Advertisement

Qualitative Examination of Voting Empowerment and Participation Among People Living With Traumatic Brain Injury

  • Author Footnotes
    ∗ Hammond, Davis, and Hirsch contributed equally to this work.
    Flora M. Hammond
    Correspondence
    Corresponding author Flora M. Hammond, MD, Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine, Rehabilitation Hospital of Indiana, 4141 Shore Dr, Indianapolis, IN 46254.
    Footnotes
    ∗ Hammond, Davis, and Hirsch contributed equally to this work.
    Affiliations
    Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine, Indianapolis, Indiana

    Rehabilitation Hospital of Indiana, Indianapolis, Indiana

    Department of Physical Medicine and Rehabilitation, Carolinas Rehabilitation, Atrium Health, Charlotte, North Carolina
    Search for articles by this author
  • Author Footnotes
    ∗ Hammond, Davis, and Hirsch contributed equally to this work.
    Christine S. Davis
    Footnotes
    ∗ Hammond, Davis, and Hirsch contributed equally to this work.
    Affiliations
    Department of Physical Medicine and Rehabilitation, Carolinas Rehabilitation, Atrium Health, Charlotte, North Carolina

    Department of Communication Studies, University of North Carolina at Charlotte, Charlotte, North Carolina
    Search for articles by this author
  • Author Footnotes
    ∗ Hammond, Davis, and Hirsch contributed equally to this work.
    Mark A. Hirsch
    Footnotes
    ∗ Hammond, Davis, and Hirsch contributed equally to this work.
    Affiliations
    Department of Physical Medicine and Rehabilitation, Carolinas Rehabilitation, Atrium Health, Charlotte, North Carolina
    Search for articles by this author
  • Julia M. Snow
    Affiliations
    Department of Communication Studies, University of North Carolina at Charlotte, Charlotte, North Carolina
    Search for articles by this author
  • Martha E. Kropf
    Affiliations
    Department of Political Science & Public Administration, University of North Carolina at Charlotte, Charlotte, North Carolina
    Search for articles by this author
  • Lisa Schur
    Affiliations
    Rutgers University, School of Management and Labor Relations, New Brunswick, New Jersey
    Search for articles by this author
  • Douglas Kruse
    Affiliations
    Rutgers University, School of Management and Labor Relations, New Brunswick, New Jersey
    Search for articles by this author
  • Andrew M. Ball
    Affiliations
    Department of Physical Medicine and Rehabilitation, Carolinas Rehabilitation, Atrium Health, Charlotte, North Carolina

    NxtGen Institute, Atlanta, Georgia

    Myopain Seminars, Bethesda, Maryland
    Search for articles by this author
  • Author Footnotes
    ∗ Hammond, Davis, and Hirsch contributed equally to this work.
Published:January 22, 2021DOI:https://doi.org/10.1016/j.apmr.2020.12.016

      Abstract

      Objective

      To examine political participation after traumatic brain injury (TBI).

      Design

      Qualitative, participatory research via interviews and observations. Each participant was interviewed to discuss their experience of voting in 2007 or 2008. Data were coded using Grounded Theory to develop themes, metacodes, and theories.

      Setting

      Community.

      Participants

      A total of 57 individuals with history of TBI and 28 family members (N=85).

      Main Outcome Measures

      Not applicable.

      Results

      Four themes emerged from the data: (1) people with TBI have barriers to voting; (2) the voting process can be improved for people with TBI; (3) voting is the responsibility of members of society; and (4) voting is one way we have a voice in society.

      Conclusions

      The data support the importance of voting as an American right regardless of the presence of disability. While persons with TBI report voting represents their freedom and voice, there may be barriers that can threaten or limit their voice.

      Keywords

      List of abbreviations:

      MMSE (Mini-Mental State Examination), PR (participatory research), TBI (traumatic brain injury), US (United States)
      Voting is the most basic means of political expression in a democratic society. For individuals with disabilities, voting is even more vital because their “life, liberty, and pursuit of happiness” may depend on laws, statues, and public services enacted and managed by elected officials that their nondisabled counterparts take for granted. Yet, data indicate people living with disability vote less often than those without.
      • Schur L.A.
      • Kruse D.L.
      What determines voter turnout?: Lessons from citizens with disabilities.
      ,
      • Schur L.
      • Kruse D.
      Fact sheet: disability and voter turnout in the 2018 elections.
      Many efforts have been implemented to improve voter participation among individuals with disability.
      AAPD. REV UP: Register, Educate, Vote, Use your Power campaign.
      After several years of decline, the 2018 United States (US) midterm election experienced an increase in disability voter turnout by 8.5 percentage points compared with 2014.
      • Schur L.
      • Kruse D.
      Fact sheet: disability and voter turnout in the 2018 elections.
      Despite this increase, there remains a 4.7-point turnout gap between those with and without disabilities, representing 2.35 million more votes by people with disabilities if voting rates were equal.
      • Schur L.
      • Kruse D.
      Fact sheet: disability and voter turnout in the 2018 elections.
      A variety of barriers may contribute to lower disability turnout,
      • Schur L.
      • Ameri M.
      • Adva M.
      Disability, voter turnout, and polling place accessibility.
      including transportation access, voter identification laws, long lines, inaccessible polling places, voting machines, or the ballot. In 2016, the General Accounting Office found that 60% of polling places reviewed have at least 1 impediment to voters with disabilities.
      US Government Accountability Office
      Voters with disabilities: observations on polling place accessibility and related federal guidance.
      The disability turnout gap in US elections is especially striking among people with cognitive impairments. Voter turnout among those with cognitive impairment was 43.5% in 2016 compared with 62.2% among people without disabilities (−18.7 points).
      • Schur L.
      • Kruse D.
      Fact sheet: disability and voter turnout in the 2018 elections.
      ,
      • Schur L.
      • Ameri M.
      • Adva M.
      Disability, voter turnout, and polling place accessibility.
      The voting rates were lower for both groups in the 2018 midterm elections (37.1% and 54.0%, respectively), but the disability gap was similar (−16.9 points).
      Although researchers have studied voting among individuals with disability at large, scholars still know little regarding the experience, thoughts, and feelings of voting and political participation from the perspective of individuals living with traumatic brain injury (TBI). A conservative estimate is that 3.2 million Americans (1.1% of the US population) are living with disability attributable to TBI.
      • Zaloshnja E.
      • Miller T.
      • Langlois J.A.
      • Selassie A.W.
      Prevalence of long-term disability, from traumatic brain injury in the civilian population of the United States, 2005.
      ,
      • Zgaljardic D.J.
      • Seale G.S.
      • Schaefer L.A.
      • Temple R.O.
      • Foreman J.
      • Elliott T.R.
      Psychiatric disease and post-acute traumatic brain injury.
      TBI may result in a range of impairments in physical, sensation, perception, communication, cognitive, emotional, and behavioral function that may complicate participation in the voting processes in both overt and subtle ways. TBI typically results in difficulty with memory, planning, initiation, cognitive flexibility, and decision making,
      • Rabinowitz A.R.
      • Levin H.S.
      Cognitive sequelae of traumatic brain injury.
      which may create challenges in complex activities such as voting. TBI may cause impaired hearing and vision and may limit one’s access to transportation. Aspects of voting may pose accessibility challenges, including navigating physically, ballot design (legibility, consistency, organization and presentation of information), and the technologies used for voting.
      Yet, little is known about the experience of and obstacles to voting participation after TBI.
      In a convenience sample of 51 registered voters with TBI (a subset of the current study), Hirsch et al
      • Hirsch M.A.
      • Kropf M.E.
      • Hammond F.M.
      • Schur L.
      • Karlawish J.H.
      Voting characteristics of individuals with traumatic brain injury.
      found statistically significant differences in voting “competence” of participants with TBI who voted and participants with TBI who did not vote in the 2007 and 2008 elections held in Mecklenburg County, North Carolina. Voting among individuals with TBI was predicted by higher Competency Assessment Tool for Voting total score and older age, while being married was inversely related to voting. Traditional predictors of voting in the general population (education, being married, not living alone, Presidential election) were not predictors among this group with TBI. The authors suggested individuals with TBI may value voting, but a partner may discourage a person with TBI from voting. In terms of education, with TBI, competence to vote may be more important to the decision to vote than having formal education. Qualitative data will shed additional light on these questions.
      Ethical, legal, and societal considerations exist regarding voting by persons with cognitive impairment due to dementia or other cognitive impairment conditions.
      • Karlawish J.A.
      • Bonnie R.J.
      • Applebaum P.S.
      • et al.
      Addressing the ethical, legal, and social issues raised by voting by persons with dementia.
      • Sabato C.P.
      • Spurgeon E.D.
      Facilitating voting as people age: implications of cognitive impairment.
      • Schields T.
      • Schriner K.F.
      • Schriner K.
      The disability voice in American politics: political participation of people with disabilities in the 1994 election.
      Comparing 14 individuals with TBI to 22 noninjured college students, Link et al
      • Link J.N.
      • Kropf M.
      • Hirsch M.A.
      • et al.
      Political knowledge: comparing individuals with traumatic brain injuries and “average” college students.
      found voting competence (measured by the Competency Assessment Tool for Voting) and political knowledge (election-specific knowledge and correct responses on United States Citizen and Immigration Services citizenship examination questions) to be similar across groups.
      A view into the experiences of voting among people living with TBI will help identify barriers and facilitators of voting and inform the development of strategies to optimize participation. The present study uses qualitative and participatory research (PR) methods to study the experience of voting among persons living with TBI through semistructured interviews and qualitative observation at polling places. The study objectives are to (1) discover and delineate how persons with TBI and other stakeholders experience political participation and (2) assess possible voting disenfranchisement.

      Methods

      Choice for analytical method

      Qualitative research methods with a PR approach was deemed the most appropriate design for this early stage research into political participation after TBI. Qualitative research methods are advantageous
      • Davis C.S.
      • Gallardo H.P.
      • Lachlan K.
      Straight talk about communication research methods.
      • Lindlof T.R.
      • Taylor B.C.
      Qualitative communication research methods.
      • Patton M.Q.
      Qualitative research and evaluation methods.
      for researching sensitive or taboo subjects or for obtaining detailed descriptions of incompletely understood and complex problems (such as political empowerment and voting).
      • Yamazaki H.
      • Slingsby B.T.
      • Takahashi M.
      • Hayashi Y.
      • Sugimori H.
      • Nakayama T.
      Characteristics of qualitative studies in influential journals of general medicine: a critical review.
      Findings from qualitative research assist with theory development and hypothesis generation and testing. PR engages the people studied (people with TBI) and their advocates as collaborators in all aspects of the research.
      • Reason P.
      • Bradbury H.
      Handbook of action research: participatory inquiry and practice.
      Many scholars use PR designs in applied disability and rehabilitation science,
      • Gordon W.A.
      • Brown M.
      Building research capacity: the role of partnerships.
      • Jagosh J.
      • Macaulay A.C.
      • Pluye P.
      • et al.
      Uncovering the benefits of participatory research: implications of a realist review for health research and practice.
      • Gaventa J.
      • Barrett G.
      So what difference does it make? Mapping the outcomes of citizen engagement.
      opening a view into the lives of individuals affected by the issue studied.
      • Ehde D.M.
      • Wegener S.T.
      • Williams R.M.
      • et al.
      Developing, testing, and sustaining rehabilitation interventions via participatory action research.
      ,
      • McIntyre A.
      Participatory action research.

      Participatory research approach

      After PR principles,
      • Heron J.
      • Reason P.
      The practice of co-operative inquiry: research ‘with’ rather than ‘on’ people.
      stakeholders significantly participated in (1) determining study focus and which questions to ask; (2) analyzing data; and (3) confirming validity through member check. The research team included a community-based PR advisory council composed of a variety of relevant stakeholders—5 university researchers, 8 medical researchers and health care providers, 4 community members, 2 people with TBI, and 2 close relatives of people with TBI. The initial research team consisted of 2 university researchers, 2 medical researchers, and 2 family members of people with TBI.

      Participants

      The research team identified potential study participants through a registry of individuals who previously received inpatient rehabilitation for TBI. Eligibility criteria for this registry include the following: age at least 16 years at time of injury; moderate-severe TBI (defined as posttraumatic amnesia >24 hours, trauma-related intracranial neuroimaging abnormalities, loss of consciousness >30 minutes, or Glasgow Coma Scale score in the emergency department <13); and received acute care hospitalization within 72 hours followed by inpatient rehabilitation. At the time of the study, this registry held 782 names. After institutional review board approval, we conducted telephone screening of 129 persons with TBI (consecutively selected when due for their follow-up interview). For the participants with TBI, the inclusion criteria for the present study consisted of the following: US citizen, 18 years or older, TBI ≥6 months prior to election day, registered to vote, and voted at least once in the previous 3 elections; and for family members: US citizen, 18 years or older, and in an interacting relationship with the survivor of TBI.

      Setting and procedure

      The study took place in Charlotte, North Carolina. Through a participatory process with a community-based PR advisory council, the research team developed a qualitative interview targeted to learn about experiences with voting in Mecklenburg County, Charlotte, North Carolina after the May 2007, November 2007, and the 2008 presidential elections. Trained research assistants administered the interview (appendix 1) and Mini-Mental State Examination (MMSE).
      • Folstein M.F.
      • Folstein S.E.
      • McHugh P.R.
      Mini-mental state". A practical method for grading the cognitive state of patients for the clinician.
      Research assistants accompanied a subset (n=21) of participants to the polls and took detailed field notes of their experience.

      Data analysis

      Interview audio recordings and field notes were transcribed and then coded using HyperRESEARCH softwarea in a grounded theory process.
      • Glaser B.
      • Strauss A.
      The discovery of grounded theory.
      ,
      • Strauss A.
      • Corbin J.
      Basics of qualitative research: grounded theory procedures and techniques.
      Raw data were categorized into themes using an inductive method in which we observed patterns in the data and took into account the relationships between the data and the categories through a constant comparison process. The codes and categories were mutable until late in the analysis. After an initial open coding step, followed by a selective coding step, our next step was to integrate our coding categories to determine conceptual relationships between and among various categories. To ensure the process met the criteria of confirmability and credibility, data coding followed the following procedures: (1) each researcher coded independently; (2) pairs of university and medical researchers discussed and resolved discrepancies; (3) the researcher group as a whole reviewed the emergent themes to combine and collapse the codes into hierarchical categories, or metacodes. Emergent theories, or explanations, began to emerge. Credibility was determined by data triangulation
      • Godwin E.
      • Chappell B.
      • Kreutzer J.
      Relationships after TBI: a grounded research study.
      ,
      • Gan C.
      • Gargaro J.
      • Brandys C.
      • Gerber G.
      • Boschen K.
      Family caregivers’ support needs after brain injury: a synthesis of perspectives from caregivers, programs, and researchers.
      through documentation of similar accounts by multiple people and a member check with the community-based PR advisory council for feedback on the results and interpretation.

      Results

      Sample

      From the 129 people with TBI contacted for telephone screening, 57 persons with TBI, 21 family members, and 7 informants of those with TBI participated in the research. Reasons people with TBI did not participate included not interested,
      • Gordon W.A.
      • Brown M.
      Building research capacity: the role of partnerships.
      no perceived deficits from TBI,
      • Karlawish J.A.
      • Bonnie R.J.
      • Applebaum P.S.
      • et al.
      Addressing the ethical, legal, and social issues raised by voting by persons with dementia.
      too low functioning,
      resides in nursing home and not interested,
      • Rabinowitz A.R.
      • Levin H.S.
      Cognitive sequelae of traumatic brain injury.
      too busy,
      • Zgaljardic D.J.
      • Seale G.S.
      • Schaefer L.A.
      • Temple R.O.
      • Foreman J.
      • Elliott T.R.
      Psychiatric disease and post-acute traumatic brain injury.
      lives too far away,
      • Zaloshnja E.
      • Miller T.
      • Langlois J.A.
      • Selassie A.W.
      Prevalence of long-term disability, from traumatic brain injury in the civilian population of the United States, 2005.
      no transportation,
      • Zaloshnja E.
      • Miller T.
      • Langlois J.A.
      • Selassie A.W.
      Prevalence of long-term disability, from traumatic brain injury in the civilian population of the United States, 2005.
      incarcerated,
      • Schur L.
      • Kruse D.
      Fact sheet: disability and voter turnout in the 2018 elections.
      felon,
      • Schur L.
      • Kruse D.
      Fact sheet: disability and voter turnout in the 2018 elections.
      and religious reason.
      • Schur L.A.
      • Kruse D.L.
      What determines voter turnout?: Lessons from citizens with disabilities.
      The 21 family members were related to the participant with TBI: parent,
      • Schields T.
      • Schriner K.F.
      • Schriner K.
      The disability voice in American politics: political participation of people with disabilities in the 1994 election.
      spouse,
      • Zgaljardic D.J.
      • Seale G.S.
      • Schaefer L.A.
      • Temple R.O.
      • Foreman J.
      • Elliott T.R.
      Psychiatric disease and post-acute traumatic brain injury.
      and sibling.
      • Schur L.A.
      • Kruse D.L.
      What determines voter turnout?: Lessons from citizens with disabilities.
      The 7 informants were 2 local poll workers and 5 employees at a local residential day care program for people with TBI, for a total of 85 participants enrolled. Of the 85 enrolled, 3 persons with TBI and 3 family members provided demographic and voting participation data but did not provide an interview (resulting in interviews with 54 persons with TBI, 21 family members, and 7 informants for a total 82 interviews). Characteristics of the participants are summarized in table 1. Only 26% were employed at the time of the elections. Participants with TBI MMSE scores were normal for the majority (70%), mild for 23%, and moderate for 7%, and none with severe cognitive impairment. Family members all had MMSE scores within normal range except 1 moderate cognitive impairment.
      Table 1Participant characteristics
      CharacteristicsParticipants With TBI n=57Family Members n=28
      MeanSDMeanSD
      Age at injury (y)41.225.552.12.1
      n%n%
      Sex
       Male4171.9932.1
       Female1628.11967.9
      Race/ethnicity
       White3764.92278.6
       Black1831.6517.9
       Other23.213.6
      Hispanic23.200
      Education level
       Less than high school1017.513.6
       High school diploma or GED1526.3517.9
       Associate or Bachelor’s degree2849.11553.6
       Graduate degree47.0621.4
       Missing013.6
      Employment
       Employed1526.31760.71
       Not employed/retired/disability3866.7821.1
       Missing47.0310.7
      MMSE score
       Normal cognition4070.22796.4
       Mild impairment1322.800
       Moderate impairment47.013.6
       Severe impairment0000
      Cause of injury
       Vehicular2645.6
       Violence610.5
       Falls47.0
       Other47.0
       Missing1628.1
      Abbreviation: GED, General Education Development.
      Interviews were conducted within an average 41.3±77.78 days of the election date. Voting participation for the persons with TBI and family members and their voting method are summarized in table 2.
      Table 2Voting participation among the sample of registered voters
      VariablesNovember 2007May 2008November 2008
      Participants with TBIn=19n=19n=19
      Did not vote, n (%)9 (47.4)9 (47.4)3 (15.8)
      Voted, n (%)10 (52.6)10 (52.6)16 (84.2)
      -- Voted by absentee ballot002
      -- Voted at polling station101014
      Family membersn=12n=4n=12
      Did not vote, n (%)4 (33.3)2 (50.0)1 (8.3)
      Voted, n (%)8 (66.7)2 (50.0)11 (91.7)
      -- Voted by absentee ballot202
      -- Voted at polling station629

      Study findings

      Data analysis revealed 4 themes describe below. Table 3, Table 4, Table 5, Table 6 specify representative findings and quotes for each respective theme. The themes provide an overarching conclusion: voting is a right and a responsibility of every citizen of the US, and the question of whether or not a person with TBI is competent to vote is not relevant because voting is a right regardless of competence.
      Table 3Representative findings and quotes for theme 1
      Theme 1. People With TBI Have Barriers to Voting
      FindingExample Quotes
      Cognitive barriers“I think it would probably just take him longer reading and the memory. I guess like the memory thing.” [FAMILY]

      “The _____ area [TBI survivors] group had a meeting about voting and I had the opportunity to listen to a lot of the survivors talk about how difficult it is for them, number one getting there, finding the polling place, getting there, the confusion of all of the people, the noise, the lights, the talking. The actual physical operation of the voting machine. Now, ours is a touch screen. I don’t know what . . . I don’t know if that’s a county type thing or not but they were talking about how they didn’t know how to use the touch screen. The abundance of choices they have to make in a very short amount of time—because they’re going to want to read everything. The pressure to hurry up and get out of there so the next person can use the machine.” [FAMILY]

      “And then barriers as far as maybe an impairment as far as sight or sound, not being able to hear. They may not be able to see the words, like, on the screen. Even though it’s a touch screen they may not be able to fully move their arm or whatever. Many of them have other injuries related to the brain injury that all occurred at the same time so physically and mentally they may not be able to read through the instructions or completely understand it so they might need someone else to read it. So that might be a barrier if there’s not people available to do that.”

      “Last time I went to the polls it was a circus for me to figure out how to vote, not the mechanics of it, but just the best thing for me to vote for.” [PERSON WITH TBI]
      Time and transportation barriers“[A barrier to my voting is] getting there, how far it would be, what time of day, because it’s only for one day. I have to figure out the most available time for me to go and I have to count on the lines and how long it would take me to get to work after that.” [PERSON WITH TBI]

      “Driving is one of them. I can’t drive anymore.” [PERSON WITH TBI]

      “Well, as far as probably transportation, many of them can’t drive so they have to wait and get a ride from somebody else or get a taxi or whatever.” [FAMILY]
      Social stigma barriers“They look at me and they think that I am mentally retarded and spaced out and that don’t count. I am so tired of that. And I have to keep reminding them, look, I’m not deaf and I’m not blind and I’m not retarded.” [PERSON WITH TBI]

      “What we encountered at the first voting place, you know, was so offensive to me and I realized that I need to call the voting election place because if they were that abrasive and that, I mean if I did not have [someone] with me I would have just gone home and probably cried and said, ‘Well maybe, God, I’m not supposed to vote’ because that man was just so abrasive.” [PERSON WITH TBI]
      Barriers because of lack of confidence and second thoughts“One of the problems, I think, for someone with a head injury if you vote, like I voted, but if you thought you understood everything, you did the best you could, but then maybe you don’t like what’s happening or you voted for somebody and now things are bad, then it makes you discouraged to vote the next time because it makes you think, oh, I’m not understanding what’s happening. And I know there’s a part of me that knows that whoever you vote for stuff doesn’t always turn out like what you would think but that is something with head injury that people if they vote and then it was a bad choice.” [PERSON WITH TBI]
      Barriers because of uncertainty of family/caregivers whether or not person with brain injury has capacity to vote“For someone like my son I just consider it, you know we prepare him ahead of time, we make sure he understands what he is voting for. And I'm just going to use him as an example because ability does, is everything for him, with the brain injury. There is one thing that, you know I was wish-washy about, you know, should we let him vote? Shouldn't we let him vote? People across the street from us have two, umm, daughters from birth that were injured and so they are mentally handicapped and they vote every time too and they understand what they are voting for also. And umm, so his ability to vote is just umm, it's precious. And that is how I look at it.” [FAMILY]

      “I know that my son there was no way in the world that he would completely understand the proposals. For example he has some strong feelings about some social issues so candidates are easier because one party basically represents one group of social issues, in general, and another represents another. But if he didn’t have somebody to help him understand those proposals, the way they are written, he would be in deep trouble. That would concern me if no one explained to brain injured people well enough so that they understood what they were voting for.” [FAMILY]

      “I think that his attention span is very short. And I think that because he was in his coma for so long that he has kind of missed out on what’s been going on in the world because a lot of things have changed real quickly. And I think that he needs to personally recover with the little things in his life and not worry so much about what higher up officials say and do because if he cannot speak, and he can barely say a couple of words, then I don’t think he’ll be able to speak his opinion. I don’t think he’s going to be comfortable with what he said and I just don’t think that he is competent enough right now to do that.” [FAMILY]

      “Seeing that he was probably, because of the state that he was in, I would have to do a lot of discussion with him just to determine whether he really knows what is going on. I would have to make the determination. If I felt he did not know what was going on, I don’t think I would let him vote, to be honest with you. There’s no sense in letting someone vote who doesn’t know what’s going on to really give the election.” [FAMILY]

      “She just doesn’t. She doesn’t understand any abstract concepts at all. She doesn’t have the ability to discern . . . I don’t even have the ability to discern who’s telling the truth, how is she going to do that? She doesn’t read anything but teen magazines and that kind of thing—she doesn’t read the paper.” [FAMILY]
      [Response to] barriers because of perception of individuals with brain injury that they should vote“We still have a mind. We can still think. We can still decide. We’re just considered to be on a different level because of that injury. It doesn’t make us stupid. It just makes us think. We think, I think a lot deeper because I don’t have other problems so I think a lot deeper.” [PERSON WITH TBI]
      Table 4Representative findings and quotes for theme 2
      Theme 2. The Voting Process Can Be Improved for People With TBI
      FindingExample Quotes
      A person with TBI has to take intentional action to be informed“I voted straight [ticket] when I did vote in the main election for the President, I voted straight down. But, yeah, I can see where I could have had a mental barrier because I would have had to make decisions [had I not voted straight ticket].” [PERSON WITH TBI]

      “I went in there with a piece of paper of who I wanted to vote for. I went to the list to find people and those were who I voted for. I did research by like reading the paper and stuff. I kept up on it.” [PERSON WITH TBI]
      A person with TBI needs support from their families to vote“I want him to feel safe and confident that he’s going in there and is really comfortable with what he’s going to do. I’ll provide him with whatever I can to help him get his research or his background.” [FAMILY]

      “I try to let him vote in his own way, his own feelings. . . . “we discuss the issues and the candidates. He knows how I feel. But we try to let him decide for himself what he wants to do. I don’t go in there and pull the lever for him.” [FAMILY]
      A person with TBI needs special support to vote[Help for people with TBI to vote would include] prompting them that today is Election Day, can you get out? Can you go to the poll? Do you need help? Providing assistance. Those are things I think, should be afforded people who have disabilities. Assistance, transportation, prompts, maybe an absentee ballot, you know, some means should always be available to people who are capable of voting.” [FAMILY]

      “Now I’m not really familiar with what the process is currently. I wasn’t here back in November when they voted. But I would think if there could be a facility specifically for people with disabilities, if transportation was provided and people were there to help them navigate that process as far as reading and whatever physical impairments they may have helping them to make their choices.” [FAMILY]

      At the polls, yes. If the polls were brought down where they could sit, if they were open . . . this room, if it were more of an open space. If they felt like they were given more time. If they felt like there wasn’t a line full of people standing behind them. If you feel like you are not being pushed. And you said, I didn’t know this, but you said that you can even take somebody in there to help you. If they had someone, just sometimes knowing that someone else is there to sit with you—“If you need any kind of help, I’m here”—sometimes that’s enough, just to do that.” [FAMILY]
      Table 5Representative findings and quotes for theme 3.
      Theme 3. Voting Is the Responsibility, Right, and Privilege to Be Members of Society.
      FindingExample Quotes
      Voting as being a member of our society“I love to vote because I’m a US citizen and I have a right to vote and I just think that you should vote if you are a citizen of the United States. You should be voting—it’s your privilege, it’s your right.” [PERSON WITH TBI]
      Voting as a symbol of belonging“[Voting is] showing that you’re . . . part of the political system.” [PERSON WITH TBI]

      “[Voting] makes her feel like she’s done something special. Yeah, yeah. She always gets the little tag that says “I voted.” She likes doing it because she feels like she’s done something to be involved.” [FAMILY]
      Voting represents the freedom to make choices and decisions and take an active role in one’s future“It’s your chance to feel like you have some sort of power and control in a small part of the way the nation is going to go.” [PERSON WITH TBI]
      Voting is a right regardless of competence“If they are able to comprehend and do everything, you’re still a person, you’re still a human. If you’re American and you’re human you can do it.” [FAMILY]

      “They have disabilities and limitations, but they are also citizens of the United States and they have that right also.” [FAMILY]

      “Because . . . you don’t want them to feel left out just because of their ability or because their brains don’t function like other people’s. They have a right to vote too even though they have a disability.” [FAMILY]

      “If they say they want to do it they should be able to do it regardless of what their cognitive impairment is or what their level of competency is. If they say they want to do it, they should be able to do it.” [FAMILY]

      “His heart beats just like ours, so if he wants to (vote) and feels comfortable with it, then whether his answers are right or wrong then he should (vote).” [FAMILY]

      “The only reason that you shouldn’t vote is if you’re dead.” [PERSON WITH TBI]
      Table 6Representative findings and quotes for theme 4.
      Theme 4. Voting Is One Way We Have a Voice in Society
      FindingExample Quotes
      A voice for people with disabilities“I voted because I feel like if I don’t vote then I was not able to express myself. I have still given my opinion, whether it changes the election or not.” [PERSON WITH TBI]

      “The ability to vote represents a privilege that I need to do because I have had an incredible recovery. If you would have seen me twenty years ago, I couldn’t have voted that year. I was so badly injured, my brain was so . . . it felt like mud—I couldn’t think right, I couldn’t remember anything. I want to vote for all the people with disabilities that are not able to get out there and vote due to the severity of their brain injury or due to their mobility problems . . . you know, I was set after my accident. When my parents arrived at the hospital, the surgeons came out and spoke to them very bluntly and said your daughter will be a vegetable if she makes it through this first night, your daughter will be a vegetable for the rest of her life. And I am so grateful because I know, after working, going in to the professional field of working with people with brain injuries I know a lot of people who didn’t ever come out of their coma, who were never able to enter back into normal life. I am probably in the top three percent . . . three to five percent of people who have been able to have the kind of recovery that I have, so I want to represent those people that now cannot vote.” [PERSON WITH TBI]
      A way to be heard“Everybody gets to voice their choices.” [PERSON WITH TBI]

      “It’s a voice that I have in the United States. . . . And it’s a way that I can be heard. And it’s an action that it doesn’t cost me anything and it’s a plus in my life to say that I was responsible for that or I tried for that, you know, to let my vote be counted. It’s my right.” [PERSON WITH TBI]
      A way to keep their needs in the forefront of the political process“Well I certainly think that they should vote and it is part of their right as members of our society. And they have particular viewpoints which need to be registered because they go through experiences that are somewhat unique from most people. And if we who have been through those experiences don’t have our voices heard then chances are that we will have less representation for our specific interests which are a little different because of what we have been through.” [FAMILY]

      “I feel that maybe we who had TBIs would be in a minority and we may not demand the press coverage that another issue may. But yes, I think it’s important that the candidate be cognizant of that for the other people.” [PERSON WITH TBI]
      Cognitive limitations may cause people with TBI to lose their voice“We have gone and we have voted, but she usually votes the way I vote.” [FAMILY]

      Theme 1

      People with TBI have barriers to voting. Multiple barriers to voting were identified, including cognitive impairment, time, transportation, physical, and social stigma. Polling places are confusing and full of stimuli, people with TBI have difficulty remembering and making choices, people with TBI may lack transportation, and poll workers interpersonally stigmatize people with TBI. Some expressed uncertainties regarding capacity to vote.

      Theme 2

      The voting process can be improved for people with TBI. Participants suggested ways the voting process can be improved for people with TBI: provide help understanding candidates and their positions, provide help reading/understanding the ballot/machine, provide special areas with more room/space, provide transportation and convenient locations, make people with disabilities comfortable voting, make the process less confusing, help them make a choice, and make ballots clearer/easier to see.

      Theme 3

      Voting is the responsibility of members of society. Participants assert voting is a way in which a person is a member of society, a symbol of belonging, a freedom to take an active role in one’s future, and, bottom line, a right regardless of competence.

      Theme 4

      Voting is one way we have a voice in society. Voting represents a voice for people with disabilities, a way to be heard, and a way to keep the need of people with TBI in the forefront of the political process. It is possible, however, for the voice of a person with TBI to be subsumed by their family members as they offer assistance in the voting process.

      Discussion

      A PR approach was used to assess the voting experience of individuals with TBI through semistructured interviews and participant observation at the polls during the 2007 and 2008 elections in North Carolina. Four themes emerged. Although people with TBI experience barriers, people with TBI may nonetheless overcome barriers because of belief in responsibility and voice in society. While we note some differences in viewpoints between family members and people with TBI, we found that for the most part, family members were supportive of their loved one with TBI voting and, as much as they could, provided assistance if the person with TBI wanted to vote.
      An interesting and unexpected finding was that overwhelmingly, both people with TBI and family members express the view that cognitive capacity should not be a factor in voting. Our participants’ view on capacity provides data that overlap with recommendations by the American Bar Association that any person who expresses a desire to vote should be permitted to vote.
      • Sabato C.P.
      • Spurgeon E.D.
      Facilitating voting as people age: implications of cognitive impairment.
      However, occasionally family members do discourage those with TBIs from voting such that they lose their voice.
      Voting is more than a political voice; it is also a rehabilitation outcome. Self-expression and membership in a larger group were particular drivers in this study with findings painting a clear picture that for people with TBI voting represents freedom, active societal participation, and having a voice.
      • Law M.
      Participation in the occupations of everyday life.
      In the general population, better subjective health has been reported among those who participate in voting and voluntary social activities than those who do not.
      • Kim S.
      • Kim C.Y.
      • You M.S.
      Civic participation and self-rated health: a cross-national multi-level analysis using the world value survey.
      From these perspectives, voting is a key outcome for rehabilitation.
      • Law M.
      Participation in the occupations of everyday life.
      Although two-thirds voted, there are barriers. We found people with TBI can require extra resources (time, effort, transportation) to vote, and people with TBI may have challenges with remembering to vote, preparing to vote, researching candidates, and arranging transportation to the polls. Some people with TBI also note challenges navigating the polls and the ballot, difficulty remembering for whom to vote, stigmatization, and health issues. In 2014, the US Department of Justice wrote that accommodations such as absentee ballots and curbside voting should take the place of polling place voting in limited circumstances
      US Department of Justice
      The Americans with disabilities act and other federal laws protecting the rights of voters with disabilities.
      ; family/caregiver assistance can help but may not fully overcome these barriers. Voting for many with TBI will require self-advocacy (informing others what one needs to meet their goal), a skill that may be compromised by the effects of the TBI.
      • Hawley L.A.
      Self-advocacy for independent life: a program for personal self advocacy after brain injury.
      Study participants did not mention by-mail absentee voting. By-mail voting may appear to be the panacea to overcome polling place barriers for people with disability. A mail-in ballot, which voters can complete at their convenience without any rush, might be among the best approaches for people with disability. Do we even need to learn about the past barriers encountered with polling places? With the convenience of by-mail voting, might everyone vote by mail and polling places be obsolete in the future? There is mixed evidence about whether by-mail voting (no-excuse absentee voting) increases voter turnout.
      • Leighley J.E.
      • Nagler J.
      Who votes now?.
      ,
      • Gronke P.
      • Miller P.
      Voting by mail and turnout in Oregon: revisiting Southwell and Burchett.
      Evidence appears to indicate reforms to increase voting by mail have made it easier for those with varied disabilities to vote.
      • Schur L.A.
      • Kruse D.L.
      What determines voter turnout?: Lessons from citizens with disabilities.
      ,
      • Miller P.F.
      • Powell S.
      Overcoming voting obstacles: The use of convenience voting by voters with disabilities.
      In the 2018 US elections, 30.7% of voters with disabilities voted by mail, compared with 22.3% of voters without disabilities.
      • Schur L.
      • Kruse D.
      Fact sheet: disability and voter turnout in the 2018 elections.
      Yet, it is often suggested that providing increased absentee voting (or curbside voting) is not adequate for those with disabilities.
      US Department of Justice
      The Americans with disabilities act and other federal laws protecting the rights of voters with disabilities.
      Expanded by-mail voting may especially increase the turnout of people with disabilities because the voting gap between people with and without disabilities was smaller in states with all-mail voting, and states with “no-excuse” mail voting where voters do not have to specify a reason (such as disability) for obtaining a mail ballot.
      • Schur L.
      • Kruse D.
      Disability and election policies and practices.
      However, mail voting is not a panacea for voters with disabilities. In the 2012 US elections, 13% of mail voters with disabilities encountered difficulties in filling out or sending their mail ballot, and 11% required assistance, compared with only 2% and less than 1%, respectively, of mail voters without disabilities.
      • Schur L.
      • Ameri M.
      • Adva M.
      Disability, voter turnout, and polling place accessibility.
      Although it sounds simple, mail-in voting can pose many challenges to a person with TBI with impairment of vision, mobility, and cognition. An audit in 2020 uncovered that more than 40 states do not have fully accessible webpages, ballot applications, and absentee ballots.
      • Abrams A.
      Absentee ballot applications are not accessible to voters with disabilities in 43 States. Time. September 30, 2020.
      In 2020, coronavirus disease 2019 focused public attention on by-mail voting
      • Persily N.
      • Stewart C.
      Ten recommendations to ensure a healthy and trustworthy 2020 election. The Lawfare Blog. March 19, 2020.
      ,
      • McReyonlds A.
      • Stewart C.
      Let’s put the vote-by-mail “fraud” myth to rest. The Hill. April 28, 2020.
      with national discourse casting questions about the legitimacy of such mail-in voting and voting preferences divided along party lines.
      • Lockhart M.
      • Hill S.J.
      • Merolla J.
      • Romero M.
      • Kousser T.
      America's electorate is increasingly polarized along partisan lines about voting by mail during the COVID-19 crisis.
      ,
      • Niebler S.
      Vote-by-mail: COVID-19 and the 2020 presidential primaries.
      More than 65.6 million Americans voted by mail in the 2020 US Presidential election (65% of all votes), up from 33.6 million (24%) in 2016.
      Election Assistance Commission
      The election administration and voting survey, 2016 comprehensive report: a report to the 115th Congress.
      ,
      US Elections Project
      2020 General election early vote statistics.
      While the extent of mail voting increased, the basic process of by-mail voting has remained similar, so difficulties in voting likely remain the same. With widespread distrust, it seems unlikely that polling places will go away soon. People with disability, like those without disability, may prefer to cast their vote in person to ensure their vote is counted or may need assistance that they do not have at home. Or, they may not be able to navigate voting at home and need to vote in person. For many with physical disability, drive-up voting appears to be a solution. However, during the 2020 Presidential election, drive-up voting was contested in Harris County, Texas courts putting approximately 127,000 votes at risk of not being counted and causing the sudden closure of 9 drive-up sites.
      • McCullough J.
      Nearly 127,000 Harris County drive-thru votes appear safe after federal judge rejects GOP-led Texas lawsuit. The Texas Tribune. November 2, 2020.

      Implications

      Strategies such as educating government officials, poll workers, election officials, brain injury advocacy groups, and persons with TBI about TBI and voting are needed to address difficulties with voting. This will rise in importance as TBI prevalence increases with the aging US population.
      • Sade R.M.
      The graying of America: challenges and controversies.
      Training materials and training expectations must be developed. People with brain injury and their family/caregivers need information about voting. This can be done through educational brochures, such as “Voting Tips for People Living With TBI.”
      • Hammond F.M.
      • Hirsch M.A.
      • Davis C.S.
      • Snow J.N.
      • Kropf M.
      • Karlawish J.
      Voting is my superpower! Voting tips for people living with disability.
      ,
      • Hammond F.M.
      • Hirsch M.A.
      • Davis C.S.
      • Snow J.N.
      • Kropf M.
      • Karlawish J.
      Voting tips for people living with TBI.
      Smith et al
      • Smith D.
      • Browne D.
      • Hart P.
      The case for importance of voting.
      pointed out that in a physicians’ mission to serve our patients is the need to encourage our patients to vote. To optimize the community integration of our patients, rehabilitation and other health care providers can routinely discuss the importance of electoral participation, identify obstacles, and explore strategies to overcome the obstacles.

      Directions for future research

      This study focuses on people with TBI who have voted, but the findings also shed light on the especially low turnout of people with cognitive impairments. Given the growing size of the population with TBI, a larger study is needed to assess the generalizability of the findings. When the 2020 presidential election participation data become available, analysis of participation methods for those with and without disability will provide important insights to add to the present study findings. It will also be important to study the use of mail-in ballots among those with TBI.

      Study limitations

      The present study is one of the first to investigate the experience of political participation among persons with disability and the first study to investigate the experience among persons with TBI. Learning about the experience directly from those affected is a strength in this exploratory study of a complex topic. This study did not quantitatively measure participation or effects of impairments and function on participation. Although a diverse array of participants was studied, our findings may not fully reflect the experiences of others living with the effects of TBI and may not generalize to individuals with TBI who do not receive inpatient rehabilitation. This was a convenience sample that included individuals with moderate-severe TBI who in general had a high level of cognitive and physical function at the time of study participation and, therefore, also may not represent individuals with TBI with more severe disability.
      Time has passed since these data about the 2007 and 2008 elections were collected, although the lessons learned continue to provide insight into current aspects of the voting experience. The disability gap in voter turnout has not narrowed since 2008, with the same factors at work then likely at work now.
      • Schur L.
      • Kruse D.
      Fact sheet: disability and voter turnout in the 2018 elections.
      The gap between people with cognitive impairments and those without disabilities was 18.4% in 2008 and 18.7% in 2016.
      • Schur L.
      • Kruse D.
      Fact sheet: disability and voter turnout in the 2018 elections.
      ,
      • Schur L.
      • Ameri M.
      • Adva M.
      Disability, voter turnout, and polling place accessibility.
      That is, the disability gap in voter turnout is remarkably stubborn over time, giving continued relevance to the study findings. Research has shown that resources, recruitment, and psychological factors are important in explaining the lower turnout of people with disabilities.
      • Schur L.
      • Ameri M.
      • Adva M.
      Disability, voter turnout, and polling place accessibility.
      ,
      • Schur L.
      • Shields T.
      • Kruse D.
      • Schriner K.
      Enabling democracy: disability and voter turnout.
      The key resource factors are income and education,
      • Schur L.A.
      • Kruse D.L.
      What determines voter turnout?: Lessons from citizens with disabilities.
      and the disability gaps in these factors have not changed in 2020, so lower education and income levels are very likely to continue to contribute to lower voter turnout among people with disabilities. The recruitment factor, whether anyone asked you to vote, was likely lower during the pandemic because of social isolation of people with disabilities. The key psychological factor is external political efficacy,
      • Schur L.A.
      Disability and the psychology of political participation.
      reflecting whether one thinks the political system is responsive to people like oneself. The difficulties of people with disabilities in the pandemic may have contributed to lower feelings of efficacy.
      • Schur L.A.
      Disability and the psychology of political participation.
      Taken together, despite the substantial increase in voting by mail in 2020,
      Election Assistance Commission
      The election administration and voting survey, 2016 comprehensive report: a report to the 115th Congress.
      ,
      US Elections Project
      2020 General election early vote statistics.
      the barriers to voting expressed by our interviewees are likely to be relevant in 2020 and beyond.

      Conclusions

      This basic and crucial act of democratic participation represents freedom and voice. Barriers continue to exist that threaten or limit the voice for people living with brain injury. Past research on determinants of voting indicate that these barriers will continue to exist, supporting further work to help ensure people living with TBI achieve this hallmark of societal participation.

      Supplier

      • a.
        HyperRESEARCH software; Researchware.

      Supplementary Data

      Appendix 1 Voting Interview Questions

      For the people with TBI:
      • 1.
        Did you used to vote before your injury? Why/why not?
      • 2.
        Did you vote in this election? Why did you vote/why not?
      • 3.
        (If they voted) What was the experience of voting like for you?
      • 4.
        (If they voted) Where there any barriers to you voting? If so, what were the barriers to voting?
      • 5.
        (If they did not vote) What has gotten in the way of your voting?
      • 6.
        Did you vote before your injury? If the answer is “no” follow up with:
      • 7.
        What, for you, were the things that really got in the way of your voting before your injury?
      • 8.
        What, for you, were the things that really got in the way of your voting after your injury?
      • 9.
        When you talk about voting with others is your TBI an issue? Explain.
      • 10.
        What does voting mean to you? What does it mean to vote? What does it mean to not vote?
      • 11.
        What words would you use to describe the experience of voting in this country?
      • 12.
        Fill in the blank: A person who votes is _____. A person who doesn’t vote is _____. Voting represents _____. The right to vote represents _____. The ability to vote represents _____.
      • 13.
        How do you feel about people with disabilities voting? How do you feel about people with TBI voting?
      • 14.
        Do you have any ideas on how the voting process could be improved for you? For people with TBI? For people with disabilities?
      • 15.
        Do you feel that your thinking ability is affected by your injury? Do you feel competent to vote?
      • 16.
        Do people think that having TBI should affect your voting? Do people say anything to you, as a person with TBI, about voting? What do people think about you, as a person with TBI, voting? Do you agree/disagree with them?
        • ASK THE FOLLOWING QUESTIONS IF THIS INFORMATION HAS NOT BEEN MENTIONED PREVIOUSLY:
      • 17.
        Does the fact that you have a TBI or had TBI have any bearing on whether or not you voted? In what way?
        • Does it have any bearing on your process of voting? On what it was like to vote? On how hard or easy it was for you to vote? On getting to the polls or navigating the polling place? On making a decision on who to vote for?
        • If you voted before your TBI, is the experience of voting now any different? In what way?
      • 18.
        Do you feel you are a person living with a disability?
        • If they answer “no.” At what point did you progress from having a TBI to being recovered? Can you describe your process?
        • If they answer “yes.” Ask them to explain what makes them feel disabled.
        • At what point, in your mind, did you progress from not being able to vote to being able to vote?
        • Do you think that you could recognize these changes in someone else with TBI? Explain.
      • 19.
        How will you know when your TBI has progressed to the point where your TBI has changed to the point that you are no longer able to vote?
        • For the primary family member/significant other:
      • 1.
        Did you vote in this election? Why did you vote/why not?
      • 2.
        (If they voted) hat was the experience of voting like for you when you voted today?
      • 3.
        (If it is not sure if they voted) Do you vote? Why/why not?
      • 4.
        What does voting mean to you? What does it mean to vote? What does it mean to not vote?
      • 5.
        What words would you use to describe the experience of voting in this country?
      • 6.
        Fill in the blank: A person who votes is _____. A person who doesn’t vote is _____. Voting represents _____. The right to vote represents _____. The ability to vote represents _____.
      • 7.
        Do you feel [the person with TBI] is competent to vote? How do you feel about people with TBI voting? How do you feel about people with disabilities voting? How do you feel about people with cognitive impairment (such as Alzheimer disease or dementia) voting?
      • 8.
        Should he/she [the persons with the TBI] vote? Why/why not?
      • 9.
        (If they voted) Were there any barriers to you voting? What do you see as the barriers to voting for you? Were there any barriers to voting for [the person with TBI]?
      • 10.
        What do you see as the barriers to voting for people with TBI, in general? What do you see as the barriers to voting for people with disabilities, in general?
      • 11.
        How will you know when the TBI of [your spouse, significant other, person with TBI] has progressed to the point where their TBI has changed to the point that they are no longer able to vote?
      • 12.
        Do you have any ideas on how the voting process could be improved for [person]? For people with disabilities? For people with TBI?
      • 13.
        Do you have any ideas on how the voting process could be improved for yourself?
        • What do people say to you about your voting? Do you agree/disagree with them?
      • 14.
        What do people say to you about [your significant other, spouse, the person with TBI] voting? Do you agree/disagree with them? Does the fact that [your significant other, spouse] has TBI or had TBI have any bearing on whether or not you voted? In what way?
      • 15.
        In your opinion, does their TBI have any bearing on his/her process of voting? On what it was like to vote? On how hard or easy it was for him/her to vote? On him/her getting to the polls or navigating the polling place? On making a decision on who to vote for?
      • 16.
        Do you consider yourself to have any deficits/difficulties/disabilities that might affect your voting experience?

      References

        • Schur L.A.
        • Kruse D.L.
        What determines voter turnout?: Lessons from citizens with disabilities.
        Soc Sci Q. 2000; 81: 571-587
        • Schur L.
        • Kruse D.
        Fact sheet: disability and voter turnout in the 2018 elections.
        (Available at:)
      1. AAPD. REV UP: Register, Educate, Vote, Use your Power campaign.
        (Available at:)
        https://www.aapd.com/advocacy/voting/
        Date accessed: January 31, 2021
        • Schur L.
        • Ameri M.
        • Adva M.
        Disability, voter turnout, and polling place accessibility.
        Soc Sci Q. 2017; 98: 1374-1390
        • US Government Accountability Office
        Voters with disabilities: observations on polling place accessibility and related federal guidance.
        (Available at:)
        https://www.gao.gov/products/GAO-18-4
        Date accessed: January 31, 2021
        • Zaloshnja E.
        • Miller T.
        • Langlois J.A.
        • Selassie A.W.
        Prevalence of long-term disability, from traumatic brain injury in the civilian population of the United States, 2005.
        J Head Trauma Rehabil. 2008; 23: 394-400
        • Zgaljardic D.J.
        • Seale G.S.
        • Schaefer L.A.
        • Temple R.O.
        • Foreman J.
        • Elliott T.R.
        Psychiatric disease and post-acute traumatic brain injury.
        J Neurotrauma. 2015; 32: 1911-1925
        • Rabinowitz A.R.
        • Levin H.S.
        Cognitive sequelae of traumatic brain injury.
        Psychiatr Clin North Am. 2014; 37: 1-11
      2. Human Systems Integration Division, Electronic Systems Laboratory, Georgia Tech Research Institute, Georgia Institute of Technology. A consideration of voting accessibility for injured OIF/OEF service members: needs assessment, Atlanta, GA2012
        • Hirsch M.A.
        • Kropf M.E.
        • Hammond F.M.
        • Schur L.
        • Karlawish J.H.
        Voting characteristics of individuals with traumatic brain injury.
        World Med Health Policy. 2019; 11: 24-42
        • Karlawish J.A.
        • Bonnie R.J.
        • Applebaum P.S.
        • et al.
        Addressing the ethical, legal, and social issues raised by voting by persons with dementia.
        JAMA. 2004; 292: 1345-1360
        • Sabato C.P.
        • Spurgeon E.D.
        Facilitating voting as people age: implications of cognitive impairment.
        McGeorge Law Rev. 2007; 38: 843-869
        • Schields T.
        • Schriner K.F.
        • Schriner K.
        The disability voice in American politics: political participation of people with disabilities in the 1994 election.
        J Disabil Policy Stud. 1998; 9: 33-52
        • Link J.N.
        • Kropf M.
        • Hirsch M.A.
        • et al.
        Political knowledge: comparing individuals with traumatic brain injuries and “average” college students.
        Elect Law J. 2012; 11: 52-69
        • Davis C.S.
        • Gallardo H.P.
        • Lachlan K.
        Straight talk about communication research methods.
        Dubuque: Kendall-Hunt Publishing, 2010
        • Lindlof T.R.
        • Taylor B.C.
        Qualitative communication research methods.
        Sage, Thousand Oaks2002
        • Patton M.Q.
        Qualitative research and evaluation methods.
        Sage, Thousand Oaks2002
        • Yamazaki H.
        • Slingsby B.T.
        • Takahashi M.
        • Hayashi Y.
        • Sugimori H.
        • Nakayama T.
        Characteristics of qualitative studies in influential journals of general medicine: a critical review.
        Biosci Trends. 2009; 3: 202-209
        • Reason P.
        • Bradbury H.
        Handbook of action research: participatory inquiry and practice.
        Sage Publications, London2002: 1-468
        • Gordon W.A.
        • Brown M.
        Building research capacity: the role of partnerships.
        Am J Phys Med Rehabil. 2005; 84: 999-1004
        • Jagosh J.
        • Macaulay A.C.
        • Pluye P.
        • et al.
        Uncovering the benefits of participatory research: implications of a realist review for health research and practice.
        Milbank Q. 2012; 90: 311-346
        • Gaventa J.
        • Barrett G.
        So what difference does it make? Mapping the outcomes of citizen engagement.
        (Available at:)
        • Ehde D.M.
        • Wegener S.T.
        • Williams R.M.
        • et al.
        Developing, testing, and sustaining rehabilitation interventions via participatory action research.
        Arch Phys Med Rehabil. 2013; 94: S30-S42
        • McIntyre A.
        Participatory action research.
        Sage Publications, Thousand Oaks2008: 15-32
        • Heron J.
        • Reason P.
        The practice of co-operative inquiry: research ‘with’ rather than ‘on’ people.
        in: Reason P. Bradbury H. Handbook of action research: participatory inquiry and practice. Sage Publications, London2002: 179-188
        • Folstein M.F.
        • Folstein S.E.
        • McHugh P.R.
        Mini-mental state". A practical method for grading the cognitive state of patients for the clinician.
        J Psychiatr Res. 1975; 12: 189-198
        • Glaser B.
        • Strauss A.
        The discovery of grounded theory.
        Aldine, Chicago1967
        • Strauss A.
        • Corbin J.
        Basics of qualitative research: grounded theory procedures and techniques.
        Sage, Newbury Park1990
        • Godwin E.
        • Chappell B.
        • Kreutzer J.
        Relationships after TBI: a grounded research study.
        Brain Inj. 2014; 28: 398-413
        • Gan C.
        • Gargaro J.
        • Brandys C.
        • Gerber G.
        • Boschen K.
        Family caregivers’ support needs after brain injury: a synthesis of perspectives from caregivers, programs, and researchers.
        NeuroRehabilitation. 2010; 27: 5-18
        • Law M.
        Participation in the occupations of everyday life.
        Am J Occup Ther. 2002; 56: 640-9
        • Kim S.
        • Kim C.Y.
        • You M.S.
        Civic participation and self-rated health: a cross-national multi-level analysis using the world value survey.
        J Prev Med Public Health. 2015; 48: 18-27
        • US Department of Justice
        The Americans with disabilities act and other federal laws protecting the rights of voters with disabilities.
        (Available at:)
        • Hawley L.A.
        Self-advocacy for independent life: a program for personal self advocacy after brain injury.
        J Soc Work Disabil Rehabil. 2016; 15: 201-12
        • Leighley J.E.
        • Nagler J.
        Who votes now?.
        Demographics, issues, inequality, and turnout in the United States. Princeton University Press, Princeton2014
        • Gronke P.
        • Miller P.
        Voting by mail and turnout in Oregon: revisiting Southwell and Burchett.
        Am Polit Res. 2012; 40: 976-997
        • Miller P.F.
        • Powell S.
        Overcoming voting obstacles: The use of convenience voting by voters with disabilities.
        Am Polit Res. 2016; 44: 28-55
        • Schur L.
        • Kruse D.
        Disability and election policies and practices.
        in: Burden B.C. Stewart C.H. The measure of American elections. Cambridge University Press, New York2014: 188-222
        • Abrams A.
        Absentee ballot applications are not accessible to voters with disabilities in 43 States. Time. September 30, 2020.
        (Available at:)
        • Persily N.
        • Stewart C.
        Ten recommendations to ensure a healthy and trustworthy 2020 election. The Lawfare Blog. March 19, 2020.
        (Available at:)
        • McReyonlds A.
        • Stewart C.
        Let’s put the vote-by-mail “fraud” myth to rest. The Hill. April 28, 2020.
        (Available at:)
        • Lockhart M.
        • Hill S.J.
        • Merolla J.
        • Romero M.
        • Kousser T.
        America's electorate is increasingly polarized along partisan lines about voting by mail during the COVID-19 crisis.
        Proc Natl Acad Sci. 2020; 117: 24640-24642
        • Niebler S.
        Vote-by-mail: COVID-19 and the 2020 presidential primaries.
        Society. 2020; 57: 547-553
        • Election Assistance Commission
        The election administration and voting survey, 2016 comprehensive report: a report to the 115th Congress.
        (Available at:)
        • US Elections Project
        2020 General election early vote statistics.
        (Available at:)
        • McCullough J.
        Nearly 127,000 Harris County drive-thru votes appear safe after federal judge rejects GOP-led Texas lawsuit. The Texas Tribune. November 2, 2020.
        (Available at:)
        • Sade R.M.
        The graying of America: challenges and controversies.
        J Law Med Ethics. 2015; : 406-409
        • Hammond F.M.
        • Hirsch M.A.
        • Davis C.S.
        • Snow J.N.
        • Kropf M.
        • Karlawish J.
        Voting is my superpower! Voting tips for people living with disability.
        Arch Phys Med Rehabil. 2020; 101: 1101-1103
        • Hammond F.M.
        • Hirsch M.A.
        • Davis C.S.
        • Snow J.N.
        • Kropf M.
        • Karlawish J.
        Voting tips for people living with TBI.
        (Available at:)
        • Smith D.
        • Browne D.
        • Hart P.
        The case for importance of voting.
        J Natl Med Assoc. 2018; 110: 304
        • Schur L.
        • Shields T.
        • Kruse D.
        • Schriner K.
        Enabling democracy: disability and voter turnout.
        Polit Res Q. 2002; 55: 167-190
        • Schur L.A.
        Disability and the psychology of political participation.
        J Disabil Policy Stud. 1998; 9: 3-31