Extremity injuries (EIs) are frequently life-threatening and result in the substantial use of healthcare services (de Putter et al., 2013). The occurrence of EI is often associated with traffic accidents. Previously, EI had brought productivity loss and disease burden in the Western world (Crowe et al., 2020; Polinder et al., 2016; Weijermars et al., 2018). On the other hand, EI's threat emerges as concerns in low- and middle-income countries (LMICs) because traffic accidents are considerably more serious than in other countries (World Health Organization, 2018). Based on the global macroeconomic burden assessments for 2015-2030, Indonesia had the highest aggregate economic burden associated with traffic-related injuries among LMICs, estimated at U.S. $22 billion (Chen et al., 2019). Furthermore, researchers reported Indonesia ranked among the top five Asian countries for economic losses due to traffic-related injuries.
The Indonesian Ministry of Health endorses the United Nations' Sustainable Development Goal 3, which aims to ensure healthy lives and promote well-being for all ages. One of the target goals is halving the number of global deaths and injuries due to road traffic accidents by 2030 (United Nations, 2016). In 2018, 10 years of data from the Ministry of Health of Indonesia showed that the injury mortality rate decreased from 6.5% to 4.7% per 100,000 population (Ministry of Health, 2018), which could likely be attributed to multiple factors, including upstream government programs and downstream advancements in trauma care. Upstream governmental actions include the introduction of injury prevention programs in five categories: road safety management, road infrastructure, vehicle safety, road user behavior, and post-crash care (Mayastinasari, 2018). Although the proportion of deaths caused by injury has decreased, this decrease has been associated with a concomitant increase in physical disabilities among the injured population, which represents another emerging challenge (Apsari & Raharjo, 2021). A national survey revealed that approximately 34% of injured individuals suffered from minimal to total disability. In addition, individuals who have experienced EI exceed 70% of the total injury population, and most of this population experiences difficulties fulfilling activities of daily living (Ministry of Health, 2018). During the transition phenomenon from mortality to disability, clinicians should be well-prepared with additional evidence for how to better assist the EI population.
Background
Societal impacts of EI extend beyond economic costs and include other sequelae, such as functional impairments (Busse et al., 2019), chronic pain (Griffioen et al., 2017), sleep disturbances (Lu et al., 2019), and depression (Turkington et al., 2018). Together, these sequelae contribute to an overall decrease in patients' quality of life (QoL). Previous research indicates that individuals who sustained EI are unable to recover their preinjury QoL (Lin et al., 2016). This QoL impairment has been reported during the first 2 months, 6 months, and may extend to 12 months following hospital discharge (Lin et al., 2016; Nasirian et al., 2020). Therefore, it is important to identify strategies to assist patients to promote their own recovery from EI.
Modifiable psychosocial factors, such as patients' illness perceptions and coping strategies, are known to contribute to postinjury QoL. Both illness perceptions and coping strategies are concepts that represent an individual's innate response to injury and their ability to control or manage health threats (Turkington et al., 2018). These concepts are part of the Self-Regulation Model (SRM), which explains that individuals' self-regulation processes begin with the perception of illness and their coping strategies in response to the influence of the perceived health outcomes (Benyamini & Karademas, 2019; McAndrew et al., 2018). Self-regulation through the use of adaptive coping strategies, such as active coping, emotional support, humor, acceptance, and religion, may improve patients' QoL (Osamika, 2018). However, during the acute phase, patients tend to show inappropriate self-regulatory responses, such as denying the current condition and blaming themselves (Gustafsson & Ahlstrom, 2006). Due to negative emotions and poor injury comprehension, patients often have difficulty developing a clear illness perception for use as a self-regulation foundation (Chen et al., 2021). The SRM positions individuals as problem-solvers who can use their common sense to frame an illness. The SRM comprises illness perceptions, coping strategies, and appraisals based on these self-regulation processes, which are then reflected in health outcomes, such as QoL (Woodhouse et al., 2018). These elements have previously been shown to influence QoL among patients with chronic illnesses (Willemse et al., 2019; Woodhouse et al., 2018). However, most injury-related studies have employed the model only partially, excluding the coping element (Chaboyer et al., 2010; Chen et al., 2021). Thus, further studies should include coping strategies when investigating the applicability of the SRM to the injury population.
The terms "illness perceptions" and "illness representations" are often used interchangeably and reflect the view formed by individuals when they encounter health threats. This concept is associated with patients' health-related beliefs and expectations. Patients' perceptions of their illnesses are guided by patients' internal logic, which may not always appear rational from an outside perspective (Leventhal et al., 2016). Regardless of the external reality of illness perceptions, Chen and colleagues' prospective study explained that illness perceptions had a predictive effect on QoL 3 months following hospital discharge (Chen et al., 2021). Moreover, after experiencing an injury, individuals may employ various coping responses, which can be either adaptive or maladaptive (Gustafsson & Ahlstrom, 2006). Coping refers to the conscious effort to solve personal and interpersonal problems to control, reduce, or tolerate stress (Stephenson et al., 2016). A previous study has found that poor coping responses were a significant predictor of decreased QoL after a major trauma (Busse et al., 2019). Although these past studies have shown that illness perceptions and coping had predictive effects on postinjury QoL, the evidence presented was not sufficient to explain QoL changes. Additionally, previous studies have indicated that interactions between illness perceptions and coping responses could significantly explain health outcomes (Bazzazian et al., 2010). Evidence has shown that illness perceptions and coping are associated with QoL; however, little is known about their longitudinal associations. Therefore, the longitudinal association among illness perceptions, coping strategies, and QoL warrants further study.
Several demographic and injury characteristics, including age, injury location, Injury Severity Score (ISS), and length of stay (LOS), during the acute phase have also been found to be determinant factors for QoL post-discharge (Chaboyer et al., 2010; Harvey-Kelly et al., 2014; Silverstein et al., 2021; Sprague et al., 2018). Older adults tend to experience persistent functional impairments that can last for several months following trauma, and this population has different recovery processes compared with younger adults (Tillou et al., 2014). Therefore, these demographic and clinical characteristics should also be considered when examining the relationships between changes in illness perceptions, coping strategies, and QoL.
Understanding patients' illness perceptions and coping strategies is vital for a care provider to develop an intervention that helps the patient cooperate with trauma care. According to Hagger et al. (2005), patients' illness perceptions and coping responses after EI may play essential roles in determining patients' efforts to contribute to treatment during the recovery process. This finding is aligned with the premise of SRM, which explains that individuals who perceive an injury or treatment as sufficiently threatening will be compelled to search for appropriate coping methods to alleviate the perceived threat (Leventhal et al., 2016). Thus far, evidence suggesting that changes in illness perceptions and coping responses can explain changes in QoL remains underreported. Understanding the longitudinal associations among illness perceptions, coping strategies, and QoL would provide a strong foundation for designing interventions that can be integrated into the clinical pathway of posttrauma care. Findings from the present study may help clinicians gain an understanding of the influence of patients' perceptions on QoL and assist in identifying potential modifiable factors to promote patients' efforts to comply with the established care plan. This study aimed to examine the changes in illness perceptions, coping strategies, and QoL within the first 3 months after hospital discharge and to examine the association among these changes in patients with EIs.
Methods
Study Design
This study was designed as a longitudinal observational study. Illness perceptions, coping strategies, and QoL were measured before hospital discharge, and a follow-up assessment was performed 3 months post-discharge. This study was reported following the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement (Atkin et al., 2017).
Setting and Sample
This study was performed at the trauma units of two similar referral medical centers, both of which have a capacity of over 200 beds and are located in Surabaya City, Indonesia. Both medical centers serve as referral centers for trauma cases within the same healthcare system. The trauma wards are specialized units that admit patients with various traumatic injuries and are staffed by multidisciplinary professionals. The research nurses at each hospital recruited participants using a convenience sampling method. The target population of this study was patients diagnosed with EI according to the International Statistical Classification of Disease and Related Health Problems, Tenth Revision (ICD-10). The inclusion criteria included patients aged 18-59 years, able to communicate in the Indonesian language, with a primary diagnosis of EI (based on ICD-10 codes), and who scored 2 or more on the Abbreviated Injury Scale (AIS), which is a measure of EI severity. Patients were excluded if they had cognitive impairments (e.g., delirium or dementia), severe brain injury or cerebrovascular disease, any injury not caused by force (e.g., pathological fracture), or any history of psychiatric illness.
A power analysis was performed using G*power Version 3.1.9.2 software to estimate whether the current sample size achieved sufficient power for the investigation (Faul et al., 2009). A sample of 138 participants was deemed appropriate because of the estimated medium effect size of 0.15 for multiple linear regression (Chen et al., 2021), the use of nine predictors, a power of 0.80, and an [alpha] value of .05.
Measurements
Sociodemographic and Injury Characteristics
Data regarding age, sex, education level, and marital status were collected through a self-administered demographic questionnaire. Patients' LOS, injury location, AIS, and ISS data were obtained from participants' medical records. The ISS is derived from the sum of the squares of the highest AIS scores (a 6-point ordinal scale ranged from minor to untreatable) for six different body regions and was developed to provide a coding system with a better fit between overall severity and survival (Baker & O'Neill, 1976). Scores range from 0-75 with 75 being the most critical or unsurvivable injuries.
The Brief Illness Perception Questionnaire
An eight-item Indonesian-language version of the Brief Illness Perception Questionnaire (BIPQ) was used to assess patients' illness perceptions (Broadbent et al., 2006). This instrument uses a rating scale ranging from 0 to 10 points to assess each dimension. A possible total score ranges from 0 to 10, with higher scores indicating greater negative injury perceptions and a more life-threatening view of the injury. The questionnaire measures eight dimensions, including consequences, timeline, personal control, treatment control, identity, concern, coherence, and emotional response (Broadbent et al., 2006). An internal consistency assessment of the BIPQ in this study resulted in a Cronbach's [alpha] score of 0.85, and a test-retest reliability assessment resulted in an intraclass correlation coefficient (ICC) of 0.84.
The Brief Coping Orientation to Problems Experienced
A 28-item Indonesian-language version of the Brief Coping Orientation to Problems Experienced (Brief-COPE) inventory was used to assess patients' coping strategies (Carver, 1997). Each item was scored on a 4-point Likert scale (1-4). The total score ranged from 1 to 4, with higher scores indicating the increased use of particular coping strategies, such as positive reframing, self-distraction, denial, anger, venting, emotional support, humor, and religion. The Brief-COPE's construct validity was examined via an exploratory analysis using a two-factor model that accounted for 69% of the total variance. In line with Knowles et al. (2017), two main coping strategies were distinguished by the exploratory factor analysis: adaptive coping (16 items) and maladaptive coping (12 items). In the present study, the internal consistency of the Brief-COPE ranged from 0.80 to 0.90, whereas the ICC ranged from 0.89 to 0.90.
The World Health Organization Quality of Life
A 26-item Indonesian-language version of the abbreviated version of the World Health Organization Quality of Life (WHOQoL-Bref) was used to assess the QoL of patients. The WHOQoL-Bref is a brief, self-reported QoL assessment developed by the WHO across 24 international field centers (The WHOQoL Group, 1998). Each item is considered an indicator of a person's QoL, which is measured across four broad domains: physical, psychological, social relationships, and environment. Each item on this scale was scored on a 5-point Likert scale (1-5). After the data were collected, the raw domain scores were transformed linearly into a 0- to 100-point scale, with higher scores denoting higher QoL (The WHOQoL Group, 1998). In this study, the WHOQoL-Bref resulted in Cronbach's [alpha] values from 0.73 to 0.84 for the subscales and 0.88 for the overall scale, and reliability assessment resulted in an ICC value of 0.87.
Data Collection
Data collection began after the investigator obtained ethics approval from the involved academic medical centers. Data collection occurred from August 2019 to April 2020. Once a discharge date was planned, the research nurse and investigator approached potential participants, requested their consent to participate in the study, and made an appointment to complete the survey prior to discharge. After the hospital discharge survey was completed, the investigator initiated an online survey system (a Google form) for the follow-up survey. Each participant was asked about their browser preference (including Chrome, Internet Explorer, or Safari) and device type (including mobile phones, computers, or tablets). At 3 months post-discharge, patients were contacted, and verbal consent was obtained again via telephone. The survey link was then sent to participants, who were asked to fill out the questionnaires.
Ethical Considerations
The research ethics committee at each medical center approved the research protocol of this study (40/RSOT/VIII/2019 and 1599/IV.6.AU/F/2019). Protection of participants' rights was considered throughout the course of this study. Written informed consent was obtained from all participants, and their responses were anonymized.
Data Analysis
Data analyses were conducted using IBM SPSS Statistics for Windows Version 24.0 (IBM Corp, Armonk, New York. Descriptive statistic and nonparametric tests were performed in the data analysis such as independent-sample t tests, one-way analyses of variance (ANOVAs), paired-sample t tests, Pearson's correlation analyses, and hierarchical multiple regression. The significance level was established at p < .05 for all tests. To obtain data for the score changes in illness perceptions, coping strategies, and QoL, the scores obtained in 3 months post-discharge were subtracted from those obtained at hospital discharge.
Hierarchical multiple regression analyses were used to identify whether changes in illness perceptions and coping strategies could explain changes in QoL at 3 months post-discharge. Three sets of variables were sequentially entered into the regression analyses: (1) covariates (demographic and clinical characteristics) and (2) changes in illness perceptions and coping strategies. Interactions among changes in illness perceptions, adaptive coping, and maladaptive coping, and QoL were explored in the last step. To further understand the moderating effects recommended by Cohen and colleagues, a simple slopes analysis was conducted based on the high and low levels of moderator variables (Cohen et al., 2013).
Results
Of the 170 participants who completed the questionnaires at hospital discharge, 138 (81%) also fully completed the questionnaires 3 months post-discharge. The 138 study participants had a mean age of 36.13 years (standard deviation [SD] 12.31 years), ranging from 18 to 59 years, and 81 (58.70%) participants were men (see Table 1). Most participants were married (73.20%) and reported more than 12 years of education (52.90%). More than half of the participants were injured in the lower extremities (61.60%), nearly half were injured due to road traffic accidents (47.10%), and most of them had surgery (76.10%). The average ISS was 11.52 (SD 5.86), and participants were hospitalized for an average of 5.38 days (SD 2.21 days).
Based on the correlation analyses, older age (r = -0.19, p = .026), greater injury severity (r = -0.62, p < .001), and longer hospital stays (r = -0.62, p < .001) were associated with decreased QoL 3 months post-discharge. Additionally, the independent t test analysis showed that the changes in QoL scores at 3 months post-discharge were significantly higher among participants with lower EI compared with those with upper EI (t = -7.02, p < .001) (see Table 2).
Table 3 shows the comparisons between illness perceptions, adaptive coping strategies, maladaptive coping strategies, and QoL before hospital discharge and 3 months post-discharge. Most participants had significant improvements in illness perceptions at 3 months after discharge compared with just before discharge (t = 6.57, p < .001). The utilization of adaptive coping strategies increased significantly over 3 months (t = -8.75, p < .001), whereas the use of maladaptive coping strategies decreased significantly for most participants over 3 months (t = 9.61, p < .001). In summary, most participants' self-regulation improved from before hospital discharge to 3 months post-discharge.
Compared with the before hospital discharge values, participants' physical health (t = -13.03, p < .001), psychological health (t = -8.65, p < .001), social relationships (t = -12.38, p < .001), and environment health (t = -10.67, p < .001) demonstrated significant improvements, as did the overall QoL score (t = 13.66, p < .001). Overall, participants' QoL after EI was relatively lower before hospital discharge and improved at 3 months post-discharge.
The results of hierarchical multiple regression analyses are shown in Table 4. No multicollinearity issues were observed at any step of regression analyses, indicating no confounding issues were likely to result in imprecise estimations of coefficients in the results of the statistical analysis. Only variables identified as being significantly related to QoL at 3 months (linearity) were included in each regression model. The overall model that explained a worse QoL at 3 months post-discharge were injury at a lower extremity ([beta]= -0.16, p = .003), greater injury severity ([beta]= -0.21, p = .001), longer hospital stays ([beta]= -0.19, p = .015), negative illness perceptions ([beta]= -0.31, p < .001), and decreased use of adaptive coping strategies ([beta]= 0.20, p = .003). Furthermore, the interaction between worse illness perceptions and the decreased use of adaptive coping strategies was significantly associated with worse QoL ([beta]= -0.11, p = .038). As illustrated in Figure 1, the magnitude of the relationship between changes in illness perceptions and QoL depended on the level of change in the use of adaptive coping techniques (moderating role).
Discussion
This study is among the first studies to examine the longitudinal associations among illness perceptions, coping strategies, and QoL during recovery after EI. The findings from this study indicated that QoL changes that occur during the first 3 months after EI could be significantly explained by changes in illness perceptions and the use of adaptive coping techniques after controlling for covariates. Importantly, the interaction between changes in illness perceptions and changes in the adaptive coping response significantly explained the observed changes in QoL, which indicated that adaptive coping strategies have a moderating role on QoL.
This study found that the site of injury, injury severity, and length of hospital stay were related to QoL changes in the first 3 months after EI. Unexpectedly, age was not related to QoL changes in the present study, which differed from the results reported by a previous study (Sprague et al., 2018). This finding may be attributed to participants' relatively young age (the mean age was 36.13 years), which may be a possible confounding factor on the effects of age, and the effects of age may be masked by the effects of other determinants and self-regulation constructs. In contrast, the findings that the injury site, injury severity, and the length of the hospital stay affected QoL correspond to a recent systematic review that found these determinants related to QoL among the injured population (Silverstein et al., 2021). Injuries to the lower limbs are well-known to result in increased tissue damage and decreased physical ability, which can hinder patients' ability to fulfill their activities of daily life (Sprague et al., 2018). Injury severity and longer hospitalization are often associated with increased complexity in patients' care (Silverstein et al., 2021). Because the injury site, injury severity, and length of hospital stay were identified as crucial determinants of worsening QoL 3 months after hospital discharge, the trauma team should be aware of patients with these determinants when providing care during the first 3 months following discharge.
In this study, a negative illness perception was significantly associated with worsened QoL, and changes in illness perception had a stronger relationship with changes in QoL than changes in other self-regulation constructs, including adaptive and maladaptive coping responses. This finding aligns with previous evidence indicating that illness perceptions may serve as the potential QoL predictor among injury populations (Chaboyer et al., 2010; Turkington et al., 2018). Injured patients develop perceptions based on their views of their condition and use these perceptions to cope with their problems or manage their conditions, which ultimately influences QoL. Early in the injury course, patients do not have clear illness perceptions; however, 3 months later, their illness perceptions naturally shifted toward more positive perceptions. explained that this phenomenon occurs because patients perform reappraisal processes, during which they utilize multiple sources, including experience of their perceived injuries. This finding implies that clinicians should attempt to understand how patients view their conditions and design interventions that aim to improve their illness perceptions, which is vital due to the potential effects on QoL.
In this study, the increased use of adaptive coping strategies was significantly related to improved QoL. Relying on adaptive coping responses is well-known to improve QoL, and the decreased use of adaptive coping techniques can worsen QoL (Osamika, 2018). In this study, most participants utilized adaptive coping less frequently before discharge, but adaptive coping improved 3 months later. The poor utilization of adaptive coping strategies at discharge is likely associated with an unclear self-regulation foundation, which includes illness perceptions, caused by confusing feedback from negative emotions and poor illness comprehension (Chen et al., 2021). However, over time, patients perform additional reappraisals, and their coping strategies improve (Leventhal et al., 2016). Therefore, clinicians should be aware of the coping orientations of patients with EI, which could contribute to either beneficial or adverse health outcomes. The positive association between adaptive coping responses and QoL changes suggests that clinicians may be able to improve patients' QoL through the use of interventions that aim to improve adaptive coping responses.
Importantly, this study's findings also revealed that the interaction between changes in illness perceptions and adaptive coping responses could significantly explain changes in QoL. This study also indicated that changes in adaptive coping were able to moderate the magnitude of the relationship between illness perceptions and QoL changes. The finding that coping response plays a moderating role in QoL is a new finding for the injury population; however, a similar finding was previously reported among the chronic illness population (Bazzazian et al., 2010). This finding introduces additional implications: if a clinician can increase the use of adaptive coping strategies, this change could weaken the effects of negative illness perceptions on QoL and strengthen the effects of positive illness perceptions on QoL among EI patients. However, these implications should be further confirmed by experimental studies.
In summary, the findings of the current study have yielded substantial evidence that improving illness perceptions and increasing the use of adaptive coping techniques were essential for improving QoL. These findings were in line with the premise of the SRM theory, in which the self-regulation process plays an important role in determining health outcomes (Leventhal et al., 2016). Additionally, more research remains necessary to provide additional evidence for the moderating role of adaptive coping on the relationship between changes in illness perceptions and QoL.
Implications for Practice
From these findings, recommendations for trauma care are made. Clinicians should be attentive to patients who are injured at the lower limb, have greater injury severity, and longer hospitalization times because these are suggestive of worsened QoL after EI. This evidence may help clinicians in designing treatment plans during the first 3 months post-discharge. Although understanding these health determinants is important, clinicians should also pay more attention to patients' self-regulation, especially illness perceptions and coping strategies, through regular monitoring. Regular assessments are crucial because this study also found that patients' illness perceptions and adaptive coping strategies changed over time. Clinicians can assess patients by using reliable instruments, such as the BIPQ and Brief-COPE, in clinical settings. If clinicians are able to identify patients with inappropriate perceptions and poor coping strategies, interventions can be applied to reshape patients' perceptions and coping strategies to improve QoL.
The evidence presented here can be translated into the development of interventions using two approaches. The first approach would be to provide bundled interventions that focus on illness perceptions and coping strategies. Previous studies found that implementing cognitive-behavioral therapy and coping skills training improved patients' illness perceptions and their use of adaptive coping strategies (Backhaus et al., 2010; Fann et al., 2021). Thus, incorporating these interventions into the treatment plan may help patients perform appropriate self-regulation and improve QoL. Because previous research has indicated that illness perceptions can change over time (Lee et al., 2010), reframing these perceptions is likely not an easy task. Therefore, the second approach is the provision of psychological interventions, such as coping skills training, which may help to weaken the negative effects or strengthen the positive effects of changes in illness perceptions on QoL after EI (Backhaus et al., 2010). Finally, incorporating these recommendations as part of standard treatment and care plans would promote patients' self-regulation and QoL.
Limitations
This study has some limitations. First, approximately 19% of the initial participants did not complete the survey 3 months later. Although no significant differences were identified between completers and withdrawals, we cannot exclude the possibility that participants may have specific traits or problems. Second, although participants were recruited from two trauma centers, they were selected using convenience sampling, which may introduce the risk of bias. Third, this study did not consider participants' ethnic backgrounds, which may limit the generalizability of the study's findings. Fourth, the changes in scores analyzed in this study were only obtained during the first 3 months, and future studies should include additional data collection points across a wider range of times. Finally, although the present study's findings cannot be used to infer causal relationships, this evidence is relatively stronger than that obtained from predictive or cross-sectional surveys.
Conclusion
In this study, we found that changes in illness perceptions and adaptive coping responses were associated with changes in QoL and indicated that adaptive coping strategies have a moderating role in this relationship. This study's findings provide new knowledge regarding modifiable factors, such as illness perceptions and adaptive coping strategies, which may explain QoL changes in patients with EI. Based on these findings, improving illness perceptions and promoting adaptive coping strategies may need to occur simultaneously to improve QoL within 3 months after hospital discharge. In addition, providing psychological interventions, such as cognitive-behavioral therapy and coping skills training, is warranted to help patients self-regulate properly. Finally, incorporating highly personalized self-regulation constructs into clinical care might be necessary to promote a patient-centered approach to trauma care.
Key Points
* Patients with extremity injuries tend to harbor negative illness perceptions and inappropriate coping strategies and experience a lower quality of life prior to hospital discharge, but these improve 3 months post-discharge.
* Lower limb injuries, greater injury severity, extended hospitalization, inappropriate illness perceptions, and reduced focus on adaptive coping strategies are factors associated with reduced quality of life after extremity injury.
* The performance of adaptive coping strategies may weaken the negative effects or strengthen the positive effects of illness perceptions on quality of life among patients with extremity injuries.
Acknowledgments
We highly appreciate the contribution of all participants in this study.
References