Introduction

Burn injuries are among the most debilitating types of trauma, leading to considerable mortality and long-term disability1. These injuries occur significantly more often in developing countries, where low- and middle-income nations account for the majority of cases2. In Iran, burn injuries represent the sixth leading cause of death, with approximately 2,920 fatalities reported annually out of 724,000 burn incidents3.

Burn severity is classified based on the depth of tissue damage. First-degree (superficial) burns affect only the epidermis. Second-degree (partial-thickness) burns extend into the dermis and are further categorized as superficial or deep partial-thickness (DPT) burns. Full-thickness (third-degree) burns involve complete destruction of the dermis4. Although they typically do not require surgical intervention, superficial partial-thickness burns are extremely painful, produce fluid exudate, and must be carefully dressed and managed to minimize the risk of scarring5.

Scarring and contractures are among the most common and challenging consequences of burn injuries. They are frequently associated with psychological effects such as social anxiety, isolation, and reduced quality of life2,6. As a result, scar prevention and management remain essential goals in burn care7. These strategies aim to reduce symptoms such as itching, thickness, erythema, and limited mobility, thereby preserving physical appearance and enhancing overall quality of life8.

However, research indicates that burn injuries can significantly impair survivors’ quality of life by affecting their physical, mental, and spiritual well-being1. The idea of health-related quality of life (HRQoL) is multifaceted and includes social, emotional, mental, and physical functioning9. Compared to the general population, burn survivors often report a lower quality of life, particularly in areas such as mental distress, interpersonal relationships, occupational functioning, and sensitivity to heat10. HRQoL in this population encompasses multiple domains, including reintegration into work or school, body image, self-esteem, perceived attractiveness, physical functioning, mobility, sexual performance, coping strategies, emotional stability, depression levels, family relationships, psychosocial development (including social reintegration), and symptom relief11.

Although burns can result in scarring and diminished quality of life, many patients do not receive consistent or coordinated professional support during the transition from hospital care to home or community settings. Barriers such as geographic distance and the cost of treatment often discourage follow-up care12. A more comprehensive approach to care transitions is essential to ensure continuity and quality of treatment for individuals with complex healthcare needs13. Healthcare professionals play a critical role in supporting burn survivors as they reintegrate into society and work to improve their overall quality of life1.

Research shows that patient- and family-centered care transition (CT) planning can reduce readmission rates, shorten hospital stays, and increase satisfaction among both patients and healthcare providers14. CT involves a series of coordinated actions from the time of hospital admission through discharge and includes transfers across units within the same institution or to external healthcare providers. When poorly executed, CT is associated with negative outcomes such as prolonged hospital stays, medication errors, and increased readmission rates15.

Literature review

Several studies have explored interventions aimed at reducing scar complications, managing scars, and improving the quality of life for burn patients. For example, Sadeghi et al.16 evaluated the impact of family caregiver training on the care of burn patients. Similarly, Bagheri Toolaroud et al.17 conducted a clinical trial assessing the effectiveness of a smartphone-based educational intervention for improving burn outcomes in children. Rezaei et al.1 compared the effects of telenursing and face-to-face education on the quality of life of burn patients in Iran.

Other studies have focused on psychological support. Mohammadzadeh et al.18 examined the impact of a family-centered empowerment model on the quality of life of children with chemical burns and on their parents’ perceived stress. Shokre et al.19 investigated the effectiveness of a psychosocial empowerment program in supporting early adjustment among adult burn survivors. Additionally, Mamashli et al.20 explored the effects of multimedia-based psychological empowerment interventions in burn patients.

Although these studies have significantly advanced burn care, most have focused on isolated aspects such as patient or family education, psychological support, or specific age groups. However, they have not addressed the implementation of a structured care transition model. Furthermore, few have comprehensively evaluated both scar-related outcomes and quality of life within a coordinated, post-discharge care framework.

Today, planning to improve health and quality of life is considered an essential component of social and economic development3, and health-related quality of life (HRQoL) is widely recognized as a critical outcome in burn care21. Despite previous efforts, a review of the literature reveals that no study has specifically evaluated the effectiveness of a hospital-to-home care transition (H2H-CT) program in preventing scar formation and enhancing HRQoL among patients with DPT burns.

The present study aims to address this gap by investigating the impact of the H2H-CT program on two primary outcomes in patients with DPT burns: the reduction of scar-related complications and the improvement of HRQoL.

Hypotheses

  1. 1.

    The H2H-CT program is effective in reducing scar-related complications in patients with DPT burns.

  2. 2.

    The H2H-CT program improves HRQoL in patients with DPT burns.

Methods

Design and setting

This quasi-experimental study was conducted in the emergency department and outpatient clinic of Shahid Motahari Burn Center, a major burn referral hospital located in Tehran, Iran.

Participants and recruitment

The participants were patients with clinically confirmed deep partial-thickness (DPT) burns who were admitted to the emergency department. Diagnosis was made by experienced burn specialists using standardized clinical assessments, including visual and tactile examination of the wound bed—characterized by a moist, mottled red appearance, presence of blisters, and delayed capillary refill—as well as the expected healing trajectory of approximately 2 to 3 weeks without requiring surgical excision or grafting. In cases where burn injuries involved mixed depths, only those in which DPT burns were the predominant type were included; patients with primarily superficial or full-thickness burns were excluded. This selection ensured a homogeneous study population and consistency in clinical outcomes. All included patients were medically stable and assessed as eligible for discharge directly from the emergency department22.

The sample size was calculated based on the study by Rouzfarakh et al.23, considering α = 0.05, β = 0.10, and a study power of 90%. Allowing for a 10% dropout rate, the sample size was estimated at 30 patients with DPT burns for each of the intervention group (IG) and control group (CG), using the following formula. Given a potential 30% dropout rate, the sample size was adjusted to include 40 participants per group.

$$n \geqslant 2\frac{{{{\left( {{z_{\alpha /2}} + {z_\beta }} \right)}^2}{\sigma ^2}}}{{{{\left( {{\mu _1} - {\mu _2}} \right)}^2}}}$$

Participants were initially selected using a convenience sampling method and then randomly assigned to the IG and CG through coin tossing. Inclusion criteria were: age over 18 years; having DPT burns not requiring surgical intervention and deemed eligible for discharge from the emergency department by the treating physician; burns covering more than 10% of the total body surface area (TBSA)—for example, at least one full leg, two full hands, half of the anterior upper torso, or half of the posterior upper torso; no reported vision or hearing impairments, cardiovascular diseases, intellectual disabilities, or severe psychiatric disorders (as reported by the patient or family); literacy; and ownership of a smartphone.

Exclusion criteria included unwillingness to continue participation and failure to complete more than 10% of the questionnaire items. Additionally, patients with inhalation injuries, burns involving more than 40% of TBSA, or those requiring intensive care or surgical intervention were excluded to ensure clinical homogeneity and the feasibility of outpatient management. Details regarding participant numbers are presented in Fig. 1.

Fig. 1
figure 1

CONSORT flow chart of the study.

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It is worth noting that in the study setting, all patients with DPT burns received a standardized course of treatment based on a uniform clinical protocol. Upon admission to the emergency department, burn wounds were initially irrigated with normal saline and then dressed with silver sulfadiazine ointment. After discharge from the emergency department, patients were advised to return for dressing changes every other day according to their clinical condition, with a total of 4 to 10 sessions. It was emphasized that at least two of these sessions should take place at the hospital outpatient clinic. After that, patients could continue further dressing changes at outpatient clinics or hospitals closer to their place of residence.

In addition to local wound care, patients received individualized education on maintaining a protein-rich diet and avoiding allergenic foods based on their personal medical history. Furthermore, prescribed analgesics were provided to support effective pain management.

Theoretical framework

The H2H-CT program was developed based on the Transitional Care Model originally proposed by Naylor24. This model is a hospital-to-community intervention comprising nine core components. These components are not delivered in a fixed sequence but can be adapted and combined according to individual needs. As such, tailoring the intervention to the specific needs of patients and family caregivers is essential for achieving optimal outcomes25. The nine core components include screening, staffing, maintaining relationships, engaging patients and caregivers, assessment and management of risks and symptoms, educating and promoting self-management, collaborating, promoting continuity, and promoting coordination. In this study, five components were employed: maintaining relationships, engaging patients and caregivers, assessment and management of symptoms, education of caregivers, and promotion of self-management and continuity of care26.

Outcome measurements

The study outcomes included the severity of scar-related complications and HRQoL. These outcomes were assessed at three time points: baseline (prior to the initiation of the H2H-CT program), follow-up 1 (at the end of the intervention, corresponding to the third week post-discharge from the emergency department), and follow-up 2 (the 12th week post-discharge). At baseline, participants received the necessary tools for the two subsequent evaluations and were instructed to complete them at the designated follow-up times. Completed forms were submitted by sending photographs via Bale, an Iranian messaging application, to the first researcher.

Measures

Demographic information questionnaire

This questionnaire collected demographic information from patients with DPT burns. It consisted of 11 items covering age, gender, marital status, education level, employment status, family size, income adequacy, cause of burn, history of previous burn-related hospitalizations, percentage of total body surface area burned, and burn location.

Patient and Observer Scar Assessment Scale

The Patient and Observer Scar Assessment Scale (POSAS) is a validated instrument used to evaluate scar symptoms and signs from both patient and observer perspectives. The scale comprises two sections: the patient scale and the observer scale, each containing six items that assess specific parameters related to the scar. Each item is rated on a scale from 1 to 10, where 1 corresponds to normal skin. Additionally, both patients and observers provide an overall scar assessment, scoring it from 1 to 10. The total score for each section is calculated by summing the six item scores, resulting in a range from 6 to 6027.

Since follow-up 2 was scheduled at 12 weeks post-discharge, direct access to participants for in-person assessment was not feasible. Based on clinical experience, it was anticipated that most patients would not return for face-to-face evaluations after the acute treatment phase; therefore, the observer component off POSAS could not be administered at this time. Consequently, this study utilized only the Patient Scar Assessment Scale, with participants self-reporting their burn scars using the scale. This approach enabled remote assessment of scar characteristics and ensured continuity of data collection without requiring physical follow-up visits. Given the self-reported nature of the tool, no specialized training was needed, as patients assessed their own scars based on the clear and validated instructions provided with the scale.

The Persian version of the Patient and Observer Scar Assessment Scale has been psychometrically validated for the Iranian population, confirming its reliability and validity. The version used in the current study was this validated Persian version28. To assess the reliability of the tool within the present study, inter-rater agreement was evaluated. This involved 10 burn patients rating their scars using the patient scale alongside the researcher’s assessment. The intraclass correlation coefficient was calculated and found to be 0.90, indicating excellent reliability.

Burn Specific Health Scale-Brief

The Burn Specific Health Scale-Brief was used to assess the HRQoL of participants. This scale includes 40 items divided into nine domains: simple activity (items 1–3), hand function (items 4–8), affect (items 10–16), interpersonal relationships (items 17–20), sexual function (items 21–23), body image (items 24–27), heat sensitivity of the skin (items 28–32), treatment regimen (items 33–37), and work (items 9, 38–40). Each item is rated on a five-point Likert scale ranging from severe (1) to not at all (5). The items are grouped into three dimensions: 18 items assess the physical aspect of HRQoL (simple activity, hand function, heat sensitivity, and treatment regimen domains), 11 items assess the psychological aspect (affect and body image domains), and 11 items assess the social aspect (interpersonal relationships, work, and sexual function domains). Higher mean scores indicate better quality of life, while lower mean scores reflect poorer quality of life. The total possible score ranges from 40 to 20029.

This tool was psychometrically validated in Iran by Pishnamazi et al.29 Factor analysis of the translated version confirmed all questionnaire domains, and a Cronbach’s alpha of 0.94 demonstrated excellent internal consistency. In the current study, a Cronbach’s alpha of 0.89 was obtained, indicating good reliability.

Hospital-to-Home Care Transition Program (H2H-CT program)

The H2H-CT program was developed based on recent scientific literature and inspired by studies conducted by Seyedoshohadaee et al.30 and Rezaei et al.1 The program was adapted to align with the routine healthcare practices at Shahid Motahari Burn Hospital, where patients with DPT burns receive dressing care and necessary education during three to ten outpatient visits, scheduled every other day according to individual needs.

The content and structure of the H2H-CT program were developed under the guidance of a multidisciplinary team, including burn specialists, clinical educators, and nursing staff at Shahid Motahari Burn Hospital. The educational materials and intervention components were carefully reviewed to ensure clinical relevance, cultural appropriateness, and feasibility prior to implementation.

The intervention was delivered following a standardized and structured protocol and checklist developed by the research team. All educators underwent prior training on the program content and delivery methods. Throughout the study, the lead investigator regularly monitored the intervention delivery to ensure consistency and fidelity across all participants.

The first session of the H2H-CT program was conducted on the day of admission to the emergency department, while the second and third sessions were held during visits to the burn clinic (Table 1). The program was delivered individually and in person, following dressing care in the clinic’s education room. Educational content was provided through lectures, written materials, and pamphlets.

Table 1 H2H-CT program for patients with DPT burns.
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The face-to-face sessions covered key topics including an introduction to the researcher and study objectives, the importance of self-care and personal responsibility, anatomy and physiology of the skin, types and complications of burns, treatment regimens and strategies to improve scar outcomes, appropriate physical activity and nutrition, interpersonal relationships, stress management, body image, and self-esteem.

The fourth and fifth sessions were conducted through phone follow-ups during the second and third weeks post-discharge, focusing on reviewing the topics previously discussed. These follow-up calls specifically addressed strategies to reduce scar-related complications and improve quality of life. Delivered in a Q&A format, the sessions aimed to reinforce and clarify patients’ understanding of the educational content.

Each face-to-face training session lasted between 15 and 30 min. Participants in both the IG and CG also received the routine discharge education provided by hospital staff.

It is worth noting that both the intervention and control groups received routine discharge education from the burn care team, including surgeons and nurses. However, this routine education lacked the structured and comprehensive approach needed to effectively address improved scar outcomes and holistic post-discharge care.

Data analysis

Data were analyzed using SPSS version 22, employing both descriptive and inferential statistics with a 95% confidence level. Descriptive statistics included means, standard deviations, frequencies, and percentages. For comparative analyses, the Chi-square test was used for demographic variables, the independent t-test for between-group comparisons, one-way repeated measures ANOVA for within-group comparisons, and two-way repeated measures ANOVA to examine the interaction effects of time and group on the study variables. Participants who failed to complete more than 10% of questionnaire items were excluded from the final analysis; therefore, no imputation methods were applied for missing data.

Results

Baseline information of participants

The results showed that the mean ± standard deviation of participants’ age was 34.25 ± 6.10 years in the IG and 35.62 ± 5.40 years in the CG. Additionally, the majority of participants in both groups were female (70% in the IG and 60% in the CG). There were no statistically significant differences between the two groups regarding age, gender, or other demographic variables (Table 2).

Table 2 Sociodemographic characteristics of participants in the CG and IG.
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Scarring changes in IG and CG

In between-group comparisons, the independent t-test showed no significant difference in mean scar scores between the IG and CG at baseline (P = 0.271). However, significant differences were observed at follow-up 1 and follow-up 2 (P < 0.001).

Within-group comparisons using one-way repeated measures ANOVA revealed a significant increase in mean scar scores from baseline to follow-up 2 in both groups (P < 0.001), with a greater increase seen in the CG (Table 3).

Table 3 Comparison the changes in the Scar prevention in IG and CG.
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Two-way repeated measures ANOVA showed that time was associated with a 5.71-unit reduction in scar scores, group membership accounted for an 8.81-unit reduction, and the interaction between time and group led to a 5.22-unit reduction (P < 0.001). These results suggest that the H2H-CT program contributed to reducing scar severity and promoted a more favorable scar maturation process in patients with DPT burns.

HRQoL changes in IG and CG

As shown in Table 4, independent t-test results indicated no significant difference in mean HRQoL scores between the IG and CG at baseline. However, significant differences were observed between the two groups at follow-ups 1 and 2 (P < 0.000).

Table 4 Comparison of changes of the HRQoL and its dimensions in CG and IG.
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Within-group comparisons using one-way repeated measures ANOVA showed that mean HRQoL scores and all its dimensions significantly improved in both groups from baseline to follow-up 2 (P < 0.001), with greater improvements observed in the IG.

Two-way repeated measures ANOVA revealed a significant increase in HRQoL over time by 21.68 units (P < 0.001). Group effects demonstrated a significant 26.74-unit increase in the IG compared to the CG (P < 0.001). Additionally, the interaction between time and group resulted in a 24.71-unit increase in HRQoL (P < 0.001), highlighting the positive effect of the H2H-CT program on improving HRQoL.

Among the HRQoL dimensions, the largest improvements were seen in the mental and physical domains, with Cohen’s d values of 11.17 and 11.02, respectively, indicating very large effects in the intervention group.

Discussion

The results of this study demonstrated that the H2H-CT program effectively improves scar outcomes and enhances HRQoL in patients with DPT burns. By combining in-person education with remote phone follow-ups, the program successfully supported both study hypotheses.

The H2H-CT program was shown to significantly improve scar outcomes in patients with DPT burns, supporting the first hypothesis. Compared to other care transition programs for burn patients, the H2H-CT program is distinguished by its intensity and extended timeline. It comprises five structured sessions, starting at admission and continuing through three weeks post-discharge, combining face-to-face education with telephone follow-ups and remote monitoring. This multi-phase design provides continuous and comprehensive support, setting it apart from interventions that are shorter or more limited in scope.

A study conducted in Iran examined patients with second- and third-degree burns from hospital discharge up to 1.5 months afterward, aligning with the current findings. The follow-up program included home visits, telenursing, and referrals to health education centers or specialists. Results demonstrated significant improvements in patients’ psychological health, scar management, and overall well-being through post-discharge follow-up31. The use of telenursing and remote follow-up in both studies highlights the important role of integrating technology and education, as implemented in the second phase of the H2H-CT program.

Similarly, Sadeghi et al.16 found that implementing educational programs for family caregivers improved their knowledge and caregiving skills in various areas, including scar care and healing. In the present study, part of the H2H-CT program focused on educating patients about scar care, reflecting a comparable approach. This underscores the importance of patient education in improving scar-related outcomes.

Moreover, Bagheri Toolaroud et al.17 examined the impact of a smartphone based educational program including audio video and text files on self care knowledge and anxiety reduction for parents of children with severe burns Their results consistent with the current study demonstrated that this type of intervention can improve scar healing in children with severe burns This further supports integrating digital tools into burn education programs as done here through smartphone messaging and structured follow ups.

In summary, the multiphase H2H-CT program is an effective and comprehensive intervention for improving scar outcomes in patients with deep partial thickness burns. Implementing this program during hospitalization and continuing it through post-discharge follow-up can significantly enhance overall health outcomes for these patients.

Regarding the second hypothesis, the results indicated that the H2H-CT program effectively improves the HRQoL of patients with DPT burns. Supporting this finding, a controlled clinical trial showed that rehabilitation education delivered through social media significantly enhanced quality of life in burn patients23. Similarly, Bayuo et al.12found that a transitional tele-rehabilitation program improved overall quality of life for adult burn survivors with burn areas exceeding 2%. In another study, Ahmadi et al.32, used a mixed methods approach to evaluate the effectiveness of a family-based education and follow-up program, concluding that such interventions can enhance quality of life in burn patients. Furthermore, Seyedoshohadaee’s study30 revealed that a five-week nursing rehabilitation model effectively improved quality of life for individuals with hand burns.

A common pattern observed in these studies, similar to the current one, is the effectiveness of educational and follow-up interventions delivered through both in-person and remote methods. Therefore, it can be concluded that the multi-dimensional and multi-phase H2H-CT program significantly contributes to enhancing the HRQoL of patients with DPT burns.

In the present study, the mental and physical domains of HRQoL showed the greatest improvements, likely due to the psychological support and physical rehabilitation components of the H2H-CT program. These elements helped enhance patients’ emotional well-being, mobility, and independence, highlighting the value of comprehensive care in burn recovery.

This study is valuable for two main reasons: it targets patients with DPT burns, a group often underrepresented in research, and it assesses the effectiveness of the novel H2H-CT program. This program combines face-to-face education, telephone follow-ups, and remote supervision to ensure continuity of care, addressing two key outcomes: reduction of excessive scar complications and improvement in HRQoL.

The predominance of female participants in this study may reflect cultural and socio-economic factors in Iran. Traditionally, women, especially housewives, face higher burn risks in domestic settings. However, with changing gender roles and increased female participation in small industries and social environments33their exposure to burn risks has expanded. Therefore, the higher number of women in this study could be due to these shifting roles, which have broadened burn risk exposure in both domestic and professional contexts. This change in gender dynamics highlights the evolving role of women in society and the associated increase in vulnerability to injuries such as burns, both at home and in the workplace.

Limitations

One primary limitation of this study was the limited number of face-to-face education sessions for patients, mainly due to inconsistent attendance at outpatient clinics after discharge. Many patients attended only one or two sessions for dressing changes post-discharge, which reduced opportunities for sustained in-person interventions. Additionally, the face-to-face sessions of the H2H-CT program took place while patients were either admitted to the emergency department or attending the clinic. These conditions may have negatively affected their ability to focus and absorb the educational content.

Another limitation of this study relates to the sample size, which was calculated based on data from a previous similar study. As a result, it may not have been sufficiently representative, limiting the generalizability of the findings. Additionally, scar maturation and the prevention of excessive scar complications typically continue over six to twelve months. Therefore, the relatively short follow-up period of twelve weeks in this study may have restricted the ability to assess meaningful long-term scar outcomes and improvements in health-related quality of life.

The absence of observer-assessed POSAS at this time point also represents a limitation, as it could have affected the objectivity of scar evaluation. Moreover, the use of a simple coin toss for random allocation might have weakened the robustness of allocation concealment compared to more rigorous methods such as computer-generated or block randomization. Moreover, the use of a simple coin toss for random allocation might have weakened the robustness of allocation concealment compared to more rigorous methods such as computer-generated or block randomization. The lack of blinding, especially for subjective outcomes such as self-reported scar assessments and health-related quality of life, may have introduced some performance or reporting bias. However, employing validated instruments helped to mitigate this concern to some extent. Finally, the single-center design, predominance of female participants, and the unique socio-cultural context in which the research was conducted may limit the applicability of the findings to broader populations.

Conclusions

According to the study’s findings, patients with deep partial-thickness burns can benefit from the H2H-CT program, which helps reduce excessive scar complications and enhances their health-related quality of life. It is recommended that nurses in burn care units and nursing managers prioritize the design and implementation of the H2H-CT program from the moment the patient is admitted. Additionally, incorporating the H2H-CT program into the accreditation requirements for burn-related healthcare institutions may help improve the overall quality of care. The study’s findings also highlight the importance of educating nurses and nursing students about the significance and application of the H2H-CT program for patients with burns.

Future studies are encouraged to replicate this research by involving patients’ families and including individuals with full-thickness burns.

Since scar maturation and prevention of complications continue for six to twelve months, a 12-week follow-up may not be sufficient to capture meaningful changes. Therefore, longer follow-up periods, such as six months to one year, are strongly recommended to better evaluate the long-term effects on scar progression and patient quality of life. Additionally, to enhance the objectivity of scar assessment, future research should use both the patient and observer components of the POSAS, possibly incorporating telemedicine methods.

Although this study was conducted in Iran, its findings may be applicable in other contexts. However, the effectiveness of the H2H-CT program could be influenced by cultural and environmental factors. In regions where limbs are more frequently exposed, such as tropical or Western countries, adapting the educational content and scar management strategies may be necessary to achieve optimal outcomes.