Elsevier

The Lancet

Volume 390, Issue 10109, 18–24 November 2017, Pages 2287-2296
The Lancet

Series
Evidence on public health interventions in humanitarian crises

https://doi.org/10.1016/S0140-6736(16)30768-1Get rights and content

Summary

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.

Introduction

Worldwide, an estimated 172 million people are affected by armed conflict,1 including 59 million people who are forcefully displaced from their homes as internally displaced persons (IDPs) within their countries or refugees who have crossed an international border. This number is the highest forcibly displaced since World War 2. Additionally, natural disasters affect around 175 million people annually.2 The health effects for these populations can be enormous. Good information is essential to understand these impacts and inform effective and accountable humanitarian responses. This Lancet Series on health in humanitarian crises seeks to highlight gaps in our understanding of health responses in humanitarian crises and to discuss ways in improving these responses. This Series focuses particularly on the use of health data, and in this paper, the first in the Series, we examine the evidence base for health interventions in humanitarian crises.

Despite epidemiological studies done on humanitarian crises over the past half century,3, 4, 5, 6, 7, 8 a high degree of concern remains over the quality of data for humanitarian crises,9, 10, 11, 12, 13, 14 how it has been used to guide humanitarian health interventions, and ultimately how effectively humanitarian relief programmes have improved health outcomes.5, 15, 16, 17, 18 This reflects broader demands for greater accountability in the humanitarian sector, which includes strengthening evidence-based decision making to improve the effectiveness of humanitarian responses.19, 20, 21, 22

In this paper, we describe the findings from a systematic review with the aim of examining the overall quantity and quality of evidence on public health interventions in humanitarian crises and identifying the key research gaps. Previous systematic reviews have been done on specific health topics in humanitarian crises, which have provided valuable guidance on the effectiveness of interventions for individual health topics such as mental health and psychosocial support (MHPSS), nutrition, and water, sanitation, and hygiene (WASH).23, 24, 25, 26, 27, 28, 29, 30, 31, 32 However, these topics commonly focused on specific interventions and outcomes. A more comprehensive examination across the range of key health topics could help to identify key research gaps across the humanitarian health sector and guide decision-making on health interventions and research.

The panel presents the methods used for the systematic review. The actual effectiveness of health interventions was not assessed in view of the wide range of health outcomes and interventions and the main focus of the review was on the overall quantity, quality, and the gaps in the evidence. Instead, we present a descriptive summary of the key findings related to the major gaps in the evidence, the strengths and quality of the evidence, and then discuss potential explanations for these findings and how to move forward.

Key messages

  • Evidence is important to guide more effective and efficient health responses in humanitarian contexts.

  • On the basis of our systematic review, we found that evidence is limited both in quantity and quality.

  • Most studies are able to show changes in health outcomes, but most are unable to attribute these changes to the intervention because of the study design used. Where logistically and ethically possible, greater use of experimental and quasi-experimental study designs is needed.

  • The findings support calls to scale up quality health research in humanitarian crises.

  • Development of innovative integrated funding mechanisms to enable the combination of research projects with humanitarian assistance and create a global humanitarian evidence platform where data and evidence can be accessible to all communities (national authorities, donors, academics, and humanitarian agencies) are needed.

Section snippets

Gaps in evidence

From an initial retrieval of nearly 50 000 papers, this systematic literature review yielded 345 papers published between Jan 1, 1980, and Dec 31, 2014, that met the inclusion criteria (appendix p 1). 131 studies were from communicable disease control, six from WASH, 77 from nutrition, 15 from sexual and reproductive health, 61 from MHPSS, eight from non-communicable diseases (NCD), and 47 from injury and rehabilitation (figure 1; see full list in the appendix p 4). Overall, the frequency of

Signs of progress?

Despite the findings from this review suggesting some major gaps in the evidence base on health interventions in humanitarian crises, there are positive developments. Our review found that the quantity and quality of evidence has substantially increased over time, with 79% of the high quality literature being produced since 2000. Several reasons could explain this increase. The high profile failures in humanitarian responses to crises in Rwanda, Darfur, Sri Lanka, and Haiti have focused efforts

Conclusion

The need for robust, high quality, useable evidence to inform, shape, and adapt health interventions in humanitarian crises is increasingly recognised. However, although the number of studies on public health interventions in humanitarian crises has grown, substantial gaps in the quantity and quality of evidence remain. Development of innovative integrated funding mechanisms to enable the combination of research projects with humanitarian assistance and create a global humanitarian evidence

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