Rehabilitation Psychology 2015, Vol. 60, No. 3, 213–221

© 2015 American Psychological Association 0090-5550/15/$12.00 http://dx.doi.org/10.1037/rep0000043

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Perceived Injustice After Traumatic Injury: Associations With Pain, Psychological Distress, and Quality of Life Outcomes 12 Months After Injury Zina Trost

Stephanie Agtarap

University of North Texas and University of Alabama

University of North Texas

Whitney Scott

Simon Driver

King’s College London

Baylor Institute for Rehabilitation, Dallas, Texas

Adam Guck

Kenleigh Roden-Foreman, Megan Reynolds, Michael L. Foreman, and Ann Marie Warren

University of North Texas

Baylor University Medical Center Objective: There is growing recognition that individuals who experience traumatic injuries perceive themselves as victims of injustice and that elevated levels of perceived injustice are associated with problematic physical and psychological outcomes. To date, research regarding injustice perception and injury outcomes has been restricted to a small number of musculoskeletal pain conditions. No research to date has examined the potential impact of perceived injustice among individuals admitted for trauma care. Method: As part of this cross-sectional study, individuals (n ⫽ 155) admitted to a Level-1 trauma center completed measures of perceived injustice, pain, depression, posttraumatic stress, and health related (physical and mental/emotional) quality of life (HRQoL) outcomes 12 months after trauma admission. Results: Bivariate analyses revealed significant associations between perceived injustice and demographic variables (education, income, race, and age) as well as injury-related variables (type of injury and length of hospital stay). Perceived injustice was correlated with greater pain intensity, depression, and PTSD symptoms, as well as poorer physical and mental HRQoL. Controlling for relevant demographic and injury-related variables, perceived injustice accounted for unique variance in pain intensity, depression severity, the presence and intensity of PTSD symptoms, mental HRQoL, and was marginally significant for physical HRQoL. Conclusions: This is the first study to examine perceived injustice in a trauma sample. Results support the presence of injustice perception in this group and its associations with pain and quality of life outcomes. Additional research is suggested to explore the impact of perceived injustice on recovery outcomes among individuals who have sustained traumatic injury. Keywords: traumatic injury, perceived injustice, pain, depression, PTSD, quality of life

Impact and Implications Although there is growing recognition that perceptions of injustice are associated with poorer physical and psychological outcomes in acute and chronic pain conditions, the current study represents the first effort to examine the impact of perceived injustice within a trauma sample.

• The current study examines a construct that has not typically received substantial empirical attention in the trauma or rehabilitation literature. • As no existing intervention directly targets perceptions of injustice, the current findings stand to inform areas of potential intervention and highlight variables that may put individuals at particular risk for negative outcomes.

This article was published Online First July 20, 2015. Zina Trost, Department of Psychology, University of North Texas; Stephanie Agtarap, Experimental Psychology Program, University of North Texas; Whitney Scott, Department of Psychology, Institute of Psychiatry, King’s College London; Simon Driver, Baylor Institute for Rehabilitation, Dallas, Texas; Adam Guck, Clinical Health Program, University of North Texas; Kenleigh Roden-Foreman, Megan Reynolds, Michael L. Foreman, and Ann Marie Warren, Division of Trauma, Baylor University Medical Center. Zina Trost is now at Department of Psychology, University of Alabama at Birmingham. The authors have no pharmaceutical or industry support and claim no conflict of interest. This research was accepted as poster presentations

for the 35th Annual Meeting of the Society of Behavioral Medicine on April 23–26, 2014 and 33rd Annual Scientific Meeting of the American Pain Society on April 30 –May 3, 2014. The authors have no disclosures of any funding from the National Institutes of Health, Wellcome Trust, or Howard Hughes Medical Institute. The authors gratefully acknowledge the generosity of the Stanley Seeger Surgical Fund of the Baylor Health Care System Foundation for their full support to this study. Correspondence concerning this article should be addressed to Zina Trost, PhD, Assistant Professor, Department of Psychology, University of Alabama, Campbell Hall, Room 415 Birmingham, AL 35294. E-mail: [email protected]

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TROST ET AL.

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Introduction Traumatic injuries comprise a leading cause of death and disability among individuals under 44 years of age, with ⬃2.8 million people hospitalized in the United States each year (World Health Organization, 2010; Krug, Sharma, & Lozano, 2000; Center for Disease Control and Prevention, 2014). The majority of individuals who sustain physical trauma show a positive adjustment trajectory (Bombardier et al., 2012; Hoffman, Bombardier, Graves, Kalpakjian, & Krause, 2011). However, for some, life after injury can be characterized by negative physical and psychological outcomes that persist long after the traumatic event (Krug et al., 2000). These outcomes can include chronic pain (Rivara et al., 2008), impaired functional status (Michaels et al., 2000), and persistent psychological distress, such as symptoms of depression and posttraumatic stress disorder (PTSD; Bryant et al., 2010; O’Donnell, Creamer, Pattison, & Atkin, 2004; Ponsford, Hill, Karamitsios, & Bahar-Fuchs, 2008; Zatzick et al., 2007). In addition to significant personal suffering, these negative sequelae contribute to substantial economic burden faced by individuals and health care systems (Finkelstein, Corso, & Miller, 2006). To improve outcome trajectories, there is growing interest in psychosocial variables that have been shown to impact recovery after traumatic injury (Archer, Abraham, Song, & Obremskey, 2011; Mayou, Bryant, & Ehlers, 2001). Recent research has drawn attention to the fact that some individuals who experience physical injuries may perceive themselves as victims of injustice (Trost, Vangronsveld, Linton, Quartana, & Sullivan, 2012), operationally defined as an appraisal reflecting the severity and irreparability of injury-related loss, blame, and unfairness (Sullivan et al., 2008; Sullivan, Scott, & Trost, 2012). Research suggests that perceptions of injustice contribute to worse physical and psychological outcomes both after acute injury and in the context of chronic health conditions (Scott, Trost, Bernier, & Sullivan, 2013; Trost et al., 2012). To date research has focused on injuries to the back and neck. For example, in a sample of individuals with musculoskeletal pain after an occupational or motor vehicle accident, Sullivan and colleagues (2008) found that perceived injustice was associated with greater self-reported pain intensity and disability, more severe depressive symptomatology, and reduced likelihood of return to work 1 year after multidisciplinary rehabilitation (Sullivan et al., 2008). Among individuals with whiplash injuries, injustice perception was linked to persistence of posttraumatic and depressive symptomatology (Scott, Trost, Milioto, & Sullivan, 2015; Sullivan, Thibault et al., 2009). The association between perceived injustice, pain intensity, disability, and psychological distress has been replicated in samples comprising whiplash injury (Scott, Trost, Milioto, & Sullivan, 2013, 2015; Sullivan, Adams, Martel, Scott, & Wideman, 2011; Sullivan, Davidson, Garfinkel, Siriapaipant, & Scott, 2009), fibromyalgia (Rodero et al., 2012), and persistent musculoskeletal pain (primarily neck and back pain; Scott & Sullivan, 2012; Scott et al., 2013). In short, there is mounting cross-sectional and prospective evidence that perceived injustice is associated with problematic physical, psychosocial, and functional outcomes. To date, research on injustice perception has focused on relatively few conditions and has not examined the presence and impact of perceived injustice among individuals who have sustained injury severe enough to require hospitalization. Given the

immediate and potentially enduring repercussions of physical trauma, it is reasonable to assume that individuals may endorse injustice-related cognitions, characterized by thoughts of undeserved suffering, blame, unfairness, and irreparable loss. The aims of the current cross-sectional study were to (a) characterize injuryrelated perception of injustice in a sample of individuals admitted to a Level-1 trauma center for acute traumatic injury, (b) examine associations between perceived injustice and demographic and injury-related variables, (c) examine associations between perceived injustice, pain, psychological outcomes, and physical and mental HRQoL, and (d) examine the unique (cross-sectional) contribution of perceived injustice to pain, psychological, and HRQoL outcomes. All assessments were performed at 12 months after admission, as previous literature suggests that differential recovery outcomes become particularly apparent ⬃1 year after traumatic injury (e.g., Jenewein et al., 2009). The findings are expected to contribute to understanding of factors that shape long-term trauma outcomes and highlight avenues for potential intervention.

Method Participants Participants were admitted to a Level 1 trauma center in the southwest United States between March 2012 and June 2013. Patients were consented after initial hospitalization; all patients meeting inclusion criteria per initial review of medical records were approached for participation by the study coordinator and were identified using daily trauma census lists, chart reviews, and biweekly interdisciplinary rounding. Eligibility criteria included admission to the trauma service for at least 24 hr, being 18 years of age or older, and the ability to provide at least one contact for follow-up. Exclusion criteria included an inability to comprehend English or Spanish and/or the presence of cognitive deficits (e.g., dementia, severe TBI) that impaired ability to provide informed consent. Cognitive deficits were assessed through chart review by the research coordinator before approaching patients for participation. Further, orientation questions (e.g., name, date, location, and time of day) from the Cognistat screening tool (Kiernan, Mueller, Langston, & Van Dyke, 1987) formerly known as the Neurobehavioral Cognitive Status Examination, were administered by the research coordinator prior to the study questionnaires. If a patient scored below 10, participation was halted and orientation was reassessed the next day. At 12 months (⫾2 months) after admission, participants completed standardized measures, administered by telephone. To maximize our potential to reach participants at a time most convenient for them, reminder emails or postcards (based on participant preference) were sent 1 month before participants’ 12 month follow up date. In each of these reminders, participants were offered the option to contact the research team if there was a certain time that would be most convenient for them to participate in the follow-up interview. During the follow-up window, researchers attempted to contact the participant a maximum of 12 times. The contact schedule included a rotating series of attempts including four calls during the week day (9 a.m. to 5 p.m.), four calls in the evening (5 p.m. to 8 p.m.), and four calls during the weekend (Friday 5 p.m.

PERCEIVED INJUSTICE AFTER TRAUMATIC INJURY

through Sunday). Study procedures were approved by the hospital Institutional Review Board.

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Measures Demographic information was obtained from participants at the time of consent and verified by chart review. Participant injuryrelated information was obtained from the hospital trauma registry (TraumaBase CDM, Conifer, CO), maintained as a criterion for Level 1 trauma center designation by the American College of Surgeons for the National Trauma Data Bank. Perceived injustice was measured using the Injustice Experience Questionnaire (IEQ; Sullivan et al., 2008). The IEQ is a 12-item scale that asks respondents to indicate the frequency with which they experience different thoughts concerning the sense of unfairness in relation to their injury using a 5-point Likert-type scale ranging from 0 (never) to 4 (all the time). Representative items reflect elements of blame (“I am suffering because of someone else’s negligence”), magnitude of loss (“I feel as if I have been robbed of something very precious”), and irreparability of loss (“My life will never be the same”). IEQ scores can range from 0 to 48, with higher scores indicating higher perceptions of injustice. The IEQ has demonstrated good psychometric properties in samples with musculoskeletal injury (Scott, Trost, Milioto et al., 2013; Sullivan et al., 2008). Pain intensity was measured using a numeric rating scale (NRS), with zero representing “no pain” and 10 representing “worst possible pain” reported on average over the past two weeks. The numerical ratings scale is supported as a valid and reliable measure of pain intensity (Downie et al., 1978). Depression was measured using the Patient Health Questionnaire-8 (PHQ-8), which is a well-validated measure of depression in clinical and general populations (Kroenke et al., 2009; Shih, Schell, Hambarsoomian, Marshall, & Belzberg, 2006). The PHQ-8 asks participants to rate the frequency of depressive symptoms over the previous 2 weeks on a 0 (not at all) to 3 (nearly every day) scale; scores range from 0 –24, with higher scores indicative of greater depressive symptomatology. Presence of posttraumatic stress symptoms was determined using the Primary Care PTSD (PC-PTSD) screen, which demonstrates diagnostic validity comparable to full-length PTSD assessments among trauma patients (Hanley, deRoon-Cassini, & Brasel, 2013; Reese et al., 2012). Scores range from 0 to 4; a score of 3 or higher was considered a positive screen for clinical levels of PTSD symptoms (Prins et al., 2003). For participants who screened positive on the PC-PTSD, severity of posttraumatic symptoms was assessed using the PTSD Checklist-Civilian Version (PCL-C; Weathers & Ford, 1996) that comprises 17 questions reflecting Diagnostic and Statistical Manual for Mental Disorders-Fourth Edition-Text Revision (DSM–IV–TR) PTSD criteria. Scores range from 17 to 85; with higher scores indicative or more severe symptoms. The PCL-C demonstrates reliability and validity in trauma samples (Zatzick et al., 2007). Health-related quality of life (HRQoL) outcomes were measured using the Veterans RAND 12-Item Health Survey, which consists of 12 items assessing eight domains: physical functioning, role limitations due to physical problems, bodily pain, general perception of health, vitality, social function, role limitation because of emotional problems, and mental health. These subscales

215

are summarized into global summary measures of physical and mental/emotional health—the Physical Component Score (VRPCS) and Mental Component Score (VR-MCS). Scores below 50 indicate diminished HRQoL. The Veterans RAND shows good psychometric properties in both veteran and civilian populations (Selim, Rogers, Qian, Brazier, & Kazis, 2011; Selim et al., 2009).

Data Analytic Plan Sample characteristics were reported for perceived injustice, outcome variables, demographic variables, and injury-related variables (Aim 1). Demographic and injury-related variables were tested for significant associations with perceived injustice (IEQ; Aim 2) using analysis of variance or bivariate correlation. Bivariate correlations were also conducted to examine associations between participants’ IEQ score and outcome variables (Aim 3), as well as interrelationships among the outcome variables. All analyses utilized demographic information obtained at baseline. Separate hierarchical regression analyses were conducted to examine the unique/incremental contribution of injustice perception (IEQ) to individuals’ pain intensity (NRS), HRQoL outcomes (VR-PCS and VR-MCS), and psychological outcomes (depressive and posttraumatic stress symptoms; PHQ-8, PCL-C; Aim 4). Logistic regression tested for presence of PTSD symptoms (PC-PTSD). For each dependent variable, potentially relevant demographic variables were entered into the first block (age at injury, gender, race, marital status, education level, and income) and injury-related variables were entered into the second block (pain intensity, injury severity, cause of injury, and trauma type). To control for the effects of general distress, participants’ VR-MCS score was entered into the third block. Participants’ IEQ score was then entered into the fourth block. VR-MCS score was not regressed onto depression score as the two measures are strongly correlated at r ⫽ .79. To achieve the most parsimonious model, following this initial analysis the model was rerun retaining only variables found to significantly contribute to criterion variance within each block. Results from the final model are reported. Initial checks confirmed assumptions of normality, linearity, and heteroscedasticity using histograms and scatterplots. Varianceinflation factors of all regression analyses were small (VIF ranged from 1.00 to 1.83) indicating no problems of multicollinearity. All analyses were cross-sectional in nature and do not denote causality. Within the body of the text, sample size is reported for all analyses for which the entire dataset (n ⫽ 155) was not available.

Results Sample Characteristics Table 1 summarizes participant demographic and injuryrelated information. Of 155 patients who completed the assessment, 58.7% were male, 56.1% identified as White, 22.6% identified as Black, and 14.2% identified as Hispanic. Participants ranged in age from 18 to 88 years (M ⫽ 47.5, SD ⫽ 17.72). The most common cause of injury was motor vehicle collision (42.6%). Figure 1 depicts the participant inclusion

TROST ET AL.

216 Table 1 Sample Characteristics (N ⫽ 155)

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Variable Demographic variables Age Gender Female Male Ethnicityⴱ Non-Hispanic White Non-Hispanic Black Hispanic (White and Black) Other Would rather not say Marital status Never married Married Divorced Separated Widowed Would rather not say Education levelⴱⴱ Less than HS HS diploma Associate’s Bachelor’s Graduate/professional Would rather not say Incomeⴱⴱ ⬍25K 25–49K 50–74K 75⫹ K Not sure/would rather not say Injury-related variables of initial hospitalization Pain (NRS)ⴱⴱ Cause of injuryⴱ Fall Motor vehicle collision Violent crime (e.g., gunshot/stab wound) Other (e.g., animal, machine) Trauma typeⴱⴱ (n ⫽ 149) Blunt Penetrating Missing/unobtainable Injury Severity Score (ISS) (n ⫽ 148) Length of stayⴱ (n ⫽ 149)

N (%) or mean (SD) 47.50 (17.72) 64 (41.3%) 91 (58.7%) 87 (56.1%) 35 (22.6%) 22 (14.2%) 4 (2.6%) 7 (4.5%) 51 (32.9%) 62 (40.0%) 25 (16.1%) 5 (3.2%) 11 (7.1%) 1 (0.6%) 29 (18.7%) 52 (33.5%) 19 (12.3%) 36 (23.2%) 17 (.6%) 2 (1.3%) 38 (24.5%) 16 (10.3%) 29 (18.7%) 39 (25.2%) 33 (21.3%) 6.52 (2.43) 47 (30.3%) 66 (42.6%) 23 (14.8%) 13 (8.4%) 133 (85.8%) 16 (10.3%) 6 (3.9%) 12.01 (8.24) 8.99 (13.13)

Note. NRS: 1-10 Numeric Rating Scale; Cause of Injury and Trauma Type reported via Trauma Registry; Injury Severity Score (ISS) is an anatomic scoring system that provides an overall score for patients with multiple injuries; ⴱ p ⬍ .05. ⴱⴱ p ⬍ .01, denote significant association with IEQ.

flowchart. For the current sample, the mean IEQ score was 17.07 (SD ⫽ 14.55), ranging from a minimum of 0 to a maximum of 48. Cronbach’s ␣ for the IEQ was ␣ ⫽ .95. IEQ scores were slightly positively skewed (.61); however, both skewness and kurtosis factors met acceptable standards (Glassnap & Poggio, 1985; Tabachnick & Fidell, 2001). We also examined differences in baseline demographic and injuryrelated characteristics between participants who completed follow-up and those who did not (i.e., participants who withdrew, were unable to be contacted, or had incomplete follow-

ups). Less retention was observed among younger participants (⌬M ⫽ 7.25, p ⬍ .001), male participants, ␹2(1) ⫽ 3.20, p ⫽ .074, participants with lower income level, ␹2(4) ⫽ 13.19, p ⫽ .010, and participants who sustained penetrating trauma, ␹2(2) ⫽ 6.05, p ⫽ .049.

Associations Between Perceived Injustice and Demographic and Injury-Related Variables In terms of demographic variables, differences in perceived injustice were found for educational level, F(5, 149) ⫽ 3.98, p ⫽ .002, and income, F(4, 150) ⫽ 4.09, p ⫽ .004. Specifically, participants with less than a high school education reported higher levels of perceived injustice than those with a bachelor’s (p ⫽ .014), graduate, or professional degree (p ⫽ .01). Participants earning ⬍$25K reported higher levels of perceived injustice than those earning $50 –74K (p ⫽ .050) or those earning ⬎$75K (p ⫽ .01). Analyses likewise revealed significant differences according to racial identification, Welch’s F(4, 16.29) ⫽ 4.07, p ⫽ .018, in that patients who identified as Black endorsed higher perceived injustice than individuals who identified as White. Finally, younger participants reported higher perceived injustice than older counterparts, r ⫽ ⫺.18, p ⫽ .022. In terms of injury-related variables, group differences emerged for cause of injury, F(3, 145) ⫽ 3.47, p ⫽ .018, and trauma type, F(1, 147) ⫽ 7.69, p ⫽ .006. Specifically, participants injured in violent crime reported greater perceived injustice than those admitted for fall injury (p ⫽ .012, n ⫽ 149) and participants with penetrating trauma reported greater perceived injustice than those with blunt trauma (p ⫽ .006, n ⫽ 149). Finally, perceived injustice was positively associated with length of stay (r ⫽ .20, n ⫽ 149), such that those with longer hospital stay reported greater perceived injustice.

Bivariate Associations Between Perceived Injustice and Outcome Variables Table 2 shows associations between perceived injustice and outcome variables, as well as means and standard deviations. 366 Trauma Patients approached from March 2012 – March 2013

310 patients agreed to participate

264 participants eligible for 12-month follow-up

14 incomplete at baseline (e.g., fatigue, nausea) 10 withdrew† 5 deceased 9 jailed 1 still hospitalized 7 incomplete 12 month follow-ups†

109 participants unable to be contacted+ 155 participants completed 12-month follow-up (58.7% retention rate)

Figure 1. Participant inclusion flow chart († denotes lost to follow-up/ missing data).

PERCEIVED INJUSTICE AFTER TRAUMATIC INJURY

217

Table 2 Means, SDs, and Associations Between Perceived Injustice and Outcome Variables Variable

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1. 3. 5. 7. 9. 11. 13.

Perceived Injustice (IEQ) Pain (NRS) Physical HrQOL (VR-PCS) Mental HrQOL (VR-MCS) Depression (PHQ-8) PTSD Screen (PC-PTSD)⫹ PTSD severity (PCL-C)

N

M (SD)

Range

1

2

3

4

5

6

155 155 155 155 155 155 46

17.07 (14.55) 4.01 (3.00) 36.61 (12.01) 47.63 (13.63) 6.94 (6.64) 1.57 (1.47) 51.24 (16.75)

0–48 0–10 11–59 9–72 0–24 0–4 26–85

.63ⴱⴱ ⫺.41ⴱⴱ ⫺.60ⴱⴱ .64ⴱⴱ .61ⴱⴱ .61ⴱⴱ

⫺.63ⴱⴱ ⫺.41ⴱⴱ .55ⴱⴱ .51ⴱⴱ .36ⴱ

.15† ⫺.43ⴱⴱ ⫺.28ⴱⴱ ⫺.08

⫺.79ⴱⴱ ⫺.60ⴱⴱ ⫺.68ⴱⴱ

.69ⴱⴱ .63ⴱⴱ

.54ⴱⴱ

Note. IEQ ⫽ Injustice Experiences Questionnaire; NRS ⫽ 1–10 Numeric Rating Scale; VR-PCS ⫽ Veterans RAND 12-Item Survey Physical Composite Score; VR-MCS ⫽ Veterans RAND 12-Item Survey Mental Composite Score; PHQ-8 ⫽ Patient Health Questionnaire-8; PC-PTSD ⫽ Primary Care PTSD Screener; PCL-C ⫽ PTSD Checklist-Civilian Version; ⫹PTSD Screen utilizes the 0 – 4 point range; only participants who screened positive (⬍3) on the PC-PTSD were subsequently administered the PCL-C. † p ⬍ .10. ⴱ p ⬍ .05. ⴱⴱ p ⬍ .01.

Greater perceived injustice was significantly associated with higher pain intensity (r ⫽ .63), poorer physical HRQoL (r ⫽ ⫺.41), poorer mental/emotional HRQoL (r ⫽ ⫺.60), greater depression (r ⫽ .64), and greater PTSD severity (r ⫽ .61, n ⫽ 46; all ps ⬍ 001).

Regression Analyses Table 3 shows the final model for each outcome variable, retaining variables found to make a unique contribution to outcome variance prior to inclusion of IEQ. Pain intensity. Of the demographic variables, education level and income accounted for 18% of the variance in pain intensity, ⌬F ⫽ 17.17, p ⬍ .001. Injury-related variables entered into the second step of the analysis failed to make a significant contribution to the prediction of pain intensity. In the third block, VR-MCS score (mental/emotional health-related quality of life) accounted for 10% of the variance, ⌬F ⫽ 21.24, p ⬍ .001. When added to the fourth block of analysis, IEQ score uniquely accounted for an additional 17% of the variance in pain intensity, ⌬F ⫽ 46.15, p ⬍ .001. Depression. Of the demographic variables, education and income accounted for 14% of the variance in participants’ depression score, ⌬F ⫽ 12.76, p ⬍ .001. Of the injury-related variables, pain intensity accounted for an additional 12% of the variance in depression, ⌬F ⫽ 42.27, p ⬍ .001. When added to the third block of analysis, IEQ score uniquely accounted for an additional 13% of variance in depression, ⌬F ⫽ 36.63 p ⬍ .001. Posttraumatic stress symptoms. Of 155 participants, 46 (29.7%) screened positive for PTSD. Participants’ age at injury and income significantly contributed to predicting presence of PTSD symptoms, ␹2(2) ⫽ 22.08, p ⬍ .01, indicating that younger participant and participants with lower income were more likely to report PTSD symptoms. Of injury-related variables, pain intensity significantly contributed to the model, ␹2(1) ⫽ 51.76, p ⬍ .001, indicating that participants reporting greater pain intensity were more likely to report PTSD symptoms. Participants’ VR-MCS score significantly contributed to the model in the third step, ␹2(1) ⫽ 77.52, p ⬍ .001, indicating greater psychological distress among individuals reporting PTSD symptoms. Finally, when added to the fourth block, IEQ score showed a significant contribution, ␹2(1) ⫽ 82.77, p ⬍ .001, indicating that participants

reporting higher perceptions of injustice were more likely to present with symptoms of PTSD. In terms of PTSD severity (PCL-C), demographic variables failed to uniquely account for variance in the final model. Of the injury-related variables, pain intensity and trauma type accounted for 38% of the variance in PTSD symptom severity, ⌬F ⫽ 12.76, p ⬍ .001. Added to the third block of analysis, participants’ VR-MCS score accounted for 25% of the variance, ⌬F ⫽ 27.93, p ⬍ .001. When added to the fourth block of analysis, IEQ score uniquely accounted for an additional 4% of the variance in severity of PTSD symptoms, ⌬F ⫽ 4.28, p ⫽ .007. Physical and mental HRQoL. Of the demographic variables, participants’ age at injury, educational level, and income accounted for 15% of the variance in physical HRQoL, ⌬F ⫽ 9.17, p ⬍ .001. Of injury-related variables, pain intensity accounted for an additional 29% of the variance, ⌬F ⫽ 81.07, p ⬍ .001. When added to the third block of analysis, participants’ VR-MCS accounted marginally accounted for 1% of the variance, ⌬F ⫽ 3.33, p ⬍ .10. When added to the fourth block of analysis, IEQ score likewise showed marginal significance, accounting for 1% of the variance in physical HRQoL, ⌬F ⫽ 3.69, p ⫽ .06, when the above demographic and injury-related variables were controlled for. In terms of mental HRQoL, educational level accounted for 6% of the variance in participants’ HRQoL, ⌬F ⫽ 9.35, p ⬍ .001, and pain intensity accounted for an additional 12% of the variance, ⌬F ⫽ 21.55, p ⬍ .001. When added to the third block of analysis, IEQ score accounted for an additional 19% of the variance in mental HRQoL, ⌬F ⫽ 46.32, p ⬍ .001.

Discussion The current study is the first to examine the impact of perceived injustice in a sample of individuals admitted with traumatic injury to a Level 1 trauma center. Results indicated that perceived injustice is uniquely associated with poorer physical and psychological outcomes in this population. Results also extend previous research by identifying demographic and injury-related correlates of perceived injustice among individuals with traumatic injury.

TROST ET AL.

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Table 3 Regression Analyses at 12-Month Follow-Up

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Outcome variable Pain intensity (0–10 NRS) Step 1 Educational level Income Step 2 Step 3 VR-MCS Step 4 IEQ Depression (PHQ-8) Step 1 Educational level Income Step 2 Pain Step 3 IEQ Presence of PTSD symptoms (PC-PTSD) Step 1 Age at Injury Income Step 2 Pain Step 3 VR-MCS Step 4 IEQ Severity of PTSD symptoms (PCL-C) Step 1 Step 2 Trauma type Pain Step 3 VR-MCS Step 4 IEQ Physical HrQOL (VR-OCS) Step 1 Age at Injury Educational level Income Step 2 Pain Step 3 VR-MCS Step 4 IEQ Mental HrQOL (VR-MCS) Step 1 Education Step 2 Pain Step 4 IEQ

2 Rchange

F

␤

.18

17.17ⴱⴱ

— .10

— 20.05ⴱⴱ

⫺.35 ⫺.23 — ⫺.33

.17

31.07ⴱⴱ

.53

.14

12.76ⴱⴱ

.19

24.90ⴱⴱ

.13

32.24ⴱⴱ

HR

␹2

70.3%

22.08ⴱⴱ

76.1%

51.76ⴱⴱ

81.9%

77.52ⴱⴱ

83.2%

82.77ⴱⴱ

— .38

— 12.76ⴱⴱ

.25

23.27ⴱⴱ

.04

19.91ⴱⴱ 9.17ⴱⴱ

.29

30.79ⴱⴱ

.01

25.68ⴱⴱ

.01

22.39ⴱⴱ

.06

9.35ⴱⴱ

.12

16.08ⴱⴱ

.19

29.36ⴱⴱ

⫺4.72ⴱⴱ ⫺3.06ⴱⴱ — ⫺4.61ⴱⴱ 6.79ⴱⴱ

⫺.29 ⫺.22

⫺3.90ⴱⴱ ⫺2.85ⴱⴱ

.48

6.50ⴱⴱ

.47 Odds

6.05ⴱⴱ Wald

.96 .71

6.13ⴱ 5.77ⴱ

1.49

22.86ⴱⴱ

.91

18.60ⴱⴱ

1.06

5.12ⴱ

—

—

.49 .37

4.03ⴱⴱ 3.06ⴱⴱ

⫺.53

⫺5.29ⴱⴱ

.24 .15

t

2.07ⴱ

⫺.23 .29 .16

3.02ⴱⴱ 3.89ⴱⴱ 2.13ⴱⴱ

⫺.60

⫺9.00ⴱⴱ

⫺.12

⫺1.82†

⫺.17

⫺1.92†

.24

3.06ⴱⴱ

⫺.37

⫺4.64ⴱⴱ

⫺.57

⫺6.81ⴱⴱ

Note. N ⫽ 155 for all analyses except PCL-C (n ⫽ 46). NRS ⫽ Numerical Rating Scale; IEQ ⫽ Injustice Experiences Questionnaire; PHQ-8 ⫽ Patient Health Questionnaire-8 item; PC-PTSD ⫽ Primary Care PTSD screen; PCL-C ⫽ PTSD Checklist-Civilian Version; VR-PCS ⫽ Veterans RAND 12-Item Health Survey Physical Component Score; VR-MCS ⫽ Veterans RAND 12-Item Health Survey Mental Component Score; Only variables found to make a unique contribution prior to inclusion of IEQ were retained in the final model. Dashed lines indicate blocks in which no variables made a significant contribution to outcome variance. † p ⬍ .10. ⴱ p ⬍ .05. ⴱⴱ p ⬍ .01.

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PERCEIVED INJUSTICE AFTER TRAUMATIC INJURY

A primary aim of the current study was to characterize perception of injustice among individuals who had sustained traumatic injury. The mean IEQ score of the current sample was comparable with studies where participants were assessed relatively soon after injury (e.g., (Sullivan et al., 2008; Sullivan, Thibault, et al., 2009) but somewhat lower than in studies of individuals with chronic pain conditions (e.g., fibromyalgia, chronic low back pain), where duration of pain symptoms ranged from 8.3 to 18.3 years (Rodero et al., 2012; Scott & Sullivan, 2012). The current study comprises a sample that is qualitatively distinct from previous research; such qualitative differences—including the relative heterogeneity of injury compared to previous studies—may account for the observed differences. As more data emerge, comparisons across studies can provide valuable insight regarding the relationship between condition chronicity, time-since-injury, and magnitude and impact of perceived injustice. A second aim of the study examined demographic and injuryrelated correlates of injustice perception. This is important as research to date has focused on examining the impact of injustice on recovery outcomes rather than identifying patients who might be most likely to develop injustice perceptions after injury. The present results indicated that individuals with lower levels of education and income reported higher perceptions of injustice after trauma. Further, individuals who identified as Black reported greater perceptions of injustice than those who identified as White. These results are in line with findings of poorer physical and psychological outcomes among lower SES and minority participants across a number of medical domains, including physical trauma (Sacks, Hill, & Rogers, 2011; Santos et al., 2008). Such differences may reflect greater burden of physical trauma on individuals with lower financial resources (Sacks et al., 2011) and individuals subject to racial discrimination (Anderson, Green, & Payne, 2009). Finally, a small but significant association was observed between age and perceptions of injustice, with younger individuals reporting greater injustice perception; such association may reflect changes in coping as well as potential changes in just world expectancies over time (Trost et al., 2012). These findings may likewise highlight the likely cumulative impact of a wide-array of sociocultural and biographical factors on people’s experience of trauma and/or injury (Iversen et al., 2007; Jones et al., 2014; Zinn, 2010). This is also the first study to examine perceived injustice within the United States and with a diverse participant sample. With the exception of one study from Spain, previous studies were conducted within the Canadian health system (Sullivan et al., 2012), comprising relatively homogenous patient samples. As noted above, it is possible that the current findings were influenced by the unique social and health care context of the current study. Significant associations were likewise observed between injustice perceptions and injury-related variables. Specifically, participants injured in violent crime reported higher perceived injustice than those admitted with a fall injury and participants with a penetrating trauma reported higher perceived injustice than those with blunt trauma. These findings are potentially consistent with research suggesting that interpersonally related traumatic events (i.e., perpetrated by another individual) contribute to worse psychological outcomes (e.g., PTSD symptom severity) than events of a noninterpersonal nature (Kelley, Weathers, Mason, & Pruneau, 2012). While the current findings require replication, they raise the interesting possibility that the effects of trauma type on negative outcomes may be mediated by the magnitude of perceived injustice.

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In line with existing literature, perceived injustice accounted for unique variance in the cross-sectional prediction of pain, depression, posttraumatic symptoms, and mental/emotional HRQoL (Sullivan et al., 2011; Sullivan et al., 2012), significantly accounting for between 4% and 19% of the variance in respective outcomes. For pain, depression, and mental HRQoL, the magnitude of effects for perceived injustice was comparable or larger than previous studies on the impact of perceived injustice (Sullivan et al., 2011; Sullivan et al., 2012). However, given the relatively new nature of the IEQ measure, it is difficult to compare current outcomes to previous studies as none had previously controlled for general distress (i.e., mental/emotional HRQoL). Further, given the high correlation between the VR-MCS and PTSD outcomes (r ⫽ .61), it is perhaps not surprising that IEQ was only able to account for a small portion of the variance (i.e., 4%) in PTSD severity. Nevertheless, current findings support the robustness of the IEQ as an independent construct/measure particularly in prediction of pain, depression and mental/emotional HRQoL. Pain intensity remained a significant predictor in all models, echoing findings of persistent moderate to severe pain in trauma survivors (Archer et al., 2011; Rivara et al., 2008). Further, the strong association between pain intensity and perceived injustice may account for the marginal unique effects of perceived injustice on self-reported physical HRQoL, as questions comprising the VRPCS explicitly ask about pain experience rather than physical function or disability per se. Although the role of perceived injustice has not been systematically examined within the trauma population, the existing literature provides substantial indirect support for the negative impact of related constructs on trauma recovery. Studies consistently find that individuals who endorse lower levels of responsibility or externalize blame for traumatic accidents experience poorer mental and physical health outcomes (Clay, Devlin, & Kerr, 2013; DeGood & Kiernan, 1996; Rusch, Dzwierzynski, Sanger, Pruit, & Siewart, 2013; Thompson, Berk, O’Donnell, Stafford, & Nordfjaern, 2014) Poorer outcomes are likewise observed among individuals who pursue compensation or litigation after injury (Elbers, Hulst, Cuijpers, Akkermans, & Bruinvels, 2013), which may serve as a proxy for retribution for an injury perceived as unjust (Sullivan et al., 2008). Finally, there is a wellestablished association between anger and negative health outcomes across various health conditions (Trost et al., 2012). Perceived injustice has been conceptualized as a cognitive antecedent to anger (Trost et al., 2012) and a recent study suggests that anger might partially explain the association between perceived injustice and problematic recovery in patients with chronic pain (Scott et al., 2013). However, despite indirect evidence, further validation of the IEQ measure in the trauma population is needed, including more in-depth psychometric and potential qualitative analysis for major trauma populations; this is particularly important as scale development occurred with input from expert clinicians (psychologists) rather than patients (Sullivan et al., 2008).

Limitations and Future Directions A number of limitations characterize the current investigation and can inform future research. First, the study is cross-sectional in nature and, therefore, causal statements regarding the impact of perceived injustice cannot be made. Prospective, cross-lagged designs could better examine the direction of association between

TROST ET AL.

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perceived injustice and outcome variables. We also used demographic information collected at baseline; certain demographic dimensions (e.g., income, marital status) may have changed by 12 month assessment, possibly affecting both outcomes and study retention, and must therefore be interpreted with caution. Second, the current study relied exclusively on self-report assessment; future studies may wish to examine potentially more meaningful indices of disability/life-interference, such as return to work or more objectively assessed measures of function. Further, future studies are encouraged to recruit more racially/ethnically diverse participant samples; while we identified significant racial differences in perceived injustice, sample size may have restricted analysis. Additionally, the current study does not provide information about individuals who did not meet study criteria at baseline, thus potentially obscuring the specific nature of the current sample. Finally, while additional research is needed to examine the role of perceived injustice after trauma, our findings raise the possibility that patients admitted for severe trauma might benefit from interventions to address perceptions of injustice. Such interventions may target anger, forgiveness, and facilitate validation of patient experiences (Scott et al., 2013; Sullivan et al., 2012; Trost et al., 2012). While preliminary, our results might suggest that such interventions could benefit patients early in the recovery process.

Conclusion In summary, the current study provides the first evidence that perceived injustice is associated with negative physical and psychological outcomes among individuals admitted for traumatic injury, and identifies a number of possible sociodemographic and injury-related risk factors for elevated injustice perception. It is recommended that additional prospective research examine the role of injustice perception in the trauma population, with the aim of developing interventions to improve recovery trajectories.

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Received October 29, 2014 Revision received March 30, 2015 Accepted April 24, 2015 䡲