Racial and Ethnic Disparities in Employment Outcomes after TBI

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.

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.

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. 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.

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.

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.

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.

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 .

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

Despite 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. 2019 • 985 pages • ISBN 978-1-61537-112-9 • Hardcover • $195.00 • Item #37112 2019 • 985 pages • ISBN 978-1-61537-247-8 • eBook • $156.00 • Item #37247

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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.