Effect of Race and Nativity on Functional Outcomes Following Traumatic Brain Injury Among Asian, Hispanic, and Non-Hispanic White Survivors in the United States: A NIDILRR TBI Model Systems Study : The Journal of Head Trauma Rehabilitation

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Original Articles

Effect of Race and Nativity on Functional Outcomes Following Traumatic Brain Injury Among Asian, Hispanic, and Non-Hispanic White Survivors in the United States: A NIDILRR TBI Model Systems Study

Kuerban, Aliya PhD, FNP, RN; Dams-O'Connor, Kristen PhD

Author Information
Journal of Head Trauma Rehabilitation: September/October 2022 - Volume 37 - Issue 5 - p E310-E318
doi: 10.1097/HTR.0000000000000736
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Abstract

ASIANS ARE PREDICTED to be the largest immigrant group in the United States in 20551; however, they are invisible in most of the studies on functional outcomes of traumatic brain injury (TBI) patients, despite the call of the National Institutes of Health to study the experience of racial/ethnic minorities with TBI.2 Due to relatively small sample sizes, most studies on TBI either exclude Asians as a group3–6 or combine them with other racial/ethnic minorities.7–11

Recently, more studies are looking into the effect of being Hispanic on the functional recovery of TBI, compared with being White or African American.12,13 To some extent, these studies may be informative in understanding the functional outcomes of TBI in Asians because both the Asian and Hispanic groups have a large percentage of foreign-born immigrants. Foreign-born immigrants experience cultural and language barriers in acquiring and utilizing resources needed to recover from TBI. Meanwhile, due to the lack of English language skills and living in an unfamiliar culture, foreign-born individuals might have to rely more on their social networks to gain information and overcome obstacles.13

Despite these similarities, Asian immigrants are different from Hispanic immigrants in many ways. Asian immigrants come from a wide range of socioeconomic, cultural, and religious backgrounds. Many of them speak different languages.14 According to Pew Research Center's report, 5 of the top 8 languages spoken by most immigrant populations are Asian languages.15 Asian immigrants also travel a longer distance to the United States than the Hispanic immigrants. The geographic distance involved in the migration process plays a dynamic role in the power struggle of migratory forces among them and therefore reduces the size of social networks developed.15 This, in turn, may indirectly affect recovery following TBI by posing additional barriers and inequities in access to resources. Indeed, studies have found associations between foreign-born status and lack of English with a lower rate of healthcare utilization among Asians, similar to other nonnative populations.16–19

In this study, nativity was defined as whether the individual was native-born (born in the United States) or foreign-born (born outside of the United States). An individual's nativity status is often considered a gross reflection of the myriad personal experiences of those who are foreign-born, which in other studies has included constructs such as years of migration, generational status, reasons of migration, port of entry, or age at migration,20 any of which may impact rehabilitation and resource access after TBI. Previous studies focused on Hispanic individuals with TBI have included the construct of nativity as defined in the current study in their analysis.13,21

Existing literature examining TBI outcomes with racial and ethnic minorities as part of their study population has found that higher social class,22,23 younger age,24–26 lower injury severity,7,25,26 nonviolent cause of injury,4 being married,7 and having private insurance5,27—all have positive effects on functional outcomes. It is not known whether these factors similarly impact TBI outcomes among Asians. The goal of the current study is to investigate how Asian TBI survivors compare to Hispanic and non-Hispanic Whites in functional recovery post-injury and further evaluate whether nativity impacts functional change over time during inpatient rehabilitation and over the first-year post-injury. This study addresses the gaps in previous studies that have been unable to investigate outcomes among Asians by using data from a large nationally representative study of individuals who received inpatient rehabilitation for TBI in the United States.

METHODS

Data sources and participants

To study the functional outcomes after inpatient rehabilitation discharge and at the 1-year post-injury of 3 racial groups (White, Hispanic, and Asian), data were extracted from the Traumatic Brain Injury Model Systems (TBIMS) National Database. This database is funded by the National Institute on Disability and Rehabilitation Research.28 Individuals included in the current study sample consisted of those who had severe TBI between 2000 and 2016 and were admitted to multiple TBIMS centers around the United States. Patients' sociodemographic variables were self-reported or from significant others of the patient, and if that was not available, the data were extracted from the admitting hospital's available data.28 This study explores functional outcomes at the 1-year follow-up, and therefore, only those with 1-year follow-up information available were included in the final sample. To be consistent with the age rages included in other TBIMS studies,3,4,7,26 we included individuals 16 years and older.

This study has 3 comparison groups based on self-identified and/or other reported racial/ethnic categories: White (non-Hispanic), Hispanic, and Asian. To examine the effect of nativity on the 2 racial minority groups, both Asian and Hispanic groups were further described as native-born Asians, foreign-born Asians, native-born Hispanics, and foreign-born Hispanics.

Individuals included in the TBIMS National Database were provided with informed consent, and their human subject rights and confidentiality were protected by the Institutional/Ethics Review Board of each individual center.28 The researcher's Institutional Review Board granted exempt status for the current study.

Measures

Outcome

Functional outcomes were measured by the Functional Independent Measure (FIM instrument) ratings. The rating of the FIM ranges from 18 to 134, with higher ratings representing greater functional independence. The validity and reliability of the FIM instrument had been evaluated extensively elsewhere.29

Covariates

Sociodemographic and injury variables

Age was analyzed as a continuous variable. The following covariates were dichotomized: marital status into married or not married; education into less than high school education (may have GED) and high school graduate and above; insurance status into used private insurance and did not use private insurance; employment status at the time of injury into actively employed and not actively employed (including full-time student, part-time student, homemaker, and other); and the nature of the injury due to violence (including gun shooting, assault, and other violent causes) and not due to violence (including motor vehicle accident, sports, falls, and other nonviolent causes). Injury severity was measured by the length of posttraumatic amnesia (PTA), which was categorized into 4 levels based on the Mississippi intervals: 0 to 14 days considered as moderate; 15 to 28 days considered as moderate-severe; 29 to 70 days considered as severe; and more than 70 days considered as extremely severe.4,30

Immigration-related variables

Nativity had 2 values: foreign-born and native-born. Whether the individual spoke English as the primary language at home was measured as either yes or no.

Data analyses

A priori power analysis was conducted first to determine required sample size for analysis of variance (ANOVA) comparison of the follow-up FIM scores of 3 groups. Results of this power analysis, with an α = .05 and power = 0.95, achieved a large effect size with a total sample size of 102. Thus, our total sample size of N = 6964 (sample for the ANOVA test) was more than adequate for this comparison. A priori power analysis was then conducted to determine required sample size for regression models with 12 variables. Results of this power analysis, with an α = .05 and power = 0.95, achieved a large effect size with a total sample size of 83. Thus, our total sample size of N = 6964 was more than adequate for this analysis as well. In consideration of the unequal sample sizes, note that the smallest group with reported FIM follow-up ratings (Asian) had n = 211. All power calculations were conducted using G*Power 3.1.9.4.31

Analyses were conducted using R version 3.6.132 and SPSS version 23.33 Sample characteristics of 3 groups are described in Table 1. Table 1 also shows comparisons of the characteristics among White, Asian, and Hispanic groups; comparisons between foreign-born and native-born Asians; and between foreign-born and native-born Hispanic groups. We used Tukey's methods to adjust for multiple comparisons. Table 1 identifies comparison which showed significant differences.

TABLE 1 - Demographic characteristics and group comparisons of the White, Asian, and Hispanic group, the native-born and foreign-born Asian group, and the native-born and foreign-born Hispanic group
White Hispanic Asian Native-born Asian Foreign-born Asian Native-born Hispanic Foreign-born Hispanic
n = 6608 n = 1094 n = 251 n = 78 n = 173 n = 573 n = 521
Age 41.4 36.2a 41.1b 28.8 46.7c 31.0 40.8d
Sex, male 71.8% 77.2%a 71.7%b 69.2% 72.8% 72.7% 81.3%d
Married 36.2% 28.2%a 37.1%b 12.8% 48.0%c 18.6% 36.8%d
High school and above 76.1% 47.0%a 78.1%b 76.9% 78.6% 56.2% 38.6%d
Actively employed 63.3% 68.5%a 54.2%a.b 48.7% 56.6% 63.3% 73.3%d
Private insurance 50.5% 27.4%a 39.7%a,b 51.3% 34.3%c 36.2% 19.4%d
Violent cause 5.8% 16.3%a 10.4%a,b 12.8% 9.4% 16.5% 16.1%
Foreign-born 4.0% 52.4%a 68.9%a,b ... ... ... ...
Primary English at home 98.4% 42.9%a 49.4%a 87.2% 32.4%c 75.0% 13.6%d
PTA: moderate 37.5% 30.1%a 39.0%b 39.5% 38.8% 30.2% 29.9%
PTA: moderate to severe 21.3% 19.8% 24.1% 26.3% 23.0% 22.0% 17.7%
PTA: severe 22.9% 25.9%a 20.7% 22.4% 20.0% 27.8% 24.2%
PTA: extremely severe 18.3% 24.2%a 16.2%b 11.8% 18.2% 20.0% 28.1%d
Abbreviation: PTA, posttraumatic amnesia.
aStatistically significantly different from White (P < .05).
bStatistically significantly different from Hispanic (P < .05).
cStatistically significantly different from Native-born Asian (P < .05).
dStatistically significantly different from Native-born Hispanics (P < .05).

Descriptive analyses of FIM ratings at admission, discharge, and 1-year follow-up across all groups are shown in Table 2. Results of the FIM follow-up ratings were compared using ANOVA. Tests for homogeneity of variances showed unequal variances, so ANOVA post hoc tests (Dunnett T3) were performed. These ANOVA results are shown in Table 3.

TABLE 2 - Descriptive analysis of FIM ratings at admission, discharge, and one-year follow-up of the white, Asian, and Hispanic groups
Admission FIM Discharge FIM 1-y FIM
Group n Mean (SD) n Mean (SD) n Mean (SD)
White 6499 51.0 (23.4) 6499 91.3 (22.2) 5845 115.6 (17.2)
Asian 247 53.7 (23.6) 245 93.0 (21.4) 211 112.6 (22.5)
Hispanic 1079 48.7 (21.6) 1069 88.8 (22.2) 908 111.2 (20.2)
Total 7825 50.8 (23.2) 7813 91.0 (22.2) 6964 115.0 (17.9)
Abbreviation: FIM, Functional Independent Measure.

TABLE 3 - ANOVA (post hoc Dunnett T3) analysis of difference of FIM ratings at admission, discharge, and one-year follow-up for White, Asian, and Hispanic groups
Rating Race Comparison race Mean difference Standard error Significance (P) 95% Lower bound 95% Upper bound
Admission FIM White Asian −2.6 1.5 .233 −6.3 1.0
Hispanic 2.3 0.7 .004 0.6 4.0
Asian White 2.6 1.0 .233 −1.0 6.3
Hispanic 5.0 1.6 .008 1.0 8.9
Hispanic White −2.3 0.7 .004 −4.0 −0.6
Asian −5.0 1.6 .008 −8.9111 −1.0
Discharge FIM White Asian −1.6 1.0 .569 −5.0 1.7
Hispanic 2.6 0.7 .001 0.8 4.3
Asian White 1.6 1.4 .569 −1.7 5.0
Hispanic 4.2 1.0 .019 0.5 7.8
Hispanic White −2.6 0.7 .001 −4.3 −0.8
Asian −4.2 1.5 .019 −7.8 −0.5
1-year FIM White Asian 2.4 1.6 .051 −0.8 6.0
Hispanic 3.9 0.7 .000 2.8 6.1
Asian White −2.4 1.6 .051 −6.7 0.8
Hispanic 1.4 1.7 .767 −2.6 5.5
Hispanic White −3.9 0.7 .000 −6.1 −2.8
Asian −1.4 1.7 .767 −5.5 2.6
Abbreviation: FIM, Functional Independent Measure.

To further explore the group differences in functional outcomes at the 1-year follow-up, 6 general linear regression models were created to predict FIM ratings, as shown in Table 4. Model 1 examined the racial/ethnic differences directly by using Whites as the reference group; no other covariates were added. Model 2 introduced the nativity variable and other covariates to explore whether the racial/ethnic differences could be explained by these additions. Model 3 included only the Asian and Hispanic groups to test the differences in functional outcomes between them; no other covariates were added. Model 4 once again introduced the nativity variable and other covariates to explore whether the differences discovered in Model 3 could be contributed to the differences in nativity and other covariates. Model 5 included Hispanics only and was designed to explore the effect of nativity and other factors. The same procedure used for model 5 was repeated in model 6; however, model 6 included only Asians.

TABLE 4 - Multivariable linear regression analyses of FIM ratings at the 1-year follow-up
Model 1 Model 2 Model 3 Model 4 Model 5 Model 6
Coefficient P value Coefficient P value Coefficient P value Coefficient P value Coefficient P value Coefficient P value
White Reference Reference
Asian −3.0 .02 −2.4 .06 Reference Reference
Hispanic −4.5 <.01 −2.1 <.01 −1.5 .35 0.4 .82
Nativity 0.4 .69 −0.0 .99 −0.3 .88 1.8 .61
Age −0.1 <.01 −0.1 <.01 −0.1 .49 −0.2 .02
Sex, male 1.6 <.01 2.4 .08 3.0 .06 −2.1 .50
Married 0.7 .12 −0.2 .87 −1.1 .50 7.0 .05
High school and above 1.2 <.01 1.5 .25 1.3 .33 2.9 .42
Actively employed 1.7 <.01 2.4 .08 1.4 .36 4.9 .09
Private insurance 2.8 <.01 1.3 .33 1.1 .47 0.5 .86
Violent cause −2.7 <.01 −5.4 <.01 −6.8 <.001 1.3 .77
Primary English at home 0.8 .45 0.6 .68 1.1 .51 −0.8 .81
PTA: moderate/severea −1.4 <.01 −1.5 .37 −0.8 .67 0.7 .49
PTA: severe −3.8 <.01 −6.0 <.001 −6.2 <.01 −3.8 .30
PTA: extremely severe −20.7 <.01 −23.3 <.001 −21.2 <.001 −36.19 <.01
Adjusted R 2 0.01 0.22 <0.01 0.22 0.20 0.34
Abbreviations: FIM, Functional Independent Measure; PTA, posttraumatic amnesia.
aPTA moderate group: the reference group.

RESULTS

Demographic results

Both Asians and Whites had a lower percentage of male participants, and a lower percentage of unmarried participants. Whites and Asians had higher levels of education than Hispanics. However, Asians' employment rate at the time of injury was the lowest among all 3 groups. Although the Hispanic group had the highest rate of employment at the time of injury, the percentage of Hispanics with private insurance was the lowest (Hispanic: 27.4%, White: 50.5%, and Asian: 39.7%). Hispanics were, on average, the youngest group. Both Asians and Hispanics had higher rates of violence-related TBI than Whites. A higher proportion of Asians than Hispanics were foreign-born (68.9% vs 52.4%), more Asians primarily spoke English at home (49.4% vs 42.9%), but the latter finding was not statistically significant. Native-born Asians and Hispanics were younger and less likely to be married than their foreign-born coethnics.

FIM ratings across White, Asian, and Hispanic groups

Descriptive data for the 3 FIM ratings for patients at admission, discharge, and 1-year follow-up are shown in Table 2. While FIM ratings were the highest for Asians at admission and discharge, at 1-year follow-up, FIM ratings for Asians were lower than Whites and only slightly higher than Hispanics.

The 3 FIM ratings were compared by racial/ethnic group (White, Asian, and Hispanic) to explore significant differences between the groups at a significance level α = .05. For the FIM admission ratings, there were significant differences between Hispanics and Whites (Whites higher) and between Hispanics and Asians (Asians higher). For FIM discharge ratings, there were significant differences between Hispanics and Whites (Whites higher). These ANOVA results are shown in Table 3.

One-year functional outcomes across White, Asian, and Hispanic groups

As shown in Table 4, both the Asian and Hispanic groups had lower functional outcomes than Whites at the 1-year follow-up. Regression analysis in model 2 (see Table 4) showed that these differences were not fully explained by nativity, violent cause, of injury, education, marital status, sex, employment, primary language spoken, or injury severity. There were no significant differences in functional outcomes between Asians and Hispanics (see Table 4, models 3 and 4). Among Asians, after adjusting for PTA severity and age, those who were married at the time of injury recovered significantly better than those who were not married. Among Hispanics, violent cause of TBI was associated with 1-year outcome. Nativity and whether the individual spoke English at home did not account for a significant amount of variance in FIM ratings in any models in Table 4.

DISCUSSION

This study revealed that Asians and Hispanics had lower functional outcomes at the 1-year follow-up post-TBI injury compared with Whites. This finding coincided with the results from previous studies on African Americans and Hispanics that found members of minority groups experience worse outcomes following injury.3,5,8–11,27,34 The current findings suggest that this conclusion can be extended to include Asians. It is notable that the lower functional outcomes of Asians and Hispanics reported herein could not be fully attributed to the differences in sociodemographic and injury factors, although these are well-documented contributors to poorer outcomes among other racial and ethnic groups. Paradoxically, the Asians' socioeconomic advantage relative to Hispanics, as measured by educational achievement and employment status in this study, did not confer benefits for TBI recovery, as demonstrated by no differences in their functional outcomes at the 1-year follow-up. This raises questions regarding other potential contributors to the relatively poor functional outcomes among Asians with TBI documented herein.

Recovery from TBI is a multidimensional process. Besides the severity and nature of the injury, TBI survivors vary in their knowledge and willingness to access rehabilitation care, and the quality and appropriateness of the care received can also differ tremendously.35 The current study sheds light on how some of these factors may differentially relate to injury outcomes for Asians as compared with other groups. For example, although the results show that Asians and Hispanics had much higher proportions of TBI due to violence than Whites as previously documented,35 the violent nature of injury was not associated with functional outcomes among Asians, but it was the only significant factor among Hispanics besides injury severity and age. The implications of the nature of injury (eg, violent vs nonviolent) for systematic social problems associated with violence warrant future study.

It was also found that, among Asians, marital status was the only factor besides age and injury severity that was significantly related to their functional outcomes at the 1-year follow-up, suggesting that being married may confer particular advantages for the functional recovery of an Asian TBI patient. A married individual may have more direct and reliable support in the rebuilding of life in a country where he/she has limited living experience. According to the report by the Agency for Healthcare Research and Quality,30 Asians reported they did not receive easy-to-understand instructions when they first received home healthcare; the disparity was in comparison to Whites and has not changed in 5 years. Being married may buffer the effects of confusing or inaccessible care guidelines among Asians. Among Hispanics in the current study, marriage status was not a significant factor in functional trajectory; one wonders whether speaking a single language (Spanish) provides broader access to information, resources, and perhaps wider social network groups. Asians speak multiple different languages and may rely more on their spouse to access resources that might otherwise not be secured due to social and structural constraints.

It was somewhat surprising that nativity and spoken English at home were not found to be predictive of functional outcomes for Asians or Hispanics in this study, given the important roles these factors play in the process of acculturation.36,37 Prior research suggests that low levels of acculturation prevent immigrants from acquiring the needed resources for long-term recovery.13,17,38,39 Recently, the effect of residential environment has increasingly been recognized in studies of Hispanic and Black survivors' postinjury outcomes,40 and similar environmental and residential constructs warrant further exploration to understand Asian immigrants' recovery after TBI. When studying racial minorities with a high proportion of immigrants, factors beyond socioeconomic status might have more consequential effects on health.

Our study takes an initial effort to investigate Asians as a discrete group when examining racial/ethnic differences in functional outcomes among native-born and foreign-born TBI survivors by using large national TBI database. An early study had explored inpatient stroke rehabilitation outcomes of the Asians and found Asians to have less improvement than the Whites; however, it used a localized community sample.41 Most prior studies using large samples to examine group differences compared only Hispanics and African Americans, and one study that found no significant differences at the 1-year follow-up3 failed to compare the relative gains of the recovery process. In the current project, the fact that statistically significant differences among racial/ethnic groups disappeared at the 1-year follow-up has important clinical implications. Often, functional status at admission is a strong predictor of functional status later, but current findings suggest that functional gains over time may differ in important ways across racial and ethnic groups. In particular, this study found that the higher functional status at admission and discharge seen among Asians in this study was not maintained at the 1-year follow-up.

LIMITATIONS

Due to the constraint of the sample size, it was not possible to explore intragroup differences among Asians and Hispanics. The use of FIM ratings as a measure of functional outcome has several limitations, such as ceiling effects, which have been reported in several TBI studies.40,42 FIM ratings also rely upon the verbal communication between the rater and the participant, and accuracy may be impacted by limited English language skill43 or cultural variations in how independent performance of the activities/behaviors are rated.8 Also, the proportion of Asians in this study is lower than that found in the US population, and findings may not reflect outcomes for those who do not receive comprehensive inpatient rehabilitation at a TBI model system of care. Finally, the retention rate of the subsamples could potentially alter the outcome presented in this study.

CONCLUSION

For over 16 years, the Agency for Healthcare Research and Quality has been documenting disparities in healthcare access and the quality of healthcare received by racial minorities.44 W. E. B. DuBois (1899) started his inquiry on the racial inequalities in health between Blacks and Whites more than 100 years ago.45 Since then, racial disparities in disease onset, the severity and progression of disease, and the effects of some risk factors have been documented.22 However, most of these studies have focused on the differences between Blacks and Whites, and these studies have noted the impact of social class on the distribution of illness. The results of the current study extend previous findings from studies of other racial and ethnic minority groups to document that Asians also have poorer functional outcomes following TBI as compared with Whites. With the high influx of recent Asian immigrants,46 it is increasingly important to understand how immigration-related social, environmental, and contextual factors might influence recovery and health following TBI.

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Keywords:

ethnicity; functional outcomes; immigrants; racial disparities; traumatic brain injury; nativity

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