Synthesis of learning through MHST 601

Through the last several months, we have examined the health issue of Acquired and Traumatic Brain Injury (ABI/TBI) and how it fits into the landscape of the Canadian Healthcare System. We covered the Social Determinants of Health, the Social Ecological Model, individual and population health, marginalized populations, chronic disease management, and the future of health care in Canada. This blog post will synthesize the learning that has occurred through the course.

To give a brief overview, acquired brain injury is the leading cause of death and disability for Canadians under the age of 40. indigenous populations are disproportionately affected by traumatic brain injury, with rates four times higher than in the rest of Canada. The homeless population of Canada is also over-represented, with one in two (53%) homeless people experiencing a TBI and one in four (25%) experiencing a TBI that is moderate or severe traumatic brain injury (Statistics - Brain Injury Canada, 2023). Brain Injury Canada estimates by 2031, TBI is expected to be among the most common neurological conditions affecting Canadians, along with Alzheimer’s disease and other dementias and epilepsy (2023). There is growing awareness about Acquired/Traumatic Brain Injury (ABI/TBI). Still, there is limited information about population-level patterns of ABI/TBI Care due to the heterogeneity of this population. The TBI population is a heterogeneous group, given the wide range of potential etiology’s of TBI. Motor vehicle accidents, traumas, falls, sports-related injuries, and domestic violence are some of the more common etiology’s of TBI.(Johnson & Diaz, 2023)

We know that one’s SDoH can impact TBI incidence, recovery and outcome. Social Determinants of Health (SDoH) are defined by the World Health Organization as the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life. (2023) SDoH can be seen as Unmodifiable (I.e., Race, age) or modifiable (i.e., Education, geographic location). We must consider that modifiable factors may be challenging to change for some. After an injury, some survivor's level of independent functioning will change, and as new medical care develops, individuals with significant injuries have an increased rate of survival. “Many survivors live with significant disabilities, possibly contributing to socio-economic burden.” (Johnson & Diaz, 2023). We learned in Unit 3 that the SDoH of geographic location can positively or negatively influence an individual’s recovery. In the instance of rural communities, there is a greater risk of obtaining an ABI/TBI (Donald Berwick, et al., 2022) yet there is limited access to specialized trauma care. Brown et al. evaluated differences in TBI mortality across urban and rural areas in the United States and found that the TBI fatality rate was 13 deaths per 100,000 persons higher in the most rural compared with the most urban (2019) Individuals

The Institute of Medicine defines the Social Ecological Model as "A model of health that emphasizes the linkages and relationships among multiple factors (or determinants) affecting health." (2003). If you would like to read in further detail please review a previous blog post. Applying the SEM model to TBI/ABI highlights the interplay of physical, psychological, and socio-economic factors, stressing the need for further research and policies to enhance health equality in TBI care. In this unit, we applied the SEM model to TBI care, and it was discovered that the rehabilitation pathway varies widely, with the SDoH playing a crucial role, either facilitating or hindering the journey toward optimal recovery. In Johnson & Diaz's research, it was determined that socio-economic status impacts an individual’s ability to receive follow-up care. (2023) and therefore moving them away from the optimal path to recovery. The inability to receive rehab and possibly return to employment can have devastating effects on individuals and families, both economic and psychosocial. Shames noted. If the post-injury status prevents the individual from returning to work, this can have profound consequences for the individual and family, both economic and psychosocial (2007). Economic hardship can increase the incidence of unstable housing and homelessness.

Recognizing the multiple spheres of influence on individual and population health, a holistic approach is necessary to reduce health inequalities. Given the heterogeneous nature of individuals with ABI, a comprehensive examination of an individual's SDoH, coupled with meticulous planning for health services and resource support, is vital for achieving public health goals, promoting access to care, and preventing health inequalities in the ABI/TBI population (Johnson & Diaz, 2023). Social Determinants of Health can compound to create health disparities and marginalized populations. There is a gap in healthcare and support services across the continuum of care for adults with ABI, and this is often exacerbated by one SDoH. Gary et al. found if a patient had belonged to one or more of the eight populations (racial and ethnic minority status, low education status, low English proficiency, abuse of substances, homelessness, psychiatric hospitalizations, psychiatric disorders, and incarceration history), they had a negative compounding effect of TBI severity, recovery and employment. (2023)

Multiple spheres of influence, such as social, political and economic, can affect an individual’s and a population's health. A positive relationship between the individual level and the population level policy can reduce health inequalities experienced by marginalized populations. On the individual level, moderate to severe ABIs most often require ongoing medical and rehabilitation due to lasting effects on the individual's physical, cognitive and emotional functioning. In Canada, individuals can access care for these acute stages of rehab, but the gap in care occurs when the individual returns to the community. Once an individual returns to the community, rehab services are largely dependent on insurance benefits. Johnson & Diaz found Insurance status significantly impacts trauma outcomes for TBI patients (2023). Furthermore, Insurance status is dependent on SDoH, such as socio-economic status and employment.  At the population level in Canada on June 2, 2022, the first reading of BILL C-277 was an act to establish a national strategy on brain injuries.  One of the strategies of note is to identify challenges resulting from brain injury, such as mental health problems, addiction, housing and homelessness issues and criminality, including intimate partner violence, and work to develop solutions in collaboration with stakeholders. (An Act to Establish a National Strategy on Brain Injuries, 2022) This strategy works to improve health outcomes at the population level.

In unit 6, we explored the vulnerable populations in Canada. A detailed blog post conducting a Comparative Analysis of Homeless Strategies in BC and AB can be found here.  Among the homeless population is an overrepresentation of individuals who have suffered an ABI/TBI. Research that’s been compiled by the Canadian Traumatic Brain Injury Research Consortium for Brain Injury Canada found that more than half of the unhoused have traumatic brain injuries, which is 14 times the rate in the general population. (Statistics - Brain Injury Canada, 2023) Johnson and Diaz call for an in-depth examination and clear understanding of an individual’s SDoH in conjunction with planning for health services and providing support to available resources, which is vital for better public health achievement, promoting access to care, and preventing health inequalities among the ABI/TBI population. (2023)

In Canada, Moderate to severe TBI is a leading cause of death and disability; however, TBI is yet to be labelled a chronic condition in Canada. The WHO defines chronic disease as having one or more of the following characteristics: permanence, non-reversible pathological alterations as the cause, requiring patient training for rehabilitation, and/or an extended period of observation, supervision, or care (World Health Organization, 2002). The cost incurred by the Canadian healthcare system is challenging to measure due to the lack of consistent reporting. Still, there are indirect costs associated with chronic TBI/ABI, such as loss of productivity, loss of employment, and disability. These indirect costs significantly impact the individual’s socio-economic status and the overall economy. Canadian studies have consistently found elevated rates of serious brain injury among people who are homeless or marginally housed (Johnson & Diaz, 2023). Brain Injury Canada and the Canadian Traumatic Brain Injury Research Consortium are requesting government officials of Canada to classify TBI/ABI as a chronic condition for the purpose of surveillance by the Canadian Chronic Disease Surveillance System. Reclassifying ABI/TBI from a single acute event to a chronic disease would prompt provinces to provide more long-term treatment and management.

Finally, we looked into the future of Canadian Health Care and explored future trends. There are some exciting technological advancements for cognitive rehabilitation. As we know, geographic location can pose a barrier to accessing rehabilitation. Patients who can access neurosurgical follow-up often have to travel extensive distances at great personal cost, and for that reason, some do not receive follow-up care. The future of follow-up care is bright with the development of follow-up treatment technologies such as digital health monitoring, custom devices, digital assistants, and video conferencing. Although research in this area is in its infancy, it is exciting to see the possibility of better follow-up care for marginalized populations in the community setting.

In conclusion, our exploration of ABI/TBI within the Canadian Healthcare System highlights the complex intersection of health, socio-economic factors, and systemic challenges. The prevalence of ABI/TBI among vulnerable populations calls for immediate action at the population level, such as  BILL C-277, to address health disparities. The promising trends in cognitive rehabilitation technology offer hope for overcoming barriers and enhancing follow-up care, signalling a potential shift towards more equitable healthcare for those affected by ABI/TBI.

References

Brenwick, D., Matney, C., & Bowman , K. (2022). Traumatic Brain Injury: A Roadmap for Accelerating Progress. National Academies Press . https://doi.org/10.17226/25394

Brown, J. B., Kheng, M., Carney, N. A., Rubiano, A. A., & Puyana, J. C. (2019). Geographical disparity and traumatic brain injury in America: Rural areas suffer poorer outcomes. Journal of Neurosciences in Rural Practice, 10(01), 10–15. https://doi.org/10.4103/jnrp.jnrp_310_18

Gary, K. W., Wallace, J., Mannix, R., & Pappadis, M. R. (2023). Editorial: Advancing the representation of minoritized groups and social determinants of health in brain injury research. Frontiers in Neurology, 14. https://doi.org/10.3389/fneur.2023.1169445

Johnson, L. W., & Diaz, I. (2023). Exploring the Social Determinants of Health and Health Disparities in Traumatic Brain Injury: A Scoping Review. Brain Sciences, 13(5), 707. https://doi.org/10.3390/brainsci13050707

Kathryn , H., McDonald, M., Hutchinson, J., & Turgeon, A. (2023). Traumatic Brain Injury a Lifelong Condition. In Brain Injury Canada. https://braininjurycanada.ca/wp-content/uploads/2023/07/TBI-Paper-English-July-19-2023.pdf

An Act to establish a national strategy on brain injuries, no. C-277, The House of Commons (2022). https://www.parl.ca/DocumentViewer/en/44-1/bill/C-277/first-reading

Rachel. (2023, March 21). Statistics - Brain Injury Canada. https://braininjurycanada.ca/en/statistics/#TBI

Shames, J., Treger, I., Ring, H., & Giaquinto, S. (2007). Return to work following traumatic brain injury: Trends and challenges. Disability and Rehabilitation, 29(17), 1387–1395. https://doi.org/10.1080/09638280701315011

Statistics - Brain Injury Canada. (2023, March 21). Brain Injury Statistics Canada. https://braininjurycanada.ca/en/statistics/#Indigenous

World Health Organization. (2023). Social Determinants of Health. World Health Organization. https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1

doi.org/10.17226/25394