Sara F. Jacoby spent several years working as a trauma nurse in Philadelphia, where she became interested in how the lived environment and experiences of people influence their ability to recover.
“If you spend time in the trauma centers in Philadelphia, it’s not hard to recognize the racialized patterns of who is hurt,” said Jacoby, an assistant professor of nursing at the University of Pennsylvania whose work looks at injuries from public health and urban health perspectives.
In a recent study from the Penn School of Nursing, Jacoby and co-investigators explored the ways that returning to work after an injury predicts mental health outcomes in Black men living and recovering in Philadelphia.
Analyzing data from 498 Black men age 18 or older living in the city who were admitted to Level I trauma centers for injuries between January 2013 and June 2017, the study found that Black men who did not return to work after serious traumatic injury had almost three times the odds of poor mental health when compared to men who did.
Psychological distress in the form of post-traumatic stress disorder and depression was common among the surveyed men, and served as one of the key barriers to getting back to work in the first place. The study notes the low-income Black men, in particular, experienced worse mental health outcomes after job loss than their white counterparts. A lot of that has to do with something Jacoby calls structural vulnerability.
Black working men in Philadelphia were more likely to have jobs that didn’t accommodate changes in physical ability or provide adequate disability relief, and their disproportionate exposure to racism in the workplace and throughout their lifetime — in the form of city planning, the education system, and public policy — predisposed them to poorer physical and mental health outcomes down the line, the study says. And about one-half of the Black men in the surveyed group had been injured intentionally, typically through a violent assault such as a gunshot wound. At least 111 people have been murdered in the city so far this year, a 29% increase over the same time in 2020, the deadliest year in three decades.
“So how does that play out in the ability for Black men, first of all, to be free from the risk for things like community violence and other forms of injury and also return to places where they are able to optimize their recovery process to either go home and restore the social and economic roles in the way that they had prior to injury or reestablish something different?” said Jacoby.
The decision to study perceptions of racism among this group was intentional. If returning to work is an indicator of healing and positive mental health outcomes for formerly injured people, research investigators wanted to understand how someone’s exposure to racism in former workplaces and social life might affect their perceptions of future employment opportunities.
“If someone perceived that … their ability to seek out work in which they wouldn’t be stigmatized and which they would be able to operationalize or to use their education was contingent on their freedom from racism, then we were interested in how that might play into the relationship between injury, work, and recovery,” said Jacoby.
Perception of mental health care costs prevented access to care
Ultimately, research shows that return to work is a dependable indicator of healing and recovery. But experts say the criteria for trauma care has historically focused on managing physical wounds incurred at the time of injury, and less so on the way one’s mental health is affected in the aftermath of the injury itself.
The Penn Nursing study notes that there were significant barriers to seeking out professional psychological care among Black men after their injuries. When compared to the general public, a much larger proportion of the surveyed group was either uninsured at the time of injury or qualified either in the hospital or otherwise for public health insurance.
And Jacoby said there was a common perception that mental health care was too expensive or would not be covered by their own insurance. Of the almost 500 men whose data was studied, a quarter of them participated in interviews in which researchers asked specific questions about factors that were incentives or disincentives to care. Investigators at Penn conducted an in-depth analysis of 32 of those interviews in a separate but related study.
“More than half of the men interviewed perceived psychological suffering, perceived that they were still suffering three months after injury,” Jacoby said. “Financial constraints or the fear of cost of mental health sort of limited access … and fear of judgment and stigmatization, fear of being labeled crazy or institutionalized on the basis of that outreach.”
Then there were the remaining men who didn’t feel as if their injuries warranted professional care. Sometimes, that meant they proceeded without any psychological care at all. But there were men in this group who also reported seeking out counsel from social networks in the Black community, such as through their clergy or church.
‘How can you be supported to recover in a healthy way?’
Returning to work after sustaining a traumatic injury is one way people can re-establish themselves in their social, economic, and familial roles. But only 37% of the Black Philadelphia men whose health data was analyzed returned to work three months post-injury. Jacoby said close to 50% of the cohort did work that entailed manual labor. So if you have the circumstance of being physically injured and then are expected to return to a job where you have to use your body for your economic well-being, she said, that creates a high level of not returning to work. And that could exasperate pre-existing, injury-induced mental health conditions and disorders like PTSD or depression.
“If your economic stability, your financial opportunity is contingent on work, which it is for many of us, then not returning to work is an additional barrier to healing … because you’re further stressed by the inability to make your day to day work,” said Jacoby.
Though this study only followed Black men three months after recovery, Jacoby said she’s worked with similar cohorts for years at a time — and that one of the resounding messages Black men express about their recovery is this need to just get back to normal.
“And so often [it’s] this idea of I just want to get back to work, I just want to provide for my family,” said Jacoby. “That was their greatest concern … even though they were experiencing psychological suffering.”
Black men in the study expressed wanting to foresee a viable future for themselves in the aftermath of their injuries. And Jacoby said an effective trauma-informed response going forward requires that doctors and trauma care practitioners understand social and structural drivers of injury for race-specific populations.
“When we ask the question, ‘What happened to you?’… we have to also understand what is your access to disability insurance, what are the physical demands of your work, what do you want to do,” said Jacoby.
“We know you were injured. We know that’s traumatic. Now what and how can you be supported to really recover and reestablish what you need to establish to live your life in a healthy way?”
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