Improvements in emergency services and advances in medical management over the last few decades have resulted in an increase in the number of individuals who survive a traumatic brain injury. During this same time, minority populations in the United States, who are at higher risk for sustaining a TBI than whites, have grown dramatically. Social scientists predict that minorities may constitute up to 45% of the country's total population by the year 2050.1 Consequently, more minority TBI survivors will likely be in need of culturally appropriate rehabilitation services to facilitate their postinjury transition and adjustment related to family, social activities, work, and community.
Over the past decade, medical and rehabilitation research has documented a range of ethnicity-related disparities in such aspects of rehabilitation care as length of wait time to see a physician, number of referrals for services, number of therapy hours received, and functional outcomes attained. In addition, minority individuals with TBI are known to have lower levels of community integration, higher levels of disability, and are less likely to return to work.2-4 Despite important advancements in the understanding of the diagnosis and rehabilitation of TBI in the past two decades, literature on the specific issues facing minority TBI survivors is surprisingly sparse. In this special issue we hope to provide information and guidance to rehabilitation professionals with two aims. Our goal is to increase providers' understanding of cultural issues that uniquely influence the brain injury recovery process of individuals with TBI from various race/ethnic backgrounds and their family members.
In the service of these objectives, this special issue brings together a series of original research studies and clinical reports to provide a comprehensive insight into several issues related to diverse TBI populations. In addition, articles in this issue provide an understanding of the unique needs and challenges of minority TBI survivors and their caregivers within the United States (eg, Native American Indians, Hispanics, and African Americans), as well as culturally and linguistically diverse individuals living in Australia.
In the first article, Niemeier and Arango-Lasprilla provide an overview of the rehabilitation, medical, and psychological scientific literature related to cultural issues and realities facing ethnically diverse TBI survivors. In addition, governmental and professional organizational mandates and guidelines for dealing with racial disparities in healthcare are presented. Research is translated into action in this article-rehabilitation professionals receive practical recommendations for their interactions with a culturally diverse patient population. This article provides an outline of a plan for providers interested in improving the cultural competence of their practices.
In the subsequent article, Cardoso and colleagues report that white American TBI survivors were 1.27 times more likely than Hispanic American survivors to obtain competitive employment after receiving vocational rehabilitation services. Hispanic American survivors had more unmet basic needs and less on-the-job supports compared to their white counterparts, even though job placement-related services such as on-the-job support predicted higher competitive employment rates in both groups. In the third article, Wehman and colleagues provide a literature review of return-to-work and return-to-school information about minority TBI survivors. Three case studies are reported in this article that illustrate the effectiveness of individualization of services for improving the chances that minority survivors will achieve positive employment and educational outcomes, even following severe TBI.
Nelson and colleagues report lifetime TBI prevalence rates of 22% to 26% for males and 8% to 15% in females in two Native American Indian communities, rates that are much higher than those reported for the white population. The authors also report associated neuropsychiatric problems in these populations.
In another article, Marquez and colleagues present findings that Hispanics with TBI in the United States had higher disability rates than white TBI survivors. The authors report that English-language proficiency was a predictor of severe disability.
Hart and colleagues focus on cultural issues of the caregivers of minority TBI survivors. African American caregivers of African American TBI survivors (who were more disabled than white TBI survivors and required more caregiving) reported more depressive symptoms than white caregivers of white TBI survivors. When functional status, as reported by the Disability Rating Scale score, was entered as a covariate, the differences in depressive symptoms were no longer significant between races. Unfortunately, the African American caregivers were also less likely to use professional emotional support services (eg, treatment from a counselor, psychiatrist, or psychologist).
In the final article, Saltapidas and Ponsford study TBI survivors of English-speaking, native-born Australians and of culturally and linguistically diverse (CALD) backgrounds. Despite similar positive attitudes toward rehabilitation and equal rates of attendance in available rehabilitation sessions, CALD survivors had greater distress about changes in ability to perform certain life roles (eg, as parent and homemaker), had less cognitive independence, had less mobility, were less socially integrated, and were less likely to be employed.
The articles in this special issue highlight the disparities that exist for members of minority groups in terms of poorer functional outcomes (eg, distress about changes in ability to perform certain life roles, cognitive independence, mobility, social integration), more severe disability, and reduced likelihood of return to work (eg, postinjury employment status, basic needs, and on-the-job support). One study shows that language proficiency is a significant predictor of severe disability and may mediate functional outcomes in a subgroup of nonnative English-speaking TBI survivors. Cultural issues may also affect time spent caring for a TBI survivor and utilization of professional emotional support services. Individualized rehabilitation plans designed to meet the specialized needs and goals of each TBI survivor appears to be a viable solution that warrants further scientific study and cost-benefit analysis.
Studies of underrepresented populations, such as Hispanics and Native American Indians, should serve to remind researchers, rehabilitation professionals, and policy makers that findings in white populations cannot be assumed to be generalizable across all survivor groups independent of cultural factors. As we move forward in providing 21st-century rehabilitation care, and recognize the disparities that exist among the diverse populations of TBI survivors, cultural awareness and sensitivity to individual differences are no longer wants, they are necessities. This special issue was intended to offer a window into the cultural issues affecting minority TBI survivors and their caregivers and a plan for improving relevance and quality of services for this patient population. It is our hope that the articles presented here have opened the door to further research with these populations, as well as additional research on the causes of these disparities. More important, we look forward to new proposals of innovative, feasible options for culturally competent rehabilitation-solutions that equalize outcomes after TBI and improve quality of life for survivors and their families.
REFERENCES