ADAPTATION TO MILD TRAUMATIC BRAIN INJURY AMONG THAI ADULTS
by
NUTTHITA PETCHPRAPAI
Submitted in partial fulfillment of the requirements
For the degree of Doctor of Philosophy
Dissertation Advisor: Dr. Chris Winkelman
Frances Payne Bolton School of Nursing
CASE WESTERN RESERVE UNIVERSITY
May, 2007
CASE WESTERN RESERVE UNIVERSITY
SCHOOL OF GRADUATE STUDIES
We hereby approve the dissertation of
______
candidate for the Ph.D. degree *.
(signed)______(chair of the committee)
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(date) ______
*We also certify that written approval has been obtained for any proprietary material contained therein. i
Table of Contents
Page
Chapter One: Background and significance
- Introduction and problem…………………………………………………….. 1
- Background…………………………………………………………………… 1
- Statement of problem…………………………………………………………. 3
- Statement of purpose………………………………………………………….. 3
- Adaptation to mild traumatic brain injury…………………………………… 4
- Stimuli related to mild traumatic brain injury recovery………………………. 6
- Process of adaptation………………………………………………………….. 10
- Adaptation…………………………………………………………………….. 11
- Quality of life as adaptation…………………………………………………… 12
- Adaptive modes after mild traumatic brain injury…………………………….. 14
- Summary………………………………………………………………………. 19
- Research questions……………………………………………………………. 19
- Assumptions…………………………………………………………………... 20
- Definitions and terms………………………………………………………… 20
- Significance to nursing……………………………………………………….. 22
Chapter Two: Literature review
- Overview……………………………………………………………………… 26
- Determinants of mild traumatic brain injury………………………………….. 26
- Influential factors……………………………………………………………… 29
- Quality of life as adaptation…………………………………………………… 40 ii
Table of Contents
Page
- Adaptation and mild traumatic brain injury…………………………………... 45
- Identifying gaps in knowledge………………………………………………... 53
- Summary……………………………………………………………………… 54
Chapter Three: Method
- Study setting and sample……………………………………………………… 57
- Measures………………………………………………………………………. 60
- Procedures…………………………………………………………………...... 74
- Data management and data analysis…………………………………………... 78
- Protection of human subjects………………………………………………….. 83
Chapter Four: Results
- Subjects……………………………………………………………………….. 89
- Stimuli………………………………………………………………………… 90
- Adaptation process……………………………………………………………. 99
- Preliminary data examination…………………………………………………. 102
- Results for research questions………………………………………………… 104
- Research question 1…………………………………………………………… 104
- Research question 2…………………………………………………………… 108
- Research question 3…………………………………………………………… 111
- Additional data analysis………………………………………………………. 122
- Summary of the findings……………………………………………………… 133
iii
Table of Contents
Page
Chapter Five: Discussion
- Summary………………………………….…………………………………. 135
- Sample………………………………………………………………………… 136
- Stimuli………………………………………………………………………… 136
- Additional findings about sample…………………………………………… 147
- Adaptation processes…………………………………………………………. 147
- Discussion for research question 1…………………………………………… 149
- Discussion for research question 2……………………………………………. 152
- Other findings of associations among variables……………………………… 156
- Discussion for research question 3……………………………………………. 161
- Predictors of quality of life……………………………………………………. 161
- Predictors of the Extended Glasgow Outcome Scale…………………………. 166
- Limitations of this study………………………………………………………. 172
- Implications and recommendations…………………………………………… 175
- Conclusion…………………………………………………………………….. 179
Reference 181
iv
List of Tables
Page
Table 1: Severity of Mild Traumatic Brain Injury for all subjects……………….. 91
Table 2: Severity of Mild Traumatic Brain injury among subjects without 92
multiple injuries…………………………………………….……………………..
Table 3: Severity of Mild Traumatic Brain injury among subjects with MTBI and
other injuries……………………………………………….…………………… 93
Table 4: Demographic characteristics of the subjects………..…………………… 95
Table 5: Differences between focal, contextual and residual stimuli among
MTBI subjects with and without multiple injuries…………….…………………. 96
Table 6: Residual stimuli among all subjects ………………….…………..……... 97
Table 7: Residual stimuli among subjects without other injuries ………………. 98
Table 8: Residual stimuli among MTBI subjects with other injuries …………... 99
Table 9: Adaptation processes among all subjects ………………..……………... 100
Table 10: Adaptation processes among subjects without other injuries ……….. 100
Table 11: Adaptation processes among subjects with MTBI and other injuries …. 101
Table 12: Differences of adaptation processes among MTBI subjects with and
without other injuries…………………………………………………………… 101
Table 13: Reliability statistics of the measurements ……………………………. 104
Table 14: Quality of life results…………………………………………………. 105
Table 15: Differences of quality of life among MTBI subjects with and without
other injuries…………………………………………………………….……… 106
Table 16: Description of the Extended Glasgow Outcome Scale……………….. 107 v
List of Tables
Page
Table 17: Differences of the Extended Glasgow Outcome Scale categories
among the subjects……………………………………………………….……….. 108
Table 18: Correlation coefficients among stimuli, processes and outcomes……. 110
Table 19: Correlation coefficients among variables…………………………….. 112
Table 20: Multiple regression of stimuli in quality of life……………..…………. 115
Table 21: Multiple regression of stimuli in quality of life after exclusion of the 117
outliers…………………………………………………………..……………..….
Table 22: Logistic regression of all stimuli in the Extended Glasgow Outcome 118
Scale……………………………………………………………………………….
Table 23: Multiple regression of stimuli in coping……………..………………… 119
Table 24: Multiple regression of stimuli in depressive symptoms…..…………… 120
Table 25: Multiple regression of coping and depressive symptoms in quality of 121
life…………………………………………………………………..……………..
Table 26: Logistic regression of coping and depressive symptoms in the
Extended Glasgow Outcome Scale……………………………………………... 121
Table 27: Multiple regression of stimuli, coping and depressive symptoms in 124
quality of life ……………………………………………………..……………….
Table 28: Logistic regression of stimuli, coping and depressive symptoms in the
Extended Glasgow Outcome Scale…………………………………..…………… 125
Table 29: Multiple regression of stimuli in quality of life with coping and
depressive symptoms were the moderators …………………………..………… 128 vi
List of Tables
Page
Table 30: Summarization of Logistic regression of stimuli in the Extended
Glasgow Outcome Scale when coping and depressive symptoms were the 131 moderators ………………………………………………………….………….
vii
List of Figures
Page
Figure 1: Conceptual model………………………………………………………. 5
Figure 2: Measures of each variable in conceptual framework ………………….. 61
Figure 3: The interaction effects of depressive symptoms on the relationship between social support and quality of life……………………………………… 129
Figure 4: The interaction effects of coping on the relationship between social support and quality of life……………………………………………….………... 130
Figure 5: The interaction effects of depressive symptoms on the relationship
between social support and the Extended Glasgow Outcome Scale…………….. 132
Figure 6: The interaction effects of coping on the relationship between social
support and the Extended Glasgow Outcome Scale…………………………….. 132
viii
List of Appendix
Page
Appendix A: Demographic data worksheet………………………………………. 220
Appendix B: Postconcussion Syndrome Checklist……………………………….. 224
Appendix C: The Life Experience Survey……………………………………….. 228
Appendix D: Social Support Questionnaire Short Form…………………………. 237
Appendix E: The Coping Adaptation Processing Scale………………………….. 241
Appendix F: Quality of Life Index……………………………………………….. 246
Appendix G: Depression Scale…………………………………………………… 255
Appendix H: Table of References..……………………………………………….. 257
Appendix I: Phone Script…………………………………………………………. 271
Appendix J: Cover Letter…………………………………………………………. 276
Appendix K: Consent Forms……………………………………………………… 284
Appendix L: IRB approval documents…………………………………………… 293
ix
ACKNOWLEDGEMENTS
I would like to thank all the adults with mild traumatic brain injury for their participations in this study and the family members of the subjects for their help in contacting participants. The data collection process would never been finished without all of them. I am very grateful for guidance and supports that I received from my advisor,
Dr. Chris Winkelman, who knew all of my dimensions and tried her best to put me in shape throughout my study process. Many thanks go to Dr. Higgins, Dr. Musil and Dr.
Ciccia, my committee members, who always wished to see the best of me.
Living and studying abroad is not an easy thing to do. My greatest thanks go to my parents and my family members who always believe in me. I admire the kindness of my long time friend, Rossukon Pichaipat, who has taken care all of my paper works and errands since I have left Thailand. I also would like to thank my best friends, Amany
Farag and Niranart Vithayachokkitikhun, who always by my side no matter how good or bad I am. Even when I was down in the dump, I knew that both of you would always around. I appreciated Dr. David Jackowe for turning himself from a surgeon to be my
English editor and my psychiatrist. You made me know the meaning of a real good friend. I would like to extend my gratitude to all of my teachers who added up all knowledge until I eventually finished my study. Finally, I would like to thank the Thai
Royal Government in their funding support for my study. For those whom I forget to mention, you will always in my thoughts.
x
Adaptation to Mild Traumatic Brain Injury among Thai Adults
Abstract
by
NUTTHITA PETCHPRAPAI
Mild traumatic brain injury (MTBI) affects more than 28,000 individuals annually in Thailand; however, little information about outcome after MTBI is known. This investigation aimed to explore adaptation, determine factors associated with adaptation, and identify the predictors of adaptation among Thai adults who experienced MTBI in the previous 3-12 months.
Roy’s Adaptation Model was the framework for this study. A descriptive- predictive, cross-sectional design was used. A sample of 135 adults was interviewed.
Subjects were typically men, middle aged, and about half were married. All of them finished the compulsory level of education and had low income. Subjects had Glasgow
Coma Scores 14 at 30 minutes after injury and 15 (full score) after 3 days. Duration of posttraumatic amnesia was six minutes while the duration of loss of consciousness was two minutes. Subjects reported low postconcussion symptoms scores, few stressful life events and few depressive symptoms. Scores of coping, social support and quality of life
(QOL) were high. All subjects worked or studied before the injury and almost of them returned to normal lives at the time of interview. However, 18% did experience moderately severe disability and 1.5% suffered severe disabilities.
Social support was positively correlated with QOL whereas none of the other stimuli were significantly associated with QOL and the Extended Glasgow Outcome
Scale (GOSE). All stimuli, coping and depressive symptoms significantly explained xi
15.8% of QOL, with social support as the only significant predictor. The same set of stimuli could not successfully explain the GOSE. Although the mediator effects of coping and depressive symptoms in the original conceptual model were not supported, moderator effects with social support were found.
Future studies with longitudinal, comparison, or predictive methodology with reduced but relevant variables are suggested. Developing a middle range theory is recommended to continue investigating QOL conceptually equivalent to adaptation.
Measures used in this study demonstrated reliability, supporting their use in Thailand.
Providing of health education or printed information about outcomes especially problems after MTBI is recommended. Further study of the small but clinically important percentage of subjects who experience ongoing disability after MTBI is needed.
1
CHAPTER ONE
Background and Significance
Introduction and Problem
Injuries and deaths from motor vehicle crashes (MVC) have become major public health and socio-economic concerns in Thailand (Suriyawongpaisal & Kanchanasut,
2003). For more than a decade, the incidence of MVC has ranked among the five leading causes of injuries and deaths of Thai people. During a week of traditional Thai New Year holidays (mid- April), the incidence of traffic related injury increased to 4,914 people/ day and 5,557 people/ day in 2003 and 2004 respectively (Narenthorn Trauma Center,
2005). Among the accidents, more than 80% were caused by motorcycle crashes
(helmetless); 64.4% involved adult (20-69 years), and 41% involved alcohol abuse
(Narenthorn Trauma Center, 2005).
Head injuries are a major cause of death and disability related to MVC (Mock,
Maier, Bolye, Pilcher, & Rivara, 1995) and 77% of traffic related injuries in Thailand are to the head and brain (Suriyawongpisal, 2003). Despite medical developments and accident prevention campaigns, the number of injured has nearly doubled in the last 10 years. The majority of adults with head injures (83.7%) have a mild to moderate severity
(Phuenpathom, Tiensuwan, Ratanalert, & Saeheng, 2000).
Background
Mild traumatic brain injury (MTBI) refers to an injury to the head or face and includes a damage to the brain (Levin, Eisenberg, & Benton, 1989; McHugh, 2002). The damage, not degenerative or congenital in nature, is caused by an external physical force and may produce an alteration of state of consciousness, impairment of cognitive or physical functioning, and disturbances of behavioral or emotional functioning (Schutt, 2
1999). The definitions of MTBI vary. The terms “closed head injury”, “traumatic brain injury”, “mild brain injury”, “minor brain injury” and “concussion” are used interchangeably with MTBI (Gasquoine, 1997).
Even though MTBI is not a life threatening condition, mortality can occur; one of one thousand MTBI sufferers dies from his/ her brain injury (af Geijerstam & Britton,
2003). In addition, nine of one thousand adults with MTBI require surgery or other intervention. At least 80 out of 1,000 with MTBI have abnormal pathology in their CT findings and at least 80:1000 require hospitalization (af Geijerstam & Britton, 2003).
Persons who experienced MTBI are one of several populations living with a potential lifelong impairment. Studies suggest that at least some MTBI adults suffer from poor performance of verbal processing, learning, and retention (Bell, Primeau, Sweet, &
Lofland, 1999), attention and concentration (Bigler & Snyder, 1995), behavior impairment (Hartlage, Durant-Wilson, & Patch, 2001), depression (Busch & Alpern,
1998), occupational disability and chronic symptoms (Binder, 1997); and report poor quality of life (Bedard et al., 2003; Berger, Leven, Pirente, Bouillon, & Neugebauer,
1999).
The economic impact from MTBI is enormous. Direct costs of treatment, both acute care and hospitalization costs, and indirect costs such as lost income and damage to property in Thailand for all individuals with MTBI or head injuries, are estimated at 40 billion bahts a year (1 billion US$). This figure is equivalent to 23% of total health expenditure or 0.9% of Thailand’s GDP (Suriyawongpaisal & Kanchanasut, 2003).
Although the incidence of MTBI and its complications are high all over the world, guidelines and protocols of care for this population are unavailable (af Geijerstam &
Britton, 2003). 3
Statement of problem
Mild Traumatic Brain Injury (MTBI) consequences may produce impairment in different areas such as coping, mood, and physical symptoms resulting in reduced quality of life (QOL) and maladaptation. People can face stressors and challenges in their daily lives when learning to adapt to physical and psychological consequences from an MTBI.
The factors that influence adaptation after MTBI are controversial. Brain injury research often includes all severities of injury. Variable outcomes after MTBI have been reported.
Studies related to MTBI outcomes have gained more attention internationally.
However, there are few studies related to MTBI in Thailand and no publications about recovery after MTBI among Thai adults. As MTBI does not usually cause life threatening or visible disability, MTBI patients seldom receive attention from health care professionals. In the United States, patients with MTBI can access care from private rehabilitation centers. Thai adults with MTBI receive care at home and are expected to recover without any rehabilitation program. There might be transcultural differences in the precursors and consequences of MTBI. Furthermore, stimuli or predictors for adaptation among the Thai population may be unique. Information about outcomes after
MTBI among Thai adults is needed to understand the depth and breadth of problems they encounter. Identifying factors that contribute to adaptation within Thai context could be useful in developing programs that help Thai MTBI adults return to their normal lives as soon as possible after their injury when post-MTBI sequelae occurs.
Statement of purpose
This study described adaptation among Thai MTBI adults. Stimuli related to MTBI recovery (i.e. severity of injury, individual characteristics, stress, social support, coping 4 processes and depressive symptoms) were identified. Finally, stimuli that could predict adaptation to MTBI among Thai adults were examined.
Adaptation to MTBI
MTBI is a stressful life event that may impact various dimensions of a person’s physical, psychological, social and environment. It may cause a person to react by exhibiting complex adverse behaviors (Martelli, Zaster, & MacMillan, 1998). Challenges to daily activities after MTBI may produce significant effects on quality of life (QOL), leading to maladaptation. In order to understand phenomena of MTBI recovery and contribute to a more coherent and comprehensive body of knowledge and to advance the science of nursing, use of nursing conceptual and theoretical work is recommended
(Fawcett, 2000, 2002). The Roy Adaptation Model (RAM) was used to guide this study.
According to Roy, a person is an adaptive system, responding to internal and external stimuli (input) through behavior. The goal of nursing is to promote adaptation for individual(s) in four adaptive modes, thus contributing to health, quality of life, and dying with dignity (Roy, 2005; Roy & Roberts, 1981). This is done by assessing behavior and factors that influence adaptive abilities and by intervening to expand those abilities and to enhance environmental interactions (Roy, 2005).
The RAM provides a global perspective for assessing individual adaptation in four adaptive modes: physical, self-concept, role function, and interdependence. Each mode is a method that a person uses to respond to stimuli by doing or acting and can be observed through behaviors (Roy & Zhan, 2001). Roy (Roy & Andrews, 1999) describes persons as bio-psycho-social open systems that are required to constantly respond positively to changing environmental stimuli. The environmental stimuli include focal, contextual, and residual stimuli. The focal stimuli are the internal and external factors that the person is 5 confronting and these stimuli have a significant influence on a person’s whole system. In this study, the focal stimuli are defined as the severity of injury. The contextual stimuli are the internal and external factors that can have an effect on a person’s perception of the focal stimuli. Individual characteristics of age, gender, time after injury, employment status, alcohol abuse and education were considered the contextual stimuli for this study.
The residual stimuli are external and internal factors that may affect the extent of focal stimuli, but the effects are not clearly supported. In this study, life stress events, social support and marital status were defined as the residual stimuli. Stress has a strong effect on coping (Lazarus & Folkman, 1984), and social support and marital status are believed to be components of the social network that can effect the way MTBI adults deal with their conditions. The relationship among stimuli, the process of coping with depressive symptoms as a potential mediator, and adaptation to MTBI among Thai adults was shown in figure 1. Adaptation was examined in all four modes of the RAM. The specific variables associated with each component of the RAM in MTBI patients are explained in the next sections.
Figure 1: Conceptual model
Focal Stimuli: *Coping Severity of MTBI *Depressive
Symptoms Contextual Stimuli:
Individual Characteristics
Residual Stimuli: Adaptation Stress and Social Support
6
Stimuli related to MTBI recovery
A person’s ability to respond depends on the situation, the person’s adaptation level, and the individual’s coping ability. Adaptation level works as the combined effects of three categories of stimuli that the person must respond to; 1) focal stimuli or stimuli immediately confronting persons, 2) contextual stimuli or other stimuli in the internal and external environment that have an impact on the strength of focal stimuli, and 3) residual stimuli or factors whose effects on the current situation are unclear and/ or difficult to validate such as beliefs, attitude, or traits that have an effect on the present situation (Roy
& Roberts, 1981).
Numerous stimuli related to severity of brain injury have been reported as having a potential influence in the response to MTBI. These include the duration of posttraumatic amnesia (PTA), duration of loss of consciousness (LOC), presence of postconcussion symptoms (PCS), and abuse of alcohol. Barth and colleagues (1996) suggest that there are also other factors influencing the outcomes after MTBI such as stress, age, education, occupation, cognitive abilities, and psychosocial functioning. In addition, complications such as life event stressors will contribute to undesirable outcomes such as persistent PCS
(Gronwall, 1991).
The following section explores factors related to MTBI in the context of the RAM.
Severity of injury was the focal stimulus, the individual characteristics were contextual stimuli, and stress, marital status and social support were residual stimuli. Both coping and depressive symptoms were described as processes of adaptation. Adaptation was the outcome and was operationalized as quality of life and the overall outcome especially the ability to return to work or study.
7
Focal stimuli: Severity of the injury
The focal stimulus was the severity of brain injury. Severity of injury was determined through Glasgow Coma Score (GCS), duration of post-traumatic amnesia
(PTA), duration of loss of consciousness (LOC), length of admission, and postconcussion symptoms (PCS). Although there was some controversy surrounding inclusion of PCS in describing MTBI, this factor was included to better understand MTBI in the Thai population. PCS and other factors defined MTBI were further described in chapter 3.
Contextual stimuli: Individual characteristics
Contextual stimuli were those intervening variables that affected the outcomes after
MTBI. The stimuli in this category were individual patient characteristics: gender, age, time postinjury, employment status, presence of alcohol use, and education. These variables had been found to affect outcomes among patients with MTBI (Altura & Altura,
1999; Englander, Hall, Stimpson, & Chaffin, 1992; Ponsford, Olver, & Curran, 1996;
Rapoport, McCullagh, Streiner, & Feinstein, 2003a; Stranjalis et al., 2004). Another variable that had demonstrated an effect on adaptation level was time post-injury (Bohnen et al., 1994; Bohnen, Jolles, Twijnstra, Mellink, & Wijnen, 1995; Deb, Lyons, &
Koutzoukis, 1998; Franulic, Carbonell, Pinto, & Sepulveda, 2004; van der Naalt, van
Zomeren, Sluiter, & Minderhoud, 1999) and it was included as contextual stimuli.
According to previous studies, men are more likely to experience an MTBI than women (De Kruijk et al., 2002; Levin et al., 2001b; Rapoport, McCullagh, Streiner, &
Feinstein, 2003b; Savola & Hillbom, 2003). This is also true among Thai MTBI victims
(Narenthorn Trauma Center, 2005). Men are believed to sustain MTBI because they have been found to be greater risk-takers, more likely to be engaged in potentially dangerous work, more impulsive, and more likely to abuse alcohol. On the other hand, a larger 8 proportion of female MTBI is found in some reports (McCauley, Boake, Levin, Contant,
& Song, 2001; Rayls, Mittenberg, Burns, & Theroux, 2000; Ruttan & Heinrichs, 2003).
The majority of MTBI sufferers are adults (Savola & Hillbom, 2003), employed
(Rapoport, McCullagh, Streiner, & Feinstein, 2003a), and educated (Trahan, Ross, &
Trahan, 2001). Older age, unemployment and less education had been associated with poorer outcomes in those people with MTBI (Franulic, Carbonell, Pinto, & Sepulveda,
2004). Employment status and age are also associated with return to work or school
(Corrigan & The Traumatic Brain Injury Technical Assistance Center, 2001).
Alcohol affects the initial GCS (Bazarian, Eirich, & Salhanick, 2003) since it can depress a person’s ability to respond. MTBI adults who use alcohol also stay in the hospital for longer periods (Altura & Altura, 1999). Although the majority of patients who develop these symptoms seem to show recovery over time, there appears to be a significant minority with persistent difficulties (van der Naalt, van Zomeren, Sluiter, &
Minderhoud, 1999). Time postinjury also affects a human’s ability to adapt with difficult situation in his/ her life (Barone, 1993).
Residual stimuli: Stress, marital status and social support
Stress refers to major stressful life events that occur in patients’ lives while recovering from MTBI. Events that happen to MTBI patients may add stressors to their lives that influence adaptation, unrelated to MTBI. Differentiating life stressors from
MTBI related events is important since subjective life stress can predict PCS (Sparrow,
2002) and stressful events are related to psychological distress (Byrne, 1989).
Social support is an environmental influence. Social support is the perception of the person with MTBI to the various types of assistance or help that he/ she receives from family, friends, and other people. As a holistic system interacting continuously with 9 environment, persons with MTBI must be considered in the context of their social support. Research shows that social support plays an important role in both coping and adaptation in a variety of illnesses. High social support helps people gain high quality of life (Brown, McCauley, Levin, Contant, & Boake, 2004) while low social support can cause stress and depression (Bay, Hagerty, Williams, Kirsch, & Gillespie, 2002;
McCauley, Boake, Levin, Contant, & Song, 2001) as well as PCS (McCauley, Boake,
Levin, Contant, & Song, 2001). Samarel and colleagues conclude that social support helps women with breast cancer adapt (Samarel et al., 1998). Carver and colleagues consider social support an important component of coping strategies (Carver, Scheier, &
Weintraub, 1989). Other data (Barone, 1993) suggest that low social support is associated with inappropriate coping strategies among spinal cord injury patients. In MTBI patients, poor social support is a risk factor of PCS at one month after the injury and group support from one who has the same experience helps to avoid prolonged loss of productivity and poor perceived QOL (McCauley, Boake, Levin, Contant, & Song, 2001). Many studies also report that social support affects family functioning or interdependent mode of adaptation (Brown, McCauley, Levin, Contant, & Boake, 2004; Ergh, Hanks, Rapport, &
Coleman, 2003; Ergh, Rapport, Coleman, & Hanks, 2002). Social support was included in this study as one of the indicators of contextual stimuli and conceptualized as the number of human resources, such as spouse, family and friends who could be called upon for assistance in daily life and emergency, and level of satisfaction of social support that
MTBI patient received.
10
Process of Adaptation: Coping and Depressive symptoms
Coping
Coping is conceptualized as a person’s ability to maintain adaptation (Yeh, 2003). It is viewed as emotional, behavioral, and neuroendocrine responses as the person reacts internally to the stressors after the person interprets and evaluates the threat of a stressor
(Olff, 1999). Roy describes coping as the regulation and cognation processes that react automatically to maintain the equilibrium of the system after confronting changing environmental stimuli (Roy & Andrews, 1991; Roy & Roberts, 1981). The results of coping can be measured through actions and behaviors (Roy & Andrews, 1991; Roy &
Roberts, 1981) or health consequences (Olff, 1999).
Coping has received attention as one that contribute the outcomes after MTBI
(Moore & Stambrook, 1992; Moore, Stambrook, & Peters, 1989). Coping includes the strategies that MTBI persons respond to, influence, and change in the environment to create human and environment integration (Roy, in review). The ability to cope is related to maintaining and attaining a good quality of life among MTBI persons in three studies
(Moore & Stambrook, 1992, 1995; Moore, Stambrook, & Peters, 1989), although one study does not support the finding that there is a relationship between coping and symptoms after MTBI (Sparrow, 2002).
Depressive symptoms
Depressive symptoms have been found to occur in 12% of persons with mild-to- moderate brain injury three months after injury (Levin et al., 2001b). Individuals with
MTBI who are depressed often report more frequent and more severe PCS symptoms than those who are not depressed (Trahan, Ross, & Trahan, 2001). Levin and colleagues
(2001) suggest risk factors for depressive symptoms, in addition to the damage to the 11 brain include female gender, older age, lack of social support, and presence of pre-injury psychiatric history. In one study, an improvement of quality of life in MTBI adults is correlated with the reduction in depressive symptoms (Bedard et al., 2003). Because depressive symptoms were associated with both coping and adaptation in previous studies, it was studied as a separate factor in the predictive model or a potential moderator.
Adaptation
As stated by Roy, the optimum goal of adaptation is to promote survival, growth, mastery, and well-being (Roy, 1997, 2005, in review; Roy & Andrews, 1999; Roy &
Zhan, 2001). This goal can be measured through quality of life (QOL). Well-being is used interchangeably with QOL in the literature (Headey & Wearing, 1989, 1991; Stewart &
Ware, 1992; Strack, Argyle, & Schwarz, 1991). Changes in subjective QOL are strongly correlated with adaptation.
In general, the definitions of well-being and QOL overlap. There are similarities between physiological adaptive mode, and health and functioning domain of QOL since both assess functions of body systems. However, there is an important difference between both measures. The physiological adaptive mode emphasizes a human’s organs and systems but, the health and functioning domain of QOL focuses on satisfaction and importance of that person for his/ her functioning. The fact that 1)very few persons with
MTBI experience disability or changes in physiological functioning, and 20 physiological disabilities from brain injury do not have much effect on adaptation when compared to psychological consequences and disturbances in role functioning; therefore, measuring health and functioning instead of physiological systems should better represent the 12 outcomes among MTBI. To better capture role function adaptive mode, the Extended
Glasgow Outcome Scale will be added to the social and economic domain.
The RAM proposes four modes of adaptation after MTBI and is congruent with domains measured in QOL: health and functioning, psychological and spiritual, social and economic, and family domain. However, the RAM may not capture a multidimensional picture of outcomes after MTBI specifically a complexity of multidimensional human responses. Each adaptive mode and QOL domain was described as follows:
Quality of life as adaptation
Quality of life (QOL) has been selected to represent adaptation to MTBI in this study. After careful comparison the propositions of the adaptive modes of the RAM, the domains of QOL have been found to be similar to those adaptive modes. The self-concept adaptive mode is represented by the psychological and spiritual domain. The role function adaptive mode is represented by the social and economic domain, and the interdependent mode is congruent with family domain. An only obvious difference between QOL and the
RAM is found between physiological adaptive mode and health and functioning domain of QOL. However, MTBI does not cause visible disability, so this study emphasizes health and functioning rather than disability. Ability to function and subjective satisfaction among the MTBI persons is more problematic than physiological disability
(Arcia & Gualtieri, 1993).
In conclusion, the RAM suggested several modes of adaptation after MTBI.
However, all of these modes emphasized functioning and performance only. Adaptive modes might not capture MTBI adults’ satisfaction in these performances or importance of these functions to MTBI adults. Therefore, using only adaptive modes might provide 13 limited information about MTBI population. Furthermore, there was no specific adaptation tool for MTBI adults associated with testing the RAM. Thus, domains of QOL were used to represent the outcome of adaptation. The Extended Glasgow Outcome Scale was added to enhance information about role function adaptation.
Many chronic diseases have an adverse effect on the QOL (Lam & Lauder, 2000).
In persons with MTBI, there may be no clinical laboratory changes in serum, on radiography or even magnetic resonance. Nevertheless, emotional and behavioral impairment may exist and these impairments rather than physical changes affect QOL
(Levine, Dawson, Boutet, Schwartz, & Stuss, 2000). QOL can be measured by disease- specific or generic instruments (Lobentanz et al., 2004).
Psychosocial and emotional adjustments are key evaluations of rehabilitation.
Emotional and social problems are the most problematic dysfunction caused by MTBI
(Schutt, 1999). Schutt also found that persons with brain injury had lower QOL than the normal population, but QOL among persons with a variety of brain injury severity at three months post-injury did not differ (Schutt, 1999). In a larger sample size,
Emanuelson and colleagues concluded that MTBI adults reported reduced QOL at 3 and
12 months after their injury (Emanuelson, Anderson, Bjorklund, & Stalhammar, 2003).
Quality of life is defined by Ferrans as "a person's sense of well-being that stems from satisfaction or dissatisfaction with the areas of life that are important to him/her"
(Ferrans, 1990, p.15). Ferrans and Powers conclude that a person with high QOL is the one who is satisfied in the aspects of life that are important for him/ her (Ferrans, 1990;
Ferrans, 1996, 1997; Ferrans & Powers, 1985, 1992). This definition of QOL captures not only functions but also the individuals’ satisfaction with their functions and their perceptions of importance of these functions to their daily lives. 14
Adaptive modes after MTBI
Physiological adaptive mode: Health and functioning dimension of QOL. The outcomes after MTBI were divided into four categories as in Roy’s four adaptive modes.
The physical mode was associated with the ways the person responded physically to stimuli from environment. Behaviors in this mode were the summation of the activities of all cells, tissues, organs, and systems throughout the human body (Roy & Roberts, 1981).
The physical mode is concerned with basic needs required for maintaining the physical and physical integrity of the human adaptive system. The physical mode focuses on five needs (i.e., oxygenation, nutrition, elimination, activity and rest) and four complex processes (i.e., senses, fluid-electrolyte-acid-base balance, neurological function, and endocrine function) (Hanna & Roy, 2001).
MTBI adults experience fatigue, sleep disorders, headaches, vertigo, dizziness, visual problems or sexual dysfunction after injury. The symptoms may occur within the first 6 months after the MTBI and persist for at least three months (American Psychiatric
Association, 1994). Jacobson (1995) reported that at 1-3 months after the injury, 44% of
MTBI adults reported headache; 28%, dizziness; 26%, fatigue; 21%, insomnia; 17%, noise sensitivity problems. At 6 months, 28% reported at least one of these symptoms, and 18% still had the symptom at 1 year after MTBI (Jacobson, 1995).
Important physiologic symptoms have been reported by Emanuelson and colleagues
(1998). They found 24-36% of the MTBI adults reported to have physiological symptoms at three months post-injury, and 16% of those adults reported that they had suffered from physiological symptoms for more than 2 years after the injury (Emanuelson, Anderson,
Bjorklund, & Stalhammar, 2003). At the same time, Igebrigtsen and colleagues noted that 15
62% of their MTBI subjects reported at least one physiological symptom at three months after the injury (Ingebrigtsen, Waterloo, Marup-Jensen, Attner, & Romner, 1998).
Physiological response to MTBI is an important measure of adaptation. The physiological adaptation in this study will be measured using the health and functioning domain of Ferrans and Powers’ Quality of life index.
Self-concept adaptive mode: Psychological and Spiritual domain of QOL. The self- concept mode is focused on the psychological and spiritual aspects of the person (Roy &
Andrews, 1991). Roy and Andrew (1991) describe self-concept as the combination of beliefs and feelings that the person has about him/herself at the given time. Self-concept is formed from internal perceptions, interpretations of the reactions from others, and behaviors or actions of that person (Roy & Andrews, 1999).
Currently, the self concept mode is concerned with people’s conceptions of their selves, including emotions (Samarel et al., 1998). The self-concept mode focuses on the psychic and spiritual integrity that help people to be or exist with the sense of unity, meaning, and purposefulness in the universe. There are two submodes in the self concept mode: 1) physical self, which is concerned at body sensation and body image, and 2) personal self, which is concerned at self-consistency, self idea, and moral-ethical-spiritual self (Hanna & Roy, 2001).
Psychological symptoms such as irritability, depressive symptoms or inappropriate social behavior are commonly reported after MTBI (Ponsford, Olver, & Curran, 1996).
The studies of neuropsychological outcomes following MTBI confirmed that the symptoms presented for weeks (Gronwall & Sampson, 1974; Levin, Eisenberg, &
Benton, 1989) and usually resolved within one to three months of injury (Dikmen,
Machamer, & Temkin, 2001; Gronwall & Sampson, 1974). In some instances, however, 16 the symptoms and impairments appeared to persist (Kay, Newman, Cavallo, Ezrachi, &
Resnick, 1992; Ruff, Mueller, & Jurica, 1996; Writghtson & Gronwall, 1999). The issue as to why those symptoms sometimes persist in some MTBI adults beyond the first few months after the injury is still controversial (Ponsford et al., 2000).
The self-concept adaptive mode focuses on the way individuals as psychological beings feel about their bodies and themselves (Gagliardi, Frederickson, & Shanley, 2002).
A combination of organic brain involvement and emotional reaction to the injury may result in mood swings, ranging from depression to irritability (Geraldina et al., 2003;
Glenn, O'Neil-Pirozzi, Goldstein, Burke, & Jacob, 2001). Spirituality may influence mental health (Fallot & Heckman, 2005). Therefore, mood and mental health issues as well as spiritual health were examined in this study as indicators of self-concept. The self- concept adaptation was measured by using the psychological/ spiritual domain of Ferrans and Powers’ Quality of life index.
Role-function adaptation to MTBI: Social and economic domain of QOL and the
Extended Glasgow Outcome Scale. The role function mode is concerned with people’s performance of their role activities within their position in the society (Samarel et al.,
1998). The basic need fulfilled by role function is social integrity. The required characteristics of social integrity are 1) knowing who one is in relation with others, 2) acting accordingly be adapting complex positions in a role set (secondary, and tertiary role), 3) involvement in role development, instrumental and expressive behaviors, and 4) role taking process (Hanna & Roy, 2001).
Role function is the performance of duties based on a person’s positions in the society. The way the person performs these duties is constantly responsive to outside stimulation. Each role exists in relation to others. The role functions adaptation was 17 measured using social and economic domain of Ferrans and Powers’ Quality of life index, and ability to return to work or school by using the Extended Glasgow Outcome Scale.
The role function adaptive mode emphasizes the way in which individuals as social beings who perform activities associated with their roles (Gagliardi, Frederickson, &
Shanley, 2002). The alterations of physical functions together with emotional and behavior changes frequently limit performance of usual activities and employment.
Hawley and colleagues (2004) have found that teenagers with MTBI rate their social isolation scores higher than normal teenagers and moderately brain-injured teenagers.
More than half of those teenagers with mild brain injury also report that they have difficulties with school work because of problems in concentration or attention, memory problems, and difficulties learning new information (Hawley, Ward, Magnay, &
Mychalkiw, 2004). Similar problems are reported among adults with mild brain injury.
Even though more than 50% of adults who suffering from mild brain injury can return to work within two weeks after the injury, 12.5% remain on sick leave for six weeks postinjury (Haboubi, Long, Koshy, & Ward, 2001). Among those MTBI adults who are able to return to work, only 28.6% can perform their normal level of work, while more than 70% return to modified work (Ruffolo, Friedland, Dawson, Colantonio, & Lindsay,
1999). Physical disturbances such as headaches, dizziness, fatigue, sleep disturbances, poor concentration and poor memory are cited as causes of delay in reemployment
(Haboubi, Long, Koshy, & Ward, 2001). The role function adaptation was measured by using the social and economic domain of Ferrans and Powers’ Quality of life index together with the Extended Glasgow Outcome Scale.
Interdependence adaptation to MTBI: Family domain of QOL and the Extended
Glasgow Outcome Scale. The interdependence mode is the final category of the Roy’s 18 adaptive mode. The interdependence mode deals with development and maintenance of satisfying affectional relationships with significant others (Samarel et al., 1998). In order to adapt in the interdependence mode, people are required to achieve relational integrity using the process of affectional adequacy such as giving and receiving of love, respect, and value through effective relations and communication (Hanna & Roy, 2001).
Roy believes that the person needs to be involved in seeking help, attention, affection, affirmation, belonging, approval, and understanding (Roy & Andrews, 1991).
Interdependence adaptive mode also focuses on giving and receiving of love, respect, and value (Roy & Andrews, 1991, 1999; Roy & Roberts, 1981; Roy & Zhan, 2001).
The interdependence adaptive mode is concerned with the way in which individuals as social beings give and receive social support (Gagliardi, Frederickson, & Shanley,
2002). Relationships with family members and friends are influenced by the alterations in cognition, emotion, behaviors, and role activities after MTBI. The psychosocial problems of decreased social contact, depression, and loneliness occur following mild brain injury create a major deficit for enhancing efforts of social reintegration (Morton & Wehman,
1995). Maladaptive interdependence mode ranges from dependence, altered relationships
(Wedcliffe & Ross, 2001) to social isolation. The majority of MTBI victims are young adults who are in the stages of establishing the independence in the areas of friendships, leisure activities, intimate relationships, residence, and employment (Morton & Wehman,
1995). Depending on others for care may lead to low self-esteem while decreased interactions with others may cause loneliness or social isolation. As discovered by Brown and colleagues (2004), MTBI adults report having fewer social supports available for them compared to general trauma adults. Lower social support has also been found to be the most prominent predictor for postconcussion symptoms (Luis, Vanderploeg, & 19
Curtiss, 2003; McCullagh, Oucherlony, Protzner, Blair, & Feinstein, 2001) and depression (Bay, Hagerty, Williams, Kirsch, & Gillespie, 2002). The interdependence mode of adaptation was measured using the family domain of Ferrans and Powers’
Quality of life index and the Extended Glasgow Outcome Scale.
Summary
The summative effects of the focal, contextual, and residual stimuli contribute to adaptation of the individual (Roy & Andrews, 1991; Roy & Roberts, 1981). Coping and depressive symptoms may mediate the effect of these stimuli on adaptation.
Empirical data suggest that social support, time-post injury, and stress may affect recovery but the factors that influence outcome are not yet well-established (De Kruijk et al., 2002; Mellman, David, Bustamante, Fins, & Esposito, 2001; Ponsford, Olver, &
Curran, 1996). Factors that can predict adaptation to MTBI are inconclusive. Knowledge about adaptation to MTBI is not established yet among Thai adults. Adaptive responses can be captured through QOL. Thus, this project aimed to explore adaptation to MTBI, determine factors associated with adaptation to MTBI, and identify factors that predicted adaptation to MTBI among Thai adults.
Research questions
1. What adaptation occurs among Thai adults after MTBI?
2. What stimuli are associated with adaptation to MTBI among Thai adult?
2.1 Do focal, contextual and residual stimuli associate with adaptation to MTBI among Thai adults?
2.2 Is coping associated with adaptation to MTBI among Thai adults?
2.3 Are depressive symptoms associated with adaptation to MTBI among Thai adults? 20
3. What are the factors that predict adaptation to MTBI among Thai adults?
3.1 Can coping predict adaptation to MTBI among Thai adults?
3.2 Can depressive symptoms predict adaptation to MTBI among Thai adults?
3.3 What are the factors that predict adaptation to MTBI among Thai adults when considering coping as a mediator of adaptation?
3.4 What are the factors that predict adaptation to MTBI among Thai adults when considering depressive symptoms as a mediator of adaptation?
Assumptions
Assumptions to this study are based on the RAM. These assumptions are:
- The MTBI patient is an adaptive system with coping processes.
- MTBI persons integrate to environment with consciousness and meaningful.
- MTBI persons are aware of their relationship with environment.
- Integration of human and environment meanings creates adaptation.
- An adaptive system with cognator and regulator subsystems acting to maintain
adaptation in the four adaptive modes: physiological, self-concept, role
function, and interdependence.
- Health is a state and process of being and becoming integrated between person
and environment.
- An additional assumption is that adaptation is desirable and promotes nursing
science, education and practice.
Definitions and Terms
- Mild traumatic brain injury (MTBI) referred to an injury to the head and brain that causes PTA for less than 24 hours, LOC for less than 30 minutes, and the GCS score of
13 or more. 21
- Posttraumatic amnesia (PTA) referred to duration that MTBI persons lose their memory, or are unable to perform consistent day-to-day memory after suffered from
MTBI.
- Loss of consciousness (LOC) referred to a state that MTBI persons are unaware or unable to response to the environment.
- Glasgow coma score (GCS) referred to a score that is composed of three parameters: best eye response (1-4), best verbal response (1-5), and best motor response
(1-6) a range of 13-15 denotes MTBI.
- Postconcussion symptoms (PCS) referred to a group of symptoms including feeling depressed or tearful, headaches, fatigue or tiring more easily, blurred vision or double vision, being irritable or easily angered, poor concentration, sleep disturbance, light sensitivity or easily upset by bright light, noise sensitivity or easily upset by loud noise, forgetfulness or poor memory, feelings of dizziness, feeling frustrated or impatient, taking longer to think, restlessness, nausea and/ vomiting and changes in sexual behaviors that persists for more than three months after MTBI. .
- Length of admission referred to number of days that persons have to stay in the hospital due to MTBI.
- Stress referred to numbers stressful life events that occur in MTBI patients’ lives in the past year. The events consist of 42 life changed events. Each event has different score ranging from 11-100. Lower scores indicate lower stress.
- Social support referred to the perception of MTBI persons to 1) numbers of family members, spouse, friends, and others who provide or can provide assistance, and 2) satisfaction to support that they receive. 22
- Coping was operationalized as coping and adaptation processing refers to the strategies whereby MTBI persons responds to, influences and changes the environment to create human and environment integration (Roy, in review).
- Depressive symptoms referred to a mental state of depressed mood characterized by feelings of sadness, despair and discouragement. Depressive symptoms range from normal feelings of the blues through dysthymia to major depression. It in many ways resembles the grief, feelings of low self esteem, guilt and self reproach, withdrawal from interpersonal contact and physical symptoms such as eating and sleep disturbances.
- Adaptation referred to responses and behaviors of persons after MTBI. It was operationalized as functional ability and satisfactory with quality of life. In this model, adaptation is outcome behaviors. These behaviors promote survival, growth, reproduction, mastery, and quality of life.
- Quality of life referred to sense of well-being that stems from satisfaction or dissatisfaction with the areas of life that are important to MTBI persons. QOL will be determined in four domains: health and functioning, psychological/ spiritual, social and economic, and family. Both satisfaction and importance of various aspects of life in those four domains will represent QOL. The aspects that are rated as more important have a greater impact on QOL than those of lesser importance.
Significance to Nursing
To achieve the goals of nursing, nurses need to use both basic and applied knowledge. The understanding of basic phenomena supports the development of nursing knowledge. Nursing knowledge or applied knowledge is gathered from theories and practice (Parse, 1997). Nursing research is the way to develop nursing science and disseminate nursing knowledge (Fawcett, 2000). It is also recommended that nursing 23 research use methodologies that are based on nursing theories (Fawcett, 2000). Decisions and actions by nurses should be performed under substantive disciplinary knowledge.
The RAM has the potential to increase understanding about how patients adapt to complex, unexpected and stressful life events after MTBI. The RAM could help nurses identify the factors that effect outcomes after MTBI and to assess adaptive and maladaptive behaviors. The RAM also provides a framework for evaluating and determining the different MTBI responses that affect their quality of life after MTBI.
In Thailand, there are several nursing theories that have been introduced. However, several nursing theories have been labeled as difficult to understand, inapplicable for practice and unable to explain clinical phenomena. Because the learning environment is increasingly complex in all education including nursing education, nursing educators have an opportunity to use nursing theories in solving clients’ problems. The nursing profession has priorities for teaching, research and services that are linked directly to the goals of the nursing discipline. Research is an important way to further knowledge in nursing, to discover new and unique knowledge, to build the bridge linking theory and practice. Applying the RAM in explaining MTBI phenomena is one way to translate theory into practice. It may also help narrow the gap between educational and practice.
Using nursing theory may further establish the uniqueness of nursing profession.
There are no published studies about MTBI in Thailand. Characteristics of Thai adults with MTBI are not known. Factors that influent the outcomes after MTBI have not been explored in this population. For example, postconcussion symptoms have never been evaluated among Thai MTBI adults, nor have coping, stress level and social support.
Results from this study provide introductory knowledge regarding the adaptation, quality of life, stress, coping, perceived social support and postconcussion symptoms after 24
MTBI among Thai adults. Applied knowledge may be developed from relationships between influential factors and outcomes after MTBI and the ability of any factor to predict adaptation. The findings may be a baseline for a development of nursing intervention or future interdisciplinary research. The measures used in this study may be useful for evaluation Thai MTBI adults in both research and clinical settings. Conducting research based on nursing theory will also support international nursing knowledge.
Despite the fact that QOL has been investigated for three decades, it is not a well- developed concept in nursing care or theory (Ferrans, 1997). In contrast, it has acceptance as a multidisciplinary evaluation (Ferrans, 1997). Exploring QOL of MTBI patients may support a conceptual framework and the value of measurement in this particular population. Using nursing theory to explain processes and factors affecting the QOL will also help integrate a nursing theory with concepts that are widely explored among other disciplines. The findings from this study may help nurses better understand abstract concepts such as QOL. Using a well-developed nursing theory, testing the various dimensions (domains) that contribute to outcomes, assessing and proposing how MTBI subjects in very similar circumstances can have the same or different QOL values, and exploring the factors that health care providers can use to improve MTBI patients’ QOL, can make important contributions to the discipline of nursing.
25
CHAPTER TWO
Literature Review
- Overview
- Determinants MTBI
a) Determinants (depth of coma, duration of LOC, duration of PTA)
b) Theoretical concepts
c) Empirical
- Influential factors: Patients’ characteristics, social support, and post-concussion symptoms (PCS)
a) Patients’ characteristics (age, gender, level of education, alcohol
abused, and employment status)
b) Social support and marital status
c) Post-concussion symptoms (PCS)
- Outcomes: Quality of life as adaptation
a) Quality of life among mild traumatic brain injury
b) Quality of life and adaptation in Roy Adaptation Model
- Physiologic adaptive modes
- Self-concept adaptive mode
- Role function adaptive mode
- Interdependence adaptive mode
- Gaps in knowledge
- Summary
26
Overview
The survival rate for patients who have sustained brain injuries has improved over the past two decades (Bazarian et al., 2005; Sosin, Sniezek, & Thurman, 1996). However, the number of traumatic brain injury (TBI) patients with neurological, psychological or behavioral problems has increased, which included concomitant adverse functional outcome and ability to return to work.
Mild traumatic brain injury (MTBI) may cause a board range of neurological, cognitive and emotional consequences. An individual can sustain MTBI despite minimal or no neurological damage. The term “MTBI” and “concussion” are often used interchangeably, which leads to more confusion within this diagnosis as symptoms after concussion can occur even without a head injury (Kibby & Long, 1996). Researchers have not yet been successful in determining the interaction between 1) pre-injury factors such as age, education, and employment status and 2) post-injury factors such as severity of the injury, social support, and time after injury and recovery after MTBI.
In this chapter, the literature related to 1) definitions of MTBI from both theoretical and empirical perspectives, 2) individual characteristics and social support as factors that influence adaptation to MTBI, and 3) examining QOL as a measure of adaptation to
MTBI are reviewed. Forty-eight studies formed the basis of this literature review
(Appendix H).
Defining determinants MTBI: Depth of Coma, duration of loss of consciousness and duration of post-traumatic amnesia
This section contains a review of the accumulated knowledge concerning both theoretical and empirical support. Three determinants of MTBI: depth of coma, duration of loss of consciousness (LOC) and post-traumatic amnesia (PTA), are detailed. This is 27 followed by an empirical review of studies with content related to these determinants and, finally, the variables that were used in this study.
Theoretical determinants. Classification of TBI severity usually depends on depth of coma, duration of loss of consciousness (LOC) and duration of posttraumatic amnesia
(PTA). Depth of coma has commonly been defined and quantified by the Glasgow Coma
Scale Score (GCS) (Fisher & Mathieson, 2001; Jennett, 2002). PTA and LOC have been reported as a predictors of PCS, another indicator of TBI severity (Savola & Hillbom,
2003), and they have usually been reported in a time-sensitive manner, ranging from minutes, hours, days or weeks. This chapter opens with a discussion of the criteria used to define MTBI. Then, factors related to the occurrence and outcomes of MTBI are explored.
Based on three parameters, traumatic brain injury (TBI) is classified as severe, moderate or mild. The focus of this study is mild traumatic brain injury (MTBI). MTBI has been described in various ways in the literature. According to Ruff and Grant (1999),
MTBI has been characterized by unclear definitions. Before DSM-IV has been established, Teasdale defined MTBI by using Glasgow Coma Score of 13-15 (Ruff &
Grant, 1999). The American Congress of Rehabilitation Medicine (ACRM) included duration of LOC and duration of PTA as well as GCS (1993). In 1994, DSM-IV defined
MTBI by using PTA and LOC with specific cut-point. Ruff and Grant noted that the definition in DSM-IV was created for postconcussion symptoms and may not define all types of MTBI. Other authors suggest that MTBI is the same as concussion and postconcussion symptoms, or that the sequelae of concussion should be included in the classification of MTBI as well. Ruff and Grant proposed that determinants of MTBI should specify the related symptoms and the time of symptom occurrence. Specifically, 28 concussion occurs immediately after mild brain injury while postconcussion symptoms appear three months after injury. Furthermore, the ACRM set the cut-point of LOC at 30 minutes or less while the DSM-IV set it at 5 minutes. The ACRM (1993) set criteria for duration of PTA in MTBI at 24 hours or less while the DSM-IV (1994) set at 12 hours or less.
Empirical determinants for MTBI. Because there were inconsistent definitions for
MTBI, findings from MTBI studies might not be comparable. There were 48 studies related to outcomes after MTBI from 1992-2005 (Table 1). Thirty-three defined MTBI with GCS and duration of PTA and /or LOC. Five of those studies defined MTBI by using GCS greater than 13 only. Four studies among those did not have a concise definition of MTBI in their reports.
Even among studies using GCS scoring, there was some controversy. One group of researchers (De Kruijk et al., 2002) divided subjects with GCS score 13 from those with
GCS score 14-15 and another group (Stranjalis et al., 2004) included only subjects with a
GCS score of 15 in the study.
The defining features of PTA and LOC in MTBI were less clear in the empirical literature. In 48 studies related to MTBI, 25 included LOC as criteria for MTBI. Among those, 19 (from 25) adopted ACRM’s criteria while only one used DSM-IV’s cut-point.
Two studies used LOC duration for up to 60 minutes and three studies included subjects with any period of LOC.
Among 48 studies related to MTBI, 28 stated the duration of PTA. Of those 28, 18 studies used ACRM’s cut-point; only two adopted the DSM-IV criteria. Two studies had more than one category of duration of PTA and six studies set duration of PTA at less than 60 minutes. 29
For this study, all subjects with GCS between 13 and 15, and any duration of PTA and LOC were recruited. Research suggested that duration of PTA and LOC might affect outcomes. Because neither of the cut-points for duration of PTA ot LOC were well- established, the presence of any duration of PTA and LOC was included in this study. As there were no baseline data relevant to the Thai population with MTBI, this study was inclusive. Medical records were used to identify GCS; LOC and PTA were collected by patient report.
Influential factors: Patients characteristics, social support, and post-concussion symptoms
This section was organized into three categories: a) patients’ characteristics (age, gender, level of education, alcohol abused, and employment status); b) social support and marital status; and c) postconcussion symptoms (PCS). Each of these categories had been reported as a potential or actual variable that influences patients’ recovery after MTBI.
Patients’ characteristics
Age. Very few studies of MTBI adults had included age. In 48 studies specific in outcomes after MTBI, only thirteen reported age. There might not be much variability in age among MTBI people. For example, among thirteen studies, mean age ranged from
27-44 years old. Among thirteen studies including age, seven of them reported only descriptive information of the age among their subjects and six other studies reported relationship of the age to outcomes. Among those six studies, only two of them found a significant relationship between age and MTBI outcomes. In those two studies with significant findings, the results were opposite. In 1992, Moore and Stambrook found that older adults with MTBI had worse outcomes than younger adults (Moore & Stambrook,
1992). Conversely, Rapoport and colleagues concluded that older adults had better 30 outcomes after MTBI since the adults age 60 or older had lower rates of depressive symptoms after MTBI when compared with those who were younger (Rapoport,
McCullagh, Streiner, & Feinstein, 2003a). In the four studies without significant findings, age was not related to MTBI outcomes such as PCS (Cicerone & Kalmar, 1995), return to work (Ruffolo, Friedland, Dawson, Colantonio, & Lindsay, 1999), incidence of major depression (Rapoport, McCullagh, Streiner, & Feinstein, 2003b), and successful rate in neurological rehabilitation after MTBI (Cicerone et al., 1996). Because the influence of age on outcomes in this population was not yet clear, age was included as a contextual stimulus.
Gender. Men were more likely to be diagnosed with MTBI. In 48 studies of MTBI adults, only four of them had a majority of women (Arcia & Gualtieri, 1993; Bryant,
Moulds, Guthrie, & Nixon, 2003; Cicerone & Kalmar, 1995; Hartlage, Durant-Wilson, &
Patch, 2001). One study purposefully recruited men and women in the study in equal numbers (Trahan, Ross, & Trahan, 2001).
There were several findings supporting the association between gender and outcomes after MTBI. In 1998, Deb and colleagues found that male subjects reported more disability problems after MTBI than did female. The score of the Edinburgh
Rehabilitation Status Scale (ERSS) was significantly higher among men (32:13). Men also reported higher scores in all subscale scores of the ERSS such as support scale
(10:5), inactivity scale (16:5), social integration scale (19:5), and effects from symptoms scale (21:5). The authors also found that men suffered from more PCS than did females
(51:23) (Deb, Lyons, & Koutzoukis, 1998). In 2004, Mahmood and other researchers found that male MTBI patients experienced sleep disturbances more than did female. The authors concluded that male gender had a medium correlation with sleep disturbance (r = 31
.21) and gender could explain 4% of sleep disturbance variance (Mahmood, Rapport,
Hanks, & Fichtenberg, 2004).
Gender role strain is a feeling reported among men after traumatic brain injury
(Gutman, 2000). Men commonly reported more frustration than women in their unsuccessful attempts to achieve a traditional adult male role post-injury. Gutman (2000) points out that at the age of 18-30 years old, men will express the highest level of role strain, as it is the time that men are expected to demonstrate high levels of achievement.
Deb and other investigators reported that women had better general outcomes (measured by the Glasgow Outcome Scale) and higher cognitive function scores (from MMSE) than men (Deb, Lyons, & Koutzoukis, 1998). However, Levin and his co-workers reported that female victims of MTBI had more depressive symptoms than men (Levin et al.,
2001b). Depressive symptoms could lead to undesired outcomes after MTBI.
As the influence of gender on outcome after MTBI was controversial, gender was included in this study as one of the contextual stimuli.
Time postinjury. Most MTBI patients recovered within weeks to months without specific treatment. A few of MTBI patients, however, continued to experience symptoms or are unable to return to work or school beyond this period (van der Naalt, van Zomeren,
Sluiter, & Minderhoud, 1999). There were controversies about the extent of persisting morbidity after MTBI since follow-up of MTBI patients at regular intervals for more than
3-6 months was often missing (van der Naalt, 2001). Among 48 studies of MTBI outcomes, 27 studies included time postinjury. There were three subsets of time post injury most frequently reported among these 27 studies. In the first group, by adopting the criteria from DSM-IV, recovery or outcomes in a period of time more than three months postinjury were reported in ten studies (Bedard et al., 2003; De Kruijk et al., 2002; 32
Emanuelson, Anderson, Bjorklund, & Stalhammar, 2003; Evered, Ruff, Baldo, &
Isomura, 2003; Kay, Newman, Cavallo, Ezrachi, & Resnick, 1992; McHugh, 2002;
Mittenberg, Tremont, Zielinski, Fichera, & Rayls, 1996; Ruffolo, Friedland, Dawson,
Colantonio, & Lindsay, 1999; Savola & Hillbom, 2003; Suhr & Gunstad, 2002). Twelve studies reported outcomes within fewer than three months after MTBI in the second group (Bryant, Moulds, Guthrie, & Nixon, 2003; Cicerone & Azulay, 2002; Echemendia,
Putukian, Mackin, Julian, & Shoss, 2001; Englander, Hall, Stimpson, & Chaffin, 1992;
Haboubi, Long, Koshy, & Ward, 2001; Hartlage, Durant-Wilson, & Patch, 2001; Levin et al., 2001b; McCauley, Boake, Levin, Contant, & Song, 2001; Ponsford et al., 2000;
Sparrow, 2002; Stranjalis et al., 2004). Finally, a third group included MTBI patients who experienced MTBI for more than one year in their studies (Alexander, 1992; Arcia &
Gualtieri, 1993; Bohnen, Jolles, Twijnstra, Mellink, & Wijnen, 1995; Glenn, O'Neil-
Pirozzi, Goldstein, Burke, & Jacob, 2001; Moore & Stambrook, 1992).
Evidence of outcomes among these three groups was conflicting. Therefore, time postinjury was included in this study.
Employment/ Student status. The impact of MTBI changes many roles in the victims’ lives. This is partly due to the variety of developmental stages and associated life changes in each person with MTBI. For example, in adulthood, it is a time of transitioning into the world of college or the world of work. Many persons with MTBI are young adults. The incidences of return to work among MTBI subjects who have been employed before the injury have been compared to the rate after the injury in many studies. The results are inconclusive. Correia and colleagues reported high rate of return to work (93%) among their 15 subjects after MTBI with anosmia (Correia, Faust, & Doty,
2001). However, the subjects were younger than 60 years old and were two years post- 33
MTBI. A reduced rate of return to work was reported by Friedland and Dawson; they found that only 42% of MTBI subjects returned to work 9 months after the injury
(Friedland & Dawson, 2001). In Another study, among those subjects who returned to work, 12% returned to the same position while 30% needed to modify their jobs (Ruffolo,
Friedland, Dawson, Colantonio, & Lindsay, 1999). In a fourth study, at 12 months after the injury, a successful rate of return to work was reported at 73% (van der Naalt, van
Zomeren, Sluiter, & Minderhoud, 1999).
Besides the incidence of return to work, employment status has received attention as a post-injury outcome. Bush and colleagues found no relationship between employment status and outcomes after the injury (Bush et al., 2003). However, other studies reported that employment status was associated with outcomes after MTBI.
Employment/ student status can be either a helpful or problematic factor after MTBI. For those who are employed before the injury, there is some economic advantage, leading to better outcomes after the injury when compared to adults with MTBI who are not employed. For example, Ponsford and colleagues found that subjects who had employment with availability of alternative duties after the injury adapted to their lives better than those who did not (Ponsford, Olver, & Curran, 1996). MTBI subjects with employment after the injury had higher life satisfaction than those who were not employed (Corrigan, Bogner, Mysiw, Clinchot, & Fugate, 2001). Subjects with MTBI who received compensation from work took a longer time to return to work than those who were unemployed pre-injury (Reynolds, Paniak, Toller-Lobe, & Nagy, 2003). MTBI subjects who could not return to work after the injury had higher levels of anxiety and depression than those who regained their jobs (Franulic, Carbonell, Pinto, & Sepulveda, 34
2004). Physical symptoms from PCS has been found to be the most frequent cause of vocational dysfunction after MTBI (Chamelian & Feinstein, 2004).
Because the employment / student status influenced outcomes after MTBI, it was included in this study as one of the contextual stimuli.
Alcohol abuse. Alcohol has been associated with adverse cerebral circulation: vasodilatation; vasoconstriction-spasm; and vessel rupture (Altura, Gebrewold, Zhang, &
Altura, 2002). In subjects who consumed alcohol before having MTBI, the level of ionized magnesium was lower than normal (Altura, Gebrewold, Zhang, Altura, & Gupta,
1998). Also, the ratio of ionized magnesium and ionized calcium was higher than normal
(Altura, Memon, Altura, & Cracco, 1995). Those deranged ionized substances were related to the presence of headaches, stroke and more severe brain injury. MTBI patients who used alcohol before the time of injury needed longer period of hospitalization (Altura
& Altura, 1999). Since alcohol abuse could increase severity of brain injury and might be associated with adaptation after MTBI, alcohol use was studied as one of the stimuli for adaptation.
Level of education. Level of education has been thought to influence MTBI outcomes. People with high education will have more ways of information seeking to solve their problems. Johnson (2000) noted that MTBI people with high level of education had better outcomes than those who were not as highly educated. However, people with high education may have greater responsibilities and more expectations in themselves (Johnson, 2000). Those expectations could lead MTBI victims to depression or unwanted outcomes.
In 48 studies done among MTBI adults, seven studies included level of education, all as pre-injury factors. Six of those seven studies reported only descriptive information 35 of level of education as the average number of years in the education system. The average of years in education ranged from 11-14 years (Cicerone & Kalmar, 1995; Kashluba et al., 2004; McCauley, Boake, Levin, Contant, & Song, 2001; McHugh, 2002; Ruffolo,
Friedland, Dawson, Colantonio, & Lindsay, 1999). One study applied the Scale of
Verhage as the measure for level of education; the authors found that the average of level of education was 4.4 from a scale of 7 (Bohnen, Jolles, Twijnstra, Mellink, & Wijnen,
1995). In study of 808 MTBI subjects, education was not a predictor for PCS after MTBI
(Kay, Newman, Cavallo, Ezrachi, & Resnick, 1992). Since the education system in
Thailand was different from the US school system and the results from the US were not yet conclusive about the influence of education on recovery from MTBI, level of education was included in this study as one of the contextual stimuli.
Stress. A person is an open system and constantly interacts consistently with his/ her environment (Roy & Andrews, 1999). Events occurring with school, work, marriage, friends, and social activities may be stressful or critical life events for some people. A stressful life event is a personal catastrophic, which depends on individual perception
(Miller, 1993). Some of the events may be interpreted as negative if they are socially undesired. On the other hand, positive events are socially desirable events. In either case, events will cause changes in an individual’s life, and adaptation will be required to deal with these changes (Miller, 1993). Stressful life events are highly correlated with other negative psychological senses such as depression, helplessness, upset, disruption, and anxiety (Byrne, 1989).
Among 48 studies related to MTBI, four of them included stress as a variable. One of those emphasized the impact of trauma on stress or posttraumatic stress disorder,
(Bryant, Moulds, Guthrie, & Nixon, 2003). Quantification of daily stress was reported by 36
Gouvier and other researchers (1992). They found that daily stress correlated with PCS
(Gouvier, Cubic, Jones, Brantley, & Cutlip, 1992). Positive correlation between stress and
PCS was confirmed by Hanna-Pladdy and colleagues (2001) who found that MTBI patients who had been exposed to high stress had increased PCS complaints (Hanna-
Pladdy, Berry, Bennett, Phillips, & Gouvier, 2001), and stress was also found to be a significant predictor for PCS (Sparrow, 2002).
Because stress was an influential factor for outcome after MTBI but stressful life events were not well explored among MTBI, stressful life events were included as residual stimuli in this study.
Social support and marital status. Social support is an effective intervention and predictor of adaptation among cancer patients (Samarel et al., 1998). However, among
MTBI patients, social support is not a powerful predictor of MTBI outcomes. Among 48 studies related to MTBI, three of them included social support. One study reported that different levels of social support in adults with MTBI correlated with race but it did not predict quality of life after MTBI (Brown, McCauley, Levin, Contant, & Boake, 2004).
Two studies reported that MTBI victims with lower social support reported more post- concussion symptoms (Luis, Vanderploeg, & Curtiss, 2003; McCauley, Boake, Levin,
Contant, & Song, 2001).
In a study in which both mild and moderate traumatic brain injury patients were included, social support did not explain depression among those subjects (Bay, Hagerty,
Williams, Kirsch, & Gillespie, 2002). In the moderate-to-severe brain injury population, social support was a powerful predictor for adaptation to life two years after the injury
(MacMillan, Hart, Martelli, & Zasler, 2002). Social support was also a good predictor for 37 return to work among severe brain injury population in Australia (Ponsford, Olver, &
Curran, 1996).
Marital status is explored as a type of social support in many studies, assuming that a person who does not live alone will have better social support than a person who is single or lives alone. In one study, about one-third of adults with MTBI were married
(Moore & Stambrook, 1992). There are no studies that examine a relationship between marital status and outcome after MTBI. One study reports that MTBI people 10 years post-injury have an unchanged marital status (Franulic, Carbonell, Pinto, & Sepulveda,
2004).
Since the relationship between social support and outcomes after MTBI was unclear, social support was included in this study as one of the residual stimuli. Marital status as one type of social support was also investigated as a contextual stimulus.
Postconcussion symptoms. Cognitive problems together with headaches, dizziness, fatigue, irritability, sleep disturbances, anxiety, sensitivity to noise, and visual disturbance, are often referred to as post-concussion symptoms or post-concussion symptoms (PCS) (Mathias & Coats, 1999). PCS has also been called “behavior dyscontrol disorder, minor variant” (Rao & Lyketsos, 2000, p. 96). PCS is the most evident in the early state of MTBI and tends to be completely resolved after a few months. However, there is a subgroup of MTBI patients who experiences PCS long after their injuries (Binder, 1997; King, 1996a). The symptoms of PCS can be broadly divided into physical (headache, nausea, dizziness, vertigo, diplopia, insomnia, deafness, tinnitus, sensitivity to light, sensitivity to noise, fatigue, and disco-ordination), cognitive (impaired memory, decreased attention, decreased concentration, dysexecutive function, and 38 conceptual disorganization), and emotional symptoms (depression, anxiety, and irritability) (Rao & Lyketsos, 2000).
Post-concussion symptoms (PCS) have been poorly defined and controversial for many years, referring to a broad range of symptoms and signs that can follow a brain injury (Savola & Hillbom, 2003). The Mild Traumatic Brain Injury Committee of the
Head Injury Interdisciplinary Special Interest Group of the American Congress of
Rehabilitation Medicine concluded that postconcussion symptom (PCS) is the consequence of brain concussion. The group defined concussion as an alteration of consciousness or disruption of memory as a result of mild trauma. There are two widely used but different criteria for PCS; DSM-IV and ICD-10. For the DSM-IV, PCS is an acquired cognitive dysfunction that presents after cerebral concussion. The DSM-IV defines cerebral concussion by the manifestation of loss of consciousness lasting for more than five minutes, posttraumatic amnesia for a period of more than 12 hours, and /or other less common symptoms such as seizures. To fulfill DSM-IV criteria of PCS, there must be three (or more) symptoms that are present for at least three months following the mild head injury. These symptoms include fatigue; sleep disorder; headache; vertigo or dizziness; irritability or aggression with little or no provocation; anxiety, depression, or affective liability; apathy or lack of spontaneity; and other changes in personality (e.g. social or sexual appropriateness).
The International Statistical Classification of Disease and Related Health Problems,
10th edition (ICD-10), published a set of guidelines based on epidemiologic studies of
PCS (World Health Organization, 1993). In the ICD-10, PCS was defined as a set of three or more symptoms that appeared for longer than 4 weeks after a history of head trauma with evidence of LOC (Mittenberg, Canyock, Condit, & Patton, 2001; Nguyen & Yablon, 39
2002). The symptoms included: 1) physical symptoms such as headache, dizziness, malaise, fatigue, noise tolerance, insomnia, reduction of alcohol tolerance, 2) emotional symptoms such as irritability, depression, anxiety, emotional liability, 3) subjective concentration, memory, or intellectual difficulties without neuropsychological evidence of marked impairment.
Boake and co-workers (2004) compared the agreement of symptoms among MTBI subjects by using both DSM-IV and ICD-10 criteria to evaluate the same subject. The results revealed that five symptoms (headache, fatigue, sleep disturbance, irritability and dizziness) were present in both criteria, and the agreement in the recognizing the presence of these symptoms were high (kappa = .83-.91). However, the agreement for meeting criteria for diagnosing PCS using both categories was poor (kappa =.13). The authors concluded that DSM-IV had a higher threshold and greater specificity. However, using
DSM-IV might not capture subjects who had few or mild PCS complaints (Boake et al.,
2004). All subjects who met ICD-10 criteria would meet DSM-IV criteria as well.
Although the definition of PCS is unclear, it is a popular concept in research among
MTBI subjects. Among 48 studies regarding outcomes after MTBI from 1992-2004, there were 32 studies that included PCS. In those studies, seven used a timeframe criteria of three months as in the DSM-IV (Alves, Macciocchi, & Barth, 1993; Cicerone & Azulay,
2002; Englander, Hall, Stimpson, & Chaffin, 1992; Evered, Ruff, Baldo, & Isomura,
2003; Kay, Newman, Cavallo, Ezrachi, & Resnick, 1992; McCauley, Boake, Levin,
Contant, & Song, 2001; McHugh, 2002). One study reported PCS as three or more symptoms (Ingebrigtsen, Waterloo, Marup-Jensen, Attner, & Romner, 1998). Most of the studies used individual symptoms at fewer than three months as diagnostic of PCS. 40
More specifically, in 33 reports of PCS, 26 suggested that PCS follows MTBI in
11-80% of patients. However, the definitions of PCS varied in these study and included symptoms occurring a few hours after injury (De Kruijk et al., 2002; Echemendia,
Putukian, Mackin, Julian, & Shoss, 2001; Emanuelson, Anderson, Bjorklund, &
Stalhammar, 2003; Haboubi, Long, Koshy, & Ward, 2001; Ponsford et al., 2000;
Sparrow, 2002) to years after injury (Bohnen, Jolles, Twijnstra, Mellink, & Wijnen,
1995). Seven studies did not find the evidence of PCS among MTBI. Two studies reported that PCS was not associated with MTBI (Santa Maria, Pinkston, Miller, &
Gouvier, 2001; Suhr & Gunstad, 2002) while five studies concluded that PCS in MTBI was not higher than PCS among the normal population or subjects with other injuries
(Echemendia, Putukian, Mackin, Julian, & Shoss, 2001; Lees-Haley, Fox, & Courtney,
2001; McCauley, Boake, Levin, Contant, & Song, 2001; Smith-Seemiller, Fow, Kant, &
Franzen, 2003; Suhr & Gunstad, 2002).
When PCS occurs, it has been associated with two outcomes: depression and stress.
In one report, depression was the most frequent symptom associated with PCS (Rapoport,
McCullagh, Streiner, & Feinstein, 2003b). Another report indicated stress was related to
PCS (Hanna-Pladdy, Berry, Bennett, Phillips, & Gouvier, 2001). Because the influence of
PCS on outcomes in MTBI patients was not well-defined in the empiric literature, PCS was included in this study. Although less specific, the ICD-10 definition was used as it appeared to be more sensitive to post-MTBI symptoms.
Outcomes: Quality of life as adaptation
This section contained a review of studies concerning quality of life (QOL) in
MTBI and the relationship of adaptation to MTBI and QOL after MTBI. 41
Many MTBI patients have to confront traumatic events and consequences after brain injury. Frustration from invisible disability and non-structured treatment from
MTBI may influence social and physical functioning, disrupt family life, and even lead to depression, affecting QOL.
Quality of life is a broad concept that has been explored among health care disciplines for years; however, goals and definition of QOL are still unclear (Bowling,
2005). Several essential attribute referents related to QOL have been the focus as major causes of controversy in QOL studies (Meeberg, 1993). Stewart and other authors conclude that there are at least two essential attributes of QOL: domain and dimension.
Domain or content area refers to aspect of life that has been evaluated. Domains of QOL may include physical functioning, functioning in daily living, psychological well-being, and social relationship. QOL may be measured as a single domain or multidomain.
Dimension refers to some level or state of behavior or a feeling (Stewart & King, 1994).
Dimension may be evaluated as a unidimensional index such as life satisfaction only, or multidimensional such as measurement that consists of both satisfaction and importance.
In QOL measurement, more essential attributes have been added. There are generic and disease specific measurements, and there are subjective and objective measurements.
While many QOL studies have described life satisfaction as QOL, Meeberg (1993) concludes that life satisfaction is a purely subjective feeling that refers to one’s level of happiness regarding his/ her life. She recommends that QOL should have both subjective and objective aspects, and that measures have more than one dimension (Meeberg, 1993).
Subjective dimension concerns feeling or perceive or opinion of the client while objective dimension such as sociodemographic variables and socioeconomic status concerns about fulfillment of those variables when compared to gold standard (May & Warren, 2001). 42
Bowling (2005) recommended that to measure QOL, responses to physical, mental and social effects of illness that influence on daily living should be included. The extent of personal satisfaction with life circumstance, adequate physical well-being, a basic level of satisfaction and a general sense of self-esteem are recommended. From Bowling’s point of view, multiple domains and more than one dimension should be included in QOL assessment.
Disease specific QOL measurements emphasize the particular problems that are often unique to the disease for which they are developed (Marra et al., 2005) while generic measurements assess broad impact of disease and treatment on functioning in everyday life (Ware et al., 1998). Disease specific measures may be more useful in determining whether treatments have their intended specific effects but they do not permit comparisons across conditions and treatments (Ware et al., 1998).
Quality of life among mild traumatic brain injury patients. There were few studies which investigate QOL among adults with MTBI. None of published literature about
MTBI adults used a holistic model such as the RAM to guide investigation. These studies were reviewed in this section.
Among 48 studies with MTBI adults, there were only two that included quality of life and a reviewed report of studies related to QOL after MTBI. In 1999, Schutt (1999) evaluated QOL among subjects after all severities of traumatic brain injury. Subjects were divided into mild, moderate, and severe TBI groups. Each group was compared to each other and to a normal control group. The McMaster Health Index Questionnaire as the indicators for quality of life and the Beck Depression Index was used to measure depression. The McMaster Health Index Questionnaire is a unidimensional that measures only patients’ abilities to perform tasks. The measure is a multi-domain index with three 43 subscales: physical, emotional and social functions. Unidimensional quality of life might not be able to capture all subjective dimensions of QOL. Moreover, there were only 13-14 subjects in each group and the difference of QOL and depression between subjects with different severity was not found (Schutt, 1999). The RAM did include subjective as well as objective approaches to measurement.
In 2003, Emanuelson and others studied quality of life among 173 MTBI persons
(Emanuelson, Anderson, Bjorklund, & Stalhammar, 2003), using the SF-36. The SF-36 is a generic and unidimensional QOL measurement which consists of two subscales: physical health and mental health. Disease specific aspects of MTBI may be missed. In this study, factors often related to quality of life such as patient characteristics and social support were not reported. PCS questionnaire was added to capture disease specific symptoms after MTBI.
Berger and colleagues reviewed studies related to quality of life after MTBI and concluded that it was inappropriate to use a generic QOL index to assess QOL after
MTBI. They also recommended the aspects of QOL after MTBI include physical, psychological, social and cognitive aspects (Berger, Leven, Pirente, Bouillon, &
Neugebauer, 1999). Both the McMaster Health Index Questionnaire and the SF-36 are generic QOL indexes. As QOL by itself is inadequate to portray a complete picture of recovery after MTBI, the Roy Adaptation Model (RAM) is used in this study to better explore MTBI among Thai adults.
Quality of life and adaptation in Roy Adaptation Mode. The nature of nursing is to anticipate outcomes related to improvement in individuals (Roy & Andrews, 1991; Roy
& Roberts, 1981; Roy & Zhan, 2001), quality of life (QOL) has been perceived to be an 44 important dimension to evaluate health or the effectiveness of treatment among nursing discipline as well.
The RAM is a global perspective for assessing individual adaptation in various domains: physiological; self-concept; role-function; and interdependence. Roy describes persons as biopsychosocial beings who are required to adapt to environmental stimuli
(Yeh, 2003). An explicit conceptual-theoretical-empirical structure of QOL using Roy
Adaptation Model (RAM) has been developed by Fawcett and Downs to test propositions of QOL in cancer patients (Nuamah, Cooley, Fawcett, & McCorkle, 1999). In Fawcett and Down’s structure, QOL was considered to be a latent variable that reflects overall response of the adaptive system to environmental stimuli. The components of QOL reflect the four adaptive modes of the RAM. More specifically, the physiological mode represented by physical symptoms; the self-concept modes was represented by affective status; the role-function was represented by functional status; and the interdependence mode was measured by using social support (Nuamah, Cooley, Fawcett, & McCorkle,
1999). However, the results from 375 cancer patients did not support the association between QOL and the RAM. The authors noted that this was a secondary data analysis and all measures were not designed for QOL or adaptation (Nuamah, Cooley, Fawcett, &
McCorkle, 1999). The authors suggested that community re-integration should be used as a measure of role-function, and the quality of social support should be added besides number of caregivers at home. QOL in Nuamah and colleagues’ study was a unidimensional perspective.
For this project, a multidimensional of QOL was used. Domains of QOL were used to represent adaptive modes in the RAM: the physiological mode by health and functioning domain; the self-concept mode by psychological / spiritual domain; the role- 45 function mode by social and economic domain; and the interdependence mode by family domain (Ferrans, 1997). Ferrans and Powers depicted QOL in two dimensions: satisfaction and importance.
Adaptation and MTBI
There are four modes of adaptation in Roy’s adaptation model: physiologic, self- concept, role function, and interdependence mode. Each of these modes is explored in relationship to outcomes in MTBI patients.
Physiological mode. The physiological mode emphasizes response to needs associated with body systems including senses and neurological functions (The Boston
Based Adaptation Research in Nursing Society, 1999). However, as MTBI patients do not typically have visible oxygenation, nutrition, elimination or protection deficits, studies related to physiologic mode among MTBI adults emphasize sensory and neurological functions. Forty-eight studies have described outcomes after MTBI; 46 included physiologic responses in the studies. Neurologic and sensory symptoms in PCS such as headaches, visual or hearing problem, sleep disturbance and dizziness have been reported as dysfunctions. Two studies used the Sickness Impact Profile to measure physiologic responses after MTBI (Levine, Dawson, Boutet, Schwartz, & Stuss, 2000; Moore &
Stambrook, 1992). Data from 43 studies were collected by observation or interviewing.
There were only three studies (Bigler & Snyder, 1995; Savola & Hillbom, 2003;
Stranjalis et al., 2004) that collected data by using other techniques such as radiography
(Bigler & Snyder, 1995) or blood samples (Savola & Hillbom, 2003; Stranjalis et al.,
2004).
One study examined in sleep disturbance, one of the physiological aspect, among all severities of traumatic brain injury. Mahmood and his colleagues found that MTBI 46 adults encountered sleep disturbance when measured by the Pittsburgh Sleep Quality
Index. MTBI subjects reported the scores of 8.54 (a score > 6 was considered sleep disturbance). Their scores were higher than those scores among moderate and severe traumatic brain injury subjects (Mahmood, Rapport, Hanks, & Fichtenberg, 2004). Other frequently reported physiological symptoms were headaches (Emanuelson, Anderson,
Bjorklund, & Stalhammar, 2003; Lovell et al., 2003; Ponsford, Olver, & Curran, 1996), tiredness (Emanuelson, Anderson, Bjorklund, & Stalhammar, 2003), dizziness
(Emanuelson, Anderson, Bjorklund, & Stalhammar, 2003; Ponsford, Olver, & Curran,
1996), and visual difficulties (Ponsford, Olver, & Curran, 1996).
Self-concept mode. The self-concept mode focuses on the ability of a person to feel or to experience and to maintain his/ her self organization under the stimuli (The Boston
Based Adaptation Research in Nursing Society, 1999). In MTBI, studies related to this ability emphasized a person’s psychological reaction after experiencing MTBI. Concepts such as depression, stress, psychological distress, neuropsychological changes or neurobehavioral changes were used to reflect self-concept outcomes after MTBI.
Among 48 studies that included self-concept in adult MTBI subjects, 44 reported psychological symptoms: 31 used symptoms included in PCS and 14 used other measures. For example, the presence of depression was reported in 8 studies (Bell,
Primeau, Sweet, & Lofland, 1999; Bryant, Moulds, Guthrie, & Nixon, 2003; Glenn,
O'Neil-Pirozzi, Goldstein, Burke, & Jacob, 2001; Levin et al., 2001b; Moore &
Stambrook, 1992; Rapoport, McCullagh, Streiner, & Feinstein, 2003a; Ruttan &
Heinrichs, 2003; Schutt, 1999), neuropsychological outcomes were reported in two studies (Bigler & Snyder, 1995; Cicerone & Kalmar, 1995) and one study each reported neurobehavioral changes (Hartlage, 2001), psychological distress (McCullagh, 47
Oucherlony, Protzner, Blair, & Feinstein, 2001), stress (Bedard et al., 2003), and sickness impact profile-psychological part (Levine, Dawson, Boutet, Schwartz, & Stuss, 2000) as self-concept responses after MTBI.
Role-function mode. The role-function mode focuses on one’s ability to maintain one’s role in the society and/ or to maintain one’s relationship with other person (The
Boston Based Adaptation Research in Nursing Society, 1999). The Extended Glasgow
Outcome Scale is another measure that will be used to capture role-function mode in this study. For many people with MTBI, going back to work or school is one of the most difficult things they are going to do. Short-term memory problems can make it hard to learn new material and fatigue may mean MTBI people have limited energy to finish their jobs or studies. Furthermore, returning to work/ school involves a social-dimension in that people really want to fit in with their peers (Johnson, 2000). Ability to resume to their role functions among MTBI adults has not been included as a major outcome after MTBI in most investigations. There are 14 studies in which included role-function. Among these
14, ten of them focused on the ability to return to work or school after MTBI (Alexander,
1992; Cicerone et al., 1996; Englander, Hall, Stimpson, & Chaffin, 1992; Haboubi, Long,
Koshy, & Ward, 2001; Ingebrigtsen, Waterloo, Marup-Jensen, Attner, & Romner, 1998;
Kay, Newman, Cavallo, Ezrachi, & Resnick, 1992; McCullagh, Oucherlony, Protzner,
Blair, & Feinstein, 2001; Rapoport, McCullagh, Streiner, & Feinstein, 2003b; Ruffolo,
Friedland, Dawson, Colantonio, & Lindsay, 1999; Stranjalis et al., 2004) while four studies emphasized community re-integration or social integration (Deb, Lyons, &
Koutzoukis, 1998; Emanuelson, Anderson, Bjorklund, & Stalhammar, 2003; Levin et al.,
2001b; McCauley, Boake, Levin, Contant, & Song, 2001; Schutt, 1999). 48
Interdependence mode. The interdependence mode involves interaction with others to complete person’s affectional needs. The responses of the interdependence mode are often seen as giving and receiving of love, respect, and value (The Boston Based
Adaptation Research in Nursing Society, 1999).
The interdependence mode has not been well explored in MTBI adults. Nine studies included variables that could be considered as markers of the interdependence mode. One used the Edinburgh Rehabilitation Status Scale to measure the frequency and extent to which the patients relied on others for self care (Deb, Lyons, & Koutzoukis, 1998) while
Levin and his co-workers (2001) used a structured interview that related independence within and outside the home to interpersonal relationships (Levin et al., 2001b). Two studies examined relationship problems (Haboubi, Long, Koshy, & Ward, 2001;
Ingebrigtsen, Waterloo, Marup-Jensen, Attner, & Romner, 1998). One reported patients’ perception on social support: quantity, availability, and satisfactory (McCauley, Boake,
Levin, Contant, & Song, 2001). Alexander (1992) used open-ended question to tap difficulties or problems after MTBI including relationship issues. Kay and co-workers used the NYU Head Injury Family Interview to find socialization problems after MTBI.
A total of nine studies can be considered having all four adaptive modes as in the
RAM. An in depth review will be done for each of these nine studies. A holistic examination of the MTBI is congruent with nursing goals and practice (Roy, 2005;
Tiedeman, 2005). Furthermore, this approach uses meta-paradigm concepts of person- environment-health-nursing, furthering nursing science development.
In 1992, Alexander was the pioneer author who considered problems after MTBI in holistic point of view. He interviewed 35 subjects after closed head injury between 6 months and 5 years. Factors such as PTA, PCS, radiographic results and return to work/ 49 school were included. Twenty-three of the subjects were MTBI patients. Most of MTBI subjects had PTA less than 1 hour. Most often reported PCS symptoms among MTBI patients were headaches and dizziness. Depression was reported by almost 90% of the subjects (Alexander, 1992). The author used mental status examination, neurological examination, psychiatric symptoms interview, the Glasgow Outcome Scale and open- ended questions as measures. Even though the study had a holistic approach, the generalization of the study might be limited from small sample size. The factors were described but predictive factors were not identified. Moreover, results from open-ended questions were varied and the method of interpretation was not clear. There is a possibility of Type II error, the probability of rejecting the null hypothesis given that the null hypothesis is true, since sample size is small. Ability to generalize the findings is also limited.
In the same year, Kay and colleagues (1992) collected data from 808 MTBI subjects. Subjects were interviewed for their outcomes and symptoms using the NYU
Head Injury Family Interview. Data were collected at a week, a month, three month, six months, and one year after MTBI. Headaches were the most common postinjury physiological symptom reported for all time points, with the incidence of 23-69%. These symptoms gradually decreased over the course of the year. Over 80% of MTBI subjects returned to work or school within 3 months postinjury (Kay, Newman, Cavallo, Ezrachi,
& Resnick, 1992). The definition of mild head injury (MHI), the injury to the head and face area with or without injury to the brain, was used as inclusive criteria in this study without duration of PTA or LOC had been stated. Factors such as age, sex, education and
LOC failed to predict outcomes after MTBI. Because this study applied a unique 50 definition of MTBI, the findings might not be comparable to other clinical settings.
Furthermore, outcome measures did not capture QOL or adaptation.
In 1998, Ingebrigtsen and colleague studied PCS among 100 MTBI adults after three months of the injury. The authors described headaches as the most frequent physiological symptom with more than 40% of the subjects reported headaches. Poor memory, fatigue, irritability, and dizziness were the next most common symptoms reported by the subjects. Age, gender, PTA, GCS, and alcohol abuse were measured but did not predict PCS (Ingebrigtsen, Waterloo, Marup-Jensen, Attner, & Romner, 1998).
Even though this study appeared to have appropriate number of subjects, factors associated to PCS were not included and a multidimensional approach to outcome measurement was not used.
In the same year, Deb and colleagues (1998) reported post-MTBI outcomes. In their study, the Glasgow Outcome Scale, the Edinburgh Rehabilitation Status Outcome, the
National Adult Reading Test, the Barthel Index, the Clinical Interview Schedule Revised, and the Psychosis Screening Questionnaire were used to interview 134 MTBI subjects.
The results revealed that all subjects had evidence of cognitive deficit (Deb, Lyons, &
Koutzoukis, 1998). Factors such as gender and age were described but the predictive factors were not examined. Even though outcomes from this study could be considered having a holistic view as in the RAM, all outcomes were measured only in one objective dimension. Subjective dimension of all outcomes was missing.
Schutt (1999) compared QOL, PCS, and QOL between 13 MTBI subjects and moderate, severe TBI, and non-injured control subjects. MTBI patients had more PCS, lower QOL, and higher depression than the control group. However, there was no difference among outcomes across subjects with different severity of TBI. Factors such as 51 age, gender, LOC, GCS and radiographic results were explored but they did not contribute to a predictive model (Schutt, 1999). This study was done in mixed severity of injury with small sample size (total sample size = 54). More than six hypotheses were tested and some results were reported to be statistically significant at p-value less than .05 even though Bonferroni’s correction of alpha at .05/6 (.008) was not done. As a result, many factors still need to be explored.
Levin and his colleagues (2001) compared depression and stress between traumatic brain injured (TBI) and general trauma patients. In the TBI group, there were 60 MTBI adults and nine moderate TBI adults. The TBI group reported higher depression in the
CES-D than standard cut point (22.14). Age, education and occupation were not related to depression and stress. However, social support was negatively correlated with stress
(Levin et al., 2001b). Even though there were several important factors included in this study, only one factor (social support) was a predictor for MTBI outcomes. As a result of mixed severity of the injury among the subjects, the results from this might not be relevant to the MTBI population.
Among 115 subjects with mixed mild (95) and moderate (20) TBI, McCauley and other researchers (2001) included PCS, depression, social support, return to work/ school and radiographic results in their study. The findings were compared with results from general trauma subjects. There was no difference in measures between both groups. The
TBI group reported depression at 22.5, social support at 2.4 (0-9), and satisfaction in social support at 5.1 (0-6) in TBI group (McCauley, Boake, Levin, Contant, & Song,
2001). This study was limited as above since it included mixed severity of TBI. Predictors of recovery from MTBI were not examined. 52
In 2003, Emanuelson and his co-workers studied QOL and PCS among 173 MTBI subjects. Subjects were interviewed at three weeks, three months and one year after their injury. QOL was measured by using the SF-36. MTBI patients reported lower QOL than control subjects. QOL remained lower than normal at one year postinjury. Headache was frequently reported physiological symptoms at all time points (30-35%) while depression was the most frequent reported self-concept symptom at three months after the injury.
Despite the fact that sample size was large, this study did not evaluate variables as predictors. The relationships between QOL and PCS were reported (-.68 to .85, p 335) but it was not clear which aspects of QOL had negative relationships with the PCS. The QOL measure in this study was a generic measure which might not depict specific perceptions of QOL after MTBI.
In 2004, Kashluba and colleagues compared symptoms between subjects 3 months post-MTBI and a control group. Each group was interviewed two times at one month apart. Two dimensions of PCS: frequency and severity were collected. There were 110
MTBI in this study. The results revealed that fatigue was the most frequently reported symptom, followed by headaches, distractibility, irritability, and forgetfulness. Headaches were reported as the most severe symptom, followed by fatigue, irritability, forgetfulness, and word finding problem respectively. The authors matched MTBI adults with non- injured adults to control for age, gender, education, and socioeconomic status (Kashluba et al., 2004). Although this study used multidimensional measures, it lacked some key factors related to PCS such as PTA, depression and social support. There was no significant difference between groups found in this study. PCS was the only outcome limiting the understanding of recovery to a single, mostly physiological outcome. 53
The inability to establish prediction was related either a small sample size, a mixed sample (more than MTBI included) or reduced model that did not examine important factors established in the extent literature. Therefore, this study needs to be done. This study will include all three sets of factors: focal, contextual, and residual to promote a holistic approach to describing and predicting variables which may influence recovery after MTBI. Moreover, these variables have not been explored among Thai adults; knowledge about these characteristics is needed.
In conclusion, among 48 studies among MTBI population, there were only two studies included QOL as an outcome after MTBI. One of the two suffered from small sample size while another adapted generic, single dimension QOL measure. There were nine studies could be concluded as having holistic approach from the RAM point-of- view. However, only few of them included factors affected on the outcomes on these studies. Most of the studies with predictor could not confirm that which factor was able to predict outcomes after MTBI. Therefore, study in which outcomes: QOL and return to work/ school will be explored is needed. Study including all three sets of factors: focal, contextual, and residual is also crucial for nurses to help MTBI patients to solve their problems. Moreover, there is no basic characteristics explored among Thai adults, knowledge about these characteristics is needed.
Identifying gaps in knowledge
It is recommended that QOL after MTBI should be evaluated during 3-12 months postinjury (Bullinger & The TBI Consensus Group, 2002). Subjective and multi- component concepts are also recommended (Power, Harper, & Bullinger, 1999; The
Constitution of the World Health Organization, 2004). Since there are no published studies about Thai MTBI available, these guidelines will help form this study. Subjective, 54 multidomain, and multidimensional concepts from Ferrans and Powers will be used with additional concepts from the RAM conceptual framework.
There are few QOL studies among MTBI adults, and almost all of those studies do not include sufficient factors affecting the QOL among those MTBI patients. As a result of these limitations, this study will incorporate concepts detailed in this chapter. These concepts are operationalized in chapter 3. Since there is no specific QOL measure for
MTBI adults in Thailand, the QOL index will be modified for both MTBI and the Thai culture. Knowledge about factors affecting MTBI will also a better understanding about what are the processes that promote adaptation. The predictors of QOL among Thai
MTBI population will also be explored as there is no published information about predictive factors for adaptation after MTBI in Thai adults.
Summary
Research findings have shown conflicting results and many of limitations. For the influences of stimuli, there were studies that found stimuli associated with outcomes after
MTBI and others that reported no relationship between selected stimuli and outcomes.
Moreover, research among MTBI adults did not consistently use the same variables or definitions so that findings might not be comparable across studies.
The biggest limitation in the review of published literatures was the lack of a consistent definition of MTBI and PCS. Also results were sometimes inconclusive and unique to one study. There were few studies related to MTBI that reflected nursing’s holistic perception. There were no studies which used nursing theory to guide the design or interpretation.
Even less clear is the outcome after MTBI among Thai adults. None of the published studies related to MTBI include the Thai population. Exploring the full process 55 of adaptation-stimuli, process, and adaptation outcome- by using nursing theory, Roy adaptation model, provides baseline information for further study. Use an established, consistent definition of MTBI and PCS for Thai population will lead future research among MTBI in Thai people.
As a practice discipline, the goal of nursing is to promote adaptation by enhancing human system and environment interaction. Using information from this study to build a predictive model will help nurses in assessing adaptive behaviors and the stimuli that influence adaptation behavior. This information will be useful for nurses in judgment nursing intervention, plan to manage stimuli and enhance coping process of MTBI adults.
Thus, based on this review of 48 published studies related to MTBI adults, three research questions were developed:
1. What adaptation occurs among Thai adults after MTBI?
2. What stimuli are associated with adaptation to MTBI among Thai adult?
2.1 Do focal, contextual and residual stimuli associate with adaptation to MTBI among Thai adults?
2.2 Is coping associated with adaptation to MTBI among Thai adults?
2.3 Are depressive symptoms associated with adaptation to MTBI among Thai adults?
3. What are the factors that predict adaptation to MTBI among Thai adults?
3.1 Can coping predict adaptation to MTBI among Thai adults?
3.2 Can depressive symptoms predict adaptation to MTBI among Thai adults?
3.3 What are the factors that predict adaptation to MTBI among Thai adults when considering coping as a mediator of adaptation? 56
3.4 What are the factors that predict adaptation to MTBI among Thai adults when considering depressive symptoms as a mediator of adaptation?
57
CHAPTER THREE
Method
The purposes of this cross-sectional descriptive, predictive study were to 1) explore adaptation to mild traumatic brain injury (MTBI), 2) determine factors that were associated with adaptation to MTBI, and 3) identify factors that predicted adaptation to
MTBI among Thai adults. In this chapter, the study setting, sample characteristics, and measures were described. Study procedures and the protection of human subjects were also described.
Study setting and Sample
Setting
The setting of this study was the Maharat Nakhon Ratchasima hospital, a 1000 bed tertiary hospital in the Nakhon Ratchasima province of Thailand. The usual care for adults with MTBI in the emergency room is admission to one of the six units: the general surgical units (two male units, one female unit), the orthopedic surgical units (one male unit, one female unit), or the neurosurgical unit. MTBI patients who were admitted to those six units were eligible for the study. Mild head injury was the most common inpatient diagnosis in this hospital into which approximately 1,102 MTBI adults were admitted each year (Maharat Nakhon Ratchasima Hospital, 2005). In the past year, there were 92,626 people visited emergency room (ER) of the Maharat Nakhon Ratchasima hospital (Maharat Nakhon Ratchasima Hospital, 2005). From a previous study, 29% of
ER clients had head injuries, and 83.7% of those with head injuries had MTBI
(Phuenpathom, Tiensuwan, Ratanalert, & Saeheng, 2000). Therefore, 22,483 people visited the ER because of MTBI.
58
Sample selection
Sample selection was purposive. All participants were recruited from the Maharat
Nakhon Ratchasima Hospital (MNH). The potential subjects were defined through the
MNH’s database. Subjects included patients who had MTBI between three and twelve months. Previous research indicated that MTBI and associated symptoms were greatest at
0-3 months post-injury with a sharp decrement at one year after the injury (Deb, Lyons, &
Koutzoukis, 1998; Emanuelson, Anderson, Bjorklund, & Stalhammar, 2003).
Inclusion criteria. Medical records of subjects discharged from the hospital with
ICD-10 code S.00 (superficial wound), S.01 (head wound), S.02 (skull fracture), S.06
(intracranial injury), S.07 (compression injury), and S.09 (other head injury) were accessed. In addition, admission records from the surgical departments were assessed for subjects with diagnoses mild head injury, minor head injury, mild brain injury, minor brain injury, and concussion. Subjects discharged from the hospital with those codes and diagnoses who met other inclusion criteria (i.e., age of 18 years or older; able to communicate by speaking or writing; initial MTBI only; and absence of psychiatric or other neurological disease), were able to provide informed consent, and were willing to participate in the interview were invited to participate this study. There were 461 eligible subjects invited to participate this study, 135 subjects returned informed consent and completed the interview. Therefore, consent rate was 29.28%.
MTBI was determined by a review of the medical chart. The chart review included
Glasgow Coma Score (GCS) and a physician’s note. Since MTBI was not an ICD-10 code or commonly written medical diagnosis, criteria for a diagnosis of MTBI was GCS of 13-15. By definition, a GCS of 13 or 14 is MTBI. If the GCS was 15 (normal), then these additional diagnoses were assessed in the physician’s note: closed head injury; 59 traumatic head injury; mild brain or head injury; minor brain or head injury, or concussion.
Exclusion criteria. Participants were excluded if they had a history of multiple head injuries, congenital or organic learning disorders, premorbid psychiatric disorders or neurological disorders unrelated to MTBI such as Alzheimer’s, multiple sclerosis,
Parkinson’s disease, stroke, and other central nervous system diseases. Patients who had a documented GCS score < 13 during first 72 hours after admission were excluded. Patients who had MTBI for less than three months or more than one year, or patients with multiple head injuries were also excluded.
Sample size
Most studies that had been done among MTBI were descriptive level and did not provide data to calculate effect size. Among studies that reported correlation or relationships of the variables, there were a few variables similar to this study. For example King and colleagues (1999) found that depression had positive correlation with
PCS at 32% (King, Crawford, Wenden, Caldwell, & Wade, 1999). From their results, an effect size of .11 could be obtained. A larger effect size related to PCS (.27) was reported by Kashluba and colleagues (2004, p 807). Because those were effect sizes of only one variable, more studies were examined.
More variables included in this study were also examined in a study from van der
Nalt and colleague (1999). Two factors in MTBI subjects explored in their study were found to effect return to work, one of the dependent variables in this study. The authors reported that numbers of PCS symptoms and duration of PTA helped explain the rate of return to work in their 67 subjects (van der Naalt, van Zomeren, Sluiter, & Minderhoud,
1999). From their report, an R-square of .18 and effect size of .22 was obtained. 60
There were 15 predictors and two covariates in this study. The sample size of 130 subjects was calculated. This sample provided a power of .90 with a small-to-moderate effect size of .22 (r2 = .18, ES = .22), with 17 predictors and alpha was equal to .05
(Buchner, Erdfelder, & Faul, 1997).
An alpha of .05 provides a small chance of Type I error or a possibility that the true hypothesis may be rejected 5/100 times (or 2.5% when two-tailed hypotheses are tested).
At this level of error, the threshold of confidence is equal to 95%. An alpha of .05 has been pursued for more than 3 decades as the conventional value when conducting any critical test (Cowles & Davis, 1982). Given the probable error (PE) of any test = .68 or
2/3 of a standard deviation, the chance of rejection level of any test is 3PE (Cowles &
Davis, 1982 p 557) or 4.56%. This number is rounded to 5% or .05. Cohen (1994) agreed with this conventional level. He also added that researchers might choose a smaller critical point, but smaller critical point might affect effect size and reduce power. A larger sample size would be needed if the researcher wanted to maintain proper power with an alpha less than .05 (Cohen, 1994).
An alpha of .05 was selected for this study because it gave readers confidence that findings were due to chance only 5% of the time. Even though there was no harm to the subjects in this study and alpha of .1 might be selected, the researcher chose to use the lower level of chance of error (.05) to enable comparison with other studies. Moreover, since the predictors were explored, a lower level of error would promote acceptance of findings across disciplines.
Measures
Since this study was conducted in Thailand, the measures unavailable in Thai were translated into Thai by the researcher and a back-translation was performed by a medical- 61 surgical nurse fluent in Thai. Next, another bilingual medical-surgical nurse reviewed both of the completed Thai and English versions to determine the appropriateness of their meaning and the equivalence between the Thai and English versions. Finally, a bilingual person checked the original and back translated versions for the equivalence of the translations. All Thai version measures were piloted with 5 Thai adults 18 years of age or older. Adjustments were done as needed, mostly adding clarification of the instruction and repeated instructions for at least three times throughout the interview. The measures that underwent translation were the Life Experience Survey, the Social Support
Questionnaire- Short Form, the Coping and Adaptation Process Scale and the
Postconcussion Symptoms Checklist. The CES-D and the Quality of Life Index were already extent in Thai.
Figure 2: Measures for each variable in conceptual framework
Focal Stimuli: Severity of MTBI Coping -Glasgow Coma Scale -The Coping and -Posttraumatic Amnesia Adaptation Processing -Loss of consciousness -Length of stay in hospital Scale Depressive -Postconcussion symptoms Symptoms Contextual Stimuli: -The CES-D Individual Characteristics Adaptation -Gender -The Quality of Life -Age Index -Employment status -The Extended -Presence of alcohol at time of injury Glasgow Outcome -Education Scale -Time post-injury
Residual Stimuli: Stress and Social Support -Stress: The Life Experience Survey -Social support: The Social Support Questionnaire-Short Form -Marital status
62
Measures of Stimuli
This section described the measures used to describe the severity of brain injury or stimuli. These measures were demographic data worksheet, medical record, the
Postconcussion symptoms checklist, the Life Experience Survey, the Coping and
Adaptation Processing, the Social Support Questionnaire Short-Form, and the CESD.
Measures of focal stimuli: Severity of MTBI
Glasgow Coma Scale (GCS). Glasgow coma scale scores from the first 30 minutes,
24 hours, 48 hours, and 72 hours after MTBI were collected from the medical record. The initial GCS score was used in analysis (Appendix A).
Mild brain injury is defined as a GCS score of 13-15 (Deb, Lyons, & Koutzoukis,
1998; Englander, Hall, Stimpson, & Chaffin, 1992; Gasquoine, 1997; Ingebrigtsen,
Waterloo, Marup-Jensen, Attner, & Romner, 1998; Iverson, Lovell, Smith, & Franzen,
2000; Keller, Hiltbrunner, Dill, & Kesselring, 2000; McCullagh, Oucherlony, Protzner,
Blair, & Feinstein, 2001; Mittenberg, Tremont, Zielinski, Fichera, & Rayls, 1996; The
Mild Traumatic Brain Injury Committee of the Head Injury Interdisciplinary Special
Interest Group of the American Congress of Rehabilitation Medicine, 1993). This score typical indicates a derangement in eye opening, verbal ability, and/or motor movement immediately after the injury. The GCS is used world-wide to categorize brain injury into mild, moderate, and severe levels.
Duration of posttraumatic amnesia (PTA) and duration of loss of consciousness
(LOC). Duration of posttraumatic amnesia and duration of loss of consciousness were extracted from the medical record. If there was no record of this duration, self-report was used. Duration was recorded in minutes (Appendix A). 63
PTA is the period that the person with MTBI is unable to access his/ her continuous memory (Vos et al., 2002) and is often characterized by confusion (Levin, Eisenberg, &
Benton, 1989). LOC is a period that MTBI person is unable to response to the environment after immediate head injury (Vos et al., 2002). PTA and LOC are hallmark features for diagnosing MTBI (Ruff & Jurica, 1999). They are found to have a positive correlation with lesions in the brain and severity of the concussive injury (Cattelani,
Gugliotta, Maravita, & Mazzucchi, 1996); PTA is independent of PCS (Ponsford et al.,
2000).
Length of stay in hospital. Length of stay in hospital was collected from the medical record. Number of days was recorded to the nearest whole number. Days in the hospital or days in observation in the emergency room were used (Appendix A).
Length of stay in the hospital refers to numbers of days that the person has to stay in the hospital due to MTBI. There is evidence that 66.7% of MTBI patients are admitted for observation (Gomez, Lobato, Ortega, & De La Cruz, 1996). Longer periods of length of stay may affect employment status, economic and daily of living.
Postconcussion symptoms. Postconcussion symptoms were measured by the
Postconcussion Symptoms Checklist (PCSC) (Gouvier, Cubic, Jones, Brantley, & Cutlip,
1992; Gouvier, Uddo-Crane, & Brown, 1988). The PCSC is a self-report questionnaire that allows subjects to rate the frequency, intensity, and duration of 10 symptoms by using the Likert-type scale (1 = not at all, 5 = constant or crippling). Four sets of scores were derived for each subject: frequency, intensity, duration, and total. Range of PCS total scores and each subscale scores are 10-50. The PSCS has high concurrent validity with other postconcussion symptoms checklists (r = .77) (Gouvier, Cubic, Jones,
Brantley, & Cutlip, 1992). It shows modest correlation with depression (r = .55) 64
(Sawchyn, Brulot, & Strauss, 2000). The accuracy rate of discrimination between persons with and without PCS is 70% in a normal healthy population and 56% in head-injured persons (Sawchyn, Brulot, & Strauss, 2000) (Appendix B).
According to DSM-IV (American Psychiatric Association, 1994), the essential feature of postconcussion symptoms (PCS) includes a reduction in cognitive functioning, accompanied by specific neurobehavioral symptoms, that occurs as a consequences of closed head injury with sufficient severity to produce a significant cerebral concussion.
Cognitive functioning symptoms are associated with either attention (concentration, shifting focus on attention, performing simultaneous cognitive tasks) or memory deficits
(learning or recall information). In addition to the cognitive disturbances, there must be three (or more) neurobehavioral symptoms that present for at least 3 months after the injury. These symptoms are: fatigue, disordered sleep, headache, vertigo or dizziness, irritability or aggressive on little or no provocation, anxiety, depression, or affective liability, apathy or lack of spontaneity, and other changes in personality (e.g. social or sexual appropriateness). Other symptoms such as visual or hearing impairment and anosmia (loss of sense of smell) may also be found. These cognitive and neurobehavioral sequelae may lead to significant impairment in social or occupational functioning, represent a significant decline from a previous level of functioning, and worsening in academic achievement dating from the trauma if the individual is in school age.
PCS were commonly reported among MTBI adults at 3 months after sustaining brain injury (Deb, Lyons, & Koutzoukis, 1998; Mittenberg, Canyock, Condit, & Patton,
2001; Mittenberg, Tremont, Zielinski, Fichera, & Rayls, 1996; Savola & Hillbom, 2003).
However, many studies reported that PCS could be found at one year after MTBI (Alves,
Macciocchi, & Barth, 1993; Bernstein, 1999) or even longer (Emanuelson, Anderson, 65
Bjorklund, & Stalhammar, 2003). Persistent PCS, symptoms that last longer than 3 months, is theorized to be an interaction of nervous system damage (Cattelani, Gugliotta,
Maravita, & Mazzucchi, 1996) such as upper motor neuron injury (Greiffenstein, Baker,
& Gola, 1996) and other environmental factors (Gronwall, 1991). There were some other variables that associated with PCS such as stress (Hanna-Pladdy, Berry, Bennett, Phillips,
& Gouvier, 2001; King, 1996a), anxiety and depression (King, 1996a; Suhr & Gunstad,
2002), low quality of life and low social support (Brown, McCauley, Levin, Contant, &
Boake, 2004) and PCS after MTBI could lead to disability (Cicerone & Kalmar, 1995).
On the other hand, Ingelbrigtsen (1998) concluded that there was no relationship between
PCS and any factor (Ingebrigtsen, Waterloo, Marup-Jensen, Attner, & Romner, 1998).
Not all studies supported the presence of PCS after MTBI. Satz and colleagues
(1999) concluded that there was no strong evidence to support that MTBI induced PCS
(Satz et al., 1999). Also, PCS could be found in other populations besides MTBI such as chronic pain (Smith-Seemiller, Fow, Kant, & Franzen, 2003), other trauma (Lees-Haley,
Fox, & Courtney, 2001; McCauley, Boake, Levin, Contant, & Song, 2001), or healthy people (Chan, 2001; Fox, Lees-Haley, Earnest, & Dolezal-Wood, 1995). In addition, except for poor sustained attention, a person with MTBI and PCS did not have worse cognitive performance when compared to healthy people (Bohnen et al., 1994).
The variable findings of PCS after MTBI seem to arise primarily from an inconsistent definition of PCS (McHugh, 2002). While most of the researchers use the
DSM-IV definition, PCS has also been defined as the symptoms experienced by MTBI persons immediately after the injury (Lees-Haley, Fox, & Courtney, 2001), as a set symptoms at one month (Alexander, 1997), and any symptoms during data collection
(Barth, Diamond, & Errico, 1996; Lovell & Collins, 1998); one group of researchers does 66 not define the definition for sets of symptoms in their study at all (Arcia & Gualtieri,
1993). PCS has never been considered among Thai patients with MTBI. Therefore, additional study with consistent definition and assessment tool of PCS is needed in Thai adult.
Measures of contextual stimuli: Individual characteristics
Demographic data. Demographic data was collected by a self-report and medical record review, using an investigator-developed questionnaire. This questionnaire included questions regarding gender, age, education, religious and marital status. Questions that extracted information from medical record were highlighted and in appendix A. Age was recorded as age in years (rounded to nearest whole number). This questionnaire also included four GCS scores for up to 72 hours after admission (30 minutes, 24 hours, 48 hours, and 72 hours), durations of PTA and LOC, length of stay in the hospital, time post- injury, employment/ student status (pre and postinjury), presence of alcohol at time of injury, and questions related return to work or school from the Extended Glasgow
Outcome Scale.
Employment status. Employment status pre-injury was collected by self-report.
Student status was counted as one type of employment status. Employment status was reported as employment status before injury and employment status after injury
(Appendix A).
Presence of alcohol at time of injury. Presence of alcohol at the time of injury was collected by self-report. Scores was coded as either 0 “did not use alcohol at the time of injury” or 1 “used alcohol at the time of injury”. Medical records were used to collect missing data as needed. (Appendix A) 67
Time post-injury. Time postinjury was calculated from the date that the subject experienced MTBI until the date that the questionnaire was completed. Time was recorded in number of days (Appendix A).
Measures of residual stimuli: Stress and social support
Stress. Stress was measured by using the Life Experience Survey (LES) (Sarason,
Johnson, & Siegel, 1978a). By adapting a well known stress assessment, the Social
Readjustent Rating Scale (Holmes & Rahe, 1967), Sarason and other researchers (1978) added more relevant items and set the rating scale from -3 to +3 for each event (Sarason,
Johnson, & Siegel, 1978a). In each event, participants can rate as 0 or no effect, positive effect (+1 to +3) and negative effect (-1 to -3). Subscale scores can be obtained in four ways 1) total number of positive events, 2) total number of negative events, 4) weighted scores of positive events, and 4) weighted scores of negative events. Total scores can be obtained from either the summation of all events (absolute value, ignore the signs) or total summation of weighted scores (both negative and positive events). Sarason and his colleagues noted that the separated scores between negative and positive events (either number of events or weighted scores) were more reliable and practically useful than total score (Sarason, Johnson, & Siegel, 1978a). For the study, weighted scores of positive events and weighted scores of negative events were used.
The LES has been adapted into several versions and widely used among different populations such as adults (Brantley et al., 2005; Sarason, Sarason, Potter, & Antoni,
1985), postpartum mothers (Hall, Kotch, Browne, & Rayens, 1996), patients in VA hospitals (Bailey, Koepsell, & Belcher, 1984), midlife women (Woods & Mitchell, 1997), patients of low income clinics (Scarinci, Ames, & Brantley, 1999), Navy personnel and their spouses (Eastman, Archer, & Ball, 1990), haemodialysis patients (Elal & Krespi, 68
1999), Taiwanese adolescents (Chang, 2001), and adolescents with psychiatric illness
(Williamson et al., 2003).
The LES has several reports of reliability. Test-retest was done with a 5-6 week interval; Pearson’s product moment correlations for negative events = .56 to .88, for positive events = .19 to .53, for total scores =. 63 to .64 (Brantley et al., 2005; Hall,
Kotch, Browne, & Rayens, 1996; Sarason, Johnson, & Siegel, 1978a; Scarinci, Ames, &
Brantley, 1999). In another study, by test-retest scores with 10 days interval, the Kappa coefficients were .3 to .6 (Bailey, Koepsell, & Belcher, 1984). Reliability of the LES in this later study was modest; however, those Kappa coefficients were generated from small sample size (n=29). In the adolescent version, with fewer items (46), the LES demonstrated higher alpha coefficients (.64) (Chang, 2001). It is noticed that negative subscale score had higher reliability coefficients in all studies.
Sarason and his co-workers reported several kinds of validity for the LES.
Construct (convergent) validity was done by correlated scores between the LES and the
State-Trait Anxiety Inventory. The negative subscale of the LES demonstrated negative correlation with anxiety measure; state (.46) and trait (.40) (Sarason, Johnson, & Siegel,
1978a).
Criterion (predictive) validity was done by correlate the LES scores with GPA
(academic achievement) and the scores from the Psychological Screening Inventory (PSI for measuring personal maladjustment). The results revealed that negative and total scores were significantly correlated with GPA (r = .38 and .40, respectively). Positive scores were found correlated with expression subscale of the PSI, and negative scores were correlated with social nonconformity and discomfort subscales. 69
Concurrent validity was done by comparing the LES scores with the SRRS scores.
Only 34 similar items were selected and compared. The results showed that the LES’s negative scores were highly correlated with depression when compared to the SRRS. The difference of both scores was also significant. The authors noted that life change unit in the SRRS was the major cause of difference (Sarason, Johnson, & Siegel, 1978b).
Although these reliabilities are not high, they are acceptable. The LES was originally developed to use with young adult population which were in the same age with the majority of MTBI population. Since there was no MTBI version for this measure and it had not been tested among MTBI population, a pilot study was performed. Each item was considered for its content validity. Cronbach’s alpha coefficient was generated for internal consistency from data collected during the study. The LES is shown in Appendix
C.
Social support. Social support was measured by using the Social Support
Questionnaire short form (SSQ6, appendix D) (Sarason, Sarason, Shearin, & Pierce,
1987). The SSQ is a 6-item scale that provides a measure of the number of persons available for support (availability) and satisfaction with the available support system
(satisfaction). The satisfaction scores use a 6-point scale ranging from “very satisfied” (6) to “very dissatisfied” (1). Higher scores indicate more support and better satisfaction.
Range of SSQ6 availability subscale is 0-54 and the satisfaction score can range from 6-
36. The SSQ6 has internal reliabilities of .90-.93 for both availability and satisfaction subscales when tested among 217 undergraduate students (Sarason, Sarason, Shearin, &
Pierce, 1987). It shows significant divergent validity when it is compared to the Multiple
Adjective Affect Check List (MAACL) (r = -.26 for number subscale and r = -.17 for satisfaction subscale) and the UCLA Loneliness Scale (r = -.49 for number subscale and r 70
= -.59 for satisfaction subscale) (Sarason, Sarason, Shearin, & Pierce, 1987). The SSQ6 has been used among MTBI and yields high specificity by its ability to discriminate the differences of score between MTBI (mean score 2.53) and general trauma (mean score
3.13) (Brown, McCauley, Levin, Contant, & Boake, 2004) (Appendix D).
Measure of Adaptation process
Coping. Coping was measured by using the Coping and Adaptation Processing
Scale (CAPS, appendix E) (Roy, in review). The CAPS is a 47-item measure with Likert- type responses ranging from 4 (always) to 1 (never). Possible scores range from 47 to 188 with a high score indicating more strategies of coping. The internal consistency of the
CAPS is high (α = .94) when it was tested among 349 spinal cord injury and brain tumor patients. Content validity of the CAPS was synthesized from 163 studies based on the
Roy Adaptation Model, and the construct validity was established by using exploratory factor analysis. The CAPS can explain 42% of self-consistency among elderly population
(Roy, in review).
The CAPS has been translated to the Thai language and tested by Prangtip
Chayaput (2004). Content validity index reported 92% agreement among Thai nurse experts. The CAPS Thai version was tested among 554 patients who were hospitalized with acute illness and yielded reliability measured by Cronbach’s alpha at .93. The CAPS was re-translated to Thai language for this study since the first Thai version was originally translated to use with hospitalized patients.
Depressive symptoms. Depressive symptoms were assessed using the Thai version of the Center for Epidemiological Studies Depression Scale (CES-D Thai-version, appendix G) (Trangkasombat, Labpboonsup, & Hawanont, n.d.). The CES-D Thai version, a modification of the CES-D, is a frequently used depressive symptoms 71 screening measure among several Thai populations such as spinal cord injury
(Kuptniratsaikul, Chulakadabba, & Ratanavijitrasil, 2002) and teenagers (Trangkasombat,
Labpboonsup, & Hawanont, n.d.). It is a self-report 20-item questionnaire used for evaluating perceived mood and level of functioning in the past 7 days. Scores range from
0-60, with higher scores indicating more depressive symptoms. Scores of 22 or higher are considered indicative of depressive symptoms (Trangkasombat, Labpboonsup, &
Hawanont, n.d.). The CES-D yields high internal consistency when tested among Thai teenagers (α = .86) and spinal cord injured patients (α = .92). The sensitivity of this measure is 72-93%, its specificity is 85-94%, and the predictive value is 82%
(Kuptniratsaikul, Chulakadabba, & Ratanavijitrasil, 2002; Trangkasombat, Labpboonsup,
& Hawanont, n.d.).
Measures of Adaptation Outcomes
The Extended Glasgow Outcome Scale. The Extended Glasgow Outcome Scale
(GOS-E) was developed from the traditional Glasgow Outcome Scale to address limitations, to be more sensitive, and to be more reliable. Jennett and other researchers
(1981) extended the GOS-E from five categories to eight categories (Sander, 2002) which are: dead, vegetative state, lower severe disability, upper severe disability, lower moderate disability, upper moderate disability, lower good recovery, and upper good recovery (Jennett, Snoek, Bond, & Brooks, 1981).
Wilson and other researchers (1998) developed a structured interview for the GOS-
E and found that the reliability of the GOS-E improved when using the structured interview (Kappa =.85) (Wilson, 1998). High reliability was also confirmed by Whitnall and colleagues (2005) when the Kappa was reported at .97 with 95% CI at .95 - 1.0
(Whitnall, McMillan, Murray, & Teasdale, 2006). Validity of the GOS-E was reported by 72
Wilson and colleagues (2000) when they found that the GOS-E was correlated with the original GOS, depression and well-being (Wilson, Pettigrew, & Teasdale, 2000), and community reintegration (Levin et al., 2001a).
The GOS-E was originally developed for assessment of severe brain injuries; therefore, some categories such as dead or vegetative state might not be appropriate to use with mild traumatic brain injury people. In this study, only six of eight categories were included, and the structured interview from Wilson and colleagues was used to guide the assessment. Those structures were:
0 = Upper good recovery
1 = Lower good recovery
2 = Upper moderately disabled
3 = Lower moderately disabled
4 = Upper severely disabled
5 = Lower severely disabled
The GOS-E consists of two domains: independence and difficulty. For an independent domain, the questions consist of ability to be independent in the home and ability to be independent outside the home (including shopping and traveling). If the
MTBI person could not do at least one of these independent tasks, he/ she was considered as in the severely disabled group. For the MTBI person who could not stay home alone for at least eight hours, he/ she was also be considered as in the lower severely disabled group. For a difficulty domain, the questions consist of ability to work (or study), social and leisure activities, and family and friendship. The MTBI person who reported at least one difficulty in these questions was considered as in the moderately disabled group. The
MTBI person who could not return to work or study at the same level as before brain 73 injury was considered as in the lower moderately disabled. The last question in the GOS-
E was about return to normal life after brain injury. This question referred to the symptoms that might occur after MTBI that might bother MTBI people and made them feel that their lives were changed. The MTBI person who did not have independence or difficulty issues but could not return to normal life was considered as in the lower good recovery group while MTBI person who did not have any issue and returned to his or her normal life was in the upper good recovery group (Wilson, 1998; Wilson, Pettigrew, &
Teasdale, 2000). Questions for the GOSE were integrated in demographic data worksheet
(Appendix A).
Quality of life. Quality of life was measured by using the Quality of Life Index
(QLI, appendix F) (Ferrans & Powers, 1992). The QLI measures both satisfaction and importance of various aspects of life. Importance ratings are used to weight the satisfaction responses, so that scores reflect the respondents' satisfaction with the aspects of life they value. Items that are rated as more important have a greater impact on scores than those of lesser importance. The instrument consists of two parts: the first measures satisfaction with various aspects of life and the second measures importance of those same aspects. Scores were calculated for quality of life overall and in four domains: health and functioning, psychological/ spiritual, social and economic, and family
(Ferrans, 1996; Ferrans & Powers, 1985; Ferrans & Powers, 1992; Ferrans, 1990;
Warnecke, Ferrans, Johnson, & et al., 1996). Total score of the QLI range from 0-30; a higher score indicates better QOL.
Ferrans and Powers have expanded the QLI to more than 14 different versions, specific for each disease. Internal consistency reliability for the QLI (total scale) is supported by Cronbach’s alphas ranging from .84 to .98 across 26 studies, test-retest 74 correlations are .87 at a two-week interval and .81 at a one-month interval (Ferrans &
Powers, 2004). Content validity of the QLI is supported by the fact that items were based both on an extensive literature review of issues related to quality of life and on the reports of patients regarding the quality of their lives (Ferrans & Powers, 1985). Support for content validity also is provided by an acceptably high rating using the Content Validity
Index. Convergent validity of the QLI was supported by strong correlations between the overall QLI score and other standard life satisfaction assessments (Ferrans & Powers,
2004). Factor analysis reveals four dimensions underlying the QLI: health and functioning, social and economic, psychological/spiritual, and family. The factor analytic solution can explain 91% of the total variance (Ferrans & Powers, 1992).
The QLI-Cardiac version in Thai (Petchprapai, 1998), the QLI-Stroke version and the QLI-Generic version were used to create a modified version that is appropriate for
MTBI subjects (Appendix F).
Procedures
Invitation Procedures
After the human subjects review boards at University Hospital of Cleveland’s and at the Maharat nakhon Ratchasima Hospital (MNH) approved, the principal investigator
(PI) identified potential subjects. The hospital database was used to list all potential subjects with selected ICD-10 codes discharged from the hospital in the previous 3-12 months. Specifically, the ICD codes associated with MTBI were S.00 (superficial wound), S.01 (head wound), S.02 (skull fracture), S.06 (intracranial injury), S.07
(compression injury), and S.09 (other head injury). A clerk in hospital database office entered ICD-10 codes and generated the list of patient names. Moreover, admission records from the surgical departments were reviewed to identify potential subjects with 75 diagnoses mild head/ brain injury, moderate head/ brain injury, and concussion. The PI then obtained each individual’s chart to determine inclusion criteria: adult age, evidence of trauma, GCS 13-15 on admission and a diagnosis of MTBI such as concussion, mild brain injury and mild head injury in the physician’s notes.
Informed Consent Procedures
After identification of a potential subject from the database described above, the PI mailed a cover letter (appendix J), two consent forms (one for the subject to keep), a stamped, addressed postcard that allowed the patient to either opt in or opt out of further contact and a stamped, addressed envelope for returning the consent form to all potential subjects. The PI waited for two weeks for the subjects to review and consider participating in this study.
If the subject mailed the opt-in postcard, the PI made a call (phone script, appendix
I) to the subject to introduce herself, explain the study and confirm the subject’s willingness to be part of the study. At that time, the PI read the informed consent document to the subject and asked the subject to re-state the purpose, risks and benefits. If the subject was able to make an accurate summary, then the PI instructed the subject to sign and date the consent form and mail it in, along with the card indicating a convenient time to call for the interview. If the subject was unable to provide a clear summary, the
PI provided additional information and asked questions until the patient could state key pieces of information such as the purpose of the study, steps to ensure privacy and confidentiality, and risks such as discomfort with some questions.
After two weeks, reminding postcard were sent to subjects who did not return postcard or informed consent. The PI waited for another two weeks for the subjects to make decision. If the postcard was not returned within two weeks, the PI made a 76 telephone call, using the number in the medical records database, to determine whether the subject received a packet and ask if s/he would like more information. The PI also answered any question about this study that the subject might have. If subject requested additional information, the PI provided information in a manner agreeable to the subject—over the phone, at a future time or via a second mailing. If the subject was willing, the PI read the informed consent at this time. If the subject indicated a willingness to participate, then the subject was instructed to return the informed consent
(if they still had it) or the PI sent a new informed consent and study information. If the informed consent was not returned within seven days, the PI made one last phone call to again invite participation and provide instructions about informed consent processes.
In the cover letter, all subjects received the PI’s phone number and were encouraged to call and ask questions about this study before they made their decision to send the postcard or the informed consent.
Only the PI obtained consent by reading the consent over the phone and asking subjects to repeat the information in their own words. Although this was complex, it ensured that the individual had a good understanding (by repeating information about the study in their own words) and adequate time to think over whether s/he wanted to participate. The PI was the sole determinant of subject understanding, listening especially for the subject to accurately state that this was a research study, the purpose of the study
(examining recovery after mild brain injury), the risks (especially discomfort with some questions) and that future care was not contingent upon participation in this study. All subjects received a copy of the informed consent, signed by the PI in the initial packet or with re-sending any information. Contact information for the PI was in the consent document. The PI alone was responsible for answering any questions by potential and 77 enrolled subjects. The interview did not occur until a signed consent was received via mail.
Interview Procedures
All subjects were interviewed by telephone at a time and place of the subject’s choosing. After receiving the signed consent, the PI scheduled a time for the interview in one of these two ways—1) the subject provided the date and time in an opt-in postcard or
2) the PI called the subject, using the telephone number shared by the subject during the follow-up phone call two weeks after a packet of information was sent when no reply was received from the potential subject.
A phone script for initiating the interview was used with all subjects. The phone script included advising the participant to be in a place which a comfortable level of privacy during the interview. The PI reminded the participant that s/he might choose not to answer any question and/or stop at any time. This statement was repeated at least 3 times during the interview.
The interview consisted of 170 questions and lasted approximately 40 minutes. The interview questions were the same for each subject (same order, same words), specifically; demographic form (appendix A, items with * only), the PCSC (appendix B), the Life Experience Survey (appendix C), the Social Support Questionnaire-Short Form
(Appendix D), the Coping-Adaptation Processing Scale (Appendix E), the Extended
Glasgow Outcome Scale (questions were included in the demographic data worksheet), the Quality of Life Index (Appendix F), and the CES-D (appendix G). Each tool was first described and the directions for answering explained. These descriptions and explanations preceded the questions in the appendices. All interviews were completed at one time point. 78
Medical Record Reviewing Procedures
Chart data was collected after the interview. Day of injury, gender, age, marital status, GCS, length of stay (date of admission and date of discharge), alcohol levels (if available) and time postinjury were collected from medical record by a research assistant
(RA) who was trained by the PI After the interview, hospital number and study number were assigned and given to the RA by landline (secure) telephone initiated by the PI. The
RA used the hospital number to obtain each subject’s medical record and completed data collection, returning the forms the PI by registered mail with signature required.
In order to maintain confidentiality, several steps were implemented:
1. The RA was a registered nurse with an active license.
2. The RA completed a course of human subjects training and committed to maintain confidentiality.
3. The data collection form used by the RA did not have identifiable information such as hospital number, name, or date of birth on it. If a mailed package became lost, there was no information to link the data with a specific individual. Linkage information for this project was kept by the RA in a locked drawer when not in use.
4. The RA did not have direct contact with any potential subjects in the normal course of her work or related to this research project. Her role was simply entering information on one page of the demographic work sheet.
Data Management and Data Analysis
Data management
A codebook for SPSS was developed to identify each variable. The subjects’ code numbers were marked on each form and all forms for each subject were checked for their completion before the PI finished the interview and by the RA before mailing. Data entry 79 and data cleaning were done by the PI. All questionnaires and the data set were kept in the investigator’s office in locked files and are available for five years after the last publication related to the study. All hospital numbers, addresses, or other information that could be used to identify a subject were erased or destroyed after data entry and cleaning was complete.
Data analysis
There were three parts of data analysis; descriptive, associative, and predictive analysis. A two-tailed alpha of .05 was used for significance for research question 1 and
2. For research question 3, an alpha of .10 was used in this exploratory study.
Descriptive analysis: Research question 1: What adaptation occurs among Thai adults after MTBI? To explore adaptation to MTBI, frequencies, percentage, means, standard deviation, median, and tests that provide inferential statistics on normality: skewness, kurtosis, P-P plots, outliers, histogram and Kolmogorov-Smirnov tests were computed to describe the extent of stimuli, coping process, and quality of life among Thai
MTBI.
Associative analysis: Research question 2: What focal stimuli, contextual stimuli, and residual stimuli are associated with adaptation MTBI among Thai adults? To determine stimuli associated with adaptation to MTBI, Pearson’s correlations for continuous variables (GCS, length of stay in hospital, postconcussion symptom, age, time post-injury, stress, social support, depressive symptom, GOS-E, and coping process) to
QOL were calculated. For categorical variables (posttraumatic amnesia, loss of consciousness, gender, employment status, and education), Chi-square correlations were used. 80
Predictive analysis: Research question 3: What are the factors that predict adaptation to MTBI among Thai adults? Multiple regression was performed to answer this question. Assumptions of multiple regression (i.e., assumption of normality, assumption of linearity, assumption of reliability and assumption of homoscedasticity) were tested as follow:
Assumption of normality. Regression assumes that variables have normal distributions. Non-normally distributed variables (highly skewed or kurtotic variables, or variables with substantial outliers) can distort relationships and significance tests
(Tabachnick & Fidell, 2001). Normality testing included visual inspection of data plots, skew, kurtosis, and P-P plots, Kolmogorov-Smirnov tests, outliers, and visual inspection of histograms or frequency distributions were performed for testing distribution of data.
The examination of standardized residuals or indices of leverage for multiple regression was calculated. When the data was not normally distributed, the removal of the outliers was considered if it reduced the probability of Type I and Type II errors and improved accuracy of estimates.
Assumption of linearity. Standard multiple regression can only accurately estimate the relationship between dependent and independent variables if the relationships are linear in nature. If the relationship between independent variables (IV) and the dependent variable (DV) is not linear, the results of the regression analysis will underestimate the true relationship. This underestimation carries two risks: increased chance of a Type II error for that IV, and, in the case of multiple regression, an increased risk of Type I errors
(overestimation) for other IVs that share variance with that IV (Tabachnick & Fidell,
2001). 81
Nonlinearity was tested by examination of residual plots (plots of the standardized residuals as a function of standardized predicted values). It is important that the nonlinear aspects of the relationship be accounted for in order to best assess the relationship between variables.
Assumption of reliability. In multiple regression, unreliable measurements cause relationships to be underestimated, increasing the risk of Type II errors. Furthermore, effect sizes of other variables can be overestimated if the covariate is not reliably measured because the full effect of the covariate(s) would not be removed. Since a goal of this study is to accurately model the relationships evident in the population, assumption of reliability are tested. The estimates of Cronbach alpha at > .7 were acceptable.
Assumption of homoscedasticity. Homoscedasticity means that the variance of errors is the same across all levels of the IV. When the variance of errors differs at different values of the IV, heteroscedasticity is indicated. Slight heteroscedasticity has little effect on significance tests; however, when heteroscedasticity is marked, it can lead to serious distortion of findings and seriously weaken the analysis, thus increasing the possibility of a Type I error.
This assumption was checked by visual examination of a plot of the standardized residuals (the errors) by the regression standardized predicted value which were included in most modern statistical packages especially the SPSS version 14.0. Ideally, residuals are randomly scattered around 0 (the horizontal line), providing a relatively even distribution. Heteroscedasticity is indicated when the residuals are not evenly scattered around the line.
According to Roy, focal stimuli have direct effect on adaptation while contextual stimuli have an effect on the strength of focal stimuli, and residual stimuli may or may 82 not have any effect (Roy & Andrews, 1999). Factors in this study were selected based on theory and literatures, and they were added into the regression model if they did not have excessive missing data.
Interactions between the categories of stimuli or within each category of stimuli were not examined in this study.
For research question 3, all factors from the conceptual model, except presence of alcohol at the time of injury, were entered in regression models to discover whether or not they could explain adaptation. Presence of alcohol at the time of injury was removed because 69% of the data were missing.
Analysis of predictive model with mediators
Eight analyses were completed in order to determine whether mediators (coping and depressive symptoms) influenced adaptation.
1. Factors predicting adaptation (quality of life),
2. Factors predicting adaptation (the GOSE),
3. Factors predicting coping,
4. Factors predicting depressive symptoms,
5. Coping and depressive symptoms predicting adaptation (quality of life),
6. Coping and depressive symptoms predicting adaptation (the GOSE),
7. Factors, coping and depressive symptoms predicting adaptation (quality of life),
and
8. Factors, coping and depressive symptoms predicting adaptation (the GOSE).
In order to meet the assumptions of mediator, conditions 3 to 6 must be significant
(Baron & Kenny, 1986; Bennett, 2000). If these conditions are significant, then the effect of mediators can be found by comparing adjusted R-squares. Adjusted R-square in 83 condition 1 is compared to adjusted R-square in condition 7. Meanwhile, adjusted R- square in condition 2 is compared with adjusted R-square in condition 8. Since eight equations were calculated, Bonferroni correction of the alpha at .10/8 (.0125) for each calculated analysis was used to reduce Type I error.
Protection of Human Subjects
This study underwent review the institutional committees from both University
Hospital of Cleveland and the Maharat Nakhon Ratchasima hospital. Adult patients with
MTBI were subjects for this study. All subjects were informed about the purpose of this study. Participation in this study was voluntary and each subject could withdraw from the study at any time. There were no direct benefits to participating in this study. There were no substantial risks involved in this study although subjects might become uncomfortable from the type or quantity of questions. Subjects could participate even if they do not wish to answer specific questions; no subject declined to answer isolated questions. No forms had subjects’ name or other information that could be used to link responses to one individual. Results were reported as aggregates only. If there was any information specific to an individual in a report on the study, an alias was used.
The subjects’ decisions about participation did not affect services that they received from the MNH. Only the PI and members of her committee could access the original questionnaires.
Risks, Discomfort or inconvenience
There were sensitive questions in the interview about religion, spousal/partner relationship, and sexual satisfaction and importance. These questions had been reviewed by the institution’s IRB and were not deemed too sensitive to ask in this context of health care inquiry. These questions are asked by health care professionals in Thailand and the 84
PI is a registered nurse and identifies herself as a registered nurse in written and verbal encounters. The subjects were informed that they could refuse to answer any question that made them feel uncomfortable throughout the interview.
The responses to these possibly sensitive questions are necessary to better understand holistic recovery after mild traumatic brain injury and are consistent with the theoretical underpinnings of this study. Information about religious affiliation is important to understanding spiritual aspects of quality of life and recovery after MTBI.
Spousal/partner relationships and sexual satisfaction/importance are also well- demonstrated to have an affect on quality of life, especially in this population which is characterized by young adults who are likely to be active sexually and to have important/ongoing spousal/partner relationships. Even though questions related to sexual lives are uncommon for Thai people, these questions are useful in understanding recovery for MTBI subjects, most of whom are young and sexually active.
The PI took several steps to minimize discomfort or stigmatization from negative views of others who might overhear the subject during the interview. The PI attended to privacy or confidentially issues, reminding subjects at the beginning of the interview that they might wish to be in a place that protected their privacy in their home/location. The subject chose a time and place for the interview. In general, it would be impossible for someone else to overhear the questions of the interview which were read by the PI. Only the responses could be overheard—and they were not typically informative (e.g.,
“sometimes”, “extremely important”, “7 times”). The subject could re-schedule an interview if the circumstances of privacy changed during the course of the telephone interview. The PI reminded the subject at the start of the interview and during directions for each tool with a potentially sensitive question (e.g. the QOL tool) that s/he could 85 decline to answer any question. In addition, the PI conducted telephone interviews in a private room, secure against unintended interruptions by placing a sign on the closed door
(“Research in progress—do not interrupt”). The call schedule was kept confidential and secured in a locked drawer when not in use. The PI piloted data collection on the first five subjects, carefully evaluating the initial problems and findings. The PI kept a diary that recorded current events and individual factors (such as being uncomfortable answering specific questions or being hard of hearing) that affected responses during data collection.
It was not anticipated that these questions will cause adverse psychological responses. If a subject indicated distress or requested information about a related condition (such as depression), the PI was prepared with contact/referral information; none of the subjects ask for. In Thailand, health care is universal and there are no out-of- pocket costs should the subject decide to act on a referral or schedule an appointment with a counselor or physician. If the subject described a problem that would benefit from a health care provider visit, the PI suggested that an appointment should be made. The PI was familiar with this health care setting and had a current list of clinics and phone numbers if referral was indicated. The PI is an experienced registered nurse and comfortable in interacting with patients in a variety of settings, including over the telephone.
There was no intervention. No blood was drawn. There was no follow-up unless an individual was unable to complete all questions in one interview. The PI anticipated no more than minimal risk for discomfort and no injury as a result of participating in this study.
86
Compensation for Injuries
This was a minimal risk, descriptive study and did not involve any treatment. There was no compensation for the injuries.
Benefits to the Subject
There were no direct benefits to the individual participating in this study.
Costs to the Subjects
There were no monetary or other costs for any subject enrolled in this study. All phone call costs (such as long distance fees) were borne by the PI. All incoming calls to cellphone or landline numbers are free of charge in Thailand. Because the PI initiated the phone call, there were no associated phone charges to the participants.
Alternative to Participants
This was a descriptive study and participation was voluntarily. Subjects could participate in any treatment of their choice.
Payments to the Subjects
There were no payments or incentives for any subject enrolled in this study.
Subject Privacy and Data Confidentiality
All subjects were interviewed over the phone. The subject could choose a time and place to ensure privacy. The subject was reminded that some questions were sensitive and would be asked to respond to the interview while located in a private place. If the subject’s circumstances changed during the interview (perhaps a family member returned home unexpectedly), the PI offered to reschedule the interview. In addition, the PI was in a private room and maintained confidentiality of the call schedule.
Data was de-identified during data entry into a SPSS spreadsheet. Any information linking responses to an individual (such as consent documents) was kept in separate 87 locked drawers. At the conclusion of the study, any linkages were erased or destroyed.
All consents and interviews were kept secure for 5 years after data collection. Data was not shared with anyone except the PI’s dissertation committee members and the IRB committees involved in this study. However, no identifiers were released with data that might be shared with committee members. The intent of the study was not to diagnose or treat, so no information was entered into a patient chart.
Data Monitoring and Safety
The PI performed data safety and monitoring. This was a descriptive study; no intervention was planned. No adverse events were anticipated beyond a feeling slightly tired after the interview. Individual subject data was reviewed for completeness and accuracy at the end of the interview by the PI. In addition, the database was reviewed for complete and accurate entry using summary statistics after every 25th enrollee (four times over the course of the study). At this time, the PI reviewed the protocol to keep it fresh in her mind and to ensure that it was being followed. The PI also reported percentage of potential subjects approached who declined to participate (and reasons for not participating) and attrition rates (numbers of subjects who did not complete the protocol).
This interim analysis and self-evaluation occurred in consultation with the PI’s dissertation advisor, Chris Winkelman, RN, PhD, Assistant Professor, Frances Payne
Bolton School of Nursing, Case Western Reserve University. The PI kept a diary during the entire recruitment and data collection process. No adverse events or protocol deviations occurred. A regulatory binder contained protocol specific information, pre- screening and enrollment logs, all IRB communication, data collection sheets/IRB- approved questionnaires, a blank set of forms on which to report adverse events and the 88
CV of the PI. The binder was kept in a secure, locked drawer when not being used by the
PI.
89
CHAPTER FOUR
Results
This study of Thai adults with mild traumatic brain injury (MTBI) has three specific aims: 1) to explore adaptation to MTBI, 2) to determine factors associated with adaptation to MTBI, and 3) to identify factors that predicted adaptation to MTBI among
Thai adults. The sample for this study consisted of 135 Thai adults with MTBI who voluntarily participated in telephone interviews from October, 2006 to January, 2007.
In this chapter, a description of the sample and results of analyses corresponding to three research questions are presented. The underlying assumptions for the Pearson product moment correlation and multiple regression analysis were examined prior to statistical analysis. The level of significance (alpha) for any multiple comparisons was set at according to Bonferroni’s adjustment for all multiples of statistical tests in order to avoid a Type I error (Gordi & Khamis, 2004; Holland & Copenharer, 1988). For research question 1 and 2, alpha was set at .05/number of tests. For research question 3, alpha was set at .0125 (.1/8). All statistical analyses were computed using SPSS 15.0 for Windows
(SPSS Inc., 2006).
Subjects
Approximately 461 invitation letters and consent forms were sent to eligible subjects who admitted in the Maharat Nakhon Ratchasima Hospital because of concussion, mild head injury, mild brain injury or closed head injury in the past 3 to 12 months. From the hospital’s database, most patients had been involved in motor vehicle crashes, falls, or physical assaults. There were 363 men (78.7%) and 98 (21.3%) women.
The overall age ranged from 18 to 82 years. The majority of them were younger than 29 years (41.4%) and the average age was 36 years. One month after the invitation packets 90 were sent, 50 consent forms were received. A reminder postcard was sent to the rest of the eligible subjects and another 40 consent forms were returned over the next two months. The rest of the subjects were randomly called by using telephone numbers provided in medical records. Of the 82 calls, 37 subjects either relocated or did not stay home at the time of calling. Forty-five subjects were reachable and all agreed to participate. Over a period of four months, 135 consent forms were returned yielding return rate of 29%. All of those 135 subjects who were willing to participate were interviewed. The proportion of men to women among 135 participants was 84% to 16%, the median age was 36 years and the mean age was 38 years. Even though only 29% of the eligible subjects were included in this study, their age and gender were not different from those 461 eligible subjects.
Among 135 subjects enrolled, 40% had MTBI without other injuries. Another 60% had other injuries, such as extremity fracture, maxilla or mandible fracture, blunt trauma to the abdomen, or lacerated wound with MTBI (Table 4). The presence of multiple injuries was not exclusionary for this study. However, adaptation after multiple injuries could vary from adaptation from MTBI alone. Therefore, descriptive data from subjects are reported as a whole as well as separately for subjects with and without other traumatic injuries. Statistical differences of stimuli, processes, and outcomes are reported after each section.
Stimuli
In the next section, a description of the subjects is reported based on the results from the focal, contextual and residual stimuli.
91
Focal Stimuli
Focal stimuli are a reflection of the severity of MTBI, as is determined by several factors. For all 135 subjects, length of stay in the hospital was between 3 and 90 days, with a mean of 8 days. Time post-injury was between 4 and 12 months, with the average being 8 months. Subjects spent between 3 and 180 days recovering at home, averaging about 50 days. The average duration of posttraumatic amnesia (PTA) was five minutes and the duration of loss of consciousness (LOC) was close to two minutes. The average
Glasgow Coma Scores (GCS) at 30 minutes after injury was 14, and 15 at 72 hours post- injury. Post-concussion symptoms (PCS) were reported for the total scale and three subscales: Frequency, intensity, and duration. The total PCS scores were between 30 and
120 and the average was 50. The average scores for three subscales were 17, 17, and 16, respectively (Table 1).
Table 1
Severity of Mild Traumatic Brain Injury for all subjects (N=135)
Variables Mean (SD) Median Range 95% CI of Mean Lower Upper Length of stay (days) 8.24 (10.62) 5.0 3-90 6.44 10.05 Time postinjury (months) 8.36 (2.15) 8.0 4-12 8.00 8.73 Recovery period (days) 48.67 (45.96) 30.0 3-180 40.85 56.50 Duration of Posttraumatic Amnesia 5.74 (14.55) 0 0-60 3.26 8.22 Duration of Loss of Consciousness 1.53 (4.42) 0 0-30 0.59 2.48 Glasgow Coma Scores - At 30 minutes 14.04 (.77) 14 13-15 13.91 14.18 - At 72 hours 14.86 (.35) 15 14-15 14.80 14.92 Postconcussion Symptoms - Frequency 17.30 (6.11) 16.0 10-40 16.26 18.34 - Intensity 16.61 (5.89) 15.0 10-40 15.61 17.62 - Duration 16.34 (6.04) 15.0 10-40 15.31 17.37 - Total 50.25 (17.92) 47.0 30-120 47.20 53.30 92
Findings related to focal stimuli in MTBI subjects without multiple injuries are presented in Table 2. Length of hospital stay ranged between 3 and 12 days for all subject, with an average of 5 days. Time post-injury was 4 to 12 months, with an average of 8 months. Recovery period was reported between 3 and 90 days and averaged about 9 days. Duration of posttraumatic amnesia ranged from 0 to 60 minutes and the average was 6 minutes. Subjects in this group reported duration of loss of consciousness at about a minute-and-a-half. The GCS at 30 minutes was 14, and 15 three days post-injury. Total score for PCS was 51. The average scores for the frequency, intensity, and duration subscales were 18, 17, and 17, respectively (Table 2).
Table 2
Severity of Mild Traumatic Brain Injury among subjects without multiple injuries (n=57)
Variables Mean (SD) Median Range 95% CI of Mean Lower Upper Length of stay (days) 4.98 (2.52) 4.00 3-12 4.31 5.65 Time postinjury (months) 7.72 (2.02) 7.00 4-12 7.18 8.25 Recovery period (days) 29.60 (18.49) 30.00 3-90 24.69 34.50 Duration of Posttraumatic Amnesia 6.23 (16.10) 0.00 0-60 1.96 10.49 Duration of Loss of Consciousness 1.40 (5.70) 0.00 0-30 -0.10 2.90 Glasgow Coma Scores -At 30 minutes 13.96 (0.76) 14 13-15 13.76 14.17 -At 72 hours 14.81 (0.40) 15 14-15 14.70 14.91 Postconcussion Symptoms -Frequency 17.56 (6.80) 16.0 10-40 15.76 19.37 -Intensity 17.02 (6.58) 15.0 10-40 15.27 18.76 -Duration 16.70 (6.81) 15.0 10-40 14.90 18.51 -Total 51.28 (20.10) 47.0 30-120 45.95 56.61
Findings for focal stimuli in subjects with other injuries concurrent with MTBI are presented in Table 3. Length of hospital stay ranged between 3 and 90 days, the average 93 being 11 days. Time post-injury was 4 to 12 months, with an average of 9 months.
Subjects spent between 3 and 180 days recovering at home, or about 60 days average.
The average duration of post-traumatic amnesia was 5 minutes and the duration for loss of consciousness was 2 minutes. The GCS was 14 at 30 minutes, and 15 at 72 hours post- injury. These numbers are the same as those for subjects with no concurrent injuries. The average for PCS score was 50. The mean scores in the frequency subscale equaled 17; 16 for both the intensity and duration scores.
Table 3
Severity of Mild Traumatic Brain Injury among subjects with MTBI and other injuries
(n=78)
Variables Mean (SD) Median Range 95% CI of Mean Lower Upper Length of stay (days) 10.59 (13.23) 6.0 3-90 7.62 13.63 Time postinjury (months) 8.90 (2.12) 8.5 4-12 8.35 9.31 Recovery period (days) 62.62 (54.42) 40.0 3-180 51.43 76.59 Duration of Posttraumatic Amnesia 6.03 (14.33) 0.0 0-60 2.36 8.41 Duration of Loss of Consciousness 1.50 (5.41) 0 0-30 0.38 2.87 Glasgow Coma Scores -At 30 minutes 14.12 (0.77) 14 13-15 13.93 14.28 -At 72 hours 14.90 (0.31) 15 14-15 14.83 14.97 Postconcussion Symptoms -Frequency 17.10 (5.59) 16.0 10-40 15.84 18.36 -Intensity 16.32 (5.35) 15.0 10-40 15.11 17.53 -Duration 16.08 (5.44) 15.0 10-40 14.85 17.30 -Total 49.50 (16.24) 46.0 30-120 45.84 53.16
Contextual Stimuli
Contextual stimuli are a reflection of demographics. The findings for the 135 subjects are presented in Table 4. The majority of the subjects were men, ranging in age from 18 to 78 years, with the average at about 40 years. All subjects were Buddhist. 94
About half of the subjects were married: 58 were single, and 11 were separated, divorced, or widowed. Education ranged from 4 to 18 years of schooling, with an average of 7 years. All of the subjects were employed or had student status prior to the injury. Ninety- six percent returned to work/study afterward. Among those who returned to work/study,
66% returned at the same level and 62% returned full-time. Income was between 2,000 and 20,000 Baht/month, mean (M) = 4,309.63 and standard deviation (SD) = 2,466.62.
Information pertaining to presence of alcohol at the time of injury was missing in 60% of the medical records. Of those records containing information related to alcohol use, 32% of report its presence at the time of injury. Additional demographic characteristics are presented in Table 4.
The majority of subjects with non-concurrent injuries were men. They were younger (average = 35 years), when compared to the average age of all subjects. More than half of the subjects were married. Subjects had an average of 6 years of education and their income was lower than the average income among all subjects. All of the subjects were employed or had student status prior to the injury and all of them returned to work/study afterward. Among those who resumed their previous work/ student status,
65% returned at the same level and 60% returned full-time. Fourteen of subjects with only MTBI reported that they involved with alcohol at the time of injury (Table 4).
There were more men among subjects who had multiple injuries with MTBI.
Subjects in this group were older, when compared to the average age of all subjects (mean
= 40 years), and less than half (45%) were married. The number of years that subjects were in the school system was comparable to all subjects. All of the subjects with MTBI and multiple injuries were employed or had student status prior to the injury. Seven percent of them could not return to work/study after the injury. For those who resumed 95 their work/ student status, 62% returned at the same level and 63% returned full-time.
Twelve subjects who had MTBI with other injuries reported that they involved with alcohol at the time of injury (Table 4).
Table 4
Demographic Characteristics of the Subjects
Characteristics All subjects MTBI only Multiple injuries (N=135) (n=57) (n=78) N % N % N % Gender -Male 113 83.7 50 87.7 63 80.8 -Female 22 16.3 7 12.3 15 19.2 Marital Status -Single 58 43.0 22 38.6 36 46.2 -Married 66 48.9 31 54.4 35 44.9 -Separated/Divorced/Widowed 11 8.1 4 7.0 7 8.1 Ability to return to work or school -Yes 129 95.6 57 100.0 72 92.3 -No 6 4.4 6 7.7 Ability to return to work or school at the same level -Yes 85 65.9 37 64.9 48 61.5 -No 44 34.1 20 35.1 30 38.5 Ability to return to work or school -Full-time 83 61.5 34 59.6 49 62.8 -Part-time 46 34.5 23 40.4 23 29.5 Alcohol used at time of injury (n=69) (n=31) (n=38) -Yes 26 31.9 14 24.6 12 15.4 -No 43 19.3 17 29.8 26 33.3 Diagnosis -MTBI only 57 42.2 -MTBI with other injuries 78 57.8
Mean(SD) Median Mean(SD) Median Mean(SD) Median
Age (18-78 years) 37.73(15.22) 36.0 34.40(13.94) 32.0 40.17(15.74) 40.0 Number of years in school (4-18 years) 6.55(3.21) 4.0 6.79(3.64) 4.0 6.37(2.87) 6.0 Income (2,000-20,000 Baht/month) 4,309.63 4,000.0 4,008.77 4,000.0 4,529.49 4,000.0 (2466.82) (1451.27) (2990.34)
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The averages of some stimuli in subjects with and without other injuries were different. Therefore, independent t-tests were performed. Results from these tests revealed that three focal stimuli were statistically different: Time postinjury, length of hospital stay and number of days in recovery (Table 5).
Table 5
Differences between focal, contextual and residual stimuli among MTBI subjects with and without other injuries
Variables MTBI w/o other MTBI with t p value* injuries other injuries Mean (SD) Mean (SD) Duration of Posttraumatic Amnesia 5.35 (14.97) 6.03 (14.33) -.265 .791 Duration of Loss of Consciousness 1.58 (5.80) 1.50 (5.41) .081 .935 Length of stay in the hospital 5.04 (3.29) 10.59 (13.23) -3.561 .001* Time post injury 7.63 (1.99) 8.90 (2.12) -3.520 .001* Recovery period 29.60 (18.49) 62.62 (54.42) -4.980 .000* Postconcussion symptoms 51.28 (20.10) 49.50 (16.24) .550 .583 Number of Stressful events 2.67 (1.98) 3.28 (2.44) -1.566 .120 Total effect of Stressful events 4.84 (4.48) 5.94 (5.07) -1.301 .196 Social support (total score) 73.83 (12.66) 72.47 (12.62) .613 .541 Age 34.40 (13.94) 40.17 (15.74) -2.204 .029 *p value was set at .05/10 = .005
Residual Stimuli
Residual stimuli focused on stress and social support. Findings of all 135 subjects are presented in Table 6. Most subjects reported about three stressful events within one year post-injury. The negative effect from these events was rated at about 6 (range 1-18); the positive effect from the events was rated at about 2 (range 0-6); and an average of total effect for all stressful events was 6 (range 0-18). Social support was reported for total score and two subscale scores: Availability and satisfaction. The average score of 97 total social support was 73, the availability subscale was 40, and the satisfaction subscale was 33 (Table 6).
Table 6
Residual stimuli among all subjects (N=135)
Variables Mean (SD) Median Range 95% CI of Mean Lower Upper Life Event Stress - Number of events 3.04 (2.29) 2.0 0-9 4.67 6.40 - Negative effect of event (n=107) -5.96 (4.76) 4.0 (-18)-(-1) -6.87 -5.05 - Positive effect of events (n=42) 2.36 (2.56) 2.0 0-6 1.56 3.16 - Total effect of events 5.46 (4.86) 4.0 0-18 5.50 8.43 Social support - Availability of social support 39.68 (10.38) 39.0 18-54 37.93 41.44 - Satisfaction of social support 33.36 (3.03) 35.0 24-36 32.85 33.88 - Total scores of social support 73.04 (12.70) 72.0 49-90 70.90 75.19
Findings related to residual stimuli among 57 subjects with MTBI only were identical with those findings from all subjects (Table 7). The number of stressful events, negative effect, positive effect, and total effect of stressful events were in the same range as all subjects. For social support, MTBI subjects without multiple injuries reported higher total scores (75.53) and the availability subscale scores (41.70) when compared to those scores from all subjects. However, the satisfaction subscale scores were consistent with finding in all subjects.
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Table 7
Residual stimuli among MTBI subjects without other injuries (n=57)
Variables Mean (SD) Median Range 95% CI of Mean Lower Upper Life Event Stress - Number of events 2.79 (2.16) 2.00 0-9 2.22 3.36 - Negative effect of event -5.18 (4.58) -4.00 (-18)-(-1) -6.57 -3.79 - Positive effect of events 2.37 (2.52) 2.00 0-6 1.15 3.58 - Total effect of events 4.79 (4.55) 4.00 0-18 3.58 6.00 Social support - Availability of social support 40.32 (10.33) 39.00 24.0-54.0 37.57 43.06 - Satisfaction of social support 33.51 (10.11) 35.00 24.0-36.0 32.67 34.35 - Total scores of social support 73.83 (12.66) 72.00 49.0-90.0 70.47 77.18
Higher negative effect scores from stressful life events were reported among subjects with MTBI and multiple injuries. In addition, lower scores of social support in total score and both subscale scores were found when compared to those scores among all subjects. However, the numbers of stressful life events, as well as the positive and total effects of these events were in the same range as in all subjects (Table 8). The differences in residual stimuli among subjects with and without other injuries were compared by independent t-tests (Table 5). The results revealed that there were no statistically significant differences in stress and social support between the two groups.
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Table 8
Residual stimuli among MTBI subjects with other injuries (n=78)
Variables Mean (SD) Median Range 95% CI of Mean Lower Upper Life Event Stress - Number of events 3.23 (2.37) 3.00 0-9 2.70 3.77 - Negative effect of event (n=63) -6.51 (4.84) -6.00 (-18)-(-1) -7.73 -5.29 - Positive effect of events (n=23) 2.35 (2.66) 2.00 0-6 1.20 3.50 - Total effect of events 5.95 (5.05) 4.00 0-18 4.81 7.09 Social support - Availability of social support 39.22 (10.33) 39.00 18.0-54.0 36.89 41.55 - Satisfaction of social support 33.26 (8.61) 34.50 24.0-36.0 32.60 33.92 - Total scores of social support 72.47 (12.62) 72.00 49.0-90.0 69.63 75.32
Adaptation Process
The adaptation process refers to coping mechanisms and depressive symptoms. For all 135 subjects, the total coping score as measured by the coping and adaptation processing scale (CAPS) was 133. The resourceful and focused subscale mean score was
29; the physical and fixed subscale mean score was 40; the alert processing subscale scores was 23; the systematic processing subscale mean score was 19; and the knowing and relating subscale mean score was 23. Depressive symptoms, as measured by the CES-
D, were between 0 and 42 and the average was 21.26 (Table 9).
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Table 9
Adaptation processes among all subjects (N=135)
Variables Mean (SD) Median Range 95% CI of Mean Lower Upper The Coping and Adaptation Processing Scale - Resourceful and focused subscale 28.81 (4.43) 29.0 19-38 28.05 29.56 - Physical and fixed subscale 40.10 (4.81) 40.0 30-49 39.29 40.92 - Alert processing subscale 22.37 (3.49) 23.0 15-29 21.78 22.96 - Systematic processing subscale 18.50 (3.08) 18.0 12-24 17.98 19.03 - Knowing and relating subscale 22.96 (3.55) 23.0 15-31 22.35 23.56 - Total scores 132.74 (12.62) 133.0 98-161 130.59 134.89 Depressive symptoms 21.26 (9.31) 18.0 0-42 19.67 22.84
The findings of coping among MTBI subjects without other injuries were not different from all subjects. However, subjects with only MTBI reported higher depressive symptoms (22.60) than all subjects (Table 10).
Table 10
Adaptation processes among MTBI subjects without other injuries (n=57)
Variables Mean (SD) Median Range 95% CI of Mean Lower Upper) The Coping and Adaptation Processing Scale - Resourceful and focused subscale 28.60 (3.98) 29.00 19.00-37.00 27.54 29.65 - Physical and fixed subscale 40.26 (4.64) 40.00 31.00-49.00 39.03 41.50 - Alert processing subscale 22.26 (3.27) 23.00 15.00-28.00 21.40 23.13 - Systematic processing subscale 18.70 (2.92) 18.00 12.00-24.00 17.93 19.48 - Knowing and relating subscale 22.93 (3.08) 23.00 15.00-29.00 22.11 23.75 - Total scores 132.75 (10.44) 133.00 98.00-154.00 129.98 135.53 Depressive symptoms 22.60 (9.63) 21.00 0.00-42.00 20.04 25.15
The findings pertaining to coping among subjects with MTBI and other injuries were also consistent with findings among all subjects (Table 11). Conversely subjects 101 with MTBI and other injuries reported lower depressive symptoms (20.28) when compared to all subjects (21.26).
Table 11
Adaptation processes among MTBI subjects with other injuries (n=78)
Variables Mean (SD) Median Range 95% CI of Mean Lower Upper The Coping and Adaptation . Processing Scale - Resourceful and focused subscale 28.96 (4.75) 29.00 19.0-38.0 27.89 30.03 - Physical and fixed subscale 39.99 (4.95) 40.00 30.0-49.0 38.87 41.10 - Alert processing subscale 22.45 (3.66) 23.00 15.0-29.0 21.62 23.27 - Systematic processing subscale 18.36 (3.20) 18.00 12.0-24.0 17.64 19.08 - Knowing and relating subscale 22.97 (3.88) 23.00 15.0-31.0 22.10 23.85 - Total scores 132.73 (14.06) 132.00 98.0-161.0 129.56 135.90 Depressive symptoms 20.28 (9.01) 17.00 2.0-42.0 18.25 22.31
However, when coping and depressive symptoms scores between subjects with and without other injuries were compared by using independent t-tests, there were no statistically significant differences between these two groups (Table 12).
Table 12
Differences of adaptation processes among MTBI subjects with and without other injuries
Variables MTBI w/o other MTBI with t p value* injuries other injuries Mean (SD) Mean (SD) Depressive symptoms 22.07 (9.28) 21.05 (9.46) .623 .534 Coping and Adaptation 2.83 (.22) 2.82 (.30) .254 .800 Processing Scale (mean) *p value was set at .025
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Preliminary Data Examination
Initially, preliminary analyses were done to confirm data accuracy, understand the nature of study variables, and to test underlying assumptions. Variable outliers, influential cases, and multicollinearity were examined for their presence. Furthermore, the internal consistency reliability of the Postconcussion Symptoms Checklist (PCSC), the Life
Events Stress (LES), the Social Support Questionnaire-Short Form (SSQ-6), the Coping and Adaptation Processing Scale (CAPS), the Center for Epidemiologic Studies
Depression Scale (CESD), the Quality of Life Index (QLI) and the Extended Glasgow
Outcome Scale (GOSE) were analyzed. The preliminary statistical analyses were computed as followed.
Data accuracy
All questionnaires were filled out and completed by only the Principle Investigator
(PI). All items were checked for missing data before ending the interview. Data were visually screened for their completeness of data entry in the SPSS files. Data screening included checking individual variables for missing values as well as possible range and outliers. Visible miscoded data/ errors in data entry were examined by using descriptive statistics, such as frequencies, mean, median, and range. Presence of alcohol at the time of injury was the only variable that had missing data. Listwise deletion was not performed since 60% of data were missing. As a result of this variable was measured in nominal level, any method of data imputation might lead to bias (Croninger & Douglas, 2005), data imputation was not performed. However, including this variable in multiple regression will result the same as listwise deletion since SPSS will automatically exclude missing cases from the equation (SPSS Inc., 2006). Results from Pearson’s product- moment correlation coefficients also showed that presence of alcohol was not 103 significantly correlated with adaptation outcomes. Therefore, presence of alcohol at the time of injury was excluded from all multiple regression models. Some data were inconsistently coded and this was corrected before conducting the main analysis.
Normality
Normality of each continuous study variable was examined through mean, median,
95% Confidence Interval (CI) of Mean, variance, standard deviation, skewness, kurtosis,
Kolmogorov-Smirnov test, Shapiro-Wilk test, histogram, stem-and-leaf plot, normal Q-Q plot, detrended normal Q-Q plot and box plot. The Kolmogorov-Smirnov (KS) tests were used for the following scores: PCSC, LES, QOL, CESD, SSQ-6 and CAPS. All of these tests showed significance. The KS test assumed that the data were sampled from a
Gaussian distribution. Significance of the KS test indicated that data were deviated from normal distribution (D'Agostino & Stephens, 1986). This can be expected, given the nature of the sample: All subjects shared the MTBI diagnoses, were recruited from the same setting and had similar demographic characteristics. The assumption of normality was not met. However, the normality assumption of multiple regression might be violated in a large sample size (more than 30 subjects) (Tabachnick & Fidell, 2001).
Reliability
Internal consistency reliabilities were tested in all questionnaires. The Cronbach’s alpha coefficients were high; all were more than .7 (Table 13). These Cronbach’s alpha coefficients indicated that the questionnaires were of high quality and were free from measurement errors. However, reliability for the Life Events Stress was not performed, due to the inherent subjectivity of the nature of stressful events. Sarason and colleagues
(Sarason, Johnson, & Siegel, 1978a; Sarason, Sarason, Potter, & Antoni, 1985) suggest test-retest reliability as the appropriate way to test reliability for this measure. However, 104 this study was a cross-sectional, and all subjects were interviewed only once. Therefore, test-retest reliability was not applicable.
Table 13
Reliability statistics of the measurements
Measures Cronbach’s Cronbach’s Alpha Number Alpha based on of items Standardized items The Postconcussion Symptoms Checklist .952 .961 30 The Coping Adaptation Processing Scale .909 .911 47 The Social Support Questionnaire – Availability .915 .919 6 The Social Support Questionnaire – Satisfaction .917 .924 6 The Quality of Life Index – Satisfaction .944 .961 33 The Quality of Life Index – Importance .933 .964 33 The CESD Thai version .789 .808 20 The Extended Glasgow Outcome Scale .750 .785 5
Results for Research Questions
Research Question 1: What adaptation occurs among Thai adults after MTBI?
Adaptation outcomes were defined as quality of life as measured by the Quality of
Life Index (QLI), and the overall outcome as measured by the Extended Glasgow
Outcome Scale (GOSE). It is assumed that high quality of life scores will reflect good adaptation. It is also expected that adults with MTBI who successfully adapt will return to their normal lives and be in the good recovery category of the GOSE.
The possible range of QLI scores is 0-30. Higher scores indicate a better quality of life. In this study, the range among all 135 subjects was 18 to 29.74; the average of total score was 24; the health and functioning domain score was 22; the psychological and 105 spiritual domain score was 25; the social and economic domain score was 25; and the family domain score was 27 (Table 14).
Table 14
Quality of life results
Domains of All subjects (n = 135) MTBI w/o multiple injury MTBI with multiple injury quality of Mean Median Range 95%CI Mean Median Range 95%CI Mean Median Range 95%CI life (SD) (SD) (SD) -Health and 21.87 21.60 11.53- 21.08- 22.21 22.40 11.53- 20.36- 21.63 21.60 11.53- 20.97- functioning (5.09) 29.67 22.80 (5.31) 29.67 23.19 (4.95) 29.67 23.17 -Psychological 24.88 24.00 17.83- 24.46- 25.32 24.00 17.83- 24.04- 24.55 23.75 17.83- 23.83- and spiritual (3.86) 30.00 25.84 (3.86) 30.00 26.10 (3.84) 30.00 25.59 -Social and 25.10 24.86 16.29- 24.20- 25.78 24.93 17.14- 24.65- 24.61 24.00 16.29- 23.83- economic (4.04) 30.00 25.52 (3.68) 30.00 26.61 (4.24) 30.00 25.76 -Family 27.02 27.60 22.50- 26.57- 27.41 27.60 22.50- 26.61- 26.73 25.85 22.50- 26.20- (2.81) 30.00 27.52 (2.74) 30.00 28.05 (2.84) 30.00 27.48 -Total quality 23.84 22.91 18.00- 23.26- 24.29 23.17 18.29- 23.02- 23.51 22.55 18.00- 22.99- of life (3.65) 29.74 24.50 (3.73) 29.74 24.97 (3.58) 29.74 24.61
The findings of QLI scores in 57 subjects with only MTBI were almost identical to the findings in all subjects. Total score and subscale scores were in the same range except that subjects with only MTBI reported higher scores in the socio-economic subscale
(Table 14). Nonetheless, this difference was not statistically significant, using independent t-tests (Table 15).
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Table 15
Difference of quality of life among MTBI subjects with and without other injuries
Domains of quality of life MTBI w/o other MTBI with other t p value* injuries injuries Mean (SD) Mean (SD) -Health and functioning 22.21 (5.31) 21.63 (4.95) .661 .510 -Psychological and spiritual 25.32 (3.86) 24.55 (3.84) 1.145 .254 -Social and economic 25.78 (3.68) 24.61 (4.24) 1.682 .095 -Family 27.41 (2.74) 26.73 (2.84) 1.398 .164 -Total quality of life 24.29 (3.73) 23.51 (3.58) 1.230 .221 *p value was set at .01
For another measure of adaptation outcome, the GOSE, subjects were first categorized in one of two domains: Independence and difficulty. They were, then, categorized in one of five categories ranging from good recovery to severely disabled. In all 135 subjects, only two reported problems in the independence domain (1.5%) and both of them were considered to be in the upper severely disabled category. Both subjects experienced other injuries with MTBI and reported that they were unable to travel outside their homes independently. Twenty-five subjects reported problems related to difficulty domain (18.6%), ten of whom had only MTBI. Sixty-seven per cent of all subjects resumed their normal lives without any issue. In the GOSE, this finding is categorized in the upper good recovery category. Thirteen percent of all subjects could not live their normal lives, although no issues were reported. This finding is considered to be in the lower good recovery category of the GOSE. Sixteen per cent of all subjects reported one or more problems and could not return to their normal lives. They were categorized in the upper moderately disabled category. Three percent of all subjects were categorized as lower moderately disabled or could not return to work/study (Table 16). 107
For the GOSE, none of the subjects with only MTBI reported problems in the independent domain. Therefore, there was no subject in this group categorized as severely disabled. Most of the subjects were in good recovery categories. Ten (18%) were in moderately disabled categories (Table 16).
Table 16
Description of the Extended Glasgow Outcome Scale
Domain/Category All subjects MTBI w/o MTBI with (N=135) other injuries other injuries (n=57) (n=78) N % N % N % Problem in the independence domain 2 1.5 0 0 2 2.6 Problem in the difficulty domain 25 18.6 10 17.2 15 19.2 Categories - Upper good recovery 91 67.4 39 68.4 52 66.7 - Lower good recovery 17 12.6 8 14.0 9 11.5 - Upper moderately disabled 21 15.6 9 15.8 12 15.4 - Lower moderately disabled 4 3.0 1 1.8 3 3.8 - Upper severely disabled 2 1.5 - - 2 2.6
More problems in adaptation outcomes were reported among subjects with MTBI and other injuries. Two of the subjects in this group reported problems in the independent domain and were in the severely disabled group. Eighteen percent of subjects were categorized in moderately disabled categories, the same proportion as in subjects with
MTBI alone. Fewer subjects with both MTBI and multiple injuries returned to their normal life, compared to subjects with only MTBI (78% vs. 82%). However, there was no significant difference in their return to work/ school, using the Chi-square test (Table 17).
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Table 17
Differences of the Extended Glasgow Outcome Scale categories among the subjects
GOSE categories Diagnosis Upper Lower Upper Lower Upper Total good good moderately moderately severely recovery recovery disabled disabled disabled MTBI w/o other injuries 39 7 10 1 0 57 MTBI with other 52 10 11 3 2 78 injuries Total 91 17 21 4 2 137 Pearson Chi-square = 2.221, df = 4, p = .695
Research Question 2: What stimuli are associated with adaptation to MTBI among Thai adults?
Pearson’s product-moment and Spearman’s Rho correlation coefficients were computed to answer this question by evaluating direct relationships between stimuli and outcomes. Pearson’s product-moment coefficients were used to calculate relationships between quality of life and other variables. Because the GOSE was measured in ordinal level, the Spearman’s Rho coefficients were used to explore relationships between the
GOSE and other variables. Data from all subjects were calculated and the results were reported as a whole. Three sub-questions were set to answer research question 2. These questions are:
RQ2.1 Do focal, contextual and residual stimuli associate with adaptation to MTBI among Thai adults? No individual scores for focal stimuli and contextual stimuli were significantly associated with quality of life scores. For residual stimuli, only social support had a significant positive medium relationship with quality of life (r = .394, p
<.001) (Table 18). However, no focal, contextual or residual stimuli were significantly associated with the GOSE. 109
RQ2.2 Does coping associate with adaptation to MTBI among Thai adults? Coping did not associate with adaptation to MTBI. Pearson’s product-moment correlation coefficient between quality of life and coping was not significant. The result was consistent with Spearman’s Rho coefficient between the GOSE and coping.
RQ2.3 Do depressive symptoms associate with adaptation to MTBI among Thai adults? Depressive symptoms had no significant associations with either measures of adaptation to MTBI. Pearson’s product-moment correlation coefficient between quality of life and depressive symptoms was not significant. The Spearman’s Rho coefficient between the GOSE and coping was not significant. 110
Table 18
Correlation Coefficients among stimuli, processes and outcomes
Income Gender Age PTA LOC Marital SSS Education Time LOS GCS Employ QLI PCS CESD CAPS LES
QLI .073 .003 .138 .132 .114 .082 .394* .118 .074 .116 .052 .091 - .042 .133 .076 .093 GOSE .009s .033s .120s .044s .050s .063s .052 .058s .045s .137s .047s .047s .031s .135s .005s .072s .033s * p < .05, s = Spearman’s Rho for the GOSE and all others values are Pearson’s Product-Moment Correlation Coefficients
QLI = quality of life scores, GOSE = Extended Glasgow Outcome Scores, PTA = duration of Posttraumatic Amnesia,
LOC = duration of Loss of Consciousness, Marital = Marital status, SSS = social support scores, Time = time postinjury, LOS
= Length of stay in the hospital, GCS = Glasgow Coma Scores in the first 30 minutes, Employ = Employment status, PCS =
Postconcussion Symptoms scores, CESD = Depressive symptoms scores, CAPS = Coping scores, and LES = Life Events
Stress scores 111
Research Question 3: What are the factors that predict adaptation to MTBI among Thai adults?
Pearson’s product-moment correlation analysis was also computed to examine the relationships among study variables. There were 8 pairs of positive relationships: Gender and time postinjury, age and marital status, PTA and LOC, LOC and numbers of year in school, LOC and LOS, time postinjury and GCS after 30 minutes, quality of life and social support, and the CESD and the LES. Their Pearson’s product moment correlation coefficients ranged from .184 to .456 (p < .05, Table 19). There were five negative significant relationships among the variables. Those were the relationships between coping and income, social support and age, LOC and employment status, LOS and
CESD, and employment status and PCS. Their Pearson’s product moment correlation coefficients ranged from -.189 to -.236 (p < .05, Table 19). These correlation coefficients were all lower than .07, indicating that there was no multicollinearity problem among independent variables (Tabachnick & Fidell, 2001).
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Table 19
Correlation Coefficients among variables
Income Gender Age PTA LOC Marital Education Time LOS GCS Employ QLI PCS CESD CAPS LES GOSE
Gender -.093 Age .008 -.017 PTA -.007 -.016 .138 LOC .080 .131 -.020 .456* Marital -.007 .026 .209* .080 -.080 Education .034 .031 -.149 .022 .218* -.298* Time .030 .262* .044 -.037 -.083 .104 .110 LOS -.001 .075 .159 .153 .276* -.061 .017 .097 GCS -.043 .079 .051 -.089 -.103 .015 -.082 .188* -.062 Employ .075 -.002 -.025 -.138 -.213* -.016 .127 .154 -.162 -.034 QLI -.073 -.003 -.138 .132 .114 -.082 .118 -.074 .116 .052 .091 PCS .004 -.040 .039 .065 .037 -.018 -.033 -.122 -.002 -.056 -.189* -.042 CESD -.102 -.057 -.055 -.022 .013 -.011 .074 -.110 -.230* -.075 -.124 -.133 .034 CAPS -.236* .078 -.144 -.113 -.123 .031 .012 -.115 .024 -.025 .121 .076 .062 -.091 LES -.025 .081 -.003 -.005 .042 -.056 .111 .105 -.036 -.054 .014 .093 -.001 .184* -.106 GOSE .009s -.033s .120s .044s -.050s .063s -.058s -.045s .137s -.047s -.047s -.031s .135s -.005s -.072s .033s SSS -.124 -.163 -.198* .067 .031 -.024 .012 -.169 -.042 -.051 -.018 .394* .011 .005 .020 .034 -.052 * p < .05, s = Spearman’s Rho for the GOSE and all others values are Pearson’s Product-Moment 113
Multiple regression was used to answer a set of questions for research question 3.
Eight multiple regressions were planned to calculate, and the alpha was set at (.1/8) .0125 in order to avoid type I error. Eight sub-questions were set to answer research question 3.
They were:
RQ3.1 What are the factors that predict adaptation to MTBI (quality of life) among Thai adults?
RQ3.2. What are the factors that predict adaptation to MTBI (the Extended
Glasgow Outcome scale) among Thai adults?
RQ3.3 Can focal, contextual and residual stimuli predict coping?
RQ3.4 Can focal, contextual and residual stimuli predict depressive symptoms?
RQ3.5 Can coping and depressive symptoms predict adaptation to MTBI (quality of life) among Thai adults?
RQ3.6 Can coping and depressive symptoms predict adaptation to MTBI (the
Glasgow Outcome Scale) among Thai adults?
RQ3.7 What are the factors that predict adaptation to MTBI (quality of life) among Thai adults when considering coping and depressive symptoms as the mediators?
RQ3.8 What are the factors that predict adaptation to MTBI (the GOSE) among
Thai adults when considering coping and depressive symptoms as the mediators?
Due to the similarity of the hypotheses being tested in these questions, the assumptions of regression are discussed first, followed by results from each sub-question.
All variables selected in the regression model were based on the Roy Adaptation
Model. All variables were measured in interval level except gender and employment status which were measured in nominal level, and the GOSE and marital status were measured in categories. The internal consistency reliabilities for all dependent and 114 independent variables were high (alpha ranged from .750 to .952, Table 13) indicating that these variables might not have measurement error problems. The correlations between independent variables (stimuli, coping and depressive symptoms) and dependent variables (coping, depressive symptoms, quality of life and the GOSE) were lower than .7 and did not suggest multicollinearity (Table 19). Regression diagnosis was run for each supported model and results were reported afterward. Each regression model was tested using a simultaneous method of entry. All stimuli suggested in the conceptual model were selected except presence of alcohol at the time of injury which was removed because of excessive missing data. Adjusted R-squares are reported since R-squares will always improve by adding more variables to the model (Tabachnick & Fidell, 2001).
RQ3.1. What are the factors that predict adaptation to MTBI (quality of life) among
Thai adults? Quality of life was regressed simultaneously on all stimuli (Table 20). The model was supported (R2 adj. = .157, F = 2.923, p = .001). The contribution of all stimuli explained 15.7% variation in quality of life (p < .0125). Social support was the only variable that was a significant factor in this statistical model (B = 1.024, beta = .374, t =
4.490, p < .0125).
The power for the statistic in this model was calculated by using G-Power version 3
(Faul, Erdfelder, Lange, & Buchner, in press). Effect size of .314 was retrieved from an
R2 of .239 (explained variance by regression = 426.423 / unexplained variance =
1358.006). With a sample size = 135, alpha = .001, and number of df = 13, a critical F of
2.926 and a power of .886 were generated. Thus the probability of making a type II error was .114 or an 11.4% chance that the null hypothesis would not be rejected when it was false.
115
Table 20
Multiple regression of stimuli in quality of life (n =135)
Variable B SE B Beta T p 95% CI of B Upper Lower GCS 30 minutes .578 .390 .122 1.484 .140 -.193 1.349 Posttraumatic Amnesia .030 .023 .119 1.300 .196 -.016 .076 Loss of Consciousness .011 .064 .016 .164 .870 -.117 .138 Length of stay in the hospital .055 .030 .159 1.848 .067 -.004 .113 Postconcussion symptoms -.104 .498 -.023 -.281 .779 -1.127 .847 Gender .459 .833 .047 .551 .583 -1.190 2.108 Age -.021 .021 -.089 -1.039 .301 -.062 0.19 Employment status 2.550 1.517 .145 1.682 .095 -.452 5.553 Numbers of years attending school .063 .100 .056 .635 .527 -.134 .260 Time postinjury -.131 .150 -.077 -.871 .385 -.428 .166 Life Event Stress .066 .061 .087 1.073 .285 -.056 .187 Social support 1.024 .228 .374 4.490 .000* .572 1.475 Marital status -.097 .338 -.025 -.287 .774 -.766 .572 Model: R2 adj. = .157, df = 13, 121, F = 2.923, p = .001 Residual analysis for the regression model was conducted. The Durbin-Watson statistic for correlation between errors was 1.733, within the normal critical values of
1.53-1.92 for sample size of 135 and 13 regressors (Savin & White, 1977), indicates that errors are not correlated (Berry & Feldman, 1985; Jaccard & Turrisi, 2003). In addition to inspection of Pearson’s product-moment correlation coefficients, multicollinearity was tested by computing tolerance and Variance-Inflating Factor (VIF). Tolerance is 1-R2 for the regression of that independent variable on all the other independent variables, ignoring the dependent variable (Berry & Feldman, 1985). If tolerance is less than .20, a problem of multicollinearity may be indicated (Tabachnick & Fidell, 2001). In this model, tolerance for each independent variable ranged from .656 - .954, and there was no 116 problem of multicollinearity. Moreover, the VIF in this study ranged from 1.048 - 1.524, and all were less than 4, indicating that multicollinearity was not found in this model.
Outliers were tested by computing the Leverage statistic and Cook’s distance. There were
8 cases that had a Cook’s distances over .0336 (4/n-k-1; when n = 135 and k = 15).
Another regression model without outliers was run and adjusted the R-square was improved. Results from the regression model without outliers are reported afterward.
As the Cook’s distance suggested that 8 cases were outliers, those cases were excluded and another regression model was performed. Similar to the previous model, quality of life was regressed simultaneously on all stimuli (Table 21). The model was supported and R-square increased when compared to the previous model (R2 adj. = .246,
F = 4.160, p = .000). The contribution of all stimuli explained 24.6% of the variation of quality of life (p < .0125). Social support was the most powerful variable that could explain the variation in quality of life significantly (B = 1.105, beta = .414, t = 5.041, p =
.000), followed by an ability to return to work/school (B = 4.067, beta = .223, t = 2.706, p
= .008) and length of hospital stay (B = .081, beta = .224, t = 2.672, p = .009, Table 14).
Durbin-Watson was 1.579 (critical values = 1.51-1.92, n = 127, 13 rgressors), tolerances were .785 to .961, and VIF were 1.041 to 1.274.
The power for the statistic in the model after exclusion of outliers was calculated by using G-Power version 3 (Faul, Erdfelder, Lange, & Buchner, in press). Effect size of
.479 was retrieved from an R2 of .324 (explained variance by regression = 519.294 / unexplained variance = 1085.072). With sample size = 127, alpha = .001, and number of df = 13, a critical F of 2.946 and a power of .989 were generated. In conclusion, the probability of making a type II error was .012 or a 1.2% chance that the null hypothesis would not be rejected when it was false. 117
Table 21
Multiple regression of stimuli in quality of life after exclusion of outliers (n =127)
Variable B SE B Beta t p 95% CI of B Upper lower GCS 30 minutes .646 .366 .141 1.767 .080 -.078 1.371 Posttraumatic Amnesia .024 .025 .080 .953 .343 -.026 .075 Loss of Consciousness -.106 .123 -.074 -.859 .392 -.350 .138 Length of stay in the hospital .081 .030 .224 2.672 .009 .021 .142 Postconcussion symptoms -.171 .467 -.029 -.366 .715 -1.096 .754 Gender .521 .818 .052 .636 .526 -1.101 2.142 Age -.031 .020 -.132 -1.559 .122 -.070 .008 Employment status 4.067 1.503 .223 2.706 .008 1.089 7.045 Numbers of years attending school .072 .099 .062 .721 .472 -.125 .268 Time postinjury -.275 .145 -.166 -1.898 .060 -.561 .012 Life Event Stress .084 .060 .115 1.410 .161 -.034 .203 Social support 1.105 .219 .414 5.041 .000* .671 1.540 Marital status -.200 .325 -.052 -.616 .539 -.844 .444 Model: R2 adj. = .246, df = 13, 113, F = 4.160, p = .000
RQ3.2 What are the factors that predict adaptation to MTBI (the Glasgow Outcome scale) among Thai adults? Because the numbers of subjects in each of the five categories were unevenly distributed, the GOSE was combined into two categories: Recovery without issue and recovery with issue. In the recovery without issue category, 91 subjects who were in the upper good recovery category, or able to return to work/ school without any problem, were included. For the recovery with issue category, 44 subjects who were in lower good recovery, moderately disabled, and severely disabled categories were included. Since the GOSE was a dichotomous variable, logistic regression was used to answer this research question. The GOSE was regressed simultaneously on all stimuli.
This model was not supported (Nagelkerke R2 = .044, χ2 = 4.301, p = .988). The 118 contribution of stimuli, coping and depressive symptoms explained 4.4% of the GOSE but was not statistically significant (Table 22). The model predicted accurately 97.8% of the subjects in the recovery-without- issue-group, but the accuracy among subjects in the recovery-with-issues-group was only 6.8% predicted. The overall prediction of this model was 68.1% correct.
Table 22
Logistic regression of stimuli in the Extended Glasgow Outcome Scale
Variable Wald p Odd 95% CI of Odd Ratio Ratio Upper Lower GCS 30 minutes .027 .870 .960 .584 1.576 Posttraumatic Amnesia .101 .750 .995 .966 1.025 Loss of Consciousness .036 .849 1.008 .927 1.097 Length of stay in the hospital .024 .877 1.003 .967 1.040 Postconcussion symptoms 1.953 .162 1.547 .839 2.853 Gender .309 .587 1.362 .458 4.044 Age .538 .463 1.010 .984 1.036 Employment status .091 .762 .744 .110 5.043 Numbers of years attending school .081 .776 .982 .864 1.115 Time postinjury .029 .866 .983 .810 1.194 Life Event Stress .002 .962 .998 .923 1.080 Social support .329 .566 .918 .686 1.229 Marital status .269 .604 1.117 .736 1.695 Model: Nagelkerke R2 = .044, χ2 = 4.301, df = 13, p = .988
RQ3.3 Can focal, contextual and residual stimuli predict coping? Coping was regressed simultaneously on all stimuli (Table 23). The model was not supported (R2 adj.
= .021, F = 1.220, p = .273). The contribution of all stimuli explained 2.1% coping but was not significant. There was no single stimulus that could explain coping significantly. 119
The result indicated that coping could not be significantly explained by stimuli and did not meet assumptions for mediator effect (Baron & Kenny, 1986; Bennett, 2000). The absence of significance for this model suggested that further analyses for RQ3.5 and
RQ3.6 were not necessary.
Table 23
Multiple regression of stimuli in coping
Variable B SE B Beta t p 95% CI of B Upper Lower GCS 30 minutes .001 .031 .002 .017 .986 -.060 .061 Posttraumatic Amnesia -.001 .002 -.043 -.435 .665 -.004 .003 Loss of Consciousness -.007 .005 -.138 -1.311 .192 -.017 .003 Length of stay in the hospital .003 .002 .128 1.382 .170 -.001 .008 Postconcussion symptoms .040 .039 .090 1.021 .309 -.038 .118 Gender .100 .066 .139 1.524 .130 -.030 .230 Age -.003 .002 -.167 -1.803 .074 -.006 .000 Employment status .191 .120 .148 1.600 .112 -.045 .428 Numbers of years attending school .001 .008 .010 .106 .916 -.015 .016 Time postinjury -.022 .012 -.181 -1.899 .060 -.046 .001 Life Event Stress -.005 .005 -.087 -.997 .321 -.014 .005 Social support .000 .018 -.002 -.023 .982 -.036 .035 Marital status .024 .027 .083 .897 .371 -.029 .077 Model: R2 adj. = .021, df = 13, 121, F = 1.220, p = .273 RQ3.4 Can focal, contextual and residual stimuli predict depressive symptoms?
Depressive symptoms were regressed simultaneously on all stimuli (Table 24). The model was not supported (R2 adj. = .037, F = 1.396, p = .171). The contribution of all stimuli explained 3.7% of depressive symptoms but was not significant. Length of stay in the hospital was the only variable that could significantly explain depressive symptoms (p < 120
.0125). The results indicated that depressive symptoms could not be significantly explained by stimuli and did not meet assumption for mediator effect (Baron & Kenny,
1986; Bennett, 2000). As a result of the absence of significance for this model, further analyses for RQ3.5 and RQ3.6 were not necessary.
Table 24
Multiple regression of stimuli in depressive symptoms
Variable B SE B Beta t p 95% CI of B Upper Lower GCS 30 minutes -.828 1.069 -.068 -.775 .440 -2.944 1.288 Posttraumatic Amnesia -.019 .063 -.029 -.296 .768 -.144 .106 Loss of Consciousness .060 .176 .036 .342 .733 -.289 .409 Length of stay in the hospital -.222 .081 -.252 -2.739 .007* -.383 -.062 Postconcussion symptoms -.106 1.367 -.007 -.077 .939 -2.813 2.602 Gender -1.208 2.285 -.048 -.528 .598 -5.731 3.316 Age -.005 .056 -.009 -.097 .923 -.117 .106 Employment status -7.599 4.160 -.168 -1.827 .070 -15.835 .637 Numbers of years attending .191 .273 .066 .700 .485 -.350 .732 school Time postinjury -.226 .412 -.052 -.549 .584 -1.041 .589 Life Event Stress .341 .168 .176 2.029 .045 .008 .673 Social support -.252 .626 -.036 -.403 .688 -1.490 .986 Marital status .144 .927 .014 .156 .876 -1.691 1.980 Model: R2 adj. = .037, df = 13, 121, F = 1.396, p = .171
RQ3.5 Can coping and depressive symptoms predict adaptation to MTBI (quality of life) among Thai adults? Quality of life was regressed simultaneously on coping and depressive symptoms (Table 25). The model was not supported (R2 adj. = .007, F = 1.473, p = .233). The contribution of coping and depressive symptoms explained less than 1% of quality of life and was not significant. The absence of significance for this model and 121 models in RQ3.3 to RQ3.4 indicated that coping and depressive symptoms were not mediators between stimuli and adaptation after MTBI (quality of life) (Baron & Kenny,
1986; Bennett, 2000).
Table 25
Multiple regression of coping and depressive symptoms in quality of life
Variable B SE B Beta t p 95% CI of B Upper Lower Coping .879 1.182 .064 .743 .459 -1.460 3.217 Depressive symptoms -.050 .034 -.127 -1.473 .143 -.116 .017 Model: R2 adj. = .007, df = 2, 132, F = 1.473, p = .233
RQ3.6 Can coping and depressive symptoms predict adaptation to MTBI (the
Glasgow Outcome Scale) among Thai adults? The GOSE was regressed simultaneously on coping and depressive symptoms by using logistic regression (Table 26). The model was not supported (Nagelkerke R2 = .003, χ2 = .298, df = 2, p = .862). The contribution of coping and depressive symptoms explained less than 1% of the GOSE and was not significant. The absence of significance for this model and models in RQ3.3 and RQ3.4 indicated that coping and depressive symptoms were not mediators between stimuli and adaptation after MTBI (the GOSE) (Baron & Kenny, 1986; Bennett, 2000). The overall prediction for this model was 67.4% corrected.
Table 26
Logistic regression of coping and depressive symptoms in the Extended Glasgow
Outcome Scale
Variable Wald P Odd Ratio 95% CI of Odd Ratio Upper Lower Coping .088 .766 .814 .210 3.159 Depressive symptoms .231 .630 .990 .952 1.030 Model: Nagelkerke R2 = .003, χ2 = .298, df = 2, p = .862 122
Additional Data Analysis
As the results in models 3.3 to 3.6 showed, coping and depressive symptoms were not the mediators for quality of life, further analyses for RQ3.7 and RQ3.8 were not conducted. However, literature suggested that coping might lead to desired outcomes while depressive symptoms might cause maladaptation (Bohnen, Jolles, Twijnstra,
Mellink, & Wijnen, 1995; Bryant, Moulds, Guthrie, & Nixon, 2003; Ruttan & Heinrichs,
2003). Therefore, both variables were tested in another two additional ways: As predictors, and moderators. Four additional conditions were set to explore effects of coping and depressive symptoms on adaptation: 1) Considering coping and depressive symptoms as other predictors of quality of life (Table 27), 2) considering coping and depressive symptoms as other predictors of the GOSE (Table 28), 3) considering coping and depressive symptoms as moderators of quality of life (Table 29), and 4) considering coping and depressive symptoms as the moderators of the GOSE (Table 30). The purpose of these additional statistical analyses was for testing limitation of conceptual framework.
The results for these additional tests were not for interferential or comparison. Therefore, the traditional alpha of .05 was set for all of these additional analyses.
Coping and depressive symptoms as other predictors of quality of life
Quality of life was regressed simultaneously on coping, depressive symptoms and other stimuli (Table 27). This model was supported (R2 adj. = .158, F = 2.683, p = .002).
The contribution of stimuli, coping and depressive symptoms explained 15.8% of quality of life (p < .05), and social support was the only significant predictor of quality of life
(beta = 4.443, p < .05).
Residual analysis for the regression model was conducted. The Durbin-Watson statistic for correlation between errors was 1.710, within the critical values of 1.50-1.95 123 for 135 subjects and 15 regressors, indicates that errors are not correlated (Berry &
Feldman, 1985; Jaccard & Turrisi, 2003). The tolerance for each independent variable ranged from .947-1.000. There was no problem of multicollinearity. Moreover, VIF in this study ranged from 1.001-1.056, all were less than 4, indicating that multicollinearity was not found in this model.
The power for the statistic in this model was calculated by using G-Power version 3
(Faul, Erdfelder, Lange, & Buchner, in press). Effect size of .338 was retrieved from an
R2 of .25 (explained variance by regression = 450.907 / unexplained variance =
1333.522). With sample size = 135, alpha = .002, and number of df = 15, a critical F of
2.610 and a power of .928 were generated. Thus the probability of making a type II error was .072 or a 7.2% chance that the null hypothesis would not be rejected when it was false.
124
Table 27
Multiple regression of coping, depressive symptoms, and stimuli in quality of life
Variable B SE B Beta t p 95% CI of B Upper Lower Coping .703 1.155 .051 .609 .544 -.231 1.315 Depressive symptoms -.403 .033 -.112 - .193 -.016 .075 1.310 GCS 30 minutes .542 .390 .115 1.388 .168 -.110 .146 Posttraumatic Amnesia .030 .023 .118 1.289 .200 -.018 .103 Loss of Consciousness .018 .065 .027 .276 .783 -1.163 .818 Length of stay in the hospital .043 .031 .124 1.395 .166 -1.329 2.001 Postconcussion symptoms -.173 .500 -.028 -.345 .731 -.061 .022 Gender .336 .841 .034 .400 .690 -.983 5.155 Age -.020 .021 -.082 -.939 .350 -.127 .268 Employment status 2.086 1.550 .118 1.346 .181 -.427 .177 Numbers of years attending .071 .100 .062 .711 .478 -.040 .207 school Time postinjury -.125 .152 -.074 -.819 .415 .562 1.465 Life Event Stress .084 .062 .111 1.344 .181 -.779 .563 Social support 1.013 .228 .370 4.443 .000* -.109 .022 Marital status -.108 .339 -.027 -.318 .751 -1.583 2.989 Model: R2 adj. = .158, df = 15, 119, F = 2.683, p = .002
Coping and depressive symptoms as other predictors of the GOSE
Logistic regression was used to find factors that explained variation of the GOSE (2 categories). Both variables were tested in the same way as other independent variables by entering all of them into the equation simultaneously (Table 28). This model was not supported (Nagelkerke R2 = .047, χ2 = 4.286, p = .988). The contribution of stimuli, coping and depressive symptoms explained 4.7% of the GOSE but was not statistically 125 significant. The model predicted accurately 98.9% of the subjects in the recover-without– any-issue-group, but the accuracy among subjects in the recover-with-issues-group was only 6.8% predicted. The overall prediction of this model was 68.9% correct.
Table 28
Logistic regression of coping, depressive symptoms, and stimuli in the Extended Glasgow
Outcome Scale
Variable Wald P Odd 95% CI of Ratio Odd Ratio Upper Lower Coping .086 .770 .803 .184 3.502 Depressive symptoms .210 .647 .990 .949 1.033 GCS 30 minutes .034 .853 .954 .581 1.567 Posttraumatic Amnesia .115 .735 .995 .965 1.025 Loss of Consciousness .024 .877 1.007 .924 1.097 Length of stay in the hospital .006 .938 1.002 .964 1.040 Postconcussion symptoms 1.998 .158 1.560 .842 2.892 Gender .277 .599 1.344 .447 4.038 Age .441 .507 1.009 .983 1.036 Employment status .067 .795 .771 .108 5.497 Numbers of years attending .064 .801 .984 .866 1.118 school Time postinjury .057 .811 .976 .801 1.189 Life Event Stress .342 .996 1.000 .923 1.084 Social support .296 .559 .916 .684 1.228 Marital status .296 .586 1.124 .739 1.709 Model: Nagelkerke R2 = .047, χ2 = 4.286, df = 15, p = .988
126
Coping and depressive symptoms as moderators of quality of life
Hierarchical multiple regression was performed to explore this effect (Table 29). In the first step, quality of life was regressed simultaneously on coping, depressive symptoms and other stimuli. This model was supported (R2 adj. = .158, F = 2.683, p =
.002). The contribution of stimuli, coping and depressive symptoms explained variation of quality of life for 15.8% (p < .05), and social support was the most powerful independent variable. It was also the only variable that could explain quality of life significantly (B = 1.013, beta = .370, t = 4.443, p < .05).
In the second step, the interaction between social support and depressive symptoms was entered. The overall model was supported (R2 adj. = .152, F = 2.495, p = .003) even though the adjusted R-square decreased. The contribution of stimuli, coping, depressive symptoms and the interaction between social support and depressive symptoms explained variation of quality of life for 15.2% (p < .05). However, there was no variable in this step that could individually explain quality of life. R-square changed as a result of entering the interaction between social support and depressive symptoms was not significant.
In the last step, the interaction between social support and coping was entered. The overall model was supported (R2 adj. = .184, F = 2.783, p = .001). The contribution of stimuli, coping, depressive symptoms, the interaction of social support and depressive symptoms and the interaction of social support and coping explained variation of quality of life for 18.4% (p < .05). In this model, coping and the interaction of social support and coping were the powerful variables that could explain quality of life (p < .05, Table 22).
R-square changed in this step was significant (R-square change = .035, F change = 5.763, p < .05). 127
Residual analysis for the regression model was conducted. The Durbin-Watson statistic for correlation between errors was 1.735, within the critical values of 1.46-1.99 for 135 subjects and 17 regressors (Savin & White, 1977), indicates that errors are not correlated (Berry & Feldman, 1985; Jaccard & Turrisi, 2003). The tolerance in the last step for each independent variable ranged from .646-.934. Moreover, VIF in this study ranged from 1.071-1.548. Both statistics indicated that multicollinearity problems were not presented even though social support and coping may share the same information.
Centering method was applied to both variables before testing the model to prevent multicollinearity problems (Kromrey & Lynn, 1998).
The power for the statistic in this model (the last step) was calculated by using G-
Power version 3 (Faul, Erdfelder, Lange, & Buchner, in press). Effect size of .405 was retrieved from an R2 of .288 (explained variance by regression = 513.726 / unexplained variance = 1270.693). With sample size = 135, alpha = .001, and number of df = 17, a critical F of 5.791 and a power of .999 were generated. Thus the probability of making a type II error was .001 or less than a 1% chance that the null hypothesis would not be rejected when it was false.
In conclusion, coping and depressive symptoms moderated causal relationship between stimuli and quality of life. Depressive symptoms decreased the strength of this relationship while coping enhanced this relationship. Since the interactions were computed from social support, it might be concluded that the effect of depressive symptoms would decrease the effect of social support in explaining quality of life. On the other hand, the effect of coping would increase the ability of social support in explaining quality of life (Table 29).
128
Table 29 Multiple regression of stimuli in quality of life when coping and depressive symptoms were moderators Variable B SE B Beta t p 95% CI of B Upper Lower Step GCS 30 minutes .542 .390 .115 1.388 .168 -.231 1.315 1 Posttraumatic Amnesia .030 .023 .118 1.289 .200 -.016 .075 Loss of Consciousness .018 .065 .027 .276 .783 -.110 .146 Length of stay in the hospital .043 .031 .124 1.395 .166 -.018 .103 Postconcussion symptoms -.173 .500 -.028 -.345 .731 -1.163 .818 Gender .336 .841 .034 .400 .690 -1.329 2.001 Age -.020 .021 -.082 -.939 .350 -.061 .022 Employment status 2.086 1.550 .118 1.346 .181 -.983 5.155 Numbers of years attending school .071 .100 .062 .711 .478 -.127 .268 Time postinjury -.125 .152 -.074 -.819 .415 -.427 .177 Life Event Stress .084 .062 .111 1.344 .181 -.040 .207 Social support 1.013 .228 .370 4.443 .000* .562 1.465 Marital status -.108 .339 -.027 -.318 .751 -.779 .563 Depressive symptoms -.043 .033 -.112 -1.310 .193 -.109 .022 Coping .703 1.155 .051 .609 .544 -1.583 2.989 Model: R2 adj. = .158, df = 15, 119, F = 2.683, p = .002 Step GCS 30 minutes .537 .393 .114 1.367 .174 -.241 1.316 2 Posttraumatic Amnesia .030 .023 .120 1.291 .199 -.016 .076 Loss of Consciousness .017 .065 .025 .255 .799 -.113 .146 Length of stay in the hospital .043 .031 .124 1.390 .167 -.018 .104 Postconcussion symptoms -.171 .502 -.028 -.340 .734 -1.166 .824 Gender .342 .845 .035 .404 .687 -1.332 2.016 Age -.020 .021 -.082 -.937 .351 -.061 .022 Employment status 2.064 1.563 .117 1.320 .189 -1.032 5.160 Numbers of years attending school .072 .101 .064 .719 .474 -.127 .271 Time postinjury -.124 .153 -.073 -.813 .418 -.428 .179 Life Event Stress .084 .063 .112 1.345 .181 -.040 .209 Social support 1.091 .582 .399 1.875 .063 -.061 2.243 Marital status -.105 .341 -.207 -.308 .758 -.780 .570 Depressive symptoms -.029 .105 -.074 -.275 .784 -.237 .179 Coping .720 1.165 .053 .618 .538 -1.587 3.027 Social support x depressive -.004 .025 -.049 -.145 .885 -.053 .045 symptoms Model: R2 adj. = .152, df = 16, 118, F = 2.495, p = .003 Step GCS 30 minutes .595 .386 .126 1.542 .126 -.169 1.360 3 Posttraumatic Amnesia .034 .023 .137 1.508 .134 -.011 .080 Loss of Consciousness .016 .064 .025 .253 .801 -.111 .143 Length of stay in the hospital .039 .030 .113 1.290 .200 -.021 .099 Postconcussion symptoms -.274 .494 -.045 -.555 .580 -1.254 .705 Gender .539 .833 .055 .647 .519 -1.111 2.188 Age -.026 .021 -.110 -1.273 .205 -.067 .015 Employment status 2.439 1.541 .138 1.583 .116 -.612 5.490 Numbers of years attending school .041 .099 .036 .407 .684 -.156 .238 Time postinjury -.117 .150 .069 -.781 .437 -.415 .180 Life Event Stress .085 .062 .113 1.388 .168 -.036 .207 Social support -4.876 2.550 -1.783 -1.912 .058 -9.926 .175 Marital status -.168 .335 -.042 -.501 .617 -.831 .496 Depressive symptoms -.069 .104 -.178 -.664 .508 -.276 .137 Coping -7.395 3.568 -.541 -2.073 .040* -14.462 -.329 Social support x depressive .005 .025 .066 .200 .842 -.044 -.54 symptoms Social support x coping 2.034 .847 2.212 2.401 .018* .356 3.712 Model: R2 adj. = .184, df = 17, 117, F = 2.783, p = .001 129
The lack of relationship between coping and outcome was not expected; previous reports in literature found small-to-moderate relationship. However, as in the previous models, depressive symptoms were neither a predictor nor mediator of quality of life. As the theoretical and empirical literature suggested that depressive symptoms might have a relationship with quality of life, the moderator effect of depressive symptoms was tested.
Cohen and Willis (1995) suggested that social support might buffer the effect of predictor on outcome (Cohen & Willis, 1985); therefore, the interaction of depressive symptoms between the relationship of social support and quality of life was tested as in Figure 3
(Soper, 2007).
Figure 3 The interaction effects of depressive symptoms on the relationship between social support and quality of life
The result in figure 3 showed that subjects with high depressive symptoms report lower quality of life than subjects with modest and low depressive symptoms. The results was consistent regardless the scores of social support.
Coping was expected to have a relationship with quality of life as previous studies suggested. After finding that coping was neither a predictor nor mediator of quality of 130 life, the interaction of coping between the relationship of social support and quality of life was tested. Findings suggest (Figure 4) subjects who had high social support and high coping would have higher scores of quality of life. It is interesting that, at the low scores of social support, subjects who had low coping scores had higher quality of life than subjects with high coping scores. Coping did not have effect on quality of life when subjects had social support scores at about 3.4 (range 1-6); all subjects with any coping scores reported the same quality of life. However, when the social support scores increased, subjects with high coping scores reported higher quality of life then subjects with modest and low coping scores (Figure 4). The findings also suggested that subjects with high coping scores reported rapid increment of quality of life scores when social support scores increased. The same trend was found among subjects with modest coping scores. However, subjects with low coping scores reported decline quality of life when their social support increased.
Figure 4 The interaction effects of coping on the relationship between social support and quality of life
131
Coping and depressive symptoms as the moderators of the GOSE
Logistic hierarchical regression was used. Two steps in the previous model to detect effect of moderator in quality of life were adopted (Table 30). This model was not supported (Nagelkerke R2 = .047, χ2 = 4.286, p = .988). The GOSE could be explained for
4.7% in all steps but was not statistically significant. R-square did not change from the previous model even after adding the interaction in an additional step. Unchanged or R- square indicated that coping and depressive symptoms could not moderate the causal relationship between stimuli and the GOSE. The model predicted accurately 98.9% of the subjects in the recover-without-any-issue-group, but the accuracy among subjects in the recover-with-issues-group was only 6.8% predicted. The overall prediction of this model was 68.9% correct.
Table 30
Summarization of Logistic regression results of stimuli in the Extended Glasgow Outcome
Scale when coping and depressive symptoms were moderators
Step Nagelkerke χ2 df P value Percent of Accuracy R2 Recover with Recover w/o overall issue issue 1 .047 4.584 15 .995 98.9 6.8 68.9 2 .047 4.600 16 .997 98.9 6.8 68.9 3 .047 4.612 17 .999 98.9 6.8 68.9
Interactions between social support and coping and social support and depressive symptoms were tested as same as in the moderated multiple regression model used for quality of life.
132
Figure 5 The interaction effects of depressive symptoms on the relationship between social support and the Extended Glasgow Outcome Scale
These results conflict with earlier findings. Subjects who had high depressive symptoms were in a better recovery category than subjects with modest or low depressive symptoms at any level of social support (Figure 5). However, there was a trend that suggests a rapid decrement the GOSE scores among subjects with low depressive symptoms occurred when their social support scores increased.
Figure 6 The interaction effects of coping on the relationship between social support and the Extended Glasgow Outcome Scale
133
The results illustrated in Figure 6 show that, at low level of social support, subjects with high coping scores had a better GOSE outcome than subjects with modest or low coping scores. When social support scores increased, the GOSE outcome was better until the effect of coping disappeared at social support scores about 5.5 (range 1-6).
In conclusion, the interaction effects of coping were found to have observable influences on the relationships between social support and adaptation outcomes. Subjects with higher coping scores had better adaptation outcomes than subjects with lower coping scores regardless the scores of social support. The interaction effects of depressive symptoms on the relationships of social support and adaptation outcomes were not as clear as those were found in coping. However, the rapid trends of better adaptation outcomes were found in subjects with fewer depressive symptoms when their social support scores increased.
Summary of the findings
Subjects in this study were typically men, middle aged, and about half were married. All of the subjects finished the compulsory level of education and had low income. Most of them worked or studied before the injury. The majority of subjects stayed in the hospital for 8 days and continued to recover at home for another 50 days before returning to the same employment status as before the injury. Most of the subjects had GCS 14 at 30 minutes after the injury, and most of them had full scores of neurological ability after 3 days of the injury. The severity of MTBI among subjects in this study was relatively mild: The mean duration of PTA was reported at six minutes, and the duration of LOC averaged less than two minutes. Subjects also reported very low scores of PCS, had few stressful life events of which had low negative influence in their lives, and reported few depressive symptoms. All questionnaires used in this study 134 yielded high internal consistency. Coping scores, social support scores and quality of life scores were high. Most of the subjects concluded that they could return to live their normal lives, although 18% experienced moderately severe disability and 1.5% suffered severe disabilities.
Quality of life was positively associated with social support but did not significantly correlate with other stimuli. The GOSE was not significantly associated with any stimuli. The mediator effect of coping and depression symptoms was not supported.
All stimuli together with coping and depressive symptoms significantly explained 15.8% of the variation of quality of life, with social support as the most powerful variable in the equation. However, all stimuli, coping, and depressive symptoms were not able to successfully explain the GOSE. Despite the fact that coping and depressive symptoms were not supported as mediators in the original conceptual model, the interactions between coping, social support, and depressive symptoms could explain quality of life.
This finding suggested that coping and depressive symptoms are the moderators of quality of life.
135
CHAPTER FIVE
Discussion
This chapter presents a discussion of the study results. Implications of the study results, relevance to nursing science and practice are addressed. Limitations of the study and recommendations for future research will also be discussed.
Summary
During a period of four months, 461 adults with MTBI were invited to participate in this study; 135 returned consent forms and completed telephone interviews. Most of the subjects were men, middle aged, and about half were married. Most of the subjects finished the compulsory level of education, worked as farmers or daily labor and had low income. Subjects spent an average of eight days in the hospital and another 50 days to recover at home. The severity of MTBI among subjects in this study was relatively mild:
The majority of the subjects had Glasgow Coma Score (GCS) 14 at admission and full scores of 15 three days after the injury. The mean duration of post-traumatic amnesia
(PTA) was reported at six minutes and the duration of loss of consciousness (LOC) averaged less than two minutes. All questionnaires used in this study yielded high internal consistency. Subjects had very low scores of postconcussion symptoms (PCS), stressful life events, and depressive symptoms. Coping scores, social support scores and quality of life scores were high. Most of the subjects concluded that they could return to live their normal lives, although 18% were disabled at the time of data collection.
Quality of life had a positive relationship with social support but did not correlate with other stimuli. The extended Glasgow Outcome Score (GOSE) was not associated with any stimuli. Coping and depression symptoms were not the mediators of either outcome measure. All stimuli together with coping and depressive symptoms could 136 explain 15.8% of quality of life, with social support as the only predictor in the equation.
However, all stimuli, coping, and depressive symptoms were not able to successfully predict the GOSE. Despite the fact that coping and depressive symptoms were not supported as mediators in the original conceptual model, the interactions between coping, social support, and depressive symptoms could predict quality of life. This finding suggested that coping and depressive symptoms are the moderators of quality of life.
Sample
The findings related to the sample are discussed in relationship to the stimuli— focal, contextual and residual—posited to influence adaptation to MTBI in the conceptual framework. These findings suggest that there are both unique and common characteristics among Thai adults when compared to other samples in studies examining adults with traumatic brain injury. Additional findings related to the potential confounding variable of multiple injuries are also discussed.
Focal Stimuli
There were five indicators of focal status: Glasgow Coma Score (GCS), duration of
Posttraumatic Amnesia (PTA), duration of Loss of Consciousness (LOC), length of hospital stay and Postconcussion Symptoms (PCS).
Glasgow coma scale (GCS): Subjects who had GCS of 13 to 15 were included in this study. Some studies suggested that a GCS of 13 might lead to different outcomes after MTBI than a GCS of 14 to 15 (Bohnen, Jolles, Twijnstra, Mellink, & Wijnen, 1995;
De Kruijk et al., 2002; Stranjalis et al., 2004). However, there were too few subjects to allow for comparative analyses; there were only 32% at admission and 5% at 72 hours with a GCS at 13. Therefore, comparison of outcomes between subjects with GCS 13 and subjects with GCS 14 or more was not conducted in this study. 137
Posttraumatic Amnesia (PTA): PTA was reported from 0 to 60 minutes in this study, the average was 5.74 minutes (SD = 14.55). This duration of PTA was shorter than the theoretical limits of 12 hours (American Psychiatric Association, 1994) or 24 hours
(Mild Traumatic Brain Injury Committee of the Head Injury Interdisciplinary Special
Interest Group of the American Congress of Rehabilitation Medicine, 1993). This PTA was also shorter than the shortest PTA of one hour (Bohnen, Jolles, Twijnstra, Mellink, &
Wijnen, 1995; De Kruijk et al., 2002).
Loss of Consciousness (LOC): LOC was reported between 0-30 minutes in this study, and the average was 1.53 minutes (SD =4.42). This average was congruent with both the ARCM (< 30 minutes) and the DSM-IV (< 5 minutes) cut-points. This finding was consistent with the results from many studies in which an average of LOC of 15 minutes or less were reported (Alexander, 1992; Bigler & Snyder, 1995; Bohnen, Jolles,
Twijnstra, Mellink, & Wijnen, 1995; De Kruijk et al., 2002; Haboubi, Long, Koshy, &
Ward, 2001; Ingebrigtsen, Waterloo, Marup-Jensen, Attner, & Romner, 1998).
Subjects in this study had all indicators that MTBI was less severe than reported in other studies. They had almost full scores of GCS (14-15) and durations of PTA and LOC that were lower than those reported in other studies. Durations of PTA and LOC in this study were collected by interviewing the subjects, asking them to recall their experiences when they were injured. Subjects who had MTBI several months ago might not be able to remember these durations accurately. Information regarding PTA and LOC were not always available in medical records. Many of the hospital records indicated “having LOC for a while”. This is might be because health care professionals at the emergency room are not aware of the value of PTA and LOC. When the subjects were admitted in the hospital, information about PTA and/or LOC was not recorded. 138
Length of stay in the hospital (LOS): First length of stay was computed for all subjects. Then, length of stay in the hospital was considered separately in subjects with
MTBI only and subjects with MTBI and other injuries because of the significant difference between groups (t = -3.52, p < .01). For MTBI subjects without other injuries, the average LOS was 4.98 days (SD = 2.52). This average LOS was consistent with
Cattelani and other researchers (1996) who found that their subjects were admitted for seven days or less. However, LOS from the present study was longer than LOS of 2 days or 3 days reported by and Alves, Macciocchi & Barth (1993) and Alexander (1992), respectively. For subjects with MTBI and other injuries, the average LOS was about three days longer (M = 10.63, SD = 13.34).
Typical care at the MNH for patients with MTBI includes observation in the hospital for at least 72 hours. Therefore, subjects with MTBI in this study would have length of hospital stay for 3 days minimum. Several subjects volunteered that they had other injuries and these injuries, especially if orthopedic, would likely require a longer hospitalization than MTBI alone. Reimbursement agencies do no drive length of stay in
Thailand as they do in the United States. In addition, outpatient and home care is limited, so Thai patients may stay longer in the hospital. Thus, the finding of longer LOS, although unique, appears to be an artifact of the Thai health care system rather than the severity of injury or treatment variation.
Postconcussion symptoms (PCS): The possible range of each of the three PCS subscales was 10-50 and total score was 30-150 with the higher scores indicating more problems. In this study, PCS scores were relatively low; the average of the frequency was
17.30 (SD = 6.11), the intensity was 16.61 (SD = 5.89), the duration was 16.34 (SD =
6.04). The total score was 50.25 (SD = 17.92). These scores were lower than the lowest 139
PCS scores reported in other studies (Hanna-Pladdy, Berry, Bennett, Phillips, & Gouvier,
2001; Sparrow, 2002), in which PCS sores were reported at 57 and 58, respectively. The findings of low PCS in this study may result from the length of time postinjury in this study, an average of 8 months. The results of PCS from the Postconcussion Checklist
(PCSC) used in this study were difficult to compare to other studies for several reasons.
First of all, other studies used different measures such as presence of absence of symptoms or only the frequency of symptoms. Therefore, findings from other studies with the exception of the frequency scores are not comparable. Second, for the frequency subscale, the PCSC combined the answer for “none” and “few” in the same category (1).
Therefore, it is impossible to distinguish no symptoms from few symptoms from the
PCSC. In addition, other authors have suggested that PCSC scores are not specific to
MTBI (Sawchyn, Brulot, & Strauss, 2000). If this suggestion is true, then other factors, such as few depressive symptoms or few stressful life events in this sample, may contribute to the relatively low PCS scores.
Contextual stimuli
Gender: The majority of the subjects in this study were men (83.7%). Consistent with findings from 44 of the 48 studies reviewed in chapter two, men were more likely to be diagnosed with MTBI, although four studies in the literature review had more women than men (Arcia & Gualtieri, 1993; Bryant, Moulds, Guthrie, & Nixon, 2003; Cicerone &
Kalmar, 1995; Hartlage, Durant-Wilson, & Patch, 2001). In general, among people with
TBI, the ratio of men to women is reported as 2:1 (Smith-Seemiller, Fow, Kant, &
Franzen, 2003), 3:1 (Emanuelson, Anderson, Bjorklund, & Stalhammar, 2003) & 4:1
(Haboubi, Long, Koshy, & Ward, 2001) with the last ratio being most similar to this study. 140
This ratio of 4 men: 1 woman with MTBI was consistent with data about traffic injuries in Thailand, the most common cause of MTBI. The victims of traffic injuries were at least 75% male (Kasantikul, Ouellet, Smith, Sirathranont, & Panichabhongse,
2005; Nakahara, Chadbunchachai, Ichikawa, Tipsuntornsak, & Wakai, 2005;
Phuenpathom, Tiensuwan, Ratanalert, & Saeheng, 2000; Suriyawongpaisal &
Kanchanasut, 2003; Thanapaisal et al., 2005). Finding men to be the majority of victims for traffic injuries were also consistent with reports from other countries in South-East
Asia, such as Vietnam (Van, Singhasivanon, Kaewkungwal, Suriyawongpaisal, & Khai,
2006) and Taiwan (Tsai & Hemenway, 1999).
Age: Subjects in this study were aged 18 to 79 years and their mean of age was 38 years. This finding was consistent with studies from other settings that also found the average age of adult with MTBI which report mean ages of 27 through 44 years
(Cicerone & Kalmar, 1995; Cicerone et al., 1996; Moore & Stambrook, 1992; Rapoport,
McCullagh, Streiner, & Feinstein, 2003a; Ruffolo, Friedland, Dawson, Colantonio, &
Lindsay, 1999). This finding contrasts with reports of injured traffic victims in Thailand who are reported as averaging 30 years old (Kasantikul, Ouellet, Smith, Sirathranont, &
Panichabhongse, 2005; Suriyawongpaisal & Kanchanasut, 2003; Thanapaisal et al.,
2005). The results from this study reflect volunteer participants while other studies reported demographic information of all patients who came to emergency departments. It is possible that younger subjects may be less concerned about their symptoms or do not want to participate in this study. Moreover, several subjects said they were encouraged by their family member to participate because the family member was concerned about their health. New addresses or new telephone number for potential subjects were provided by their family member in order to contact several subjects even after relocations. Younger 141 subjects were more likely to be single, lived alone and worked far from home. Therefore, it is possible that invitation letter could not be forwarded to them in time to participate in data collection.
Employment status: All subjects in this study were employed or had a student status. Even the 14 subjects who were 60 years or older had their jobs. The majority of the subjects were farmers and daily labors. These jobs may not require the same integration of executive brain functions as other work. Therefore, cognitive consequences from MTBI might not affect their ability to work. There was one subject who changed his job from a daily labor worker to handcrafting at home. This subject is especially notable:
He could not return to the same work as before the injury but earned more income after the injury.
It may be that the interview question regarding ability to return to work and questions about independence on the GOSE may not capture the reality of adjusting work after MTBI. It may be that subjects who were farmers or laborers did not notice subtle cognitive changes in their daily work. Also, work as farmers and daily laborers does not require an employment leave to recover at home. Only a few subjects had job that required a high levels of executive brain function (such as a post-secondary student or accountant). Since the majority of participants were employed as a farmer or daily laborer, their ability to return to work or study may have been easier than other occupations.
The socioeconomic environment in Thailand is different from many other countries in which MTBI has been studied. For example, most of the subjects live in rural settings and their average income is at the minimum wage; results related to employment status 142 may not be comparable. In other studies pertaining to traffic injuries conducted in
Thailand, type of jobs or employment status was not reported.
Presence of alcohol at time of injury: Presence of alcohol at time of injury was collected from medical records and there were only 66 records that included this information. Incidence of alcohol used was found in 21 (32%) of the eligible records.
Even with missing data in this study, the finding related to alcohol used was consistent with findings from studies related to traffic accidents conducted in Thailand; the presence of alcohol was reported from 31% to 43% (Kasantikul, Ouellet, Smith, Sirathranont, &
Panichabhongse, 2005; Lapham et al., 1998; Nakahara, Chadbunchachai, Ichikawa,
Tipsuntornsak, & Wakai, 2005; Ouellet & Kasantikul, 2006).
Education: The number of years in schooling system reported by subjects in this study ranged from 4-18 years and the average was 7 years. The number of years completed in school was low, compared to the average range of 11-14 years in the literature (Cicerone & Kalmar, 1995; Kashluba et al., 2004; McCauley, Boake, Levin,
Contant, & Song, 2001; McHugh, 2002; Ruffolo, Friedland, Dawson, Colantonio, &
Lindsay, 1999). However, considering the average age of the subjects, this finding was consistent with the history of compulsory education system in Thailand. This educational system has changed. Forty years ago, the Thai population was required to finish at least the elementary level (4 years). Ten years later, the elementary level increased to six years so people who are in their 30s now completed at least six years in school. In the past 20 years, the compulsory educational level increased to high school. Since the subjects in this study were at their late 30s, it was reasonable that their number of year completed school was about 7 years. Results related to education were not reported among traffic injury studies conducted in Thailand. 143
The finding of low education is also consistent with the majority occupations reported. In support of findings related to employment is this study, other authors have suggested that subjects with low education may report less cognitive impairment when they are not in cognitively demanding jobs (Drake, Gray, Yoder, Pramuka, & Llewellyn,
2000; Franulic, Carbonell, Pinto, & Sepulveda, 2004; Ruffolo, Friedland, Dawson,
Colantonio, & Lindsay, 1999).
Time postinjury: Time postinjury in this study ranged from 4 to 12 months. The average time postinjury was 8.36 months (SD = 2.51). There is an interesting explanation as to why both the mean and median time postinjury is eight months. Interviews were completed between October and January. Most subjects were interviewed around eight months after the Thai traditional New Year in April. The incidence of traffic accidents is consistently high during the April celebration of the Thai New Year because many, many people travel from big cities to visit their hometowns. Subjects who experienced MTBI during this vacation would be in the period of six to nine months post-injury at the time of data collection.
Range of time post-injury at 4-12 months in this study is different from most of the literature in which time post-injury is typically classified according to categories of less than three months, 3-6 months, and more than one year postinjury. Most of the studies related to traffic injuries conducted in Thailand report outcomes immediately after the injury. There is only one study that reported outcomes after six months postinjury
(Phuenpathom, Tiensuwan, Ratanalert, & Saeheng, 2000). The authors included outcomes of all severities of brain injury; therefore, it was not comparable with this study. The goal of this study was different than other studies: Explored the patient characteristics related to MTBI, thus a broad cross-section of time postinjury was used. Further studies may 144 want to use categories of less than three months, 3-6 months, 7-12 months and more than one year postinjury to provide data comparable to the empiric literature on MTBI.
Residual stimuli
Stress: Number of stressful life events was reported up to nine events with the average of three events occurring between the time of onset of injury and the interview.
The measure used to capture stressful life events, the LES, has never been used among
MTBI patients; therefore, the findings from this study were not able to be compared with results in other studies about MTBI. However, comparing this finding to normative data collected from college students (average at 12 events) (Sarason, Johnson, & Siegel,
1978a), the findings from this study indicated that MTBI subjects had fewer stressful life events than young adults. The negative effect score in this study was 6 (range = 1-18), higher than the negative effect reported by college students (5). However, the positive effect reported in this study was lower (2, range 1-6) than those scores reported among college students (7). Subjects in this study were older than college students, so
Differences may simply be due to the difference in ages.
The results in this study indicated that subjects with MTBI did not have many events/ changes occur in their lives after the injury. For those who had events/ changes in their lives, the effect was minimal. The effect of stress on PCS was reported in one study
(Machulda, Bergquist, Ito, & Chew, 1998). The authors concluded that subjects who had high intensity of PCS reported high perceived stress. However, in that study, subjects with MTBI were asked to recall their stress within the last month, rather than over one year.
The reason for lower scores of stress might be because the LES was designed to capture changes in the last 12 months. In the LES, time was roughly categorized at 1-6 145 months or 7-12 months. These periods of time were long enough for the subjects to adapt to changes if they occurred. In addition, most of the stressful events reported by the subjects were related to changes in work or income. However, at the time of data collection, most of them were able to return to work or study. Therefore, it can be appears that subjects with MTBI in this study did not have undue problems with stress or stressful events at the time of their interview.
Social support: Social support reported by subjects with MTBI in this study was high both as a total and as subscores of availability and satisfaction with support. The averaged availability scores were 40 (range 18-54), the satisfaction scores were 33 (range
24-36), and the total scores were 73 (range 49-90). There was only one study in the literature using the same measure of social support (Brown, McCauley, Levin, Contant, &
Boake, 2004) and the scores in that study were computed differently. The scores of social support in this study were re-calculated in order to compare scores. The re-calculated availability scores were 6.63 (SD = 1.73), higher than the availability scores among
MTBI in the study (2.94, SD = 1.79). This indicates that when asking the subjects to list up to nine individuals who support them, Thai adults had about seven individuals for support whereas U.S. citizens had about three individuals. Total social support and satisfaction of social support scores were not reported in that study.
It is not surprising to find that social support is high among Thai subjects with
MTBI. Thai families are composed of extended members; adult offspring live in the same house as their parents and relatives live in the same area. Relatives visit each other frequently especially when one of the family members becomes sick or injured. After their injuries, most of the subjects with MTBI stayed at home and were likely taken care of or comforted by their family members. Even after they returned to work, their family 146 members were still concerned about their well-being. These concerns were evident to the
PI; several family members contacted the PI on behalf of the subject when the invitation letters were received at home. Some of the family members raised their concerns about the consequences after MTBI by calling the PI to report some additional information.
The Thai social network is strong. Social support is not only the family members. It is common to see that many subjects with MTBI also mentioned about their community leaders when asked about the availability of social support. Since many subjects were involved in traffic accidents and the legal system, subjects with MTBI relied on their community leaders to help them deal with legal problems. All treatment expenses related to traffic accidents in Thailand are covered by the Bureau of Motor Vehicles Insurance, even if the victims are not insured. It is inevitable that the subjects with MTBI have to deal with filling out many forms and the complicated government system of the Bureau.
Therefore, the community leaders, who are powerful and knowledgeable, can be very helpful for the subjects with MTBI.
The subjects with MTBI receive both physical care and emotional support from their family members, together with help from other social networks. The subjects with
MTBI perceived that they received high social support. The findings of high social support were consistent in studies across different Thai samples, such as subjects with tuberculosis (Jittimanee, 2005) and subjects with postpartum depression (Srisaeng, 2003).
Marital status: There were almost the same proportions of married and single subjects in this study (49% vs. 43%). Marital status is believed to be a part of social support. Given familial and societal support, it is not surprising that unmarried status was not significantly associated with either the process or outcome of adaptation.
147
Additional findings about the sample
During the interview, it became apparent that patients with major orthopedic or other injuries responded differently to many questions, especially questions related to length of hospital stay and time to recover at home. It is not uncommon to see subjects having both MTBI and other injuries since the cause of injures is traffic accidents. The finding of other associated injuries, together with brain injury, was also reported in other studies conducted in Thailand (Phuenpathom, Tiensuwan, Ratanalert, & Saeheng, 2000) and in the US (Read et al., 2004). However, questions have arisen whether the outcomes would occur because of MTBI. In general, patients with MTBI alone were similar to those patients with both MTBI and other injuries. Subjects with and without other injuries reported similar stimuli, processes and outcomes. The differences were found only for length of hospital stay and time to recover at home. One measure, length of hospital stay was significantly less with MTBI alone (Table 1). Another finding was that subjects with
MTBI alone had a reduced recovery period at home. The variable of additional injuries was not in the conceptual framework. These findings suggest that there are more similarities than differences when comparing patients who experience MTBI with and without additional injuries.
Adaptation process
Coping: Coping was measured with the Coping and Adaptation Processing Scale
(CAPS). The CAPS was tested among Thai patients who were admitted in the hospitals
(Chayaput, 2004) but baseline scores were not reported. In this study, subjects with
MTBI, coping scores were high (average = 133, range 98-161). The finding of adaptive coping behaviors was also found in subjects with MTBI in the United States (average = 148
185, range 130 – 218, Sparrow, 2002). In contrast, maladaptive coping behaviors were reported in subjects with MTBI in one study (Krpan, 2004).
Social support might have an important role in coping. Thai subjects with MTBI did not have to cope with many problems because their social networks were willing to help them. Moreover, there were few stressful events requiring them to cope. Some of coping behaviors that are categorized as maladaptive in American-European culture may be considered normal in Thailand. Finally, the rating scales in the CAPS are broad and subjects may select a middle response, especially during a lengthy interview. It is suggested that the scale of the responses should be revised in order to better capture coping behavior among Thai people.
Depressive symptoms: Few depressive symptoms were reported among the subjects with MTBI in this study (average = 21, range = 0-42). The average scores were lower than the normative scores for Thai teenagers (22) (Trangkasombat, Labpboonsup, &
Hawanont, n.d.) but higher than scores reported by subjects with postpartum depression
(16) (Srisaeng, 2003). As in the United States, mental health disorders are stigmatized and subjects may be unwilling to report depressive symptoms.
The finding of low depressive symptoms in this study is consistent with McCauley and other researchers (2001) who reported depressive symptom scores among MTBI subjects at 23. Depressive symptom scores among subjects with general trauma were lower at 19. In their study, subjects rated their depressive symptoms at one month postinjury. The additional passage of time in this study may help explain the differences in results. The finding in this study contrasted with findings from Bell and other researchers (1999) who concluded that subjects with MTBI had depressive symptoms of
15, higher than a score of 9 among subjects with headaches. However, the use of a 149 different depressive symptoms measure and a data collection period at one month after injury may explain the unique results in Thai adults.
Time postinjury may be the reason of low depressive scores in this study. The CES-
D asks only for depressive symptoms in the past 7 days. After 4-12 months of the injury, the subjects may have very few depressive symptoms. Collecting information about depressive symptoms among subjects with earlier time postinjury or longitudinal methodology is recommended to capture depressive symptoms comparable to other studies.
The next section is a discussion of the findings according to each of the research questions.
Research Question 1: What adaptation occurs among Thai adults after MTBI?
Quality of life: Quality of life (QOL) scores were high in this study. Total scores of
QOL (23.88) was slightly higher than QOL scores among Thai subjects with valvular heart disease (VHD) (22.80)(Petchprapai, 1998). Considering that subjects with MTBI were not as symptomatic as subjects with VHD, a larger difference was expected.
Supporting the findings related to social support, the family domain had the highest scores. The health and functioning domain had the lowest scores.
There was only one study that explored QOL among MTBI and the results were different. The QOL score among adults with MTBI were lower than normal control population (Emanuelson, Anderson, Bjorklund, & Stalhammar, 2003). There is no control sample in this study to determine whether the quality of life scores are similar between adults with and without MTBI. The Quality of Life Index has been tested in college students but normative data are not reported (Ferrans & Powers, 1985). 150
The health and functioning scores were reported at 22 in this study. The finding is consistent with the PCS scores which were relatively low (indicating few post concussive symptoms) in this study. The health and functioning scores indicate that subjects with
MTBI do not suffer from many symptoms after their injury and they were satisfied with their health. The relationship between PCS and quality of life could not be detected in this study. It may be useful to examine correlation between subscales, especially health and functioning on the QLI, with total score of the PCS. PCS scores in this study were also too modest to associate with the quality of life scores. Another reason is that there are only three items in the health and functioning domain related to symptoms after MTBI.
The rest of the health and functioning questions are concerned with health and functioning in general not specifically to MTBI .
The psychological and spiritual scores were reported at 24. The finding is consistent with few depressive symptoms discussed earlier. However, a significant relationship between depressive symptoms and quality of life was not found. Depressive symptoms may adversely influence quality of life. Lack of depressive symptoms scores may not influence with the quality of life scores as presence of depressive symptoms appears to do.
The social and economic scores were reported at 25. This domain contained of items that could be either social support or social integration. Since the subjects in this study had high social support scores and most of them were able to resume their social activities and return to work, it was not surprising to see that their scores in this domain were high. High scores in this domain and the family domain may be the reasons that make quality of life has positive relationship with social support. 151
The family domain scores were the highest scores among all domain scores (28).
Social support scores are also positively correlated with the quality of life scores. It is noted that social support measure used in this study assessed the same dimension of social or family support as in the quality of life (satisfaction). Because both measures examined similar concepts related to social support it is not surprising that both scores were in the high ranges and correlated.
Glasgow outcome scale: A total of 27 subjects were categorized as moderately or severely disabled and could not return to work or study in this study. This finding contrasts with one study which reported that only 42% of adults with MTBI could return to work/ study (Ruffolo, Friedland, Dawson, Colantonio, & Lindsay, 1999). Other studies, however, have findings similar to this one, reporting that 84-88% of their subjects returned to work or study (Englander, Hall, Stimpson, & Chaffin, 1992; Kay, Newman,
Cavallo, Ezrachi, & Resnick, 1992). The finding of unable to return to work or study after the averaged time postinjury of eight months was unexpected. Subjects in this study had a low severity of brain injury as measured by a combined high GCS, short duration of PTA and short duration of LOC. With this type of mild injury, all of the subjects were expected to return to work or study 3 months after injury.
The inability of return to work or study for subjects in this study may be a result of multiple concurrent injuries at the time of MTBI. However, even among subjects with only MTBI, 18% could not return to work or study. This is a small figure but important clinically. The results were similar with one study that conducted in Thailand in 1985.
The authors found that 84% of subjects with MTBI were in the good recovery categories.
The same authors replicated the study in 1995 and found that there were only 3% of subjects with MTBI were still in the disability categories at six months postinjury 152
(Phuenpathom, Tiensuwan, Ratanalert, & Saeheng, 2000). Several reasons may explain for the differences of incidence of disability following MTBI. First of all, many injuries occurred in the municipal area in which the helmet rule is successfully enforced to all riders. Helmets may alter the mechanism of injury in the brain and subsequent disability may not occur. Second, the treatment settings may have different standards of care; this study was conducted among patients who received care at a tertiary public hospital. In the other study completed in Thailand, their sample size was huge (3,194 in 1985 and 4,217 in 1995); they collected data from all subjects who came to their hospital and all subjects at this University-based medical center followed a common standard of hospital care and follow-up that evaluated function with the GOSE at six months. In this study, GOSE was self-reported rather than the result of a physical exam. It may be that this study under- reported disability since only volunteer participants were included. In addition, disability may vary over time and this study did not examine immediate responses to MTBI. It is recommended that the GOSE be used a structured time intervals for all subjects with the same condition (either with or without multiple injuries but not both) to better understand the incidence and prevalence of disability after MTBI. Alternatively, evaluation by research personnel rather than self-report may provide a more valid approach to GOSE scoring.
Research Question 2: What stimuli are associated with adaptation to MTBI among
Thai adults?
From RQ2.1: Do focal, contextual and residual stimuli associate with adaptation to
MTBI among Thai adults? For quality of life, only social support was positively correlated with quality of life (Table 18, r = effect size = .394). All other focal, contextual 153 and residual stimuli were not associated with quality of life. Meanwhile, the GOSE was not associated with any stimuli (Table 8).
Among 48 studies reviewed in Chapter Two, there was only one that explored a relationship between social support and quality of life and the relationship was not found
(Brown, McCauley, Levin, Contant, & Boake, 2004). Finding of a positive relationship between social support and quality of life was similar to findings among subjects with mixed severity of brain injury (Farmer, Clark, & Sherman, 2003). This positive relationship has been commonly found across other subjects, such as among patients with chronic heart failure (Bennett et al., 2001), dementia caregivers (Haley, Levine, Brown, &
Bartolucci, 1987), patients with strokes (Kim, Warren, Madill, & Hadley, 1999; King,
1996b) and elderly patients in the ICU (Kleinpell & Ferrans, 2002). The reason for a positive relationship between social support and quality of life are that the measures of social support and quality of life tap the same dimension--satisfaction. There are 12 items in the Quality of Life Index that measure the same attributes as in social support.
The GOSE was not correlated with any variables, even with social support. The findings were similar to Tate and Broe (1999) who reported that age, gender and type of occupation before the injury were not correlated to the GOSE among severe brain injury subjects. However, age and other demographic data have been correlated to return to work and/ or community re-integration, one of the questions in the GOSE, in other studies. For example, age had a positive and strong relationship with return to work among MTBI in one study (Drake, Gray, Yoder, Pramuka, & Llewellyn, 2000).
Meanwhile, among subjects with more severe brain injury, Dawson and other researchers
(2004) concluded that age and severity of the injury had a negative relationship with an ability to return to work among subjects who had mixed severity of brain injury while 154
Wood and Rutterford (2006) found that demographic data correlated to community reintegration in another study (Wood & Rutterford, 2006).
The GOSE was designed for capturing functional independence or disability which was not a problem among subjects in this study. There was too large of a variation in the
GOSE scores (from good recovery or return to normal to severely disabled), and the distribution of subjects in each categories was uneven, especially, some categories of ability/ disability had very few subjects. If the variability is large, there is more chance that variables will be “lost among the scattered data” (Tulman & Jacobsen, 1989). Thus, no correlation between the GOSE and other variables may simply reflect variability and/ or skewness. Only 27 subjects were in moderately or severely disabled categories and these subjects might experience more adverse consequences after MTBI. The relationship between quality of life and the GOSE was stronger and relationship between the GOSE and PCS became significant among these 27 subjects (data not reported). Further investigation targeting more adults who experience disability after MTBI (with and without other injuries) is recommended to better explore these relationships.
From RQ2.2: Does coping associate with adaptation to MTBI among Thai adults?
Coping did not associate with either quality of life or the GOSE.
Relationships between coping and quality of life were not reported in the 48 studies reviewed in Chapter 2. However, there were reports suggesting that coping had a positive relationship with other outcomes after MTBI such as adjustment (Moore, Stambrook, &
Peters, 1989) or locus of control. However, coping was not associated with outcome after
MTBI as reported by Sparrow (2002) who concluded that coping was not related with
PCS in her sample. 155
The reason that coping was not related to outcomes after MTBI in this study may be because the Coping and Adaptation Processing Scale (CAPS) was designed to measure coping skills in general. Items in the CAPS were not intended to capture coping after a specific event or illness. Subjects in this study had high coping scores, indicating that they did not have problem in coping. Moreover, subjects in this study were not required to cope with many problems, considering they had very few PCS symptoms, few depressive symptoms and few stressful life events. The subjects also had high social support, and high satisfaction with their lives, further reducing the need for coping.
From RQ2.3: Do depressive symptoms associate with adaptation to MTBI among
Thai adults? Neither the GOSE nor quality of life was associated with depressive symptoms.
Depressive symptoms were not correlated with either quality of life or the GOSE.
However, depressive symptoms had a small and positive relationship with a residual stimulus: stressful life events (Table 19, r = .394, p < .05, effect size = .394). The effect size indicates a clinical small but important relationship. None of the 48 studies in
Chapter Two explored a relationship between depressive symptoms and quality of life.
However, depressive symptoms were found to have a negative relationship with quality of life across other samples such as among general population (Abbey & Andrews, 1985), patients with stroke (King, 1996a), patients with brain tumor (Pelletier, Verhoef, Khatri,
& Hagen, 2002), and patients with multiple sclerosis (Fruehwald, Loeffler-Stastka, Eher,
Saletu, & Baumhackl, 2001; Lobentanz et al., 2004).
The reason for a lack of correlation between depressive symptoms and outcomes may be explained by low depressive symptom scores. Subjects had very few stressful life events over one year and depressive symptoms in the last 7 days. There is little variability 156 in the scores in this study and , likely, reduced effect size compared to other studies (Bay,
2001; Iverson & Lange, 2003; McCauley, Boake, Levin, Contant, & Song, 2001).
Other findings of associations among variables
All variables in this study were selected based on the Roy Adaptation Model and review of literature. All stimuli were expected to be correlated. However, there were only a few other modest correlations found in this study. In addition to relationships already discussed, there were correlations between age and marital status, PTA and LOC, LOC and LOS, social support and age, LOC and employment status, LOS and CESD, and employment status and PCS.
Very few studies in the literature described multiple relationships among variables in MTBI. When relationships were found, investigators concluded that PCS was related to stress (Sparrow, 2002), and LOC and PTA were correlated to PCS (Savola & Hillbom,
2003). In this study, additional relationships between variables within categories of stimuli and across categories of stimuli were not surprising. For example, married status was correlated to age; older people are more likely to be married more than those who are younger. PTA was anticipated to correlate with LOC since each of them contribute to the determinants of severity after the injury; the correlational finding of the PTA and LOC in this study was consistent with the diagnosis of injury severity (Cattelani, Gugliotta,
Maravita, & Mazzucchi, 1996). The subjects that had longer LOC had more severe injury and it was not uncommon that they also stayed in the hospital longer. Longer LOC was associated with inability to return to work or school; subjects with any duration of LOC were less likely to be able to return to work or school as quickly as subjects without LOC.
Findings about the relationship between LOC and severity of symptoms were consistent with findings reported by Cicerone and other researchers (1995) and Savola and Hillborn 157
(2003). High PCS scores were also associated with inability to return to work or school.
Finally, high social support was associated with younger ages; in Thai culture it would be expected subjects who were younger would have more support from their family and social network than subjects who were older (TABLE 19).
Depressive symptoms are not related to other stimuli or outcomes, in exception of stressful life event in this study. However, depressive symptoms were correlated with many stimuli in other studies. For example, Bohnen and other researchers (1995) found that depressive symptoms were correlated with PCS; however, PCS was measured as an emotional subscale, while in this study PCS included both physical items and emotional items. Levin and other researchers (2001) concluded that depressive symptoms related to social support, but their subjects were interviewed at three months after the injury while the subjects in this study were interviewed at 4-12 months post-injury. Meanwhile,
McCauley and other researchers (2001) found that depressive symptoms related to both social support and PCS, but their research was also conducted at three months. With time post-injury at six months, Suhr and Gunstad (2002) found that depressive symptoms were associated with PCS among their subjects. However, they mentioned that PCS was not related to MTBI. Therefore, anybody who had PCS might experience depressive symptoms even though they did not suffer from MTBI. Depressive symptoms were found to correlate with age; subjects who were 60 years or older reported more depressive symptoms.
Income was the only variable that had a negative small relationship with coping.
Income is a source of material support that may help people to cope better with the injury or illness. The subjects in this study are covered with universal health insurance or the universal car insurance and do not have to pay out of their pocket when they come to the 158 hospital. However, the subjects still have to pay for transportation to the hospital and/ or other expenses when they stay in the hospital or come to follow-up. Perhaps income also buys small comforts such as food or entertainment that can enhance coping. Findings of relationship between income and coping were found in other studies not specific to MTBI but in Thailand (Jirapaet, 2001; Jongudomkarn & West, 2004; Sethabouppha & Kane,
2005).
Failure to find correlations among the variables in the conceptual framework was unexpected. However, the lack of relationship among some variables was not new for subjects with MTBI. Conflicting findings are reported among the literature. Specifically, marital status was not related to outcome in at least two studies (Corrigan, Bogner,
Mysiw, Clinchot, & Fugate, 2001; Franulic, Carbonell, Pinto, & Sepulveda, 2004). Also,
PCS has not been linked to GCS (Ingebrigtsen, Waterloo, Marup-Jensen, Attner, &
Romner, 1998; McCullagh, Oucherlony, Protzner, Blair, & Feinstein, 2001), presence of alcohol, (Ingebrigtsen, Waterloo, Marup-Jensen, Attner, & Romner, 1998) or PTA
(Ingebrigtsen, Waterloo, Marup-Jensen, Attner, & Romner, 1998; Ponsford et al., 2000) in previous research. One study reported that PTA and LOC were not related to symptoms after MTBI (Cicerone & Azulay, 2002). In another study, coping was not related to PCS (Sparrow, 2002). Depressive symptoms were not related to outcome
(Ruttan & Heinrichs, 2003). Age was not associated with PCS (Savola & Hillbom, 2003).
Despite constructing this study to respond to flaws in earlier research, theorized correlations were not found. The few associations that were supported were very small to small. Because so many people with MTBI in this study and in most other studies recover over time, it may be that time is the factor that needs further exploration. However, there was a small but important number of patients who reported clinically compelling levels of 159 disability. It may be useful in future studies to concentrate on patients with poor outcomes
(low quality of life or in the recover-with-issue category of the GOSE) to better understand if there are factors that influence poor adaptation in this vulnerable population.
A lack of relationships among variables on the conceptual framework may be the result of convenience sampling. First, subjects in this study were recruited from only one setting. Second, subjects were volunteers who were selected by convenience. Only the subjects who could read and write and the subjects who had a mailing address and telephone number were invited to participate. Third, only the subjects who returned consent forms were interviewed. Finally, only the subjects who were healthy enough would be interested in interviewing for one hour. These factors reasons may select for subjects with few depressive symptoms, low PCS scores, high social support, and good adaptation after the injury. An increased rate of return would provide confidence to this researcher that subjects represent a cross-section of adults with MTBI in Thailand.
Nonetheless, 29% is a respectable return rate and, given family members assistance in contacting participants who relocated and the procedure of calling potential subjects who did not opt out, bias in this convenience sample is likely to be small.
The lack of relationship between the GOSE and quality of life was particularly unexpected based on the theoretical and empirical literature. It was anticipated that people with MTBI who could return to their normal life would have a better quality of life. The reason behind this lack of correlation may be because the GOSE mainly measures the ability to function independently and free from difficulty. Most people with MTBI do not have problems with independence and MTBI does not typically cause any visible disability. This was supported in this study. The two subjects who reported independence 160 problems had multiple injuries, not only MTBI. Of the other ten subjects with MTBI who reported that they had problems in the difficulty domain, most of their concerns were related to work.
Responses for each question in the GOSE were dichotomous. The subjects had to answer “yes” or “no” and “same” or “change”. The objectives of the GOSE were to measure the physical and social functioning of the subjects. The Quality of Life Index
(QLI) used in this study was a multidomain and multidimensional measure. There were only a few questions related to functioning. The subjects rated their satisfaction and importance for each item. Mainly, the GOSE measures whether the subjects can perform each activity in each item or not. On the other hand, the QLI asks if the subjects are satisfied with each item, regardless of whether they can or cannot perform. Moreover, there were many questions that related to lives in general and only three questions that related to consequences of symptoms after MTBI. Considering the nature of both measures used to assess outcomes, it is not unreasonable to find no association between them.
To measure the relationship between quality of life and overall outcome after
MTBI, it would be more appropriate to assess quality of life and function with disease- specific measures. The GOSE measures global functional outcome but does not address the specific of functional limitations (Kirkness et al., 2002). The GOSE may be appropriate for screening purposes as it is fast and easy to use. However, to capture a better picture of overall outcome, a more sophisticated tool such as Community
Integration Questionnaire or the Functional Status Examination should be considered.
Other measures that can assess the ability in return to work or performance in school such as the Employability Rating Scale, the Supervision Rating Scale-S and the 161
Neurobehavioral Rating Scale should also be considered (van Baalen, Odding, van
Woensel, & Roebroeck, 2006). Quality of life and the GOSE have not been used together in previous reports; therefore, their relationship could not be compared with other studies.
Another approach might be to use length of stay and time for recovery at home as outcome measures that indicate return to function. In this study, they were used as stimuli to distinguish severity of injury but, as they had no relationship with GCS or PTA or
LOC, they may better capture recovery.
Research Question 3: What are the factors that predict adaptation to MTBI among
Thai adults?
Multiple regression was used to answer questions for research question 3. All variables selected in this study were based on the Roy Adaptation Model and literature review and, so, all were entered into the regression model. All stimuli suggested in the conceptual model were entered except presence of alcohol at the time of injury which was not entered because of excessive missing data (Tabachnick & Fidell, 2001).
The results of this research question are discussed in three sections. The first section is the discussion of predictors of quality of life; the second section is the discussion of predictors of the GOSE, and the last section is the discussion of mediators.
Predictors of quality of life
From RQ3.1: What are the factors that predict quality of life among Thai adults?
Two multiple regression models were calculated to answer this question; both were supported. In the original model, all variables were entered and all subjects were included. In the adjusted model, all variables were entered but eight subjects were excluded because they were outliers in what way. 162
In the original model, all stimuli could explain 15.7% of quality of life. Social support was the only unique stimulus that could predict quality of life. A person is an open system, interact with changes, and adapt with their environment continuously.
Capturing predictors for psychosocial concept is always challenging. Sixteen percent of explanation in quality of life may be small effect statically. However, from psycho- sociology point of view, this number is significant, considering the sample size was 135.
The regression diagnostics suggested that eight subjects were outliers. These outliers may affect the accuracy of the predictive model especially when the model is a low additive model (low correlation) as in this study (Motulsky & Brown, 2006). After adjustment by removing the outliers (8 subjects), social support and two more stimuli, length of hospital stay and employment, could predict quality of life while GCS at 30 minutes and time postinjury almost reached a significant level. Although a modest increase, quality of life was explained for 25% by all stimuli in the adjusted model. Social support was the most powerful variable in both models, suggesting that social support affected outcome after MTBI even with smaller sample size.
From RQ3.5: Can coping and depressive symptoms predict quality of life among
Thai adults?
Coping and depressive symptoms explained less than 1% of quality of life and neither of them could not predict quality of life.
From RQ3.7: What are the factors that predict quality of life among Thai adults when considering coping and depressive symptoms as the mediators?
This model was not calculated because coping and depressive symptoms failed to predict quality of life. Thus they were not the mediators for quality of life. 163
Additional findings exploring the effects of coping and depressive symptoms on adaptation
Adding coping and depressive symptoms to stimuli in the statistical model explain
15.8% of quality of life; social support remained the only unique stimulus that could predict quality of life. By adding coping and depressive symptoms into the regression model, quality of life was explained less than 1% more, compared to the original model with all 135 subjects. Thus coping and depressive symptoms do not add to the ability to predict adaptation. However, with a moderate effect size of .338, there is the suggestion that all of these factors combined to have an important clinical response. Implications for clinical practice are addressed later in this chapter.
When coping and depressive symptoms were evaluated as possible moderators, rather than mediator, adjusted R2 increased from 15.8% to 18.4%. Again, this was a modest increase but suggests future studies may need to modify the conceptual model used in this study such that coping and depressive symptoms be tested for moderating
(interaction) effects rather than mediating influences. Coping and the interaction between social support and coping were the predictors of quality of life. Coping and depressive symptoms were the moderators of quality of life and their interactions with social support could explain 2.6% more of quality of life.
The results in Figure 3-4 show that subjects with high depressive symptoms report lower quality of life than subjects with modest and low depressive symptoms. The results was consistent regardless the scores of social support. Subjects who had high social support and high coping would have higher scores of quality of life. With low social support, subjects who had low coping scores in this study had higher quality of life than subjects with high coping scores. Coping did not have effect on quality of life when 164 subjects had social support scores at about 3.4 (range 1-6); all subjects with any coping scores reported the same quality of life. However, when the social support scores increased, subjects with high coping scores reported higher quality of life then subjects with modest and low coping scores (Figure 4). The findings also suggested that subjects with high coping scores reported rapid increment of quality of life scores when social support scores increased. The same trend was found among subjects with modest coping scores. However, subjects with low coping scores reported decline quality of life when their social support increased.
Depressive symptoms could not predict or mediate quality of life here but they successfully predicted quality of life in another study (Underhill et al., 2003). However, their subjects had more severe injury and higher depressive scores. There were few depressive symptoms in this sample. It is uncommon to express feeling of depression even with health care professionals. Perhaps, subjects in this study were also uncomfortable reporting sign of depression over the phone. Future study may engage subjects with a sympathetic face-to-face interview to capture self-reported depressive symptoms; using a different method may confirm or refute findings from this study and help build the science around MTBI recovery.
In conclusion, social support was a consistent predictor for quality of life. The ability of social support in predicting quality of life was reported in two studies with mixed severity of traumatic brain injury (Farmer, Clark, & Sherman, 2003; Underhill et al., 2003). Because social support was correlated with quality of life, its finding as a predictor is expected. In a statistical model, high correlation leads to high prediction.
Severity of the injury in this study was not a predictor of quality of life. It is consistent with a conclusion from Dijkers (2004) who reviewed quality of life studies in 165 traumatic brain injury patients (Dijkers, 2004). However, this finding was inconsistent with results from Dawson and other researchers in which subjects had mixed severity of brain injury (60% were MTBI) (Dawson, Levine, Schwartz, & Stuss, 2004).
Four more variables were also able to predict quality of life after eight subjects were removed. They were length of hospital stay, employment status, GCS at 30 minutes and time postinjury. Length of hospital stay and the GCS are both focal stimuli represented severity of the injury. It is anticipated that subjects with MTBI who had more severe MTBI (longer length of stay in hospital and lower GCS scores) might have low quality of life. Therefore, it is expected that length of hospital stay and GCS should be able to predict quality of life. On the other hand, employment status was contextual stimulus for this study. Since most of the subjects in this study were daily laborers and rely on their wages, ability to go back to work should predict their quality of life. The finding that employment status was a predictor of quality of life was also reported by
Underhill and other researchers (2003). Marital status was not a predictor in this study but successfully predicted quality of life in another study (Hicken, Putzke, Novack, Sherer, &
Richards, 2002).
Despite the fact that quality of life was explained by all stimuli in all previous models, 75-85% of the variation of quality of life was unexplained. Thus, there are other variables that may explain quality of life that were not included in this study. Some of the other stimuli that have been suggested in the literature are cognitive functions (Dawson,
Levine, Schwartz, & Stuss, 2004), social integration (Pierce & Hanks, 2006), functional disability (Hicken, Putzke, Novack, Sherer, & Richards, 2002), growth hormone level
(Kelly et al., 2006), behavioral regulations and memory functioning (Tate & Broe, 1999).
Further studies should include these variables. 166
Predictors of the Extended Glasgow Outcome Scale
Logistic regression was used to answer the question related to the GOSE. Similar to quality of life, all stimuli were entered except presence of alcohol at the time of injury.
From RQ3.2: What are the factors that the GOSE among Thai adults?
The GOSE was explained for only 4.4% by all stimuli and none of the stimuli was a predictor of the GOSE.
From RQ3.6: Can coping and depressive symptoms the GOSE among Thai adults?
The answer is no. Coping and depressive symptoms could explain less than 1% of the GOSE; neither were the predictors of the GOSE.
From RQ3.8: What are the factors that predict the GOSE among Thai adults when considering coping and depressive symptoms as the mediators?
This model was not analyzed because coping and depressive symptoms could not predict and were not the mediators for the GOSE.
It was unexpected that stimuli, coping and depressive symptoms could not predict the GOSE. This suggests that the variables in the conceptual model do not predict disability captured by the GOSE. This study did not examine baseline functional disability. It may be change in ability is a more accurate reflection of recovery rather than a single post-event measure. One unique finding in this study was the amount of time patients spent in the hospital and recovering at home. It is noted that the GOSE may not capture the ability of return to work. Future study using return to work as a future measure of adaptation and including recovering period as additional explanation is recommended. Also, imaging studies (e.g. computerized tomography scan, magnetic resonance imaging) were not included. Adding imaging studies may help understanding of outcomes. Additional methods of data collection such as physical examination may 167 also help capture disability better than self-report. Information from a close proxy may also help identify disability not recognized by the subject.
Inability to determine predictive variables for the GOSE were also reported in other studies. Age was a predictor of return to work among adults with MTBI in one study
(Drake, Gray, Yoder, Pramuka, & Llewellyn, 2000). In other studies with mixed and severe levels of injury, other results have been reported. Tate and Broe (1999) reported that age, gender and type of occupation before the injury could not predict the GOSE among severe brain injury subjects. On the other hand, age and other demographic data were the predictors of return to work and or community re-integration, one of the questions in the GOSE. For example, Dawson and other researchers (2004) concluded that age and severity of the injury were the predictors of return to work among subjects who had mixed severity of brain injury and demographic data of subjects with severe brain injury were the predictors of community reintegration in another study (Wood &
Rutterford, 2006).
Patients with MTBI do not have severe brain injury. Thus, it would be expected that they retain their independence and not exhibit disability. It may be that the GOSE does not capture subtle cognitive or behavioral changes that influence adaptation. Future study may want to develop and use a more sensitive and specific measure of functions in adults with MTBI or they may want to use an objective observer when using the GOSE.
In conclusion, relationships among stimuli and between stimuli and coping, depressive symptoms and adaptation found in this study are few and small. Perhaps more associations are too modest to discern even in this relatively large sample. Alternatively, perhaps the passage of time is more influential to recovery after MTBI and the lack of 168 relationships is the result of “the tincture of time” since the average time elapsed since injury in this study is eight months.
Additional analysis considering coping as the moderator
Adding the interactions between social support and coping and depressive symptoms did not increase the variation of the GOSE that was already explained by all stimuli, coping and depressive symptoms. Therefore, coping and depressive symptoms were not the moderators for the GOSE. However, results in Figure 5-6 suggested that subjects with higher coping scores of fewer depressive symptoms were more likely to have better adaptation outcomes when their social support scores increased. There are only few subjects in this study reporting problems via GOSE scores. Increasing sample size or including more subjects with problems defined by the GOSE may show moderator effects of coping and depressive symptoms on the relationship of social support and the
GOSE.
Since all stimuli, coping and depressive symptoms could not predict the GOSE, there might be other predictors for the GOSE. Several predictors of the GOSE have been reported in other studies. Among subjects with severe brain injury, severity of the injury, neurophysical impairment, memory functioning, cognitive functioning and behavioral regulations were predictors of the GOSE (Tate & Broe, 1999). For ability to return to work or study, several factors for further investigation include cognitive functioning (Rao
& Kilgore, 1992), frontal lobe functions (Simpson & Schmitter-Edgecombe, 2002), verbal memory, verbal fluency, speed test and planning strategies (Drake, Gray, Yoder,
Pramuka, & Llewellyn, 2000), functional independence and functional assessment (Gurka et al., 1999), and performance in IQ score (Ip, Dornan, & Schentag, 1995). All of these 169 factors are indicators of subtle neuro-cognitive dysfunction and may be more sensitive to derangement caused by mild brain injury undetected by the GOSE.
Mediators
From RQ3.3: Can focal, contextual and residual stimuli predict coping?
No. All stimuli could explain 2.1% of coping. On the other hand, coping also could not predict quality of life and the GOSE. Therefore, coping was not a mediator for both quality of life and the GOSE.
From RQ3.4: Can focal, contextual and residual stimuli predict depressive symptoms?
No; stimuli could explain only 3.7% of depressive symptoms. Depressive symptoms also could not predict quality of life and the GOSE. Therefore, depressive symptoms were not a mediator for either quality of life or the GOSE.
Interestingly, coping and depressive symptoms were not related in this study (Table
19). It was expected that coping related to depressive symptoms, and both were processes of adaptation. There was one study reported similar result that coping was not related to depressive symptoms among single parent families (Hall, Gurley, Sachs, & Kryscio,
1991). However, several studies across population reported that coping and depressive symptoms were related such as among dementia caregivers (Enns & Cox, 2005), chronic disease patients (Schroder, 2004), and severe brain injury (Mellman, David, Bustamante,
Fins, & Esposito, 2001). It is noted that depressive symptoms among dementia caregivers, chronic diseases and severe brain injury are high unlike the low symptoms in this sample.
Further, the two measures use different time scales. The CES-D asks for depressive symptoms for the past week only whereas the CAPS measures coping over a lifetime. 170
Perhaps, narrowing the CAPS reference to time to the previous week would alter association with the CES-D.
In this study, neither coping nor depressive symptoms were mediators or predictors for quality of life and the GOSE among Thai adults with MTBI. However, coping could moderate the relationship between stimuli and quality of life. This finding was consistent with Rutterford and Wood (2006) who concluded that the interaction between coping and appraisal was a moderator for quality of life among 131 subjects greater 10 years post brain injury. The interaction between coping and social support did not affect the GOSE here while in another study, their findings were inconclusive. Rutterford and Wood
(2006) found that the interaction between coping and appraisal was the predictor of community re-integration but not of return to work. The finding that coping was not a predictor of quality of life conflicted with a study among dementia caregivers (Haley,
Levine, Brown, & Bartolucci, 1987). Conceptually, it is difficult to understand why coping does not mediate adaptation. It may be that the measure of coping is not specific to adults with MTBI. Recently, Roy suggested that coping and adaptation are combined
(Roy, in review) rather than separate as presented in this study’s conceptual model. The results of this study suggested that the need for further refinement of the RAM is supported.
The finding that depressive symptoms could not predict any adaptation outcome in this study was surprising and inconsistent with other studies. Depressive symptoms could predict quality of life in general population (Abbey & Andrews, 1985), patients with multiple sclerosis (Fruehwald, Loeffler-Stastka, Eher, Saletu, & Baumhackl, 2001;
Lobentanz et al., 2004), patients with stroke (King, 1996a), and patients with brain tumor
(Pelletier, Verhoef, Khatri, & Hagen, 2002). All of these studies had high depressive 171 symptom scores. Again, high scores indicating many depressive symptoms may be associated with lower QOL but the reverse relationship may not necessarily be true (i.e. low depressive symptom scores do not have to associate with high QOL). It would be useful to test this in a sample of age, gender matched controls, comparable to the sample in this study without other injuries but with similarly low depressive symptoms, high social support and high QOL.
This might be because subjects in this study reported low scores of depressive symptoms and their scores were lower than healthy Thai teenagers. They also had low scores of stress. It is expected that high stress will lead to depressive symptoms (Sangon,
2001; Srisaeng, 2003). A similar, although modest, relationship between stress and depressive symptoms appeared in this study, suggesting low stress and low depressive symptoms are correlated. An additional factor that could trigger depressive symptoms was PCS (Luis, Vanderploeg, & Curtiss, 2003; Ponsford, Olver, Ponsford, & Nelms,
2003) which were found to be very low among Thai adults with MTBI. Further study examining cause and effect (does stress trigger depression or viceversa) is recommended.
Another reason that depressive symptoms are unique in this study is that depression has been studied as an effect (outcome) in other studies (Bay, Hagerty, Williams, Kirsch,
& Gillespie, 2002; Haley, Levine, Brown, & Bartolucci, 1987; Ponsford, Olver, Ponsford,
& Nelms, 2003; Sangon, 2001; Srisaeng, 2003) while they were explored as causes (i.e., predictor, mediator or moderator) here. Future study should revise the conceptual model with depression as an outcome indicating maladaptation.
Finally, passage of time post-injury might be another reason helping Thai adults with MTBI deal with their problems. All subjects were 4-12 months after the injury and might have already adapted after experiencing MTBI. Any and all of these reasons could 172 explain why so few factors including depressive symptoms were not found to have any effect on adaptation after MTBI, while coping had minimal effect and only after it interacted with social support.
In conclusion, there were some stimuli that could predict quality of life. High social support had the moderate positive association with quality of life. The predictive statistical models suggested a medium contribution (15% - 25%) from the combined variables. Most of the subjects recovered and returned to their previous lives, with only
18% still reporting some problems. This small proportion of problem in recovery measured by the GOSE could not be explained by any factors. Adaptation measures, quality of life and the GOSE were not related to each other. Different aims for each of these two measures might be a reason for the lack of association. In addition, the quality of life examines a subjective response whereas the GOSE uses an objective approach.
Finally, the GOSE may not be the best tool to capture the minor or subtle neurological or functional derangements after mild TBI.
Limitations of this study
In this study, there was a moderate response rate of 29%. Several tactics were used to obtain this response rate. The initial response rate was 10.85% after the invitation letters were sent, increased to 19.5% with the second letter and reached the final participation rate with a follow-up phone call when a patient did not return the “opt-out” postcard. Despite all these efforts, the response rate limits generalizability, even among adults with MTBI in Thailand. However, given the level of education of potential subjects and the process of enrollment required by human subjects protection (e.g., reading 5-6 pages of information, returning a signed consent form in the mail), 29% may be a reasonable response rate. Interestingly, consent forms continued to arrive after the 173 requisite number of enrollees was achieved. Extending data collection period would have increased the response rate and will be considered in future studies.
In order to be a subject in this study, one needed a working telephone and mailing address. Therefore, it was not possible for homeless people or one who does not have telephone to be a participant in this study. However, telephone service is common in homes in Thailand and, with extensive family being normative; it is not common for most individuals to experience homelessness. The PI compared the differences of demographic data accessed from medical records among the potential and actual enrollees. The results indicated that the sample and the population had similar range of age and the proportion of gender, suggesting that the sample reflects at least some of the characteristics of the target population.
Subjects in this study were unique compared to other studies among adults with
MTBI. The subjects were in the rural area, worked mostly as farmers and day laborers, had low education and low income. The findings may not be applicable for subjects who live in the urban area or have higher socio-economic status. However, the findings do reflect the overall population in Thailand, where people more commonly live in rural areas, have little education and limited incomes. These characteristics are changing and it may be necessary to revisit this study as the population shifts to urban centers and education levels increase with new compulsory requirements.
Time of data collection might have affected some variables such as social support and quality of life. During the time of interviews, many subjects were looking forward to get together with all family members to celebrate the New Year. The anticipatory pleasure at this time of year may have masked depressive symptoms or pushed away stressful life events. 174
All subjects were recruited after treatment at a tertiary public hospital which may have different standard of care than those hospitals in an educational system or small local facilities. Discharge planning, follow-up and home care were not examined in this study and may influence adaptation; it is not known if these care factors influenced coping or depressive symptoms. These factors were not the focus of this study and could be investigated in the future as variables that influence recovery from MTBI, especially among patients with poor adaptation.
There may have been issues with honesty or self-revelation during the interview.
The PI was the only person who interviewed subjects including answering any questions the subject raised during the interview (such as queries for examples, definitions or queries about health and health care). Since the PI is a woman and most of the subjects are men, some questions may evoke anxiety or shame due to gender expectations. Many strategies were applied to reduce the subject’s anxiety and make them feel comfortable when answering questions. First of all, the PI was identified as a registered nurse, which is a position of trust. Identification as “a PhD student from a university in the US” was never mentioned as it might make the subjects feel too distanced from the PI. The PI’s telephone number in Thailand was provided for subjects to call at anytime. If the PI was not available, subjects received a return call within 24 hours. Since this setting is between the central and the northeast parts of Thailand, different dialects are used. During the interview, the PI used three different dialects, taking her cues from the respondent to promote comfort by using words and pronunciations that were familiar. Finally, all phone interviews were initiated by the PI so costs for telephoning were not passed on to subjects. Finally, care was taken to ask that subjects were in a place of privacy and comfortable before starting the interview to prevent any potential stigmatization from an 175 overheard conversation. These measures were taken to promote honesty and openness.
Interestingly, several participants chose to conduct that interview within hearing of a least one person. The PI could occasionally hear a side discussion of a response offended by the subject with someone nearby. Only the subject’s response was recorded but this observation of conversations around responses leads to the suggestion to interview a proxy who may view recovery and abilities differently than the adult with MTBI.
Implications and Recommendations
Theory development
This study based on a nursing theory, the Roy Adaptation Model (RAM). The
RAM is useful in guiding a broad picture of stimuli, process and outcome after MTBI.
Researchers may need to consider transcultural differences since each setting may be unique. In this study, social support, which had little effect in other studies and is categorized as residual stimuli, was the most powerful predictor. Meanwhile, severity of injury, a direct effect or focal stimuli, did not predict outcome in this study. Furthermore, the RAM showed some limitations in applying moderator effect in the framework. Based on the system theory, each independent variable can be either factor (stimuli) or mediator
(process). The basic framework of system theory does not provide information about the interaction effect between variable. Adaptation outcome is clearly stated in the RAM; however, measures of adaptation need to be developed. In subjects with MTBI, the physiological mode may not necessary to be measured at all. On the other hand, spirituality is missing from the framework. In this study, all subjects were Buddhist and this belief system may have influenced results in coping, depressive symptoms or even quality of life scores. For Buddhist, “Life is Suffering”, human beings are born to repay their old sin from the past lives (Banja, 2006). This belief brings a dilemma to Buddhist 176 followers. On one hand, this belief may help some subjects with MTBI to cope better.
Most of Buddhist believes that MTBI happened to them because they have hurt someone or some animals at the head. Experiencing MTBI is one way to repay the hurt they have made in the past. After repaying, they will then look forward for a new live or a next life with less suffering, or, ultimately, never reborn again. On the other hand, Buddhist beliefs may cause more guilts or depressive symptoms in some subjects. A prohibition of alcohol is one of the five basic rules for all Buddhist. Subjects with MTBI who use alcohol might experience more depressive symptoms than other.
The measure that has been developed by the theorist combined a concept of coping and adaptation together. This measure has been tested twice among Thai subjects and yielded high reliability. However, combining coping with adaptation leads to entanglement that may threaten its validity. Coping and adaptation are two different variables that have causal relationship with each other (Lazarus, 1966, 1991). However, some authors still argue that coping does not lead to a desired psychosocial outcomes
(Rutterford & Wood, 2006). By putting two different variables together and developing the CAPS, some attributes of coping or adaptation may not be captured. Considering factors that explained by the CAPS, (i.e., 1] resourceful and focused, 2] physical and fixed, 3] alert processing, 4] systematic processing, and 5] knowing and relating), it is clear that the CAPS was purposively developed to measure the process of coping, not adaptation outcomes (Chayaput, 2004; Roy, in review). Therefore, developing an adaptation measure is needed.
A middle range theory using the RAM is recommended for theory development.
For example, quality of life as an indicator adaptation has been used in two studies; this study and another among cancer patients (Nuamah, Cooley, Fawcett, & McCorkle, 1999). 177
The results are similar; quality of life appears to be a promising approach to capture adaptation. Similar work developing stimuli into middle range theoretical concepts is needed.
Nursing education
The findings in this study provide information about the importance of social support for good quality of life after MTBI. Perhaps teaching assessment of social support should be incorporated into curriculum since there are many disease processes which seem to benefit from this factor. Also, there were a small number of patients with MTBI that could not live their normal lives after the injury; including information about severity of brain injury and outcomes to help students anticipate the possible recovery pathway of an individual can be incorporated when teaching about brain injury. Teaching recognition of disability in patients with MTBI should be one of the assignments for students who are training in surgical or neurological departments so that intervention is not unduly delayed.
Nursing practice
The findings from this study revealed that there were 18% of subjects with MTBI could not return to their normal lives. Even though the GOSE is not a sensitive tool to capture outcome after MTBI, it is easy to use and can be finished in a few minutes.
Health care professionals could develop or provide an information pamphlet regarding
“what to expect after having MTBI” to the patients. Health care assessment on admission after MTBI should include social support or social network. Patients and health care professionals should be educated to evaluate outcomes after 3, 6, 9 and 12 months.
Patients should be advised that if their symptoms or disabilities persist beyond 3 months, that they should re-contact the health care facility or health care provider. 178
Several measures used in this study were translated into Thai, tested and yielded high reliability coefficients. These tools can be implemented among Thai adults with
MTBI to assess their outcomes, although some may need refinement or adaptation to a clinical setting (e.g. shorter length, greater ease of scoring).
Nursing research
Findings from this study provided descriptive information regarding adults with
MTBI in Thailand. For future study, it is recommended that concurrent data collection with a matching normal population be included to provide baseline information.
Replication studies could extend the science. For example, stratifying subjects with different categories of time postinjury, applying longitudinal methodology, recruiting subjects from multi-settings for a variation of demographic data, and increasing sample size to gain more variations.
Future studies that compare outcomes between different groups with MTBI such as genders, age categories, diagnosis (with and without multiple injuries), time postinjury and those with low social support should be conducted. In addition, the role of spirituality or religion could be added as a potential variable. Future studies that explore the same concepts but use different measures may provide additional validation.
Multiple regression models used in this study may not be the best way to examine the data. One strategy for this study is to re-examine the statistical models with transformation of data points that did not demonstrate optimal linearity. Another strategy is to enter variables into the statistical model only if there are demonstrated relationships.
Health policy
There was at least one standard of care that was different between this setting and other hospitals. It is recommended that subjects with MTBI should have an appointment 179 for follow-up at least six months after the injury to identify those patients with maladaptation so as to intervene and promote adaptation as measured by independence, lack of disability and quality of life. Health education about outcomes after MTBI should be routine before patients are discharged. Printed information regarding unexpected symptoms or adverse outcomes after MTBI requiring follow-up should be available. The value of treatment or follow-up for patients should also be investigated.
Conclusion
This study of adaptation after MTBI among Thai adults within the conceptual framework of Roy Adaptation Model indicated that social support was the most powerful predictor for quality of life. However, none of the stimuli predicted adaptation as measured by the GOSE. Additional analyses revealed that a moderating effect between social support and coping help explain quality of life. The two measures of adaptation in this study were not related; however, they provided important information about different aspects of recovery in adult Thais who experienced MTBI. Functionally, 18% of the subjects could not return to work. However, subjectively, most of the subjects were satisfied with their lives and adapted 4-12 months after injury.
The findings from this study provide a basis for future studies which can be longitudinal, comparison, or predictive study with fewer but relevant variables.
Developing a middle range theory is suggested for further, investigating, defining, stimuli and quality of life as adaptation, especially after MTBI. Several measures used in this study were reliable as measured by internal consistency and can be used within the Thai context. Health education or printed information about outcomes after MTBI is recommended for both health care students and victims of MTBI. Further study to better 180 understand why a small but clinically important percentage of subjects experience ongoing disability after MTBI is needed.
181
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APPENDIX 220
Study ID [ ][ ][ ] Appendix A Demographic Data Worksheet The following questions will be interviewed via phone interview
Direction: For the next nine questions, I will ask questions about you and your general information. If there is any information you cannot remember now, we can skip that question and come back to that question later at your convenience.
* 1. How old are you? ______years
* 2. How long did it take for you to remember everything after the injury? (Duration of
posttraumatic amnesia______minutes)
or medical record if patient unable to report ______minutes from record
* 3. How long did you faint or black out after the injury? (Duration of loss of
consciousness______minutes)
or medical record if patient unable to report ______minutes from record
* 4. What did you do for living before the injury?______
* 5. Are you back to school or work now? [ ](0) No [ ](1) Yes
* 6. What did you do for living after the injury?______
* 7. Did you go back to work or study at the same level as before the injury?
[ ](0) No [ ](1) Yes
* 8. If you were back to work or school, did you do it full time or part time?
[ ](1) Full time [ ](2) Part time
* 9. How long did it take for you to go back to school or work after the injury?
______days
221 Study ID [ ][ ][ ] The following information will be retrieved from medical record.
10. Gender [ ](1) Male [ ](2) Female
11. Marital Status [ ](1) Single / Never Married [ ](2) Married
[ ](3) Divorced [ ](4) Separated
[ ](5) Widowed
12. Religion [ ](1) Buddhist [ ](2) Other (please specify)______
13. Educational Level [ ](1) 4th grade or less [ ](2) 6th or 7th grade
[ ](3) Junior high school (7th-9th grade) [ ](4) High school
graduate [ ](5) 2yrs college/vocational/special training
[ ](6) 4 yrs college/ university [ ](7) Graduate level
[ [(8) Doctoral degree
14. Date Of injury ______(month)______(year)
15. Length of Stay______days
a. Date of admission______(month)______(year)
b. Date of discharge______(month)______(year)
16. Presence of alcohol at time of injury [ ](0) No [ ](1) Yes, or
medical record if patient unable to report
17. GCS At 30 minutes____At 24 hours_____At 48 hours_____ At 72 hours______
Duration of posttraumatic amnesia______minutes
Duration of loss of consciousness______minutes
*indicates 9 interview questions
222
แบบบันทึกขอม ูลสวนบุคคล Study ID [ ][ ][ ]
คําชี้แจง: คําถามตอไปนี้เปนคําถามทั่วๆไปเกี่ยวกับตัวทาน ทานอาจจะขอใหผูถามขามคําถามบางคําถามไปกอน และกลับมาตอบคําถามภายหลังได หากทานไมสามารถจําขอมูลบางสวน
*1. ปจจุบันทานอายุ______ป *2. ภายหลังการบาดเจ็บศีรษะ ทานมึนงง จําอะไรไมไดนาน (Duration of Posttraumatic amnesia) ___นาที หรือจากแฟมประวัติ หากผูรวมวิจัยไมสามารถที่จะจําได______นาที (จากแฟมประวัติ) *3. ทานหมดสติภายหลังการบาดเจ็บศีรษะนาน (Duration of loss of consciousness) ______นาที หรือจากแฟมประวัติ หากผูรวมวิจัยไมสามารถที่จะจําได______นาที (จากแฟมประวัติ) *4. กอนการบาดเจ็บ ทานประกอบอาชีพใด______*5. ภายหลังการบาดจ็บศีรษะ ทานกลับไปทํางานหรือกลับไปเรียนตอหรือไม [ ]ไมใช [ ]ใช *6. หลังการบาดเจ็บ ทานประกอบอาชีพใด______*7. ทานกลับไปเรียนหรือทํางานในระดับเดิมหรือไม [ ]ไมใช [ ]ใช *8. ทานกลับไปเรียนหรือทํางานเต็มเวลาหรือไม [ ]ทํางานหรือเรียนเต็มเวลา [ ]ทํางานหรือเรียนเปนบางสวน *9. ภายหลังการบาดเจ็บ ทานใชเวลาในการพักฟนนานเทาใดจึงสามารถที่จะกลับไปทํางานหรือเรียนได นาน______วัน
223 Study ID [ ][ ][ ] ขอมูลตอไปนี้รวบรวมจากแฟมประวัติของผูปวย 10. เพศ [ ]1. ชาย [ ]2. หญิง 11. สถานภาพสมรส [ ]1. โสด [ ]2. แตงงาน [ ]3. หยา [ ]4. แยก [ ]5. หมาย 12. ศาสนา [ ]1. พุทธ [ ]2. อื่นๆ โปรดระบ ุ 13. ระดับการศึกษา [ ]1. ประถมศึกษาชั้นปที่ 4 หรือต่ํากวา [ ]2. ประถม 6หรือ7 [ ]3. มัธยมตน [ ]4. มัธยมปลาย [ ]5. อนุปริญญา [ ]6. ปริญญาตรี [ ]7. ปริญญาโท [ ]8. ปริญญาเอก 14. วันที่ไดรับบาดเจ็บศีรษะ เดือน______พ.ศ.______15.ระยะเวลาที่เขารับการรักษาในโรงพยาบาล______วัน -วันที่เขารับการรักษาในโรงพยาบาล เดือน______พ.ศ.______-วันที่จําหนายออกจากโรงพยาบาล เดือน______พ.ศ.______16. ประวัติการดื่มสุราระหวางการบาดเจ็บครั้งนี้ [ ]0. ไมดื่ม [ ]1. ดื่ม 17. คะแนนการประเมินดานระบบประสาท หลังการบาดเจ็บ 30 นาที__หลังการบาดเจ็บ 24 ชั่วโมง____ หลังการบาดเจ็บ 48 ชั่วโมง____ หลังการบาดเจ็บ 72 ชั่วโมง_____ Duration of Posttraumatic amnesia) _____นาที Duration of loss of consciousness) ______นาที
* เปนคาถามทํ ี่ใชในการสัมภาษณ 224
Appendix B Postconcussion Syndrome Checklist (PCSC)
Direction: Some people experience some disturbances following their mild traumatic brain injury. Below is a list of symptoms that you may have experienced after your injury. Please answer whether each symptom happened to you. When you tell me that a symptom is present, I will then ask you to please tell me how often (frequency), how severe (intensity) and how long (duration) each symptom occurred. Please rate each item from 1 to 5 when 1 means not at all and 5 means constant or crippling.
Symptoms Not at all constant Anxiety - Frequency 1 2 3 4 5 - Intensity 1 2 3 4 5 - Duration 1 2 3 4 5 Dizziness - Frequency 1 2 3 4 5 - Intensity 1 2 3 4 5 - Duration 1 2 3 4 5 Headache - Frequency 1 2 3 4 5 - Intensity 1 2 3 4 5 - Duration 1 2 3 4 5 Memory - Frequency 1 2 3 4 5 - Intensity 1 2 3 4 5 - Duration 1 2 3 4 5 Visual Problems - Frequency 1 2 3 4 5 - Intensity 1 2 3 4 5 - Duration 1 2 3 4 5 Concentration - Frequency 1 2 3 4 5 - Intensity 1 2 3 4 5 - Duration 1 2 3 4 5 Fatigue - Frequency 1 2 3 4 5 - Intensity 1 2 3 4 5 - Duration 1 2 3 4 5 Irritability - Frequency 1 2 3 4 5 - Intensity 1 2 3 4 5 - Duration 1 2 3 4 5
225
Symptoms Not at all constant Judgment Problems - Frequency 1 2 3 4 5 - Intensity 1 2 3 4 5 - Duration 1 2 3 4 5 Noise Sensitivity - Frequency 1 2 3 4 5 - Intensity 1 2 3 4 5 - Duration 1 2 3 4 5
226
แบบวัดอาการภายหลังการบาดเจ็บศรษะแบบไมี รุนแรง วิจัยเรื่อง การปรับตัวภายหลังการบาดเจ็บศรีษะแบบไมรุนแรงของผูใหญชาวไทย คําชี้แจง ผูปวยบางรายอาจเคยมีอาการหรือการเปลี่ยนแปลงบางอยางภายหลังการบาดเจบศ็ ีรษะ ชนิดไมรุนแรง อาการดังตอไปนี้เปนอาการที่ผูปวยภายหลังการบาดเจบศ็ ีรษะอาจประสบได โปรด พิจารณาวาอาการตอไปนี้เคยเกิดขึ้นกับทาน ภายหลังการบาดเจ็บศีรษะแบบไมรุนแรงหรือไม หาก ทานประสบกับอาการดังนี้ โปรดระบความถุ ี่ของอาการที่เกิดกับทาน ความรุนแรงของอาการนั้นๆ และระยะเวลาที่เกิดอาการ โปรดเลือกหมายเลขที่ใกลเคียงกับความเปนจร ิงที่เกิดกับทานมากที่สุด โดยหมายเลข 1 หมายถึง นอยหรือไมมีอาการเลย และ หมายเลข 5 หมายถึงเปนมากหรือตลอดเวลา
อาการ นอยหรือไม เปนมากหรือ มีเลย ตลอดเวลา วิตกกังวล - ความบอย 1 2 3 4 5 - ความรุนแรง 1 2 3 4 5 - ระยะเวลา 1 2 3 4 5 วิงเวียนศีรษะ - ความบอย 1 2 3 4 5 - ความรุนแรง 1 2 3 4 5 - ระยะเวลา 1 2 3 4 5
ปวดศีรษะ - ความบอย 1 2 3 4 5 - ความรุนแรง 1 2 3 4 5 - ระยะเวลา 1 2 3 4 5 หลงลืม - ความบอย 1 2 3 4 5 - ความรุนแรง 1 2 3 4 5 - ระยะเวลา 1 2 3 4 5 ปญหาเกี่ยวกับการมองเห็น - ความบอย 1 2 3 4 5 - ความรุนแรง 1 2 3 4 5 - ระยะเวลา 1 2 3 4 5 227
อาการ นอยหรือไม เปนมากหรือ มีเลย ตลอดเวลา ไมมีสมาธ ิ - ความบอย 1 2 3 4 5 - ความรุนแรง 1 2 3 4 5 - ระยะเวลา 1 2 3 4 5
ออนเพลีย ไมมีแรง - ความบอย 1 2 3 4 5 - ความรุนแรง 1 2 3 4 5 - ระยะเวลา 1 2 3 4 5 กระสับกระสาย อยูไมสุข - ความบอย 1 2 3 4 5 - ความรุนแรง 1 2 3 4 5 - ระยะเวลา 1 2 3 4 5 มีปญหาเกี่ยวกับการเลือกหรือการตัดสินใจ - ความบอย 1 2 3 4 5 - ความรุนแรง 1 2 3 4 5 - ระยะเวลา 1 2 3 4 5 มีความไวตอเสียงมาก รูสึกวาเสียงรอบตัว ดังผิดปกต ิ - ความบอย 1 2 3 4 5 - ความรุนแรง 1 2 3 4 5 - ระยะเวลา 1 2 3 4 5
228
Appendix C
The Life Experience Survey
Direction: Listed below are a number of events which sometimes bring about change in the lives of those who experience them and which necessitate social readjustment. Please choose those events which you have experienced in the recent past and indicate the time period during which you have experienced each event whether it occurred in less than or more than 6 months.
For the item that happened to your life, I will ask whether you view it to have positive, negative, or no impact to you. Finally, I will ask you to rate the extent of each impact between extremely, moderately and somewhat.
You do not have to answer a question in this series if you do not want to do so. If you want to skip one question, we will simply proceed to the next question
0 to 6 month 7 mo to 1 yr -3 Extremely negative -2 Moderately negative -1 Somewhat negative 0 No impact +1 Slightly positive +2 Moderately positive positive +3 Extremely Score for this item 1. Marriage 2. Detention in jail or comparable institution 3. Death of spouse 4. Major change in sleeping habits (much more or much less sleep) 5. Death of close family member: a. Mother b. Father c. Brother d. Sister e. Grandparent f. Other (specify)______6. Major change in eating habits (much more or much less food intake) 7. Foreclosure on mortgage or loan 8. Death of close friend 229
0 to 6 month 7 mo to 1 yr -3 Extremely negative -2 Moderately negative -1 Somewhat negative 0 No impact +1 Slightly positive +2 Moderately positive positive +3 Extremely Score for this item 9. Outstanding personal achievement 10. Minor law violations (traffic tickets, disturbing the peace, etc.) 11. Male: Wife/ girlfriend’s pregnant 12. Female: Pregnancy 13. Changed work situation (different work responsibility, major change in working conditions, working hours, etc.) 14. New job 15. Serious illness or injury of close family member: a. Father b. Mother c. Brother d. Sister e. Grandparent f. Spouse g. Other (specify)______16. Sexual difficulties 17. Trouble with employer (in danger of losing job, being suspended, demoted, etc.) 18. Trouble with in-laws 19. Major change in financial status (a lot better off or lot worse off) 20. Major change in closeness of family members (increased or decreased closeness) 21. Gaining a new family member (through birth, adoption, family member moving in, etc.) 22. Change of residence 23. Marital separation from mate (due to conflict) 24. Major change in church activities (increased or decreased attendance) 25. Marital reconciliation with mate 230
0 to 6 month 7 mo to 1 yr -3 Extremely negative -2 Moderately negative -1 Somewhat negative 0 No impact +1 Slightly positive +2 Moderately positive positive +3 Extremely Score for this item 26. Major change in number of arguments with spouse ( a lot more or a lot less arguments) 27. Married male: Change in wife’s work outside the home (beginning work ceasing work, changing to a new job, etc.) 28. Married female: Changing in husband’s work (loss of job, beginning new job, retirement, etc.) 29. Major change in usual type and/ or amount of recreation 30. Borrowing more than 10,000 (buying home, business, etc.) 31. Borrowing less than 10,000 (buying car, TV, getting school loan, etc.) 32. Being fried from job 33. Male: Wife/ girlfriend having abortion 34. Female: Having abortion 35. Major personal illness or injury 36. Major change in social activities, e.g., parties, movies, visiting (increased or decreased participation) 37. Major change in living conditions of family (building new home, remodeling, decoration of home, neighborhood, etc.) 38. Divorce 39. Serious injury or illness of close friend 40. Retirement from work 41. Son or daughter leaving home (due to marriage, college, etc.) 42. Ending of formal schooling 43. Separation from spouse (due to work, travel, etc.) 44. Engagement 231
0 to 6 month 7 mo to 1 yr -3 Extremely negative -2 Moderately negative -1 Somewhat negative 0 No impact +1 Slightly positive +2 Moderately positive positive +3 Extremely Score for this item 45. Breaking up with boyfriend/ girlfriend 46. Leaving home for the first time 47. Reconciliation with boyfriend/ girlfriend
Other recent experiences with have had an impact on your life, list and rate 48.
49.
50.
232
แบบวัดเหตุการณที่กอใหเกิดความเครียด วิจัยเรื่อง การปรับตัวตอการบาดเจ็บศีรษะแบบไมรุนแรงของผูใหญชาวไทย คําชี้แจง รายการตอไปนี้เปนเหต ุการณที่อาจเกิดขึ้นและมีผลทําใหบุคคลที่ประสบเหตการณตอง ปรับตัว โปรดพิจารณารายการดังกลาววามีเหตการณใดที่ตรงกับชีวิตทานในรอบปที่ผานมาหรอไมื และโปรดระบุวาเหตการณนั้นเกิดขึ้นกับทานในช วงนอยกวาหรือมากกวา 6 เดือนที่ผานมา จากนั้นขอใหทานโปรดพิจารณาวา ขณะทเกี่ ิดเหตุการณนั้น มีผลกระทบตอชีวิตของทานหรือไม และมี ผลกระทบในแงบวกหรือแงลบ หากมผลกระทบผี ูวิจัยจะขอใหทานระบุวามีผลกระทบอยางมาก ปาน กลาง หรือนอย หากคําถามใดทําใหทานรูสึกไมสบายใจหรือไมตองการที่จะตอบ โปรดบอกใหขามคําถามนั้นไปโดยที่ทานไมจําเปนที่ จะตองตอบคําถามนั้นก็ได
างมาก ็ กน อย างใด ป
อย ั บปนากลาง นอย างเล างร ุ นแรง
ึง 1 ื อน ื อนถ ุ การณ เด านลบอย านลบระด านลบบ างเล ็ กน อย านบวกบ นบากระด ั บปานกลาง านบวกเป 0-6 เด 7 ผลกระทบแต มี ผลด มี ผลด มี ผลด มี ผลด มี ผลด มี ผลด ไม มี ในระยะ ในระยะ -3 -2 -1 0 +1 +2 +3 คะแนนเหต 1. แตงงาน 2. ติดคุก 3. คูสมรสเสียชีวิต 4. มีการเปลยนแปลงพฤตี่ ิกรรมการนอน (เพิ่มขึ้นหรือลดลง) 5. มีการเสียชีวิตของคนในครอบครัว ก. มารดา ข. บิดา ค. พี่หรือนองชาย ง. พี่หรือนองสาว จ. ปู ยา ตา ยาย ฉ. อื่นๆ (ระบุ)______6. มีการเปลยนแปลงพฤตี่ ิกรรมการ รับประทาน (มากขึ้นหรือนอยลง) 233
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ึง 1 ื อน ื อนถ ุ การณ เด านลบอย านลบระด านลบบ างเล ็ กน อย านบวกบ นบากระด ั บปานกลาง านบวกเป 0-6 เด 7 ผลกระทบแต มี ผลด มี ผลด มี ผลด มี ผลด มี ผลด มี ผลด ไม มี ในระยะ ในระยะ -3 -2 -1 0 +1 +2 +3 คะแนนเหต 7. บานถูกยึด 8. เพื่อนสนิทเสียชีวิต 9. ประสบความสําเร็จ 10. ทําผิดกฏหมายเล็กนอย (คาปรับ เกี่ยวกับการจราจร) 11. สําหรับเพศชาย-ภรรยา/ แฟน ตั้งครรภ 12. สําหรับเพศหญิง-ตั้งครรภ 13. มีการเปลยนแปลงของการงานี่ (เปลี่ยนแปลงความรับผิดชอบ เปลี่ยน เงื่อนไขในการทํางาน เปลี่ยนแปลงชั่วโมง ของการทํางาน เปนตน) 14. เปลี่ยนงานใหม 15. เกิดการเจ็บปวยหรือการบาดเจ็บ รุนแรงกับคนในครอบครัว ก. บิดา ข. มารดา ค. พี่หรือนองชาย ง. พี่หรือนองสาว จ. ปู ยา ตา ยาย ฉ. คูสมรส ช. อื่นๆ (ระบุ)______16. มีปญหาเกยวกี่ ับเพศสัมพนธั
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ึง 1 ื อน ื อนถ ุ การณ เด านลบอย านลบระด านลบบ างเล ็ กน อย านบวกบ นบากระด ั บปานกลาง านบวกเป 0-6 เด 7 ผลกระทบแต มี ผลด มี ผลด มี ผลด มี ผลด มี ผลด มี ผลด ไม มี ในระยะ ในระยะ -3 -2 -1 0 +1 +2 +3 คะแนนเหต 17. มีปญหากับหัวหนา นายจาง หรือ ผูบังคับบัญชา (ถูกภาคทัณฑ ถูกยาย อาจถูกไลออก) 18. มีปญหากับบิดา-มารดาของคูสมรส 19. มีการเปลยนแปลงดี่ านการเงิน (ดี ขึ้นหรือแยลง) 20. มีการเปลยนแปลงที่ ี่กระทบตอความ ใกลชิดกันของคนในครอบครัว (ใกลชิด มากขึ้นหรือหางเหิน) 21. มีสมาชิกใหมเพมขิ่ ึ้นในครอบครัว (จากการคลอด การรับบุตรบุญธรรม หรือ การยายเข า) 22. ยายบาน 23. แยกจากคูสมรสเพราะปญหาความ ขัดแยง 24. มีการเปลยนแปลงของการที่ ํา กิจกรรมทางศาสนา (เพิ่มขึ้นหรือลดลง) 25. คืนดีกับคูสมรส 26. มีการเปลยนแปลงจี่ ํานวนของการมี ปากเสียงกับคูสมรส (เพมขิ่ ึ้นหรือลดลง) 27. ชายทสมรสแลี่ ว-ภรรยาออกไป ทํางานนอกบาน หรือเปลี่ยนงาน 28. หญิงสมรสแลว-สามีตกงาน เปลี่ยน งาน หรือเกษียณ 29. มีการเปลยนแปลงชนี่ ิดและจํานวน ของงานอดิเรก 30. กูยืมเงินมากกวา 100,000 บาท 235
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ึง 1 ื อน ื อนถ ุ การณ เด านลบอย านลบระด านลบบ างเล ็ กน อย านบวกบ นบากระด ั บปานกลาง านบวกเป 0-6 เด 7 ผลกระทบแต มี ผลด มี ผลด มี ผลด มี ผลด มี ผลด มี ผลด ไม มี ในระยะ ในระยะ -3 -2 -1 0 +1 +2 +3 คะแนนเหต 31. กูยืมเงินนอยกว า 100,000 บาท 32. ถูกไลออกจากงาน 33. ชาย-ภรรยา/ แฟนแทง 34. หญิง-แทง 35. มีการเจ็บปวยหรือบาดเจ็บรุนแรง 36. เปลี่ยนแปลงกิจกรรมทางสังคม (รม กิจกรรมมาขึ้นหรือนอยลง) 37. เปลี่ยนแปลงที่อยูอาศัย เชน สราง บานใหม ตกแตง ขยายเพมเติ่ ิม หรือ ซอมแซมบาน 38. หยาราง 39. เพื่อนสนิทเจ็บปวยหรือไดรับ บาดเจ็บอยางร นแรงุ 40. เกษียณ 41. บุตรยายออกจากบาน (เพราะ แตงงานหรือไปเรียนตอ) 42. จบการศึกษา 43. หางจากคูสมรสเพราะเรองงานื่ การ เดินทาง 44. หมั้นหมาย 45. เลิกกับแฟน/ คูรัก 46. ยายออกจากบานเปนครั้งแรก 47. คืนดีกับแฟน/ คูรัก
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ึง 1 ื อน ื อนถ ุ การณ เด านลบอย านลบระด านลบบ างเล ็ กน อย านบวกบ นบากระด ั บปานกลาง านบวกเป 0-6 เด 7 ผลกระทบแต มี ผลด มี ผลด มี ผลด มี ผลด มี ผลด มี ผลด ไม มี ในระยะ ในระยะ -3 -2 -1 0 +1 +2 +3 คะแนนเหต โปรดระบุเหตุการณอื่นๆทเกี่ ิดขึ้นและมี ผลกระทบตอชีวิตของทาน 48.
49.
50.
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Appendix D Social Support Questionnaire Short Form (SSQ6)
Direction: The following questions ask about people in your environment who provide you with help or support. Each question has two parts. For the first part, please list all the people you know, excluding yourself, whom you can count on for help or support in the manner described. Give the person’s initial and their relationship to you.
For the second part, please answer whether you “satisfied” or “dissatisfied” with the overall support you have from each person. Then, please rate degree of the satisfaction or dissatisfaction between very, fairly, and a little.
If you have no support for a question, please answer “NO ONE”, but still rate your level of satisfaction. Do not list more than nine persons per question. Please answer all questions as best as you can. All your responses will be kept confidential.
1. Whom you can really count on to be dependable when you need help? No One 1) 4) 7) 2) 5) 8) 3) 6) 9) How satisfied? 6 - very 5 – fairly 4 - a little 3 - a little 2 – fairly 1 - very satisfied satisfied satisfied dissatisfied dissatisfied dissatisfied
2. Whom can you really count on to help you feel more relaxed when you are under pressure or tense? No One 1) 4) 7) 2) 5) 8) 3) 6) 9) How satisfied? 6 - very 5 - fairly 4 - a little 3 - a little 2 – fairly 1 - very satisfied satisfied satisfied dissatisfied dissatisfied dissatisfied
3. Who accepts you totally, including both your worst and your best point? No One 1) 4) 7) 2) 5) 8) 3) 6) 9) How satisfied? 6 - very 5 - fairly 4 - a little 3 - a little 2 - fairly 1 - very satisfied satisfied satisfied dissatisfied dissatisfied dissatisfied
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4. Whom can you really count on to care about you, regardless of what is happing to you? No One 1) 4) 7) 2) 5) 8) 3) 6) 9) How satisfied? 6 - very 5 - fairly 4 - a little 3 - a little 2 - fairly 1 - very satisfied satisfied satisfied dissatisfied dissatisfied dissatisfied
5. Whom can you really count on to help you feel better when you are feeling generally down-in-the-dumps? No One 1) 4) 7) 2) 5) 8) 3) 6) 9) How satisfied? 6 - very 5 - fairly 4 - a little 3 - a little 2 - fairly 1 - very satisfied satisfied satisfied dissatisfied dissatisfied dissatisfied
6. Whom can you count on to console you when you are very upset? No One 1) 4) 7) 2) 5) 8) 3) 6) 9) How satisfied? 6 - very 5 – fairly 4 - a little 3 - a little 2 - fairly 1 - very satisfied satisfied satisfied dissatisfied dissatisfied dissatisfied
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แบบวัดแรงสนับสนุนทางสงคมั วิจัยเรื่องการปรับตัวตอการบาดเจ็บศีรษะแบบไมรุนแรงในผูใหญชาวไทย
คําชี้แจง ตอไปนี้เปนคําถามเกี่ยวกับบุคคลรอบขางของทานที่ใหความชวยเหลือทาน แตละคาถามํ ประกอบไปดวย 2 สวน สวนที่หนึ่ง ใหทานระบุคนที่ทานรูจัก ไมเกิน 9 คน รวมทั้งตัวของทานเอง ที่ สามารถชวยเหลือทานในเรื่องนั้นๆได สวนที่สอง ขอใหทานพิจารณาวา ทานพงพอใจหรึ ือไมพึงพอใจ ในความชวยเหลือที่ไดรับ จากนั้นขอใหทานระบุระดบของความพอใจหรั ือไมพอใจในแตละขอวาอย ู ในระดับ มาก ปานกลาง หรือ นอย หากทานไมมีผูที่ใหการชวยเหลือ โปรดตอบ ไมมีเลย และระบุ ระดับของความพึงพอใจหรือไมพึงพอใจ
1. มีใครบางที่ทานสามารถที่จะพึ่งพาอาศัยไดเมื่อทานต องการความชวยเหลือ ไมมีเลย 1) 4) 7) 2) 5) 8) 3) 6) 9) ทานรูสึกพึงพอใจหรือไม 6 – พอใจมาก 5 - คอนขาง 4 - พอใจบาง 5 - ไมพอใจ 2 - คอนขางไม 1- ไมพอใจอยาง พอใจ เล็กนอย บางเล็กนอย พอใจ มาก
2. มีใครบางที่จะทําใหทานรูสึกผอนคลายได ในยามที่ทานรูสึกเครียดหรือกดดัน ไมมีเลย 1) 4) 7) 2) 5) 8) 3) 6) 9) ทานรูสึกพึงพอใจหรือไม 6 – พอใจมาก 5 - คอนขาง 4 - พอใจบาง 5 - ไมพอใจ 2 - คอนขางไม 1- ไมพอใจอยาง พอใจ เล็กนอย บางเล็กนอย พอใจ มาก
3. มีใครบางที่ยอมรับทานไดทุกอยางที่ทานเปน ไมวาจะเปนเรื่องดีหรือเรื่องราย ไมมีเลย 1) 4) 7) 2) 5) 8) 3) 6) 9) ทานรูสึกพึงพอใจหรือไม 6 – พอใจมาก 5 - คอนขาง 4 - พอใจบาง 5 - ไมพอใจ 2 - คอนขางไม 1- ไมพอใจอยาง พอใจ เล็กนอย บางเล็กนอย พอใจ มาก
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4. มีใครบางที่เปนหวงเปนใยทาน ไมวาอะไรจะเกิดขึ้นกับทานกตาม็ ไมมีเลย 1) 4) 7) 2) 5) 8) 3) 6) 9) ทานรูสึกพึงพอใจหรือไม 6 – พอใจมาก 5 - คอนขาง 4 - พอใจบาง 5 - ไมพอใจ 2 - คอนขางไม 1- ไมพอใจอยาง พอใจ เล็กนอย บางเล็กนอย พอใจ มาก
5. มีใครบางที่จะสามารถทําใหทานรูสึกดีขึ้นได ในยามที่ทานรูสึกย่ําแยมากๆ ไมมีเลย 1) 4) 7) 2) 5) 8) 3) 6) 9) ทานรูสึกพึงพอใจหรือไม 6 – พอใจมาก 5 - คอนขาง 4 - พอใจบาง 5 - ไมพอใจ 2 - คอนขางไม 1- ไมพอใจอยาง พอใจ เล็กนอย บางเล็กนอย พอใจ มาก
6. มีใครบางที่จะชวยปลอบใจทาน ในยามที่ทานรูสึกผิดหวัง ไมมีเลย 1) 4) 7) 2) 5) 8) 3) 6) 9) ทานรูสึกพึงพอใจหรือไม 6 – พอใจมาก 5 - คอนขาง 4 - พอใจบาง 5 - ไมพอใจ 2 - คอนขางไม 1- ไมพอใจอยาง พอใจ เล็กนอย บางเล็กนอย พอใจ มาก
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Appendix E The Coping-Adaptation Processing Scale
Direction: Sometimes people experience very difficult events or crises in their lives. Below is a list of ways in which people respond to those events. For each item, please choose the number closest to how you personally respond. For example, if you never respond to events this way, please answer “never”; If you respond to events using this way for 25% or ¼ of the time, please answer “rarely; If you respond to events using this way for 50% or ½ of the time, please answer “sometime”; and, if you respond to events using this way for 75% or ¾ of the time, please answer “always”.
You do not have to answer a question in this series if you do not want to do so. If you want to skip one question, we will simply proceed to the next question
“When I experience a crisis, or extremely difficult Never Rarely Sometimes Always event, I……” 1.Can follow a lot of directions at once, even in a crisis 1 2 3 4 2.Generally come up with a new solution to a new 1 2 3 4 problem 3.Call the problem what it is and try to see the whole 1 2 3 4 picture 4.Gather as much information as possible to increase 1 2 3 4 my options 5.Commonly have difficulty completing tasks or 1 2 3 4 projects when I am troubled 6.Try to recall strategies/ solutions that worked for me 1 2 3 4 in the past 7.Generally try to make everything work on my favor 1 2 3 4 8.Can think of nothing else, except what’s bothering me 1 2 3 4 9.Feel good knowing that I’m handling the problem the 1 2 3 4 best I can 10.Identify how I want the solution to turn out, then see 1 2 3 4 how can I get there 11.less effective under stress 1 2 3 4 12.give myself time in the situation and do not act until 1 2 3 4 I have a full grasp of the situation 13.Find a crisis too complex with more parts that I can 1 2 3 4 handle 14.Think through the problem systematically step by 1 2 3 4 step 15.Seem to start slowing down for no particular reason 1 2 3 4 16.Work hard to re-channel my feelings to a 1 2 3 4 constructive approach
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“When I experience a crisis, or extremely difficult Never Rarely Sometimes Always event, I……” 17.Feel alert and active through out the day during the 1 2 3 4 crisis 18.Put feelings aside and am very objective about what 1 2 3 4 it is happening 19.Keep my eyes and ears open for anything related to 1 2 3 4 the event 20.Tend to overreact at first 1 2 3 4 21.Remember things that helped in the other situations 1 2 3 4 22.Put the event into perspective by seeing it for what it 1 2 3 4 really is 23.Tend to freeze and feel somewhat confused for at 1 2 3 4 least awhile 24.Find it hard to tell what the problem really is 1 2 3 4 25.Am good at handling problems that have many parts 1 2 3 4 to them 26.Try to get more resources to deal with the situation 1 2 3 4 27.Can still find my way around better than most 1 2 3 4 people when I have to go unfamiliar place 28.Use humor in handling the situation 1 2 3 4 29.Am likely to disrupt my life with radical changes to 1 2 3 4 get out of the crisis 30.Try to maintain balance in my activity and rest 1 2 3 4 31.Am more effective under stress 1 2 3 4 32.Can relate what’s happening to my past experience 1 2 3 4 or future plans 33.Tend to blame myself for whatever difficulties I 1 2 3 4 have 34.Try to be creative and come up with a new solution 1 2 3 4 35.Don’t seem to benefit from my prior experience for 1 2 3 4 some reason 36.Learn about solutions that I have worked for others 1 2 3 4 37.Look at the event in a positive light, as an 1 2 3 4 opportunity or challenge 38.Brainstorm as many possible solutions as I can even 1 2 3 4 if they seem far out 39.Experience changes in physical activity 1 2 3 4 40.Get a hold on the situation by quickly taking in the 1 2 3 4 details as they happen 41.Try to clear up any uncertainties before I do 1 2 3 4 anything else 42.Am likely to attack the crisis head on 1 2 3 4 43.Find I become ill 1 2 3 4
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“When I experience a crisis, or extremely difficult Never Rarely Sometimes Always event, I……” 44.Take a new skill pretty quickly, when it can solve 1 2 3 4 my difficulty 45.Too often give up easily 1 2 3 4 46.Develop a plan with a series of actions to deal with 1 2 3 4 the event 47.Seem to do a lot of wishful thinking about how 1 2 3 4 things will turn out
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แบบวัดกลยุทธในการปรับตัวตอปญหาหรือภาวะวิกฤต
คําชี้แจง แบบสอบถามนี้มีวัตถุประสงคในการประเมินกลยุทธในการปรับตัวตอภาวะวิกฤตหรือเหตุการณที่ ยากลําบากในชีวิต คําตอบที่ทานตอบไมมีถูกหรือผิด เพราะแตละบุคคลจะเลือกใชกลยุทธหรือหนทางในการแกไข ปญหาตางกัน ขอความขางลางนี้เปนรายการของกลยุทธหรือหนทางที่คนเราตอบสนองตอภาวะวิกฤตหรือเหตุการณ ที่ยากลําบากเหลานั้น ผูวิจัยจะอานขอความใหทานฟงทละขี อและโปรดเลือกขอความที่ใกลเคียงกับทางเลือกในการ แกปญหาของทานตามความเปนจริงมากที่สุด โดยที่ หากทานไมเคยทําเชนนี้เลยเมื่อประสบปญหา กรุณาตอบ ไมเคย หากทานทําเชนนี้นานๆครั้ง หรือรอยละ 25 หรือ 1 ใน 4 ของเวลาที่ประสบปญหา กรุณาตอบ นานๆครั้ง หากทานทําเชนนี้บางครั้ง หรือรอยละ 50 หรือ 1 ใน 2 ของเวลาที่ประสบปญหา กรุณาตอบ บางครั้ง หากทานทําเชนนี้เสมอ หรือมากกวารอยละ 75 หรือ 3 ใน 4 ของเวลาที่ประสบปญหา กรุณาตอบ เสมอๆ หากคําถามใดทําใหทานรูสึกไมสบายใจหรือไมตองการที่จะตอบ โปรดบอกใหขามคําถามนั้นไปโดยที่ทานไม จําเปนที่จะตองตอบคําถามนั้นก็ได เมื่อฉันมีปญหาหรือพบกับความยากลําบาก ฉัน...... ไมเคย นานๆ บางครั้ง เสมอๆ ครั้ง 1. สามารถที่จะทาตามหลายๆแนวทางหรํ ือหลายๆคําชแจงไดี้ ทันที แมจะอยูในภาวะวิกฤต 1 2 3 4 2. หาทางแกไขใหมสําหรับปญหาใหม 1 2 3 4 3. นึกวาปญหาคืออะไรและพยายามมองภาพรวมของปญหา 1 2 3 4 4. รวบรวมขอมูลใหมากที่สุด เพื่อเพมทางเลิ่ ือกในการแกปญหา 1 2 3 4 5. มักทํางานหรือโครงการตางๆไมสําเร็จ เมื่อพบกับปญหา 1 2 3 4 6. พยายามนึกถึงกลยุทธหรือวิธีแกปญหาที่เคยใชไดผลมากอน 1 2 3 4 7. พยายามทําใหทุกอยางเปนไปในทางที่ฉันไดประโยชนหรือพอใจ 1 2 3 4 8. ไมคิดถึงสิ่งอื่นเลย นึกถึงแตปญหาที่มีอยู 1 2 3 4 9. รูสึกดีที่ไดรูวาตวเองจั ัดการปญหาอยางดีที่สุดแลว 1 2 3 4 10. แยกแยะวาฉันตองการใหทางออกเปนอยางไรและดูวาจะไปถึงตรงนั้นไดอยางไร 1 2 3 4 11. ทํางานมีประสทธิ ินอยลงเมื่อเครียด 1 2 3 4 12. ใหเวลากับตัวเองในสถานการณนั้นๆและจะยังไมลงมือแกปญหา จนกวาจะเขาใจ 1 2 3 4 สถานการณอยางถองแท 13. พบวาปญหาซบซั อนเกินไป และมีหลายสวนจนฉันรับมือไมไหว 1 2 3 4 14. มองทะลุปญหาอยางเปนระบบ ทีละขั้น ทีละตอน 1 2 3 4 15. ดูเหมือนจะเรมทิ่ ําอะไรชาลง โดยไมมีเหตุผล 1 2 3 4 16. พยายามอยางหนักที่จะปรับเปลี่ยนชองของความรูสึกไปสูวีธีการที่มั่นคงขึ้น 1 2 3 4 17. รูสึกตื่นตัวและกระฉับเฉงทั้งวันระหวางที่มีปญหาหรือภาวะวักฤต 1 2 3 4 18. ตัดเอาเรื่องอารมณออกไปและพยายามใชเหตุผลเพอหาวื่ าเกิดอะไรขึ้น 1 2 3 4 19. เปดหูเปดตาร บอะไรกั ็ตามที่เกี่ยวกับเหตุการณนี้ 1 2 3 4 20. มีแนวโนมที่จะแสดงออกเกินกวาเหต ุ/ตีโพยตีพายในตอนแรกๆ 1 2 3 4 21. จดจําในสิ่งที่เคยชวยแกปญหาในเหตุการณอื่นๆ 1 2 3 4 22. มองปญหาตามความเปนจริง 1 2 3 4 23. มีแนวโนมที่จะเกร็งและสับสนไปชั่วขณะ 1 2 3 4 24. พบวามันยากที่จะบอกวาปญหาที่แทจริงคืออะไร 1 2 3 4 245
เมื่อฉันมีปญหาหรือพบกับความยากลําบาก ฉัน...... ไมเคย นานๆ บางครั้ง เสมอๆ ครั้ง 25. เกงในการแกปญหาที่มีหลากหลายสวนประกอบ 1 2 3 4 26. พยายามหาแหลงชวยแกปญหาเพิ่ม 1 2 3 4 27. ยังหาทางออกไดดีกวาคนอื่นๆเมื่อตองไปในที่ๆไมคุนเคย 1 2 3 4 28. ใชอารมณขันในการรับมือกับสถานการณ 1 2 3 4 29. มักจะทําใหชีวิตตัวเองยุงเหยิงดวยการเปลี่ยนแปลงอยางใหญหลวง เพื่อที่จะไดออกจาก 1 2 3 4 ปญหา 30. พยายามรักษาสมดุลยของการทํากิจกรรมและการพักผอน 1 2 3 4 31. ทํางานมีประสทธิ ิมากขึ้นเมื่อเครยดี 1 2 3 4 32. พยายามหาความเกี่ยวของของปญหาก ับประสบการณในอดีตหรือแผนการอนาคต 1 2 3 4 33. มีแนวโนมที่จะโทษตัวเองในทุกความลาบากทํ ี่ตองประสบ 1 2 3 4 34. พยายามสรางสรรคและหาทางออกใหมๆ 1 2 3 4 35. ไมคอยไดประโยชนจากประสบการณในอดีต 1 2 3 4 36. เรียนรูเกี่ยวกับทางออกที่ฉันเคยชวยเหลือคนอื่น 1 2 3 4 37. มองเหตุการณในทางบวก เหมือนกับวาเปนโอกาสหรือการทาทายความสามารถ 1 2 3 4 38. ระดมสมองหาทางออกใหไดมากที่สุด แมวาบางทางออกจะยังอยูอีกไกล 1 2 3 4 39. ประสบกับการเปลี่ยนแปลงเรื่องของกิจกรรมทางรางกาย (physical activity) 1 2 3 4 40. พยายามควบคุมถานการณดวยการเก็บรายละเอียดของเหตุการณทันทีที่มันเกิด 1 2 3 4 41. พยายามกําจัดสิ่งที่ไมแนนอนกอนที่จะลงมือทําอยางอื่น 1 2 3 4 42. ดูเหมือนจะลุยกับปญหาโดยตรง 1 2 3 4 43. พบวาตวเองปั วย 1 2 3 4 44. รับเอาทักษะใหมๆที่ชวยแกปญหาไดอยางรวดเร็ว 1 2 3 4 45. ยอมแพกับปญหาอยางงายๆอยูบอยๆ 1 2 3 4 46. พัฒนาแผนการพรอมกับขั้นตอนการรับมือกับปญหา 1 2 3 4 47. ดูเหมือนจะภาวนาใหเหตุการณคลี่คลายไปไดดวยด ี 1 2 3 4
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Appendix F © Ferrans and Powers QUALITY OF LIFE INDEX BRAIN INJURY VERSION PART 1. Direction: For each of the following, please choose the answer that best describes how satisfied you are with that area of your life. There are no right or wrong answers. For each item, please answer that you “satisfied’ or ‘dissatisfied’. After that I will ask you to rate degree of each satisfaction or dissatisfaction whether it is very (>70%), moderately (30-70%) or slightly (<30%). You do not have to answer a question in this series if you do not want to do so. If you want to skip one question, we will simply proceed to the next question
HOW SATISFIED ARE YOU WITH:
Very Dissatisfied Dissatisfied Very Moderately Dissatisfied Slightly Dissatisfied Slightly Satisfied Moderately Satisfied Very Satisfied 1.Your health? 1 2 3 4 5 6 2.Your health care? 1 2 3 4 5 6 3.The amount of physiological symptoms such as 1 2 3 4 5 6 headache, dizziness or sleep disturbance that you have? 4.The amount of emotional symptoms such as 1 2 3 4 5 6 anger easily or irritability that you have? 5.Your ability to remember or think as before? 1 2 3 4 5 6
6.The amount of energy you have for everyday 1 2 3 4 5 6 activities? 7.Your ability to take care of yourself without 1 2 3 4 5 6 help? 8.The amount of control you have over your life? 1 2 3 4 5 6 247
HOW SATISFIED ARE YOU WITH:
Very Dissatisfied Dissatisfied Very Moderately Dissatisfied Slightly Dissatisfied Slightly Satisfied Moderately Satisfied Very Satisfied 9.Your chances of living as long as you would 1 2 3 4 5 6 like? 10.Your family’s health? 1 2 3 4 5 6 11.Your children? 1 2 3 4 5 6 12.Your family’s happiness? 1 2 3 4 5 6 13.Your sex life? 1 2 3 4 5 6 14.Your spouse, lover, or partner? 1 2 3 4 5 6 15.Your friends? 1 2 3 4 5 6 16.The emotional support you get from your 1 2 3 4 5 6 family? 17.The emotional support you get from people 1 2 3 4 5 6 other than your family? 18.Your ability to take care of family 1 2 3 4 5 6 responsibilities? 19.How useful you are to others? 1 2 3 4 5 6 20.The amount of worries in your life? 1 2 3 4 5 6 21.Your neighborhood? 1 2 3 4 5 6 22.Your home, apartment, or place where you 1 2 3 4 5 6 live? 23.Your job or not having a job? 1 2 3 4 5 6 24.Your education? 1 2 3 4 5 6 25.How well you can take care of your financial 1 2 3 4 5 6 needs? 26.The things you do for fun? 1 2 3 4 5 6 248
HOW SATISFIED ARE YOU WITH:
Very Dissatisfied Dissatisfied Very Moderately Dissatisfied Slightly Dissatisfied Slightly Satisfied Moderately Satisfied Very Satisfied 27.Your chances for a happy future? 1 2 3 4 5 6 28.Your peace of mind? 1 2 3 4 5 6 29.Your faith in God? 1 2 3 4 5 6 30.Your achievement of personal goals? 1 2 3 4 5 6 31.Your happiness in general? 1 2 3 4 5 6 32.Your life in general? 1 2 3 4 5 6 33.Your personal appearance? 1 2 3 4 5 6
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© Ferrans and Powers QUALITY OF LIFE INDEX BRAIN INJURY VERSION PART 2. Direction: For each of the following, please choose the answer that best describes how important that area of your life is to you. There are no right or wrong answers. For each item, please answer that you think it is “important’ or “unimportant”’. Then, I will ask you to rate degree of each importance or unimportance whether it is very (>70%), moderately (30-70%) or slightly (<30%).
HOW IMPORTANT TO YOU IS:
Very Unimportant Unimportant Very Moderately Unimportant Slightly Unimportant Slightly Important Important Moderately Important Very 1.Your health? 1 2 3 4 5 6 2.Your health care? 1 2 3 4 5 6 3.The amount of physiological symptoms such as 1 2 3 4 5 6 headache, dizziness or sleep disturbance that you have? 4.The amount of emotional symptoms such as anger easily 1 2 3 4 5 6 or irritability that you have? 5.Your ability to remember or think as before? 1 2 3 4 5 6
6.The amount of energy you have for everyday activities? 1 2 3 4 5 6 7.Your ability to take care of yourself without help? 1 2 3 4 5 6 8.The amount of control you have over your life? 1 2 3 4 5 6 9.Your chances of living as long as you would like? 1 2 3 4 5 6 10.Your family’s health? 1 2 3 4 5 6 11.Your children? 1 2 3 4 5 6 12.Your family’s happiness? 1 2 3 4 5 6 250
HOW IMPORTANT TO YOU IS:
Very Unimportant Unimportant Very Moderately Unimportant Slightly Unimportant Slightly Important Important Moderately Important Very 13.Your sex life? 1 2 3 4 5 6 14.Your spouse, lover, or partner? 1 2 3 4 5 6 15.Your friends? 1 2 3 4 5 6 16.The emotional support you get from your family? 1 2 3 4 5 6 17.The emotional support you get from people other than 1 2 3 4 5 6 your family? 18.Your ability to take care of family responsibilities? 1 2 3 4 5 6 19.How useful you are to others? 1 2 3 4 5 6 20.The amount of worries in your life? 1 2 3 4 5 6 21.Your neighborhood? 1 2 3 4 5 6 22.Your home, apartment, or place where you live? 1 2 3 4 5 6 23.Your job or not having a job 1 2 3 4 5 6 24.Your education? 1 2 3 4 5 6 25.How well you can take care of your financial needs? 1 2 3 4 5 6 26.The things you do for fun? 1 2 3 4 5 6 27.Your chances for a happy future? 1 2 3 4 5 6 28.Your peace of mind? 1 2 3 4 5 6 29.Your faith in God? 1 2 3 4 5 6 30.Your achievement of personal goals? 1 2 3 4 5 6 31.Your happiness in general? 1 2 3 4 5 6 32.Your life in general? 1 2 3 4 5 6 33.Your personal appearance? 1 2 3 4 5 6
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แบบวัดคุณภาพชีวิตของผูปวยภายหลังการบาดเจ็บศีรษะแบบไมรุนแรง
สวนที่ 1 คําชี้แจง: ในแตละข อตอไปนี้ โปรดเลือกคาตอบทํ ตรงกี่ ับ ระดับความพึงใจ ที่ทานมีตอ แงมุมตางๆในชีวิตของทาน ภายหลังจากที่ไดรับบาดเจ็บศีรษะ คําตอบของทานไมมีการผิดหรือถูก ดังนั้นโปรดเลอกคื ําตอบทตรงกี่ ับความเปนจร ิงมากที่สุด ในแตละขอขอใหทานตอบวาทาน “พอใจ” หรือ “ไมพอใจ” ประเด็นนนๆั้ จากนั้นผูวิจัยจะขอใหทานใหน้ําหนักของความพอใจหรือไมพอใจวา มากหรือมากกวารอยละ 70 ปานกลางหรือรอยละ 30-70 หรือนอยหรือนอยกวารอยละ 30 หากคําถามใดทําใหทานรูสึกไมสบายใจหร ือไมตองการที่จะตอบ โปรดบอกใหขามคําถามนนไปั้ โดยที่ทานไมจําเปนที่จะตองตอบค ําถามนั้นก็ได
อย าง
ูบ อย น าง
นอย าง ็ กน ทานรูสึกพึงพอใจหรือไม เพียงใดตอสิ่งตางๆ
างย ิ่ง พอใจเป พอใจอย พอใจเล ็ กน อย ไม ไม ไม พอใจเล พอใจอย ูบ พอใจเป มาก ตอไปน ี้ ปานกลาง 1.ภาวะสุขภาพ 1 2 3 4 5 6 2.การดูแลทางดานสุขภาพที่ไดรับอย ู 1 2 3 4 5 6 3.อาการทางรางกายตางๆท เกี่ ิดกับทานภายหลังการ 1 2 3 4 5 6 บาดเจ็บศีรษะ เชน ปวดศีรษะ วิงเวียน นอนไมหลับ 4.การเปลี่ยนแปลงทางอารมณที่เกิดกับทานภายหลัง 1 2 3 4 5 6 การบาดเจ็บศรษะี เชน หงุดหงิดงาย โกรธงาย 5.ความสามารถในการคิด การจําเหมือนกอนบาดเจ็บ 1 2 3 4 5 6 6.การมีพละกําลังในการประกอบกิจวัตรประจําวัน 1 2 3 4 5 6 7.ความสามารถในการทําสงติ่ างๆไดดวยตนเอง 1 2 3 4 5 6 8.ความสามารถในการควบคุมและตดสั ินใจเกี่ยวกับ 1 2 3 4 5 6 ชีวิตของตนเอง 9.ความหวังที่จะมีชีวิตยืนยาว 1 2 3 4 5 6 10.สุขภาพของสมาชิกในครอบครัว 1 2 3 4 5 6 11.ความสําเร็จของบุตรหลานหรือบุคคลใกลชิด 1 2 3 4 5 6 12.ความสุขในครอบครัว 1 2 3 4 5 6 252
อย าง
ูบ อย น าง
นอย าง ็ กน ทานรูสึกพึงพอใจหรือไม เพียงใดตอสิ่งตางๆ
างย ิ่ง พอใจเป พอใจอย พอใจเล ็ กน อย ไม ไม ไม พอใจเล พอใจอย ูบ พอใจเป มาก ตอไปน ี้ ปานกลาง 13.เพศสัมพันธ 1 2 3 4 5 6 14.ความสัมพันธกับคูครองหรือบุคคลที่มี 1 2 3 4 5 6 ความสําคัญ 15.ความสัมพันธกับเพื่อนและผูรวมงาน 1 2 3 4 5 6 16.ความชวยเหลือ ความเหนอกเห็ ็นใจ กําลังใจที่ 1 2 3 4 5 6 ไดรับจากครอบครัว 17.ความชวยเหลือ ความเหนอกเห็ ็นใจ กําลังใจที่ 1 2 3 4 5 6 ไดรับจากบุคคลอื่น นอกเหนือจากคนในครอบครัว 18.ความสามารถที่จะทําหนาท ี่ในครอบครัว 1 2 3 4 5 6 19.ความมีประโยชนหรือมีคุณคาตอผูอื่น 1 2 3 4 5 6 20.ระดับความเครียดหรือความวิตกกังวลในชีวิต 1 2 3 4 5 6 21.ความสัมพันธกับเพื่อนบาน 1 2 3 4 5 6 22.บานเรือนและสิ่งแวดลอมที่อยูอาศัย 1 2 3 4 5 6 23.การมีหรือไมมีงานทํา 1 2 3 4 5 6 24.การศึกษา 1 2 3 4 5 6 25.ความสามารถในการพึ่งตนเองดานการเงิน 1 2 3 4 5 6 26.งานอดิเรกหรือกิจกรรมในยามวาง 1 2 3 4 5 6 27.ความหวังที่จะมีความสุขในอนาคต 1 2 3 4 5 6 28.ความสงบทางใจ 1 2 3 4 5 6 29.ความเชื่อมั่น ความเลื่อมใสศรัทธาในศาสนาหรือ 1 2 3 4 5 6 สิ่งศักดิ์สิทธิ์ตางๆ 30.ความสําเร็จในสิ่งที่มุงหวังในชีวิต 1 2 3 4 5 6 31.ความสุขโดยทั่วไป 1 2 3 4 5 6 32.ชีวิตโดยทั่วไป 1 2 3 4 5 6 33.รูปรางหนาตาและลักษณะที่ปรากฏภายนอก 1 2 3 4 5 6
253
สวนที่ 2 คําชี้แจง: ในแตละข อตอไปนี้ โปรดเลือกคาตอบทํ ตรงกี่ ับ ระดับความสําคัญ ที่ทานใหตอ แงมุมตางๆในชีวิตของทานภายหลังจากที่ไดรับบาดเจบศ็ ีรษะ คําตอบของทานไมมีการผิดหรือถูก ดังนั้นโปรดเลอกคื ําตอบทตรงกี่ ับความเปนจร ิงมากที่สุด ในแตละขอขอใหทานตอบวาทานคดวิ า ประเด็นนั้น “สําคัญ” หรือ “ไมสําคัญ” จากนนผั้ ูวิจัยจะขอใหทานใหน้ําหนักของความสําคัญหรือไม สําคัญวา มากหรือมากกวารอยละ 70 ปานกลางหรือรอยละ 30-70 หรือ นอยหรือนอยกวารอยละ 30
อย
กน ัญ
ปาน าง
สํ าค าง างเล ็ างมาก ูบ ูบ
ญเลย ญอย ูบ ั ั อย
ั ญอย ั ญอย ั ญอย สํ าค สํ าค สํ าค สํ าค กลาง สํ าค ไม อนข างไมค ไม สิ่งตอไปนี้มีความสําคัญกับทานเพียงใด เล ็ กน 1.ภาวะสุขภาพ 1 2 3 4 5 6 2.การดูแลทางดานสุขภาพที่ไดรับอย ู 1 2 3 4 5 6 3.อาการทางรางกายตางๆท เกี่ ิดกับทานภายหลังการ 1 2 3 4 5 6 บาดเจ็บศีรษะ เชน ปวดศีรษะ วิงเวียน นอนไมหลับ 4.การเปลี่ยนแปลงทางอารมณที่เกิดกับทานภายหลัง 1 2 3 4 5 6 การบาดเจ็บศรษะี เชน หงุดหงิดงาย โกรธงาย 5.ความสามารถในการคิด การจําเหมือนกอนบาดเจ็บ 1 2 3 4 5 6 6.การมีพละกําลังในการประกอบกิจวัตรประจําวัน 1 2 3 4 5 6 7.ความสามารถในการทําสงติ่ างๆไดดวยตนเอง 1 2 3 4 5 6 8.ความสามารถในการควบคุมและตดสั ินใจเกี่ยวกับ 1 2 3 4 5 6 ชีวิตของตนเอง 9.ความหวังที่จะมีชีวิตยืนยาว 1 2 3 4 5 6 10.สุขภาพของสมาชิกในครอบครัว 1 2 3 4 5 6 11.ความสําเร็จของบุตรหลานหรือบุคคลใกลชิด 1 2 3 4 5 6 12.ความสุขในครอบครัว 1 2 3 4 5 6 13.เพศสัมพันธ 1 2 3 4 5 6 14.ความสัมพันธกับคูครองหรือบุคคลที่มี 1 2 3 4 5 6 ความสําคัญ 15.ความสัมพันธกับเพื่อนและผูรวมงาน 1 2 3 4 5 6 254
อย
กน ัญ
ปาน าง
สํ าค าง างเล ็ างมาก ูบ ูบ
ญเลย ญอย ูบ ั ั อย
ั ญอย ั ญอย ั ญอย สํ าค สํ าค สํ าค สํ าค กลาง ไม ไม สํ าค เล ็ กน สิ่งตอไปนี้มีความสําคัญกับทานเพียงใด อนข างไมค 16.ความชวยเหลือ ความเหนอกเห็ ็นใจ กําลังใจที่ 1 2 3 4 5 6 ไดรับจากครอบครัว 17.ความชวยเหลือ ความเหนอกเห็ ็นใจ กําลังใจที่ 1 2 3 4 5 6 ไดรับจากบุคคลอื่น นอกเหนือจากคนในครอบครัว 18.ความสามารถที่จะทําหนาท ี่ในครอบครัว 1 2 3 4 5 6 19.ความมีประโยชนหรือมีคุณคาตอผูอื่น 1 2 3 4 5 6 20.ระดับความเครียดหรือความวิตกกังวลในชีวิต 1 2 3 4 5 6 21.ความสัมพันธกับเพื่อนบาน 1 2 3 4 5 6 22.บานเรือนและสิ่งแวดลอมที่อยูอาศัย 1 2 3 4 5 6 23.การมีหรือไมมีงานทํา 1 2 3 4 5 6 24.การศึกษา 1 2 3 4 5 6 25.ความสามารถในการพึ่งตนเองดานการเงิน 1 2 3 4 5 6 26.งานอดิเรกหรือกิจกรรมในยามวาง 1 2 3 4 5 6 27.ความหวังที่จะมีความสุขในอนาคต 1 2 3 4 5 6 28.ความสงบทางใจ 1 2 3 4 5 6 29.ความเชื่อมั่น ความเลื่อมใสศรัทธาในศาสนาหรือ 1 2 3 4 5 6 สิ่งศักดิ์สิทธิ์ตางๆ 30.ความสําเร็จในสิ่งที่มุงหวังในชีวิต 1 2 3 4 5 6 31.ความสุขโดยทั่วไป 1 2 3 4 5 6 32.ชีวิตโดยทั่วไป 1 2 3 4 5 6 33.รูปรางหนาตาและลักษณะที่ปรากฏภายนอก 1 2 3 4 5 6
255
Appendix G
Depression scale: Center for Epidemiology Studies Depression Scale (CES-D) Direction: Below is a list of the ways you might have felt or behaved. Please tell me how often you have felt this way during the past week. For each feeling or behavior, please answer how many days during the past week, from 1 to 7 days, that you felt or behaved that way? If you did not feel or behave that way, please answer 0 day per week for that item. During the past week
Rarely or Some or a Occasionally Most or none of the little of or a all of the time (less the time moderate time (5-7 than one (1-2 days) amount of days) day) time (3-4 days) 1. I was bothered by things that usually [ ] [ ] [ ] [ ] don’t bother me 2. I did not feel like eating: my appetite [ ] [ ] [ ] [ ] was poor. 3. I felt that I could not shake off the blues [ ] [ ] [ ] [ ] even with help from my family or friends. 4. I felt I was just as good as other people. [ ] [ ] [ ] [ ] 5. I had trouble keeping my mind on when [ ] [ ] [ ] [ ] I was doing. 6. I felt depressed. [ ] [ ] [ ] [ ] 7. I felt that everything I did was an effort. [ ] [ ] [ ] [ ] 8. I felt hopeful about the future. [ ] [ ] [ ] [ ] 9. I thought my life had been a failure. [ ] [ ] [ ] [ ] 10. I felt fearful. [ ] [ ] [ ] [ ] 11. My sleep was restless. [ ] [ ] [ ] [ ] 12. I was happy. [ ] [ ] [ ] [ ] 13. I talked less than usual. [ ] [ ] [ ] [ ] 14. I felt lonely. [ ] [ ] [ ] [ ] 15. People were unfriendly. [ ] [ ] [ ] [ ] 16. I enjoyed life. [ ] [ ] [ ] [ ] 17. I had crying spells. [ ] [ ] [ ] [ ] 18. I felt sad. [ ] [ ] [ ] [ ] 19. I felt that people dislike me. [ ] [ ] [ ] [ ] 20. I could not get “going”. [ ] [ ] [ ] [ ] SCORING: zero for answers in the first column, 1 for answers in the second column, 2 for answers in the third column, 3 for answers in the fourth column. The scoring of positive items is reversed. Possible range of scores is zero to 60, with the higher scores indicating the presence of more symptomatology.
256
แบบคัดกรองภาวะซึมเศรา ฉบับภาษาไทย (พัฒนาโดยศาสตราจารยอุมาพร ตรังคสมบัติ)
คําชี้แจง รายการตอไปนี้เปนส ิ่งที่ทานอาจรูสึกหรือแสดงในรอบ 1 สัปดาหที่ผานมา โปรดพิจารณาวา ทานมีความรูสึกดังตอไปนี้บอยเพียงใดใน 1 สัปดาหที่ผานมา โดยระบุเปนจํานวนวัน 1 ถึง 7 วัน ที่ ทานรูสึกหรือทําพฤติกรรมนั้น สําหรับขอที่ทานไมเคยรูสึกหรือทํา โปรดตอบ 0 ในระยะ 1 สัปดาหที่ผานมา
ไมเลย นานๆครั้ง บอยๆ ตลอดเวลา ( < 1 วัน) (1-2 วัน) (3-4 วัน) (5-7 วัน) 1. ฉันรูสึกหงุดหงิดงาย [ ] [ ] [ ] [ ] 2. ฉันรูสึกเบื่ออาหาร [ ] [ ] [ ] [ ] 3. ฉันไมสามารถขจัดความเศราออกจากใจได แมจะมี [ ] [ ] [ ] [ ] คนคอยชวยเหลือก็ตาม 4. ฉันรูสึกวาตนเองดีพอๆกับคนอื่น [ ] [ ] [ ] [ ] 5. ฉันไมมีสมาธิ [ ] [ ] [ ] [ ] 6. ฉันรูสึกหดหู [ ] [ ] [ ] [ ] 7. ทุกๆสิ่งที่ฉันกระทําจะตองฝนใจ [ ] [ ] [ ] [ ] 8. ฉันมีความหวังเกี่ยวกับอนาคต [ ] [ ] [ ] [ ] 9. ฉันรูสึกวาชีวิตมีแตความลมเหลว [ ] [ ] [ ] [ ] 10. ฉันรูสึกหวาดกลัว [ ] [ ] [ ] [ ] 11. ฉันนอนไมคอยหลับ [ ] [ ] [ ] [ ] 12. ฉันมีความสุข [ ] [ ] [ ] [ ] 13. ฉันไมคอยอยากคุยกับใคร [ ] [ ] [ ] [ ] 14. ฉันรูสึกเหงา [ ] [ ] [ ] [ ] 15. ผูคนทั่วไปไมคอยเปนมิตรกับฉัน [ ] [ ] [ ] [ ] 16. ฉันรูสึกวาชีวิตนี้สนุกสนาน [ ] [ ] [ ] [ ] 17. ฉันรองไห [ ] [ ] [ ] [ ] 18. ฉันรูสึกเศรา [ ] [ ] [ ] [ ] 19. ผูคนรอบขางไมชอบฉัน [ ] [ ] [ ] [ ] 20. ฉันรูสึกทอถอยในชีวิต [ ] [ ] [ ] [ ]
Table of References
Author(s) / Subjects MTBI Outcomes Results design & Time post-injury Determinants
Family Health and Functioning and Spiritual Psychological Socio-economic Socio-economic 1992 (Alexander, 23 MTBI (61% male) GCS 13-15, Y Y Y Y 43% of subjects reported dizziness, 30% 1992) LOC < 15 depression; 87% headaches; *Descriptive Up to 5 years post-injury minutes, 48% needed work compensation Cross Sectional PTA < 24 hours Location: USA 1992 (Englander, 77 MTBI (68% male) GCS 13-15, Y Y Y N/A At 3 m, 26% reported symptoms, 88% Hall, Stimpson, & LOC (any), (PCS (PCS (Return to return to work (average at 8wk), and 16% Chaffin, 1992) 3 months post injury admitted < 3 3months) 3months) work) desired to see doctors because of their *Descriptive days to hospital symptoms. Location: USA 1992 (Kay, 808 mild head injury; GCS, LOC and Y Y Y Y At 3 m, 84% return to work. At 1 year, 11% Newman, Cavallo, number of MTBI was not PTA were not (PCS) (PCS) Return to were unable to return to work and reported Ezrachi, & reported reported work headache, fatigue, forgetfulness and sleep Resnick, 1992) disturbance *Summarized Time postinjury 1 week, 3 The authors concluded that MTBI was a from 4 studies months, 6 months and 1 subset of MHI. MHI patients might or (originals not year might not have injuries to their brain but published). MTBI patients must have injuries to the Descriptive brain. Longitudinal Location: USA 1993 (Arcia & 32MTBI (39%Male) LOC < 1 hr Y Y N/A N/A Subjects who reported subjective Gualtieri, 1993) Time postinjury > 3 years GCS and PTA complaints tended to have lower *Descriptive were not reported performance in all tests. Subjective Location: USA complaints were reliable to objective test performance.
257
Author(s) / Subjects MTBI Outcomes Results design & Time post-injury Determinants
Family Health and Functioning and Spiritual Psychological Socio-economic Socio-economic 1993 (Alves, 587 MTBI (67% male) GCS 13-15 Y Y N/A N/A 50%of all subjects reported headaches Macciocchi, & were randomly assigned LOC and PTA (PCS) (PCS) and 15%dizziness Barth, 1993) into 3 groups (routine, were not reported There were no differences in the number of *Interventional information, and complaints among 3 groups, although the Location: USA information + Admitted to number of symptoms increased at 6 and 12 reassurance, hospital < 2 days months compared to 3 months. time post-injury at 3, 6, 12 months 1994 (Bohnen et 231MTBI, (66% Male) GCS (not Y Y N/A N/A Age, gender, neurological complications, al., 1994) Time postinjury 5 years reported) and emotional were related to low cognitive *Descriptive LOC < 20 min. performance, MTBI *Comparison PTA < 60 min. study with healthy After 1-5 yrs of injury, MTBI subjects subjects reported more severe of complaints than Location: USA control
1995 (Bigler & 4 MTBI (50% Male) GCS > 13 Y Y N/A N/A There was no difference of ventricular-to- Snyder, 1995) Time postinjury 5-12 LOC 0-brief ventricular Neuropsyc brain measure among MTBI who *Descriptive months PTA 5-15 min. -to-brain hological demonstrated different neuropsychological Location: Europe ratio) scores score. 1995 (Bohnen, 22MTBI (54% Male), 11 GCS 15 Y Y N/A N/A MTBI+PCS reported lower in sustained Jolles, Twijnstra, with PCS, 11without PCS LOC < 15min. attention, depression was correlated with Mellink, & PTA < 1hr, PCS emotional scale, at 12-34m postinjury, Wijnen, 1995) Time postinjury > 1year both MTBI w or w/o PCS performed the *Descriptive same level of their neurobehaviors *Comparison between MTBI Location: USA
258
Author(s) / Subjects MTBI Outcomes Results design & Time post-injury Determinants
Family Health and Functioning and Spiritual Psychological Socio-economic Socio-economic 1995 (Cicerone & 50 MTBI GCS 13-15 Y Y N/A N/A LOC had inversed relationship with severity Kalmar, 1995) (38% Male) LOC< 30 min, of symptoms. Frequently reported *Descriptive Time postinjury 3-52 PTA < 24 hrs symptoms were headache, sleep Location: USA months disturbance, numbness, hearing loss, change in taste or smell, anxiety, depression, problems in memory or concentration, dizziness, imbalance, and sensitivity to noise and light. 1996 (Cattelani, 53MTBI (62% Male) with GCS > 13, Y Y N/A N/A Longer PTA and LOC, and higher mean Gugliotta, PCS LOC < 20 min, (PCS) (PCS) score of MMPI related to abnormal findings Maravita, & PTA < 7hrs in radiation Mazzucchi, 1996) Time postinjury 2-60 admit < 7days, *Descriptive months Location: Italy 1996 (Cicerone et 20MTBI with PCS (10 in GCS (not Y Y Y N/A Subjects who received neurorehabilitation al., 1996) good outcome or resume reported) Return to program with good outcome group reported *Descriptive to work and 10 in poor LOC < 30 min. work improved cognitive functioning for 46%, *Comparison outcome), PTA < 24hrs PCS for 75%, improved attention, between MTBI Time postinjury > 3 decreased cognitive dysfunction and Location: USA months severity Other 10 subjects received the same intervention but had poor outcomes
259
Author(s) / Subjects MTBI Outcomes Results design & Time post-injury Determinants
Family Health and Functioning and Spiritual Psychological Socio-economic Socio-economic 1996 (Mittenberg, 58MTBI (69% Male), 29 GCS 13-15 Y Y N/A N/A Brief early psychological intervention could Tremont, in control, 29 in PTA < 24hrs reduce PCS symptoms. Subjects in Zielinski, Fichera, experiment intervention group reported fewer & Rayls, 1996) symptomatic days (.5 VS 1.3) and lower *Experimental Time postinjury 6 months mean of severity of symptom. study (2 groups of MTBI) Location: USA 1998 (Deb, Lyons, 134 MTBI (68% Male), GCS > 13, Y Y Y Y Twenty five percent of the subjects met the & Koutzoukis, LOC (any) requirement for moderate disability. More 1998) Time postinjury 1 year than half (55.2%) reported PCS and 17.2% *Descriptive met the assumption of psychotic problems. Location: USA 1998 100MTBI (66% Male) GCS > 13, Y Y Y Y Mean PCS was 3.1 symptoms with 40% (Ingebrigtsen, The authors Sick leave/ reported 3 or more and 62% reported at Waterloo, Marup- Time postinjury 3 months considered all return to least one symptom at 3 months. Subjects Jensen, Attner, & subjects with work who off work or who had higher PCS Romner, 1998) PTA as also reported higher RPQ score. PTA, GCS, *Descriptive having LOC (<1, HISS, alcohol abuse, duration of sick leave Location: Norway, 1-5, 6-15, were not significant correlated with PCS or Sweden >15min) RPQ.
1999 (Bell, 20MTBI (45% Male) GCS 13-15 Y Y N/A N/A MTBI group reported higher depression and Primeau, Sweet, & compared to migraineers LOC < 30 min. cognitive disability than subjects in Lofland, 1999) and chronic non-headache migraine and chronic non-headache pain *Descriptive pain groups. *Comparison study (to Time postinjury > 1 year migraine) Location: USA 260
Author(s) / Subjects MTBI Outcomes Results design & Time post-injury Determinants
Family Health and Functioning and Spiritual Psychological Socio-economic Socio-economic 1999 (Ruffolo, 50MTBI (62% Male) Subjects with Y Y Y return to N/A Forty two percent returned to work at 6-9 Friedland, GCS 13-15, LOC work m. after injury, 12% went to the same level Dawson, Time postinjury 6-9 < 20 min, PTA < while 30% needed to modify their job. Colantonio, & months 24 hrs were Social interaction, difficulty of job (decision Lindsay, 1999) included but making) and discharge to home were related *Descriptive there was no to return to work while cognitive Location: USA report about all impairment at 1 m. after injury could not three variables predict return to work. among the subjects 2000 (Levine, 12 MTBI (58% Male) GCS 13-15, Y Y N/A N/A After 6 hr postinjury 11 MTBI gained Dawson, Boutet, LOC (not GOAT >74, R-SAT negative correlated Schwartz, & Time postinjury 3-4 years reported), with physical SIP (50%) and psychological Stuss, 2000) PTA < 6 hrs, SIP (34%). There was no correlation *Descriptive between CT results and R-SAT score. Location: USA 2000 (Ponsford et 84MTBI (62% Male) GCS 13-15 Y Y N/A N/A WAIS-R score was very low at 1 week after al., 2000) compared to 53 other LOC < 30 min. TBI but it was improved after 3 months. *Descriptive minor injuries PTA < 24 hrs 24% still suffered from at least 1 PCS. PTA *Comparison did not correlate with PCS. Student, female, study (to other Time postinjury 1 week history of HI/ neurological/ psychological minor trauma) and 3 months problem, and having MVC were factors Location: related to poor outcomes at 3 months. Australia
261
Author(s) / Subjects MTBI Outcomes Results design & Time post-injury Determinants
Family Health and Functioning and Spiritual Psychological Socio-economic Socio-economic 2001 29MTBI, (90% Male) GCS,LOC and Y Y N/A N/A MTBI reported lower performance in all (Echemendia, compared to 20 control PTA were not measures at 2 h, improved from time to Putukian, Mackin, reported time, and reported the same performance as Julian, & Shoss, Time postinjury 2 hrs, control at 1 m. 2001) 2days, 1week and 1month *Descriptive * Comparison study to 20 normal control 2001 (Haboubi, 639MTBI (74% Male) GCS 13-15 Y Y Y Y From 391 employed MTBI, 219 were Long, Koshy, & LOC < 15 min Return to unable to return to work at 2 weeks after the Ward, 2001) Time postinjury 2 and 6 work injury, 49 still off sick after 6 weeks of the *Descriptive weeks injury. Common complaints PCS were Location: UK fatigue, headache, dizziness, irritability, sleep disturbance, poor concentration and poor memory. 2001 (Hanna- 44MTBI (45% Male), 22 GCS 13-15 Y Y N/A N/A PCS groups reported more subjective Pladdy, Berry, with PCS, 22 without PCS LOC < 11 hrs symptoms than non-PCS. Bennett, Phillips, (37.4% = 0, 9 MTBI reported more symptoms than non- & Gouvier, 2001) Time postinjury 35% < 1 % > 1hr) MTBI. *Descriptive year PTA < 24 hrs PCS+MTBI+stress reported higher PCS and *Comparison 65% 1-15 years (57.5% = 0) lower performance in all cognitive study (among functions. MTBI) Location: USA
262
Author(s) / Subjects MTBI Outcomes Results design & Time post-injury Determinants
Family Health and Functioning and Spiritual Psychological Socio-economic Socio-economic 2001 (Hartlage, 70MTBI (45%M) with GCS, PTA and Y Y N/A N/A Within 6 months after injury 39 behaviors Durant-Wilson, & persistent neurobehavioral LOC were not were reported by MTBI more than normal Patch, 2001) problems compare to 40 reported control. Of those 39, MTBI still reported 36 *Descriptive normal control more than normal control at 12 months. *Comparison Time postinjury 6-12 study (to healthy months subjects) Location: USA 2001 (Lees-Haley, 24MTBI (58%Male), GCS 13-15 Y Y N/A N/A MTBI reported more frequent of short-term Fox, & Courtney, compare to subjects with LOC < 60 min. memory loss, reading problems, and partial 2001) other injuries) PTA < 24hr LOC but there was no difference of total *Descriptive number of item endorsed by both groups. *Comparison Time postinjury (not study (to other reported) trauma) Location: USA 2001 (Levin et al., 60MTBI (82% Male), GCS 13-15 Y Y Y Y At 3months, MTBI developed depression 2001) compared to 52 general LOC < 20 min. Community more than GT (11:3). Mean CES-D score of *Descriptive trauma integration those MTBI was 22.14. MTBI also reported *Comparison higher VASF-D, PTSD but lower social study (to general Time postinjury > 3 support and community re-integration. trauma) months Among those MTBI with depression, social Location: USA support and community re-integration score also lower than MTBI without depression.
263
Author(s) / Subjects MTBI Outcomes Results design & Time post-injury Determinants
Family Health and Functioning and Spiritual Psychological Socio-economic Socio-economic 2001 (McCauley, 95MTBI (21% Male), GCS 13-15 Y Y Y Y At 3 months, 3.30% of MTBI reported PCD Boake, Levin, compared to 85 General LOC < 20min. compared to 15.3% among GT and 30.8% Contant, & Song, Trauma among moderate TBI. For past MDD, 7.9% 2001) MTBI met the criteria while 21.4% met *Descriptive Time postinjury 3 months current MDD criteria (both MDD were *Comparison lower than moderate TBI and GT). MTBI study (to general with PCD reported poorer GOS, higher trauma) anxiety, higher depression, lower social Location: USA support and social re-integration. 2001 (McCullagh, 57 MTBI (56% Male), GCS 13-15 Y Y Y N/A MTBI with GCS 13-14 had longer PTA Oucherlony, compared between GCS LOC < 20 min. Return to duration and higher rate of CT abnormality Protzner, Blair, & 15 and GCS 13-14 PTA < 24 hrs work than those with GCS 15. There was no Feinstein, 2001) significant difference of any *Descriptive Time postinjury 6 months neurobehavioral, somatic, or psychological *Comparison outcomes between MTBI with GCS 15 and study (among with GCS13-14. MTBI) Location: Canada
264
Author(s) / Subjects MTBI Outcomes Results design & Time post-injury Determinants
Family Health and Functioning and Spiritual Psychological Socio-economic Socio-economic 2001 (Santa 50MTBI with PCS GCS (not Y Y N/A N/A MTBI was not associated with PCS Maria, Pinkston, (gender not reported) reported) reported. In low symptom group, gender Miller, & Gouvier, Time postinjury 3 months LOC < 20min was not revealed difference but MTBI had 2001) - 10years higher symptom than control. In high *Descriptive symptom group, male had more stable Location: USA scores than female did but MTBI was not different than control. 2001 (Trahan, 40MTBI (50% Male) GCS 13-15 Y Y N/A N/A Gender, race, and education were not Ross, & Trahan, LOC < 30min associated with PCS in MTBI. PCS among 2001) Time postinjury (not MTBI and normal control was not different. *Descriptive reported) PCS was highly related to depression, *Compare to anxiety, and physical and cognitive depressed symptoms. subjects, normal control Location: USA 2002 (McHugh, 26 MTBI, GCS 13-15 Y Y N/A N/A At 4 month, 19.2% of MTBI met PCS 2002) Time postinjury 1wk, 4 PTA < 24 hrs criteria. Neurological profiles of MTBI with *Descriptive and 7 months PCS significantly differed from MTBI w/ Location: Canada PCS’s and matching normal control.
265
Author(s) / Subjects MTBI Outcomes Results design & Time post-injury Determinants
Family Health and Functioning and Spiritual Psychological Socio-economic Socio-economic 2002 (Cicerone & 32 MTBI (gender not GCS 13-15 Y Y N/A N/A PCS group had more attention disturbance Azulay, 2002) reported) with PCS LOC < 30 min. than control. *Descriptive compared to 32 normal PTA < 24 hrs, There was no difference of any measures *Comparison control between subjects after >12m and <12 m study (to healthy Time postinjury > postinjury. subjects) 3months There was no difference of any measure Location: USA between subjects with different PTA and LOC. 2002 (De Kruijk 79MTBI (56%Male) GCS 14-15, Y Y N/A N/A Headaches 61%, dizziness 18%, neck pain et al., 2002) Time postinjury initial LOC < 15 min. 17% *Descriptive admission, 2weeks and PTA < 1 hour, Subjects who reported headaches, dizziness, Location: The 6months or pain at admit, also reported those Netherlands symptoms at 6 m postinjury. Rate of full recovery increased from 50% to 78% when the initial symptoms decreased from 3 to 0. 2002 (Sparrow, 38 MTBI (45% Male) GCS 13-15 Y Y N/A N/A There was no relationship between coping 2002) Time postinjury 3weeks LOC < 30 min. resources and PCS. Stress was a significant *Descriptive and 3months PTA < 24 hrs predictor for PCS. Location: USA
266
Author(s) / Subjects MTBI Outcomes Results design & Time post-injury Determinants
Family Health and Functioning and Spiritual Psychological Socio-economic Socio-economic 2002 (Ponsford et 202MTBI (gender not GCS 13-15 Y Y N/A N/A Experiment group received an information al., 2002) reported), 79 in LOC < 30 min. booklet about common symptoms, time *Experimental experiment, 123 in PTA < 24hrs course, and coping strategies. design (2 groups control, Experiment group reported less PCS at 3m, of MTBI) Time postinjury 5-7days and lower symptom checklist-90-revised Location: and 3months score. Australia 2002 (Suhr & 63MTBI (38% Male), 31 GCS 13-15 Y Y N/A N/A Subjects were young (undergraduate Gunstad, 2002) without and 32 with LOC < 30 min. students and more female than male), *Descriptive depression, compare to 25 depression was associated with PCS while *Comparison depressed and 50 control, MTBI was not. PCS reported among MTBI study (between Time postinjury > 6 and control was not different. MTBI, to months depressed and healthy subjects) Location: USA 2003 (Bryant, 24 MTBI with stress PTA < 24hrs, N/A Depression N/A N/A After 5 wks of intervention, 8% of subjects Moulds, Guthrie, (33% Male) GCS 13-15 stress in cognitive behavioral therapy group & Nixon, 2003) reported PTSD while 58% of control did. *Descriptive Time postinjury 6 months 6 months after injury, 17% of intervened MTBI with known group met PTSD criteria while 58% of PTSD normal control did. Location: USA
267
Author(s) / Subjects MTBI Outcomes Results design & Time post-injury Determinants
Family Health and Functioning and Spiritual Psychological Socio-economic Socio-economic 2003 101MTBI (65% Male) GCS 13-15 Y Y N/A N/A MTBI reported different score of SF-36 at (Emanuelson, LOC < 30 min. 3wk and 3m but the scores were not Anderson, Time postinjury 3week, different at 3m and 1y. Bjorklund, & 3months and 1year Stalhammar, 2003) *Descriptive Location: Sweden 2003 (Evered, 129 MTBI with PCS GCS 13-15 Y Y N/A N/A 63.5% had emotional pathologies which led Ruff, Baldo, & (54%Male) LOC < 30 min, to impairment following MTBI Isomura, 2003) PTA < 24hrs, *Descriptive Time postinjury > MIBI with known 3months PCS Location: USA 2003 (Rapoport, 210 MTBI (40% Male), GCS 13-15 Y Y N/A N/A MTBI who were older than 60 year old McCullagh, 30% were older than 60 PTA < 24 hrs reported lower rate of depression when Streiner, & years old compared to those who were younger. Feinstein, 2003a) *Descriptive Time postinjury 49 days *Comparison study (of depression between different age group) Location: USA
268
Author(s) / Subjects MTBI Outcomes Results design & Time post-injury Determinants
Family Health and Functioning and Spiritual Psychological Socio-economic Socio-economic 2003 (Rapoport, 170MTBI (gender not GCS 13-15 Y Y Y return to N/A 15.3% met criteria for major depression. McCullagh, reported) LOC < 30 min. work MTBI w depression reported more Streiner, & Time postinjury 49 days PTA < 24hrs dysfunction, distress, and neurobehavioral Feinstein, 2003b) disturbance. GOS and return to work were *Descriptive not different among those w and w/o Location: USA depression. 2003 (Ruttan & 122 MTBI (38% Male) GCS 13-15 Y Y N/A N/A The authors measured depression and Heinrichs, 2003) Time postinjury > 3 yrs LOC < 30 min. depression anxiety through MCMI-II and did not find *Descriptive PTA < 24 hrs any correlation of depression and cognitive Location: Canada performance
2003 (Smith- 32 MTBI (59% Male), GCS13-15 Y Y N/A N/A There was no difference of the endorsed Seemiller, Fow, compared to 63 chronic PTA < 24 hrs PCS symptoms among MTBI and chronic Kant, & Franzen, pain pain subjects. 2003) *Descriptive Time postinjury > 1 year *Comparison study (to chronic pain) Location: USA
2003 (Savola & 224 MTBI (76% Male) GCS 13-15 Y Y N/A N/A 22% had PCS. 81% of whom with PCS had Hillbom, 2003) Time postinjury 2-6 week LOC < 30min. at least 2 symptoms at 1 m postinjury. Age *Descriptive and 8-30 m. was not associated with PCS (16-49y). Location: Europe LOC, PTA, dizziness and headache at ER were predictors of PCS.
269
Author(s) / Subjects MTBI Outcomes Results design & Time post-injury Determinants
Family Health and Functioning and Spiritual Psychological Socio-economic Socio-economic 2004 (Kashluba et 110 MTBI (67% Male) GCS 13-15 Y Y Y Y Compare symptoms at 1m and 3m, and al., 2004) compared to 118 normal LOC < 30 min. between MTBI and control group. Number Location: Canada control PTA < 24 hrs of symptoms between MTBI and control Time post-injury 1m. and was NS but MTBI rated rate severity rate. 3-4 months Symptoms decreased after 3 m. 2004 (Stranjalis et 100 MTBI (gender not GCS 15 Y N/A Y N/A 32% of the subjects had the level of S-100B al., 2004) reported) LOC and PTA S-100B Return to elevated. Among those, 37.5% failed to *Descriptive Time postinjury 3 hrs and (not reported) level only work return to work compared to 4.7% of those Location: Greece 1 week who had normal level of S-100B.
270
271
Appendix I
Phone Script
After initial contact in the clinic OR After sending in the “opt in” postcard OR
After NOT sending in the “opt out” postcard after two mailings
“Hello [NAME], my name is Nutthita Petchprapai and I am a nurse and an instructor at the Boromratchachonnani Nakhornratchasima Nursing College, Muang district,
Nakhornratchasima and now I am studying in a doctoral program at Case Western
Reserve University in USA. I want to invite you to participate in a research study entitled
“Adaptation to Mild Traumatic Brain Injury among Thai Adults”. Do you have a moment to talk with me?
IF NO – “thanks for your time. May I call you back? (if yes: When is a convenient time for me to call?
IF YES - “Thank you so much. The purpose of this study is to explore the outcomes and the factors that are associated with outcomes after mild traumatic brain injury in Thai adults like you. Before I interview you about your experiences from this injury, I want to be sure that you understand the study and that your questions are answered. Can I explain about the study?
For this study I will ask about 170 questions over the telephone. Your responses will include telling me a little about yourself, such as age and education and the circumstances of your injury—when it occurred and what symptoms you experienced at that time. I will then ask about physical, mood, and social changes you may have experienced after the injury—whether these changes are present and how often or how intense these changes are. Then I will ask questions about how satisfied you are with your life now as well as 272
how important physical, mood and social aspects of your life are to you. I expect this
telephone survey to take about 45 minutes. You will not receive any pay or gifts for
participating. There are no direct benefits. There is a chance some of the questions may
make you feel uncomfortable. You can choose not to answer any question and you can
stop the telephone survey at any time. I will call you at a phone number of your choice.
Please select a time and place where you can have privacy while you are answering questions. After the phone survey, I will also look at your medical record to record your diagnosis, physical exam, the history of the injury, signs and symptoms, and treatments at the time you were injured. This study will help us understand if there are health-related issues that occur after mild injuries like yours. Right now, we have no information about how patients recover after mild brain injury in Thailand.
Are you interested in participating? [IF NOT, THEN “THANK YOU FOR YOUR TIME
AND GOODBYE.”]
Do you have any questions for me? [ANSWER QUESTIONS]
Before we start, I will need you to sign a form that indicates you understand the purposes, risks and benefits from participating in this study. I have sent two forms to you in the mail (or gave them to you in the clinic). Can I read the form to you now to be sure that you understand? Please stop me at anytime for an explanation.
Do you have any questions? Can you tell me in your own words what you think the study will involve for you? (If there are misconceptions, I will explain further).
Please sign the blue one and return it to me with the stamped, addressed envelope that will be in the package. Keep the white form for yourself—it is your copy! I also enclosed (gave you) a separate description of the study and a pink sheet of paper on 273 which you can tell me the best times to call you. Please keep the description of the study.
Use the pink form to let me know the best times to call you and put it in the envelope with the blue form—unless you want to tell me now. Do you still have the envelope to send the blue form (and pink form) to me?
After I receive your papers, I will call you again for the interview.
Do you have any questions?
IF NO- Please confirm your mailing address.
IF YES- Address questions, then confirm mailing address.
Thank you for your time today [NAME].
274
บทสนทนาทางโทรศัพท
ภายหลังการตดติ อกับผูรวมวิจัยที่หองตรวจ หรือภายหลังจากที่ไดรับไปรษณียบัตรตอบตกลงจากผูรวมวิจัย หรือภายหลังจากที่ผูรวมวิจัยไมไดสงไปรษณียบัตรปฏิเสธแมจะไดรับเอกสารทั้ง 2 รอบ
“สวัสดีคะ คุณ (ชื่อ) ดิฉันชื่อ ณัฐฐิตา เพชรประไพ เปนพยาบาลวิชาชีพ และเปนอาจารยพยาบาลอยูที่วิทยาลัย พยาบาลบรมราชชนนี นครราชสีมา อําเภอเมือง นครราชสีมา ปจจุบันดิฉันกําลังศึกษาในระดับปริญญาเอกอยูที่ มหามหาวิทยาลัย เคส เวสเทิรน รีเสิรฟ สหรัฐอเมริกา ดิฉันอยากจะขอเชิญคุณเขารวมในการวิจัยเรื่อง การปรับตัว ของผูปวยไทยภายหลังการเกิดการบาดเจ็บศีรษะแบบไมรุนแรง ไมทราบวาคุณพอที่จะมีเวลาคุยเกี่ยวกับรายละเอียด บางไหมคะ
หากปฏิเสธ – ไมเปนไรคะ ขอบคุณ คุณ (ชื่อ) มากที่เสียสละเวลาในวันนี้ ไมทราบวาดิฉันจะโทรมาหาคุณ (ชื่อ) ใหมไดไหมคะ (หากตกลง คุณ(ชื่อ)จะพอมีเวลาใหดิฉันโทรกลับมาเมื่อไหรดีคะ
หากตกลง – ขอบคุณมากคะที่เสียสละเวลาใหในวันนี้ การวิจัยครั้งนี้มีวัตถุประสงคเพื่อศึกษาเกี่ยวกับชีวิตของผูปวย หลังไดรับบาดเจ็บศีรษะแบบไมรุนแรงภายใน 1 ป และหาปจจัยที่ทําใหชีวิตของพวกเขาเหลานั้นดีขึ้นหรือแยลง กอนที่ดิฉันจะถามคําถามใดๆได ดิฉันจําเปนที่จะตองแนใจกอนวา คุณ (ชื่อ) เขาใจวัตถุประสงคและขั้นตอนของ การวิจัย จนไมมีขอสงสัยใดๆแลว ขอเวลาใหดิฉันไดอธิบายเกี่ยวกับการวิจัยสักครูไดไหมคะ
ในการวิจัยครั้งนี้ ดิฉันจะสอบถามคําถามทางโทรศัพทประมาณ 170 คําถาม คําถามจะเกี่ยวกับขอมูลทั่วไป เชน อายุ ระดับการศึกษา ขอมูลเกี่ยวกับการเจ็บปวยและการเปลี่ยนแปลงที่เกิดขึ้นกับทานภายหลังการบาดเจ็บศีรษะทั้ง ดานรางกาย อารมณและสังคม ความถี่และความรุนแรงของการเกิดการเปลี่ยนแปลงนั้นๆ จากนั้นดิฉันจะถาม คําถามเกี่ยวกับความพึงพอใจของทานตอการเปลี่ยนแปลงเหลาน ั้นและระดับความสําคัญที่ทานใหตอการปลี่ยน แปลงที่เกิดขึ้น ดิฉันคาดวาจะใชเวลาในการสัมภาษณครั้งนี้ประมาณ 45 นาที ทานจะไมไดรับคาตอบแทนใดๆใน การตอบคําถามครั้งน้ ี และจะการวิจัยครั้งนี้จะไมเอื้อประโยชนโดยตรงใดๆตอทาน ทานอาจรูสึกไมชอบใจที่จะตอง ตอบบางคําถามที่เกี่ยวของกับเรื่องสวนตัวของทาน ทานอาจเลือกที่จะไมตอบบางคําถามที่ทําใหทานรูสึกไมสบายใจ หรือขอหยุดการสัมภาษณไดทุกเมื่อ เพื่อใหการสัมภาษณครั้งนี้สะดวกตอทานที่สุด ดิฉันจะโทรศัพทไปยังหมายเลข ที่ทานระบุ ตามวันและเวลาที่ทานแจงไว เพื่อความเปนสวนตัวของทานในการสัมภาษณครั้งนี้ ดิฉันขอใหทานเลือก วัน เวลา และสถานที่ในการใหสัมภาษณที่เปนสัดสวนที่สุด หลังสัมภาษณเสร็จแลว ดิฉันจะศึกษาแฟมประวัติของ ทานที่โรงพยาบาลมหาราช นครราชสีมา เพื่อศึกษาขอมูลเกี่ยวกับการบาดเจ็บศีรษะและการรักษาเพิ่มเติมอีกครั้ง ทั้งนี้การศึกษาแฟมประวัติของผูปวยทุกราย ไดรับการอนุญาตจากทางโรงพยาบาลมหาราช นครราชสีมาเรียบรอย แลว การวิจัยครั้งนี้จะชวยใหเกิดความเขาใจวามีปญหาสุขภาพใดเกิดขึ้นกับผูที่ไดรับบาดเจ็บศีรษะแบบไมรุนแรง หรือไม จนถึงปจจุบันนี้ ในประเทศไทยยังไมมีการศึกษาขอมูลเหลาน ี้
ไมทราบวาคุณ (ชื่อ) สนใจที่จะเขารวมในการวิจัยครั้งนี้ไหมคะ (ถาปฏิเสธ ขอบคุณมากคะที่สละเวลาในวันนี้ สวัสดีคะ) ไมทราบวาคุณ (ชื่อ) มีขอสงสัยไหมคะ (ตอบคําถาม) 275
กอนที่เราจะเริ่มการสัมภาษณ ดิฉันจะขอใหคุณ (ชื่อ) ลงชื่อในใบเซ็นตยินยอม (เอกสารสีฟา) เพื่อเปนการยืนยันวา คุณรับทราบและเขาใจเกี่ยวกับการวิจัยครั้งนี้ ดิฉันไดจัดสงเอกสารใหคุณทางไปรษณีย (หรือมอบใหที่หองตรวจ) ดิฉันจะอานเอกสารใหคุณฟงไดไหมคะ เพื่อใหแนใจวาคุณเขาใจเอกสารที่ไดรับ ถาคุณมีขอสงสัย กรุณาบอกใหดิฉัน หยุดอาน เพื่อที่จะไดถามคําถามไดทันทีคะ
คุณ (ชื่อ) มีขอสงสัยหรือไมคะ คุณ (ชื่อ) ชวยสรุปตามความเขาใจของคุณไดไหมคะวา คุณ (ชื่อ) จะตองทํา อะไรบาง หากตกลงที่จะเขารวมในการวิจัยครั้งนี้ (หากมีการเขาใจผิด ผูวิจัยจะอธิบายใหผูเขารวมการวิจัยฟงจน เขาใจ)
กรุณาลงชื่อในเอกสารสีฟาและสงกลับคืนใหดิฉันดวยซองที่สงมาพรอมกับเอกสาร กรุณาเก็บเอกสารสีขาวซึ่งมี รายละเอียดของการวิจัยครั้งนี้อยูไว เพื่อเปนตนฉบับ สวนเอกสารสีชมพูจะเปนเอกสารที่ใหคุณ (ชื่อ) ระบุวัน เวลา และหมายเลขโทรศัพทที่คุณ (ชื่อ) ตองการใหดิฉันติดตอเพื่อสัมภาษณ คุณ (ชื่อ) สามารถที่จะสงเอกสารสีชมพูให ดิฉันในซองเดียวกันกับเอกสารสีฟา หรือบอกวัน เวลา และหมายเลขโทรศัพทที่คุณสะดวก ใหดิฉันทราบตอนนี้เลย ก็ได ไมทราบวาคุณ (ชื่อ) ยังมีซองที่จะสงเอกสารสีฟา (และสีชมพู) อยูหรือไมคะ
หลังจากที่ดิฉันไดรับเอกสารทั้งหมดแลว ดิฉันจะโทรศัพทถึงคุณ (ชื่อ) อีกครั้งเพื่อสมภาษณั คะ คุณ (ชื่อ) มีคําถามหรือขอสงสัยไหมคะ หากไมมี ดิฉันจะทบทวนชื่อ และที่อยูของคุณ (ชื่อ) นะคะ (อานชื่อ ที่อยู)
ถามี – กรุณาถามไดเลยคะ (แลวทบทวนชื่อและที่อยู, อานชื่อ ที่อยู)
ขอบพระคุณ คุณ (ชื่อ)มากนะคะที่ใหความรวมมือ ดิฉันหวงวั าจะไดรับเอกสารจากคุณ (ชื่อ) ภายในเร็ววันนี้นะคะ
สวัสดีคะ 276
Appendix J
Cover letter DATE
Dear (NAME),
I am a nurse. I am studying how patients recover from brain injury. You were diagnosed with a brain injury this past year. To do this research study, I call patients like you with a recent brain injury and ask many questions about health. When I call, before asking questions, I will explain the study and ask if you have any questions or need more information about the study. It will take about 45 minutes over the phone. Are you willing to answer questions about how you feel since your injury? There is a postcard with this letter. If you check “YES”, I will call you with more information and to set time to interview you over the phone. If you check “NO”, you will not hear from me again.
I have enclosed a sheet of paper with more information to help you decide if you want to be a part of this study. You can also call me at 087-879-9171 if you have any questions
Thank you very much, Nutthita Petchprapai Registered nurse, Clinical Instructor Boromratchachonnani Nakhornratchasima Nursing College Nakhornratchasima, Thailand 30000 Email: [email protected] Tel: 087-879-9171 277
More details about the study “Adaptation to Mild Traumatic Brain Injury among Thai Adults”
I am writing you to request your help with a research study, “Adaptation to Mild Traumatic Brain Injury among Thai Adults”. In the past year, you were diagnosed with a mild brain injury after an accident. The purpose of this research study is to look at what happens to adults like you after a mild brain injury and the factors that are associated with outcomes after injury. We do not have any information about how recovery happens after mild brain injury in Thailand.
If you agree to participate in this research study, I will call you on the phone for an interview. Everyone who participates will be asked the same questions. First, I will ask you information about yourself, such as age and education. Then I will ask you about physical symptoms, mood and life experiences after your injury. Finally I will ask questions about your satisfaction with your health and related matters and how important these health-related matters are to you. There are about 170 questions; the interview will take about 45 minutes.
I can call you at a phone number of your choice and at a time of your choice. Some of the questions may be private to you or make you uncomfortable, so I will advise you to be in a quiet place when I call for the interview. You can decide not to answer any question and still participate and you do not have to answer questions that make you uncomfortable. I will also be in a private room where no one can overhear our conversation.
In this packet there is a postcard. If you wish to participate, check the box which says “You can call me.” When I receive this postcard, I will call you to introduce myself and to confirm your willingness to be part of this research study and answer any questions. Then I will ask you to return the blue form in this packet, with your signature. I will also set up an appointment to call you for the interview. You can also send me information about the best times to reach you on the postcard.
If you do not wish to participate, check the “Do not call me” box on the postcard. I will not contact you further. If I do not hear from you, I will call you to see if you received the packet, introduce myself and ask whether you wish to participate. If you say “no, I do not wish to participate” at any time, I will not contact you further.
Before I can interview you, you must sign a green form indicating that you understand the purpose of the research study and the risks and benefits. I have enclosed this blue form and a stamped, addressed envelope—you can return it to me now if you wish to participate. If you would rather I call first, then just return the postcard.
I very much appreciate your time in letting me explain this research study. I look forward to hearing from you. Please feel free to contact me at 087-879-9171 if you have any questions about the research study.
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Thank you again for your help,
Nutthita Petchprapai, PhDc, RN Instructor, the Boromratchachonnani Nakhornratchasima Nursing College Muang district, Nakhornratchasima, 30000 Phone 087-879-9171 Email [email protected], [email protected] 279
[Postcard] DATE……………………………………………………………………………..
Please check one and return it in the mail (free of charge) within one week
Please call me about the research study, Adaptation to Mild Traumatic Brain Injury among Thai Adults. The best time to call is ______
Do not call me.
(NAME--preprinted)……………………………………………………………….. 280
จดหมายแนะนําตัว การปรับตัวของผูปวยไทยภายหลังการเกิดการบาดเจ็บศีรษะแบบไมรุนแรง วันท………………………………………………..ี่ ชื่อ-ที่อยู……………………………………………. เรียน คุณ (ชื่อ)………………………………………..
ดิฉัน ชื่อนางสาวณัฐฐิตา เพชรประไพ พยาบาลวิชาชีพ ตอนนี้กําลังศึกษาเกี่ยวกับการฟนตัวของผูปวยหลัง การบาดเจ็บศีรษะหนึ่งป ในการศึกษาครั้งนี้ ดิฉันจะโทรศัพทหาผูปวยบาดเจ็บศีรษะแบบไมรุนแรงเชนเดียวกับคุณ และถามคําถามตางๆเกี่ยวกับสุขภาพภายหลังการบาดเจ็บศีรษะ กอนที่ดิฉันจะเริ่มถามคําถามตางๆ ดิฉันจะอธิบาย รายละเอียดเกี่ยวกับการวิจัยใหทราบกอน และเปดโอกาสใหคุณไดถามคําถามหรือขอขอมูลเพิ่มเติมกอนที่คุณจะ ตัดสินใจวาจะเขารวมในการวิจัยหรือไม การตอบคําถามจะใชเวลาประมาณ 45 นาที คุณตองการที่จะเขารวมในการ วิจัยครั้งนี้หรือไมคะ ถาคุณตองการที่เขารวมในการศ ึกษาครั้งนี้ กรุณาทําเครื่องหมายในชอง ขาพเจาตองการเขาร วมใน การวิจัยเรื่อง การปรับตัวของผูปวยไทยภายหลังการเกิดการบาดเจ็บศีรษะแบบไมรุนแรง เพื่อที่ดิฉันจะได โทรศัพทถึงคุณเพื่ออธิบายรายละเอียดของการศึกษาและนัดวันที่คุณจะสะดวกที่จะตอบคําถาม ถาคุณทําเครื่องหมายในชอง ขาพเจาไมตองการเขารวมในการวิจัยเรื่อง การปรับตัวของผูปวยไทย ภายหลังการเกิดการบาดเจ็บศีรษะแบบไมรุนแรง ดิฉันจะไมรบกวนคุณอีก พรอมกับจดหมายนี้ ดิฉันไดแนบรายละเอียดของการศึกษาครั้งนี้มาใหคุณไดอานประกอบการตัดสินใจใน การเขารวมการวิจัยครั้งนี้ดวย หากคุณตองการสอบถามรายละเอียดเพิ่มเติม กรุณาติดตอดิฉันไดที่หมายเลข โทรศัพท 087-879-9171
ขอขอบพระคุณ ณัฐฐิตา เพชรประไพ พยาบาลวิชาชีพ 5, อาจารยพยาบาล วิทยาลัยพยาบาลบรมราชชนนี นครราชสีมา อําเภอเมือง นครราชสีมา 30000 โทรศัพท 087-897-9171 อีเมล [email protected], [email protected]
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รายละเอียดการวิจัยเรื่อง การปรับตัวของผูปวยไทยภายหลังการเกิดการบาดเจ็บศีรษะแบบไมรุนแรง วันท………………………………………………..ี่ ชื่อ-ที่อยู……………………………………………. เรียน คุณ (ชื่อ)………………………………………..
ดิฉันชื่อ นางสาวณัฐฐิตา เพชรประไพ พยาบาลวิชาชีพและอาจารยพยาบาล วิทยาลัยพยาบาลบรมราชชนนี นครราชสีมา ดิฉันสงจดหมายฉบับนี้มาเพื่อเรียนเชิญใหทานเขารวมตอบคําถามในการวิจัยเรื่อง การปรับตัวของ ผูปวยไทยภายหลังการเกิดการบาดเจ็บศีรษะแบบไมรุนแรง ทั้งนี้เพราะในรอบปที่ผานมา ทานเปนอีกผูหนึ่งที่ ไดรับการวินิจฉัยและรับการรักษาอาการบาดเจ็บศีรษะแบบไมรุนแรงที่โรงพยาบาลมหาราช นครราชสีมา การวิจัย ครั้งนี้มีเปาหมายเพื่อหาวามีการเปลี่ยนแปลงใดเกิดขึ้นกับผูปวยบาดเจ็บศีรษะแบบไมรุนแรงบาง และมีปจจัยอะไรที่ เกี่ยวของกับการเปลี่ยนแปลงเหลานั้น ซึ่งในประเทศไทยยังไมเคยมีผูศึกษาในเรื่องนี้มากอน หากทานตกลงที่จะเขารวมในการวิจัยครั้งนี้ ดิฉันจะโทรศัพทมาสัมภาษณทานอีกครั้งหนึ่ง ผูที่เขารวมใน การวิจัยครั้งนี้ทุกทานจะถูกถามคําถามแบบเดียวกัน โดยในตอนแรก ดิฉันจะสอบถามขอมูลทั่วไปของทาน เชนอายุ และระดับการศึกษา จากนั้นดิฉันจะถามเกี่ยวกับอาการทางกาย อารมณ และสิ่งที่ทานประสบหลังการบาดเจ็บศีรษะ แบบไมรุนแรง ทายที่สุด ดิฉันจะถามเกี่ยวกับความพึงพอใจในสุขภาพและสิ่งตางๆ รวมทั้งขอใหทานใหคะแนน ความสําคัญของสุขภาพและสิ่งตางๆรอบตัวทาน โดยคําถามทั้งหมดมีประมาณ 170 คําถามและใชเวลาประมาณ 45 นาที ดิฉันจะโทรศัพทมาสัมภาษณทานทางหมายเลขและเวลาที่ทานคิดวาสะดวกตอทานที่สุด คําถามบางคําถาม อาจเกี่ยวโยงกับเรื่องสวนตัวของทานและทานอาจรูสึกไมสะดวกใจที่จะตอบคําถาม ดังนั้นระหวางการสัมภาษณ ดิฉันขอแนะนําใหทานอยูในหองสวนตัวหรือสถานที่ที่เปนสัดสวน ทานอาจปฏิเสธการตอบคําถามบางคําถามที่ทาน รูสึกไมสบายใจที่จะตอบ ระหวางการสัมภาษณ ดิฉันเองก็จะอยูในหองที่เปนสัดสวน เพื่อปองกันไมใหมีบุคคลอื่นได ยินเนื้อหาของการสัมภาษณ ในเอกสารที่ทานไดรับพรอมกับจดหมายนี้ ทานจะไดรับไปรษณียบัตรดวย 1 ใบ หากทานตองการเขารวม ในการวิจัย กรุณาขีด X ที่ชอง ขาพเจาตองการเขารวมในการวิจัยเรื่อง การปรบตั ัวของผูปวยไทยภายหลังการ เกิดการบาดเจ็บศีรษะแบบไมรุนแรง เมื่อดิฉันไดรับไปรษณียบัตรแลว ดิฉันจะโทรศัพทถึงทานเพื่อแนะนําตัว ชี้แจงเกี่ยวกับการศึกษาครั้งนี้ และตอบขอสงสัยเกี่ยวกับการศึกษาครั้งนี้ หากทานมีขอสงสัย จากนั้นดิฉันขอใหทาน ลงชื่อในเอกสารแผนสีฟาและสงกลับมาใหดิฉันในซองเปลาติดแสตมปที่สงมาดวย ระหวางการพูดคุยทางโทรศัพท ดิฉันจะนัดวันและเวลาที่ทานสะดวกในการใหสัมภาษณ ทานสามารถที่จะระบุเวลาและหมายเลขโทรศัพทที่ทาน สะดวกในการใหสัมภาษณลงในไปรษณียบัตรดวยก็ได หากทานไมตองการเขารวมในการวิจัยครั้งนี้ กรุณาขีด X ที่ชอง ขาพเจาไมตองการเขารวมในการวิจัย เรื่อง การปรับตัวของผูปวยไทยภายหลังการเกิดการบาดเจ็บศีรษะแบบไมรุนแรง และสงไปรษณียบัตรกลับคืน ใหดิฉัน และดิฉันจะไมรบกวนทานอีก หากดิฉันไมไดรับไปรษณียบัตรคืนจากทานภายใน 2 สัปดาห ดิฉันจะ โทรศัพทเพื่อแนะนําตัว สอบถามเพื่อใหแนใจวาทานไดรับเอกสารครบถวน และสอบถามความสมัครใจของทาน หากทานปฏิเสธ ดิฉันจะไมรบกวนทานอีก 282
กอนที่จะทําการสัมภาษณทานได ดิฉันจําเปนที่จะตองไดรับการยินยอมจากทานเปนลายลักษณอักษร โปรดลงนามในใบเซ็นตยินยอม (เอกสารสีเขียว) เพื่อใหดิฉันไดรับทราบวาทานเขาใจในการวิจัยครั้งนี้แลว ทั้งเรื่อง วัตถุประสงค ประโยชนที่คาดวาจะไดรับและความเสี่ยงที่อาจเกิดขึ้นได โปรดสงเอกสารสีฟากลับคืนดิฉันดวยซอง เปลาติดแสตมปที่แนบมาดวย หากทานตองการเขารวมในการวิจัยโดยเร็ว โปรดสงทั้งไปรษณียบัตรและเอกสารสีฟา ที่ทานไดลงชื่อ กลับคืนสูดิฉันในซองที่เตรียมใหพรอมกัน แตหากทานไมแนใจและตองการสอบถามดิฉันกอน โปรด กาชองตองการเขารวมและสงไปรษณียบัตรถึงดิฉัน เพื่อที่ดิฉันจะไดโทรศัพทถึงทานอีกครั้ง ดิฉันขอกราบขอบพระคุณที่ทานเสียสละเวลาในการทําความเขาใจในการศึกษาครั้งนี้ ดิฉันหวงเปั นอยางยิ่ง วาจะไดรับไปรษณียบัตรและเอกสารสีเขียวพรอมลายเซนตของทานจากทานในเร็ววันนี้ ขอมูลของทานจะเปน ประโยชนอยางยิ่งในการเรียนรูปญหาที่แทจริงในผูปวยบาดเจ็บศีรษะแบบไมรุนแรงในประเทศไทย ผูวิจัยขอกราบ ขอบพระคุณทานเปนอยางสูงในความกรุณาครั้งนี้ หากทานมีปญหาหรือขอสงสัยใดๆเกี่ยวกับการวิจัยครั้งนี้ โปรด ติดตอผูวิจัยไดทันทีที่หมายเลขโทรศัพท 087-879-9171 ขอขอบพระคุณ
ณัฐฐิตา เพชรประไพ พยาบาลวิชาชีพ 5, อาจารยพยาบาล วิทยาลัยพยาบาลบรมราชชนนี นครราชสีมา อําเภอเมือง นครราชสีมา 30000 โทรศัพท 087-897-9171 อีเมล [email protected], [email protected]
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ไปรษณียบัตร
วันที่......
กรุณาทําเครื่องหมาย X หนาขอความทตรงกี่ ับความตองการของทาน และสงทางไปรษณีย (โดยไมตองตดแสตมปิ หรือเสียคาใชจายใดๆ) ภายใน 1 สัปดาห
ขาพเจาตองการเขารวมในการวิจัยเรื่อง การปรับตัวของผูปวยไทยภายหลังการเกิด การบาดเจ็บศีรษะแบบไมรุนแรง โปรดโทรศัพทถึงขาพเจาในวนทั ี่...... เวลาประมาณ......
ขาพเจาไมตองการเขารวมในการวิจัยเรื่อง การปรับตัวของผูปวยไทยภายหลังการเกิด การบาดเจ็บศีรษะแบบไมรุนแรง
ลงชื่อ......
APPENDIX K UNIVERSITY HOSPITALS OF CLEVELAND 284 CONSENT FOR INVESTIGATIONAL STUDIES
Project Title: Adaptation to Mild Traumatic Brain Injury among Thai Adults
Principal Investigator: Nutthita Petchprapai
Adaptation to Mild Traumatic Brain Injury among Thai Adults
Introduction You are being asked to participate in a research study about outcomes after mild traumatic brain injury and factors that are associated with the outcomes. These outcomes focus on quality of life after mild brain injury. Factors that may influence outcomes included in this study are age, gender, education, employment and marital status, severity of the injury, anatomical lesion of the injured brain, stress, depressed mood, symptoms at the hospital and later, social support, and coping strategies. Before you can decide whether or not to volunteer for this study, you must understand the purposes of the research study, how this study may help you, any risks to you, and what is expected of you. This process is called informed consent.
You do not have to participate in this study. You may stop your participation in this study at any time without changing your current or future relations with the Maharaj Nakhornrajsima Hospital or its doctors.
If you decide to participate in this study, you will be told about any new information learned during the course of the study that might cause you to change your mind about staying in the study.
Why is this study being done? The purposes are to explain quality of life after mild brain injury, and to see if there are any links between potential influential factors and outcome. Studies like this have occurred in other countries and the results show that some people with mild head injuries experience changes in their body functions, emotions and behaviors for years after the injury. In Thailand, there is no information about factors which may influence outcomes after mild head injury among Thai people. This study will help us understand what adults experience and how they recover after mild brain injury in Thailand.
How many people will take part in this study? One hundred and thirty people who are 18 years or older and who have their first mild head injury within one year of the beginning of this study will be asked to participate in this study.
What is involved in the study? This study involves both a phone interview and a review of your medical record from the time you were seen for you injury. The phone interview will take about 45 minutes. I will first ask questions about you such as your age and education. Then I will ask you about physical symptoms, mood and life experiences after your injury. Finally, you will be asked about your satisfaction with your health and related matters and how important
Version date: 09/17/2006 UNIVERSITY HOSPITALS OF CLEVELAND 285 CONSENT FOR INVESTIGATIONAL STUDIES
Project Title: Adaptation to Mild Traumatic Brain Injury among Thai Adults
Principal Investigator: Nutthita Petchprapai
these health-related matters are to you. I will interview you by reading questions and ask you to answer the option that is closest to your feeling or your experience. All of the questions are related to your health. After each question, I will state the options that you can choose from. You can ask questions at any time if you do not fully understand how to respond to the questions. Some questions may be viewed as sensitive to some patients. I will encourage you to arrange to be called for the interview at a time and place of your own choosing to protect your privacy. You can still participate in this study even if you do not want to answer questions which make you feel uncomfortable.
Soon after the interview, I will review your medical information when you came to the hospital with traumatic brain injury. This information includes medical diagnosis, physical and neurological examinations, present history of the injury, time of the injury, signs and symptoms, and treatments that you were given at the time of traumatic brain injury. All information will be reviewed only once.
If the interview cannot be completed in one session, I will make appointment with you to ask the rest of the questions within 1 week.
What happens if I discontinue or withdraw from the study? Withdrawing from this study will not effect or change the treatments or services you receive from the Maharaj Nakhornrajsima Hospital.
What are the risks of this study? Your participation in this study may cause some uncomfortable feelings as a result of personal information revealed during the interview. You may become fatigued from answering questions. You can stop the interview or decline to answer a question if you become uncomfortable. You can take a break or reschedule the interview if you become fatigued.
Are there any benefits to taking part in the study? There are no specific benefits to you for participating in this study.
What are the costs? There is no cost to you for participating in this study.
Will I be paid for participate in this study? You will not be paid or compensated for your participation in this study.
Version date: 09/17/2006 UNIVERSITY HOSPITALS OF CLEVELAND 286 CONSENT FOR INVESTIGATIONAL STUDIES
Project Title: Adaptation to Mild Traumatic Brain Injury among Thai Adults
Principal Investigator: Nutthita Petchprapai
What about confidentiality? No information that can directly link you to the study such as name, hospital number or date of birth will be recorded in the questionnaire. I will keep your research record private and only the Maharaj Nakhornrajsima Institute Review Board, the University Hospital of Cleveland Institute Review Board, and the research advisory committee can look at your record. Only the information that you participated in this study can be accessed. There is no possibility that your answers and your name will be linked to each other. If the results of this study are published or presented in public, no particular name will be used.
All the information collected for this study such as your age and diagnosis, and all questionnaires will be stored in a password-protected computer in the office of Nutthita Petchprapai at the Boromrajchonnee Nakhronrajsima College of Nursing, Amphur Muang, Nakhornrajsima, Thailand. Data being stored on the computer will not contain any information that will identify you.
Summary of your rights as a participant in a research study
Your participation in this research study is voluntary. Refusing to participate will not alter your usual health care or involve any penalty or loss of benefits to which you are otherwise entitled. If you decide to join the study, you may withdraw at any time and for any reason without penalty or loss of benefits. If information generated from this study is published or presented, your identity will not be revealed. In the event new information becomes available that may affect the risks or benefits associated with this study or your willingness to participate in it, you will be notified so that you can decide whether or not to continue participating.
Authorization to Use and Disclose your Information
You authorize Nutthita Petchprapai, the Principal Investigator, to use and disclose information concerning your medical history and information collected during this study for the following purposes: for accessing patient’s history information of age, gender, diagnosis, time after injury, symptoms at time of injury, duration of posttraumatic amnesia, duration of loss of consciousness, anatomical lesion of brain injury, and a history of alcohol use at time of injury. Such information may also be disclosed or used by others involved in or overseeing the study including the UHC Institutional Review Board, the study sponsor and its agents, as well as U.S., European, your and other governmental, regulatory and accrediting agencies. Foreign laws governing privacy, use and disclosure of health information may provide less protection than the laws of your country. Once disclosed your information may be redisclosed by others who are not required to maintain the privacy of your information. You may withdraw authorization to
Version date: 09/17/2006 UNIVERSITY HOSPITALS OF CLEVELAND 287 CONSENT FOR INVESTIGATIONAL STUDIES
Project Title: Adaptation to Mild Traumatic Brain Injury among Thai Adults
Principal Investigator: Nutthita Petchprapai
collect additional information about you at any time by writing to the local Principal Investigator, but information already collected may be continue to be used and disclosed. This authorization has no expiration date.
Contact information
Nutthita Petchprapai has described to you what is going to be done; the risks, hazards, and benefits involved, and can be contacted at (087) 879-9171. Further information with respect to illness or injury resulting from a research procedure as well as a research subjects' rights is available from the Institutional Reviewing Board, Medical Education Center, the Maharat Nakhornratchasima Hospital (044) 295-615. Dr. Thanin Asawawichienjinda, a representative from the board, can be reached at the same telephone number, in case you need further information.
Signature
Signing below indicates that you have been informed about the research study in which you voluntarily agree to participate; that you have asked any questions about the study that you may have; and that the information given to you has permitted you to make a fully informed and free decision about your participation in the study. By signing this consent form, you do not waive any legal rights, and the investigator(s) or sponsor(s) are not relieved of any liability they may have. A copy of this consent form will be provided to you.
______Date______Signature of Participant Printed Name of Participant
______Date______Signature of Person Obtaining Consent Printed Name of Person Obtaining Consent (Must be study investigator or individual who has been designated in the Checklist to obtain consent)
______Date______Signature of Principal Investigator (Affirming subject eligibility for the Study and that informed consent has been obtained.)
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โรงพยาบาลมหาราช นครราชสีมา ใบเซ็นตยินยอมเพื่อเขารวมในการวิจัย โครงการวิจัยเรื่อง: การปรับตัวตอการบาดเจ็บศีรษะแบบไมรุนแรงของผูใหญชาวไทย หัวหนาโครงการวิจัย: ณัฐฐิตา เพชรประไพ พยาบาลวิชาชีพ5, อาจารยวิทยาลัยพยาบาลบรมราชชนนี นครราชสีมา การปรับตัวตอการบาดเจ็บที่ศีรษะแบบไมรุนแรงของผูใหญชาวไทย บทนํา ทานถูกเลือกใหเขารวมการวิจัยเกี่ยวกับสภาพชีวิตภายหลังจากเกิดการบาดเจบศ็ ีรษะแบบไม รุนแรง ในการวิจัยครั้งนี้ทานจะถูกสอบถามเกี่ยวกับการปรับตัว คุณภาพชีวิต อาการทางกายและใจ ภาวะซึมเศรา ภาวะเครียด และความสามารถในการแกปญหา ขอมูลบางอยางของทาน เชน อายุ เพศ ระดับการศึกษา สถานภาพสมรส ความรุนแรงของการบาดเจ็บ ตําแหนงของสมองที่ไดรับการบาดเจ็บ และระยะเวลาภายหลังการเกิดการบาดเจบท็ ี่ศีรษะ จะถกรวบรวมจากแฟู มประวัติของทานที่ โรงพยาบาลมหาราช นครราชสีมา กอนที่ทานจะตดสั ินใจที่จะเขารวมการวิจัยครั้งนี้หรือไม ผูวิจัยจะ อธิบายวัตถุประสงคของการวิจัย วิธีการดาเนํ ินการวิจัย ประโยชนและความเสี่ยงที่ทานอาจจะไดรับให ทานเขาใจ การเขารวมการวิจัยครั้งนี้เปนไปดวยความสมัครใจ ทานอาจจะไมเขารวมในการวิจัยครั้งนี้ก็ ได โดยที่การตัดสนใจของทิ าน จะไมมีผลตอบริการที่ทานจะไดรับจากโรงพยาบาลมหาราช นครราชสีมาแตอยางใด หากทานตดสั ินใจที่จะเขารวมในการวิจัยครั้งนี้ และมีการเปลี่ยนแปลงใดๆเกิดขึ้นกบขั ั้นตอน การวิจัย ผูวิจัยจะแจงใหทานทราบทันท ี เพื่อที่ทานจะสามารถเลือกไดวาจะยังคงรวมในการวิจัยตอไป หรือไม ทําไมถึงจะตองมีการวิจัยครั้งน ี้ การวิจัยครั้งนี้มีวัตถุประสงค เพื่ออธบายผลของการเกิ ิดการบาดเจบศ็ ีรษะที่มีตอการปรับตัว และคุณภาพชีวิตภายหลังการบาดเจบศ็ ีรษะ และเพื่อหาความเกี่ยวของระหวางปจจัยตางๆกับผลของ การปรับตัวและคุณภาพชีวิต งานวิจัยคลายๆก ันนี้ มีการศึกษากนอยั างแพรหลายในตางประเทศและ ผลการวิจัยพบวา แมจะเปนเพ ียงการบาดเจ็บศีรษะแบบไมรุนแรง ผูปวยหลายๆคนก็อาจมีอาการ ทางดานรางกาย อารมณและมีการเปลี่ยนแปลงพฤติกรรมไดนานเปนป หรือหลายป แตในประเทศ ไทย การวิจัยเกี่ยวกับเรื่องนี้ยังไมมีมากนัก โดยทั่วไปแลว ผูปวยหลังการบาดเจ็บศรษะแบบไมี รุนแรง มักไมไดรับการรักษาอยางใดเปนพิเศษ เพราะผูปวยกลุมนี้มักไมมีอาการทางกายใหเห็นอยางชัดเจน งานวิจัยครั้งนจะเปี้ นฐานขอมูลใหเห็นถึงปญหาในผูปวยเหลานี้ไดดียิ่งขึ้น และจะเปนพื้นฐานใหแพทย และพยาบาลในการหาวิธีการดูแลและฟนฟูสภาพผูปวยไดอยางเหมาะสมต อไป
ฉบับ 21 สิงหาคม 2549 289
โรงพยาบาลมหาราช นครราชสีมา ใบเซ็นตยินยอมเพื่อเขารวมในการวิจัย โครงการวิจัยเรื่อง: การปรับตัวตอการบาดเจ็บศีรษะแบบไมรุนแรงของผูใหญชาวไทย หัวหนาโครงการวิจัย: ณัฐฐิตา เพชรประไพ พยาบาลวิชาชีพ5, อาจารยวิทยาลัยพยาบาลบรมราชชนนี นครราชสีมา จะมีผูเขารวมการวิจัยครั้งนี้มาก-นอยเพียงใด ผูวิจัยจะสัมภาษณผูปวยภายหลังการบาดเจ็บศีรษะแบบไมรุนแรงที่อายุ 18 ปขึ้นไป และ ไดรับบาดเจบมาไม็ เกิน 1 ป จํานวน 130 ราย จะเกิดอะไรขึ้นบางระหวางการวิจัย การรวบรวมขอมูลครั้งนี้มี 2 สวน คือดวยการสัมภาษณและการศึกษาจากประวัติของทานที่ โรงพยาบาลมหาราช นครราชสีมา การสัมภาษณจะใชเวลาประมาณ 45 นาที โดยทานจะถ ูกถาม เกี่ยวกับขอมูลทั่วไป เชน อายุและระดับการศึกษา อาการทางรางกาย อารมณ และสงทิ่ ี่ทานประสบ หลังการบาดเจ็บศีรษะแบบไมรุนแรง ทายที่สุดทานจะถูกถามเกี่ยวกับความพึงพอใจในสุขภาพและ ประเด็นอนๆื่ รวมทั้งความสําคัญของสุขภาพและประเดนอ็ ื่นๆ ผูวิจัยจะอานแบบสอบถามใหทานฟง ทีละขอและขอใหทานตอบตามตัวเลือกที่ทานเห็นวาตรงกับความเปนจร ิงที่ทานประสบมากที่สุด ผูวิจัยจะอธบายติ ัวเลือกและวิธีการตอบใหฟงอยางละเอียดอีกครั้ง ทานสามารถที่จะถามไดทันที หาก ทานไมเขาใจหรือไมแนใจวาจะตอบอยางไร คําถามบางคําถามอาจจะเปนค ําถามที่คอนขางจะละลาบละลวงเรื่องสวนตัวของทาน ผูวิจัยจะ ขอใหทานกําหนดเวลาและสถานที่ในการสัมภาษณทางโทรศัพทที่เปนส ัดสวนและปกปองความเปน สวนตัวของทาน ทานยังคงมีสิทธิ์ที่จะเขารวมในการวิจัยครั้งนี้ แมจะไมตอบบางคาถามทํ ี่ทําใหทาน รูสึกไมสบายใจ หลังการสัมภาษณ ผูวิจัยจะศึกษาแฟมประวัติของทานซงไดึ่ รับความยนยอมจากทางิ โรงพยาบาลมหาราช นครราชสีมาแลว เพื่อรวบรวมขอมูลเกี่ยวกับการวิจิจฉัยโรค ผลการตรวจรางการ และระบบประสาท ประวัติการเจ็บปวยปจจุบัน ระยะเวลาที่เกิดการบาดเจ็บ อาการและอาการแสดง และการรักษาที่ทานไดรับเมอเกื่ ิดการบาดเจ็บศีรษะ โดยที่แฟมประวัติของทานจะถกศู ึกษาเพียงครั้ง เดียว หากการสัมภาษณไมเสร็จในครั้งเดียว ผูวิจัยอาจนัดทานเพื่อตอบคําถามที่เหลืออีกครั้ง ทั้งนี้ การสัมภาษณครั้งที่สองจะนัดภายในหนึ่งสัปดาหหลังการสัมภาษณครั้งแรก ในวันและเวลาที่ทาน สะดวก
ฉบับ 21 สิงหาคม 2549 290
โรงพยาบาลมหาราช นครราชสีมา ใบเซ็นตยินยอมเพื่อเขารวมในการวิจัย โครงการวิจัยเรื่อง: การปรับตัวตอการบาดเจ็บศีรษะแบบไมรุนแรงของผูใหญชาวไทย หัวหนาโครงการวิจัย: ณัฐฐิตา เพชรประไพ พยาบาลวิชาชีพ5, อาจารยวิทยาลัยพยาบาลบรมราชชนนี นครราชสีมา จะเกิดอะไรขึ้นหากทานหยุดการใหขอมูลหรือขอถอนตัวจากการวิจัยกลางคัน การถอนตัวออกจากการวิจัยหรือการไมเขารวมในการวิจัยครั้งนี้ของทาน จะไมมีผลกระทบตอ การบริการที่ทานจะไดรับจากโรงพยาบาลมหาราช นครราชสีมาแตอยางใด ทานจะยงคงไดั รับบริการ ในมาตรฐานทเที่ าเทียมกันกับผูปวยรายอนๆื่ ของทางโรงพยาบาลมหาราช นครราชสีมาดังเดิม การวิจัยครั้งนี้มีความเสี่ยงตอผูที่เขารวมการวิจัยหรือไม การวิจัยครั้งนี้ไมไดมีความเสี่ยงตอผูที่เขารวมการวิจัยแตอยางใด ทานอาจรูสึกไมคอยชอบใจ ที่ถูกถามเกี่ยวกับเรื่องสวนตวในบางคั ําถาม ทานอาจรูสึกเหนื่อยไดบางที่ตองคําถามเปนเวลานานถึง 30 นาที ทานอาจเลือกที่จะไมตอบคาถามทํ ี่ทําใหทานรูสึกไมคอยชอบใจ หรือเลอกทื ี่จะหยุดการให สัมภาษณไดทุกเมื่อ ทานอาจขอพักหรือนัดสัมภาษณในวันใหม หากทานร ูสึกเหนื่อยลาหรือมีงานอื่น รออยู การเขารวมวิจัยครั้งนี้มีผลประโยชนตอทานอยางไรบาง ทานจะไมไดรับประโยชนโดยตรงจากการว ิจัยครั้งนี้ แตขอมูลที่ทานใหจะเปนประโยชนอยาง ยิ่งในการวางแผนการดูแลและการพยาบาลผูที่ประสบปญหาคล ายๆก ับทานในอนาคต ตองเสียคาใชจายหรือไม ทานไมตองเสยคี าใชจายใดๆเพิ่มเติมในการเขารวมการวิจัยครั้งน ี้ หากเขารวมการวิจัย จะไดรับคาตอบแทนหรือไม ทานจะไมไดรับคาตอบแทนใดๆในการเขาร วมการวิจัยครั้งน ี้ ขอมูลหรือคําตอบที่ใหจะถูกเก็บเปนความลับหรือไม ผูวิจัยจะไมบันทึกชื่อ ที่อยู เลขที่โรงพยาบาล หรือขอมูลอื่นๆที่สามารถใชในการสืบคนถึง ทานได คําตอบของทานจะถกเกู ็บเปนความลับ มีเพียงเฉพาะคณะกรรมการจริยธรรมการวิจัยของ โรงพยาบาลมหาราชฯ และของมหาวิทยาลัยที่ผูวิจัยศึกษาอยู รวมทั้งกรรมการที่ปรึกษาของการวิจัย ครั้งนี้เทานั้น ที่จะดูแบบสอบถามเหลานี้ได ในแบบสอบถามจะไมมีการใสชื่อหรือขอมูลสวนตัวของ ทาน การเสนอผลการวิจัยครั้งนี้ จะนาเสนอในภาพรวมและไมํ มีการชเฉพาะถี้ ึงตัวบคคลุ คําตอบ ทั้งหมดจะถูกเก็บไวในคอมพิวเตอรและเก็บรักษาไวที่วิทยาลัยพยาบาลบรมราชชนนี นครราชสีมา ขอมูลที่บันทึกไวในคอมพิวเตอรจะไมมีการบันทึกชื่อหรือขอมูลสวนตัวที่สามารถใชในการสืบคนถึง ทานได
ฉบับ 21 สิงหาคม 2549 291
โรงพยาบาลมหาราช นครราชสีมา ใบเซ็นตยินยอมเพื่อเขารวมในการวิจัย โครงการวิจัยเรื่อง: การปรับตัวตอการบาดเจ็บศีรษะแบบไมรุนแรงของผูใหญชาวไทย หัวหนาโครงการวิจัย: ณัฐฐิตา เพชรประไพ พยาบาลวิชาชีพ5, อาจารยวิทยาลัยพยาบาลบรมราชชนนี นครราชสีมา สรุปสิทธิของผูเขารวมการวิจัยครั้งน ี้ การเขารวมการวิจัยครั้งนี้เปนไปดวยความสมัครใจ แมทานไมเขารวมในการวิจัย ทานก็จะไม เสียประโยชนใดๆในการเขาร ับการรักษาที่โรงพยาบาลมหาราช นครราชสีมา หากทานตกลงที่จะเขา รวมในการวิจัยครั้งนี้ ทานมีสิทธิที่จะขอถอนตัวจากการวิจัยไดทุกเมื่อ โดยไมตองเสยคี าใชจายหรือ เสียสิทธิประโยชนใดๆ ขอมูลสวนบุคคลของทานจะไมถูกเปดเผย การนําเสนอผลการวิจัย เมื่อการ วิจัยเสร็จสิ้น จะเปนไปในภาพรวมเทานั้น หากมีการเปลี่ยนแปลงใดๆของขั้นตอนการวิจัยเกิดขึ้น ระหวางที่กําลังดําเนนการวิ ิจัยอยู และการเปลี่ยนแปลงนั้นๆอาจกระทบตอความปลอดภัยหรือสิทธิ สวนบุคคลของทาน ผูวิจัยจะแจงใหทานทราบทันท ี การยินยอมใหศึกษาขอมูล ทานยินยอมให ณัฐฐิตา เพชรประไพ ผูวิจัยศึกษาขอมลของทู านจากแฟมประวัติผูปวยและ การสัมภาษณประกอบการศึกษาวิจัย ขอมูลเหลานี้ประกอบดวย อายุ เพศ การวินิจฉัยโรค ระยะเวลา ภายหลังการเกิดการบาดเจบศ็ ีรษะ อาการและอาการแสดงเมื่อเกิดการบาดเจ็บศีรษะ ระยะเวลาของ การเกิดอาการมึนงงสับสน และการหมดสติภายหลังการเกิดการบาดเจ็บศีรษะ ตําแหนงของศีรษะ และสมองที่เกิดการบาดเจ็บ และประวัติการดื่มสุรากอนการเกิดการบาดเจบของศ็ ีรษะ ขอมูลเหลานี้ อาจถูกศึกษาหรือใชโดยผูที่มีสวนเกี่ยวของกับงานวิจัยครั้งนี้ เชน คณะกรรมการจริยธรรมการวิจัยของ โรงพยาบาลมหาราช นครราชสีมา และ โรงพยาบาลมหาวิทยาลัย แหงเมืองคลิฟแลนด รัฐบาล คณะกรรมการที่มีหนาที่ในการควบคุมและตรวจสอบการวิจัยครั้งนี้ ทั้งในประเทศไทยและ สหรัฐอเมริกา ทั้งนี้มาตรฐานในการปกปองความเป นสวนต ัวของแตละประเทศอาจไม เทากัน ขอมูล ที่ไดรับการปกปดในประเทศหนึ่ง อาจไดรับการเปดเผยในอีกประเทศหนึ่ง ทานอาจเพิกถอนการ อนุญาตใหศึกษาขอมูลตางๆเม ื่อใดก็ได โดยการแจงใหผูวิจัยทราบ อยางไรก็ตามการเพิกถอนนั้นๆ จะไมมีผลตอขอมูลที่ไดมีการศึกษาไปกอนหนานี้แลว โดยขอมูลที่ไดมีการรวบรวมไปแลวจะยังคงถูก ศึกษาตอไป ทั้งนี้การยินยอมใหศึกษาขอมูลของทานในครั้งนี้ เปนไปโดยไม มีวันหมดอาย ุ
ฉบับ 21 สิงหาคม 2549 292
โรงพยาบาลมหาราช นครราชสีมา ใบเซ็นตยินยอมเพื่อเขารวมในการวิจัย โครงการวิจัยเรื่อง: การปรับตัวตอการบาดเจ็บศีรษะแบบไมรุนแรงของผูใหญชาวไทย หัวหนาโครงการวิจัย: ณัฐฐิตา เพชรประไพ พยาบาลวิชาชีพ5, อาจารยวิทยาลัยพยาบาลบรมราชชนนี นครราชสีมา การติดตอผูวิจัย ณัฐฐิตา เพชรประไพ ผูวิจัย ไดอธบายใหิ ทานเขาใจถึงขั้นตอนการวิจัย อันตราย ความเสี่ยง และประโยชนที่เกี่ยวของกับการวิจัยครั้งนี้เปนอยางดแลี ว ทานสามารถที่จะตดติ อผูวิจัยไดที่ วิทยาลัย พยาบาลบรมราชชนนี นครราชสีมา อําเภอเมือง นครราชสีมา หรือที่ หมายเลขโทรศัพท 087-879- 9171 หากทานมีขอสงสัยเกี่ยวกับการเจ็บปวยหรือการบาดเจ็บอนเนั องมาจากการวื่ ิจัยครั้งนี้ หรือมี ขอสงสัยเกี่ยวกับสิทธิของผูเขารวมการวิจัย กรุณาตดติ อผ ูวิจัยตามทอยี่ ูขางตน หรอตื ิดตอ คณะกรรมการจริยธรรมการวิจัยในมนุษย ศูนยแพทยศาสตรศ ึกษา โรงพยาบาลมหาราช นครราชสีมา ที่หมายเลขโทรศัพท (044) 295-615 หรือติดตอนายแพทยธนินทร อัศววิเชียรจินดา ตัวแทนคณะกรรมการจริยธรรมการวิจัยในมนุษย โรงพยาบาลมหาราช นครราชสีมา ที่หมายเลข โทรศัพทเดียวกัน การลงนาม โดยการลงนามในในยินยอมนี้ ทานไดรับทราบเกี่ยวกับการวิจัยครั้งนี้เปนอยางด ี โดยไมมีขอ สงสัย และเตมใจท็ ี่จะเขารวมการวิจัย ทานไดสอบถามเกี่ยวกับขอสงสัยตางๆและลงนามในเอกสารนี้ ภายหลังจากที่ไดรับขอมูลตางๆอยางเพียงพอ กอนที่จะตัดสนใจเขิ ารวมการว ิจัย หลังการลงนามใน เอกสารนี้ ทานยังคงมีสิทธิตามกฏหมายครบถวนและไมเสียสิทธิใดๆ ผูวิจัยไดมอบเอกสารพรอม ลายเซ็นตให ทานเก็บไวดวย 1 ฉบับ
______วันท______ี่ ลายเซนตผูเขารวมการวิจัย ชื่อ-สกุลของผูเขารวมการวิจัย ______ณัฐฐิตา เพชรประไพ______วันท ี่ 4 ต.ค. 49 ลายเซนตผูขอลายเซนตผูเขารวมการวิจัย ชื่อ-สกุลของผูขอลายเซนตผูเขารวมการวิจัย (ตองเปนบคคลในคณะวุ ิจัยหรือบุคคลทไดี่ รับการมอบหมายใหทําการขอลายเซนตผูเขารวมการวิจัย เทานั้น) ______ณัฐฐิตา เพชรประไพ______วันที่4 ต.ค.49 ลายเซนตผูวิจัย ชื่อ-สกุลของผูวิจัย
ฉบับ 21 สิงหาคม 2549
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of Nursing :lJtnll'1tJ1~tJ Case Western Reserve University llJm Cleveland 1~ Ohio 1J':i :;;Il'1fl'{1''I11~m:lJ~fll , o Q.I 0 oQo Q,l ~ i .do fllft-:ll'111'Um 'Hl-:l Adaptation to Mild Traumatic Brain Injury among Thai Adults tl91tJ:lJ Dr. Chris
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Adaptation to Mild Traumatic Brain Injury among Thai Adults
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01 " ('W1VtlW~f1~ ~'l1~Ui:l6) q '" H'fll'W ltJf1l l' i l' 'l~tJ1Uli:l:lJ'I111'1'lf'Wm 1'l'lf-ffm '" The Institutional Review Board, Medical Education Center at the Maharat Nakhon Ratchasima Hospital Chang Phueak Road, Mueang, Nakhon Ratchasima, Thailand 30000
October 24,2006
Nutthita Petchprapai, PhD( c) Frances Payne Bolton School of Nursing Case Western Reserve University 10900 Euclid Ave., Cleveland Ohio 44106 USA Tel: 001-1-216-368-5866 Fax: 001-1-216-368-8864
Dear Ms . Petchprapai:
I am pleased to grant permission accessing database of the Maharat Nakhon Ratchasima hospital, reviewing medical record of patients with mild traumatic brain injury, and interviewing patients with mild traumatic brain injury for your dissertation research entitled "Adaptation to Mild Traumatic Brain Injury among Thai Adults". This permission is granted under a careful review by the Institutional Review Board, Medical Education Center, the Outpatient Department, the Emergency department, and the Surgical Department at the Maharat Nakhon Ratchasima hospital.
This permission includes use of the data collected for this purposes outlined in the proposal and also publication of the results from this data.
My very best wishes for the success of this phase in your work and your contributions to health care society in the future. UNIVERSITY HOSPITALS OF CLEVELAND INSTITUTIONAL REVIEW BOARD FOR HUMAN INVESTIGATION
Th e Univers ity Hospitals Institutional Review Board has reviewed the proposal and informed consent Submitted by Petchpra pai, Nutthita Entitled : Adaptation to Mild Traumatic Brain Injury Among Tha i Adults [06-06-36]
Please be advised that with respect to: (1) The rights and welfare of the Individuals (2) The appropriateness of the methods to be used to secure informed consent (3) The risks and potential medical benefits of the investigation The Board Considers This Project:
~ FULLY ACCEPTABLE, without reservation; approved through 10/2/2007 o NOT ACCEPTABLE for reasons noted : REMARKS: The continuing review is due by the date noted above . IRB requires prompt reporting of the completion of a study. Please reference the IRB number on future reviews and correspondence HIPAA Authorization Approved (Privacy Board) Research in local context for Thailand was considered at the IRB meeting of October 3, 2006
Date of Committee Review: 10/3/2006 Date of Approval : 10/16/2006
TYPE PROJECT o New o Renewal o Addendum/Amendm ent HUMAN RISK D Yes ~ No SOURCE OF SUPPORT ~ None 0 Departmental 0 Outside Funding Agency: Agenc y Study Number: ARE ANY OF THE FOLLOWING INVOLVED? :::J No 0 Yes o Minors [] Neonates 0 Fetuses/Abortuses [] Prisoners 0 Pregnant 0 Mentally [] Mentally Women Retarded Disabled Protocol s involving children approved under U 45 CFR 46.40 4 o 45 CFR 46.405 D 45 CFR 46.406* *Both parents mus t give their permission unless one par ent is deceased . unknown. incompetent. or not reasonab ly available. or when on ly one has legal responsib ility for the care and custody o f the child. The UHC IRB operates under the HHS Federal Wide Assurance of Compliance number 00003937 and IRB registration numbers 00000684 and 00001691
Joseph Gibbons. MD. Chairma n: Barbara Daly. PhD, RN. Vice Chair: or William T Dahms , MD. Vice Chair. or Ravi Nair. MD., Vice Chair VH