Elsevier

Public Health

Volume 128, Issue 7, July 2014, Pages 587-618
Public Health

Review Paper
The impacts of injury at the individual, community and societal levels: a systematic meta-review

https://doi.org/10.1016/j.puhe.2014.04.004Get rights and content

Abstract

Objectives

Injury is a major public health problem. While the impacts of injury on the injured person are well documented, there is relatively little knowledge about the impacts of injury on those individuals and groups in the community connected to the injured person. This study seeks to describe this breadth of research using a meta-review methodology.

Study design

Systematic meta-review.

Methods

To gain a better understanding of the known impacts of injury on family, community and society, a systematic meta-review of injury outcomes research literature was conducted. Seventy-eight peer-reviewed published literature reviews were included in the meta-review.

Results

Of these, 70 reported outcomes at the level of the injured person including mortality, body functions, activity and participation limitations. Nine reviews reported impacts at the level of the community including impacts on family members, work colleagues and carers. Six studies reported impacts at the societal level including economic, health system and injury compensation system impacts.

Conclusions

In summary, the meta-review identified a substantial body of knowledge at the individual level outcomes of injury, and a relative lack of information regarding the community and societal impacts of injury. An injury outcome framework is proposed on the basis of the findings of the meta-review to guide future research activity, particularly with regard to injury outcome domains where there is currently limited evidence. A comprehensive framework that takes account of all levels of impact is necessary for effective policies, systems and strategies to support recovery following injury.

Introduction

There is substantial and robust published literature on the impacts of injury on the injured person including commonly reported outcomes such as mortality,1, 2 morbidity,3 and quality of life.4, 5 These and other impacts have been systematically studied, and form the basis of estimates of injury burden that influence government investment in injury prevention, treatment and rehabilitation programs.6

In contrast, knowledge of the impacts of injury beyond the injured person is relatively sparse. Individual studies suggest that families,7, 8, 9 work colleagues and employers,10 health systems,6 and social services11 are all affected by an injury incurred by another. In other words, injury has a ‘ripple effect’ that can extend far beyond the injured person.12, 13, 14 Despite this knowledge, there have been few systematic attempts to describe these broader impacts. This study seeks to describe this breadth of research using a meta-review methodology.

In the past decade a number of conceptual frameworks that describe the impacts of injury have been established. While some are context specific (e.g., workplace injury12), others attempt to conceptualize and categorize the multidimensional nature of the full injury burden.14, 16 Such frameworks can provide important guidance for public policy development by providing direction and structure to discussions on key issues, through streamlining communication of ideas using a defined framework, providing a medium on which to translate ideas between jurisdictions, and identifying expected outcomes both positive and negative of action or inaction. Frameworks can also inform outcome measurement, and be used to establish a clear understanding of the impact of preventive, treatment and rehabilitation strategies. In the field of injury research, existing frameworks do not sufficiently capture the multidimensional impacts of injury. Some are narrowly focussed and, as such, have substantial depth in one area, but limited breadth. For example, the International Classification of Functioning (ICF) is primarily concerned with impacts on the individual (body structure, body function, activity and participation).14 The ICF framework appears to be an ideal model for conceptualizing the impact of injury in the context of the individual and their direct and indirect network. However, it maintains at every level a focus on the individual, and how that individual is affected rather than the broader impacts at community and societal levels. Similarly, the framework described by Dembe and colleagues is focussed exclusively on the impacts of workplace injury.12 Other frameworks cover multiple domains but fail to incorporate important outcomes in some areas (i.e., they have breadth but lack depth). For example, the List of All Deficits (LOAD) framework describes 20 potential areas of outcome across the three broad domains of the individual, family and societal levels. However, the LOAD framework does not include impacts on co-workers or employers, now recognized as a significant outcome of many injuries.12, 17 This framework has also been developed by expert consensus rather than by systematic capture and analysis of published, peer reviewed research literature. We propose that a systematic approach to the description and capture of injury outcome information is necessary to advance the field.

To address this objective, this study sought to: first, summarize the published research literature in the field of injury outcomes using a meta-review methodology and; second, to describe an injury outcome framework that both captures the impacts of injury arising from the meta-review and is sufficiently flexible to allow extension and elucidation as further research evidence emerges.

Section snippets

Search strategy and selection criteria

The literature search sought to identify peer-reviewed literature reviews describing adolescent and adult injury outcomes. Injury was operationally defined to include cases of harm inflicted on an individual through unintentional (e.g., falls, motor vehicle crash) actions and included both physical (e.g., fracture, soft-tissue injury) and psychological harm (i.e., mental health conditions). Six on-line databases [Medline, Psychinfo, Embase, International Bibliography of Social Sciences (IBSS),

Results

The literature search identified 3178 abstracts. Following application of the inclusion and exclusion criteria, 78 studies were included in the final set for analysis. A summary of the included articles is shown in Table 1. Of the 78 reviews included, there were 32 systematic reviews, 28 narrative reviews and 18 meta-analyses. Six of these studies included information relevant to more than one domain (as noted by an * in Table 2, Table 3, Table 4), and a total of 96 distinct impacts were

Discussion

The results identified that the vast majority of injury outcomes literature identified in this meta-review focused on the impacts of injury on the injured person. More than 83% of included reviews reported individual level impacts including changes in body function, activity, participation and mortality. The remaining literature reported on the community and societal impacts of injury. Literature identified in the individual and community domains was dominated by serious injuries, such as TBI

Practical applications

The study has important implication for the design of injury surveillance systems. Most injury surveillance systems collect data relating to the injured person, but include relatively little information on community and societal factors, despite these factors being substantial predictors of injury outcome. For example, databases used in work-related injury compensation systems collect detailed information on injury type and mechanism, person-specific demographic information such as age, gender

Limitations

The framework is currently limited by its reliance on review papers. In practice, this means that some primary studies that identify outcomes beyond those reported in the review literature have not been included in the draft framework. For example, we did not identify some outcomes in the LOAD framework, such as the development of secondary conditions subsequent to a primary injury. However, as already noted the framework is designed to be extended and revised as this evidence is added, and as

Conclusion

In summary, this meta-review has identified a substantial body of knowledge at the individual level, and a relative lack of information regarding the community and societal impacts of injury. The results have allowed translation of the evidence into an injury outcome framework that provides a foundation for understanding the impacts of injury beyond the injured person. Such information is crucial for effective public policy development and implementation, and for systems and strategies to

Ethical approval

Not required.

Funding

ARC-Linkage project.

Competing interests

None declared.

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