Determinants of post-traumatic stress disorder among survivors of road traffic accidents in dessie comprehensive specialized hospital North-East Ethiopia

A facility-based, unmatched case–control study design was carried out in Dessie Comprehensive Specialized Hospital, which is located in Amhara regional state’s South Wollo zone. DCSH is the primary center for RTA injury admission in the South Wollo zone and neighboring zones and regions (Afar). It serves more than 7 million people. The hospital offers different inpatient and outpatient services (preventive, promotive, curative, and rehabilitative health care services). DCSH serves road traffic accident patients as both outpatients and inpatients service. It has emergency services and general management for RTA patients. Due to its geographical location, DCSH has a high burden of road traffic accident patients and serves for referrals from all woredas of South Wollo zone, Afar regional state, and some areas of Oromia zone. DCSH is working together with Wollo University, to advance orthopedic service through the continuous professional development of surgical nurses, intensive care unit (ICU) nurses, orthopedics, neurosurgeon specialization of general practitioners, and psychiatric professionals. DCSH also has mental health treatment wards for both inpatient and outpatient settings. The study was conducted from February 15 to April 25, 2021.

Cases: were RTA survivors who had developed PTSD based on post-traumatic stress disorder checklist edition five (PCL-5) score greater than or equal to 40 (PCL-5 ≥ 40).

Controls: RTA patients without PTSD or PCL-5 score less than 40 (PCL-5 score < 40).

For cases: All RTA patients with PTSD present at DCSH.

For controls: All RTA patients present at DCSH.

For cases; All PTSD patients secondary to RTAs in DCSH during the time of data collection period.

For controls; All RTA patients visited DCSH other than PTSD during the time of data collection period.

Was age at trauma, sex, marital status, educational status, occupation status, family history of mental illness, personal psychiatric history, previous RTA, and medical illness. loss of family/ close friend, presence of bone(s) fracture, loss of property, perceived life-threatening events, witnessed death or serious injury, loss of consciousness (LOC), types of injury, duration since RTA, comorbidity, regular income, intensive care unit (ICU) duration, presence of chronic pain, disability, and social support.

The sample size calculation was done using Epi Info, statistical software, version 7.2.3.1, by considering all the following assumptions; 2.1 odds ratio, a control to case ratio of 2:1, and 17.88% of controls among the exposed group with social support variable, from previous studies done in Addis Ababa, Ethiopia [16]. There was an accepted error of 5%, a power of 80%, and a 95% confidence level. The sample size obtained considering the above assumptions was 381 (127 for cases and 254 for controls). Adding 10% non-response rate, the total sample size was 419, which is 139 cases and 280 controls.

Among orthopedic patient charts registration, a total of 512 RTA survivors were listed out, then prepared sampled attendants’ sheets, which give a sampling frame, from both inpatients and patients who had been appointed for follow-up services during the data collection period.

Cases and controls were identified based on the screening tool's PCL-5 cutoff point score [3]. All diagnosed cases were selected by counting all cases (interviewed all) when RTA survivors both treated inpatients and took follow-up services in the orthopedic department. All diagnosed cases were included until the required sample size for cases was reached.

Controls were selected using a patient list from prepared sample attendants’ sheets (prepared sampling frame) using registered inpatients and patients who had been appointed for follow-up services during the data collection period. Controls were selected using simple random sampling (SRS) by the lottery method when RTA survivors were both treated as inpatients and received follow-up services in the orthopedic department.

Comorbidity: mental health problems with the presence of other psychiatric disorders like depression, and anxiety.

Disability: impairment in social, occupational, or other important areas of functioning [3]. Disability was assessed by the Sheehan disability assessment scale. This was measured with the help of 3 items summed into a single-dimensional measure of global functional impairment that ranges from 3–15. Patients who scored 5 or greater on any of the 3 scales indicated a significant functional disability [18].

Mental disease: a behavioral or mental pattern that causes significant distress or impairment of personal functioning.

Perceived life-threatening: patient feeling his or her life was endangered or believed he or she was dead or faced severe injury during the accident.

PTSD: is characterized by exposure to a traumatic RTA in which the individual witnessed or confronted with RTA which involved actual or threatened death or serious injury or a threat to the physical integrity of self or others and that the individual responded to such an accident with intense fear and/or helplessness or horror. Measured by PCL-5, with responses range 0 to 4, and the total score (range = 0–80). PCL-5 ≥ 40 = PTSD.

RTA: defined as a collision /crash involving at least one road vehicle in motion that could be caused death or injury to people, and destruction of property.

Social Support: assesses perceived availability and satisfaction with support received from family, friends, and other special persons with whom one can share his or her joys and sorrows. Social support was collected by Oslo 3-item social support scale (OSS-3). It is a 3-item questionnaire that provides a brief measure of social support and functioning. In order to score OSS-3, total scores are calculated by adding up the raw scores for each item [1]. The sum of the raw scores has a range from 3–14. A score ranging from 3–8 as poor, 9–11 as moderate, and 12–14 as strong social support [19].

Post-traumatic stress disorder is not diagnosed by physical examination or routine laboratory investigation; rather, it is diagnosed using the PCL-5 questionnaire [20]. PCL-5 was a consistent, reliable, and valid tool adopted by DSM-5, which was studied in different populations in different countries over different periods. So it was the gold standard for screening PTSD and was scored to provide a provisional PTSD diagnosis [3].

The post-traumatic stress disorder checklist edition-5 (PCL-5), asks about symptoms in relation to an identified stressful experience. It aims to link symptom endorsements to a specified event; in this study, the event was RTA. It has 20 items, and a 5-point Likert response scale (“0 = not at all,” “1 = a little bit,””2 = moderately," “3 = quite a bit,” "4 = extremely”).

A total symptom severity score (range = 0–80) can be obtained by summing the scores from each of the 20 items that have response options ranging from 0 “not at all” to 4 “extremely”.

The cut point was dependent on the population and the use of the measure [21]. A provisional DSM-5 PTSD diagnosis is obtained from the PCL-5 by considering items rated 2 = ”moderately” or higher as symptoms endorsed following the DSM-5 diagnostic rule [20]. Therefore, according to the DSM-5 rule using instrument tool PCL-5, PTSD is identified at least when the respondent scores 2 or more, i.e. ≥ total sum score of 40 [3].

Social support was assessed by the Oslo 3-item social support scale (OSS-3) [22]. Disability was also screened by the Sheehan disability assessment scale [18].

The data was collected using structured, interview-administered questionnaires adapted from different works of literature [7, 14, 23, 24]. The questionnaires were translated into Amharic and back to English to ensure consistency. The data was collected by two BSc nurses, who were selected from other health facilities and supervised by one BSc public health professional. Its quality was controlled by designing proper data collection tools, pre-testing, and continuous supervision, and before actual data collection, training was provided to BSC nurse data collectors for two days on the data collection techniques to familiarize them with the tool.

The data collection was conducted in which data collectors contacted study participants while RTA survivors were receiving clinical care and follow-up evaluation services at the orthopedic department. Data quality for PCL-5 scores was checked in the pre-test assessment and gave excellent validity and reliability of the tool (Cronbach’s α = 0.9004). The Oslo 3-item social support scale (OSS-3) measurement was assessed for its reliability and validity in the pre-test of this study, and it was acceptable (Cronbach’s α = 0.6927). The data quality of the Sheehan disability scale was checked for its consistency during the pre-test of this study, and its validity and reliability test was checked, and it was good (Cronbach's α = 0.8515).

Data were entered in Epi-Info, and it was checked, cleaned, and edited before analysis. It was exported to STATA version 14.2.3 for analysis. Frequency distributions and cross-tabulations were used to check for missed values and outliers during the analysis. Descriptive statistics were computed as frequency, percentage, and results were displayed using tables and graphs. The relationship between the independent variable and the outcome variable was determined using a multivariable binary logistic regression model. Model fitness was checked by Hosmer and Lemeshow test, and multicollinearity was checked by VIF. The first bivariable analysis was made for each independent variable to the outcome variable, and those variables resulting in a p-value less than 0.2 were entered into the multivariable binary logistic regression model. In the final model, those variables with a p-value less than 0.05 were considered as statistically significant, and it was presented by odds ratio (OR), with a 95% confidence level (CI) to show the strength and direction of the association.

Seventy-nine (58.52%) cases and 89 (67.04%) controls were females. The median (IQR) respondents of age in cases were 38(+ 33) years and the median (IQR) ages of controls were 38.5 (+ 28) years. Twenty-one percent of the respondents had less than 1000 Birr monthly income in cases while controls had 17.41% less than 1000 Birr. Of the total respondents, 58(42.96%) among cases and 74(27.41%) among controls were having higher education (diploma and above) respectively. (Table 1.)

Among orthopedics RTA patients with PTSD cases and their corresponding controls based on occupational status (Fig. 1).

Among the total participant, 82 (60.74%) cases and 69 (25.56%) controls had a personal psychiatric history. Two third of PTSD cases 81(60.00%) and among controls, 80 (29.63%) were having a family history of mental illness (Table 2).

Among survivor orthopedic respondents 104 (77%) of cases and 143 (53%) from total controls suffered from a bone fracture. Study participants from cases 71 (52.59%) and controls 69 (25.56%) experienced a witness of death or serious injury while a road traffic accident occurred.

Eighty-one among 135 cases (60%) respondents reported the death of a family or close friend while the accident happened and only 36% suffered from controls. Among total survivors, 37% in cases and 44% in controls faced compound injury. Patients who had faced lower limp injury both in cases and controls were 19% and 26% respectively (Table 3).

Patients with case 67(49.63) developed other comorbid medical diseases whereas 99(36.67) from controls also developed similar comorbidity among traffic accident survivors. Survivors among cases 126(93.33%) developed a functional disability. Unfortunately similar proportion of patients 253(93.70) from the total of controls developed social, occupational, or other important areas of functional impairment secondary to RTA. (Table 4.)

Among orthopedics RTA patients with PTSD cases and their corresponding controls based on the level of social support (Fig. 2).

On the bi-variable, binary logistic regression factors that had a P-value ≤ 0.2; include, sex, educational status, marital status, family history of mental illness, psychiatric history, previous RTA, part of body injured, bone fracture, perceived life threatened during the accident, the family lost, current health status, job loss, witnessed serious injury or death of a loved one, ICU duration, long-lasting pain, development of new behaviors, loss of consciousness, regular income after an accident, comorbidity, and social support. These variables were candidates for final multivariable logistic regression analysis (Table 5).

During the multivariable analysis; male sex [AOR = 0.57, 95% CI: 0.3–0.99], primary educational status of participants [AOR = 3.4, 95% CI: 1.04–11], respondents who had higher education and above [AOR = 4.9, 95% CI: 1.53–15.6], personal psychiatric history [AOR = 2.12, 95% CI: 1.17- 3.92], moderate social support [AOR = 0.52, 95% CI: 0.28–0.97], good social support [AOR = 0.29, 95% CI: 0.12–0.68], presence of bone(s) fracture [AOR = 2.41, 95% CI: 1.2–4.8], witnessed of death or serious injury [AOR = 2.25, 95% CI: 1.26–4], presence of comorbid illness [AOR = 2.29, 95% CI: 1.28–4] had showed significant association with the development of PTSD among RTA survivors.

The study assessed only the latest RTA subjects, being treated for. Other different traumas that could have occurred in the subjects’ lifetimes were not taken into account. These could have an influence on these results. However, its major strength was used a standardized instrument for measuring PTSD.