Biopsychosocial barriers affecting recovery after a minor transport‐related injury: A qualitative study from Victoria

Abstract Objective The aim of the study was to understand the recovery phenomena and to explore participants' perspectives on the biopsychosocial facilitators and barriers affecting their recovery after a minor transport injury. Methods A qualitative method was used involving semi‐structured interviews with 23 participants who sustained a minor transport injury. Interviews and analysis were guided by the biopsychosocial model (BPS) of health. The outcomes were themes capturing biopsychosocial barriers to, and personal experiences of, recovery using a previously defined framework. Results The themes indicate that recovery is a multifaceted phenomenon affected by comorbidities such as chronic pain, depression and anxiety. A range of subsequent complexities such as the inability to self‐care and undertaking daily domestic duties, and incapacity to participate in recreational activities were major barriers to recovery. These barriers were found to be an on‐going source of frustration, dissatisfaction and a perceived cause of depressive symptomatology in many participants. Most participants reported mixed feelings of the care received. Other common issues raised included a lack of understanding of the assessment time, regular follow‐up, guidance and on‐going support. Conclusion This study revealed that recovery after a minor transport‐related injury was a challenging, complex, demanding and a long‐term process for the individuals in this study. Findings from this limited cohort suggested that, for participants to return to their pre‐accident health status, a more coordinated approach to information and care delivery may be required.

transport accidents result in minor injuries (75%), mostly musculoskeletal and/or soft tissue injuries. 5 The injury itself, regardless of severity, may lead to permanent mental and physical impairments and disabilities. [6][7][8] Even though minor injuries comprise approximately 75% of all road transport injuries, poor physical and mental health outcomes in this group have received little attention. 9 Among participants with minor injuries, there are individuals at high risk of substantial poor recovery and on-going disability. 7,10 Hence, permanent or temporary disabilities arising from minor injuries pose an on-going problem for the compensation and health-care system. 11,12 It has been acknowledged that this particular group is at risk of being left alone with problems and symptoms that are difficult to understand and often invisible to others. 13,14 Previous research indicates differences in factors affecting recovery, yet the most commonly reported factors are high pain intensity, chronic pain, older age, pain catastrophizing, poor recovery expectations and poor pre-accident health status. 15 Other reasons suggested for a poor recovery, or even for permanent disability, include factors other than purely injury-related ones. Few qualitative studies have identified factors that largely depend on a person's environment and health-care and compensation systems. 13,16 Others reported factors such as lack of family support, 17 legal involvement 18,19 and the compensation claim. 20,21 However, it is still unclear how these factors impact the recovery outcome; how they interact; and which from an injured person's perspective are the most important to measure to identify people at high risk for poor recovery.
There is currently no standardized definition of what poor recovery means, yet in this study, it was defined as chronic pain, depression, anxiety, incapacity to return to work, limited physical activity and mobility, limitations in daily living and similar symptomatology that prevents patients to return to their pre-accident health state.
The academic literature posits that disability and recovery is best understood and managed using the BPS model, which systematically considers biological, psychological and social factors, as well as their complex interaction in understanding health and disability. 22 The International Classification of Functioning, Disability and Health framework (ICF) provides a multi-perspective, biopsychosocial approach to describing and measuring disability 23 and has been used by other studies to understand factors impacting health outcomes road trauma. [24][25][26][27] Recent work has extended the BPS to consider its application in a transport compensation setting. 28 Victoria is a state in south-eastern Australia and has a population of 5.4 million, representing 25% of the national census. 29 The Transport Accident Commission (TAC) is a Victorian Government-owned organization set up to pay for treatment and benefits for people injured in transport accidents, promote road safety and improve Victoria's road trauma system. 26 The TAC recognized the importance of better understanding minor injury claims and individual needs of the claimants, mainly because of the high cost involved in managing their claims, but also because approximately 20% of those who claim do not recover even 7 years after their accident. 30 As such, there is an urgent need to further explore reasons for poor recovery to better understand minor injury claims and individual needs of the claimants and identify those at high risk of poor recovery.
The primary aim of this research study was to understand, from injured persons' perspective, the biological, psychological and social factors impacting their recovery outcomes; the recovery processes; quality of care provided to participants; and common social impacts. By understanding these issues, we anticipate earlier identification of people at risk of poor recovery, thereby enabling the development of intervention strategies to address barriers and accelerate recovery.

| Study setting
Participants in this study had sustained a minor transport-related injury and lodged a compensation claim at the TAC. Injuries classified as minor, and involved in this study, included sprain, strain, whiplash-associated disorder, contusion, abrasion, laceration or subluxation and any clinically associated sequelae, as defined by Minor Injury Guidelines. 31

| Sampling strategy
The qualitative study sample was drawn from participants who con-

| Profile of participants in the COS survey
The mean age of the 2015/16 survey participants was 48 years of age; there were more males than females (56% and 45%, respectively); and the majority were English speaking (91%) and were considered as participants for whom a certain level of recovery was expected based on their initial injury status (94%). Additionally, most participants were employed at the time of the survey (72%) and almost half had suffered minor injuries (49%).

| Inclusion criteria
Participants were eligible to be included in this qualitative research study if during the COS survey they expressed an interest in participating in future research. This study was aimed at exploring the differences between recovered and non-recovered individuals, by discussing their reported barriers and facilitators of recovery. The LBoT, a single-item recovery instrument, was used to divide the participants into a 'good recovery' group and a 'poor recovery' group. A cut-off score of 7 on the LBoT has routinely been used by the TAC to distinguish recovered (LBoT score ≥7) from non-recovered (LBoT score <7) participants and was used in this study as well.

| Qualitative study design
This qualitative study aimed to understand a wide range of experiences of, and barriers to, recovery of traffic accident victims who sustained a minor transport-related injury. The study anticipated gaining an understanding of recovery, particularly focusing on aspects which were most important to participants. This approach allowed each participant's voice to be 'heard' and to clearly discuss what influenced their experience of recovery. With this view, we sought to establish a more holistic view of recovery, which was person-centred and focused on multiple layers of recovery (following a previously developed framework) and their complex interaction.

| Conceptual framework and interview guide
The interview guide (Table 1) was developed in a way to allow the exploration of each topic across the biological, psychological and social domains of the framework. 28 Some interview topics aimed to explore one domain, while others were expected to explore two or three pertinent domains. For example, the first topic 'general health and the role of general practitioners' explored both the biological (medical history and health status) and the social domain (the healthcare system and culture), whereas 'expectations of recovery after injury' explored only the psychological domain of the framework.
Apart from this, each topic was designed to explore both the factors and outcomes within the framework. Additionally, multifaceted interaction of these factors, within each domain, was explored in detail.
The interview guide and questionnaire were developed based on the current literature 23,24,33,34 by the main researcher and a qualitative research expert. The questionnaire contained a mix of direct and semi-structured questions, which, during interviews, were expanded to capture individual experiences (supplementary material).
This approach allowed participants to speak freely, especially about negative experiences or behaviours.

| Recruitment and ethical considerations
The recruitment process was coordinated by the Compensation research manager. As per the study protocol, participants were sent an explanatory statement and an invitation letter via post or email explaining the purpose of the research, its benefits and relevant participation information. An opt-out approach was used whereby participants were given 2 weeks to decline participation in the study. It was chosen because the inclusion criteria included only participants who had already denoted that they were happy to participate in future research activities. This approach was more likely to achieve a higher response rate compared to an opt-in consent model. For people who did not actively decline participation, a researcher contacted them after the 2 weeks opt-out period expired to arrange a time and place for the interview. Permission to record the interview was sought. The study was approved by the Monash University Human Research Ethics Committee (MUHREC 2016 0971 7666).
When contacted by telephone to arrange the interview, the participants were informed that interview questions will explore their experiences of recovery from transport-related injury in depth. In addition, they could decline to respond to questions if they wished, and could end the interview at any stage. Participants were advised that their anonymity would be assured. For this study, it was very important to ensure that participants felt they could talk freely and in confidence about their experiences.
Recruitment was conducted in three phases to avoid recruiting more participants than required to gain data saturation. Data saturation defines the point at which no new themes are identified, and it is suggested that it is usually reached at around 12 interviews. 35 This phased approach also enabled the researcher to review the interview questions at the conclusion of the first phase, and to allow adjustments to be made in subsequent interviews. The first phase was conducted between March and May 2017. Ten participants were interviewed during phase 1. After phase 1, purposive sampling was employed to ensure adequate representation of male participants TA B L E 1 Interview guide developed for the purposes of this study based on the previously defined biopsychosocial conceptualized framework and participants from regional areas. The second phase was conducted between May and August 2017. Ten participants were interviewed during phase 2. The final phase was conducted between August and September 2017, during which three participants were interviewed. The average time of the interview was approximately 1 hour.
Each interview was audiotaped and transcribed by the main researcher. To ensure rigour in data analysis, a second qualitative researcher blindly coded the data and developed concepts were reviewed and examined. 36 There were no major discrepancies in coding between the two researchers.

| Analysis
Audio files were transcribed verbatim and reflexive notes taken by the researcher. The process of data collection has been described as involving 'spiral patterns of activity' where data were collected and analysed, feeding into the focus of further data collection. 37 Repeated reading of transcripts was carried out after each interview to highlight and understand meaningful and dominant concepts. These were labelled in the first initial coding stage. As initial codes emerged, interview focus changed to understand the emerging concepts in more depth. Thus, following interviews were depended on themes and concepts highlighted in previous interviews.
Following final stages of the coding, meaningful categories and refined codes were created and described, using the aforementioned framework. The data were coded in NVivo, a qualitative research software. For comprehensive reporting throughout the article, we have used the COREQ guidelines 38 (supplementary material).

| RE SULTS
The characteristics of the sample extracted from the COS survey can be seen in Table 2 In this section, themes relating to the biopsychosocial recovery following minor injury are discussed. Due to the sampling issues, which heavily relied on a newly developed LBoT instrument, we were not able to report on facilitators to recovery, as most participants in the 'good recovery' group reported not being in good recovery at the time of the interview. Therefore, they have focused their stories on barriers that impacted their recovery. Other minor (contusions) 2 6 Region Metropolitan 7 11 Regional 4 1

Married 4 8
Never married 1 1 Divorced/separated 6 2 Widowed 0 1 LBoT score to cope). Participants perceived that their chronic pain was poorly managed as health practitioners' attention was focused on treating symptoms rather than the underlying cause of the pain.
Well… I don't know. My doctor just fills me with pills and Lyrica and he just "masked" it and put it away.
Lyrica is horrible I hate it.

| Subtheme: Limitations to mobility and activities of daily living
One of the major issues raised by participants was the inability to ambulate due to pain and the consequent disability it created. Most participants (n = 15) reported some degree of functional limitations that affected their daily life. This was particularly raised by younger and middle-aged participants who used to be physically active before the accident. Participants reported with anger and frustration their inability to attend to simple tasks such as dressing and shopping. While some participants (n = 5) received home assistance support immediately following the accident, most (n = 14) did not receive any assistance with their daily activities.
Yes I was and I was able to walk and run but my

| Subtheme: Inability to take part in former social and recreational activities
Most participants discussed how involvement in sport or physical recreation offered many benefits, ranging from simple enjoyment to improved health and the opportunity for social interaction.
Participation in sport was particularly important for participants who said that they were fit and physically active before their ac-

| Subtheme: Poor expectations of full recovery
Recovery expectations were generally described as poor by participants. Despite some participants (n = 5) feeling they were initially positive about their hopes of a full recovery, many were not able to reach full recovery. Full recovery was perceived by a few participants as 'getting back to where they were prior their accidents'. Many participants (n = 18) felt they would never fully or successfully recover or that they had reached the maximum extent of their recovery, which, in their case, was not full recovery. This was concerning to some participants, especially if they did not expect it. They also talked about feeling helpless in their recovery as they could not deal with chronic pain and side-effects caused by medications they were taking. As chronic pain persisted for many years, participants expressed that they would never recover and had lost faith in achieving a good recovery outcome.
Look I have accepted I will never get better, it's been 4 years now and it's not improving. I tried everything possible and now have accepted that I will never be 100%.

| Subtheme: Anger and frustration due to unexpected recovery trajectory resulting in poor coping abilities
Anger and frustration were common emotions expressed by the participants who articulated that they were not at fault for their accident. These participants described feelings of injustice and unfairness, as they were not the cause or reason for on-going pain and disability. Some participants discussed not being able to adjust to the new situation, which became a source of on-going daily frustration and anger.
Yes it's a problem for me. I get angry and depressed at the same time but I try to keep on with living. I volunteer in the local community centre, helping people because I can't work. Pain is killing me and the worse thing is that this was not my fault.
(Female, 63, contusion, soft-tissue-hip) Participants (n = 17) raised concern about health professionals not eager to participate in their recovery process because they were going through compensation process, and that they did not trust in the persistence of their symptoms such as chronic pain and functional disability.

| Subtheme: Anxiety and depressioncommon comorbidities resulting from injuries
I'll be like trying to find a good GP is very difficult in itself. And even you know, I really didn't have a good GP. I tried to find someone who you can trust and talk to, not someone rejecting you because you claim compensation.

| D ISCUSS I ON
To our knowledge, this is the first study in Victoria providing in-depth information of participants' experiences of recovery after a minor transport-related injury. Others have reported the recovery journey from the perspective of people who have sustained more serious injuries. We found that the complexities and challenges identified in this cohort were similar to those reported in participants who sustained more severe injuries. 39,40 As seen from the results, participants identified a number of barriers which affected their recovery.
A number of participants reported challenges with chronic symptoms, sometimes persisting for years. This was particularly evident in participants suffering chronic back pain and whiplash-associated disorder. It is well-known that high level of pain is common following injury and is a strong predictor of chronic pain. 41,42 In this cohort, the impact of injury was mostly related to unresolved limitation to physical function and chronic pain, which hampered participants' ability to participate in social, leisure and other activities of daily life.
There was a perception among participants that poor pain management involving long-term usage of pain medications seemed to have done more harm than good. Consistent with our study, others have reported similar findings in minor 16 and severe 40 injury cohorts.
Even though physical recovery seemed to be first priority during recovery, it was only one element of the overall recovery progress.
Participants emphasized that the psychological and social components of their recovery were vital parts of their journey. As confirmed in previous studies, the complexity and duration of emotional impacts varies in trauma cohorts, [43][44][45] as do the physical consequences. In this particular group, these impacts were largely related to an inability to work and negative experiences with recovery processes and complex system procedures. Lack of GP engagement is concerning from an ethical and financial perspective, and it is well-known that timely intervention and coordinated treatment is crucial for successful recovery. 47,48 In summary, using the biopsychosocial framework in this study enabled detection of important obstacles and barriers to recovery.
If these problems had been identified during the recovery process, tailored interventions could have been developed and recovery outcomes may have been improved. The results of this study call for a regular assessment of barriers affecting recovery through a targeted survey or an existing instrument that has the capacity to assess these barriers and complexities. An important next step would be to develop an approach and formulate questions to be asked in a larger similar cohort to examine the prevalence of issues raised as barriers to recovery among a larger cohort. If these are indeed issues, then strategies will need to be developed to appropriately address them.
A consistent and reliable point of contact for treatment, followup and information is necessary to improve and provide support to facilitate better recovery outcomes. Improved clarity in delivering information and timeliness of the delivery of required medical services would be beneficial to improve the level of care and support.
However, participants' perceptions and observations require further exploration with health professionals, as they play a crucial role in facilitating better recovery outcomes. 26 This is an area requiring further research, as it is still unclear why this cohort perceived to be left alone in managing their recovery, considering the amount of problems they experienced.
The combination of qualitative findings and subsequent information obtained through quantitative research will assist policy leaders in developing a longer-term roadmap to assist patients who have sustained a minor injury with a protracted recovery path.
This research provides valuable and rich information about recovery after a minor transport-related injury. However, there are a number of important limitations worthy of mention. Firstly, this study is not intended to be representative. Qualitative research is hypothesisgenerating. As such, we are unable to determine the extent to which issues raised by respondents are common among all minor transport injured victims. Secondly, the sample was limited to those who sought compensation for their injuries. We cannot assume that issues raised by this group are similar to those who do not claim for compensation.
Third, respondent bias is likely among this cohort; even though the participants were told that their participation in the interview would not affect their claim, some may have not been truthful about their experiences of recovery for fear of how this may impact their claim.
Fourth, we are unable to gauge the extent to which the symptoms expressed by participants such as anxiety and depression pre-dated the injury. Next, we did not obtain opinions of health professionals who treat these patients and may not have supported their views.
This is an important future research step which may help to identify strategies to engage clinicians in treating people with compensable injuries. Finally, we were unable to report on facilitators or enablers of recovery due to the insensitivity of the LBoT instrument to identify those who reported good or successful recovery.

CO N FL I C T O F I N T ER E S T
Authors have no conflict of interest to report. The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.