Sense of Community and Its Impact on the Life Satisfaction of Adults With Brain Injury

Abstract

Sense of community (SOC) refers to feelings of belonging and attachment one has for a community. Despite a growing focus on adjustment and community outcomes following disability, this construct has received little attention in the rehabilitation literature. The primary aim of this study was to examine the extent to which SOC and social identification with one’s town contribute to life satisfaction outcomes among adults with brain injury, controlling for demographic, disability, and other related social constructs (e.g., social support and social integration). Members from brain injury associations across the United States (N = 177) participated in a survey-based study. Results from hierarchical regression analysis indicated that the final model accounted for 45% of the variance in life satisfaction, with SOC variables contributing 11%. Symptom severity, perceived emotional support, and the SOC dimension reinforcement of needs were significant independent predictors of life satisfaction. Findings from this study highlight the importance of examining SOC variables among clients with brain injury to enhance subjective well-being.

Keywords

brain injury sense of community social integration social support life satisfaction

The field of rehabilitation counseling has long recognized the importance of community integration and participation outcomes for people with disabilities (e.g., Heinemann, 2005). The World Health Organization’s International Classification of Functioning and Disability and Health (ICF; 2001) stresses the importance of recognizing functioning and disability from a multidimensional standpoint. Specifically, the ICF proposes a biopsychosocial conceptualization of the experience of disability, positing that interactions among individual and environmental factors impact life experiences, functioning, and outcomes for individuals with disabilities (Dunn & Elliott, 2008; Smart, 2001; Wright, 1983). Community experiences are an integral part of the disability experience. Yet, despite increased focus on community participation in the field of rehabilitation, individuals’ sense of community (SOC)—or one’s feelings of influence and belonging—has received little attention in the rehabilitation literature. This is a particularly relevant construct for people with brain injury, who are at considerable risk for social isolation, loneliness, and restricted community integration in the years following injury (Stalnacke, 2007).

SOC

SOC was introduced by Sarason (1974) and has gained status as one of the overarching concepts guiding the field of community psychology. SOC focuses on the individual experience of community rather than its structure, setting, or other features. SOC theory, as posited by McMillan and Chavis (1986), defines SOC as “a feeling that members have of belonging, a feeling that members matter to one another and to the group, and a shared faith that members’ needs will be met through their commitment to be together” (p. 9).

According to this theory, SOC consists of four elements:

Membership refers to the feeling of belonging that comes with being part of a defined community. Membership offers a source of emotional safety, security and sense of identification.

Reinforcement of needs refers to the idea that common needs, goals, beliefs, and values provide the integrative force for a cohesive community so that both the needs of the collective and individual are met.

Influence is a bidirectional concept that captures the idea of the community’s influence on its individual members as well as the individual’s feelings of control and influence over the community (directly or indirectly).

Shared emotional connection refers to the bonds that form over time through positive interaction and shared identity with other community members.

These four elements work dynamically together to create and maintain an overall SOC (McMillan & Chavis, 1986). SOC is posited to be applicable to all types of communities where members feel a sense of belonging, influence, need fulfillment, and an emotional connection with other members. Thus, communities including towns, neighborhoods, workplaces, faith communities, political affiliations, and even virtual communities can be associated with SOC. Most research on SOC has focused on feelings about specific places or geographic entities such as towns or neighborhoods (Hill, 1996). These referents have particular application when considering individuals with brain injury and the central goals of community-based rehabilitation to increase functioning and integration within one’s community (Burleigh, Farber, & Gillard, 1998). In particular, towns (or cities) represent geographic community referents that may be of particular importance because these communities have designated boundaries and represent areas that typically have political and administrative structures (as opposed to neighborhoods or blocks) more conducive for effecting community-level change.

Application of SOC to Disability and Brain Injury Rehabilitation

Despite the fact that little research has been conducted regarding SOC and disability populations, McMillan and Chavis (1986) explicitly state that understanding SOC has implications for community treatment programs for individuals with cognitive and psychiatric disabilities, “where ‘community’ means more than residency outside of an institution” (p. 20). Incorporating the SOC theoretical framework into rehabilitation has the potential to increase understanding about the impact of disability, such as brain injury, on community life in several key ways. Sustaining a disability or change in functional status may not only result in experiencing new physical or attitudinal barriers that hinder participation or access within a geographic community but may even result in the denial of access to communities, such as educational or vocational settings. With an awareness of SOC theory, rehabilitation service providers may be better positioned to assist individuals with (a) identifying communities that are important to their identity, (b) problem-solving challenges and barriers, and (c) providing relevant supports in an effort to maximize feelings of membership, influence, and connections within communities.

Furthermore, constructs related to quality of life, such as perceived well-being, happiness, and life satisfaction—the primary goals of rehabilitation services and research efforts—have consistently been associated with SOC in general population studies (Albanesi, Cicognani, & Zani, 2007; Davidson & Cotter, 1991; Peterson, Speer, & Hughey, 2006; Prezza, Amici, Roberti, & Tedeschi, 2001; Prezza & Constantini, 1998). It has been theorized that SOC encourages a greater sense of identity and greater self-confidence, which promotes well-being as opposed to anonymity and loneliness (Martini & Sequi, 1995; Prezza & Constantini, 1998). In particular, life satisfaction focuses on an individual’s global appraisal of his or her life (Diener, 1984; Diener, Emmons, Larsen, & Griffin, 1985) and is closely related to other long-term outcomes following neurological injury (Fuhrer, 2000). Moreover, there is evidence suggesting that people with brain injury are at risk for lower levels of life satisfaction (Djikers, 2004), especially those with limited functional independence (Resch et al., 2009). Understanding the relationship between SOC and well-being measures, such as life satisfaction, for disability populations has the potential to inform more effective rehabilitation interventions and strategies. Yet, to date research has not investigated the relationship between SOC and indicators of subjective well-being for individuals with brain injury.

In fact, only a handful of published studies have looked at SOC within specific disability populations and even these have been primarily qualitative and descriptive in nature. The most notable research in this area include several studies examining the benefits of connecting to volunteer communities for people with HIV (Omoto & Snyder, 2002) and a study on the community perspectives of adolescents with and without intellectual disabilities in Australia (Bramston, Bruggerman, & Pretty, 2002). Studies involving individuals with physical disabilities include a study focusing on identification with the disability community among individuals with spinal cord injury living in France (Ville, Crost, Ravaud, & Tetrafigap Group, 2003) and a study by Goodwin and colleagues (2009) examining the social experiences of wheelchair rugby players within the theoretical context of SOC. However, these studies have not explicitly examined SOC toward individuals’ towns.

More recently, there has been a series of studies examining SOC among people with psychiatric disabilities in their geographic communities finding that neighborhood characteristics (relationships, safety, satisfaction, tolerance toward mental illness) and housing type are associated with SOC among adults with severe mental illness (Townley & Kloos, 2009, 2011). However, the link between SOC and well-being among this population was not studied. Thus, little remains known about SOC and its impact on life satisfaction for disability populations.

Related Constructs

SOC theoretically relates to similar social constructs, such as social identification, as well as those more commonly examined in the rehabilitation literature, such as perceived social support and social integration. However, research on the extent to which SOC is distinguished from these constructs is limited.

Social support

Social support is widely studied in rehabilitation and generally found to be a consistent predictor of life satisfaction, particularly among those with brain injuries (Jacobsson, Westerberg, Malec, & Lexell, 2011; Seidl et al., 2015; Tomberg, Toomela, Ennok, & Tikk, 2007). Social support is considered to be multidimensional. Types of functional social support relevant to rehabilitation include emotional (expressing concern, affection, listening) and instrumental (financial, physical, tangible assistance) support (Chronister, Johnson, & Berven, 2006). Social support is hypothesized to be distinct from SOC albeit conceptually linked. Omoto and Malsch (2005) explain that while SOC may develop or be enriched by supportive social networks, it is distinct from social support because the key feelings of belonging, connection, and esteem that are attached to a psychologically identifiable community are not necessarily linked to support of particular individuals. In addition, perceptions of community support may persist even as community members enter and exit (Omoto & Malsch, 2005). Yet, the extent to which social support variables correlate with SOC for individuals with brain injury is unknown. Furthermore, it is unclear whether SOC predicts life satisfaction for people with brain injury when controlling for their existing perceptions of social support.

Social integration

Social integration is often viewed as a product of functional independence, and people are considered integrated socially into their communities to the extent they are able to participate in social activities (Willer, Rosenthal, Kreutzer, Gordon, & Rempel, 1993). Social integration is of particular concern for people with brain injury who are at risk for social isolation and lower levels of social integration than their peers without disabilities (e.g., M. Brown, Gordon, & Spielman, 2003). Social integration measures primarily assess frequency (or sometimes satisfaction with the level) of community involvement and have been found to predict life satisfaction and quality of life among people with brain injury (Huebner, Johnson, Bennett, & Schneck, 2003; Stalnacke, 2007). However, it is unclear the extent to which SOC predicts life satisfaction over and above social integration. SOC is distinct from social integration in that it emphasizes the individual’s sense of belonging. For example, an individual whose integration in the community is assessed to be high (e.g., accesses community venues regularly) may not necessarily feel a strong sense of shared identity with other community members. In line with this assumption, research looking at the relationship between social integration measures and SOC in general populations has found only small to moderate correlations (Albanesi et al., 2007; Cicognani et al., 2008). With regard to individuals with disabilities, Cummins and Lau (2003) have argued that service provision efforts should work toward promoting SOC and connectedness, rather than being only concerned with physical integration within the general population.

Social identification

Social identification is a third construct that should be further examined in relation to SOC and life satisfaction. Several theorists have suggested that levels of SOC may be understood in terms of the degree to which members identify with a specific community (Chavis & Pretty, 1999; Chipuer & Pretty, 1999; Fisher & Sonn, 1999, 2002). Individuals exist within many community systems (Bronfenbrenner, 1979), and they may attribute greater significance to specific communities in shaping their social identity and potentially life satisfaction. Although some researchers have incorporated social identity measures as an aspect of SOC (Fisher & Sonn, 1999; Obst, Smith, & Zinkiewicz, 2002), others have conceptualized social identification as a distinct construct and a predictor of overall SOC (Smith, Zinkiewicz, & Ryall, 1999). In much of the existing literature, the idea of identification with the community is discussed in relation to understanding members’ attachment to their communities (Brodsky & Marx, 2001; Obst & White, 2007; Puddifoot, 2003). Research findings support the notion that differential levels of social identification and SOC are ascribed to different community contexts (e.g., Obst et al., 2002). The extent to which individuals perceive their residential community (i.e., town) membership as a central aspect of their identity may affect the extent to which levels of SOC relate to overall life satisfaction.

Study Purpose

The idea that people belong to communities that provide benefits and responsibilities continues to gain notable appreciation across disciplines. Increasing the understanding of community experiences for individuals with disabilities has the potential to impact the effectiveness of rehabilitation service efforts. Poor community outcomes, social isolation, and changes in support network are particularly prevalent following an acquired brain injury. Recognizing (a) how individuals with brain injury perceive their felt experience of community, and (b) the extent to which individual’s sense of belonging and value as a member in their community affect their life satisfaction will benefit the field of rehabilitation. Thus, the primary purpose of this study was to examine the impact on life satisfaction of the four dimensions of SOC and related constructs among adults with brain injury. Specifically, the following research questions were addressed:

Research Question 1: To what extent do social support and social integration variables predict life satisfaction for individuals with brain injury, controlling for demographic (age, gender, income) and disability (symptom severity) variables?

Research Question 2: Does social identification with one’s town predict greater life satisfaction over and above demographic, disability, social integration, and social support variables?

Research Question 3: Controlling for demographic, disability, and related social constructs (social support and social integration), does SOC predict life satisfaction of adults with brain injury?

Research Question 4: What is the unique, independent contribution of the four dimensions of SOC (membership, reinforcement of needs, influence, and shared emotional connection) to life satisfaction outcomes?

Method

Participants and Procedure

After receiving Institutional Review Board approval, participants were recruited from brain injury associations across the United States to participate in an online survey study. The research team reached out to the Brain Injury Association of America (BIAA), as well as individual state brain injury associations and alliances, for support in recruiting for this study. Depending on the state organization preference, the study opportunity was disseminated through emails to membership listservs and/or posted on brain injury organization websites. The online survey was set up through Qualtrics survey software. The study ran from January 2014 through March 2015. To be eligible for inclusion in the study, participants had to meet the following criteria: (a) be at least 18 years of age; (b) have a brain injury that occurred at minimum 6 months prior; and (c) currently reside in the community (i.e., not currently in an inpatient rehabilitation center or program). A total of 177 usable questionnaires were returned (i.e., had complete data related to the key study variables) and were included in the analyses.

Descriptive data for the participants are presented in Table 1. Participants ranged in age from 21 to 78 years (Mdn = 50.0). Nearly two thirds of the participants were female (63.8%), and the vast majority of the sample described themselves as White (88.7%). Over two thirds (68.9%) of the participants obtained a college degree, yet over one third (39.0%) of the participants reported being unemployed. When asked about relationship status, most participants reported being married (42.4%), followed by divorced or separated (26.5%) and never married (23.7%). The majority of participants (82.5%) reported a traumatic brain injury (TBI) as the type of injury they had acquired. Most participants classified their injuries as severe (44.1%) or moderate (41.8%). Time since injury ranged from 6 months to 52 years (Mdn = 10.7 years).

Table 1.

Participant Demographic, Injury, and Community Characteristics (N = 177).

Variables	n	(%)	M	(SD)
Demographic characteristics
Gender
Female	113	(63.8)
Male	64	(36.2)
Age			49.4	(11.8)
Household income			US$45,537	(40,215)
Race/ethnicity^a
White	157	(88.7)
Hispanic/Latino/a	11	(6.2)
African American/Black	4	(2.3)
Native American	11	(6.2)
Other	7	(4.0)
Education level
Less than high school	2	(1.2)
High school graduate	7	(4.0)
Some college	32	(18.1)
Associates/technical school	14	(7.9)
College graduate	66	(37.3)
Graduate school	56	(31.6)
Employment status
Unemployed	69	(39.0)
Retired	36	(20.3)
Employed	52	(29.3)
Student or volunteer	16	(9.1)
Not reported	4	(2.3)
Relationship status
Never married	42	(23.7)
Married/partnered	75	(42.4)
Widowed	6	(3.1)
Divorced or separated	47	(26.5)
Cohabitating	5	(2.8)
Not reported	2	(1.1)
Injury characteristics
Years since injury			12.8	(10.9)
Cause of injury^a
TBI	146	(82.5)
Stroke, TIA, or aneurysm	26	(14.7)
Epilepsy/seizure disorder	20	(11.3)
Other	26	(14.7)
Self-reported severity of injury
Mild	23	(13.0)
Moderate	74	(41.8)
Severe	78	(44.1)
Not reported	2	(1.1)
Community characteristics
U.S. region
West	60	(33.9)
Midwest	40	(22.6)
South	18	(10.2)
Northwest	16	(9.0)
Northeast	6	(3.4)
Southwest	2	(1.1)
Not reported	35	(19.8)
Town description^b
Urban/suburban	110	(77.5)
Rural	11	(6.2)
Split	21	(11.9)
Not reported	35	(20.3)
Town class description
Upper class, affluent	18	(10.7)
Upper middle class	36	(20.3)
Middle class	77	(43.5)
Low middle class	26	(14.7)
Poverty	5	(2.8)
Unsure	15	(8.5)
Years of residence in town			18.0	(15.2)
Living in town prior to injury
Yes	102	(57.6)
No	73	(41.2)
Not reported	2	(1.1)
Percent of time spent in town			74.6	(32.1)
Less than 10%	17	(9.6)
11% to 25%	9	(5.1)
26% to 50%	11	(6.2)
51% to 75%	21	(11.9)
76% to 90%	32	(18.1)
91% to 100%	80	(45.2)
Not reported	7	(4.0)

Note. TBI = traumatic brain injury; TIA = transient ischemic attack.

More than one category could be coded, resulting in totals exceeding 100%. ^bTown description categories based on Census data associated zip codes provided by the participants.

Participants were also asked to describe their town of residence. Participants came from 23 different states in the United States, with most from the West (33.9%) and Midwest (22.6%). Based on zip code data, participants’ towns could be primarily categorized as urban/suburban (77.5%). Most participants described their towns as middle class and had been living in their towns on average 18 years (SD = 15.2, Mdn = 14.0). More than half (57.6%) were living in their towns prior to acquiring a brain injury. Close to two thirds (63.3%) of participants reported spending at least 75% of their time in their towns, and nearly half (45.2%) reported spending more than 90% of their time in their towns.

Measures and Variables

Symptom severity

Physical and cognitive symptoms were assessed through the short version of the Problem Checklist (PCL; Kay, Cavallo, Ezrachi, & Vavagiakis, 1995). A total symptom severity index was based on combining the Physical/Dependency (7 items) and the Cognitive (nine items) subscales. The PCL is a component of the Head Injury Family Interview and is a checklist of symptoms that are common problems after head injury. One problem item listed on the original Physical/Dependency subscale (“needing supervision”) was omitted prior to conducting the study because it did not appear to be a specific symptom. Items were rated on a 7-point Likert-type scale to indicate whether a symptom was endorsed, and if so, the extent to which it presented as a problem in their daily functioning. Response options ranged from not present (0) to very much (6). Although the original PCL was initially intended to be administered through interview, the PCL has previously been used in self-report questionnaire format with individuals with brain injury (e.g., Trehan, Pépin, & Hopps, 2006) and has been found to be sensitive to differences in symptom reporting between individuals with brain injury and those without (Paniak, Phillips, Toller-Lobe, Durand, & Nagy, 1999). Internal consistency of the composite scale was supported in this study, with a Cronbach’s alpha of .93.

Perceived social support

The National Institute of Health (NIH) Social Relationship Scales were used to measure perceived social support (Cyranowski et al., 2013). For this study, the emotional support and instrumental support subscales were used. The emotional support scale has eight items that measure perceived availability of emotional support (e.g., “I have someone who will listen to me when I need to talk.”). The instrumental support scale contains eight items related to perceived availability of support for help with daily activities, such as preparing meals and transportation (e.g., “I have someone to take me shopping if I need it.”). Items were rated from never (1) to always (5). Factor analysis has supported the multidimensional nature of the scale and the two subscales (Cyranowski et al., 2013), and there is evidence for the internal consistency of the subscales (α = .97 and .95, respectively). Internal consistency estimates for the emotional and instrumental scales in this study were .97 and .96, respectively.

Social integration

Social integration was measured using a modified version of the social integration subscale of the Community Integration Questionnaire (CIQ; Willer et al., 1993), which reflects frequency of presence in the community and is a widely used measure of community outcomes following brain injury (Seale et al., 2002). To ensure physical presence in the community was being captured, the item “How often do you travel outside the home?” was added, while two items related to having a best friend with whom to confide and personal finances were removed. The final scale used in this study consisted of five items (scored from 0 to 2) with higher mean scores indicative of greater levels of social integration. In samples of persons with brain injury, reliability has been reported with a test–retest coefficient of .91, participant proxy coefficient of .89 for the total score, and Cronbach’s alpha of .83 specifically for the social integration subscale (Willer et al., 1993). Cronbach’s alpha for the current study was .74.

Social identification

Social identification refers to the extent which a community is perceived to be a salient feature of an individual’s self-image or identity. As related to the individual’s town of residence, this was assessed using a single item developed for this study “How important is being a member of this town to your overall self-image and how you feel about yourself?” This item was adapted from an existing item included in Cameron’s (2004) centrality subscale of the Three-Dimensional Strength of Group Identification Scale to assess the prominence attributed to membership in a specific group or community. Ratings from not at all important (1) to very important (7) were used for this study.

SOC

SOC was measured using the Sense of Community Index–2 (SCI-2; Chavis, Lee, & Acosta, 2008), which is based on McMillan and Chavis’ (1986) four-dimensional theory of SOC. The SCI-2 consists of 24 items ranging from 1 (not at all) to 4 (completely). In this study, participants were asked to reflect on their town. The four subscales were used in the analysis. Membership refers to feelings of belonging (e.g., “I can trust people in this town”). Reinforcement of needs refers to getting one’s needs met as a member of the community (e.g., “This town has been successful in getting the needs of its members met”). Influence refers to both the influence the community has on the individual (e.g., “This town has good leaders”) as well as the influence one has on the community (e.g., “I have influence over what this town is like”). Finally, shared emotional connection refers to bonding and connection among community members (e.g., “I am with other town members a lot and enjoy being with them”). The SCI-2 has been shown to be a reliable measure, with Cronbach’s alphas of .94 for the total score and ranging from .79 to .86 for the subscales (Chavis et al., 2008). In this study, internal consistency was supported with Cronbach’s alphas of .96 for the total score, .84 for membership, .91 for reinforcement of needs, .84 for influence, and .88 for shared emotional connection subscales.

Life satisfaction

The dependent variable in this study was life satisfaction, as measured by the Satisfaction With Life Scale (SWLS) (Diener et al., 1985). The SWLS contains five items that examine an individual’s global satisfaction with his or her life. The items are each scored on a 7-point Likert-type scale ranging from strongly disagree (1) to strongly agree (7), and include items such as “In most ways my life is ideal.” The overall scale scores range from 5 to 35 with higher scores indicative of greater life satisfaction (Pavot & Diener, 1993). A score of 20 represents the neutral point on the scale. Studies using the SWLS with various samples have found that most groups generally fall in the range of 23 to 28, indicating slightly satisfied to satisfied (Pavot & Diener, 1993). However, mean scores on the SWLS have been found to be lower among samples of individuals with brain injury. Sokol, Heinemann, Bode, Shin, and Van de Venter (1999) report a mean of 16.2 (slightly dissatisfied) on the SWLS for a sample of over 800 people with brain injury residing in the community. The measure has demonstrated internal consistency (α = .87) and test–retest reliability ranging from .82 to .84 at 2-month intervals (Diener et al., 1985; Pavot, Diener, Colvin, & Sandvik, 1991) and .54 at 4 years (Pavot et al., 1991). This scale has been studied widely in samples of persons with brain injury (e.g., Corrigan, 2000; Corrigan, Smith-Knapp, & Granger, 1998; Sokol et al., 1999; TBI Model Systems National Data and Statistical Center, 2010). The Cronbach’s alpha for the present sample was .90.

Data Analysis

Hierarchical regression analysis (HRA) was used to measure the incremental variance accounted by each predictor set and to determine the unique contribution and predictive ability of each predictor variable to the variance of the dependent variable (life satisfaction). The change in R² (ΔR²) was examined as a measure of each predictor set’s contribution. Four blocks were entered to address the research questions: (a) demographic and disability variables (age, income, gender, symptom severity); (b) related social constructs (emotional support, instrumental support, social integration); (c) social identification (i.e., extent to which town is perceived as central to one’s self-image); and (d) SOC variables (membership, reinforcement of needs, influence, and shared emotional connection). This order of blocks was used to facilitate more accurate understanding of the effect of SOC variables (both collectively and individually) while controlling for the other predictors of life satisfaction. (Note. Including employment status as a control variable in the first step of the analysis was considered, but given that more than 20% of the sample reported being retired it was left out). Significance tests for the regression coefficients for each predictor variable were assessed at each block and at the final model to assess unique relationships to the dependent variable (life satisfaction). A priori power analysis was conducted using G*Power (Faul, Erdfelder, Lang, & Buchner, 2007) and supported that a sample size of 177 would be sufficient to detect a medium effect size. Specifically, it was estimated that to achieve a power level of .8 with an alpha level of .05, and 12 predictors in multiple regression, the required sample size to detect an effect size of .15 was 127. Prior to the analysis, zero-order correlations were examined for correlations of .80 or larger and Variance Inflation Factors (VIF) were examined for scores of 10 or greater (Belsley, Kuh, & Welsch, 1980). VIF scores in this study did not exceed 1.5 suggesting multicollinearity was not a concern.

Results

Descriptive Statistics

Means, standard deviations, and correlations are summarized in Table 2. On average, participants reported relatively low levels of life satisfaction (M = 17.51; SD = 8.0, range = 5–33), but generally consistent with mean levels reported in other studies of people with brain injury (Corrigan et al., 1998; Sokol et al., 1999). Participants in this study reported low to moderate levels of SOC for their towns (M = 1.9; SD = 0.6; range = 1–4). Among the subscales of the SCI-2, mean scores were relatively similar. Significant correlations among scores on the various measures were generally small to medium (i.e., not exceeding r = .49), with the exception of the SOC subscales, which as expected were more highly correlated with one another (r = .71–.76). The strongest bivariate correlations with life satisfaction were perceived emotional support (r = .49) and the shared emotional connection dimension of SOC (r = .40).

Table 2.

Means, Standard Deviations, and Correlations of Study Variables (N = 177).

Variables	M	(SD)	1	2	3	4	5	6	7	8	9	10	11	12
1. Age	49.4	(11.8)	—
2. Income	45,537	(40,215)	−.03	—
3. Sex (1 = male)	0.36	(0.48)	−.03	.08	—
4. Symptom severity	4.02	(1.05)	.12	−.04	−.16*	—
5. Identification	3.71	(1.68)	.15*	.02	.00	.12	—
6. Social integration	1.25	(0.47)	−.11	.08	.03	−.24**	.06	—
7. Emotional support	3.62	(1.07)	−.08	.18*	.03	−.15*	−.09	.38***	—
8. Instrumental support	3.35	(1.21)	−.15	.23**	.08	−.18*	−.02	.35***	.52***	—
9. Membership (SOC)	1.79	(0.62)	.09	.10	.17*	−.07	.47***	.34***	.22**	.15*	—
10. RN (SOC)	1.94	(0.73)	.06	.26**	.15*	−.17*	.36***	.38***	.38**	.24**	.72***	—
11. Influence (SOC)	1.88	(0.62)	.00	.13	.22**	−.09	.42***	.30***	.20**	.14	.75***	.71***	—
12. EC (SOC)	2.08	(0.70)	.03	.24**	.14	−.07	.45***	.39***	.29**	.25**	.76***	.72***	.76***	—
13. Life satisfaction	17.51	(7.98)	.02	.22**	.17*	−.29***	.09	.28***	.49***	.36***	.37***	.37***	.33***	.40***

Note. Identification = social identification with town community; SOC = sense of community; RN = reinforcement of needs; EC = shared emotional connection.

p < .05. **p < .01. ***p < .001.

HRA

HRA was used with four predictor sets to address the research questions. The results of the analysis are presented in Table 3.

Table 3.

Hierarchical Regression Analysis of Predictors of Life Satisfaction (N = 177).

Variable	R ²	ΔR²	B	SE B	β
Step 1 (control variables)	.14***	—
Age			0.04	0.05	.06
Household income			0.00	0.00	.20**
Sex (1 = male)			1.83	1.19	.11
Symptom severity			−2.06	0.55	−.27***
Step 2 (related constructs)	.33***	.19***
Age			0.06	0.04	.10
Household income			0.00	0.00	.11
Sex (1 = male)			1.84	1.06	.11
Symptom severity			−1.48	0.50	−.19**
Emotional social support			2.81	0.57	.38***
Instrumental social support			0.56	0.51	.09
Social integration			1.00	1.20	.06
Step 3 (identification variable)	.35***	.02*
Age			0.05	0.04	.08
Household income			0.00	0.00	.11
Sex (1 = male)			1.80	1.05	.11
Symptom severity			−1.60	0.50	−.21**
Emotional social support			2.95	0.57	.40***
Instrumental social support			0.53	0.50	.08
Social integration			0.67	1.20	.04
Identification			0.64	0.31	.13*
Step 4 (SOC variables)	.45***	.11***
Age			0.03	0.04	.04
Household income			0.00	0.00	.03
Sex (1 = male)			1.22	1.00	.07
Symptom severity			−1.27	0.47	−.17**
Emotional social support			1.94	0.55	.26**
Instrumental social support			0.62	0.47	.09
Social integration			−0.84	1.17	−.05
Identification			−0.06	0.34	−.01
Membership			0.23	1.33	.02
Reinforcement of needs			4.96	1.10	.45***
Influence			−1.59	1.34	−.12
Shared emotional connection			0.52	1.24	.05

Note. Identification = social identification with one’s town community. SOC = sense of community. F(12, 164) = 11.362, p < .001 for the full model; F(4, 172) = 7.07, p < .001 for Step 1; ΔF(3, 169) = 16.06, p < .001 for Step 2; ΔF(1, 168) = 4.37, p = .038 for Step 3; ΔF(4, 164) = 7.90, p < .001 for Step 4.

p < .05. **p < .01. ***p < .001.

In the first step of the regression analysis, demographic and symptom severity variables were entered. These variables collectively accounted for 14% of the variance in life satisfaction scores, R² = .14, F(4, 172) = 7.07, p = .001. Greater household income (β = .20, p < .01) and lower levels of reported symptom severity (β = −.27, p < .001) were associated with greater life satisfaction outcomes in this step. Social support and social integration variables were entered in the second step to answer the first research question. In this step, perceived emotional and instrumental social support measures were entered along with level of social integration. As a block, these variables explained an additional 19% of the variance in life satisfaction outcomes over and above what had been explained by the control variables, R² = .33, ΔR² = .19, ΔF(3, 169) = 16.06, p < .001. An examination of the standardized partial regression coefficients revealed that of the added variables, perceived emotional support contributed significantly to explaining variance in life satisfaction, β = .38, p < .001. Symptom severity also remained a significant independent predictor in this step (β = −.19, p < .01), but household income was no longer significant. As a set, the social construct variables were indeed associated with greater life satisfaction; however, emotional support was the only significant independent predictor of life satisfaction.

Research Question 2: Does social identification with one’s town positively predict life satisfaction over and above demographic, disability, social integration, and social support variables?

To answer the second research question, social identification was entered as a single variable in the third step of the HRA. Social identification refers to the extent to which town membership is perceived to be salient to the individual’s self-image. Social identification accounted for a small but significant amount of additional variance in life satisfaction scores beyond that explained by the variables entered in the previous steps, R² = .35, ΔR² = .02, ΔF(1, 168) = 4.37, p = .038. The standardized partial regression coefficients for social identification (β = .13, p < .05) as well as symptom severity (β = −.21, p < .01) and emotional support (β = .40, p < .001) were significant in this step.

Research Question 3: Controlling for demographic, disability, and related social constructs (social support and social integration), does SOC predict life satisfaction of adults with brain injury?

To answer the third research question, SOC variables were entered as the final block in the analysis. This set of variables predicted life satisfaction of adults with brain injury. Specifically, the inclusion of these variables explained an additional 11% of the variance in life satisfaction scores over and above the previous variables entered into the analysis, R² = .45, ΔR² = .11, ΔF(4, 164) = 7.90, p < .001.

Of the SOC variables, reinforcement of needs was found to be the only significant independent predictor (β = .45, p < .001). It was also found to be the strongest predictor of all the variables in the final model. In the final step, the standardized regression coefficients for symptom severity (β = −.17, p < .01) and emotional support (β = .26, p < .01) also remained significant although their magnitude decreased.

Severity of symptoms, perceived emotional support, and appraisal of needs met by one’s town (reinforcement of needs) were significant independent predictors of life satisfaction in the final model. The final regression model accounted for nearly half of the variance in life satisfaction scores, R² = .45, F(12, 164) = 11.36, p < .001. According to Cohen’s (1988, 1992) standards for the behavioral sciences, this is considered a large effect size. Overall, the results indicated that (a) after controlling for demographic and disability variables, social support and social integration variables collectively predicted greater life satisfaction, with emotional support being the strongest predictor; (b) social identification had a small effect on life satisfaction at entry into the model, but this effect did not remain when SOC variables were included; (c) SOC variables collectively accounted for 11% of the variance in life satisfaction outcomes; (d) reinforcement of needs was the strongest individual predictor of life satisfaction; and (e) the effects of emotional support and symptom severity on life satisfaction outcomes were reduced when SOC variables were entered in the model.

Discussion

Individuals with brain injury are at risk for social isolation and poor quality of life, yet the extent to which their perceptions of community membership affect subjective well-being has received relatively little attention. This study is the first to investigate the relationship between SOC and life satisfaction for individuals with brain injury. SOC toward one’s town predicted life satisfaction outcomes even after controlling for demographic, disability, and social variables. In addition, findings from this study are consistent with previous studies documenting lower ratings of life satisfaction by people with brain injury relative to ratings reported by the general population (e.g., Sokol et al., 1999), supporting the continued emphasis of rehabilitation efforts focused on improving subjective aspects of quality of life for individuals with brain injury. The findings from this study contribute to the rehabilitation counseling literature in a number of key ways.

Study results indicate that social integration and social support collectively predict life satisfaction among individuals with brain injury. This is not surprising given previous research documenting these relationships (e.g., Jacobsson et al., 2011; Stalnacke, 2007). In particular, emotional support was the strongest predictor of life satisfaction among these variables in the present study. However, its impact was weakened when SOC variables were included in the model. It is plausible to assume that individuals who receive emotional support from people in their town likely perceive stronger reliance and shared connections within their towns. However, the measure of emotional support used in this study was not specific to a town context. It is possible that those receiving emotional support even outside their communities are more open to accepting and sensing support from others, such as neighbors. Clearly, these are complex processes, and further research is needed to tease this out.

Social identification was also associated with life satisfaction outcomes when initially entered in the model following the control and related social construct variables, but this relationship was relatively weak and diminished with the inclusion of the SOC variable set. The social identification variable in this study reflected the extent to which individuals view their membership in the town community as salient to their self-image, and research findings suggest that an individual ascribes different levels of social identification and SOC depending on the specific community context (e.g., Obst et al., 2002). On average, participants did not report identifying strongly with their town membership in this study. This is not surprising given that individuals may be associated with a number of communities (e.g., faith communities, work settings) and likely identify with other communities more strongly. Alternatively, it is also possible that individuals with brain injury facing increased social isolation may not identify strongly with any communities. Despite weak identification with the town community (and controlling for this identification), SOC related to town was still predictive of overall life satisfaction. This suggests that while it is important to work with clients to ascertain and recognize the specific communities they most strongly identify with, one’s town still appears to be a central community to one’s life that can affect life satisfaction. This is likely because most people spend considerable time in this community, as is reflected in this study’s finding that nearly half of the participants reported spending more than 90% of their time in their towns.

SOC was found to have moderate positive correlations with life satisfaction in this study’s sample of individuals with brain injury. This is consistent with previous research documenting small to moderate correlations between SOC and life satisfaction, happiness, and well-being with other populations (e.g., Albanesi et al., 2007; Pretty, Conroy, Dugay, Fowler, & Williams, 1996; Prezza & Constantini, 1998). Moreover, findings from this study suggest that even when controlling for variables related to life satisfaction (demographics, symptom severity, social support and social integration), an individual’s felt experience of their town community uniquely affected life satisfaction. The results suggest that SOC more strongly predicts life satisfaction over social support and social integration variables. This is surprising given that these latter variables continue to gain attention as important considerations and outcomes of the rehabilitation process (e.g., M. Brown et al., 2003; Stalnacke, 2007), while SOC is seldom addressed. These findings suggest that it may not be enough to examine the extent to which individuals are leaving their homes, as most measures of social integration and community participation do; rather, the individual’s felt experience of community and sense of belonging should also be considered. Strategies to assess and improve individuals’ SOC would greatly benefit the rehabilitation process.

Of the SOC domains, reinforcement of needs was the strongest predictor of life satisfaction. This is an important finding that warrants future research. According to SOC theory, reinforcement of needs reflects integration within a community based on common needs, beliefs, and goals, along with sharing a desire for both collective and individual needs to be met (McMillan & Chavis, 1986). An association between met needs and life satisfaction has been documented in the literature, although this finding was specific to service needs of people with brain injury (Pickelsimer et al., 2007). The extent to which the community-related needs assessed by SOC measures relate to the service, daily living, or instrumental support needs of people with brain injury is not well understood. In this study, there was a small bivariate correlation between reinforcement of needs and the instrumental support measure; however, in the regression model, instrumental support did not contribute to the variance in life satisfaction. This finding suggests that rehabilitation counselors should work with clients to understand their need for community ties and optimum access to contexts aligning with their social identity, in addition to the standard assessment of instrumental support needs (e.g., activities of daily living [ADLs]). Moreover, the extent to which natural supports occurring in the community could ameliorate the impact of unmet service needs is also an area for further investigation. Rehabilitation counselors should work with clients to build the self-advocacy, social skills, and self-efficacy necessary to effectively ensure that the client’s community-related needs are being met. To date, there is a lack of research examining evidence-based strategies for enhancing self-advocacy among people with brain injury, although there is some emerging evidence that bringing together motivated individuals with brain injury in either self-directed or curriculum-guided interventions may improve advocacy skills (A. W. Brown et al., 2015).

Finally, the study’s findings are consistent with previous literature showing a negative relationship between severity of injury and life satisfaction for people with brain injury (Bushnik, Englander, Wright, & Kolakowsky-Hayner, 2012; Resch et al., 2009). Severity may indeed be an initial benchmark in understanding well-being outcomes, but individuals’ personal and community resources are also important to recognize. In this study, the addition of social variables, such as social support and SOC variables, appeared to lessen the negative impact of severity on life satisfaction. In other words, life satisfaction of people with brain injury is not merely equated with symptom severity, but differences in personal and social variables appear to help explain the variations found in reported life satisfaction among individuals with similar levels of severity.

Limitations

There are several limitations that should be considered when interpreting the results of the present study. The generalizability of the sample is limited. Compared with demographic characteristic reports from the TBI Model Systems National Data and Statistical Center (2014), the present study’s sample included a greater proportion of females and constitutes a somewhat older, more highly educated, and less ethnically diverse sample than the true brain injury population in the United States. Given the older age of the participants, there were a number of individuals retired in the sample that made examining employment status less straightforward. However, employment status is an important variable to include in future studies examining life satisfaction and SOC among working-age individuals with disabilities. Another concern regarding the study’s sample is that individuals associated with brain injury networks may have different experiences of community and are not necessarily representative of the true population. It was not possible to estimate a response rate because the number of persons who were invited to participate who met eligibility criteria is unknown. Nonetheless, it can be assumed that a large proportion of eligible individuals chose not to participate. Although a majority of participants indicated that they had acquired moderate and severe brain injuries, it is likely that individuals with more significant functional limitations, such as extensive problems related to fatigue, memory, vision, or reading comprehension, would have difficulty completing the survey. Furthermore, the self-report nature of the study poses an important limitation for these same reasons, and it is possible that cognitive limitations associated with brain injury affected some participants’ ability to respond accurately to survey items.

This study looked at SOC regarding one’s town. Although salience of social identification with one’s town was controlled for in the analysis, individuals likely belong to other communities (e.g., faith communities, workplaces, brain injury organizations) that may have a greater impact on their life satisfaction. In addition, the precise boundary of one’s town may be difficult to define. These geographic spaces are quite varied with regard to size and density which hinders interpretation of the study results. Furthermore, there is limited evidence for the reliability and validity of the social identification variable used in this study because it was based on a single item. Finally, because the present study uses HRA with cross-sectional data, it is not possible to determine directionality of the effects or causality.

Implications for Practice and Research

There are several implications for rehabilitation counseling practice based on the study’s findings. First, SOC is an important construct to consider when working with clients with disabilities because of its association with life satisfaction. In particular, counselors need to evaluate the extent to which clients with brain injury, who are at great risk of social isolation following injury, view their role in their town. Counselors are increasingly aware of the importance of working with clients to improve their community integration and participation, but they should also focus on the clients’ felt experience of community, as it appears this is even more strongly related to subjective well-being outcomes. Incorporating brief assessment tools such as the SCI-2 could be a useful strategy for gaining this information, identifying concerns across the four SOC domains, and assessing progress.

Second, research supporting evidence-based strategies to improve SOC for clients is sorely needed. Findings from a recent study of individuals with brain injury examining predictors of SOC suggest that focusing on strategies to increase social self-efficacy and social networks may lead to increased SOC (Ditchman, Chan, Haak, & Easton, 2015). SOC may be amenable to change by using intervention strategies designed to foster involvement in community life. For example, engagement in prosocial behaviors with neighbors and community members could affect SOC. At the individual treatment level, social skills training and intervention strategies aimed at building social-self efficacy, such as counseling specifically designed to help individuals develop a personally relevant sense of self and positive outcome expectancies related to social interactions, may be important for increasing overall SOC. Interventions at the community level may also be effective, although these have not received much attention even in the community psychology literature. One notable study in a Latino community, although small (n = 28), examined the impact of a neighborhood intervention involving individuals inviting neighbors into their homes and found increased SOC, social capital, and collective efficacy outcomes based on pre- to post-test changes (O’Connor, 2013). The extent to which community interventions could foster these kinds of outcomes for people with disabilities in their communities would be a valuable line of research.

Third, these findings also suggest that advocacy efforts are needed to ensure the full integration of people with disabilities in community life. Active involvement in neighborhood and civic organizations has been predictive of higher SOC at both individual and community levels (Brodsky, O’Campo, & Aronson, 1999). More research is needed to understand effective strategies for counselors to work with clients to build the necessary personal advocacy skills and self-efficacy needed to effectively address community needs. At the same time, rehabilitation counselors are called to be advocates alongside people with disabilities, and it is essential that counselors also take a look at their own communities and take active roles in informing policy and community action to improve the SOC of all community members. The primary reason town was chosen as the community referent for this study is that towns (or cities) represent areas that generally have more familiar political and administrative units relative to other distinctions, such as a neighborhoods or blocks. Thus, advocacy and policy efforts that have the potential to inform community practices may be better received, enacted, and financed at the town level (e.g., through political avenues such as city board decisions or mayoral endeavors).

Fourth, this study looked at town membership as the reference community; however, other communities may be of greater importance to individuals with disabilities. For example, there is much potential for SOC to be a useful construct in vocational rehabilitation to understand barriers and facilitators of employment outcomes. In addition, the extent to which individuals identify with disability advocacy or support groups is an important direction of research to be continued. This study provides a foundation for acknowledging the relationship between life satisfaction and SOC for one’s town; however, future research is needed to examine the extent of this relationship with regard to other communities of interest. In addition, longitudinal research would be particularly beneficial to more thoroughly examine the causal relationships between these constructs.

Fifth, the extent to which employment fosters SOC and life satisfaction among people with brain injury is an important area for future research. Employment status was not included in the present study’s analysis given that more than 20% of the participants reported they were retired. Employment status has indeed been associated with greater participation and life satisfaction among people with brain injury (e.g., Corrigan, Bogner, Mysiw, Clinchot, & Fugate, 2001; Pierce & Hanks, 2006). However, whether work status may also be associated with increased SOC for people with disabilities has not been examined. Furthermore, the extent to which individuals with disabilities feel belonging and influence in their workplace as a community is an important consideration in assessing job retention and quality of work life. Finally, this study examined individuals with brain injury, but future research should investigate this relationship among other disability populations as well as the extent to which SOC may mitigate some of the challenges facing caregivers and family members of people with disabilities.

Conclusion

The results of this study underscore that the SOC of persons with brain injury is critical to promoting life satisfaction and positive well-being outcomes. Indeed, emotional support and severity of symptoms play an important role in affecting life satisfaction, but these findings suggest that SOC, and in particular reinforcement of needs in the community, is of unique importance. Yet, assessment related to SOC in counseling practice is virtually nonexistent. This study is among the first studies to examine SOC for adults with brain injury, and much is left to be explored to promote effective SOC-related assessment and interventions in the rehabilitation field. In particular, additional research determining effective strategies for improving SOC for people with disabilities, such as brain injury, is needed.

Footnotes

Acknowledgements

We would like to acknowledge and thank the Brain Injury Association of America and all the state Brain Injury Associations and Brain Injury Alliances who assisted with the dissemination of this study. We would also like to thank all the individuals who took part in this study for their time and participation.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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