Men's gendered experiences of rehabilitation and recovery following traumatic brain injury: A reflexive thematic analysis.

Research shows that gender influences men's health-related beliefs and behaviours - including those within the context of traumatic brain injury (TBI) - making it a factor that should be considered when designing and implementing interventions for this population. To incorporate an understanding of such gendered influences in future educational materials for men with TBI, as well as their caregivers and clinicians, this qualitative study was informed by social constructionism, and aimed to explore how gender is related to men's post-TBI perceptions and behaviours in rehabilitation and recovery. Semi-structured interviews were conducted with 22 men with mild and moderate-severe TBI at the acute (≤ 3 months post-TBI) and chronic (> 3 months post-TBI) phases of injury. A reflexive thematic analysis approach was applied to interview data, guided by the concept of hegemonic masculinity as described by Connell, R.W. (2005. Masculinities [2nd ed.]. Polity). Three key themes were identified: (1) "I'm a man, I'm a rock": Undermining treatment, (2) "I'm going to face that challenge": Facilitation of recovery, and (3) "I don't feel as useful as a guy as I was before": Perceptions on return to work. These findings may be translated into gender-informed therapy strategies and materials.

Perspectives of parents of working adolescents in Ontario, Canada.

BACKGROUND: More than half of adolescents have jobs in summer or sometime during the year. While employers are ultimately responsible for their safety, parents are often important in helping their children navigate the work environment. Our study examines the attitudes, beliefs and types of involvement parents have in their children's work. METHODS: We modeled a telephone survey of 507 English-speaking parents of working adolescents in Ontario, Canada on a US study and examined their perspectives, comparing to earlier findings from the U.S. parents. RESULTS: Most Ontario parents helped their teens consider questions to ask about work, for example, work hours (90.7%) and job tasks (78.2%) and fewer about workplace safety (57.9%). Parents overall were concerned about their teens, especially younger teens, getting behind on schoolwork (69.3%), being rushed on the job (60.1%) and doing hazardous tasks (58.3%) or working alone (51.9%), or being at work during a robbery (74.5%). Parents of 14-17-year-old daughters were more concerned about their child being assaulted than were parents of sons (62.4% vs. 51.4%), particularly if the teen was in the 18-19 age group (74.3% vs. 52.5%). Half the parents indicated 10-19 h per week was the right amount of work time for their teen, and most agreed that laws should limit the number of hours of youth work. CONCLUSIONS: Overall, Ontario parents appear to be more concerned about the safety and also more involved in the work of their adolescent children than U.S. parents previously surveyed. Parents are engaged with their children about their work and may serve as valuable assets to helping to advocate for safe work policies and environments.

Rehospitalization After Traumatic Brain Injury: A Population-Based Study.

OBJECTIVE: To examine, from a Canadian population-based perspective, the incidence and etiology of long-term hospital utilization among persons living with traumatic brain injury (TBI) by age and sex. DESIGN: Retrospective cohort study. SETTING: Acute care hospitals. PARTICIPANTS: Index cases of TBI (N=29,269) were identified from the Discharge Abstract Database for fiscal years 2002/2003 through 2009/2010 and were followed-up until 36 months after injury. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Rehospitalization was defined as admission to an acute care facility that occurred up to 36 months after index injury. Diagnoses associated with subsequent rehospitalization were examined by age and sex. RESULTS: Of the patients with TBI, 35.5% (n=10,390) were subsequently hospitalized during the 3-year follow-up period. Multivariable logistic regression (controlling for index admission hospital) identified men, older age, mechanism of injury being a fall, greater injury severity, rural residence, greater comorbidity, and psychiatric comorbidity to be significant predictors of rehospitalization in a 3-year period postinjury. The most common causes for rehospitalization differed by age and sex. CONCLUSIONS: Rehospitalization after TBI is common. Factors associated with rehospitalization can inform long-term postdischarge planning. Findings also support examining causes for rehospitalization by age and sex.

A thematic analysis of patients' and their informal caregivers' gendered experiences in traumatic brain injury.

PURPOSE: Research shows that patients' perceptions of themselves and others, in addition to their understanding of the concept of gender, changes after traumatic brain injury (TBI). Little is known about gendered experiences in TBI and care delivery. This study aims to explore perceptions of gender through life experiences and interactions between adult patients with TBI and their informal caregivers. MATERIALS AND METHODS: Seven patients with mild and moderate-severe TBI and eight informal caregivers were interviewed. Transcripts were coded and analysed according to Braun and Clarke's thematic analysis. The Consolidated Criteria for Reporting Qualitative Research guidelines were followed in reporting results. RESULTS: The participants described a transformation of their understanding and experiences of gender following the TBI event. Three themes were identified: (1) Gender designations of "man" and "woman";( 2) Post-injury performativity of gender; and (3) Gender in giving and receiving care. CONCLUSIONS: The findings emphasize the importance of raising awareness among researchers and practitioners on gender as a transformative process for patients with TBI and informal caregivers after the injury. The diversity of patient-caregiver experiences and critical needs based on gender call for intervention approaches that mitigate gender disparities in giving and receiving care. Implications for RehabilitationHistorically, rehabilitation of persons with traumatic brain injury has targeted physical and cognitive impairments, with little attention to their gendered demands in the lived environment.Gender prevails in the lived experiences of persons with traumatic brain injury, and their informal caregivers, and in giving and receiving quality care.A major challenge for clinicians is identifying harmful gendered roles, norms, and relations and the affective/behavioral problems they produce to alleviate enduring distress and reduce disability.Rehabilitation interventions focusing on flexible and adaptive responses to gendered demands in the lived environment of persons with traumatic brain injury are timely.

Is it prime time for sex and gender considerations in traumatic brain injury? Perspectives of rehabilitation care professionals.

PURPOSE: The purpose of this study was to explore rehabilitation clinicians' understanding of how sex and gender facilitate or hinder care provided to patients with traumatic brain injury (TBI). MATERIALS AND METHODS: Sixteen clinicians from various specialities, attending to patients with TBI from a large rehabilitation hospital in Ontario, Canada, were recruited using purposive sampling. Data was collected through semi-structured interviews and thematic analysis was used to identify reoccurring themes. RESULTS: Three themes that facilitate or hinder care of TBI patients were identified: (1) knowledge and evidence; (2) gender and other aspects of recovery; and (3) family caregiving. Lack of education about the topic and inconsistent scientific evidence limited clinicians' attention to sex and gender topics. Social, financial, and cultural characteristics of patients were considered to be more relevant than their sex and gender. The gendered nature of caregiving and its burden on caregivers' health were acknowledged. CONCLUSIONS: Currently, attention to topics of sex and gender as they may influence patients' recovery is limited. However, clinicians are willing to be educated on these topics to enhance rehabilitation care. Further research on the gendered nature of interactions between patient, clinician, and family caregiver during recovery is warranted.IMPLICATIONS FOR REHABILITATIONSex and gender matter for patients undergoing recovery for their traumatic brain injury; however, clinical attention to this topic is limited.Based on the clinicians' perceptions, resources that address patients' psychosocial vulnerabilities should be prioritized (e.g., unequal access to care, financial status, cultural diversity etc.).Clinicians highlighted that psychosocial vulnerability and patients' life roles, before and after injury, are sex and gender specific.Guidelines about sex and gender influences in traumatic brain injury rehabilitation have the potential to enhance clinical practice.

Knowledge of sex and gender and related information needs in patients with traumatic brain injury: in-depth interview study.

AIM: This research aimed to gain an understanding of biological sex and social gender phenomena experienced by patients with traumatic brain injury in recovery, and to understand the educational needs of this group. METHODS: We conducted semi-structured interviews of 40 adult patients (22 men, 18 women) of different ages, education levels, and ethnicities, with diagnoses of mild and moderate-severe traumatic brain injury at the acute and chronic stages post-injury. RESULTS: Applying classic content analysis with inductive coding, three overarching themes that limited patients' knowledge and subsequent efforts to obtain information on the topic emerged: (1) the complexity of sex and gender subject matters, (2) patients' dependence on others, and (3) uncertainty about the course of recovery. The first diminished the patient's desire to seek further information. Dependence on others and trust that others were in a better position to use the information, compelled patients to redirect the need for education to clinicians, significant others, and the public on the unique post-injury experiences of men and women. Uncertainty about what to expect in the acute phases, and a feeling of identity loss in the chronic phases, established patients' desire to seek out only the information they believed to be necessary for them to carry on with life. CONCLUSIONS: In developing recommendations for patient education, variations in patients' knowledge and desire for information, and the reasons behind these variations, should be considered. Improving injury prognosis requires taking into account the gendered context of injury and recovery from it.IMPLICATIONS FOR REHABILITATIONSex/gender issues in traumatic brain injury are complex; the challenge is identifying which information is most relevant for patients; this research assessed patients' knowledge of and interest in sex/gender-related topics in traumatic brain injury.Evidence shows most patients unable to differentiate between sex and gender, but when asked about living as a man or woman with traumatic brain injury, disturbed gender roles and identities became evident.Gender shapes the health status trajectory and outcomes of patients with traumatic brain injury which becomes evident when attention is paid to patients' personal life stories.To improve traumatic brain injury prognosis, clinicians should tailor management plans taking into account gender, an amalgamation of biological, behavioural, cultural, and social characteristics of their patients.In research, explicit and consistent consideration of the interrelated constructs of sex and gender would produce a better understanding of the different mechanisms that shape the course of traumatic brain injury.

Hospitalizations and emergency department visits for TBI in Ontario.

OBJECTIVE: The aim of this study was to determine the number of annual hospitalizations and overall episodes of care that involve a traumatic brain injury (TBI) by age and gender in the province of Ontario. To provide a more accurate assessment of the prevalence of TBI, episodes of care included visits to the emergency department (ED), as well as admissions to hospital. Mechanisms of injury for overall episodes were also investigated. METHODS: Traumatic brain injury cases from fiscal years 2002/03-2006/07 were identified by means of ICD-10 codes. Data were collected from the National Ambulatory Care Reporting System and the Discharge Abstract Database. RESULTS: The rate of hospitalization was highest for elderly persons over 75 years-of-age. Males generally had higher rates for both hospitalizations and episodes of care than did females. The inclusion of ED visits to hospitalizations had the greatest impact on the rates of TBI in the youngest age groups. Episodes of care for TBI were greatest in youth under the age of 14 and elderly over the age of 85. Falls (41.6%) and being struck by or against an object (31.1%) were the most frequent causes for a TBI. CONCLUSIONS: The study provides estimates for TBI from the only Canadian province that has systematically captured ED visits in a national registry. It shows the importance of tracking ED visits, in addition to hospitalizations, to capture the burden of TBI on the health care system. Prevention strategies should include information on ED visits, particularly for those at younger ages.

Examining occupational traumatic brain injury in Ontario.

OBJECTIVE: Occupational traumatic brain injuries disrupt the lives of workers and carry major economic repercussions. To date, there has been limited information on brain injuries that occur at work across injury severity levels in Canada. The aim of this study was to provide an overview of occupational traumatic brain injuries in Ontario, with a focus on the sex of the workers. METHODS: For this cross-sectional study, data from the Ontario Workplace Safety and Insurance Board were used. A retrospective chart review was conducted of over 1,500 claim files from the year 2004 with the diagnostic codes of concussion and intracranial injury. Severity was assessed according to data on days off work. RESULTS: The average age of those injured was 37.8 years. The breakdown by sex shows that 57.8% of claims for occupational traumatic brain injury involved males. The most common mechanism of injury was being "struck by or against", followed by "falls". Most of the occupational traumatic brain injuries were from the manufacturing, and government and related services sectors. The highest rate, however, was shown for transportation and storage (81.5/100,000), followed by government and related services (56.6/100,000) and primary industries (47/100,000). CONCLUSIONS: An examination of occupational traumatic brain injuries across a range of severities reveals a profile that is different from that associated with more severely injured workers: there were many more women in particular industries who were injured and more injuries involving being struck by an object. This paper provides data on key industries, mechanisms and contributing factors involved in work-related traumatic brain injury that result in claims to the Workplace Safety and Insurance Board.

Workplace experiences of young workers in Ontario.

OBJECTIVE: We examine the workplace experiences of Ontario youth in the service sector, with a particular interest in hazard exposures, safety training and supervision. METHOD: A cross-sectional telephone survey in 2008 of working youth aged 14-18. Items queried respondents about the tasks performed, worker training and supervision. The study parallels one already published in the US. This is the first Canadian study of its kind. RESULTS: Although teens reported working more hours during vacation, a substantial number of youth are working at least 20 hours per week when school is in session, and many reported having worked after 11 pm on a night before school. Young workers engaged in a variety of hazardous tasks, including heavy lifting, using sharp objects, working with hot equipment, or working around falling objects. A small subset (7.5%) of teens had suffered an injury at work that was severe enough to cause them to miss a day of school or work or require medical attention. The majority of workers had received training on how to use equipment safely and how to avoid an injury. More females than males received training. Although regular check-ins were common, many youth (38%) said they had worked at least part of the day without supervision. Young females were most likely to work without supervision or to work alone. CONCLUSION: This study questions whether the regulations in Ontario are sufficient to protect young workers from exposures to work-related hazards.

Sleep before and after work-related concussion: Sex differences in effects and functional outcomes.

BACKGROUND: Recent studies have started disentangling components of disturbed sleep as part of the post-concussive syndrome, but little is known about the workers with an injury' perspectives on post-injury sleep changes or what causes these changes. OBJECTIVES: To determine the effects of work-related concussion/mild traumatic brain injury (wr-mTBI) on perceptions of refreshing sleep in workers with an injury and to identify the relevant factors responsible for sleep changes. METHODS: We studied post-concussive changes in sleep in 66 adults (50% male workers, 42% aged 30-50 years, median post-injury days: 155) who had sustained wr-mTBI and experienced functional limitations long after the injury. We collected sociodemographic, occupational and health status data and identified variables related to post-concussive changes in refreshing sleep. RESULTS: Forty-seven workers with wr-mTBI (79% of male workers, 64% of female workers) perceived their sleep as being refreshing before injury and unrefreshing afterwards (χ2 = 67.70 for change, χ2 = 27.6 for female and χ2 = 41.1 for male workers, p < 0.0001). Post-concussive losses in refreshing sleep were associated with socio demographic, occupational, and health status data variables. Sex stratification revealed differences between male and female workers. CONCLUSIONS: Workers with wr-mTBI experience clinically meaningful changes in refreshing sleep that are associated with modifiable variables. The observed differences in functional outcomes between male and female workers warrant further study.

Traumatic brain injuries in the construction industry.

OBJECTIVE: This study analyses factors associated with work-related traumatic brain injury (TBI), specifically in the construction industry in Ontario, Canada. METHODS: This cross-sectional study utilized data extracted from the Ontario Workplace Safety and Insurance Board (WSIB) records indicating concussion/intracranial injury that resulted in days off work in 2004-2005. RESULTS: Analyses of 218 TBI cases revealed that falls were the most common cause of injury, followed by being struck by or against an object. Mechanisms of injury and the temporal profile of injury also varied by age. For instance, a significantly higher proportion of injuries occurred in the mornings for young workers compared to older workers. CONCLUSIONS: The results of this study provide important information for prevention of TBI which suggest important age-specific strategies for workers in the construction industry.

Work-related traumatic brain injury: A brief report on workers perspective on job and health and safety training, supervision, and injury preventability.

BACKGROUND: Although work-related injuries are on the decline, rates of work-related traumatic brain injury (wrTBI) continue to rise. As even mild wrTBI can result in cognitive, behavioural, and functional impairments that can last for months and even years, injury prevention is a primary research focus. Administrative claims data have provided valuable insights into the mechanisms that cause wrTBI; however, data from the perspective of injured workers on wrTBI prevention is limited. OBJECTIVE: Our study aimed to better understand the factors that precipitate wrTBI, as perceived by injured workers. METHODS: We recruited 101 injured workers from a neurology services clinic with a province-wide catchment area in a large, urban teaching hospital and studied perceived preventability of these injuries from the injured workers' perspective. RESULTS: Key findings were that nearly 80% of injuries were perceived as preventable, and nearly 25% and 50% of workers reported that they did not receive job and health and safety training, respectively. Less than half of all workers reported being regularly supervised, and of those who were supervised, approximately two-thirds reported that supervision was adequate. Moreover, 84% and 77% reported they were advised to rest and take time-off after the injury, respectively. CONCLUSIONS: Our study is the first to show that the vast majority of injured workers consider their wrTBI to be preventable. In addition, we found that training and supervision are two areas that can be targeted by wrTBI prevention strategies. Our study provides valuable and unique perspectives to consider when designing wrTBI prevention initiatives.

Conceptualizing and Managing Medical Emergencies Where No Formal Paramedical System Exists: Perspectives from a Remote Indigenous Community in Canada.

(1) Background: Remote communities in Canada lack an equitable emergency medical response capacity compared to other communities. Community-based emergency care (CBEC) training for laypeople is a model that has the potential to enhance the medical emergency response capacity in isolated and resource-limited contexts. The purpose of this study was to understand the characteristics of medical emergencies and to conceptualize and present a framework for what a medical emergency is for one remote Indigenous community in northwestern Ontario, in order to inform the development of CBEC training. (2) Methods: This study adhered to the principles of community-based participatory research and realist evaluation; it was an integrated component of the formative evaluation of the second Sachigo Lake Wilderness Emergency Response Education Initiative (SLWEREI) training course in 2012. Twelve members of Sachigo Lake First Nation participated in the training course, along with local nursing staff, police officers, community Elders, and course instructors (n = 24 total), who participated in interviews, focus groups, and a collaborative discussion of local health issues in the development of the SLWEREI. (3) Results: The qualitative results are organized into sections that describe the types of local health emergencies and the informal response system of community members in addressing these emergencies. Prominent themes of health adversity that emerged were an inability to manage chronic conditions and fears of exacerbations, the lack of capacity for addressing mental illness, and the high prevalence of injury for community members. (4) Discussion: A three-point framework of what constitutes local perceptions of an emergency emerged from the findings in this study: (1) a sense of isolation; (2) a condition with a potentially adverse outcome; and (3) a need for help.

Seniors Falls Investigative Methodology (SFIM): a systems approach to the study of falls in seniors.

An in-depth understanding of human factors and human error is lacking in current research on seniors' falls. Additional knowledge is needed to understand why seniors are falling. The purpose of this article is to describe the adapting of the Integrated Safety Investigation Methodology (ISIM) (used for investigating transportation and industrial accidents) to studying seniors' falls. An adapted version-the Seniors Falls Investigative Methodology (SFIM)-uses a systems approach to take an investigation beyond the immediate cause of an incident and reveal unsafe acts and deeply imbedded unsafe conditions that contribute to adverse outcomes. An example case study is used to describe six phases of the investigative process in detail. The SFIM has the potential to identify safety deficiencies; utilize existing knowledge about falls; establish a standardized reporting system; shift focus from the faller to the system; and guide targeted prevention.

Sex differences in work-related traumatic brain injury due to assault.

OBJECTIVES: To examine the etiology, prevalence and severity of assault-precipitated work-related traumatic brain injury (wrTBI) in Ontario, Canada through a sex lens. METHODS: Cross-sectional study using data abstracted from the Ontario Workplace Safety and Insurance Board (WSIB) claims files in 2004. Descriptive analyses were conducted to determine the distribution of worker/employment/incident characteristics. RESULTS: Workplace physical violence that resulted in a TBI accounted for 6.6% percent of all TBI injury claims. Female workers, primarily in the health care/social services sector, accounted for over half of all TBIs. Most workers were assaulted by consumers/clients. Forty five percent of injuries occurred among workers with less than 3 years of employment. CONCLUSIONS: This paper identifies profiles of workers and workplaces for targeted preventive efforts. Future studies are needed to further address risk factors by sex and outcomes, such as length of disability and health care cost.

Construction fatality due to electrical contact in Ontario, Canada, 1997-2007.

BACKGROUND: Electrical contact is a leading cause of occupational fatality in the construction industry. However, research on the factors that contribute to electricity-related fatality in construction is limited. OBJECTIVES: To characterize, using an adapted Haddon's Matrix, the factors that contribute to electricity-related occupational fatalities in the construction industry in Ontario, Canada. METHODS: Coroner's data on occupational electricity-related fatalities between 1997-2007 in the construction industry were acquired from the Ontario Ministry of Labour. Using an adapted Haddon's Matrix, we characterized worker, agent, and environmental characteristics of electricity-related occupational fatalities in the province through a narrative text analysis. RESULTS: Electrical contact was responsible for 15% of all occupational fatalities among construction workers in Ontario. Factors associated with said occupational fatalities included direct contact with electrical sources, lower voltage sources, and working outdoors. CONCLUSIONS: This study provides a profile of electricity-related occupational fatalities among construction workers in Ontario, and can be used to inform safety regulations.

Return to work after work-related traumatic brain injury.

BACKGROUND: Work-related traumatic brain injury (wrTBI) comprises up to 24% of TBIs, yet relatively little is known about it even though wrTBI incurs high costs to employers, insurers, and injured. OBJECTIVES: To compare demographic, clinical, and occupation-related factors following mild-to-moderate TBI of those who successfully returned to work (RTW) versus those who did not, and to determine perceived facilitators of and barriers to RTW. METHODS: Retrospective cohort study from a consecutive sample of persons with TBI seen in an outpatient assessment clinic. Surveys were mailed to eligible potential participants. Consenting participants were interviewed by telephone or returned a completed survey via mail. RESULTS: Fifty of 116 eligible individuals participated in the study. Half of the participants returned to work. Participants in this group were significantly younger and had more years of education than the no-RTW group. The most common factors perceived to assist the RTW group were support of family and friends (92%) and of treatment providers (80%), and employers who provided accommodations (76%). Difficulty thinking and concentrating (94%) and fatigue (94%) were the most common barriers to RTW. CONCLUSIONS: This study highlights the importance of support from family, friends and employers as RTW facilitators. These factors merit further investigation in TBI rehabilitation studies.

Measuring adolescent smoking expectancies by incorporating judgments about the expected time of occurrence of smoking outcomes.

French and English Canadian adolescents completed a smoking expectancy questionnaire and 2 measures of current smoking status. Multiple regression revealed that beliefs about the expected time of occurrence of smoking outcomes explained unique variance in current smoking after controlling for judgments about the probability and desirability of these outcomes. In addition, the relationship between the perceived probability of the general costs of smoking and current smoking was moderated by beliefs about the expected time of occurrence of these costs. There was no relationship between perceived probability of general costs and smoking for adolescents who expected the costs to occur far in the future, whereas there was a significant negative relationship between these 2 variables for adolescents who expected the costs to occur soon after smoking. The authors' results suggest that it may be possible to increase the concurrent validity of traditional smoking expectancy measures by incorporating expected-time-of-occurrence judgments.

Danger zone: Men, masculinity and occupational health and safety in high risk occupations.

The workplace is a key setting where gender issues and organizational structures may influence occupational health and safety practices. The enactment of dominant norms of masculinity in high risk occupations can be particularly problematic, as it exposes men to significant risks for injuries and fatalities. To encourage multi-disciplinary collaborations and advance knowledge in the intersecting areas of gender studies, men's health, work and workplace health and safety, a national network of thirteen researchers and health and safety stakeholders completed a critical literature review examining the intersection between masculinities and men's workplace health and safety in order to: (i) account for research previously undertaken in this area; (ii) identify themes that may inform our understanding of masculinity and workplace health and safety and; (iii) identify research and practice gaps in relation to men's workplace health and safety. In this paper we present key themes from this review. Recommendations are made regarding: (i) how to define gender; (ii) how to attend to and identify how masculinities may influence workers' identities, perceptions of occupational risks and how institutionalized practices can reinforce norms of masculinity; (iii) the importance of considering how masculinities may intersect with other variables (e.g. historical context, age, class, race, geographical location) and; (iv) the added significance of present-day labour market forces on men's occupational health and safety.

A comparison of the mediational properties of four adolescent smoking expectancy measures.

This prospective study compared the ability of 4 smoking expectancy measures to mediate the influence of peer, parent, and current smoking on adolescents' cigarette use 3 months later. No evidence for mediation was found when expectancies were operationalized as unidimensional subjective expected utility (SEU), multidimensional SEU, or unidimensional SEU decomposed into probability and desirability main effects and their interaction. Evidence for partial mediation was found for the decomposed multidimensional SEU measure. The results suggest that (a) peer and current cigarette use may influence future smoking indirectly through adolescents' probability estimates that smoking will control negative emotions and (b) the relationship between current and future smoking also may be mediated by adolescents' beliefs about the desirability of weight control.