Association Between Social Determinants of Health and Traumatic Brain Injury: A Scoping Review

Abstract

Traumatic brain injury (TBI) is a leading cause of death and disability worldwide. Disparities exist in the populations that acquire TBIs, however, with a greater burden and poorer outcomes associated with communities of color and lower socioeconomic status. To combat health inequities such as these, institutions have begun to target social determinants of health (SDoH), which are environmental factors that affect health outcomes and risks. The SDoH may play a role in sustaining a TBI and provide modifiable targets for action to reduce the risk of TBI, especially in high-risk communities. In this study, we describe the existing literature regarding SDoH and their association with sustaining a TBI. We performed a scoping review with a comprehensive search of the Ovid MEDLINE/Embase databases. To summarize the literature, this review adapts the World Health Organization's Commission on SDoH's conceptual framework. Fifty-nine full-text articles, including five focusing on lower and middle-income countries, met our study criteria. Results of the scoping review indicate that several structural determinants of health were associated with TBI risk. Lower educational attainment and income levels were associated with higher odds of TBI. In addition, multiple studies highlight that minority populations were identified as having higher odds of TBI than their White counterparts. Literature highlighting intermediate determinants of health examined in this review describes associations between sustaining a TBI and rurality, work environment, medical conditions, medication/substance use, and adversity. Recommended exploration into lesser-researched SDoH is discussed, and the expansion of this review to other aspects of the TBI continuum is warranted.

Introduction

Traumatic brain injury (TBI) is a devastating condition that has long since been recognized as a major cause of death and disability worldwide. It is estimated that approximately 69 million persons worldwide have TBI from all causes each year,¹ and in the United States alone, the direct and indirect medical costs associated with TBI care are estimated to be in the range of 80 billion dollars per year.²

Outside of the costs associated with TBI, individuals who survive a TBI may have lifelong health challenges related to the injury including social, physical, and mental health sequelae. The distribution of TBI risk and the burden of these sequelae disproportionately affects the elderly, persons of color, and low socioeconomic communities, however. A TBI is more likely to happen in these communities and the worldwide TBI burden falls largely in lower- and middle-income countries (LMICs).^3
–5

In addition, multiple studies have confirmed poorer treatment, functional, neurobehavioral, and quality of life outcomes in these communities post-TBI, a pervasive concern that covers the realms of emergency department (ED), inpatient and rehabilitation care.⁶ Such disparities demonstrate the health inequities associated with TBI.

Health inequities are systematic differences in the health status of different population groups. These inequities bear significant social and economic costs for societies. To improve health risks and reduce disparities and inequities, health institutions have begun to target and address social determinants of health (SDoH). Healthy People 2030 defines SDoH as, “the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning and quality of life outcomes and risks.”⁷

According to the World Health Organization's Commission on Social Determinants of Health (CSDH), health inequities are caused by a range of determinants that can be categorized as structural and intermediary determinants, which together are termed social determinants of health.⁸ The CSDH framework concludes that structural determinants refer to the interplay between the socioeconomic-political context, structural mechanisms generating social stratification, and the resulting socioeconomic position of the individual.⁸

These structural determinants include social and public policies, gender, race, education, and income. Intermediary determinants focus on more downstream factors and include determinants such as material circumstances including food security and housing, psychosocial and health system level factors.

The CSDH framework can be used to identify the structural and intermediary determinants of health inequities, including determinants linked to sustaining a TBI, and understand the mechanisms and connection between these factors. Multiple studies have adapted the CSDH framework to ascertain key SDoH factors that influence outcomes in health topics ranging from asthma to maternal health.^9

–12

Comprehensive literature on the influence of SDoH on TBI risk is limited. Recent studies have focused on SDoH association with the use of rehabilitation services and outcomes after TBI or SDoH and TBI risk in specific patient populations such as indigenous groups.^13

–16 Given the high burden of disease and disparities in its acquisition and associated outcomes, it is of the utmost importance to better understand the factors that contribute to TBI. Further, determining what factors are associated with an increased risk of TBI is necessary to develop public health programs to prevent the injury event.

This scoping review aims to summarize the current evidence from the literature and identify gaps in knowledge to guide further research that will improve understanding of the association between SDoH and the risk of sustaining a TBI. To summarize the current evidence on the association between SDoH and the acquisition of a TBI, this review adapts the World Health Organization CSDH framework to TBI (Fig. 1). The CSDH framework will help to put into context how an individual's unique social and behavioral factors, as shaped by elements of society's structural and intermediary determinants of health, influence the risk of TBI.

FIG. 1.

Adapted WHO Framework for the Social Determinants of Health in Traumatic Brain Injury.

In this review, through the frame of structural determinants, we identify socioeconomic and political contexts such as social and public policy and important variables used to identify socioeconomic position including income, education, and race/ethnicity and their association with the acquisition of TBI. Further, we distinguish psychosocial factors (adversity and violence), behavior and biological factors (aging, health conditions, medication and substance use), material circumstances (living and working conditions) and health systems-related factors (health access and utilization) that constitute the intermediary determinants that are linked to TBI.

Methods

Study identification

Identification and retrieval of studies were conducted in accordance with the PRISMA extension for scoping reviews (PRISMA-ScR).¹⁷ A comprehensive search strategy, which employed both subject headings and keywords, was run in Ovid MEDLINE & Ovid Embase on April 28, 2022, with no date restrictions. The Ovid Embase search query was designed to search only for full-length articles and exclude conference proceedings. The full search queries are available in Supplementary Appendix A. Search results were exported and de-duplicated into the Covidence software.¹⁸

Eligibility criteria and study selection

The strategy for this scoping review was to identify the existing literature on the association between SDoH factors and TBI in adults using the WHO CSDH framework as a foundation for the SDoH topics to include. To identify all of the existing literature on this topic, we were broadly inclusive of all types of study design. Articles were eligible for inclusion if the studies were empirical studies that were published in a peer-reviewed journal, documented a SDoH associated with sustaining a TBI, published in English, contained only human subjects, and data were available for participants 18 years of age or older.

Non-English studies, non-peer reviewed studies, non-empirical studies (systematic reviews, meta-analyses, narrative reviews and commentary, etc.), studies evaluating chronic or repetitive TBI, and studies featuring data for children with TBI that were not stratified from adults were excluded. In addition, if study populations included individuals with TBI but did not report findings on the TBI subgroup separately, the study was excluded from the review.

After deduplication, the search yielded 2821 articles. Five reviewers (ST, NA, BS, YS, KB) independently screened titles and abstracts against the inclusion and exclusion criteria. To ensure reliability between reviewers, a series of training exercises was conducted before commencing screening including a pilot test on a random sample of 20 citations. The full text of articles that passed title/abstract screening was independently reviewed by two of six reviewers (ST, NA, BS, YS, KB, CC). In each round, the abstract or full text required two “yes” votes to proceed to the next round.

Conflicts about the eligibility of an article were resolved by a secondary reviewer who did not initially review that article. The secondary reviewer made the final determination of eligibility. A PRISMA flowchart of study identification and reasons for exclusion is depicted in Figure 2. Fifty-nine studies were included in the final review, from which data were extracted and described below. The format for the outline of this review coincides with the placement of the social determinants of health as depicted in the adapted CSDH framework.

FIG. 2.

PRISMA flowchart.

Results

The comprehensive search and review yielded 59 full-text articles that met our study criteria. Each article presented at least one structural or intermediary determinant factor as it relates to the adapted WHO CSDH framework. For details about the articles included, see Supplementary Appendix B. Following are the summaries of the findings of the included articles under the respective categories or subcategories of structural or intermediary determinants and the association with the acquisition of a TBI.

Structural determinants

Socioeconomic and political context

Social policy

Recent studies have shown an association between housing stability and TBI.^19,20 In a multi-site longitudinal study, residential stability had a protective effect on the incidence of TBI during a three-year follow-up period, even after adjusting for gender, ethnicity, city, and history of epilepsy (AOR 0.75).¹⁹ In further examining TBI incidence, among the homeless or vulnerably housed individuals, 37.2% reported at least one incident of TBI during the three-year follow-up period.¹⁹ Rosendale and associates²⁰ found a greater prevalence of TBIs in homeless populations, compared with housed populations (31.9% vs. 9.2%), with TBI being one of the most common indications for hospitalization among homeless individuals.²⁰

Public policy

Motor vehicle crashes (MVCs) are one of the leading causes of TBI ^21,22,24,26 for both minority and non-minority groups.²¹ Both helmet ^22,23,24,27 and seatbelt use ^25,27 appear to have significant protective effects for traffic-related TBIs, while intoxication is a risk factor for TBI.^{22, 27}

One prospective study examined the effect of a “helmet use law” and “drunk driving law” on TBIs in an urban and rural setting over time.²² Regardless of the setting, after legislative action, there were decreased rates of severe TBIs on admission (Taipei: 12% in 1991 vs. 7% in 2001; Hualien: 14% vs. 8%), decreased rates of traffic accidents (Taipei: 66% vs. 45%; Hualien: 80% vs. 55%), and increased helmet use (Taipei: 15% vs. 87.2%; Hualien: 7% vs .96.5%).²²

Socioeconomic position

Education

Overall, higher education was found to be a protective factor against TBI.^28

–31 One study of older adults in Singapore found the odds ratio (OR) for sustaining a TBI among participants with no education, primary education, and secondary education to be 19.45, 10.09, and 12.96, respectively, when compared with participants who had completed tertiary education.²⁸

In a study of adults in China, participants with less education were at a higher risk of TBI. Compared with the participants with a pre-school education level, participants with a primary school, middle school, and college or higher education were at 3.4, 2.8- and 1.6-times odds of TBI, respectively.³⁰ Of the five studies in this review that demonstrate a relationship between education and TBI risk,^28

–32 only one found higher odds of TBI in participants with some college education or higher (OR = 1.44), compared with participants with a high school degree or lower.³

Gender, sex and orientation

Multiple studies have established sex differences in the acquisition of a TBI.^{28, 31

–46} These studies focused on an assortment of sampling locations with data demonstrating ED visit, community, athletics, and workplace claims represented in their analyses. The majority of studies reviewed categorized TBI as head injury with loss of consciousness without further severity specification.

On average, female patients with TBI were older than males. In the majority of the studies examined, males were more likely to sustain a TBI than females with likelihood ranging from 1.6–2.36 times that of females. This finding was found to reverse in older adults with females 65 years or older having rates as high as 1.5 times that of their male counterparts.^37,43 In subgroup analysis, Jager and coworkers⁴³ found that female patients older than 85 years of age were more than four times as likely to have a TBI than patients 65 years or older with more than 70% associated with a fall.⁴³

A few studies found a higher prevalence of TBI in females. One study performed in a sample of ED visits for mild TBI in older adults captured by the National Hospital Ambulatory Medical Care Survey found higher rates in females compared with males.³³ Khan and colleagues³¹ evaluated adults 65 years or older across eight low- or middle-income countries (LMIC) and found in the urban regions of China and India, females had a higher prevalence of TBI than males.

For TBI from work-related physical violence in Ontario, Canada, Mollayeva and associates⁴⁵ found that female workers had a higher percentage of claims at 59% of all claims. Interestingly, female workers primarily in the health care/social services and educational sectors had a six- and four-fold higher rate of TBI, respectively, than their male counterparts.⁴⁵

In the field of athletics, Covassin and colleagues⁴⁰ observed data on student athletes and found that female athletes sustained a higher percentage of concussions or mild TBI during games than male athletes but a lower percentage of concussions during practice. Of the total reported injuries, female athletes sustained 167 (3.6%) during practices and 304 (9.5%) concussions during games. Male athletes sustained 148 (5.2%) and 254 (6.4%) concussions during practices and games, respectively. No studies were reviewed that examined the relationship between gender-based roles or sexual orientation and TBI.

Race/Ethnicity

Self-identification as a racial or ethnic minority group was associated with greater TBI risk. Studies from various regions of the world including Australia, New Zealand, Ecuador, and the United States confirmed this association.^{21,32,42
–44,47

–51} When examining studies from the United States, the association between TBI and race/ethnicity was found in both military and civilian populations.

In a cohort of veterans, Dismuke and associates.⁴⁸ found that non-Hispanic Blacks and Hispanics had 1.44 and 1.47 times higher odds of moderate or severe TBI, respectively, than their non-Hispanic White counterparts. Similarly, using the National Hospital Ambulatory Medical Care Survey, Jager and coworkers⁴³ found that in U.S. EDs, the population-based incidence rate of TBI was 35% higher in Blacks than Whites.⁴³

Interactions of minority status with other social risk factors have been found in the literature. Burnett and colleagues²¹ found that minorities who sustained TBI generally were young men with lower levels of employment and more likely to have sustained the TBI through an act of violence. In addition, Kisser and colleagues⁴⁴ found that older African Americans (58–64 years old) living in poverty had greater odds of TBI than other age groups and economic statuses. Utilizing National Health and Nutrition Examination Survey (NHANES) data, one study did find significantly lower odds of self-reported head injury with loss of consciousness (LOC) in Mexican-American or Hispanic, non-Hispanic Black, and Asian American respondents compared with White respondents.³²

Findings from international racial and ethnic minority groups align with the results from U.S. studies. Studies based on ED and hospital admission data in Australia showed that indigenous populations were 1.7–1.93 times more likely to sustain a TBI than the general population.^{42, 51} In New Zealand, compared with persons of European origin, the Maori, an indigenous Polynesian group, had a greater risk of mild TBI and TBI from assault, which were 3 to 4 times more likely in this group.⁴⁹

Last, using hospital discharge records, Ortiz-Prado and coworkers⁵⁰ found that in Ecuador, Mestizos and indigenous persons had the highest adjusted incidence rates for TBI while non-Hispanic Whites had the lowest rate.

Occupation/Activity

Occupation and activity types influence exposure to head injuries. Multiple studies on populations in Canada and Australia have described the epidemiology of work-related TBI.^35,38,45,52 The occupation categories associated with TBI varied based on gender. For male workers, the largest proportion of TBIs reported occurred in men engaged in physically demanding occupations such as law enforcement, skilled agricultural, mining, and plant and construction-based operations. Most work-related TBIs in female workers occurred in managerial, healthcare, educational, clerical and service and sales-related occupations.

Molleyeva and associates⁴⁵ also found that job experience was a factor in work-related TBI because 45% of these injuries occurred in employees with fewer than three years of experience at their job. In China, using the 157 National Disease Surveillance Points System, Sun and colleagues³⁰ found that when compared with active workforce participants, individuals who were farmers were at a 1.9 times risk of TBI.

When evaluating employment status or ability to work, those seeking employment or unable to work were more likely to have a moderate or severe TBI compared with those who were employed or students.³⁹ Specifically, in the population of those unable to work, there were 2.75-fold greater odds of sustaining a TBI with loss of consciousness than individuals who were employed.³⁹ No further information was given on the causes of inability to work in this TBI population including possible advanced age or physical or mental disability.

Specific military occupational categories are also associated with increased exposure to TBI. In the Naval Health Research Center's Millennium cohort study, 27% of all participants reported experiencing a service-related TBI.⁵³ Among the specific military occupational categories, infantry/tactical operations had 1.45 times the odds of service-related TBI compared with administration and executives, a low-risk occupational category.⁵³

Among Marines in high-risk occupations, there were 1.45 times greater odds of sustaining a probable mild TBI than those in low-risk occupations. High-risk occupations include those involving ammunition, explosives, and field artillery. Low-risk occupations were categorized as food and legal services.⁵⁴ One study evaluated previous active duty status and its association with TBI in the past year.²⁹ Hale and colleagues²⁹ found 1.97 times adjusted odds of TBI in the past year in those with previous active duty status compared with individuals without a history of active military duty.

Leisure and sport activities were also found to be associated with exposure to TBI. In a sample of college athletes, women's soccer and men's lacrosse were found to have the highest rate of concussions when compared with gymnastics, basketball, and softball/baseball.⁴⁰

In horse racing, O'Connor and colleagues⁵⁵ found that concussions or mild TBI occurred in approximately 15% of horse races in Ireland. Amateur jockeys sustained a higher fall rate than professional jockeys with a relative risk of 35.47 and 2.72 for flat racing and jumps, respectively. In falls from a horse, jockeys experienced approximately 10 concussions per 1000 falls.⁵⁵ Concussions per 1000 rides increased throughout the nine-year period of the study, but this increase was not significant.⁵⁵

Income

Several articles suggested a link between low-income status and the likelihood of TBI. Authors used different income definitions and populations, and outcomes were heterogeneous. Coxe and coworkers³² utilized NHANES data to examine multiple factors associated with reported lifetime head injury with loss of LOC. The rate of reported head injury with LOC in the sample of U.S. adults was 12.8%, and those with income above the median annual household income level of $45,000 had an adjusted odds ratio of 0.78 (95% CI 0.65, 0.94) for head injury with LOC compared with those below the median income threshold.³²

Corrigan and colleagues³⁹ examined the lifetime prevalence of TBI with LOC using the 2014 Ohio Behavioral Risk Factor Surveillance System, which sampled 6998 adult, non-institutionalized Ohio residents. The survey found an overall 21.7% lifetime prevalence of TBI with LOC, with a weighted lifetime prevalence of 29.3% and 26.6% in the two lowest income quartiles, respectively (<$15,000 and $15,000–$24,999), compared with 19.6% lifetime prevalence in the highest income quartile (>$50,000).

The authors also found that those in the two lowest income brackets were more likely to have had a greater number of TBI with LOC, and their worst injury was more severe when compared with those in the highest income bracket. The odds of having sustained three or more TBI with LOC was 4.1 times greater for those making <$15,000 compared with those making >$50,000.³⁹

Kisser and coworkers⁴⁴ used data from the African American and White Individuals in Healthy Aging in Neighborhoods of Diversity across the Life Span (HANDLS) study, in which 2881 individuals from the Baltimore, Maryland area self-reported income and lifetime history of TBI. Poverty was defined as an annual household income less than 125% of the 2004 Department of Health and Human Services poverty guidelines. The study found that poverty status had an odds ratio of 3.59 (95% CI 1.39, 9.30) for history of TBI, which was the strongest association among variables including age, sex, and race.⁴⁴

The authors of these studies caution that measurement of the lifetime prevalence of TBI may confound the direction of causality in relation to income/poverty, with TBI leading to low income through cognitive, emotional, or general health effects. The relationship between income and TBI, however, was also noted in a study that looked only at TBI incidence in the preceding year.

Hale and associates²⁹ used the National Epidemiological Survey on Alcohol and Related Conditions, a population-based and nationally representative U.S. sample that surveyed 36,309 individuals in 2012–2013. Among 193 individuals (0.53%) reporting TBI within the last year, those with an annual household income less than $20,000 had nearly double the odds of having TBI (adjusted odds ratio for annual income ≥$20,000 of 0.51 (95% CI 0.31, 0.84).²⁹

Other studies that were reviewed addressed relationships between income/poverty and TBI using different methodologies. Khan and colleagues³¹ examined the lifetime prevalence of head injury using cross-sectional surveys of 16,430 residents age 65 and older in defined sites in specific low-and-middle income countries (LMICs): China, Cuba, Dominican Republic, India, Venezuela, Mexico, Peru, and Puerto Rico. Poverty was approximated based on the reported number of assets defined as a car, television, refrigerator, telephone, plumbed toilet, and water and electricity mains. The prevalence ratio based on the number of assets was found to be 0.92 (95% CI 0.88, 0.96) overall across sites, with in-country ranges of 0.87 to 1.53.³¹

Liao and coworkers⁵⁶ performed a case-control study of 83,175 patients in Taiwan with TBI using reimbursement claims and found an increased risk of TBI in those with low income (OR 1.94, 95% CI 1.75, 2.11). Cancelliere and associates³⁷ performed a population-based study of minor TBI (MTBI) seen in United States EDs using a Nationwide Emergency Department Sample of 20% of visits. This study found that the frequency of MTBI was similar in all income quartiles, but lower quartiles were more likely to have a non-isolated injury. The lowest quartile was found to have 21.7% lower odds of isolated MTBI compared with the highest income quartile.

Finally, Kisser coworkers⁴⁴ examined interactions between poverty status, race, and age in the HANDL study and found that there was a higher prevalence of TBI among younger Whites living in poverty and among older African Americans living in poverty.

Intermediary Determinants

Material circumstances

Living conditions

Several studies have looked at the impact of the environment on the acquisition of TBIs. Four studies examining geographic disparities in TBI found that rural residents had higher rates of TBI compared with their urban counterparts.

A study in Taiwan found that the population-based incidence of TBI in the rural county of Hualien (417/ 100,000) was almost double the incidence in urban Taipei city (218/100,000).²² The study postulated that this was because of higher motorcycle use in Hualien in the absence of mass transit systems available in urban areas such as Taipei City. Similarly, a study of TBIs in rural versus urban New Zealand found that rural residents (73/ 100,000) had 2.5 times the risk of moderate or severe TBI compared with their urban counterparts (31/ 100,000).⁴⁹

An Australian study found that participants living in the most remote regions of New South Wales were at a similar risk of TBI (1.7%) as an elderly resident (75+) of any region, 2.8 times the general population (0.6%).⁵¹ A Colorado study comparing urban and rural residents found that rural, remote counties had both the highest overall rate (172.1/100,000) and the highest mortality rate (33.8/ 100,000) for TBIs at almost twice the rate of urban counties (18.3/100,000 and 97.8/100,000, respectively).⁵⁷

There are other factors related to living conditions that can impact the risk of TBI in older adults. One study in adults aged 60 years or older found that when compared with falls resulting in soft tissue injuries, men were at higher odds of sustaining a TBI after a fall with indoor falls (OR = 1.92), while women were at higher risk of TBI when negotiating stairs (OR = 7.13).⁵⁸

A second study found that falls in older adults that involved negotiating stairs had a 3.12-fold increase in moderate to severe TBIs compared with falls that occurred while walking.⁵⁹ A third study found a significant increase in head injuries attributed to treadmill use over a 17-year period ending in 2014 and a 14-fold increase in the risk of inpatient hospitalizations for adults over 50 years old with a treadmill-associated head injury compared with younger patients.⁶⁰

Work conditions

Environmental hazards that people face while working play a role in the risk of TBI. Retrospective cohorts of work-related TBI (wrTBI) demonstrate an average incidence of about 20/100,000 workers per year.³⁸ For male workers that sustain wrTBI, a common theme for work-related hazards was the use of heavy machinery/equipment and skilled labor needs. For female workers, common themes for work-related hazards include healthcare, education, and community professions.

For all workers, the most common mechanism of sustained TBI was struck by/against an object (53.1%), followed by falls (23.7%) and assaults/violence (12.5%).³⁸ The percentage of falls causing wrTBI increased with age and replaced “struck by/against” as the most common cause in older workers.³⁸

In the construction industry, falls constituted 49.6% of all work-related TBIs.⁵² The most common occupational hazard attributed to work-related TBI was “unexplained human phenomenon” (32.6%), followed by “equipment breakdown or malfunction” and “inappropriate safety measures taken.”³⁵

In a retrospective cohort of veterans receiving healthcare in the Veterans Affairs system, between 2004 and 2010, 133,000 veterans received a diagnosis of TBI, of whom about one quarter had mild TBI and three quarters had moderate to severe TBI.⁴⁸ Approximately 26% of those with TBI had combat exposure.⁴⁸ The majority of combat-related TBIs were the result of a blast injury.⁵⁴

Recurrent occupational overpressure exposures (ROPE), such as from firing heavy caliber weapons or breaching charges, have been shown to be a risk factor for increased susceptibility to TBI after a blast.⁵⁴ Marines who experienced a blast during deployment were 45% more likely to sustain a probable TBI if they worked in an occupation at high risk (vs. low risk) of ROPE.⁵⁴ Thus, both blast exposure and occupational risk of ROPE were independently and jointly associated with the likelihood of TBI during deployment.

Behavior and Biological

Aging

Single center and national database studies have observed an association between TBI and aging. Age at the time of injury has been found to be associated with a higher incidence of TBI^{33,37,61
–63} and higher odds of concomitant injury to other body regions.³⁷ In a national sample of ED visits, Albrecht and associates³³ found that rates of ED visits for mild TBI were 386/100,000, 777/100,000 and 1205/100,000 among those 65–74, 75–84, and more than 84 years old, respectively. In older adults, average annual increases in mild TBI have been found in both sexes,³⁷ with a significant trend toward an increase in mean age each year.⁶² With regards to gender, each study except for one,³³ had a larger percentage of male than female older adults in their TBI analysis.^34,37,61,62

Health conditions and medication use

A history of specific medical conditions and medication use were factors found to be associated with TBI. In multiple studies, psychiatric conditions or history of mental illness were associated with TBI. A study utilizing the Traumatic Brain Injury Model Systems database found that individuals who sustained a TBI secondary to a suicide attempt had greater psychiatric and psychosocial health problems.⁶⁴

Nikoo and colleagues¹⁹ found that in a sample of homeless and vulnerably housed persons, a history of mental health diagnosis at baseline and poorer mental health were associated with incident TBI during a three-year follow-up period. Similarly, when evaluating more than 80,000 reimbursement claims, Liao and associates⁵⁶ found that individuals with mental health disorders or receiving advanced psychiatric healthcare were at increased risk of TBI.⁵⁶ This study also found that psychiatric medication intensity was significantly correlated with TBI in a severity-dependent relationship.⁵⁶

Last, in an analysis of the National Health and Nutrition Examination Survey with data collected from more than 7000 adults, the odds of head injury with LOC was higher among those with moderate to severe depression (AOR = 1.25) when compared with adults with mild or no history of depression.³²

Conditions such as hypertension, diabetes mellitus, cardiac arrhythmias, hyperlipidemia, liver disease, stroke, epilepsy, and renal dialysis have shown to be more common in patients with TBI.^41,56,65 The direction and strength of association for these conditions were not examined. Commonly, in older adults, the presence of Parkinson disease, Alzheimer disease and other dementias was more likely in those with TBI, and in women, the presence of Parkinson disease was independently associated with 10 times higher odds of TBI.^58,65

In older adults of the Well-being of the Singapore Elderly study, patients with a history of fainting or blackouts had 3.59 times the odds of TBI after adjusting for sociodemographic factors.²⁸ Similarly, when comparing falls in older Taiwanese patients with subsequent soft tissue injuries versus TBI, Hwang and coworkers⁵⁹ found that individuals who took antiarrhythmic medications within 4h of a fall and those who were prescribed two or more medications were 2.59 and 3.07 times, respectively, more likely to have suffered a moderate to severe TBI during the fall than those who took none.

Substance use

It is well documented that alcohol and substance use are associated with sustaining a TBI.^{19,27,29,32,64,66

–71} Data from two acute inpatient brain injury rehabilitation programs have estimated that between 22–59% and 12–34% of their patient samples had self-reported pre-injury alcohol misuse and illicit drug use, respectively.^66,68 Associated toxicology reports showed that 37% of samples were positive for illicit drug use, slightly higher than the percentage of self-reported illicit drug use of 34%.⁶⁶ Similarly, Kolakowsky-Hayner and coworkers⁷⁰ found that 42% of patients undergoing inpatient rehabilitation programs for brain injury at their trauma center were heavy drinkers compared with approximately 10% in the general population.

Patients who use alcohol and illicit substances have been found to have higher odds of sustaining a TBI. Coxe and colleagues³² found that adults who reported illicit drug use had 1.76-fold higher odds of TBI compared with adults who reported no drug use.³² This association was also seen in the homeless and vulnerably housed. Problematic alcohol and drug use were independently associated with a 2.42- and 1.35-times higher odds of incident TBI, respectively, compared with individuals without these concerns.¹⁹ Wilson et al. evaluated patient data from rural Norway and found that there were 5.33 times higher odds of testing positive for a psychoactive substance during evaluation for individuals discharged from the hospital after a TBI diagnosis due to a fall.⁷¹ These odds increase significantly to 18.54 times higher odds of testing positive for a psychoactive substance if the incident that led to TBI was due to violence.⁷¹ When analyzing TBI among injured roadway users, an interaction between rurality and alcohol and/or drug use was found. Individuals who had an injury event in a rural location were more likely to sustain a TBI than those who had an injury event in an urban location among those who tested positive for alcohol and/or drugs.²⁷ The presence of a positive test for alcohol and/or drugs at the time of the roadway event in rural and urban settings were associated with 1.51- and 1.26-times odds respectively of sustaining a TBI compared to events in rural and urban settings without subsequent positive tests.²⁷

Psychosocial factors

Adversity

Compared with individuals without adverse childhood experiences (ACEs), those reporting at least three ACEs had greater odds of having a TBI (3 ACEs: OR 4.16, 4 or more ACEs: OR 3.39), regardless of age, race/ethnicity, gender, and income.⁷² Specifically, sexual abuse (OR 3.16), physical abuse (OR 2.40), household mental illness (OR 2.53), and incarcerated household members (OR 3.41) in childhood were significantly associated with TBIs after adjusting for aforementioned demographics.⁷²

In addition, Wand and colleagues⁷³ reported a significantly greater proportion of TBI among those born to mothers younger than 20 years old (35%) compared with those born to older mothers (22%). One study examining refugee survivors found that those reporting TBIs were more likely to have endured a greater number of types of torture experiences; however, the number of days detained and involvement of sexual assault were not significantly associated with TBI.⁷⁴

Violence

An overview of five studies found that certain populations tend to be at a higher risk of violence-related traumatic brain injury (vrTBI): minorities, male gender, and lower socioeconomic status. Based on three studies, racial minorities are at an increased risk of having a vrTBI. One study found minorities have vrTBIs at three times the rate of non-minorities (33.4% and 11.4%, respectively).²¹

In another study, when compared with Whites, Native Americans (OR = 3.13) and Blacks (OR = 1.95) had statistically significant (p < 0.001) increased odds of experiencing a vrTBI.⁷⁵ A third study found vrTBIs occurred in African Americans at twice the rate of Whites, 64% and 29%, respectively.⁷⁶

Of the three studies on vrTBIs that evaluated gender, two agree that adult males are at a higher risk of vrTBIs compared with adult females.^75,76 One of the studies found men accounted for 86% of vrTBIs, compared with 14% in women.⁷⁶ Interestingly, one study on work-related TBIs, found that TBIs related to physical assault (6.6% of all TBIs in workers) occurred more frequently in female workers (59%).⁴⁵ In addition, female workers in the healthcare/social services field were six times more likely to have a TBI as a result of physical assault.⁴⁵

VrTBIs are more common in lower-income and less-educated populations. One study evaluated countries with high income, upper middle income, or lower middle income and found vrTBIs in these populations to be 4%, 7%, and 12% of TBIs, respectively.⁷⁷ Another study found that individuals who sustained TBIs as a result of violence were more likely to have a high school degree or less education (82%) and to be unemployed (50%).⁷⁶

Health system

There were limited data on the association between access or utilization of healthcare resources and subsequent rates of TBI, with only two authors examining some aspect of health system access and utilization as a variable. Coxe and colleagues found that having insurance coverage and having a routine place for healthcare were not statistically significant factors associated with the odds of having a head injury with LOC (adjust OR 0.99 [95% CI 0.81, 1.23] and 1.16 [95% CI 0.89, 1.51], respectively).³²

Liao and coworkers⁵⁶ investigated the correlation between psychiatric care utilization and the prevalence of TBI in Taiwan. The authors found that having advanced psychiatric healthcare had an OR of 2.98 for TBI and 1.92 for post-injury death. Psychiatric outpatient care was associated with an OR of 1.77, with odds increasing with an increasing number of outpatient visits in the preceding 24 months.

Psychiatric hospitalization and ED visits for psychiatric complaints were associated with ORs of 3.21 and 3.53, respectively. It was noted that 33% of adults with TBI had mental disorders compared with 18% without TBI. The higher risk of TBI in patients with mental disorders was attributed to poor attention to disease and medication use leading to injury, reduced bone density because of psychiatric medication, self-harm, and violence.⁵⁶

Discussion

The objective of this review was to assess the scope of the literature on SDoH and their association with sustaining a TBI. This is the first scoping review to examine in depth how SDoH are being studied in relation to TBI. We utilized the World Health Organization CSDH framework to provide the foundation for understanding this literature in the context of structural and intermediary determinants of health. This approach allowed us to identify an individual's unique social circumstances while also considering the broader contexts of environmental influences on health.

Several structural and intermediary factors were identified in the literature. Most of the 59 studies included in this review have been published in the last decade, highlighting the recent interest and increased attention to the impact of SDoH in TBI. Our review found that SDoH categories such as occupation and race/ethnicity have been explored more than other social determinants such as health system access/utilization and economic status. Other factors, such as governance and macroeconomic policies, have not been discussed, indicating that significant gaps exist within SDoH literature and further exploration is necessary.

Many of the studies included in this review explored the impact of an individual's specific circumstances with regard to structural determinants, highlighting how educational and income gaps, as well as racial and ethnic minority status, are associated with sustaining a TBI. Lower educational attainment and lower income levels were linked with higher odds of sustaining a TBI.

Similarly, Black, Hispanic and indigenous minority patients were identified as having higher odds of TBI than their non-Hispanic White counterparts, a disparity that was widened for those experiencing TBI from violence. This result is consistent with previous studies showing racial and ethnic minority status is independently associated with traumatic injuries and outcomes, especially because of intentional mechanisms.^78

–82

Therefore, researchers should emphasize studying the effect of structural determinants such as race/ethnicity, education, or income on TBI to promote the development of interventions such as health literacy programs or community-based initiatives aimed at reducing these disparities.

The results from the studies that examined intermediary determinants highlighted the breadth and complexity of factors associated with sustaining a TBI. Several determinants were found to be associated with TBI including rurality, aging, work-related environment, medical conditions, medication or substance use as well as adversity.

The studies that examined living conditions found a greater risk of TBI in rural or remote regions compared with urban regions. Trauma studies have shown that patients in rural and remote areas also experience higher mortality rates than those in urban areas.^83,84 Examples of possible reasons for this disparity include a lack of crash reduction features and traffic control devices on rural roads, uneven terrain, greater alcohol consumption, and a reduced density of traffic enforcement officials in rural areas resulting in a lack of enforcement of traffic safety laws.^85
–87 There is a clear need to further elucidate differences in injury risk factors in rural and urban areas and evaluate prevention programs in rural communities.

Aging plays a significant role in sustaining a TBI. The aging process is associated with slower cognitive processing and mobility concerns. These impairments alongside increased medical comorbidity burden and polypharmacy place older adults at greater risk of falls and subsequent TBI. This is exemplified by the increased risk of TBI found in older adults when negotiating stairs and while using equipment at home in the studies of this review.

These results coincide with previous literature examining the circumstances that led to falls in older adults. These studies showed common indoor activities performed at the time of fall included walking on stairs and housekeeping and common causes of falls were because of incorrect weight shifting or stumbling incidents.^88,89

These data suggest that careful planning or modification of the indoor environment as well as interventions tailored to increasing the strength and balance of older adults may help contribute to decreasing the incidence of falls and subsequent TBI. These interventions could include providing mobility assist devices where needed, physical therapy consultation, and careful review of medications to reduce potentially inappropriate medication use in older adults.

It is increasingly important to recognize the potential impact of substance abuse as a factor in TBI. In 2020, more than 40 million persons aged 12 years or older in the United States had a substance use disorder in the past year.⁹⁰ In the same age group, approximately 4 million persons initiated alcohol use and 1–2 million users were introduced to drugs such as painkillers and hallucinogens during the same time frame.⁹⁰

Results from this review demonstrate that a significant proportion of individuals who sustain a TBI have a pre-injury alcohol misuse or illicit drug use history.^66,68,70 Targeting prevention and harm reduction strategies for alcohol and illicit drug users may help mitigate future TBI risks. Data from the studies in this review also suggest a potential intersectionality of rurality and substance use in TBI because individuals who experienced an injury event in a rural location were most likely to have a TBI if they tested positive for alcohol and/or drugs.²⁷

The concept of intersectionality was first used in 1989 by Kimberle Crenshaw to describe the interactions and multiplicative effects of inequalities within individuals.⁹¹ Rural dwellers experience health inequalities because of reduced access to care, low educational attainment, isolation, unemployment, and poverty.⁹² These factors also contribute to the prevalence of substance use.^93,94 Evidence-based strategies to improve access to drug education, detoxification, and counseling services, especially in high-risk rural communities may help mitigate the risk of subsequent TBI.

Traumatic or adverse experiences were found to be associated with TBI.^72
–74 These experiences ranged from physical or sexual abuse to incidents of torture in refugee survivors. The likelihood of physical injury is high in situations of abuse and torture.^95
–97 Previous literature shows that there may be a cyclical risk of TBI because of these circumstances. Consequences of TBI include antisocial thinking, impulsivity, seeking immediate gratification, and personality change.⁹⁸

A TBI is also associated with inappropriate social and sexual behaviors and aggression.⁹⁹ These post-TBI behavioral and personality changes may lead to physical or sexual abuse and subsequent TBI to restart the cycle. Provider awareness of the long-term effects of the individual's TBI and adverse experiences could help identify more tailored interventions that may prove successful in the management of their conditions and the reduction of abuse-related TBI.

The majority of the studies included in this review were based in high-income countries (HICs). Five of the 59 studies were conducted in LMICs. Despite the significant TBI burden in LMICs, compared with HICs, the volume of TBI research generated by these countries is limited. Because of resource limitations, few LMICs have the established infrastructure and national databases or neurotrauma registries necessary to track the burden of TBI.¹⁰⁰

Most of the research in this area is produced by a small minority of LMICs, which do not necessarily represent the complete picture of TBI in low-resource settings. A recent retrospective analysis of TBI-focused randomized controlled trials (RCTs) revealed that while 67% of the RCTs found in the literature review were conducted in LMICs, three countries (Iran, China and India) comprised 75% of the published studies.¹⁰¹ Similarly, a recent systematic review of neurosurgical RCTs found that only approximately 27% of published RCTs had been performed in LMICs with studies from China comprising approximately 70% of these trials.¹⁰²

Enhancing research infrastructure in LMICs through capacity-building initiatives and collaborative partnerships with HICs could significantly boost the output of TBI research from LMICs. This approach could allow for a deeper insight into the burden of TBI and its associated risk factors in these nations.

As described previously, the majority of the data for this review highlights HICs. Geographic, cultural, political, and socioeconomic differences between HICs and LMICs may lead to observed inconsistencies in the SDoH that are associated with TBI risk. Recent literature from LMICs demonstrates that structural determinants may play a key role in TBI because of the burden of armed conflict, assaults, and road traffic accidents in these countries.^{4,100,103,104}

Strategies for TBI prevention in LMICs have focused on public policy and safety legislation for road injuries and violence prevention^1,105
–107; however, this review found few public policy or governance-related studies in concordance with the demonstrated needs of LMICs.

The data from HICs in this review included a spectrum of structural and intermediate health determinants associated with TBI. The variations noted in this review compared with the existing published literature may stem from the observed epidemiology of TBI, differing research priorities for LMICs, and the current infrastructure and resource constraints in these nations. Conducting additional research on intermediate determinants of health, including living and working conditions, healthcare accessibility, and substance abuse in LMICs, is essential to identify novel and mitigable risk factors for TBI prevention.

This review used the WHO CSDH framework to summarize the association between SDoH and TBI risk. Through this framework, we identified individual-level SDoH that may impact the risk of injury. The assessment of individual-level SDoH in clinical practice is not routinely performed because of the challenges of collecting patient-reported data.¹⁰⁸

Hospital systems, governmental agencies, and other healthcare stakeholders often rely on publicly available composite measures or indices as a proxy for an individual patient's risk related to poor health outcomes. These indices, such as the Area Deprivation Index (ADI) or Social Deprivation Index (SDI), are a composite of multiple socioeconomic dimensions that may reflect SDoH or health-related social needs at the community level.^109,110 Current use of these indices in the TBI literature has focused on the association between neighborhood disadvantage and TBI outcomes rather than the initial risk of injury.^111,112

The results from this review demonstrate that there are several singular and overlapping patient-level social factors associated with sustaining a TBI. Utilizing indices of neighborhood disadvantage to evaluate the risk of TBI may allow for the identification of communities that would benefit from targeted intervention. Further assessment of these individual and community risk profiles is needed and the inclusion of validated composite measures in the analyses of patient-level data may allow for a more robust understanding of the differential impact that individual social risk and neighborhood disadvantage have on sustaining a TBI.

Limitations

Some potential limitations of our scoping review are worth mentioning. Terminology related to both SDoH and TBI is highly variable, potentially leading to missed studies based on our search strategy. We only included studies published in peer-reviewed journals and excluded review articles; therefore, potential publication bias could not be excluded. We were also not able to include other relevant aspects of the WHO framework (such as governance, international laws, policies and treaties). This could have also been because of the lack of studies on these topics or the limitations of our search strategy.

In addition, some of the studies included in this review had small sample sizes, which may limit our interpretation of the findings. Further, there may be an interdependence or synergy of some of the determinants presented in this review that affects the interpretation of the results. These relationships may produce additive effects on TBI risk that are difficult to discern without a more nuanced investigation of how these intersectional associations affect patient outcomes.

Considerations for future studies of SDoH and TBI should include utilizing qualitative or quantitative methods to evaluate the interactions between these variables. Prior literature has commonly used methods such as regression with interaction terms or models using stratification to identify and quantify these relationships.¹¹³ Last, the identified studies were limited to adults. The exclusion of TBI data in children may affect the generalizability of our findings.

Conclusion

Utilizing the WHO framework, we were able to organize the evidence from existing studies to produce a more comprehensive picture of factors associated with sustaining a TBI in terms of structural and intermediary determinants and their mechanisms and directionality of influence. The body of evidence supports the connection between SDoH and TBI. Moving forward, it will be important to expand this review to the association of SDoH to TBI in children, TBI-related outcomes, and encourage researchers to assess intersectionality for a more nuanced understanding of SDoH because inequalities do not occur in a vacuum.

The review of governance, laws and policies and their association with TBI would also be an important step because it would provide evidence for more focused context-specific policy and legislative recommendations as they pertain to reducing the burden of TBI. Researchers should consider SDoH measures when developing future studies.

A more comprehensive understanding of the connection between TBI and SDoH will help better position researchers to design new patient-centered interventions that could improve health equity and reduce the burden of TBI. Significant improvements in the global TBI burden will not be made without addressing the underlying societal conventions and social structures that have created persistent disparities that lead to events such as TBIs.

Footnotes

Transparency,Rigor,and Reproducibility Summary

A review protocol was developed but not registered for this study. The protocol is available for review by request from the corresponding author. This study followed the six-stage methodological framework for scoping reviews developed by Arksey and O'Malley. A search strategy incorporating the key concepts (traumatic brain injury and social determinants of health) and related words and phrases was developed with the help of an academic librarian. The search strategy is presented in the supplementary materials. Using Ovid MEDLINE and Embase electronic databases, data were acquired on April 28, 2022, with no date restrictions. Following the search, all references were uploaded to Covidence for reviewer screening. After de-duplication measures, the initial search yielded 2,821 results. Each reference was screened by two reviewers against the eligibility criteria in two phases (title/abstract and full-text screening). Disagreements between two reviewers were resolved by a third reviewer vote. Fifty-nine eligible studies were included in this study for further analysis. The final 59 studies were stored in the EndNote reference management tool.

Acknowledgments

The content of this article is solely the responsibility of its authors and does not necessarily represent the views or official position of the Mount Sinai Health System. The authors would like to acknowledge Levy Library at Mount Sinai for providing access to Covidence and EndNote software.

Authors' Contributions

Shameeke Taylor: Conceptualization, Methodology, Investigation, Data Curation, Writing-Original Draft, Writing-Review and Editing, Project administration; Kira Brayan: Conceptualization, Investigation, Resources, Writing-Original Draft, Writing-Review and Editing; Bess Storch: Investigation, Writing-Original Draft, Writing-Review and Editing; Young Suh: Investigation, Writing-Original Draft, Writing-Review and Editing; Samantha Walsh: Conceptualization, Methodology, Resources, Data Curation, Writing-Original Draft; Nita Avrith: Investigation, Writing-Original Draft, Writing-Review and Editing; Ben Wyler: Writing-Original Draft, Writing-Review and Editing; Catrina Cropano: Investigation; Kristen Dams-O'Connor: Conceptualization, Supervision, Writing-Review and Editing. All authors read and approved the final manuscript.

Funding Information

There was no funding provided for this research

Author Disclosure Statement

No competing financial interests exist.

Supplementary Material

Supplementary Appendix A

Supplementary Appendix B

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