The continuity of intermediate care in low-middle-income countries (LMIC) is fundamental to support the sustainability of hospital care. Continuity of care is needed for patients with TBI and their caregivers, including intermediate care. However, there is not much literature that discusses intermediate care in patients with TBI and caregivers in LMIC. Therefore, this article is a narrative review to identify inter-mediate care programs for patients with TBI and caregivers in LMIC. This narrative review was conducted the electronic databases: Proquest, PubMed, Science Direct, MedLine, and Google Scholar. The search terms were developed based on MESH terms: intermediate care, traumatic brain injury, outcome, caregiver, and low-middle income countries. The articles searched with participants were patients with TBI after discharge from the hospital ≥ 18 years old. At the same time, the caregivers were the person who cared for the patients after discharge at home, published in English between January 2011–December 2021. This article search resulted in articles discussing intermediate care for patients with TBI and their caregivers in LMIC on several continents, including Asia, Africa, Latin America, and Europe. In general, there are no intermediate care programs that specifically treat patients with TBI and caregivers at LMIC. When a patient with TBI is discharged from the hospital, a patient rehabilitation program will be provided in the rehabilitation unit in the hospitals outpatient departments. There is variability among LMICs regarding public support for rehabilitative services and disability-related care, in part due to very diverse economic and cultural conditions. The intermediate care program for patients with TBI and caregivers at LMIC is currently undergoing reconstruction and rehabilitation of the health care system. Therefore, a particular program is needed in the intermediate period that focuses on patients with TBI and caregivers to optimize continuity of care and discharge outcomes.
Intermediate has turned into an approach to fore-stalling medical clinic confirmation and supporting patients prepared to leave the clinic yet need further help at home (Cornes et al., 2018). According to the Ministry of Health, (2009) intermediate care is a role that combines multiple services based on the context of local needs and available facilities. The continuity of intermediate care in low-middle-income countries (LMIC) is fundamental to support the sustainability of hospital care. This is a challenge for countries included in the LMIC category (Nugraha et al., 2023).
Traumatic brain injury (TBI) is a complex injury with a broad spectrum of symptoms that can cause several impairments or the disabilities (Sharp et al., 2014). The impact of the TBI on a person and their caregivers can be devastating, as these injuries are not only physical but can cause mental & emotional challenges to the patient (Carlozzi et al., 2015). Therefore, continuity of care is needed for patients with TBI and their caregivers, including intermediate care. Evidence highlights the importance of compre-hensive assessment, empowerment, & rehabilitation to optimize function, especially in times of deteriora-ting health or the when moving between homes, hospitals, or nursing homes (Sezgin et al., 2020). Intermediate care is an essential element of the continuum of care that enables patients with TBI to maintain or restore their independence after a period of illness, injury, or hospitalization (Fleming et al., 2012).
After a patient with TBI goes through clinical adjust-ment, they can take different treatment bearings (Lee et al., 2019). For instance, patients might be moved to an actual restoration unit at an overall emergency clinic, a specific recovery care focus, or a talented consideration unit. Physical, word related, discourse, mental, & neuropsychological administrations can be given seriously in every one of these setting regions. A few patients dont need talented nursing care and might be moved to a unit for mind injury patients. A few patients will return home with their parental figures and return to an emergency clinic or specific short term program for treatment and drug. Patients requiring expanded talented nursing care might be moved to long haul care offices, while certain patients will get back to get nonstop treatment and care. In the rehabilitation phase, some processes help individuals achieve optimal functioning by providing various services. However, the essential care team members are the patients and their caregivers. In all of these processes, intermediate care is a treatment that can cover the procedure. However, there is not much literature that discusses intermediate care in patients with the TBI and their caregivers in LMIC. Therefore, this article is a narrative review to the identify inter-mediate care programs for patients with TBI and caregivers in LMIC.
This narrative review aims to describe intermediate care programs for patients with TBI and caregivers in LMIC. The search was conducted the electronic databases: Proquest, PubMed, Science Direct, Med-Line, & the Google Scholar. The search terms were developed based on the MESH terms: intermediate care, traumatic brain injury, outcome, caregiver, and low-middle income countries. We also scanned reference lists of the relevant studies, searched vital journals, & searched relevant internet sources. Studies needed to meet the following inclusion criteria: the article with participants was patients with TBI after discharge from the hospital ≥ 18 years old, while the caregivers were the person who cared for the patients after discharge at home, published in English between January 2011 - December 2021, including the research for patients with TBI and their caregivers.
This article search resulted in the articles discussing intermediate care for patients with TBI and their caregivers in LMIC on several continents, including Asia, Africa, America, and Europe. These articles include intervention research, the descriptions, and reviews. The following are the search results for articles on intermediate care in patients with TBI and their caregivers in LMIC.
Asia
Srilangka
A study in Sri Lanka identified patients with TBI after discharge from the hospital. No intermediate care program specifically handles patients with TBI and their caregivers. Of the patients who lived three months after injury, 43(86%) stayed at home while the rest were in a rehabilitation center or a hospital. This study demonstrated the feasibility of telephone follow-up in patients with moderate and severe TBI admitted to a tertiary neuro-critical care unit in this LMIC setting (Samanamalee et al., 2018).
India
An Indian study identified patients with TBI after the discharge from the hospital. The study had an appropriate follow-up of 61.4% of patients at six months and showed poor outcomes in this subgroup of patients. The study also showed that most patients (nearly 85%) who were the discharged in an uncon-scious state would die or become vegetative. How-ever, hospital deaths only tell part of the story about these patients outcomes (Agrawal et al., 2015). Six-month outcomes are often poor due to a lack of rehabilitative care and facilities. In situ, most of the patients were discharged to home-based rehabili-tation with tracheostomy and the orogastric tube. In addition, unconscious patients with severe TBI were discharged with a tracheostomy tube in situ after confirming that the patient could maintain oxygen saturation in the room air and after training relatives about tracheostomy tube care, the suctioning, and rehabilitation at home (Agrawal et al., 2015).
Cambodia
A study of 1200 patients with TBI in the Cambodia showed that the discharge was obtained from 757 patients, with 7% reporting a good Glasgow Out-come Scale (GOS) score of 5, allowing the return to work; 90.0% of patients were GOS 3 or 4 on discharge, so unable to live independently (Peeters et al., 2017). The Cambodia is a low-income country showing signs of rapid economic growth & improve-ments in health care. It undergoes a period of recon-struction and rehabilitation of its health care system (WHO, 2012). In parallel, efforts are underway to train a new generation of health care professionals capable of delivering modern care.
Pakistan
The study was conducted on 1378 patients with TBI in a Pakistani tertiary hospital (Umerani et al., 2014). Most of our patients (77.9%) made a com-plete recovery after TBI. However, long-term rehabi-litation was required in 17.8% of moderate to severe disability patients. In Pakistan, when a patient with the TBI is discharged from the hospital home, the patients rehabilitation program will be provided in the outpatient rehabilitation unit of the department. A Pakistani study of 384 patients with TBI showed that patients receiving occupational therapy in an established hospitals acute care outpatient depart-ment showed significant recovery in the functional independence in self-care, sphincter control, transfer, locomotion, and communication and social cognition (Zehra, 2020).
Africa
Cameroon
The study was conducted on 101 patients with TBI in Cameroon (Ndoumbe et al., 2018). The patient mortality in this study was 32.59%, with 44 deaths. Ninety-one (67.41%) patients survived, seventy-four (54.81%) had a permanent neurological disability, and only 17 (12.59%) made a full recovery. More-over, although most of the survivors of this series were functionally independent (51.85%), 33.34% exhibited cognitive or behavioral impairment. In the long term, although most patients with STBI will show good physical recovery with independence in movement and essential life skills, most will remain with neuropsychological disabilities such as the cognitive and behavioral disorders that hinder social reintegration. However, there is no intermediate care program for patients with TBI in Cameroon.
Kenya
As one of Africas fastest-growing countries, Kenya has a very high traffic-related death and disability rate, primarily due to brain injury (Kinyanjui, 2016). As there are no hospital-affiliated outpatient brain rehabilitation programs and no private sector, TBI survivors in Kenya currently have nowhere to go to brain injury rehabilitation services such as cognitive rehabilitation, which will enable them to the gain independence and improve their quality of life, including getting a job whenever possible. These patients are usually sent home to their caregivers, where they continue to be present as a direct financial burden to the family and indirectly to society (Saidi et al., 2014). Or, they go to fend for themselves, consequently increasing the chance of additional brain injury. This is in stark contrast to the attention paid to other types of disability conditions in Kenya, such as visual impairment, deafness, and developmental disabilities, where the rehabilitation services include vocational training programs.
Latin America
This article discusses the intermediate care program for patients with TBI in Latin American countries (Bonow et al., 2018). There is significant variability among the countries represented the trial concerning public support for rehabilitative services & disability -related care, in part due to very diverse economic conditions (Dudzik et al., 2002). Older estimates suggest that some public rehabilitative services and that the proportion may be as small as 1% among individuals with disabilities living in rural settings (Kirsh et al., 2009). The direct costs of these services are prohibitive for many, limiting benefits in post-injury rehabilitation in patients with more significant family resources. In addition, the socio-cultural implications of the injury persisting with severe disability vary widely between cultures & countries. For example, in some study sites, the concept of withdrawal of care for patients who are unlikely to make a meaningful recovery is unfamiliar to the providers and the families; to others, the family is willing to let a loved one die if the prognosis is not good. Since cultural conditions also vary quite a bit by race, it is not surprising that the results are highly dependent on these two variables (Bonow et al., 2018).
Europe
Globally, LMIC Europes economies are growing and investing in healthcare infrastructure, providing opportunities to fill the existing gaps (Bloom et al., 2004). The LMIC countries of the Republic of Armenia, Georgia, and the Republic of Moldova are developing European economies. As a result, health care training in these countries is intense & evolving. Still, TBI treatment lacks specialists, adequate diag-nostic equipment, & the facilities, particularly for rehabilitation (Bloom et al., 2004; Dulf et al., 2021). Trauma hospitals are only located in large cities, and prehospital care, in particular, has gaps in standard triage and transport protocols (Dulf et al., 2021). Without standard triage and transport protocols, patients may be admitted to the hospitals that do not have the trauma specialization required for their optimal care.
This article is a narrative review identifying inter-mediate care programs for patients with TBI and caregivers at LMIC. Continuity of care in patients with TBI and caregivers needs particular attention, especially in LMICs. This condition is due to the higher incidence of TBI in LMIC compared to high-income countries (Bonow et al., 2018). In addition to a higher incidence of TBI in LMIC, the mortality rate is higher in LMIC for the same injury compared with high-income settings (Krebs et al., 2017). Currently, the intermediate care program for patients with TBI and caregivers at LMIC is still in the process of being developed. This condition is due to several states. For example, the government has not adequately diverted resources towards prevention, management, and rehabilitation of head injuries in LMICs such as India (Agrawal et al., 2015). As a result of a lack of rehabilitative facilities and health insurance, most patients with TBI in developing countries are discharged to the home-based care. Furthermore, patients who are released unconscious are extremely difficult to treat at home, and they are vulnerable to pressure ulcers, lung infections, poor nutrition, & physiotherapy. Epidemiological studies indicate that approximately 43% of the patients with TBI experience disability for six months or more, characterized by functional limitations. These post-injury symptoms limit activity, cognitive complaints, and mental health problems (Rabinowit & Levin, 2014). The literature explains that cognitive impair-ment in patients with TBI requires special attention and continuity of post-discharge programs from hospitals to optimize patient out-comes and quality of life (Barman et al., 2016). However, treatment among patients with cognitive impairment and other disabilities due to TBI in LMIC is unavailable. From these initial conditions, it appears that although TBI is a widespread public health problem in Kenya, it has not received proper attention in the public and private sectors, as evidenced by the lack of post-acute rehabilitation services for the TBI sufferers (Kinyanjui, 2016). Therefore, steps must be taken to prevent TBI-related deaths and the rehabilitation of those who acquire cognitive disability due to TBI to help them return to independent and productive lifestyles. At LMIC, access to the neurosurgical services, advanced critical care and rehabilitation is limited (Fuller et al., 2016). In addition, follow-up services that facilitate long-term rehabilitation, & require considerable equipment and personnel, are less well developed, making treatment outcomes & complications more difficult to ascertain and limiting improvement efforts. Similar to other critically ill patients in the LMIC setting, the reason is that long-term effects for TBI patients, including functional status, patient independence, and economic impact after TBI, are unknown in Sri Lanka and not widely known for other LMICs (Samanamalee et al., 2018).
The social and economic status condition can be the reason for the lack of good intermediate care for TBI patients and caregivers at LMIC. In high-income settings, race & socioeconomic status are inextric-ably linked in many Latin American countries, with whites earning significantly more wages than non-whites (De Ferranti et al., 2004). The out-of-pocket costs of these services are prohibitive for many, limiting post-injury rehabilitation benefits in patients with more significant care givers resources. Also, the sociocultural implications of injury persisting with severe disability vary widely between cultures and countries. For example, in some study sites, the concept of withdrawal of care for patients who are unlikely to make a meaningful recovery is unfamiliar to providers and families; on the other hand, families are willing to let a loved one die if the prognosis is the unfavorable (Bonow et al., 2018). This article highlights the importance of developing intermediate care for patients with TBI & caregivers in LMIC. Similar to high-income countries, post-discharge outcomes in patients with TBI & care-givers need to receive significant attention from the government. Most significantly, urgent consideration should be given to establishing rehabilitation facilities for TBI patients so that they can resume an independent life-style and participate in life activities like their peers.
The continuity of intermediate care in low-middle-income countries (LMIC) in patients eith TBI and their caregivers is the essential to help the man-ageability of clinic care. As a rule, there are no intermediate consideration programs that explicitly treat patients with TBI and their caregivers at LMIC. At the point when a patient with TBI is released from the emergency clinic, a patient recovery the program will be given in the restoration unit in the clinics short-term divisions. The intermediate consi-deration program for patients with TBI & guardians at LMIC is going through remaking and recovery of the medical services framework. Along these lines, a specific program is required in the transitional period that spotlights patients with TBI and caregivers to upgrade congruity of care and release results.
Researchers would like to thank PSU Extension Center program, Faculty of Nursing, prince of Songkla University.
All authors stated that there was no conflict of interest in this study.
Academic Editor
Dr. Abduleziz Jemal Hamido, Deputy Managing Editor (Health Sciences), Universe Publishing Group (UniversePG), Haramaya, Ethiopia.
Associate Professor, Faculty of Nursing, Prince of Songkla University, Hat Yai, Thailand.
Ganefianty A, Songwathana P, and Damkliang J. (2023). Intermediate care for traumatic brain injury patients and caregivers in low-middle income countries: a narrative review, Eur. J. Med. Health Sci., 5(6), 218-223. https://doi.org/10.34104/ejmhs.023.02180223