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Abstract
BACKGROUND Evidence suggests that those who have sustained a traumatic brain injury (TBI) are at increased risk of adverse behaviors and health indicators, such as certain chronic physical and mental health conditions. However, little is known about the prevalence of these behaviors and health indicators among these individuals, information that could help decrease their risk of developing such conditions.
METHODS Data (N = 4733) from the 2018 North Carolina Behavioral Risk Factor Surveillance System (BRFSS) were analyzed to determine the prevalence of behaviors and health indicators among individuals who report having a lifetime history of TBI with loss of consciousness (LOC).
RESULTS North Carolinians who report a lifetime history of TBI with LOC were at increased risk of reporting a range of 3 negative health behaviors: less than always seatbelt use (adjusted odds ratio [AOR] = 1.7; 95% confidence interval [CI] = 1.2–2.4), HIV risk behaviors (AOR = 1.7; 95% CI = 1.1–2.6), and reporting less than 7 hours of sleep (AOR = 1.5; 95% CI = 1.2–1.8); more difficulty obtaining health care (not seeing a doctor due to health care cost in the past 12 months [AOR = 1.3; 95% CI = 1.0–1.8]; not getting a routine medical check-up in the past 12 months [AOR = 1.5; 95% CI = 1.2–2.0]); worse self-reported health (fair or poor general health [AOR = 1.8; 95% CI = 1.4–2.3]); and reporting fair or poor mental health (AOR = 2.1; 95% CI = 1.6–2.8) compared with individuals who did not report a history of TBI.
LIMITATIONS There are several limitations to the study, such as the sample being biased toward more severe brain injuries. Additionally, because the data in the BRFSS are retrospective and cross-sectional, it is not possible to determine temporality and causality between TBI history and the behaviors and health indicators examined.
CONCLUSION Despite these limitations, this paper is one of the first to directly examine the association between history of TBI with LOC and a range of current behaviors and health care utilization. Assessing positive and negative behaviors and health indicators can help identify and tailor evidence-based interventions for those who have a history of TBI.
Previous research demonstrates that individuals living with traumatic brain injury (TBI) are at increased risk for developing chronic health conditions such as depression [1, 2], diabetes [3], and heart disease [3], and having overall poor health [4]. Those with a moderate/severe TBI have an increased risk of dying within 5 years of the injury [5]. Sustaining a TBI has also been linked to moderate-to-severe problem gambling [6], risky sexual behavior [7], substance use disorders [8, 9], increased risk for sustaining an unintentional injury (such as a motor vehicle crash) [10], and suicidal thoughts and behaviors [2].
Physical activity, proper sleep hygiene, community-based support services, routine medical check-ups, and wearing seatbelts and taking other safety precautions can contribute to good physical and mental health, including for individuals with a history of TBI [4, 11, 12]. However, less is known about whether people who have sustained a TBI engage in protective health behaviors. The goal of this paper is to examine and present the prevalence of selected positive and negative behaviors and health indicators among individuals who report having a lifetime history of TBI with self-reported loss of consciousness (LOC). It is hypothesized that those with a history of TBI with LOC were more likely to engage in risk-taking behaviors.
Methods
Study Population
The Behavioral Risk Factor Surveillance System (BRFSS) is an annual, nationally representative telephone survey of non-institutionalized US adults, aged 18 and older that collects information pertaining to health-related conditions and behaviors [13]. BRFSS collects data from all 50 states, the District of Columbia, and 3 US territories. It is the largest continuously conducted health survey system in the world and is a powerful tool for targeting and building health promotion activities (https://www.cdc.gov/brfss/about/index.htm). The BRFSS survey consists of 3 parts: the core component, optional modules, and state-added questions (https://www.cdc.gov/brfss/questionnaires/index.htm). The BRFSS employs a complex sampling design [14]; it uses a disproportionate stratified sample design for respondents who complete the survey by landline and a random sample design for those who complete the survey by cell phone. The BRFSS also uses iterative proportional fitting to weight the data. BRFSS data are deidentified and considered exempt from human subjects review by CDC’s Institutional Review Board. Analyses for this study only used data from North Carolina BRFSS respondents as North Carolina is one of the few states that incorporated a module that asked TBI-related questions. Data from the other states that included a TBI module in 2018 could not be combined due to differences in the TBI-related questions. In 2018, 4733 adults in North Carolina completed the core sections of the BRFSS using a landline or cell phone (response rate of 43.5%).
Traumatic Brain Injury Module
Similar to the Ohio BRFSS TBI state module [15], the North Carolina BRFSS TBI module is a modified version of the Ohio BRFSS TBI module and focused on questions on lifetime history of TBI with LOC only. TBI is a heterogeneous disorder with various symptoms. LOC is one such symptom with a prevalence between 5.7% and 12% [2, 16, 17]. LOC is more accurately self-reported with certainty than other symptoms and may signify a disruption of brain function [18]. After completing the core sections of the BRFSS, the TBI module was administered. For the TBI module, all respondents received the following prompt:
For these next questions, please think about injuries you have had during your entire lifetime, especially those that affected your head or neck. It might help to remember times you went to the hospital or emergency room. Think about injuries you may have received from a car or motorcycle wreck, bicycle crash, being hit by something, falling down, being hit by someone, playing sports, or an injury during military service.
This prompt was followed by the questions: “Thinking about any injuries you have had in your lifetime, were you ever knocked out or did you lose consciousness?” and “How old were you the first time you were knocked out or lost consciousness?” Responses to the first question were dichotomized as yes/no. The number of years since a respondent’s first TBI with LOC was calculated by subtracting age of first TBI from the age of the respondent at the time of the survey.
Behaviors and Health Indicators
The slate of behaviors and health indicators examined in this paper were chosen due to previous research, which demonstrated that having a past history of TBI is associated with risk-taking [2, 6–10], poor overall health status [4], and difficulty obtaining adequate health care [19]. In order to examine the association of risk-taking behaviors and TBI, we selected seatbelt usage, HIV risk behaviors, and problem/pathological gambling. To examine difficulty obtaining health care, we selected the variables that assessed not seeing a doctor due to health care cost, recent routine checkup, and health care coverage. To examine the association between TBI history and overall health status, we selected self-rated general health and mental health and sleep. The behaviors, health indicators, and dichotomized responses are displayed in Table 1.
Behaviors and Health Indicators from the North Carolina Behavioral Risk Factor Surveillance System, 2018
Statistical Analysis
Descriptive statistics were calculated to describe the demographic characteristics (sex, age, race/ethnicity, veteran status, marital status, educational attainment, and employment status) of North Carolina adults (Table 2). These statistics were limited to those who answered “yes” or “no” to the lifetime TBI with LOC question (N = 3570). To account for the complex design of the BRFSS, frequencies and weighted percentages were estimated and compared across subgroups using χ2 tests, along with corresponding 95% confidence intervals (CI). The bivariate statistics were also limited to those who answered “yes” or “no” to the lifetime TBI with LOC question and the respective health behavior or outcome. To determine the association between TBI with behaviors and health indicators (i.e., seatbelt use, HIV risk behaviors, gambling, health care coverage, not seeing a doctor due to health care cost, recent routine check-up, general health, mental health, and sleep), separate multivariable binomial logistic regression was used to create models for each independent variable (i.e., lifetime history of TBI with LOC, number of years since first TBI with LOC), using the “no outcome” or “worse outcome” conditions as the reference group and adjusting for the demographic characteristics that were significant in the χ2 tests. Separate analyses were conducted for each of the behavior or health indicator variables. Additionally, if the primary outcome of interest (lifetime TBI with LOC) was not significant in the multivariable binomial logistic regression, then the secondary outcome of number of years since first TBI with LOC was not conducted. All analyses were performed in SAS 9.4 (SAS Institute, Cary, NC).
Characteristics of Adult Respondents in North Carolina Behavioral Risk Factor Surveillance System, 2018a
Results
A quarter of the respondents (24.8%) in North Carolina in 2018 had a self-reported history of TBI with LOC (Table 2). Among these respondents, the median age in which it was first experienced was 16.1 years, with most respondents experiencing a mild TBI (85.2%). Among all respondents, approximately: 7.7% reported “less than always” using a seatbelt, 6.1% reported at least 1 risk behavior for HIV, 5.0% reported problem/pathological gambling, 14.6% reported not having current health care coverage, 16.3% reported not seeing a doctor due to health care cost in the past 12 months, 19.7% reported not getting a routine medical check-up in the past year, 20.6% reported fair or poor health, 12.6% reported not having good mental health, and 34.5% reported sleeping less than 7 hours a night on average.
Risk-Taking Health Behaviors
After adjustment for demographic factors that were significantly associated with each behavior or health indicator (Supplementary Table 1), lifetime history of TBI with LOC was associated with increased odds of reporting less-than-always seatbelt use (adjusted odds ratio [AOR] = 1.7; 95% confidence interval [CI] = 1.2–2.4) and HIV risk behaviors (AOR = 1.7; 95% CI = 1.1–2.6), (Table 3). The bivariate association between lifetime history of TBI with LOC and problem/pathological gambling was not significant; thus, no multivariable modeling was conducted for this variable.
Adjusted Odds Ratio and 95% Confidence Interval for the Relationship between Traumatic Brain Injury Exposure and Health Behaviors: North Carolina Behavioral Risk Factor Surveillance System, 2018
After adjustment for significant demographic factors (Supplementary Table 1), number of years since first TBI with LOC was not associated with reported seatbelt use or HIV risk behaviors in the bivariate analyses (Table 3). Additionally, since there was no association between the primary outcome variable (lifetime history of TBI with LOC) and problem/pathological gambling, the multivariable analysis for number of years since first TBI with LOC and problem/pathological gambling was not conducted.
Difficulty Obtaining Health Care
After adjustment for significant demographic factors (Supplementary Table 1), lifetime history of TBI with LOC was associated with increased odds of reporting not seeing a doctor due to health care cost in the past 12 months (AOR = 1.3; 95% CI = 1.0–1.8) and not getting a routine medical check-up in the past 12 months (AOR = 1.5; 95% CI = 1.2–2.0) (Table 3). The bivariate association between lifetime history of TBI with LOC and health care coverage was not significant; thus, no multivariate modeling was conducted.
Select Health Behaviors by Demographic Characteristics and Lifetime History of Traumatic Brain Injury with Loss of Consciousness, North Carolina Behavioral Risk Factor Surveillance System, 2018
After adjustment for significant demographic factors (Supplementary Table 1), number of years since first TBI with LOC was not associated with not seeing a doctor due to health care cost in the past 12 months or getting a routine checkup in the past 12 months (Table 3).
Health Status
After adjustment for significant demographic factors (Supplementary Table 1), lifetime history of TBI with LOC was associated with increased odds of reporting fair or poor general health (AOR = 1.8; 95% CI = 1.4–2.3), reporting fair or poor mental health (AOR = 2.1; 95% CI = 1.6–2.8), and reporting < 7 hours of sleep (AOR = 1.5; 95% CI = 1.2–1.8) (Table 3).
The bivariate association between number of years since first TBI with LOC and general health or sleep was not significant; thus, no multivariable modeling was conducted. After adjustment for significant demographic factors (Supplementary Table 1), number of years since first TBI with LOC was not associated with mental health (Table 3).
Discussion
Our study indicates that individuals in North Carolina who reported a lifetime history of TBI with LOC were at increased risk of reporting a range of adverse behaviors and health indicators (e.g., negative health behaviors, more difficulty obtaining health care, and worse self-reported health than individuals who do not report a history of TBI). For example, findings suggest that individuals with a lifetime history of TBI with LOC had increased odds of reporting 3 risk behaviors: less than always using a seatbelt, HIV risk behaviors, and fewer than 7 hours of sleep, though the prevalence of less than always using a seatbelt and HIV risk behaviors is still very low among respondents in North Carolina. No previous studies have specifically examined the relationship between seatbelt usage after TBI or HIV risk behaviors and TBI; however, 1 study did find a high prevalence of previous head trauma (74%) among a sample of 173 individuals living with HIV [20]. Development of interventions that address impulsivity and risk-taking behaviors following a TBI, such as those that might put an individual at risk for HIV, is an area that deserves further study [21]. The relationship between sleep and TBI, on the other hand, is well-researched [22–27]. A 2012 meta-analysis reported that sleep disturbances are present in 50% of individuals who have sustained a TBI and that these individuals were 2–4 times more likely to experience problems with sleep maintenance, early awakenings, and excessive sleepiness (e.g., falling asleep during the day or sleeping longer at night) than people who did not have a history of TBI [23]. This relationship between TBI and poor sleep outcomes is particularly striking given the critical role that good sleep plays in recovery from TBI [28]. Future research may examine the extent to which people living with TBI are provided with guidance from health care providers on sleep hygiene following a TBI, as well as whether they receive referrals to specialists when symptoms persistent.
Lifetime history of TBI with LOC was also associated with increased odds of reporting not seeing a doctor due to health care cost in the past 12 months and not getting a routine medical check-up in the past 12 months. Previous research has shown that failure to obtain care after a suspected concussion can have lasting health implications, prolong recovery, and increase the possibility that a person will sustain a second concussion before symptoms resolve from the first one [29–31]. However, our study did not allow us to determine the relationship between the timing of the TBI and health care usage soon after the injury. Generally, preventive care services (such as routine health screenings and immunizations) help to reduce death and disability [32]. Consequently, lack of access to health care and other inequalities (e.g., lower hospital admission rates based on a patient’s insurance status, race, and sex) may partially explain poor patient outcomes [19]. Future longitudinal studies may explore these factors as mediators to better understand the impacts in order to reduce some of the harmful long-term effects of sustaining a TBI. Moreover, evaluation of interventions to overcome these barriers may be beneficial.
Finally, our study also demonstrated that lifetime history of TBI with LOC was associated with increased odds of reporting fair or poor general health and reporting fair or poor mental health. In a sample of 1129 male service members with a history of blast-related mild TBI, Heltemes and colleagues reported that service members with mild TBI were 5 times more likely to report a major negative change in health compared to members with other mild injuries [33]. Additionally, there is a robust literature demonstrating the relationship between post-TBI mental illness and personality changes [34–37]. For example, secondary attention deficit hyperactivity disorder (S-ADHD), aggression, and personality changes was more common with increasing TBI severity [35, 38]. Future research may explore the effectiveness of rehabilitation services for veterans with TBI complicated by psychological sequelae [39]. Health care providers can consider screening for these adverse health outcomes in individuals with TBI and provide referrals for evidence-based services as needed.
There are several limitations to this study. First, the TBI questions are biased toward more severe brain injuries due to the requirement about needing to have experienced LOC as a result of the TBI. Second, because the data in the BRFSS are retrospective and cross-sectional, it is not possible to determine temporality and causality between TBI history and the onset of the reported health behaviors, health care usage, or self-reported health status. There may also have been recall bias for respondents to not accurately remember details of an event (especially for recall of lifetime history of TBI). However, each of the behaviors and health indicators examined were current or within the past 12 months, so it is likely that in most cases the TBI preceded the behavior or health indicator. Third, these data were collected among respondents in North Carolina only and may not be generalizable to other US states. For example, our study found a prevalence of TBI with LOC of 24.8%, but other studies report a prevalence between 5.7% and 12% [2, 16, 17]. According to the US Department of Veterans Affairs, North Carolina ranks 8th among US states with the highest population of veterans [40], a population that is more likely to report a history of TBI with LOC, and this may contribute to the higher prevalence of TBI seen in this study. It is important to collect data on the TBI experience among residents of other states to see how it varies. Fourth, there was a high percentage of missing data for the lifetime TBI with LOC question (e.g., 22% of respondents did not answer the question, n = 1094). This was due to partial completion of the survey (i.e., respondents who ended the interview before the TBI optional module) or respondents who moved to North Carolina but kept their old cell phone number and thus were only asked questions from the core BRFSS. Further, respondents who did not answer this question compared to those who did were different on all demographic characteristics, as well as health care cost and general health. For example, respondents who answered the self-reported lifetime TBI with LOC question were more likely to be female, older, less likely to have a college education or higher, had not seen a doctor in the past 12 months due to health care cost, and had worse general health compared to respondents who had missing data. Fifth, the sleep variable was defined as a binary variable (less than 7 hours of sleep and 7 hours or more of sleep). Hypersomnia and excessive sleep are often problematic in individuals who sustain a TBI [23]. However, only 3.2% of respondents in our data endorsed more than 9e hours of sleep, and due to a lack of stability of the data caused by a low N, an analysis with tertiary levels was not possible. Future studies may want to examine this relationship. Sixth, it may be the case that those at risk for TBI are more impulsive or risky in general and there may not be a direct relationship between TBI and adverse health outcomes. Seventh, this study did not analyze TBI severity or number of TBIs. Though descriptive statistics were presented for TBI severity, there was too small a sample size for further analysis. Future studies may want to examine these variables as well.
Despite these limitations, this paper is one of the first to directly examine the association between history of TBI with LOC and a range of current behaviors and health care utilization. Further, it adds to the established literature showing a strong correlation between history of TBI with LOC and self-reported poor physical and mental health. Additionally, these findings may help inform screening and referral strategies for health care providers for the care of patients with a history of TBI to promote a healthy lifestyle.
Conclusion
Taken together, the results of this analysis demonstrate that individuals who have sustained a TBI with LOC in their lifetime had increased odds of reporting certain negative health behaviors, less health care usage, and poor physical and mental self-rated health than individuals who have not sustained a TBI with LOC. Targeted TBI prevention efforts of modifiable risk and protective behaviors (such as seatbelt use), as well as the adaptation of evidence-based programs, are needed in order to reduce adverse health outcomes in patients with TBI. Additionally, health care providers can consider screening patients with a lifetime history of TBI with LOC for mental health and sleep problems and provide referrals for evidence-based services as needed.
Acknowledgments
The findings and conclusions in this manuscript are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
Disclosure of interests: All authors report no relevant disclosures.
- ©2022 by the North Carolina Institute of Medicine and The Duke Endowment. All rights reserved.
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