1. :: TBI and Resources in
Rural America
A Supplement to the “Quick Guide”
Census data in the last decade indicates that
over 60 million people, or approximately 21% of
Americans, live in rural areas.
Schopp, Johnstone,
and Reid-Arndt
(2005) People in rural areas have been found to be
more likely to have difficulty obtaining medical
and psychological resources than members of
urban societies. Over half of counties in the U.S.
do not have psychologists, social workers, or
psychiatrists and over 70% of shortages in
federal mental health services are found in
rural areas.
WHY IS THIS PRODUCT IMPORTANT (THE PROBLEM OF ABI IN
THIS POPULATION, CURRENT GAPS, AND THE PURPOSE OF THE
PRODUCT)?
As seen below, it is evident that rural areas experience deficits in
treatment resources, including those for TBI. The related product
sheds light on these concerns and offers ideas for change.
Practices within rural communities and urban-centered options
are proposed.

2. THE SCOPE OF THE PROBLEM
Traumatic brain injury (TBI) itself has 1.5 to 2
Johnstone, million sufferers a year, nationally. The cost for
Nossaman, Schopp,
TBI treatment ranges from $9 to $10 billion for
Holmquist, and
Rupright (2002) emergency and rehabilitative care, however,
persons with TBI in rural areas tend to have the
most difficulty a receiving such treatment.
Among Americans ages one to fifty-three,
accidental injury is a leading cause of death.
Typically, members of rural populations incur
an atypically high number of such fatal injuries.
As a rule of thumb, accident rates increase the
Coben, Tiesman, more rural (sparse) the area. For injuries that
Bossarte, and can result in TBI, rural areas attribute their
Furbee (2009)
fatal accidents to motor vehicle incidents, falls
and poisonings, unlike urban areas, whose high
accident rates align with assaults. Per capita,
hospital costs for accidental injuries are highest
for rural areas. The high rate of injury in these
regions has drawn attention to needed
prevention and intervention programs there.
Stallones, Gibbs-
In Colorado, for example, incidence of TBI is
Long, Gabella, and
Kakefuda (2008) higher in rural counties than in urban counties,
and, in Iowa, vehicular accidents and falls have
Schootman and a higher incident rate in rural counties.
Fuortes (1999)

3. Traumatic brain injuries that result in death
often occur in the workplace. Following
construction workers, employees in the
Tiesman, Konda, agriculture, forestry, and fishing industries are
and Bell (2011) most likely to incur fatal TBIs. A call for care
has been made for members of these groups,
likely to reside in rural areas, seeking
preventative measures on these work sites.
WHAT ARE THE COMMON SHORT AND
LONG TERM DIFFICULTIES THAT
THIS GROUP MAY EXPERIENCE?
Trauma care systems exist in the US for the
sake of transporting injured persons to the most
accessible facility providing services for a
Tiesman et al. designated injury. Unfortunately, greatest
(2007) accessibility is in urban areas. In rural areas,
travel is less efficient (longer, farther) between
patient retrieval and appropriate facilities.
Because immediate care of TBI contributes to a
more positive prognosis, speedy hospital arrival
is key. In the long-term, delays in urgent care
can contribute to patient death following TBI.
In rural areas, such as regions of Missouri,
where a third of the population lives outside of
metropolitan areas, a common obstacle to care
for TBI is a lack of resources. Necessary
practitioners for care, such as
Johnstone, neuropsychologists and rehabilitation
Nossaman, Schopp, psychologists with training in brain injury, are
Holmquist, and
Rupright (2002)

4. not accessible. Fewer rehabilitation sites,
psychologists, physiatrists, and support groups
are found in rural areas than in cities. Less
than a fifth of a state’s licensed practitioners
may be found in a rural region. Typically,
clients have to receive urgent care in an urban
setting then return to the city for ongoing
treatment, see a general practitioner in their
rural community or terminate care altogether.
As of a year to year-and-a-half following TBI,
survivors in rural areas are more likely to be
dependent on others and less advanced in
Schootman and recovery than those in urban areas. Reasons for
Fuortes (1999) this difference include cause of injury, care
immediately following injury, long-term/rehab
care, and community supports. Notably, quality
and quantity of care is notably different
between urban and rural populations.
Specifically, in Iowa, a structured trauma care
system is not available.
WHAT ARE RISK AND PROTECTIVE
FACTORS AFFECTING
REHABILITATION?
Low economic status impedes participation in
Schopp, Johnstone, urgent or long-term care following TBI. Twenty-
and Reid-Arndt five percent of rural employees earn less than
(2005) minimum wage and lives below the poverty line,
compared to sixteen percent of employees in
urban areas.

5. Limited access to intervention is a marked
barrier for proper recovery. Facilities and
trained practitioners are limited, notably for
financial reasons. Physicians and therapists are
Johnstone, not attracted to working in rural areas because
Nossaman, Schopp, they may spend up to 16% more time in the
Holmquist, and office and have 38% more patients than
Rupright (2002)
clinicians in urban areas and this does not
correlate with higher earnings, unfortunately.
Medical care is usually covered by Medicare or
Medicaid programs, which reimburse at a much
lower rate than private insurance companies.
Essentially, practitioners in rural areas work
harder than those in the city but earn less for it.
An advantage toward recovery is community
support. The traditionally close-knit
Johnstone, environment of rural areas corresponds with
Nossaman, Schopp, stronger emotional and psychological health
Holmquist, and following injury. As well, the slower pace in
Rupright (2002) those regions reduces risk of physiological or
mental stress on the patient, advancing
recovery.
WHAT ARE YOUR SUGGESTED RECOMMENDATIONS AND
RESOURCES AND WHY DID YOU SELECT THEM?
Mainly, the options available to patients in rural areas are located
in urban settings. This requires long-distance travel that can be
time-consuming and expensive, so patients have to turn to local,
less-skilled practitioners or not receive care. Community-based
programs for injury prevention and telehealth systems have been
shown to be useful for rural healthcare.

6. WHAT SYSTEMS ARE INVOLVED IN
THE CARE, REHABILITATION OF THIS
GROUP?
When available, urgent and long-term care
provided by specialty physicians,
nurses/physician assistants, occupational
therapists, physical therapists, speech-language
pathologists, neuropsychologists, rehabilitation
Johnstone, specialists, counselors, psychiatrists and social
Nossaman, Schopp, workers contributes to care of TBI patients. As
Holmquist, and well, community services, such as
Rupright (2002) transportation for the disabled, state disability
programs and TBI support groups, are useful
resources. Typically, care systems of this
magnitude are more common to urban areas, so
patient travel is required. Commonly, regular
care must be provided through a rural general
practitioner and community supports occur in a
less structured form, as the help of family and
neighbors.
WHAT ARE SOME APPROPRIATE
INTERVENTIONS/APPROACHES THAT
LEAD TO POSITIVE OUTCOMES?
Telehealth technology (telecommunication
within a health and rehabilitation system) has
been of focus, providing persons with TBI in
rural areas long-distance connections to care.
Evaluation interviews for rehabilitation
Schopp, Johnstone, recommendations can be performed in spite of
and Merrell (2000)
geographical obstacles, relieving obligations to

7. spend time and money on travel to regional
urban facilities. It has been indicated that
patients preferred long-distance contact from a
clinician for these reasons, and that this
technology also allows for communication with
needed psychologists and rehabilitation
programs funded by the state.
Telecommunication technology is also being
encouraged for training purposes, allowing
physicians local to rural areas with a suitable
Schopp, Johnstone,
background in diagnosing and treating TBI.
and Merveille
(2000) Such telehealth training programs have already
been implemented so members of rural
populations can receive appropriate care from
practitioners local to their areas.
Preventative measures against brain injury are
being undertaken within communities.
Stallones, Gibbs- Community-wide prevention programs promote
Long, Gabella, and regular health maintenance and safety
Kakefuda (2008)
guidelines to build resilience against injury. The
more support from the community, the more
effective these initiatives.
Improved statewide trauma care systems have
been installed to reduce post-injury deaths due
to sparseness of resources. For example, Iowa
instated a Trauma System Development Act in
1995 to enact a statewide trauma care system;
the program went into full effect in 2001. The

8. Tiesman et al.,
(2007) system included a hospital classification system
(Level 1/State or Level 2/Regional), provided
Advanced Trauma Life Support training and
determined a triage protocol. Level 1 and 2
hospitals were required to have coverage for
TBI, including neurosurgery. Tracking data
revealed that the Trauma System successfully
transported injured patients to Level I and II
hospitals as needed, resulting in a significant
decrease in risk of death within the first 72
hours following injury and in the long term.
Also, diagnostic accuracy and treatment
recommendations for TBI cases improved
significantly.
WHAT RESOURCES ARE AVAILABLE
FOR ADDITIONAL INFORMATION
AND/OR SUPPORT, SPECIFIC TO A
GEOGRAPHIC AREA?
Because support for community health and
safety initiatives can vary according to culture,
it is important to assess the readiness of a
community before implementing such programs.
It is possible that issues receiving widespread
attention at the federal or state level are not
considered important in the household because
local issues or perspectives take priority. This is
especially the case in rural counties. Colorado
State University developed a Community
Readiness Model and accompanying evaluation
system to lay the groundwork for community-
based programs. Through Community

9. Stallones, Gibbs-
Long, Gabella, and
Kakefuda (2008)
Readiness Interviews (semi-structured, open-
ended questionnaires), the model takes into
account individual attitudes toward readiness
(e.g. awareness of the problem at hand,
dedication to care within their households) and
community commitment (e.g. steps taken within
local healthcare systems, leadership
involvement). These assessments have proven to
provide more information about community
perspectives than typical statewide data
acquired through medical, insurance and
government databases and surveys. The
Community Readiness Model and Interviews
have been shown to help communities
implement change, including in the area of
injury prevention. Such a tool would be useful
for starting programs in communities
elsewhere. For more information,
http://triethniccenter.colostate.edu/communityR
eadiness_home.htm
The National Institute on Disability and
Rehabilitation Research has developed a model
for telehealth training programs. Trial runs of
the program have been implemented in the
Midwest to evaluate its efficacy in providing
treatment to rural residents with brain injuries.
Simply, the design involves two to three online
training sessions that last 1 to 2 hours. Lessons
are facilitated by a board-certified
neuropsychologist at an urban facility and a
general practitioner with experience treating

10. Schopp, Johnstone,
rural patients. In addition to medical
and Reid-Arndt interventions, the training highlighted family
(2005) involvement in patient care and TBI resources
at the state and community levels (e.g. state
TBI service coordinators, vocational
rehabilitation counselors, the state Brain Injury
Association, and TBI support groups). Ratings
following these trial runs indicated that trained
practitioners improved significantly between
pre- and post-tests on TBI. Also, patient surveys
were compared between those who had received
care from trainees and those who did not;
patients of trainees reported higher confidence
in their physicians and greater satisfaction and
guidance. Among these benefits, telehealth has
also been considered efficient, customizable,
convenient, as interactive as a classroom
setting, more engaging than self-education via
lectures or reading, requiring only limited
technological awareness, and less expensive
than a traditional training setting.
Residents of Iowa, Minnesota and Wisconsin
can refer to the National Institute for Disability
and Rehabilitation Research (NIDRR)/Midwest
Advocacy Project (MAP) website to participate
in advocacy research
http://mayoresearch.mayo.edu/mayo/research/tb
ims/midwest.cfm

11. Resources and contacts by state are available
through Brainline.org: preventing, treating and
living with traumatic brain injury (TBI)
http://www.brainline.org/resources/site_map.ph
p
News regarding research into using
telecommunication networks to facilitate
TBI treatment in rural areas is available
through the Mayo Clinic website
http://www.mayoclinic.org/news2012-
rst/7151.html
WHAT AUDIENCE WAS THIS PRODUCT DESIGNED FOR?
This product was designed for advocate organizations for TBI,
medical and psychological training programs, families and
patients. This information is beneficial not only for understanding
limitations in resources for TBI care but also to draw attention to
these deficits, for the sake of improvement. This information can
be taken to legislators to install regulations and supports such as
those in Iowa. Training programs can look into telehealth
education to generate more practitioners capable of assisting rural
patients.
WHY WAS THE FORMAT FOR THE PRODUCT CHOSEN?
The product was placed in a quick guide format to be easily
distributed within hospitals, from advocacy groups and for other
interested parties. It should be a quick and easy read, with not too
many words and just enough information to make readers aware of
the situation. Placing only key information that stands out should
pique interest, and if anyone wants more information, they can
refer to the webpage.

12. HOW WAS THE PRODUCT DEVELOPED?
Data related to the topic was compiled in full for the guide, then,
the most salient and interesting points were placed into the quick
guide for fast reading. A note is present at the bottom of the guide
referring readers to the website if they desire more information.
PRODUCT PREVIEW
The quick guide can be accessed at the following website:
http://www.slideshare.net/RuralTBIData/a-quick-guide-to-tbi-in-
rural-america-15321364. Simply go to the link and scroll down the
slideshow. The quick guide can also be downloaded and printed
through this setup.
LIMITATIONS TO USING THE PRODUCT
The only caution for readers is to acknowledge that the information
and research on rural populations does not account for all
situations and just provides an overall picture. As well, data for
individual states can suggest potential scenarios for similar regions
but does not actually indicate sameness between the areas.

13. REFERENCES
1. Coben, J. H., Tiesman, H. M., Bossarte, R. M., &
Furbee, P. M. (2009). Rural-urban differences in
injury hospitalizations in the U.S.,
2004.American Journal of Preventive
Medicine, 36(1), 49-55.
2. Johnstone, B., Nossaman, L. D., Schopp, L. H.,
Holmquist, L., & Rupright, S. J. (2002).
Distribution of services and supports for people
with traumatic brain injury in rural and urban
Missouri. The Journal of Rural Health, 18(1),
109-117.
3. Schootman, M., & Fuortes, L. (1999). Functional
status following traumatic brain injuries:
Population-based rural-urban differences. Brain
Injury: [BI], 13(12), 995-1004.
4. Schopp, L. H., Johnstone, B. J., & Merrell, D.
(2000). Telehealth and neuropsychological
assessment: New opportunities for
psychologists. Professional Psychology:
Research and Practice, 31, 179-183.
5. Schopp, L. H., Johnstone, B., & Merveille, O. C.
(2000). Multidimensional telehealth care
strategies for rural residents with brain injury.
Journal of Telemedicine and Telecare, 6 (Suppl.
l), 146–149.
6. Schopp, L. H., Johnstone, B., & Reid-Arndt, S.
(2005). Telehealth brain injury training for
rural behavioral health generalists: Supporting

14. and enhancing rural service delivery
networks. Professional Psychology: Research
and Practice, 36(2), 158-163.
7. Stallones, L., Gibbs-Long, J., Gabella, B., &
Kakefuda, I. (2008). Community readiness and
prevention of traumatic brain injury. Brain
Injury, 22(7-8), 555-564.
8. Tiesman, H. M., Konda, S., & Bell, J. L. (2011).
The epidemiology of fatal occupational
traumatic brain injury in the U.S. American
Journal of Preventive Medicine, 41(1), 61-67.
9. Tiesman, H., Young, T., Torner, J. C.,
McMahon, M., Peek-Asa, C., & Fiedler, J.
(2007). Effects of a rural trauma system on
traumatic brain injuries. Journal of
Neurotrauma, 24(7), 1189-1197.