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3 Methods

3.2 Systematic literature review on contextual factors

3.2.1 Introduction

The aim of this study was to conduct a systematic evidence review of the quantity and quality of evidence on the influence of contextual factors on public health interventions in humanitarian crises. Again, the methodology and reporting adheres to the PRISMA statement.[1]

Contextual factors are taken here to mean the physical, political and social characteristics of the environment that are related to the effectiveness of humanitarian intervention.  The six contextual factors are given below:

Access to healthcare: This encompasses both the access that end-users have to healthcare as well as the access that healthcare workers have to end-users.  Accessibility of healthcare to end-users will specifically include the four over-lapping dimensions of (i) Physical accessibility, (ii) Economic accessibility, (iii) Informational accessibility, and (iv) Non-discrimination.   Accessibility for workers to provide healthcare to end-users will include the dimensions of (i) Physical accessibility, (ii) Economic accessibility, and (iii) Political accessibility.

Health assessment methods:  This will look for studies specifically seeking to test, develop or validate measurement methods (e.g. mortality estimation, population estimation, nutritional assessment etc.).

Coordination: The quality of coordination and leadership in the implementation of public health interventions during humanitarian crises at the local, regional or international level via local or OCHA-led mechanisms influences their impact.  In addition to the logistical aspects of coordination, the effects of competition among local and international agencies for funding and recognition, and the lack of consensus on which public health actions are considered humanitarian and which are considered developmental will also be included.

Accountability to end-users: The Humanitarian Charter emphasises the importance of accountability of agencies to crisis-affected populations.   Accountability will include the following dimensions based on a human rights-based approach to health: (i) Availability of functioning public healthcare facilities, goods and services in sufficient quantity, with sufficient capabilities, and in a timely manner; (ii) Acceptability of public healthcare facilities, goods and services in terms of medical ethics and cultural appropriateness; and (iii) Quality of public healthcare facilities, goods and services that are scientifically and medically appropriate and of good quality, and using trained and skilled personnel adhering to accepted professional standards.

Security of healthcare workers: Closely related to contextual factor 1 above (in particular the political dimension influencing the access of healthcare providers to end-users), both the interest in and the corpus of literature available on the specific issue of security of healthcare workers in humanitarian crises call for the study of this as a distinct contextual factor in this review.  It will include influences which secure the respect of healthcare interventions as off-limits to deliberate attack and disruption, and those which make it conducive to hold humanitarian health action hostage (e.g. attacks on polio workers in Pakistan and Nigeria).  It will also include strategies used in humanitarian health diplomacy relevant to the security of healthcare workers.

Urbanisation: Rapid global urbanisation, particularly in low- and middle-income countries, means that humanitarian crises are increasing likely to affect populations in urbanised settings. At present, the similarities and differences between the strategies and processes leading to effective public health interventions in humanitarian crises occurring in rural and urbanised environments is grossly understudied. These will be included in the analysis of this contextual factor as well as the identification of characteristics that are particular to the urban environment in terms of the physical, mental and social health challenges this setting poses to crisis-affected populations.

[1] Moher, D., et al., Preferred reporting items for systematic reviews and meta – analyses: the PRISMA statement. BMJ, 2009. 339: p. b2535.

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