How effects on health equity are assessed in systematic reviews of interventions

Searching for the social determinants of health: observations from evidence synthesis publications

BACKGROUND

The social determinants of health (SDOH) are the focus of an exponentially increasing number of publications, including evidence syntheses. However, there is not an established standard for searching for SDOH literature. This study seeks to identify published evidence syntheses pertaining to the SDOH, analyzing the search strategies used and the studies included within these reviews. The primary objectives are to compare search strategies and create a test set of SDOH publications.

METHODS

We searched PubMed, Embase, and Scopus for evidence syntheses that mentioned the SDOH in their research questions and included an SDOH search strategy. Relevant data extracted from each review included databases searched; search terms used for the SDOH; conceptual frameworks referenced; and the citations of primary studies included in the reviews, which were compiled to form a test set of cited papers. The relative recall of the respective search strategies was tested by documenting the total number of MEDLINE results each retrieved and the number of test set papers retrieved.

RESULTS

Sixty-four evidence syntheses were identified and included in the analysis, and 2750 cited papers were extracted. Findings indicate few commonalities across search strategies in search terms used, the total number of results retrieved, and the number of test set cited papers retrieved. One hundred and ninety-three unique MeSH terms and 1385 unique keywords and phrases were noted among the various search strategies. The number of total results retrieved by the SDOH search strategies ranged from 21,793 to over 16 million. The percentage of cited papers retrieved by the search strategies ranged from 2.46 to 97.9%. Less than 3% of the cited papers were indexed with the Social Determinants of Health MeSH.

CONCLUSIONS

There has been little consistency across evidence syntheses in approaches to searching for SDOH literature. Differences in these strategies could have a significant impact on what literature is retrieved, included in reviews, and, consequently, incorporated into evidence-based practice. By documenting these differences and creating a set of papers relevant to SDOH, this research provides a snapshot of the current challenges in searching for SDOH content and lays the groundwork for the creation of a standardized search approach for SDOH literature.

Effect of a Multicomponent Food Pantry Intervention in Client Subgroups

Nutrition promotion programs may have varying effects and influence health disparities. SuperShelf promotes healthy choices in food pantries through inventory changes and nudge implementation (e.g., choice architecture). This secondary analysis of the SuperShelf cluster-randomized trial assessed whether the effect of SuperShelf on client diet quality differed by equity characteristics. English-, Spanish-, or Somali-speaking adult clients from 11 food pantries in Minnesota were included (N = 193). We measured change in diet quality by the Healthy Eating Index 2015 (HEI-2015; maximum score 100) using up to two 24 h dietary recalls from pre-intervention and post-intervention periods. We used linear mixed-effects models to determine whether the effect of SuperShelf on diet quality varied by self-reported gender, race/ethnicity, education, and employment status. In separate adjusted models, the interactions of SuperShelf and gender, education, or employment status were not significant. The interaction of SuperShelf and race/ethnicity was significant (p-interaction = 0.008), but pairwise comparisons in diet quality were non-significant in all racial/ethnic subgroups. SuperShelf did not have differential effects on diet quality by gender, race/ethnicity, education, or employment status, suggesting it does not worsen dietary disparities among food pantry clients, though more subgroup analyses are needed to explore potential racial/ethnic disparities in this context.

Sex-Based Analysis of Quality Indicators of End-of-Life Care in Gastrointestinal Malignancies

Indices of aggressive or supportive end-of-life (EOL) care are used to evaluate health services quality. Disparities according to sex were previously described, with studies showing that male sex is associated with aggressive EOL care. This is a secondary analysis of 69,983 patients who died of a GI malignancy in Ontario between 2006 and 2018. Quality indices from the last 14-30 days of life and aggregate measures for aggressive and supportive EOL care were derived from administrative data. Hospitalizations, emergency department use, intensive care unit admissions, and receipt of chemotherapy were considered indices of aggressive care, while physician house call and palliative home care were considered indices of supportive care. Overall, a smaller proportion of females experienced aggressive care at EOL (14.3% vs. 19.0%, standardized difference = 0.13, where ≥0.1 is a meaningful difference). Over time, rates of aggressive care were stable, while rates of supportive care increased for both sexes. Logistic regression showed that younger females (ages 18-39) had increased odds of experiencing aggressive EOL care (OR 1.71, 95% CI 1.30-2.25), but there was no such association for males. Quality of EOL care varies according to sex, with a smaller proportion of females experiencing aggressive EOL care.

What matters to adolescents with obesity, and their caregivers, when considering bariatric surgery or weight loss devices? A qualitative evidence synthesis

BACKGROUND

Bariatric surgery and weight loss devices have been considered as a therapeutic option in some settings for adolescents with severe obesity. We conducted a systematic review and qualitative evidence synthesis of factors affecting adolescent and caregiver decision-making processes around such interventions, as well as post-surgery demands and challenges, so that their experiences might be better understood and improved support given. No previous qualitative evidence synthesis has been published on this topic.

METHODS AND FINDINGS

We searched 10 bibliographic databases and followed-up gray literature and citations sources. We performed a qualitative evidence synthesis on 19 primary qualitative research studies in adolescents aged 13 years or older. They reported diverse motivations and incentives for considering these interventions, including the physical and social problems resulting from living with obesity, and an awareness of the benefits and limitations of interventions. They reported that they need: information, physical and emotional support and, in some cases, financial assistance. There was high confidence in a majority of these findings (GRADE CERQual).

CONCLUSIONS

We found that supportive interventions accompanying bariatric surgery should be in place to offer: practical help; address anxieties and uncertainties; and facilitate both appropriate decision-making and the achievement of young people's desired outcomes.

Climate change and health equity: A public health perspective on climate justice

Background

The discourse on climate justice has developed from the theoretical approaches and discussions on environmental justice. A central tenet of the concept of environmental and climate justice is that environmental and climate issues cannot be seen in isolation from issues of social justice.

Methods

A conceptual model was developed on the relationship between climate change impacts, social dimensions, adaptive capacities, biological sensitivity, and health equity in order to systematically analyse climate justice. Based on an exploratory literature review and the evaluation of the individual contributions of the status report on climate change and health, the evidence in Germany on social inequalities in exposure to climate change impacts and vulnerability to their direct and indirect health effects was summarised.

Results

This paper provides an overview of the international debate and examples of evidence on climate justice in Germany. Climate justice in the sense of avoidable, unjust social inequalities in exposure, vulnerability, and the effects of climate mitigation and adaptation measures on health inequalities is still insufficiently addressed in Germany.

Conclusions

A consistent integration of equity issues into climate policy is necessary. With reference to the international literature, options for action and research needs are identified.

The Commercial Determinants of Health and Evidence Synthesis (CODES): methodological guidance for systematic reviews and other evidence syntheses

BACKGROUND

The field of the commercial determinants of health (CDOH) refers to the commercial products, pathways and practices that may affect health. The field is growing rapidly, as evidenced by the WHO programme on the economic and commercial determinants of health and a rise in researcher and funder interest. Systematic reviews (SRs) and evidence synthesis more generally will be crucial tools in the evolution of CDOH as a field. Such reviews can draw on existing methodological guidance, though there are areas where existing methods are likely to differ, and there is no overarching guidance on the conduct of CDOH-focussed systematic reviews, or guidance on the specific methodological and conceptual challenges.

METHODS/RESULTS

CODES provides guidance on the conduct of systematic reviews focussed on CDOH, from shaping the review question with input from stakeholders, to disseminating the review. Existing guidance was used to identify key stages and to provide a structure for the guidance. The writing group included experience in systematic reviews and other forms of evidence synthesis, and in equity and CDOH research (both primary research and systematic reviews).

CONCLUSIONS

This guidance highlights the special methodological and other considerations for CDOH reviews, including equity considerations, and pointers to areas for future methodological and guideline development. It should contribute to the reliability and utility of CDOH reviews and help stimulate the production of reviews in this growing field.

Prioritising Cochrane reviews to be updated with health equity focus

BACKGROUND

The prioritisation of updating published systematic reviews of interventions is vital to prevent research waste and ensure relevance to stakeholders. The consideration of health equity in reviews is also important to ensure interventions will not exacerbate the existing inequities of the disadvantaged if universally implemented. This study aimed to pilot a priority setting exercise based on systematic reviews of interventions published in the Cochrane Library, to identify and prioritise reviews to be updated with a focus on health equity.

METHODS

We conducted a priority setting exercise with a group of 13 international stakeholders. We identified Cochrane reviews of interventions that showed a reduction in mortality, had at least one Summary of Findings table and that focused on one of 42 conditions with a high global burden of disease from the 2019 WHO Global Burden of Disease report. This included 21 conditions used as indicators of success of the United Nations Universal Health Coverage in attaining the Sustainable Development Goals. Stakeholders prioritised reviews that were relevant to disadvantaged populations, or to characteristics of potential disadvantage within the general population.

RESULTS

After searching for Cochrane reviews of interventions within 42 conditions, we identified 359 reviews that assessed mortality and included at least one Summary of Findings table. These pertained to 29 of the 42 conditions; 13 priority conditions had no reviews with the outcome mortality. Reducing the list to only reviews showing a clinically important reduction in mortality left 33 reviews. Stakeholders ranked these reviews in order of priority to be updated with a focus on health equity.

CONCLUSIONS

This project developed and implemented a methodology to set priorities for updating systematic reviews spanning multiple health topics with a health equity focus. It prioritised reviews that reduce overall mortality, are relevant to disadvantaged populations, and focus on conditions with a high global burden of disease. This approach to the prioritisation of systematic reviews of interventions that reduce mortality provides a template that can be extended to reducing morbidity, and the combination of mortality and morbidity as represented in Disability-Adjusted Life Years and Quality-Adjusted Life Years.

Evidence Clearinghouses as Tools to Advance Health Equity: What We Know from a Systematic Scan

Evidence clearinghouses evaluate and summarize literature to help decision-makers prioritize and invest in evidence-informed interventions. Clearinghouses and related practice-oriented tools are continuously evolving; however, it is unclear the extent to which these tools assess and summarize evidence describing an intervention's impact on health equity. We conducted a systematic scan to explore how clearinghouses communicated an intervention's equity impact and reviewed their underlying methods and how they defined and operationalized health equity. In 2021, we identified 18 clearinghouses that were US-focused, web-based registries of interventions that assigned an intervention effectiveness rating for improving community health and the social determinants of health. We reviewed each clearinghouse's website and collected publicly available information about their health equity impact review, review methods, and health equity definitions and values. We conducted a comparative analysis among select clearinghouses using qualitative methods. Among the 18 clearinghouses, fewer than half (only seven) summarized an intervention's potential impact on health equity. Overall, those seven clearinghouses defined and operationalized equity differently, and most lacked transparency in their review methods. Clearinghouses used one or more approaches to communicate findings from their review: summarize study findings on differential impact for subpopulations, curate interventions that reduce health disparities, and/or assign a disparity/equity rating to each intervention. Evidence clearinghouses can enhance equity-focused methods and be transparent in their underlying values to better support the uptake and implementation of evidence-informed interventions to advance health equity. However, clearinghouses are unable to do so without underlying equity-focused empirical evidence.

Using the WHO-INTEGRATE evidence-to-decision framework to develop recommendations for induction of labour

BACKGROUND

In 2019, WHO prioritized updating recommendations relating to three labour induction topics: labour induction at or beyond term, mechanical methods for labour induction, and outpatient labour induction. As part of this process, we aimed to review the evidence addressing factors beyond clinical effectiveness (values, human rights and sociocultural acceptability, health equity, and economic and feasibility considerations) to inform WHO Guideline Development Group decision-making using the WHO-INTEGRATE evidence-to-decision framework, and to reflect on how methods for identifying, synthesizing and integrating this evidence could be improved.

METHODS

We adapted the framework to consider the key criteria and sub-criteria relevant to our intervention. We searched for qualitative and other evidence across a variety of sources and mapped the eligible evidence to country income setting and perspective. Eligibility assessment and quality appraisal of qualitative evidence syntheses was undertaken using a two-step process informed by the ENTREQ statement. We adopted an iterative approach to interpret the evidence and provided both summary and detailed findings to the decision-makers. We also undertook a review to reflect on opportunities to improve the process of applying the framework and identifying the evidence.

RESULTS

Using the WHO-INTEGRATE framework allowed us to explore health rights and equity in a systematic and transparent way. We identified a lack of qualitative and other evidence from low- and middle-income settings and in populations that are most impacted by structural inequities or traditionally excluded from research. Our process review highlighted opportunities for future improvement, including adopting more systematic evidence mapping methods and working with social science researchers to strengthen theoretical understanding, methods and interpretation of the evidence.

CONCLUSIONS

Using the WHO-INTEGRATE evidence-to-decision framework to inform decision-making in a global guideline for induction of labour, we identified both challenges and opportunities relating to the lack of evidence in populations and settings of need and interest; the theoretical approach informing the development and application of WHO-INTEGRATE; and interpretation of the evidence. We hope these insights will be useful for primary researchers as well as the evidence synthesis and health decision-making communities, and ultimately contribute to a reduction in health inequities.

Engagement Mediates the Relationship Between Emotion and Achievement of Chinese EFL Learners

Since the coming of Positive Psychology in the field of second language acquisition (SLA), the significance of emotion, especially positive emotion, has been well recognized by researchers. Educational research has indicated that both emotion and engagement play fundamental roles in learning process and psychological wellbeing, but research on their relationship is scant in SLA. The present study contributed to the development of Positive Psychology in SLA by investigating the relationships between achievement emotions, behavioral engagement, and self-reported English achievements. 633 students from four senior high schools in China participated in the study. Data collected through questionnaires revealed: (1) Participants reported a medium to high level of foreign language enjoyment (FLE), foreign language classroom anxiety (FLCA), and behavioral engagement; females had a higher level of FLE and behavioral engagement than males; the participants reported more anxiety and less enjoyment than western samples; (2) significant correlations were found between FLE, FLCA, behavioral engagement, and self-reported achievement; (3) significant mediating effects of behavioral engagement were found between both achievement emotions and self-reported achievement, and the mediating effect of engagement was stronger between FLCA and self-reported achievement. The findings extended the nomological network of achievement emotions, developed our insights into the complex relationships between emotions, learner engagement and language achievement, and revealed the mediating effects of behavioral engagement. Finally, directions for future study and implications for foreign language educators were provided.

Reporting of health equity considerations in equity-relevant observational studies: Protocol for a systematic assessment

Background: The mitigation of unfair and avoidable differences in health is an increasing global priority. Observational studies including cohort, cross-sectional and case-control studies tend to report social determinants of health which could inform evidence syntheses on health equity and social justice. However, the extent of reporting and analysis of equity in equity-relevant observational studies is unknown. Methods: We define studies which report outcomes for populations at risk of experiencing inequities as “equity-relevant”. Using a random sampling technique we will identify 320 equity-relevant observational studies published between 1 January 2020 to 27 April 2022 by searching the MEDLINE database. We will stratify sampling by 1) studies in high-income countries (HIC) and low- and middle-income countries (LMIC) according to the World Bank classification, 2) studies focused on COVID and those which are not, 3) studies focused on populations at risk of experiencing inequities and those on general populations that stratify their analyses. We will use the PROGRESS framework which stands for place of residence, race or ethnicity, occupation, gender or sex, religion, education, socioeconomic status, social capital, to identify dimensions where inequities may exist. Using a previously developed data extraction form we will pilot-test on eligible studies and revise as applicable. Conclusions: The proposed methodological assessment of reporting will allow us to systematically understand the current reporting and analysis practices for health equity in observational studies. The findings of this study will help inform the development of the equity extension for the STROBE (Strengthening the Reporting of Observational studies in Epidemiology) reporting guidelines.

Toward the Role of Teacher Empathy in Students' Engagement in English Language Classes

This paper aimed at examining the related studies on the relationship between teacher empathy and learner engagement in English as a Foreign Language (EFL) learning contexts. The positive and significant relationship between teacher empathy and learner engagement has been verified in the literature. Studies have shown the positive influence of teacher-learner rapport on learner engagement. Moreover, studies indicated that teacher empathy leads to learner self-confidence in educational contexts. The literature review has also shown that teachers' provision of a positive environment through empathy, sympathy, and kindness can trigger learner motivation and engagement. Moreover, teachers' empathy can reduce the stress level which, in turn, positively affects learners' engagement level. Eventually, the pedagogical implications to engage learners and teachers in academic contexts have been provided. However, some suggestions have been offered to expand the insights over the associations between positive psychological constructs and teachers' emotions.

A Theoretical Review on the Impact of EFL/ESL Students' Self-Sabotaging Behaviors on Their Self-Esteem and Academic Engagement

Learner emotions have been considerably emphasized in SLA research and practice with the advent of positive psychology. This has led to a surge of scholarly interest in this strand of research over the past years all around the world. However, the impact of students' negative emotions such as self-sabotage that actually occur in english as a foreign language (EFL) classrooms on the construction and development of positive learner emotions like self-esteem and academic engagement has been mostly overlooked by second/foreign language researchers. Against this shortcoming, the present review article presented the theoretical and empirical underpinnings of these three crucial variables in SLA focusing on their conceptualizations, dimensions, typologies, related studies, and research gaps. Finally, the study offers a number of practical implications to [EFL/english as a second language (ESL)] teachers, students, teacher trainers, and SLA researchers in order to increase their awareness of learner emotions and the power of such feelings in language teaching and learning processes.