BMJ Open...Waleed salah eldin, Community, Environmental and Occupational Medicine Department, AinShams University, Cairo, Egypt Email: [email protected], Tel: 002-012-519-02-04

For peer review only

Health-Related Quality of Life after Serious Occupational Injury in Egyptian workers

Journal: BMJ Open

Manuscript ID: bmjopen-2011-000413

Article Type: Research

Date Submitted by the Author: 08-May-2012

Complete List of Authors: Salah Eldin, Waleed; Faculty of medicine-AinShams University, community, ocupational and environmental medicine El setouhy, Maged; Faculty of medicine-AinShams University, community, ocupational and environmental medicine Hirshon, Jon Mark; University of Maryland School of Medicine, Department of Emergency Medicine; University of Maryland School of Medicine, Charles McMathias, Jr. National Study Center for Trauma and EMS, of the Shock, Trauma, and Anesthesia Research Center

Smith, Gordon; University of Maryland School of Medicine, Charles McMathias, Jr. National Study Center for Trauma and EMS, of the Shock, Trauma, and Anesthesia Research Center Kamal, Abdel-Aziz; Faculty of medicine-AinShams University, community, ocupational and environmental medicine Abou-El-Fetouh, Aisha; Faculty of medicine-AinShams University, community, ocupational and environmental medicine

Primary Subject Heading:

Occupational and environmental medicine

Secondary Subject Heading: Rehabilitation medicine

Keywords: OCCUPATIONAL & INDUSTRIAL MEDICINE, REHABILITATION MEDICINE,

Epidemiology < THORACIC MEDICINE

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml

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Health-Related Quality of Life after Serious Occupational Injury in Egyptian

workers

Waleed Salah Eldin, MD1, Jon Mark Hirshon, MD2, 3, Gordon S. Smith, MD

3, Abdel-Aziz

Mohamad Kamal, MD1, Aisha Abou-El-Fetouh, MD

1, Maged El-Setouhy, MD

1

1-Community, Environmental and Occupational Medicine Department, AinShams University,

Egypt

2- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore,

Maryland, USA

3- Charles McMathias, Jr. National Study Center for Trauma and EMS, of the Shock, Trauma,

and Anesthesia Research Center, University of Maryland School of Medicine, Baltimore,

Maryland, USA

Corresponding Author:

Waleed salah eldin, Community, Environmental and Occupational Medicine Department,

AinShams University, Cairo, Egypt

Email: [email protected], Tel: 002-012-519-02-04

Abstract Word Count: 232 Manuscript Word Count: 2,535

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Abstract

Occupational injuries are common and can result in severe socio-economically consequences.

However, there is little research examining the health related quality of life of workers following

occupational injuries especially in developing countries.

Objectives: To study the impact of occupational injury on workers’ health six months after

injury, and to identify potential reduction in health-related quality of life (HRQOL) and possible

determinants of this reduction.

Methods: A cross-sectional study among workers six months after hospitalization for

occupational injury. During the July-December 2008, all injured workers visiting the Nile

Insurance Hospital, six months after an injury were asked to describe their health using the EQ-

5D quality of life instrument.

Results: 131 injured workers were recruited. Cases were mostly males (90%) with mean age

41.5 years. Fractures were the most common type of injury (73.3%). The most frequently injured

body part was the lower limbs (53.4%). At 6 months post injury participants identified problems

related to mobility (60%), self-care (53%), performing usual activities (83%), pain/discomfort

(91%) and anxiety/depression (41%). The perceived health status estimated by visual analogue

scale (VAS) among injured workers was 61.6± 17.9. Multivariate linear regression showed poor

VAS score associated with amputations, mobility limitation, self-care problems, pain/discomfort,

and anxiety/depression.

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Conclusions: Occupationally injured workers experience significant decrease in their perceived

health status. Improvement in pain management, physical and psychological rehabilitation after

injury may improve the health related quality of life of injured workers.

Key words: occupational injury; health related quality of life; EuroQol 5-D; Egyptian workers

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INTRODUCTION

Work related injuries are an important public health problem because they involve large numbers

of workers, especially young people at productive ages. They can also be disabling, leading to

major social and economic consequences for the worker and his or her family.[1] These adverse

consequences of work related injuries can lead to deterioration in the health related quality of life

(HRQoL) of injured workers. HRQoL has a variety of domains, but generally it includes ”the

dimensions of physical functioning, social functioning, role functioning, mental health and

general health perceptions”.[2] In other words, health-related quality of life refers to a person or

group's perceived physical and mental health over time.[3]

In recent years, researchers have recognized that HRQoL is an important outcome measure in

people with traumatic injuries,[4] since individuals who survive traumatic injury do not always

return to their pre-injury health status.[5-7] For example, people who sustained a traumatic injury

reported poorer health and functioning than did population norms when assessed 3 months after

hospitalization in the United States[8] and Australia,[9] and15 months after hospitalization in a

Dutch study.[4] In one study of people who had experienced lower extremity injuries, 50% had

physical limitations related to daily activities and mobility, and up to 60% were not able to walk

3 months after traumatic injury.[10] In other research, patients with traumatic injury experienced

a decrease in physical strength and fatigue when performing physical activity,[11] that could

result in an inability or delayed ability to resume work.[5,12] Long-term effects, both physical

and psychological, are also common after minor injuries.[13] Research has also focused on the

relationships between injury events and the risk of development of posttraumatic stress syndrome

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(PTSD).[14] However, there has been very little investigation of the extent to which work related

injuries affect the health-related quality of life (HRQol) of the individual.[15]

Many factors are known to impact quality of life (QoL) after injury, but predictors of diminished

QoL remain incompletely understood.[16] The severity of injury using the Injury Severity Score

(ISS)[9,17] and age,[4,7,9] have been shown to be independent predictors of HRQoL. However,

ISS was not a predictor in an earlier study.[18] In one qualitative study of recovery after

traumatic injury, recovery was complex and did not conform to the views of most clinicians,[19]

suggesting that it is important to understand the perspective of patients’ with regards to the

impact of traumatic injuries.

This research studies the HRQoL, and factors that influence it, from the perspective of

occupationally traumatized Egyptian workers through the Euro Qol five Dimensions

questionnaire (EQ-5D).[20]

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METHODOLOGY

Study design, setting, and sample

The study was designed as a hospital-based cross sectional study among workers having an

occupational injury 6 month prior to study inclusion. It was conducted in the Nile Insurance

Hospital, which is the primary hospital responsible for treating medically insured workers

working in the Qaluobia governorate of Egypt.

During the second half of the year 2008, all workers hospitalized at least overnight for an

occupational injury 6 month prior to evaluation were invited to participate. These injured cases

are characterized by having an occupational injury that need 6 month leave from work; they were

invited during their follow up visit to the Nile-Insurance Hospital, as they were required to return

for re-evaluation for ability to return to work. Recruitment and data collection were done by a

physician working in the Nile-Insurance Hospital, trained to administer the research instrument.

The questionnaire was developed in English and then translated into Arabic. The questionnaire

was tested in a pilot study and validated prior to implementation.

Study tools

An interview questionnaire completed by participants consisted of 3 main parts:1]Socio-

demographic background: Details were collected on age, sex, education, residence, and marital

status; 2]Details about current injury: Details were collected on the type of injury suffered and

the injured body organ; and 3]Health status: Injured workers were also required to respond to the

EQ-5D generic measure of health status, developed by the EuroQol Group.[21]

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The EQ-5D is a brief, standardized, generic measure of HRQoL that provides a profile of patient

function and a global health state rating.[20] The EQ-5 D standardized instrument allows 1) for

the study the effect of occupational injury on workers’ physical, social and psychological status 6

months after injury, 2) for the measure of the HRQoL of injured workers from their own

perspective, and 3) for the determine predictors of diminished HRQoL in injured workers. This

information can be used to provide better guidance in the management of workers after

occupational injuries. The EQ-5D questionnaire developed by the EuroQoL Group, an

international research network established in 1987 by researchers from Finland, the Netherlands,

Sweden, and the United Kingdom. The EQ-5D questionnaire defines health in terms of five

dimensions: mobility, self-care, usual activities (work, study, housework, family, or leisure), pain

or discomfort, and anxiety or depression. Each dimension is subdivided into three categories,

which indicate whether the respondent has no problem, a moderate problem, or an extreme

problem.[22] The instrument includes a global rating of current health using a visual analog scale

(VAS) ranging from 0 (worst imaginable) to 100 (best imaginable)[23].

The EQ-5D questionnaire comprises two pages; on the first page respondents record the extent of

their problem in each of the five dimensions and on the second page they record their perception

of their overall health on a visual analogue scale.[22] The workers were asked to complete both

sections. The self-rated health status was collected from injured workers by asking them to report

their current health status after injury. The mean of the self-rated health status collected by EQ

VAS from injured workers was calculated and compared according to different variables.

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Data management and analysis

The data collected was coded and entered into a Microsoft Access database. SPSS 15.0.1(SPSS

Inc., Chicago, IL, USA), was used to statistically analyze the data. Independent sample T-test

was used to compare VAS score according to grouping variables with less than 3 groups and

ANOVA was used in case of grouping variables with 3 or more groups. Pearson Correlation was

used to test the linear relation between age and VAS score. Data were analyzed using

multivariate linear regression method with mean current VAS score of injured workers as a

dependent factor and variables age, gender, marital status, education, type of injury, injured body

part, and theEQ-5D health dimensions as predictor variables.

Ethical considerations

Institutional Review Board approval was obtained from University of Maryland School of

Medicine, Ain Shams University and the Egyptian Ministry of Health and Population. Informed

consent from interviewed workers was obtained. All data were de-identified and kept

confidential.

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RESULTS

There were 131 individuals who returned for their 6 month post-injury evaluation and enrolled in

the study. Most subjects were male (90.1%) and married (87.1%) with a mean age 41.5years

(range 18-60 years). The main type of injury among study participants was fracture (73%),

followed by amputation (11.5%).The most frequently body part injured were the lower limbs

(53.4%), followed by the upper limbs (33.6%)(Table 1).

The responses on the EQ5D are presented in Table 2. More than half of respondents (59.5%)

reported experiencing some problems with mobility 6 months post injury. Almost 91% of

participants reported having moderate pain and/or discomfort, while only about 40% reported

moderate anxiety and/or depression. The Mean EQ VAS score, the participant's self-rating of

their current own health state, was 61.6± 17.9.

The VAS score did not show statistical significant difference when compared according to

gender, residence, educational level or marital status of injured workers. Also there was no

significant correlation between age of injured workers and their VAS score (data not shown)

The VAS score of injured workers showed a highly statistically significant difference when

related to mobility limitation, self-care affection, usual activities (work, study, housework,

family, or leisure) affection, pain/discomfort sensation, and anxiety or depression of injured

workers. Workers who had problems in any of the above health domain had a lower mean of

VAS score. However, the mean VAS score didn’t show statistical significant difference when

compared to injured body part, or type of injury which was grouped into three groups, the first

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one includes workers with wounds, cuts, tear and foreign body, the second group was fractures

and burn cases, while the third group includes workers with amputations (Table 3).

Multiple linear regression analysis was used to investigate the collective influence of background

variables with VAS score as the dependent variable (Table 4). Multivariate modeling suggested

several independent risk factors for poorer HRQoL. After adjustment for these factors,

significant risk factors for a poorer VAS score included amputation versus other type of injuries

(P


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DISCUSSION

There were 131 workers who presented to the Nile Insurance Hospital during the study period

who had been injured six months previously and were still off work at their 6 month revaluation.

This study provides the first preliminary data on the impact of occupational injury on the

HRQoL of Egyptian workers from the injured workers’ perspective. The EuroQol 5D

questionnaires was the instrument of choice because it is simple, short, with acceptable

reliability,[21] and is easily understood and answered by the patients. The EuroQol 5D

questionnaire is a generic HR-QOL instrument that, apart from permitting estimation of an

overall quality of life index, specifically measures a range of physical and nonphysical

dimensions.[24]

In terms of health problems experienced by workers still off work six month after injuries , the

findings indicate that the majority of the recruited workers experience problems concerning

moderate levels of pain or discomfort (90.8%), performing usual activities (83.2%), mobility

(59.5%), self-care (52.7%), reflecting the multifaceted impact of occupational injury on the

health conditions of the injured workers. Anxiety or depression was not as prevalent, as more

than half indicated having no problems with anxiety or depression, though approximately 40%

did report moderate anxiety or depression problem.

Our findings were consistent with a Swedish study of quality of life 5 years after major trauma,

where 68% and 41% of the patients reported considerable physical or psychological disabilities,

respectively.[6] Granja et al., found that six months post-injury, as many as 78% of injured

patients experienced pain/discomfort.[25] Another study conducted in a level I trauma center in

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the Netherlands of outcome 1 year after major trauma found a 58% incidence of

pain/discomfort.[26] In a follow up study 2-7 years after trauma, 58% of patients still

experienced pain/discomfort and 15% had problem with self-care, which differ from our finding

where much higher percentages of injured workers complained from pain/discomfort and

problems with self-care. This difference may be explained by the difference in time of

recruitment, in our study the injury is only 6 months ago while in the other study injury was 2-7

years ago.[27].

Our study showed that pain is a problem for the majority the patients, reported by about 91% of

injured workers. This demonstrates that pain management in the acute and subacute phase of

trauma is clearly important. Improved pain management in the trauma patient not only increases

comfort and reduces unnecessary suffering, but has also been shown to reduce morbidity and

improve long-term outcomes.[28-29] The reported problems in our study were primarily

moderate, which agrees with the previously mentioned study that reported predominately

moderate pain 2–7 years after severe trauma.[27]

The mean VAS score of the injured workers in our study 6 months post injury was 61.6(SD =

17.9). Similarly, Holtslag et al., founded that among traumatized patients 3 months after injury,

the mean visual analog scale score was 73.5 (SD = 17.8).[30]

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The VAS score did not show significant difference when compared according to age categories,

gender, educational level, marital status, injured body part or type of injury. The results of the

current study was partially consistent with a Dutch study, where the univariate analyses revealed

non-significant differences in EQ VAS scores relating to sex and injury localization while age,

educational level, were significant.[30] In other studies the relationship between age and HRQoL

after trauma is uncertain, although older patients have been reported to experience the greatest

impairment.[6,31]

When evaluating the possible determinants of HRQOL denoted by VAS score after injury,

background variables have to be taken into consideration. Adjusting for age, sex, residence,

marital status, educational level, in a multivariate analysis, we found amputations, mobility

limitation, pain or discomfort, depression/anxiety, and affection of self-care, educational level

were significant determinant of poorer HRQoL while the injured body part or the affection of

usual activities performance were not significant in the model.

The injured body part was not a significant determinant of poorer HRQoL. This was consistent

with a previous study that found no significant differencein quality of life between patients with

or without severe head injury 2 years after discharge from the ICU.[31] One would expect that

patients with severe head injury had the lowest quality of life. However, it was found that

patients with severe head injury reported not only equal but even better quality of life than the

other severely injured patients.[27]

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In our study, the regression model indicated that amputation was a significant determinant for

poorer VAS score, which was consistent with findings by GustafssonM. and AhlströmG., who

reported that patients with amputations more often experienced a worse life situation.[32]

In a Dutch study, multivariate linear regression analysis was used to explore the relation between

socio-demographic factors, physical factors, injury localization and ISS on the one hand, and the

EQ VAS on the other. This analysis showed that injury localization (spinal cord injury, lower

extremity injury, or brain injury), educational level and co-morbidity were significantly

associated with poorer EQ VAS., while age, gender, and ISS did not have independent effects on

the long-term functional consequences of major trauma as measured by EQ vas.[30]

Limitations in this study include the absence of definition for the severity of injury (Injury

Severity Scoring) in insurance hospital for injured workers which could make comparisons with

other studies better. However all our cases required at least 6 months off work for their injury.

We also did not ask regarding quality of life measures before the injury. All were employed in

the formal work sector as they were covered by workers compensation insurance. Our findings

are limited to workers hospitalized at least overnight for an occupationally related injury who

required at least 6 month leave from work. Additionally, as this work was conducted in a middle-

income Arab country, the cultural circumstances may have influenced the self-perceived quality

of life and may limit generalizability beyond this setting.

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CONCLUSIONS:

Occupationally injured workers may experience problems, such as pain or discomfort, functional

limitations, and anxiety or depression, after an injury. We found a significant decrease in their

perceived health status six months after injury. Certain factors, such as mobility problems after

injury, may help identify injured workers with poorer HRQol so that additional care can be

directed to them. The clinical practice of caring for occupationally injured workers should

include not only surgical or medical treatment at time of injury but also need follow up for issues

such as pain management as well as physical and psychological rehabilitation in order to

improve the health related quality of life of injured workers.

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Table 1 Socio-demographic and injury profile of injured workers

Socio-demographic and health Total

N=131 %

Gender Male 118 90.1

Female 13 9.8

Age Range 18–60

Mean yrs& SD 40.1 ± 11.6

Education level Illiterate 26 19.8

Read and write 16 12.2

Primary education 17 13

Preparatory education 10 7.6

Secondary education 42 32.1

Institute/university 20 15.3

Residency Rural 73 55.7

Urban 58 44.3

Marital status Single 16 12.2

Married 115 87.8

Type of injury Fracture 96 73.3

Amputation 15 11.5

Cut 7 5.3

Foreign body 7 5.3

Wound 2 1.5

Tear 2 1.5

Burn 2 1.5

Injured part Head / neck 7 5.3

Upper limb 44 33.6

Trunk 10 7.6

Lower limb 70 53.4

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Table 2: Numbers (percentages) of respondents reporting a problem in each EuroQoL

dimension and their mean VAS score

Total

N (131) %

Mobility

- No problems 53 40.5

- Some problems 78 59.5

- Confined to bed 0 0

Self-care



- Extreme problem 0 0

Usual activities



- Extreme problem 0 0

Pain/discomfort

- None 12 9.2

- Moderate 119 90.8

- Extreme 0 0

Anxiety/depression

- None 80 61.1

- Moderate 51 39.9

- Extreme 0 0

EQ VAS score

-Mean & SD 61.6 ± 17.9

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Table 3: Comparison of Health status after injury (VAS score) according to Euro QoL five

dimensions

N

VAS score t/F

P-

value Mean S.D

Mobility affection No problems 53 71.8 18.40 5.8* .0001

Some problems 78 54.61 13.83

Self care

No problems 62 70.64 16.3 6.28* .0001


Usual activity No problems 22 80 18.51 5.93* .0001


Anxiety/Depression No anxiety/depression 80 66.25 18.7 4.19* .0001

Moderate anxiety/depression 51 54.31 13.74

Pain/Discomfort No pain or discomfort 12 83.33 19.6 4.75* .0001

Moderate pain/ discomfort 119 59.41 16.2

Injured body part

Head or neck 7 57.14 19.7

1.71** .167 Upper limb 44 66.13 16.31

Trunk 10 55 15.81

Lower limb 70 60.14 18.68

Type of injury

Cuts/wound/ tear/foreign

body 18 63.8 18.83

.222** .801 Fractures/Burn 98 61.02 17.08

Amputation 15 62.66 22.82

*independent sample t test

** ANOVA test

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Table 4: Multivariate regression model describing the relation between perceived Health

status (VAS score) as a dependent variable and other independent variables

B Sig. 95% Confidence Interval for B

Lower Bound Upper Bound

Age -.064 .586 -.296 .168

Sex(Females) 1.290 .762 -7.116 9.695

Residence(Urban) -1.717 .491 -6.643 3.210

Education^

Read & write/primary 3.798 .092 1.055 .294

Preparatory .256 .004 .049 .961

secondary 4.977 .130 1.383 .169

High education .175 .004 .041 .968

Marital status(Married) 3.404 .388 -4.370 11.177

Injury type‡

Fracture/burn -4.537 .226 -11.921 2.847

Amputation -10.946 .040* -21.393 -.499

Injury localization66

Upper limb 5.326 .405 -7.308 17.959

Trunk 6.280 .377 -7.737 20.296

Lower limb 9.193 .128 -2.675 21.062

Mobility affection -16.545 .000** -24.335 -8.755

Self-care affection -12.042 .000** -17.069 -7.016

Usual activity affected -2.879 .502 -11.338 5.580

Anxiety or depression -5.331 .036* -10.312 -.350

Pain/discomfort -13.446 .005** -22.655 -4.237

*Significant (P


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WHAT THIS PAPER ADDS:

This study provides the first preliminary data on the impact of serious occupational injury on

Egyptian workers’ health six months after injury. It identifies potential reduction in health-

related quality of life (HRQOL) due to occupational injuries and possible determinants of this

reduction. It recommends ways for management of occupationally injured cases that may

improve their health related quality of life.

FUNDING: This work was supported by the U. S. National Institutes of Health Fogarty

International Center Fogarty Grant 5D43TW007296.

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3 CDC, health related quality of life. Available athttp://www.cdc.gov/hrqol/Accessed on January

06, 2009

4 Holtslag HR, Post MW, Lindeman E, et al. Long-term functional health status of severely

injured patients. Injury 2007;38(3): 280–289

5 DePalma JA, Fedorka P, & Simko LC. Quality of life experienced by severely injured trauma

survivors. AACN Clinical Issues: Advanced Practice in Acute and Critical Care 2003;14(1):54–

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7 Richmond TS, Kauder D, Hinkle J, et al. Early predictors of long-term disability after injury.

American Journal of Critical Care 2003;12(3);197–205.

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21 Rabin R, de Charro F. EQ-5D: a measure of health status from the EuroQol Group. Ann Med.

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27 Ulvik A, KvaLe R, Wentzel-Larsen T, et al. Quality of life 2–7 years after major trauma.

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Questionnaire for the assessment of health related quality of life of occupationally

injured workers in Qaluobia governorate, Egypt

Age -----------------------------

Sex : a)Male

b)female

Residence:

a)rural

b)urban

Education: a)illiterate

b)Read and write

c)Primary

d)Preparatory

e)Secondary

f)Institute/University

Marital status: a)single

b)married

c)divorced

e)widow

Type of injury sustained

a) Open wounds b) Cut c) Tear d) foreign body e) Burns f) Fractures g) Amputation

Body part injured a)head/neck

b)upper limb

c)trunk

d)lower limb

Mobility:

I have no problems in walking --------

I have some problems in walking----

I am confined to bed--------------------

Self-care I have no problems with self-care---------------------------------

I have some problems washing or dressing myself-----------------

I am unable to wash or dress myself-----------------------------

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Usual activities (e.g. work, study, housework, family or leisure activities)

I have no problems with performing my usual activities-------------

I have some problems with performing my usual activities-----------

I am unable to perform my usual activities---------------------------

Pain/ discomfort I have no pain or discomfort -------------

I have some moderate pain or discomfort-------------

I have extreme moderate pain or discomfort---------------------

Anxiety/ depression I am not anxious or depressed-------------------------

I am moderately anxious or depressed----------------

I am extremely anxious or depressed------------

We would like you to indicate on this scale how good or bad your own health after your work related

injury, in your opinion. Please do this by drawing a line from the box below to whichever point on the

scale that represent your health.

100

90

80

70

60

50

40

30

20

10

0

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Assessment of health related quality of life of occupationally injured

workers in Qaluobia governorate, Egypt.

Before agreeing to participate in this study, it is important that you read and understand the

following explanation of the proposed study procedures. In order to decide whether you

wish to participate in this research study, you should understand enough its risks and

benefits to be able to make an informed decision.

Title of study: Assessment of health related quality of life of injured workers in Eastern

Delta Region of Egypt.

Name of investigator: Dr.Waleed Salah El-Din

Sponsor: University of Maryland supported by a Fogarty Center, National Institute of

Health (NIH), USA Training Grant"

Purpose: Injuries that occur due to exposures at work or work related events affect the

lives of many workers. These events also cause significant impact to an injured worker’s

physical and psychological wellbeing and can overwhelm family resources which can lead

to deterioration in the quality of life (QOL) of injured workers. The purpose of this study is

to determine the degree of affection of the quality of life (QOL) of injured workers and to

identify factors highly affecting QOL that could be then targeted resulting in better

improvement of the QOL.

Procedure: Because you are a worker who has been injured 6 months ago during work

or work-related event, you are asked to participate in this study. We are going to ask you

few questions through an interview questionnaire. The questions will be about your

physical, psychological, social and economic status after you had experienced your last

injury. The questionnaire will last for about 5-10 minutes. Anytime you want to stop the

questionnaire or not answering a question you are able to do this without any affection of

the medical care you receive.

Risks: There is the potential for the loss of confidentiality, however research staff will

only use research identification numbers and will not store your data with identifiers. You

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may experience some discomfort disclosing some private information related to your

injury, however you may stop the interview the interview at any time or refuse to answer

any question. By doing so will not affect the care you receive at Nile Insurance Hospital.

Benefits: You will not receive any direct benefits from this study. Your participation in

this study will help in better understanding of the QOL of injured workers; it will help in

setting priorities for the factors responsible for deteriorating the QOL, and so better

management of these factors can help in improving QOL. Participation in this study is

voluntary; refusal to participate does not affect you or the level of medical care you

receive.

Alternative: there is no alternative to participating in this study.

tConsen

The interviewer informed me about the purpose, the procedure and the possible risks of the

study. I read and understood the content of this document, and I accept to participate in this

research.

Participant signature……………………………..…

Interviewer signature…………………………….…

Date: …. / …/ …..

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Health-Related Quality of Life after Serious Occupational Injury in Egyptian Workers: A Cross Sectional Study

Journal: BMJ Open

Manuscript ID: bmjopen-2011-000413.R1

Article Type: Research

Date Submitted by the Author: 09-Aug-2012

Complete List of Authors: Salah Eldin, Waleed; Faculty of medicine-AinShams University, community, ocupational and environmental medicine Hirshon, Jon Mark; University of Maryland School of Medicine, Department of Emergency Medicine; University of Maryland School of Medicine, Charles McMathias, Jr. National Study Center for Trauma and EMS, of the Shock, Trauma, and Anesthesia Research Center Smith, Gordon; University of Maryland School of Medicine, Charles McMathias, Jr. National Study Center for Trauma and EMS, of the Shock,

Trauma, and Anesthesia Research Center Kamal, Abdel-Aziz; Faculty of medicine-AinShams University, community, ocupational and environmental medicine Abou-El-Fetouh, Aisha; Faculty of medicine-AinShams University, community, ocupational and environmental medicine El setouhy, Maged; Faculty of medicine-AinShams University, community, ocupational and environmental medicine

Primary Subject Heading:

Occupational and environmental medicine

Secondary Subject Heading: Rehabilitation medicine, Epidemiology, Global health

Keywords: OCCUPATIONAL & INDUSTRIAL MEDICINE, REHABILITATION MEDICINE,

Epidemiology < THORACIC MEDICINE


BMJ Open on July 2, 2021 by guest. P

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1

Health-Related Quality of Life after Serious Occupational Injury in Egyptian

Workers: A Cross Sectional Study

Waleed Salah Eldin, MD1, Jon Mark Hirshon, MD2, 3

, Gordon S. Smith, MD3, Abdel-Aziz

Mohamad Kamal, MD1, Aisha Abou-El-Fetouh, MD

1, Maged El-Setouhy, MD

1

1-Community, Environmental and Occupational Medicine Department, Ain Shams University,

Egypt

2- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore,

Maryland, USA

3- Charles McMathias, Jr. National Study Center for Trauma and EMS, of the Shock, Trauma,

and Anesthesia Research Center, University of Maryland School of Medicine, Baltimore,

Maryland, USA

Corresponding Author:

Waleed Salah Eldin, Community, Environmental and Occupational Medicine Department, Ain

Shams University, Cairo, Egypt

Email: [email protected], Tel: 002-012-519-02-04

Abstract Word Count: 232 Manuscript Word Count: 2,535

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Abstract

Objectives: Occupational injuries are common and can result in severe socio-economic

consequences. However, there is little research examining the health related quality of life

(HRQoL) of workers following occupational injuries especially in developing countries. This

research used the European Health Related Quality of Life Five Dimensions (EQ-5D) tool to

measure health-related quality of life six month following serious occupational injury in insured

workers in the East Delta Region of Egypt.

Design: This study was a cross-sectional, study conducted from July-December 2008 among

workers injured severely enough to be off work for at least six months after an occupational

injury.

Setting: All injured workers visiting the Nile Insurance Hospital, Egypt, six months after an

injury.

Participants: There were 131 adult workers returning for follow-up after previously been given

six months off work by a physician for an occupational injury. All eligible workers participated

in the research.

Outcomes: The workers described their health using the EQ-5D quality of life instrument.

Results: Cases were mostly males (90%) with mean age 41.5 years. Fractures were the most

common type of injury (73.3%). The most frequently injured body part was the lower limbs

(53.4%). Participants identified persistent problems related to mobility (60%), self-care (53%),

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3

performing usual activities (83%), pain/discomfort (91%) and anxiety/depression (41%). The

perceived HRQoL estimated by visual analogue scale (VAS) among injured workers was 61.6±

17.9. Multivariate linear regression showed poor VAS score associated with amputations,

mobility limitation, self-care problems, pain/discomfort, and anxiety/depression.

Conclusions: Occupationally injured workers with serious injuries experience marked

impairment in their perceived HRQoL. Improvement in pain management, physical and

psychological rehabilitation after injury may improve the health related quality of life of injured

workers.

Key words: occupational injury; health related quality of life; EuroQol 5-D; Egyptian workers

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INTRODUCTION

Work related injuries constitute an important public health problem because they involve large

numbers of workers, especially young people at productive ages. They can also be disabling,

leading to major social and economic consequences for the worker and his or her family.[1]

These adverse consequences of work related injuries can lead to deterioration in the health

related quality of life (HRQoL) of injured workers. HRQoL has a variety of domains, but

generally it includes” the dimensions of physical functioning, social functioning, role

functioning, mental health and general health perceptions”.[2] In other words, HRQoL refers to a

person’s or group's perceived physical and mental health over time.[3]

In recent years, researchers have recognized that HRQoL is an important outcome measure in

people with serious injuries,[4] since individuals who survive injury do not always return to their

pre-injury HRQoL.[5-7] For example, people who sustained an injury reported poorer health and

functioning than did population norms when assessed 3 months after hospitalization in the

United States[8] and Australia,[9] and15 months after hospitalization in a Dutch study.[4] In a

study of people who had experienced lower extremity injuries, 50% had physical limitations

related to daily activities and mobility, and up to 60% were not able to walk 3 months after

injury.[10] In other research, patients with injury experienced a decrease in physical strength and

fatigue when performing physical activity,[11] that could result in an inability or delayed ability

to resume work.[5,12] Long-term effects, both physical and psychological, are also common

after minor injuries.[13] Research has also focused on the relationships between injury events

and the risk of development of posttraumatic stress syndrome (PTSD).[14] However, there has

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been very little investigation of the extent to which work related injuries affect the health-related

quality of life (HRQol) of the individual, especially in developing countries such as Egypt.[15]

Many factors are known to impact health related quality of life (HRQoL) after injury, but

predictors of diminished HRQoL remain incompletely understood.[16] The severity of injury

using the Injury Severity Score (ISS)[9,17] and age,[4,7,9] have been shown to be independent

predictors of HRQoL. However, ISS was not a predictor in an earlier study.[18] In one

qualitative study of recovery after injury, recovery was complex and did not conform to the

views of most clinicians,[19] suggesting that it is important to understand the perspective of

patients’ with regards to the impact of injuries.

This research uses the European Health Related Quality of Life Five Dimensions tool to measure

health-related quality of life six month following serious occupational injury in insured workers

in the East Delta Region of Egypt.[20]

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METHODOLOGY

Study design, setting and sample

The study was designed as a hospital-based cross sectional study among workers with a history

of an occupational injury 6 months prior to study inclusion. It was conducted in the Nile

Insurance Hospital, which is the primary hospital responsible for treating medically insured

workers working in the Qaluobia governorate of Egypt. Egyptian law requires that all workers be

covered by a workers insurance policy. During 2008, there were 2129 work injuries presenting to

the Nile Insurance Hospital. Our study population was the subset of injured workers whose

injury was severe enough to require 6 months or more time off from work.

From July to December 2008, all workers with an occupational injury severe enough to be off

work for 6 months or more were invited to participate in the study. Physicians in charge of

patient treatment determine the time away from work, and individuals with 6 months leave are

among the most severely injured. As part of Egyptian workers compensation insurance policy all

injured workers who have been off work for 6 months are required to return at the 6 month

period post injury for a formal evaluation at one of the Governorates (counties) Insurance

Hospitals. This evaluation is required to determine ability to return to work and payment of

benefits. Further determination of time off from work is determined by a committee after the

follow-up visit, which was not impacted by the data collected for research purposes. The

identified individuals worked in different jobs in different industries within the East Delta

Region. Cases were recruited in the clinic by a physician working in the Nile-Insurance Hospital,

trained to administer the research instrument. The questionnaire was developed in English and

then translated into Arabic. A senior faculty member at the university who has an excellent

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command of English reviewed and approved the translation. The questionnaire was tested in a

pilot study and validated prior to implementation.

Sample size was calculated using the statistical package software program (STATA v.11), setting

the type-1 error (α) at 0.05 and the power (1-β) at 0.8. Results from a study of ICU patients [25],

showed that as many as 78% of injured patients experienced pain/discomfort six months post-

injury. We assumed in our study that 88% of injured workers would still be complaining from

pain/discomfort six month after injury. Calculation according to these values produced a minimal

sample size of 118 cases. We allocated the period from 1st of July to 31 of December 2008 to

obtain our cases during which period we were able to recruit 131 cases. This sample size has

enough power (98%) for detecting such difference in VAS score between patients with and

without anxiety/depression manifestations if that difference is statistically significant.

Study tools

An interview questionnaire completed by participants consisted of 3 main parts: 1] Socio-

demographic background: Details were collected on age, sex, education, residence, and marital

status; 2] Details about current injury: Details were collected on the type of injury and the injured

body part; and 3] HRQoL: Injured workers were also required to respond to the EQ-5D generic

measure of HRQoL, developed by the EuroQol Group.[21]

The EQ-5D is a brief, standardized, generic measure of HRQoL that provides a profile of

patient’s function and a global health state rating.[20] The EQ-5 D standardized instrument

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allows for 1) the assessment of an individual’s physical, social, and psychological status, 2) the

measure of HRQoL from the subjective view of the individual, and 3) the identification of

possible predictors of diminished HRQoL in specific individuals and groups This information

can be used to provide better guidance in the management of workers after occupational injuries.

The EQ-5D questionnaire was developed by the EuroQoL Group, an international research

network established in 1987 by researchers from Finland, the Netherlands, Sweden, and the

United Kingdom. The EQ-5D questionnaire defines health in terms of five dimensions: mobility,

self-care, usual activities (work, study, housework, family, or leisure), pain or discomfort, and

anxiety or depression. Each dimension is subdivided into three categories, which indicate

whether the respondent has no problem, a moderate problem, or an extreme problem.[22] The

instrument includes a global rating of current health using a visual analog scale (VAS) ranging

from 0 (worst imaginable) to 100 (best imaginable)[23].

The EQ-5D questionnaire comprises two pages; on the first page respondents record the extent of

their problem in each of the five dimensions and on the second page they record their perception

of their overall health on a visual analogue scale.[22] The workers were asked to complete both

sections. The self-rated HRQoL was collected from injured workers by asking them to report

their current HRQoL after injury. The mean of the self-rated HRQoL collected by EQ VAS from

injured workers was calculated and compared according to different variables. Approval for the

use of the copyrighted instrument was obtained from the EuroQol Executive Office.

Data management and analysis

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The data collected was coded and entered into a Microsoft Access database. SPSS 15.0.1(SPSS

Inc., Chicago, IL, USA), was used to statistically analyze the data. Independent sample T-test

was used to compare groups of patients (only 2 groups) as regard VAS score to examine the

effect of different patients’ characteristics on VAS score. We used it to compare between

patients with problems in one health dimension and patients without problems with regard to

VAS score. ANOVA test was used to compare VAS scores between groups of patients (3 groups

or more). We used it to compare between patients with different types of injury (more than 2

types) as regard VAS score. Pearson Correlation was used to test the linear relation between age

and VAS score and to show if increasing age was associated with decreases in VAS score.


variables (independent variables) with VAS score as the dependent variable. Independent

variables were selected based on their significant relation with VAS score in univariate analysis.

Age, gender, marital status, education, type of injury, injured body part, and theEQ-5D health

dimensions were included in the model as independent variables.

Ethical considerations

Institutional Review Board approval was obtained from University of Maryland School of

Medicine, Ain Shams University and the Egyptian Ministry of Health and Population. Informed

consent from interviewed workers was obtained. All data were de-identified and kept

confidential.

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RESULTS

There were 131 individuals who returned for their 6 month post-injury evaluation over the 6

month period; all agreed to participate in the study. Most subjects were males (90.1%) and

married (87.1%) with a mean age 41.5years (range 18-60 years). The main type of injury (most

severe based on chart review by the physician first author) among the study participants was

fracture (73%), followed by amputation (11.5%). The most frequently injured body part was the

lower limbs (53.4%), followed by the upper limbs (33.6%) (Table 1). More than half of

respondents (59.5%) reported experiencing some problems with mobility 6 months post injury

(Table 2). Almost 91% of participants reported having moderate pain and/or discomfort, while

only about 40% reported moderate anxiety and/or depression. The Mean EQ VAS score (

participant's self-rating of their current own health state) was 61.6± 17.9 (out of a possible

maximum of 100).

The VAS score did not differ significantly between groups such as gender, residence,

educational level or marital status of injured workers (data not shown). Also there was no

significant correlation between age of injured workers and their VAS score.

The VAS score of injured workers showed a highly statistically significant difference when

related to mobility limitation, self-care activities, usual activities (work, study, housework,

family, or leisure), pain/discomfort sensation, and anxiety or depression of the injured workers.

Workers who had problems in any of the above health domains had a lower mean VAS score

compared to those who did not have any problems. However, the mean VAS score didn’t show

statistical significant difference when compared to injured body part, or type of injury which was

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grouped into three groups, the first one includes workers with wounds, cuts, tear and foreign

body, the second group was fractures and burn cases, while the third group includes workers

with amputations (Table 3).


variables with VAS score as the dependent variable (Table 4). Multivariate modeling suggested

several independent risk factors for poorer HRQoL. After adjustment for these factors,

significant risk factors for a poorer VAS score included amputation versus other type of injuries

(P


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DISCUSSION

There were 131 workers who presented to the Nile Insurance Hospital during the study period

who had been injured six months previously and were still off work at their 6 month revaluation.

This study provides the first data on the impact of serious occupational injury on the HRQoL of

Egyptian workers from the injured workers’ perspective. The EuroQol 5D questionnaire was the

instrument of choice because it is simple, short, and has acceptable reliability. ,[21] It is also

easily understood and answered by the patients. Additionally, the questionnaire permitted

estimation of an overall quality of life index and specifically measured a range of physical and

nonphysical dimensions.[24]

In terms of health problems experienced by workers still off work six month after injuries , the

findings indicate that the majority of the recruited workers experience problems concerning

moderate levels of pain or discomfort (90.8%), performing usual activities (83.2%), mobility

(59.5%), self-care (52.7%), reflecting the multifaceted impact of occupational injury on the

health conditions of the injured workers. Anxie

Documents

BMJ Open...Waleed salah eldin, Community, Environmental and Occupational Medicine Department, AinShams University, Cairo, Egypt Email: [email protected], Tel: 002-012-519-02-04