Development of A Mental Health Inclusive Pediatric Traumatic Brain Injury Register for Low-Resource Settings (The Grey Register)

Abstract

Background/Objectives:Pediatric traumatic brain injury (pTBI) is a leading cause of injury-related morbidity and mortality among children globally and is associated with significant long-term neuropsychiatric sequelae. These complications affect academic achievement, social functioning, emotional regulation, and behavioral development, contributing to broader public health and socioeconomic challenges worldwide. While high-income countries (HICs) have advanced the understanding of pTBI outcomes through structured data systems and longitudinal research, data from low- and middle-income countries (LMICs), particularly in sub-Saharan Africa, remain scarce and fragmented. Strengthening context-appropriate data systems is therefore essential to improve documentation, support research, and enable long-term follow-up of pTBI outcomes. Methods: This mixed-method study employed a retrospective record review and qualitative interviews. The quantitative component involved analyzing 156 pediatric TBI cases (<18 years) managed and followed up at Lagos State University Teaching Hospital (LASUTH) between 2020 and 2024 to identify documentation gaps across the care pathway. The qualitative component included 20 in-depth interviews with multidisciplinary healthcare providers, data managers, and policymakers to assess the feasibility of implementing a multi-disciplinary mental health-inclusive pTBI registry. Results: Documentation completeness varied across domains representing various stages of the care continuum. Acute clinical management variables demonstrated the highest completeness (96.03%), whereas follow-up and long-term outcome documentation exhibited the lowest completeness (12.66%). Mental health documentation was markedly limited: although some behavioral symptoms and diagnoses were partially recorded, no standardized mental health assessment tools were documented. Interview participants described documentation practices as treatment-focused, summary-based, and constrained by workload pressures in a high-volume tertiary setting. While the current paper-based system was perceived as fragmented and vulnerable to data loss, there was strong cross-disciplinary support for a structured, digital, mental health–inclusive registry. Implementation challenges included infrastructure instability, workforce shortages, limited hardware availability, and the need for structured training. Conclusion: Findings suggest that institutional willingness to improve documentation practices exists, and that barriers to implementation are structural rather than ideological. Documentation gaps across the pediatric TBI care pathway, particularly in mental health assessment and long-term follow-up, underscore the need for structured data systems in resource-limited trauma settings. Implementing a context-adapted registry could enhance clinical coordination, strengthen research capacity, and improve long-term outcomes for children with pTBI in LMICs.