Opportunities for preventing subsequent injuries: a qualitative study exploring perspectives of people who have experienced injuries
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People can experience multiple injury events over time. Preventing subsequent injuries (not necessarily the same type or cause as an index injury) is one way to reduce the overall burden of injury which is considerable, comprising 10% of the disability burden globally.[[1]] The financial burden is also high with injury claims costing the Accident Compensation Corporation (ACC, New Zealand’s universal no-fault injury insurer) $5.2 billion NZD in 2020/21.[[2]] The incidence of subsequent injuries is substantial, making it an important and specific contributor to this burden. In a previous study, 38% of participants had >1 subsequent injury claim in the 12 months following an ACC entitlement claim (involving compensation for >1 week off work or other rehabilitation assistance); by 24 months this had risen to 58%.[[3]] Other studies examining specific injury types,[[4]] or population groups such as workers,[[5,6]] also report a high incidence of subsequent injury.
Importantly, when someone is injured, there may be an opportunity to intervene to prevent subsequent injuries. For specific injury types, particular techniques or treatments may reduce re-injury, e.g., neuromuscular training among those presenting with an ankle sprain helping prevent future ankle sprains.[[7]] Previously, a range of predictors of subsequent injuries (of any type) have been reported among a general injury population.[[8,9]] Factors associated with an increased risk of subsequent injury included the index injury being caused by assault,[[8]] having >2 chronic health conditions,[[9]] and having a prior injury affecting them.[[9]] While knowledge of these factors may inform targeted prevention initiatives, the nature of initiatives to address such factors may warrant a wide-ranging approach. A recent study has examined the prevention of subsequent injuries from the perspectives of healthcare providers.[[10]] However, it is also vitally important to also consider the perspectives of people who have experienced subsequent injuries. This study aims to examine opportunities for subsequent injury prevention from the perspectives of people who have recently experienced subsequent injury events.
Methods
This qualitative descriptive study[[11]] recruited participants via advertising on community noticeboards and healthcare provider clinics. Potential participants were required to be aged >18 years and to have had >2 injury events requiring some form of treatment in the previous 12 months. Participation involved an individual face-to-face semi-structured interview conducted by AR, who is experienced in conducting qualitative interviews. The interview guide included questions about opportunities for subsequent injury prevention, as well as about actions health professionals could take to prevent subsequent injuries for their patients. Participants received a $20 NZD voucher.
Interviews were audio-recorded, transcribed verbatim and then thematic analysis was undertaken.[[12]] Initially AR and HH independently developed a draft coding framework based on two interview transcripts. These were discussed with the wider research team to determine a final coding framework that was applied to four transcripts independently by AR and HH. Coding was compared and discrepancies discussed and resolved. The framework was applied to the remaining transcripts by AR. Analyses were carried out using NVivo 12 software.[[13]] Ethical approval was obtained through the University of Otago Human Research Ethics Committee (Health) (H19/034).
Results
Sixteen interviews were completed, lasting between 23–56 minutes. The majority of participants (n=12) were aged 18–30 years; 12 were female and the majority (n=11) reported sole New Zealand European ethnicity. Participants had experienced a range of injuries including fractures, sprains, low back injuries and concussion.
Participants held a variety of views about subsequent injury prevention. Ideas ranged from asserting that individuals were primarily responsible for preventing their own subsequent injuries, to healthcare providers having a key role in preventing subsequent injuries. Others discussed broader societal and environmental aspects. Potential opportunities have therefore been categorised for discussion as: 1) the individual who has experienced an injury, 2) healthcare providers, 3) healthcare systems and processes, and 4) environments and broader contexts.
The individual who has experienced an injury
Attention to subsequent injury prevention
Some participants recognised that they themselves were not always focused on subsequent injury prevention. A lack of attention occurred particularly when people were busy, had other priorities/competing demands or when they were fatigued or distracted (Quote[Q]1, Table 1). Increased awareness of injury prevention and the consequences of actions was recommended (Q2). However, even when people were aware of prevention strategies, these were not always remembered, and it was suggested it could be beneficial to ensure that prevention advice is visible at times when people are undertaking activities that may cause injury (Q3).
Modification of activity
The idea was raised that to prevent subsequent injuries people could sometimes better recognise their own limits and be willing to not undertake activities/tasks beyond their capabilities (Q4). Correspondingly, there could be increased acceptance of individual’s limitations from others (Q5). It was also noted that sometimes people felt they had to, or wanted to, continue with their activities, regardless of injury risk (Q6). A balance between reducing or modifying particular activities to prevent injury and a desire not to restrict activities were also raised (Q7). A desire to know about a range of options for activity was expressed (Q8).
Motivation
Persisting with rehabilitation to prevent subsequent injuries was recommended (Q9); however, it was also noted that people might not be motivated to carry out prevention strategies when benefits may not be immediately obvious (Q10). The nature and severity of the presenting injury and possible consequences were noted to affect injury prevention motivation (Q11).
Attitudes
Overarching attitudes towards injury and injury prevention could also potentially influence subsequent injury prevention with some feeling that injuries “could happen to anyone” (Participant[P]10), while another participant raised that sometimes people would not expect that they would be injured (Q12). The idea was raised that subsequent injury prevention may be dependent on people’s attitudes towards the severity of their presenting injury, and that attitudes could vary between people (Q13). Participants noted that negative attitudes towards preventive equipment could be problematic when this was an optional requirement, or when requirements changed over time (Q14, Q15).
View Tables 1–4.
Healthcare providers
Focus on subsequent injury prevention
Having healthcare providers specifically focus on preventing subsequent injuries, as well as treating the presenting injury, was felt by some to be an important opportunity (Q1, Table 2). However, this did not always occur (Q2), with a lack of time perceived as a potential contributor (Q3, Q4). Participants noted they did not necessarily know, or think about, preventing subsequent injuries themselves and such information from healthcare providers would be useful (Q5–7).
Relationships/rapport
While interactions with healthcare providers were noted as offering opportunities for preventing subsequent injuries, having a good relationship/rapport between healthcare providers and the person injured was felt to be critical. With good rapport it was suggested those injured might be more likely to be open with their provider, enabling the provider to have a better understanding of the underlying cause of injury. Alongside this, it was felt important that providers took time to get to know the person and their injury to tailor their approach to that person (Q8–10) including gaining an understanding of their attitude towards preventing subsequent injuries (Q11). Good rapport could also mean that people may be more inclined to listen to advice and recommendations from healthcare providers (Q12). Ensuring healthcare providers were not perceived as judgemental was raised as important for helping people access healthcare for their injuries (Q13).
Providing alternatives and taking a proactive approach
Rather than taking a didactic approach, providing people with alternative activities for the rehabilitation/recovery phase was felt important (Q14). Healthcare providers proactively offering support and referring people to other appropriate healthcare providers was also raised as an opportunity for subsequent injury prevention (Q15).
Healthcare systems and processes
To facilitate healthcare provider actions focused on preventing subsequent injuries, a range of aspects relating to healthcare systems and processes were discussed.
Time
Increasing healthcare appointment length was raised as enabling an increased focus on prevention (Q1, Table 3). Correspondingly, increasing the number of healthcare professionals was also mentioned (Q2).
Specific proactive approaches
A targeted focus on those with multiple injury events was suggested (Q3). One idea was that people experiencing multiple injury events could automatically be connected with healthcare providers to help prevent subsequent injuries (Q4). Routinely asking people questions about whether they might need to see an allied health professional within healthcare settings, such as emergency departments (EDs), was also suggested (Q5, Q6). Ensuring people are aware of the resources and supports they may be able to access following an injury was discussed (Q7, Q8), as well as ensuring timely access to equipment (Q9). It was suggested there could be a dedicated person within hospitals to ensure people have the required equipment and other injury prevention aspects in place prior to discharge, as a way of helping prevent subsequent injuries (Q10). It was also suggested that a range of healthcare providers could provide subsequent injury prevention advice (Q11).
Costs
One participant suggested that if people had to pay for their treatment, if the same injury was occurring multiple times, they might have fewer similar injuries (Q12). However, costs of seeing healthcare providers were also noted as barriers to treatment, with people not completing their rehabilitation negatively impacting on subsequent injury prevention (Q13).
Resources
It was suggested that resources communicating information about preventing subsequent injuries could be provided through a range of approaches, including brochures, posters and websites (Q14); however, these should be engaging and “fun” (P6). It was noted there could potentially be an increase in programmes such as falls prevention programmes and that prevention programmes like these could be advertised across a range of settings e.g., “church groups… or social service agencies” (P13), as well as within healthcare settings, particularly through general practitioner (GP) clinics (Q15).
Environments and broader aspects
Social support
Family and social supports were highlighted as being of particular importance following injury, and specifically in helping prevent subsequent injury (Q1, Q2, Table 4). There could potentially be an opportunity for providing funded support if people did not have adequate social support (Q3). Support was noted to provide both practical support such as assisting with tasks, as well as emotional support. Correspondingly, the idea of the importance of mental health in injury prevention was also raised (Q4).
Financial aspects
Participants noted that people’s financial situations could mean they returned to work earlier than they should, and that providing adequate financial assistance was an opportunity for subsequent injury prevention (Q5). Cost was noted as a barrier to some prevention activities, such as accessing community facilities like gyms and pools (Q6) and obtaining safety equipment (Q7). Accessibility issues were not just limited to costs, however, with other practical issues such as transport and parking also noted.
Broader environments
Opportunities to prevent subsequent injuries through modification of built environments included addressing slippery and hazardous surfaces and ensuring good lighting (Q8). Opportunities for other settings were also raised e.g., implementing injury prevention education in schools. Gyms were noted as a setting where there may be opportunities to make people aware of injury prevention e.g., by having proactive staff and information available. This also aligned with a recommendation that information (e.g., brochures) about injury prevention be provided in non-clinical settings (Q9). However, others raised the idea that although they felt gyms and other facilities had a certain level of responsibility for prevention, there was also a degree of individual responsibility required in such spaces (Q10). The idea was raised that there could be a targeted approach focusing on high-risk sports (Q11) or among particular population groups, such as the elderly (Q12).
Work environment
The importance of work settings was highlighted, with it noted that work is where many people spend a lot of time (Q13). The idea was raised that there seemed to be an increased awareness and focus on health and safety compared to the past. Participants appreciated employers taking “a proactive approach” (P11) and felt health and safety inductions were important (Q14). An opportunity to prevent subsequent injury in the workplace included adequate staffing levels. This aligns with ideas raised about allowing staff adequate breaks (Q15) and adequate time to carry out work tasks (Q16). The enforcement of health and safety at work was also considered important for subsequent injury prevention (Q17).
Discussion
This study has explored potential opportunities for subsequent injury prevention from the perspectives of people who have had multiple injury events. Suggestions were broad, ranging from those centred on individuals, those that could be implemented by healthcare providers and within health systems, as well as broader societal and environmental modifications.
As with many preventive actions, participants noted the benefits of such actions are, by their nature (i.e., preventing something from occurring), often not immediately obvious,[[14]] highlighting the importance of effective strategies to enhance people’s motivation with preventive activities. Aspects relating to individuals, such as motivation, attitudes and awareness, underscore the importance of the way that subsequent injury prevention strategies are communicated. Participants noted a range of communication approaches could be utilised. This aligns with previous research advocating that the communication of injury prevention strategies be based on communication theory.[[15]] Suggested guidelines include using a range of media and voices to convey prevention information to reach different groups and populations, focusing on keeping key messages simple and “encouraging the confidence to make change” (p.262).[[15]] Participants noted they were less cognisant of subsequent injury prevention when they were distracted or fatigued highlighting the importance of being cognisant of the underlying principles of injury prevention more broadly, for example the benefits of also employing passive strategies that do not require specific actions by individuals.[[16]]
Participants suggested many potential subsequent injury prevention opportunities in people’s interactions with healthcare providers and one recommendation was that healthcare providers explicitly include subsequent injury prevention as part of their practice. However, to do this, healthcare providers need to have the time to be able incorporate this into their interactions with patients; they need to feel that it is part of their role and they need to have the skills and knowledge to be able to offer appropriate advice and strategies to their patients. While prevention is within the scope of practice of healthcare providers who treat people following injury such as physiotherapists,[[17]] emergency physicians[[18]] and GPs,[[19]] some participants noted that subsequent injury prevention was not part of their interactions with their healthcare provider and noted that time pressures within clinical interactions may be a barrier to incorporating subsequent injury prevention. As well as addressing underlying issues such as staffing shortages which could affect time pressures for healthcare providers, incorporating subsequent injury prevention strategies that are not only effective, but also time-efficient, may facilitate their incorporation into consultations with healthcare providers.
Thinking beyond individuals and individual healthcare providers, a range of health system level opportunities were suggested. Having a process where those injured multiple times were given additional support/attention from healthcare providers was suggested. Correspondingly, it was noted that healthcare providers should consider the injury history of the person and address/examine any potential underlying causes. However, there can be barriers to people obtaining treatment from healthcare providers, such as cost and accessibility issues. Addressing these barriers are important to enable people to complete their full rehabilitation programme, as raised by participants in this study, and previously by healthcare providers.[[10]] Having someone within healthcare settings dedicated to injury prevention was recommended. Having a dedicated injury prevention champion is not routine in New Zealand healthcare settings although champions have been recommended in specific areas, such as wound care in aged care facilities,[[20]] and healthcare navigators have been used in areas such as cancer care.[[21]] Internationally, trauma prevention co-ordinators are mandatory in some places such as trauma centres in the US, with these centres also required to undertake injury prevention activities.[[22]] The involvement of a range of healthcare professionals in subsequent injury prevention in different settings was recommended in this study. One suggestion was that a question about whether the injured person should see an allied health professional could be routinely included in consultations. Specific programmes incorporating a range of healthcare providers have been found to reduce subsequent injuries. For example, in Australia, people attending a fracture prevention clinic following a minimal trauma fracture ED presentation were found to have fewer subsequent fractures over the next 24 months.[[23]] This clinic was co-ordinated by a fracture prevention nurse and involved a rheumatologist and referral to a falls prevention clinic or other relevant programmes as necessary.[[23]]
While actions at the level of individuals and within the health system are important, as noted by participants, wider societal/environmental/policy opportunities are also important. Ensuring that people have adequate social support following an injury is something that participants recommended. This aligns with findings of a previous study examining the perspectives of healthcare providers,[[10]] and may be something they could examine in their consultations with injured people. However, there also needs to be processes in place for healthcare professionals to be able to refer people to appropriate places/services if this is to be accompanied by action. In addition to social support being important for subsequent injury prevention, the reach of some interventions provided following injury may also extend beyond the individual who has been injured to those providing social support such as family, friends and colleagues. It was noted that continued cognisance of injury prevention opportunities within the built and natural environment for councils and town planners is also important for subsequent injury prevention.
A strength of this study it that it has considered opportunities for subsequent injury prevention from the perspectives of people who themselves have experienced multiple injury events. However, the study had a small sample, and although participants included a range of ages and ethnicities, most were female, aged between 18–30 years, and none were Māori. It is important that all these perspectives are considered in the development of any future interventions. In particular, it is important that future research and intervention development ensures the perspectives of Māori are included. Māori experience greater injury-related health loss[[24]] and poorer outcomes following injury compared to non-Māori.[[25,26]] Subsequent injuries occur frequently with a previous study of 566 Māori who had injury involving an ACC entitlement claim reporting that 62% had at least one subsequent injury ACC claim in 24 months.[[27]] In addition, this study has examined subsequent injury prevention opportunities in general rather than focusing on a specific injury type, severity or mechanism of injury. Particular injury types or mechanisms may have specific prevention opportunities that are important, however, such as examining specific injury types, severities or mechanisms was not within the scope of this study.
A range of potential opportunities to prevent subsequent injuries have been suggested. Importantly, these are from the perspectives of those who could directly benefit from such interventions—people who have experienced multiple injury events. While there would be a financial cost to implement some of the suggested interventions, the costs (financial and otherwise) of subsequent injuries are high, not only for individuals but also for wider society. Future research to trial interventions suggested in this research is warranted to determine their feasibility and effectiveness.
Summary
Abstract
Aim
This study aims to examine opportunities for subsequent injury prevention from the perspectives of people who have recently experienced subsequent injury events.
Method
This qualitative study involved individual semi-structured interviews with people who had >2 injury events in the previous 12 months. Interviews were audio-recorded, transcribed verbatim and thematic analysis undertaken.
Results
Sixteen interviews were completed with participants who had experienced a range of index and subsequent injury types. Potential opportunities raised were wide-ranging. Some related to individuals, e.g., motivation to carry out prevention strategies. Other opportunities were related to healthcare providers and the health system. For instance, increasing consultation times to allow a focus on subsequent injury prevention, building rapport and tailoring their approach to the individual, proactively referring people to a range of healthcare providers, and ensuring people are aware of resources and supports available following injury. Broader environmental and societal opportunities were also suggested, such as ensuring adequate social support following injury, ensuring accessibility to rehabilitation and community facilities and the modification of built environments.
Conclusion
A broad range of potential opportunities to prevent subsequent injuries were raised. These opportunities are promising and future research to trial interventions raised in this study is warranted to determine their feasibility and effectiveness.
Author Information
Acknowledgements
Correspondence
Correspondence Email
Competing Interests
1) Haagsma JA, Graetz N, Bolliger I, et al. The global burden of injury: incidence, mortality, disability-adjusted life years and time trends from the Global Burden of Disease study 2013. Inj Prev. 2016;22(1):3-18. doi: 10.1136/injuryprev-2015-041616.
2) Accident Compensation Corporation. Pūrongo-a-tau Annual report [Internet}. Wellington, New Zealand: The Accident Compensation Corporation; 2021. Available from: https://www.acc.co.nz/assets/Annual-report-segments/ACC8278-Annual-Report-2021.pdf.
3) Harcombe H, Davie G, Wyeth E, et al. Injury upon injury: a prospective cohort study examining subsequent injury claims in the 24 months following a substantial injury. Inj Prev. 2018;24(6):437-44. doi: 10.1136/injuryprev-2017-042467.
4) de Visser HM, Reijman M, Heijboer MP, et al. Risk factors of recurrent hamstring injuries: a systematic review. Br J Sports Med. 2012;46(2):124-30. doi: 10.1136/bjsports-2011-090317.
5) Ruseckaite R, Collie A. The incidence and impact of recurrent workplace injury and disease: a cohort study of WorkSafe Victoria, Australia compensation claims. BMJ open. 2013;3(3):e002396. doi: 10.1136/bmjopen-2012-002396.
6) Cherry NM, Sithole F, Beach JR, et al. Second WCB claims: who is at risk? Canadian Journal of Public Health/Revue Canadienne de Sante'e Publique. 2010:S53-S7.
7) Verhagen EA, Bay K. Optimising ankle sprain prevention: a critical review and practical appraisal of the literature. Br J Sports Med. 2010;44(15):1082-8. doi: 10.1136/bjsm.2010.076406.
8) Harcombe H, Derrett S, Samaranayaka A, et al. Factors predictive of subsequent injury in a longitudinal cohort study. Inj Prev. 2014;20(6):393-400. doi: 10.1136/injuryprev-2014-041183.
9) Harcombe H, Davie G, Wyeth E, et al. Predictors of severe or multiple subsequent injuries over 24 months among an already-injured cohort in New Zealand. Injury. 2020;51(3):620-7. doi: 10.1016/j.injury.2019.12.038.
10) Harcombe H, Richardson AE, Wyeth EH, et al. Preventing subsequent injury: Healthcare providers' perspectives on untapped potential. Injury. 2022;53(3):953-8. doi: 10.1016/j.injury.2021.11.029.
11) Sandelowski M. Whatever happened to qualitative description? Res Nurs Health. 2000;23(4):334-40.
12) Braun V, Clarke V. Successful qualitative research: A practical guide for beginners London: Sage; 2013.
13) NVivo qualitative data analysis Software; QSR International Pty Ltd. Version 12. 2018.
14) Fineberg HV. The paradox of disease prevention: celebrated in principle, resisted in practice. JAMA. 2013;310(1):85-90. doi: 10.1001/jama.2013.7518.
15) Aldoory L, Bonzo S. Using communication theory in injury prevention campaigns. Injury Prevention. 2005;11(5):260-3. doi: 10.1136/ip.2004.007104.
16) Haddon W, Jr. Advances in the epidemiology of injuries as a basis for public policy. Public Health Rep. 1980;95(5):411-21.
17) Physiotherapy Board of New Zealand. General scope of practice: physiotherapist. 2022. Available from: https://www.physioboard.org.nz/i-am-registered/scopes-of-practice.
18) American College of Emergency Physicians. Role of the emergency physician in injury prevention and control for adult and pediatric patients. Ann Emerg Med. 2008;52(5):594-5. doi: 10.1016/j.annemergmed.2008.08.017.
19) Lee R. A hazardous life - our role in injury prevention. Aust Fam Physician. 2012;41(4):167.
20) Pagan M, Trip H, Burrell B, et al. Wound programmes in residential aged care: a systematic review. Wound Pract Res. 2015;23(2):52-60.
21) New Zealand Ministry of Health – Manatū Hauora. Community Cancer Support Services Pilot Project Evaluation. Wellington; 2011. Available from: https://www.health.govt.nz/publication/community-cancer-support-services-pilot-project-evaluation.
22) American Trauma Society. 2016-2 Trauma centre-based injury prevention initiatives. 2022. Available from: https://www.amtrauma.org/page/PosState162/2016-2-Trauma-Center-Based-Injury-Prevention-Initiatives.htm.
23) Van der Kallen J, Giles M, Cooper K, et al. A fracture prevention service reduces further fractures two years after incident minimal trauma fracture. Int J Rheum Dis. 2014;17(2):195-203. doi: 10.1111/1756-185X.12101.
24) New Zealand Ministry of Health – Manatū Hauora, Accident Compensation Corporation. Injury-related Health Loss: A report from the New Zealand Burden of Diseases, Injuries and Risk Factors Study 2006-2016. Wellington: Ministry of Health; 2013. Available from: https://www.moh.govt.nz/notebook/nbbooks.nsf/0/C62EF09112754AFACC257BD30072F245/$file/injury-related-health-loss-aug13.pdf.
25) Derrett S, Wilson S, Samaranayaka A, et al. Prevalence and predictors of disability 24-months after injury for hospitalised and non-hospitalised participants: results from a longitudinal cohort study in New Zealand. PLoS One. 2013;8(11):e80194. doi: 10.1371/journal.pone.0080194.
26) Maclennan B, Wyeth E, Davie G, et al. Twelve-month post-injury outcomes for Maori and non-Maori: findings from a New Zealand cohort study. Aust N Z J Public Health. 2014;38(3):227-33. doi: 10.1111/1753-6405.
27) Wyeth E, Lambert M, Samaranayaka A, et al. Subsequent injuries experienced by Maori: results from a 24-month prospective study in New Zealand. N Z Med J. 2019 Jul 26;132(1499):23-35.
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Opportunities for preventing subsequent injuries: a qualitative study exploring perspectives of people who have experienced injuries
View Article PDF
People can experience multiple injury events over time. Preventing subsequent injuries (not necessarily the same type or cause as an index injury) is one way to reduce the overall burden of injury which is considerable, comprising 10% of the disability burden globally.[[1]] The financial burden is also high with injury claims costing the Accident Compensation Corporation (ACC, New Zealand’s universal no-fault injury insurer) $5.2 billion NZD in 2020/21.[[2]] The incidence of subsequent injuries is substantial, making it an important and specific contributor to this burden. In a previous study, 38% of participants had >1 subsequent injury claim in the 12 months following an ACC entitlement claim (involving compensation for >1 week off work or other rehabilitation assistance); by 24 months this had risen to 58%.[[3]] Other studies examining specific injury types,[[4]] or population groups such as workers,[[5,6]] also report a high incidence of subsequent injury.
Importantly, when someone is injured, there may be an opportunity to intervene to prevent subsequent injuries. For specific injury types, particular techniques or treatments may reduce re-injury, e.g., neuromuscular training among those presenting with an ankle sprain helping prevent future ankle sprains.[[7]] Previously, a range of predictors of subsequent injuries (of any type) have been reported among a general injury population.[[8,9]] Factors associated with an increased risk of subsequent injury included the index injury being caused by assault,[[8]] having >2 chronic health conditions,[[9]] and having a prior injury affecting them.[[9]] While knowledge of these factors may inform targeted prevention initiatives, the nature of initiatives to address such factors may warrant a wide-ranging approach. A recent study has examined the prevention of subsequent injuries from the perspectives of healthcare providers.[[10]] However, it is also vitally important to also consider the perspectives of people who have experienced subsequent injuries. This study aims to examine opportunities for subsequent injury prevention from the perspectives of people who have recently experienced subsequent injury events.
Methods
This qualitative descriptive study[[11]] recruited participants via advertising on community noticeboards and healthcare provider clinics. Potential participants were required to be aged >18 years and to have had >2 injury events requiring some form of treatment in the previous 12 months. Participation involved an individual face-to-face semi-structured interview conducted by AR, who is experienced in conducting qualitative interviews. The interview guide included questions about opportunities for subsequent injury prevention, as well as about actions health professionals could take to prevent subsequent injuries for their patients. Participants received a $20 NZD voucher.
Interviews were audio-recorded, transcribed verbatim and then thematic analysis was undertaken.[[12]] Initially AR and HH independently developed a draft coding framework based on two interview transcripts. These were discussed with the wider research team to determine a final coding framework that was applied to four transcripts independently by AR and HH. Coding was compared and discrepancies discussed and resolved. The framework was applied to the remaining transcripts by AR. Analyses were carried out using NVivo 12 software.[[13]] Ethical approval was obtained through the University of Otago Human Research Ethics Committee (Health) (H19/034).
Results
Sixteen interviews were completed, lasting between 23–56 minutes. The majority of participants (n=12) were aged 18–30 years; 12 were female and the majority (n=11) reported sole New Zealand European ethnicity. Participants had experienced a range of injuries including fractures, sprains, low back injuries and concussion.
Participants held a variety of views about subsequent injury prevention. Ideas ranged from asserting that individuals were primarily responsible for preventing their own subsequent injuries, to healthcare providers having a key role in preventing subsequent injuries. Others discussed broader societal and environmental aspects. Potential opportunities have therefore been categorised for discussion as: 1) the individual who has experienced an injury, 2) healthcare providers, 3) healthcare systems and processes, and 4) environments and broader contexts.
The individual who has experienced an injury
Attention to subsequent injury prevention
Some participants recognised that they themselves were not always focused on subsequent injury prevention. A lack of attention occurred particularly when people were busy, had other priorities/competing demands or when they were fatigued or distracted (Quote[Q]1, Table 1). Increased awareness of injury prevention and the consequences of actions was recommended (Q2). However, even when people were aware of prevention strategies, these were not always remembered, and it was suggested it could be beneficial to ensure that prevention advice is visible at times when people are undertaking activities that may cause injury (Q3).
Modification of activity
The idea was raised that to prevent subsequent injuries people could sometimes better recognise their own limits and be willing to not undertake activities/tasks beyond their capabilities (Q4). Correspondingly, there could be increased acceptance of individual’s limitations from others (Q5). It was also noted that sometimes people felt they had to, or wanted to, continue with their activities, regardless of injury risk (Q6). A balance between reducing or modifying particular activities to prevent injury and a desire not to restrict activities were also raised (Q7). A desire to know about a range of options for activity was expressed (Q8).
Motivation
Persisting with rehabilitation to prevent subsequent injuries was recommended (Q9); however, it was also noted that people might not be motivated to carry out prevention strategies when benefits may not be immediately obvious (Q10). The nature and severity of the presenting injury and possible consequences were noted to affect injury prevention motivation (Q11).
Attitudes
Overarching attitudes towards injury and injury prevention could also potentially influence subsequent injury prevention with some feeling that injuries “could happen to anyone” (Participant[P]10), while another participant raised that sometimes people would not expect that they would be injured (Q12). The idea was raised that subsequent injury prevention may be dependent on people’s attitudes towards the severity of their presenting injury, and that attitudes could vary between people (Q13). Participants noted that negative attitudes towards preventive equipment could be problematic when this was an optional requirement, or when requirements changed over time (Q14, Q15).
View Tables 1–4.
Healthcare providers
Focus on subsequent injury prevention
Having healthcare providers specifically focus on preventing subsequent injuries, as well as treating the presenting injury, was felt by some to be an important opportunity (Q1, Table 2). However, this did not always occur (Q2), with a lack of time perceived as a potential contributor (Q3, Q4). Participants noted they did not necessarily know, or think about, preventing subsequent injuries themselves and such information from healthcare providers would be useful (Q5–7).
Relationships/rapport
While interactions with healthcare providers were noted as offering opportunities for preventing subsequent injuries, having a good relationship/rapport between healthcare providers and the person injured was felt to be critical. With good rapport it was suggested those injured might be more likely to be open with their provider, enabling the provider to have a better understanding of the underlying cause of injury. Alongside this, it was felt important that providers took time to get to know the person and their injury to tailor their approach to that person (Q8–10) including gaining an understanding of their attitude towards preventing subsequent injuries (Q11). Good rapport could also mean that people may be more inclined to listen to advice and recommendations from healthcare providers (Q12). Ensuring healthcare providers were not perceived as judgemental was raised as important for helping people access healthcare for their injuries (Q13).
Providing alternatives and taking a proactive approach
Rather than taking a didactic approach, providing people with alternative activities for the rehabilitation/recovery phase was felt important (Q14). Healthcare providers proactively offering support and referring people to other appropriate healthcare providers was also raised as an opportunity for subsequent injury prevention (Q15).
Healthcare systems and processes
To facilitate healthcare provider actions focused on preventing subsequent injuries, a range of aspects relating to healthcare systems and processes were discussed.
Time
Increasing healthcare appointment length was raised as enabling an increased focus on prevention (Q1, Table 3). Correspondingly, increasing the number of healthcare professionals was also mentioned (Q2).
Specific proactive approaches
A targeted focus on those with multiple injury events was suggested (Q3). One idea was that people experiencing multiple injury events could automatically be connected with healthcare providers to help prevent subsequent injuries (Q4). Routinely asking people questions about whether they might need to see an allied health professional within healthcare settings, such as emergency departments (EDs), was also suggested (Q5, Q6). Ensuring people are aware of the resources and supports they may be able to access following an injury was discussed (Q7, Q8), as well as ensuring timely access to equipment (Q9). It was suggested there could be a dedicated person within hospitals to ensure people have the required equipment and other injury prevention aspects in place prior to discharge, as a way of helping prevent subsequent injuries (Q10). It was also suggested that a range of healthcare providers could provide subsequent injury prevention advice (Q11).
Costs
One participant suggested that if people had to pay for their treatment, if the same injury was occurring multiple times, they might have fewer similar injuries (Q12). However, costs of seeing healthcare providers were also noted as barriers to treatment, with people not completing their rehabilitation negatively impacting on subsequent injury prevention (Q13).
Resources
It was suggested that resources communicating information about preventing subsequent injuries could be provided through a range of approaches, including brochures, posters and websites (Q14); however, these should be engaging and “fun” (P6). It was noted there could potentially be an increase in programmes such as falls prevention programmes and that prevention programmes like these could be advertised across a range of settings e.g., “church groups… or social service agencies” (P13), as well as within healthcare settings, particularly through general practitioner (GP) clinics (Q15).
Environments and broader aspects
Social support
Family and social supports were highlighted as being of particular importance following injury, and specifically in helping prevent subsequent injury (Q1, Q2, Table 4). There could potentially be an opportunity for providing funded support if people did not have adequate social support (Q3). Support was noted to provide both practical support such as assisting with tasks, as well as emotional support. Correspondingly, the idea of the importance of mental health in injury prevention was also raised (Q4).
Financial aspects
Participants noted that people’s financial situations could mean they returned to work earlier than they should, and that providing adequate financial assistance was an opportunity for subsequent injury prevention (Q5). Cost was noted as a barrier to some prevention activities, such as accessing community facilities like gyms and pools (Q6) and obtaining safety equipment (Q7). Accessibility issues were not just limited to costs, however, with other practical issues such as transport and parking also noted.
Broader environments
Opportunities to prevent subsequent injuries through modification of built environments included addressing slippery and hazardous surfaces and ensuring good lighting (Q8). Opportunities for other settings were also raised e.g., implementing injury prevention education in schools. Gyms were noted as a setting where there may be opportunities to make people aware of injury prevention e.g., by having proactive staff and information available. This also aligned with a recommendation that information (e.g., brochures) about injury prevention be provided in non-clinical settings (Q9). However, others raised the idea that although they felt gyms and other facilities had a certain level of responsibility for prevention, there was also a degree of individual responsibility required in such spaces (Q10). The idea was raised that there could be a targeted approach focusing on high-risk sports (Q11) or among particular population groups, such as the elderly (Q12).
Work environment
The importance of work settings was highlighted, with it noted that work is where many people spend a lot of time (Q13). The idea was raised that there seemed to be an increased awareness and focus on health and safety compared to the past. Participants appreciated employers taking “a proactive approach” (P11) and felt health and safety inductions were important (Q14). An opportunity to prevent subsequent injury in the workplace included adequate staffing levels. This aligns with ideas raised about allowing staff adequate breaks (Q15) and adequate time to carry out work tasks (Q16). The enforcement of health and safety at work was also considered important for subsequent injury prevention (Q17).
Discussion
This study has explored potential opportunities for subsequent injury prevention from the perspectives of people who have had multiple injury events. Suggestions were broad, ranging from those centred on individuals, those that could be implemented by healthcare providers and within health systems, as well as broader societal and environmental modifications.
As with many preventive actions, participants noted the benefits of such actions are, by their nature (i.e., preventing something from occurring), often not immediately obvious,[[14]] highlighting the importance of effective strategies to enhance people’s motivation with preventive activities. Aspects relating to individuals, such as motivation, attitudes and awareness, underscore the importance of the way that subsequent injury prevention strategies are communicated. Participants noted a range of communication approaches could be utilised. This aligns with previous research advocating that the communication of injury prevention strategies be based on communication theory.[[15]] Suggested guidelines include using a range of media and voices to convey prevention information to reach different groups and populations, focusing on keeping key messages simple and “encouraging the confidence to make change” (p.262).[[15]] Participants noted they were less cognisant of subsequent injury prevention when they were distracted or fatigued highlighting the importance of being cognisant of the underlying principles of injury prevention more broadly, for example the benefits of also employing passive strategies that do not require specific actions by individuals.[[16]]
Participants suggested many potential subsequent injury prevention opportunities in people’s interactions with healthcare providers and one recommendation was that healthcare providers explicitly include subsequent injury prevention as part of their practice. However, to do this, healthcare providers need to have the time to be able incorporate this into their interactions with patients; they need to feel that it is part of their role and they need to have the skills and knowledge to be able to offer appropriate advice and strategies to their patients. While prevention is within the scope of practice of healthcare providers who treat people following injury such as physiotherapists,[[17]] emergency physicians[[18]] and GPs,[[19]] some participants noted that subsequent injury prevention was not part of their interactions with their healthcare provider and noted that time pressures within clinical interactions may be a barrier to incorporating subsequent injury prevention. As well as addressing underlying issues such as staffing shortages which could affect time pressures for healthcare providers, incorporating subsequent injury prevention strategies that are not only effective, but also time-efficient, may facilitate their incorporation into consultations with healthcare providers.
Thinking beyond individuals and individual healthcare providers, a range of health system level opportunities were suggested. Having a process where those injured multiple times were given additional support/attention from healthcare providers was suggested. Correspondingly, it was noted that healthcare providers should consider the injury history of the person and address/examine any potential underlying causes. However, there can be barriers to people obtaining treatment from healthcare providers, such as cost and accessibility issues. Addressing these barriers are important to enable people to complete their full rehabilitation programme, as raised by participants in this study, and previously by healthcare providers.[[10]] Having someone within healthcare settings dedicated to injury prevention was recommended. Having a dedicated injury prevention champion is not routine in New Zealand healthcare settings although champions have been recommended in specific areas, such as wound care in aged care facilities,[[20]] and healthcare navigators have been used in areas such as cancer care.[[21]] Internationally, trauma prevention co-ordinators are mandatory in some places such as trauma centres in the US, with these centres also required to undertake injury prevention activities.[[22]] The involvement of a range of healthcare professionals in subsequent injury prevention in different settings was recommended in this study. One suggestion was that a question about whether the injured person should see an allied health professional could be routinely included in consultations. Specific programmes incorporating a range of healthcare providers have been found to reduce subsequent injuries. For example, in Australia, people attending a fracture prevention clinic following a minimal trauma fracture ED presentation were found to have fewer subsequent fractures over the next 24 months.[[23]] This clinic was co-ordinated by a fracture prevention nurse and involved a rheumatologist and referral to a falls prevention clinic or other relevant programmes as necessary.[[23]]
While actions at the level of individuals and within the health system are important, as noted by participants, wider societal/environmental/policy opportunities are also important. Ensuring that people have adequate social support following an injury is something that participants recommended. This aligns with findings of a previous study examining the perspectives of healthcare providers,[[10]] and may be something they could examine in their consultations with injured people. However, there also needs to be processes in place for healthcare professionals to be able to refer people to appropriate places/services if this is to be accompanied by action. In addition to social support being important for subsequent injury prevention, the reach of some interventions provided following injury may also extend beyond the individual who has been injured to those providing social support such as family, friends and colleagues. It was noted that continued cognisance of injury prevention opportunities within the built and natural environment for councils and town planners is also important for subsequent injury prevention.
A strength of this study it that it has considered opportunities for subsequent injury prevention from the perspectives of people who themselves have experienced multiple injury events. However, the study had a small sample, and although participants included a range of ages and ethnicities, most were female, aged between 18–30 years, and none were Māori. It is important that all these perspectives are considered in the development of any future interventions. In particular, it is important that future research and intervention development ensures the perspectives of Māori are included. Māori experience greater injury-related health loss[[24]] and poorer outcomes following injury compared to non-Māori.[[25,26]] Subsequent injuries occur frequently with a previous study of 566 Māori who had injury involving an ACC entitlement claim reporting that 62% had at least one subsequent injury ACC claim in 24 months.[[27]] In addition, this study has examined subsequent injury prevention opportunities in general rather than focusing on a specific injury type, severity or mechanism of injury. Particular injury types or mechanisms may have specific prevention opportunities that are important, however, such as examining specific injury types, severities or mechanisms was not within the scope of this study.
A range of potential opportunities to prevent subsequent injuries have been suggested. Importantly, these are from the perspectives of those who could directly benefit from such interventions—people who have experienced multiple injury events. While there would be a financial cost to implement some of the suggested interventions, the costs (financial and otherwise) of subsequent injuries are high, not only for individuals but also for wider society. Future research to trial interventions suggested in this research is warranted to determine their feasibility and effectiveness.
Summary
Abstract
Aim
This study aims to examine opportunities for subsequent injury prevention from the perspectives of people who have recently experienced subsequent injury events.
Method
This qualitative study involved individual semi-structured interviews with people who had >2 injury events in the previous 12 months. Interviews were audio-recorded, transcribed verbatim and thematic analysis undertaken.
Results
Sixteen interviews were completed with participants who had experienced a range of index and subsequent injury types. Potential opportunities raised were wide-ranging. Some related to individuals, e.g., motivation to carry out prevention strategies. Other opportunities were related to healthcare providers and the health system. For instance, increasing consultation times to allow a focus on subsequent injury prevention, building rapport and tailoring their approach to the individual, proactively referring people to a range of healthcare providers, and ensuring people are aware of resources and supports available following injury. Broader environmental and societal opportunities were also suggested, such as ensuring adequate social support following injury, ensuring accessibility to rehabilitation and community facilities and the modification of built environments.
Conclusion
A broad range of potential opportunities to prevent subsequent injuries were raised. These opportunities are promising and future research to trial interventions raised in this study is warranted to determine their feasibility and effectiveness.
Author Information
Acknowledgements
Correspondence
Correspondence Email
Competing Interests
1) Haagsma JA, Graetz N, Bolliger I, et al. The global burden of injury: incidence, mortality, disability-adjusted life years and time trends from the Global Burden of Disease study 2013. Inj Prev. 2016;22(1):3-18. doi: 10.1136/injuryprev-2015-041616.
2) Accident Compensation Corporation. Pūrongo-a-tau Annual report [Internet}. Wellington, New Zealand: The Accident Compensation Corporation; 2021. Available from: https://www.acc.co.nz/assets/Annual-report-segments/ACC8278-Annual-Report-2021.pdf.
3) Harcombe H, Davie G, Wyeth E, et al. Injury upon injury: a prospective cohort study examining subsequent injury claims in the 24 months following a substantial injury. Inj Prev. 2018;24(6):437-44. doi: 10.1136/injuryprev-2017-042467.
4) de Visser HM, Reijman M, Heijboer MP, et al. Risk factors of recurrent hamstring injuries: a systematic review. Br J Sports Med. 2012;46(2):124-30. doi: 10.1136/bjsports-2011-090317.
5) Ruseckaite R, Collie A. The incidence and impact of recurrent workplace injury and disease: a cohort study of WorkSafe Victoria, Australia compensation claims. BMJ open. 2013;3(3):e002396. doi: 10.1136/bmjopen-2012-002396.
6) Cherry NM, Sithole F, Beach JR, et al. Second WCB claims: who is at risk? Canadian Journal of Public Health/Revue Canadienne de Sante'e Publique. 2010:S53-S7.
7) Verhagen EA, Bay K. Optimising ankle sprain prevention: a critical review and practical appraisal of the literature. Br J Sports Med. 2010;44(15):1082-8. doi: 10.1136/bjsm.2010.076406.
8) Harcombe H, Derrett S, Samaranayaka A, et al. Factors predictive of subsequent injury in a longitudinal cohort study. Inj Prev. 2014;20(6):393-400. doi: 10.1136/injuryprev-2014-041183.
9) Harcombe H, Davie G, Wyeth E, et al. Predictors of severe or multiple subsequent injuries over 24 months among an already-injured cohort in New Zealand. Injury. 2020;51(3):620-7. doi: 10.1016/j.injury.2019.12.038.
10) Harcombe H, Richardson AE, Wyeth EH, et al. Preventing subsequent injury: Healthcare providers' perspectives on untapped potential. Injury. 2022;53(3):953-8. doi: 10.1016/j.injury.2021.11.029.
11) Sandelowski M. Whatever happened to qualitative description? Res Nurs Health. 2000;23(4):334-40.
12) Braun V, Clarke V. Successful qualitative research: A practical guide for beginners London: Sage; 2013.
13) NVivo qualitative data analysis Software; QSR International Pty Ltd. Version 12. 2018.
14) Fineberg HV. The paradox of disease prevention: celebrated in principle, resisted in practice. JAMA. 2013;310(1):85-90. doi: 10.1001/jama.2013.7518.
15) Aldoory L, Bonzo S. Using communication theory in injury prevention campaigns. Injury Prevention. 2005;11(5):260-3. doi: 10.1136/ip.2004.007104.
16) Haddon W, Jr. Advances in the epidemiology of injuries as a basis for public policy. Public Health Rep. 1980;95(5):411-21.
17) Physiotherapy Board of New Zealand. General scope of practice: physiotherapist. 2022. Available from: https://www.physioboard.org.nz/i-am-registered/scopes-of-practice.
18) American College of Emergency Physicians. Role of the emergency physician in injury prevention and control for adult and pediatric patients. Ann Emerg Med. 2008;52(5):594-5. doi: 10.1016/j.annemergmed.2008.08.017.
19) Lee R. A hazardous life - our role in injury prevention. Aust Fam Physician. 2012;41(4):167.
20) Pagan M, Trip H, Burrell B, et al. Wound programmes in residential aged care: a systematic review. Wound Pract Res. 2015;23(2):52-60.
21) New Zealand Ministry of Health – Manatū Hauora. Community Cancer Support Services Pilot Project Evaluation. Wellington; 2011. Available from: https://www.health.govt.nz/publication/community-cancer-support-services-pilot-project-evaluation.
22) American Trauma Society. 2016-2 Trauma centre-based injury prevention initiatives. 2022. Available from: https://www.amtrauma.org/page/PosState162/2016-2-Trauma-Center-Based-Injury-Prevention-Initiatives.htm.
23) Van der Kallen J, Giles M, Cooper K, et al. A fracture prevention service reduces further fractures two years after incident minimal trauma fracture. Int J Rheum Dis. 2014;17(2):195-203. doi: 10.1111/1756-185X.12101.
24) New Zealand Ministry of Health – Manatū Hauora, Accident Compensation Corporation. Injury-related Health Loss: A report from the New Zealand Burden of Diseases, Injuries and Risk Factors Study 2006-2016. Wellington: Ministry of Health; 2013. Available from: https://www.moh.govt.nz/notebook/nbbooks.nsf/0/C62EF09112754AFACC257BD30072F245/$file/injury-related-health-loss-aug13.pdf.
25) Derrett S, Wilson S, Samaranayaka A, et al. Prevalence and predictors of disability 24-months after injury for hospitalised and non-hospitalised participants: results from a longitudinal cohort study in New Zealand. PLoS One. 2013;8(11):e80194. doi: 10.1371/journal.pone.0080194.
26) Maclennan B, Wyeth E, Davie G, et al. Twelve-month post-injury outcomes for Maori and non-Maori: findings from a New Zealand cohort study. Aust N Z J Public Health. 2014;38(3):227-33. doi: 10.1111/1753-6405.
27) Wyeth E, Lambert M, Samaranayaka A, et al. Subsequent injuries experienced by Maori: results from a 24-month prospective study in New Zealand. N Z Med J. 2019 Jul 26;132(1499):23-35.
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Opportunities for preventing subsequent injuries: a qualitative study exploring perspectives of people who have experienced injuries
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People can experience multiple injury events over time. Preventing subsequent injuries (not necessarily the same type or cause as an index injury) is one way to reduce the overall burden of injury which is considerable, comprising 10% of the disability burden globally.[[1]] The financial burden is also high with injury claims costing the Accident Compensation Corporation (ACC, New Zealand’s universal no-fault injury insurer) $5.2 billion NZD in 2020/21.[[2]] The incidence of subsequent injuries is substantial, making it an important and specific contributor to this burden. In a previous study, 38% of participants had >1 subsequent injury claim in the 12 months following an ACC entitlement claim (involving compensation for >1 week off work or other rehabilitation assistance); by 24 months this had risen to 58%.[[3]] Other studies examining specific injury types,[[4]] or population groups such as workers,[[5,6]] also report a high incidence of subsequent injury.
Importantly, when someone is injured, there may be an opportunity to intervene to prevent subsequent injuries. For specific injury types, particular techniques or treatments may reduce re-injury, e.g., neuromuscular training among those presenting with an ankle sprain helping prevent future ankle sprains.[[7]] Previously, a range of predictors of subsequent injuries (of any type) have been reported among a general injury population.[[8,9]] Factors associated with an increased risk of subsequent injury included the index injury being caused by assault,[[8]] having >2 chronic health conditions,[[9]] and having a prior injury affecting them.[[9]] While knowledge of these factors may inform targeted prevention initiatives, the nature of initiatives to address such factors may warrant a wide-ranging approach. A recent study has examined the prevention of subsequent injuries from the perspectives of healthcare providers.[[10]] However, it is also vitally important to also consider the perspectives of people who have experienced subsequent injuries. This study aims to examine opportunities for subsequent injury prevention from the perspectives of people who have recently experienced subsequent injury events.
Methods
This qualitative descriptive study[[11]] recruited participants via advertising on community noticeboards and healthcare provider clinics. Potential participants were required to be aged >18 years and to have had >2 injury events requiring some form of treatment in the previous 12 months. Participation involved an individual face-to-face semi-structured interview conducted by AR, who is experienced in conducting qualitative interviews. The interview guide included questions about opportunities for subsequent injury prevention, as well as about actions health professionals could take to prevent subsequent injuries for their patients. Participants received a $20 NZD voucher.
Interviews were audio-recorded, transcribed verbatim and then thematic analysis was undertaken.[[12]] Initially AR and HH independently developed a draft coding framework based on two interview transcripts. These were discussed with the wider research team to determine a final coding framework that was applied to four transcripts independently by AR and HH. Coding was compared and discrepancies discussed and resolved. The framework was applied to the remaining transcripts by AR. Analyses were carried out using NVivo 12 software.[[13]] Ethical approval was obtained through the University of Otago Human Research Ethics Committee (Health) (H19/034).
Results
Sixteen interviews were completed, lasting between 23–56 minutes. The majority of participants (n=12) were aged 18–30 years; 12 were female and the majority (n=11) reported sole New Zealand European ethnicity. Participants had experienced a range of injuries including fractures, sprains, low back injuries and concussion.
Participants held a variety of views about subsequent injury prevention. Ideas ranged from asserting that individuals were primarily responsible for preventing their own subsequent injuries, to healthcare providers having a key role in preventing subsequent injuries. Others discussed broader societal and environmental aspects. Potential opportunities have therefore been categorised for discussion as: 1) the individual who has experienced an injury, 2) healthcare providers, 3) healthcare systems and processes, and 4) environments and broader contexts.
The individual who has experienced an injury
Attention to subsequent injury prevention
Some participants recognised that they themselves were not always focused on subsequent injury prevention. A lack of attention occurred particularly when people were busy, had other priorities/competing demands or when they were fatigued or distracted (Quote[Q]1, Table 1). Increased awareness of injury prevention and the consequences of actions was recommended (Q2). However, even when people were aware of prevention strategies, these were not always remembered, and it was suggested it could be beneficial to ensure that prevention advice is visible at times when people are undertaking activities that may cause injury (Q3).
Modification of activity
The idea was raised that to prevent subsequent injuries people could sometimes better recognise their own limits and be willing to not undertake activities/tasks beyond their capabilities (Q4). Correspondingly, there could be increased acceptance of individual’s limitations from others (Q5). It was also noted that sometimes people felt they had to, or wanted to, continue with their activities, regardless of injury risk (Q6). A balance between reducing or modifying particular activities to prevent injury and a desire not to restrict activities were also raised (Q7). A desire to know about a range of options for activity was expressed (Q8).
Motivation
Persisting with rehabilitation to prevent subsequent injuries was recommended (Q9); however, it was also noted that people might not be motivated to carry out prevention strategies when benefits may not be immediately obvious (Q10). The nature and severity of the presenting injury and possible consequences were noted to affect injury prevention motivation (Q11).
Attitudes
Overarching attitudes towards injury and injury prevention could also potentially influence subsequent injury prevention with some feeling that injuries “could happen to anyone” (Participant[P]10), while another participant raised that sometimes people would not expect that they would be injured (Q12). The idea was raised that subsequent injury prevention may be dependent on people’s attitudes towards the severity of their presenting injury, and that attitudes could vary between people (Q13). Participants noted that negative attitudes towards preventive equipment could be problematic when this was an optional requirement, or when requirements changed over time (Q14, Q15).
View Tables 1–4.
Healthcare providers
Focus on subsequent injury prevention
Having healthcare providers specifically focus on preventing subsequent injuries, as well as treating the presenting injury, was felt by some to be an important opportunity (Q1, Table 2). However, this did not always occur (Q2), with a lack of time perceived as a potential contributor (Q3, Q4). Participants noted they did not necessarily know, or think about, preventing subsequent injuries themselves and such information from healthcare providers would be useful (Q5–7).
Relationships/rapport
While interactions with healthcare providers were noted as offering opportunities for preventing subsequent injuries, having a good relationship/rapport between healthcare providers and the person injured was felt to be critical. With good rapport it was suggested those injured might be more likely to be open with their provider, enabling the provider to have a better understanding of the underlying cause of injury. Alongside this, it was felt important that providers took time to get to know the person and their injury to tailor their approach to that person (Q8–10) including gaining an understanding of their attitude towards preventing subsequent injuries (Q11). Good rapport could also mean that people may be more inclined to listen to advice and recommendations from healthcare providers (Q12). Ensuring healthcare providers were not perceived as judgemental was raised as important for helping people access healthcare for their injuries (Q13).
Providing alternatives and taking a proactive approach
Rather than taking a didactic approach, providing people with alternative activities for the rehabilitation/recovery phase was felt important (Q14). Healthcare providers proactively offering support and referring people to other appropriate healthcare providers was also raised as an opportunity for subsequent injury prevention (Q15).
Healthcare systems and processes
To facilitate healthcare provider actions focused on preventing subsequent injuries, a range of aspects relating to healthcare systems and processes were discussed.
Time
Increasing healthcare appointment length was raised as enabling an increased focus on prevention (Q1, Table 3). Correspondingly, increasing the number of healthcare professionals was also mentioned (Q2).
Specific proactive approaches
A targeted focus on those with multiple injury events was suggested (Q3). One idea was that people experiencing multiple injury events could automatically be connected with healthcare providers to help prevent subsequent injuries (Q4). Routinely asking people questions about whether they might need to see an allied health professional within healthcare settings, such as emergency departments (EDs), was also suggested (Q5, Q6). Ensuring people are aware of the resources and supports they may be able to access following an injury was discussed (Q7, Q8), as well as ensuring timely access to equipment (Q9). It was suggested there could be a dedicated person within hospitals to ensure people have the required equipment and other injury prevention aspects in place prior to discharge, as a way of helping prevent subsequent injuries (Q10). It was also suggested that a range of healthcare providers could provide subsequent injury prevention advice (Q11).
Costs
One participant suggested that if people had to pay for their treatment, if the same injury was occurring multiple times, they might have fewer similar injuries (Q12). However, costs of seeing healthcare providers were also noted as barriers to treatment, with people not completing their rehabilitation negatively impacting on subsequent injury prevention (Q13).
Resources
It was suggested that resources communicating information about preventing subsequent injuries could be provided through a range of approaches, including brochures, posters and websites (Q14); however, these should be engaging and “fun” (P6). It was noted there could potentially be an increase in programmes such as falls prevention programmes and that prevention programmes like these could be advertised across a range of settings e.g., “church groups… or social service agencies” (P13), as well as within healthcare settings, particularly through general practitioner (GP) clinics (Q15).
Environments and broader aspects
Social support
Family and social supports were highlighted as being of particular importance following injury, and specifically in helping prevent subsequent injury (Q1, Q2, Table 4). There could potentially be an opportunity for providing funded support if people did not have adequate social support (Q3). Support was noted to provide both practical support such as assisting with tasks, as well as emotional support. Correspondingly, the idea of the importance of mental health in injury prevention was also raised (Q4).
Financial aspects
Participants noted that people’s financial situations could mean they returned to work earlier than they should, and that providing adequate financial assistance was an opportunity for subsequent injury prevention (Q5). Cost was noted as a barrier to some prevention activities, such as accessing community facilities like gyms and pools (Q6) and obtaining safety equipment (Q7). Accessibility issues were not just limited to costs, however, with other practical issues such as transport and parking also noted.
Broader environments
Opportunities to prevent subsequent injuries through modification of built environments included addressing slippery and hazardous surfaces and ensuring good lighting (Q8). Opportunities for other settings were also raised e.g., implementing injury prevention education in schools. Gyms were noted as a setting where there may be opportunities to make people aware of injury prevention e.g., by having proactive staff and information available. This also aligned with a recommendation that information (e.g., brochures) about injury prevention be provided in non-clinical settings (Q9). However, others raised the idea that although they felt gyms and other facilities had a certain level of responsibility for prevention, there was also a degree of individual responsibility required in such spaces (Q10). The idea was raised that there could be a targeted approach focusing on high-risk sports (Q11) or among particular population groups, such as the elderly (Q12).
Work environment
The importance of work settings was highlighted, with it noted that work is where many people spend a lot of time (Q13). The idea was raised that there seemed to be an increased awareness and focus on health and safety compared to the past. Participants appreciated employers taking “a proactive approach” (P11) and felt health and safety inductions were important (Q14). An opportunity to prevent subsequent injury in the workplace included adequate staffing levels. This aligns with ideas raised about allowing staff adequate breaks (Q15) and adequate time to carry out work tasks (Q16). The enforcement of health and safety at work was also considered important for subsequent injury prevention (Q17).
Discussion
This study has explored potential opportunities for subsequent injury prevention from the perspectives of people who have had multiple injury events. Suggestions were broad, ranging from those centred on individuals, those that could be implemented by healthcare providers and within health systems, as well as broader societal and environmental modifications.
As with many preventive actions, participants noted the benefits of such actions are, by their nature (i.e., preventing something from occurring), often not immediately obvious,[[14]] highlighting the importance of effective strategies to enhance people’s motivation with preventive activities. Aspects relating to individuals, such as motivation, attitudes and awareness, underscore the importance of the way that subsequent injury prevention strategies are communicated. Participants noted a range of communication approaches could be utilised. This aligns with previous research advocating that the communication of injury prevention strategies be based on communication theory.[[15]] Suggested guidelines include using a range of media and voices to convey prevention information to reach different groups and populations, focusing on keeping key messages simple and “encouraging the confidence to make change” (p.262).[[15]] Participants noted they were less cognisant of subsequent injury prevention when they were distracted or fatigued highlighting the importance of being cognisant of the underlying principles of injury prevention more broadly, for example the benefits of also employing passive strategies that do not require specific actions by individuals.[[16]]
Participants suggested many potential subsequent injury prevention opportunities in people’s interactions with healthcare providers and one recommendation was that healthcare providers explicitly include subsequent injury prevention as part of their practice. However, to do this, healthcare providers need to have the time to be able incorporate this into their interactions with patients; they need to feel that it is part of their role and they need to have the skills and knowledge to be able to offer appropriate advice and strategies to their patients. While prevention is within the scope of practice of healthcare providers who treat people following injury such as physiotherapists,[[17]] emergency physicians[[18]] and GPs,[[19]] some participants noted that subsequent injury prevention was not part of their interactions with their healthcare provider and noted that time pressures within clinical interactions may be a barrier to incorporating subsequent injury prevention. As well as addressing underlying issues such as staffing shortages which could affect time pressures for healthcare providers, incorporating subsequent injury prevention strategies that are not only effective, but also time-efficient, may facilitate their incorporation into consultations with healthcare providers.
Thinking beyond individuals and individual healthcare providers, a range of health system level opportunities were suggested. Having a process where those injured multiple times were given additional support/attention from healthcare providers was suggested. Correspondingly, it was noted that healthcare providers should consider the injury history of the person and address/examine any potential underlying causes. However, there can be barriers to people obtaining treatment from healthcare providers, such as cost and accessibility issues. Addressing these barriers are important to enable people to complete their full rehabilitation programme, as raised by participants in this study, and previously by healthcare providers.[[10]] Having someone within healthcare settings dedicated to injury prevention was recommended. Having a dedicated injury prevention champion is not routine in New Zealand healthcare settings although champions have been recommended in specific areas, such as wound care in aged care facilities,[[20]] and healthcare navigators have been used in areas such as cancer care.[[21]] Internationally, trauma prevention co-ordinators are mandatory in some places such as trauma centres in the US, with these centres also required to undertake injury prevention activities.[[22]] The involvement of a range of healthcare professionals in subsequent injury prevention in different settings was recommended in this study. One suggestion was that a question about whether the injured person should see an allied health professional could be routinely included in consultations. Specific programmes incorporating a range of healthcare providers have been found to reduce subsequent injuries. For example, in Australia, people attending a fracture prevention clinic following a minimal trauma fracture ED presentation were found to have fewer subsequent fractures over the next 24 months.[[23]] This clinic was co-ordinated by a fracture prevention nurse and involved a rheumatologist and referral to a falls prevention clinic or other relevant programmes as necessary.[[23]]
While actions at the level of individuals and within the health system are important, as noted by participants, wider societal/environmental/policy opportunities are also important. Ensuring that people have adequate social support following an injury is something that participants recommended. This aligns with findings of a previous study examining the perspectives of healthcare providers,[[10]] and may be something they could examine in their consultations with injured people. However, there also needs to be processes in place for healthcare professionals to be able to refer people to appropriate places/services if this is to be accompanied by action. In addition to social support being important for subsequent injury prevention, the reach of some interventions provided following injury may also extend beyond the individual who has been injured to those providing social support such as family, friends and colleagues. It was noted that continued cognisance of injury prevention opportunities within the built and natural environment for councils and town planners is also important for subsequent injury prevention.
A strength of this study it that it has considered opportunities for subsequent injury prevention from the perspectives of people who themselves have experienced multiple injury events. However, the study had a small sample, and although participants included a range of ages and ethnicities, most were female, aged between 18–30 years, and none were Māori. It is important that all these perspectives are considered in the development of any future interventions. In particular, it is important that future research and intervention development ensures the perspectives of Māori are included. Māori experience greater injury-related health loss[[24]] and poorer outcomes following injury compared to non-Māori.[[25,26]] Subsequent injuries occur frequently with a previous study of 566 Māori who had injury involving an ACC entitlement claim reporting that 62% had at least one subsequent injury ACC claim in 24 months.[[27]] In addition, this study has examined subsequent injury prevention opportunities in general rather than focusing on a specific injury type, severity or mechanism of injury. Particular injury types or mechanisms may have specific prevention opportunities that are important, however, such as examining specific injury types, severities or mechanisms was not within the scope of this study.
A range of potential opportunities to prevent subsequent injuries have been suggested. Importantly, these are from the perspectives of those who could directly benefit from such interventions—people who have experienced multiple injury events. While there would be a financial cost to implement some of the suggested interventions, the costs (financial and otherwise) of subsequent injuries are high, not only for individuals but also for wider society. Future research to trial interventions suggested in this research is warranted to determine their feasibility and effectiveness.
Summary
Abstract
Aim
This study aims to examine opportunities for subsequent injury prevention from the perspectives of people who have recently experienced subsequent injury events.
Method
This qualitative study involved individual semi-structured interviews with people who had >2 injury events in the previous 12 months. Interviews were audio-recorded, transcribed verbatim and thematic analysis undertaken.
Results
Sixteen interviews were completed with participants who had experienced a range of index and subsequent injury types. Potential opportunities raised were wide-ranging. Some related to individuals, e.g., motivation to carry out prevention strategies. Other opportunities were related to healthcare providers and the health system. For instance, increasing consultation times to allow a focus on subsequent injury prevention, building rapport and tailoring their approach to the individual, proactively referring people to a range of healthcare providers, and ensuring people are aware of resources and supports available following injury. Broader environmental and societal opportunities were also suggested, such as ensuring adequate social support following injury, ensuring accessibility to rehabilitation and community facilities and the modification of built environments.
Conclusion
A broad range of potential opportunities to prevent subsequent injuries were raised. These opportunities are promising and future research to trial interventions raised in this study is warranted to determine their feasibility and effectiveness.
Author Information
Acknowledgements
Correspondence
Correspondence Email
Competing Interests
1) Haagsma JA, Graetz N, Bolliger I, et al. The global burden of injury: incidence, mortality, disability-adjusted life years and time trends from the Global Burden of Disease study 2013. Inj Prev. 2016;22(1):3-18. doi: 10.1136/injuryprev-2015-041616.
2) Accident Compensation Corporation. Pūrongo-a-tau Annual report [Internet}. Wellington, New Zealand: The Accident Compensation Corporation; 2021. Available from: https://www.acc.co.nz/assets/Annual-report-segments/ACC8278-Annual-Report-2021.pdf.
3) Harcombe H, Davie G, Wyeth E, et al. Injury upon injury: a prospective cohort study examining subsequent injury claims in the 24 months following a substantial injury. Inj Prev. 2018;24(6):437-44. doi: 10.1136/injuryprev-2017-042467.
4) de Visser HM, Reijman M, Heijboer MP, et al. Risk factors of recurrent hamstring injuries: a systematic review. Br J Sports Med. 2012;46(2):124-30. doi: 10.1136/bjsports-2011-090317.
5) Ruseckaite R, Collie A. The incidence and impact of recurrent workplace injury and disease: a cohort study of WorkSafe Victoria, Australia compensation claims. BMJ open. 2013;3(3):e002396. doi: 10.1136/bmjopen-2012-002396.
6) Cherry NM, Sithole F, Beach JR, et al. Second WCB claims: who is at risk? Canadian Journal of Public Health/Revue Canadienne de Sante'e Publique. 2010:S53-S7.
7) Verhagen EA, Bay K. Optimising ankle sprain prevention: a critical review and practical appraisal of the literature. Br J Sports Med. 2010;44(15):1082-8. doi: 10.1136/bjsm.2010.076406.
8) Harcombe H, Derrett S, Samaranayaka A, et al. Factors predictive of subsequent injury in a longitudinal cohort study. Inj Prev. 2014;20(6):393-400. doi: 10.1136/injuryprev-2014-041183.
9) Harcombe H, Davie G, Wyeth E, et al. Predictors of severe or multiple subsequent injuries over 24 months among an already-injured cohort in New Zealand. Injury. 2020;51(3):620-7. doi: 10.1016/j.injury.2019.12.038.
10) Harcombe H, Richardson AE, Wyeth EH, et al. Preventing subsequent injury: Healthcare providers' perspectives on untapped potential. Injury. 2022;53(3):953-8. doi: 10.1016/j.injury.2021.11.029.
11) Sandelowski M. Whatever happened to qualitative description? Res Nurs Health. 2000;23(4):334-40.
12) Braun V, Clarke V. Successful qualitative research: A practical guide for beginners London: Sage; 2013.
13) NVivo qualitative data analysis Software; QSR International Pty Ltd. Version 12. 2018.
14) Fineberg HV. The paradox of disease prevention: celebrated in principle, resisted in practice. JAMA. 2013;310(1):85-90. doi: 10.1001/jama.2013.7518.
15) Aldoory L, Bonzo S. Using communication theory in injury prevention campaigns. Injury Prevention. 2005;11(5):260-3. doi: 10.1136/ip.2004.007104.
16) Haddon W, Jr. Advances in the epidemiology of injuries as a basis for public policy. Public Health Rep. 1980;95(5):411-21.
17) Physiotherapy Board of New Zealand. General scope of practice: physiotherapist. 2022. Available from: https://www.physioboard.org.nz/i-am-registered/scopes-of-practice.
18) American College of Emergency Physicians. Role of the emergency physician in injury prevention and control for adult and pediatric patients. Ann Emerg Med. 2008;52(5):594-5. doi: 10.1016/j.annemergmed.2008.08.017.
19) Lee R. A hazardous life - our role in injury prevention. Aust Fam Physician. 2012;41(4):167.
20) Pagan M, Trip H, Burrell B, et al. Wound programmes in residential aged care: a systematic review. Wound Pract Res. 2015;23(2):52-60.
21) New Zealand Ministry of Health – Manatū Hauora. Community Cancer Support Services Pilot Project Evaluation. Wellington; 2011. Available from: https://www.health.govt.nz/publication/community-cancer-support-services-pilot-project-evaluation.
22) American Trauma Society. 2016-2 Trauma centre-based injury prevention initiatives. 2022. Available from: https://www.amtrauma.org/page/PosState162/2016-2-Trauma-Center-Based-Injury-Prevention-Initiatives.htm.
23) Van der Kallen J, Giles M, Cooper K, et al. A fracture prevention service reduces further fractures two years after incident minimal trauma fracture. Int J Rheum Dis. 2014;17(2):195-203. doi: 10.1111/1756-185X.12101.
24) New Zealand Ministry of Health – Manatū Hauora, Accident Compensation Corporation. Injury-related Health Loss: A report from the New Zealand Burden of Diseases, Injuries and Risk Factors Study 2006-2016. Wellington: Ministry of Health; 2013. Available from: https://www.moh.govt.nz/notebook/nbbooks.nsf/0/C62EF09112754AFACC257BD30072F245/$file/injury-related-health-loss-aug13.pdf.
25) Derrett S, Wilson S, Samaranayaka A, et al. Prevalence and predictors of disability 24-months after injury for hospitalised and non-hospitalised participants: results from a longitudinal cohort study in New Zealand. PLoS One. 2013;8(11):e80194. doi: 10.1371/journal.pone.0080194.
26) Maclennan B, Wyeth E, Davie G, et al. Twelve-month post-injury outcomes for Maori and non-Maori: findings from a New Zealand cohort study. Aust N Z J Public Health. 2014;38(3):227-33. doi: 10.1111/1753-6405.
27) Wyeth E, Lambert M, Samaranayaka A, et al. Subsequent injuries experienced by Maori: results from a 24-month prospective study in New Zealand. N Z Med J. 2019 Jul 26;132(1499):23-35.
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Opportunities for preventing subsequent injuries: a qualitative study exploring perspectives of people who have experienced injuries
People can experience multiple injury events over time. Preventing subsequent injuries (not necessarily the same type or cause as an index injury) is one way to reduce the overall burden of injury which is considerable, comprising 10% of the disability burden globally.
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