28], yet lower in others [21], [28]. In these latter two studies, lower levels of resilience presented with higher levels of stress symptoms. In addition, the gender differences were thought to be mediated by higher levels of social support for males in the local cultural environment, but this was not statistically investigated. However, associations between gender and PTG differed to the associations between gender and resilience, with women reporting higher levels of PTG compared to men [30], although another study found no gender differences [23].
Most studies showed larger TBSA being associated with higher levels of PTG [18][19][20]23,31]; however, another study found no relationship between TBSA and PTG [30], but this was possibly due to study design. The positive association between TBSA and PTG might be due to the influence of high levels of stress leading to more growth [20], which is consistent with theories of PTG [8,61]. In addition, scar visibility might affect resilience or PTG [9,40,43], although functionality might be more important to recovery than aesthetics [40]. As time moves on after the burn event, burn survivors may do better [57], and those burnt as children might do better in terms of social support compared to adults [43]. Not all studies reported time since burn, and further research is required to assess long-term trajectories.
Individual factors related to resilience or PTG included personality and potential psychopathology. Optimism is a personality factor that might contribute to resilience [21,23] and has been suggested to boost PTG by affecting subjective wellbeing [23]. Optimism has been found to promote PTG in other clinical populations such as patients with HIV [62]. The personality trait of extraversion was found to predict positive change, whilst neuroticism was found to increase distress and impede PTG [27].
The role of spirituality is interesting, those who have a faith find more inner strength, and both spiritual change and inner strength are components of PTG [55]. Spirituality has been shown to have a positive association with resilience [31] and growth [19,27] and the importance of offering pastoral support to patients should not be underestimated [17].
Adaptive coping mechanisms (such as positive reframing, humor, planning, resourcefulness, downward comparison, acceptance, and focusing on the future in a positive way) were all found to promote resilience and PTG [18,26,35,39,40,43,44,48,58]. Distress was found to be related to resilience and PTG, and it is thought that this is because those in distress might need to adopt new ways of thinking about a situation that is not able to be changed. Stress is thought to precede PTG [18,20] and stress and PTG co-exist [30]. This theory is supported in research with other populations, whereby more stress or distress is associated with more PTG [12,63]. Depression and anxiety were found to impede resilience and PTG in some studies [26,36,40], but not others [18]. Studies in other populations (i.e., cancer) have found that PTG is related to fewer symptoms of depression [64]. Burn-related studies that found depression to be a barrier to growth, suggest that this is due to the overwhelming of coping resources that are necessary for growth to occur [58] or due to the negative reframing that naturally occurs in depression [18].
Social support was overwhelmingly identified in this review to facilitate both resilience and PTG. Specifically, we found that social support [17,18,20,22,31,34,37,39,40,44,49,51,65], spirituality/religion [17,31,35,39,40,44,46,51], and a positive life purpose [35,37,39,40,44] were the most commonly reported enablers of resilience and PTG. Further, having quality relationships [26] and recognizing you are not alone [17,31] were notably important. It should be stated though, that cultural differences may impact on the relationship between spirituality and religion [51]. Concerns about burdening others by sharing experiences were a social barrier that was a barrier to PTG [40,44]. The results found in this study are in line with research on PTG in non-burn populations, such as rheumatoid arthritis [59]. The process by which growth occurs can only be explored with rich contextual data from qualitative studies, and these suggest that growth arises from deep introspection [39] that leads to a new worldview to create coherence in their own personal narratives of their lives [48] and the need to find some meaning in the situation [51]. This is similar to PTG after other types of trauma, and is central to related background theories [55,65].
One qualitative study conducted an intervention to promote resilience and found that encouraging social support via a burn camp could help improve resilience in children [49]. One other study audited peer support as a potential mechanism for intervention to promote resilience and PTG and noted it would be a promising area to target [58], which is logical given the overwhelming evidence in this study supporting social factors in the encouragement of resilience and PTG [17,18,20,22,31,34,37,39,40,44,49,51,65]. Future studies should target adult populations, as there were no interventions for this group despite poor psychosocial outcomes being an issue for this population [4]. Interventions could focus on methods to promote deliberate rumination and introspection [39], teach adaptive coping styles [58], and teach clinicians and parents how to recognize 'red flags' and promote 'green flags' (i.e., symptoms of PTSD and PTG) [58]. Finally, as it appears that depression is a factor in resilience and PTG, clinicians should screen burn patients for symptoms of depression, to optimize psychosocial recovery and ensure a good personal environment for PTG to occur.

Interventions, Limitations, and Future Considerations
This study found several limitations in the existing literature on resilience and PTG in populations that have experienced a burn, which could drive future research and clinical practice. Firstly, the studies were heterogeneous in their scope and methodology, which made synthesis difficult and rendering us unable to conduct a meta-analysis. There needs to be more research in the underlying mechanisms of both resilience and PTG. Further to this, there were only two small longitudinal studies on the progression on PTG [18,58], which makes understanding PTG as a process difficult. There also needs to be more research conducted on child and adolescent populations, given this is a large demographic for burn injuries. We do not currently know how the presentation or trajectory of PTG differs in pediatric versus adult populations.

Conclusions
Resilience and PTG are important constructs to understand given that individuals who experience a burn injury are a high-risk population for longer term mental health issues. This study has presented a variety of factors that inhibit or encourage resilience and PTG, such as demographic, individual, and social factors. We also present suggestions on interventions that may be used to promote growth following this adverse event, such as improving social support, coping styles, and deliberate positive introspection. Ideally, clinicians and family members/parents would also be aware of the importance of resilience and PTG and be able to look out for and promote these phenomena when treating burns patients.