Equity considerations in clinical practice guidelines for traumatic brain injury and homelessness: a systematic review.

Background: Clinical practice guidelines (CPGs) predominantly prioritise treatment and cost-effectiveness, which encourages a universal approach that may not address the circumstances of disadvantaged groups. We aimed to advance equity and quality of care for individuals experiencing homelessness and traumatic brain injury (TBI) by assessing the extent to which homelessness and TBI are integrated in CPGs for TBI and CPGs for homelessness, respectively, and the extent to which equity, including consideration of disadvantaged populations and the PROGRESS-Plus framework, is considered in these CPGs. Methods: For this systematic review, CPGs for TBI or homelessness were identified from electronic databases (MEDLINE, Embase, CINAHL, PsycINFO), targeted websites, Google Search, and reference lists of eligible CPGs on November 16, 2021 and March 16, 2023. The proportion of CPGs that integrated evidence regarding TBI and homelessness was identified and qualitative content analysis was conducted to understand how homelessness is integrated in CPGs for TBI and vice versa. Equity assessment tools were utilised to understand the extent to which equity was considered in these CPGs. This review is registered with PROSPERO (CRD42021287696). Findings: Fifty-eight CPGs for TBI and two CPGs for homelessness met inclusion criteria. Only three CPGs for TBI integrated evidence regarding homelessness by recognizing the prevalence of TBI in individuals experiencing homelessness and identifying housing as a consideration in the assessment and management of TBI. The two CPGs for homelessness acknowledged TBI as prevalent and recognised individuals experiencing TBI and homelessness as a disadvantaged population that should be prioritised in guideline development. Equity was rarely considered in the content and development of CPGs for TBI. Interpretation: Considerations for equity in CPGs for homelessness and TBI are lacking. To ensure that CPGs reflect and address the needs of individuals experiencing homelessness and TBI, we have identified several guideline development priorities. Namely, there is a need to integrate evidence regarding homelessness and TBI in CPGs for TBI and CPGs for homelessness, respectively and engage disadvantaged populations in all stages of guideline development. Further, this review highlights an urgent need to conduct research focused on and with disadvantaged populations. Funding: Canada Research Chairs Program (2019-00019) and the Ontario Ministry of Health and Long-Term Care (Grant #725A).

An educational intervention to promote a culture of gender equity among persons with traumatic brain injury and caregivers: A pilot study.

Background: Traumatic brain injury (TBI) outcomes are dependent on patients' biological sex (e.g., hormone levels) and sociocultural gender (e.g., norms, responsibilities). Informal caregivers additionally experience disruptions to identity and roles post-TBI. However, information on this topic remains largely unavailable to patients and caregivers. Purpose: This study aimed to determine the effectiveness of a one-time educational intervention on sex and gender influences in TBI for patients and informal caregivers. Materials and methods: We conducted a pilot pre-test/post-test randomized control-group design study. Groups (i.e., passive, active and control) consisted a total of 16 persons with TBI and caregivers (75% persons with TBI, 63% women). Individual and group learning gains, and group-average normalized gain, were computed for three learning domains: knowledge, attitude, and skill. An intervention with an average normalized gain of ≥30% was considered effective. Educational intervention evaluation and qualitative comments post-participation were summarized. Results: The passive group demonstrated the highest average normalized gain across the three learning domains, including 100% for knowledge, 40% and 61% for attitude, and 37% for skill. The remaining groups did not reach an average normalized gain of ≥30%, except for the attitude domain of the control group (33% and 32%). Two key categories were identified qualitatively: (1) gendered self-expectations post-injury and (2) implications of gender stereotypes in rehabilitation, including the need for rehabilitation treatment to look beyond sex and gender. The post-participation educational session evaluation conveyed high appraisal of content, organization, and usability of the intervention. Conclusion: A one-time passive educational intervention on sex and gender in TBI may improve knowledge, attitude, and skill on the topic of sex and gender among adults with TBI and caregivers. Obtaining knowledge and skill on sex and gender effects in TBI can potentially help persons with TBI and caregivers adapt to changes in roles and behaviours post-injury.

Employment and accommodation needs and the effect of COVID-19 on men and women with traumatic brain injury.

BACKGROUND: Traumatic brain injury (TBI) impacts an individual's workforce involvement post-injury. Support services and workplace accommodations that can help with work re-integration post-TBI may differ based on a person's sex and gender. The added impact of COVID-19 remains under-explored. OBJECTIVE: We aimed to investigate the support services and workplace accommodation needs and the impact of COVID-19 on work and mental health for persons with TBI, considering sex and gender. METHODS: A cross-sectional online survey was distributed. Descriptive and regression analyses were applied to uncover sex and gender differences, along with content analysis for open-ended responses. RESULTS: Thirty-two persons with TBI (62% women, 38% men) participated. Physiotherapy, occupational therapy, and counselling services were indicated as the most needed services by women and men. Modified hours/days and modified/different duties were the most needed workplace accommodations. Mental challenges impacting well-being was a highlighted concern for both men and women. Women scored poorer on the daily activity domain of the Quality of Life after Brain Injury - Overall Scale (p = 0.02). Assistance with daily activities was highlighted by women for a successful transition to work, including housekeeping and caregiving. Men were more likely than women to experience change in employment status because of COVID-19 (p = 0.02). Further, a higher percentage of men expressed concern about the inability to pay for living accommodations, losing their job, and not having future job prospects. CONCLUSION: Findings reveal important differences between men and women when transitioning to work post-TBI and emphasize the need for sex and gender considerations.

A thematic analysis of patients' and their informal caregivers' gendered experiences in traumatic brain injury.

PURPOSE: Research shows that patients' perceptions of themselves and others, in addition to their understanding of the concept of gender, changes after traumatic brain injury (TBI). Little is known about gendered experiences in TBI and care delivery. This study aims to explore perceptions of gender through life experiences and interactions between adult patients with TBI and their informal caregivers. MATERIALS AND METHODS: Seven patients with mild and moderate-severe TBI and eight informal caregivers were interviewed. Transcripts were coded and analysed according to Braun and Clarke's thematic analysis. The Consolidated Criteria for Reporting Qualitative Research guidelines were followed in reporting results. RESULTS: The participants described a transformation of their understanding and experiences of gender following the TBI event. Three themes were identified: (1) Gender designations of "man" and "woman";( 2) Post-injury performativity of gender; and (3) Gender in giving and receiving care. CONCLUSIONS: The findings emphasize the importance of raising awareness among researchers and practitioners on gender as a transformative process for patients with TBI and informal caregivers after the injury. The diversity of patient-caregiver experiences and critical needs based on gender call for intervention approaches that mitigate gender disparities in giving and receiving care. Implications for RehabilitationHistorically, rehabilitation of persons with traumatic brain injury has targeted physical and cognitive impairments, with little attention to their gendered demands in the lived environment.Gender prevails in the lived experiences of persons with traumatic brain injury, and their informal caregivers, and in giving and receiving quality care.A major challenge for clinicians is identifying harmful gendered roles, norms, and relations and the affective/behavioral problems they produce to alleviate enduring distress and reduce disability.Rehabilitation interventions focusing on flexible and adaptive responses to gendered demands in the lived environment of persons with traumatic brain injury are timely.

Is it prime time for sex and gender considerations in traumatic brain injury? Perspectives of rehabilitation care professionals.

PURPOSE: The purpose of this study was to explore rehabilitation clinicians' understanding of how sex and gender facilitate or hinder care provided to patients with traumatic brain injury (TBI). MATERIALS AND METHODS: Sixteen clinicians from various specialities, attending to patients with TBI from a large rehabilitation hospital in Ontario, Canada, were recruited using purposive sampling. Data was collected through semi-structured interviews and thematic analysis was used to identify reoccurring themes. RESULTS: Three themes that facilitate or hinder care of TBI patients were identified: (1) knowledge and evidence; (2) gender and other aspects of recovery; and (3) family caregiving. Lack of education about the topic and inconsistent scientific evidence limited clinicians' attention to sex and gender topics. Social, financial, and cultural characteristics of patients were considered to be more relevant than their sex and gender. The gendered nature of caregiving and its burden on caregivers' health were acknowledged. CONCLUSIONS: Currently, attention to topics of sex and gender as they may influence patients' recovery is limited. However, clinicians are willing to be educated on these topics to enhance rehabilitation care. Further research on the gendered nature of interactions between patient, clinician, and family caregiver during recovery is warranted.IMPLICATIONS FOR REHABILITATIONSex and gender matter for patients undergoing recovery for their traumatic brain injury; however, clinical attention to this topic is limited.Based on the clinicians' perceptions, resources that address patients' psychosocial vulnerabilities should be prioritized (e.g., unequal access to care, financial status, cultural diversity etc.).Clinicians highlighted that psychosocial vulnerability and patients' life roles, before and after injury, are sex and gender specific.Guidelines about sex and gender influences in traumatic brain injury rehabilitation have the potential to enhance clinical practice.

Comorbidity in traumatic brain injury and functional outcomes: a systematic review.

INTRODUCTION: Comorbidities in people with traumatic brain injury (TBI) may negatively impact injury recovery course and result in long-term disability. Despite the high prevalence of several categories of comorbidities in TBI, little is known about their association with patients' functional outcomes. We aimed to systematically review the current evidence to identify comorbidities that affect functional outcomes in adults with TBI. EVIDENCE ACQUISITION: A systematic search of Medline, Cochrane Central Register of Controlled Trials, Embase and PsycINFO was conducted from 1997 to 2020 for prospective and retrospective longitudinal studies published in English. Three researchers independently screened and assessed articles for fulfillment of the inclusion criteria. Quality assessment followed the Quality in Prognosis Studies tool and the Scottish Intercollegiate Guidelines Network methodology recommendations. EVIDENCE SYNTHESIS: Twenty-two studies of moderate quality discussed effects of comorbidities on functional outcomes of patients with TBI. Cognitive and physical functioning were negatively affected by comorbidities, although the strength of association, even within the same categories of comorbidity and functional outcome, differed from study to study. Severity of TBI, sex/gender, and age were important factors in the relationship. Due to methodological heterogeneity between studies, meta-analyses were not performed. CONCLUSIONS: Emerging evidence highlights the adverse effect of comorbidities on functional outcome in patients with TBI, so clinical attention to this topic is timely. Future research on the topic should emphasize time of comorbidity onset in relation to the TBI event, to support prevention, treatment, and rehabilitation. PROSPERO registration (CRD 42017070033).

Comorbidity in adults with traumatic brain injury and all-cause mortality: a systematic review.

OBJECTIVES: Comorbidity in traumatic brain injury (TBI) has been recognised to alter the clinical course of patients and influence short-term and long-term outcomes. We synthesised the evidence on the effects of different comorbid conditions on early and late mortality post-TBI in order to (1) examine the relationship between comorbid condition(s) and all-cause mortality in TBI and (2) determine the influence of sociodemographic and clinical characteristics of patients with a TBI at baseline on all-cause mortality. DESIGN: Systematic review. DATA SOURCES: Medline, Central, Embase, PsycINFO and bibliographies of identified articles were searched from May 1997 to January 2019. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Included studies met the following criteria: (1) focused on comorbidity as it related to our outcome of interest in adults (ie, ≥18 years of age) diagnosed with a TBI; (2) comorbidity was detected by any means excluding self-report; (3) reported the proportion of participants without comorbidity and (4) followed participants for any period of time. DATA EXTRACTION AND SYNTHESIS: Two independent reviewers extracted the data and assessed risk of bias using the Quality in Prognosis Studies tool. Data were synthesised through tabulation and qualitative description. RESULTS: A total of 27 cohort studies were included. Among the wide range of individual comorbid conditions studied, only low blood pressure was a consistent predictors of post-TBI mortality. Other consistent predictors were traditional sociodemographic risk factors. Higher comorbidity scale, scores and the number of comorbid conditions were not consistently associated with post-TBI mortality. CONCLUSIONS: Given the high number of comorbid conditions that were examined by the single studies, research is required to further substantiate the evidence and address conflicting findings. Finally, an enhanced set of comorbidity measures that are suited for the TBI population will allow for better risk stratification to guide TBI management and treatment. PROSPERO REGISTRATION NUMBER: CRD42017070033.

Comorbidity and outcomes in traumatic brain injury: protocol for a systematic review on functional status and risk of death.

INTRODUCTION: Reports on the association between comorbidity and functional status and risk of death in patients with traumatic brain injury (TBI) have been inconsistent; it is currently unknown which additional clinical entities (comorbidities) have an adverse influence on the evolution of outcomes across the lifespan of men and women with TBI. The current protocol outlines a strategy for a systematic review of the current evidence examining the impact of comorbidity on functional status and early-term and late-term mortality, taking into account known risk factors of these adverse outcomes (ie, demographic (age and sex) and injury-related characteristics). METHODS AND ANALYSIS: A comprehensive search strategy for TBI prognosis, functional (cognitive and physical) status and mortality studies has been developed in collaboration with a medical information specialist of the large rehabilitation teaching hospital. All peer-reviewed English language studies with longitudinal design in adults with TBI of any severity, published from May 1997 to April 2017, found through Medline, Central, Embase, Scopus, PsycINFO and bibliographies of identified articles, will be considered eligible. Study quality will be assessed using published guidelines. ETHICS AND DISSEMINATION: The authors will publish findings from this review in a peer-reviewed scientific journal(s) and present the results at national and international conferences. This work aims to understand how comorbidity may contribute to adverse outcomes in TBI, to inform risk stratification of patients and guide the management of brain injury acutely and at the chronic stages postinjury on a population level. PROSPERO REGISTRATION NUMBER: CRD42017070033.