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The Evidence Speaks

Injury Prevention Day: Advancing Health Research on Traumatic Brain Injury

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Today is Injury Prevention Day in Canada. This bonus edition of the Evidence Speaks will feature a more detailed look at policy-informing research on traumatic brain injury and helmet legislation by CHÉOS Scientists.

Song MJ, Nikoo M, Choi F, Schütz CG, Jang K, Krausz RM. Childhood trauma and lifetime traumatic brain injury among individuals who are homeless. J Head Trauma Rehabil. 2017 May 17 epub ahead of print.

Traumatic Brain Injury (TBI), which can lead to seizures, mental health conditions, drug use problems, poor physical health, and diminished cognitive function, is especially prevalent among homeless individuals. Recently, CHÉOS Scientists Drs. Michael Krausz and Christian Schütz investigated whether childhood trauma from abuse or neglect was associated with TBI among adults who were homeless in Vancouver, Victoria, and Prince George.

Previous research showed that childhood trauma could increase the risk of mental illness in adulthood, as well as risk for future physical and sexual assault or abuse. These risk factors could themselves predispose people to head injuries, such as traumas to the head during abuse, the authors hypothesized.

They found that, among the different types of childhood trauma, physical abuse and emotional abuse were significantly associated with a history of TBI, although sexual abuse, physical neglect, and emotional neglect were not. However, a greater total number of childhood trauma types correlated with an overall greater likelihood of TBI history. This finding pointed to a “cumulative effect of childhood trauma types” on TBI, the researchers noted. This effect has also been observed in depression, post-traumatic stress disorder, and the age of initial homelessness.

The study did not examine when TBIs occurred relative to childhood trauma and did not establish a causal relationship, so the authors encouraged further study of how childhood trauma could lead to TBI. They point to “behavioral and emotional patterns” arising from childhood maltreatment that could play a role. Specifically, emotional abuse has been linked with psychological distress and a diminished capacity for regulating emotions and managing stressful situations, which can increase a person’s vulnerability to assaults or accidents that result in TBI.

The study demonstrates the important role that childhood trauma prevention strategies can play in preventing TBI among homeless people. The authors further note that clinicians and staff who care for the homeless should inform their practice, based on the associations between childhood trauma and TBI, to emphasize safety and address the “broad clinical consequences of childhood trauma to facilitate recovery.”

To MJ, O’Brien K, Palepu A, Hubley AM, Farrell S, Aubry T, Gogosis E, Muckle W, Hwang SW. Healthcare utilization, legal incidents and victimization following traumatic brain injury in homeless and vulnerably housed individuals: A prospective cohort study. J Head Trauma Rehabil. 2014 Mar 19. Epub ahead of print.

Prior research on traumatic brain injury has shown that those with a history of TBI are both more likely to behave violently and be victim of violence themselves. In this study, the researchers, including CHÉOS Scientist Dr. Anita Palepu, interviewed homeless and vulnerably housed people about their health history and sociodemographic characteristics to identify relationships between TBI history and future access to health care, legal incidents, and victimization within a one year follow-up period.

Among the population studied, the lifetime prevalence of TBI was seven times higher than in the general population. The authors found that homeless and vulnerably housed people with a history of TBI were more likely to have experienced a greater number of years of homelessness, be in poorer health, and live with a chronic condition. They were also involved in a greater number of legal incidents, 1.5 times more likely to have sought care at an emergency department, and twice as likely to have been incarcerated, compared to people without a history of TBI. The researchers noted these results could be attributed to the pathology of TBI: impaired cognition and emotional regulation, disturbances of personality, or aggression.

Additionally, those with TBI were nearly three times more likely to have been physically assaulted, leading the authors to conclude that sustaining a TBI is “an independent risk factor for becoming a future victim of physical assault.” The authors note that efforts to screen homeless and vulnerably housed people for TBI, manage its consequences, and rehabilitate the victims can improve the health and social outcomes and possibly reduce victimization, the need for costly health care, and interactions with the legal system.

Olson Z, Staples JA, Mock C, Nguyen NP, Bachani AM, Nugent R, Verguet S. Helmet regulation in Vietnam: impact on health, equity and medical impoverishment. Inj Prev. 2016 Aug;22(4):233-8.

In 2007, only 30% of motorcycle riders wore helmets on the streets of Vietnam. That number jumped to 93% in a matter of months, thanks to new legislation involving fines of just under a third of an average person’s monthly income. The policy itself would cost the government a model-estimated $24 million to implement.

Road traffic accidents are not only one of the top causes of mortality globally, but also represent a large burden to the health care system, including, in some cases, significant out-of-pocket medical expenses. Previous research shows that helmet use has health benefits, but this study’s authors, including CHÉOS Scientist Dr. John Staples, set out to quantify both the health and financial advantages of the new regulations. They performed an extended cost-effectiveness analysis to simulate the policy’s effect on road death or injury, acute care costs for individuals, income loss from missed work, and protection from impoverishing financial losses.
The results of the analysis showed that, in a year following the introduction of the Vietnamese government’s policy on helmet use:

  • 2200 deaths were prevented
  • 29 000 head injuries were prevented
  • $18 million were saved by individuals for acute care costs
  • $29 million in individual’s income losses (from missed work) were saved
  • 11 000 cases of poverty were averted (due to prevented health care expenditure, etc.), of which the greatest number of cases were low and middle-income individuals
  • Motorcycle accident deaths dropped from 29% to 14%

The authors noted that governments should invest in enforcing regulation not only for riders, but also for helmet manufacturers and retailers to meet safety standards, in order to maximize the cost effectiveness of the policy. Overall, the team concluded that for individuals with lower income, “injury prevention is also poverty prevention.”

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