226
G. Månum et al.
health problems and healthcare needs of the terror vic-
tims (e.g. 10–13). These authors found that only somatic
symptoms were associated with mental health service
utilization when adjusting for psychological symptom
level (10), proposing that the somatic symptoms result
from somatization. Stene et al. investigated the Utøya
attack survivors’ healthcare needs, experiences, and
satisfaction with post-terror healthcare 2.5 years after
the attack (11). Among the 261 participants (52% of the
survivors), 51% (n = 133) a large benefit of healthcare,
while 17% (n = 45) reported little or no benefit. Also,
20% (n = 53) reported unmet needs for treatment of
psychological reactions. Twenty one percent (n = 56)
experienced a need for help with physical health issues,
while half (n = 21) of the 43 individuals who reported
having significant need for help due to attack-related
physical health problems had been physically injured
during the attack. The studies regarding PTSD and so-
matization have suggested that physical injuries and pain
worsen the burden of psychological symptoms (12, 13).
Based on the available literature, being injured has
been construed as an indicator of high exposure to the
traumatic event and a predictor of the level of psy-
chological distress, rather than a risk factor for func
tional limitations and healthcare needs. Likewise, the
terror literature is relatively less focused on physical
disability and its implication for overall functioning.
Similar to natural disasters (14–16), impairments after
terror attacks vary in severity, and might include spinal
cord injuries, traumatic brain injuries, limb amputa-
tion, fractures, soft-tissue injuries, and psychological
sequelae (e.g. PTSD, alterations in lifestyle, changes
in self-concept, and decreased quality of life).
None of the publications regarding the 2011 Norwe-
gian terror victims have presented long-term findings
from comprehensive clinical examinations paired with
acute medical data, nor has long-term physical function
and health satisfaction in this particular sub-sample of
terror victims been investigated.
The main aim of this study was to describe the
medical characteristics, physical functioning and
life satisfaction of people hospitalized with physical
injuries due to the 2011 Norway terror events 3–4
years after the attacks. Based on these assessments, a
secondary aim was to identify the current physical and/
or psychological healthcare needs of the terror victims.
MATERIAL AND METHODS
Research design and ethics
This cross-sectional study includes retrospective acute medical
data from Oslo University Hospital Ullevål (OUHU) trauma
register and medical records. The study was approved by the
Regional Committee for Medical and Health Research Ethics,
www.medicaljournals.se/jrm
Norway. Letters with informed consent forms were delivered
by post, including one reminder letter. Non-responders were
contacted by telephone. All participants provided written in-
formed consent.
Participants, setting and procedures
Hospital records at the OUHU regional trauma centre for the
South-Eastern Health Region in Norway and Vestre Viken local
hospitals were used to identify those who had spent at least 1
night in hospital.
Data collection was performed at Sunnaas Rehabilitation
Hospital in Norway between May 2014 and March 2015 (3–4
years post-injury). Acute trauma scores were checked for
validity against the OUHU trauma registry. The participants
underwent a structured clinical interview, medical examination,
psychological assessment, neuropsychological screening, and
several standardized questionnaires and assessment methods
were applied.
Three experienced medical doctors and 3 rehabilitation
psychologists extracted data from medical records, clinical
examinations, and interviews, using consistent techniques and
standardized procedures developed and adjusted in joint training
sessions and consensus processes. The results were presented to
and discussed with the participants. A clinical consideration of
the participants’ healthcare needs and whether needs were met at
the time of assessment was conducted. Clinical discharge sum-
maries were sent to participants and their general practitioners
(GPs). Referrals to healthcare services were made, if needed.
Data
Injury characteristics. The Abbreviated Injury Scale (AIS)
(17) was used to describe the anatomical injuries. The AIS
ranks injuries from 1 to 6 (6 is not survivable). The New Injury
Severity Score (NISS), which is the sum of the squares of the
3 highest AIS scores regardless of body region affected, was
used to describe the injury severity, classified as minor–mode-
rate (1–8), serious (9–15) or severe–critical (16–75) (18). The
acute Glasgow Coma Scale (GCS) (19), number of days in the
intensive care unit (ICU), number of surgical procedures, ampu-
tations, length of stay in acute hospital, and place of discharge
were also registered.
Clinical characteristics. A clinical examination, including
neurological, musculoskeletal, and internal organ status was
performed. The skin was inspected for presence (yes/no) of
scars related to the terror events, and self-perceived burden of
injury-related scars was evaluated on a 0–10 numerical rating
scale (NRS) (20). A score of 4 or more was used as a cut-off
for scar-related distress (20).
The participant’s post-traumatic stress (PTS) symptoms in
the preceding month were measured using the University of
California at Los Angeles PTSD Reaction Index (21). The total
score comprises 17 items that correspond to the 17 DSM-IV
symptoms of PTSD, rated on a 5-point Likert scale (range
0 = never; 4 = most of the time). Total scores and numbers of
participants with clinical levels of PTS symptoms (cut-off value
≥ 38) are presented (22). Pain impact was measured on a 0–10
NRS assessing the mean pain severity over the previous week
(23). A score of 3 or more was used as a cut-off for clinically
significant pain (24).
A neuropsychological screening was performed. The Cali-
fornia Verbal Learning Test (CVLT-II) (25) and the WAIS-IV
digit span tests (26) were included, together with performance-