Why health equity matters and how to address it ... - KT Canada

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

Agree Strongly Agree Proposed equity extension item Responses (%) 61.7 37.3 33.3 47.9 2.4 9.3 1.2 1.0 1.4 4.5

51.8 39.3 5.5 1.3 2.1 48.5 40.4 7.0 0.8 3.3 31.4

42.8 14.7 2.8 8.3 33.1 47.3 12.6 1.7 5.3 48.0 41.8

5.1 0.9 4.3 38.8 46.3 8.6 1.1 5.2 33.8 44.5 13.6

1.5 6.5 36.3 46.2 51.4 39.3 6.6 9.6 0.6 1.5 5.1 3.3 47.9 43.0

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

Strongly Agree Proposed equity extension item Responses (%) 61.7 37.3 33.3 47.9 2.4 9.3 1.2 1.0 1.4 4.5 51.8

39.3 5.5 1.3 2.1 48.5 40.4 7.0 0.8 3.3 31.4 42.8

14.7 2.8 8.3 33.1 47.3 12.6 1.7 5.3 48.0 41.8 5.1

0.9 4.3 38.8 46.3 8.6 1.1 5.2 33.8 44.5 13.6 1.5

6.5 36.3 46.2 51.4 39.3 6.6 9.6 0.6 1.5 5.1 3.3 47.9 43.0 43.0

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

of PRISMA-Equity? Join us! [email protected], [email protected] http://equity.cochrane.org Follow us: @CochraneEquity, @vawelch

Recently Viewed Presentations

  • CIC - Local Immigration Partnerships

    CIC - Local Immigration Partnerships

    LIPs Program . Design and Management. Local Immigration Partnerships (LIPs) Delivery *. Program participants are engaged in newcomer settlement . Adapted programming and service delivery by mainstream institutions. Services (needed by newcomers) coordinated at the community level. Improved accessibility of...
  • Securing your IP based Phone System By Kevin

    Securing your IP based Phone System By Kevin

    Different topologies. IPBX has one network interface card (NIC) on a private address. Remote users VPN in. not practical since not many phones support VPN natively yet and complex to setup the VPN endpoints.
  • Jackson and Lee Strike Back

    Jackson and Lee Strike Back

    The Battle of Seven Pines and the Accession of Lee. Confederates were driven back to their starting point at the road between Seven pines and fair oaks ( battle is called by both names) Battle was uncoordinated and bloody -...
  • Overview to B2B Managed Services - MMorley - 070917

    Overview to B2B Managed Services - MMorley - 070917

    Thank you for joining Stein Mart & OpenText for the Image and Attribute discussion. The call will begin at approximately 2pm ET.It will run for approximately 1 hour. The . lines will remain silent until the start of the call....
  • Chapter 1

    Chapter 1

    The most significant information communication occurs through the grapevine that is separate form management's formal, official communication channels. Information passed along the grapevine may relate to the job or it may be gossip and rumor. The accuracy of grapevine information...
  • Presentazione standard di PowerPoint

    Presentazione standard di PowerPoint

    double Debye model. The basic idea. The description of the condensedmatterderiving from the interactions: among the components of the system. between the particles and the (ever -present) electromagneticfield. doesn't include only the . time-independent.
  • WESSEX BGS Meeting, October 5th 2001 Comprehensive geriatric ...

    WESSEX BGS Meeting, October 5th 2001 Comprehensive geriatric ...

    Beyond the geriatric giants: moving from elderly care to evidence-based medicine for the older person. Conference to honour the career of Professor Peter Crome Keele, March 21st 2
  • GHS Differences in Consumer Products and I&I Products

    GHS Differences in Consumer Products and I&I Products

    EU Regulation (EC) No 1272/2008 on Classification, Labelling and Packaging entered into force on 20 January 2009. It replaces the Dangerous Substances Directive and the Dangerous Preparations Directive. There is a transitional period 2010 -2015 during which time both classification...