Trauma-informed approaches in primary healthcare and community mental healthcare: a mixed methods systematic review of system change interventions (TAPCARE study)

Abstract

A Trauma-informed approach in healthcare services is a framework for system-level interventions that address the universal prevalence and impact of trauma. This mixed methods systematic review integrated evidence on the models, effects, and programme theories of trauma-informed system-level interventions in primary healthcare and community mental healthcare. We searched five electronic databases (January 1990-June 2021) and grey literature and consulted subject experts. The quantitative descriptive and qualitative framework syntheses were integrated through a line of argument and mapped onto a logic model. We included six studies (two non-randomised quantitative, one non-randomised mixed methods, three qualitative) that evaluated eight interventions with varied theoretical development, components, and outcome measures. The common components were budget allocation, workforce development, identification/response to violence and trauma, evaluation. The varied outcomes were grouped into eleven domains and mapped onto intermediate psychological/behavioural and long-term health outcomes constructs of the logic model. We found limited conflicting evidence for intervention effects on patient and provider psychological, behavioural, and health outcome domains. Four studies reported improvement in organisational readiness to provide trauma-informed care and sense of community while three reported conflicting effects on provider behaviour. Four studies reported some improvement in patient readiness for disease management and access to services; however, the evidence for patient satisfaction was conflicting. Two studies found that patients and providers felt safe. Interventions worked as a whole package and through tailoring to the local context, staff education and self-care activities, safe environments, shared decision making. Intervention effects were moderated by contextual (health system values, policies, governance, business models, trauma-informed movement, organisational culture, social determinants of health) and intervention factors (buy-in from all staff, collective learning through conversations, equal attention to well-being of staff and patients, sustainable funding). No studies measured adverse events/harm, cost effectiveness, staff health.

Competing Interest Statement

The authors have declared no competing interest.

Clinical Protocols

https://bmjopen.bmj.com/content/11/2/e042112

Funding Statement

This study was funded by the NIHR Biomedical Research Centre at University Hospitals Bristol NHS Foundation Trust and the University of Bristol. The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.

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Data Availability

All data produced in the present work are contained in the manuscript.

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