COMMUNITY HEALTH STUDIES
VOLUME VIII, NUMBER 2. 1984
CONVALESCENCE FOLLOWING PHYSICAL TRAUMA: SOCIAL DETERMINANTS OF
SUBJECTIVE RECOVERY
Ronald L. Somers
Accident Anal-vsis Group, Laboratory for Public Health and Health Economics, Odense University
Hospital, DK-5000 Odense C, Denmark.
Present address: NH & MRC Road Accident Research Unit, University of Adelaide, G.P.O.Box 498.
Adelaide, South Australia 5001.
Abstract
Few of the many past studies of interpersonal
differences in reaction to illness have investigated
social determinants of convalescence, particularly
with regard to convalescence from physical
trauma. In this study a group of patients with
uncomplicated nose fractures was followed closely
from initial treatment at a large hospital in
Denmark t o self-reported recovery. Rapid
recovery among patients aged 15-26 was found to
be associated with larger household size and higher
socio-economic status. Recovery time among
patients aged 27-56 was not related to any of the
social factors investigated in this study.
Introduction
Several factors might influence the length of
time required for a person to feel recovered from
acute disease or injury. These factors include the
nature of the illness or injury; the nature (and
quality) of the curative treatment received; the
person’s biological reaction: t h e person’s
psychological reaction and the person’s social
environment and social obligations.
This study aimed t o identify social
determinants of subjective recovery from physical
injury. The study was designed to standardize as
far as possible intersubject variation in the type of
injury sustained, the nature of the medical
treatment received and the expected biological
reaction. The type of injury was standardized by
recruiting only individuals with fractured noses
who did not develop complications and who did
not sustain significant concomitant injuries.
Variation in medical care was controlled by
including only persons who received standard
nose-fracture diagnosis and treatment at Odense
University Hospital.* Variation in expected
biological reaction was minimized by excluding
from the study relatively young or old people and
by analyzing those remaining by age group.
SOMERS
Past studies of psycho-social determinants of
healing have tended to concentrate almost entirely
on the influence of personality,’-* that is, on
psychological factors. Few studies have centred
specifically o n social d e t e r m i n a n t s of
convalescence, particularly from physical trauma.
Nevertheless, in studying head injury a few social
factors have been found to be associated with the
course of recovery. Six weeks after they had
sustained minor head injury, post-concussion
symptoms were more frequent among women and
among those who blamed their employers or other
“large impersonal organizations” for their
injuries.9 Age and social class were not shown to
have a n effect o n recovery. Age over 40 years,
however, has been deemed an important factor in
hindering patients’ return to work following severe
head injurylo and recovery from head injury has
also been reported as inversely proportional to
age. I I
*The medical treatment received by subjects in the
present study was generally similar from case to case. All
subjects presented first to the emergency room where
they were examined, x-rayed and given a diagnosis of
nose fracture. All but three of the subjects (who were
referred to the department of plastic surgery) were
referred for treatment at the ear. nose and throat
department. This treatment was typically scheduled for
the next day. although in a few cases longer delays (of up
to four days) were experienced. Treatment typically
consisted of closed reduction and fixation with nasal
tampons and an external plaster of Paris cast. More than
80 percent of the subjects were admitted to hospital.
typically for one or two days. although in a few instances
for slightly longer periods. One week after hospital
discharge subjects returned to hospital for removal of the
cast and for final examination.
Odense University Hospital is the sole hospital
serving a number of municipalities in Funen County,
Denmark. The Hospital houses the only emergency
medical facility available to residents of the area. All
outpatient and inpatient care is provided without direct
cost to the patient.
167 COMMUNITY HEALTH STUDIES
 With regard to the effects of social variables
on convalescence the earlier studies cited suffer
considerably from the fact that the severity of
injury might well have varied significantly from
individual to individual; this could account for
much of the observed interpersonal difference in
recovery. In the present study nose fracture was
selected as the injury for investigation because of
its low rate of complications, its standard method
of treatment and its relative lack of associated
physical disablement. Specifically, it was
hypothesized that interpersonal variation in the
time required for a person to feel recovered from a
nose fracture could be partly explained on the basis
of the size of the person’s household, the person’s
socio-economic status and the amount of
responsibility the person had for the livelihood of
self and family.
Material and Methods
For a period of six months starting in late-
December, 1979, the medical records of all persons
examined for nose fracture in the emergency room
of Odense University Hospital were reviewed
within one or two days of initial examination.
Persons with simple nose fractures and without
significant other injuries were contacted by mail on
the third day following their injury. These persons
received a small booklet of questions
(Questionnaire 1) and a cover letter soliciting their
cooperation. The letter deliberately obfuscated the
purpose of the study stating that the research
aimed to define the groups in the community which
were using the emergency room. No specific
mention was made of the fact that the study
concerned only people with nose fractures.
Prospective subjects who did not respond to the
first letter within one week were sent a second letter
by mail and those who still did not respond were
contacted by telephone.
On the twenty-first day after injury each
person who had responded to the first
questionnaire was sent a second series of questions
(Questionnaire 2) which focussed mainly on the
period of convalescence. An enclosed letter
emphasized that it was particularly important to
indicate on the questionnaire whether the
respondent currently felt healthy again, “more or
less.” Being more or less healthy was carefully
defined as ”being able to manage dressing,
housework, shopping, work, recreation, etc. about
as well as before the injury”. Minor sequelae such
as stiffness, itching, aching, or scarring were not to
be considered if such sequelae did not actually
hinder normal functioning. If the respondent felt
SOMERS
recovered (that is felt again able to d o the things
that were usually done before the injury occurred)
he/she was asked to indicate the date on which full
activity resumed. Persons who did not reply to
Questionnaire 2 were contacted by mail and
telephoned as for Questionnaire 1.
A person who reported not feeling recovered
at the time of completing Questionnaire 2 was
followed weekly by mail with a letter and a much
abbreviated questionnaire containing only a single
item, the question about whether he/she currently
felt healthy. The definition of health, as given
above, was repeated with each new mailing and the
general tone of the accopanying letter was as
neutral as possible to minimize its potential effect
on the natural course of recovery. This procedure
continued, sometimes for several weeks, until the
person at last reported that he/ she felt recovered as
of some particular date. Only persons who
completed both questionnaires and eventually
reported a recovery date were considered subjects
in the study.
Included with each questionnaire was a
stamped, self-addressed envelope for returning the
questionnaire. All questions were constructed for
easy item-check or short free text responscs. The
questionnaires were designed to elicit personal
information relating to three social factors that
were thought likely to influence convalescence,
household size, sopcioeconomic status, and “press
of responsibility”. Socio-economic status was
assessed with questions on personal and household
income, type of housing (including number of
rooms, type of building and ownership status),
amount and type of education, and profession.
“Press of responsibility” was investigated by a
number of diverse questions on personal
circumstances which might directly act to‘
encourage a rapid resumption of one’s normal
role: there were items about current employment
status, type of employer (self or other), proportion
of total household income contributed by the
respondent, and responsibility for children, farm
animals or general farm tasks.
In addition to the questionnaire items which
concerned the three hypothesized social factors a
number of items were included to control for
possible confounding circumstances. Most
importantly, subjects were requested t o
characterize their health at the point in time just
prior to the occurrence of their injury. They were
asked to list any diseases or conditions which were
prevalent at the time of injury and any that
developed or recurred during convalescence from
the injury. The subjects were also asked if their
168 COMMUNITY HEALTH STUDIES
injury was purriculurly disabling because of the
specific nature of their work. (A spray painter,-for
example, might be unable to wear a required
protective mask over a broken nose.) Respondents
whose recovery time might be so affected were
excluded from the study.
Basic information relating to age, sex,
residence, and injury circumstances (such as fight
or accident) was obtained from emergency-room
records. The diagnosis and treatment received by
the trauma victims could be determined using a
combination of emergency-room records and a
computer synopsis of all related inpatient care.
Trauma victims who did not receive the standard
diagnosis and treatment protocol were excluded
from the study.
Prior to statistical analysis two Likert-type
scales12 were developed, one for socioeconomic
status and one for press of responsibility. The
scales were constructed on the basis of what was
considered a reasonable assignment of points to
individual questionnaire items. A subject’s score
on a particular scale was calculated as the total of
the points received for items relating to that scale.
Having once been set, the system of scaling was not
modified in response to the outcome of the
statistical analysis.
Results
Of the 124 trauma victims who presented to
the emergency room and met the age, diagnosis
and treatment criteria of the study, 99 (80 percent)
returned the first questionnaire and 84(68 percent)
returned the second questionnaire as well. Of the
latter prospective subjects, five reported prevalent
illness conditions and one reported special work
circumstances which necessitated their exclusion
from the study. In addition six persons were
excluded for withholding specific important
Number
of
subjects
1 0 DBOOOO.BB0
DO
I I I 000
I I I I 0 0 0 0 0 0 ~ *0*0 0 0 B 0 0 0 0 00.0
I I I I
0 5 10
Figure 1: Distribution of nose-fracture victims by self-reported duration
of convalescence.
SOMERS
information and two never reported a recovery
date in spite of long periods of follow up. One 52-
year-old man who was injured on the job reported
a recovery time of 74 days; this was more than one
month longer than the next longest recovery time
and more than six standard deviations from the
mean recovery time reported by the other eligible
subjects, 15.9 days. This subject was also excluded
from the main analysis. The remaining 69 subjects
consisted of 50 males and 19 females.
Both male and female subjects were classified
by age into two groups, 15-26 (N=38) and 27-56
(N=3I), in order to control as far as possible for
potential differences in biological reaction to
injury. The sex- a n d age-group-specific
distributions of recovery time are shown in Figure
1. The mean recovery time for men, 16.8 days, was
slightly, though not significantly, longer than that
for w m e n 13.4 days. The mean recovery time for
the older group, 15.5 days, was not significantly
different from that for the younger group, 16.2
days.
The multiple regression analysis of recovery
time in the younger age group demonstrated that
large household size and high socioeconomic
status were significantly associated with short
recovery time. These two social factors alone gave
rise to an adjusted RSQ of 24.7 percent (Fz7.07;
df=2,, 35; p<0.003). Use of age, sex, press of
responsibility and injury circumstances (fight vs.
accident) did not increase the adjusted RSQ. The
results of the multiple regression for the younger
age group are presented in Table 1. For the older
age group no combination of the studied social
factors explained a significant proportion of the
observed variation in recovery time.
.
0 male, aged 27-56 (N=23)
0 female, aged 27-56 (N= 8)
0 male, aged 15-26 (N=27)
female, aged 15-26 (N=ll)
0
0
0. 0
0000 0
. 0 0
I I I I
0 1 I I I 1 , , , , 1 , ,
000
, , , , , , , , , , ,
0
15 20 25 30 35 40
Recovery t i m e (in days)
169 COMMUNITY HEALTH STUDIES
 TABLE 1
Results of the multiple regression analysis for younger accident victims aged 15-26 (N=38).
Dependent variable was the number of days of convalescence. Adjusted squared multiple correlation 24.7%.
Independent Standardized
Variable regression
coefficient
Household size - 0.554
Socio-economic status - 0.426
An effort was made to compare on a number
of points the 69 subjects included in the main
analysis with the 55 trauma victims excluded from
the analysis because of non-response o r other
circumstances. The two groups were found not to
differ significantly as to age o r sex. Furthermore, a
comparable proportion of the persons in each
group sustained their fractures during work hours.
Fewer members of the analyzed group had been
injured in fights (28 percent) than was the case for
the non-analyzed group (44 percent), but this
difference was not significant at the five percent
level., The only appreciable difference found
between the groups concerned the place of injury.
Relatively more of the analyzed group had been
injured in athletic facilities, while relatively more
of the non-analyzed group had been injured on the
street o r in places of public entertainment (x2 =
12. I , df M 4, p < 0.025).
Discussion
The results support the hypothesis that factors
related to one’s social environment can act to speed
or delay subjective recovery from nose fracture.
Since healing is influenced by many factors, it is
perhaps not surprising that only a relatively small
proportion of the observed variance in recovery
time could be explained statistically by the few
social factors investigated. There is no clear
explanation of the fact that no social mediators of
convalescence could be identified for the subject
group aged 27-56. This negative finding may be
due in part to the considerable differences which
existed between the older and younger subject
groups. As compared to the younger subjects those
aged 27-56 had significantly smaller households,
significantly higher socio-economic status, and
significantly greater press of responsibility.
SOMERS
Two-tail
t statistic significance
of coefficient
- 3.52 0.001
- 2.70 0.010
The two social factors identified as important
in the younger subject group are not unexpected in
light of the literature. In his social-behavioural
overview of studies on the health of families
Litman’) cites evidence that the larger the family
size the fewer the health services used per person,
that patients in larger families tend to be laid up for
shorter periods of time, and that such patients are
less likely to pose serious problems for their
families or to have any dramatic effect on their
families’ role-relations. Schaefer, Coyne and
Lazarusl4 report that the amount of tangible
support received by a n ill individual is inversely
correlated with depression and negative morale.
Perhaps it is via this mechanism that large families
are better able to ameliorate the impact of illness
on stricken menbers.
Socio-economic status, or social class, has
likewise been observed to be associated with
various aspects of health behaviourl5-19 It is
important to note that the range of socioeconomic
status in the present study is undoubtedly smaller
than that in may previous studies. Investigation of
recovery among injured persons who are not
supported by the sophisticated Danish welfare
system might well demonstrate that socio-
economic status plays a larger role than that shown
in the present findings. .
A significant problem with the present study is
that psychological differences between subjects
were not controlled for. As discussed above,
psychological factors, especially those relating to
personality, have been shown to influence
convalescence. If such factors correlated well with
social factors investigated in the present study it is
possible that the demonstrated statistical
association between recovery time and social
factors is indirect (that is, non-causal) rather than
I 70 COMMUNITY HEALTH STUDIES
direct. Future investigators would d o well to
consider the practicability of psychological
stratification of subjects prior to analysis of social
factors affecting recovery.
It must be acknowledged that nose-fracture
victims, who have often been injured in fights, may
not be socially representative of the general
population. In verifying and extending the present
findings one would hope first to see replications
using nose-fracture patients, followed by studies of
other injuries and illnesses, which might explain a
greater part of the healing phenomenon and lead to
practical steps to speed recovery.
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SOMERS
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171 COMMUNITY HEALTH STUDIES