DEPARTMENT OF PSYCHOLOGY UNIVERSITY OF GHANA
INJURY SEVERITY, COPING STRATEGIES AND PSYCHOSOCIAL OUTCOMES OF INDIVIDUALS WITH TRAUMATIC BRAIN INJURY
BY EMMANUEL SARKU (10328043)
THIS THESIS IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE AWARD OF MPHIL CLINICAL PSYCHOLOGY DEGREE
JULY 2011
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DECLARATION I confirm that this work is my own and has not been presented by anyone for any academic award in this or any other university. All references used in the work have been fully acknowledged. ….………………………………… Emmanuel Sarku (Student)
We hereby certify that this thesis was supervised in accordance with procedures laid down by the University.
……………………………
………………………………
Prof. S. A. Danquah
Date
(Principal Supervisor)
.…………………………..
...…………………………….
Dr. Adote Anum
Date
(Co – Supervisor)
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DEDICATION This work is dedicated to Chananjah who has continually sustained me, my parents and siblings, who have stood by me at all times, and brain injury survivors who helped make this study possible.
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ACKNOWLEDGEMENT First and foremost I will like to take this opportunity to thank EL Shaddai who watches over me as I go through life’s journey. I am also indebted to my academic supervisors Prof. Samuel A. Danquah and Dr Adote Anum for being willing to give me the opportunity to study at this level, and for their support, mentorship and encouragement. I would like to take this opportunity to express my gratitude to the participants of this study without whom this study would not have been possible. I am also indebted to management of Korle-bu Teaching Hospital and 37 military Hospital for granting me access to both their premises. Thanks go to the Institutional Review Board of Noguchi Memorial Institute of Medical Research of the University of Ghana for providing clearance for this project Acknowledgments are due my colleagues at the department of psychology particularly Joana Salifu, Lily Kpobi, Samuel Adjorlolo, Mary Anpomah and Jennifer Peprah who helped in various ways to make this study a success. I would like to thank Dr. Kinsley Nyarko of the Department of psychology and Nandy Walker for their support and advice, especially throughout the final days of my thesis. You made me think beyond what I see and much contributed to the quality of the thesis. Last but not least, I want to thank my family and in particular my parents, Beatrice Deih, and Mr. Abel Sarku and my siblings Dinah Sarku and Enoch Sarku who encouraged me and stood by me every step of the way. You never stopped believing me and I am forever grateful for your love and support. iv
ABSTRACT The present study examined the influence of injury severity, coping strategies, religious coping and social support on the psychosocial outcomes of individuals with traumatic brain injury (TBI) in Ghana. 40 participants with TBI who had come for clinical review at both 37 military and Korle-bu Teaching hospitals and met the inclusion criteria completed the Galveston Orientation and Amnesia Test, where their post traumatic amnesia was assessed to determine their level of injury severity. Other measures include Brief Cope where coping strategies were rated; the Religious Coping Activities Scale to assess extent to which people turn to religion to cope with stressful psychosocial changes; the Multi-dimensional Social Support Scale to assess the availability of social support; the Mayo Portland adaptability inventory-4 to evaluate psychosocial outcomes. Results indicated a significant difference in the psychosocial outcomes of at least two TBI severity groups. Injury severity was significantly associated with poor psychosocial outcome while coping strategies (problem focused and emotion focused) strategies was significantly associated with better psychosocial outcome. Social support was also associated with better psychosocial outcome. However Religious coping was not significant predictors of psychosocial outcome when demographics were controlled. The relationship between injury severity and psychosocial outcome was not dependent on coping strategies. The results however suggest that individuals with TBI may benefit from interventions that make use of social support, problem focused, and emotion focused coping strategies. Implications of the findings are discussed Key Words: TBI, Injury Severity, Coping Strategies, Religious Coping, Social Support, Psychosocial Outcome. v
TABLE OF CONTENT Title Page……………………………………………………………………………….........i Declaration………………………………………………………………………….…ii DEDICATION………………………………………………………………………..iii AKNOWLEDGEMENT……………………………………………………………...iv ABSTRACT…………………………………………………………………………...v TABLE OF CONTENT………………………………………………………….........x LIST OFTABLES…………………………………………………………………….xi LIST OF FIGURES…………………………………………………………………..xii LIST OF ABBREVIATIONS……………………………………………………….xiii CHAPTER ONE………………………………………………………………….......1 INTRODUCTION………………………………………………………………...…...1 Background....................................................................................................................1 Aetiology of TBI............................................................................................................3 Epidemiology of TBI………………………………………………………………......5 Types of TB………………………………………………………………………........6 Open Head injury……………………………………………………………………...6 Closed Head injury…………………………………………...………………………..7 Severity of TBI………………….. ……………………………...…………………….7 Outcomes of TBI……………………………………………………………………....9 vi
Psychosocial Outcomes………………………………………………………….…...10 Social Impact of TBI…………………..……………………………………………..10 Life Style Consequences…………………………………………………………......11 Coping with Outcomes…………………………………………………………….....12 Statement of the Problem………………………………………………………….....12 Relevance…………………………………………………………………………....15 Aims and Objectives………………………………………………………………....16 CHAPTER TWO…………………………………………………………………....17 LITERATURE REVIEW……………………………………………………….........17 Theoretical Framework……………………………………………………………....17 Theory of Humans in Crisis and Coping……………………………………………..17 The shock phase………………………………………………………………….......17 The reaction phase………………………………………………………………........18 The adaptation phase……………………………………………………………........18 Reorientation phase……………………………………………………………...…...18 Coping Theories………………………………………………………………...……19 Problem-Focused Coping Strategies…………………………………………............21 Emotion-Focused Coping……………………………………………………….........21 Religious Coping……………………………………………………………………..23 Social support………………………………………………………………………...26 Related studies……………………………………………………………………......28 vii
Injury severity and psychosocial outcomes……………………………………..........28 Coping and psychosocial functioning following TBI…………………………..........31 Religious coping and psychosocial outcomes following TBI…………………..........33 Social support and psychosocial outcomes following TBI…………………….…….35 Demographics and psychosocial outcomes…..……………………………...............37 Hypotheses……………………………………………………………...…..………..41 Conceptual Framework……………………………………………………..………..42 Operational Definition of Terms/Concepts………………………………..…............43 CHAPTER THREE………………………………………………………………...44 METHODOLOGY…………………………………………………….…...………...44 Setting…………………………………………………………….………...………...44 Population………………………………………………………….…………............44 Samples………………………………………………………….……………...........44 Sample size determination……………………………………………………………44 Sampling Technique………………………………………….………………............45 Inclusion/Exclusion Criteria for Participants in this Study…….…………….............45 Participants……………………………………………………….……………..........46 Research Design……………………………………………….………………..........47 Measures……………………………………………………..………………….……47 Injury severity……………………………….……………..…………………............47 Coping strategies………………..………………………...…………………….........48 viii
Religious coping……………………………………………………………………...49 Social support ………………………………………………………………………..51 Psychosocial outcome…………………………………...…………………………...52 Pilot study……………………………………………...……………………………..54 Ethical Consideration………………………………...……………………...……….54 Informed Consent, Confidentiality and Risks.……………………………..………...54 Ethical Clearance……………………………………………………….……….........55 Procedure……………………………………………………………………………..55 CHAPTER FOUR…………………………………………………………………..57 RESULTS……………………………………………………………………….........57 Data analysis…………………………………………………………………….........57 preliminary analysis……………………………………………………………….....57 Psychosocial outcome………………………………….…………………………….58 Test of Hypotheses…………………………………….…………………………......58 Summary of findings…………………………………….……………………….......67 CHAPTER FIVE……………………………………….…………………………...68 DISCUSSION…………………………………………….……………………….....68 Difference in psychosocial outcome of TBI severity groups....…………………......68 Association of coping strategies with phsychosocial outcom….………………….....70 Relationship between religious coping strategies and psychosocial outcomes……....72
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Relationship between social suport and phsychosocial outcome…………………….73 Moderating Effect of Coping Strategies on the effect of TBI Severity on………… Psychosocial Outcomes……………………………………………………………....74 Implication of the study……………………………………………………………....76 theoretical implication………………………………………………………………..76 Implication for practic………………………………………………………………..77 Limitations…………………………………………………………………………....78 Recommendations………………...............................................................................79 Summary and Conclusion……………………………………………………………79 References……………………………………………………………………….........81 APPENDICES………………………………………………………………….........114 Appendix A: Ethical Clearance………………….……………………………….…114 Appendix B: Consent Form……………………….………………………………...115 Appendix C: Measures………………………….……………………………….….121 1: Demographics……………………………….…………………………………...121 2: The Galveston Orientation and Amnesia test………………………………….....121 3: Brief Cope…………………………………………………………………..........123 4: Religious Coping Activity Scale…….…………………………………………...125 5: The Multi-Dimensional Support Scale.…………………………………………..127 6:Mayo-Portland Adaptability Inventory-4……………………………………........129
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LIST OF TABLES Table 1: Classification of traumatic brain injury (Lucas, 1998)………………….......8 Table 2: Basic demographics of participants………………………………………...46 Table 3: MPAI-4 items by subscale......................................………………………...53 Table 4: Means and Standard Deviation (SD) of the study variables of Individuals with traumatic Brain Injury………………………………………......58 Table 5:Summary of One-Way ANOVA of injury severity and psychosocial outcome of individuals with TBI………………....…………………………………………....59 Table 6: Summary of Tukey HSD of the injury severity of individuals with TBI…...59 Table 7: Multiple regression model summary………………………………………..60 Table 8: Hierarchical Regression analysis of variables predicting Psychosocial outcome of Individuals with Traumatic brain Injury (N = 40………………….........61 Table 9: Hierarchical Multiple Regression of the Moderation Effect of Coping Strategies on the Relationship between Injury Severity and Psychosocial Outcome (N = 40)……………………………………………………………...…….65
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LIST OF FIGURES Figure 1: Frame work of the association of psychosocial outcome with injury severity, coping strategies, religious coping and social support..................................42
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LIST OF ABBREVIATIONS 1. ABI
Acquired Brain Injury
2. APA
American Psychology Association
3. BDI
Beck Depression Inventory
4. BMMRS
Brief Multidimensional Measures of Religiousness/ Spirituality
5. CIHI
Canadian Institutes of Health Information
6. CSA
Coping Scale for Adults
7. DAI
Diffuse Axonal Injury
8. DVBIC
Defense and Veterans Brain Injury center
9. EFNS
European Federation of Neurological Societies
10. GCS
Glasgow Coma Scale
11. GOAT
Galveston Orientation and Amnesia Test
12. GOS
Glasgow Outcome Scale
13. HADS
Hospital Anxiety Depression Scale
14. HSD
Honestly Significant Difference
15. KAS
KATZ Adjustment Scale
16. KBTH
Korle-Bu Teaching Hospital
17. LOC
Loss of Consciousness
18. MDSS
Multi-Dimensional Support Scale
19. MPAI-4
Mayo-Portland adaptability Inventory- 4
20. MRC
Medical Research Council
21. MRC
Multiple regression Analysis
22. MTBI
Mild Traumatic Brain Injury
23. MVAs
Motor Vehicle Accidents xiii
24. NFI
Neurobehavioral Functioning Inventory
25. NIH
National Institute of Health
26. One-Way ANOVA
One-Way Analysis of Variance
27. PTA
Post Traumatic Amnesia
28. RTA
Road Traffic Accidents
29. PTSD
Post Traumatic Stress Disorder
30. RTP
Return to Productivity
31. SD
Standard Deviation
32. SPRS
Sydney Psychosocial Reintegration Scale
33. STAI
State- Trait Inventory
34. TBI
Traumatic Brain Injury
35. VR
Vocational Rehabilitation
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CHAPTER ONE INTRODUCTION Background Traumatic brain injury (TBI) is now an everyday incidence with adverse psychosocial problems that have a significant impact on capacity for work, functional independence, social functioning and relationships (Kreutzer, Marwitz, Walker, Sander, Sherer, & Bogner 2003; Ponsford, Sloan, & Snow, 1995). Changes in social and psychological outcome are the major determinants of the ability of an individual to function adequately in society following TBI (Lezak, 1995; Silver, McAllister, & Arciniegas, 2009). For many individuals, TBI may bring about a sudden change from an expected way of life to a situation where psychosocial status have changed and prospects of the future are not known (Godfrey, Knight, & Partridge, 1996). Adaptation to these sudden changes can vary, with a number of interrelating factors, such as demographic variables, injury-related characteristics and coping strategies influencing outcome (Stratton & Gregory, 1994). Coping is broadly defined as a person’s constantly changing cognitive and behavioural efforts used to manage external and/or internal demands (Lazarus 1993). The coping strategies used to deal with problems associated with TBI can play a key role in the adaptation to changes in psychosocial outcome. However, there is much debate as to whether the individuals’ appraisal of TBI as more manageable or less manageable plays a role in the choice of coping strategies and in the psychosocial outcomes associated with the trauma. The baseline is however, that in the long term, emotion oriented and avoidant coping styles may be 1
less adaptive than problem/task oriented and approach strategies (Lazarus & Folkman, 1984). Research specifically addressing the role of coping strategies in post-TBI adjustment and disabilities such as amputation, consistent with the wider coping literature, suggests that active/task-oriented strategies such as problem solving and perceiving control over the disability are conducive to positive psychosocial adjustment (e.g. Barlow, Allen, & Choate, 2004; Curran, Ponsford, & Crowe, 2000; Finset & Andersson, 2000) whereas emotion focused and passive strategies such as cognitive disengagement, catastrophizing and wishful thinking have been associated with poor psychosocial outcomes (Anson & Ponsford, 2006; Livneh, Antonak, & Gerhardt, 1999 ). For example, Livneh et al. (1999) found that greater active problem solving was negatively associated with depression and internalized anger and positively associated with adjustment and acceptance of disability. On the contrary, emotion focused coping and cognitive disengagement were positively associated with depression, externalized hostility and lack of acceptance of disability. Some researchers are however, of the view that the distinction of coping as problem focused or emotion focused is too simplified (Carver, Scheier, & Weintraub, 1989). This was based on the opinion that within these two general forms of coping there may be different methods. For instance, to cope emotionally with a stressful situation, a person may use denial, humour, or look for social support (Carver et al., 1989). The lack of or availability of social support can impact on psychosocial outcome. Coping with the implications of TBI related problems could be a difficult and often lifelong process. Patients may cope by adjusting their social role to fit the demands and challenges associated with the injury, or they may cope by trying to reframe their 2
experiences viewing the situation in a more positive light, or rely on religion and social support. Accepting the reality of the trauma and developing a positive attitude toward rehabilitation is thought to be critical for successful coping and recovery (Decoster, 1993). Sometimes, some individuals with TBI find faith helpful in their recovery while others may find it a source of distress. However, Religion may provide individuals with a variety of ways of coping with and making meaning of TBI in addition to non-religious material, psychological, and social coping resources (Waldron-Perrine, Rapport Hanks, Lumley, Meache, & Hubbarth, 2010). However, literature pertaining to associations between coping strategies, religious coping and social support and psychosocial adaptation to TBI is relatively scarce and several methodological issues limit the conclusions drawn and generalizability of these investigations. In response to these issues, this study investigated the level of injury severity of TBI, TBI-related coping strategies, religious coping and level of social support and their association with psychosocial outcome. Aetiology of TBI TBI is defined as injury to the brain as a result of an external force or contact forces, inertia forces (acceleration and/or deceleration) that may cause a diminished consciousness or altered state of consciousness or coma and/or post traumatic amnesia (Povlishock & Katz, 2005; Stratton & Gregory, 1994), neurological impairment and cognitive deficit (Lucas, 1998). The anterior and inferior frontal and temporal areas of the brain are the most commonly and severely affected parts of the brain following TBI (Bigler, 2007). 3
Falls, motor vehicle accidents (MVAs), assaults and struck by an object are the four most predominant causes of brain injury (Canadian Institutes of Health Information [CIHI], 2006). Blasts are also primary cause of TBI for active duty military personnel in war zones (Defense and Veterans Brain Injury Center [DVBIC], 2006). Many factors are thought to be related to risk for TBI. Demographic factors such as age, gender, race, and socioeconomic factors are thought to influence risk for TBI. Kraus (1993) found that teenagers and young adults are more likely to be injured in vehicular crashes or through violence, while older adults are more likely to be injured in falls. Overall, males are about 1.5 times to sustain TBI compared to females (Langlois, Rutland-Brown, & Thomas, 2006). This ratio is highest during adolescence and early adulthood, peak times for interpersonal violence and MVAs, and can approach or exceed 3 to 4:1 (Bruns & Hauser, 2003). These demographic factors can also interact to influence relative risk of TBI. Gender interacts with age as it relates to TBI risk. Ip, Hesch, Brandys, Dornan, and Schentag (2000) found the highest rate of injury occurred between the ages of 21 to 40 years for males, and between the ages of 31 to 40 years for females. There also appears to be an interaction between race and age, with males and ethnic minorities more at risk during adolescence and early adulthood. This is related to the increased risk of violence and MVAs in these age groups (Bruns & Hauser, 2003). Individuals with violent TBI are also more likely to have used illegal drugs and been arrested (Bushnik Hanks, Kreutzer & Rosenthal, 2003), and have higher blood alcohol levels in the emergency department (Machamer, Powell, & Temkin, 2003). These findings have implication for individuals’ with TBI. we belief that the demographic characteristics of TBI 4
patients will be associated with TBI severity and psychosocial outcomes. This is an important consideration that need be investigated in the current study. Epidemiology of TBI According to Medical Research Council [MRC] CRASH Collaborators (2008), TBI has been identified as the leading cause of death and disability all over the world. Every year, about 1.5 million affected individuals die and several millions receive emergency treatment (Bruns & Hauser, 2003; Fleminger & Ponsford, 2005). Hofman, Primack, Keusch, and Hrynkow (2005) stated that most of the burden (90%) is in low and middle income countries. In Ghana existing epidemiological data suggests that road traffic accidents (RTA) are responsible for majority of brain injury (El-Gindi, Mahdy, & Abdel-Azeem, 2001). The annual incidence of injuries is over 900 per 100,000 persons as indicated in admission and discharge books in Selected Ghanaian Hospitals (Mock, Farjuog, & Rivera, 1999). Mock, Farjuog, and Rivera (1999) found that in urban areas passengers are injured in minibus and taxi crashes, or pedestrians are struck by these vehicles, and the most common road traffic accidents in rural areas were bicycles crashes followed by vehicle accidents involving commercial rather than private vehicles. ElGindi et al. (2001) were of the view that the inability of some of the injured individuals to seek treatment creates both social and psychological problems. Moreover, more men than women were found to sustain brain injury and they were between the ages of 20-45 years (Mock et al., 1999). These epidemiological data presents clinical and experimental challenges to both clinicians and researchers to understand and to manage the outcome of TBI.
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Types of TBI The initial event of brain trauma involves energy (impulse) transmission to the head which results in sudden acceleration, deceleration or rotation of the brain (Vos, Battistin, Birbamer, Gerstenbrand, Potapov, Prevec, Stepan, Traubner, Twijnstra, Vecsei, & von Wild, 2002). As a result, direct focal injury may occur as the brain makes contact with the sharp bony surfaces of the skull (Ashman, Gordon, Cantor, & Hibbard, 2006). However, majority of TBI’s result in widespread shearing and stretching of nerve fibres called diffuse axonal injury (Ashman et al., 2006). When an external force impact upon the brain, either of two types of injury namely closed head injury and open head injury or penetrating injury may occur (Ashman et al., 2006). Open Head Injury. Open head injury results from fractured skull or when the skull and the dura are penetrated by sharp foreign objects such as gunshot, knives, screwdrivers, arrows, darts, and debris (Bayston, de Louvois, Brown, Johnston, Lees, & Pople, 2000). The resulting damage can cause immediate or primary injury (Kraus & McArthur, 1999). secondary injury may also occur as a result of interruption of the flow of blood to adjacent tissues in the brain, edema (swelling) of tissues in the brain, brain infections and post traumatic epilepsy or seizure (Gennarelli & Graham, 2005). Lack of oxygen supply to the brain as well as changes in heart rate and elevated intra cranial pressure can also cause secondary damage (Rose & Johnston, 1996). Tertiary complications such as critical illness, polyneuropathy, disabilities, sepsis and thromboembolic complications may manifest days or weeks following the trauma due to altered catabolic state or increased thrombosis following prolong bed rest, paralysis or infection (Gerstenbrand, 1977).
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Lezak (1995) reported that an open or penetrating injury is less common in the civilian population accounting for fewer than 10 per cent of injuries compared to the military population where the incidence is common. Closed Head Injury. In closed head injury, the skulls remain intact due to none penetration but damage to the brain tends to be diffused (Ashman et al., 2006). The rapid acceleration and deceleration of the brain as when an individual’s head hit an object during a fall leads to what is called coup (Ashman et al., 2006). Following the initial impact the brain can rebound and strike the skull opposite the initial blow. The resulting lesions are referred to as contre coup lesions, and may be larger than those at the initial site of impact (Lucas, 1998). The rapid acceleration and deceleration movement can result in the disruption of fibres causing defuse axonal injury (DAI) (Ashman et al., 2006). The areas of the brain most susceptible to coup after head injury include the poles and inferior aspects of the frontal lobes, and the poles and lateral and inferior aspects of the temporal lobes (Gennarelli & Graham, 2005). Severity of TBI Normally, TBI is classified as mild, moderate and severe. Measures that are commonly used to define severity of brain injury are Loss of Consciousness (LOC), Post Traumatic Amnesia (PTA) and Glasgow Coma Scale (GCS) (table 1). Arlinghaus, Shoaib, and Price (2005) identified LOC as the rate of time it takes for a patient to regain consciousness, and PTA as the intervening period until the person is oriented and can consistently recall details of his or her environment. The duration of PTA has been identified as the best indicator of the extent of cognitive and functional deficits after TBI (Khan, Baguley & Cameron, 2003).
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Lucas (1998) identified the GCS as the measure of responsiveness following TBI. GCS has high sensitivity to severe and moderate injuries in predicting behavioural outcomes but is less sensitive to milder brain injuries (Lucas, 1998). The GCS generates a score between 3 and 15 based on a person’s abilities in eye opening and motor and verbal function (Teasdale & Jennett, 1974). It is a quick and easy tool used to assess the severity of TBI in the acute setting and it gives a prognosis for survival rather than for functional outcomes (Khan et al., 2003). Classification of TBI is important when measuring outcome. It establishes a baseline for the identification of TBI severity groups and how their difference in psychosocial outcome can be established. Table 1:
Mild TBI
Classification of TBI (Lucas, 1998) Loss of
Posttraumatic
Glasgow Coma
Consciousness;
Amnesia;
Scale;
(LOC)
(PTA)
(GCS)
For 30 minutes
Less than 1 hour
At least 13 points.
1 – 24 hours
9 – 12 points
or less.
Moderate TBI
Longer than 30 minutes but less than 60 minutes
8
Severe TBI
Very
Severe
Longer than 30
Longer than 24
minutes
hours to 7 days
TBI Loss of pupillary
(critical)
Longer than 7
reactions and absent
8-5 points
3-4 points
days
or decerebrate motor reactions.
Outcomes of TBI Due to recent medical and technological advances, many individual with TBI are surviving injuries that previously would have been fatal (Klimczak, Donovick, & Burright, 1997). As a result those affected by TBI may face permanent disabilities that affect their cognitive function, productivity and quality of life (e.g., Christensen, Colella, Inness, Hebert, Monette, Bayley, & Green, 2008; Dawson, Levine, Schwartz, & Stuss, 2004; Ruttan, Martin, Liu, Colella, & Green, 2008; Till, Colella, Verwegen, & Green, 2008). The consequence is impairment of physical skills, cognition (Karol, 2003), psychosocial dysfunction (Anson & Ponsford, 2006; Draper, Ponsford, & Schonberger, 2007). Psychosocial Outcomes Studies show that an estimated 40-75% of severely brain-injured individuals experience persisting psychosocial problems 6-8 years post-injury (Tate, Lulham, Broe, Strettles, & Pfaff, 1989; Oddy, Coughlan, Tyerman, & Jenkins, 1985). Research among mild head-injury patients have also identified changes in various domains of psychosocial functioning (Andrasik & Wincze, 1994) namely ability, adjustment and participation. TBI can have profound impact on an individual’s emotion, possibly 9
leading to adverse effect on behavioural and social functioning (Family Caregiver Alliance, 1993; Draper et al., 2007). Individuals with TBI are at high risk of developing mental health disorders (Williams & Evans, 2003). Symptoms that may worsen in the course of the first six months posttrauma are variability in mood, depression, emotional withdrawal, agitation/hostility, and apathy (Dunlop, Udvarhelyi, Stedem, O'Connor, Isaacs, Puig et al., 1991). Assaults, prior history of alcohol abuse, location of injury (Dunlop et al., 1991) premorbid impulsivity and male gender (Burton & Volpe, 1988) can severely impact on emotional pathology. Psychosocial difficulties following TBI can result in recurrent difficulties with substance abuse (Delmonico, Hanley-Peterson, & Englander, 1998). Social Impact of TBI A health conference held on rehabilitation of persons with TBI revealed that the consequences of TBI can be pervasive and endure across the lifespan, impacting on individuals and their families economically, and placing additional burdens on the community (National Institute of Health Consensus Conference, 1999). Moderate disability may bring about changes in personality and disrupt families and friends. Severe TBI leading to changes or impairments in a person’s social skills, cognitive capacities, physical appearance and abilities, often results in fewer social contacts, disruption of marriage, alienation and isolation (Levin, Benton, & Grossman, 1982; Nadell, 1991). Individuals with TBI may also experience a variety of difficulties in returning to work, particularly those who previously held high level positions (Shames, Treger, Ring, & Giaquinto, 2007).
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Changes in social skills can also create challenges for many people with TBI, as the quality of their social contact may affect their long-term psychosocial adaptation (Crisp, 1994). There may be reduced prospects for forming new social interactions and friends, and engaging in leisure activities, often due to high incidence isolation and of individuals living at home with their families (Morton & Wehman, 1995). This indicates that the availability of social support is important in dealing with psychosocial difficulties. In a recent study with chronically ill individuals, Sacco and Yanover (2004) found that poor social support was positively correlated with depression and poor physical health. These finding highlighted the importance of interpersonal factors when considering the physical and mental health of individuals. The ability to predict social and occupational outcome for those who have suffered a severe TBI is also a complex task (Prigatano, 1991a), as recovery may not proceed evenly across various cognitive areas and psychosocial changes may take some time to become obvious. Prigatano (1991a) is of the view that attempting to resume former social and work activities prematurely may bring disappointment and rejections, which in turn may result in an increasing reliance on family members for support and a decline in satisfying relationships with peers. The consequence is poor psychosocial outcome. Life Style Consequences Khan, Baguley, and Cameron (2003) have also identified lifestyle consequences as a further problem area following TBI. These include: Unemployment and financial hardship, inadequate academic achievement, inadequate recreational opportunities, difficulties in maintaining interpersonal relationships and marital breakdown, loss of pre-injury roles and loss of independence. In addition, psychological status can be 11
altered and adjustment to disability is frequently encountered by people with head injury (Khan, Baguley & Cameron, 2003). Coping with outcomes Although Severity has an impact negatively on the psychosocial outcome of individuals following TBI, adequate coping mechanisms may reduce these negative effects (Moore & Stambrook, 1995). As a result, the possibility of encouraging favourable coping strategies represents a significant pathway towards prevention of problems associated with psychosocial adaptation (Desmond & Mac Lachlan, 2006). In Ghana, following TBI, individuals may make use of psychological coping strategies, religion and/or spirituality and availability of social support to cope. Statement of the Problem TBI has been identified as a major health problem that undyingly affects the lives of countless number of individuals, posing a considerable emotional and financial burden to the injured individual and their families or those close to them (Ashman et al., 2006; Dikmen, Machamer, Powell, & Temkin, 2003). These effects are largely due to the adverse psychosocial changes that follow TBI (Draper et al., 2007). These may, in turn, have a significant impact on Ability (i.e., sensory, motor, and cognitive abilities); Adjustment (i.e., mood, interpersonal interactions, anxiety, depression); and Participation (e.g., employment, school, social and recreational activities, initiation, money management) (Malec, Kragness, & Lezak, 2003). Moreover, numerous studies have shown that difficulty in psychosocial function is not only highly prevalent after TBI, but also that the severity of psychosocial impairment do not remit over time (Draper, Ponsford, & Schonberger, 2007; Hoofien, Gilboa, 12
Vakil, & Donovick, 2001; Koponen, Taiminen, Portin, Himanen, Isoniemi, Heinonen, Hinkka, & Tenovuo, 2002; Kreutzer, Seel, & Gourley, 2001). Despite these observations, there has been limited research into the identification of effective coping mechanisms that can be used to develop rehabilitative programmes, particularly in Ghana to meet the psychosocial needs of individuals with TBI. This may explain in part why psychosocial problems after brain injury remain undertreated in primary health care settings (Ashman et al., 2006). Quite often, many professionals particularly in Ghana are of the mistaken assumption that individuals who experience a mild to moderate TBI will make a full recovery of functioning within a brief period of time (Kay, Harrington, Adams. Anderson, Berrol, Cicerone, Dahlberg, Gerber, Goka et al., 1993; Mittl, Grossman & Hiehle, 1994). As a result when patients express any difficulty, family members and many professionals may suppose that these individuals are exaggerating their symptoms or “faking” (Bordini, Chaknis, Ekman-Turner, & Perna, 2002; McAllister & Arciniegas, 2002). The consequence is that social, emotional or behavioral problems are seen as psychogenic (Mayou, Black, & Bryant, 2000) and this can lead to inappropriate treatment (Holtzer, Burright, Lynn, & Donovick, 2004). It is important that Ghanaians get to know what TBI is all about in order to understand Victims of TBI. The availability of Social support to person with TBI is of great importance when dealing with changes in psychosocial outcome. However, Twumasi (2005) was of the opinion that the current Ghanaian society is going through a major transition from ruralisation to urbanization which has led to the breakdown of the extended family system, with corresponding increase in nuclear family system. This has resulted in an alienation from traditional culture where social support is paramount. Due to the 13
cultural transition, many Ghanaians now live in urban areas far from extended family members. This has resulted in a situation whereby social support for individuals with TBI is limited.
This raises a question of the availability of social support to
individuals with TBI to help them manage changes in psychosocial outcome resulting from their disability. It is therefore important that the current study identified the availability of social support to persons with TBI and how it affect their psychosocial functioning. Recently an important regulator of psychosocial outcome changes has been ascribed to the coping strategies individuals use to manage outcomes associated with injury (Endler, Corace, Summerfeldt, Johnson, & Rothbart, 2003). Therefore, the prospect of promoting satisfactory coping strategies represents a pathway aimed at preventing psychosocial problems. Nevertheless, there has not been any clearly identified agreement on which of the coping strategies is most helpful in resolving psychosocial difficulties (Karlsen & Bru, 2002). In order to address this issue, it would be of clinical and scientific interest to examine the influence of coping strategies on the psychosocial changes of individuals with TBI in the Ghanaian setting in order to help health professionals design an intervention programme, aimed to improve adaptive coping and reduce psychosocial problems within TBI population. In the traditional Ghanaian society, there is no clear cut conceptual separation of the natural or physical from the supernatural (Sefa- Dedeh, 2001). As a result, symptoms associated with TBI and poor psychosocial outcomes may be attributed to an attack by evil spirits. To seek relieve, the sufferer may resort to religious coping mechanism 14
(Sefa- Dedeh, 2001). Yet, virtually little is known of the role of religious coping on post TBI psychosocial outcome in Ghana. Due to the lack of community health care in Ghana for TBI patients, the psychosocial status, coping strategies, religious coping and the level of availability of social support of individuals with TBI are unclear and need to be identified. However, no relevant studies in Ghana could be located. To address this gap of knowledge, this research seek to find out the extent to which injury severity and coping strategies as well as religious coping mechanisms and social support influence psychosocial outcome following TBI in Ghana. Relevance There is a need for this study because:
The study will help health practitioners in Ghana to be aware of the possible problems associated with TBI severity in order to provide appropriate coping strategy education and rehabilitation to individuals with TBI.
The study will help Ghanaians to understand the influence of injury severity and coping in relation to psychosocial outcome in individuals with TBI. This will enable them give the needed support to TBI patients.
It will Increase knowledge of demographics and psychosocial adjustment of individuals with TBI in Ghana
The study will also add to existing literature. 15
Aims and Objectives The aim of the research is:
To examine the difference in psychosocial outcomes between 3 injury severity groups (mild, moderate and severe).
To investigate coping strategies used by individuals with TBI in Ghana.
The research seeks:
To determine which coping strategies are associated with better psychosocial outcomes.
To find out whether the effect of injury severity on psychosocial outcomes depends on coping strategies.
To investigate the relationship between the uses of different types of religiously based coping mechanisms and psychosocial outcomes.
To examine association of psychosocial outcome with social support and religious coping strategies.
To investigate the association of some demographic characteristics with psychosocial outcomes
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CHAPTER TWO LITERATURE REVIEW Theoretical Framework This chapter examines the literature concerning (a) Humans in Crisis and Coping, (b) Coping Theories, (c) Religion, (d) Social Support, and (e) related Studies Theory of Humans in Crisis and Coping Adopting Johan Cullberg’s (2003) theory of humans in crisis may help us to understand the mechanisms that underlie the use of coping strategies following TBI. Cullberg (2003) identified four phases in any crisis. These phases are the Shock phase, Reactions phase, Adaptation phase and Reorientation phase. He used these phases to describe how individuals react to and deal with dramatic events such as TBI in their lives in order to return themselves to some acceptable level of functional normality. Cullberg (2003) considered the first two phases to be separate halves of an acute whole. Every phase however, may have its own unique defence mechanism to cope with the situation as it appears at the moment. The shock phase. This face may last anywhere from a few seconds up to several days following a crisis or TBI (Cullberg, 2003). The person in shock following TBI removes him or herself from the outer world in order to protect his or her ego for a time (Cullberg, 2003). Accordingly, at this point even though persons in shock may on the outside appear to be normal, their inner self may be in complete turmoil. Things that have been said or events that have occurred during the shock phases can 17
be completely repressed and/or forgotten (Cullberg, 2003). Some may be vocal or hysterical while others may simply sit and stare at the floor (Cullberg, 2003). The reaction phase. This phase indicates that the individual with TBI has begun to realize what has actually happened and opening their eyes, started to meet the new reality of post-TBI. The afflicted person often repeats the same questions: “why has this happened to me?” “What have I done to deserve this?” “Why now?” (Cullberg, 2003). At this point, feelings of guilt can plague the person, who convinces him or herself that they are to blame for the incident (self-criticism; Cullberg, 2003). This phase as Cullberg (2003) stated should not last longer than 4- 6 weeks. The adaptation phase. This is the phase whereby the person has finally started the process of accepting the accident, illness or TBI and are working to leave the incident behind them while beginning to look forward (planning) (Cullberg, 2003). This phase may continue up to a year after an accident or injury. This is a critical phase, where the patient is now often at home, away from a clinical environment (Cullberg, 2003). At this point it is crucial that the person has the support of their family and/or social circle in order to continue with the ongoing, inner adaptation work (social support) (Cullberg, 2003). Reorientation phase. This phase is as Cullberg (2003) put it “the point where the person has accepted (successful coping) the fact that they are suffering from TBI and begun to live their life in their new situation” (Cullberg, 2003). They have naturally not forgotten what has happened, but have come to terms with it and perhaps have found, for example, a new hobby or sporting activity which they are capable of participating in, in spite of the brain injury (Cullberg, 2003). 18
The individual’s ability to go through this phases successfully depends on the coping strategies used, and this has implication for the adaptation to psychosocial changes resulting from TBI. Coping Theories Coping has been identified as an approach adopted in response to daily difficulties and/or major life events (Lazarus, 1993). Early theories viewed coping as a process; for example, psychoanalytic theorists viewed coping as an unconscious defence mechanism (Freud, 1933), which ranged from healthy to pathological. Freud emphasized defence mechanisms as a means of allowing the individual to deal (cope) with unconscious urges and anxiety. Thoughts or feelings that troubled the individual were moved to the unconscious level or were distorted by defence mechanisms (Snyder & Dinoff, 1999). However, measuring the concept of defence mechanism as a coping process has been a difficult undertaking, as this approach produces a one dimensional characteristic to coping (Lazarus & Folkman, 1991). More recent theories of coping tend to be based upon coping process in relation to stress (e.g. Lazarus & Folkman, 1984). Theoretically, Lazarus and Folkman (1984) viewed coping as a constantly changing, dynamic process between the person and their environment. According to Lazarus and Folkman (1984), the individual cognitively evaluates demands of the environment as stressful when he or she subjectively perceives the demands as exceeding or taxing his or her resources to manage them (internal and/or external). Depending on the nature of the appraisal, the individual determines what actions or coping strategies they will employ to reduce stress associated with the demands (i.e. the TBI) (Folkman, Lazarus, Greuen, & Delongis, 1986). 19
Lazarus and Folkman (1984) were of the opinion that coping strategies used should be regarded as a dynamic process that is shiftable in nature throughout the process of the stressful situation. Furthermore, Lazarus and Folkman (1984) hypothesize that there are three processes involved when coping with stress: Process 1 – The primary appraisal whereby the initial process of perceiving a threat to oneself is activated. Process 2 – The secondary appraisal whereby the process of bringing to mind a potential response to deal with the threat is formulated. Process 3 - The process of executing the response, coping. Lazarus and Folkman (1984) stated that the coping procedure does not occur in a purely linear sequence but more in a cyclical manner. Thus if the individual with TBI perceived an inadequate coping response as not readily available or is less effective than expected, then the individual may reappraised the situation as more threatening and vice versa (Lazarus & Folkman, 1984). A TBI patient’s coping strategy may depend on factors such as life experiences, religion, education, age, culture and personality (Cronqvist, Kiang, & Bjorvell, 1997). From literature, coping has been classified as problem-focused and emotion-focused (Curran, Ponsford, & Crowe, 2000; Finset & Andersson, 2000; Lazarus & Folkman, 1980; Malia, Powell, & Torode, 1995) which may be employed by individuals with TBI to deal with changes in psychosocial outcome. Coping strategies are essential for managing the outcomes of TBI and is strongly correlated with managing emotions during the period of distress (Folkman & Moskowitz, 2004).
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Problem-Focused Coping Strategies Lazarus and Folkman (1984) identified problem-focused coping as characterized by strategies that actively seek a solution to a problem or stressful event (TBI). This involves the modification of oneself or one’s environment (Martin & Dahlen, 2005) in order to manage psychosocial outcomes associated with TBI. Problem-focused coping includes strategies such as defining the problem (i.e. TBI outcomes), weighing and generating alternative solutions. Lazarus and Folkman (1984) considered these strategies as more analytic and cognitive in nature.
Problem-focused coping is
associated with the implementation of effective health behaviors (Lee-Baggley, DeLongis, Voorhoeave, & Greenglass, 2004) and has important implications for living with physical illness or post-TBI (De Ridder & Schreurs, 2001). When individuals with TBI use a problem focused strategy, they believe that they can change the deficit that was caused by their injury or change their resources to manage the deficit, and this type of strategy is important to cope with TBI. Emotion-Focused Coping Emotion-focused coping has been considered by Lazarus and Folkman (1984) as a form of coping, whereby the individual manages stress (problems associated with TBI) through emotional reactions. This involves utilizing cognitive coping strategies to change the meaning of demanding events (TBI) and lessen subsequent emotional suffering (Martin & Dahlen, 2005). To Lazarus and Folkman (1984) Emotion-focused coping may be characterized by escape-avoidance behaviour, denial, wishful thinking, self-blame, worrying, crying and substance abuse that may be employed by an individual with TBI to deal with psychosocial outcomes.
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Individuals with TBI may cope by adjusting their way of life to fit the demands and challenges associated with the deficits, or they may cope by trying to reframe their experiences viewing the condition in a more positive light. Accepting the reality of the injury and developing a positive attitude toward managing the outcomes can be critical for successful coping and recovery (Decoster, 2005). Lazarus and Folkman (1984) viewed both problem-focused and emotion-focused coping strategies as adaptive. However, later
research has shown that emotion-
focused coping strategies in the long run may be less adaptive than problem- focused strategies, although the effect of these coping strategies seem to depend on the specific constraints imposed by the demanding situation (De Ridder & Schreurs, 2001; Karlsen & Bru, 2002). While problem-focused strategies might be used to better manage the impairments associated with TBI, emotion-focused strategies might be induce by the strain associated with knowing that there is currently no cure for deficits accompanying TBI. Sometimes, most stressful situations tend to elicit both types of coping. However, when the individual with TBI feels that something constructive can be done about his or her situation then problem focused coping predominates. In contrast, if the individual feels that the stressor beyond control and it is something that must be endured then an emotion focused coping style will prevail (Folkman & Lazarus, 1980). This theory of coping will be used to identify the mode of coping strategies commonly used in the Ghanaian TBI population and how it is related to psychosocial outcomes.
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Religious Coping The use of religious coping strategies among Ghanaians who encountered TBI is of great importance when considering coping. Argyle and Beit-Hallahmi (1997) identified religion as the relationship of the individual to spiritual beings who inhabit the supernatural world. Pargament (1997) however, defines religion as a search for significance in ways related to the sacred. The search component of this definition refers to the pathways that people use to navigate toward their desired destinations. Significance refers to the elements that individuals perceive to be of greatest importance in their lives. The sacred refers to people’s perceptions of God, the divine, or any transcendent reality that takes on a spiritual character and significance because of its association with the sacred core (Pargament & Mahoney, 2005). What makes religion distinctive to Individuals with TBI, according to Pargament’s definition, is the involvement of the sacred in the beliefs, practices, relationships and experiences that make up an individual’s pathways and/or the individual’s destinations toward recovery from deficits associated with TBI. What then determines when religion is involved in coping with outcomes associated with TBI? Pargament (1997) suggests that the availability of religious coping within a person’s orienting framework and the overall compelling character of religion help determine whether and when people turn to religion in coping. Religion and coping converge among those who are more committed and involved in their religion especially following TBI (Pargament, 1992).
23
Persons with TBI often use religious coping when they appraised the deficits associated with their TBI to be more threatening, harmful, and challenging (Pargament, 1996a). Pargament, Olsen, Reilly, Falgout, Ensing, and Van Haitsma (1992) in a study found that religious congregants who used religious coping were more religious in terms of praying and attending church more often, reporting closer, more loving relationships with God, and endorsing greater religious orthodoxy and commitment. Those whose religion is more strongly rooted in their orienting system can more easily find ways in which to religiously cope with problems associated with TBI and life stressors. Religious coping methods are also more likely to be used when they are compelling (Pargament, 1992). By compelling, implies that religious coping offers its users (e.g. TBI patients) a unique resource that overcomes the limitations and boundaries of comparable finite and limited secular resources (Pargament, 1992). Religious coping is often viewed as more enriching than its secular counterparts precisely because it can maximize significance for some people in a way that was previously unavailable to them (Pargament, Olsen, Reilly, Falgout, Ensing, & Van Haitsma, 1992). According to Folkman and Moskowitz (2004), religion can interact with all phases of the coping process. Pargament, Koenig, and Perez (2000) have distinguished between benevolent religious reappraisals and punishing God reappraisals. Benevolent religious reappraisals seek to redefine stressful events by using religion as a means to perceive the stressor as benevolent and possibly constructive. For example, an individual who is experiencing TBI related stressors may view these stressors as an opportunity for test of character and preparation to deal 24
with the world in another way. Essentially this person might perceive their stressors as blessings in disguise from an understanding and loving God. On the other hand, punishing God reappraisals seek to redefine stressful events as a punishment from God in reaction to one’s transgressions. For instance, an individual with severe TBI may perceive his or her injury to be a punishment from God for his or her previous sins. Pargament (1997) identified three types of religious coping: the self-directing approach, the deferring approach, and the collaborative approach. The self-directing approach refers to a coping strategy wherein people rely solely on themselves during stressful events and purposefully exclude God. One example might be an individual with moderate TBI who is worried about inability to perform well at work. He might cope with his worries by carrying the possible burden by himself by assuming that his current functional status is the cause for any potential problems. In this case, he may seek out expert medical advice and/or other forms of secular knowledge to help cope with the stressor of possible psychosocial deficit. In contrast, the deferring approach refers to a coping strategy in which the responsibility for coping is submissively deferred to God. For instance, the same man might offer his worries to God because he earnestly believes that ultimate control is within God’s hands alone. The collaborative approach refers to an individual’s perception that there is shared responsibility between both he and God for dealing with stressful situations (Pargament, 1997). Again, the person with TBI might pray to God for the strength to deal with his situation and that God will offer him the means by which he could emotionally cope with the difficulties that might accompany problems associated with 25
TBI. Thus, the fit between the chosen coping style and the stressor is very important. When a chosen form of religious coping does not adapt to the changing demands of the stressor, a variety of undesirable psychosocial and health outcomes may abound, including increased symptoms of depression, anxiety, interpersonal relationship problems and other psychosocial difficulties (Pargament, 1997). In view of the fact that most Ghanaians are very religious, it is of great importance to identify the extent to which Ghanaian TBI patient use religion to cope with psychosocial outcomes related to TBI. Social Support Social support is a multi-dimensional concept (Helgeson, 2003) that cannot be measured and defined in a homogenous way (Jackson & Antonucci, 1992). Kahn (1979) however viewed social support as interpersonal transactions that include one or more of the following: the expression of positive affect (feeling liked or loved) of one person toward another; the affirmation (feeling appreciated or admired) or supporting and respecting another person’s perceptions, behaviors, or expressed views and the giving of material such as money or symbolic aid to another following TBI. Aneshensel, Pearlin, Mullan, Zarit, and Whitlatch (1995) defined social support as the degree in which a person’s basic social needs are met through informal or formal social networks while enhancing health and well-being, regardless of their TBI severity levels. In the social support literature, the terms social support and social network are often used interchangeably (Ell, 1996). The social network refers to a web-like structure comprising one’s relationships (Hall & Wellman, 1985). This network includes family, neighbors, friends, employers, relatives, fellow employees, 26
professional networks, and groups with which a family shares common goals, interests, lifestyles or social identity following TBI (Friedman, Bowden & Jones, 2003). In spite of the conflict among researchers on the types of support and which type is more important to consider for example, when dealing with TBI, most of the researchers agree that there are three types of support, emotional, instrumental, and informational (Cohen & Willis, 1984; Ryan & Austin, 1989; Tilden, 1985). Emotional support refers to personal behaviors such as having someone available to listen, to provide empathy, reassurance, caring, love and trust following TBI. Instrumental or tangible support is the result of concrete behaviors that help a person directly: the helping person intervenes personally in the problem situation and takes practical action such as help in household chores, giving a financial assistance, helping with work responsibilities, or giving some other form of material aid to persons with TBI. Informational support helps individuals help themselves by providing them with information, guidance or advice that they can use to cope and manage psychosocial outcome following TBI (Cohen & Willis, 1985; Helgeson, 2002). The availability of social support can play a vital role in the adjustment of individuals with a TBI. The availability of social support may help to stabilize these individuals through reducing the impact of the injury’ stressors, by influencing the individuals appraisal of the stressor; or by assisting with revision of the individual’s world view. Yet the social support available for families of individuals with TBI tends to be inadequate (Wood, 2008) and this has great implication for coping with changes associated with psychosocial outcome of TBI. 27
Related Studies Injury severity and psychosocial outcome Injury severity is significant when measuring outcomes following TBI. Yet, in recent years only few studies have attempted to measure outcome based on injury severity (e.g. Draper et al., 2007; Wagner, Hammond, Grigsby, & Norton, 2000) Draper, Ponsford, and Schonberger (2007) investigated psychosocial and emotional outcomes 10 years following TBI across the spectrum of injury severity groups. The groups were made up of 53 participants with mild to very severe TBI sustained 10 years previously, and significant others who were related to the TBI patients. Outcomes were measured using Sydney Psychosocial Reintegration Scale (SPRC; occupational activity; interpersonal relationships; and independent living skills), Extended Glasgow Outcome Scale, Hospital Anxiety and Depression Scale, Neurobehavioral Functioning Inventory (NFI) Aggression scale, Fatigue Severity Scale, Alcohol Use Disorders Identification Test, neuropsychological tests of attention/processing speed, memory, and executive function. The result of their analyses revealed that those who were engaged in occupational activity had the lowest psychosocial outcome and those who were engaged in living skills domains had the highest psychosocial outcome. Moreover, they found that variables including education, posttraumatic amnesia duration, numerous cognitive measures, concurrent fatigue, alcohol use, aggression, anxiety, and depression were all significantly associated with poorer psychosocial outcome as measured by SPRC. The finding of this study raise the question of what coping strategies are available to individuals with TBI, and to what extent can these coping strategies mitigate the problems associated 28
with outcomes. Although the study compared the ratings of TBI severity groups with relatives, it failed to compare the TBI severity groups with each other in order to identify differences in psychosocial outcome between the groups. Other researchers such as Wagner, Hammond, Sasser, and Norton (2000) also conducted a study to identify the effect of injury severity on community integration after TBI. Their study incorporated a heterogeneous sample of 378 patients hospitalized after TBI. Severity profile was established for each patient using Glasgow Coma Scale, Revised Trauma Score, Injury Severity Score, and Trauma and Injury Severity Score; tools designed specifically for determining the injury severity level of the brain injury population, along with other demographic and premorbid values. Of this cohort, they contacted 120 patients 1 year post-injury for follow-up assessment with the Disability Rating Scale, Community Integration Questionnaire, and employment data. Based on the methodology employed, the findings revealed that Injury severity variables were significant single outcome predictors and, in combination with premorbid and demographic variables, help predict long-term disability and community integration for individuals hospitalized with TBI. This indicate that the more severe an individual’s injury the more likely that individual will have functional and psychosocial difficulties. The methodological strengths of the study include its large sample size and the utilization of outcome measures. However, other factors such as coping and social support that may impact on outcome were not considered. Wood and Rutterford (2006) conducted a study to investigate long term psychosocial outcomes following severe brain injury in a large group of TBI patients. Psychosocial 29
outcomes were measured using community integration questionnaire, functional competency ratings and Hospital anxiety depression scale. Of the TBI patients studied, they found that 72.0% lived independently, 28.7% were in full time employment, and 60.0% were married or cohabiting. The authors however reported that no serious emotional problems were evident from self-report ratings on the Hospital Anxiety Depression Scale (HADS). They also found that mean functional competency ratings and community integration levels were just below those reported for non-disabled patients, a view that may be associated with sub-optimal social participation as measured by the Community Integration Questionnaire (Wood & Rutterford, 2006). This implies that the possible outcome of injury severity depends on the measures being used. Although the above findings shed light on the psychosocial outcome of individuals with severe TBI, there is the need to identify data for individuals with mild to severe TBI based on different outcome measure. In general, the reviewed studies on injury severity explain a significant association between injury severity and psychosocial outcome. However, patients with mild and moderate injury severity cases have also been demonstrated to experience significant declines in psychosocial functioning. This implies that injury severity alone may not be the only variable accounting for difficulties in post-injury psychosocial outcome (Kervick, 2002). Most of these studies in their measurement of outcome based on injury severity have also not considered the influence of coping on outcome which has gain attention more recently. It is therefore of both scientific and clinical importance to study coping when measuring outcome
30
Coping and psychosocial functioning following TBI. Studies with Brain injury samples have shown that problem-focused coping is associated with higher self-esteem and better psychological outcomes, while emotion focused coping is associated with poorer psychological outcomes and depression (Anson & Ponsford, 2006; Wolters, Stapert, Brands & Van Heugten, 2010) Anson and Ponsford (2006) investigated the relationship between coping style and emotional adjustment in 33 survivors of TBI. They reported that coping domains such as avoidance, worry, wishful thinking, self-blame, and using drugs and alcohol was associated with higher levels of anxiety, depression, and psychosocial dysfunction and lower levels of self-esteem (Anson & Ponsford, 2006). Coping strategy domains namely, actively working on the problem, using humor and enjoyable activities to manage stress was associated with higher self-esteem. Severity, as measured by length of posttraumatic amnesia, was however not found to be associated with coping style (Anson & Ponsford, 2006). In their study, coping strategies was assessed with Coping Scale for Adults (CSA), and outcome depression and anxiety was measured with Hospital Anxiety and Depression Scale (HADS). There is the need to identify a different coping measure for the purpose of comparison. Wolters et al. (2010) conducted a study to investigate the changes in coping styles of patients with brain injury who underwent cognitive rehabilitation, and the effects of these changes on their quality of life. 110 patients in the chronic phase post-injury, who underwent outpatient cognitive rehabilitation, participated in the study. In their study, coping style was assessed using Utrecht Coping List. Quality of life was measured using Life Satisfaction Questionnaire and Stroke-Adapted Sickness Impact 31
Profile. Coping style was measured at the start of rehabilitation (T0) and repeated at least 5 months later (T1). Result indicated that coping style was related to quality of life measured at T1 and active problem-focused coping styles decreased while passive emotion-focused coping styles increased significantly between T0 and T1. Furthermore, the study showed that increases in active problem-focused coping styles and decreases in passive emotion-focused coping styles predicted a higher quality of life in the long term. The authors concluded that these changes in coping styles are adaptive for the adjustment process in the chronic phase post-injury. However, overall, most participants showed maladaptive changes in coping styles (Wolters et al., 2010) The finding of the study implies that passive emotion focused coping is less adaptive and it is associated with lower quality of life compared to problem focused. The methodological strength of the study is its large sample size and the utilization of outcome measures. However, due to the possibility of cultural differences in choice of coping strategies, the above finding may not reflect how individuals with TBI in Ghana cope. There is the need to find out how the situation is like in among Ghanaian samples. Littleton, Horsley, John, and Nelson (2007) conducted a meta-analysis of thirty nine studies of coping following traumatic events (interpersonal violence and severe injury). In their analysis, the authors evaluated the relationship between the use of approach and avoidance strategies. Results of the meta-analysis indicated that there was a significant positive association between reliance on avoidance coping strategies to cope with trauma and psychological distress. Littleton et al., however found no significant association between approach coping and distress. Despite the variability in measures used the results were consistent with literature indicating that the use of 32
different coping styles has implication for outcomes. This would indicate that irrespective of injury severity, the type of coping strategy use is important to outcome. There is therefore the need to identify coping strategies available to the TBI population in Ghana and how it is associated with outcome. The finding would enable comparison across different cultural studies. The relevant literature review indicates that most of the studies on coping have ignored the influence of both religious coping mechanism and social support on psychosocial outcome following TBI. In the Ghanaian settings, religion and social support are of great importance when considering coping since they play an important role in outcome management. Although areas of coping mechanisms such as social support and religion have been incorporated into existing coping measures (e.g. Carver, 1997; Carver & Weintraub, 1989), it is important to identify measures of religious coping and social support and their association with outcome. Religious coping and psychosocial outcome following TBI A search in the research literature indicated that there was limited research on the use religious coping following TBI. This may be due to the reliance on a more psychological measure of coping strategies. Only few researchers have ventured thus far so as to study how religious use of coping mechanism may help manage outcome following TBI. For example, Johnstone, Yoon, Rupright, and Reid-Arndt (2009) conducted a study to determine the relationships between spiritual beliefs, religious practices, support from the congregation and health status for individuals with TBI. In
their
study,
they
used
the
Brief
Multidimensional
Measure
of
Religiousness/Spirituality (BMMRS) and the Medical Outcomes Scale-Short Form 36 33
(SF-36). The authors found that the physical health of individuals with TBI was associated with spiritual beliefs but was not associated with religious practices or congregational support. Johnstone et al. (2009) also found that Religious practices (i.e. praying) were not related to either physical or mental health, as some individuals with TBI may increase prayer with declining health status (Johnstone et al., 2009). This implies that it is likely religious and spiritual influences may potentially positively or negatively affect outcome. The finding ought to be interpreted with caution since the result may be based on the methodological measure. The study however failed to consider the association of religious coping activities to psychosocial outcome. Whether these religious practice and spiritual belief were linked to poor psychosocial outcome or better outcome was not identified by the study. This is an important consideration that needs to be identified in the current research. Waldron-Perrine, Rapport Hanks, Lumley, Meache, and Hubbarth ( 2010) conducted a study to investigate the use of elements that have been specifically defined in relation to religion and spirituality as coping resources in a sample adults with TBI. They also explored various mechanisms by which religion and spirituality may affect outcome. Their result indicated that public religious practice was not a unique predictor of any outcome measures after accounting for demographic and injuryrelated characteristics. “Existential well-being (a sense of meaning and purpose in life) was also not a unique predictor for any outcome, but religious well-being (a sense of connection to a higher power) was a unique predictor for life satisfaction, distress and functional ability” (Waldron-Perrine et al., 2010). Similarly, their findings indicated that ability to find benefit, emotion-focused coping and perceived 34
detriment from trauma each partially explained the relationship between religious well-being and psychological outcomes, whereas task-oriented coping partially explained the relationship between religious well-being and functional outcome. Overall health behaviour profile partially explained the relationship between religious well-being and life satisfaction and religious well-being and functional outcome. After accounting for general coping style, Waldron-Perrine et al. (2010) also found that perceived benefit from trauma was a unique predictor for psychological outcomes, whereas perceived detriment and negative religious coping were unique significant predictors only for life satisfaction. They concluded that specific aspects of religious and spiritual belief systems do play direct and unique roles in predicting outcomes (Waldron-Perrine et al., 2010). The findings indicated that the influence of religion and spirituality on outcomes may be partly due to its indirect effects on social support and coping. Particularly, a self-reported individual connection to a higher power was seen as an extremely robust predictor of both subjective and objective outcome (Waldron-Perrine et al, 2010). The implication is that the relationship between religious coping and psychosocial outcome is likely to be complex. The findings however, may due to how relationship between religion and psychosocial outcome was conceptualized. Social support and psychosocial outcome following TBI Social support is considered an important determinant of psychosocial outcome following TBI (Wood, 2008). However, to the best of the author’s knowledge extensive research is lacking. Most research on social support focused primarily on caregiver or family functioning and/or distress following TBI. Only few researchers 35
have ventured thus far to consider social support among TBI patients (e.g. Farmer, Clark, & Sherman, 2003; Tomberg, Toomela, Ennok, & Tikk, 2007). Farmer et al (2003) conducted study to investigate personal beliefs about seeking social support following TBI (TBI) and the relationship of these appraisals to demographic and injury variables, social integration, and quality of life ratings. They used fifty-six adults with TBI who were more than 6 months post injury and living in the community, and predictors of higher quality of life ratings such as more positive appraisals about seeking social support, living in a rural area, and the ability to engage in productive activity. Their result indicated that negative attitudes and beliefs about seeking social support were significantly related to lower perceptions of social support, lower ratings of quality of life, longer time since injury, being divorced or separated, and living in an urban area. They concluded that Positive outcomes after TBI appear to be moderated by living in a rural area, which is associated with more openness to seeking social supports and contributes to better quality of life. The finding implies that outcome is determined by the individuals’ perception of the ability to seek social support. As to whether the support is truly available, the study did not say. Also the relationship between social support and psychosocial outcome is not clearly defined. Tomberg, Toomela, Ennok, & Tikk (2007) also undertook a study to investigate changes in psychological coping strategies, social support, life orientation and healthrelated quality of life in the late period after TBI. Thirty-one patients with TBI who were first investigated on average 2.3 years after injury and were prospectively followed on average 5.7 years later. Using Estonian versions of the COPE-D Test, the 36
Brief Social Support Questionnaire, the Life Orientation Test and the RAND-36 health survey questionnaire, they found that during the late follow-up period healthrelated quality of life and resuming work did not improve significantly. Persons with TBI reported an increase in seeking social/emotional support, frequent use of avoidance-oriented styles and reduced use of task-oriented styles. This was accompanied by low social support and low satisfaction with support, both of which were associated with health-related quality of life and resuming work after TBI. Although the patients had become more optimistic, this did not correlate with their health status and social well-being. The conclusion was that as social support, satisfaction with support and health-related quality of life did not improve, then rehabilitation, social and psychological support are continuously needed. What is the situation in Ghana? It is important that aspect of this question is addressed in the current study. Demographics and psychosocial outcome Most studies on the influence of demographic variable on outcomes following TBI indicates that factors such as, injury duration, , age, Gender, Pre-injury Substance use, employment status and years of educational appear to play a major role in psychosocial outcome. However, findings have been mixed. Machamer, Temkin, and Dikmen (2003) in a study to investigate neuropsychological and psychosocial outcomes following TBI, found that personal characteristics such as age, gender, race, and education were more important to outcome than the severity of the injury. Significantly, they found people with more severe injuries, lower education, older age, male gender, and nonwhite race had worse neuropsychological 37
and psychosocial outcome. Although these predictive factors were considered to be more important to outcome, the extent to which one factor may be considered as of high predictive power was not identified. Schopp, Shigaki, Bounds, Johnstone, Stucky, and Conway (2006) in their studies on outcomes in TBI following violent versus non-violent etiology found however, that persons with TBI commonly report poor functioning on post-injury psychosocial variables including alcohol and drug abuse, limited financial resources and social support, emotional disturbances, and low rates of vocational rehabilitation (VR) services. Nevertheless, how patients attempt to cope with poor function on these psychosocial variables was not identified by the study. MacMillan, Hart, Martelli, and Zasler (2002) undertook a study to measure outcome in 45 adults who suffered a moderate or severe TBI at least 2 years earlier. Their result indicated that a pre-injury psychiatric and substance abuse history was predictive of employment status and that pre-injury substance abuse predicted independent living status. They also reported that social support following TBI predicted significant other's assessment of the patients' neurobehavioural status. These findings were however limited by lack of randomization of sample. As a result, the extent to which the findings can be generalized to the TBI population is limited. Recently, Wise, Mathews-Dalton, Dikmen, Temkin, Machamer, Bell, and Powell (2010) conducted a study to determine how participation in leisure activities for people with TBI (TBI) changes from before injury to 1 year after injury. Fuctional status examination scale was used to measure outcome of 160 patients with moderate to severe TBI. Their findings indicated that at 1 year after injury, 81% had not 38
returned to pre-injury levels of leisure participation. Activities most frequently discontinued included partying, drug and alcohol use, and various sports. The activity most often reported as new after injury was watching television. Of the small fraction who returned to pre-injury levels, 70% did so within 4 months of injury. Sixty percent of those who did not return to pre-injury levels were moderately to severely bothered by the changes (Wise et al., 2010). However, factors that impact on outcome are not well known. Review of relevant literature revealed that, despite the variability of reported psychosocial outcomes following TBI, the consequences of TBI severity can be pervasive and long term. A remaining question is, to what extent does injury severity impacts on psychosocial outcomes, and how might coping and other factors be associated with psychosocial outcome. In Ghana much less is known to the author about the influence of injury severity and coping strategies on psychosocial outcome following TBI. Measurement on how coping strategies, religion, social support and demographic factors are predictive of psychosocial outcome following TBI is a difficult undertaking given the multifaceted impact of TBI on cognition and behavior (Draper et al., 2007). The measurements of coping and outcome following TBI have involved the use of several variable measures, but not all of them are appropriate to the assessment of psychosocial outcome. In most effect such measures need to assess functioning across a broad range of domains including ability, adjustment and participation. This is a limitation of some outcome measures that need be considered in the current research.
39
Most studies have identified emotion focused coping to be associated with poor psychosocial outcome and problem focused coping to be associated with better psychosocial outcome following TBI. However the helpfulness of any coping strategy may depend as much on the individual and the situation in which he or she find him or herself as the strategy itself (Kleiber, Hutchinson, & Williams, 2002). As a result, certain coping strategies are clearly not better than others since the nature and success of the specific coping strategies are associated with the individuals appraisal of the situation as controllable or uncontrollable (Lazarus & Folkman, 1994). Thus, if coping is viewed as a dynamic process, both problem-focused and emotion-focused coping can be viewed as essential parts of the total coping effort that at multiple points in time may even facilitate each other (Lazarus, 1999). The remaining question is, “can these coping strategies moderate the effect of injury severity level on psychosocial outcome? If yes, to what extent? Of all literature reviewed, none has consider the moderating effect of coping strategies on psychosocial outcome. As a result it is difficult to explain how coping strategies interact with injury severity to influence outcome. This is an important gap in the literature which this study sought to address. The availability and benefit of social support to individuals with TBI is also essential when dealing with psychosocial outcome changes (Wood, 2008) Also religion might be particularly valuable to individuals with TBI when they are facing problems that push them to the limit of their own personal and social resource (Waldron-Perrine et al, 2010). Literature on the role of coping strategies, religious coping and social support on psychosocial outcome is scattered. As a result, a research that study the role of Injury 40
severity, coping strategies, religious coping and social support on psychosocial outcome in the TBI population in one and the same study is lacking. This is an important omission that limits the conclusions drawn and generalizability of these previous investigations. This study sought to address the gaps in literature by investigating the role of injury severity, and the different coping mechanisms and social support on psychosocial outcome in one study. Hypotheses Based on the review of literature, the following hypotheses were derived: 1. Level of injury severity will account for individual differences in psychosocial outcome 2. Coping strategies would significantly predict better psychosocial outcome. 3. Religious coping strategies would be negatively associated with psychosocial outcome 4. Social support would be negatively associated with psychosocial outcome. 5. Coping strategies would moderate the effect of injury severity on psychosocial outcome.
41
Conceptual Framework Based on our hypotheses, a conceptual framework on the expected relationship between injury severity level, coping strategies, religious coping, and psychosocial outcome was developed (figure 1). Figure 1: Frame work of the association of psychosocial outcome with injury severity, coping strategies, religious coping, social support and demographics
Coping Strategies Problem focused Emotion focused
Severity of TBI Mild
Psychosocial Outcome
Moderate
Ability
Severe Adjustment Participation
Religious Coping Social Support
Based on the framework in figure 1, it is expected that injury severity level will affect psychosocial outcomes. Coping strategies would moderate the relationship between injury severity level and psychosocial outcomes. Religious coping and social support would be associated with psychosocial outcome
42
Operational Definition of Terms/Concepts TBI: injuries sustained to the brain from road traffic accidents, falls and/or assaults. Severity of injury: the duration of PTA as measured by The Galveston Orientation and Amnesia Test (Levin, O'Donnell, & Grossman, 1979) Coping strategies: ways by which individuals manage psychosocial outcomes associated with their injury as measured by the Brief COPE (Carver, 1997) Religious coping: The extent to which individuals with TBI use religion to cope with psychosocial outcomes as measured by Religious Coping Activities Scale (Pargament, Ensing, Falgout, Oslen, Reilly, Van Haitsma, & Warren, 1990) Social support: The level of support from significant others as measured by The Multi-Dimensional Support Scale (MDSS) (Winifield, Winifield, & Tiggemann, 1992). Psychosocial Outcomes: Changes in social and psychological functioning as measured by the Mayo-Portland Adaptability Inventory (MPAI-4) ( Malec & Lezak, 2003).
43
CHAPTER THREE METHODOLOGY Setting Participants for the study were recruited from the neurosurgery and neuropsychiatry units at Korle-bu Teaching Hospital and 37 Military hospitals. Population The population of the study was individuals with traumatic brain injury in the Greater Accra region of Ghana. This region was selected because being the capital city of Ghana, it consists of people from different ethnic groups and cultural backgrounds. Samples The study sample consisted of 40 participants with GCS score of mild, moderate and severe traumatic brain injury who were in Korle-Bu Teaching Hospital (KBTH) and 37 Military Hospital for review. The samples was grouped into three severity levels of mild, moderate and severe TBI groups as determined by PTA, for the purpose of comparison. Sample size determination Based on the recommendation of Tabachnick and Fidell (1996), for regression analysis, ten (10) subjects to a variable would be appropriate. As a result, a minimum of thirty (30) subjects would be appropriate for the current study since there are three main variables: Injury severity, Coping mechanisms and psychosocial outcomes.
44
Sampling Technique Both convenience and purposive sampling techniques was used for this study. The sampling techniques were used because the research settings were at the convenience of the researcher and the researcher was interested in only TBI population. The advantages of choosing convenience sampling are that it is inexpensive, accessible, and requires less time than other types of samples (Burns & Grove, 1997). On the other hand, the disadvantage of convenience sampling is that it provides little opportunity to control for biases because subjects are included in the study because they happened to be in the right place at the right time (Burns & Grove, 1997). This may result in recruiting subjects who are not representative of the population of interest and may decrease the generalizability of the findings. However, convenience sampling is a useful sampling method and is commonly used in behavior studies (Burns & Grove, 1997). Inclusion/Exclusion Criteria for Participants in this Study Participants in this study were selected based on the following criteria:
The person must have sustained a mild, moderate or severe TBI (0-5 years)
Must be at least 18 years of age
Potential participants were excluded if the following conditions applied: • The person had experienced any neurologic deficits before their accident • Patients were also excluded if there were co-morbid spinal cord injuries, serious burns, serious facial disfigurement and/or amputations
45
Participants All individuals with TBI referred to the KBTH and 37 Military Hospitals for review were considered for the study. However, 40 participants who met the inclusion criteria were recruited. Demographic and injury severity information was ascertained through clinical interview/assessment and review of medical records. Table 2 presents demographic and injury severity information for all participants as shown below TABLE 2: Basic Demographics of participants N (%)
Mean (SD)
Range
Age
40
35.30 (11.90)
18-65
Years Of Education
40
10.30 (3.90)
0-20
GCS
40
11.60 (3.45)
3-15
Pre-Injury Substance Use
40
0.15 (0.43)
0-2
TBI Duration
40
1.40 (0.87)
1-4
Gender Male Female
28 (70) 12 (30)
Injury Source Road Traffic Accident (RTA) Falls And Assaults
32 (80) 8 (20)
Relationship Status Single Married Divorced Widowed
18 (45) 22 (55) 0 (00) 0 (00)
46
Injury Severity (PTA) Mild Moderate Severe
17 (42.5) 17 (42.5)
91.88 71.29
7.33 3.74
6 (15)
49.33
16.73
Research Design The purpose of this study was to investigate the relationship between injury severity, coping strategies and psychosocial outcome. The study design was a correlational design that involves the collection of data from the population of interest. This design was selected for the study following the recommendations of Polit and Hungler (1999). Correlational studies allow flexibility in investigating and describing the relationships among phenomena or variables at a fixed point in time. Such studies also provide a baseline for future and more rigorous research studies (Brink & Wood, 1989). The design is correlational because there is the need to identify variables that relate to one each other and to make predictions of one variable from another variable. Measures Injury Severity. The level of injury severity was determined using the Galveston Orientation and Amnesia Test (GOAT; Levin, O'Donnell, & Grossman, 1979). The GOAT) consist of ten questions that assess post-traumatic amnesia (PTA) in victims of a traumatic brain injury (TBI). The GOAT tests memory and orientation.
The questions of the GOAT are orally administered to patients, and each question has a determined number of error scores that is assigned when any response goes astray 47
from the correct one. This score is displayed in parentheses after each question of the instrument (Levin et al., 1979).
The GOAT's total score is achieved by subtracting from 100 the total amount of error scores (Total score = 100 - total amount of error scores). Scores lower than 75 point to the fact that the victim is still experiencing amnesia. In assessing injury severity by the PTA duration, a period of amnesia time of less than one hour indicates a light trauma, and the trauma is moderate for a time that ranges between one and 24 hours. Victims who‟s PTA extends for over a day are considered as having a severe encephalic injury The reliability coefficient α = .76. Validation showed that the GOAT scores were strongly related with the Eye Opening and Verbal and Motor Response measurements of the GCS (Levin et al, 1979). At the same time, the application of the scale was quite relevant in assessing the relationship between the PTA duration established by the test and TBI long-term results (Levin et al, 1979). In addition, in the GOAT's performance analysis against computerized tomography, the bilateral, diffuse injury was more strongly associated with an amnesia interval > 14 days when compared with a restricted injury to one cerebral hemisphere (Levin et al, 1979). The reliability coefficient for the Ghanaian sample was α = .77.
Coping Strategies. TBI related coping strategies was measured using the Brief Cope Scale (Carver 1997). The Brief COPE scale was designed to assess a broad range of coping responses among adults for all diseases (Carver 1997). It contains 28 items and is rated by the four-point Likert scale, ranging from “I haven‟t been doing this at all” (score one) to “I have been doing this a lot” (score four). In this study, the higher 48
score represents greater coping strategies used by the respondents. In total, 14 dimensions are covered by this scale. These are self-distraction, active coping, denial, substance use, use of emotional support, use of instrumental support, behavioural disengagement, venting, positive reframing, planning, humour, acceptance, religion and self-blame. Every dimension has two items. Written instructions were slightly modified to direct the participant to base his/her responses specifically on coping with TBI. A previous report to establish the reliability and validity of the scale indicated a high Cronbach‟s alpha values for some domains such as Religion (α=0.82) and Substance use (α=0.90). Other domains indicated acceptable values of Cronbach‟s alpha. They are Active coping (α=0.68), Planning (α=0.73), Positive Reframing (α=0.64), Acceptance (α=0.57), Humor (α=0.73), Using Emotional Support (α=0.71), Using Instrumental Support (α=0.64), Self-distraction (α=0.71), Denial (α=0.54), Venting (α=0.50), Behavioral disengagement (α=0.65) and Self-blame (α=0.69) (Carver 1997). In the Ghanaian sample, the alpha coefficient for the subscales were Religion (α=0.66), Substance use (α=0.70), Active coping (α=0.65), Planning (α=0.62), Positive Reframing (α=0.67), Acceptance (α=0.67), Humor (α=0.61), Using Emotional Support (α=0.66), Using Instrumental Support (α=0.65), Self-distraction (α=0.67), Denial (α=0.66), Venting (α=0.68), Behavioral disengagement (α=0.68) and Self-blame (α=0.65). Religious Coping. The use of religious coping mechanisms among individuals with TBI was measured using Religious Coping Activities Scale (RCAS; Pargament et al., 49
1990). The Religious Coping Activities scale measures the extent to which people turn to religion to cope with stressful life circumstances. The Religious Activities Coping Scale monitors six types of religious coping. The Spiritually Based subscale records an individual‟s reliance on a loving relationship with God. With the Good Deeds subscale, high score reveals attempt to cope by behaving more in conformity with religious commitments. The Discontent subscale records an angry and alienated reaction to God and to the church. Interpersonal Religious Support operationalizes tendencies to lean on the support of clergy and church members. The plead subscale reveals tendencies to question and bargain with God in hopes of obtaining a miraculous solution to personal problems. Religious Avoidance measures a religiously based attempt to divert attention away from stressful circumstances. The response is rated on a 4-point Likert scale ranging from “not at all” to “a great deal” (Pargament et al., 1990). The internal reliability for all the six scales was adequate for research purposes (Pargament et al., 1990). Cronbach‟s alphas were described as ranging from low to moderately high: Religious Avoidance (α = .61), Plead (α = .61), Discontent (α = .68), Interpersonal Religious Support (α = .78), Good Deeds (α = .82) and Spirituality Based Activity (α = .92). The validity scale indicates that the Spirituality Based Activities subscale proved to be an especially strong predictor of successful coping outcome. The Good Deeds, Religious Support and Religious Avoidance also displayed consistently positive effect. Plead and Discontent displayed mixed consequences (Pargament et al., 1990). The six subscales also exhibited significant correlations with measures of non50
Religious Coping Activities and an increment in the predictability of outcome. The psychometric properties of the subscales for the Ghanaian sample were Religious Avoidance (α = .71), Plead (α = .69), Discontent (α = .71), Interpersonal Religious Support (α = .73), Good Deeds (α = .66) and Spirituality Based Activity (α = .65). Social Support. The level of social support available to individuals following TBI was measured using the Multi-Dimensional Support Scale (MDSS) (Winifield et al., 1992) The Multi-Dimensional Support Scale is a self-report measure of the availability and adequacy of social support from various sources. The principle of the MDSS is that the sources of support asked about can be varied according to the situation (Winifield et al, 1992). According to Winifield et al., the first group is always the confidants (family and closest friends, i.e. attachment figures), the second group is always peers (others like the respondent who are facing the same challenges, e.g. other people with the same chronic illness maybe in a selfhelp group, workmates in a high-stress job, other victims of the natural disaster, other unemployed youth, etc.), and the third group is always the “experts” (those who have an official role to provide specialist help for whatever challenge it is, e.g. if the stress is illness the experts are health professionals, if the stress is unemployment the experts are staff in the employment agency, if the stress comes from one‟s work the expert source of support is your supervisor, etc.) (Winifield et al., 1992). The items were varied to fit the traumatic brain Injury situation in the Ghanaian setting. The items on the MDSS include emotional, practical and informational support. To score the MDSS as per the Ghanaian setting, the availability of support is shown by the total frequency of the supportive behaviours - never, sometimes, often, usually or 51
always; scored 1-4; (Winifield et al., 1992). The reliability coefficient of MDSS was high (.75 and above). The reliability coefficient for the Ghanaian sample was .89. Psychosocial Outcomes. As the main measure of psychosocial outcomes, the MayoPortland Adaptability Inventory (MPAI-4) (Malec & Lezak, 2003) was used. The Mayo-Portland Adaptability Inventory (MPAI) is a 35 item inventory designed to assist in the clinical evaluation of people during the post-acute (post hospital admission) period following TBI, to assist in the evaluation of rehabilitation programs designed to serve these people, and to better understand the long-term outcomes of TBI ( Malec & Lezak, 2003). MPAI-4 items represent the range of physical, cognitive, emotional, behavioral, and social problems that people may encounter after TBI. MPAI-4 items also provide an assessment of major obstacles to community integration which may result directly from TBI as well as problems in the social and physical environment (Malec & Lezak, 2003). The MPAI-4 has three subscales (table 2) namely Ability (i.e., sensory, motor, and cognitive abilities); Adjustment (i.e., mood, interpersonal interactions); and Participation (e.g., social contacts, initiation, money management). The first 29 items of the MPAI-4 indicate current status or “outcome” after TBI. Item 30 to 35 measures other preexisting or coexisting conditions that are present and may be contributing to restrictions rated in the first 29 items( Malec & Lezak, 2003). Scores ranges from 0 (no problem) to 4 (severe problem; interferes with activities more than 75% of the time). Scores on the MPAI-4 indicated that the higher the individual score, the poorer the outcome and the lower the score, the better the 52
outcome. The reliability for the three subscales showed satisfactory internal consistency (Person Reliability = .88; Item Reliability = .99) and traditional psychometric indicators (Cronbach's alpha = .89). Three rationally derived subscales for Ability, Activity, and Participation demonstrated psychometric properties that were equivalent to subscales derived empirically through item cluster and factor analyses (Malec & Lezak, 2003). For the 3 subscales, Person Reliability ranged from .78 to .79; Item Reliability, from .98 to .99; and Cronbach's alpha, from .76 to .83. Subscales correlated moderately (Pearson r = .49 - .65) with each other and strongly with the overall scale (Pearson r = .82 - .86) (Malec & Lezak, 2003). The reliability coefficient of the MPAI-4 for the Ghanaian sample was .91. The alpha values for the subscales were Ability (α = .70), Adjustment (α = .69) and Participation (α = .85). Table 3: MPAI-4 items by subscale Ability Index Mobility
Dizziness
Adjustment Index
Participation Index Leisure/recreational activities
Use of Hands
Anxiety
Initiation
Vision
Depression
Social contact
Audition
Irritability, anger, aggression
Leisure/recreational activities
Motor Speech
Pain and headache
Self-care
Communication
Fatigue
Residence
Attention/Concentration
Sensitivity to mild symptoms
Transportation
Memory
Inappropriate social interaction
Work/school
Fund of Information
Impaired self-awareness
Money management
Novel problem-solving
Family/significant relationships
Visuo-spatial Abilities
53
Pilot Study An initial pilot study was conducted before the main data collection. The purpose of the pilot study was to establish the procedures and parameters to use for the research, clarify instructions, to establish the suitability of the measures on Ghanaian sample, estimate the time needed to test participants and to know whether the number of test to be used would be too much for the participants to handle. It also served to determine the reliability of the scale for the population of individuals with TBI in Ghana. In pre –testing these scales, both Korle-Bu Teaching Hospital and 37 military Hospital were conveniently sampled and used for the study. Fifteen (15) participants from the two institutions were used.
The sample included males and females of different age groups and injury severity level. Participants expressed less difficulty in responding to the items on all the scales. However some of the respondents reported that, the items on the scales as a whole contain too many variables. Reliability analysis also produced acceptable values for all the scales. The reliability results for the scales in the Ghanaian samples were reported in the measures.
Ethical Consideration The study was conducted under the adherence of the American psychology association (APA) ethical principles and codes of conduct pertinent to conducting research on human participants (APA, 2002). Informed Consent, Confidentiality and Risk. Participants were given the Information Sheet regarding the present study on the first appointment once they fulfilled criteria for inclusion in the study. The consent guaranteed their anonymity, that details other 54
than those required for the study would be kept confidential and also offered to let them know of the study results should they be interested. During the study period, questions asked by participants were answered satisfactorily, and precaution was taken to ensure that nobody felt under duress to consent to participation in the study. They were also informed of the risk involved in participating and assured that they could „drop out‟ of the study if they so wanted. Ethical Clearance Ethical Clearance for the study was obtained from Noguchi memorial institute of medical research (see Appendix A). Procedure Letter of introduction was obtained from the department of psychology of the University of Ghana to obtain clearance from hospitals of interest. An office space was secured at the various hospitals for the purpose of data collection. Participants who met the criteria for inclusion were invited for the study. During the appointment, the investigator explained the purpose of the research and the procedures involved. If the participant wished to proceed, the consent form was reviewed and then signed by both the participant and the investigator. A second copy of the consent form was also signed and given to the participant. An initial assessment was conducted by the researcher to obtain basic demographic along with his/her brain injury history. The participants were then given the GOAT test. Afterwards, the participants completed a booklet of self-report questionnaires with the help of the researcher. For participants who had difficulty reading or focusing on text, the researcher assisted them by reading the questions aloud and marking the 55
answers. Participants who were too fatigued to complete the entire procedure in one sitting were given the option to schedule an additional appointment to finish the questionnaires or to complete them independently. Data collection lasted for 4 months.
56
CHAPTER FOUR RESULTS Data analysis Data was analyzed using SPSS 16 Statistical Package. Analysis was conducted in stages. First, preliminary analysis was conducted to compute means, standard deviation and reliability test involving the study variables. One-Way ANOVA was used to investigate the difference in psychosocial outcome between three groups of injury severity. Multiple Regression analyses (MRC) was used to test the association of psychosocial outcome with injury severity, coping strategies, religious coping and social support. Categorical variables (gender, Employment status) that were employed in the analysis were entered as dummy variables.
Preliminary Analysis A preliminary analysis was conducted on the dependent variable (psychosocial outcome) to assess its normality of distribution to the total sample. The Shapiro-Wilk test indicated normality for the psychosocial outcome measure (p = .996) on the MPAI-4. Descriptive analysis was conducted to determine the means, standard deviations and reliability for the study variables. Although most of the reliabilities were low, they were adequate for research purposes. Summary of results are presented in table 4.
57
TABLE 4: Means and Standard Deviation (SD) of the study variables of Individuals with traumatic Brain Injury Mean
SD
α
Problem Focused Coping Strategies
48.8000
4.92612
.72
Emotion Focused coping Strategies
20.9750
2.04422
.60
88.2000
7.45310
.70
39.10
4.72
.79
Ability
9.63
4.77
.72
Adjustment
9.95
3.6
.68
Participation
5.88
2.84
.66
Coping Strategies
Religious Coping Social Support Psychosocial Outcomes (MPAI-4)
Total Number Responses (N=40) SD = Standard Deviation Psychosocial outcomes In the present study, the scores of ability, adjustment and participation on the MPAI-4 scale were computed into overall psychosocial outcome score. A high score indicate poor psychosocial outcome and a low score indicates better psychosocial outcome. The mean score for overall psychosocial outcome in the sample based on MPAI-4 scoring manual was 24.85 (SD = 6.51) (range = 10-39; α = .63). Test of Hypotheses The One-Way ANOVA analysis was conducted to compare effect of injury severity on psychosocial outcome in mild, moderate and severe injury conditions. The result is presented in Table 5.
58
Table 5: Summary of One-Way ANOVA of Injury Severity and Psychosocial Outcome of individuals with TBI Mean Sum of Squares
df
Square
F
P
387.45
2
193.73
5.67
.007**
Within Groups 1263.65
37
34.15
Total
39
Between Groups
1651.10
**p ≤ .01
Result from Table 5 shows that there was a significant effect of injury severity on psychosocial outcome for the three conditions (F(2, 37) = 5.672, p < .01). This means that at least the ratings on Psychosocial Outcome of two Injury Severity groups differ significantly from each other. Tukey Honestly Significant Difference (HSD) multiple comparison was conducted to investigate the difference in psychosocial outcome ratings between the various Injury Severity groups (Table 6). TABLE 6: Summary of Tukey HSD of the Injury Severity of Individuals with TBI
1
Mild
2
Moderate
3
Severe
1
2
3
-
3.77
1.12*
-
5.35 -
*p ≤ 0.05
59
The Tukey HSD multiple comparison, at the 0.05 level of significance, indicates that no significant difference exist between Mild and moderate (p = 0.159 > 0.05). Also no significant difference was observed between Moderate and Severe (p = 0.145 > 0.05). However, there was a significant difference between mild and Severe (p = 0.006 ≤ 0.05). This suggests that individuals with mild TBI have better psychosocial outcome than individuals with severe TBI. Hierarchical regression analysis was conducted to determine if injury severity, coping strategies, religious coping and social support account for unique variance in psychosocial outcomes after controlling demographic factors. Due to the large number of predictors and the relatively small sample size, it was necessary to reduce the number of variable included in the regression analysis. Religious coping was removed as it had no significant correlation with the criterion variable. Four steps were used in the analyses. Demographic variables were entered in the first step as a control variable (both gender and employment status were dummy coded). Social support was entered in the second step as a culture variable. Coping strategies was entered in the third step. Injury severity was entered in the fourth step. Results of the regression analysis are presented in tables 7 and 8. Table 7: Multiple regression Model Summary Model
R2
ΔR2
F
p
1
.15
.15
.94
.48
2
.24
.10
4.16*
.05
3
.49
.25
7.35**
.003
4
.65
.15
12.62**
.001
**p < .01, *p < .05 60
Table 8: Hierarchical Regression Analysis of Variables Predicting Psychosocial Outcome of Individuals with TBI (N = 40) B SE
Β
Step 1 Gender
.00
2.34
.00
Employment Status
-3.15
2.57
-.25
Age
.06
.10
.11
Years Of Education
.38
.33
.23
TBI Duration In Years
2.43
1.33
.33
Pre-injury Substance Use
.15
2.65
.01
Gender
.10
2.29
.07
Employment Status
-4.65
2.57
-.36
Age
.05
.09
.09
Years Of Education
.44
.31
.26
TBI Duration In Years
2.08
1.28
.28
Pre-injury Substance Use
.62
2.54
.04
Social Support
-.47
.23
-.34*
Gender
2.81
1.10
.20
Employment Status
-2.73
2.30
-.21
Age
.05
.08
.09
Years Of Education
.25
.27
.15
Step 2
Step 3
61
TBI Duration In Years
1.25
1.14
.17
Pre-injury Substance Use
3.79
2.32
.25
Social Support
-.21
.22
-.16
Problem Focused
-.39
.22
-.29
Emotion Focused
-1.44
.46
-.45**
Gender
1.49
1.73
.11
Employment Status
-2.76
1.95
-.21
Age
.11
.07
.19
Years Of Education
.34
.23
.21
TBI Duration In Years
1.14
.97
.15
Pre-injury Substance Use
.29
2.20
.02
Social Support
-.15
.19
-.11
Problem Focused
-.38
.19
-.29*
Emotion Focused
-1.19
.40
-.38**
Injury Severity
4.35
1.23
.48**
Step 4
**P≤ .01 * p ≤ .05 In determining factors that uniquely predict Psychosocial outcome in the current sample, hierarchical regression analysis indicate that after entering the first step, demographics did not explain a significant amount of the variance in Psychosocial Outcome [R2 = .15, (F(6, 33) = .94, p = .48)]. When social support was added into the second step, it explain a significant amount of the variance in Psychosocial Outcome [ΔR2 = .10, (F(1, 32) = .4.16, p = .05]. The effect of social support was also 62
significant (β = -.34, p = .05). This means that high level of social support is significantly associated with better psychosocial outcome and low level of social support is associated with poorer psychosocial outcome. Coping strategies was entered in the third step, which also explain a significant amount of variance in psychosocial outcome [ΔR2 = .49, (F(2, 30) = 7.35, p < .01)]. Emotion focused coping strategies had a significant effect (β = -.45, p < .01) In the final model when injury severity was entered in the fourth step, the model as a whole explained 52% of the total variance and was statistically significant [R2 = .65, (F(1, 29) = 12.62, p < .01)]. A large effect size was found using Cohen’s (1992) conventions (f2 = .46) along with 83% power using G*Power 3.1.2 (Faul, Erdfelder, Buchner, & Lang, 2009). Further examination indicate that in the final model emotion focused coping strategies (β = -.38, p < .01) and problem focused coping strategies (β = -.29, p = .05) made unique contribution in predicting psychosocial outcome. This means that high use of coping strategies is associated with better psychosocial outcome and low use of coping strategies is associated with poor psychosocial outcome following TBI. Injury severity also made a unique contribution in predicting psychosocial outcome (β = .48, p < .01). This means that the severe the injury, the poorer the psychosocial outcome. Hierarchical multiple regression was conducted to investigate the moderating effect of coping strategies on the effect of injury severity on psychosocial outcome. The test of moderation is the process through which the moderator (M) Z influences the direction
63
and/or strength of the relationship between the independent variable (IV) X and the dependent Variable (DV) Y (Baron & Kenny, 1986). According to Baron and Kenny (1986), testing for moderation effects requires the following steps: 1. Prepare the data set by (a) centering the IV and the Moderator variables other than the dependent variable (compute IV – mean score for the IV) and,(b) if there is a categorical mediator, dummy code it. 2. Then create a new variable for the interaction term (centered predictor by centered moderator) and, if your moderator was categorical (with more than 2 categories), dummy code the interaction term. Centring is a linear transformation method which reduces multicollinearity and other problems (Aiken & West, 1991). 3. Perform a new regression analysis, with centered predictor and centered moderator in their appropriate order (within the regression model), and then the interaction term in a separate block. 4. If the interaction term is significant, then there is a moderation effect. If not, there is no moderation occurring. This procedure was employed to test our hypothesis. Injury severity was used as a dummy (0 1). In centering, the mean value of the variable is subtracted from the individual score of the variable (i.e. Independent variable – Mean), (i.e. Moderator – Mean). Summary of regression analysis is displayed in Table 8.
64
TABLE 9: Hierarchical Multiple Regression of the Moderation Effect of Coping Strategies on the Relationship between Injury Severity and Psychosocial Outcome (N = 40) B
SE B
β
.69
1.04
.51
-2.68
1.39
-.41
-4.57**
1.39
-.70
-3.15*
.77
-.48
severe
-4.56***
1.16
-70
Coping
-3.32***
1.15
-.51
-3.16*
1.15
-.48
severe
-4.56***
1.15
-.70
Coping
-3.15***
.80
-.49
-8.26
.78
-.13
Step 1 mild
Step 2 mild severe
Step 3 mild
Step 4 mild
Mild*Coping
65
Step 5 mild
-3.22**
1.18
-.50
severe
-4.65***
1.18
-.72
Coping
-3.06**
.82
-.47
Mild*Coping
-.33
1.09
-.05
Severe*coping
.78
1.19
.11
Note: R2 = .11 for Step 1; ΔR2 =22 for Step 2; ΔR2 = .26 for Step 3; ΔR2=.02 for Step 4; ΔR2=.01 for Step 5
***p ≤ .001 **p≤ .01
* p ≤ .05
Results showed that the interaction mild*coping strategies was not predictive of changes in psychosocial outcome (B = -8.26, p = .30). Comparison with the reference group (moderate) indicate that the variance in psychosocial outcome accounted for by mild*coping is not significantly different from the variance in psychosocial outcome accounted for by moderate*coping. The interaction severe*coping was also not predictive of change in psychosocial outcome (B = -78, p = .51). Comparison indicates that the coefficient of severe*coping was not significantly different from moderate*coping. The non-significant interaction effect of injury severity levels and coping strategies on psychosocial outcome indicates that coping strategies was not a significant moderator of the effect of injury severity on psychosocial outcome.
66
Summary of Findings
Significant effect of injury severity was observed on the psychosocial outcomes of the three TBI severity groups.
Coping strategies (problem focused and emotion focused) strategies were significant predictors of better psychosocial outcome.
Religious coping was not significantly associated with psychosocial outcome
Social support was a significant predictor of psychosocial outcome
TBI Severity was a unique predictor of changes in psychosocial outcome
Coping strategies was not a significant moderator of the effect of Injury severity on psychosocial outcome.
67
CHAPTER FIVE DISCUSSION The purpose of this study was to investigate the influence of injury severity (PTA), coping strategies, religious coping and social support on psychosocial outcomes of individuals with TBI. The study also aimed to determine the extent to which coping can moderate the effect of injury severity on Psychosocial Outcome. The main findings of this study are discussed in relation to main hypotheses that were identified in the study. The final section of this study discussed the implication of this work to clinical practise. The limitation and recommendations for future directions were also discussed. Difference in psychosocial outcome of TBI severity groups The first hypothesis was that the level of severity would account for individual differences in psychosocial outcome. Result shows that there was a significant effect of injury severity on psychosocial outcome for the three conditions. This means that psychosocial outcome rating was significantly different for at least two of the injury severity groups. Multiple comparisons indicate that individuals with mild TBI have better psychosocial outcome compared to individuals with severe TBI. This means that individuals with severe TBI have poorer psychosocial outcome compared to mild and moderate. Injury severity was observed to be uniquely predictive of psychosocial outcome. The findings indicate that the severe the severity level of injury, the poorer the psychosocial outcome and the milder the injury severity, the better the psychosocial 68
outcome. This finding was expected since individuals with severe TBI usually display varying degrees of cognitive, physical and behavioural difficulties compared to individuals with mild and moderate TBI which affects their level of psychosocial functioning (Ashman et al., 2006). For many individuals, TBI may bring about sudden psychosocial changes which can be exacerbated by the severity of the injury such that the prospects for the future are no known (Godfrey et al., 1996). However an individual with mild TBI may assume that he or she is able to resume normal psychosocial activity within a short time following injury (Silver et al., 2009). As a result they may rate their psychosocial outcome as better even though they may face persistent impairment which may affect their health, education, and social functioning (Christensen et al., 2008; Dawson et al, 2004). This may account for the better psychosocial outcome of individuals with mild TBI. Persons with moderate TBI may assume that they have the ability to adjust and participate in activities within the community. They may attain independence and even resume work following injury (Dikmen et al., 1995). As a result, they may rate their psychosocial outcome as not problematic. However they may encounter difficulties associated with ability, adjustment and participation in activities of the community ( Malec & Lezak, 2003). Persons with severe TBI by reason of varying degrees of cognitive, physical and behavioural difficulties (Ashman et al., 2006) may exaggerate problems associated with their deficits. As a result their rating of psychosocial outcome may be poor compared to other levels of severity. Although return to work may not be possible (Christensen et al., 2008) rehabilitation may help them to adjust. From the forgoing it
69
can be said that the individual’s expectation of what the future hold is important for recovery and this may account for variations in psychosocial outcomes. This finding may explain why individuals with severe TBI have poorer psychosocial outcome compared to individuals with moderate and mild TBI. This result which supports our hypothesis is consistent with previous research (Draper, Ponsford, & Schonberger, 2007; Hellawell et al., 1999; Machamer et al., 2003; Schopp et al., 2006) which found increased severity to be associated poorer outcomes although injury severity may have less influence on outcome as time from injury increases (Wagner et al., 2000). Association of coping Strategies with psychosocial outcome The second hypothesis was coping strategies would significantly predict better psychosocial outcome. The results showed that problem focused and emotion focused coping strategies were negatively associated with psychosocial outcome. This indicates that high use of both problem and emotion focused coping strategies is linked with better psychosocial outcome. When an individual is confronted with sudden changes in psychosocial status following TBI, attempts are made to manage the new situation. However, when the individual perceived that the psychosocial outcome changes associated with TBI is beyond his or her ability to manage, he or she will employ coping strategies to reduce the stress associated with the situation (Folkman et al., 1986). When the individual feels something can be done about the situation given the needed effort, then problem focused coping predominates. If the individuals feels that nothing can be done about the situation, and it is something that must be endured then emotion focused style may be used. Sometimes changes in psychosocial outcome are chronically stressful to the 70
individual, to the extent that they are compelled to use both problem focused and emotions focused coping strategies. The current finding indicates that the high use of these two strategies is associated with better psychosocial outcome. This implies that both problem focused and emotion focused coping strategies are both adaptive (Lazarus & Folkman, 1984). However, our result contradicts other findings (e.g. Anson & Ponsford, 2006). Anson and Ponsford (2006), in a study found problem focused coping strategies such as selfdistraction, venting, denial, substance use, self-blame to be associated with better outcomes (e.g. depression). Emotion focused strategies such as self-distraction, venting, denial, substance use, self-blame was related to poor psychosocial outcome. This indicates that emotion focused coping strategies is associated with poorer psychosocial outcome such as depression, anxiety, and return to productivity (Anson & Ponsford, 2006; Dawson et al., 2006). The contradictory findings may be due to the fact that the other studies have primarily focused on emotional outcomes (e.g. depression, anxiety) at the expense of other aspects of psychosocial outcome. Moreover, the helpfulness of any coping strategy may depend as much on the individual with TBI and the situation he or she finds herself (e.g. employment, school) in as the strategy itself (Kleiber et al., 2002). This implies that problem focused coping may not necessarily be better than emotion focused coping strategies. As a result, the nature and success of these two coping strategies are associated with the individual’s perception of the controllability or uncontrollability of the situation (Lazarus & Folkman, 1984). Our finding also indicated that most of the participants may have positively appraised their injury as stressful and threatening and attempted to develop effective coping 71
strategies to maintain their psychosocial wellbeing. An encouraging finding from the present study was that the majority of the participants responded to their injury severity related problems by problem-focused coping strategies more than emotionfocused coping strategies. Relationship between religious coping and psychosocial outcomes The third hypothesis was that religious coping would be negatively associated with psychosocial outcome. The hypothesis was not supported by the result, since religious coping was not significantly associated with psychosocial outcome. The traumatic changes brought about by TBI may compel the individual to ask question especially in the case of severe TBI, concerning death and mortality, the meaning of life and the injury itself, control, and autonomy and alienation (Waldron- Perrine et al, 2010). As a result they may turn to religion at any time to help them cope with their disability. Religion may give new meaning to the life of the individual with TBI and give them hope of establishing new life in the future (Johnstone et al., 2009). The inability to adapt to psychosocial changes may influence an individual’s desire to reestablish a sense of meaning in life and hope for the future through religion (McGrath, 2004). However, the lack of significant relationship between religious coping and social psychosocial outcome in the current study is an indication that the religious resources available for the Ghanaian individual with TBI are inadequate. This may be due to the limited attention that individuals with TBI receive from religious bodies. This finding provide support for other researches (e.g. Johnstone et al., 2009; Waldron-Perrine et al., 2010) which did not find significance association between religious coping and quality of life.
72
In Ghana, religious bodies are supposed to be the bedrock of individuals with traumatic brain injury who desire to reestablish a sense of meaning in life and hope for the future through religion. However, the limited knowledge of the effect of TBI on an individual’s psychosocial functioning may bring about a mistaken assumption that individuals who experience a TBI will make a full recovery of functioning within a brief period of time (Kay, et al., 1993; Mittl et al., 1994). As a result when patients express any difficulty, religious bodies and many professionals may suppose that these individuals are exaggerating their symptoms or they are not being religious (Bordini, Chaknis, Ekman-Turner, & Perna, 2002; McAllister & Arciniegas, 2002). Religion is an important factor in the rehabilitation of individuals with TBI (Wegner, 2008). However, the limited availability of religious care to the individuals with TBI may compel them to rate religion to be non-significant when adapting to psychosocial outcome changes. Relationship between social support and psychosocial outcome The fourth hypothesis was that social support would be significantly associated with psychosocial outcome. Result showed that there was a significant negative relationship between social support and psychosocial outcome. This means that high level of social support is associated with better psychosocial outcomes and low level of social support is associated with poorer psychosocial outcomes. Many individuals with TBI may adopt coping strategies and religious coping to enable them deal with psychosocial outcome. However, the social support available to encourage them may be inadequate, especially from the extended family, who may show limited understanding of the changes in the life of an individual with TBI and
73
the effect of those changes on the person’s psychosocial status. The consequences may be poorer psychosocial outcome. Currently, in Ghana, many individuals live in urban centres far removed from family members (Twumasi, 2005). As a result, when TBI occurs, only limited people are available to help. Moreover, the consequence of TBI can be more pervasive and endures across the lifespan (NIH, 1999). As a result, moderate to severe TBI may bring about disruption in family and friends resulting in fewer social contacts, alienation and isolation (Levin et al., 1982). The inadequacy of social support may therefore compel individuals with TBI to value any little support available to aid recovery. The consequence is that social support may be rated as highly significant when adapting to changes in psychosocial outcome following TBI. This may account for why social support is significantly related to psychosocial outcome changes of individuals with TBI. This finding supports other research findings (e.g. Ergh et al., 2002; Farmer et al., 2003; Tomberg et al., 2007) which illustrated that that social support plays an important role in the psychosocial functioning of individuals with TBI. Moderating effect of coping strategies on the effect of TBI severity on psychosocial outcome The fifth hypothesis was that coping strategies would moderate the effect of injury severity on psychosocial outcome. The hypothesis was not confirmed by the result. This indicates that coping strategies is not a significant moderator of the effect of injury severity on psychosocial outcome. What determine how injury severity affect psychosocial outcome was not identified in the current study. Failure to find a buffer effect of coping strategies on the relationship between injury severity and 74
psychosocial outcome may be due to small sample size and the methodological measure. Quite often individuals with TBI often perceived their severity to be beyond their control. As a result, they try to confront the deficits associated with the TBI with variety of behaviours, perceptions and cognitions that are often perceived as capable of altering the difficulties related to their deficits. Following from which they may make persistent use of coping strategies aimed at managing the deficits associated with the injury. However, with time when the individual perceived that the severity of symptoms do not remit, they may subsequently perceive coping strategy to be more important to adapting to psychosocial changes than the injury itself. This means that coping strategies may be used independent of injury severity to manage psychosocial outcome. Moreover, research on coping with psychosocial outcome has always been based on the mediated model of coping by Lazarus and Folkman (1984). Others such as Kendall (1996) proposed appraisal and coping as mediators in the relationship between personal, environmental resources, situational factors and psychosocial adaptation after TBI. This indicates that coping strategies are perceived as more of a mediator rather than a moderator. The use of Lazarus model of coping for the current study may have accounted for lack of moderation. This call for a new model that identify coping strategies as moderators. However, the identification and development of a moderator model is beyond the scope of this study. We belief that despite the lack of significance our finding will serve as a reference point for future research.
75
Implication of the study Theoretical implication Injury severity, coping strategies, and social support have all been significantly associated with psychosocial outcome namely ability, adjustment and participation. However, injury severity was a unique predictor of poorer psychosocial outcome while coping strategies emerged as uniquely associated with better psychosocial outcome. These findings have implications for coping theories. Coping theorists often emphasize the benefits of problem focused coping, such as acceptance, positive reframing, and turning to religion or spirituality (Carver, 1997; Carver et al., 1989; Livneh & Martz, 2007; Roth & Cohen, 1986). A considerable number of research with various patient groups show that an increase use of problem focused coping strategies is associated with better quality of life, and increase use of emotion focused coping is associated with depression, anxiety, anger management problems and psychosocial distress (e.g. Anson & Ponsford, 2007; Barlow et al., 2004; Curran et al, 2000; Finset & Andersson, 2000; Hoofien, Gilboa, Vakil, & Donovick, 2001; Kreutzer, Sell, & Gourley, 2001). As a result problem focused and emotion focused coping strategies have been dichotomize as adaptive and maladaptive coping strategies. The current findings however indicate that both problem focused and emotion focused coping strategies are both adaptive. This supports the opinion of Lazarus and Folkman (1984) who viewed both problem focused coping strategies and emotion focused coping strategies as adaptive although the effect of this coping strategies may depend on the specific constraints imposed by the demanding situation (De Ridder & Schreurs, 2001; Karlsen & Bru, 2002). 76
The differences in findings of this study and those of previous studies, regarding the effect of problem focused and emotion focused coping strategies on outcomes may be as a result of cultural differences in how patients from various cultures cope with outcomes related to TBI and other chronic disabilities. Most of the participants in this study may have positively appraised their injury as stressful and threatening and attempted to develop effective coping strategies to maintain their psychosocial wellbeing. Implication for practice The results of the current study hold important implications for health professionals who work with traumatic brain injury patients. The findings of the study suggest that health professionals should thoroughly assess patients to identify coping strategies and the level of social support that has kept them going. While planning the treatment of patients with TBI, evaluating their level of coping strategies use and and the availability of social support might help to provide interventions aimed at providing appropriate social support, coping strategies education and rehabilitation. The favourable role of coping strategies and social support, suggests the potential benefits of interventions to stimulate more coping strategies and encourage more social support to deal with difficulties and challenges associated with changes in psychosocial outcome. Effective religious coping should also be encouraged in order to facilitate adaptation and manage problems associated with psychosocial outcome changes. The findings also have implication for Ghanaians. Ghanaians need to understand the influence of injury severity and coping in relation to psychosocial outcome in
77
individuals with TBI. This will enable them give the needed support to TBI patients within the community setting. Limitations The role of coping strategies, religious coping and level of social support for TBI patients were unclear in the Ghanaian population. This research is one of few studies in Ghana that address the gap. This is the strength of our study. However, the findings of this study are somewhat limited by the small sample size as a result of the difficulty involved in obtaining adequate clinical samples within the limited research time frame. Adequate research time frame will help address this problem. Moreover, the participants in this study represent a subset of TBI survivors who attend clinical reviews. As a result, contextual and environmental factors may have, in part, influenced our findings. Therefore it is not clear to what extent these findings will generalize to TBI survivors in Ghana who were not attending review. However, we believe the sample was representative for the population of patients with mild, moderate and severe TBI in Ghana, as it was a usual procedure that all patients with TBI were referred to the 2 hospitals from which we included patients. The low reliability of some of the measures is also an important issue that need to be addressed in future research. The relatively low reliability coefficient of some measures may be due to the small sample size used in this study. A larger sample in future study may help address this issue. Furthermore, all questionnaire data were collected at the same time point. As a result, changes in outcome over a period may not be identified. Longitudinal study will address this problem. This implies that any assumptions made regarding causality are to be regarded as speculative. 78
Recommendations Further investigation, including adequate research period and a larger sample size with a broad range of intracultural coping strategies, religious coping, and social activity as well as multiple measurement time points are required to confirm our findings. Based on the findings of the study, it is also recommended that when providing interventions, professionals need to assist patients in establishing appropriate coping mechanisms based on self-evaluations. For example, encouraging the use of problememotion focused or religious coping as a coping strategy can assist in decreasing psychosocial distress. In addition, identifying TBI individuals who are more likely to encounter difficulties dealing with the impact of TBI severity and then assisting them with the appropriate social support and coping mechanism can help foster good health behaviours and better psychosocial functioning. Summary and Conclusion The results of this study confirm that injury severity plays an important role in psychosocial outcome namely ability, adjustment and participation following traumatic brain injury. However outcome is a multidimensional construct (Draper et al., 2007) making it difficult to measure. Considerable care therefore needs to be taken in its measurement and in the drawing of conclusions regarding its predictors. These depend on what is being measured and by whom (Draper et al., 2007). PTA duration as a measure of injury severity and coping strategies remains a relatively strong predictors of outcome. Other factors, such as religious coping and social support, appear to be associated with ability, adjustment and participation, thereby indirectly influencing psychosocial outcome. Previous studies have not investigated 79
the association of these variables on outcome in one study, a greater understanding of which should form the foundation upon which more effective rehabilitation services and long-term support can be built (Draper et al., 2007). The findings of this study provided essential information, about Ghanaian individuals with TBI, concerning: (1) Injury severity, (2) coping strategy mechanisms used, and (3) psychosocial outcome This study also provides greater insight into the relative contribution of coping strategies, religious coping and social support to specific facets of psychosocial functioning in individuals with TBI in Ghana. The findings also suggest implication for clinical practice. Interventions to promote high use of the various coping mechanisms may be an effective approach to promoting positive psychosocial adaptation among individuals with TBI.
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APPENDICES APPENDIX A: ETHICAL CLEARANCE
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Appendix B:
CONSENT FORM
Title: Injury Severity, Coping strategies and psychosocial outcome of Individuals with Traumatic Brain Injury Principal Investigator: Emmanuel Sarku Address: Department Of Psychology University of Ghana LG 84 Legon Email:
[email protected] General Information about Research You have been invited to participate in our research of the influence of injury severity and coping strategies on the psychosocial outcome of individuals with traumatic brain injury. This study would further our understanding of how the severity of traumatic brain injury affects an individual’s thought process, behaviour, emotions and his or her ability to function in the society and the coping styles that he or she uses to manage the difficulties that result from the injury. It is expected that the identification of coping styles will help design interventions to improve your wellbeing and teach ways to help you cope with your injury. Your participation in the research study is voluntary. Before agreeing to be part of this study, please read and/or listen to the following information carefully. Feel free to ask questions if you do not understand something. 115
Description of Procedure. If you participate in this study, you will (may) be asked to: 1. Participate in a brief interview including questions about past medical and family history. 2. Perform brief screening tests, designed to assess cognitive functioning such as attention, memory, and orientation. 3. Respond to 2 separate set of questionnaires. One set of test measures coping strategies such as psychological, religious and social support. The second set measures physical, psychological and social functioning. 4. The entire experiment will be approximately 45 minute. Possible Risks and Discomforts The following risks, actual or potential, may occur as part of your participation in this research: Some of the tests and the exercises may be easy, while others may be difficult. No one is expected to be able to answer all the questions correctly, though some questions do not contain right or wrong answers. Please understand that recall may bring back some bad memories which may create psychological discomfort. However, therapy will be given to help you overcome your psychological discomfort. Also, understand that you may experience fatigue during testing. Ample time will also be given for periodic breaks to prevent fatigue.
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Possible Benefits This study was not designed to benefit you directly. However, participation in the study will enhance our understanding of the role of coping strategies in the management of psychosocial difficulties resulting from the severity of brain injury. Hopefully, these results can be used to design rehabilitation programmes that will maximize coping in the traumatic brain injury population. Confidentiality Any and all information obtained from you during the study will be confidential. Your privacy will be protected at all times. You will not be identified individually in any way as a result of your participation in this research. The data collected however, may be used as part of publications and papers related to brain injury research Compensation You will receive 5 sessions of therapy at the Accra Psychiatric hospital, Psychology Unit, which will help you to feel better emotionally. The therapy session will also help in your rehabilitation. Voluntary Participation and Right to Leave the Research Your participation in this study is entirely voluntary. You may refuse to participate in this research. Such refusal will not have any negative consequences for you. If you begin to participate in the research, you may at any time, for any reason, discontinue your participation without any negative consequences.
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Contacts for Additional Information If you have further questions about this research project, please contact the principal investigator,
Mr.
Emmanuel
Sarku,
at
(+233)208447362,
e-mail:
[email protected]. In case of pertinent questions about the research and research related injury, you can also contact the research supervisors, Prof. S. A. Danquah, Consulting Clinical Psychologist and Coordinator of the Post Graduate programme, department of Psychology, University of Ghana at +233244333196, email:
[email protected] and Dr. Adote Anum, Lecturer, department of Psychology, University of Ghana at (+233) 249107770, email:
[email protected]. Your rights as a Participant This research has been reviewed and approved by the Institutional Review Board of Noguchi Memorial Institute for Medical Research (NMIMR-IRB). If you have any questions about your rights as a research participant you can contact the IRB Office between the hours of 8am-5pm through the landline 0302916438 or email addresses:
[email protected] or
[email protected] .
You may also
contact the chairman, Rev. Dr. Ayete-Nyampong through mobile number 0208152360 when necessary.
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VOLUNTEER AGREEMENT The above document describing the benefits, risks and procedures for the research title Injury Severity, Coping Strategies and Psychosocial Outcome of Individuals with Traumatic brain Injury has been read and explained to me. I have been given an opportunity to have any questions about the research answered to my satisfaction. I agree to participate as a volunteer.
_______________________ ____________________________________ _____________ Date
Signature or mark of volunteer
If volunteers cannot read the form themselves, a witness must sign here: I was present while the benefits, risks and procedures were read to the volunteer. All questions were answered and the volunteer has agreed to take part in the research.
_______________________ _________________________________________________ Date
Signature of Witness 119
I certify that the nature and purpose, the potential benefits, and possible risks associated with participating in this research have been explained to the above individual.
_______________________ __________________________________________________ Date
Signature of Person Who Obtained Consent
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APPENDIX C:
MEASURES
1: Demographics Age………… Gender……………… Years of education……………… Occupation………………………
Glasgow coma score………………
Duration of TBI…………………
Relationship status………………..
Injury type……….. 2: THE GALVESTON ORIENTATION AND AMNESIA TEST 1. What is your name? -2 _____ 2. When were you born?
Must give both first name and surname.
-4 _____
3. Where do you live?
-4 _____
4. Where are you now:
(a) City
Must give day, month, and year.
Town is sufficient. -5 _____
Must give actual town.
(b)Building -5 _____ Usually in hospital or rehab center. Actual name necessary. 5. When were you admitted to this hospital?
-5 _____
6. How did you get here?
Mode of transport.
-5 _____
Date.
7. What is the first event you can remember after the injury? -5 _____ Any plausible event is sufficient (record answer) 8. Can you give some detail?
-5 _____
Must give relevant detail.
9. Can you describe the last event you can recall before the accident? -5_____ Any plausible event is sufficient (record answer) 10. What time is it now? -5 _____ 11. What day of the week is it?
-1 for each half-hour error.
-3 _____ 121
-1 for each day error.
12. What day of the month is it? (i.e. the date)
-5 _____
-1 for each day
error. 13. What is the month?
-15 _____
-5 for each month error.
14. What is the year?
-30 _____
-10 for each year error.
Total Error: Total Actual Score = (100 - total error) = 100 - _____ =
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3:
Brief COPE
These items deal with ways you've been coping with the stress in your life since you found out you had brain injury. There are many ways to try to deal with problems associated with brain injury. These items ask what you've been doing to cope with this one. Obviously, different people deal with things in different ways, but I'm interested in how you've tried to deal with it. Each item says something about a particular way of coping. I want to know to what extent you've been doing what the item says. How much or how frequently. Don't answer on the basis of whether it seems to be working or not—just whether or not you're doing it. Use these response choices. Try to rate each item separately in your mind from the others. Make your answers as true FOR YOU as you can. 1 = I haven't been doing this at all 2 = I've been doing this a little bit 3 = I've been doing this a medium amount 4 = I've been doing this a lot 1. I've been turning to work or other activities to take my mind off things. 2. I've been concentrating my efforts on doing something about the situation I'm in. 3. I've been saying to myself "this isn't real.". 4. I've been using alcohol or other drugs to make myself feel better. 5. I've been getting emotional support from others. 6. I've been giving up trying to deal with it. 7. I've been taking action to try to make the situation better. 8. I've been refusing to believe that it has happened. 9. I've been saying things to let my unpleasant feelings escape. 123
10. I’ve been getting help and advice from other people. 11. I've been using alcohol or other drugs to help me get through it. 12. I've been trying to see it in a different light, to make it seem more positive. 13. I’ve been criticizing myself. 14. I've been trying to come up with a strategy about what to do. 15. I've been getting comfort and understanding from someone. 16. I've been giving up the attempt to cope. 17. I've been looking for something good in what is happening. 18. I've been making jokes about it. 19. I've been doing something to think about it less, such as going to movies, watching TV, reading, daydreaming, sleeping, or shopping. 20. I've been accepting the reality of the fact that it has happened. 21. I've been expressing my negative feelings. 22. I've been trying to find comfort in my religion or spiritual beliefs. 23. I’ve been trying to get advice or help from other people about what to do. 24. I've been learning to live with it. 25. I've been thinking hard about what steps to take. 26. I’ve been blaming myself for things that happened. 27. I've been praying or meditating. 28. I've been making fun of the situation. ------------------------------------------------------------------------
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4:
RELIGIOUS COPING ACTIVITIES SCALE
Please read the statement listed below and for each statement please indicate to what extent each of the following was involved in your coping with traumatic brain injury. Please use the following scale to record your answers. 1= not at all
2= somewhat
3= quite a bit
4= a great deal
Spiritually Based Coping 1. Trusted that God would not let anything terrible happen to me. 2. Experience God’s love and care. 3. Realized that God was trying to strengthen me. 4. In dealing with the problem, I was guided by God. 5. I realized that I didn’t have to suffer since Jesus suffered for me. 6. Used Christ as an example of how I should live. 7. Took control over what I could and gave the rest to God. 8 My faith showed me different ways to handle the problem 9. Accepted the situation was not in my hands but in the hands of God 10. Found the lesson from God in the event. 11. God showed me how to deal with the situation. 12. Used my faith to help me decide how to cope with the situation. Good Deeds 13. Tried to be less sinful. 14. Confessed my sins. 15. Led a more loving life. 16. Attended religious services or participated in religious rituals. 17. Participated in church groups (support groups, prayer groups, Bible studies). 125
18. Provided help to other church members. Discontent 19. Felt angry with or distant from God. 20. Felt angry with or distant the members of the church. 21. Questioned my religious beliefs and faith. Interpersonal Religious Support 22. Received support from the clergy. 23. Received support from other members of the church. Plead 24. Asked for a miracle. 25. Bargained with God to make things better. 26. Asked God why it happened. Religious Avoidance 27. Focused on the world-to-come rather than the problem of this world. 28. I let God solve my problems for me. 29. Pray or read the bible to keep my mind of my problems.
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5:
THE MULTI-DIMENSIONAL SUPPORT SCALE (MDSS)
Below are some questions about the kind of help and support you have available to you in coping with your life at present. The questions refer to three different groups of people who might have been providing support to you since the event. For each item, please indicate the alternative which shows your answer. 1. Never 2.
sometimes
3. often 4. always A. Firstly, think of your family and close friends, especially the 2 -3 who are most important to you 1. How often did they really listen to you when you talked about your concerns or problems? 2. How often did you feel that they were really trying to understand your problems? 3. How often did they really make you feel loved? 4. How often did they help you in practical ways, like doing things for you or lending you money? 5. How often did they answer your questions or give you advice about how to solve your problems? 6. How often could you use them as examples of how to deal with your problems?
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B. Now, think of other people of about your age that you know, who are like you in being employed, unemployed, or studying. 1. Never
2. Sometimes
3. Often
4. always
1. How often did they really listen to you when you talked about your concerns or problems? 2. How often did you feel that they were really trying to understand your problems? 3. How often did they help you in practical ways, like doing things for you or lending you money? 4. How often did they answer your questions or give you advice about how to solve your problems? 5. How often could you use them as examples of how to deal with your problems?
C. Lastly, think of the people in some sort of authority over you. If you are employed, this means your supervisors at work. If you are unemployed, it means your guardians/care givers. If you are a full-time student, it means your lecturers and tutors. Depending on which ones are relevant for you, answer for the 2-3 that you see most. 1. How often did they really listen to you when you talked about your concerns or problems? 2. How often did you feel that they were really trying to understand your problems? 3. How often did they fulfil their responsibilities towards you in helpful practical ways? 4. How often did they answer your questions or give you advice about how to solve your problems? 5. How often could you use them as examples of how to deal with your problems? 128
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