Rates of violence-related injuries. While the national rate of deaths due to firearm injuries has been declining over the past decade (National Center for Injury Prevention and Control, 1999), violence remains a significant public health issue for the United States. The annual nonfatal firearm-related injury rate decreased 40%, from 40.5 per 100,000 in 1993 to 24.0 per 100,000 in 1997. Firearm incidents have remained among the leading causes of nonfatal, violence-related injuries (National Center for Injury Prevention and Control, 2002). There is also more recent evidence of decreasing firearm-related injuries in local jurisdictions such as the District of Columbia (Cheng, et al., 2001). Despite declines, the rate of 24 firearm related injuries per 100,000 is still significantly higher than the goal of 8.6 injuries that was formulated as a Healthy People 2010 objective (U.S. Department of Health & Human Services, 2000). Reports on declining rates and absolute numbers of violence-related mortality camouflage the fact that violence is still a significant factor in causing significant, permanent disability in the United States.

Gunshot wounds are currently the second leading cause of spinal cord injury (SCI) in the United States (McKinley, Johns & Musgrove, 1999), and historical trends indicate that the proportion of all SCI cases due to violence is increasing. Between 1973 and 1977, violence accounted for approximately 14 percent of all SCI. Between 1994 and 1998, this proportion had increased to nearly 22% of all SCI cases (Nobunaga, Go & Karunas, 1999).

Sociodemographic Disparities of VASCI. VASCI patients tend to be younger, are more likely to be male, and more likely to be unmarried and unemployed relative to persons with spinal cord injury due to other causes (McKinley, Johns & Musgrove, 1999). In a study on violent injuries among adolescents in the District of Columbia (Cheng et al., 2001) male subjects accounted for 61% of all injury events, and African American youth accounted for 86% of all violence-related emergency department visits. A recent study of the demographic profile of VASCI compared to other SCI patients showed that the former are predominantly African American (74.5% compared to 23.5%). VASCI survivors were also less likely to be married or employed, either before or after their injury (Farmer, Vaccaro, Balderston, Albert & Cotler, 1998).

Societal and Personal Costs of VASCI. Cost estimates indicate that first year medical charges associated with VASCI averaged $217,868 in 1995. The estimated annual aggregate direct costs of SCI in the United States due to violence, including emergency medical services, hospitalizations, attendant care, equipment, supplies, medications, environmental modifications, physician and outpatient services, nursing homes, household assistance, and vocational rehabilitation amounted to $1.81 billion in 1995 (DeVivo, 1997). Victims of violence are more likely to have unmet needs than persons injured in other ways because they are less likely to have insurance or funds available to pay for services (DeVivo, 1997). Separate studies found that more than 80% of all individuals injured by firearms in San Francisco and Los Angeles lacked health insurance (Martin, Hunt, & Hulley, 1988; Klein, et al., 1991). The cost of VASCI are tremendous in terms of lost productivity and personal independence among survivors and their families. The large cost figure for acute treatment of predominantly young VASCI survivors is likely overshadowed by the cost of caring for these individuals for the remainder of their lives. Many of these costs of interpersonal violence are likely to be passed on to tax payers and society at large (Song, Naude, Gilmore & Bongard, 1996).

VASCI Rehabilitation. The primary objective of spinal cord injury rehabilitation is to restore, enhance, and maintain individual-level physical functioning, personal independence, and to enhance the potential for attainment of personal goals. The rehabilitation process primarily works to achieve these objectives through interventions at the individual level – such as physical therapy and occupational therapy.

The goals of our larger study implicitly acknowledge that in order for VASCI rehabilitation outcomes to be optimized, knowledge of the social and environmental context of VASCI survivors must be incorporated into plans for rehabilitation and follow-up. Our research activities are implicitly guided by a “relational model” of disability. Below we outline three basic models for understanding disability, and describe the ways in which the relational model has guided our efforts to understand the VASCI experience.

BASIC CONCEPTUAL MODELS OF DISABILITY

Medical Rehabilitation Model. There are a number of basic models that have been used, either explicitly or implicitly, to understand disability. Traditionally in the United States, the dominant framework for understanding disability has been the rehabilitation paradigm (DeJong, 1979). In the rehabilitation paradigm, also known as the “medical model,” the “problem” of disability is seen as residing strictly in the individual. Medical rehabilitation’s principal objective, based on the medical or acute care model, is to restore individual functional ability and to minimize disability, mostly irrespective of environmental or social context factors.

Independent Living Paradigm. The independent living paradigm emerged as a response to the rehabilitation model from the community of individuals with disabilities (DeJong, 1979). In the independent living model, disability is not conceptualized as individual functional impairment, but as a product of the barriers to independence found in the social and built living and work environments . Proponents of this paradigm strive to remove these barriers in order to promote the greatest degree of personal independence for people with disabilities.

Relational Models of Disability. The rehabilitation and independent living models represent two rather extreme, simplified views of disability. One focuses on individual determinants, and the other focuses on social / environmental determinants of disability. There are a number of “relational models” of disability that focus on both individual and environmental determinants of disability (See Figure 1). One of the earliest relational models of disability was devised by sociologist Saad Nagi. Nagi (1965) believed that “disability is the expression of a physical or a mental limitation in a social context.” According to Nagi’s model and other relational views of disability, the same “physical or mental” limitation may produce different levels of disability in two different individuals, depending on their personal characteristics, and their physical and social living environment.

Nagi’s model has been further elaborated in a number of recent reports issued by the Institute of Medicine (IOM, 1991; IOM, 1997). Other relational models that are conceptually related to Nagi’s model of disability include the World Health Organization’s (WHO) “International Classification of Impairments, Disabilities and Handicaps (WHO, 1980), and the WHO’s International Classification of Functioning, Disability, and Health (WHO, 2001).

Figure 1. Relational Model of Disability (based on Nagi, 1965).

* Social and rehabilitation context is broadly defined and includes social-interactive variables, characteristics of the built environment, health care delivery, health and social policy and economic variables.

AN APPLICATION OF THE RELATIONAL MODEL OF DISABILITY

To describe and contextualize the physical, psychological and social consequences of VASCI, and to identify rehabilitative support and intervention needs of people with VASCI, we conducted two sets of interviews with 20 VASCI survivors who had been treated at the National Rehabilitation Hospital (NRH) between 1996 and 2002. Further, we interviewed 11 rehabilitation professionals of various disciplines who had many years of work experience in the area of spinal cord injury rehabilitation. The interview with rehabilitation professionals focused on the following content areas, which cover both the person level and social and rehabilitation context variables that may help determine levels of disability experienced by VASCI survivors:

q Specific medical and sociodemographic characteristics of the VASCI patient population compared with SCI survivors of other injury causes (person level).

q Similarities and differences in the rehabilitative approach for VASCI patients (social and rehabilitation context).

q Perceived strengths and weaknesses of the existing VASCI rehabilitation program (social and rehabilitation context).

The first interview with each VASCI survivor also included in-depth questions about both individual-level and contextual variables:

q Pre- and post-injury characteristics at the person level (age, race, educational level, employment status, use of alcohol or drugs)

q Pre-and post-injury social context of the VASCI survivor (social anr rehabilitation context)

q Physical, social, and psychological consequences of VASCI (relationship between person level and social and rehabilitation context variables).

The second survivor interview focused exclusively on the rehabilitation context that was available to the VASCI survivor. Specifically, we were interested in:

q General perceptions of and satisfaction with the rehabilitation program (social and rehabilitation context)

q Most and least beneficial components of the existing VASCI rehabilitation program at NRH (social and rehabilitation context).

ANALYSIS

All interviews were audio-recorded after having obtained written, informed consent from each study participant. Audiotapes were transcribed and anonymized, and subsequently imported into the qualitative software package NVivo (Richards, 1999) for analysis. Content coding and analysis was guided by the relational model of disability to include codes for person level as well as social and rehabilitation context variables.

RESULTS

Sample Description

VASCI Survivors. 19 of the 20 VASCI survivors that we interviewed were male. 19 survivors were African American, and one was of Hispanic origin. Survivors’ median age at the time of the interview was 25 (min 20; max 39 years), their median age at the time of their injury 19 years (min 15; max 32 years).

Rehabilitation Professionals. Nine of the 11 rehabilitation professionals we interviewed were women. They had worked with spinal cord injury patients between four and 14 years. The following rehabilitation disciplines were represented in this study: one physician, two rehabilitation nurses, two physical therapists, two occupational therapists, one rehabilitation counselor/discharge planner, one social worker/case manager, one psychologist, one vocational rehab counselor.

Principal Findings

Our findings, when viewed from within the relational model of disability, provide strong suggestions for enhancing VASCI rehabilitation programs. VASCI survivors and the clinicians who provide services to them agree that the rehabilitation program meets individuals’ physical rehabilitation needs at least as long as they are in the hospital. This finding suggests that rehabilitation programs for VASCI (and other potentially disabling conditions) operate squarely within DeJong’s “rehabilitation model” of disability – by focusing its efforts and resources almost exclusively on addressing the physical “source” of disability irrespective of the physical and social living environment of the VASCI survivor after discharge.

Rehabilitation Meets Primary Physical Rehabilitation Needs. Both VASCI survivors and rehabilitation professionals agree that most physical needs are sufficiently and efficiently addressed through the inpatient rehabilitation program. However, medical complications such as pressure sores and urinary tract infections, as well as other preventable but poorly managed complications are frequent after discharge. The following quote from a VASCI survivor, illustrates the complexity of the rehabilitation experience and the interdependence of physical and emotional factors on the one hand, and environmental context factors on the other.

“They prepare you physically for going out into the world. They prepare you physically, but they don’t prepare you mentally. I’m going out into the world thinking everything is still the same going back home, but the whole thing has changed”

Current programs and services are not structured and reimbursed in ways that allow them to sufficiently address contextual factors that play a strong role in determining the levels of disability that people ultimately experience.

Need For Additional Focus on Contextual Determinants of Disability. Our interview data indicate that VASCI survivors and clinicians agree that there are a number of social and environmental factors that exist outside of the rehabilitation setting that have the potential to increase levels of disability that are experienced after individuals leave the rehabilitation setting. These social / contextual factors include: (1) lack of health insurance at time of injury, and reliance on sometimes restrictive public health insurance programs following injury, (2) lack of reliable, accessible transportation in the community, (3) lack of safe and accessible housing in the community, (4) lack of a responsive vocational rehabilitation system to facilitate return to school or work, (5) unstable family and social support networks.

It is beyond the scope of the current paper to provide an in-depth discussion of each of the social context factors. A discussion of the substantive areas of education, employment, and vocational rehabilitation, though, can provide a strong illustration of the complex ways in which individual-level factors interact with social and environmental level factors to produce varying levels of disability among VASCI survivors.

Figure 2. An Illustration of the Relational Model: Meeting Vocational Goals.

Almost all of the VASCI survivors we interviewed expressed a desire to continue their education, and / or to obtain gainful employment in the community. Despite these near universal educational and vocational goals, we found in our interviews that the interaction of person level with social context factors seriously impede progress toward meeting these goals.

Person-level Determinants of Vocational Rehabilitation Outcomes. Many VASCI survivors we interviewed had relatively limited formal education. Many had not finished high school at the time of their injury. In addition, most of the VASCI survivors had little or no formal work history –either before or after their injury. Both of these findings are a function of the young age at which the injury occurred.

Social and Rehabilitation Context Determinants of Vocational Rehabilitation Outcomes.

Our interviews with VASCI survivors and rehabilitation clinicians also uncovered a number of social context and rehabilitation context factors that impede VASCI survivors’ ability to achieve educational and vocational goals. One of the primary rehabilitation context factors refers to the under-funded and understaffed vocational rehabilitation programs at rehabilitation hospitals. A vocational rehabilitation counselor that we interviewed described the fact that vocational rehabilitation services are not generally covered by private or public health plans. As a result, rehabilitation programs are not able to provide extensive vocational rehabilitation services to VASCI survivors, who mostly have more extensive vocational suport needs than other patient populations seen at the hospital:

“The VASCI Group is going to need to have a lot more vocational rehab because they don’t have degrees, or if they do, it’s rare.”

A VASCI survivor described hospital-based vocational rehabilitation programs in the same terms:

“They need a team of people to do that…… You need people to really help….. not just come in and talk to you about it…... That branch of the department needs to be broadened…… They need foot-workers and social workers that will get out there and do that, helping people get started at least.”

Once VASCI survivors leave the rehabilitation hospital, vocational rehabilitation support at the state level does not appear to be any more responsive to the needs of VASCI survivors. States have federally-mandated vocational rehabilitation (VR) programs to assist people with disabilities as they seek employment and education. According to the hospital-based vocational rehabilitation counselor we interviewed, the state-level VR programs in the Washington DC area are overburdened and provide insufficient response to the queries of VASCI survivors:

“Eventually they can go to the state’s Department of Vocational Rehab Services, where they will be one of 150 or 200 people on someone’s caseload.”

In addition to under-staffed and under-funded vocational rehabilitation programs at the hospital and state levels, there is an additional barrier at Federal and state policy levels that restrict vocational achievement among VASCI survivors. Because many VASCI survivors lack health insurance at the time of their injury, they must go through the steps of applying and qualifying for health care coverage through the Medicaid and / or Medicare programs.

To qualify for Medicare health coverage – which is primarily for people aged 65 and over and for people with disabilities, a working-age person must demonstrate that they have a significant disability that precludes them from active participation in the workplace. To qualify for Medicaid health coverage – which is primarily for working-age people who are poor and / or people with disabilities, a person must have very low levels of income and assets. People with health care coverage through Medicare or Medicaid face a very real risk of losing access to health care services and nominal income supplements if they achieve their vocational goals by obtaining employment – either because they demonstrate that they are not too disabled to work, or because they surpass income restrictions. In either case, the risk of losing access to health care usually supercedes the potential benefit of finding entry-level employment.

The vocational rehabilitation counselor that we interviewed had the following to say about policy-level work disincentives faced by VASCI survivors:

“……you get it (health care and income benefits) because you can’t go to work of any kind, and then they’re being asked to consider going to work. They’ve just been through the process of being asked all of these questions and having to substantiate a physical disability that impairs their ability for substantial gainful activity, and as soon as they get through that, someone says, ‘well, what about finding a job.’ They are, as most people would be, resentful of that. How would I be able to find a job if I’m living in a nursing home? How do I find a job and not lose my Medicare benefits, which are keeping me in the nursing home, which are keeping me off the street?”

This work disincentive inherent in Medicaid and Medicare eligibility requirements is problematic for all people with disabilities who have coverage for the wide variety of health and long term care that they need through public programs. The disincentive is especially acute for VASCI survivors who are often beginning careers in entry-level positions that do not include health care coverage or benefits of any kind.

In sum, VASCI survivors’ levels of long-term disability and vocational rehabilitation outcomes are determined by individual characteristics such as low educational levels and inconsistent work history, in combination with under-funded vocational rehabilitation programs and counterproductive eligibility requirements for Medicaid and Medicare health care coverage. The relational model of disability provides a framework for the study of person and social context factors that are crucial for the understanding of rehabilitation outcomes.

CONCLUSION

Among the greatest challenges for VASCI survivors upon discharge from inpatient rehabilitation are the lack of insurance coverage, and the absence of effective vocational rehabilitation opportunities. The relational model of understanding disability and rehabilitation outcomes suggests that consumers of rehabilitation have a great deal to gain if rehabilitation programs would be shaped in response to person level and social context factors. It is in society’s interest to improve continued, comprehensive access to long term rehabilitation services for people with VASCI in order to prevent costly secondary medical complications, and to assist VASCI survivors with their reintegration into society, education, and employment. Community outreach and support programs need to be improved to establish a link between acute rehabilitative care services and outpatient needs.

At the environmental level, we need to improve insurance coverage for needed health care services in order to facilitate speedy community reentry for VASCI survivors. We also need to strengthen the links between hospital based and community based vocational rehabilitation services. Better coverage for vocational rehabilitation counseling as part of inpatient rehabilitation and state levels is necessary.

REFERENCES:

Cheng, T. L., Wright, J. L., Fields, C. B., Brenner, R. A., O'Donnell, R., Schwarz, D., & Scheidt, P. C. (2001). Violent Injuries Among Adolescents: Declining Morbidity and Mortality in an Urban Population. Annals of Emergency Medicine, 37(3), 292-300.

DeJong, G. (1979). Independent living: From social movement to analytic paradigm. Archives of Physical Medicine and Rehabilitation. 60: 435-446.

DeVivo, M. J. (1997). Causes and costs of spinal cord injury in the United States. Spinal Cord, 35, 809-813.

Farmer, J. C., Vaccaro, A. R., Balderston, R. A., Albert, T. J., & Cotler, J. (1998). The Changing Nature of Admissions to a Spinal Cord Injury Center: Violence on the Rise. Journal of Spinal Disorders, 11(5), 400-403.

Institute of Medicine (1991). Disability in America: Toward a National Agenda for Prevention. Pope, A., Tarlov, A., (Eds). Washington, DC: National Academy Press

Institute of Medicine (1997). Enabling America : Assessing the Role of Rehabilitation Science and Engineering. Brandt, E., Pope, A. (Eds). Washington, DC: National Academy Press.

Klein, S., Kanno, I., Gilmore, D. & Wilson, S. (1991). The socioeconomic impact of assault injuries on an urban trauma center. American Surgeon, 57(12), 793-797.

Martin, M., Hunt, T., & Hulley, S. (1988). The Cost of Hospitalization for Firearm Injuries. Journal of the American Medical Association, 260(20), 3048-3050.

McKinley, W. O., Johns, J. S., & Musgrove, J. J. (1999). Clincal Presentations, Medical Complications, And Functional Outcomes of individuals with Gunshot Wound-Induced Spinal Cord Injury. American Journal of Physical Medicine and Rehabilitation, 78(2), 102-107.

Nagi S.Z. (1965). Some conceptual issues in disability and rehabilitation. In: Sociology and Rehabilitation (Edited by Sussman M.B.), p. 100-113. Washington, DC: American Sociological Association.

National Center for Injury Prevention and Control (1999). Nonfatal and Fatal Firearm-Related Injuries -- United States, 1993-1997. Morbidity and Mortality Weekly Report, 48(45);1029-1034.

National Center for Injury Prevention and Control (2002). Leading Causes of Nonfatal Violence-Related Injury, United States 2001. Retrieved February, 26 2003, from http://webapp.cdc.gov/sasweb/ncipc/nfirates.html

Nobunaga, A. I., Go, B. K., & Karunas, R. B. (1999). Recent Demographic and Injury Trends in People Served by the Model Spinal Cord Injury Care Systems. Archives in Physical Medicine and Rehabilitation, 80, 1372-1382.

Richards L. (1999). Using NVivo in Qualitative Research. Buundora, Australia: QSR Pty Lmt.

Song, D. H., Naude, G. P., Gilmore, D. A., & Bongard, F. (1996). Gang Warfare: The Medical Repercussions. The Journal of Trauma: Injury, Infection, and Critical Care, 40(5), 810-815.

U.S. Department of Health and Human Services. Healthy People 2010. 2nd ed. With Understanding and Improving Health and Objectives for Improving Health. 2 vols. Washington, DC: U.S. Government Printing Office, November 2000.

Waters, R. L., Adkins, R. H., Sie, I., & Cressy, J. (1998). Postrehabilitation Outcomes After Spinal Cord Injury Caused by Firearms and Motor Vehicle Crash Among Ethnically Diverse Groups. Archives of Physical Medicine and Rehabilitation, 79, 1237-1243.

Waters, R. L., Sie, I. H., Adkins, R. H. & Yakura, J.S. (1999). The neuropathology of violence-induced spinal cord injury. Topics in Spinal Cord Injury Rehabilitation, 4(3), 23-28.

World Health Organization (1980). International Classification of Impairments, Disabilities, and Handicaps : a Manual of Classification Relating to the Consequences of Disease. Geneva: World Health Organization

World Health Organization (2001). International Classification of Functioning, Disability, and Health. Geneva: World Health Organization.

Acknowledgement

The study is funded by the Agency for Healthcare Research and Quality (AHRQ Grant # R03 HS13039-01).