Quality of life and associated factors 1 year after road traffic injuries in Ethiopia

Abstract

Background:

Road traffic injuries (RTIs) can cause serious physical, psychological, and social consequences, impacting survivors’ quality of life (QoL). This study assessed the QoL and associated factors 1 year after RTIs in Ethiopia.

Design and Methods:

A cohort study with one-time follow-up phone interview was conducted among 330 adult RTI patients 1 year after discharge from a Trauma Hospital in Ethiopia. Predictors were collected using structured questionnaires, and QoL was assessed using the WHOQOL-BREF tool. Descriptive statistics were used to summarize participant characteristics and QoL scores, while a multivariable linear regression model was employed to identify predictors of QoL.

Results:

A total of 326 survived, and four deaths occurred in 1 year. Most participants were male (n = 258, 78.2%), and the median age was 31.5 years (IQR: 25–44). Mean scores for physical health, psychological health, social relationship, and environmental health QoL domains were 56.2, 73.6, 70.5, and 57.8, respectively. More than half (58.0%) reported poor overall QoL. Concussion, amputation and internal injuries (β = −4.39, p = 0.022), history of surgical intervention (β = −5.56, p = 0.037), poor health satisfaction (β = −31.4, p < 0.001), not returning to normal life (β = −17.9, p < 0.001) or work (β = −5.95, p = 0.030), and perceived lack of opportunities (β = −8.98, p = 0.001) were significantly associated with reduced overall QoL.

Conclusions:

A substantially high number of survivors experience poor QoL. The findings highlight that injury type, health status, and post-injury reintegration status were key determinants. Enhancing post-discharge rehabilitation, psychosocial support, and employment reintegration programs is essential to improve QoL.

Introduction

Road traffic injuries (RTIs) are a major global public health concern, disproportionately affecting low- and middle-income countries (LMICs). ¹ Ethiopia, like many other LMICs, faces a growing burden of RTIs due to rapid urbanization, increasing motorization, inadequate infrastructure, and weak enforcement of traffic laws.^2,3 Recent studies in the country have shown that RTIs are a leading cause of injury-related hospitalizations^4,5 and a pooled prevalence of 31.5% among trauma patients, ⁶ placing immense pressure on the healthcare system and contributing to significant morbidity and economic loss. ⁷

Road traffic crashes result in both fatal and non-fatal injuries, which are well-documented globally. ¹ However, RTIs significantly disrupt survivors’ lives. Severe injuries may result in disability or chronic health problems, limiting survivors’ ability to return to work and reducing productivity.^8,9 As a consequence, a prolonged recovery period and lack of capacity to work diminish the socioeconomic status of patients and their families, and often push them into economic vulnerability. ¹⁰ Furthermore, the impact of injuries is not only physical impairments, but also emotional and psychological consequences are common among survivors, as injuries may trigger fear, anxiety, and feelings of isolation, ultimately leading to withdrawal from social interactions and activities.^9,11

Existing evidence highlights that RTIs significantly impact survivors’ physical, psychological, and socioeconomic well-being, leading to a profound decrease in QoL. ¹¹ The World Health Organization Quality of Life (WHOQOL) conceptual framework provides a comprehensive approach to understanding QoL across four domains: physical health, psychological well-being, social relationships, and environmental context. This framework underscores not only functional capacity but also an individual’s overall enjoyment of life and ability to thrive within their environment. ¹² Within this perspective, RTI survivors who experience severe outcomes, such as disability, handicap, or chronic pain, consistently report lower QoL scores compared to the general population.^13,14 Prior studies have identified various factors associated with QoL among RTI survivors, including age, gender, socioeconomic status, injury severity, and the type of medical interventions received.^11,15,16

Despite increasing global evidence of the long-term consequences of RTIs, research in Ethiopia has primarily focused on acute injury outcomes. Most studies have emphasized hospitalization rates, injury patterns, and short-term health effects.^17–19 Consequently, there is a significant gap in understanding the QoL after hospital discharge, particularly in the physical, psychological, social, and environmental dimensions. This study aimed to bridge this gap by assessing the QoL of RTI survivors 1 year after hospital discharge and identifying associated factors. The findings may provide a comprehensive understanding of the lasting consequences of RTIs, which can inform strategies to improve well-being through supporting health care, their work, and social reintegration.

Methods

Study design and setting

A prospective cohort study was conducted among patients with RTIs admitted to Addis Ababa Burn, Emergency, and Trauma (AaBET) Hospital in Addis Ababa, Ethiopia. AaBET Hospital, affiliated with St. Paul’s Hospital Millennium Medical College, is the largest trauma hospital in Ethiopia, with over 250 beds. It provides specialized and subspecialized care for patients presenting directly or referred from other hospitals and health centers across Addis Ababa and other regions. ¹⁷ Baseline data were collected in the hospital from August 16, 2021, to May 12, 2022, and follow-up interviews were conducted 1 year after discharge, between September 17, 2022, and May 10, 2023.

Study participants

Adult patients aged 18 years and older who were admitted for at least 24 h due to RTIs were eligible for inclusion. However, patients with pre-existing disabilities at the time of the accident were excluded from the study.

Sample size and sampling procedure

It was difficult to find a similar study in Ethiopia on QoL among road traffic injuries. Hence, a sample size of 443 participants was calculated using a single-population proportion formula with the assumption of a 50% proportion of poor QoL, 5% margin of error, 95% confidence level, ²⁰ and 15% added for nonresponse. Eligible patients who presented to the emergency department with RTIs who met the inclusion criteria were consecutively recruited.

Study variables

The dependent variables were overall QoL and the four QoL domains (physical health, psychological health, social relationships, and environmental health) 1 year after hospital discharge. The physical domain assessed bodily functioning and the ability to perform daily activities; the psychological domain evaluated emotional and mental well-being; the social domain measured interpersonal interactions and social support; and the environmental domain assessed external conditions influencing well-being. ¹²

Independent variables were categorized into three main domains:

1. Sociodemographic characteristics: sex, age, educational level, marital status, family size, employment status, and annual income in Ethiopian birr (ETB).

2. Traffic accident and injury characteristics: location of the accident, types of roads, vehicle types, road users, injured body region, nature of the injury, Glasgow coma scale score, surgical intervention, and length of hospital stay.

3. Status at 1 year after discharge: survival status, self-perceived health, overall QoL, return to normal life, resumption of work or education, current work ability, and perceptions regarding opportunities to participate in and benefit from work or educational activities.

Data collection procedure and tools

Data collections were conducted in two phases. The first phase was conducted at the hospital, focused on sociodemographic information, accident, and injury characteristics. The second phase, conducted 1 year after discharge, assessed QoL, health status, return to normal life, work reintegration, and opinions on opportunities to engage as other community members do.

Hospital-level data were collected through face-to-face interviews using a structured questionnaire translated into Amharic (the local language). Patient medical records were also reviewed using a checklist to extract clinical data. The data collection tools were developed based on the World Health Organization (WHO) injury surveillance guideline and other relevant literature.^21,22 The questionnaire and checklist (Supplemental File 1) were entered electronically via tablet software and deployed to collect the data using tablets. Data were collected by four trained nurses under the supervision of a master-level public health professional. It was conducted 24 h a day, 7 days a week, during hospitalization.

The follow-up data were collected via telephone interviews. The interviews were conducted by an experienced public health professional with a master’s degree, who administered approximately two to three interviews per day due to the limited number of participants available for each appointment date. The data collection tools were the Amharic language-translated WHOQoL questionnaire-Brief Version (WHOQOL-BREF) to assess the QoL, ¹² and along with additional questions developed based on existing literature.^23,24

WHOQOL-BREF is open-source and was developed by the WHO to assess QoL in relation to individuals’ perceptions of their position in life, taking into account their culture, value systems, personal goals, and expectations. It has been shown to have good validity and is a widely used tool globally,^25,26 and has been translated into more than 80 languages, including the local language (Amharic). ²⁷ It comprises 26 questions: two independent items assessing overall QoL and satisfaction with health (questions 1 and 2); and the other 24 items explore physical health (questions 3, 4, 10, 15–18), psychological health (questions 5–7, 11, 19, 26), social relationships (questions 20–22), and environmental health (questions 8–9, 12–14, 23–25). The questions of each item are rated on a Likert scale from 1 to 5, with the responses for different items including: “very poor” to “very good,” “not at all” to “extremely,” “not at all” to “completely,” “very dissatisfied” to “very satisfied,” and “never” to “always.”

Participants’ perceptions of health status and QoL referred to the previous 2 weeks. Health satisfaction was measured with the item: “How satisfied are you with your health?” with the response of a Likert scale ranging from “very dissatisfied” to “very satisfied.” ²⁶  Overall QoL was assessed with the item: “How would you rate your quality of life?” with the response of a Likert scale ranging from “very poor” to “very good .” ¹²

Return to normal life was assessed using question with response of yes/no question “Have you currently returned to normal life?.” Return to work/education measure was “Have you returned to work/education at any time since your injury?” with three response options “Yes,” “Seldom,” and “No”; comparison of ability to work before and after the accident was measured by the question of “When you compare your ability to work or any activities today and before the accident, do you think that your ability has decreased?” with three response options “Yes,” “Seldom,” and “No”; and the opinion on participation opportunities measure was “Do you think you have the same opportunities as others to participate and benefit from education/work?” with three response options “Yes,” “No,” and “Not know” for not clearly recognize a difference.

Data quality control

The instrument was carefully designed by researchers with clear, concise, and context-appropriate questions to minimize ambiguity and respondent misinterpretation. The questionnaires were initially developed in English and then translated into the local language by health professionals familiar with the relevant terminology. It was then back-translated into English by another expert to ensure consistency. Data collectors received intensive training on the study objectives, data items, interview approach, and ethical considerations, and the use of electronic data collection tools. Both hospital-level and follow-up tools were pretested among 25 participants.

The principal investigator and supervisor provided ongoing supervision throughout data collection, including weekly and monthly data quality checks. Daily collected hospital and follow-up data were uploaded to a central server for review by the research team to ensure completeness and consistency.

Operational definitions

Perceived QoL.

participants’ responses to the overall QoL question were categorized as “good QoL” if they answered “good” or “very good”; all other responses were categorized as “poor QoL.” ²⁶

Perceived health.

participants’ perceptions of their health were categorized as “satisfied” if they responded “satisfied” or “very satisfied”; all other responses were categorized as “not satisfied.” ²⁶

Return to normal life status.

self-response to return to pre-injury activities 1 year after trauma with response options being either “Yes” if they return, and “No” for those not at the time of the interview.

Return to work/education status.

self-reported work return was categorized as “Yes” if participants fully returned to work or were working, “No” if they had not returned completely, or “Seldom” if they were working some time or only partially.

Decrease work ability.

self-reported and compared with pre-injury status, categorized as “Yes” if decreased significantly, “Seldom” if moderately decreased, and “No” if the same.

Opportunities to participate.

participants’ perceptions of having equal opportunities to participate were categorized as “Yes” if they believed they had equal opportunities, “No” if they perceived unequal opportunities, and “not known” if they could not clearly recognize a difference between before and after the injury.

Statistical analyses

The data were exported from the server as an Excel file, cleaned and coded using SPSS version 21, and subsequently imported into Stata version 17 for statistical analysis.

Responses to each WHOQOL-BREF item were scored on a 5-point Likert scale (1–5). Three negatively phrased items (questions 3, 4, and 26) were reverse-coded (1 → 5, 2 → 4, 3 → 3, 4 → 2, 5 → 1). Following reverse coding, item scores within each domain were summed according to WHOQOL-BREF guidelines. The raw domain scores were first converted to a 4–20 scale (mean domain score × 4) and then linearly transformed to a 0–100 scale for comparability with the WHOQOL-100 instrument, with higher scores indicating better QoL using the following formula^12,25,26:

$$TransformedScore(0-100)=\left[\frac{\left(Actualrawscore-lowestpossiblerawscor\right)}{Possiblerawscorerange}\right]\times 100$$

Where “Actual raw score” was the value achieved through summation, “lowest possible raw score” was the lowest possible value was 4, and “possible raw score range” was 16.^25,26

The WHOQOL-BREF scores were categorized into four domains, and the reliability of the data was checked through the analysis of internal consistency using Cronbach’s alpha. The results showed good internal consistency: α = 0.96 for the total scale; α = 0.93 for physical health; α = 0.85 for psychological health; α = 0.71 for social relationships; and α = 0.93 for environmental health domains. Descriptive statistics were calculated using frequencies, means, standard deviations (SD), medians, and interquartile range (IQR).

Four participants died during the follow-up, and we excluded their data from the multiple linear regression analysis, resulting in 326 participants as the final sample size. The sample size of 326 was adequate for the number of predictors included in the models across the domains and overall QoL. This sample size provided sufficient statistical power to detect small-to-medium effect sizes. ²⁸ Fifteen theoretically relevant variables were included in the model. Then, stepwise (both forward and backward, pr (0.10) pe (0.05)) variable selection was applied to identify the predictors. The multiple linear regression was done separately to assess QoL across four dimensions and overall QoL. Separate multiple linear regression models were fitted for each of the four QoL domains and overall QoL. Model assumptions, including normality and homoscedasticity, were verified and met. The result showed that the assumptions of normality and homoscedasticity were not violated in all models. In the final models, variables with a p-value < 0.05 were considered statistically significant.

This manuscript was prepared in line with the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) statement ²⁹ (Supplemental File 2).

Results

One year after hospital discharge, phone interviews were conducted, with 330 participants (74.5% of the sample) successfully reached. Despite attempts made for more than five consecutive days, 149 participants could not be contacted (Figure 1).

Figure 1.

Study participant selection procedure.

Socio-demographic characteristics

Most participants were male (n = 258, 78.2%), with median age of 31.5 years (IQR: 25–44). A large proportion (n = 286, 86.7%) of participants had received formal education, and about one-fourth (n = 89, 27.0%) were salaried workers. The self-reported median annual income in ETB was 36,000 (IQR: 24,000–60,000; Table 1).

Table 1.

Socio-demographic characteristics (n = 330).

Variables categories	Frequency	Percent
Sex
Male	258	78.2
Female	72	21.8
Age category in years
18–24	68	20.6
25–34	114	34.6
35–44	69	20.9
≥45	79	23.9
Education level
No formal	44	13.3
Grades 1–6	57	17.3
Grades 7–12	170	51.5
College/University and above	59	17.9
Marital status
Married	180	54.5
Never married	133	40.3
Divorced/widowed	17	5.2
Family size
1	88	26.7
2–4	130	39.4
>4	112	33.9
Employment status
Daily-wage worker	46	13.9
Salary worker	89	27.0
Self-employed/ business	141	42.7
Homemaker/student/no job	54	16.4
Average annual income in ETB a
≤20,000	75	22.7
20,001–30,000	66	20.0
30,001–50,000	93	28.2
>50,000	96	29.1

^a49.378 ETB equivalent to 1 USD on December 30, 2021, National Bank of Ethiopia exchange rate

Road traffic accident and injury characteristics

Almost half (n = 159, 51.8%) of road traffic accidents were reported in rural areas, whereas 171 (48.2%) occurred in urban settings. More than half of the accidents occurred on highways (57.0%). Collisions involving minibuses or vans (29.4%) were the most common (Table 2). Passengers (45.2%) represented the largest group of injured road users, followed by pedestrians (33.6%). The head and face were the most affected body parts (n = 122, 36.8%), followed by the lower extremities (n = 106, 32.2%); fracture (n = 184, 55.8%) was the most common type of injury outcome, and 83 (25.1%) patients underwent surgery. Over half of the patients (n = 170, 51.5%) stayed in the hospital for over a week, with a median of 8 days (IQR: 2–19).

Table 2.

Road traffic accident and injury characteristics (n = 330).

Variables categories	Frequency	Percent
Type of road
Highway	188	57.0
Main road	122	37.0
Side street/village road/other	20	6.0
Vehicles type
Mini-bus/van	97	29.4
Car	78	23.6
Bus/truck/lorry	80	24.3
Motor/auto-rickshaw	71	21.5
Non-motorized	4	1.2
Road users
Pedestrian	111	33.6
Passenger	149	45.2
Driver (include non-motorized)	70	21.2
Most severely injured anatomies
Head/face and neck	122	37.0
Lower extremities	106	32.1
Upper extremities	65	19.7
Abdomen chest and skin	37	11.2
Nature of injury
Fracture	160	48.5
Concussion, amputation, and other internal injuries	131	39.7
Soft tissue injury and dislocation	39	11.8
Glasgow Coma Scale score
Mild (13–15)	270	81.8
Moderate (9–12)	52	15.8
Severe (3–8)	8	2.4
Surgical intervention
No operation	247	74.9
1 operation	67	20.3
≥2 operations	16	4.8
Length of hospital stay in days
1	63	19.1
2–7	97	29.4
8–15	71	21.5
>15	99	30.0

Status of patients 1 year after hospital discharge

Of the 330 patients, 326 (98.8%) survived and four families reported that the RTIs were confirmed dead after being discharged from the Hospital. Of the survivors, about two-thirds (n = 202, 62.0%) reported unsatisfactory health, and one-fourth (n = 84, 25.8%) perceived poor or very poor QoL status (Table 3). A total of 174 patients (53.4%) successfully returned to work, and half (n = 170, 52.1%) reported a decrease in their current work ability compared to before the accident. Furthermore, 190 (58.3%) patients felt no equal opportunities to participate in and benefit from work or education.

Table 3.

Status of RTI patients 1 year after hospital discharge (n = 326).

Status of RTI patients	Frequency	Percentage
Perceived health
Very dissatisfied	23	7.1
Dissatisfied	72	22.1
Neither satisfied nor dissatisfied	107	32.8
Satisfied	67	20.6
Very satisfied	57	17.4
Perceived quality of life status
Very poor	24	7.4
Poor	60	18.4
Neither poor nor good	105	32.2
Good	76	23.3
Very good	61	18.7
Returned to normal life
Yes	279	85.6
No	47	14.4
Returned to work/education since injury
Yes	174	53.4
Seldom	33	10.1
No	119	36.5
Comparison of current ability to work before and after the accident
Yes decreased	170	52.1
Seldom decreased	67	20.6
Not decreased	89	27.3
Had the same opportunities as others to participate in and benefit from work/education
Yes	116	35.6
No	190	58.3
Not known	20	6.1

Quality of life

Of all participants, 189 (58%, CI: 52.8–63.8) reported a poor overall QoL. The mean (±SD) overall QoL score was 56.9 ± 29.5. While the domain-specific mean scores were 56.2 ± 29.8 for physical health, 73.6 ± 23.1 for psychological health, 70.5 ± 23.1 for social relationships, and 57.8 ± 27.1 for environmental health.

Factors associated with QoL

In the multiple linear regression analysis with stepwise selection, only models that were statistically significant (p < 0.10) and satisfied the assumptions of linear regression were retained and reported. The selected variables explained 61.1% of the variation in overall QoL (R² = 0.618, adjusted R² = 0.611, F(6,319) = 86.1, p < 0.001). Domain-specific models explained 72.0% of the variation in physical health (R² = 0.726, adjusted R² = 0.720, F(6,319) = 140.6), 51.7% in psychological health (R² = 0.530, adjusted R² = 0.517, F(9,316) = 39.6), 38.1% in social relationships (R² = 0.392, adjusted R² = 0.381, F(6,319) = 34.39), and 69.2% in environmental health (R² = 0.701, adjusted R² = 0.692, F(9,316) = 82.3), all with p < 0.001.

Perceived poor health satisfaction, failure to return to normal life, and lack of equal opportunities for participation or benefit were consistent predictors of reduced QoL in four domains (Table 4). Furthermore, in the physical health domain with not returning to work or education and decreased work ability; in the psychological domain, lower educational level, being never married, and employment as a daily laborer or homemaker/student/unemployed, decreased work ability were associated with poorer outcomes, whereas sustaining a lower extremity injury was linked to better outcomes. The social relationship domain, lower education level, being unmarried, and not returning to work/education were significant predictors of lower scores and for the environmental health domain, being female, being young, undergoing surgical intervention, not returning to work/education, and decreased work ability were associated with poorer outcomes. Overall QoL was significantly reduced among participants with sustained a concussion, amputation, or other internal injuries, undergoing surgical intervention, had poor health perception, failed to return to normal life, had unequal participation opportunities, and those who did not return to work or education.

Table 4.

Multiple linear regressions of factors associated with QoL in the four domains (n = 326).

Predictor variables	PHY	PSY	SOC	ENV	Overall
	β (P)	β (P)	β (P)	β (P)	β (P)
Constant	91.27 (<0.001)	92.71 (<0.001)	92.05 (<0.001)	85.82 (<0.001)	89.45 (<0.001)
Sex (reference, male)
Female	-	-	-	−4.84 (0.019)	-
Age (in years)	-	-	-	0.15 (0.028)	-
Education level (reference: College/University, and above)
No formal education- grade 6	-	-	−7.94 (0.014)	-	-
Secondary/High School (reference: grades 7–12)	-	3.28 (0.072)	−5.81 (0.035)	-	-
Marital status (reference, married)
Never married	-	−4.17 (0.016)	−7.82 (<0.001)	-	-
Employment status (reference, Salary worker)
Daily-wage laborer	-	−5.86 (0.027)	-	-	-
Homemaker/student/no job	-	−5.98 (0.027)	-	-	-
Most severely injured anatomies (reference, upper extremities)
Lower extremities	-	5.18 (0.008)	-	-	-
Nature of injury (reference, soft tissue injury and dislocation)
Concussion, amputation, and other internal injuries	-	-	-	-	−4.39 (0.037)
Surgical intervention (reference, No)
Yes	-	-	-	−3.31 (0.096)	−5.56 (0.022)
Perception of current health status (reference, satisfy)
Perceived poor satisfaction	−23.52 (<0.001)	−14.91 (<0.001)	−13.34 (<0.001)	−20.84 (<0.001)	−31.40 (<0.001)
Returned to normal life (reference, yes)
No	−18.05 (<0.001)	−25.28 (<0.001)	−15.91 (0.001)	−23.51 (<0.001)	−17.9 (<0.001)
RTW/education since injury (reference, yes)
Seldom	−6.71 (0.013)	-	−5.59 (0.039)	-	-
No	−14.47 (<0.001)	-	-	−5.91 (0.010)	−5.95 (0.030)
Comparison of the ability to work before and after the accident (reference, no)
Yes decreased	−7.80 (0.003)	−4.19 (0.058)	-	−8.76 (<0.001)	-
Seldom decreased	-	-	-	−7.03 (0.006)	-
Had the same opportunities as others to participate in and benefit from work/education (reference, yes)
No	−12.28 (<0.001)	−6.67 (0.006)	−6.28 (<0.001)	−11.77 (<0.001)	−8.98 (0.001)

ENV: environmental health domain; Overall: overall perceptions of QoL; PSY: psychological health domain; SOC: social relationship domain.

Discussion

This comprehensive analysis highlights the impact of road traffic accidents on the QoL of RTI patients, particularly in developing countries where such road traffic accidents pose a major public health concern. The majority of participants were young adult males from low-income households. More than half (58.0%) of participants reported poor overall QoL, and about two-thirds (62.0%) were unsatisfied with their health after 1 year of hospital discharge. Factors associated with QoL were the nature of injury, surgical intervention, health status, return to normal life, return to work, and opportunities to participate in and benefit from work or education.

Most participants in the current study were male (78.2%). This finding is consistent with previous studies on road traffic injuries in Ethiopia, which reported similar proportions of male victims (79.0%) ³⁰ and 76.4%. ³¹ This may be explained by the fact that men are often the primary household heads and income earners in Ethiopia. ³² Similar to the previous studies,^21,31 young adults with a median age of 31.5 years were the most affected group. This age group is generally more active and prone to risk-taking behaviors in their daily activities. ³³ Consequently, they might be more likely to engage in outdoor economic activities or travel frequently for work, and such conditions might increase their exposure to road traffic accidents. The self-reported median annual income was 36,000 Ethiopian Birr, equivalent to approximately 729 USD. This income level is below the poverty line (Poverty Rate at 3.00 USD per Day in 2021), ³⁴ and might indicate that many of the affected individuals belong to economically disadvantaged groups.

The poor QoL has impacts on the productivity of individuals, families, communities, and society. ¹⁵ The current study reported a higher magnitude of poor overall QoL than the study conducted in France, with 47.0%. ²⁶ Furthermore, it showed that the mean QoL regarding psychological health was the highest, followed by the social relationship domain scores. These findings contrast with similar studies, where social relationships are highest, followed by physical health, and lowest in psychological health.^26,35 The discrepancy may be due to socioeconomic and cultural differences among study participants in developed and low-income countries.^36,37 Ethiopia is a low-income country with a diverse culture. According to the previous finding, those from developing countries reported worse environmental, psychological, and physical QoL, but better social QoL than those from developed. ³⁸ This post-trauma status of patients has significant public health implications in the Ethiopian context, where trauma care primarily focuses on acute clinical management at the hospital level, while long-term recovery, disability management, and follow-up health services are often neglected.^17,39,40

Furthermore, the current study revealed that concussions, amputation and internal injuries were significantly associated with overall WHOQOL-BREF scores. These injuries refer to the removal of body parts, damage to internal organs, tissues, or blood vessels, and are generally considered severe forms of trauma. ²² Consistent with the present findings, previous studies have also reported that severe injuries among RTI patients are associated with lower QoL scores. ²⁶ Additionally, the current finding revealed that participants who underwent surgical intervention had low QoL compared with those who did not. Similarly, this finding was reported from a study in Rwanda. ¹¹ This low QoL might be due to the lasting effects of severe injuries, which can delay full recovery even 1 year after the accident. ⁴¹ These findings highlight the importance of early identification and continuous follow-up of patients with severe injuries to prevent chronic health complications and reduce the long-term social and economic consequences.

Road traffic injury survivors might develop post-traumatic health problems like depression and disability,^9,15 which have the potential to decline the QoL. Self-reported unsatisfied health status and inability to return to normal life were negatively associated with overall QoL in the current study. The explanation for this finding might be that unsatisfactory health outcomes following an accident led to diminished physical capabilities, impaired psychological well-being, strained social relationships, and reduced ability to return to normal life.^23,26,42 Poor post-trauma health and inability to return to normal life might reduce survivors’ productivity; affecting household income and community contributions.

This study reported that patients who did not RTW had a significant association with lower QoL than those who fully returned to work. This finding aligns with a previous study on occupational injury. ⁴³  The justification of these relationships might be due to the deep interconnection between injury severity, disability, pain, RTW, and QoL.^9,35 Furthermore, the patients’ opinion of not having equal opportunities to participate in and benefit from work and education was negatively associated with overall QoL. This finding may be explained by the fact that patients might face challenges with long-term health issues as they attempt to engage in everyday life and which might lead to a disconnect between their needs and the available support. ⁴⁴ These experiences may contribute to difficulties in participating in education and employment after a severe injury. ⁴⁵ The strong link between failure to return to work and poor QoL underscores the need for policies that promote employment reintegration for RTI survivors in Ethiopia.

The physical QoL domain refers to the aspects related to bodily functions and the ability to perform daily activities, and the environmental QoL domain evaluates external conditions that affect well-being. ¹² The current study findings revealed that not returning to work, decreased ability to work, and the perception of having no equal opportunities or benefits in work or education were significantly and negatively associated with both physical and environmental QoL domains. A study reported similar findings among patients with work-related musculoskeletal disorders. ⁴⁶ A possible explanation could be that diminished physical functioning among RTI survivors might restrict their capacity to work, whereas environmental constraints, including limited access to equal opportunities, exacerbate their reduced QoL. These findings highlight the importance of comprehensive rehabilitation programs that address both physical recovery and environmental or social barriers.

The findings of this study might have several policy implications for Ethiopia and other similar low-income settings. The high burden of poor QoL among RTI survivors highlights the need to strengthen post-injury rehabilitation, psychosocial care, and employment reintegration programs within the national post-trauma care system. Ethiopia’s current trauma care model focuses mainly on clinical management during hospitalization; therefore, integrating long-term rehabilitation and social reintegration into health service delivery is essential.

Strengths and limitations

The study utilized the WHOQOL-BREF, a well-established and validated instrument. This enhances the reliability and comparability of the results with other studies worldwide. A longer follow-up period might provide more comprehensive insights into the long-term QoL outcomes. However, this study has several limitations that should be acknowledged. First, this analysis relies heavily on self-reported data collected via phone interviews through a one-time follow-up. This may be subject to recall bias and social desirability bias. Second, the use of structured, closed-ended questions during the follow-up interviews may have had a leading nature, particularly for items assessing current health, return to work, ability to perform activities, and perception of opportunities. This could have influenced participants’ responses by guiding them toward certain interpretations of their situation rather than allowing more nuanced expressions. Third, injury recovery after hospital discharge, mental health status, access to rehabilitation services, and social support systems could significantly influence QoL outcomes. Finally, this study’s findings are based on a moderate response rate, participants from a single hospital, and phone interviews during follow-up. These situations might introduce selection bias and limit representativeness. Despite the limitations of this study, the follow-up data collector was experienced with similar data collection procedures and made efforts to avoid leading participants’ responses. Although the participants were recruited from a single center, they represented a wide range of demographic and socioeconomic backgrounds, providing a more nuanced understanding of patients’ post-road traffic crash QoL.

Conclusion

More than half of the participants reported poor overall self-perceived QoL. However, physical health and environmental QoL were rated as moderate, while the highest scores were observed in the social relationships and psychological QoL domains. Injury nature; unsatisfied health status, inability to return to normal life and work; and perceived no opportunities for work or education after injury had negative implications on QoL. These findings suggest the need of post-discharge follow-up among severely injured patients to enhance their health, support their reintegration into work, and improve their overall QoL. Further research on the long-term psychosocial and economic consequences, and the factors influencing return to work are recommended.