People living in rural areas are not only at higher risk of sustaining severe head injuries in transport-related accidents; they are also less likely to survive, according to a global review of head trauma studies undertaken by JCU Medicine Honours student, Julia Chequer De Souza.
Julia analysed 36 studies, involving some 2.5 million head trauma patients, to identify differences in demographics, types of injury, and health outcomes between rural and urban patients. Eight of the studies were conducted in Australia, where one in three people live in rural areas, and head injuries are the most common injury requiring aeromedical transfer.
The systematic review and meta-analysis is the first phase of her two-year head trauma research project, under the supervision of JCU College of Medicine and Dentistry trauma experts, Professor Geoffrey Dobson and Dr Hayley Letson. Next year, Ms Chequer De Souza will seek to identify patterns of head trauma and their health outcomes in regional, rural and remote North Queensland, then compare those findings with the results of the global review.
“Ultimately, the aim of this project is to identify the populations that are at greatest risk of head trauma in North Queensland. We really want to see who is at risk, why they're at risk, and also look at the outcomes, especially for those patients that live outside regional cities. Are they similar to the review findings and if so, what can we do about it?” she said.
Shortly after she began the project early this year, it acquired personal meaning for Ms Chequer De Souza, when one of her colleagues, a JCU sixth year medical student, died from a traumatic head injury sustained in a road accident, while travelling to a rural posting in the North.
“It was a very difficult time for all of the medical students,” she said. “Hopefully, our research will help prevent this sort of story from happening again.”
The review found that rural people were 30 per cent more likely to suffer head trauma from a transport accident than their urban counterparts.
A subgroup analysis by age groups in 15 studies, involving 79,558 patients, also revealed that transport-related head injuries were significantly more common in rural children and adolescents, compared with urban youngsters.
“That is definitely very scary,” said Ms Chequer De Souza. “Previous studies had shown that adolescents/teenagers are more likely to take risks, and that can come with consequences. But if we're looking at younger patients – our toddlers and children – obviously, they're not the ones driving the cars. So I think it would come down to the fact that they're just less likely to survive traumatic injuries, in general.”
Many of the reviewed studies mentioned behavioural factors that predispose rural people to transport-related accidents, including unsafe driving practices, such as driving under the influence of alcohol and failure to wear a seatbelt.
However, environmental factors are also likely to play a role. These include lower road quality, unpredictable weather conditions, and the presence of livestock and wildlife.
The review also found that rural head trauma patients are half as likely to leave hospital with a good outcome, compared to their urban counterparts. Longer transportation times to hospital and limited access to specialist neurosurgical care mean patients are more likely to deteriorate in the meantime.
“The distances involved to obtain treatment can mean the difference between making it out of hospital well, or unfortunately not making it out of hospital, or ending up with a severe disability,” said Ms Chequer De Souza.
Given the important role that paramedics and air retrieval services play in the initial treatment and stabilisation of patients with severe head injuries, she was surprised that very few studies included pre-hospital data. This is a crucial knowledge gap she plans to address in her North Queensland study.
“As severe head trauma can cause mortality before you even arrive at the hospital, we don't know the number of patients that were excluded from the mortality data in the studies we reviewed. So it is possible that our risk of mortality is actually underestimated,” she said.
Ms Chequer De Souza was also concerned that none of the reviewed studies had evaluated rural/urban differences in Indigenous patients, even though previous research has shown that Indigenous Australians and Americans are at greater risk of head trauma and often represent a larger proportion of rural communities.
She hopes that her research findings will aid the development of acute care guidelines, targeted health promotion strategies to address behavioural factors that predispose rural residents to transport-related accidents – and also infrastructure interventions to make rural roads safer.
The stakes are very high.
“Traumatic brain injury is considered a ‘silent epidemic’, because the effects can be lifelong,” she observed. “Any trauma to the brain is going to affect the way that it functions. Struggling to deal with such an injury can also lead to psychiatric complications. Major depressive disorder is quite widespread within these patients. And depending on the circumstances of the accident, they can also develop Post Traumatic Stress Disorder. There is also a significant burden on families and caregivers.”
The results of her research, to date, prompted Ms Chequer De Souza to issue the following warning in the lead up to the Christmas-New Year holiday road toll season.
“I think we often under-estimate the impact that our location has on our health,” she said. “Making safe decisions on the roads have never been more important.”
Ms Chequer De Souza’s systematic review, titled Epidemiology and Outcomes of Head Trauma in Rural and Urban Populations A systematic review and meta-analysis, has been submitted to the international journal, Rural and Remote Health.
