Our study found that the majority of blunt trauma patients continued to report disability three months after hospital discharge. This finding highlights the significant burden disability pose due to injuries on population health of the Kingdom. The prevalence of disability presented here is higher than the findings of other international studies. For example, Kalahroudi et al. found that 55.8% reported disability at three months follow up (Abedzadeh-Kalahroudi et al. 2015). This discrepancy may be due to the differences between the two populations or differences in the instrument to capture disability. A similar finding by holtslag et al. was also reported in the five EQ-5D-5L dimensions of mobility (48%), self-care (18%), daily activities (55%), pain and discomfort (63%), and anxiety or depression (28%) for patients following trauma (Holtslag et al. 2007). It is noteworthy to state that their follow up period was long (between 12–18 months). It was not possible to compare our findings to local studies since none of the previous literature in Saudi Arabia followed patients longitudinally.
The purpose of this study is to determine the impact of family cohesion on the quality of life and disability of patients after blunt trauma. Patients who reported suboptimal family cohesion were less likely to recover in the mobility domain. These results are consistent with Prang et al., where they found that having strong social support from family and friends had a positive impact on physical improvement and return to optimal function after road traffic injury (Prang et al. 2015a). Additionally, Harms et al. reported that having strong social support could affect recovery from injury and reduce the number of related complications (Harms and Talbot 2007). However, our results differ from those of Richmond et.al, where they reported that availability of social support at the time of injury did not reduce disability (Richmond et al. 2003). A possible explanation for this might be the difference in the assessment tools, follow up time, and cultural background.
As stated earlier, family structure in Saudi Arabia may increase reliance on relatives due to several factors, including religious beliefs, large family size, and cultural views (Abdul Salam et al. 2014). The average household size in Saudi Arabia is 6.4, which is large relative to other developed nations (Abdul Salam et al. 2014). However, other studies suggested that social support could have a negative impact by increasing reliance on others and decreasing independence (Turk et al. 1992). More research is needed not only to identify the link between the presence of social support and enhanced resilience after blunt injury but also effective ways through which the provision of social support can enable achieving positive health outcomes.
Our study suggests that patients who have suboptimal family cohesion reported higher depression and anxiety at baseline. After 90 days, depression and anxiety were still significant disabilities among participants who lacked social support. In the literature, the relationship between social support and mental health is well established (Birkeland et al. 2017)(Yaşan et al. 2009)(Thoits 2011). Guest et al. showed that psychological stress had been an essential factor in the recovery of musculoskeletal injuries, and psychological stress has strong ties with a lack of social support (Guest et al. 2017). In addition, Coronas et al. found that social support is associated with the onset of post-traumatic stress disorders after road traffic injuries (Coronas et al. 2008).
The absence of appropriate social support may lead to depression, anxiety. Jansen et al. suggest that having strong social support plays a central role in processing traumatic experiences (Janssen et al. 2008). This is in line with the evidence presented by Charuvastra et al., who reports that the presence of social support results in better emotional control, which in turn diminishes the likelihood of developing post-traumatic stress disorders (Charuvastra and Cloitre 2008). Studies showed that the availability of a social network reduced both physical and psychological disability (Symonette et al. 2013)(Mortimore et al. 2008)(Hilari et al. 2010). These findings may point to the need for early detection and intervention by healthcare personnel, social workers in particular.
The most common cause of trauma in our study was traffic crashes. This is expected since they are the leading cause of trauma admissions in the country. Every year, there are over one million traffic crashes in Saudi Arabia (Alwatan 2015). More importantly, over 86,000 victims died because of crashes in the last two decades (Mansuri et al. 2015). Thus, the government started to invest heavily in traffic safety as part of a nationwide initiative known as Saudi vision 2030(Saudi Vision 2030 2016). One of the most effective preventive measures is the speed camera system, which was implanted in 2010 and was found to reduce mortality and severity of injuries (Alghnam et al. 2017a). Another significant preventive method is the enforcement of road traffic laws such as wearing seat belt law. One study found that seatbelts use ranged between 4%-40% among drivers passengers in Saudi Arabia, which is substantially lower than in developed countries (Bendak 2005).Our findings can facilitate efforts aimed to raise awareness on the effectiveness of adherence to safety measures by highlighting some of the consequences of not following them. Further investment is needed to implement new public health strategies that can reduce the frequency and severity of traffic crashes.
The findings of this study have several important implications for future practice. The high prevalence of disability should guide policymakers to evaluate whether more rehabilitation centers are needed in order to reduce the disability burden in the country. Rehabilitation centers can provide patients with comprehensive recovery programs that focus on improving physical, social, and mental factors. Additionally, this study highlights the need to identify patients with suboptimal social support in order to offer early intervention and reduce the likelihood of long-term disability. These include health home services, psychological counseling, and support groups. Understanding the social determinants of health is a critical step in clinical practice. We suggest that healthcare providers and social workers collaborate to develop interventions that strengthen social support.
There are several limitations to this study that need to be acknowledged. First, this study included a relatively small sample size, which may have affected the power to evaluate all the factors associated with recovery. Only 169 patients out of 249 were reached in the second interview. Those who did not respond could have had worse disability levels, which may underestimate the level of disability presented in this study. Second, the generalizability of these results is limited because it was conducted in a single trauma center. It is also important to highlight that KAMC is one of the few hospitals that provide advanced trauma care nationwide. Thus, we might underestimate the prevalence of disability in the country. Third, the follow-up period was limited to 3 months; therefore, long term disability and recovery were not evaluated. Scarce data exist on the ideal follow-up timeframe of trauma patients. Most trauma survivors appear to recover reasonably quickly as within the first three months, which is why we chose this follow up timeframe (Mitchell et al. 2012). Fourth, our study did not capture pre-existing conditions. Though, our patient population was relatively young, and it is reasonable to assume the prevalence of preexisting conditions was minimal and that it did not differ between the two groups.
Despite limitations, this study has several strengths. It is a prospective study that used a well-validated health status scale to measure QOL with a standardized timeframe of the outcome assessment. To our best knowledge, no previous study has investigated the association of family cohesion on quality of life after trauma in Saudi Arabia.