The experience of traumatic brain injury in Botswana

Traumatic Brain Injury (TBI) is commonly associated with a number of physical, cognitive and behavioral changes, which have a significant, long-term impact on peoples’ ability to perform previous life roles. The consequences of TBI also impact on caregivers and families. The outcomes of TBI have been well documented in Western cultures, but much less so in non-Western countries. Whilst there is some evidence that cultural background and beliefs affect responses to TBI and outcome, the knowledge base is inadequate in low and middle-income countries where health services and socioeconomic factors are different from those of high income industrialised nations. More relevant to this current study, there are issues unique to Botswana, which have not received research attention. There is currently no information regarding the specific needs of people with TBI in Botswana, whose care and outcomes may be influenced by socio-cultural factors, economic factors, the country’s small population, lack of infrastructure, and the recency of development. Accordingly, in this doctoral thesis I aimed to: examine the cultural understandings and impact of injury on people with TBI in Botswana, including problems of a practical, vocational, social and psychological nature. Specifically, in this study I first explored the experiences of brain injury from the perspectives of individuals with TBI, their caregivers, and healthcare professionals. Treatment practices received by individuals with TBI and their caregivers’ experience within the healthcare system and local community were also examined. Second, I explored the beliefs about TBI amongst people who had sustained injury, their families, and healthcare workers involved in their care. I also explored the experiences of family caregivers of people with TBI and examined their psychological functioning. To gather this data, I employed a qualitative mixed-methods approach using semi structured interviews and questionnaires. Participants (people with moderate to severe TBI, caregivers and health care workers) were recruited from the two tertiary hospitals in the two capital cities, Francistown and Gaborone and data from a total of 71 participants were utilised in the studies. Results indicated that assault was a major cause of TBI in Botswana, along with motor vehicle accidents. Participants experienced a range of cognitive, sensory, emotional and behavioural effects of their injuries and they had numerous physical limitations largely consistent with those commonly associated with TBI. These consequences of TBI led to associated ongoing difficulties in areas such as education and employment and social and psychological functioning. Further, the common perceptions of the etiology of TBI among patients and their family caregivers was that TBI was associated with supernatural forces or witchcraft, bad luck, and the will of God. The study also revealed that for many participants, the quality of care received, both in and out of hospital, was low and there was limited knowledge and information provided about TBI, what to expect and how to care for the individual. This appeared to be associated with several factors including insufficient healthcare staff, language barriers, inadequate hospital services, a lack of training, and limited resources. The study further revealed that caregiving in the Botswana context creates a significant burden, for caregivers, with many having difficulty meeting the needs of their injured relatives. Caregivers of participants who were more dependent in activities of daily life tended to be very distressed, experiencing significant levels of depression and anxiety. Other factors that impacted negatively on caregivers’ wellbeing included growing social isolation, financial difficulty and a lack of support from distant relatives and friends. Despite the numerous challenges that caregivers faced, it was clear from this study that Batswana have a strong sense of family and strong community ties as well as faith in God. These mediators had a positive influence on their adjustment and participants with TBI and their families generally coped well and showed immense resilience in the face of adversity. Caregiving therefore resulted in certain reported positive effects for many families and brought families together. This research has highlighted some specific cultural, economic and social factors, which influence the experience of TBI in Botswana. There is clearly a need to improve communication, support and rehabilitation services. In addition to providing valuable feedback in formulating policies, the study findings can potentially contribute to the development of intervention programs at community, district and national levels. The study findings will provide the basis for development of culturally sensitive educational resources for people with TBI, their families and health professionals in Botswana