Date Presented Accepted for AOTA INSPIRE 2021 but unable to be presented due to online event limitations.
We used two different quantitative analytic approaches to examine whether there were sex differences in self-reported participation restrictions among male and female veterans with traumatic brain injury. Findings suggest that women have more challenges with leisure and employment and fewer challenges with residence and financial management than men. Total raw scores may obscure important differences in how men and women self-report participation restrictions.
Primary Author and Speaker: Alison M. Cogan
Contributing Authors: Jennifer A. Weaver, Trudy Mallinson, Theresa Bender Pape, and Joel Scholten
PURPOSE: Participation restrictions among Veterans with traumatic brain injury (TBI) in outpatient rehab programs is routinely assessed in Veterans Health Administration (VHA) polytrauma clinics using the Mayo-Portland Adaptability Inventory Participation subscale (M2PI). Since most Veterans are males, their responses typically define overall group measures and potential differences in how women view participation can be obscured. The purpose of this study was to examine sex differences in self-reported participation restrictions among Veterans with TBI.
DESIGN: Retrospective analysis of data from the National TBI Veterans Health Registry. Veterans’ records were included in the sample if they had received care in a VA clinic, a confirmed history of TBI, and a complete self-reported M2PI record.
METHOD: The M2PI is an 8-item assessment of participation restriction. Perceived level of restriction for each item is rated on a 5-point Likert-type scale from 0 (no restriction) to 4 (severe restrictions) on initiation, social contact, leisure, self-care, residence management, transportation, employment, and financial management. Two quantitative analytic approaches were used to evaluate sex differences in participation restrictions by item: (1) multinomial logistic regression to calculate the relative risk ratio (RRR) for females compared to males using raw, ordinal data and (2) differential item functioning (DIF) analysis based on a Rasch partial credit model, in which raw scores have been transformed into equal-interval measures.
RESULTS: 6,065 Veterans were included in the study (94% male). Multinomial logistic regression showed that female Veterans but significantly more likely to be unemployed (RRR = 1.5) or working part-time (RRR = 2.1). Female Veterans also were significantly less likely to report needing extensive assistance or supervision for financial management (RRR = 0.40) or any level of restriction on residence management. In the Rasch partial credit model, the employment item misfit indicating this item is not a good indicator of participation restriction. Although the hierarchy of item difficulty was not different by sex, DIF analysis showed that female Veterans identified more restrictions with leisure and transportation items but significantly fewer restrictions for residence and financial management items.
CONCLUSION: Findings indicate that participation strengths and limitations are different for male and female Veterans with TBI. The two analytic approaches produced complementary results. Both MLR and Rasch models identified that women experience more restriction with leisure and less restriction with residence and financial management than men. Both models identified restrictions in employment; the Rasch model suggested that employment status for both men and women is affected by factors unrelated to participation restriction.
IMPACT STATEMENT: Caution is needed when interpreting M2PI total raw scores in Veteran populations with TBI. Occupational therapists should examine specific items on which clients report participation restrictions to develop treatment plans. Different intervention approaches may be needed for male and female Veterans with TBI to support full community participation.
References
Waid-Ebbs, J. K., Wen, P.-S., Graham, D. P., Leroux, A. J., O’Connor, M. K., & Helmer, D. A. (2019). Measurement properties of the MPAI-4 in veterans with mTBI. Archives of Physical Medicine and Rehabilitation. https://doi.org/10.1016/j.apmr.2019.10.191
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O’Rourke, J., Critchfield, E., Soble, J., Bain, K., Fullen, C., & Eapen, B. (2019). The utility of the Mayo-Portland Adaptability Inventory Participation Index (M2PI) in US military veterans with a history of mild traumatic brain injury. The Journal of Head Trauma Rehabilitation, 34(1), 30–35. https://doi.org/10.1097/HTR.0000000000000405
Malec, J. F., & Lezak, M. D. (2008). Manual for the Mayo-Portland Adaptability Inventory (MPAI-4) for Adults, Children and Adolescents. http://www.tbims.org/combi/mpai/manual.pdf
