Evidence Aid Health equity in humanitarian emergencies: A role for Evidence Aid Kevin Pottie Scientist, Bruyère Research Institute and Campbell and Cochrane Collaborations Equity Methods Group; Departments of Family Medicine and Epidemiology and Community Medicine, Ottawa, Canada
Correspondence: Kevin Pottie, Scientist, Bruyère Research Institute and Campbell and Cochrane Collaborations Equity Methods Group; Departments of Family Medicine and Epidemiology and Community Medicine, 75 Bruyère Street, Ottawa, Canada K1N 5C8. Tel: 613-241-1154; Fax: 613-241-1154; Email:[email protected] Received 27 September 2014; accepted for publication 28 October 2014. Running title: Health equity in humanitarian emergencies. Keywords Health equity; Humanitarian emergencies; Evidence Aid
This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as doi: 10.1111/jebm.22137.
This article is protected by copyright. All rights reserved.
1
Abstract
Humanitarian emergencies require a range of planned and coordinated actions: security, healthcare, and, as this article highlights, health equity responses. Health equity is an evidence based science that aims to address unfair and unjust health inequality outcomes. New approaches are using health equity to guide the development of community programs, equity methods are being used to identify disadvantaged groups that may face health inequities in a humanitarian emergency, and equity is being used to prevent unintended harms and consequences in interventions. Limitations to health equity approaches include acquiring sufficient data to make equity interpretations, integrating disadvantage populations in to the equity approach, and ensuring buy-in from decision makers. This article uses examples from World Health Organization, Refugee Health Guidelines and Health Impact Assessment to demonstrate the emerging role for health equity in humanitarian emergencies. It is based on a presentation at the Evidence Aid Symposium, on 20 September 2014, at Hyderabad, India.
This article is protected by copyright. All rights reserved.
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Introduction Humanitarian emergencies require decisive action, coordination among a range of inter-professional and international actors, close attention to security and logistics and programs to meet basic human needs(1). Until recently, humanitarian aid has been a field led by action and driven by passion and experience and this has brought benefits but also harms (2). Over the past decade, evidence in the form of effectiveness and harms, often with a focus on public health (3) or health systems has begun to play a bigger and bigger role in guidelines. (updatedWHO Handbook for Guideline Development, in press) One example of the role for evidence is the Evidence Aid knowledge translation program which emerged from the Indian Ocean Tsunami disaster. As organizations worked with survivors of the 2004 tsunami, members of The Cochrane Collaboration and other began to ask questions around the benefits and harms of interventions such as brief psychotherapy for victims of trauma. This approach changed the common wisdom that any intervention is worthwhile in a disaster, and sought to document the harms and benefits for field interventions. Why integrate health inequity considerations? Margaret Whitehead has defined health equity as “The term ‘inequity' has a moral and ethical dimension. It refers to differences which are unnecessary and avoidable but, in addition, are also considered unfair and unjust” (4). Health equity was identified by WHO’s Commission on Social Determinants as a key step to promote health equity, for example in relation to Health Equity Impact Assessment (5,6). Health equity is a strategic priority for WHO, United Kingdom’s NICE, Public Health Agency of Canada, and a GRADE Methods group which sets the methods for evidence based guidelines. Addressing health equities may require additional methods and steps, and these steps need to be clearly reported. See, for example, the PRISMA-Equity Reporting Guideline (7). Health equity is another key element that is being recognized as a critical resource for settings caught in humanitarian crises. For example, strategies to improve health equity may assist in finding an entry point for equity oriented political will; they may strengthen state policy making capacity and service delivery; they may help build provider capacity to ensure equitable service provision and finally they may help harness non-governmental organisations (NGOs) as non-state providers (8). The integration of health equity may occur in several ways and using various equity methods and processes. Discussion In this section, I will focus on three health equity strategies that are relevant to humanitarian emergencies and provided examples for each. These include defining and finding room for health equity to strengthen policy and program assessment and modifications. Examples include recognition of health equity methods, which can be applied to systematic reviews and interventions to improve service delivery. And finally, the use of health equity methods to inform evidence based guidelines for migrant populations to improve health provider capacity. The commission on social determinants of health places health equity as a priority for health services worldwide. One concrete process that they have endorsed is the process that addresses program, policy change and using health impact assessment with health equity at the heart of that program (9). Using health equity as a driving force, this process collects data and engages disadvantaged communities, analyses data and puts forward recommendation to reduce health inequities (10). The Human Impact Partners (11) health impact assessment on the impact of deportation of non-status persons on American children in the US engaged NGOs, immigrant communities and public health officials in it health impact assessment. Another example of where a focus on health equity has assisted persons in humanitarian situations is the Canadian Refugee Health Guidelines (12). This evidence based guideline series develop equity methods to This article is protected by copyright. All rights reserved.
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adapt and tailor evidence for diverse refugee populations. Specifically, it considered baseline risks for populations, ethnicity, religion, lifestyles, refugee values and preferences and, finally, practitioner values and preferences (13). Refugee community advisors, public health and primary care practitioners worked together to produce relevant and equity oriented guidelines for newly arriving refugees from around the world. Ultimately, the effectiveness of interventions, programs and policies will benefit from an early consideration of health equity methods. This applies to both communities facing discrimination and limited resource, and persons living in humanitarian crises. The Equity Methods group, which works closely with PAHO, has developed several practical tools to assist in the integration of equity in applied research. For example, the Campbell and Cochrane Equity Methods Group were launched in 2004 as an official Cochrane Methods Group. Since then, it has built a network of researchers interested in equity and effectiveness and created an equity lens, the PRISMA-Equity checklist for considering equity in systematic reviews, and has monitored the inclusion of equity within systematic reviews (7). PRISMA- Equity uses the PROGRESS acronym to identify health equity factors that should be considered in research and programs. These are Place of residence; Racism/migration; Occupation; Gender; Religion; Education; Socioeconomic status; Social capital (14). PRISMA-Equity is a reporting guideline for equity-focused systematic reviews; such as an upcoming Cochrane Review on Rapid Voluntary Counselling and Treatment (VCT) (15). The checklist provides structured guidance on transparently reporting the methods and results of a review, and it aims to improve reporting of health outcome and health care use inequities. It brings equity into the process from the beginning, which can be important for stakeholder and decision maker engagement. The Equity Methods Group promotes equity in evidence-based research and up-take of research by providing policy and methods advice, providing training, knowledge translation (KT) and systematic reviews, monitoring quality of published reviews and serving as a discussion forum for equity methods and equity-focussed reviews. KT or implementation science helps to put evidence into practice. In order to maximize effects of health equity in systematic reviews, a KT strategy is recommended that focuses on appropriate end-users and recognizes messages are likely context-dependent. Early engagement with disadvantaged communities is an important step for this. For example, through the Cochrane Migrant Health subgroup- podcasts, open access checklist to guide practitioners, e-learning for students and decision aids for migrant communities (12). Conclusions Health equity guided research can show opportunities for equity oriented action, it can be used to strengthen the capacity of state policy making and to build provider capacity to ensure equitable service provision. In addition, it may be able to strengthen policy making and service delivery, and play a role in engaging non-state providers in equity efforts. Knowledge translation for health equity work demands early engagement with stakeholders and disadvantaged populations and tailoring of final recommendations and products.
This article is protected by copyright. All rights reserved.
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Reference 1. Ratnayake R, Degomme O, Roberts B, Spiegel P. Conflict and Health: seven years of advancing science in humanitarian crises. Conflict and health 2014; 8: 7. 2. Salama P, Spiegel P, Talley L, Waldman R. Lessons learned from complex emergencies over past decade. Lancet 2004; 364(9447):1801-13. 3. Leaning J, Spiegel P, Crisp J. Public health equity in refugee situations. Confl Health, 2011; 5: 6. 4. Whitehead M. The concepts and principles of equity and health. Int J Health Serv 1992; 22(3): 429-45. 5. Social determinants of health, Report by the Secretariat. World Conference on Social Determinants of Health, WHO, 2012. Avariable at: http://www.who.int/sdhconference/en/.(Accessed 30 Oct 2014) 6. Marmot M, Friel S, Bell R, Houweling TA, Taylor S. Closing the gap in a generation: health equity through action on the social determinants of health. Lancet 2008; 372(9650): 1661-9. 7. Welch V, Petticrew M, Tugwell P, Moher D, O'Neill J, Waters E, et al. PRISMA-Equity 2012 extension: reporting guidelines for systematic reviews with a focus on health equity. PLoS Med 2012; 9(10): e1001333. 8. Bornemisza O, Ranson MK, Poletti TM, Sondorp E. Promoting health equity in conflict-affected fragile states. Social Science & Medicine 2010;70:80-8. 9. Povall SL, Haigh FA, Abrahams D, Scott-Samuel A. Health Promot Int 2014; 29(4): 621-33. 10. Ontario Ministry of Health and Long Term Care. Health Equity Impact Assessment (HEIA) Tool. Avariable at: http://www.health.gov.on.ca/english/providers/pub/child/hbabies/policy_statement.html. (Accessed 30 Oct 2014) 11. Sara SMM, Alice HM, Jonathan HP, Lili FM. How Family-Focussed Immigration Reform Will Mean Better Health for Children and Families Health Impact Assessment. 2013, US, US Human Impact Partners . 12. Pottie K, Greenaway C, Feightner J, Welch V, Swinkels H, Rashid M, et al. Evidence-based clinical guidelines for immigrants and refugees. CMAJ 2011; 183(12): E824-925. 13. Tugwell P, Pottie K, Welch V, Ueffing E, Chambers A, Feightner J. Evaluation of evidence-based literature and formulation of recommendations for the clinical preventive guidelines for immigrants and refugees in Canada. CMAJ 2011; 183(12): E933-8. 14. O'Neill J, Tabish H, Welch V, Petticrew M, Pottie K, Clarke M, et al. Applying an equity lens to interventions: using PROGRESS ensures consideration of socially stratifying factors to illuminate inequities in health. J Clin Epidemiol 2014; 67(1): 56-64. 15. Pottie K, Dahal G, Logie C, Welch V. Rapid testing for improving uptake of HIV/AIDS services in people with HIV infection (Protocol). Cochrane Database of Systematic Reviews 2011; 11: CD003507.
This article is protected by copyright. All rights reserved.
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Correspondence: Kevin Pottie, Scientist, Bruyère Research Institute and Campbell and Cochrane Collaborations Equity Methods Group; Departments of Family Medicine and Epidemiology and Community Medicine, 75 Bruyère Street, Ottawa, Canada K1N 5C8. Tel: 613-241-1154; Fax: 613-241-1154; Email:[email protected] Received 27 September 2014; accepted for publication 28 October 2014. Running title: Health equity in humanitarian emergencies. Keywords Health equity; Humanitarian emergencies; Evidence Aid
This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as doi: 10.1111/jebm.22137.
This article is protected by copyright. All rights reserved.
1
Abstract
Humanitarian emergencies require a range of planned and coordinated actions: security, healthcare, and, as this article highlights, health equity responses. Health equity is an evidence based science that aims to address unfair and unjust health inequality outcomes. New approaches are using health equity to guide the development of community programs, equity methods are being used to identify disadvantaged groups that may face health inequities in a humanitarian emergency, and equity is being used to prevent unintended harms and consequences in interventions. Limitations to health equity approaches include acquiring sufficient data to make equity interpretations, integrating disadvantage populations in to the equity approach, and ensuring buy-in from decision makers. This article uses examples from World Health Organization, Refugee Health Guidelines and Health Impact Assessment to demonstrate the emerging role for health equity in humanitarian emergencies. It is based on a presentation at the Evidence Aid Symposium, on 20 September 2014, at Hyderabad, India.
This article is protected by copyright. All rights reserved.
2
Introduction Humanitarian emergencies require decisive action, coordination among a range of inter-professional and international actors, close attention to security and logistics and programs to meet basic human needs(1). Until recently, humanitarian aid has been a field led by action and driven by passion and experience and this has brought benefits but also harms (2). Over the past decade, evidence in the form of effectiveness and harms, often with a focus on public health (3) or health systems has begun to play a bigger and bigger role in guidelines. (updatedWHO Handbook for Guideline Development, in press) One example of the role for evidence is the Evidence Aid knowledge translation program which emerged from the Indian Ocean Tsunami disaster. As organizations worked with survivors of the 2004 tsunami, members of The Cochrane Collaboration and other began to ask questions around the benefits and harms of interventions such as brief psychotherapy for victims of trauma. This approach changed the common wisdom that any intervention is worthwhile in a disaster, and sought to document the harms and benefits for field interventions. Why integrate health inequity considerations? Margaret Whitehead has defined health equity as “The term ‘inequity' has a moral and ethical dimension. It refers to differences which are unnecessary and avoidable but, in addition, are also considered unfair and unjust” (4). Health equity was identified by WHO’s Commission on Social Determinants as a key step to promote health equity, for example in relation to Health Equity Impact Assessment (5,6). Health equity is a strategic priority for WHO, United Kingdom’s NICE, Public Health Agency of Canada, and a GRADE Methods group which sets the methods for evidence based guidelines. Addressing health equities may require additional methods and steps, and these steps need to be clearly reported. See, for example, the PRISMA-Equity Reporting Guideline (7). Health equity is another key element that is being recognized as a critical resource for settings caught in humanitarian crises. For example, strategies to improve health equity may assist in finding an entry point for equity oriented political will; they may strengthen state policy making capacity and service delivery; they may help build provider capacity to ensure equitable service provision and finally they may help harness non-governmental organisations (NGOs) as non-state providers (8). The integration of health equity may occur in several ways and using various equity methods and processes. Discussion In this section, I will focus on three health equity strategies that are relevant to humanitarian emergencies and provided examples for each. These include defining and finding room for health equity to strengthen policy and program assessment and modifications. Examples include recognition of health equity methods, which can be applied to systematic reviews and interventions to improve service delivery. And finally, the use of health equity methods to inform evidence based guidelines for migrant populations to improve health provider capacity. The commission on social determinants of health places health equity as a priority for health services worldwide. One concrete process that they have endorsed is the process that addresses program, policy change and using health impact assessment with health equity at the heart of that program (9). Using health equity as a driving force, this process collects data and engages disadvantaged communities, analyses data and puts forward recommendation to reduce health inequities (10). The Human Impact Partners (11) health impact assessment on the impact of deportation of non-status persons on American children in the US engaged NGOs, immigrant communities and public health officials in it health impact assessment. Another example of where a focus on health equity has assisted persons in humanitarian situations is the Canadian Refugee Health Guidelines (12). This evidence based guideline series develop equity methods to This article is protected by copyright. All rights reserved.
3
adapt and tailor evidence for diverse refugee populations. Specifically, it considered baseline risks for populations, ethnicity, religion, lifestyles, refugee values and preferences and, finally, practitioner values and preferences (13). Refugee community advisors, public health and primary care practitioners worked together to produce relevant and equity oriented guidelines for newly arriving refugees from around the world. Ultimately, the effectiveness of interventions, programs and policies will benefit from an early consideration of health equity methods. This applies to both communities facing discrimination and limited resource, and persons living in humanitarian crises. The Equity Methods group, which works closely with PAHO, has developed several practical tools to assist in the integration of equity in applied research. For example, the Campbell and Cochrane Equity Methods Group were launched in 2004 as an official Cochrane Methods Group. Since then, it has built a network of researchers interested in equity and effectiveness and created an equity lens, the PRISMA-Equity checklist for considering equity in systematic reviews, and has monitored the inclusion of equity within systematic reviews (7). PRISMA- Equity uses the PROGRESS acronym to identify health equity factors that should be considered in research and programs. These are Place of residence; Racism/migration; Occupation; Gender; Religion; Education; Socioeconomic status; Social capital (14). PRISMA-Equity is a reporting guideline for equity-focused systematic reviews; such as an upcoming Cochrane Review on Rapid Voluntary Counselling and Treatment (VCT) (15). The checklist provides structured guidance on transparently reporting the methods and results of a review, and it aims to improve reporting of health outcome and health care use inequities. It brings equity into the process from the beginning, which can be important for stakeholder and decision maker engagement. The Equity Methods Group promotes equity in evidence-based research and up-take of research by providing policy and methods advice, providing training, knowledge translation (KT) and systematic reviews, monitoring quality of published reviews and serving as a discussion forum for equity methods and equity-focussed reviews. KT or implementation science helps to put evidence into practice. In order to maximize effects of health equity in systematic reviews, a KT strategy is recommended that focuses on appropriate end-users and recognizes messages are likely context-dependent. Early engagement with disadvantaged communities is an important step for this. For example, through the Cochrane Migrant Health subgroup- podcasts, open access checklist to guide practitioners, e-learning for students and decision aids for migrant communities (12). Conclusions Health equity guided research can show opportunities for equity oriented action, it can be used to strengthen the capacity of state policy making and to build provider capacity to ensure equitable service provision. In addition, it may be able to strengthen policy making and service delivery, and play a role in engaging non-state providers in equity efforts. Knowledge translation for health equity work demands early engagement with stakeholders and disadvantaged populations and tailoring of final recommendations and products.
This article is protected by copyright. All rights reserved.
4
Reference 1. Ratnayake R, Degomme O, Roberts B, Spiegel P. Conflict and Health: seven years of advancing science in humanitarian crises. Conflict and health 2014; 8: 7. 2. Salama P, Spiegel P, Talley L, Waldman R. Lessons learned from complex emergencies over past decade. Lancet 2004; 364(9447):1801-13. 3. Leaning J, Spiegel P, Crisp J. Public health equity in refugee situations. Confl Health, 2011; 5: 6. 4. Whitehead M. The concepts and principles of equity and health. Int J Health Serv 1992; 22(3): 429-45. 5. Social determinants of health, Report by the Secretariat. World Conference on Social Determinants of Health, WHO, 2012. Avariable at: http://www.who.int/sdhconference/en/.(Accessed 30 Oct 2014) 6. Marmot M, Friel S, Bell R, Houweling TA, Taylor S. Closing the gap in a generation: health equity through action on the social determinants of health. Lancet 2008; 372(9650): 1661-9. 7. Welch V, Petticrew M, Tugwell P, Moher D, O'Neill J, Waters E, et al. PRISMA-Equity 2012 extension: reporting guidelines for systematic reviews with a focus on health equity. PLoS Med 2012; 9(10): e1001333. 8. Bornemisza O, Ranson MK, Poletti TM, Sondorp E. Promoting health equity in conflict-affected fragile states. Social Science & Medicine 2010;70:80-8. 9. Povall SL, Haigh FA, Abrahams D, Scott-Samuel A. Health Promot Int 2014; 29(4): 621-33. 10. Ontario Ministry of Health and Long Term Care. Health Equity Impact Assessment (HEIA) Tool. Avariable at: http://www.health.gov.on.ca/english/providers/pub/child/hbabies/policy_statement.html. (Accessed 30 Oct 2014) 11. Sara SMM, Alice HM, Jonathan HP, Lili FM. How Family-Focussed Immigration Reform Will Mean Better Health for Children and Families Health Impact Assessment. 2013, US, US Human Impact Partners . 12. Pottie K, Greenaway C, Feightner J, Welch V, Swinkels H, Rashid M, et al. Evidence-based clinical guidelines for immigrants and refugees. CMAJ 2011; 183(12): E824-925. 13. Tugwell P, Pottie K, Welch V, Ueffing E, Chambers A, Feightner J. Evaluation of evidence-based literature and formulation of recommendations for the clinical preventive guidelines for immigrants and refugees in Canada. CMAJ 2011; 183(12): E933-8. 14. O'Neill J, Tabish H, Welch V, Petticrew M, Pottie K, Clarke M, et al. Applying an equity lens to interventions: using PROGRESS ensures consideration of socially stratifying factors to illuminate inequities in health. J Clin Epidemiol 2014; 67(1): 56-64. 15. Pottie K, Dahal G, Logie C, Welch V. Rapid testing for improving uptake of HIV/AIDS services in people with HIV infection (Protocol). Cochrane Database of Systematic Reviews 2011; 11: CD003507.
This article is protected by copyright. All rights reserved.
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