Abstract
Background
Although economic stability, social context, and healthcare access are well-known social determinants of health associated with more challenging recovery after traumatic injury, little is known about how these factors differ by mechanism of injury. Our team sought to use the results of social determinants of health screenings to better understand the population that engaged with psychosocial support services after traumatic musculoskeletal injury and fill a gap in our understanding of patient-reported social health needs.
Question/purpose
What is the relationship between social determinants of health and traumatic musculoskeletal injury?
Methods
Trauma recovery services is a psychosocial support program at our institution that offers patients and their family members resources such as professional coaching, peer mentorship, post-traumatic stress disorder screening and treatment, educational resources, and more. This team engages with any patient admitted to, treated at, and released from our institution. Their primary engagement population is individuals with traumatic injury, although not exclusively. Between January 2019 and October 2021, the trauma recovery services team interacted with 6036 patients. Of those who engaged with this service, we considered only patients who experienced a traumatic musculoskeletal injury and had a completed social determinants of health screening tool. During the stated timeframe, 13% (814 of 6036) of patients engaged with trauma recovery services and had a complete social determinants of health screening tool. Of these, 53% (428 of 814) had no physical injury. A further 26% (99 of 386) were excluded because they did not have traumatic musculoskeletal injuries, leaving 4.8% (287) for analysis in this cross-sectional study. The study population included patients who interacted with trauma recovery services at our institution after a traumatic orthopaedic injury that occurred between January 2019 and October 2021. Social determinants of health risk screening questionnaires were self-administered prospectively using a screening tool developed by our institution based on Centers for Medicare and Medicaid Services social determinants of health screening questions. Mechanisms of injury were separated into intentional (physical assault, sexual assault, gunshot wound, or stabbing) and unintentional (fall, motor vehicle collision, or motorcycle crash). During the study period, 287 adult patients interacted with trauma recovery services after a traumatic musculoskeletal injury and had complete social determinant of health screening; 123 injuries were unintentional and 164 were intentional. Patients were primarily women (55% [159 of 287]), single (73% [209 of 287]), and insured by Medicaid or Medicare (78% [225 of 287]). Mechanism category was determined after a thorough medical record review to verify the appropriate category. An initial exploratory univariate analysis was completed for the primary outcome variable using the Pearson chi-squared test for categorical variables and a two-tailed independent t-test for continuous variables. All demographic variables and social determinants of health with p < 0.20 in the univariate analysis were included in a multivariate binary regression analysis to determine independent associations with injury mechanism. All variables with p < 0.05 in the multivariate analysis were considered statistically significant.
Results
After controlling for potential demographic confounders, younger age (odds ratio [OR] 0.93 [95% confidence interval (CI) 0.90 to 0.96]; p < 0.001), Black race (compared with White race, OR 2.71 [95% CI 1.20 to 6.16]; p = 0.02), Hispanic ethnicity (compared with White race, OR 5.32 [95% CI 1.62 to 17.47]; p = 0.006), and at-risk status for food insecurity (OR 4.27 [95% CI 1.18 to 15.39]; p = 0.03) were independently associated with intentional mechanisms of injury.
Conclusion
There is a relationship between the mechanism of traumatic orthopaedic injury and social determinants of health risks. Specifically, data showed a correlation between food insecurity and intentional injury. Healthcare systems and providers should be cognizant of this, as well as the additional challenges patients may face in their recovery journey because of social needs. Screening for needs is only the first step in addressing patient’s social health needs. Healthcare systems should also allocate resources for personnel and programs that support patients in meeting their social health needs. Future studies should evaluate the impact of such programming in responding to social needs that impact health outcomes and improve health disparities.
Level of Evidence
Level IV, prognostic study.
Introduction
Background
Social determinants of health have been robustly studied in the past 20 years and are known to affect multiple health outcomes ranging from cardiovascular to the immune system, as well as overall mortality and morbidity [14]. These social determinants of health refer to the environments and conditions in which people are born, live, learn work, and play. Examples of social determinants of health include income level, educational opportunities, occupation and workplace safety, access to housing and utility services, social support, exposure to violent behavior, availability of transportation, and more [10].
To define specific social needs of our patients, our institution implemented a social determinants of health screening tool for all our patients (Supplemental Digital Content 1; http://links.lww.com/CORR/A980). This screening tool provides insight into a variety of domains known to impact physical well-being and health [5]. At our institution, this effort was established in 2019, and our population reflects those who were surveyed at the initial launch of the screening. Universal screening is a valuable tool in health systems. However, we were curious about whether certain social determinants of health might be associated with specific injuries. Having this knowledge may equip providers and support services to expeditiously resource and aid patients to best position them to recover from their injury, and potentially reduce the causes of health inequities.
Rationale
Although key social determinants of health metrics have been identified, their application and role in patients with traumatic injuries have been only recently evaluated. Historically, orthopaedic trauma research has focused on postinjury socioeconomic impact and outcomes. This large body of research has confirmed that orthopaedic injury can have a substantial downstream impact on socioeconomic well-being, but only a few studies we know of have evaluated social health and its upstream impact on orthopaedic trauma [3, 7, 9, 11]. We therefore asked: What is the relationship between social determinants of health and traumatic musculoskeletal injury?
Patients and Methods
Study Design and Setting
This cross-sectional study was performed at a large, urban, Level I trauma center. Our center primarily serves uninsured and underinsured individuals and is the county safety net hospital. At our center, all patients admitted for traumatic injuries are approached by trauma recovery services staff and offered social and psychologic support. This department offers numerous free services to patients and family members such as emotional coaching from licensed counselors, educational materials, peer mentorship from trauma survivors, and programming for people who have experienced harm from violent crime. Trauma recovery services operates as a department on site in the hospital with a staff of trained coaches. Staff review patient admissions daily and round on all patients admitted for traumatic injuries. They provide basic education on services and offer opportunities for patients and family members to engage in additional resources, peer mentorship, and other services. Patients participate at their discretion and for as long as they desire. A team of trained individuals who were formerly injured regularly visit current patients to offer peer-to-peer support through shared experience.
Our population was limited to individuals who engaged (defined as at least having one interaction) with trauma recovery services, because this is one of the primary avenues from which patients in this population may receive resources and support for their social health needs.
Participants
Between January 2019 and October 2021, the trauma recovery services team interacted with 6036 patients. Of those who engaged with this service, only patients who experienced a traumatic musculoskeletal injury and had a social determinants of health screening tool were included. During the stated time frame, 13% (814 of 6036) of patients engaged with trauma recovery services and had a complete social determinants of health screening tool. Of these, 53% (428 of 814) had no physical injury. A further 26% (99 of 386) were excluded because they did not have musculoskeletal injuries, leaving 287 for analysis (Fig. 1).
Fig. 1.
This STROBE flow diagram demonstrates the inclusion and exclusion criteria for the study population.
Based on the above criteria, patients were not included if they were severely injured (for example, had a severe brain injury or died shortly after arrival to the hospital) because they would be unable to complete the social health screening tool or engage with trauma recovery services.
Patients’ Baseline Data
Of the 287 adult patients who interacted with trauma recovery services after traumatic injury, 43% (123) had unintentional injuries and 57% (164) had intentional injuries (Table 1). All demographic information was extracted from the electronic health record. The mean age was 41 ± 18 years, and patients were most likely to be women (55% [159 of 287]), White (43% [122 of 287]) or Black (42% [121 of 287]), single (73% [209 of 287]), insured by Medicaid or Medicare (78% [225 of 287]), had a primary care physician (68% [194 of 287]), were unemployed (52% [148 of 287]), and earned a median income of either less than USD 20,000 (44% [125 of 287]) or between USD 20,000 and USD 44,999 (47% [134 of 287]) (Table 1).
Table 1.
Demographics of patients referred to trauma recovery services at our institution
| Parameter | Intentional traumatic injury (n = 164) | Accidental traumatic injury (n = 123) | p value |
| Age in years, median (range) | 28 (19-79) | 56 (19-94) | < 0.001 |
| Women, % (n) | 64 (105) | 44 (54) | < 0.001 |
| Race/ethnicity, % (n)a | < 0.001 | ||
| White | 21 (35) | 71 (87) | |
| Black | 58 (95) | 21 (26) | |
| Hispanic | 18 (29) | 6 (7) | |
| Other | 3 (5) | 2 (3) | |
| Relationship status, % (n) | < 0.001 | ||
| Single | 87 (143) | 54 (66) | |
| Married, significant other, or domestic partner | 7 (11) | 26 (32) | |
| Legally separated, divorced, or widowed | 6 (10) | 20 (25) | |
| Insurance type, % (n) | 0.003 | ||
| Medicaid or Medicare | 85 (139) | 70 (86) | |
| Private | 10 (16) | 24 (30) | |
| Self-pay or uninsured | 5 (9) | 6 (7) | |
| Primary care provider, % (n) | 68 (112) | 67 (82) | 0.77 |
| Median income in USD, % (n) | < 0.001 | ||
| Less than 20,000 | 59 (96) | 24 (29) | |
| 20,000 to 44,999 | 31 (52) | 66 (82) | |
| 45,000 to 139,999 | 4 (6) | 8 (10) | |
| NA | 6 (10) | 2 (2) | |
| Education level, % (n) | 0.007 | ||
| Less than high school | 9 (15) | 4 (5) | |
| High school | 16 (26) | 22 (27) | |
| Above high school | 13 (21) | 25 (31) | |
| Unknown | 62 (102) | 49 (60) | |
| Employment, % (n) | < 0.001 | ||
| Unemployed | 58 (95) | 43 (53) | |
| Employed or student | 36 (59) | 35 (43) | |
| Retired | 1 (1) | 17 (21) | |
| Unknown | 5 (9) | 5 (6) |
aRace and ethnicity included as reported by patients and extracted from the electronic health record; NA = not answered.
Description of Experiment
The screening survey, created at our institution and based on the Centers for Medicare and Medicaid social determinants of health screening tool [4], includes 28 questions under nine domains. The nine domains include financial resource strain, food insecurity, intimate partner violence, physical activity, social connections, stress, transportation needs, housing stability, and digital connectivity. The tool is not validated but uses questions obtained from previously validated surveys [5].
Patients completed the self-administered social determinant of health survey through their patient electronic health management tool (for example, MyChart) before admission or were asked the survey questions during their admission as part of the standard of care. Survey responses were automatically calculated as part of system processes. Calculated totals categorize patients as at risk, at some risk, or not at risk for various social determinants of health based on responses to subdomain questions (Supplemental Digital Content 2; http://links.lww.com/CORR/A981). Demographics were retrospectively extracted from the electronic medical record.
Primary Study Outcomes
Our primary study goal was to understand what, if any, is the relationship between social determinants of health and traumatic musculoskeletal injury? To answer this question, we organized patients into intentional injury (for example, physical assault, sexual assault, gunshot wound, or stabbing) and unintentional injury (such as, fall, motor vehicle collision, or motorcycle crash) mechanism groups. Groups were created based on reported injury mechanisms and after a thorough medical record review. The unintentional and intentional injury groups were then assessed for an association with each of the individual social determinants of health to determine their impact and relationship.
Ethical Approval
We obtained exempt approval from our institutional review board for this study.
Statistical Analysis
An initial exploratory univariate analysis was completed for the primary outcome variable using the Pearson chi-squared test for categorical variables and a two-tailed independent t-test for continuous variables. These analyses were completed for demographic variables (Table 1) and social determinants of health (Table 2). All variables with p < 0.20 in the univariate analysis were included in a single multivariate binary regression model to determine variables that are independently associated with intentional and unintentional injury. Demographic variables included in the multivariate analysis were age, gender, race or ethnicity, relationship status, insurance type, median income, education, and employment status. Social determinants of health risk factors included in the multivariate analysis were the total number of social determinants of health, food insecurity, intimate partner violence, social connection, daily stress, transportation, and housing and utilities. All variables with p < 0.05 in the multivariate analysis were considered statistically significant.
Table 2.
Social determinants of health risks
| Parameter | All patients referred to trauma recovery services (n = 287) | Intentional traumatic injury (n = 164) | Accidental traumatic injury (n = 123) | p valuea |
| Number of social determinants of health risks, mean ± SD | 1.7 ± 1.7 | 39 ± 1.8 | 25 ± 1.4 | 0.015 |
| Financial strain, % (n) | 0.11 | |||
| At risk | 12 (35) | 15 (25) | 8.1 (10) | |
| Some risk | 38 (109) | 35 (58) | 42 (51) | |
| Not at risk | 25 (73) | 23 (37) | 29 (36) | |
| NA | 24 (70) | 27 (44) | 21 (26) | |
| Food insecurity, % (n) | < 0.001 | |||
| At risk | 25 (72) | 34 (56) | 13 (16) | |
| Some risk | 0 | 0 | 0 | |
| Not at risk | 56 (161) | 48 (79) | 67 (82) | |
| NA | 19 (54) | 18 (29) | 20 (25) | |
| Intimate partner violence, % (n) | 0.002 | |||
| At risk | 9.1 (26) | 13 (21) | 4.1 (5) | |
| Some risk | 0 | 0 | 0 | |
| Not at risk | 46 (132) | 38 (63) | 56 (69) | |
| NA | 45 (129) | 49 (80) | 40 (49) | |
| Physical activity, % (n) | 0.65 | |||
| At risk | 19 (54) | 17 (27) | 22 (27) | |
| Some risk | 18 (52) | 17 (28) | 20 (24) | |
| Not at risk | 17 (49) | 18 (29) | 16 (20) | |
| NA | 46 (132) | 49 (80) | 42 (52) | |
| Social connection, % (n) | 0.04 | |||
| At risk | 37 (107) | 40 (66) | 33 (41) | |
| Some risk | 21 (59) | 18 (29) | 24 (30) | |
| Not at risk | 2.1 (6) | 0.6 (1) | 4.1 (5) | |
| NA | 40 (115) | 42 (68) | 38 (47) | |
| Daily stress, % (n) | 0.006 | |||
| At risk | 20 (57) | 24 (40) | 14 (17) | |
| Some risk | 29 (84) | 22 (36) | 39 (48) | |
| Not at risk | 11 (31) | 10 (17) | 11 (14) | |
| NA | 40 (115) | 43 (71) | 36 (44) | |
| Transportation, % (n) | 0.004 | |||
| At risk | 22 (62) | 27 (45) | 14 (17) | |
| Some risk | 0 | 0 | 0 | |
| Not at risk | 68 (196) | 62 (102) | 76 (94) | |
| NA | 10 (29) | 10 (17) | 9.8 (12) | |
| Housing and utilities, % (n) | 0.004 | |||
| At risk | 25 (72) | 32 (52) | 16 (20) | |
| Some risk | 0 | 0 | 0 | |
| Not at risk | 33 (96) | 27 (45) | 42 (51) | |
| NA | 42 (119) | 41 (67) | 42 (52) | |
| Digital connectivity, % (n) | 0.32 | |||
| At risk | 1.7 (5) | 0.6 (1) | 3.3 (4) | |
| Some risk | 6.3 (18) | 7.3 (12) | 4.9 (6) | |
| Not at risk | 37 (106) | 37 (60) | 37 (46) | |
| NA | 55 (158) | 56 (91) | 55 (67) | |
aRelative risk, odds ratio, or some other suitable effect-size metric was used for categorical variables, and mean difference (95% CI) or difference of medians was used for continuous variables; NA = not answered.
Results
Relationship Between Social Determinants of Health and Traumatic and Accidental Injury
After controlling for the potential confounders listed above, younger age (odds ratio [OR] 0.93 [95% confidence interval (CI) 0.90 to 0.96]; p < 0.001), Black race (compared with White race, OR 2.71 [95% CI 1.20 to 6.16]; p = 0.02), Hispanic ethnicity (compared with White race, OR 5.32 [95% CI 1.62 to 17.47]; p = 0.006), and at-risk status for food insecurity (OR 4.27 [95% CI 1.18 to 15.39]; p = 0.03) were independently associated with intentional mechanisms of injury. There was no association of the total number of social determinants of health or any of the other defined social determinants of health with intentional mechanisms of injury (Table 3).
Table 3.
Social determinant of health at-risk categories for unintentional versus intentional injury
| Category (at risk) | Intentional (n = 164) | Unintentional (n = 123) | p value |
| Food insecurity | 34% | 13% | < 0.001 |
| Interpersonal violence | 38% | 56% | 0.01 |
| Social connection | 40% | 33% | 0.23 |
| Daily stress | 24% | 14% | 0.03 |
| Transportation | 27% | 14% | 0.01 |
| Housing and utilities | 32% | 16% | 0.003 |
Discussion
Social determinants of health; access to food, transportation, and safe housing; and other social and environmental factors have been shown to impact physical health. In patients with orthopaedic trauma, injury has been associated with poor social and psychosocial health. This study sought to understand the correlation between the social health needs of patients experiencing orthopaedic injury and injury mechanisms. By identifying certain social health needs that are associated with specific injury categories, we aimed to better equip providers in supporting their patients’ recovery. Our results suggest a correlation between food insecurity and intentional injury. Providers and healthcare systems can use this information to inform patient support services. For example, patients with intentional injuries could be referred to food resources as they recover.
Limitations
Our study has several limitations. The injuries in our patients were categorized as intentional versus unintentional based on a thorough medical record review. However, some injuries might have been miscategorized if information regarding the injury was not accurately captured in the medical record (for example, injuries sustained in a motor vehicle collision may have been intentional but may have been categorized as unintentional). We included individuals who engaged with trauma recovery services and had a complete social determinants of health screening questionnaire. This department participated in the rollout of the screening tool and directly resources patients. During the study period, the social determinants of health screening tool used in this population was only recently included into routine care for all patients in our hospital. The screening tool is completed during admission or via a patient electronic health management tool (such as MyChart). Because of this, our results are likely underpowered, and it would be beneficial to repeat this study after screening has been completed. However, there are limited studies assessing baseline social needs in this population, and these results provide a foundation for understanding patient-reported social needs as they relate to injury type. The screening tool used was created at the study institution and is rooted in standard social determinant of health domains. The questions were taken from validated surveys, but the tool has not been validated. Some of the questions may be confusing to participants, and because this tool is self-administered, patients may answer inaccurately because of wording or reading level. However, the questions capture a range of social health domains, and the questions have been validated [5]. The current study did not account for self-administration habits, and data may be skewed because of this. In the future, it would be useful to validate a social determinants of health screening tool using intentional questions at an appropriate reading level. Ideally, guided screening may produce the most reliable results.
Finally, we did not include patients with more severe injuries (for example, those with severe brain injury or those who died shortly after arrival to the hospital). Practically, this population would be unable to complete the screening relevant to social health and represents a limitation to our results. However, our results are valuable for patients who will potentially re-engage meaningfully in society.
Discussion of Key Findings
Several factors were independently associated with a greater likelihood of an injury being the result of an intentional incident, rather than an accident, including younger age, Black race, Hispanic ethnicity, and being at risk for food insecurity. Younger people are often perpetrators or victims of crime [7, 13, 15]. Persons of specific ethnic and racial backgrounds have also been at risk for intentional trauma, as denoted by prior work [2, 7, 13, 15]. Our institution primarily serves individuals who are Black, Hispanic, or White, with a small percentage of people who are of other races and ethnicities (Table 1). We included race and ethnicity intentionally to highlight social health disparities among diverse populations. When interpreting and applying these results, Black and Hispanic patients may have unique underlying health disparities [12, 13]. In caring for patients with injuries because of intentional incidents, care should be taken in addressing social heath needs and resources to ensure successful recovery.
We were surprised to see that patients with more social determinants of health were no more likely to have experienced a traumatic event than those with fewer social determinants of health. This presents an opportunity to target populations more accurately, both before they arrive at the hospital and after injury. Health systems should allocate resources to supporting patients with referral and resourcing to meet known social heath needs. Although food security may seem outside the purview of health systems, Kamalapathy et al. [6] found that patients with poor nutrition had an increased risk of readmission and revision after surgery for hip fractures and infection and readmission after surgery for ankle fracture [6]. Health systems can allocate resources by partnering with and advocating for already existing food access programs in their region and educating providers in how to connect patients to these resources.
Addressing the psychosocial needs of injured individuals (musculoskeletal or otherwise) has become an area of growing focus in our society and in our hospital. The American College of Surgeons acknowledges the importance of providing this more holistic approach to care, stating that Level I and II trauma centers should prioritize adopting strategies for reintegrating patients into their communities [1]. They suggest some of the interventions the trauma recovery services in this study already uses, such as peer-to-peer mentoring and programming of trauma survivors. This is an encouraging recommendation and an embrace of the patient as more than their injury. As Matkin and Ring [8] describe, surgeons and providers should anticipate social health needs and manage them in a multidisciplinary and proactive manner. Surgeons and providers should be aware of the connection between social health and injury. Using the findings in this study, they can discuss potential social needs with their patients. Although they may not be the agent to deliver social health services to patients, they should champion, endorse, and connect patients with those who do. In practice, this means advocating for comprehensive and standard-of-care psychosocial support services that engage patients who have traumatic injuries while they are in the hospital and throughout their recovery. Providers must position themselves as active stakeholders in the social health of their patients to reduce health disparities and improve overall health.
Conclusion
Relationships exist between the mechanism of injury and social determinants of health risks; specifically, there is a correlation between food insecurity and intentional injury. Healthcare systems and providers should be cognizant of this relationship and the additional challenges patients may face in their recovery journey because of social needs. Resources for personnel and programs that support patients in meeting their social health needs are warranted. Future studies should evaluate the impact of such programming in responding to social needs, which impact health outcomes and improve health disparities.
Footnotes
Each author certifies that there are no funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members.
All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request.
Ethical approval for this study was obtained from the MetroHealth System, Cleveland, OH, USA (number IRB 21-00431).
This work was performed at the MetroHealth System, Cleveland, OH, USA.
Contributor Information
Mary A. Breslin, Email: maryalicebreslin@gmail.com.
Abigail Bacharach, Email: arb227@case.edu.
Dedi Ho, Email: dxh480@case.edu.
Mark Kalina Jr, Email: mkalina@metrohealth.org.
Tyler Moon, Email: Tyler.Moon@uhhospitals.org.
Ryan Furdock, Email: furdockr@gmail.com.
References
- 1.American College of Surgeons. Resources for optimal care of the injured patient (2022 standards). Available at: https://www.facs.org/quality-programs/trauma/quality/verification-review-and-consultation-program/standards/. Accessed August 25, 2022.
- 2.Agarwal S. Trends and burden of firearm-related hospitalizations in the United States across 2001-2011. Am J Med. 2015;128:484-492. [DOI] [PubMed] [Google Scholar]
- 3.Archer KR, Castillo RC, MacKenzie EJ, Bosse MJ; LEAP Study Group. Perceived need and unmet need for vocational, mental health, and other support services after severe lower-extremity trauma. Arch Phys Med Rehabil. 2010;91:774-780. [DOI] [PubMed] [Google Scholar]
- 4.Centers for Medicare and Medicaid Services. AHC health-related social needs screening tool. Available at: https://innovation.cms.gov/files/worksheets/ahcm-screeningtool.pdf. Accessed August 25, 2022.
- 5.Chagin K, Choate F, Cook K, Fuehrer S, Misak JE, Sehgal AR. A framework for evaluating social determinants of health screening and referrals for assistance. J Prim Care Community Health. 2021;12:21501327211052204. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Kamalapathy PN, Dunne PA, Yarboro S. National evaluation of social determinants of health in orthopedic fracture care: decreased social determinants of health is associated with adverse complications after surgery. J Orthop Trauma. 2022;36:e278-e282. [DOI] [PubMed] [Google Scholar]
- 7.MacKenzie EJ, Bosse MJ. Factors influencing outcome following limb-threatening lower limb trauma: lessons learned from the Lower Extremity Assessment Project (LEAP). J Am Acad Orthop Surg. 2006;14:S205-S210. [DOI] [PubMed] [Google Scholar]
- 8.Matkin L, Ring D. Creating value by prioritizing mental and social health after injury. J Orthop Trauma. 2019;33:S32-S37. [DOI] [PubMed] [Google Scholar]
- 9.Mikhail JN, Nemeth LS, Mueller M, Pope C, NeSmith EG. The social determinants of trauma: a trauma disparities scoping review and framework. J Trauma Nurs . 2018;25:266-281. [DOI] [PubMed] [Google Scholar]
- 10.NEJM Catalyst. Social determinants of health (SDOH). Available at: https://catalyst.nejm.org/doi/full/10.1056/CAT.17.0312. Accessed August 25, 2022.
- 11.O’Hara NN, Isaac M, Slobogean GP, Klazinga NS. The socioeconomic impact of orthopaedic trauma: a systematic review and meta-analysis. PLOS One. 2020;15:e0227907. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Purnell TS, Calhoun EA, Golden SH, et al. Achieving health equity: closing the gaps in health care disparities, interventions, and research. Health Aff (Millwood). 2016;35;1410-1415. [DOI] [PubMed] [Google Scholar]
- 13.Thornton RL, Glover CM, Cené CW, Gilk DC, Henderson JA, Williams DR. Evaluating strategies for reducing health disparities by addressing the social determinants of health. Health Aff (Millwood). 2016;35:1416-1423. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Uchino BN. Social support and health: a review of physiological processes potentially underlying links to disease outcomes. J Behav Med. 2026;29:377-387. [DOI] [PubMed] [Google Scholar]
- 15.Wan JJ, Morabito DJ, Khaw L, Knudson MM, Dicker RA. Mental illness as an independent risk factor for unintentional injury and injury recidivism. J Trauma. 2006;61:1299-304 [DOI] [PubMed] [Google Scholar]