Populations: Family and Peer Influences George Kazolis, BSc (Hons), - - PowerPoint PPT Presentation

Strategic Teams in Applied Injury Research (STAIR)

Preventing TBI in Vulnerable Populations: Family and Peer Influences

George Kazolis, BSc (Hons), University of Toronto Lorne Tepperman, PhD, University of Toronto

Brain Injury Association of Canada 10th annual conference September 26th, 2013

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Research Objective

Objective: to improve our understanding of traumatic brain injury (TBI) by exploring the social and developmental histories of unintentional fall-based TBI participants.

Funding: CIHR (grant # TIR-103946), and the Ontario Neurotrauma Foundation. Principal Investigator: Dr. Michael Cusimano, St. Michael’s Hospital.

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Risk factors associated with TBI

Falls and TBI:

• Unintentional falls are the leading cause of non-fatal

TBI.

• Individuals that fall are 2–3 times more likely to

sustain a recurrent fall. Substance abuse and TBI:

• Approximately two thirds of individuals with TBI have

a history of substance abuse pre-injury.

• Young adult males have the highest incidence of TBI

and the highest incidence of substance abuse.

• 1. Study Design
• The data for analysis was collected through

structured open-ended interviews with (unintentional fall-based) TBI participants.

• All interviews were tape-recorded and

transcribed.

• The transcribed materials were analyzed using

qualitative methods to search for patterns and major themes.

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• 1. Study Design

Structured open-ended interview:

• Details about a) most recent, b) first, and c)

most severe TBI.

• The participant elaborated on key events

and episodes prior to the injury, including childhood.

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• 2. Subjects and setting

Inclusion Criteria

• Age equal to or greater than 18 years;
• Patients with Glasgow Coma Scale score of

13 or less (i.e. moderate to severe TBI);

• TBI sustained due to an unintentional fall

within the preceding 1-3 years. Exclusion Criteria

• Are unable to undergo MRI scanning;
• Medically unstable or still hospitalized in-

patients.

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• 2. Subjects and setting
• 27 participant transcripts were included for

data coding. Samples were stratified by age and gender.

• Participants were recruited from St. Michael’s

Hospital (SMH); a major regional trauma centre in Toronto.

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• 3. Data Analysis
• Transcript analysis was based on the Grounded

Theory method. The Coding Process: ▪ The coding process involved the generation of codes, which led to categories, and finally themes that helped formulate a theory. ▪ Three coding steps were used: open coding, axial coding, and selective coding.

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The Coding Process

Level III

SELECTIVE coding

Level II

AXIAL coding

Level I OPEN coding

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Level I – Open coding

Table 1. Level I Codes - codes ranked in (descending) order of linkages

Code

# of Sources # of References

Prior history of risky behaviour 23 119 Prior alcohol or substance abuse 17 52 Participant's friends or co-workers abuse recreational drugs or alcohol 16 27 Participant believes they are suffering from memory deficits since the accident 14 18 Participant has displayed more emotional or irritable behaviour since the accident 12 25 Participant accepts responsibility for causing their accident 12 23 Family history of alcoholism 12 22 Participant's friends or co-workers involved in risky activities 11 21 Participant had suffered a head injury in the past 11 13 Participant believes they are suffering from deficits in attention or concentration since the accident 11 12 Participant believes there is nothing they could have done to prevent the accident 11 12 Participant believes their recent head injury could have been avoided 11 14

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Level II – Axial coding

Table 2. Level II Categories (Axial coding)

Category # of Sources # of References Dispositional factors 27 225 Family influences 21 90 Peer influences 21 58 Physical vulnerabilities 19 53 Situational factors 16 30 Psychological vulnerabilities 9 26 Community influences 6 19

RISK theme coding flowchart

(partial)

Open codes Axial codes Selective code

RISK Situational Influences

Safety helmet not required at work Work-related unintentional fall

Physical Vulnerabilities

Pre-existing medical conditions

Prior head injury

Under the influence of alcohol at time of injury

Psychological Vulnerabilities

Stress prior to injury History of mental illness

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OPPORTUNITY theme coding flowchart

(partial)

Open codes Axial codes Selective code

OPPORTUNITY

Family Influences

Family history of alcoholism

Childhood history of verbal conflict

Dispositional Factors

Prior alcohol or substance abuse Prior history of risky behaviour

Peer Influences

Friends or co-workers abuse drugs or alcohol

Friends or co-workers involved in risky activities

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Level III – Selective coding

Opportunity theme

Table 3. Level III Oppor

• rtuni

unity ty Theme with sample Level II Cate tego gori ries and Level I Codes

Theme Categor y Code Example from t ranscripts Opportunity Family Influence s Family history of alcoholism I: Okay and besides your dad, has drinking ever been a problem for anybody else? P:

• Yep. My uncles –

they were all

• alcoholics. My grandfather.

And my mother’s brothers. Yeah I was surrounded. Growing up it was rampant . Participant’s family involved in risky activities M y brother was a bad boy so there’s that … most of his friends I don’t hang out with because I’ll go to jail if I hang out with them. Peer Influences Participant’s friends

• r co
• workers abuse

drugs or alcohol P: I normally drink with friends I don’t like to drink by myself I: did drinking ever cause any of your friends’ problems? P: health wise yeah, quite a few of them di ed I: because of alcohol? P: yeah Participant’s friends

• r co
• workers

involved in risky activities Oh for hockey I was in a team but we used to do all kinds of crazy stuff. Dirt bike, you know you wipe out. I’m sure there’s been a few times I smacked my

• head. Yeah.

Level III – Selective coding

Opportunity theme

Family history of alcoholism I: “Okay and besides your dad, has drinking ever been a problem for anybody else?” P: “Yep. My uncles – they were all

• alcoholics. My grandfather. And

my mother’s brothers. Yeah I was

• surrounded. Growing up it was

rampant.” Family members involved in risky activities P: “My brother was a bad boy so there’s that… most of his friends I don’t hang out with because I’ll go to jail if I hang out with them.”

Level III – Selective coding

Opportunity theme

Participant’s friends or co- workers abuse drugs or alcohol P: “In the last 20 years, there’s not many people I’ve met that don’t, you know? I know there are, here and there, but no, most people I know do drugs.” Participant’s friends or co- workers involved in risky activities P: “Oh for hockey I was in a team but we used to do all kinds of crazy stuff. Dirt bike, you know you wipe out. I’m sure there’s been a few times I smacked my

• head. Yeah.”

RISK theme - ‘Stumblers’

• Participants that are more

vulnerable to fall-based TBI due to internal vulnerabilities and external situations. OPPORTUNITY theme - ‘Tumblers’

• Participants that played an

active role in their fall-based TBI through their involvement in risky and/or delinquent behaviours.

Level III – Selective coding

Risk and Opportunity themes

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Two pathways to fall-based injury: ‘Stumblers’ vs. ‘Tumblers’

‘Stumblers’ Stumblers played a passive role in their TBI injury event. i) Physical vulnerabilities ii) Situational influences iii) Psychological vulnerabilities ‘Tumblers’ In contrast, Tumblers played an active role in their TBI injury event i) Dispositional influences ii) Family influences iii) Peer influences

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Family and Peer influences

Social Learning Theory (SLT): behaviours are learned by observing the social environment.

• A child learns behaviours through modeling

processes early in development.

• SLT suggests that youth learn to be violent by
• bserving the behaviour of intimate primary groups,

such as family and peers.

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The life course perspective and later TBI

The life course perspective focuses on the social organization of lives by positing the concept of trajectories.

• A ‘cumulation of disadvantages’.
• Earlier family conflict and delinquent peer

relationships can lead to other negative events and transitions in an individual’s life.

• These consequences, in turn, can lead to

actively making riskier choices – contributing to these individuals’ TBI event later in life.

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Conclusions

▪ For a subset of our participants – the active fallers termed Tumblers – early personal history played an important role in the precipitation of later injury.

• Their life course trajectories were altered by

early psychosocial influences leading to increased involvement in substance abuse and risky activities -- which ultimately contributed to their TBI event.

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Prevention

Effective prevention lies in reducing psychosocial risk factors in many domains: 1) Reduce Media Violence

• Adolescents have reported committing homicides to impress

peers or be on TV (Kashani, Darby, Allan, Hartke, & Reid,1997).

2) Limit Youth Access to Drugs and Alcohol

• Stricter national laws, harsher penalties on local businesses

(e.g., liquor stores that sell alcohol to minors).

3) Involve Schools

• Teachers and school counsellors can assist mental

health professionals in early identification.

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Limitations

▪ Limits on generalizing the findings due to the use of purposive sampling (only studied TBI patients). ▪ The stigma and fear associated with delinquency and substance abuse lead to these events often being unreported, making it difficult to collect accurate data.

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