COVID-19, health inequities, and methodology’s mission

      As has often been emphasized, the COVID-19 pandemic is amplifying pre-existing health inequities in the world, in both lower and higher income countries. This is the more a matter of concern, since pre-existing health disparities were already substantial [
      • Mackenbach J.P.
      • Valverde J.R.
      • Bopp M.
      • Brønnum-Hansen H.
      • Deboosere P.
      • Kalediene R.
      • et al.
      Determinants of inequalities in life expectancy: an international comparative study of eight risk factors.
      ,
      • Islam M.S.
      • Mondal M.N.
      • Tareque M.I.
      • Rahman M.A.
      • Hoque M.N.
      • Ahmed M.M.
      • et al.
      Correlates of healthy life expectancy in low- and lower-middle-income countriesBMC Public Health.
      ]. Even in high income countries such as The Netherlands, the life expectancy and the healthy life expectancy differences at birth between those with academic or similar education and those with basic education only are 6.3 years and 14.7 years, respectively []. And in Canada indigenous communities have a reduced life expectancy of up to 13 years [
      • Kermode-Scott B.
      Canadian life expectancy varies greatly depending on ethnic origin.
      ].
      The end of this highly worrying development is not yet in sight. Given the much higher health, social, environmental, and economic susceptibilities of the disadvantaged, this is leading to ongoing, disproportionate harm for this group in this Covid-19 pandemic [
      • Adhikari S.
      • Pantaleo N.P.
      • Feldman J.M.
      • Ogedegbe O.
      • Thorpe L.
      • Troxel A.B.
      Assessment of community-level disparities in Coronavirus disease 2019 (COVID-19) infections and deaths in large US metropolitan areas.
      ]. This includes both health damage directly caused by the virus and indirect health damage resulting from severely affected regular health care provision. In addition, we observe sharply decreased incomes and social well being of many people and impaired national and regional economies, which again disproportionately affects the poorest individuals and communities. Since economies, population health, and health care are strongly intertwined, this process may end in a race to the bottom, threatening global health as a whole. Given what we have seen in and after previous crises, we must anticipate declines in life expectancy, and increasing morbidity and mental distress [
      • Nolte E.
      • Shkolnikov V.
      • McKee M.
      Changing mortality patterns in East and West Germany and Poland. II: short-term trends during transition and in the 1990s.
      ,
      • Ettman C.K.
      • Abdalla S.M.
      • Cohen G.H.
      • Sampson L.
      • Vivier P.M.
      • Galea S.
      Prevalence of depression symptoms in US Adults before and during the COVID-19 pandemic.
      ], especially in those who are most susceptible.
      Furthermore, standard anti-pandemic measures may be less effective for these groups and have a higher risk of serious side effects, so well-tailored efforts are needed. For example, social distancing is much more difficult in the manufacturing industry than in banking and academia. Lockdowns are particularly drastic for families living in crowded houses or small apartments without a garden and without green space in the neighborhood, and this is provoking increased rates of domestic violence. These problems are all the more serious, as the expected duration of the pandemic is still unclear and the crisis conditions and their aftermath could last for several years.
      In this situation, solid, independent knowledge is urgently needed to prepare and promote the recovery, strengthening and renewal of public health and socio-economic infrastructures, and to improve the functioning of governments and politics to appropriately address the many new problems they are facing [
      • Viens A.M.
      • Eyawo O.
      COVID-19: the rude awakening for the political elite in low- and middle-income countries.
      ,
      • Thorpe J.
      • Viney K.
      • Hensing G.
      • Lönnroth K.
      Income security during periods of ill health: a scoping review of policies, practice and coverage in low-income and middle-income countries.
      ]. Reflecting the mission of our journal, in our May 2020 editorial we presented a research agenda to address specific methodological challenges in (1) countering the current COVID-19 pandemic crisis, (2) managing post-crisis issues, and (3) preventing/anticipating future pandemics [
      • Knottnerus J.A.
      • Tugwell P.
      Methodological challenges in studying the COVID-19 pandemic crisis.
      ]. Since then, we have published methodological articles on the history of pandemics, the evaluation of COVID-19 tests, quality of COVID-19-related trials, data sharing and open science, COVID-19-focused evidence synthesis methods, the role of social media, and what evidence-based medicine researchers can do to help clinicians fighting COVID-19. But contributions focusing on methodologically strengthening research on COVID-19-related (increases of) health disparaties were scarce.
      But now we welcome the work of Glover et al., who developed a framework for identifying and mitigating the equity harms of COVID-19 policy interventions. As the authors aptly describe it: “Governments have implemented combinations of ‘lockdown’ measures of various stringencies, including school and workplace closures, cancellations of public events, and restrictions on internal and external movements. These policy interventions are an attempt to shield high-risk individuals and to prevent overwhelming countries' healthcare systems, or, colloquially, ‘flatten the curve.’ However, these policy interventions may come with physical and psychological health harms, group and social harms, and opportunity costs. These policies may particularly affect vulnerable populations and not only exacerbate pre-existing inequities but also generate new ones.” The framework developed by these authors, building on previously developed frameworks, enables researchers to take up the challenge to systematically study these harms and to contribute to evaluating and improving policy interventions especially in relation to equity implications. With the framework the authors provide help to identify and categorize adverse effects of COVID-19 lockdown measures. They tested its application on policy examples from around the world, taking a wide range of potential physical, psychological, and social harms, as well as opportunity costs into account, in each of the ‘PROGRESS’ equity domains [
      • 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.
      ]: Place of residence, Race/ethnicity, Occupation, Gender/sex, Religion, Education, Socioeconomic status, Social capital, and Plus (age, and disability). For each lockdown policy they found examples of inequitably distributed adverse effects, in low- or middle-income and high-income countries, in every domain. They also identified policy interventions intended to mitigate adverse effects. It was concluded that the developed framework highlights that COVID-19 policy interventions can generate or exacerbate equity harms, and that it can help to identify areas where interventions may generate inequitable adverse effects; mitigate these by facilitating systematic examination of evidence; and plan for lifting lockdowns and policy interventions.
      In order to effectively address health inequities in fighting the COVID-19 pandemic crisis worldwide, the pre-existing risk profiles in lower and middle income countries must be taken into account [
      • Ahmed S.
      • Mvalo T.
      • Akech S.
      • Ambrose A.
      • Baker K.
      • Bar-Zeev N.
      • et al.
      Protecting children in low-income and middle-income countries from COVID-19.
      ,
      • Hamadani J.D.
      • Hasan M.I.
      • Baldi A.J.
      • Hossain S.J.
      • Shiraji S.
      • Bhuiyan M.S.A.
      • et al.
      Immediate impact of stay-at-home orders to control COVID-19 transmission on socioeconomic conditions, food insecurity, mental health, and intimate partner violence in Bangladeshi women and their families: an interrupted time series.
      ]. Special attention should therefore be paid to studies such as the one by Anderegg c.s, who evaluated mortality estimates in HIV-positive people on antiretroviral therapy in Mozambique. As they report, people living with human immunodeficiency virus (HIV) on antiretroviral therapy (ART) may be lost to follow-up (LTFU). This severely hampers the proper assessment of outcomes, given that patients lost to follow-up usually experience higher mortality than those remaining in care, while their deaths are not recorded. This can lead to underestimation of overall program-level mortality. For their evaluation, the authors analyzed data from patients lost to follow-up who were traced by phone and home visits, correcting for LTFU by using different inverse probability weights and competing risk models, also identifying risk factors for death and LTFU. This increased the observed 4-year mortality after starting ART from 11.9% to 21.6%–23.5% after correction using various risk models. This huge difference underlines the substantial problems in follow-up care and its scientific evaluation, and the opportunities for quality improvement. The authors therefore emphasize that ART programs should trace patients lost to follow-up to bring them back into care and that program-level estimates of mortality should be corrected, taking LTFU into account.
      The above studies demonstrate the importance of connecting research methodology with clinical, public health and health policy challenges. This is never an easy thing to do, and we are therefore happy with the new series on ‘Key concepts in clinical epidemiology’. As the team of Associate Editors co-ordinating this series - van Amelsvoort, Bours, Dans and Dans –make clear in their introductory editorial, studying clinical epidemiological methods should ultimately be relevant to clinical practice. In this new series of two-pagers, each article will provide a concise overview of a relevant methodological key concept for scientifically substantiated practice. The first article by Palileo-Villanueva and Dans addresses the topic of composite endpoints. We hope that this series will contribute not only to better dissemination of methodological knowledge and skills, but also to better understanding and critically appraising practice-relevant research reports.
      Critical appraisal is also a basic skill for all who are involved in making a scientific journal. For JCE it continues to be vital that members of the research community are available to assure and further improve the Journal's quality. We are therefore extremely grateful to all reviewers of the 2020 JCE articles for their crucial contributions We especially compliment our Reviewers of the Year, Samantha Morais and Christopher Cates, for their outstanding reviews that combined critical and constructive feedback to authors. We also congratulate Ignacio Atal and Mitchell N Sarkies, the winners of The David Sackett Young Investigator Award 2019, for their excellent work on the definition of a fragility index for meta-analyses [
      • Atal I.
      • Porcher R.
      • Boutron I.
      • Ravaud P.
      The statistical significance of meta-analyses is frequently fragile: definition of a fragility index for meta-analyses.
      ], and video strategies to improve health professional knowledge [
      • Sarkies M.N.
      • Maloney S.
      • Symmons M.
      • Haines T.P.
      Video strategies improved health professional knowledge across different contexts: a helix counterbalanced randomized controlled study.
      ], respectively, as highlighted in this issue.
      Finally, we are pleased to announce the appointment of David I. Tovey, as incoming co-Editor-in-Chief of the Journal of Clinical Epidemiology. He will succeed André Knottnerus, effective January 2021, and will join Peter Tugwell, as co-Editor-in-Chief. David was the inaugural Editor-in-Chief of Cochrane Library and, prior to that, was the Editorial Director at the BMJ Knowledge Department. He has worked with internationally leading methodologists and has a wide network in the evidence synthesis and meta-epidemiology worlds. On our website David Tovey says “I am very excited to take on this new challenge. These are exciting and changing times for the role of evidence in informing clinical and health policy decision making. The JCE's mission of supporting the advancement and application of innovative methods that help to improve health care is perfectly placed to play a leading role in this evolution.” The first author of this editorial is proud that David Tovey, with such vast experience in the fields of both scientific publishing and evidence synthesis, is his successor as Editor-in-Chief.

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