Independence in activities after injury in humanitarian settings : assessment, change over time and associated factors

Abstract

Background: Injury represents a significant burden in humanitarian settings, overwhelming the limited trauma care resources. Trauma care in these settings mainly focuses on saving lives and limbs, and not on recovery in daily activities. Rehabilitation, including physiotherapy, is often delayed and not systematic. Moreover, the lack of adequate measures of recovery of independence in activities limits the understanding of patients’ needs beyond survival. This thesis aimed at assessing recovery over the first six months after an acute orthopedic, visceral, and/or skin injury in different humanitarian settings, first revising and evaluating a measure of independence in activities, the Activity Independence Measure–Trauma (AIM-T).

Methods: The three studies were conducted in eight health facilities supported or run by Médecins Sans Frontières in humanitarian settings, located in Burundi, Central African Republic, Cameroon, Iraq, Haiti, and Yemen. Study I used routine clinical data to run an inter-item correlation matrix and assess floor and ceiling effects of the initial AIM-T (AIMT1), aiming for a shortened version (AIM-T2). Then, the adequacy of the AIM-T2 was evaluated through semi-structured interviews with patients and healthcare professionals (HCPs), informing additional revisions for AIM-T3. Study II evaluated the construct validity and reliability of the AIM-T3. Study III assessed recovery at four time points (hospital admission, discharge, three and six months after injury), with different measures of recovery, including the AIM-T3. Factors associated with independence in activities (AIMT3) were identified using multivariable logistic regressions for each of three time points (i.e., discharge, three and six months).

Results: In Study I (n=635), the identified redundant AIM-T1 items were removed, leading to AIM-T2. All remaining items were considered adequate by the 60 patients and 23 HCPs interviewed. Some items were revised to improve the adequacy of the content, and one item added to provide AIM-T3. In Study II (n=195), the AIM-T3 construct validity was supported, and inter-rater reliability was found to be good to excellent within a subset of 77 patients. In Study III (n=554), patients improved in all aspects of recovery across the four time points. Factors significantly associated with increased independence at one or several time points were age, type and location of injury, baseline independence and trauma care interventions, including early inpatient physiotherapy.

Conclusions: The AIM-T was considered adequate to assess independence in activities after acute injury in humanitarian settings, and its validity and reliability were supported. The AIM-T has thus potential for use as an indicator of recovery in humanitarian settings. Regarding recovery, most patients still experience difficulties at six months. The association of early physiotherapy with better recovery of independence suggests that physiotherapy may be beneficial and may potentially be a modifiable factor to enhance recovery in humanitarian settings.