Quality of life in road traffic accident survivors

About 50 million people around the world suffer from non-fatal road traffic accident (RTA) injuries every year (1). In 2018, 13,989 people were injured in RTAs in Croatia (2). The non-fatal consequences of RTAs are numerous: functional and cognitive impairments, psychological consequences and a decrease in the quality of life of the survivors (3).

Decreased quality of life (QoL) is the major consequence of RTAs (4). Research shows that the physical and mental components of health-related QoL are decreased in the long-term, even in RTA survivors with minor injuries (5, 6, 7). QoL consistently and independently predicts return to pre-injury employment and life participation among RTA survivors who sustained mild/moderate injuries (8). Research also shows that psychiatric disorders in RTA survivors decrease QoL (9), especially PTSD (4, 7, 10, 11), depressive disorder (4, 9) and anxiety disorder (9). Other potential factors that influence QoL in RTA survivors are expectations regarding recovery, pain level, social support, perceived life-threat in the RTA (4, 12, 13), level of education, injury severity, compensation claim, early medical complications and socioeconomic factors, especially financial problems (11). The research regarding the impact of RTA injury severity on the QoL following the RTA is inconsistent, some studies found that injury severity does not predict later QoL (4, 6, 9), while others found the contrary (11, 14).

However, all published studies on QoL following an RTA only include the injured RTA survivors, and thus there is no knowledge on the QoL of the uninjured survivors. Furthermore, there are no QoL studies conducted among RTA victims in Croatia.

The research aim was therefore to evaluate the quality of life of the RTA survivors regardless of whether or not they sustained injures, and to identify factors associated with decreased quality of life after the RTA.

A cohort of 200 RTA survivors recruited at the Institute of Emergency Medicine of the Vukovar-Srijem County in Croatia were included in a prospective study. They were assessed 1 month following the RTA. Inclusion criteria for participating were being an RTA survivor and aged 18 and older. RTA survivors with cognitive dysfunctions and inability to give consent were excluded, as well as those aged under 18. Recruitment of the participants and data collection was done by a medical doctor.

During the research period, from October 2016 to December 2017, 640 people were involved in RTAs. Figure 1 gives details on the formation of the prospective cohort.

Figure 1

Using a specially designed questionnaire the following data about RTA survivors was collected in this study: age, gender, place of residence, education, employment, marital status, self-assessed economic status and religiousness. Using the same questionnaire, data regarding pre-RTA health-related factors such as smoking, alcohol consumption, drug abuse, earlier road crash experience, traumatic exposures, prior PTSD, chronic diseases, psychiatric diseases and previous permanent pain was also collected.

Finally, the RTA-related factors explored through the same questionnaire were the type of road user, number of motor vehicles that were involved in the RTA, the injured and fatalities, fault for causing the RTA, compensation status, memory loss after the RTA, loss of consciousness in the RTA, injury status and severity, hospitalization, surgery and rehabilitation, self-assessed life-threat and pain following the RTA. The classification and detailed description of all collected data are shown in Tables 1, 2 and 3.

Based on medical records related to the RTA, the injury severity was assessed using the Abbreviated Injury Scale (AIS) (15). The final score was assigned using the New Injury Severity Scale (NISS). NISS classifies injuries as minor, moderate, serious, severe and critical (16).

The PTSD Checklist for Civilians (PCL-C) was used for the assessment of PTSD symptoms following the RTA (17). A cut-point of 30 was used, as suggested for general population (18).

The Beck Anxiety Inventory (BAI) was used for the assessment of anxiety symptoms following the RTA, with the cut-point of 22 (19).

The Beck Depression Inventory—I (BDI—I) was used for the assessment of depression symptoms following the RTA, with the cut-point of 11 (20).

The Short Form-36 (SF-36) was used for the assessment of QoL following the RTA (21). In this QoL is a multidimensional concept describing a satisfactory, balanced and healthy life comprising both biopsychosocial and socioeconomic aspects (22), such as physical health, psychological status, independence level, social relations, personal beliefs and relations within a specific environment (11). SF-36 is the most widely used instrument for assessing health-related QoL, and has been standardized and validated. This self-reporting measure contains 36 items and is used for the assessment of health status across eight domains: physical function (PF), role limitations due to physical health (RP), role limitations due to emotional problems (RE), vitality (VT), mental health, referring to the absence of anxiety and depression, (MH), social functioning (SF), bodily pain (BP) and general health (GH). The result scores range from 0 to 100, and higher obtained values present better perception of the QoL (23). The Croatian version of SF-36 was validated and found reliable in the Croatian population (24).

The normality of data distribution was tested with the Kolmogorov-Smirnov test; thereafter descriptive statistics were applied. The Mann-Whitney U test and Kruskal-Wallis test were applied for the comparison of numerical variables. Spearman’s correlation was applied to test the correlation between the QoL domains and psychological outcomes following the RTA. The statistical significance level was set at p<0.05. The statistical package Statistica for Windows 2010 (version 10.0, StatSoft Inc., Tulsa, OK, USA) was used for the analysis.

The study explored the QoL following an RTA and the prospective cohort included RTA survivors both with and without injuries, unlike other studies exploring RTA outcomes only among the injured. The QoL of the RTA survivors one month after the experienced RTA was below the average scores for the general Croatian population in the following QoL domains: RP (0.0 vs. 61.5) and BP (55.0 vs. 64.6) (24). Other studies also found RTA survivors had lower QoL than general population norms (4, 6, 12, 23, 25).

The sociodemographic factors found associated with lower scores of the QoL domains in this study, i.e. older age, female sex, lower education level, unemployment, and lower economic level, are consistent with other research data. The Croatian general population sample reported lower QoL scores in the older age group and among females (24). Other studies of RTA victims also found older age to be associated with lower QoL after the RTA (4, 5, 6, 9, 11, 23, 25, 26, 27). A few studies also found female RTA survivors reporting lower QoL than males (5, 25, 28). Lower education level (7, 11, 12), unemployment (6, 9, 11) and lower economic status (11) of RTA victims were associated with lower QoL after the RTA in several studies. Irreligiousness has not been explored in the earlier studies, but was found relevant in this cohort.

Pre-RTA health status was found to be associated with lower QoL after the RTA. Other studies also found pre-injury health status (6, 9, 11, 12, 23, 27, 29), pre-injury chronic illness (6, 9, 11, 12, 23, 29) and pre-injury psychological history (7, 12, 23, 27, 29) to be associated with decreased QoL in the RTA victims. Use of medications and psychiatric medication use were found associated with all QoL domains except RE. This factor should be further explored, since people may not want to report a psychiatric disease due to stigmatization, but may report information regarding medications they use (30). This study also found previous traumatic exposure to be associated with lower VT and GH. Alcohol consumption was found to be positively associated with all QoL domains, indicating that moderate alcohol use has a positive effect on the QoL (31).

The most important injury-related factors associated with all QoL domains were pain following the RTA and self-assessed life-threat, with the latter also found to be significant in other studies (9, 12). Pain following an RTA is a well-known predictor of QoL (4, 6, 7, 9, 13, 27, 29). Given that a high baseline pain after the RTA is associated with poor long-term health outcomes, strategies to reduce pain levels should be introduced early following an RTA to reduce the risk of long-term health consequences (28). The results with regard to injury severity are inconsistent in the literature, some studies found it to be associated with lower QoL (3, 11, 12, 14, 23, 28, 32), while others found no association (5, 6, 9) or a negative association (4). However, in all studies where RTA survivors with mild injuries reported similar or worse QoL scores than RTA victims with more severe injuries, data were obtained from compensable injury claim registers restricted to a certain level of injuries i.e. mild to moderate. It can be argued that decreased QoL outcomes are the result of the compensable nature of the injury, leading to reporting bias for secondary gain (12). The current study showed not only that more severely injured had lower QoL scores, but also that RTA survivors without injuries had better QoL scores. Other research exploring traumatic injuries also showed that sustaining a traumatic (not RTA) injury was associated with lower QoL (33). Therefore, in order to obtain reliable data, research regarding the impact of RTA injury on health outcomes should include RTA victims with all injury levels along with those who are uninjured, possibly outside compensation settings.

Factors indirectly injury-related, i.e. hospitalization, duration of hospitalization, surgery, loss of consciousness during RTA and rehabilitation after the RTA, had a negative impact on the QoL after an RTA. Other research also found hospitalization to be associated with lower QoL scores (3, 9, 12, 27). Psychological consequences after the RTA, namely PTSD, depression and anxiety symptoms, showed correlations with all QoL domains. Other studies also found psychological distress (27), PTSD (4, 7, 11, 29) and anxiety/depression (4, 5, 6 9) to be independent predictors of QoL following the RTA. Vulnerable road users, i.e. pedestrians/cyclists reported lower scores of PF, BP and GH. This association is also probably injury-related, since there were no uninjured cyclists nor pedestrians in this study. These findings all corroborate that RTA injury and its severity are both relevant for the QoL outcomes.

Compensation claim is a thoroughly investigated factor showing a negative association with the QoL following an RTA in many studies (5, 7, 11, 27, 34, 35). In addition to the negative association of compensation claim with the QoL, this study showed that obtaining compensation was associated with a lower score of RE. Furthermore, not being at fault in the RTA was associated with higher scores of BP. Other research also found that not-at-fault RTA victims had lower QoL and reported significantly higher rate of neck and back pain than the at-fault group (28). This suggests that non-physical factors such as victimization, frustration and anger at being involved in an RTA that was the fault of someone else all affect well-being (28).

Most of the studies investigating the QoL of RTA survivors used the SF-36 questionnaire (4, 5, 14, 23, 28, 33, 34, 35) or its shortened version. the Short Form – 12 (SF-12) (6, 8, 9, 12, 13, 26, 27), while a minority used other available instruments for assessing QoL (7, 26, 31). Therefore, the data from this study are comparable with that in other QoL studies.

Decreased QoL following an RTA showed associations with the low socioeconomic status of the RTA victims, poor pre-RTA health, injury-related factors and psychological disorders after the RTA. Identifying the predictors of decreased QoL following an RTA will enable planning interventions targeting the most important factors influencing health of RTA victims. Assessing and recording of self-reported QoL should be a part of the routine protocol in RTA survivors’ healthcare.