557876 research-article2014
HPQ0010.1177/1359105314557876Journal of Health PsychologyShiloh et al.
Article
A common-sense model of injury perceptions
Journal of Health Psychology 1–11 © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1359105314557876 hpq.sagepub.com
Shoshana Shiloh1, Irit Heruti1,2 and Ronit Leichtentritt1
Abstract The aim of this study was to clarify the difference between perceptions of injury and illness. A qualitative study using semi-structured interviews was conducted with 38 individuals who had been injured in the past, 8 medical psychologists, 62 graduate psychology students, and 19 health professionals treating injured patients. Data were analyzed by modified analytic induction and constant comparison methods. Commonsense perceptions of injury overlapped with some perceptions of illness, and 4 new themes were elicited. It was concluded that there are themes unique to injury perceptions that should be recognized in research as well as in clinical interventions.
Keywords beliefs, disability, health psychology, model, phenomenology, qualitative methods
Introduction Injury is one of the top ten causes of death or disability worldwide, accounting for one-sixth of the world’s health burden (World Health Organization (WHO), 2008). While among the most common and oldest health problems facing people, injury began to be addressed with scientific rigor using public health methods only in the past 50 years (Sleet et al., 2012). In addition to the physical difficulties, injury victims often report psychological sequelae ranging from slight distress to posttraumatic stress disorder (PTSD) and related psychiatric morbidity (Zatzick et al., 2007). Despite their great significance, injuries are barely acknowledged as a distinct category in health psychology and remain to be conceptualized. This paper aims to fill the gap. The confusion between injury and illness can be traced to Waller’s (1987) paper entitled
‘Injury as Disease’. In it, the author ‘medicalized’ injuries in order to promote greater scientific, technological, and public health attention to them. These contentions, which were right for their time, objectives and audiences, are problematic with respect to health psychology. The model in Figure 1 illustrates the conceptual space in which injury is situated today as a category of traumatic events that can lead to impairment, like other agents including illness.
1Tel 2Tel
Aviv University, Israel Aviv-Yaffo Academic College, Israel
Corresponding author: Shoshana Shiloh, School of Psychological Sciences, Tel Aviv University, Tel Aviv 69978, Israel. Email: [email protected]
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Figure 1. A conceptual model of injury within the space of similar concepts.
Teasing apart the ways in which injury and illness are treated in the literature brings one to three general concepts in which injury is embedded: disability, trauma, and disease/illness. Injuries are described variously as health conditions tied to disability (Molloy et al., 2009); as one of four broad types of disabilities together with congenital, chronic illness, and psychiatric disabilities (Milligan and Neufeldt, 2001); as impairment – any loss or abnormality of psychological, physiological, or anatomical structure or function that may involve a disease or trauma (Johnston and Pollard, 2001); and as one of three categories of disability: (a) a person who has lived with a disability from birth or early life, (b) an otherwise healthy person who acquires a disability through an acute event of disease or trauma, and (c) a person who has lived with a progressive chronic illness (Robinson et al., 2006). Note that injury is not mentioned in the last two classifications, implying that it could be either a type of trauma or disease. Some researchers classify injury as a type of trauma (Littleton et al., 2007), along with sexual victimization and illness. Seeing injury as a
form of trauma is quite common, as attested to by the frequently used terms ‘traumatic injury’ or ‘traumatic physical injury’, e.g., (Jones et al., 2012). At the same time, more and more scientists address physical illness (cancer, cardiac disease, AIDS, etc.) as trauma (Sherr et al., 2011). Thus, the common denominators of disability on the one hand and trauma on the other may explain the intriguing overlap between the concepts of injury and disease/illness often found in the literature e.g. (Hurley and Lebbon, 2012). Despite the fact that injury and illness are separate triggering events of chronic disabilities (Livneh, 2001), the leading life event scale, the Social Readjustment Rating Scale (Holmes and Rahe, 1967), groups ‘major personal injury or illness’ into one item, and the International Classification of Diseases (Practice Management Information Corporation, 1997) classifies injury as a type of disease! In an effort to identify the similarities and differences between injury and illness, we turned to the Self-Regulatory model, which was developed in the context of chronic illness and health-threatening messages (Leventhal et al.,
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Shiloh et al. 1998). According to the model, coping procedures in response to illness or threat of illness depend on cognitive and emotional representations. Similarly, the key role of perceptions and representations for understanding people’s reactions to injury has been demonstrated (Haden et al., 2007). The theory maintains that illness perceptions are organized along five cognitive dimensions: Identity - a person’s beliefs about the symptoms of the illness and its label; Cause - the factors that the individual believes caused the illness; Consequences - a person’s evaluation of the impact the illness has on a patient’s life and activities; Timeline - an individual’s perception of the course of the illness, chronic or acute; Personal control – the evaluation of whether there are effective measures available to the individual to control or cure the illness. Together, these representations form a person’s cognitive representation of illness threat. The emotional representation component of the theory refers to a person’s evaluation of the potential emotional impact of the illness. The theory has become very popular because it provides an explicit, testable framework to understand the processes by which social cognitive constructs influence coping behaviors and outcomes in many health conditions e.g., (Hagger and Orbell, 2003). The Self-Regulation Theory has also been applied to the study of injuries (Chaboyer et al., 2010; Hagger et al., 2005; Medley et al., 2010; Wong et al., 2011). The common idea in those studies is that injury is a special type of illness, and that the measures of illness perceptions just need to be slightly modified in order to be applicable. Modifications included adding to the identity scale a few symptoms typical to injuries, like ‘discomfort walking’; replacing ‘my illness’ with ‘my injury’; omitting items from the ‘cause’ scale deemed inappropriate for injuries, like ‘smoking’, and adding injury-specific items, like ‘overtraining’. Findings showed modest correlations among the representation variables, coping procedures, and injury outcomes in accordance with the hypothesized pattern. Medley et al. (2010), however, noted the limitations of using illness perceptions for the study of injuries, in
particular the inadequacy of the causal attributions scale which does not take into account self/ other blame attributions that are especially salient among injured individuals. We took the Self-Regulatory model as a framework for identifying themes that are common to or unique to injury and illness and carried out an exploratory qualitative study to examine how injury is represented in comparison with illness perceptions, an approach recommended for areas with little knowledge (Leventhal, 1985). Our basic argument is that illness and injury are perceived differently, and themes specific to injury must be identified independent of those ascribed to illness.
Methods Participants Participants were volunteers recruited in Israel through advertising and the snowball technique: recruiting one individual with the desired characteristics and using that person’s social networks to recruit similar participants, who then help recruit others in a multistage process (Faugier and Sargeant, 1997). Semi-structured interviews were conducted in Hebrew with four groups with different perspectives on injury: Group 1) Thirty-eight individuals who had been injured in the past; 23 women and 15 men; mean age 37.93, SD = 9.04; 22 sport/dance injuries, 6 car accidents, 4 terror-related injuries, 4 military injuries and 2 work injuries; all but one had post-high school education. Group 2) Eight senior medical psychologists working with injured patients; 5 women and 3 men; mean age 50.00, SD = 8.81. Group 3) Sixty-two graduate students in medical psychology (n = 43) and rehabilitation psychology (n = 19) programs who do volunteer work with injured people; 47 women and 15 men; mean age 27.15, SD = 2.37. Group 4) Nineteen health professionals treating injured patients; 13 women and 6 men; mean age 40.00, SD = 9.64; 4 surgeons, 5 orthopedic nurses, 6 physiotherapists and 4 occupational therapists. The heterogenic sampling technique resulted in 127 participants with rich and
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diverse perspectives on the phenomenon under study. Group comparisons were beyond the scope of this study.
Procedure Ethical approval for the study was obtained from the relevant University authorities and guidelines on patient consent were met. Participants consented to volunteer in the study presented as ‘thoughts about injuries’, and met at their preferred location for a semi-structured interview of 30-60 minutes (Patton and Patton, 1990). All interviews were conducted and transcribed verbatim by the second author (I.H.). Participants were asked broad pre-prepared questions, followed by more specific probes, in accordance with guidelines for conducting semi-structured interviews (Smith, 2008). The interviewer often requested further details to elicit fuller accounts. The three leading questions developed for the interview protocol were: 1. ‘Think about an (your) injury. Now, express all the associations, thoughts, feelings or questions that come to your mind’. 2. ‘Think about injured and ill individuals. In your opinion, are there differences between them? If so, what are they?’ 3. ‘Imagine that you were asked to write a magazine article about someone who was injured. What would you like to know about his/her injury in order to write the most comprehensive article?’
Data analysis The answers to the interview questions were analyzed using modified analytic induction and constant comparison, which are complementary analysis methods. Modified analytic induction can begin with a pre-existing model that guides the investigator’s approach to the data (Smith and Manning, 1982). The pre-existing model is then compared with the facts and when they do not match, (i) assumptions are modified so that
the new facts will fall under them, and/or (ii) the phenomenon to be explained is re-defined to exclude the cases that defy explanation by the model (Robinson, 1951). The constant comparison method was first used in this study in a deductive manner, where all incidents observed for all participants were compared to dimensions of illness perceptions (Leventhal et al., 1998) and the labels were checked to see if they accurately matched the words of the participants. Secondly, the method was used as an inductive process in which ideas presented in the interviews that did not match the dimensions of illness perceptions were identified, categorized, and later labeled.
Results All participants1 thought that illness and injury are not the same, even when they cause a similar impairment or disability. In view of this inductive understanding, the similarities in injury and illness dimensions are reported first, followed by the unique dimensions relevant only to injury. One should note, however, that even when participants discussed similar dimensions for illness and injury, they noted aspects of injury that distinguished it from illness. Table 1 summarizes the main dimensions of injury perceptions compared with the common-sense model of illness perceptions (Leventhal et al., 1998).
Perceptions common to both injury and illness Identity. Identity refers to the illness label and symptoms. Like with illness, many symptoms were mentioned, some of them physical and some psychological: ‘Injury is related to amputation, fractures (Shelly, physiotherapist); ‘In injury one needs to pay attention if the injured has symptoms of psychological trauma’ (Lea, surgeon). But, unlike illness, injuries lack medical diagnostic labels like ‘diabetes’. Instead, the identity of an injury is determined by 1) a physical identity, delineating the type of damage, like burn or cut and the affected body part,
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Shiloh et al. Table 1. Dimensions of injury perceptions in comparison with the common-sense model of illness perceptions (Leventhal et al., 1998). Dimension
Illness
Injury
Common dimensions Identity
Symptoms + medical label
Examples Consequences
Sore or swollen glands Consequences
Examples
My illness is a serious condition
Time-line Examples
Acute / chronic My illness will last for a long time
Control Examples
Self & treatment control My treatment will be effective in curing my illness Causes A germ or virus caused my illness Emotions My illness makes me feel afraid
+ PTSD + body part + social identity Nightmares, Eyes, Traffic accident Focus on visibility, aesthetics & positive consequences My injury damaged my body’s wholeness; My injury showed me positive things about my surroundings + Time distance from the event I feel like my injury happened just yesterday Self & treatment control My treatment will be effective in curing my injury Focus on external factors Actions by others caused my injury + Specific emotions My injury makes me feel disgusted
Cause Examples Emotional representations Examples Unique dimensions Coping Examples Responsibility / blame Examples Event / Drama Examples Self – Injury Examples
– – – –
like leg or eyes; and 2) the social identity of the injury, like military injury, sport injury, suicide attempt, etc. ‘When I think of an injury, the first thing I think about, at an immediate level… physical… what kind of injury? Where in the body? How serious is it?’ (Tom, military injury); ‘Injury for me is first of all a bodily damage and only later psychological… physical changes, in organs… burnt skin, a screw that hasn’t been removed from the frontal lobe… it is a physical trauma, in a specific organ’ (Dafna, medical psychologist); ‘The background of injury, in the military, for example, … the knowledge that I was injured defending my country and the
Coping efforts and motivation It is hard to cope with my injury Failure to avoid; who perpetrated? I am not responsible for my injury Images, scenario, drama, urgency Broken items; Ambulance, Screams Me - Not me? Even when you are injured, you are actually a healthy person
support I received after the injury… have given me a better feeling’ (Ran, military injury); ‘..an injury related to war or terror has some aspect of heroism that maybe helps coping more easily, because people ‘understand’…’ (Naomi, terror injury); ‘When injury is a result of attempted suicide, then the attitude is different… the circumstance of injury is important… car accident, terror attack or attempted suicide… it’s not the same injury’ (Tali, occupational therapist).
Consequences. Like in illness, the consequences dimension of injury refers to beliefs regarding the physical, psychological and social impacts of injury on one’s life.
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Journal of Health Psychology ‘An injury occurring within one second can change one’s life… what are the consequences for the future?… will it cause disability?… what are the chances of returning to normal functioning?…’ (Ruth, car accident injury); ‘Injury causes changes in plans, it leads to functional disability, it leaves marks, scars that you cannot ‘‘erase’ (Shira, car accident injury).
As hinted in Shira’s quote, there were repeated allusions to the visibility of the injury, ‘Is it showing? Can it be concealed?’ (Gil, car accident injury); ‘Injury many times entails more consequences for body deformation and visible aesthetic defects in addition to functional … that exist in illness (Hadas, psychology graduate student). Positive consequences of the injury were also mentioned. Considerable attention was paid to self-growth and resilience, but participants also discussed insurance and monetary compensation in this category: ‘This was the best thing that happened to me; it enabled making a change for better’ (Lital, professional sport injury); ‘Parallel to the uncertainty and hindrance of plans, injury is also an opportunity to meet an unfamiliar part of yourself, an opportunity to change priorities, to test values and life philosophies, it is not just bad…’ (Maya, graduate psychology student); ‘An injury legitimizes a lawsuit, ‘I’m entitled’, social security, disability compensation, group support, ‘Beit Halochem’,2 special Olympics games for people with disability, fundraising day, ministry of defense… (Hadas, graduate psychology student).
Time-line. Time-line issues were translated into questions of whether or not the injury causes permanent disability (chronic), or is a temporary condition: ‘It is reversible, you get over it after some time’ (Adi, occupational therapist); ‘An injured person can recover, an ill person cannot… the chances of an injured person to get out of this trouble are higher..’ (Dan, work injury). Injury among participants was associated with a temporary condition, a situation that one can overcome, depending on one’s willpower and motivation. In addition, there were references to the time lapsed from the injury:
‘When did it happen? It was a long time ago’ (Dina, graduate psychology student); ‘With injury there is a time dimension – it would interest me to ask the patient how long it has been since he was injured…the conceptual perception of injury involves a short and limited time frame: the minute of the event, medical treatment/rehabilitation… you are not injured all the time… like a chronic disease’ (Yael, medical psychologist).
Causes. This dimension represents beliefs about the factors at the root of the illness or the injury. With regard to injury, special attention was paid to external causes which are irrelevant to illness like war, terror attacks and violence: ‘In injury there is an external factor… can be like a sharp object… or something related to the environment, nature, chemical agent, can be related to harsh weather, can be related to other people’s failures, to wrongdoings of others…’ (Adi, occupational therapist).
Personal/treatment control. Similar to illness, the texts included quotes about personal and treatment control: ‘The treatment in the hospital gave me a good feeling… I think it helped me recover in the long run’ (Tami, work injury); ‘When injured, I was busy thinking if I recover at the right pace… will I recover completely?.. will I return to normal functioning as I was…’ (David, war injury).
Attention was also paid to a sense of empowerment resulting from personal coping behaviors and the effectiveness of treatment. Emotional representations. Similar to illness, injury elicited many negative emotional representations, some of them specific to injury, like pity, helplessness and disgust: ‘Disgust… in injury there is a smell that sticks to you for a long time, and it is usually disgusting’ (Rachel, terror injury); ‘Injury is anxiety, death anxiety, suffering, sadness, sorrow, blame, shame’ (Yael, medical psychologist); ‘Helplessness, pain, fear, shock, depression, self-pity’ (Abigail, orthopedic nurse).
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Components unique to injury The illness perception dimensions of identity, consequences, timeline, causes, personal/treatment control and emotional representations were insufficient to account for all the participants’ responses regarding injury. Modifications of the analytic induction and constant comparison methods resulted in the following additions: Coping. There were many references to coping efforts and resources required from an injured individual that are not part of the illness perceptions model, in particular how difficult or easy it is to cope with the injury. This dimension emphasizes the coping efforts rather than healing and/or coping outcomes: ‘It requires much effort to get back to yourself; motivation, and drive to rehabilitate are very important’) Sara, terror injury);’Injury… is not the end of the world, you can cope, difficult but possible, you need much willpower, motivation, mobilization of strengths and coping skills’ (Yosef, medical psychologist). ‘An injured… feels more strong, stands up to his rights more than an ill person’ (Dan, work injury).
Responsibility/blame. Issues of fault, blame and accountability were elicited mainly with regard to failure to avoid or prevent the injury. Participants clearly pointed out that issues of blameworthiness and responsibility are critical in injury, unlike in illness: ‘Who caused the accident?’ (Michal, graduate psychology student). There were specific allusions to actions by others: ‘Did I contribute to causing the accident? How did it happen? Who was the offensive driver?… how could the driver allow himself to drive so carelessly…?’ (Ruth, car accident injury); ‘Was it bad luck? Destiny? Who is to blame? Why did it happen? Who is to blame?’ (Yonatan, military injury).
Event/drama. This theme did not have a comparable dimension in illness representations. Participants described vivid scenes including visual, auditory, and olfactory stimuli: ‘It is like
in a movie, broken things and ambulance sirens, the smell of smoke and people’s cries (Assaf, emergency physician). There were repeated allusions to the surprise/ suddenness of the situation: ‘Everything sudden, no announcement, impossibility to prepare oneself… everything happens so fast, under threat of loss… blood, infusion, lost consciousness, ambulance, paramedic staff, a stretcher, policemen, busy medical staff, to which hospital are they rushing me? tests, head immobilizing, white coat, danger… (Ruth, car accident injury).
Self - injury relationship. A repeated theme that distinguished between illness and injury was that injury was represented as more external to the self than illness: ‘An injured person is basically a healthy person. Injury goes with the young and illness with the old (Sharon, medical psychologist); ‘The injured… looks with dismay on the wound in his body and tries to distance himself from the wound… to tell himself that it is just a wound and it is in the body, like a punctured wheel that can be replaced… as if it’s not his’ (Tom, war injury); ‘It is easier to contain injury in comparison to illness, injury helps you keep a feeling of ‘being well’. It is something external, it is less ‘absorbed’ into one’s self-image… it is something coming from outside and is less threatening to one’s selfesteem’(Uri, car accident injury).
Discussion The qualitative study reported here supports the notion that common-sense perceptions of injury differ from common-sense perceptions of illness, although there is some overlap. Not only did the contents of dimensions differ (e.g., types of symptoms), a variance that is often seen across diseases, but new dimensions unique to injuries emerged. These included social identities, coping, event/drama representations, perceived time lapsed from the event, issues related to responsibility and blame, and to the distance between an injury and the self of the injured person. The different representations may explain
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previous findings regarding the split between illness and injury fears (Carleton et al., 2006), and the different attitudes towards ill and injured individuals (Shiloh et al., 2011). The identification of a ‘self’ dimension in injury representation deserves special attention. Leventhal et al. (1999) discussed the importance of the ‘me? - not me?’ question with regard to the representation of an illness as acute or chronic. An injury also involves reassessment and renegotiation of a person’s identity, especially if it marks the onset of disability. The injured individual must identify which aspects of his/her self have been lost, which remain, and which are part of a new identity (Dickson et al., 2008). The distancing stance (injury is external to the self, unlike illness) that was elicited in our study may represent the process of renegotiating one’s identity. There is evidence that considering injured patients’ selfconcepts is important for improving rehabilitative progress (Doering et al., 2011). Also, while the Self-Regulatory model (Leventhal et al., 1998) presents coping as following illness representations, our findings suggest that coping is part of the representation. The penetration of coping into the injury schema is consistent with findings that activation of a schematic representation of illness automatically activates information related to coping procedures encoded in memory with the illness (Henderson et al., 2009). Another noteworthy dimension unique to injury is the event/drama representation, which has tremendous importance in injury representations mainly because of its close relationship to the development of PTSD. Re-experiencing the traumatic event in the form of spontaneous flashbacks is a core symptom of PTSD (Brewin, 2002) involving vivid and intense memory of the traumatic event (Gil et al., 2006). The event/ drama and the social identity dimensions point to features of the context in which injury occurred. As such, it may represent a step toward developing a multi-level model, in which injury is not only situated in the individual, but is also part of the wider social-ecological environment.
Several new themes of injury, related to the original illness dimensions, were also found. They parallel the literature showing that body image dissatisfaction is an important indicator of subsequent quality of life among patients after disfiguring injuries (Fauerbach et al., 2002); that there are positive consequences of injury (Wadey et al., 2011); that coping strategies and self-efficacy are main topics in an injury trajectory (Bonanno et al., 2012); and that length of time elapsed since the injury is an important factor in the adjustment process (Bryant, 2011). The emphasis on responsibility and blame issues in injury also dovetails with the literature. Blaming the accident victim is often part of legal proceedings for compensation in the workplace (de Almeida et al., 2000). Blaming is also a main issue when the injury is perpetrated by another person (DeRoon-Cassini et al., 2010). The only studies with which we can compare our findings used interpretative phenomenological analysis to investigate small samples of individuals with spinal cord injury, one of the most devastating and traumatic neurological impairments (Dickson et al., 2008). Despite the differences in samples and the fact that we addressed injury as a generic category, our themes (coping, self, etc.) were similar to the main appraisal themes discovered in those studies, which were: ‘Making sense of traumatic experience’ - thoughts about what had happened and whether the injury was avoidable; ‘Impact’ - losses, gains, hopes, and fears for the future; ‘Coping’ -evaluations of coping resources; ‘Altered view of self and life’ increased self-awareness; ‘Loss of control’; ‘Loss of independence;’ and ‘Loss of identity’. Published studies on injury generally deal with a specific type of physical injury like spinal cord, or a specific social category of injuries like sport accidents (Wadey et al., 2012). Hence, they relate to the two-dimensional identity facets – physical and social – discovered in the present study. Specific injuries may elicit different perceptions, same as perceived differences between specific acute and chronic illnesses. Despite the
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Shiloh et al. variety, our findings suggest that there is an overarching perception of injury unrelated to its particular manifestation, similar to the cognitive concept of illness, which also encompasses a large variety of manifestations.
more salient in injury representations – the event itself, the social identity of the injury, and issues of visibility, blame and self. Further research on more populations is required to confirm and expand these suggestions.
Limitations
Funding
The large sample representing several perspectives would appear to be an advantage of our study, but the fact that all participants were from the same cultural background might have introduced a bias (Kleinman et al., 1978). Further research on other, perhaps more culturally heterogeneous populations is needed to confirm our findings. Although the qualitative approach is recommended for exploring new fields, it introduces subjective biases, calling for studies using more objective, quantitative methods to explore injury perceptions. Alternatively, a more sophisticated qualitative study could be used to collect data and conduct a broad-based, comprehensive comparative analysis.
Conclusions The theoretical review and the results of our qualitative study both lead to the conclusion that injury is represented cognitively as a unique construct, distinguishable from illness and other types of trauma. Thus, it is not enough for researchers to measure injury perceptions by slight modifications of illness perceptions. A measure tapping unique injury perceptions is needed. Such a scale based on this study is in preparation. It will allow comparisons between injured and caretakers, between different injury groups, etc. For clinicians, our results support the concept that identifying patients’ key perceptions and restructuring them can lead to better rehabilitation outcomes (Petrie et al., 2002). Key perceptions differ between ill and injured patients, even when their physical impairment is similar, calling for interventions tailored to the perceptions found to be
This research received no specific grant from any funding agency in the public, commercial, or not-forprofit sectors.
Notes 1. All names mentioned in the text are pseudo names. 2. An organization devoted to helping Israeli disabled veterans and victims of terrorism.
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Wadey R, Evans L, Evans K, et al. (2011) Perceived benefits following sport injury: A qualitative examination of their antecedents and underlying mechanisms. Journal of Applied Sport Psychology 23: 142–158. Wadey R, Evans L, Hanton S, et al. (2012) An examination of hardiness throughout the sport injury process. British Journal of Health Psychology 17: 103–128. Waller JA (1987) Injury as disease. Accident Analysis and Prevention 19: 13–20. Wong EC, Kennedy D, Marshall GN, et al. (2011) Making sense of posttraumatic stress disorder: Illness perceptions among traumatic injury survivors. Psychological Trauma: Theory, Research, Practice, and Policy 3: 67–76. World Health Organization (WHO) (2008) The Global Burden of Disease: 2004 Update. Geneva: WHO. Zatzick DF, Rivara FP, Nathens AB, et al. (2007) A nationwide US study of post-traumatic stress after hospitalization for physical injury. Psychological Medicine 37: 1469–1480.
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HPQ0010.1177/1359105314557876Journal of Health PsychologyShiloh et al.
Article
A common-sense model of injury perceptions
Journal of Health Psychology 1–11 © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1359105314557876 hpq.sagepub.com
Shoshana Shiloh1, Irit Heruti1,2 and Ronit Leichtentritt1
Abstract The aim of this study was to clarify the difference between perceptions of injury and illness. A qualitative study using semi-structured interviews was conducted with 38 individuals who had been injured in the past, 8 medical psychologists, 62 graduate psychology students, and 19 health professionals treating injured patients. Data were analyzed by modified analytic induction and constant comparison methods. Commonsense perceptions of injury overlapped with some perceptions of illness, and 4 new themes were elicited. It was concluded that there are themes unique to injury perceptions that should be recognized in research as well as in clinical interventions.
Keywords beliefs, disability, health psychology, model, phenomenology, qualitative methods
Introduction Injury is one of the top ten causes of death or disability worldwide, accounting for one-sixth of the world’s health burden (World Health Organization (WHO), 2008). While among the most common and oldest health problems facing people, injury began to be addressed with scientific rigor using public health methods only in the past 50 years (Sleet et al., 2012). In addition to the physical difficulties, injury victims often report psychological sequelae ranging from slight distress to posttraumatic stress disorder (PTSD) and related psychiatric morbidity (Zatzick et al., 2007). Despite their great significance, injuries are barely acknowledged as a distinct category in health psychology and remain to be conceptualized. This paper aims to fill the gap. The confusion between injury and illness can be traced to Waller’s (1987) paper entitled
‘Injury as Disease’. In it, the author ‘medicalized’ injuries in order to promote greater scientific, technological, and public health attention to them. These contentions, which were right for their time, objectives and audiences, are problematic with respect to health psychology. The model in Figure 1 illustrates the conceptual space in which injury is situated today as a category of traumatic events that can lead to impairment, like other agents including illness.
1Tel 2Tel
Aviv University, Israel Aviv-Yaffo Academic College, Israel
Corresponding author: Shoshana Shiloh, School of Psychological Sciences, Tel Aviv University, Tel Aviv 69978, Israel. Email: [email protected]
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Figure 1. A conceptual model of injury within the space of similar concepts.
Teasing apart the ways in which injury and illness are treated in the literature brings one to three general concepts in which injury is embedded: disability, trauma, and disease/illness. Injuries are described variously as health conditions tied to disability (Molloy et al., 2009); as one of four broad types of disabilities together with congenital, chronic illness, and psychiatric disabilities (Milligan and Neufeldt, 2001); as impairment – any loss or abnormality of psychological, physiological, or anatomical structure or function that may involve a disease or trauma (Johnston and Pollard, 2001); and as one of three categories of disability: (a) a person who has lived with a disability from birth or early life, (b) an otherwise healthy person who acquires a disability through an acute event of disease or trauma, and (c) a person who has lived with a progressive chronic illness (Robinson et al., 2006). Note that injury is not mentioned in the last two classifications, implying that it could be either a type of trauma or disease. Some researchers classify injury as a type of trauma (Littleton et al., 2007), along with sexual victimization and illness. Seeing injury as a
form of trauma is quite common, as attested to by the frequently used terms ‘traumatic injury’ or ‘traumatic physical injury’, e.g., (Jones et al., 2012). At the same time, more and more scientists address physical illness (cancer, cardiac disease, AIDS, etc.) as trauma (Sherr et al., 2011). Thus, the common denominators of disability on the one hand and trauma on the other may explain the intriguing overlap between the concepts of injury and disease/illness often found in the literature e.g. (Hurley and Lebbon, 2012). Despite the fact that injury and illness are separate triggering events of chronic disabilities (Livneh, 2001), the leading life event scale, the Social Readjustment Rating Scale (Holmes and Rahe, 1967), groups ‘major personal injury or illness’ into one item, and the International Classification of Diseases (Practice Management Information Corporation, 1997) classifies injury as a type of disease! In an effort to identify the similarities and differences between injury and illness, we turned to the Self-Regulatory model, which was developed in the context of chronic illness and health-threatening messages (Leventhal et al.,
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Shiloh et al. 1998). According to the model, coping procedures in response to illness or threat of illness depend on cognitive and emotional representations. Similarly, the key role of perceptions and representations for understanding people’s reactions to injury has been demonstrated (Haden et al., 2007). The theory maintains that illness perceptions are organized along five cognitive dimensions: Identity - a person’s beliefs about the symptoms of the illness and its label; Cause - the factors that the individual believes caused the illness; Consequences - a person’s evaluation of the impact the illness has on a patient’s life and activities; Timeline - an individual’s perception of the course of the illness, chronic or acute; Personal control – the evaluation of whether there are effective measures available to the individual to control or cure the illness. Together, these representations form a person’s cognitive representation of illness threat. The emotional representation component of the theory refers to a person’s evaluation of the potential emotional impact of the illness. The theory has become very popular because it provides an explicit, testable framework to understand the processes by which social cognitive constructs influence coping behaviors and outcomes in many health conditions e.g., (Hagger and Orbell, 2003). The Self-Regulation Theory has also been applied to the study of injuries (Chaboyer et al., 2010; Hagger et al., 2005; Medley et al., 2010; Wong et al., 2011). The common idea in those studies is that injury is a special type of illness, and that the measures of illness perceptions just need to be slightly modified in order to be applicable. Modifications included adding to the identity scale a few symptoms typical to injuries, like ‘discomfort walking’; replacing ‘my illness’ with ‘my injury’; omitting items from the ‘cause’ scale deemed inappropriate for injuries, like ‘smoking’, and adding injury-specific items, like ‘overtraining’. Findings showed modest correlations among the representation variables, coping procedures, and injury outcomes in accordance with the hypothesized pattern. Medley et al. (2010), however, noted the limitations of using illness perceptions for the study of injuries, in
particular the inadequacy of the causal attributions scale which does not take into account self/ other blame attributions that are especially salient among injured individuals. We took the Self-Regulatory model as a framework for identifying themes that are common to or unique to injury and illness and carried out an exploratory qualitative study to examine how injury is represented in comparison with illness perceptions, an approach recommended for areas with little knowledge (Leventhal, 1985). Our basic argument is that illness and injury are perceived differently, and themes specific to injury must be identified independent of those ascribed to illness.
Methods Participants Participants were volunteers recruited in Israel through advertising and the snowball technique: recruiting one individual with the desired characteristics and using that person’s social networks to recruit similar participants, who then help recruit others in a multistage process (Faugier and Sargeant, 1997). Semi-structured interviews were conducted in Hebrew with four groups with different perspectives on injury: Group 1) Thirty-eight individuals who had been injured in the past; 23 women and 15 men; mean age 37.93, SD = 9.04; 22 sport/dance injuries, 6 car accidents, 4 terror-related injuries, 4 military injuries and 2 work injuries; all but one had post-high school education. Group 2) Eight senior medical psychologists working with injured patients; 5 women and 3 men; mean age 50.00, SD = 8.81. Group 3) Sixty-two graduate students in medical psychology (n = 43) and rehabilitation psychology (n = 19) programs who do volunteer work with injured people; 47 women and 15 men; mean age 27.15, SD = 2.37. Group 4) Nineteen health professionals treating injured patients; 13 women and 6 men; mean age 40.00, SD = 9.64; 4 surgeons, 5 orthopedic nurses, 6 physiotherapists and 4 occupational therapists. The heterogenic sampling technique resulted in 127 participants with rich and
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diverse perspectives on the phenomenon under study. Group comparisons were beyond the scope of this study.
Procedure Ethical approval for the study was obtained from the relevant University authorities and guidelines on patient consent were met. Participants consented to volunteer in the study presented as ‘thoughts about injuries’, and met at their preferred location for a semi-structured interview of 30-60 minutes (Patton and Patton, 1990). All interviews were conducted and transcribed verbatim by the second author (I.H.). Participants were asked broad pre-prepared questions, followed by more specific probes, in accordance with guidelines for conducting semi-structured interviews (Smith, 2008). The interviewer often requested further details to elicit fuller accounts. The three leading questions developed for the interview protocol were: 1. ‘Think about an (your) injury. Now, express all the associations, thoughts, feelings or questions that come to your mind’. 2. ‘Think about injured and ill individuals. In your opinion, are there differences between them? If so, what are they?’ 3. ‘Imagine that you were asked to write a magazine article about someone who was injured. What would you like to know about his/her injury in order to write the most comprehensive article?’
Data analysis The answers to the interview questions were analyzed using modified analytic induction and constant comparison, which are complementary analysis methods. Modified analytic induction can begin with a pre-existing model that guides the investigator’s approach to the data (Smith and Manning, 1982). The pre-existing model is then compared with the facts and when they do not match, (i) assumptions are modified so that
the new facts will fall under them, and/or (ii) the phenomenon to be explained is re-defined to exclude the cases that defy explanation by the model (Robinson, 1951). The constant comparison method was first used in this study in a deductive manner, where all incidents observed for all participants were compared to dimensions of illness perceptions (Leventhal et al., 1998) and the labels were checked to see if they accurately matched the words of the participants. Secondly, the method was used as an inductive process in which ideas presented in the interviews that did not match the dimensions of illness perceptions were identified, categorized, and later labeled.
Results All participants1 thought that illness and injury are not the same, even when they cause a similar impairment or disability. In view of this inductive understanding, the similarities in injury and illness dimensions are reported first, followed by the unique dimensions relevant only to injury. One should note, however, that even when participants discussed similar dimensions for illness and injury, they noted aspects of injury that distinguished it from illness. Table 1 summarizes the main dimensions of injury perceptions compared with the common-sense model of illness perceptions (Leventhal et al., 1998).
Perceptions common to both injury and illness Identity. Identity refers to the illness label and symptoms. Like with illness, many symptoms were mentioned, some of them physical and some psychological: ‘Injury is related to amputation, fractures (Shelly, physiotherapist); ‘In injury one needs to pay attention if the injured has symptoms of psychological trauma’ (Lea, surgeon). But, unlike illness, injuries lack medical diagnostic labels like ‘diabetes’. Instead, the identity of an injury is determined by 1) a physical identity, delineating the type of damage, like burn or cut and the affected body part,
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Shiloh et al. Table 1. Dimensions of injury perceptions in comparison with the common-sense model of illness perceptions (Leventhal et al., 1998). Dimension
Illness
Injury
Common dimensions Identity
Symptoms + medical label
Examples Consequences
Sore or swollen glands Consequences
Examples
My illness is a serious condition
Time-line Examples
Acute / chronic My illness will last for a long time
Control Examples
Self & treatment control My treatment will be effective in curing my illness Causes A germ or virus caused my illness Emotions My illness makes me feel afraid
+ PTSD + body part + social identity Nightmares, Eyes, Traffic accident Focus on visibility, aesthetics & positive consequences My injury damaged my body’s wholeness; My injury showed me positive things about my surroundings + Time distance from the event I feel like my injury happened just yesterday Self & treatment control My treatment will be effective in curing my injury Focus on external factors Actions by others caused my injury + Specific emotions My injury makes me feel disgusted
Cause Examples Emotional representations Examples Unique dimensions Coping Examples Responsibility / blame Examples Event / Drama Examples Self – Injury Examples
– – – –
like leg or eyes; and 2) the social identity of the injury, like military injury, sport injury, suicide attempt, etc. ‘When I think of an injury, the first thing I think about, at an immediate level… physical… what kind of injury? Where in the body? How serious is it?’ (Tom, military injury); ‘Injury for me is first of all a bodily damage and only later psychological… physical changes, in organs… burnt skin, a screw that hasn’t been removed from the frontal lobe… it is a physical trauma, in a specific organ’ (Dafna, medical psychologist); ‘The background of injury, in the military, for example, … the knowledge that I was injured defending my country and the
Coping efforts and motivation It is hard to cope with my injury Failure to avoid; who perpetrated? I am not responsible for my injury Images, scenario, drama, urgency Broken items; Ambulance, Screams Me - Not me? Even when you are injured, you are actually a healthy person
support I received after the injury… have given me a better feeling’ (Ran, military injury); ‘..an injury related to war or terror has some aspect of heroism that maybe helps coping more easily, because people ‘understand’…’ (Naomi, terror injury); ‘When injury is a result of attempted suicide, then the attitude is different… the circumstance of injury is important… car accident, terror attack or attempted suicide… it’s not the same injury’ (Tali, occupational therapist).
Consequences. Like in illness, the consequences dimension of injury refers to beliefs regarding the physical, psychological and social impacts of injury on one’s life.
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Journal of Health Psychology ‘An injury occurring within one second can change one’s life… what are the consequences for the future?… will it cause disability?… what are the chances of returning to normal functioning?…’ (Ruth, car accident injury); ‘Injury causes changes in plans, it leads to functional disability, it leaves marks, scars that you cannot ‘‘erase’ (Shira, car accident injury).
As hinted in Shira’s quote, there were repeated allusions to the visibility of the injury, ‘Is it showing? Can it be concealed?’ (Gil, car accident injury); ‘Injury many times entails more consequences for body deformation and visible aesthetic defects in addition to functional … that exist in illness (Hadas, psychology graduate student). Positive consequences of the injury were also mentioned. Considerable attention was paid to self-growth and resilience, but participants also discussed insurance and monetary compensation in this category: ‘This was the best thing that happened to me; it enabled making a change for better’ (Lital, professional sport injury); ‘Parallel to the uncertainty and hindrance of plans, injury is also an opportunity to meet an unfamiliar part of yourself, an opportunity to change priorities, to test values and life philosophies, it is not just bad…’ (Maya, graduate psychology student); ‘An injury legitimizes a lawsuit, ‘I’m entitled’, social security, disability compensation, group support, ‘Beit Halochem’,2 special Olympics games for people with disability, fundraising day, ministry of defense… (Hadas, graduate psychology student).
Time-line. Time-line issues were translated into questions of whether or not the injury causes permanent disability (chronic), or is a temporary condition: ‘It is reversible, you get over it after some time’ (Adi, occupational therapist); ‘An injured person can recover, an ill person cannot… the chances of an injured person to get out of this trouble are higher..’ (Dan, work injury). Injury among participants was associated with a temporary condition, a situation that one can overcome, depending on one’s willpower and motivation. In addition, there were references to the time lapsed from the injury:
‘When did it happen? It was a long time ago’ (Dina, graduate psychology student); ‘With injury there is a time dimension – it would interest me to ask the patient how long it has been since he was injured…the conceptual perception of injury involves a short and limited time frame: the minute of the event, medical treatment/rehabilitation… you are not injured all the time… like a chronic disease’ (Yael, medical psychologist).
Causes. This dimension represents beliefs about the factors at the root of the illness or the injury. With regard to injury, special attention was paid to external causes which are irrelevant to illness like war, terror attacks and violence: ‘In injury there is an external factor… can be like a sharp object… or something related to the environment, nature, chemical agent, can be related to harsh weather, can be related to other people’s failures, to wrongdoings of others…’ (Adi, occupational therapist).
Personal/treatment control. Similar to illness, the texts included quotes about personal and treatment control: ‘The treatment in the hospital gave me a good feeling… I think it helped me recover in the long run’ (Tami, work injury); ‘When injured, I was busy thinking if I recover at the right pace… will I recover completely?.. will I return to normal functioning as I was…’ (David, war injury).
Attention was also paid to a sense of empowerment resulting from personal coping behaviors and the effectiveness of treatment. Emotional representations. Similar to illness, injury elicited many negative emotional representations, some of them specific to injury, like pity, helplessness and disgust: ‘Disgust… in injury there is a smell that sticks to you for a long time, and it is usually disgusting’ (Rachel, terror injury); ‘Injury is anxiety, death anxiety, suffering, sadness, sorrow, blame, shame’ (Yael, medical psychologist); ‘Helplessness, pain, fear, shock, depression, self-pity’ (Abigail, orthopedic nurse).
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Components unique to injury The illness perception dimensions of identity, consequences, timeline, causes, personal/treatment control and emotional representations were insufficient to account for all the participants’ responses regarding injury. Modifications of the analytic induction and constant comparison methods resulted in the following additions: Coping. There were many references to coping efforts and resources required from an injured individual that are not part of the illness perceptions model, in particular how difficult or easy it is to cope with the injury. This dimension emphasizes the coping efforts rather than healing and/or coping outcomes: ‘It requires much effort to get back to yourself; motivation, and drive to rehabilitate are very important’) Sara, terror injury);’Injury… is not the end of the world, you can cope, difficult but possible, you need much willpower, motivation, mobilization of strengths and coping skills’ (Yosef, medical psychologist). ‘An injured… feels more strong, stands up to his rights more than an ill person’ (Dan, work injury).
Responsibility/blame. Issues of fault, blame and accountability were elicited mainly with regard to failure to avoid or prevent the injury. Participants clearly pointed out that issues of blameworthiness and responsibility are critical in injury, unlike in illness: ‘Who caused the accident?’ (Michal, graduate psychology student). There were specific allusions to actions by others: ‘Did I contribute to causing the accident? How did it happen? Who was the offensive driver?… how could the driver allow himself to drive so carelessly…?’ (Ruth, car accident injury); ‘Was it bad luck? Destiny? Who is to blame? Why did it happen? Who is to blame?’ (Yonatan, military injury).
Event/drama. This theme did not have a comparable dimension in illness representations. Participants described vivid scenes including visual, auditory, and olfactory stimuli: ‘It is like
in a movie, broken things and ambulance sirens, the smell of smoke and people’s cries (Assaf, emergency physician). There were repeated allusions to the surprise/ suddenness of the situation: ‘Everything sudden, no announcement, impossibility to prepare oneself… everything happens so fast, under threat of loss… blood, infusion, lost consciousness, ambulance, paramedic staff, a stretcher, policemen, busy medical staff, to which hospital are they rushing me? tests, head immobilizing, white coat, danger… (Ruth, car accident injury).
Self - injury relationship. A repeated theme that distinguished between illness and injury was that injury was represented as more external to the self than illness: ‘An injured person is basically a healthy person. Injury goes with the young and illness with the old (Sharon, medical psychologist); ‘The injured… looks with dismay on the wound in his body and tries to distance himself from the wound… to tell himself that it is just a wound and it is in the body, like a punctured wheel that can be replaced… as if it’s not his’ (Tom, war injury); ‘It is easier to contain injury in comparison to illness, injury helps you keep a feeling of ‘being well’. It is something external, it is less ‘absorbed’ into one’s self-image… it is something coming from outside and is less threatening to one’s selfesteem’(Uri, car accident injury).
Discussion The qualitative study reported here supports the notion that common-sense perceptions of injury differ from common-sense perceptions of illness, although there is some overlap. Not only did the contents of dimensions differ (e.g., types of symptoms), a variance that is often seen across diseases, but new dimensions unique to injuries emerged. These included social identities, coping, event/drama representations, perceived time lapsed from the event, issues related to responsibility and blame, and to the distance between an injury and the self of the injured person. The different representations may explain
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previous findings regarding the split between illness and injury fears (Carleton et al., 2006), and the different attitudes towards ill and injured individuals (Shiloh et al., 2011). The identification of a ‘self’ dimension in injury representation deserves special attention. Leventhal et al. (1999) discussed the importance of the ‘me? - not me?’ question with regard to the representation of an illness as acute or chronic. An injury also involves reassessment and renegotiation of a person’s identity, especially if it marks the onset of disability. The injured individual must identify which aspects of his/her self have been lost, which remain, and which are part of a new identity (Dickson et al., 2008). The distancing stance (injury is external to the self, unlike illness) that was elicited in our study may represent the process of renegotiating one’s identity. There is evidence that considering injured patients’ selfconcepts is important for improving rehabilitative progress (Doering et al., 2011). Also, while the Self-Regulatory model (Leventhal et al., 1998) presents coping as following illness representations, our findings suggest that coping is part of the representation. The penetration of coping into the injury schema is consistent with findings that activation of a schematic representation of illness automatically activates information related to coping procedures encoded in memory with the illness (Henderson et al., 2009). Another noteworthy dimension unique to injury is the event/drama representation, which has tremendous importance in injury representations mainly because of its close relationship to the development of PTSD. Re-experiencing the traumatic event in the form of spontaneous flashbacks is a core symptom of PTSD (Brewin, 2002) involving vivid and intense memory of the traumatic event (Gil et al., 2006). The event/ drama and the social identity dimensions point to features of the context in which injury occurred. As such, it may represent a step toward developing a multi-level model, in which injury is not only situated in the individual, but is also part of the wider social-ecological environment.
Several new themes of injury, related to the original illness dimensions, were also found. They parallel the literature showing that body image dissatisfaction is an important indicator of subsequent quality of life among patients after disfiguring injuries (Fauerbach et al., 2002); that there are positive consequences of injury (Wadey et al., 2011); that coping strategies and self-efficacy are main topics in an injury trajectory (Bonanno et al., 2012); and that length of time elapsed since the injury is an important factor in the adjustment process (Bryant, 2011). The emphasis on responsibility and blame issues in injury also dovetails with the literature. Blaming the accident victim is often part of legal proceedings for compensation in the workplace (de Almeida et al., 2000). Blaming is also a main issue when the injury is perpetrated by another person (DeRoon-Cassini et al., 2010). The only studies with which we can compare our findings used interpretative phenomenological analysis to investigate small samples of individuals with spinal cord injury, one of the most devastating and traumatic neurological impairments (Dickson et al., 2008). Despite the differences in samples and the fact that we addressed injury as a generic category, our themes (coping, self, etc.) were similar to the main appraisal themes discovered in those studies, which were: ‘Making sense of traumatic experience’ - thoughts about what had happened and whether the injury was avoidable; ‘Impact’ - losses, gains, hopes, and fears for the future; ‘Coping’ -evaluations of coping resources; ‘Altered view of self and life’ increased self-awareness; ‘Loss of control’; ‘Loss of independence;’ and ‘Loss of identity’. Published studies on injury generally deal with a specific type of physical injury like spinal cord, or a specific social category of injuries like sport accidents (Wadey et al., 2012). Hence, they relate to the two-dimensional identity facets – physical and social – discovered in the present study. Specific injuries may elicit different perceptions, same as perceived differences between specific acute and chronic illnesses. Despite the
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Shiloh et al. variety, our findings suggest that there is an overarching perception of injury unrelated to its particular manifestation, similar to the cognitive concept of illness, which also encompasses a large variety of manifestations.
more salient in injury representations – the event itself, the social identity of the injury, and issues of visibility, blame and self. Further research on more populations is required to confirm and expand these suggestions.
Limitations
Funding
The large sample representing several perspectives would appear to be an advantage of our study, but the fact that all participants were from the same cultural background might have introduced a bias (Kleinman et al., 1978). Further research on other, perhaps more culturally heterogeneous populations is needed to confirm our findings. Although the qualitative approach is recommended for exploring new fields, it introduces subjective biases, calling for studies using more objective, quantitative methods to explore injury perceptions. Alternatively, a more sophisticated qualitative study could be used to collect data and conduct a broad-based, comprehensive comparative analysis.
Conclusions The theoretical review and the results of our qualitative study both lead to the conclusion that injury is represented cognitively as a unique construct, distinguishable from illness and other types of trauma. Thus, it is not enough for researchers to measure injury perceptions by slight modifications of illness perceptions. A measure tapping unique injury perceptions is needed. Such a scale based on this study is in preparation. It will allow comparisons between injured and caretakers, between different injury groups, etc. For clinicians, our results support the concept that identifying patients’ key perceptions and restructuring them can lead to better rehabilitation outcomes (Petrie et al., 2002). Key perceptions differ between ill and injured patients, even when their physical impairment is similar, calling for interventions tailored to the perceptions found to be
This research received no specific grant from any funding agency in the public, commercial, or not-forprofit sectors.
Notes 1. All names mentioned in the text are pseudo names. 2. An organization devoted to helping Israeli disabled veterans and victims of terrorism.
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