Voting Characteristics of Individuals With Traumatic Brain Injury

AuthorJason H. Karlawish,Mark A. Hirsch,Flora M. Hammond,Martha E. Kropf,Andrew M. Ball,Lisa Schur
Date01 March 2019
Published date01 March 2019
Voting Characteristics of Individuals With Traumatic
Brain Injury
Mark A. Hirsch , Martha E. Kropf, Flora M. Hammond, Lisa Schur,
Jason H. Karlawish, and Andrew M. Ball
Voting is the foundation of democracy. Limited data exist about voting characteristics of individuals
with neurologic impairment including those living with a traumatic brain injury (TBI). To
statistically examine voting characteristics using a convenience sample of registered voters with TBI
during elections held in Mecklenburg County, North Carolina—2007, 2008. Data were collected on
51 participants with TBI during May 2007, 2008 general, and 2008 Presidential Election. (i) There
was a signif‌icant difference between the Competence Assessment Tool for Voting (CAT-V) total
score of participants with TBI who voted and the CAT-V total score of participants with TBI who
did not vote and the CAT-V total score predicted voting; (ii) the age of the participants with TBI
was predictive of voting; and (iii) being married was inversely related to voting. We f‌ind that there
is variation in voting even among this small sample interviewed for the present study, and that the
variation is predictable. Those with the highest CAT-Vs are most likely to vote. In addition, we f‌ind
that traditional predictors of voting simply are not predictors among this TBI group, and even one,
whether the person is married, has a negative effect on voting.
KEY WORDS: traumatic brain injury, political participation, voting
Voting is a fundamental aspect of any democracy and one of the most basic
forms of political participation. Although it is known that relative to other chronic
health conditions, neurodegenerative brain diseases have among the strongest of
negative association with voter turnout (Sund, Lahtinen, Wass, Mattila, &
Martikainen, 2017), only four studies that we know of have examined voting
among individuals with cognitive impairment, and no data exist concerning the
voting characteristics of individuals with traumatic brain injury (TBI). Research
suggests that those with self-reported “cognitive impairments” were less likely to
vote in recent elections (2008 and 2010) than those without disabilities (Schur &
Adya, 2012; Schur, Adya, & Kruse, 2013). The Schur et al. study (2013) analyzed
the Census Bureau’s Current Population Survey, where “cognitive impairments”
World Medical & Health Policy, Vol. 11, No. 1, 2019
doi: 10.1002/wmh3.296
#2019 Policy Studies Organization
was operationalized with the question, “Because of a physical, mental, or
emotional condition, does anyone have serious diff‌iculty concentrating, remem-
bering, or making decisions?” Schur et al. (2013) give us a broad picture of the
voting life of people with cognitive impairments, and Sund et al. (2017) conclude
that individuals with neurodegenerative conditions are among the least likely to
vote, when compared with individuals with any other chronic health conditions.
Scholars are in the initial phases of def‌ining voter participation characteristics
within each neurodegenerative condition subgroup such as people living with
Alzheimer’s disease/cognitive impairment (Appelbaum, Bonnie, & Karlawish,
2005; De Cauwer, 2005; Karlawish, 2008; Karlawish, Casarett, James, Propert, &
Asch, 2002; Karlawish et al., 2008), mental illness/schizophrenia (Agran,
MacLean, & Kitchen, 2016; Doron, Kurs, Stolovy, Secker-Einbinder, & Raba, 2014;
Lawn, McMillan, Comley, Smith, & Brayley, 2014; Melamed et al., 2007; Raad,
Karlawish, & Appelbaum, 2009; Rees & Reed, 2016; Yates, 2016), and stroke
(Hammel, Jones, Gossett, & Morgan, 2006); but information on the voting
participation characteristics of other neurodegenerative condition subgroups such
as epilepsy, Huntington disease, Parkinson’s disease, amyotrophic lateral sclero-
sis, and (the focus of the current study) TBI, remains less robust. While the
chances of a race being decided by tossing a coin is very small,
federal, state,
and local elections are often decided by narrow margins (Hayes, 2017; Mulligan
& Hunter, 2003; Teixiera, 2001). Additional justif‌ication for this particular paper
lies in the theory of inclusive democracy (Young, 2002) and political equality:
who votes matters in terms of who gets elected and which group become
represented in the decision-making processes. This, ultimately, makes a difference
in terms of whose preferences are accommodated in outputs of legislation. Thus,
understanding who votes and who does not is increasingly important, but
especially in populations experiencing disenfranchisement—either legally im-
posed or self-imposed. Thus, the research question we consider herein is: “how
do voters with TBI differ from individuals with TBI who do not vote?”
Voting Among Those With Cognitive Decline
Scholarship on disenfranchisement among U.S. citizens with neurological and
neurodegenerative conditions is both sparse and narrowly focused. Empirical
research on voting among the neurological/neurodegenerative subgroup of
dementia has focused primarily upon the elderly and progressive dementia
disorders such as Alzheimer’s disease. Work by Appelbaum (2000) has examined
cognitive capacity to vote in this population, and Karlawish et al. (2002) show
that those mildly affected by dementia can and did independently cast a vote in
the 2000 election. More recent work by Karlawish et al. (2008) shows that long-
term care facility staff assessed the capacity to vote of patients across facilities in
different ways (independent of government authorization or direction, and
without any standardized assessment tool), and used those informal observa-
tional assessments in deciding whether to assist residents in registering and
voting. Such a nonstandardized process could be subject to raising the threshold
Hirsch et al.: Voting With TBI 25

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