Health Disparities within Rehabilitation Outcomes: A Theoretical Framework and Application

Abstract

In America 5.3 million men, women, and children are living with the often devastating and permanent long-term Traumatic Brain Injury-related disabilities. TBIs require thousands of dollars in resources for immediate and often long-term and intermittent rehabilitation to address deficits related to physical and cognitive impairments. This dissertation explores human development interrupted by TBI and evaluates how contextual factors that may impact rehabilitation outcomes above and beyond premorbid status, injury type, and severity. Study 1 consists of a theory adaptation that establishes a new foundational theory that explains rehabilitation outcomes and provides a model against which to test lower order needs of mental health and neighborhood effects, called the Hierarchy of Elevated Rehabilitation Outcomes (HERO). The HERO model consists of a five-level hierarchy: Mental Health; Neighborhood effects; Religion, Culture, and Social Support; Self-Efficacy; and Health Locus of Control. Each level was analyzed to define components and provide a rationale for inclusion. The application of this model was demonstrated via the use of a medical case study. Study 2 was designed to test components of the first two levels of the HERO model to identify model interactions. Measures of depression (Level 1) and neighborhood disadvantage (Level 2) were selected from the HERO framework. Using secondary data from the Traumatic Brain Injury Model Systems (TBIMS) dataset, the sample consisted of Alabama residents, 63% male, 62.5% European Americans, and 21.5% African American, with an an average age of 39.76 (SD = 36.96). Study 2 consisted of the following study aims: 1) To determine if TBI survivors’ residing in disadvantaged neighborhoods experienced lower levels of function as measured by Functional Independence Measures (FIMS) scores over time; 2) To determine if the presence of depression in TBI survivors explained the relationship between neighborhood disadvantage and FIMS scores over time; and, 3) To determine if race has a moderating effect on the relationship between neighborhood disadvantage and depression. The findings indicated no significant main effects of neighborhood disadvantage on FIM scores, no indirect effects of neighborhood disadvantage on FIM scores via depression, and no moderating effects of race. Further research testing various interactions of specific individual contextual factors may better reflect the unique human experiences and factors above and beyond injury type, medical profiles, and treatment modalities. Continued examination of neighborhood context as a predictive factor will be an important next step in fully understanding patient outcomes.