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Equity considerations in clinical practice guidelines for traumatic brain injury and the criminal justice system: A systematic review [1]
['Zoe Colclough', 'Department Of Forensic Science', 'University Of Toronto', 'Mississauga', 'Maria Jennifer Estrella', 'Department Of Occupational Science', 'Occupational Therapy', 'Toronto', 'Julie Michele Joyce', 'Sara Hanafy']
Date: 2024-08
CPGs were identified from electronic databases (MEDLINE, Embase, CINAHL, PsycINFO), targeted websites, Google Search, and reference lists of identified CPGs on November 2021 and March 2023 (CPGs for TBI) and May 2022 and March 2023 (CPGs for CJS). Only CPGs for TBI or CPGs for CJS were included. We calculated the proportion of CPGs that included TBI- or CJS-specific content, conducted a qualitative content analysis to understand how evidence regarding TBI and the CJS was integrated in the CPGs, and utilised equity assessment tools to understand if and how equity was considered. Fifty-seven CPGs for TBI and 6 CPGs for CJS were included in this review. Fourteen CPGs for TBI included information relevant to the CJS, but only 1 made a concrete recommendation to consider legal implications during vocational evaluation in the forensic context. Two CPGs for CJS acknowledged the prevalence of TBI among individuals in prison and one specifically recommended considering TBI during health assessments. Both CPGs for TBI and CPGs for CJS provided evidence specific to a single facet of the CJS, predominantly in policing and corrections. The use of equity best practices and the involvement of disadvantaged groups in the development process were lacking among CPGs for CJS. We acknowledge limitations of the review, including that our searches were conducted in English language and thus, we may have missed other non-English language CPGs in this review. We further recognise that we are unable to comment on evidence that is not integrated in the CPGs, as we did not systematically search for research on individuals with TBI who intersect with the CJS, outside of CPGs.
Traumatic brain injury (TBI) is disproportionately prevalent among individuals who intersect or are involved with the criminal justice system (CJS). In the absence of appropriate care, TBI-related impairments, intersecting social determinants of health, and the lack of TBI awareness in CJS settings can lead to lengthened sentences, serious disciplinary charges, and recidivism. However, evidence suggests that most clinical practice guidelines (CPGs) overlook equity and consequently, the needs of disadvantaged groups. As such, this review addressed the research question “To what extent are (1) intersections with the CJS considered in CPGs for TBI, (2) TBI considered in CPGs for CJS, and (3) equity considered in CPGs for CJS?”.
Clinical practice guidelines (CPGs) are “statements that include recommendations intended to optimise patient care that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options” [ 18 ]. However, despite their potential to enhance care, CPGs have been critiqued for dictating a one-size-fits-all approach to care [ 19 ] and lacking consideration for equity [ 20 ] or health inequities [ 21 – 23 ]. As such, existing CPGs may not be serving disadvantaged populations if they include recommendations that may not be applicable or beneficial to their needs. To the best of our knowledge, there has been no systematic review conducted to date that has examined the extent to which CPGs for TBI consider intersections with the CJS and the extent to which equity is considered in CPGs for CJS. This systematic review assesses the extent to which (1) intersections with the CJS is considered in CPGs for TBI; (2) TBI is considered in CPGs for CJS; and (3) equity is considered in CPGs for CJS.
Research has identified a relationship between having a history of TBI and experiencing adverse outcomes within the CJS. For example, a longitudinal study found that individuals completing sentences in federal correctional facilities who have a history of TBI were 39% more likely to incur serious disciplinary charges than those without a history of TBI [ 11 ]. Research has also demonstrated that a history of TBI is associated with an increased risk of reoffending upon release [ 12 – 15 ]. Unfortunately, health inequities experienced by individuals with TBI who intersect with the CJS also contribute to higher rates of chronic and infectious diseases, mental health challenges, substance use disorders, and serious psychological distress compared to the general population [ 16 ]. These health inequities are exacerbated by social determinants of health (SDoH), such as structural racism, that can limit healthcare access for groups that are disadvantaged, and lead to worse health outcomes for the high proportion of black, Indigenous, and people of colour who intersect with the CJS [ 17 ].
Traumatic brain injury (TBI) affects 69 million people every year [ 1 ] and may cause long-term challenges in behaviour, cognition, and communication [ 2 ] with functional limitations in various areas of life [ 2 , 3 ]. TBI is particularly prevalent among disadvantaged populations, such as individuals who intersect with the criminal justice system (CJS) [ 4 – 8 ]. Prevalence rates of TBI among individuals who intersect with the CJS far exceed the rates found in the general population [ 5 ], with rates ranging from 25% to 86% among individuals who are incarcerated [ 7 ], 47% among those on probation [ 9 ], and 17% to 72% among youth [ 6 ]. Most recently, a meta-analysis published in 2023 found that the prevalence of TBI among individuals within the CJS was 46% [ 10 ].
Narrative synthesis, informed by the Guidance on the Conduct of Narrative Synthesis in Systematic Reviews [ 45 ], was conducted. CPGs were grouped based on their characteristics (e.g., country, type of guideline, target audience), in addition to text-positive and text-negative categories. Tabulation (defined in Table 3 ), qualitative content analysis of text-positive CPGs, and quality appraisal were used to address the objectives of the review. Qualitative content analysis [ 46 ] were used to evaluate how evidence regarding TBI and CJS was integrated in CPGs for CJS and CPGs for TBI, respectively.
First, the content and reference lists of CPGs were assessed for (a) keywords for TBI and CJS involvement; and (b) content related to the definitions displayed in Table 2 . CPGs were then categorised into text-positive and text-negative CPGs. Text-positive CPGs for TBI and CPGs for CJS were guidelines that contained at least one of the keywords for and content consistent with the definition of CJS involvement and TBI, respectively. Text-negative CPGs for TBI and CPGs for CJS were guidelines that, within the body of their text, did not contain keywords or content related to the definition of CJS involvement or TBI, respectively.
Two independent reviewers (ZC, MJE, JMJ, or SH) assessed all items on the Grey Matters checklist and the first 10 pages of Google Search to identify potentially relevant websites using the title and/or short text underneath the title. At the title and abstract screen, the executive summaries and/or table of contents were reviewed if an abstract was not available. Similar to the study selection of peer-reviewed literature, CPGs that focused on (a) the broader brain-injured population without specific mention of TBI; or (b) non-criminal aspects of the legal system were also considered for full-text review to confirm that they focused on populations with TBI or those involved with the CJS. Abstracts or executive summaries not in the English language were translated and assessed using identical procedures to the peer-reviewed literature screening. CPGs were then screened using the eligibility criteria outlined in Table 1 for the full-text screen. The PRISMA flow chart [ 42 ] ( Fig 1 ) illustrates the study selection process for grey literature.
EndNote X8 [ 40 ] was used for reference management and de-duplication, and Covidence [ 41 ] was used for de-duplication and study selection. Two independent reviewers (ZC, MJE, JMJ, or SH) screened all articles. Prior to formal title and abstract screening and full-text screening, a pilot screen of 20 articles and 10% of full-text articles, respectively, was conducted until a minimum 80% agreement was achieved between 2 independent reviewers. At the title and abstract screen, articles that focused on (a) the broader brain-injured population without specific mention of TBI or (b) non-criminal aspects of the legal system were included for the full-text screen to confirm whether they focused on the populations with TBI or those involved with the CJS. Scoping and systematic reviews of CPGs for TBI or CJS-involved individuals were also included and their reference lists were manually reviewed to identify additional CPGs not retrieved from the search. All non-English language CPGs were translated and assessed for eligibility using the English full-text translation, DeepL Translate, Google Translate, DocTranslate, or reviewers with knowledge of the language. CPGs that could not be translated were excluded and documented in the PRISMA flow chart. Discrepancies were resolved through consensus or by consulting a third reviewer (VC). The PRISMA flow chart [ 42 ] ( Fig 1 ) illustrates the study selection process for peer-reviewed literature.
The overarching search strategy involved the search structure (a+b) OR (a+c) for text words and subject headings related to (a) CPG; (b) TBI; and (c) CJS. This search was conducted in 2 stages. The first stage was to identify CPGs for TBI (i.e., a+b), reported in a systematic review assessing equity in CPGs for TBI and CPGs for individuals experiencing homelessness [ 24 ]. The second stage was to identify CPGs related to CJS (i.e., a+c). For this stage, the following databases were searched: MEDLINE ALL (in Ovid, including Epub Ahead of Print, In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily), EMBASE and EMBASE Classic (Ovid), CINAHL (EBSCO), and APA PsycInfo (Ovid).
The CJS, in this review, encompasses 4 distinct facets in which direct involvement frequently occurs: policing (i.e., police interactions and arrests), courts (i.e., trials, including prosecution, adjudication, and sentencing), corrections (i.e., detention), and parole and probation [ 29 – 31 ]. Disadvantaged is a term used throughout this review to convey the lack of opportunities that ultimately place individuals in a disadvantaged position. While it is recognised that this term can be stigmatising, along with other terms such as marginalised or underserved, it was used to remain consistent with the language used by the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) guideline series [ 32 ] that informed equity assessment for this review. Additionally, we recognise that the term “criminal legal system” is used more recently to refer to the criminal justice system; however, we decided to use “criminal justice system” in this paper to be consistent with the language currently used in CPGs.
The protocol for this systematic review was registered on PROSPERO [CRD42022331499] and is an extension of our published systematic review assessing equity in CPGs for TBI and CPGs for individuals experiencing homelessness [ 24 , 25 ]. The reporting of the systematic review search strategy follows the Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) extension for searching (PRISMA-S) [ 26 , 27 ] and the reporting of the systematic review followed the PRISMA Equity Extension [ 28 ] (please see Fig 1 ). A meta-analysis was not conducted, as the aim of the review was to specifically assess if and to what extent equity was considered; as such, combining and getting an overall effect estimate of the varying outcomes reported by CPGs was not necessary.
Four CPGs for CJS were devoted entirely to singular health issues (hepatitis viruses [ 53 – 55 ] and mental health [ 50 ]). CPGs for CJS included considerations for culture [ 50 , 52 , 54 , 55 ], race and/or ethnicity [ 50 – 52 , 54 , 55 ], geographic location and proximity to medical care [ 50 , 51 ], financial status [ 51 , 52 ], disability [ 50 , 51 , 54 ], as well as sexual identity, sex, and gender [ 50 – 52 , 54 ]. However, these considerations were often only present in the reporting or synthesis of evidence and rarely in the guidelines’ list of recommendations. Specifically, only 2 of the 6 CPGs for CJS included evidence-based recommendations that highlighted disability [ 50 , 51 ] and only 4 highlighted gender or sex [ 50 – 52 , 54 ] and race or ethnicity [ 50 , 52 , 54 , 55 ].
Equity considerations in searching, synthesising, and reporting evidence on disadvantaged groups were often present in CPGs for CJS. Five CPGs (83.3%) reported searching for evidence specific to populations that were disadvantaged [ 50 – 54 ], and 2 (33.3%) explored databases for intervention outcomes that were critical to disadvantaged populations, addressed evidence from non-health-related disciplines that consider disadvantaged populations, and made considerations for equity when specifying the evidence eligibility criteria [ 50 , 51 ]. Three CPGs were published after the development of the PRISMA-equity statement [ 50 , 51 , 55 ]; however, none reported following the PRISMA-equity statement when reporting findings of systematic reviews and including good practice statements that address equity issues.
CPGs for CJS were often cognizant of equity issues as these guidelines were developed specifically for individuals intersecting with the CJS, a disadvantaged population. All CPGs for CJS offered distinct recommendations for those who are disadvantaged [ 50 – 55 ]; 4 (66.7%) noted differences in disease epidemiology between privileged versus disadvantaged populations [ 50 , 52 , 54 , 55 ], and 5 (83.3%) addressed the burden of disease on disadvantaged groups [ 50 , 52 – 55 ], provided solutions to barriers that hinder the implementation of recommendations in these populations [ 50 – 52 , 54 , 55 ], and evaluated data on cost, resource use, impact on equity, acceptability, and viability of interventions for populations that were disadvantaged [ 50 – 54 ].
Two CPGs for CJS (33.3%) were text-positive for TBI keywords [ 50 , 51 ]. The National Institute for Health and Care Excellence (NICE) 2017 guideline for mental health in the criminal justice system referenced epidemiological data regarding individuals with TBI without recommendations (category 2) [ 50 ], specifically noting the prevalence of TBI among individuals in prison compared to the general population. The NICE 2016 guideline for physical health of people in prison provided evidence-based recommendations for individuals with TBI (i.e., category 1), [ 51 ] to consider head injury in health assessments for all individuals in prison. Specifically, at first reception into prison, healthcare professionals should assess physical injuries (including head injuries) and document any treatments received. Further questions concerning the frequency of head injuries and/or loss of consciousness (LOC), the duration of the LOC, and difficulties with memory or concentration should then be asked during the second-stage health assessments [ 51 ]. The remaining 4 CPGs for CJS were text-negative and included no keywords or content specific to TBI within the body of the guidelines or their reference lists. The proportion of text-positive and text-negative CPGs for CJS for each category is summarised in Fig 2 .
Five CPGs integrated CJS-related information when reporting on guideline development [ 75 , 76 , 86 , 106 , 118 ]. One CPG listed police associations as a target user of the CPG [ 118 ], while 2 mentioned lawyers and physicians working in prison in the groups that contributed to the development recommendations [ 75 , 76 ]. One CPG included an explanation of the guideline development process and listed “effective identification of TBI in prisons” as part of the agreed-upon list of topics to be covered by the guideline [ 86 ]. One reported not including literature on aggression among prison populations, as it was too difficult to generalise to the larger population of individuals with brain injury [ 106 ].
Three CPGs reported on the role of CJS staff in increasing awareness about TBI, but did not provide recommendations for individuals with TBI who intersect with the CJS [ 81 , 82 , 84 ]. These CPGs highlighted the role of police officers in encouraging patients to immediately seek medical advice regarding TBI that they or others have sustained, regardless of injury severity [ 82 ], and ensuring that patients with TBI understand the risks of not being transported to the hospital following a head injury [ 81 ]. One CPG highlighted the need for TBI rehabilitation programs to increase awareness regarding TBI through information and education activities regarding the challenges and needs of individuals with TBI. This CPG listed police and parole officers under groups most likely to encounter individuals with TBI [ 84 ].
Three CPGs mentioned CJS-related keywords in the context of TBI evaluation in the CJS [ 86 , 97 , 102 ], one of which provided a concrete recommendation regarding vocational evaluation in the forensic context, noting that evaluators must consider medical-legal contexts during vocational evaluation, as they can influence the validity, completion, and reporting of evaluation findings [ 97 ]. One incorporated history of arrests in a checklist for behavioural affective symptoms associated with TBI [ 102 ] while the other identified prison inmates as a group who may not have received an initial assessment despite sustaining a TBI [ 86 ] but did not provide further recommendations.
Discussion
To the best of our knowledge, this is the first systematic review to explore the extent to which CPGs for TBI consider CJS intersection or involvement and, likewise, the degree to which CPGs for CJS consider TBI. This review also evaluated equity considerations in CPGs for CJS. Findings show that evidence-based recommendations for individuals with TBI who intersect with the CJS and equity considerations are lacking in CPGs for TBI and CPGs for CJS. We identified the following opportunities to advance equity in healthcare for individuals with TBI who intersect with the CJS: (1) conduct research with disadvantaged groups; (2) investigate TBI screening in all parts of the CJS, and (3) utilise equity assessment tools in guideline development.
First, there is an urgent need to conduct research with disadvantaged groups to build the evidence base on the intersections of TBI, CJS, health equity, and SDoH. Our findings showed the lack of specific evidence-based guidance regarding TBI care for individuals who intersect with the CJS. While a quarter of CPGs for TBI included CJS keywords, only one provided a concrete evidence-based recommendation regarding vocational evaluation for individuals who intersect with the CJS [97]. In contrast, only two of the CPGs for CJS included were text-positive for TBI, and only one of the two provided a specific recommendation to consider TBI when assessing the health of individuals in prison [51]. Specifically, individuals should be asked if they ever suffered a head injury or lost consciousness. Follow-up questions should include the number of times they suffered a head injury or lost consciousness, how long they were unconscious, and whether or not they have challenges with memory or concentration [51]. However, no specific instruments or tools to screen for a TBI were recommended. Policing and corrections were the predominant focus in CPGs for TBI and CPGs for CJS, with the courts, parole, and probation systems being largely neglected. It is also worth noting that 4 out of 7 CPGs that focused on policing were focused on police officers as patients themselves and not necessarily police interactions with individuals with TBI. The largely singular focus of the CPGs is likely due to the overwhelming focus of research on the CJS on persons who experience incarceration [122]. However, other parts of the CJS, such as parole, probation and courts, require equal attention, given the overrepresentation of TBI among persons on probation [9], the lower rates of successful probation completion among those with TBI, and the difficulties experienced by individuals with TBI in comprehending legal language [123]. More research focusing on, and with individuals who intersect with all parts of the CJS, is needed to build the evidence base and advance care for this population.
Second, this review identified an opportunity to investigate TBI screening in all parts of the CJS. For decades, public health organisations such as the Centers for Disease Control and Prevention have recognised the high prevalence of TBI in individuals intersecting with the CJS as a public health problem [124]. However, to date, TBI screening is inconsistently implemented in the CJS [125–127] due to a lack of funding and staff, poor awareness of TBI, and high rates of turnover among individuals in prison [126]. The findings of this systematic review echo this contrast. While a significant portion of TBI guidelines recognised intersections with the CJS as an important consideration, screening for TBI was not mentioned; only 1 out of 6 CJS CPGs recommended inquiring about head injuries when assessing the physical health of individuals in prison [51]. Importantly, several studies have reported on the potential benefits of screening for TBI in the CJS. A scoping review on rehabilitation programs for individuals with TBI who intersect with the CJS found that TBI screening is a crucial first step in the identification of unmet needs and the development of individualised intervention plans for this group [127]. Another study found that the aggressive and violent behaviours often exhibited by individuals with TBI are correlated with recidivism, and TBI screening in correctional facilities can be used to identify individuals at risk for reoffending, advise inmate behavioural management, and improve their safety [128]. These findings acknowledge the potential of TBI screening in supporting individuals with TBI. However, despite these potential benefits, we also recognise that screening for TBI may come with the risk of being identified as someone with a potential cognitive disability, which could put persons in the CJS at further risk of victimisation. As such, there is a clear need to further explore and understand the best way to incorporate screening for TBI in all parts of the CJS. Considerations for screening, including duration of screening, recommended tools and resources, procedures and supports following screening, and communication of screening results between different levels of the CJS and the community need to be explored through future research. Such information will also inform the feasibility, processes, and implications of screening for TBI in all parts of the CJS [127].
Lastly, through our assessment of equity, we identified a need to utilise equity assessment tools in guideline development and to incorporate considerations for disadvantaged groups into the evidence-based recommendations. CPGs for CJS lacked good practice statements and did not report using the PRISMA equity statement even though half were published after the statement’s publication in 2012. Considerations for race or ethnicity, financial status, and disability were largely absent from the recommendations. These considerations are important to include, as SDoH such as sex, gender, race, disability, and financial status can implicate the relevance and efficacy of the recommended interventions. Incorporating these equity best practices in the formulation of recommendations and using equity assessment tools in the development of CPGs are necessary first steps to reduce healthcare disparities between privileged and disadvantaged populations. Ultimately, the findings from this review provide a foundation to address equitable healthcare for individuals with TBI who intersect with the CJS.
While our review addressed an important gap in the literature regarding TBI, CJS, and equity considerations in CPGs, we recognise the following limitations. First, we did not systematically search for research on individuals with TBI who intersect with the CJS, outside of CPGs. As such, we are unable to comment on evidence that is not integrated into existing CPGs. Second, while we did not place restrictions on language or country in our search, our searches were conducted in English language. As such, we may have missed other non-English language CPGs in this review. Finally, although our eligibility criteria were selected in accordance with guideline development best practices [129], selecting only CPGs that rated the strength of their recommendations may have resulted in the exclusion of CPGs from certain lower-income countries, where rating the level of evidence or recommendations is a less prevalent or not commonly reported practice [130,131].
Despite these limitations, our systematic review is strengthened by its application of the externally peer-reviewed and published protocol of a systematic review that was conducted in tandem with this review [25], as well as the rigorous search strategy. Validated search filters for CPGs [33] and methodological guides to searching grey literature [37,39] were used to increase transparency and replicability. Additionally, our search strategy for searching grey literature was a core strength, particularly given the enhanced precision that has been shown to be associated with searches beyond bibliographic databases [33]. Furthermore, this systematic review assessed numerous key facets of the CJS, thus providing a comprehensive overview of CJS intersection. This was important because although research on individuals in correctional facilities is ample, the remaining facets of the CJS are largely neglected. As such, our systematic review highlights the gaps in the literature regarding the court, sentencing, and parole systems [132]. Lastly, through the identification of text-positive CPGs, we have established a collection of CPGs for TBI that address the needs of those within the CJS and CPGs for CJS that address individuals with TBI, which serve as a foundation for individuals providing TBI care in forensic settings.
Collectively, this systematic review highlights a lack of published guidance for the care of individuals with TBI who intersect with the CJS and an overwhelming need to recognise healthcare inequities for individuals intersecting with the CJS and take meaningful action to address current gaps in guidance for care delivery. Critical next steps in advancing equity and healthcare for this disadvantaged group include continuing to grow an evidence base for the intersection of TBI and CJS care, addressing the vulnerabilities stemming from brain injury that are unique to those who intersect with the CJS within our approaches to care, exploring opportunities to screen for TBI across all facets of the CJS to understand the impacts of brain injury among those who intersect with the CJS, and utilizing equity assessment tools in the development and implementation of CPGs. Furthermore, it is important that CPGs make considerations for the differing needs of distinct populations and address relevant SDoH, such as sex, gender, and race, as the healthcare needs, effectiveness of clinical recommendations, and structural barriers for different groups can vary substantially. Achieving these goals will be a step forward in delivering high-quality care for disadvantaged populations experiencing TBI.
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