**1. Introduction**

Traumatic brain injury (TBI) is a leading cause of injury-related disabilities and mortality [1–4]. Surviving severe traumatic brain injury (STBI) often causes suffering and limitations in daily life, especially among young adults [1,2], and for some, there is a comprehensive and lifelong impact on health and well-being. Injury severity of TBI is defined according to the Glasgow Coma Score (GCS) [5]. Functional outcome following TBI and STBI is assessed using the Glasgow Outcome Scale-Extended (GOSE) [6,7]. GOSE includes functional, physical, emotional and social domains but does not measure fully how these impairments and disabilities affect health and well-being. The definition of health established by WHO in 1948 [8] has been developed with a focus on well-being and the ability to adapt and self-manage one's life [9]. Health is also described in a contemporary way as disease and disabilities co-existing together with health along a continuum from total health to total absence of health and from something temporary or limited to something more permanent [10]. Well-being covers a more individual, subjective and holistic view and is often described in narratives and interviews on the basis of, for example, personal feelings [11,12]. When the concept Health Related Quality of Life (HRQoL) is used by clinicians and researchers to define long-term satisfaction by the patient-reported outcome,

**Citation:** Stenberg, M.; Stålnacke, B.-M.; Saveman, B.-I. Health and Well-Being of Persons of Working Age up to Seven Years after Severe Traumatic Brain Injury in Northern Sweden: A Mixed Method Study. *J. Clin. Med.* **2022**, *11*, 1306. https:// doi.org/10.3390/jcm11051306

Academic Editors: Aaron S. Dumont, Nada Andelic, Cecilie Røe, Eirik Helseth, Emilie Isager Howe, Marit Vindal Forslund and Torgeir Hellstrom

Received: 26 January 2022 Accepted: 23 February 2022 Published: 27 February 2022

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**Copyright:** © 2022 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

it refers to how specific diseases or treatments affect life but also how they affect health after trauma [13]. Persons with STBI report lower HRQoL compared with the general population [14]. The two concepts of health and well-being are sometimes intertwined and used interchangeably. In accordance with previous research, we suggest in this paper, that health can be measured through self-reporting and described by others [15,16], while well-being is the person's own interpretation of their health, which can be described in narratives [17]. TBI is one of the most common reasons for physical, emotional and cognitive disabilities [18]. It has an impact on functioning and reintegration into society [19–21] and is linked to health and well-being [14]. In an earlier study on individuals with unemployment and disability, persons with TBI reported poor psychological well-being [22]. It is, therefore, of importance to study these areas further in order to help people into employment and to gain a better understanding of psychological well-being after TBI [23]. However, since treatment and outcome may differ between women and men, it is also important to study gender differences [24]. Initially, low GCS is in many cases not equivalent to severe outcomes, as described in other studies [25,26] and is also of interest to be studied further. Many studies have focused on responses by proxy [27], but self-reported health and well-being as described by the injured person are of importance. This can be accomplished through self-reported measures and interviews despite STBI [28]. Outcomes after STBI differ three months after STBI, and the outcomes can range from fully recovered to death [29]. However, severe cognitive impairment and impaired self-awareness are STBI consequences [30,31] that are commonly associated with disability and reduced health and well-being [32,33]. High energy trauma is prioritised in trauma triage because it is known such trauma causes more severe injury, but it is also important to be aware of low energy falls [34]. Repeated TBI is known as a risk factor for outcome [35]. Most follow-up studies on STBI have used a quantitative design with validated instruments [36], although there have also been qualitative studies [37,38]. The use of both surveys and interviews for a more complete evaluation of the outcome is recommended because validated instruments used by the injured person and proxy have a different input on what a good outcome is. Moreover, the outcome from interviews can be influenced by personal factors or the adjustment that has taken place over time [39]. A mixed-method study covering both health by self-reported surveys and well-being by narrative interviews, which enables an integration of results [40,41], can provide additional health information for trauma and STBI afflicted persons [42–44]. In order to find out what a mixed-method can add concerning similarities and differences as well as new insights in the results between surveys and interviews, the aim of this study was to explore an overall perspective of health and well-being for persons who had suffered a severe traumatic brain injury (STBI) seven years previously.

#### **2. Material and Methods**

#### *2.1. Design*

A mixed-method was chosen in order to allow the drawing of inferences from both quantitative and qualitative findings in response to the purpose of the study. A convergent parallel mixed method was conducted.

#### *2.2. Participants*

In an earlier Swedish-Icelandic multi-centre study (the Probrain study) where 5 of 6 university hospitals in Sweden and one in Iceland participated (*n* = 114) [29,45], 37 patients with STBI were recruited prospectively to the Regional Neurotrauma Centre in northern Sweden during 2010–2011, as part of the multi-centre study. Inclusion criteria were age 18–65 years, with acute STBI with the lowest non-sedated GCS 3–8 within 24 h post-trauma. The exclusion criterion was death within 3 weeks after injury. Initial severity in the Probrain study was GCS median 6 (3–8). The Regional Neurotrauma Centre in northern Sweden are responsible for approximately one million inhabitants in an area corresponding to almost half of Sweden with both urban and rural areas. Patients were assessed at 3 weeks, 3 months and 1 year after trauma. Of the 37 injured persons from the north of Sweden, there were 28 survivors at follow-up 7 years after injury. Two persons were not reachable. Two persons declined participation: one of them had a full recovery and the other one gave no reason. Three persons had either answered only a questionnaire or only participated in interviews and were not included. In this study, there were 21 participants, two-thirds of whom were men. For those who participated in this study, GCS was median 6 (3–8). The first author (M.S.), who had been in contact with the injured persons in earlier followup studies [45,46], contacted the injured person or their legal trustee and informed them verbally and in writing about the study and obtained their written consent.

## *2.3. Procedure*
