All Media
All Media

Race, Ethnicity, and Traumatic Brain Injury in America

Categories: Professionals, Research, THE Challenge!

By Kelly Sarmiento, Director of Outreach Programs, Brain Injury Association of America, and Jill Daugherty, PhD, Director, Innovation Center, National Association of State Head Injury Administrators

Every year in the United States, millions of people experience a traumatic brain injury (TBI). But not everyone is affected in the same way. A new systematic review published in Injury Prevention shows that race and ethnicity play a large role in who gets injured, who survives, and how often these injuries occur.

In general, the authors found that American Indian/Alaska Native children and adults were found to have the highest rate of negative outcomes related to TBI than other racial/ethnic groups. In fact, studies show that TBI-related deaths may be as much as 380 percent higher among American Indian/Alaska Native children and adults than other racial and ethnic groups.1-4

However, biological differences do not explain the disparities. Lead author Vincent Gia-Bao Doan and colleagues emphasize that race and ethnicity are social categories, not biological ones.5 Prior research shows that when people are provided with the same access to healthcare, outcomes do not vary by race or ethnicity.6

After a review of more than two decades of research on TBI among different racial and ethnic groups, the authors were able to piece together a clearer picture of which factors are most likely linked to disparities in TBI care and outcomes. TBI disparities likely reflect a mix of factors related to access to care, socio-economic conditions, and cultural and systemic barriers:

  • Access to care: Some groups face longer waits, longer distances to emergency medical care, fewer referrals to specialists, or lower odds of receiving rehab after a TBI.7 For example, the authors found that non-Hispanic Black and Hispanic patients are less likely to receive follow-up care and rehabilitation following a TBI compared to non-Hispanic white patients.7-13 Racial and ethnic minorities are also more likely to have poor psychosocial, functional, and employment-related outcomes after sustaining a TBI than non-Hispanic white individuals.14-18
  • Socioeconomic conditions: Poverty, unstable housing, and lack of insurance all shape how often people seek care for a TBI and how well they recover. Higher exposure to violence and unsafe roads or driving practices increases the risk for TBIs. Studies found that rates of motor vehicle crashes and suicide, as well as difficulties in accessing appropriate
    healthcare among American Indian and Alaska Native communities, are linked to higher rates of TBI.19
  • Cultural and systemic barriers: Stigma, mistrust of the medical system, and communication gaps can all reduce care-seeking after an injury. Research on disparities in
    the incidence of TBI and healthcare-seeking behaviors found that white children were more likely to seek care for TBIs than children from other racial/ethnic groups.20
  • Addressing these gaps will take research that is more inclusive and efforts to tackle the social and economic forces that put certain groups in harm’s way.

The review by Doan and colleagues makes clear that some communities — especially American Indian and Alaska Native people — carry disproportionately negative outcomes
as a result of brain injury. Yet these groups are often underrepresented in studies, making it harder to design targeted solutions. The authors call for oversampling these populations in future research to better understand their needs. They also urge researchers and policymakers to look beyond sports concussions, which dominate current studies, and consider the full spectrum of causes: motor vehicle crashes, falls, and violence. And critically, future studies should explore the “why” behind the disparities, not just the “what.”

Understanding racial and ethnic differences in TBI is not just about numbers. It’s about justice, prevention, and making sure that everyone, regardless of background, has access to evidence-based care for TBI.

Other Health Disparities in TBI

Health disparities are differences in health outcomes and their causes among groups of people. Groups can be defined by factors such as race, ethnicity, sex, education, income, disability, geographic location (e.g., rural or urban), and sexual orientation. The Centers for Disease Control and Prevention examined disparities in TBI and has outlined which groups are most affected by TBI. While anyone can be at risk of getting a TBI, some groups have a greater likelihood of dying from a TBI or living with long-term health problems as a result of their injury, including:

  • Older Adults: People aged 75 years and older have the highest numbers and rates of TBI-related hospitalizations and deaths. According to the CDC, this age group accounts for about
    32 percent of TBI-related hospitalizations and 28 percent of TBI-related deaths.
  • Military Service Members and Veterans: Since 2000, more than 500,000 service members have been diagnosed with a TBI. Studies suggest that service members and veterans who have sustained a TBI may have ongoing symptoms, experience co-occurring health conditions such as posttraumatic stress disorder and depression, have difficulty accessing healthcare, and report having thoughts of suicide.
  • Survivors of Intimate Partner Violence: An estimated 36 percent of intimate partner violence (IPV) survivors have sustained injuries to the head, neck, or face.21 Survivors of IPV who have a TBI due to an assault are also more likely to be diagnosed with post-traumatic stress disorder, insomnia, and depression, and report worse overall health.
  • People Experiencing Homelessness: Compared to the general population, people who experience homelessness are two to four times more likely to have a history of any type of TBI, and are up to 10 times more likely to have a history of a moderate or severe TBI.

References

  1. Menon DK, Schwab K, Wright DW, Maas AI. Position statement: definition of traumatic brain injury. Arch Phys Med Rehabil. Nov 2010;91(11):1637–40. doi:10.1016/j.apmr.2010.05.017
  2. Coronado VG, Xu L, Basavaraju SV, et al. Surveillance for traumatic brain injury-related deaths: United States, 1997-2007. MMWR. 2011;60:1–32.
  3. Peterson AB, Zhou H, Thomas KE. Disparities in traumatic brain injury-related deaths-United States, 2020. Journal of Safety Research. 2022;83:419–426. doi:https://dx.doi.org/10.1016/j.jsr.2022.10.001
  4. Daugherty J, Sarmiento K, Waltzman D, Xu L. Traumatic Brain Injury-Related hospitalizations and deaths in urban and rural counties – 2017. Ann Emerg Med. 2022;79(3):288–296.e1.
  5. Lujan HL, DiCarlo SE. Misunderstanding of race as biology has deep negative biological and social consequences. Exp Physiol. Aug 2024;109(8):1240–1243. doi:10.1113/ep091491
  6. Liou-Johnson V, Merced K, Klyce DW, et al. Exploring racial/ethnic disparities in rehabilitation outcomes after TBI: A Veterans Affairs Model Systems study. NeuroRehabilitation. 2023;52(3):451–462. doi:10.3233/nre-220225
  7. Gao S, Kumar RG, Wisniewski SR, Fabio A. Disparities in Health Care Utilization of Adults With Traumatic Brain Injuries Are Related to Insurance, Race, and Ethnicity: A Systematic Review. J Head Trauma Rehabil. May/Jun 2018;33(3):E40–e50. doi:10.1097/htr.0000000000000338
  8. Dismuke CE, Gebregziabher M, Egede LE. Racial/Ethnic Disparities in VA Services Utilization as a Partial Pathway to Mortality Differentials Among Veterans Diagnosed With TBI. Global journal of health science. Jul 19 2015;8(2):260–72. doi:10.5539/gjhs.v8n2p260
  9. Jimenez N, Quistberg A, Vavilala MS, Jaffe KM, Rivara FP. Utilization of Mental Health Services After Mild Pediatric Traumatic Brain Injury. Pediatrics. Mar 2017;139(3)doi:10.1542/peds.2016-2462
  10. Jimenez N, Symons RG, Wang J, et al. Outpatient Rehabilitation for Medicaid-Insured Children Hospitalized With Traumatic Brain Injury. Pediatrics. 2016;137(6)
  11. Meagher AD, Beadles CA, Doorey J, Charles AG. Racial and ethnic disparities in discharge to rehabilitation following traumatic brain injury. Journal of neurosurgery. Mar 2015;122(3):595–601. doi:10.3171/2014.10.Jns14187
  12. Schiraldi M, Patil CG, Mukherjee D, et al. Effect of insurance and racial disparities on outcomes in traumatic brain injury. Journal of Neurological Surgery. 2015;76(3):224–32.
  13. Asemota AO, George BP, Cumpsty-Fowler CJ, Haider AH, Schneider EB. Race and insurance disparities in discharge to rehabilitation for patients with traumatic brain injury. Journal of neurotrauma. 2013;30(24):2057–2065.
  14. Arango-Lasprilla JC, Ketchum JM, Gary K, et al. Race/ethnicity differences in satisfaction with life among persons with traumatic brain injury. NeuroRehabilitation. 2009;24(1):5–14. doi:10.3233/nre-2009-0449
  15. Arango-Lasprilla JC, Ketchum JM, Lewis AN, Krch D, Gary KW, Dodd BA, Jr. Racial and ethnic disparities in employment outcomes for persons with traumatic brain injury: a longitudinal investigation 1-5 years after injury. PM & R : the journal of injury, function, and rehabilitation. Dec 2011;3(12):1083–91. doi:10.1016/j.pmrj.2011.05.023
  16. Arango-Lasprilla JC, Kreutzer JS. Racial and ethnic disparities in functional, psychosocial, and neurobehavioral outcomes after brain injury. J Head Trauma Rehabil. 2010;25(2):128–136.
  17. Arango-Lasprilla JC, Rosenthal M, Deluca J, et al. Traumatic brain injury and functional outcomes: does minority status matter? \ Brain Inj. 2007;21(7):701–8.
  18. Gary KW, Arango-Lasprilla JC, Stevens LF. Do racial/ethnic differences exist in post-injury outcomes after TBI? A comprehensive review of the literature. Brain Inj. 2009;23(10):775–789.
  19. Kerr WC, Ye Y, Williams E, Mulia N, Cherpitel CJ. Trends and disparities in American Indian/Alaska Native unintentional injury mortality from 1999 to 2016. Injury prevention : journal of the International Society for Child and Adolescent Injury Prevention. Oct 2021;27(5):435–441. doi:10.1136/injuryprev-2020-043951
  20. Shen J, Shi J, Cooper J, Chen C, Taylor HG, Xiang H. A Population-Based Study of the Incidence, Medical Care, and Medical Expenditures for Pediatric Traumatic Brain Injury. Journal of Surgical Research. 2021;268:87–96. doi:https://dx.doi.org/10.1016/j.jss.2021.06.025
  21. Wilson, Sharon. R. (2009). Traumatic brain injury and intimate partner violence in Connie Mitchell’s Intimate Partner Violence: A Health-based Perspective. 187. Oxford University Press, Inc., New York: NY.
  22. Shiroma, E. J., Ferguson, P. L., & Pickelsimer, E. E. (2012). Prevalence of traumatic brain injury in an offender population: A meta-analysis. The Journal of Head Trauma Rehabilitation, 27(3), E1-E10.