Community Integration After Traumatic Brain Injury: Conceptualisation and Measurement
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Community integration remains the ultimate goal of rehabilitation for persons affected by Traumatic Brain Injury (TBI). A number of studies have presented different definitions of community integration over the past few decades, however a standardised conceptual model of community integration has not yet been articulated. Varying definitions and a lack of agreement regarding the theoretical underpinnings of the construct community integration, has presented problems for both the measurement of community integration and its use when implementing and evaluating rehabilitation interventions aimed at improving community integration outcomes. The key aims of this research were to gain a more in-depth understanding of the concept of community integration in order to develop a comprehensive conceptual framework of community integration and inform the development of a conceptually sound, robust, culturally relevant, and contemporary measure of community integration for people with TBI. The thesis includes a concept analysis to explore how community integration has been conceptualised in the healthcare literature pertaining to brain injury, followed by a measurement review to identify a widely used outcome measure of community integration, with acceptable psychometric properties. The empirical work used a mixed methods approach comprising of three studies which endeavoured to examine and enhance psychometric properties of the most prominent measure: the Community Integration Questionnaire (CIQ) and an updated version of the measure made available during the course of the research, known as the Community Integration Questionnaire-Revised (CIQ-R). The measure was evaluated using two quantitative studies. One study was based on a longitudinal TBI cohort and the other on cross-sectional TBI data, including 117 individuals with TBI for the CIQ-R that was collected specifically as a part of this doctoral research. These studies applied Classical Test Theory methods and Rasch analysis methods to examine psychometric properties of the CIQ and CIQ-R and enhance functioning of their items and precision of the scale. A qualitative study using a ‘concurrent nested approach’ was conducted with 12 people with TBI, to examine the content and appropriateness of the CIQ-R. Several findings from this research challenge and/or enhance existing knowledge on the conceptualisation and measurement of community integration. One of the key contributions was the development of a more comprehensive definition and conceptual framework of community integration. The proposed definition describes community integration as ‘being independent and having a sense of belonging within the community; having a place to live; being socially and psychologically integrated into the community; and involved in meaningful occupational activity’. The CIQ-R was found to be providing only limited coverage of the multi-dimensional construct, community integration. The quantitative work determined that the CIQ-R has sound psychometric properties while Rasch analysis identified some non-functioning items and provided a conversion algorithm to transform ordinal responses to interval-level data. The qualitative findings revealed that the content of the CIQ-R was mostly appropriate. However, the scale requires several amendments to enhance its relevance, comprehensiveness and interpretability for people with TBI. This research makes significant contributions to the field of community integration for people with TBI in terms of conceptual clarity and raises an overarching issue that self-report measures assessing constructs such as community integration, return to work, psychosocial reintegration may not always provide very useful information when measured objectively. The study also depicted the process of outcome measure selection in research or clinical settings and alluded to advanced methods that can be applied in future practice.