Telebehavioral Health Interventions That Support Caregivers of Traumatic Brain Injury Survivors: A Systematic Review

Background and Purpose: Unpaid family caregivers of traumatic brain injury (TBI) survivors often experience negative psychological, emotional, and social outcomes associated with the stress and burden of caregiving. Accessing psychosocial care may be difficult due to the demands of caregiving, economic disadvantages, and lack of geographical access to professional supports. Telebehavioral health interventions may help bridge these gaps. The objectives of this study were to: 1) Examine the literature to determine the existing telebehavioral health interventions for caregivers of TBI survivors; 2) Investigate the rigor and level of research evidence of selected studies; and 3) Examine the psychosocial outcomes for these caregivers.

Methods: A systematic review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies published between 1999 – 2019 and in English language were identified through CINHAL, Embase, ERIC, PsycInfo, PubMed, Scopus, and Web of Science. Eligible studies were included if: a) caregivers were the main target of treatment; b) the primary intervention was telebehavioral health; c) treatments focused on social, behavioral, or mental health outcomes; d) TBI was the majority diagnosis of survivors; and e) the study used a randomized controlled trial (RCT) or quasi-experimental design. Data were extracted on study characteristics, caregiver characteristics, TBI characteristics, technology type, intervention description, professional who delivered the intervention, main psychosocial outcomes, study measures, and quantitative results. Methodological quality of studies was assessed independently by two coders using the PEDro-P scale for RCTs and quasi-experimental designs.

Results: Of 916 initially identified articles, 12 met inclusion criteria. Three studies used quasi-experimental designs, seven were RCT with one-group comparison, one was RCT with a two-group comparison, and one was RCT with a three-group comparison. Technology included telephones, videophones, web-conferencing software, interactive websites, and interactive earpieces. The provider implementing the intervention varied by study, with most provider’s being psychologists (63.6%), followed by social workers (27.3%), then nurses (9.1%). Outcomes primarily focused on caregiver depression symptoms, stress/distress, satisfaction with life, caregiving, and healthcare, perceived mastery over caregiving, problem solving skills, burden, and efficacy. Among studies that reported effect sizes on psychosocial outcomes, 46.6% of these outcomes were moderate and 36.7% were large. However, only half of studies included effect sizes and few studies assessed long-term outcomes. The mean level of research evidence was 6.5 (Range = 3 – 11; Inter-rater agreement = 98.5%).

Conclusions and Implications: Caregiver psychosocial outcomes after telebehavioral health interventions were generally positive and have potential to reach and assist caregivers remotely. More research is needed to determine how provider educational background may impact caregiver outcomes when using a telebehavioral approach. Overall, studies lacked data on caregiver and TBI survivor characteristics which may contribute to psychosocial outcomes. Additional research is also needed to assess how caregiver demographics and injury severity moderate caregiver outcomes.