PROJECT SUMMARY Traumatic brain injury (TBI) is a common, costly, and at times devastating condition associated with cognitive impairment, disproportionately affecting U.S. racial/ethnic minorities and individuals in low and middle-income countries. Asylum-seekers and refugees represent one especially vulnerable group that have high rates of TBI due to experiences such as war, torture, and interpersonal violence. Existing cognitive rehabilitation interventions targeting cognitive symptoms following TBI present an effective and evidence-based approach to address the cognitive sequalae of TBI in this population; but they require adaptation and evaluation. The central objective of this research proposal is to optimize and evaluate the first culturally adapted, trauma-informed cognitive rehabilitation intervention (“SMART-Plus”) delivered by community health workers (CHWs) using video-based telemedicine. This approach addresses several individual and system-level challenges such as linguistic barriers, cultural variations in perception of, and stigma around TBI, high trauma exposure, healthcare mistrust, lack of access to specialty-trained clinicians, and transportation barriers that make in-person interventions less feasible. Given the epidemiology of TBI in this population and to reduce sample heterogeneity in the early stages of intervention adaptation, the project will focus on those with interpersonal violence related mild TBI. The three Specific Aims are: (1) To develop SMART-Plus for asylum-seekers and refugees with interpersonal related mild TBI using input from asylum-seekers and refugees to tailor content, incorporate intervention delivery preferences, and identify engagement determinants; (2) To conduct an open pilot of SMART-Plus delivered by trained CHWs using telemedicine and further refine the intervention, study procedures, and outcome targets; and (3) To conduct a pilot feasibility randomized trial of SMART-Plus compared to wait-list control to improve post-concussive and cognitive impairment symptoms. These aims are consistent with the NIH Stage Model, representing a Stage IA (Aim 1 and 2) and Stage 1B (Aim 3) study, as well as Barerra’s stage model for cultural adaptation that involves information gathering (Aim 1); preliminary adaptation design and testing (Aim 2), and full adaptation design and testing (Aim 3). The findings of this project will fill an existing gap in a high impact research area that will inform the care of a growing and vulnerable population. At the same time, it offers a translational model for cultural and trauma-informed adaptation for other health disparities populations experiencing cognitive impairment and similar barriers to care, both domestically and globally. The PI, Dr. Saadi, is an early-career clinician investigator and neurologist, who will use this career development award to enhance her skills in mixed methods research for intervention adaptation, cognitive rehabilitation therapy and neuropsychiatric outcomes, equity-centered technology-based approaches, and RCT design involving vulnerable groups. She will leverage this training to launch an independent research career in scalable, technology-enhanced, community- engaged interventions to promote brain health equity. Throughout the award period, Dr. Saadi will work closely with an expert, committed and multidisciplinary mentorship and advisory team to carry out her stated career objectives and specific aims.

PROJECT NARRATIVE Due to physical harms suffered because of persecution in their home countries, asylum-seekers and refugees have significantly high rates of traumatic brain injury (TBI), leading to cognitive impairment that is a substantial source of morbidity for affected individuals, their families, and society. This career development award will adapt and evaluate the first ever cognitive rehabilitation intervention that is culturally tailored, trauma-informed, and delivered by community health workers using video-based telemedicine to address the unique needs of asylum-seekers and refugees.