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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
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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
- No problems 62 47.3
- Some problems 69 52.7
- Extreme problem 0 0
Usual activities
- No problems 22 16.8
- Some problems 109 83.2
- 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
Some problems 69 53.47 15.22
Usual activity No problems 22 80 18.51 5.93* .0001
Some problems 109 57.88 15.4
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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20
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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22 Kind P, Dolan P, Gudex C, et al. Variations in population health status: results from a United
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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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29 Cohen SP, Christo PJ, Moroz L. Pain management in trauma patients. Am J Phys Med
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30 Holtslag HR, van Beeck EdF, Lindeman E, et al. Determinants of Long-Term Functional
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2007;62(4) :919 -927
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31 Vazquez MG, Rivera FR, Perez AA. Analysis of quality of life in poly traumatized patients
two years after discharge from an intensive care unit. J Trauma 1996;41:326–32.
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hand injury - a prospective study. Journal of Clinical Nursing 2004;13(8):986–995
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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
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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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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.
Multiple linear regression analysis was used to investigate the collective influence of background
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).
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 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
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