This thesis is submitted in partial fulfillment of the requirements for the degree of Master of Science in Emergency Medicine( Msc Med EM), Division of Emergency Medicine, University of Witwatersrand , Faculty of Health Sciences , School of Clinical Medicine, Department of Family Medicine, 2012 / 1. BACKGROUND AND SETTING The study was conducted at Vryheid district hospital in the Kwazulu- Natal province. The increasing number of traumatic brain injuries seen at the hospital has prompted me to describe traumatic brain injuries in the community. Data was collected from the records of casualty department and the hospital wards. 2. AIM This thesis describes traumatic brain injuries at Vryheid district hospital during 2009. 3. METHODS It is a retrospective cohort study with a total sample size of 596 participants; retrieved from patients’ registers at the hospital’s casualty department and hospital wards. 4. RESULTS - The peak age of occurrence of traumatic brain injuries (TBI) at Vryheid is between 20 and 30 years with 75% of injuries happening in younger than 35 years and a mean age of 29 years. - 78% of traumatic brain injuries occurred in female patients but it is important to note that females are in greater number than males at Abaqulusi municipality. - Blacks are the most affected by the traumatic brain injuries at Vryheid: 97% versus 2.4% in white and 0.3 in Asians. - Blunt traumatic brain injuries are the most common type of TBI at Vryheid: 97%. - Assault injuries constitute the major cause of traumatic brain injuries ( 57 %) followed by motor vehicle accidents (40%) - Mild traumatic brain injuries represent 75% of traumatic brain injuries presenting at Vryheid during 2009. - The majority of TBI patients at Vryheid were discharged either from casualty department or from the wards and only as small number of patients died or was transferred out. Moreover, 60% of patients were treated as ambulatory patients. - 94% of TBI at Vryheid hospital had a good prognosis and only a small percentage was associated with bad prognosis. - The mean hospital length stay at Vryheid was 2.2 days with a minimum of less than a day (62%) and a maximum of 129 days. 5. CONCLUSION In 2009, traumatic brain injuries were found to be common at Vryheid hospital in the black population and were mainly due to assault injuries and motor vehicle accidents. Moreover, motor vehicle accidents were associated with high mortality. Although, the majority of traumatic brain injuries at Vryheid hospital were mild, 10% were severe. Thus, TBI at Vryheid constitutes a public health concern that needs to be addressed by the SA government in consultation and collaboration with various stakeholders.

No description available.

The primary historical focus of this thesis falls in the years between 1940 and 1970. My main area of interest lies in the individual subject and how that child, adolescent or adult functions in particular situations and most importantly, how my chosen African American writers have portrayed their male and female protagonists in various environments and circumstances. Each of the seven chapters of this thesis covers specific experiences: an emotional journey toward one‘s sexual orientation; a trans-national urban experience of homosexuality; 1950s suburbia and the socio-cultural issue of interracial relationships; historical and legal concepts of interraciality; rural poverty and childhood trauma; communal responsibility and child abuse; and maturation and intergenerational relationships. An emphasis upon family, community and environment are threads that run throughout the thesis. Accordingly, social, political and legal histories are engaged, as are environmental studies. Furthermore, queer, black feminist, trauma and gender theories are utilised along with sociological studies, child development and psychology. This research has enabled my close textual examination of each narrative so as to ascertain how each writer deals with the relationship between subject and society, thus, I argue how they offer differing viewpoints than the ones we find presented by traditional theories and criticism that predominantly comprise issues of race. Finally, the aim of this thesis is to propose alternative avenues of critical inquiry regarding the treatment of child development and individual trauma through individual readings of these mid-twentieth-century examples of autobiography, drama and novel.

Study one is a meta-analysis of the relationship between childhood adversity and bipolar disorder. The results suggest that individuals with bipolar disorder are 2.63 times more likely to experience childhood adversity than non-clinical controls. This effect remained significant even when controlling for bias and when considering epidemiological and case control studies separately. Levels of adversity in bipolar disorder were comparable to those observed in samples diagnosed with unipolar depression and schizophrenia. In adversity subtype analysis, emotional abuse conveyed the greatest risk of bipolar disorder with an odds ratio of 4.04. The results suggest that childhood adversity, particularly emotional abuse, may play an important role in the development of bipolar disorder. This challenges the notion that bipolar disorder is solely the result of a genetic predisposition. Study two is cross-sectional research investigating the association between childhood adversity and social functioning across the continuum of psychosis, and possible mediators of this relationship (i.e. attachment style, theory of mind ability, clinical symptoms). Fifty-four clinical and 120 non-clinical participants completed self-report questionnaires, interviews and tasks of theory of mind ability. The author used multiple group structural equation modelling to fit mediation models, whilst allowing for differential relationships across the samples. In the final model, only depression mediated the relationship between childhood adversity and social functioning. Childhood adversity did not significantly predict theory of mind ability in this data. The results suggest that psychosocial interventions for improving social functioning should also target low mood, particularly in individuals with a history of childhood adversity. Taken together this thesis suggests that childhood adversity can have long-reaching and negative effects on individuals' mental well-being. The author explores the wider clinical, academic and theoretical implications, and potential limitations, of the research in paper three. This section also contains the author's reflections on the research process and a justification of key methodological and analytical decisions.

In 2009 four men were trafficked from their native Bangladesh to work in the Scottish Highlands. They were promised jobs as professional chefs. Instead they were forced into modern-day slavery. This is their story.

Faculty of Health Sciences School of Therapelitics 0009448d jasmin@tiscali.co.za / Currently the role of the Emergency Nurse in South Africa is not clearly defined. Nursing legislation does not effectively guide these nurses to enable them to cope with the high expectations and increasing demands for emergency care. Nor does it provide adequate legislative protection especially with regard to the responsibilities within the prehospital environment. This creates role confusion and conflict, which has a negative impact on the patient who requires emergency care, the advanced nurse practitioner and the emergency team. . The purpose of this research was to explore and describe the role of the South African emergency nurse in the prehospital environment and the emergency room and to formulate an instrument that can be used for policy formation, education, training and evaluation. The purpose was addressed though an action research process where data was collected in four phases that included both qualitative and quantitative methods. The process involved a group of experts who utilized their expert knowledge, skills and attitudes to explore and describe the phenomena being researched. They confirmed that the environment in which emergency nurses worked included the pre-hospital environment and emergency room. The data/roles identified and analysed were weighted to provide a weighting scale by means of a methodology referred to as “ Modelling of Human Judgement”. A competency rating was done to provide a three-point competency rating. The data/roles obtained was developed into a questionnaire and sent to the rest of the emergency nurse population for validation and verification. After validation and verification the information gathered was reduced, organized and with the assistance of a statistician (throughout all the phases) the data was analysed and an instrument developed for use as a policy framework for e.g. a scope of practice and unit standards. The instrument was quantified for educational and evaluation purposes. The instruments can be used to develop high levels of competency to encourage interdependent and autonomous decision-making, which is based on the knowledge of role expectations and sound professional decision making, which in turn is supported by appropriate legislation.

archives@tulane.edu / There is a veil that divides those willing to discuss the construct of race and those participating in racial ambivalence or color blindness. It is because of that veil or divide that discussing race, racism, and the traumatic effects of racism is a task that many are still learning how to do successfully. This study is among the first to question how social workers engage with the construct of racism-based trauma. Furthermore, this study beckons a consideration to racism based stressed experienced by the incarcerated person. By not considering racialized stress and harm, one not only has limitations in the intervention process but runs the risk of perpetuating more harm. The goals for the study were as follows: To identify how justice system social workers define racism-based trauma; to understand whether or not justice system social workers consider the carceral experience to be racially traumatic; to inform practice approaches to racism-based trauma among justice system social workers. In-depth, semi-structured interviews were conducted with twelve social workers to learn how they conceptualized racism-based trauma in their work with the incarcerated person. Inductive and abductive coding from the transcribed interviews revealed that racism-based stress was considered to be an experience often unbeknownst, long-lasting, and accentuated by locale. Reflections on the incarceration experience also suggest that the experience is racially stressful and that it occurs before, during, and after incarceration. Findings highlight the importance of increasing knowledge in the construct of racism-based trauma to be beneficial in practice while confronting whiteness and allyship were identified challenges. The findings for this study suggest that an engagement with one’s racial identity before and during a critique of racialized systems is beneficial in social work practice. Some examples of engagement include conceptualizing race and racism-based trauma experienced by the client, considering how to assess and relieve stress from racism, and how to maintain wellness while doing so. In these engagements, a shift from being culturally competent to being racially competent is possible and encouraged for the social worker. The aims of engaging with construct ultimately strengthens and diversifies social work pedagogy, training, and policies. / 1 / Curtis Davis

Doctor of Philosophy / Work-related injuries and road traffic injuries are common causes of morbidity and are major contributors to the burden of disease worldwide. In developed countries, these injuries are often covered under compensation schemes, and the costs of administering these schemes is high. The compensation systems have been put in place to improve the health outcomes, both physical and mental, of those injured under such systems; yet there is a widespread belief, and some evidence, that patients treated under these schemes may have worse outcomes than if they were treated outside the compensation system. Chapter One of this thesis explores the literature pertaining to any effect that compensation may have on patient outcomes. It is noted that the concept of “compensation neurosis” dates from the nineteenth century, with such injuries as “railway spine”, in which passengers involved in even minor train accidents at the time, would often have chronic and widespread symptoms, usually with little physical pathology. Other illnesses have been similarly labelled over time, and similarities are also seen in currently diagnosed conditions such as repetition strain injury, back pain and whiplash. There are also similarities in a condition that has been labelled “shell shock”, “battle fatigue”, and “post-traumatic stress disorder”; the latter diagnosis originating in veterans of the Vietnam War. While there is evidence of compensation status contributing to the diagnosis of some of these conditions, and to poor outcomes in patients diagnosed with these conditions, there is little understanding of the mechanism of this association. In contrast to popular stereotypes, the literature review shows that malingering does not contribute significantly to the effect of compensation on health outcomes. Secondary gain is likely to play an important role, but secondary gain is not simply confined to financial gain, it also includes gains made from avoidance of workplace stress and home and family duties. Other psychosocial factors, such as who is blamed for an injury (which may lead to retribution as a secondary gain) or the injured person’s educational and occupational status, may also influence this compensation effect. The literature review concludes that while the association between compensation and health after injury has been widely reported, the effect is inconsistent. These inconsistencies are due, at least in part, to differences in definitions of compensation (for example, claiming compensation versus using a lawyer), the use of different and poorly defined diagnoses (for example, back pain), a lack of control groups (many studies did not include uncompensated patients), and the lack of accounting for the many possible confounding factors (such as measures of injury severity or disease severity, and socio-economic and psychological factors). The literature review also highlighted the variety of different outcomes that had been used in previous studies, and the paucity of literature regarding the effect of compensation on general health outcomes. This thesis aims to explore the association between compensation status and health outcome after injury. It addresses many of the methodological issues of the previously published literature by, i selecting study populations of patients with measurable injuries, ii clearly defining and separating aspects of compensation status, iii including control groups of non-compensated patients with similar injuries iv allowing for a wide variety of possible confounders, and v using clearly defined outcome measures, concentrating on general health outcomes. Before commencing the clinical studies reported in Chapters Three and Four, a systematic review and meta-analysis was performed to quantify and analyse the effect of compensation on outcome after surgery. This allowed a clearly defined population of studies to be included, and was relevant to the thesis as the surgeries were performed as treatment of patients who had sustained injuries. The study, which is reported in Chapter Two, hypothesised that outcomes after surgery would be significantly worse for patients treated under compensation schemes. The study used the following data sources: Medline (1966 to 2003), Embase (1980 to 2003), CINAHL, Cochrane Controlled Trials Register, reference lists of retrieved articles and textbooks, and contact with experts in the field. The review included any trial of surgical intervention where compensation status was reported and results were compared according to that status, and no restrictions were placed on study design, language or publication date. Data extracted were study type, study quality, surgical procedure, outcome, country of origin, length and completeness of follow-up, and compensation type. Studies were selected by two unblinded independent reviewers, and data were extracted by two reviewers independently. Data were analysed using Cochrane Review Manager (version 4.2). Two hundred and eleven papers satisfied the inclusion criteria. Of these, 175 stated that the presence of compensation (worker's compensation with or without litigation) was associated with a worse outcome, 35 found no difference or did not describe a difference, and one paper described a benefit associated with compensation. A meta-analysis of 129 papers with available data (20,498 patients) revealed the summary odds ratio for an unsatisfactory outcome in compensated patients to be 3.79 (95% confidence interval 3.28 to 4.37, random effects model). Grouping studies by country, procedure, length of follow-up, completeness of follow-up, study type, and type of compensation showed the association to be consistent for all sub-groups. This study concludes that compensation status is associated with poor outcome after surgery, and that this effect is significant, clinically important and consistent. Therefore, the study hypothesis is accepted. However, as data were obtained from observational studies and were not homogeneous, the summary effect should be interpreted with caution. Determination of the mechanism for the association between compensation status and poor outcome, shown in the literature review (Chapter One) and the systematic review (Chapter Two) required further study. Two studies were designed to further explore this association and these are reported in Chapters Three and Four. The retrospective study reported in Chapter Three, the Major Trauma Outcome Study (MTOS), aimed to explore the association between physical, psychosocial, and compensation-related factors and general health after major physical trauma. The primary hypothesis predicted significantly poorer health outcomes in patients involved in pursuing compensation, allowing for possible confounders and interactions. The study also examined other health outcomes that are commonly associated with compensation, and examined patient satisfaction. Consecutive patients presenting to a regional trauma centre with major trauma (defined as an Injury Severity Score greater than 15) were surveyed between one and six years after their injury. The possible predictive factors measured were: general patient factors (age, gender, the presence of chronic illnesses, and the time since the injury), injury severity factors (injury severity score, admission to intensive care, and presence of a significant head injury), socio-economic factors (education level, household income, and employment status at the time of injury and at follow-up), and claim-related factors (whether a claim was pursued, the type of claim, whether the claim had settled, the time to settlement, the time since settlement, whether a lawyer was used, and who the patient blamed for the injury). Multiple linear regression was used to develop a model with general health (as measured by the physical and mental component summaries of the SF-36 General Health Survey) as the primary outcome. The secondary outcomes analysed were: neck pain, back pain, post-traumatic stress disorder, and patient satisfaction. On multivariate analysis, better physical health was significantly associated with increasing time since the injury, and with lower Injury Severity Scores. Regarding psychosocial factors, the education level and household income at the time of injury were not significantly associated with physical health, but pursuit of compensation, having an unsettled claim, and the use of a lawyer were strongly associated with poor physical health. Measures of injury severity or socio-economic status were not associated with mental health. However, the presence of chronic illnesses and having an unsettled compensation claim were strongly associated with poor mental health. Regarding the secondary outcomes, increasing neck pain and back pain were both significantly associated with lower education levels and the use of a lawyer, but not significantly associated with claiming compensation. The severity of symptoms related to post-traumatic stress disorder was not associated with measures of injury severity, but was significantly and independently associated with the use of a lawyer, having an unsettled compensation claim, and blaming others (not themselves) for the injury. The strongest predictor of patients’ dissatisfaction with their progress since the injury was having an unsettled compensation claim, and as with the other secondary outcomes, patient satisfaction was not significantly associated with injury severity factors. Factors relating to the compensation process were among the strongest predictors of poor health after major trauma, and were stronger predictors than measures of injury severity. The hypothesis that general physical and mental health would be poorer in patients involved in seeking compensation for their injury was accepted. This study concludes that the processes involved with claiming compensation after major trauma may contribute to poor health outcomes. The prospective study reported in Chapter Four, the Motor Vehicle Accident Outcome Study (MVAOS), aimed to explore the effect of compensation related factors on general health in patients suffering major fractures after motor vehicle accidents (MVAs). The study hypothesized that general health would be poorer in patients claiming compensation for their injuries. Patients presenting to 15 hospitals with one or more major fractures (any long bone fracture, or fracture of the pelvis, patella, calcaneus or talus) after a motor vehicle accident were invited to participate in this prospective study. Initial data was obtained from the patient and the treating doctors. Both the patients and treating surgeons were followed up with a final questionnaire at six months post injury. General factors (age, gender, treating hospital, country of birth, presence of chronic illnesses and job satisfaction), injury factors (mechanism of injury, number of fractures, and the presence of any non-orthopaedic injuries), socioeconomic factors (education level, income, and employment status), and compensation-related factors (whether a claim was made, the type of claim, whether a lawyer was used, and who was blamed for the injury) were used as explanatory variables. The primary outcome was general health as measured by the physical and mental component summaries of the SF-36 General Health Survey. The secondary outcomes were neck pain, back pain, and patients’ ratings of satisfaction with progress and of recovery. Multiple linear regression was used to develop predictive models for each outcome. Completed questionnaires were received from 232 (77.1%) of the 301 patients included in the study. Poor physical health at six months was strongly associated with increasing age, having more than one fracture, and using a lawyer, but not with pursuit of a compensation claim. Poor mental health was associated with using a lawyer and decreasing household income. Increasing neck pain and back pain were both associated with the use of a lawyer and with lower education levels. Higher patient satisfaction and patient-rated recovery were both strongly associated with blaming oneself for the injury, and neither were associated with pursuit of compensation. Although the use of a lawyer was a strong predictor of the primary outcomes, the pursuit of a compensation claim was not remotely associated with these outcomes, and therefore the study hypothesis was rejected. The studies reported in this thesis are compared in the final chapter, which concludes that poor health outcomes after injury are consistently and strongly associated with aspects of the compensation process, particularly the pursuit of a compensation claim, involvement of a lawyer, and having an unsettled claim. Compensation systems may be harmful to the patients that these systems were designed to benefit. Identification of the harmful features present in compensation systems my allow modification of these systems to improve patient outcomes.

Doctor of Philosophy / Work-related injuries and road traffic injuries are common causes of morbidity and are major contributors to the burden of disease worldwide. In developed countries, these injuries are often covered under compensation schemes, and the costs of administering these schemes is high. The compensation systems have been put in place to improve the health outcomes, both physical and mental, of those injured under such systems; yet there is a widespread belief, and some evidence, that patients treated under these schemes may have worse outcomes than if they were treated outside the compensation system. Chapter One of this thesis explores the literature pertaining to any effect that compensation may have on patient outcomes. It is noted that the concept of “compensation neurosis” dates from the nineteenth century, with such injuries as “railway spine”, in which passengers involved in even minor train accidents at the time, would often have chronic and widespread symptoms, usually with little physical pathology. Other illnesses have been similarly labelled over time, and similarities are also seen in currently diagnosed conditions such as repetition strain injury, back pain and whiplash. There are also similarities in a condition that has been labelled “shell shock”, “battle fatigue”, and “post-traumatic stress disorder”; the latter diagnosis originating in veterans of the Vietnam War. While there is evidence of compensation status contributing to the diagnosis of some of these conditions, and to poor outcomes in patients diagnosed with these conditions, there is little understanding of the mechanism of this association. In contrast to popular stereotypes, the literature review shows that malingering does not contribute significantly to the effect of compensation on health outcomes. Secondary gain is likely to play an important role, but secondary gain is not simply confined to financial gain, it also includes gains made from avoidance of workplace stress and home and family duties. Other psychosocial factors, such as who is blamed for an injury (which may lead to retribution as a secondary gain) or the injured person’s educational and occupational status, may also influence this compensation effect. The literature review concludes that while the association between compensation and health after injury has been widely reported, the effect is inconsistent. These inconsistencies are due, at least in part, to differences in definitions of compensation (for example, claiming compensation versus using a lawyer), the use of different and poorly defined diagnoses (for example, back pain), a lack of control groups (many studies did not include uncompensated patients), and the lack of accounting for the many possible confounding factors (such as measures of injury severity or disease severity, and socio-economic and psychological factors). The literature review also highlighted the variety of different outcomes that had been used in previous studies, and the paucity of literature regarding the effect of compensation on general health outcomes. This thesis aims to explore the association between compensation status and health outcome after injury. It addresses many of the methodological issues of the previously published literature by, i selecting study populations of patients with measurable injuries, ii clearly defining and separating aspects of compensation status, iii including control groups of non-compensated patients with similar injuries iv allowing for a wide variety of possible confounders, and v using clearly defined outcome measures, concentrating on general health outcomes. Before commencing the clinical studies reported in Chapters Three and Four, a systematic review and meta-analysis was performed to quantify and analyse the effect of compensation on outcome after surgery. This allowed a clearly defined population of studies to be included, and was relevant to the thesis as the surgeries were performed as treatment of patients who had sustained injuries. The study, which is reported in Chapter Two, hypothesised that outcomes after surgery would be significantly worse for patients treated under compensation schemes. The study used the following data sources: Medline (1966 to 2003), Embase (1980 to 2003), CINAHL, Cochrane Controlled Trials Register, reference lists of retrieved articles and textbooks, and contact with experts in the field. The review included any trial of surgical intervention where compensation status was reported and results were compared according to that status, and no restrictions were placed on study design, language or publication date. Data extracted were study type, study quality, surgical procedure, outcome, country of origin, length and completeness of follow-up, and compensation type. Studies were selected by two unblinded independent reviewers, and data were extracted by two reviewers independently. Data were analysed using Cochrane Review Manager (version 4.2). Two hundred and eleven papers satisfied the inclusion criteria. Of these, 175 stated that the presence of compensation (worker's compensation with or without litigation) was associated with a worse outcome, 35 found no difference or did not describe a difference, and one paper described a benefit associated with compensation. A meta-analysis of 129 papers with available data (20,498 patients) revealed the summary odds ratio for an unsatisfactory outcome in compensated patients to be 3.79 (95% confidence interval 3.28 to 4.37, random effects model). Grouping studies by country, procedure, length of follow-up, completeness of follow-up, study type, and type of compensation showed the association to be consistent for all sub-groups. This study concludes that compensation status is associated with poor outcome after surgery, and that this effect is significant, clinically important and consistent. Therefore, the study hypothesis is accepted. However, as data were obtained from observational studies and were not homogeneous, the summary effect should be interpreted with caution. Determination of the mechanism for the association between compensation status and poor outcome, shown in the literature review (Chapter One) and the systematic review (Chapter Two) required further study. Two studies were designed to further explore this association and these are reported in Chapters Three and Four. The retrospective study reported in Chapter Three, the Major Trauma Outcome Study (MTOS), aimed to explore the association between physical, psychosocial, and compensation-related factors and general health after major physical trauma. The primary hypothesis predicted significantly poorer health outcomes in patients involved in pursuing compensation, allowing for possible confounders and interactions. The study also examined other health outcomes that are commonly associated with compensation, and examined patient satisfaction. Consecutive patients presenting to a regional trauma centre with major trauma (defined as an Injury Severity Score greater than 15) were surveyed between one and six years after their injury. The possible predictive factors measured were: general patient factors (age, gender, the presence of chronic illnesses, and the time since the injury), injury severity factors (injury severity score, admission to intensive care, and presence of a significant head injury), socio-economic factors (education level, household income, and employment status at the time of injury and at follow-up), and claim-related factors (whether a claim was pursued, the type of claim, whether the claim had settled, the time to settlement, the time since settlement, whether a lawyer was used, and who the patient blamed for the injury). Multiple linear regression was used to develop a model with general health (as measured by the physical and mental component summaries of the SF-36 General Health Survey) as the primary outcome. The secondary outcomes analysed were: neck pain, back pain, post-traumatic stress disorder, and patient satisfaction. On multivariate analysis, better physical health was significantly associated with increasing time since the injury, and with lower Injury Severity Scores. Regarding psychosocial factors, the education level and household income at the time of injury were not significantly associated with physical health, but pursuit of compensation, having an unsettled claim, and the use of a lawyer were strongly associated with poor physical health. Measures of injury severity or socio-economic status were not associated with mental health. However, the presence of chronic illnesses and having an unsettled compensation claim were strongly associated with poor mental health. Regarding the secondary outcomes, increasing neck pain and back pain were both significantly associated with lower education levels and the use of a lawyer, but not significantly associated with claiming compensation. The severity of symptoms related to post-traumatic stress disorder was not associated with measures of injury severity, but was significantly and independently associated with the use of a lawyer, having an unsettled compensation claim, and blaming others (not themselves) for the injury. The strongest predictor of patients’ dissatisfaction with their progress since the injury was having an unsettled compensation claim, and as with the other secondary outcomes, patient satisfaction was not significantly associated with injury severity factors. Factors relating to the compensation process were among the strongest predictors of poor health after major trauma, and were stronger predictors than measures of injury severity. The hypothesis that general physical and mental health would be poorer in patients involved in seeking compensation for their injury was accepted. This study concludes that the processes involved with claiming compensation after major trauma may contribute to poor health outcomes. The prospective study reported in Chapter Four, the Motor Vehicle Accident Outcome Study (MVAOS), aimed to explore the effect of compensation related factors on general health in patients suffering major fractures after motor vehicle accidents (MVAs). The study hypothesized that general health would be poorer in patients claiming compensation for their injuries. Patients presenting to 15 hospitals with one or more major fractures (any long bone fracture, or fracture of the pelvis, patella, calcaneus or talus) after a motor vehicle accident were invited to participate in this prospective study. Initial data was obtained from the patient and the treating doctors. Both the patients and treating surgeons were followed up with a final questionnaire at six months post injury. General factors (age, gender, treating hospital, country of birth, presence of chronic illnesses and job satisfaction), injury factors (mechanism of injury, number of fractures, and the presence of any non-orthopaedic injuries), socioeconomic factors (education level, income, and employment status), and compensation-related factors (whether a claim was made, the type of claim, whether a lawyer was used, and who was blamed for the injury) were used as explanatory variables. The primary outcome was general health as measured by the physical and mental component summaries of the SF-36 General Health Survey. The secondary outcomes were neck pain, back pain, and patients’ ratings of satisfaction with progress and of recovery. Multiple linear regression was used to develop predictive models for each outcome. Completed questionnaires were received from 232 (77.1%) of the 301 patients included in the study. Poor physical health at six months was strongly associated with increasing age, having more than one fracture, and using a lawyer, but not with pursuit of a compensation claim. Poor mental health was associated with using a lawyer and decreasing household income. Increasing neck pain and back pain were both associated with the use of a lawyer and with lower education levels. Higher patient satisfaction and patient-rated recovery were both strongly associated with blaming oneself for the injury, and neither were associated with pursuit of compensation. Although the use of a lawyer was a strong predictor of the primary outcomes, the pursuit of a compensation claim was not remotely associated with these outcomes, and therefore the study hypothesis was rejected. The studies reported in this thesis are compared in the final chapter, which concludes that poor health outcomes after injury are consistently and strongly associated with aspects of the compensation process, particularly the pursuit of a compensation claim, involvement of a lawyer, and having an unsettled claim. Compensation systems may be harmful to the patients that these systems were designed to benefit. Identification of the harmful features present in compensation systems my allow modification of these systems to improve patient outcomes.

The expressive writing (EW) paradigm developed by Pennebaker (1985) has been found to provide health benefits in populations with medical and psychological conditions. Several theories have been proposed to explain the effectiveness of EW such as: the inhibition theory, increased social connections theory, the cognitive adaptation theory, and the exposure/emotional processing theory. Some studies have suggested that the effects of EW on health outcomes are mediated by varying degrees of depth processing (DP). The present study examines differences in emotional expression (EE) and DP in self-identified gay (GM) and straight men (SM), and assesses changes in levels of depression and PTSD symptoms from pre- to post-intervention. It was hypothesized that GM would display higher levels of EE, and consequently DP, in their written essays. This hypothesis was based on the notion that GM are behaviorally and emotionally more similar to women, who typically display higher levels of EE. Lower levels of depression and PTSD symptoms at follow-ups sessions were expected because theories to explain the effectiveness of EW address several common life experiences of GM. Results showed that GM expressed significantly more negative emotion words and were significantly more involved in the writing process than SM. However, when education was controlled for, the findings were no longer significant. The two groups did not differ from each other in their slope of change in levels of depression and PTSD symptoms from pre- to post-intervention, although the SM group displayed a significant within-group reduction in PTSD symptoms. It appears that EW may actually be more beneficial for HIV-positive SM than GM in alleviating PTSD symptoms. Interpretations and implications for future research are also discussed.