Sex, Gender and Race Considerations within the Canadian TBI Guideline

Summary

Sex and Gender

There is a recognized need for including sex and gender-specific evidence in clinical practice guideline recommendations to facilitate gender-appropriate care, but it has not been common practice to do so. Increased understanding and awareness of the influence of sex and gender on brain injury, treatment and recovery has facilitated greater inclusion in research studies but unfortunately most research still does not fully address this gap.

Sex differences are complex and found at many levels of the nervous system: the thickness of the skull, brain, and cord fluid spaces, functional parts of the brain, sensory neural pathways, motor neural pathways, reflexes, and the autonomic nervous system (Mollayeva et al., 2022).

Gender considerations related to norms and roles within an individual's sociocultural environment can modify TBI-induced impairments. Further, a TBI of the same severity will impact particular groups more than others because of the interactions between gender, sex, and other social inequities that lead to many adverse outcomes (Mollayeva et al., 2022).

Moving forward in the living guideline process, the Canadian TBI Guideline will integrate the ever increasing evidence related to sex and gender related. It should be noted that considerations for the influence of sex and gender should be made for each recommendation but there are some recommendations where it is clear the specific direction with regard to sex and/or gender is appropriate and needed. Where appropriate we will use icons to denote recommendations where there are specific recommendations related to sex and/or gender of the person with TBI. By marking these recommendations clearly, it will also serve to highlight topics where current research does not exist for differentiation and this information can be used to advocate for where more sex and gender-specific evidence is needed.

The terms "sex" and "gender" have been defined by several recognized sources, including the Canadian Institutes of Health Research (CIHR), the National Institutes of Health, and the World Health Organization. The definitions for sex and gender provided by CIHR will be used:

Sex: a set of biological attributes in humans and animals. It is primarily associated with physical and physiological features, including chromosomes, gene expression, hormone levels and function, and reproductive/sexual anatomy.

Gender: socially constructed roles, behaviours, expressions, and identities of girls, women, boys, men, and gender-diverse people, including how people perceive themselves and each other, how they act and interact, and the distribution of power and resources in society.

There are several ongoing challenges in the development of sex and gender-informed recommendations:

1. The conflation of the terms "sex" and "gender." Studies often report baseline characteristics (male/female or men/women) but do not state if they refer specifically to sex or gender.
2. Publications often do not stratify outcomes based on sex.
3. Gender is often not included as a study variable and/or not appropriately assessed using a standardized instrument.
4. Current guideline development instruments, including AGREE (Appraisal of Guidelines, Research and Evaluation) II and GRADE (Grading of Recommendations Assessment, Development and Evaluation), do not provide guidance on synthesizing sex and gender evidence.

The Canadian TBI guideline approach will use a structured framework to guide sex and gender-specific generation of recommendations. This framework was adapted from Tannenbaum and colleagues (2019).

The approaches adapted from this framework are provided below:

1. Inclusion of an individual within the Guideline expert panel who will "champion the formal appraisal of the literature for associations between sex and the outcomes of interest" (Tannenbaum et al., 2019).
2. Determine whether sex and gender differences apply to the domain being updated (e.g., fatigue and sleep disorders, medical and nursing management, motor function and control).
3. Include an individual with expertise in sex and gender differences and the specific domain being updated within the working group.
4. Developing a specific search strategy to identify sex and gender-related evidence.
   1. Song and colleagues (2016) published a validated search strategy for identifying literature that reports sex and gender-specific diagnostic and treatment evidence. This search strategy will guide future literature searches for a specific domain.
5. Assessing evidence. The working groups will:
   1. Determine whether sex- and gender-specific outcomes are reported and whether the study outcomes justify sex and gender-specific recommendations.
   2. Determine if the quality of data enables sex and gender-specific recommendations.
      1. If yes, develop sex or gender-specific recommendations.
      2. If no, include text alongside recommendations which indicate that the "best available evidence does not indicate any relevant sex or gender differences" (Tannenbaum et al., 2019).
   3. Clearly provide the state of the evidence to highlight where additional sex and gender-specific evidence is required and drive future research.
6. Develop relevant implementation tools that assist clinicians in applying sex and gender-specific recommendations in practice.

Race and Ethnicity

Epidemiologic studies have found that racial and ethnic minorities have an increased incidence of TBI than Caucasians (Bazarian et al., 2003; Jager et al., 2000). Racial and ethnic minorities are more likely to experience longer emergency department wait times, a greater number of inpatient complications, lower quality of rehabilitation services received, higher likelihood of early discharge, lower levels of community integration, lower rates of employment, increased disability, increased levels of caregiver burden and challenges coping with TBI, reduced life satisfaction and quality of life among many other disparities (Saadi et al., 2022). Potential contributing factors include adverse childhood experiences, lack of tailored interventions and services for diverse patient populations, societal factors, institutional racism and policy-level factors influencing employment opportunities and community resources (Saadi et al., 2022).

Cultural competence within healthcare is defined as: "the ability of providers and organizations to understand and integrate these factors into the delivery and structure of the health care system. The goal of culturally competent health care services is to provide the highest quality of care to every patient, regardless of race, ethnicity, cultural background, English proficiency or literacy." (https://hpi.georgetown.edu/cultural/)

Some common strategies for improving the patient-provider interaction and institutionalizing changes in the health care system include:

1. Provide interpreter services
2. Recruit and retain minority staff
3. Provide training to increase cultural awareness, knowledge, and skills
4. Coordinate with traditional healers
5. Use community health workers
6. Incorporate culture-specific attitudes and values into health promotion tools
7. Include family and community members in health care decision making
8. Locate clinics in geographic areas that are easily accessible for certain populations
9. Expand hours of operation
10. Provide linguistic competency that extends beyond the clinical encounter to the appointment desk, advice lines, medical billing, and other written materials

Developed by: https://hpi.georgetown.edu/cultural/

The Canadian TBI Guideline approach will use the following strategies to promote culturally competent and informed care:

1. Provide a clear definition of "race," "systemic racism," and "ethnicity." The definitions for race, systemic racism, and ethnicity provided by the Canadian Institute for Health Information (CIHI) will be used:
   1. Race: a social construct used to judge and categorize people based on perceived differences in physical appearance in ways that create and maintain power differentials within social hierarchies. There is no scientifically supported biological basis for discrete racial groups.
   2. Systemic Racism: racism that occurs at societal and organizational levels, giving rise to other forms of racism. It is often pervasive and subtle, and not always intentional. It is embedded in societal and institutional policies, regulations, legislation and ideologies that perpetuate racial disadvantage.
   3. Ethnicity: a multi-dimensional concept referring to community belonging and a shared cultural group membership. It is related to socio-demographic characteristics, including language, religion, geographic origin, nationality, cultural traditions, ancestry and migration history, among others.
2. Use critical race theory as a framework during the guideline update process (Flanagin et al., 2021). Critical race theory helps us to understand the effect of racism on differences in outcomes for racially marginalized groups. Two tenets of critical race theory are beneficial when discussing clinical practice guidelines:
   1. Tenet 1: Critiquing the notion of race as a biological factor or a biological plausibility for conclusions in research. Race will not be considered a risk factor for pathology as it is socio-politically constructed and assigned.
   2. Tenet 2: Examining racial essentialism to better understand intersectionality. Clinical practice guidelines should not "essentialize race as a key variable" that can explain all health disparities as it can perpetuate structural racism within medicine (Gilliam et al., 2022). We will focus our efforts on identifying and helping to overcome barriers that have contributed to the marginalization of individuals (e.g., structural racism, poverty, and access to care). For instance, in circumstances where a particular disparity is reported within a certain racial group, the expert panel will explore the barriers that individuals within this racial group may experience when seeking care, including how systemic racism affects an individual's health and poverty.
3. Describe and discuss ongoing research and gaps in clinical practice related to race and ethnicity and make recommendations toward practice change. Examples of the appropriate use of race within future directions are provided by Gilliam and colleagues (2022).

To review evidence-based recommendations, click HERE

Glossary of Related Terms

The terms below are relevant to these concepts and may be used in the Guideline where appropriate:

Colonialism: colonization is not only a process of taking political control over Indigenous lands, but also a system designed to maintain power and influence (e.g., imposition of colonial institutions of education, health care and law).

Cultural Competence: the ability of providers and organizations to understand and integrate these factors into the delivery and structure of the health care system. The goal of culturally competent health care services is to provide the highest quality of care to every patient, regardless of race, ethnicity, cultural background, English proficiency or literacy.

Culture: the overt and subtle value systems, traditions and beliefs that influence our decisions and actions.

Ethnicity: a multi-dimensional concept referring to community belonging and a shared cultural group membership. It is related to socio-demographic characteristics, including language, religion, geographic origin, nationality, cultural traditions, ancestry and migration history, among others.

Gender: socially constructed roles, behaviours, expressions, and identities of girls, women, boys, men, and gender-diverse people, including how people perceive themselves and each other, how they act and interact, and the distribution of power and resources in society.

Health Equity: the absence of unjust, avoidable differences in health care access, quality, experience or outcomes.

Health Inequality: differences in health between individuals, groups or communities. Measuring health inequalities is a first step toward identifying and reducing health inequities.

Implicit Bias: unconscious thoughts, attitudes or reactions that precipitate unintentional discriminatory behaviour.

Internalized Racism: the acceptance by a marginalized racialized group of negative messages concerning their abilities and worth.

Race: a social construct used to judge and categorize people based on perceived differences in physical appearance in ways that create and maintain power differentials within social hierarchies. There is no scientifically supported biological basis for discrete racial groups.

Racialized Group: a social construct describing groups that have racial meanings associated with them that affect their economic, political and social life. This term is sometimes preferred over "race" because it acknowledges the process of racialization.

Racism: includes thoughts or actions that establish or reinforce the superiority or dominance of one racialized group over another. Racism exists on a spectrum and acts on multiple levels — internalized, interpersonal and systemic.

Reference List

Bazarian JJ, Pope C, McClung J, Cheng YT, Flesher W. Ethnic and racial disparities in emergency department care for mild traumatic brain injury. Acad Emerg Med. 2003(10), 1209–17.

Cooper KD, Tabaddor K, Hauser WA, Shulman K, Feiner C, Factor PR. The Epidemiology of Head Injury in the Bronx. Neuroepidemiology. 1983(2), 79–88.

Flanagin, A., Frey, T., Christiansen, S. L., & AMA Manual of Style Committee. (2021). Updated guidance on the reporting of race and ethnicity in medical and science journals. Jama, 326(7), 621-627.

Guidance on the use of standards for race-based and Indigenous identity data collection and health reporting in Canada. Ottawa: Canadian Institute for Health Information; 2022. Available: https://www.cihi.ca/sites/default/files/document/guidance-and-standards-for-race-based-and-indigenous-identity-data-en.pdf (accessed 2023 Jan. 16).

Jager TE, Weiss HB, Coben JH, Pepe PE. Traumatic brain injuries evaluated in US emergency departments, 1992-1994. Acad Emerg Med. 2000;7:134-40.

Mollayeva, T., Mollayeva, S., & Colantonio, A. (2022). The implications of sex and gender in traumatic brain injury. In Cellular, Molecular, Physiological, and Behavioral Aspects of Traumatic Brain Injury (pp. 13-28). Academic Press.

Saadi, A., Bannon, S., Watson, E., & Vranceanu, A. M. (2021). Racial and ethnic disparities associated with traumatic brain injury across the continuum of care: a narrative review and directions for future research. J Racial Ethn Health Disparities, 1-14.

Song, M. M., Simonsen, C. K., Wilson, J. D., & Jenkins, M. R. (2016). Development of a PubMed based search tool for identifying sex and gender specific health literature. J Women's Health, 25(2), 181-18

Tannenbaum, C., Norris, C. M., & McMurtry, M. S. (2019). Sex-specific considerations in guidelines generation and application. Can J Cardiol, 35(5), 598-605.