Why health equity matters and how to address it ... - KT Canada
WHY HEALTH EQUITY MATTERS AND HOW TO ADDRESS IT IN YOUR SYSTEMATIC REVIEW Vivian Welch Bruyere Research Institute, Ottawa Cochrane and Campbell Equity Methods Group Acknowledgements David Moher, Jennifer ONeill, Mark Petticrew, Peter Tugwell, PRISMA-Equity Bellagio Group: Rifat Atun, Imperial College London, UK; Shally Awasthi, King George's Medical College, India; Virginia Barbour, PLOS Medicine, UK; Zulfiqar Bhutta, Husein Laljee Dewraj Professor and Chairman, Department of Paediatrics and Child Health, Aga Khan University Medical Center, Pakistan; Luis Gabriel Cuervo, Research Promotion & Development, Pan American Health Organization, USA; Jeremy Grimshaw, Ottawa Hospital Research Institute, Canada; Trish Groves, Deputy Editor, BMJ, UK; Tracey Koehlmoos-Perez, Health Systems and Infectious Disease Division, International Centre for Diarrhoeal Disease Research (ICDDR,B), Bangladesh; Elizabeth Kristjansson, School of Psychology, Faculty of Social Sciences, University of Ottawa, Canada; David Moher, Ottawa Hospital Research Institute, Canada; Jennifer O'Neill, Campbell and Cochrane Equity Methods Group, Centre for Global Health, University of Ottawa, Canada; Andy Oxman, Global Health Unit, Norwegian
Knowledge Centre for Health Services, Cochrane EPOC Review Group, WHO Advisory Committee on Health Research, Norway; Tomas Pantoja, Universidad Catlica de Chile, Santiago, Systematic Review Methods Centre Cochrane EPOC editor, Alliance for Health Systems and Policy Research, Chile; Mark Petticrew, London School of Hygiene and Tropical Medicine, Campbell and Cochrane Equity methods group, UK; Terri Pigott, Campbell Methods Coordinating Group; Campbell Statistics Group, Loyola University Chicago, USA; Kent Ranson, Alliance for Health Systems and Policy Research, WHO, Switzerland; Tessa TanTorres, World Health Organization, Choosing Interventions that are Cos-Effective (WHO-CHOICE), Switzerland; Prathap Tharyan, Cochrane Evidence Aid, Department of Psychiatry; Cochrane Schizophrenia Group; Coordinator, South Asian Cochrane Network - India, India; David Tovey, The Cochrane Library, UK; Peter Tugwell, University of Ottawa, Cochrane Musculoskeletal Review Group, Campbell and Cochrane Equity methods group, Canada; Jimmy Volmink, Cochrane HIV/AIDS Review Group; South Africa Cochrane Centre, Medical Research Council of South Africa; Stellenbosch University, South Africa; Liz Wager, Sideview, UK; Elizabeth Waters, Melbourne School of Population Health, The University of Melbourne, Australia; Vivian Welch, Ottawa Hospital Research Institute, Campbell and Cochrane Equity Methods Group, Institute of Population Health, Centre for Global Health, University of Ottawa, Canada; George Wells, Cardiovascular Research Methods Centre, University of Ottawa Heart Institute, Cochrane Non- Learning objectives
To become familiar with concepts of health equity, and how health equity is considered in systematic reviews To become familiar with methods used to develop these PRISMA-Equity reporting guidelines To understand knowledge translation efforts used for PRISMA-Equity and discuss how to monitor their impact using altmetrics and other indicators Campbell and Cochrane Equity Methods Group Encourages to include descriptions of
effect on the disadvantaged ability to reduce socioeconomic inequalities in health promote their use to the wider community Ultimate goal: build the evidence base on such interventions and increase our capacity to act on the health gap between rich and poor. Why do we need Equity Methods Group? 1. 2. 3. 4.
5. 6. Average conceal differences in subgroups Interventions aimed to reduce inequities benefit the affluent and middle class more than the poor Millennium development goals targets can be met without improving health of the poor Staircase effect: need more effort to reach poorest Health interventions may increase health inequities Importance of Social Determinants of Health equity.cochrane.org Equity Methods Group Meet the team:
Migrant Health Subgroup: Govinda Dahal, Kevin Pottie Sex/Gender Methods Group: Madeline Boscoe, Stephanie Coen, Marion Doull, Lorri Puil, Vivien Runnels, Bev Shea, Sari Tudiver http://equity.cochrane.org Health inequity Difference in Health Outcomes Unavoidable Acceptable Potentially
avoidable Unacceptable and unjust 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. - Whitehead, 1992 Talk with your neighbour Example of an unfair and avoidable difference in health outcomes Intervention that could be effective in improving health of the worst-off PROGRESS + PROGRESS (ONeill et al. 2014)
Place of residence Race/ethnicity/culture/language Occupation Gender/sex Religion Education Socioeconomic status Social Capital . . . . . . .
PROGRESS + Plus (Oliver et al. 2012) 1. Personal characteristics associated with discrimination and/or exclusion (e.g. age, disability); 2. Features of relationships (e.g. smoking parents, excluded from school); 3. Time-dependant relationships (e.g. leaving the hospital, respite care, other instances where a person may be temporarily at a disadvantage). Effective Intervention examples PROGRESS factor Religion LMI C HIC
Educati on LMI C HIC Burden of disease Efficacious Intervention In East Africa, uncircumcised Medical circumcision for men is Christian males are at effective at preventing heterosexual increased risk of HIV infection ( HIV transmission and has been shown 58). to be acceptable to men from studies in Uganda, Kenya, and South Africa ( 59-61). Lower immunization rates
Vaccine information provided by among Amish populations trusted medical providers leads to leads to outbreaks of disease ( increased immunization rates (63). 62). Prevalence and length of Educating girls and mothers can childhood diarrhoea episodes improve food safety and reduces the are inversely related to risk of diarrhoea for infants (65). mothers education(64). Lower maternal and paternal Education (for both boys and girls) education is associated with leads to increased likelihood of reduced rates of breastfeeding breastfeeding initiation (66). (66). Learning objectives
To become familiar with concepts of health equity, and how health equity is considered in systematic reviews To become familiar with methods used to develop these PRISMA-Equity reporting guidelines To understand knowledge translation efforts used for PRISMA-Equity and discuss how to monitor their impact using altmetrics and other indicators PRISMA-E 2012 Talk with your neighbour What types of questions for systematic reviews require a
significant focus on health equity and might need different methods? What is an equity focused SR? Systematic reviews with a major focus on health equity are those designed to: 1. Assess effects of interventions in disadvantaged population(s) 2. Assess effects of interventions aimed at reducing social gradients across populations and/or 3. Assess effects of interventions not aimed at reducing inequity but where it is important to understand the effects of the intervention on equity, either positively or negatively Overarching Goals: PRISMA-Equity 2012 17
Improve evidence-base for equityoriented policy by : Providing clear guidance on reporting equity-focused systematic review methods Emphasizing the importance of reporting health equity results Developing reporting guidelines: steps from Moher et al 2010 18 19 20 22
Reporting of population characteristics: Cochrane review, n=34 studies LMIC Place of residence Race/ethnicity/culture Occupation Gender Religion Education Socioeconomic status Social capital Welch et al 2010 SRs (n=95) Primary studies (n=260) 23
24 Global Survey Survey open from December 17, 2011 until January 5, 2012 Plos Medicine blog BMJ blog Equity listserv
HIFA2015 listserv Evidence Based Health listserv KT Canada listserv CHAIN listserv EQUIDAD listserv
SR Round Table listserv DialoguePH listserv Equity.cochrane.org website CGH website 3ie website Campbell Collaboration website NCCMT website http://www.h2mw.eu/redac tionmedicale/ website NCCDH website and twitter Cochrane facebook Respondents, n=325 (423 for first question)
44% members of Cochrane or Campbell review group field, or methods group 20% equity (EQUIDAD) listserv, 20% evidence-based health listserv 51% with over 5 years systematic review experience (27% over 10 years) 26% systematic review authors, 16% clinicians/practitioners, 11% methodologists How was our response? Reporting health equity is important in systematic reviews. Equity Extension A: Equity in title Equity Extension B: Abstract reports how health equity is considered Equity Extension C: Abstract reports effects on health equity
Equity Extension D: Analytic framework shows effects on health equity Equity Extension E: Theory-based rationale related to health inequity Equity Extension F: Describe how disadvantage is planned to be assessed Equity Extension G: Likelihood of different relative effects for any of PROGRESS+ populations Equity Extension H: Rationale for eligible study designs to assess effects on health inequalities Equity Extension I: Outcomes relevant for disadvantaged Equity Extension J: Equity search strategies Equity extension, K- method of assessing inequalities Equity Extension L: Subgroup analysis related to health equity Equity Extension M: Effect Modifiers related to health equity Dont Know Strongly disagree Disagree
43.0 47.0 4.8 4.9 1.5 0.9 2.7 4.3 Survey Results Reporting health equity is important in systematic reviews. Equity Extension A: Equity in title Equity Extension B: Abstract reports how health equity is considered Equity Extension C: Abstract reports effects on health equity Equity Extension D: Analytic framework shows effects on health equity
Equity Extension E: Theory-based rationale related to health inequity Equity Extension F: Describe how disadvantage is planned to be assessed Equity Extension G: Likelihood of different relative effects for any of PROGRESS+ populations Equity Extension H: Rationale for eligible study designs to assess effects on health inequalities Equity Extension I: Outcomes relevant for disadvantaged Equity Extension J: Equity search strategies Equity extension, K- method of assessing inequalities Equity Extension L: Subgroup analysis related to health equity Equity Extension M: Effect Modifiers related to health equity Dont Know Strongly disagree Disagree Agree
47.0 4.8 4.9 1.5 0.9 2.7 4.3 29 30 Face to face consensus meeting Held February 8-10, 2012: Rockefeller
Foundation, Bellagio Center, Italy 20 participants from 12 countries 31 PRISMA-E: Reporting guidelines for equityfocused SRs Section Title Title Ite Standard PRISMA Item m Extension for Equity-Focused Reviews 1 Identify equity as a focus of the review, if relevant, using the term equity Abstract
Structure 2 d summary 2A 2B Introduct ion Rationale 3 Identify the report as a systematic review, meta-analysis, or both. 2. Provide a structured summary including, as State research question(s) related to health applicable: background; objectives; data equity. sources; study eligibility criteria, participants, and interventions; study appraisal and synthesis methods; results; limitations; conclusions and implications of key findings; systematic review registration number. Present results of health equity analyses (e.g.
subgroup analyses or meta-regression). Describe extent and limits of applicability to disadvantaged populations of interest. Describe the rationale for the review in the context of what is already known. 3A Objective 4 s Provide an explicit statement of questions being addressed with reference to participants, interventions, comparisons, Describe assumptions about mechanism(s) by which the intervention is assumed to have an impact on health equity. Provide the logic model/analytical framework, if done, to show the pathways through which the intervention is assumed to affect health equity and how it was developed.
Describe how disadvantage was defined if used as criterion in the review (e.g. for selecting studies, conducting analyses or judging PRISMA-E: Reporting guidelines for equity-focused SRs Section Ite Standard PRISMA Item m Methods Eligibility 6 criteria 6A Informati 7 on sources Search 8
Data items 11 Synthesis 14 of results Additiona 16 l analyses 6. Specify study characteristics (e.g., PICOS, length of follow-up) and report characteristics (e.g., years considered, language, publication status) used as criteria for eligibility, giving rationale. Extension for Equity-Focused Reviews Describe the rationale for including particular study designs related to equity research questions.
Describe the rationale for including the outcomes - e.g. how these are relevant to reducing inequity. Describe all information sources (e.g., Describe information sources (e.g. health, nondatabases with dates of coverage, contact with health, and grey literature sources) that were study authors to identify additional studies) in searched that are of specific relevance to the search and date last searched. address the equity questions of the review. Present full electronic search strategy for at Describe the broad search strategy and terms least one database, including any limits used, used to address equity questions of the review. such that it could be repeated. List and define all variables for which data List and define data items related to were sought (e.g., PICOS, funding sources) and equity,where such data were sought (e.g. using any assumptions and simplifications made. PROGRESS-Plus or other criteria, context). Describe the methods of handling data and Describe methods of synthesizing findings on combining results of studies, if done, including health inequities (e.g. presenting both relative measures of consistency (e.g., I2) for each and absolute differences between groups).
meta-analysis. Describe methods of additional analyses (e.g., Describe methods of additional synthesis sensitivity or subgroup analyses, metaapproaches related to equity questions, if done, regression), if done, indicating which were pre- indicating which were pre-specified specified. PRISMA-E: Reporting guidelines for equity-focused SRs Section Ite m Results Study 18 characteri stics Synthesis of results 21
Additional 23 analysis Discussion Conclusion 26 s 26A Standard PRISMA Item Extension for Equity-Focused Reviews For each study, present characteristics for which data were extracted (e.g., study size, PICOS, follow-up period) and provide the citations. Present results of each meta-analysis done, including confidence intervals and measures of consistency. Give results of additional analyses, if done (e.g., sensitivity or subgroup analyses, metaregression [see Item 16]).
Present the population characteristics that relate to the equity questions across the relevant PROGRESS-Plus or other factors of interest. Provide a general interpretation of the results in the context of other evidence, and implications for future research. Present extent and limits of applicability to disadvantaged populations of interest and describe the evidence and logic underlying those judgments. Provide implications for research, practice or policy related to equity where relevant (e.g. types of research needed to address unanswered questions). Present the results of synthesizing findings on inequities (see 14). Give the results of additional synthesis approaches related to equity objectives, if done, (see 16).
Learning objectives To become familiar with concepts of health equity, and how health equity is considered in systematic reviews To become familiar with methods used to develop these PRISMA-Equity reporting guidelines To understand knowledge translation efforts used for PRISMA-Equity and discuss how to monitor their impact using altmetrics and other indicators With thanks Knowledge translation
models Push Pull Linkage and exchange Knowledge brokers Push models Five key questions What should be transferred? To whom should research knowledge be
transferred? By whom should research knowledge be transferred? How should research knowledge be transferred? With what effect should research knowledge be transferred? Lavis JN, Robertson D, Woodside JN, Mcleod CB, Abelson J (2003) Milbank Quarterly Disseminating PRISMAEquity Primary audience Reviewers use PRISMA-Equity to guide conduct and reporting of systematic reviews Secondary audiences
Editors require PRISMA-Equity to be used in submitted SRs Funders require PRISMA-Equity to be use in final reports of SRS Users of reviews (consumers, health care professionals, decision makers) be aware of PRISMA-Equity, better understanding of quality of systematic reviews. Disseminating PRISMA-Equity Barriers to change Reviewers
knowledge about scientific conduct of SRs (in general) and PRISMA-Equity in particular); attitudes about importance of scientific conduct of SRs; failure to use PRISMA-Equity when planning review ease/difficulty of use (retrofitting flow diagram) Lack of incentives Disseminating PRISMA-Equity Barriers to change Editors lack of knowledge, negative or
ambivalent attitudes, concerns about irritating authors, resources to police PRISMA-Equity Funders - lack of knowledge, negative or ambivalent attitudes (lack of requirement for final reports!) Users lack of knowledge Disseminating PRISMA-Equity Possible approaches Reviewers Multiple channel approach to promote PRISMA- Equity
Publication in high impact journal User friendly version of elaboration document (how to do a SR that is compliant with PRISMA-Equity) Resources for SR courses Web resources Journal/funder Equity requirement to use PRISMA- Disseminating PRISMA-Equity Possible approaches
Editors/funders Linkage and exchange Practical tools Users Multiple channel approach to promote PRISMA- Equity Publication in high impact journal User friendly version of elaboration document (how to identify a high quality (PRISMA-Equity compliant) SR Talk to your neighbour
What are the top 2 strategies you suggest we pursue to optimize our KT? PRISMA-E 2012: Conferences Official launch: Beijing Health Systems Symposium 2012 Conferences: Cochrane Canada Symposium 2013, IGH conference 2012, Peer Review Congress 2013, Cochrane Canada Symposium 2014 Webinars: Cochrane Canada 2013, KT Canada 2014 Linkage and exchange CIHR IGH newsletter: Spring 2013 CIHR Knowledge synthesis program
CIHR IGH Newsletter, Spring 2013 CIHR knowledge synthesis resources Web resources and other strategies EQUATOR-Network Social Media: twitter: @CochraneEquity, @vawelch Published in Spanish in PAHO journal
Explanation and Elaboration paper, in development Cochrane Handbook chapter on Equity Web resources: online checklist on our website Twitter examples Downloadable checklist Results so far: Viewed 12,283 times Downloaded 1780 times Cited 20 times (22 times on Google
Scholar) Saved 35 times into citeulike and Mendeley Shared 106 times Talk with your neighbour What other outcomes related to impact and KT would be helpful? The next 20 years of equity-focused systematic reviews JECH, 2014 Please help us! What else should we do regarding knowledge translation
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