One-year outcomes of traumatic injuries among survivors in Ethiopia: a cross-sectional study on the employment outcomes and functioning state

Study design and setting

An institution-based cross-sectional study design was conducted at the Addis Ababa Burn, Emergency, and Trauma (AaBET) hospital. AaBET is a public hospital in the capital city of Ethiopia and is the largest among the national referral centers for accidents and emergencies, including traumatic injuries for specialized trauma care. It has a capacity of nearly 200 inpatient and emergency care beds.26

Population

The study population was all injury survivors who had visited the AaBET hospital emergency department for healthcare services within 3 months of a year before the data collection began (ie, October 11, 2020, to January 8, 2021). Potential participants were identified from hospital records (ie, Health Management Information System (HMIS) and patients' charts), then contacted by telephone to invite them to participate in the study.

Participant recruitment

The HMIS database was reviewed to identify potential participants according to the inclusion criteria: patients who reported traumatic injury as a reason for their hospital visit that is, working age group (18 to 60 years), discharged alive and/or referred to another institution, stayed in the hospital for ≥24 hours and self-identified as they were employed at the time of the injury. Each patient had a unique Medical Registration Number (MRN), a reference number used to locate the charts at any time. The HMIS registration contains many variables, including important variables utilized for this study: MRN, age, sex, reasons for hospital visits, date of arrival, date of discharge, and status at discharge, among others.

Of 2042 patients in the data set, 1222 met initial eligibility requirements. The required information was extracted from 638 charts. This information included injury characteristics and contact information (ie, name and telephone number). The chart extraction used a structured checklist, which was pretested in the same setting among patients who received healthcare 6 months before the data collection. Extractions were conducted by a trained team of two health professionals (ie, a nurse and a health officer). Before the telephone interview, a unique identification code (UIC) was assigned to each eligible participant that was not related to patients’ information. A total of 254 participants provided verbal consent to participate in the study and those who were not interested in participating were thanked for their time and was recorded as ‘declined to participate’ (see figure 1 for details).

Request permission

Data collection

The telephone survey was conducted by six trained health professionals with graduate training, who were different from the chart extraction team. The telephone survey was conducted both in Amharic and Afaan Oromo, the dominant local languages, based on participants’ preferences. The telephone interview used a structured questionnaire (online supplemental file 1) that included tailored questions designed for this study, informed by existing literature in the field21 27 as well as standard tools.28 29 The questionnaire addressed sociodemographic factors (eg, education, living arrangement, and residence), employment characteristics (eg, RTW status, job type and changes after the injury) and injury and health-related information (eg, disability and chronic illness).

The return-to-work status was defined according to participants’ self-response to the question ‘Are you currently returned to any work?’ with response options being either ‘yes’ for those working at the time of the interview and ‘no” for those not working. Furthermore, the disability status was assessed using the WHODAS-2 assessment tool.28 30 Participants’ workability at the time of the interview was assessed using a question based on the Work Ability Index,29 with a question ‘How do you rate your current work ability compared with your ability before the traumatic injury?’ The measurement is based on a six-point Likert scale (ranging from ‘0=can’t work at all’ to ‘5=same as preinjury’). The questionnaire was pretested among patients identified for the chart extraction pilot test.

Data analysis

Data entry and data set standardization were carried out independently. The data sets from the hospital HMIS registration, chart extraction and telephone interview were exported to SPSS software V.28 for further data management and analysis. Then, the Principal Investigator (PI) merged the three data sets into one SPSS file using a UIC and prepared for further analysis. Descriptive statistics were used to compute frequencies and percentages for categorical variables (eg, RTW status, sex, mechanism and types of injury, and job types). Continuous variables were classified into meaningful categories; for example, age was grouped into ‘young, young adult and older adult’ and hospital admission days were classified into ‘<1 week, 1 week to a month, and>1 month’. Results are presented with narrative descriptions, followed by tables.

Pre-injury characteristics

Postinjury status

Social implications of injury

In this study, the highest rate of traumatic injury was experienced by young, urban dwelling men. This result affirms the finding of earlier studies in Ethiopia2 4 and other LMIC.32 33 Men, young people, and urban residents bear the highest burden of traumatic injury, which could be due to their high level of mobility and social interactions. Men are at particular risk because of their role as breadwinners of the family, a typical context in Ethiopia, which makes them more vulnerable than women as they are the primary member of the labor market. The effect of injury on the young male population, the most productive segment of Ethiopian society, has broad socioeconomic implications.

The result indicates that Ethiopia is seriously impacted by road traffic collision, which is a similar finding to earlier studies4 32 33 and a recent global report.34 Violence is the second leading mechanism of injury in this study, which reflects unrest and the ongoing war in Ethiopia, particularly during the study period. A high prevalence of violence has been reported in other African countries as well35; however, it was the least reported cause in earlier research in Ethiopia.4 Furthermore, fractures at various body regions and traumatic brain injury were the most recorded types of injuries; head and lower extremities were the body parts most frequently injured. These injuries may require specialized healthcare and rehabilitation support that may be responsible for delayed recovery.

Impacts of delayed healthcare after injury

Timely access to healthcare is crucial for recovery and better outcomes after injury. The findings of this study indicate that one-third of participants did not arrive at the hospital on the same day of the injury occurrence. Various factors could contribute for the delay from injury to admission after injury. A study in Africa36 described important factors that could delay access to healthcare services for patients with trauma: personal factors (lack of awareness of the healthcare), physical barriers (distance and transport access to healthcare) and financial factors related to healthcare costs. A study in Cambodia37 reported that the longer the time from injury to admission, the longer the length of hospital stay and associated implications. Nonetheless, the length of hospital stay may not necessarily be because of the delay in obtaining healthcare services, it may also be due to the severity of the injury. In our study, nearly half of the participants were admitted to the hospital for more than a week, and 18% of them were admitted for more than a month. Moreover, 23% of the participants had a revisit to health institutions more than six times due to health problems associated with the injury. Higher needs for ongoing healthcare by injury survivors were reported by a previous study in Ethiopia.23 Experiences of the injured population during the healthcare process and after discharge have not been well investigated; hence, more study is required with in-depth exploration of major barriers to early healthcare access and associated long-term impacts.

Impairment as a consequence

A year after the injury, 61% of participants had some form of impairment. Recent studies among road traffic injury survivors in Ethiopia25 28 and earlier studies in other countries19 38 also reported high disability status among injury survivors. Given that most injuries were due to road traffic collisions, it suggests that transport-related injuries are serious enough to lead to disability among survivors. The occurrence of injuries and associated consequences are preventable health problems with due attention from public health and rehabilitation scientists to improve injury prevention and enhance rehabilitation interventions. Furthermore, chronic illnesses can be aggravated or caused by injuries. One-third of the participants had at least one type of chronic illness. Existing health problems, including chronic illnesses, can influence individuals’ functioning and may jeopardize their potential to resume preinjury life.39

Implications for participation and economic activity

Employment in general is a proxy measure for functioning in the real world. For injury survivors, work has multidimensional benefits. For example, a recent study in the UK reported on the importance of resuming work after injury for enhancing survivors' sense of purpose in life, nurturing self-identity and encouraging social interaction.40 The current study reflects a slightly lower return-to-work success rate (59%) than the other two studies in Ethiopia. Tamene and colleagues reported in 2022 that 73.5% of participants returned to work 45 days after the injury,24 while in an earlier study, researchers found that 83% had returned to their preinjury work 6 months after the injury was reported.23 The difference could be because of differences in the sources of data, where the Tamene et al study extracted the data from the records of employers in manufacturing industries, and the latter study included interviews from surrogates. The actual success rate of return to work (RTW) might have varied if these studies had interviewed the injury survivors directly, as this is the case with the current study. For example, a very recent study among road traffic injury survivors in Ethiopia reported a 56% RTW rate with a 1-year follow-up after the injury based on telephone interviews with survivors.25 In addition, our study setting is a referral hospital where more serious and complicated cases of injuries would be referred to, hence their RTW potential could be restrained. Our finding is similar to studies in many other countries with reported RTW success rates up to 65%.15 20 21 However, a study in Uganda13 reported a much lower RTW rate (35%) 1 year after injury. The variation in RTW rates compared with studies in other countries could be justified by differences in workplace systems, policy frameworks and enforcement as well as differences in data management and reporting.

A closer look into participants’ employment conditions and their income revealed that nearly a third of the work-returned participants earn lower employment income compared with their preinjury. The economic implication of injuries with reduced employment income after injury was reported by earlier study in Ethiopia,14 23 and also in other countries.41 The reduction in employment income after injury could be due to the changes in their employment conditions after injury. For instance, our study indicates that injury survivors who fail to return to their preinjury employer had to change their job types. Earlier study also indicates that changes in employer and job types after injury could impact the health outcomes of survivors.42 Therefore, skills training and building employers’ competency on inclusive employment could be vital to consider for a smooth transition to work after injury and to avoid loss of income. Therefore, the preferred goal of RTW planning should be to be with the same employer and job.

Our findings highlighted various challenges to RTW experienced by injury survivors. Some of these challenges may have been avoided had injured parties received timely and appropriate care. The most common challenges were physical stressors (ie, barriers related to their workstation, working materials, and mobility). Challenges related to the presence of physical stressors and unavoidable residual functional loss could be addressed with ergonomics interventions that help to fit the work demands with the needs, capacities and limitations of injury survivors (eg, work design, flow, and materials).43 Overall, the outcome of RTW after an injury is mediated by a range of factors at various system levels16 27; this calls for research to examine factors that support RTW in LMIC.

Shift of care and support to informal social systems

Arrangement of a functional RTW support system is vital. According to social capital theory, social resources are crucial in helping individuals to cope with external barriers and access facilitators of necessary supports. Earlier studies indicated the role of social supports during recovery from injury as vital resources for RTW success.44 45 Lack of appropriate rehabilitation services and RTW support systems could contribute to long-term consequences of injuries that may leave the injury survivors’ recovery on the shoulders of families and other informal support systems. Likewise, this study revealed that members of informal social networks have stepped up in the RTW process to fill the gap left by the healthcare and labor systems. Participants who returned to work after the injury had accessed support mainly from non-professional supports, including religious institutions, family, relative, and friends, while small portion of participants had access to RTW support from their workplaces (42%) and health providers (20%). This reflects the lack of a formal RTW support system and could be linked to the Ethiopian sociocultural structure, where supports from family, relatives and neighbors are common, with a foundation in spirituality or religiousness.46 47 This perspective holds deep societal expectations to support individuals in one’s life, including persons with disabilities, and may be the reason for the prevailing lack of expectation that more formalized structures (eg, health, rehabilitation, and worker’s compensation systems) should hold responsibility in this regard. Overall, policies are required to vitalize the healthcare and workplace system to respond for the needs of trauma survivors in relation to RTW. In addition, education is key at all levels to improve the role of formal support while nurturing informal resources for RTW support.

Overall, this study employed a rigorous process in participant recruitment and data collection, which is the strength of the study given the poor data recording system in Ethiopia’s healthcare system. Furthermore, the method of data collection (telephone interview) is less feasible in the Ethiopian context.23 Nevertheless, the study has some important limitations to be considered. The trauma data recording system was weak, with a major obstacle being the difficulty reconnecting with former patients due to unavailable or inaccurate contact information. Also, we were not able to trace some patient medical records. Hence, of the 1222 potential participants, only 254 survivors ultimately completed the survey. This study is cross-sectional, with measurements collected at one point in time. The use of data drawn from one study setting and a retrospective analysis, as is the case of this study, introduces limitations such as selection bias, thus impeding the generalizability of the findings. Further investigation is required involving multiple settings to generate a comprehensive understanding.