Monique R. Pappadis

What Is Community Integration Anyway?: Defining Meaning Following Traumatic Brain Injury

Full community integration, or participation in society, is the ultimate goal of rehabilitation and of research conducted in the field of rehabilitation for persons with traumatic brain injury (TBI). Community integration has been traditionally defined by 3 main areas: employment or other productive activity, independent living, and social activity. However, these have not always received equal weighting and attention in clinical or research efforts. Significant gaps remain in our understanding of factors that impact community integration and in our ability to intervene to improve participation for persons with TBI. This article describes 3 main challenges for researchers and rehabilitation professionals. First, a comprehensive meaning of community integration is needed, which includes the viewpoints and preferences of persons with TBI. Second, cultural competence in measurement and intervention is needed. Third, a thorough assessment of environmental factors impacting participation is needed and should be incorporated into research and treatment planning.

Examining the contribution of social communication abilities and affective/behavioral functioning to social integration outcomes for adults with traumatic brain injury

Objective:To evaluate the contribution of social communication abilities and affective/behavioral functioning to socialintegration outcomes for persons with traumatic brain injury (TBI). Design:Prospective cohort study. Participants:A total of 184 adults with TBI (72.8% men) evaluated at least 6 months postdischarge from acute care orinpatient rehabilitation hospitals and after living at least 3 months in the community postdischarge (Mean = 7.84 monthspostinjury). Measures:La Trobe Communication Questionnaire (LCQ), Assessment of Interpersonal Problem-Solving Skills(AIPSS), Affective Behavioral subscale From the Problem Checklist of the Head Injury Family Interview (AB-HIFI), Craig HandicapAssessment and Reporting Technique–Short Form Social Integration subscale (CHART-SF-SI), Community Integration QuestionnaireSocial Integration subscale (CIQ-SI). Results:Social communication measures (LCQ, AIPSS) and self-reported behavioralfunctioning (AB-HIFI) contributed significantly to concurrently measured social integration outcomes after controlling for demographicand injury-related variables. Separate hierarchical multiple regression analyses revealed that social communication and behavioralvariables accounted for 11.3% of variance in CIQ-SI and 16.3% of variance in CHART-SF-SI. Conclusions:Social communication abilities and affective/behavioral functioning make a substantial contribution to social integration outcomes after TBI. The implications of such evidence for clinical assessment and intervention are discussed.

Relationship of race/ethnicity and income to community integration following traumatic brain injury: investigation in a non-rehabilitation trauma sample.

The purpose of the current study was to determine the contribution of race/ethnicity and income to community integration at approximately 6 months following traumatic brain injury (TBI). Participants were 151 persons with mild to severe TBI (38% Black; 38% Hispanic; 24% White) recruited from consecutive admissions to the Neurosurgery service of a county Level I trauma center. A large number of participants had low income and low education. Community integration was assessed using the Community Integration Questionnaire (CIQ), Craig Handicap Assessment and Reporting Technique - Short Form (CHART-SF), and Community Integration Measure (CIM). Results of analysis of covariance (ANCOVA) indicated that, after accounting for injury severity, age, education, and income, race/ethnicity contributed significantly to the variance in CIQ Total score, Home Integration Scale, and Productive Activity Scale scores. Blacks had lower CIQ Total scores compared to Whites. Black and Hispanic participants had lower scores than Whites on the Home Integration Scale, and Blacks had lower scores than Whites and Hispanics on the CIQ Productive Activity Scale. Low income ( < or =

Sexual functioning 1 year after traumatic brain injury: Findings from a prospective traumatic brain injury model systems collaborative study

20,000) was related to lower scores on the CIQ and CHART-SF Social Integration Scales, and scores on the CIM Total, Belonging, and Independent Participation scales. These results indicate that racial/ethnic differences in community integration exist, even after accounting for income. However, income was more predictive than race/ethnicity for certain aspects of community integration, indicating that it should be accounted for in all studies investigating racial/ethnic differences in outcomes.

Perceptions of communication abilities for persons with traumatic brain injury: Validity of the La Trobe Communication Questionnaire

OBJECTIVE To investigate the incidence and types of sexual difficulties in men and women with traumatic brain injury (TBI) 1 year after injury, as well as their comfort level in discussing problems with health care professionals. DESIGN Prospective cohort study. SETTING Community. PARTICIPANTS Persons with TBI (N=223; 165 men and 58 women) who had been treated at 1 of 6 participating TBI Model Systems inpatient rehabilitation units and were living in the community. INTERVENTIONS None. MAIN OUTCOME MEASURES Derogatis Interview for Sexual Functioning-self-report (DISF-SR); Global Sexual Satisfaction Index (GSSI); structured interview regarding changes in sexual functioning; and comfort level discussing sexuality with health care professionals. RESULTS Women with TBI scored significantly below the normative sample for all subscales of the DISF-SR, including sexual cognition/fantasy, arousal, sexual behavior/experience, and orgasm. Men scored significantly below the normative sample on all scales except arousal. Women reported greater dysfunction than men for sexual cognition/fantasy and arousal. Twenty-nine percent of participants reported dissatisfaction with sexual functioning on the GSSI, with a greater percentage of men reporting dissatisfaction. Sixty-eight percent of participants indicated that they would spontaneously raise issues of sexual difficulties with health care professionals, while the remainder would either bring it up only if directly asked or would not discuss it at all. CONCLUSIONS Sexual difficulties were present in a substantial portion of community-dwelling people with TBI at 1 year after injury. Educational interventions to increase awareness among people with TBI and rehabilitation professionals are warranted, as well as interventions to improve sexual functioning.

Common misconceptions about traumatic brain injury among ethnic minorities with TBI

Primary objective: To further evaluate the construct validity of the La Trobe Communication Questionnaire (LCQ) and to investigate the extent to which self-ratings of adults with traumatic brain injury compared to ratings made by close others and self-ratings made by non-injured matched controls. Research design: Prospective cohort study. Methods and procedures: Two hundred and seventy-six adults with TBI (121 of which are >1-year post-injury and previously enrolled in TBI Model Systems and 155 of which were consecutively admitted to a Level 1 trauma centre and were at least 6-months post-injury) completed the La Trobe Communication Questionnaire. In addition, for the TBI Model systems sample, 88 friends/family members and 80 non-injured matched controls participated. Main outcomes and results: Principle components analysis with varimax rotation yielded four factors: Initiation/Conversational Flow, Disinhibition/Impulsivity, Conversational Effectiveness and Partner Sensitivity, which were found to have adequate internal consistency. Adequate discriminative validity was obtained in comparing adults with TBI to non-injured matched controls, while no significant differences were found between self-ratings of communication abilities by adults with TBI and those made by close others. Conclusions: Additional support for the LCQ as a useful measure of perceived social communication abilities was obtained. Confirmatory factor analysis with a larger sample of adults with TBI will be a useful step in further development of this tool.

Predictors of sexual functioning and satisfaction 1 year following traumatic brain injury: A TBI model systems multicenter study

Objective:To investigate common TBI misconceptions among ethnic minorities with TBI. Design:Cross-sectional study. Setting:Level I trauma center. Participants:Fifty-eight persons with TBI (28 black and 30 Hispanic) discharged from the neurosurgery unit and living in the community. Main Measure:Forty-item Common Misconceptions about Traumatic Brain Injury Questionnaire (CM-TBI). Results:Participants displayed misconceptions about approximately one-third of the 40 items, most regarding amnesia and recovery. Fewer misconceptions were found in the brain damage/injury and sequelae categories. A greater percentage of TBI misconceptions was associated with having lower education, actively practicing religion, being Spanish-speaking and non-US born. After controlling for education and actively practicing religion, Spanish-speaking Hispanics reported a greater percentage of misconceptions than English-speaking Hispanics and blacks. Conclusions and Implications:Understanding common TBI misconceptions can assist rehabilitation staff in tailoring education programs for racial/ethnic minorities including those who are Spanish-speaking. Educational attainment and cultural factors should be considered when developing educational interventions for persons with TBI from diverse backgrounds. Inaccurate information regarding TBI, especially the recovery process, may hinder treatment planning by rehabilitation professionals and may result in disappointment and the setting of unrealistic goals for persons with injury and their families.

The Community Integration Questionnaire: factor structure across racial/ethnic groups in persons with traumatic brain injury.

Objective:To investigate predictors of sexual functioning 1 year following traumatic brain injury (TBI). Design:Prospective cohort study. Setting:Community. Participants:A total of 255 persons with TBI (187 males; 68 females) who had been treated at 1 of 6 TBI Model Systems inpatient rehabilitation units and were living in the community. Main Measures:Derogatis Interview for Sexual Functioning-Self-Report (DISF-SR); Global Satisfaction With Sexual Functioning (Global Sexual Satisfaction Index); Participation Assessment With Recombined Tools-Objective; Patient Health Questionnaire-9. Results:Older age, female gender, and more severe injury were associated with greater sexual dysfunction 1 year following injury. As age increased from 24 to 49 years, the odds of sexual impairment increased more than 3-fold (95% confidence interval: 1.82-5.88). Females had a 2.5 increase in odds of sexual impairment compared with males (95% confidence interval: 1.23–5.26). Greater social participation was predictive of better sexual functioning. Dissatisfaction with sexual functioning was predicted by older age and depression. Conclusions and Implications:Older persons and females appear to be at greater risk for sexual dysfunction after TBI and may benefit from specialized assessment and treatment services. Relationships were identified between social participation and sexual function and between depression and sexual satisfaction that may serve as clinical indicators for further assessment and intervention. Further research is needed to elucidate these relationships and identify effective clinical approaches.

Perceptions of community integration in an ethnically diverse sample.

Objective:To examine the factor structure and construct validity of the Community Integration Questionnaire, a widely used measure of community participation among individuals with traumatic brain injury (TBI), among 3 racial/ethnic groups. Design:Prospective longitudinal cohort study. Setting:Enrollment in acute inpatient TBI rehabilitation with follow-up at 1 year after injury. Participants:A total of 1756 persons with TBI enrolled in the Traumatic Brain Injury Model Systems (TBIMS) national Database. Main Outcome Measure:Community Integration Questionnaire at 1 year after injury. Results:The goodness of fit for the factor structure of the Community Integration Questionnaire, separating items into Home Competency, Social Integration, and Productive Activity, was satisfactory for whites but not for blacks or Hispanics. Conclusions:Clinicians and researchers should take race/ethnicity into account when utilizing measures of community integration.

Sexual Functioning, Desire, and Satisfaction in Women with TBI and Healthy Controls

Objective:To investigate the meaning of community integration in an ethnically diverse sample. Design:Prospective study using mixed qualitative and quantitative methods. Setting:County level I trauma center. Participants:Fifty-eight blacks, 57 Hispanics, and 52 whites with traumatic brain injury living in the community 6 months postinjury. Main Measures:Open-ended interview questions and a questionnaire assessing perceived importance of community integration activities. Results:Resulting themes indicated that feeling part of the community was related to type and quality of community relationships, perceived safety and security, active involvement, feeling included and respected, and familiarity with the community. Themes regarding barriers included the following: environmental and social barriers; injury-related cognitive and physical changes; dissimilarities to others; relocation; and financial issues. Blacks and Hispanics placed more emphasis on domestic activities than did whites. Conclusions and Implications:Feeling integrated into the community relates to aspects of the environment as much as to involvement in specific activities. Environmental barriers can be just as important as injury-related changes. Different racial/ethnic groups place different value on participation activities. The results emphasize the importance of assessing subjective aspects of community integration, individualizing rehabilitation goals, and intervening in the environment to facilitate participation.