Conceptual model of acid attacks based on survivor’s experiences: Lessons from a qualitative exploration

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Conceptual model of acid attacks based on survivor’s experiences: Lessons from a qualitative exploration Mohammad Sabzi Khoshnami a, Elham Mohammadi b, * , Hamideh Addelyan Rasi b, Hamid Reza Khankeh c , Maliheh Arshi d a

Department of Social Work, Research Center of Social Welfare Management, University of Social Welfare and Rehabilitation Science (USWR), Tehran, Iran b Department of Social Work, Faculty of Social Sciences, Allameh Tabataba’i University (ATU), Tehran, Iran c Department of Disaster and Emergency Health, University of Social Welfare and Rehabilitation Science (USWR), Tehran, Iran d Department of Social Work, University of Social Welfare and Rehabilitation Science (USWR), Tehran, Iran

article info

abstract

Article history:

Introduction: Acid attack, a worldwide phenomenon, has been increasing in recent years. In

Accepted 4 October 2016

addition to severe injuries to the face and body, such violence leads to psychological and

Available online xxx

social problems that affect the survivors’ quality of life. The present study provides a more indepth understanding of this phenomenon and explores the nature and dimensions of acid

Keywords: Acid attack Grounded theory Physical and psychological wounds Survivor Iran

attacks based on survivors’ experiences. Method: A grounded theory study using semi-structured, recorded interviews and applying purposeful theoretical sampling was conducted with 12 acid attack survivors in Iran. Data were analysed using constant comparison in open, axial and selective coding stages. Results: A conceptual model was developed to explain the relationships among the main categories extracted through the grounded theory study. Physical and psychological wounds emerged as a core category. Traditional context and extreme beauty value in society acted as the context of the physical and psychological wounds experienced. Living with a drug abuser with behavioural disorders and lack of problem-solving skills in interpersonal conflict were found to be causal conditions. Action strategies to deal with this experience were found to be composed of individual, interpersonal and structural levels. Education, percentage and place of burning acted as intervening conditions that influenced survivors’ strategies. Finally, adverse consequences of social deprivation and feeling helpless and hindered were found to have an important impact. Conclusions: Acid attack lead to physical and psychological wounds in survivors. This is a multi-dimensional phenomenon involving illness, disability, and victimization, and requires a wide range of strategies at different levels. The conceptual model derived through this study can serve as a good basis for intervention programs. © 2016 Elsevier Ltd and ISBI. All rights reserved.

* Corresponding author. E-mail addresses: [email protected] (M. Sabzi Khoshnami), [email protected] (E. Mohammadi), [email protected] (H. Addelyan Rasi), [email protected] (H.R. Khankeh). http://dx.doi.org/10.1016/j.burns.2016.10.003 0305-4179/© 2016 Elsevier Ltd and ISBI. All rights reserved.

Please cite this article in press as: M. Sabzi Khoshnami, et al., Conceptual model of acid attacks based on survivor’s experiences: Lessons from a qualitative exploration, Burns (2016), http://dx.doi.org/10.1016/j.burns.2016.10.003

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Introduction

Acid attack is a revengeful act and a vicious form of aggression which leads to severe injuries to the face and body [1]. Survivors of acid attacks experience psychological problems and social isolation. Acid attack creates short-term effects such as serious physical pain; its long-term effects include blindness, defacement, and severe psychological distress. Deformities and resultant disabilities isolate and marginalize survivors in society [2]. The common scenario of acid attack in most countries, and particularly in developing countries, is that a person buys sulphuric acid (which is used in automobile batteries or for plumbing) from a retail store and uses it to take revenge on someone who may have rejected their marriage proposal or because of a family dispute [3,4]. Historical evidence shows that acid attacks were common in England and the United States in the 1800s [5], and by 1980 several acid attacks had occurred in developing countries [6]. According to statistical data, acid attacks have become more prevalent in developing countries, especially in south Asian, southeast Asia, and sub-Saharan Africa since 1980 [1,7,8]. For instance, in Bangladesh about 9% of burns are acid burns [9] and it is estimated that there are 200 acid attacks each year in Pakistan [8]. In Cambodia, acid burns comprise 20% of all burns [6]. Waldron et al. [10] indicated that between 2000 and 2013, 254 patients were survivors of an acid attack in Cambodia. In Iran, despite the lack of official statistics, some studies have shown that about 11.5% of all patients with burns were injured through criminal attempts to throw acid [11]. Although most acid attacks are perpetrated by men to destroy young women’s physical appearance, men are also survivors of acid attacks. There are different reasons and risk factors for acid attacks. Milton et al. [12] reported on the motives for acid attacks and occurrence by gender in different countries. For example, in India the survivors were often male and the motive was most often to get revenge on someone after a quarrel [13,14] but in Nigeria even though the survivors were often male, theft and altercations were the main reasons [15]. In the United Kingdom, survivors were more often men who were usually attacked by gangs of male adolescents or young men with the motives of racial bias and robberies [16]. Jamaican survivors of acid attacks were both men and women; the female perpetrators commit this crime as a consequence of their husbands’ infidelity [17]. In Pakistan, acid attack survivors were women; their husbands or other family members carried out acid attacks as a result of spousal and family disputes and dowry issues [8]. In Bangladesh, a country with the highest incidence of acid attacks, most survivors were women under the age of 18 years who attempted to be emancipated from cultural and traditional rules that created their subordinated positions [9]. Most survivors were female in Taiwan [18] and Ugandan survivors were both male and female; the motives for half of these acid attacks were robbery (car or motorcycle theft) and house burglary [7]. The occurrence of these violent attacks among both genders shows that various patterns and processes exist around this phenomenon. Consequently, this can challenge the feminist perspective that considers acid attack as genderbased violence, i.e. male perpetrators intend to destroy what

society considers the most valuable trait in a woman, her beauty [2]. Survivors of acid attacks experience psychological problems such as anxiety, depression, social isolation [4,19] and social exclusion [20]. Social isolation creates difficulties in finding a suitable job; limits marriage opportunities and increases relational problems within the family. Similar to neighbouring developing countries, Iran has a high incidence of burn by acid attack. The actual incidence in Iran is likely to be much higher than that registered at burn centres and hospitals [21]. Research on acid attack globally has been carried out using quantitative methods and was limited to the study of its prevalence, outcomes, claimed reasons, and level of burning. Because acid attack is a multi-dimensional culture-based phenomenon, qualitative research methods are not used to study it. However, qualitative approaches can potentially provide deeper understanding about phenomena that are less recognised and are culturally constructed. Consequently, rigorous application of qualitative methodologies can promote and develop our knowledge on burns [22,23]. We believe acid attack is a phenomenon that is socially and culturally constructed. We applied the grounded theory method to explore different aspects of this phenomenon based on Iranian survivors’ experiences.

2.

Method

2.1.

Study design

We used grounded theory to guide sampling and collection and analysis of data. Grounded theory is a research approach or method in qualitative research that uses inductive analysis as a principal technique. Strauss and Corbin [24] defined grounded theory as follows: A grounded theory is one that is inductively derived from the study of the phenomenon it represents. That is, it is discovered, developed and provisionally verified through systematic data collection and analysis of data pertaining to that phenomenon. Therefore, data collection, analysis and theory stand in reciprocal relationship to one another analysis. (p22)

2.2.

Setting and participants

The setting for this research was Shahid Mottahari Accident and Burn Injury Hospital in Iran. This hospital is under supervision of Iran University of Medical Sciences (IUMS) and is the main centre for admission of patients with burns. Patients involved in acid attacks during the last 5 years (2009– 2014) were introduced to the researchers by burns unit supervisors. The patients who were currently in the hospital and those already discharged were contacted about their participation in the study. Purposive sampling was applied to select the participants. The inclusion criteria for the participating in this study were as follows: (1) having experience about acid attacks during the last 5 years (2009–2014), (2) being in an appropriate psychological and physical state for

Please cite this article in press as: M. Sabzi Khoshnami, et al., Conceptual model of acid attacks based on survivor’s experiences: Lessons from a qualitative exploration, Burns (2016), http://dx.doi.org/10.1016/j.burns.2016.10.003

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interview and (3) willingness to participate in the study. In total, 12 patients with burns (six women and six men) participated in this study.

2.3.

Data collection

We used a semi-structural interview to collect the data. Data collection was not time discrete but was done in parallel with data analysis until the researchers determined that a point of saturation had been reached. Theoretical sampling was used for data saturation. This strategy is based on the emergence and then saturation of concepts, categories and subcategories that are used to develop a substantial theory [25]. For our interviews, we designed some general questions to understand participants’ perceptions and experiences; for example, please describe your narrative regarding being attacked by acid. How do you realize this experience and what is your perception? What are the effects of acid attack on your life? How can you cope with your situation after acid attack? Besides the general questions, we asked several probing questions to provide in-depth understanding of the participants’ situations, beliefs, and perceptions. All interview sessions were audio-recorded and transcribed. The interview sessions lasted between 40 to 75min. Moreover, field notes were written and then used as complementary data and for trustworthiness.

2.4.

Data analysis

All data were analysed using constant comparative analysis [22]. This method of constantly comparing and contrasting data and results was used in all steps of the constant comparative analysis. We followed a three-phase analytic process according to Strauss and Corbin [24]. In the first phase, termed open or substantive coding, participants’ transcripts and researchers’ notes were read several times to extract codes. During weekly research team debate sessions, codes were integrated and refined to develop concepts and categories and subcategories. In the next phase, termed axial coding, after merging, removing and reducing the number of categories as needed, the relationships between them were discovered. In the third and last phase, selective coding via saturation of the concepts, categories and subcategories, a core category was identified and then other categories were linked to it. This allowed us to propose a conceptual model based on participants’ responses. Moreover, asking probing and directed questions and constantly comparing the accumulating structure with the evidence were inseparable components of our data analysis process.

2.5.

Trustworthiness

In this study, trustworthiness was evaluated by three criteria recommended by Schwandt et al. [26]: credibility, confirmability, transferability and dependability. Analytic triangulation was used to increase the credibility. Field notes and prolonged engagement in the subject matter also added to credibility. Moreover, peer checks, a process of having the four researchers review the data and code the texts separately and then integrating their results, was used until appropriate

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consensus was reached regarding analysis of the data. Formal member checking was applied as a technique to establish the credibility of this research. Conformability of this research was enhanced through reflexivity. The research group referred back and critically investigated their assumptions and actions several times during the research. Offering a comprehensive description of the subject, the participants, data gathering, data analysis and study limitations provides transferability of the study, so that other researchers can decide about translation of the findings to their study settings [27,28]. Dependability was demonstrated through similar findings or conclusions reached by the researchers in the study team.

2.6.

Ethical considerations

The research design received ethical clearance from the research ethics board in the University of Social Welfare and Rehabilitation Sciences and IUNS. Participation in this study was voluntary. We used informed consent to explain the procedure and the aims of this research in detail to the participants. To help protect the privacy of the participants, pseudonyms were used throughout to protect anonymity and provide confidentiality.

3.

Results

Twelve people took part in this study (six men and six women). The mean age was 29.5 years (range, 23–44 years) and seven of the participants were married, four were single and one was divorced. Nine people had a high school education or lower and three people had some form of college education. Through constant comparative analysis, a conceptual model on acid attack emerged from the data. The core category of the model was physical and psychological wounds and other categories related to it were (a) causal conditions: living with an addicted person with a behavioural disorder, lack of problem-solving skills in interpersonal relationships; (b) intervening conditions: education, sexuality, percentage of burning and loss of beauty; (c) context: beauty value, traditional context; (d) action/interactional strategies: individual, interpersonal, and structural: (e) consequences: social deprivation and feeling helpless and hindered (Fig. 1).

3.1.

Core category

The core category, physical and psychological wounds, involves three subcategories: physical suffering, being victimised, and psychological disarray.

3.1.1.

Suffering for the sake of the body

This subcategory consists of concepts such as physical pain, dissatisfaction with appearance, suffering from being strange and weird, comparing new appearance with the old one, chagrin about previous beauty and visual impairment and its consequences. Acid attack survivors’ problems include many serious injuries to the face and neck areas because the acid attack offender’s aim is to eliminate the survivor’s beauty. These injuries affect not only the appearance of their face but they also have to tolerate the pain of losing some parts of their

Please cite this article in press as: M. Sabzi Khoshnami, et al., Conceptual model of acid attacks based on survivor’s experiences: Lessons from a qualitative exploration, Burns (2016), http://dx.doi.org/10.1016/j.burns.2016.10.003

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Causal condions Living beside of an addicted person with behavioral disorder Lack of problem solving skill in interpersonal relaonship

Context

Intervening condions Characteriscs of burn Educaon

Phenomenon

Beauty value

Physical and Psychological Wounds

Tradional context

Acon/interaconal strategies Individual strategies

Interpersonal strategies

Avoidance

Family support

Self-restoraon

Friend assistance

Structural strategies Lack of structural supporve acceptance

Personal acve strategies

Consequences Personal

Social

Be helpless and hindered

Social deprivaon

Fig. 1 – Conceptual model of acid attack based on survivors’ experiences.

face such as the eyes. Acid attack survivors always suffer from chagrin about their previous life: what I was and now what I am (Table 1).

situation in order to show them the depth of their catastrophe, concerns, and despair (Table 1).

3.1.3. 3.1.2.

Being victimised

Concepts in this subcategory include unexpected trauma by the perpetrator, lack of appropriateness between the conflict and the injury as revenge, feeling of being victimised, unfair judgements and unequal opportunity for revenge. It seems that some survivors did not expect to be injured by acid for their incorrect behaviour and mistakes. Consequently, accepting this unfair behaviour is extremely hard. Most participants feel that they are survivors of the perpetrator’s egotism and greediness. Perpetrators judged them harshly and enjoyed seeing their suffering. Survivors experienced pain because they were not able to do the same to the attacker in an equal

Psychological disarray

This subcategory is composed of different concepts: feeling unsafe, severe irritation, feeling disdained and frustrated and being pitied. In addition to losing the beauty of their face, participants experienced psychological disturbance and disarray, which lasted for years for some people. The severity of the event was so inexplicable that some survivors were permanently afraid of recurrence. Moreover, the survivors felt that significant others’ pitiful behaviour was unpleasant and painful. They experienced many expostulatory and reprehensive behaviours in their family relations. Their families blamed them for the acid attack and, in this situation, they were so sensitive and had less control on their behaviour.

Please cite this article in press as: M. Sabzi Khoshnami, et al., Conceptual model of acid attacks based on survivor’s experiences: Lessons from a qualitative exploration, Burns (2016), http://dx.doi.org/10.1016/j.burns.2016.10.003

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Table 1 – Examples of quotations related to concepts in each category and main categories. Quotations related to concepts in each category I am so worried about my present appearance. I cannot accept my new face. I do not like it and I am shocked and upset when other people look at me like a weird and strange person. (P. 9) When I think what I was and now what has happened to my face, I feel exhausted and I always have the chagrin of my previous face . . . (P. 6, 7) I could not find any answer to this question of why my relative caused such a nuisance to me while I did not do any evil to her. (P. 6) I know I did wrong against her but it was not so much; she destroyed my life by her acid attack. (P. 10, 4). People unfairly judge me and talk behind my back without knowing everything about the event and this makes me upset. (P.2). After years of following up the case in court, finally they sentenced the attacker to pay a fine and spend several years in prison. This is not fair, I wish to punish him/her by myself. (P. 6, 7) I have no hope of recovery and I am also very exhausted. (P. 5). Compared with the past, I lose my temper several times. In the past, I could control my anger better. (P.12). When I go out I am frightened that the attack will happened to me again. The pitiful behaviours that occur in my family annoy me very much. (P. 8) My husband did it because he was a heavy drug abuser; drugs had changed his behaviour. Sometimes his behaviours and talking terrified me. When his drug abuse worsened, he became mad more and more aggressive to me. (P.10) I saw a married man who asked me to date. I was in a predicament and it was difficult to decide. I knew from the beginning that this relationship was completely wrong but I had been on some dates with him several times. After sometimes, I understood that this relationship was futile and if my family knew about it, it would be disaster. So I decided to end the relationship. When I told him that I didn’t want to see him anymore he became angry. Several times we had arguments about it but it was not helpful and he threatened me some times but I didn’t take any notice of this. I never thought he would carry out his threats. Indeed, he was planning for my annihilation. (P.12). Because of this, I imprisoned myself at home and I seldom went out. In the first few months, I was broken. My situation changed because of that terrible event and I was not the previous person. I couldn’t bear anything. (P. 11, 9) After a long time, I found my condition unchanged and I said to myself I should do something before it is too late and the only one who can help me is myself. I accepted this acid splashing as my fate and I cope with it and now I am not worried about it very much. (P.1). Before I was very sensitive to what people talked about behind my back and it upsets me but now I know I cannot change people’s mind so I don’t pay attention to what they say. (P. 12) I read about people who were in difficulties as a method to recover my mood. I was tired of my life and living environment because I had negative memories there, so I discussed with my family about moving to a new place. (P. 1, 8). I tried to communicate more with people; at the beginning it was very difficult but as time passed it became better. When I behaved well with people they treated me well too. (P.2). I thought to myself how long I can imprison myself so I decided to go out more.

Categories

Main categories

Suffering for the sake of the body

Phenomenon

Being victimised

Psychological disorder

Causal conditions

Living with an addicted person who has behavioural disorders

Lack of problem-solving skills in interpersonal relationships

Avoidance

Individual strategies

Action strategies

Self-restoration

Personal active strategies

(continued on next page) Please cite this article in press as: M. Sabzi Khoshnami, et al., Conceptual model of acid attacks based on survivor’s experiences: Lessons from a qualitative exploration, Burns (2016), http://dx.doi.org/10.1016/j.burns.2016.10.003

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Table 1 (continued) Quotations related to concepts in each category Sometimes I went to the parks and shopping with my friends. (P.12) My sons and dauthers try more to protect and support me. They are worried of the recurrence (P.3). Hopefully after this incident my family could cope with the problem and accompanied and tolerated me. (P. 7) I became friends with someone in the hospital who was burned like me by a coward. When we talked to each other, we both had good feelings, perhaps because she also felt the pain through her flesh like me so we understand each other well. We are now good friends. (P. 5). During those dark days my old friends watched out for me, they took me out and tried to make good times for me. (P. 1) I went to various governmental institutions, particularly the presidential office and the supreme leader’s office to get financial help but they were not helpful and they did not understand my situation. I also went to several charities to get help but it was futile. (P. 6, 8). One of my concerns is that my case in the court, which has been investigated for a long time, wouldn’t end in a fair result and the punishment would be unjust. Since my family and I have been engaged in this case for a long time, we expect it to end justly. (P.7). After this assault I was depressed and isolated. I used drugs for my mental illnesses (P.9)I tried to commit suicide (P.12). I am very worried about my face. I don’t know what will happen in the future, I don’t know whether my face will improve, I don’t know how my life plans will turn out, such as marriage and a job. (P.1). Because I was terribly burnt on my face, I didn’t go out with my children; they insisted on me going shopping with them but I didn’t like it and I can't make it (P.8). my husband stands by me and performs my motherhood responsibilities, especially those that require going out. (P. 5) I can’t do any job and this has made my life more difficult than others. (P. 11). Wherever I go for a job, I am rejected because of my burns. (P.7) I cannot go out easily because all my face is burnt and deformed . . . my eyes are the most important part. Many who are burnt less have fewer problems, but when one has extensive burn like me, everything is harder, much harder. (P. 5) This event was hard to accept and tolerate, but during my studies at the university, I learnt and increased my knowledge and the information that gave me a sense of being able, being strong and empowered. If I hadn’t learnt those things, I would have had a much more difficult time. (P. 2) As you know, beauty is important for women(P. 12). When your beauty is affected and lost, not only your beauty is destroyed but also you became like a ghost without a face. I am glad that the acid burnt my face less than others because appearance is really important for me. (P. 2) It was a small community ;a community the people had close relations (P.12). In such a small community when one person knew you, that was enough to spread all the news about you. My town was not big like Tehran. Everything that happened there, everyone will know about very soon. (P. 7).

Categories

Family support

Main categories

Interpersonal strategies

Friends’ assistance

Lack of structural supportive acceptance

Feeling helpless and hindered

Structural strategies

Consequences

Social deprivation

Characteristics of burns

Intervening conditions

Education

Beauty value

Context

Traditional context

Please cite this article in press as: M. Sabzi Khoshnami, et al., Conceptual model of acid attacks based on survivor’s experiences: Lessons from a qualitative exploration, Burns (2016), http://dx.doi.org/10.1016/j.burns.2016.10.003

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Consequently, they experienced hopelessness as a result of their negative experience of the acid attack (Table 1).

life. This endeavour leads to self-restoration and hopefulness in their lives (Table 1).

3.2.

3.3.1.3. Personal active strategies. Going out into society, spending leisure time, using effective interactional skills, leaving previous living environment and seeking and accessing more information to better cope with the problem were the main concepts in this category. Some survivors tried to deal with this tragedy by seeking and increasing their knowledge about coping with the situation and controlling their lives. Spending leisure time and going out could help the survivors to cope with their loneliness and isolation. In fact they fell into the habit of socializing with their new face as a member of society, which finally increased their self-confidence about living and acting in society (Table 1).

Causal conditions

This category includes two subcategories: living with an addicted person who has behavioural disorders and lack of problem-solving skills in interpersonal relationships.

3.2.1. Living with an addicted person who has behavioural disorders Based on participants’ experiences, a definite context for occurrence of acid attack is living with an addicted person who is impaired psychologically and emotionally. The drug abuser does not function normally as a family mainly because of the effects of the drugs. Also their behaviour becomes out of control in family conflicts and they decide to hurt the others using acid. It can be assumed that drug abuse, especially hallucinogen abuse, increases the risk of psychological and physical health deterioration in the abuser and eventually leads to attacking others using acid (Table 1).

3.2.2. Lack of problem-solving skills in interpersonal relationships Research participants either had serious conflicts with the perpetrator because of a unilateral break up or they were engaged in offensive relations with their relatives that intensified the conflicts. Lack of problem-solving skills in these situation increased illogical and destructive responses of the both parties, which resulted in acid attack (Table 1).

3.3.

Action strategies

Action strategies can be divided into three categories: individual, interpersonal and structural strategies.

3.3.1.

Individual strategies

This category consists of three subcategories: avoidance, selfrestoration and personal active strategies.

3.3.1.1. Avoidance. The concepts in this category that emerged from the data were stopping contact with the community, difficulty in tolerating new situations and abandoning the treatment process. Some participants (especially women) stayed at home and did not tend to go out because of the severity of their burns. Life was difficult and annoying for them. On the other hand, several time-consuming surgical operations frustrated survivors and sometimes they lost their motivation to continue the treatment process (Table 1). 3.3.1.2. Self-restoration. This subcategory is composed of several concepts: belief in personal independence in life, ignoring other’s judgement and accepting the fatalism, which helps them to feel serenity in their life. Some participants, after experiencing the difficulties that emerged from the acid attack, tried to control themselves and their environment. They also accepted the event as part of their destiny and challenged less about people’s judgement; they tried to use their ability to increase their independence and autonomy in

3.3.2.

Interpersonal strategies

Two subcategories exist in this category: family support and friends’ assistance.

3.3.2.1. Family support. The main concepts of this subcategory were extreme concern of the family about a recurrence, family acceptance and support. Participants’ families behaved in two ways; they not only were upset about this event but also helped survivors with the problems. All survivors were satisfied with the supportive behaviour of their families and in fact they could not face and solve different physical, psychological, medical and financial problems imposed by the event without their assistance (Table 1). 3.3.2.2. Friends’ assistance. This subcategory involves communicating with people who have similar problems and old friends’ support. Some participants became friends with people who were also survivors of acid attack so when they talked about their facial burns and related problems, they could understand each other better because there was a special empathy and sympathy for each other. These relationships helped them to reach serenity. Moreover, their old empathic/accommodating friends supported them in meeting the problems. They never left them alone and assisted them in their attempts to improve their situation (Table 1). 3.3.3.

Structural strategies

Lack of structural supportive acceptance is an important category.

3.3.3.1. Lack of structural supportive acceptance. The concepts in this category include being labelled, being abandoned by governmental institutions and non-governmental institutions, lack of judicial justice, lack of sympathy and commitment of the medical team, and ignorance of survivors’ abilities by employers. Most problems that participants experienced were related to their expectations of being supported by society. Some participants felt dissatisfied due to lack of support by the societal system and they felt abandoned. In addition some survivors had complaints about the laws on punishment against perpetrators, who were sentenced to only fines and several years in prison; they believe the punishment is not appropriate for the crime (Table 1).

Please cite this article in press as: M. Sabzi Khoshnami, et al., Conceptual model of acid attacks based on survivor’s experiences: Lessons from a qualitative exploration, Burns (2016), http://dx.doi.org/10.1016/j.burns.2016.10.003

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3.4.

Consequences

According to participants’ quotations, two categories emerged from the data as consequences of acid attack: (a) feeling helpless and hindered and (b) social deprivation. These outcomes were experienced by survivors despite all the strategies that had been used to manage their situation.

3.6.1.

3.6.2. 3.4.1.

Feeling helpless and hindered

The main concepts of this subcategory were committing suicide, experiencing psychological illnesses, ambiguity of life plans, trouble in parenting duties and polarization of parenting tasks. Some participants were unable to accept and deal with the event and were isolated such that they could not function normally and had to use prescribed drugs for their psychological illness. Some of them committed suicide to end their suffering. The participants who were parents could not perform their duties as parents and felt bad accompanying their children in public because of their scars and burns (Table 1).

3.4.2.

Social deprivation

This category includes two concepts: limitations through being labelled and unemployment. After years of primary treatment and relative improvements, some survivors meet many problems at social and community levels when they decide to come back to society. They need to break through many obstacles to participate in society. For example, there are some jobs that they cannot do because of their facial deformity and they encounter some obstacles in getting a job that they are able to do (Table 1).

3.5.

Intervening conditions

Characteristics of burns and education were the subcategories in this component that affected survivors’ lives. Every participant’s burns had unique characteristics that made their experience unique.

3.5.1.

Characteristics of burns

Characteristics of burns included two concepts: extent of burns and location of burns. These items had important effects on survivors’ problems and coping strategies; the less the percentage of burns, the fewer problems. The location of burns was an important factor that could increase survivors’ difficulties, e.g. when burns occurred in the survivor’s face, they experienced more difficulties coping with this situation. Participants who were burnt on their face and eyes had more serious problems that those who were burnt on their neck, hands and chest (Table 1).

3.5.2.

Education

Education had a significant effect on survivors’ experiences. Those who had higher education had better self-control and could manage the problems caused by the event in comparison with others who had less education (Table 1).

3.6.

Context

The two subcategories were beauty value and traditional context.

Beauty value

Beauty and good appearance is valued in every culture. In this study, it means that when two people have a quarrel, one of them decides to destroy the beauty of the other one as a way of devaluing and stigmatizing the person. This is especially more important for women (Table 1).

Traditional context

Traditional context creates an intervening culture that leads to increasing problems, anomy and less tolerance of differences and diversities. Traditional contexts, such as small communities where survivors live, are full of interwoven relations so that the problems and incidents that one person experiences are easily exaggerated and given negative meanings. Consequently, this leads to more pressure, labels and stigma for survivors (Table 1).

4.

Discussion

An acid attack is not just a temporary situation; it creates a new life and difficult experiences of perpetual pain and suffering. As our study shows, acid attack is a violent act that caused serious physical and psychological wounds in the research participants. survivors not only suffered from facial deformities and other physical problems such as blindness and pain but also experienced negative thoughts that occupied their mind such as feeling insecure, agitated, disdained, disappointed and victimised. Solberg [8] and Guerrero [4] found that fear of recurrence of the event, loss of self-esteem and loss of self-confidence were prevalent among survivors. Other studies also reported acid attacks as a kind of revengeful action [29] with the aim of destroying facial appearance [21] resulting in deep feelings of being victimised. Because most of these types of violence happened in small traditional communities, people’s unfair judgements affected the survivors’ psychological distress. Survivors were not only suddenly faced with their altered body image but were also in serious physical pain accompanied by movement disorders as a result of burns on their face and body muscles. Alongside these painful physical changes, their self-concepts also deteriorated. These losses induced major changes in their mental health. The context in which this phenomenon was experienced strongly emphasises and values beauty. Beauty is so important that society, the media, and cultural and social stereotypes consider it a desirability criterion for both men and (especially) for women [30]. Qualitative research in Tehran on plastic and cosmetic surgery in the general population who did not have any scars or physical wounds showed that in both men and women experiences, beauty is so important and socially desirable that they decide to undergo unnecessary surgeries. Of course, these procedures are just a sign of society members’ internalised perception of culture, which places great emphasis on beauty [31,32]. In this context, having a normal physical appearance becomes very important for survivors of an acid attack, because even after undergoing the latest surgeries to restore their physical appearance, they have to live with an abnormal face and body in a culture that highly appreciates physical attractiveness.

Please cite this article in press as: M. Sabzi Khoshnami, et al., Conceptual model of acid attacks based on survivor’s experiences: Lessons from a qualitative exploration, Burns (2016), http://dx.doi.org/10.1016/j.burns.2016.10.003

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Encountering physical and psychological wounds in this context required different strategies beyond individual reactions and included interpersonal and structural reactions. At the individual level, participants used the reaction spectrum to alleviate suffering from acid attack. This spectrum consisted of positive strategies on one side and negative ones on the opposite side. On the negative side of the spectrum was avoidance strategies such as stopping contact with the community, tolerating the new situation and abandoning the treatment process. There were two strategies on the positive side of this spectrum: self-restoration and personal active strategies. Participants varied in their reactions and this was due to intervening factors such as the percentage of burns, loss of beauty and education. As the results showed, the less visible the burns were, the better the participants’ self-image was. Consistent with current results, a study in Iran among burn patients showed that location of burning on the body is associated with their quality of life. Patients with burns on their feet had better quality of life in contrast to those whose burns were on their face, neck and hands. Moreover, patients experienced poorer psychological health the more severe the burns were [33]. Education as another intervening factor also affected the participants’ experience of suffering and its management. Education and knowledge is a cognitive resource that influence a person’s actions. Research has shown that education level and a person’s awareness determines his/ her goals, approaches and strategies in dealing with health issues [34] and improves his/her personal efficacy and positive coping strategies [35]. Thus, education in the current study affected the survivors’ coping strategies in the same manner. In addition to individual strategies, family and friends as an informal social network, provided support for participants at the interpersonal level. Crowell [36] believed that diversity of bonds provides different kinds of support, including instrumental, emotional and information support. The diversity of bonds that is characteristic of a diverse personal network also provides the highest social support for people [37]. Social support enables people to face daily problems and life crises. The family provides cohesive and useful relations for cooperation, support and supervision, and friends are involved in people’s close and active network and provide supportive bonds. Friendly bonds in contrast to relations between parents and elder children provide less support, considering the quality of the relationship, but in view of the quantity and variety of support, they act similarly to sibling relations [38]. Using the support of family and friends as an interpersonal level strategy also has an impact on people’s positive individual strategies and resilience in intense situations [39]. Participants managed their physical and psychological wounds by using individual and interpersonal strategies positively but at the structural level, they faced lack of structural support from formal and governmental organisations. For instance, the medical team did not act professionally, especially when considering the psychological issues when communicating with survivors, and this shocked participants and caused them more suffering. Moreover, supportive governmental organisations such as welfare organisations and NGOs did not have clear procedures for supporting and assisting these survivors.

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Despite all the strategies, survivors faced consequences at personal and social levels such as feeling helpless and hindered and experiencing social deprivation. Researchers have found that psychological trauma, isolation, depression and psychological problems are inherent consequences of acid attacks [29,40,41]. As our study revealed, those survivors who used negative strategies, felt more helpless and were disposed to commit suicide, experience depression and other difficulties in family roles. Alongside these problems in their personal life, those survivors who were parents had problems with their parenting duties. Rahzani et al. [42], in their qualitative study on individuals with burn disfigurement, found that lives were ruined, i.e. an unclear future, lagging behind in life and separation from children were part of the experiences of burn survivors. All participants experienced social deprivation and problems related to participating in society despite positive strategies. They were unemployed, had much less chance of marriage and were labelled and treated without dignity. Social deprivation refers to lack of societal rewards such as lack of dignity, power, social status and the chance to participate in organisations [43]. Thorns [44] stated that social deprivation/ exclusion can exist at different levels including employment opportunities, education, housing, skills and private and public settings. Other researchers also reported social isolation, quitting education, unemployment and loss of social interactions as types of social deprivation among survivors as a consequence of acid attack [19,21,29]. In a thorough look at the starting point or causal factors of an acid attack, we traced this to a social problem. From participants’ experiences, one of the risk factors or causes of an acid attack was living with a drug abuser. In Iran, drug abuse is among the top three social problems [45,46]. Thus, from the findings of this study, acid attack is not gender violence; it is an output of drug abuse. In reality, of the different drugs, use of hallucinogens such as crystal by family members (especially the spouse) triggered aggression and violence against survivors. Several studies have investigated the relationship between violence and drug abuse and showed that addicted spouses had significantly more aggressive and violent behaviours towards their partners than non-addicted people. Moreover, results showed that methamphetamine is the most common illegal drug among perpetrators. Chronic methamphetamine abuse causes aggressive behaviour and a psychotic state involving auditory and visual hallucinations, delusion, paranoia, delusion and mood disorders; these problems increase the risk of violent behaviour, suicide and homicide [47,48]. Lack of problem-solving skills in intense relations between survivors and perpetrators was another factor in acid attacks. Problem-solving skills help one to show adaptive reactions in social situations. Results show that people with problemsolving skills can control particularly physical and verbal aggression and hostility [49,50]. The present study has shown that lack of problem-solving skills caused people to choose the acid attack as a solution to meet their problems. Problemsolving skills enable a person to think systematically and consider all aspects of problems (e.g. interpersonal conflict) in advance instead of applying harmful solutions (such as unilateral break up) to find efficient ways to solve the problem

Please cite this article in press as: M. Sabzi Khoshnami, et al., Conceptual model of acid attacks based on survivor’s experiences: Lessons from a qualitative exploration, Burns (2016), http://dx.doi.org/10.1016/j.burns.2016.10.003

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and avoid any harmful effects. This skill can empower a person to think more systematically and make deliberate decisions in a way that they can see all aspects of a problem and understand that running away from problems can be harmful and negotiation is a useful strategy to resolve conflicts. In this study, the conflicts ended by a unilateral decision by either the survivor or the perpetrator. The important point was lack of mutual acceptance and contentment, which led to dangerous threats as a reaction to breaking up; what worsened the situation was the survivor’s neglect of those threats and no attempt to resolve the conflict. Other researchers have found that interpersonal conflicts and tensions including family or work conflicts [51] and domestic conflicts about dowry or properties [52] increased acid attacks. It seems these conflicts were not the main factors in the attack but were the setting for it; accordingly lack of negotiation and problem-solving skills lead to violent action.

5.

Conclusions and implications

In this study, survivors’ experiences of acid attack showed that drug abuse and lack of problem-solving skills in severe interpersonal conflicts were the main reasons for acid attacks in Iran. The causes of acid attacks are different in other countries such as India, Bangladesh and Uganda. In these countries, extremely traditional contexts in society and being principled about cultural customs are causes of acid attack, increasing gender violence and discrimination in society; thus acid attack can become a subculture and is related to honour crimes. Although in this study, acid attack occurred in a traditional context, the context did not act as a facilitator of this violence. In fact, the traditional setting mostly influences people’s discriminatory and stigmatising behaviour towards survivors after an acid attack. In other words, whereas in Pakistan inadequacy of a dowry can motivate acid attack, in India it brings dishonour on the family, and in Uganda, acid is used as a disabling weapon in theft. But in Iran, acid attacks are related to interpersonal violence. In other societies, acid attack has a gender and subcultural nature, mostly aimed at women, and is mainly explained by a feminist approach, but in the current study acid attack occurred at similar rate for women and men, so it can be assumed that in Iran it is a type of interpersonal violence rather than a gender issue. Based on the model that has emerged from this study, we suggest implementing intervention programmes with special emphasis on an ecology system perspective. This perspective not only supports social, cultural and organisational interventions but also encourages intervention programmes at personal and family levels that can lead to empowerment in a person and useful development in the social environment [53,54]. We also suggest that intervention programmes from both preventive and rehabilitative perspectives are designed for practitioners in the fields of social work and nursing. Prevention programmes aimed at improving problem-solving skills and coping strategies in children and families can empower people in their personal and family relations and reduce the risk of acid attack. Alipour et al. [55] have shown that lack of suitable systems to deliver psychosocial interventions for different disastrous and traumatic incidences

worsens survivors’ experiences. Thus, designing a system of supportive rehabilitation services could help to improve the recovery of survivors of acid attacks.

5.1.

Strengths and limitations

Although there are many studies on acid attack, qualitative research on acid attack is very scarce. This qualitative study could help in our understanding of the reasons and characteristics of this phenomenon. The semi-structured interviews used in this study provides real valuable information about the context, strategies, causes and consequences of acid attack. Moreover, the conceptual model of acid attack derived from the study could assist practitioners to apply it in social and cultural interventions. This study has some limitation with regard to access to survivors. Because the research was restricted to survivors of acid attack in a 5-year period (2009– 2014), locating some of the survivors because of a change of address was difficult and sometimes impossible and therefore the data collection took a long time.

Conflict of interest The authors declare that they have no conflict of interest.

Acknowledgements The authors wish to express their gratitude to all who participated in the study. Moreover, the authors thank the head of medical faculty of Iran University, the Chief of the Shahid Mottahari Accident and Burn Injury Hospital, head of research of Alborz Provincial Department of Justice and Iran social work clinics for their consultative assistance in this study.

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Please cite this article in press as: M. Sabzi Khoshnami, et al., Conceptual model of acid attacks based on survivor’s experiences: Lessons from a qualitative exploration, Burns (2016), http://dx.doi.org/10.1016/j.burns.2016.10.003