Brain Injury Profession: Health Equity in Traumatic Brain Injury

BRAIN INJURY professional vol. 19 issue 2

Health Equity in Traumatic Brain Injury

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vol. 19 issue 2

departments

5 7

Editor in Chief Message Guest Editor’s Message

features

8 12

Healthcare Disparities in Hispanic Individuals with TBI

Gloria M. Morel Valdés, PsyD • Carolina Fernanda Serrano Román, MS Fabiola Cristina Mercado Nieves, MS • Juan Carlos Arango Lasprilla, PhD

Traumatic Brain Injury and Arrest Probability: Racial/Ethnic Considerations Mickeal Pugh Jr., MS • Paul B. Perrin, PhD

16

Rehabilitation and Outcome Disparities in Older Adults with Traumatic Brain Injury

Carmen M. Tyler, MA, MEd • Paul B. Perrin, PhD

18

Racial and Ethnic Disparities in Employment Outcomes after TBI

Juan Carlos Arango Lasprilla, PhD • Gloria M. Morel Valdés, PsyD Carolina Fernanda Serrano Román, MS • Fabiola Cristina Mercado Nieves, MS

22

Rehabilitation Disparities: Examining Micro and Macro-level Barriers among Ethnic and Racial Populations Recovering from a Brain Injury

Patricia Garcia, PsyD • Jessica L. Peramo, MS • Sheryl Katta-Charles, MD Frank Moreno, PharmD

26

Moving the Field Toward Health Equity in Traumatic Brain Injury

Monique R. Pappadis, PhD • Chinedu K. Onwudebe, BS Anthony H. Lequerica, PhD • Angelle M. Sander, PhD, FACRM

IBIA would like to acknowledge the education grant from Abbott for this publication. They have had no influence on the content.

Brain Injury Professional is a membership benefit of the North American Brain Injury Society and the International Brain Injury Association

NORTH AMERICAN BRAIN INJURY SOCIETY CHAIRMAN Mariusz Ziejewski, PhD VICE CHAIR Debra Braunling-McMorrow, PhD IMMEDIATE PAST CHAIR Ronald C. Savage, EdD TREASURER Bruce H. Stern, Esq. SECRETARY Brian Greenwald, MD FAMILY LIAISON Skye MacQueen EXECUTIVE DIRECTOR/ADMINISTRATION Margaret J. Roberts EXECUTIVE DIRECTOR/OPERATIONS J. Charles Haynes, JD MARKETING MANAGER Megan Bell-Johnston BRAIN INJURY PROFESSIONAL PUBLISHER J. Charles Haynes, JD CO-EDITOR IN CHIEF Beth Slomine, PhD - USA CO-EDITOR IN CHIEF Nathan Zasler, MD - USA ASSOCIATE EDITOR Juan Arango-Lasprilla, PhD – Spain TECHNOLOGY EDITOR Stephen K. Trapp, PhD - USA EDITOR EMERITUS Debra Braunling-McMorrow, PhD - USA EDITOR EMERITUS Ronald C. Savage, EdD - USA DESIGN AND LAYOUT Kristin Odom ADVERTISING SALES Megan Bell-Johnston EDITORIAL ADVISORY BOARD Nada Andelic, MD - Norway Philippe Azouvi, MD, PhD - France Mark Bayley, MD - Canada Lucia Braga, PhD - Brazil Ross Bullock, MD, PhD - USA Fofi Constantinidou, PhD, CCC-SLP, CBIS - USA Gordana Devecerski, MD, PhD - Serbia Sung Ho Jang, MD - Republic of Korea Cindy Ivanhoe, MD - USA Inga Koerte, MD, PhD - USA Brad Kurowski, MD, MS - USA Jianan Li, MD, PhD - China Christine MacDonell, FACRM - USA Calixto Machado, MD, PhD - Cuba Barbara O’Connell, OTR, MBA - Ireland Lisandro Olmos, MD - Argentina Caroline Schnakers, PhD - USA Lynne Turner-Stokes, MD - England Olli Tenovuo, MD, PhD - Finland Asha Vas, PhD, OTR - USA Walter Videtta, MD – Argentina Thomas Watanabe, MD – USA Alan Weintraub, MD - USA Sabahat Wasti, MD - Abu Dhabi, UAE Gavin Williams, PhD, FACP - Australia Hal Wortzel, MD - USA Mariusz Ziejewski, PhD - USA EDITORIAL INQUIRIES Managing Editor Brain Injury Professional PO Box 131401, Houston, TX 77219-1401 Tel 713.526.6900 Email: mbell@hdipub.com Website: www.nabis.org ADVERTISING INQUIRIES Megan Bell-Johnston Brain Injury Professional HDI Publishers PO Box 131401, Houston, TX 77219-1401 Tel 713.526.6900 Email: mbell@internationalbrain.org NATIONAL OFFICE North American Brain Injury Society PO Box 1804, Alexandria, VA 22313 Tel 703.960.6500 / Fax 703.960.6603 Website: www.nabis.org ISSN 2375-5210 Brain Injury Professional is a quarterly publication published jointly by the North American Brain Injury Society and HDI Publishers. © 2022 NABIS/HDI Publishers. All rights reserved. No part of this publication may be reproduced in whole or in part in any way without the written permission from the publisher. For reprint requests, please contact, Managing Editor, Brain Injury Professional, PO Box 131401, Houston, TX 77219-1400, Tel 713.526.6900, Fax 713.526.7787, e-mail mbell@hdipub.com.

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from the

editor in chief

As BIP co-editor, I am excited to introduce this issue of Brain Injury Professional which is being guest edited by our esteemed colleague and BIP Associate Editor, Dr. Juan Carlos Arango–Lasprilla. The thematic topic for this issue is "Health Equity and Traumatic Brain Injury". This is an important topic that does not get the attention it deserves either in terms of acknowledgment or addressing the problems associated with same.

Nathan D. Zasler, MD, DABPM&R, FAAPM&R, FACRM, BIM-C, CBIST

The six articles that make up this issue span a number of diverse albeit important topics germane to the theme of healthcare disparities. Drs. Valdes and colleagues address issues amongst Hispanic persons with TBI and among other comments address factors that can influence evaluation and rehabilitation of this growing sector of persons with TBI. They also provide recommendations for restructuring, implementing and advocating for services for said individuals. Pugh and Perrin have contributed an article on racial considerations in crime and TBI as it relates to arrest probability and examine the very disturbingly high rates of TBI amongst incarcerated adults of juveniles. They point out that racial and ethnic considerations for arrest outcomes are clearly justified based on findings in both psychological and criminal justice literature. In the next article Tyler and colleagues discuss disparities in rehabilitation service provision and outcome for older adults with TBI. The authors point out that research on rehabilitation outcomes of older persons has been relatively ignored and given increasing lifespans that further research examining factors contributing to outcomes is critical. Dr. Arango Lasprilla and colleagues then examine racial and ethnic disparities and employment outcomes following TBI. One of the important points that they make in this manuscript is the fact that the efficacy of vocational rehabilitation services has not been critically examined as related to race and ethnicity. They posit that existing disparities may be related to a number of factors, but obviously further study is warranted to determine how much of these disparities are influenced by systemic racism, healthcare practitioner biases, discrimination versus other variables. In the article by Garcia and colleagues issues relating to micro and macro level barriers are addressed across rehabilitation settings. This article provides some interesting insights in terms of systemic as well as individual barriers that may be driving such disparities. They conclude their article by providing some recommendations to address the disparities both systemically and individually. The last article of this issue by Pappadis and colleagues provides a wrap-up overview of how we collectively can move the field forward to provide better health equity to persons with traumatic brain injury in the context of ethnic and racial diversity in terms of individual, interpersonal, community, suicidal influences. In that context, the authors provide a "call to action" to facilitate this goal.

We hope that readers will find the content informative and more importantly that the information will help drive further interest in examining and addressing issues and healthcare disparity for those with traumatic brain injury.

Editor Bio Nathan Zasler, MD, is an internationally respected physician specialist in acquired brain injury (ABI) care and rehabilitation. He is CEO and Medical Director of the Concussion Care Centre of Virginia, an outpatient neurorehabilitation practice, as well as, the Medical Director of Tree of Life, a living assistance and transitional neurorehabilitation program for persons with acquired brain injury in Richmond, Virginia. He is board certified in Physical Medicine and Rehabilitation and fellowship trained in brain injury, as well as, Brain Injury Medicine certified.

Dr. Zasler is an Adjunct Professor of PM&R at VCU in Richmond, Virginia, as well as, an Adjunct Associate Professor of PM&R at the University of Virginia, Charlottesville, Virginia. He is a fellow of the American Academy of Disability Evaluating Physicians, and a diplomat of the American Academy of Pain Management.

Dr. Zasler has lectured and written extensively on neurorehabilitation issues in ABI. He is active in national and international organizations dealing with acquired brain injury and neurodisability, serving in numerous consultant and board member roles including currently serving as Vice-Chairperson of IBIA.

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from the

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The US minority population is growing and is projected to constitute up to 51.3% of the country’s total population by the year 2045. Research studies have shown that the risk of certain types of serious illnesses (i.e., diabetes, cardiovascular disease, cancer, hypertension) and injuries (i.e,, traumatic brain injury (TBI), and spinal cord injury) are disproportionately higher in minorities.

This phenomenon may be influenced by factors associated with ethnic minority status such as poverty, restricted occupational/educational opportunities, dangerous residential environments, limited access to health care, experience of discrimination, and/or culture-specific health behaviors.

Juan Carlos Arango-Lasprilla, PhD

Regarding TBI specifically, during the past two decades numerous studies have shown that, compared to Caucasians, minority individuals with TBI have less favorable rehabilitation outcomes. For instance, minorities with TBI are more likely to be unemployed post-injury, have a longer waiting time to see a physician in emergency care, have lower levels of social functioning and higher rates of alcohol abuse after TBI, have fewer social supports available to them, are more likely to be discharged home than to an assisted living or rehabilitation institution, are less likely to be placed in rehabilitation, among others. Most of the studies have found these results to be independent of demographic, health-related variables, functional status at discharge, injury severity and insurance status.

For this issue, we have put together a collection of six articles on very relevant topics that include 1) health care disparities in Hispanic individuals with TBI, 2) racial and ethnic considerations on arrest probability after TBI, 3) rehabilitation and outcome disparities in older adults with TBI, 4) racial and ethnic disparities in employment outcomes after TBI, 5) micro and macro level barriers to rehabilitation, and 6) how to move the field toward increased health equity in TBI. Even though raising awareness of these disparities is very important for the field, we think that now is the time to start generating solutions to improve health equity in TBI. For instance, capacity building for healthcare professionals working in brain injury evaluation and rehabilitation is needed, in particular on how to work with minority individuals with TBI. This might take the form of continuing education trainings, workshops, seminars, web-based training, etc.. Finally, it is important to develop rehabilitation programs that are specifically tailored to the needs of different minority groups following a TBI.

Editor Bio Juan Carlos Arango-Lasprilla, PhD, is currently a Research Professor at BioCruces Vizcaya Health Research Institute in Bilbao, Spain. He has been instrumental in securing grant funding as PI and co-PI. Dr. Arango has received many awards for his accomplishments in the area of neuropsychology including awards from the National Academic of Neuropsychology, the American Psychological Association, the International Brain Injury Association, the International Neuropsychological Society and The American Congress of Rehabilitation Medicine. He has published more than 350 articles and book chapters and edited 11 books. Dr. Arango has been a guest editor of 12 special issues in prominent rehabilitation journals. Dr. Arango has lectured at Grand Rounds at more than 100 different universities across the globe. He organized and chaired 4 international conferences on neuropsychology, cultural issues and Brain Injury Rehabilitation.

Dr. Arango is a founding member of the Colombian Neuropsychological Society, and he founded the IberoAmerican Journal of Neuropsychology. His research focuses on understanding and addressing the cognitive, psychological, and emotional needs of individuals with brain injury and their families. He is particularly interested in under-served populations, such as Spanish speakers, and carries out research in the US, Europe, and Latin America. He was PI of a large, multi-center norming study in which more than 14,000 adults and children from over 15 Latin American countries participated. Thanks to his leadership, normative data by country is now available for the 12 most commonly used neuropsychological tests in each respective population.

BRAIN INJURY professional 7

Healthcare Disparities in Hispanic Individuals with TBI Gloria M. Morel Valdés, PsyD Carolina Fernanda Serrano Román, MS Fabiola Cristina Mercado Nieves, MS Juan Carlos Arango Lasprilla, PhD

Hispanic individuals are the second fastest growing ethnic group in the United States, with over 62 million individuals living in this country and accounting for 18.7% of the total population1. Hispanic individuals are a heterogenous group with different origins (21 different countries), cultural backgrounds, linguistics, socioeconomic status, and educational systems2. In the United States, Hispanic individuals are more likely to have lower educational attainment, lower quality of education, higher poverty rates, barriers in language, lack citizenship, and lack access to healthcare services3,4.

Hispanic individuals are more vulnerable to cardiovascular disease (e.g., obesity, hypertension, diabetes, heart disease, stroke),3 asthma, chronic liver disease, mental health disorders (depression, substance use), and neurological conditions such as Alzheimer’s disease, Parkinson’s disease, spinal cord injuries, and traumatic brain injury (TBI),5–11 among others.

Regarding TBI, current incidence and prevalence rates for the Hispanic population are difficult to establish due to a scarcity of recent epidemiological studies in the literature. The 1993 Epidemiological Bronx study reported an incidence rate of 262 per 100,000 individuals for Hispanic individuals versus the national average of 200 per 100,00012. Disparities exist, Hispanic individuals with TBI have a longer waiting time to see a physician in emergency care13, have lower levels of social functioning and higher rates of alcohol abuse after TBI14, and have fewer social support available to them15. Furthermore, Hispanic TBI survivors are 2.24 times more likely than Caucasian individuals with TBI to be discharged home than to an assisted living or rehabilitation institution, independent of demographic, health-related variables, and functional status at discharge16. Shafi and colleagues17 also found that Hispanic TBI survivors are less likely to be placed in rehabilitation, even after controlling for injury severity and insurance status. Hispanics with TBI are also more likely than Caucasians to be dependent on others for their standard of living, engagement in leisure activities, and return to work or school18. Hispanics TBI survivors were 1.27 times less likely than Caucasian TBI survivors to obtain employment and receive on-the-job support services, which were the most significant predictors of successful employment outcomes19. Finally, compared to Caucasian individuals with TBI, Hispanics are more likely to rely on their family for economic assistance and psychological support20.

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The aforementioned studies suggest that Hispanic ethnicity may play a key role in the receipt of quality healthcare and health in general after a TBI, and that these effects are statistically independent of some demographic (e.g., socio-economic status) and injury characteristics. These disparities are furthered explained by several factors that could influence the diagnosis, evaluation, and rehabilitation of Hispanic individuals with TBI. Some of these components can be generally categorized into: 1) Sociodemographic characteristics (income, education, residence, employment, race, nationality, age, immigration status, number of years living in the U.S, health care insurance, native language proficiency, level of acculturation), 2) Cultural values (collectivism, familism, family cohesion, hierarchy, matriarchy, gender roles, machismo, presenteeism, superstitions, use of folk remedies, spiritualism), 3) Factors related to interactions with the health system: mistrust and perceived racism, patterns of abilities, one-toone relationship, performance, isolated environment, special type of communication, speed, internal or subjective issues, specific test elements and testing strategies.

Some examples of how these factors can influence the evaluation and rehabilitation of Hispanics individuals with TBI are provided.

1.

The median income for Hispanic individuals, according to the US Census Bureau (2017)21, is around $50,000. Many Hispanic individuals are not offered coverage through their employer22; thus, their ability to pay for rehabilitation services is a factor influencing access to and quality of rehabilitation services.

Many Hispanic individuals, despite Obamacare, do not have health care insurance, or are under-insured, and do not have enough resources to pay for these services or the co-pay associated with receiving them23.

2.

Approximately 38 million people speak Spanish at home in the US, and approximately 16,000 million of these individuals speak English less than very well24. However, the overwhelming majority of services are provided in English because less than 1% of neuropsychologists in the US are fluent in Spanish25.

Therefore, language proficiency is another factor to consider and ensure adequate evaluation and rehabilitation services.

3.

Hispanic individuals may be unfamiliar with the testing environment and the tools used to conduct these assessments.

The evaluator may assume that pictures, blocks, and figures that assess a specific domain (e.g., memory) are similar in all cultures. However, the examinee may not be familiar with such materials, eading to poorer performance in Hispanic individuals with TBI26.

4.

Folk remedies are common in Hispanic culture27 and this may be a barrier to care seeking behavior and acceptance of Western medical advice.

To improve evaluation and rehabilitation outcomes for Hispanic individuals with TBI, it is imperative for services to be culturally appropriate. Therefore, healthcare professionals are encouraged to consider the following recommendations for re-structuring, implementing, and advocating services for Hispanic individuals that have sustained a TBI.

5.

Capacity building for students and young professionals is also essential. Existing training programs should have a module on working with Hispanics with TBI. Furthermore, Spanishspeaking individuals should be encouraged to specialize in healthcare professions and brain injury and neurorehabilitation specifically. This might be facilitated through outreach programs in different universities, fellowship programs at specific centers, and/or specialized scholarships.

6.

Hospitals and rehabilitation centers should have available information in Spanish about how to access services after brain injury.

7.

Health systems should use bilingual patient navigators to assist Hispanic individuals with TBI and their families access needed services and programs in order to facilitate payment of related costs.

8.

In general, more research is needed to better understand the state-of-the-art of Hispanics with TBI’s to identify relevant met and unmet needs.

9.

National and state-level brain injury organizations are encouraged to advocate for improved services for Hispanics with TBI and, thus; improve access to these services.

10. Primary prevention programs, such as awareness campaigns can help TBI’s from occurring in the first place. For instance, Spanish-language advertised regarding seatbelt and helmet use, appropriate use of car seats, and dangers of driving under the influence, can be further advertised on Spanish-language TV stations (i.e., Univision), internet (i.e., YouTube) and social media platforms (e.g., Facebook, Twitter, and Instagram).

References

1.

Development of culturally sensitive instruments to measure cognitive, emotional, and neurobehavioral problems in Hispanic individuals with TBI.

2.

Development of rehabilitation programs that are specifically tailored to the needs of Hispanic individuals following a TBI.

3.

Family is the principal source of information, care, and social support for Hispanic individuals with TBI. Injuries create stress, burden, and emotional distress within the family. Therefore, rehabilitation programs are encouraged to incorporate family members of Hispanic individuals with TBI.

4.

Capacity building for healthcare professionals working in brain injury evaluation and rehabilitation on how to work with Hispanic individuals with TBI is important. This might take the form of continuing education trainings, workshops, seminars, web-based training, etc.

1.

Krogstad JM, Noe-Bustamante L. Key facts about US Latinos for national hispanic heritage month.

2020.

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Strutt AM, Burton VJ, Resendiz CV, Peery S. Neurocognitive assessment of Hispanic individuals residing in the United States: Current issues and potential solutions. 2016.

3.

Artiga S, Díaz M. Health Coverage and Care of Undocumented Immigrants [Internet]. Kaiser Family Foundation; 2019. Available from: https://www.kff.org/racial-equity-and-health-policy/issue-brief/ health-coverage-and-care-of-undocumented-immigrants/

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Guadamuz JS, Kapoor K, Lazo M, Eleazar A, Yahya T, Kanaya AM, et al. Understanding Immigration as a Social Determinant of Health: Cardiovascular Disease in Hispanics/Latinos and South Asians in the United States. Curr Atheroscler Rep. 2021 Jun;23(6):25.

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Dominguez K, Penman-Aguilar A, Chang MH, Moonesinghe R, Castellanos T, Rodriguez-Lainz A, et al. Vital signs: leading causes of death, prevalence of diseases and risk factors, and use of health services among Hispanics in the United States - 2009-2013. MMWR Morb Mortal Wkly Rep. 2015 May 8;64(17):469–78.

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Balfour PC, Ruiz JM, Talavera GA, Allison MA, Rodriguez CJ. Cardiovascular disease in Hispanics/ Latinos in the United States. J Lat Psychol. 2016 May;4(2):98–113.

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Budnick HC, Tyroch AH, Milan SA. Ethnic disparities in traumatic brain injury care referral in a Hispanic-majority population. J Surg Res. 2017 Jul;215:231–8.

8.

Kanavos, P, Colville Parkin, G, Gill, J, Kamphuis, B. Latin America Healthcare System Overview: A comparative analysis of fiscal space in healthcare [Internet]. London School of Economics and Political Science; 2019. Available from: http://www.lse.ac.uk/business-and-consultancy/consulting/ consulting-reports/latin-america-healthcare-system-overview

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Flores LE, Verduzco-Gutierrez M, Molinares D, Silver JK. Disparities in Health Care for Hispanic Patients in Physical Medicine and Rehabilitation in the United States: A Narrative Review. Am J Phys Med Rehabil. 2020 Apr;99(4):338–47.

10.

McKnight-Eily LR, Okoro CA, Strine TW, Verlenden J, Hollis ND, Njai R, et al. Racial and Ethnic Disparities in the Prevalence of Stress and Worry, Mental Health Conditions, and Increased Substance Use Among Adults During the COVID-19 Pandemic — United States, April and May 2020. MMWR Morb Mortal Wkly Rep. 2021 Feb 5;70(5):162–6.

11.

Alzheimer’s disease facts and figures. Alzheimers Dement. 2021 Mar;17(3):327–406.

12.

Cooper KD, Tabaddor K, Hauser WA, Shulman † K, Feiner C, Factor PR. The Epidemiology of Head Injury in the Bronx; pp. 79–88. Neuroepidemiology. 1983;2(1–2):79–88.

13.

Bazarian, J. J., Pope, C., McClung, J., Cheng, Y. T., Flesher, W. Ethnic and racial disparities in emergency department care for mild traumatic brain injury. Acad Emerg Med. 2003;10(11):1209–17.

14.

Jorge RE, Robinson RG, Starkstein SE, Arndt SV. Influence of major depression on 1-year outcome in patients with traumatic brain injury. J Neurosurg. 1994 Nov;81(5):726–33.

15.

Brown SA, McCauley SR, Levin HS, Contant C, Boake C. Perception of Health and Quality of Life in Minorities After Mild-to-Moderate Traumatic Brain Injury. Appl Neuropsychol. 2004 Mar;11(1):54–64.

16.

Chang PFJ, Ostir GV, Kuo YF, Granger CV, Ottenbacher KJ. Ethnic Differences in Discharge Destination Among Older Patients With Traumatic Brain Injury. Arch Phys Med Rehabil. 2008 Feb;89(2):231–6.

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17.

Shafi S, de la Plata CM, Diaz-Arrastia R, Bransky A, Frankel H, Elliott AC, et al. Ethnic Disparities Exist in Trauma Care. J Trauma Inj Infect Crit Care. 2007 Nov;63(5):1138–42.

18.

Staudenmayer KL, Diaz-Arrastia R, de Oliveira A, Gentilello LM, Shafi S. Ethnic Disparities in Long-Term Functional Outcomes After Traumatic Brain Injury. J Trauma Inj Infect Crit Care. 2007 Dec;63(6):1364–9.

19.

Cardoso ES, Romero MG, Chan F, Dutta A, Rahimi M. Disparities in Vocational Rehabilitation Services and Outcomes for Hispanic Clients With Traumatic Brain Injury: Do They Exist? J Head Trauma Rehabil. 2007 Mar;22(2):85–94.

20.

Sabella SA, Suchan CS. The Contribution of Social Support, Professional Support, and Financial Hardship to Family Caregiver Life Satisfaction After Traumatic Brain Injury. J Head Trauma Rehabil.

2019 Jul;34(4):233–40.

21.

United States Census Bureau. Detailed languages spoken at home and ability to spea English for the population 5 years and over: 2009-2013 [Internet]. 2017. Available from: https://www.census.gov/ data/tables/2013/demo/2009-2013-lang-tables.html

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Torralba E. Despite Health Insurance Gains in California, Latinos Still Lag in Coverage, Access. UCLA Newsroom Httpsnewsroom Ucla Edureleaseslatinos-Health-Insur-Cover-Calif. 2019;32.

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Manuel JI. Racial/Ethnic and Gender Disparities in Health Care Use and Access. Health Serv Res. 2018 Jun;53(3):1407–29.

24.

Sander AM, Lequerica AH, Ketchum JM, Hammond FM, Gary KW, Pappadis MR, et al. Race/Ethnicity and Retention in Traumatic Brain Injury Outcomes Research: A Traumatic Brain Injury Model Systems National Database Study. J Head Trauma Rehabil. 2018 Jul;33(4):219–27.

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Salinas CM, Salinas SL, Arango-Lasprilla JC. Hispanic/Latino Neuropsychology. In: Kreutzer J, DeLuca J, Caplan B, editors. Encyclopedia of Clinical Neuropsychology [Internet]. Cham: Springer International Publishing; 2018 [cited 2022 Apr 26]. p. 1–8. Available from: http://link.springer.com/10.1007/9783-319-56782-2_9169-1

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Ardila A. Cultural Values Underlying Psychometric Cognitive Testing. Neuropsychol Rev. 2005 Dec;15(4):185.

27.

Ortiz BI, Shields KM, Clauson KA, Clay PG. Complementary and Alternative Medicine Use Among Hispanics in the United States. Ann Pharmacother. 2007 Jun;41(6):994–1004.

Author Bios Gloria M. Morel Valdés, PsyD, Assistant Professor, Department of Neurology. University of Wisconsin School of Medicine and Public Health, University of Wisconsin. Madison. USA. Gloria M. Morel Valdes, PsyD is an assistant professor of Department of Neurology at the within the School of Medicine and Public Health at the University of Wisconsin. Dr. Valdes has a Doctorate of Psychology at the Albizu University in Miami, Florida. She has held internships at the William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin and a Post-Doctoral Fellowship at the University of Wisconsin Hospitals and Clinics in Madison, Wisconsin. Here areas of research and medical interest are Dementia, Traumatic Brain Injury, and Epilepsy.

Carolina Fernanda Serrano Román, MS, is a Clinical Psychology Doctorial student at Ponce Health Sciences University with an emphasis in neuropsychology.

Fabiola Cristina Mercado Nieves, MS, Ponce Health Science University, Ponce, Puerto Rico.

Juan Carlos Arango Lasprilla, PhD, BioCruces Bizkaia Health Research Institute, 48903 Barakaldo, Spain. IKERBASQUE, Basque Foundation for Science, Bilbao, Spain. Department of Cell Biology and Histology, University of the Basque Country, Leioa, Spain.

Professor Harvey Steven Levin Sadly Passes Away It is with a sad heart that I share the news that Harvey Steven Levin, PhD passed away peacefully on April 1, 2022. He was born on December 12, 1946 in New York City to Nathan and Mary Levin. A graduate of the City College of New York, he earned a doctorate in psychology at the University of Iowa under the tutelage of Arthur Benton, PhD and completed his internship in psychology at the Illinois Masonic Medical Center in Chicago. Harvey joined the faculty at the University of Texas Medical Branch in Galveston where he began an internationally renowned career in clinical work, teaching, and, most of all, pioneering research on brain injury. He also held positions at Baylor College of Medicine with a joint appointment at the Michael E. DeBakey Veterans Affairs Medical Center. During his career, Professor Levin authored and co-authored more than 300 articles in scientific journals and numerous books that advanced knowledge of and treatments for traumatic brain injury (TBI), epilepsy, and other illnesses that affect brain functioning. He received many prestigious awards, including the American Congress of Rehabilitation Gold Key Award and Distinguished Lifetime Contribution to Neuropsychology Award from the National Academy of Neuropsychology.

Harvey Steven Levin, PhD

In 1995, Professor Levin established the Cognitive Neuroscience Laboratory (CNL) at Baylor College of Medicine's Neurosensory Center, which was supported by federal grants, including National Institutes of Health, Department of Defense, the Department of Veterans Affairs, and the Centers for Disease Control and Prevention. The CNL integrates rehabilitation and neuroplasticity research with multimodality brain imaging, cognitive psychology, and neuropsychology. CNL focuses on multidisciplinary traumatic brain injury research involving adult and pediatric populations and has pursued both observational studies and clinical trials. Other areas of research have included sports-related concussion and TBI sustained by veterans in combat. His contributions to the fields of neuropsychology, cognitive neurosciences and brain injury medicine were paramount to moving the field forward. Those of us who got to know him knew not only of his sharp intellect and commitment to his work but also his gusto for life including family, food and travel. He will be sorely missed by all. His books have been high on my reading list for many years and remain brain injury classics in so many ways. I was also fortunate enough to have Dr. Levin agree to write the forward to Brain Injury Medicine: Principals and Practice, 2nd edition….a gesture not soon forgotten.

Harvey is survived by his son Marc and his partner of 15 years, Ruth Buryakovsky. He was married to Ellen M. Levin, PhD from 1967 to 1996. He is also survived by his brother Arthur Levin, Ph.D,, his sister Patty Levin and nephew Alexander Setzepfandt, and cousins with whom he was close, Elaine Apter, Felice Apter and Judy Carson.

Donations can be made to the Brain Injury Association of America and World Jewish Relief Ukraine Crisis Appeal.

Nathan Zasler, MD Co-Editor, Brain Injury Professional

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Traumatic Brain Injury and Arrest Probability: Racial/Ethnic Considerations Mickeal Pugh Jr., MS • Paul B. Perrin, PhD

Nearly 27 million cases of traumatic brain injury (TBI) occur globally each year1, and TBI has become one of the fastest growing conditions contributing to death and disability. James and colleagues1 reported 8.1 million new global cases of TBIcaused long-term disability in 2016 (e.g., at least one year of disability). Given TBI’s widespread prevalence across the globe and the diversity of populations impacted, considerations for health disparities are paramount.

Regarding race/ethnicity in the U.S., American Indian/Alaskan Natives have the highest rates of age-adjusted hospitalization, whereas Asian individuals have the lowest.2 The U.S. Black population annually experiences TBI at 485 per 100,000 people, whereas the White population’s rate is 399 per 100,000.3 TBI can be caused by falls, motor vehicle collisions, sports-related mechanisms, or violence, and racial/ethnic disparities in a violent mechanism of injury exist.4 – 9 Latinx people with TBI experience reduced long-term rehabilitation outcomes as well as higher rates of disability postinjury relative to White individuals.8 Black TBI patient populations similarly report worse functional independence and higher disability than their White counterparts.10 White people with TBI experience a greater degree of secure work and independence in comparison to Black and Latinx individuals.11 – 12 Black patients with TBI who endorse more traditional cultural beliefs, such as religiosity, cultural distrust, and family values, show lower overall neuropsychological performance.13 Prior literature has shown Black, Latinx, Asian, and Native American people with TBI to be more likely unemployed than White individuals.14 Further, Latinx people with TBI are less likely to receive disability-related support from their employers compared to White people15, even after controlling for education and injury cause.7, 16 Black patients with TBI report higher depression and posttraumatic stress compared to White individuals.17 – 18 Racial/ethnic disparities in TBI rates and outcomes may overlap directly with experiences in the criminal justice system. Perkinson19 classified the criminal justice system as a system of racial and social

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control instead of its intent to alleviate crime. The incarceration rate in the U.S. is approximately six to seven times higher than the rates of Western European nations.20 – 21 One in three Black and one in six Latino men will be incarcerated in their lifetime, compared to six percent of White men. 22 Lifetime TBI rates among incarcerated adults and juveniles are 60% and 30%, respectively.23 – 25 History of TBI is associated with a higher likelihood of psychiatric diagnosis, a greater number of previous lifetime arrests, and violent TBI cause.26 Vaughn and colleagues26 found that 53% of individuals who were released from a correctional facility experienced recidivism between one and two-and-a-half years. Notably, previous TBI, racial/ethnic minority status, and arrest history were associated with recidivism. Outside of TBI contexts, studies have shown systemic racial/ethnic inequality of resource allocation and state-level criminal policy contributing to higher recidivism rates for Black and ex-convicted persons.27 – 29 Male sex30 – 32, younger age,31 lower educational achievement, and prior arrest history,32-33 are associated with increased arrest likelihood. Individuals who received mental health treatment for major depressive disorder34 or alcohol and substance misuse32, 34 are more likely to experience criminal arrest in the future.

Additionally, individuals who sustained TBI via assault are more likely to report arrest prior to injury.30 Arrest outcomes may be linked to racial/ethnic disparities observed in TBI risk, cause, and post-injury outcomes. Individuals from racial/ ethnic minority backgrounds may endure similar social structures that contribute to criminal arrests and barriers regarding post-TBI rehabilitation. This series of relationships inform a set of clinical and public health considerations which are supported by previous research. For example, if someone with TBI who is also from a racial/ethnic minority background is younger, male, less educated, with a pre-injury arrest history or pre-injury substance use issues, and without competitive pre-injury employment, these variables could put them at risk for arrest after TBI.

These factors have similarly been associated with higher likelihood of violent and more severe injury.

In conclusion, clinicians in rehabilitation settings may provide unique and tailored rehabilitation support for patients with characteristics putting them at risk for arrest after TBI, including being of a racial/ethnic minority background. Racial/ethnic considerations for arrest outcomes are justified by findings in psychological and criminal justice literature. Culturally informed care should be considered among Native American, Black, and Latinx populations by incorporating a social justice lens in their treatment planning. Doing so may introduce conversation about racial/ethnic disparities in arrest probability outcomes for people with TBI among rehabilitation providers. These efforts could be at the structural level, with including employment trials in rehabilitation, and at the individual level, with assessment of injury, health, and sociodemographic risks that contribute to reduced rehabilitation outcomes, including criminal arrests.

References 1.

James SL, Theadom A, Ellenbogen RG, et al. Global, regional, and national burden of traumatic brain injury and Spinal Cord Injury, 1990–2016: A systematic analysis for the global burden of disease study 2016. The Lancet Neurology. 2019;18(1):56-87. doi:10.1016/s1474-4422(18)30415-0

6.

Arango-Lasprilla JC, Ketchum JM, Gary K, et al. Race/ethnicity differences in satisfaction with life among persons with Traumatic Brain Injury. NeuroRehabilitation. 2009;24(1):5-14. doi:10.3233/ nre-2009-0449

7.

Gary KW, Arango-Lasprilla JC, Stevens LF. Do racial/ethnic differences exist in post-injury outcomes after Tbi? A comprehensive review of the literature. Brain Injury. 2009;23(10):775-789. doi:10.1080/02699050903200563

8.

Arango-Lasprilla JC, Rosenthal M, DeLuca J, Cifu DX, Hanks R, Komaroff E. Functional outcomes from inpatient rehabilitation after traumatic brain injury: How do hispanics fare? Archives of Physical Medicine and Rehabilitation. 2007;88(1):11-18. doi:10.1016/j.apmr.2006.10.029

9.

Linton KF, Kim BJ. Traumatic brain injury as a result of violence in Native American and black communities spanning from childhood to older adulthood. Brain Injury. 2014;28(8):1076-1081. doi: 10.3109/02699052.2014.901558

10.

Hart T, O'Neil-Pirozzi TM, Williams KD, Rapport LJ, Hammond F, Kreutzer J. Racial differences in caregiving patterns, caregiver emotional function, and sources of emotional support following traumatic brain injury. Journal of Head Trauma Rehabilitation. 2007;22(2):122-131. doi:10.1097/01. htr.0000265100.37059.44

11.

Arango-Lasprilla JC, Rosenthal M, Deluca J, et al. Traumatic brain injury and functional outcomes: Does minority status matter? Brain Injury. 2007;21(7):701-708. doi:10.1080/02699050701481597

12.

de la Plata CM, Hewlitt M, de Oliveira A, et al. Ethnic differences in rehabilitation placement and outcome after Tbi. Journal of Head Trauma Rehabilitation. 2007;22(2):113-121. doi:10.1097/01. htr.0000265099.29436.56

13.

Kennepohl S, Shore D, Nabors N, Hanks R. African American acculturation and neuropsychological test performance following Traumatic Brain Injury. Journal of the International Neuropsychological Society. 2004;10(4):566-577. doi:10.1017/s1355617704104128

14.

Arango-Lasprilla JC, Ketchum JM, Williams K, et al. Racial differences in employment outcomes after Traumatic Brain Injury. Archives of Physical Medicine and Rehabilitation. 2008;89(5):988-995. doi:10.1016/j.apmr.2008.02.012

15.

Cardoso Eda, Romero MG, Chan F, Dutta A, Rahimi M. Disparities in vocational rehabilitation services and outcomes for Hispanic clients with Traumatic Brain Injury. Journal of Head Trauma Rehabilitation. 2007;22(2):85-94. doi:10.1097/01.htr.0000265096.44683.6b

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Rosenthal M, Ricker J. Traumatic brain injury. Handbook of rehabilitation psychology. 2000:49-74. doi:10.1037/10361-003

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Seel RT, Kreutzer JS, Rosenthal M, Hammond FM, Corrigan JD, Black K. Depression after traumatic brain injury: A National Institute on Disability and Rehabilitation Research Model Systems Multicenter Investigation. Archives of Physical Medicine and Rehabilitation. 2003;84(2):177-184. doi:10.1053/apmr.2003.50106

2.

Rutland-Brown W, Wallace LJ, Faul MD, Langlois JA. Traumatic brain injury hospitalizations among American Indians/Alaska natives. Journal of Head Trauma Rehabilitation. 2005;20(3):205-214. doi:10.1097/00001199-200505000-00004

3.

Langlois JA, Rutland-Brown W, Wald MM. The epidemiology and impact of Traumatic Brain Injury.

Journal of Head Trauma Rehabilitation. 2006;21(5):375-378. doi:10.1097/00001199-20060900000001

18.

Kreutzer JS, Marwitz JH, Walker W, et al. Moderating factors in return to work and job stability after traumatic brain injury. Journal of Head Trauma Rehabilitation. 2003;18(2):128-138. doi:10.1097/00001199-200303000-00004

Greenspan AI, Stringer AY, Phillips VL, Hammond FM, Goldstein FC. Symptoms of post-traumatic stress: Intrusion and avoidance 6 and 12 months after TBI. Brain Injury. 2006;20(7):733-742. doi:10.1080/02699050600773276

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Perkinson R. Texas Tough: The Rise of America's Prison Empire. New York: Metropolitan Books; 2010.

Arango-Lasprilla JC, Ketchum JM, Dezfulian T, et al. Predictors of marital stability 2 years following traumatic brain injury. Brain Injury. 2008;22(7-8):565-574. doi:10.1080/02699050802172004

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Western B, Wildeman C. The Black Family and mass incarceration. The ANNALS of the American Academy of Political and Social Science. 2009;621(1):221-242. doi:10.1177/0002716208324850

4.

5.

Brain and Spinal Cord Injury Rehabilitation Programs for People of all Ages

Residential Programs • Outpatient Services • Day Treatment • Spinal Cord Rehabilitation Home & Community-Based Rehabilitation • Home Care • Vocational Programs Comprehensive Rehabilitation • Medical Care • NeuroBehavioral Programs To schedule a tour or to speak with an Admissions team member, call 800.968.6644

rainbowrehab.com BRAIN INJURY professional 13

21.

Alexander M. The New Jim Crow: Mass Incarceration in the Age of Colorblindness. New York: New Press; 2010.

22.

The Sentencing Project. Report of the sentencing project to the United Nations Human Rights Committee: Regarding racial disparities in the United States Criminal Justice System. National Institute of Corrections. https://nicic.gov/report-sentencing-project-united-nations-human-rightscommittee-regarding-racial-disparities-united. Published February 25, 2021. Accessed March 10, 2022.

23.

Farrer TJ, Hedges DW. Prevalence of traumatic brain injury in incarcerated groups compared to the general population: A meta-analysis. Progress in Neuro-Psychopharmacology and Biological Psychiatry. 2011;35(2):390-394. doi:10.1016/j.pnpbp.2011.01.007

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Frost RB, Farrer TJ, Primosch M, Hedges DW. Prevalence of traumatic brain injury in the general adult population: A meta-analysis. Neuroepidemiology. 2013;40(3):154-159. doi:10.1159/000343275

25.

Shiroma EJ, Ferguson PL, Pickelsimer EE. Prevalence of traumatic brain injury in an offender population. Journal of Head Trauma Rehabilitation. 2012;27(3). doi:10.1097/htr.0b013e3182571c14

26.

Vaughn MG, Salas-Wright CP, DeLisi M, Perron B. Correlates of traumatic brain injury among juvenile offenders: A multi-site study. Criminal Behaviour and Mental Health. 2014;24(3):188-203. doi:10.1002/cbm.1900

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Kubrin C, Stewart E. Predicting who reoffends: The neglected role of Neighborhood Context in recidivism studies*. Criminology. 2006;44(1):165-197. doi:10.1111/j.1745-9125.2006.00046.x

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Reisig MD, Bales WD, Hay C, Wang X. The effect of racial inequality on Black male recidivism. Justice Quarterly. 2007;24(3):408-434. doi:10.1080/07418820701485387

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Canoeing at

Author Bios Mickeal Pugh Jr, MS, is a PhD candidate in Counseling Psychology at Virginia Commonwealth University. Currently, he is completing his predoctoral internship at the University of Washington specializing in Rehabilitation Psychology. Mike received his BS in Psychology from Lebanon Valley College and a Master’s in Clinical Psychology from Loyola University Maryland. He began Vinland’s main campus in Loretto, Minnesota his doctoral studies at Virginia Commonwealth University where he completed the bulk of his clinical rehabilitation training in VA hospitals and academic medical centers. Mike has been involved in numerous research projects focused on psychological adjustment and cultural factors that contribute to rehabilitation and health outcomes.

drug & alcohol treatment for adults with disabilities

Paul Perrin, PhD, is a Professor of Psychology and Physical Medicine & Rehabilitation at Virginia Commonwealth University, where he is the Director of the Health Psychology PhD Program.

Visher CA, Travis J. Transitions from prison to community: Understanding individual pathways. Annual He has a joint appointment as a research psychologist at the Review of Sociology. 2003;29(1):89-113. doi:10.1146/annurev.soc.29.010202.095931 Vinland Center provides drugCentral andVirginia alcohol treatment for System, adults with Veterans Affairs Health Care where he Kolakowsky-Hayner SA, Kreutzer JS. Pre-injury crime, substance abuse, and co-directs the Polytrauma Rehabilitation Center Traumatic Brain cognitive disabilities, including traumatic brain injury, fetal alcohol neurobehavioural functioning after traumatic brain injury. Brain Injury. 2001;15(1):53-63.

Injury Model Systems Program. Paul's area of research is called doi:10.1080/02699050150209138 spectrum disorder and learning makeand allhepossible "Socialdisabilities.

Justice in DisabilityWe and Health," is passionate Colantonio A, Stamenova V, Abramowitz C, Clarke D, Christensen B. Brain injury in a forensic about using and teaching students to use science in order to fight accommodations psychiatry population. Brain Injury. 2007;21(13-14):1353-1360. doi:10.1080/02699050701785054for cognitive deficits and individual learning styles. oppression in all of its forms, particularly as it manifests itself in Perron BE, Howard MO. Prevalence and correlates of traumatic brain injury among Delinquent within health care systems and rehabilitation services in the U.S. Youths. Criminal Behaviour and Mental Health. 2008;18(4):243-255.

Located in Loretto, Minnesota justHe20 miles west ofand Minneapolis. and— globally. teaches undergraduate doctoral courses on Williams WH, Mewse AJ, Tonks J, Mills S, Burgess CN, Cordan G. Traumatic brain injury in a prison health disparities, social determinants of health, multiculturalism, population: Prevalence and risk for re-offending. Brain Injury. 2010;24(10):1184-1188. doi:10.3109/ community intervention, research methods, and applied 02699052.2010.495697 multivariate statistics.

(763)479-3555 • VinlandCenter.org

Moore E, Indig D, Haysom L. Traumatic brain injury, mental health, substance use, and offending among incarcerated young people. Journal of Head Trauma Rehabilitation. 2014;29(3):239-247. doi:10.1097/htr.0b013e31828f9876

Restore-Ragland

Restore-Roswell

Restore-Lilburn

Restore Neurobehavioral Center is a residential, post acute healthcare organization dedicated exclusively to serving adults with acquired brain injury who also present with moderate to severe behavioral problems.

Services range from intensive inpatient neuro-rehabilitation and transitional community re-entry services to long term supported living services. Restore Neurobehavioral Center, located in a suburb north of Atlanta, is the site of our inpatient post acute neuro-rehabilitation program as well as one of our supported living sites. We operate two other community living sites, Restore-Lilburn (GA) and Restore-Ragland (AL).

www.restorehealthgroup.com 800-437-7972 ext 8251 BRAIN INJURY PROFESSIONAL

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BRAIN INJURY professional 15

Rehabilitation and Outcome Disparities in Older Adults with Traumatic Brain Injury Carmen M. Tyler, MA, MEd • Paul B. Perrin, PhD

Older adults represent a progressively increasing number and proportion of the world’s population1 as lifespans rise worldwide.2 For example, in the U.S., the percentage of older adults age 65 and above rose from 12.76% to 16.21% of the population over the ten years from 2009-2019, while other age groups remained about the same percentage or decreased.3 By 2060, projections are that the over-65 age group will be approximately double what it was in 2018, comprising nearly one-quarter of the U.S. population. The number of oldest old (ages 85 and over) is expected to double in the next 15 years and triple by 2060 to approximately 19 million people.4 TBI rates are increasing for older adults, with the greatest number of TBIs incurred by those aged 80 years and older.5 TBI-related morbidity and mortality rates are highest for older adults compared to other groups,6,7 with the primary cause for TBI in older adults being falls.8 As age increases, the likelihood of returning to live alone or at a private residence after TBI decreases, perhaps because although older adults experience less severe TBIs, rehabilitation takes longer with less improvement in functionality and greater disability.9 The increased risk associated with TBI in older adults is not a recent observation,10 but explanations about causality and severity differ.

Some theorize that commonly used TBI assessment instruments like the Glasgow Coma Scale (GCS), in addition to having problems with inter-rater reliability and confounds,11 are not as sensitive for older adults as they are for younger adults, leading to underestimations of TBI severity.12 Several studies have demonstrated that older adults with GCS scores in the normal range are at higher risk for undetected intracranial lesions.7 Neuroinflammatory pattern differences in older versus younger adults have been noted up to 6 months after TBI, but it is still unclear as to whether these differences are age- or injury-related.13 Physical health conditions commonly experienced in older age are linked with increased fall risk14 and may contribute to worse outcomes for older adults with TBI.15 Others propose that physiological changes related to aging16 may increase vulnerability accompanying TBI in older adults. As adults age, structural and metabolic changes occur in the brain16 and throughout the body,17 resulting in reductions in functional efficiency of bodily systems.

TBI may also increase vulnerability to developing illnesses like Parkinson’s disease18 and Alzheimer’s disease19 and mental health conditions such as schizophrenia20 and depression,21 which could limit function. Although observation of the link between sustaining moderate-to-severe TBI and subsequent development of Alzheimer’s disease is not new,22 ongoing research is elucidating the physiological

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processes that contribute to neurodegenerative diseases such as dementia and Parkinson’s disease after TBI.23 Older adults tend to sustain less severe TBI than younger people, but they have more disability post-TBI and are more likely to have a change in where they live after hospital discharge.9 TBI severity and GCS score can predict function in older adults at discharge from the hospital,24 and level of functioning at that time also predicts long-term functioning.25 However, greater age is associated with lower functional independence for older adults with TBI.26 Not only have older adults shown lower functional independence ratings than younger adults at discharge from the hospital and at 6 months post-discharge and more declines in ability 5 years post-injury, but these lower levels of functional independence have occurred despite lower injury ratings.27,28 Older age has also been noted as a consideration in postacute TBI treatment decisions. Early, intensive, and continuous implementation of rehabilitation is more effective at improving long-term functional outcomes for those with severe TBI than rehabilitation started in the subacute phase.29 Discharge from the hospital to a specialized rehabilitation facility has been associated with greater functional independence, and younger people are admitted directly to TBI rehabilitation more frequently than older adults with TBI, despite equivocal injury severity levels. 30 In addition to traditional demographics and psychosocial variables, research has established the detrimental effects of ageism on health outcomes.31 Negative aging stereotypes portraying older adults as being unattractive, incompetent, frail, and financial and social liabilities are ubiquitous, including in healthcare settings.32 Health care professionals who hold ageist beliefs may engage in discriminatory practices such as underordering diagnostic tests and treatments33 or dismissive, infantilizing, and patronizing communication or behaviors34 with older adults in their care.

Perceptions of age discrimination by others and internalized ageist beliefs have been associated with greater functional impairment and higher mortality in older adults.35-37

Conclusion Although functional outcomes after TBI have been examined in various studies,30 research on older adults with TBI has been relatively sparse.

Lifespan is increasing worldwide,2 and as a result, the proportion and number of older adults is increasing steadily.1 Morbidity and mortality rates are higher for older adults after TBI than they are for younger adults,6,7 and older adults have worse recovery outcomes even when injury severity is milder.9,28 As the risk for incurring a TBI increases with age5 and given the ubiquity of ageism,32 the greater number of older adults alone makes examination of factors contributing to poorer functional independence outcomes an important area of study and clinical intervention. Older adults with TBI have less chance of returning to independent living or employment after TBI,9,25 and their increased need for post-TBI assistance could have serious repercussions for additional demands imposed on healthcare systems, health insurance systems, local and national economies, and family and social systems.

Older age has also been noted as a consideration in post-acute TBI treatment decisions.

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Ikonomovic MD, Mi Z, Abrahamson EE. Disordered APP metabolism and neurovasculature in trauma and aging: Combined risks for chronic neurodegenerative disorders. Ageing Res Rev. 2017;34:51-63. doi:10.1016/j.arr.2016.11.003

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Molloy C, Conroy RM, Cotter DR, Cannon M. Is traumatic brain injury a risk factor for schizophrenia? A meta-analysis of case-controlled population-based studies. Schizophrenia Bulletin.

2011;37(6):1104-1110. doi:10.1093/schbul/sbr091

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Jean-Bay E. The biobehavioral correlates of post-traumatic brain injury depression. Journal of Neuroscience Nursing. 2000;32(3):169-176.

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Plassman BL, Havlik RJ, Steffens DC, et al. Documented head injury in early adulthood and risk of Alzheimer’s disease and other dementias. Neurology. 2000;55(8):1158-1166. doi:10.1212/ wnl.55.8.1158

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Brett BL, Gardner RC, Godbout J, Dams-O’Connor K, Keene CD. Traumatic brain injury and risk of neurodegenerative disorder. Biol Psychiatry. Published online June 2, 2021:S0006-3223(21)01359-7. doi:10.1016/j.biopsych.2021.05.025

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Thompson HJ, Dikmen S, Temkin N. Prevalence of comorbidity and its association with traumatic brain injury and outcomes in older adults. Res Gerontol Nurs. 2012;5(1):17-24. doi:10.3928/19404921-20111206-02

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Testa JA, Malec JF, Moessner AM, Brown AW. Outcome after traumatic brain injury: Effects of aging on recovery. Archives of Physical Medicine and Rehabilitation. 2005;86(9):1815-1823. doi:10.1016/j. apmr.2005.03.010

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Sendroy-Terrill M, Whiteneck GG, Brooks CA. Aging with traumatic brain injury: Cross-sectional follow-up of people receiving inpatient rehabilitation over more than 3 decades. Archives of Physical Medicine and Rehabilitation. 2010;91(3):489-497. doi:10.1016/j.apmr.2009.11.011

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Mosenthal AC, Livingston DH, Lavery RF, et al. The effect of age on functional outcome in mild traumatic brain injury: 6-month report of a prospective multicenter trial. Journal of Trauma and Acute Care Surgery. 2004;56(5):1042-1048. doi:10.1097/01.TA.0000127767.83267.33

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Marquez de la Plata CD, Hart T, Hammond FM, et al. Impact of age on long-term recovery from traumatic brain injury. Archives of Physical Medicine and Rehabilitation. 2008;89(5):896-903. doi:10.1016/j.apmr.2007.12.030

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Andelic N, Bautz-Holter E, Ronning P, et al. Does an early onset and continuous chain of rehabilitation improve the long-term functional outcome of patients with severe traumatic brain injury? J Neurotrauma. 2012;29(1):66-74. doi:10.1089/neu.2011.1811

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Sveen U, Røe C, Sigurdardottir S, et al. Rehabilitation pathways and functional independence one year after severe traumatic brain injury. European Journal of Physical and Rehabilitation Medicine.

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Chang ES, Kannoth S, Levy S, Wang SY, Lee JE, Levy BR. Global reach of ageism on older persons’ health: A systematic review. PLOS ONE. 2020;15(1):e0220857. doi:10.1371/journal.pone.0220857

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Wyman, M, Shiovitz-Ezra, S, & Bengel, J. Ageism in the health care system: Providers, patients, and systems. In Ayalon L, Tesch-Römer C, eds. Contemporary Perspectives on Ageism. Vol 19. Springer International Publishing; 2018. doi:10.1007/978-3-319-73820-8

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Gardner RC, Burke JF, Nettiksimmons J, Goldman S, Tanner CM, Yaffe K. Traumatic brain injury in later life increases risk for Parkinson’s disease. Ann Neurol. 2015;77(6):987-995. doi:10.1002/ana.24396

Author Bios Carmen M. Tyler, MA, MEd, is a licensed clinical mental health counselor and a doctoral candidate in the Counseling Psychology program at Virginia Commonwealth University. Carmen graduated summa cum laude with a BS in Psychology from Saint Leo University in 2014 and master’s degrees in Psychology (Adult Development and Aging-2017) and Education (Clinical Mental Health Counseling-2018) from Cleveland State University. Carmen’s research and clinical work has focused on older adults with chronic illnesses or neurological impairments associated with neurocognitive disorders, brain injuries, and severe mental illness and their caregivers.

Paul Perrin, PhD, is a Professor of Psychology and Physical Medicine & Rehabilitation at Virginia Commonwealth University, where he is the Director of the Health Psychology PhD Program. He has a joint appointment as a research psychologist at the Central Virginia Veterans Affairs Health Care System, where he co-directs the Polytrauma Rehabilitation Center Traumatic Brain Injury Model Systems Program. Paul's area of research is called "Social Justice in Disability and Health," and he is passionate about using and teaching students to use science in order to fight oppression in all of its forms, particularly as it manifests itself in within health care systems and rehabilitation services in the U.S. and globally. He teaches undergraduate and doctoral courses on health disparities, social determinants of health, multiculturalism, community intervention, research methods, and applied multivariate statistics.

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Racial and Ethnic Disparities in Employment Outcomes after TBI Juan Carlos Arango Lasprilla, PhD • Gloria M. Morel Valdés, PsyD Carolina Fernanda Serrano Román, MS • Fabiola Cristina Mercado Nieves, MS

Traumatic Brain Injury (TBI) is an acquired injury to the brain caused by an external mechanical force resulting in temporary or longterm cognitive, physical, and emotional changes1. The Incidence of TBI increases annually worldwide and according to the Centers for Disease Control and Prevention, TBI is considered a leading cause of death and disability in the United States2. Some individuals recover without permanent disabilities, while a substantial amount experience persistent deficit3. These deficits can lead to problems with independent living, social and interpersonal relations, problems engaging in leisure activities, satisfaction with life, emotional distress, community, and work reintegration and difficulties obtaining or/and maintaining employment4–10.

Regarding employment, studies have shown that approximately 50% of individuals who sustain a TBI return to work during the first 10 years post injury11,12. Return to work (RTW) has been considered a good indicator of increased quality of life13, satisfaction with life, and successful rehabilitation after TBI14. Several studies have indicated that injury severity15–18, Glasgow Coma Scale admission score (GCS;19), duration of Posttraumatic amnesia19,20, pre-injury substance use21, pre-injury employment14,16,18,19, length of stay in an intensive care unit22, rehabilitation services17, healthcare and welfare systems(17, processing speed scores22, level of metacognition,22, age10,15,21–24, gender21,23,25, education21, marital status10,19,23, and race/ ethnicity6,21,23,26 are significant predictors of employment outcomes after TBI.

Catalano et al.,29 analyzed the Rehabilitation Services Administration (RSA) case service report (RSA-911) data for the fiscal year 2004 and examined the effects of demographic characteristics, work disincentives, and vocational rehabilitation services patterns on employment outcomes of persons with traumatic brain injuries (TBI). The results indicated that European Americans (53%) had appreciably higher competitive employment rates than Native Americans (50%), Asian Americans (44%), African Americans (42%), and Hispanic/Latino Americans (41%).

Another study30 focusing on disparities in vocational rehabilitation services following a TBI compared 5, 831 European Americans and Hispanic individuals and found that European Americans were 1.27 times more likely to obtain employment than were Hispanics.

Arango-Lasprilla et al.31 found racial differences in employment outcomes between minorities and Whites at one-year post-injury.

Another study led by the same author32 found that minority TBI survivors were more likely than Caucasians to be unemployed or unstably employed. Compared to Caucasians, the adjusted odds for minorities were 3.587 times greater for being unemployed versus being stably employed and 1.911 times greater for being unstably employed versus being stably employed. Consequently, minority status was an independent predictor of short-term job stability after TBI.

Between 1988 to 2022, nine studies have examined the relationship between employment and race/ethnicity in individuals with a TBI. Sherer et al.27 investigated the impact of race on productivity outcome following a TBI and 1-year productivity follow-up on 1083 adults. They found that the impact of race on productivity is affected by confounding factors such as pre-injury productivity, educational level, and the cause of injury. As a result, they suggested that African Americans were 2.76 times more likely to be unproductive than Caucasians and that other minorities were 1.92 times more likely to be unproductive than Caucasians.

Gary et al.23 examined racial differences in competitive employment outcomes at 1, 2, and 5 years between Blacks and Caucasians with TBI. The repeated-measures logistic regression indicated that the odds of not being competitively employed were significantly greater for Blacks than Caucasians regardless of the follow-up year.

Additionally, for each race, the odds of not being competitively employed declined significantly over time, and the odds of not being competitively employed over time did not differ significantly over time. They concluded that employment is not favorable for people with TBI regardless of race; however, Black individuals had worse employment outcomes than Caucasians in both short- and long-term employment.

Another study28 focusing on job stability in a group of 186 individuals at 1, 2, and 3, or 4 years post-injury (between 18 and 62 years of age at injury) found that 34% of respondents were employed, 27% were unemployed, and 39% were unemployed at all three follow-ups.

They found that minority group members, individuals who did not complete high school, and unmarried people were more likely to be unemployed.

Arango-Lasprilla et al5 investigated the differences in employment rates between Caucasians, African American, and Hispanics individuals with TBI at 1, 2, and 5 years pos-injury. They found that employment rates were significantly greater for Caucasians versus African Americans at all time points quitarle el and was even more significant for Caucasians when compared to Hispanics at 1 and 2 years after injury.

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Also, Caucasians and Hispanics did not differ significantly at 5 years post-injury; and also African Americans and Hispanics were not significantly different at 1, 2, or 5 years after injury.

4.

Job search assistance. Staff assists in searches for an appropriate job, helps to prepare a resume, identifies suitable job opportunities, provides interview skill training, and contacts employers on behalf of the individual with TBI35.

A study conducted by Cuthbert et al.21 found that unemployment prevalence at 2-year post-injury was significantly associated with race/ethnicity, particularly in Hispanic individuals. It was observed that part-time employment was more predominant in this cohort of employed individuals than before; however, only gender, pre-injury employment status, and physical and psychosocial functioning were found to be significantly associated with this outcome21.

5.

Job coaching. Staff provides one-on-one individualized training services to manage the sequela associated with TBI37.

Vocational rehabilitation services exist in some areas to prepare individuals with physical and cognitive impairments for work placement. Specific vocational rehabilitation programs are available for individuals with TBI33 and may include the following components: 1.

Assessment. The individual's potential, aptitude, interests, learning abilities, and skills for returning to work are evaluated34.

2.

Diagnosis and treatment for impairments. Services are provided to meet the medical and psychosocial (e.g., mental and emotional) needs of the individual with TBI35.

3.

Counseling and guidance. Counselors help to (1) determine abilities and support needs in the workplace, (2) locate and negotiate suitable work, (3) identify and secure an array of workplace supports or accommodations to enhance job performance, and (4) help to develop problem solving skills to deal with issues at work36.

Vocational rehabilitation services have been shown to be effective in improving employment outcomes after TBI38; however, the extent to which such programs are effective in racial and ethnic minorities is not well-understood.

Current evidence suggests that racial and ethnic disparities in employment outcomes after TBI exist, even after controlling for some sociodemographic and injury characteristics. These disparities could be related to a number of factors, such as systemic racism and/or discrimination as well biased behaviors by individuals in the health and employment sectors. In addition, some barriers disproportionately affect racial and ethnic minority communities and may hinder access to vocational rehabilitation services or job opportunities. For instance, employment outcomes may be influenced by the availability of vocational rehabilitation services, financial ability to pay for services, transportation and other challenges to access existing services, language barriers, mistrust, and legal status / permission to work. Eradicating these racial and ethnic disparities is key to improving rehabilitation services for minorities who have sustained a TBI. Vocational rehabilitation services require culturally-based adaptations24 and effectiveness data. Moreover, additional research to better understand the factors associated with the relationship between racial and ethnic disparities in employment outcomes after TBI is warranted in order to provide targeted recommendations that reduce these disparities.

Textbook of Traumatic Brain Injury, Third Edition Edited by Jonathan M. Silver, M.D., Thomas W. McAllister, M.D., and David B. Arciniegas, M.D.

D

espite the increased public awareness of traumatic brain injury (TBI), the complexities of the neuropsychiatric, neuropsychological, neurological, and other physical consequences of TBI of all severities across the lifespan remain incompletely understood by patients, their families, healthcare providers, and the media.

Keeping pace with advances in the diagnosis, treatment, and science of TBI, the Textbook of Traumatic Brain Injury, Third Edition, comprehensively fills this gap in knowledge. Nearly all 50 chapters feature new authors, all of them experts in their field. The Textbook of Traumatic Brain Injury is a must-read for all of those working in any of the multitude of disciplines that contribute to the care and rehabilitation of persons with brain injury. This new volume is also a potentially useful reference for policymakers in both the public and private sectors.

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BRAIN INJURY professional 19

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Andelic N, Stevens LF, Sigurdardottir S, Arango-Lasprilla JC, Roe C. Associations between disability and employment 1 year after traumatic brain injury in a working age population. Brain Inj. 2012 Mar;26(3):261–9.

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Ketchum JM, Almaz Getachew M, Krch D, Baños JH, Kolakowsky-Hayner SA, Lequerica A, et al. Early predictors of employment outcomes 1 year post traumatic brain injury in a population of Hispanic individuals. Arango-Lasprilla JC, editor. NeuroRehabilitation. 2012 Feb 15;30(1):13–22.

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Arango-Lasprilla JC, Perez PK, Ramos-Usuga D. Teleneuropsicología en países de habla hispana: Una mirada crítica al uso de Tecnologías de Información y Comunicación en la evaluación neuropsicológica. Revista Iberoamericana de Neuropsicología. 2021;4(1)

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Cuthbert JP, Harrison-Felix C, Corrigan JD, Bell JM, Haarbauer-Krupa JK, Miller AC. Unemployment in the United States After Traumatic Brain Injury for Working-Age Individuals: Prevalence and Associated Factors 2 Years Postinjury. J Head Trauma Rehabil. 2015 May;30(3):160–74.

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Gary KW, Arango-Lasprilla JC, Ketchum JM, Kreutzer JS, Copolillo A, Novack TA, et al. Racial Differences in Employment Outcome After Traumatic Brain Injury at 1, 2, and 5 Years Postinjury. Arch Phys Med Rehabil. 2009 Oct;90(10):1699–707.

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J Vocat Rehabil. 2010;33(1):65–75.

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Author Bios Juan Carlos Arango Lasprilla, PhD, BioCruces Bizkaia Health Research Institute, 48903 Barakaldo, Spain. IKERBASQUE, Basque Foundation for Science, Bilbao, Spain. Department of Cell Biology and Histology, University of the Basque Country, Leioa, Spain.

Gloria M. Morel Valdés, PsyD, Assistant Professor, Department of Neurology. University of Wisconsin School of Medicine and Public Health, University of Wisconsin. Madison. USA. Gloria M. Morel Valdes, PsyD is an assistant professor of Department of Neurology at the within the School of Medicine and Public Health at the University of Wisconsin. Dr. Valdes has a Doctorate of Psychology at the Albizu University in Miami, Florida. She has held internships at the William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin and a Post-Doctoral Fellowship at the University of Wisconsin Hospitals and Clinics in Madison, Wisconsin. Here areas of research and medical interest are Dementia, Traumatic Brain Injury, and Epilepsy.

Carolina Fernanda Serrano Román, MS, is a Clinical Psychology Doctorial student at Ponce Health Sciences University with an emphasis in neuropsychology.

Fabiola Cristina Mercado Nieves, MS, Ponce Health Science University, Ponce, Puerto Rico.

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Rehabilitation Disparities: Examining Micro and Macro-level Barriers among Ethnic and Racial Populations Recovering from a Brain Injury Patricia Garcia, PsyD • Jessica L. Peramo, MS • Sheryl Katta-Charles, MD Frank Moreno, PharmD

Introduction Due to greater technological advances, more patients are surviving what used to be fatal brain injuries (BI), and those who survive have their lives impacted across occupational, social, and interpersonal domains of life. Adding to the challenges of BI care, minority groups in the US are at a disproportionate risk for traumatic brain injury (TBI). This is concerning given the anticipated growth of ethnic and racial groups in the next 30 years. For example, Hispanics in the US are projected to expand to 111 million by 2060, becoming the largest ethnic population group by 20541. Considering this anticipated expansion, rehabilitation professionals are maximizing efforts to eradicate persistent healthcare disparities and offer equitable services to minoritized groups.

Much has been written on healthcare disparities and rehabilitation outcomes related to race and ethnicity. Variables include 1) mechanisms of injury, with motor vehicle crashes and violence/ blunts to the head as injury mechanisms overly represented among ethnic minorities, 2) hospitalization, with African Americans and Hispanics experiencing longer hospital stays, and 3) increased in-hospital mortality rate. Factors such as poverty, high rate of employment in physically demanding jobs and limited occupational and educational opportunities have been identified as direct contributors to the increased incidence of TBI among Hispanics2.

Disparities across Rehabilitation Settings The full spectrum of rehabilitation following a brain injury encompasses acute hospital services, inpatient rehabilitation care, long-term therapies and social/community re-integration, making it possible for healthcare disparities to be differentially represented across the continuum of recovery. Compared to Caucasians, minoritized groups receive less medical care after a TBI and experience worse functional outcomes3. Specific to acute inpatient rehabilitation, many factors can affect the discharge plan of each individual patient. Yet studies have shown that race and insurance status play a significant role. Even when insured, Hispanic patients are less likely to receive inpatient rehabilitation, and this disparity persists even in Hispanic-majority regions3,4.

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Additionally, minoritized individuals recovering from TBI wait longer to see a physician, have fewer number of referrals for services, tend to receive fewer therapy sessions from rehabilitation experts during their inpatient stay, and receive significantly less intense therapy treatment (as determined by minutes per day)5. Ethnic groups are also known to have lower levels of community integration, higher levels of disability, and are less likely to return to work6. In fact, the odds of being unemployed at 1 year post TBI are over two times greater for minority groups than for Caucasians, also being less likely to have stable employment at three years post-TBI7. All these aspects contribute to poorer long-term outcomes as compared to Caucasians, as well as negative self-perceptions regarding quality of life.

Macro-level/Systemic Barriers The healthcare structure is susceptible to personal and institutional biases that perpetuate existing disparities. Variables such as lack of health insurance and limited knowledge regarding eligibility for publicly funded insurance undoubtedly influence whether minoritized groups gain access to and benefit from healthcare services. Existing literature identifies reduced healthcare utilization

by Hispanics, which is highly correlated with insurance status. Lack or loss of private health insurance is an important deterrent, as it is possible that the insurance status of patients either changed or was lost after their injuries, especially if their healthcare insurance was employment-based6. Care organizations who have an unstated preference for private insurance, or that limit the number of patients on public insurance accepted for services, further complicates the accessibility of health services by minority groups. Furthermore, reduced household income has consistently been shown to be confounded with minority status, limiting families’ ability to afford necessary rehabilitation services long-term8.

Recent immigration status, poorer assimilation into mainstream US culture, and the location of a facility that is not easily accessible to those using public transportation (structural bias) could also affect marginalized populations in a negative way. Specific to rehabilitation centers with well-defined admission criteria, which often includes having familial and/or social support post discharge, may inadvertently serve as a barrier for accessing inpatient

rehabilitation services, as many Hispanics and other immigrant groups lack the social support explained by the realities of migration.

Institutional discrimination and providers’ unconscious biases directed at their patients may further widen the gap in accessing services. For example, African American patients are less likely to be prescribed analgesics for their injuries during their hospital stay and at their outpatient follow up appointments, as there is greater anticipation for developing substance dependence by this racial group9. The lack of diversity among healthcare workers and across institutional levels may further contribute to systemic and communication barriers and diminish perception of quality of care rendered. This is especially relevant when one considers that interpersonal interactions are actively shaped by cultural characteristics. Examples include mannerisms and use of hands when speaking, facial expressions, physical proximity, degree of eye contact, “personalismo” (formal friendliness), and even comfort level in asking a rehabilitation provider to clarify BI education, are all aspects of interpersonal dynamics in healthcare that help create a perception of understanding, safety, and inclusion.

Micro-level/Individual Barriers Public health experts are increasingly recognizing and bringing attention to cultural and social aspects of health that can have implications in long-term recovery. There is greater appreciation for the social environment in which individuals function, such as work and family, and how this could contribute to existing healthcare disparities. Ethnic and immigrant populations bring unique cultural considerations to patient care, further amplifying the reasons for disparities in long-term outcomes.

A noteworthy consideration, for example, is language barriers in the rehabilitation setting. Individuals with limited proficiency in the English language report that an inability to communicate with physicians in their native language detracts from the patientprovider relationship, as they may not adequately understand their diagnosis, treatment, and plan for follow-up care. In addition, language barriers may also render rehabilitation less effective.

Worse yet, one study found that individuals who did not speak English were rated lower on functional communication outcomes at discharge from inpatient rehab, reflecting a potential bias in Functional Independence Measure (FIM) testing5. Thus, language barriers may negatively impact access to rehabilitative services and long-term outcomes, placing predominantly Spanish-speaking individuals at even greater risk than African Americans and other English-speaking minority groups.

Regardless of English proficiency, cultural factors such as race, ethnicity, and educational attainment have strong relationships with health literacy, also putting minority groups at a greater disadvantage10. Healthcare providers appear more concerned with health literacy aspects of care, which involves educating the patient and family on injuries, prognosis, implications, and recommendations for maximizing recovery. However, this educational interaction can be very ethnocentric, with little consideration for functional literacy, or the degree to which this education is being analyzed, understood, and appreciated by the patient and family. Inadequate health literacy in caregivers can also contribute to poorer health outcomes, especially when considering that a substantial portion of persons with moderate to severe TBI require supervision up to nine years post-injury. Caregiving duties often include aiding with securing necessary healthcare services, making medical appointments, and managing health issues for their loved ones11.

However, if neither the patient nor the family can access or appreciate the services they need, they are unlikely to benefit or be rehabilitated to their fullest potential. The recognition that health literacy is more complex given the unfamiliar rehabilitation context and vocabulary used by professionals should help guide educational interactions that move away from ethnocentrism and towards a polycentric approach which avoids making cultural impositions.

Polycentrism considers specific cultural characteristics of the individual patient and tailors education accordingly11.

Cultural attitudes and beliefs about disability and rehabilitation may also contribute to poorer long-term outcomes in minority groups. African Americans, for example, are less likely to trust their physicians, which could be explained by high levels of cultural mistrust that can interfere with seeking necessary services after inpatient rehabilitation. Similarly, African American caregivers are less likely to seek professional mental health services. It should also be noted that symptoms of psychological distress often carry a stigma in the Hispanic and African American cultures, whereas physical symptoms may be considered more acceptable reasons for seeking medical care12.

Both Hispanic and African American cultures share characteristics such as collectivism and more traditional gender roles and generational expectations. These same distinctive characteristics may further amplify a sense of responsibility towards an injured family member, and thus caregivers may hold a negative perception towards allowing discharge to nursing homes or other institutions even if this is the safest recommendation. Rehabilitation providers must identify when these assumptions are being made so the patients and families can receive additional guidance and counseling during their hospitalization.

Factors such as poverty, high rate of employment in physically demanding jobs and limited occupational and educational opportunities have been identified as direct contributors to the increased incidence of TBI among Hispanics.

BRAIN INJURY professional 23

There needs to be an emphasis on improving access, equity, and outcomes for ethnic and racial groups through active collaborations between healthcare professionals, institutions, and policymakers.

Bridging the Gap As the US continues to diversify in the coming decades, healthcare will be regarded as excellent to the degree that healthcare disparities in rehabilitation are mitigated. Efforts at eradicating disparities begin with recognizing ways in which healthcare has perpetrated racism in the past and empowering minority groups to take an active role in addressing healthcare barriers13,14. An ongoing commitment to advocacy efforts towards improving the lives of individuals living with a brain injury is imperative. Also necessary is continuing to strive for acknowledging and proactively changing unconscious biases that permeate interactions in healthcare, and which directly impact the quality of provider-patient relationship.

Lastly, there needs to be an emphasis on improving access, equity, and outcomes for ethnic and racial groups through active collaborations between healthcare professionals, institutions, and policymakers. These collaborations may extend to developing evidence-based brain injury interventions for Spanish-speaking patients, building strong relationships with institutions actively engaged with various ethnic and immigrant groups, and reinforcing trainings and education with an emphasis on healthcare equity as part of the academic curriculum for rehabilitation professionals.

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Jamison, Laura, Stephanie A. Kolakowsky-Hayner, and Jerry Wright. "Preliminary investigation of longitudinal sociodemographic, injury and psychosocial characteristics in a group of non-English speaking Latinos with brain injury." Brain injury 26.6 (2012): 805-813.

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Hahn, Elizabeth A., et al. "Health literacy, health outcomes, and the caregiver role in traumatic brain injury." Rehabilitation psychology 65.4 (2020): 401.

12.

Lavizzo-Mourey, Risa J., Richard E. Besser, and David R. Williams. "Understanding and mitigating health inequities—past, current, and future directions." New England Journal of Medicine 384.18 (2021): 1681-1684.

13.

Brown, Arleen F., et al. "Structural interventions to reduce and eliminate health disparities."

American journal of public health 109.S1 (2019): S72-S78.

14.

Quiñones, Ana R., et al. "Interventions that reach into communities—promising directions for reducing racial and ethnic disparities in healthcare." Journal of racial and ethnic health disparities 2.3 (2015): 336-340.

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Author Bios Patricia Garcia, PsyD, HSPP is a Clinical Neuropsychologist at the Rehabilitation Hospital of Indiana and Adjunct Clinical Assistant Professor of PM&R at Indiana University School of Medicine. She received her doctoral degree in Clinical Psychology from Albizu University with a neuropsychology focus in 2017. She completed her pre-doctoral internship at Jackson Memorial Hospital and her post-doctoral fellowship at the University of Miami and Jackson Memorial Hospital affiliated with the University of Miami Leonard M. Miller School of Medicine. Her research focuses on cross-cultural disparities after a BI and mitigating barriers in accessing treatment for improving outcomes by racial/ethnic populations.

Jessica L. Peramo, MEd, MS, CCC-SLP, is a bilingual Speech-Language Pathologist. Ms. Peramo earned her Master’s in Early Childhood Education from the University of Florida in 2003 and her Master’s in Speech-Language Pathology from Nova Southeastern University in 2012. Her professional experience encompasses outpatient, pediatric extended care, and Skilled Nursing Facility settings.

Additionally, she has expertise in working with adults in acute hospital and inpatient rehabilitation settings, most recently at Jackson Memorial Hospital. Ms. Peramo currently owns her own practice, Step Up Learning LLC, treating children and adults with and without traumatic brain injuries via Teletherapy and in-home services.

Sheryl Katta-Charles, MD, joined IU Health Physicians and IU School of Medicine Department of PM&R Faculty in July 2015. Inspired by her family's contributions to Leprosy Rehabilitation in India, she completed residency in Physical Medicine and Rehabilitation at the Rehabilitation Institute of Michigan/Wayne State University in Detroit, MI. She received her medical doctorate degree from St. George’s University School of Medicine in Grenada, West Indies and her undergraduate degrees in Biology and Psychology from University of Illinois at Chicago. She currently cares for patients with traumatic and non-traumatic brain injuries at the Rehabilitation Hospital of Indiana.

Frank C. Moreno, PharmD, BCPS, is a bilingual clinical pharmacist.

He obtained his Doctor of Pharmacy from Nova Southeastern University in 2020, graduating with the highest honors. He was the recipient of the Chancellor’s Award for his outstanding academic performance and was also chosen for the ACE Program at Jackson Memorial Hospital. Dr. Moreno is currently completing a two-year specialty-residency in Critical Care at Baptist Hospital in Miami, FL, and has training in Emergency and Oncology Medicine. Dr. Moreno serves the Hispanic patient population of South Florida and has experience with healthcare disparities among ethnic populations at medical settings.

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Moving the Field Toward Health Equity in Traumatic Brain Injury Monique R. Pappadis, PhD • Chinedu K. Onwudebe, BS Anthony H. Lequerica, PhD • Angelle M. Sander, PhD, FACRM

Significant research-based efforts have been made to explore disparities in access to healthcare and outcomes following traumatic brain injury (TBI), particularly over the last five years. We know that health disparities exist in racialized/minoritized ethnic groups, women, children and older adults, underserved persons living in rural areas, and socioeconomically disadvantaged populations in TBI.1-6 The vast majority of the literature has focused on racialized/ minoritized ethnic groups, such as Black/African American and Hispanic/Latinx individuals. Other health disparity populations with TBI, such as sexual and gender minorities, religious minorities, language minorities, and those with disabilities, have not received as much attention. Furthermore, the social identities of these groups have been explored in isolation, but now there is a movement towards using an intersectionality approach, where we acknowledge that each individual is unique with multiple social identities that can be associated with different social positions.7 This approach acknowledges the role of power and one’s social context at the individual or interpersonal level, as well as inequalities or inequities experienced. This intersectional approach is a first step toward promoting health equity and, more broadly, toward fairness and social justice.

Social determinants of health (SDoH) play a significant role in health and health outcomes. SDoH are the economic and social conditions in our environments, where we are born, live, learn, work, play, worship, and age, and that affect our health, functioning, associated risks, and outcomes.8 Examples include sociodemographic factors, health behaviors, family functioning, structural discrimination, availability of services, and health care policies.

26 BRAIN INJURY professional

When SDoH are unevenly distributed, the result is health disparities.

Therefore, health disparities are preventable, historical or current differences in the “burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by socially disadvantaged populations”.9 By addressing SDoH to reduce disparities, we can move towards health equity, where everyone can live to their healthiest potential and have access to needed healthcare services regardless of who we are, our abilities, where we live, insurance status, or what financial resources we have.

The National Institute on Minority Health and Health Disparities Framework is a multi-dimensional model that represents a variety of SDoH that are important to understanding and addressing minority health and health disparities over time.10 The model suggests that there are five key domains of influence, including biological, behavioral, physical/built environment, sociocultural environment, and healthcare system domains. Within each of these domains are four different levels of influence, which include the individual, interpersonal, community and societal levels.

These domains and their respective levels impact individual, family/ organizational, community, and population health outcomes. It is important to remember that facilitators and barriers to health may change over time from the individual to societal level; therefore, any framework to understand health disparities must be flexible to change. Most of the work in TBI research has focused on the individual level rather than on the sociocultural environment and health system domains.

For example, numerous studies have explored sociodemographic differences, US born vs non-US born status, rurality, and insurance status and their impact on rehabilitation or health outcomes after TBI. However, there is a dearth of research focused on the health care system from the individual level (e.g., health literacy) to the societal level (e.g., quality of care). Within the past five years, there has been emerging research on individuals’ perceived discrimination and racism, but not on systemic biases at the community and/or societal level.

Individual Influences Consistently, financial resources and health behaviors are identified as key drivers of health and health outcomes following TBI.11,12 However, there may be other individual factors that influence health that have yet to be explored. For example, increasing evidence suggests that abnormal growth hormone secretion and altered gut microbiome following TBI may influence neurocognitive and behavioral deficits.13 Future work is needed to explore the mechanistic determinants that will promote health and reduce the risk of biological changes that negatively impact health outcomes.

At the sociocultural domain, we know from limited research that persons with TBI with limited English proficiency, particularly Spanish speakers in the US, have unique experiences and report negative TBI outcomes.14,15 More efforts are needed to improve care and access to resources to improve outcomes for persons with TBI with limited English proficiency.

The field has done well with identifying many of the aforementioned individual factors in disparities, but not much has been done with addressing the identified gaps.

Future work should consider the development of educational materials to address health knowledge or health literacy gaps, culturally-relevant interventions to improve health and health behaviors, and training on responding to discrimination or racism that may negatively impact health. In addition, it is worth considering supports and resources that individuals can be taught to use to facilitate health and well-being, such as the use of health monitoring interventions and technology. This is by no means an exhaustive list but are considerations for addressing individual-level health disparities.

Interpersonal Influences Caregiving burden, family dysfunction, and decreased social networks are recognized consequences of TBI given considerable attention.16-18 In addition, school and work functioning are other important behavioral SDoH that can influence the health of the family unit. Providing services and treatment to support the entire family, promoting awareness and health of caregivers, and therapy to address social difficulties following injury are some examples to address the family and social consequences of injury.

Resource facilitation is an effective service that provides support to persons with TBI who are reintegrating back into their community, work or school, as well as addressing family needs. There has been promising results from studies that have explored resource facilitation among persons with TBI.19,20 In addition, several state brain injury organizations have either already implemented RF services or are pursuing legislation to support its implementation at the state level. More coordinated efforts are needed to explore the implementation of programs and services to improve family functioning, as well as work and school outcomes.

Community Influences At the health system level, significant disparities in access to rehabilitation are evident, particularly for children and adolescents with limited English proficiency and Medicaid, and older Black and Hispanic adults.21 These groups face barriers in the availability and proximity of rehabilitation services. In addition, in areas where Hispanics made up a majority of the population, they were still less likely to be discharged to rehabilitation and nursing facilities,22 but it is possible that these findings are driven by patient and family preferences to be home versus institutionalized. More work is needed to explore the availability of services beyond inpatient rehabilitation, such as access to emergency departments, acute hospitals, nursing homes, and outpatient services. Future studies should take into account the number of providers in the community as a factor that can affect the health of persons with TBI, particularly providers who are as diverse as the populations that they serve.

At the behavioral and physical environmental domain of influence, community integration and neighborhood environmental factors (e.g., crime, poverty, housing) influence health disparities following TBI.23,24 Several strategies have been suggested by service users with TBI and housing service providers,25 which include service coordination and forming partnerships, as well as engaging in social activities and designing home and neighborhood environments. Changes at the neighborhood level would require improved coordination of services, developing policies to improve access and safety, and providing community efforts to connect persons with TBI and their families to needed services.

Societal Influences Although the different state and federal laws, particularly in the US, are beyond the scope of this article, it must be acknowledged how existing laws and policies influence the behaviors of patients, families, clinicians, organizations, institutions, payers, and governments. In the US, most states currently have Medicaid Homeand Community-Based Services (HCBS) waivers to provide care and services to persons with disabilities and older adults, but only about half of them include TBI specific services. There is significant variability in how states provide HCBS waiver services to persons with brain injury, which may include a variety of services such as cognitive rehabilitation, supportive employment, care management, durable medical equipment, and rehabilitative/therapy services, among others. As one can imagine, there are numerous opportunities where such practices can further create inequities to care and disparities in health outcomes.

Furthermore, structural racism or discrimination can influence health by contributing to psychosocial stress and trauma, and poor access to health and social resources can impact the health, environment, and opportunities of individuals, families and communities.26 Although many have incorporated racism or discrimination in the interpretation of their TBI-related studies, many have not directly examined its role in disparities in health outcomes.27 In a recent study, discrimination was associated with vascular burden, particularly among Black individuals with TBI compared to those who identified as White.28 More work is needed to explore structural factors that impact health and well-being among persons with TBI. In addition, advocacy efforts are needed to create new policies to increase access and better health outcomes for all with TBI.

BRAIN INJURY professional 27

Clinicians and researchers must be committed to evaluating and addressing health disparities following TBI.

In addition, advocacy efforts are needed to create new policies to increase access and better health outcomes for all with TBI.

Call to Action A powerful tool in combating health disparities in brain injury is targeted outreach. This can be conducted by focusing efforts on centers frequently utilized by underserved populations, such as community health centers, clinics or health fairs. An approach that has been implemented in community clinics to lower disparities are health advocates, who are tasked with surveying patients on their SDoH, assessing their needs, and equipping them with resources, if desired, to mitigate those needs to improve their health holistically.

This method can be applied to the field of brain injury as well.

Interventions should be implemented at the individual level of need. For example, if a patient’s need was overlooked, involve their primary care physician in referring the appropriate practitioner.

If interruptions with employment were a concern, then equip them with the knowledge and assistance in applying for workers’ compensation. If rehabilitation is not covered by insurance, assist the patient in appealing for the care to be covered. If the patient lacks insurance or the means to pay for desired rehabilitation, aid them in applying for Medicaid or finding a practitioner that accepts payment on a sliding scale. There is an emergence of no-cost or low-cost health clinics run by medical and rehabilitation students to address the needs of socioeconomically disadvantaged populations with disabilities, and this model should be expanded to reach groups who might otherwise not receive rehabilitation or medical services.

Clinicians and researchers must be committed to evaluating and addressing health disparities following TBI. We must acknowledge and work towards addressing our own biases, both conscious and unconscious, that may play a role in how we interact with patients and their family members, provide care, evaluate health and health outcomes, and develop interventions and programs to address the health, social, and environmental needs of patients with TBI. We also have to do better with supporting and training caregivers and family members to improve outcomes for not only the person with TBI but the functioning of the entire family and its members.

At the community level, we need to advocate for more community resources, increase the availability of health care services, evaluate environmental factors influencing health and outcomes, and work towards improving the health of communities impacted by TBI. Forming partnerships with community-based organizations and advocating for more funding to support home and communitybased services is one of many possible solutions. Furthermore, we must acknowledge and address the systemic factors, such as systemic racism, diversity within the workforce, current local, state, and federal healthcare laws, barriers to access to healthcare and services across the continuum of care, and the quality of care received, that may impact populations with TBI and their families.

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There is significant work left to do with incorporating SDoH into clinical practice and research, examining health disparities after injury, developing treatments and programs to ameliorate health disparities, and advocating for institutional and systemic change to improve health care access, delivery, and quality of care for persons with TBI and their families, especially among groups who have been historically disadvantaged and often denied quality health care and rehabilitation.

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Brown JB, Kheng M, Carney NA, Rubiano AM, Puyana JC. Geographical Disparity and Traumatic Brain Injury in America: Rural Areas Suffer Poorer Outcomes. J Neurosci Rural Pract. 2019;10(1):10-15.

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Flores LE, Verduzco-Gutierrez M, Molinares D, Silver JK. Disparities in Health Care for Hispanic Patients in Physical Medicine and Rehabilitation in the United States: A Narrative Review. Am J Phys Med Rehabil. 2020;99(4):338-347.

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Gorman E, Frangos S, DiMaggio C, et al. Is trauma center designation associated with disparities in discharge to rehabilitation centers among elderly patients with Traumatic Brain Injury? Am J Surg.

2020;219(4):587-591.

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Mollayeva T, Mollayeva S, Colantonio A. Traumatic brain injury: sex, gender and intersecting vulnerabilities. Nat Rev Neurol. 2018;14(12):711-722.

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Moore M, Conrick KM, Fuentes M, et al. Research on Injury Disparities: A Scoping Review. Health Equity. 2019;3(1):504-511.

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Odonkor CA, Esparza R, Flores LE, et al. Disparities in Health Care for Black Patients in Physical Medicine and Rehabilitation in the United States: A Narrative Review. PM R. 2021;13(2):180-203.

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Bilge S, Collins PH. Intersectionality. Cambridge, UK: Polity. 2016.

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Lin JS, Hoffman L, Bean SI, et al. Addressing Racism in Preventive Services: Methods Report to Support the US Preventive Services Task Force. JAMA. 2021;326(23):2412-2420.

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Control CfD, Prevention. Community health and program services (CHAPS): health disparities among racial/ethnic populations. Atlanta, GA: US Department of Health and Human Services. 2008.

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Alvidrez J, Castille D, Laude-Sharp M, Rosario A, Tabor D. The national institute on minority health and health disparities research framework. American Journal of Public Health. 2019;109(S1):S16-S20.

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Lequerica AH, Sander AM, Pappadis MR, et al. The association between payer source and traumatic brain injury rehabilitation outcomes: a TBI Model Systems study. The Journal of Head Trauma Rehabilitation. 2022:10.1097.

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Driver S, Juengst S, Reynolds M, et al. Healthy lifestyle after traumatic brain injury: a brief narrative.

Brain Inj. 2019;33(10):1299-1307.

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Yuen KCJ, Masel BE, Reifschneider KL, Sheffield-Moore M, Urban RJ, Pyles RB. Alterations of the GH/IGF-I Axis and Gut Microbiome after Traumatic Brain Injury: A New Clinical Syndrome? J Clin Endocrinol Metab. 2020;105(9).

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Pappadis MR, Sander AM, Struchen MA, Kurtz DM. Soy diferente: a qualitative study on the perceptions of recovery following traumatic brain injury among Spanish-speaking U.S. immigrants.

Disabil Rehabil. 2020:1-10.

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Arango-Lasprilla JC. Traumatic brain injury in Spanish-speaking individuals: research findings and clinical implications. Brain Inj. 2012;26(6):801-804.

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Sodders MD, Killien EY, Stansbury LG, Vavilala MS, Moore M. Race/Ethnicity and Informal Caregiver Burden After Traumatic Brain Injury: A Scoping Study. Health Equity. 2020;4(1):304-315.

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Baker A, Barker S, Sampson A, Martin C. Caregiver outcomes and interventions: a systematic scoping review of the traumatic brain injury and spinal cord injury literature. Clinical Rehabilitation.

2017;31(1):45-60.

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Gordon WA, Cantor J, Tsaousides T. Long-term social integration and community support. Handbook of Clinical Neurology. 2015;127:423-431.

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Trexler LE, Parrott D. The impact of resource facilitation on recidivism for individuals with traumatic brain injury: A pilot, non-randomized controlled study. Brain Inj. 2022:1-8.

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Trexler LE, Parrott DR, Malec JF. Replication of a Prospective Randomized Controlled Trial of Resource Facilitation to Improve Return to Work and School After Brain Injury. Arch Phys Med Rehabil.

2016;97(2):204-210.

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Moore M, Jimenez N, Rowhani-Rahbar A, et al. Availability of Outpatient Rehabilitation Services for Children After Traumatic Brain Injury: Differences by Language and Insurance Status. Am J Phys Med Rehabil. 2016;95(3):204-213.

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Budnick HC, Tyroch AH, Milan SA. Ethnic disparities in traumatic brain injury care referral in a Hispanic-majority population. J Surg Res. 2017;215:231-238.

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Sander AM, Pappadis MR, Clark AN, Struchen MA. Perceptions of community integration in an ethnically diverse sample. J Head Trauma Rehabil. 2011;26(2):158-169.

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Pappadis MR, Sander AM, Leung P, Struchen MA. The impact of perceived environmental barriers on community integration in persons with traumatic brain injury. Acta Neuropsychologica.

2012;10(3):385-397.

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25.

Estrella MJ, Kirsh B, Kontos P, et al. Critical Characteristics of Housing and Housing Supports for Individuals with Concurrent Traumatic Brain Injury and Mental Health and/or Substance Use Challenges: A Qualitative Study. Int J Environ Res Public Health. 2021;18(22).

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Omar S, Nixon S, Colantonio A. Integrated Care Pathways for Black Persons With Traumatic Brain Injury: A Critical Transdisciplinary Scoping Review of the Clinical Care Journey. Trauma Violence Abuse. 2021:15248380211062221.

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Davis BA. Discrimination: a social determinant of health inequities. Health Affairs Blog. 2020.

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Bernier RA, Venkatesan UM, Soto JA, Rabinowitz AR, Hong JS, Hillary FG. Perceived discrimination and blood pressure in individuals aging with traumatic brain injury. Rehabil Psychol. 2021;66(2):148-159.

Author Bios Monique R. Pappadis, PhD, MEd, is an Assistant Professor of the Department of Nutrition, Metabolism, and Rehabilitation Sciences at the University of Texas Medical Branch at Galveston (UTMB) and an Investigator at the TIRR Memorial Hermann’s Brain Injury Research Center. Since 2004, Dr. Pappadis has conducted patient-centered outcomes research in stroke and traumatic brain injury. She has won several research awards, published over 40 peer-reviewed publications, and disseminated several educational materials for persons with TBI and their caregivers. Her current research includes elder mistreatment, health literacy, minority aging, and equity/disparities in care and outcomes among older adults with TBI. Chinedu K. Onwudebe, MS, is a rising 3rd year medical student at the University of Texas Medical Branch at Galveston (UTMB). He previously earned a bachelor’s degree in Biology with a minor in African Diaspora Studies at the University of Texas at Austin as well as a master’s degree in Biology with a certificate in Biomedical Sciences at the University of Houston. He currently serves as the Vice-Chair of the National Finance Committee of the Student National Medical Association (SNMA) and plans to pursue a career in physiatry and research. His interests include promoting health equity in minority and underserved populations, traumatic brain injury, and health outcomes in the incarcerated population.

Anthony H. Lequerica, PhD, is a Senior Research Scientist at Kessler Foundation’s Center for TBI Research and a Research Associate Professor at Rutgers – New Jersey Medical School in the Department of Physical Medicine and Rehabilitation. As Director of the Brain and Behavioral Outcomes Lab, his research focuses on cultural and sociodemographic factors affecting brain injury rehabilitation outcomes. He is Co-Chair of the Inclusion, Diversity, Equity, and Accessibility Special Interest Group within the Traumatic Brain Injury Model Systems sponsored by the National Institute on Disability, Independent Living, and Rehabilitation Research. He is a Staff Neuropsychologist at Kessler Institute for Rehabilitation where he provides neuropsychological services to Spanishspeakers with a variety of neurological conditions. He has over 50 peer-reviewed publications and has given numerous presentations across the U.S. and abroad to researchers, health care professionals, and individuals with brain injury and their families.

Angelle M. Sander, PhD, FACRM, is Professor in the H. Ben Taub Department of Physical Medicine and Rehabilitation at Baylor College of Medicine and Director of TIRR Memorial Hermann’s Brain Injury Research Center. She is Project Co-Director for the Texas Traumatic Brain Injury Model Systems at TIRR. She has been PI or Co-Investigator on federally funded studies addressing prediction and treatment of cognitive, emotional, and psychosocial problems in persons with TBI, intimacy and sexuality after TBI, impact of TBI on caregivers, and cultural disparities in outcomes following TBI. She co-chairs the TBI Model System Special Interest Group on Inclusion, Diversity, Equity, and Accessibility. She has over 120 peer-reviewed publications, numerous book chapters and published abstracts, and multiple consumer-oriented dissemination products, including fact sheets, educational manuals, webcasts, and videos.

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Conference Thank you Program supporters!

The International Paediatric Brain Injury Society and the North American Brain Injury Society would like to acknowledge the following supporters of the Joint Conference on Brain Injury which takes place in New York City at the Wyndham New Yorker.

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PHOTO BY HERMAN PRIVETTE

Madison Schwartz, Stanford Law, Randall H. Scarlett, Randall A. Scarlett, Ronnie Pang, Olga Rios, Mary Anne Scarlett, and Brendan D. Nay.

SCARLETT LAW GROUP Scarlett Law Group is a premier California personal injury law firm that in two decades has become one of the state’s go-to practices for large-scale personal injury and wrongful death cases, particularly those involving traumatic brain injuries.

With his experienced team of attorneys and support staff, founder Randall Scarlett has built a highly selective plaintiffs’ firm that is dedicated to improving the quality of life of its injured clients. “I live to assist people who have sustained traumatic brain injury or other catastrophic harms,” Scarlett says. “There is simply no greater calling than being able to work in a field where you can help people obtain the treatment they so desperately need.”

To that end, Scarlett and his firm strive to achieve maximum recovery for their clients, while also providing them with the best medical experts available. “As a firm, we ensure that our clients receive both

the litigation support they need and the cutting-edge medical treatments that can help them regain independence,” Scarlett notes.

Scarlett’s record-setting verdicts for clients with traumatic brain injuries include $10.6 million for a 31-year-old man, $49 million for a 23-year-old man, $26 million for a 7-year-old, and $22.8 million for a 52-year-old woman. In addition, his firm regularly obtains eight-figure verdicts for clients who have endured spinal cord injuries, automobile accidents, big rig trucking accidents, birth injuries, and wrongful death.

Most recently, Scarlett secured an $18.6 million consolidated case jury verdict in February 2014 on behalf of the family of a woman who died as a result of the negligence of a trucking company and the dangerous condition of a roadway in Monterey, Calif. The jury awarded $9.4 million to Scarlett’s clients, which ranks as

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one of the highest wrongful death verdicts rendered in recent years in the Monterey County Superior Court.

“Having successfully tried and resolved cases for decades, we’re prepared and willing to take cases to trial when offers of settlement are inadequate, and I think that’s ultimately what sets us apart from many other personal injury law firms,” observes Scarlett, who is a Diplomate of the American Board of Professional Liability Attorneys.

In 2015, Mr. Scarlett obtained a $13 million jury verdict for the family of a one year old baby who suffered permanent injuries when a North Carolina Hospital failed to diagnose and properly treat bacterial meningitis that left the child with severe neurological damage. Then, just a month later, Scarlett secured an $11 million settlement for a 28-year-old Iraq War veteran who was struck by a vehicle in a crosswalk, rendering her brain damaged.