Emily Warren

Evidence on public health interventions in humanitarian crises

Recognition of the need for evidence-based interventions to help to improve the effectiveness and efficiency of humanitarian responses has been increasing. However, little is known about the breadth and quality of evidence on health interventions in humanitarian crises. We describe the findings of a systematic review with the aim of examining the quantity and quality of evidence on public health interventions in humanitarian crises to identify key research gaps. We identified 345 studies published between 1980 and 2014 that met our inclusion criteria. The quantity of evidence varied substantially by health topic, from communicable diseases (n=131), nutrition (n=77), to non-communicable diseases (n=8), and water, sanitation, and hygiene (n=6). We observed common study design and weaknesses in the methods, which substantially reduced the ability to determine causation and attribution of the interventions. Considering the major increase in health-related humanitarian activities in the past three decades and calls for a stronger evidence base, this paper highlights the limited quantity and quality of health intervention research in humanitarian contexts and supports calls to scale up this research.

Systematic review of the evidence on the effectiveness of sexual and reproductive health interventions in humanitarian crises

Objectives This systematic review aims to evaluate evidence on the effectiveness of sexual and reproductive health (SRH) interventions delivered in humanitarian crises. Setting Crisis affected low-income or middle-income countries. Participants Crisis-affected populations in low-income or middle-income countries. Method Peer-reviewed and grey literature sources were systematically searched for relevant papers detailing interventions from 1 January 1980 until the search date on 30 April 2013. Data from included studies were then extracted, and the papers’ quality evaluated using criteria based on modified STROBE and CONSORT checklists. Primary and secondary outcome measures Primary outcomes include, but are not limited to, changes in morbidity, mortality, sexually transmitted infection (STI) diagnosis or gender-based violence. Secondary outcomes include, but are not limited to, reported condom use or skilled attendance at birth. Primary outputs include, but are not limited to, condoms distributed or education courses taught. Results Of 7149 returned citations, 15 studies met the inclusion criteria. Only one randomised controlled trial was identified. The remaining observational studies were of moderate quality, demonstrating limited use of controls and inadequate attempts to address bias. Evidence of effectiveness was available for the following interventions: impregnated bed nets for pregnant women, subsidised refugee healthcare, female community health workers, and tiered community reproductive health services. Conclusions The limited evidence base for SRH interventions highlights the need for improved research on the effectiveness of public health interventions in humanitarian crises. While interventions proven efficacious in stable settings are being used in humanitarian efforts, more evidence is required to demonstrate the effectiveness of delivering and scaling-up such interventions in humanitarian crises.

Realist trials and the testing of context- mechanism-outcome configurations: a response to Van Belle et al.

BackgroundVan Belle et al. argue that our attempt to pursue realist evaluation via a randomised trial will be fruitless because we misunderstand realist ontology (confusing intervention mechanisms with intervention activities and with statistical mediation analyses) and because RCTs cannot comprehensively examine how and why outcome patterns are caused by mechanisms triggered in specific contexts.MethodsThrough further consideration of our trial methods, we explain more fully how we believe complex social interventions work and what realist evaluation should aim to do within a trial.ResultsLike other realists, those undertaking realist trials assume that: social interventions provide resources which local actors may draw on in actions that can trigger mechanisms; these mechanisms may interact with contextual factors to generate outcomes; and data in the ‘empirical’ realm can be used to test hypotheses about mechanisms in the ‘real’ realm. Whether or not there is sufficient contextual diversity to test such hypotheses is a contingent not a necessary feature of trials. Previous exemplars of realist evaluation have compared empirical data from intervention and control groups to test hypotheses about real mechanisms. There is no inevitable reason why randomised trials should not also be able to do so. Random allocation merely ensures the comparability of such groups without necessarily causing evaluation to lapse from a realist into a ‘positivist’ or ‘post-positivist’ paradigm.ConclusionsRealist trials are ontologically and epistemologically plausible. Further work is required to assess whether they are feasible and useful but such work should not be halted on spurious philosophical grounds.

Electronic discharge summaries in cross-border care in the European Union: How close are we to making it happen?

Introduction The political drive for cross-border care within the European Union and an increasing focus on integrated care both have implications for electronic health records. The hospital discharge summary is a critical component of systems to ensure quality and continuity of care, and in a cross-border setting would particularly benefit from an electronic version. We have explored the extent to which European Union level policy and practice on electronic health records address issues pertinent to the development and implementation of electronic discharge summaries for patients treated outside their own country. Methods We approached the topic by analysing data from two different sources: European Union policy documents on topics relevant to electronic health records and deliverables of European Union-funded electronic health record-focused research and development projects. Elements pertinent to different aspects of interoperability – legal, semantic and technical – were extracted from both sources and their content compared to assess the degree of consistency between policy and implementation targets. Results We identified 25 policy documents and 14 European Union-funded projects. Our results show that European legislation is increasingly aligned with projects funded through European Union sources and substantial progress has been accomplished in achieving electronic communication across European health systems. Nevertheless, the achievement of a European level interoperable discharge summary is still a distant goal, while inadequate attention has been paid to the coordination of current discharge summary practices in Member States. Discussion If the harmonized European Union patient summary is also to function as an electronic discharge summary, further specific steps are needed that address issues of both content and processes related to communication.

Are randomised controlled trials positivist? Reviewing the social science and philosophy literature to assess positivist tendencies of trials of social interventions in public health and health services

BackgroundWe have previously proposed that trials of social interventions can be done within a “realist” research paradigm. Critics have countered that such trials are irredeemably positivist and asked us to explain our philosophical position.MethodsWe set out to explore what is meant by positivism and whether trials adhere to its tenets (of necessity or in practice) via a narrative literature review of social science and philosophical discussions of positivism, and of the trials literature and three case studies of trials.ResultsThe philosophical literature described positivism as asserting: (1) the epistemic primacy of sensory information; (2) the requirement that theoretical terms equate with empirical terms; (3) the aim of developing universal laws; and (4) the unity of method between natural and social sciences. Regarding (1), it seems that rather than embodying the epistemic primacy of sensory data, randomised controlled trials (RCTs) of social interventions in health embrace an anti-positivist approach aiming to test hypotheses derived deductively from prior theory. Considering (2), while some RCTs of social interventions appear to limit theorisation to concepts with empirical analogues, others examine interventions underpinned by theories engaging with mechanisms and contextual contingencies not all of which can be measured. Regarding (3), while some trialists and reviewers in the health field do limit their role to estimating statistical trends as a mechanistic form of generalisation, this is not an inevitable feature of RCT-based research. Trials of social interventions can instead aim to generalise at the level of theory which specifies how mechanisms are contingent on context. In terms of (4), while RCTs are used to examine biomedical as well as social interventions in health, RCTs of social interventions are often distinctive in using qualitative analyses of data on participant accounts to examine questions of meaning and agency not pursued in the natural sciences.ConclusionWe conclude that the most appropriate paradigm for RCTs of social interventions is realism not positivism.