Search

Background Injury mortality rates have declined in many countries largely because of the development of sophisticated Trauma and injury prevention systems and improved patient care. However the morbidity following severe traumatic physical injury is increasingly recognized as an important public health matter. Little is known about injury recovery patterns and associated causes once patients are discharged home to their communities. Here, prevention activities are targeted at the secondary and tertiary levels in community settings, aiming to reduce or eliminate impairment and disability, minimize suffering and pain, and maximize quality of life for irremediable conditions. Studies show that factors in patients’ socio-ecological environments contribute to poor outcomes. Socioeconomic disadvantage, blue collar jobs, and low levels of family, social and community support frequently appear as significant covariates in inception cohort studies of trauma patients. The socio-ecological model is a well-recognized framework for activating prevention strategies. For trauma patients their ‘eco-system’ incorporates resilient and healthy caregivers and families, supportive social networks and community and rehabilitation services. It also encompasses a neighborhood, defined by economic, social and physical properties that provide access to resources, enabling trauma recovery. Variations in individuals’ resilience and in their resilient resources might explain why some people experience better outcomes compared to others, after suffering the same type of adversity. Resilience is rapidly becoming a factor of interest in trauma rehabilitation. It is a positive, protective quality, amenable to interventions, and bolstered by social and environmental factors. Resilience promotion, in rehabilitation could potentially, support people and families exposed to severe trauma. The over-arching aim of this thesis is to develop a program of research that investigated ‘resilience’ as part of the trauma patients’ socio-ecological system. Firstly, resilience at the community level was examined by synthesizing the research evidence of the effectiveness of socio-ecological resilience rehabilitation programs on the outcomes of people sustaining traumatic physical injuries. Secondly, a form of ‘neighborhood’ resilience characterized by the physical, social and economic aspects of patient’s neighborhoods were analysed in relation to rurality and short-term patient outcomes. And finally, resilience was examined in a cohort of primary informal caregivers of patients sustaining severe traumatic musculoskeletal injuries Methods A systematic review was conducted to identify the effectiveness of multifaceted community socio-ecological rehabilitation programs aimed at fostering resilience. Twenty-one studies were retrieved and reviewed (11,904 participants). The results of 19 randomised intervention studies of moderate to high methodological quality were then pooled using a random-effects meta-analysis. Mean differences for continuous outcomes and risk ratios for outcomes including return to work (RTW), self efficacy and stress reduction were calculated. To examine the influence of factors characterizing neighborhood resilience on trauma patients’ outcomes, data were accessed from the Gold Coast University Hospital Trauma Registry. A cross-sectional study design was employed, and geocoding methods enabled the creation of two area-level explanatory variables describing relative Socioeconomic Disadvantage, and remoteness from services. These variables were linked to individual patients represented on the Trauma Registry, along with data items including age, injury severity, anatomical region, discharge disposition, number of comorbidities, injury mechanism, postcode of injury occurrence, and the first provider of care. From this study sample, the association of these two neighborhood indices with inpatient outcomes was analysed using a retrospective cohort design. Outcome variables were acute length of stay days (ALSD) and inpatient mortality. Step-wise multivariable negative binomial regression and proportional hazards regression analyses were conducted, adjusting for age, injury severity, mechanism and comorbidity and sites of injury. Finally, a prospective cohort study was designed to examine resilience in primary, informal caregivers of severe musculoskeletal trauma patients. Patient and caregiver dyads were recruited, shortly after the injury event and followed up three months later. Resilience was measured, using the Connor Davidson resilience scale (CD-RISC 10). Primary outcomes were caregiver burden and quality of life measured respectively, using the Caregiver Strain Index and the Short Form Version 12 (SF-12) Health Survey. Results Resilience based community rehabilitation: Resilience rehabilitation programs significantly increased the likelihood of RTW (OR 2.09 95% CI 0.99-4.44 p=0.05), decreased the time taken to RTW (Mean difference -7.80, 95% CI -13.16 - -2.45 p=