Voting Characteristics of Individuals With Traumatic Brain Injury

• Date: 01 March 2019
• Published date: 01 March 2019
• DOI: http://doi.org/10.1002/wmh3.296

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

Introduction

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

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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,

1

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