Informing Humanitarian Response: a Review of the Evidence for Injury and Rehabilita;on Interven;ons in Crisis SeEngs James Smith,1 Bayard Roberts,2 Abigail Knight,1 Richard Gosselin,3 Karl Blanchet1 Email:
[email protected] 1 Public Health in Humanitarian Crises Group, London School of Hygiene & Tropical Medicine, London, UK 2 ECOHOST – The Centre for Health and Social Change, London School of Hygiene & Tropical Medicine, London, UK 3 Department of Orthopaedic Surgery, University of San Francisco, California, USA
Introduc;on
Results
Humanitarian crises con.nue to pose a significant threat to health. In 2012, the United Na.ons iden.fied 144 million people directly affected by conflict or environmental disasters. During the acute phase of most humanitarian crises, the provision of surgical support remains a priority. A surge in the number of trauma.c injuries in the can overwhelm pre-‐ exis.ng health services. At the same .me, there is oJen a need to supplement rou.ne surgical ac.vi.es in the wake of widespread infrastructural damage and disrup.on to the local medical human resource pool. Rehabilita.on interven.ons play an equally important role as efforts are made to support pa.ents during their longer term recovery.
Orthopaedic injuries (n = 14), of which the repair of fractures featured prominently, were the most studied health outcome. Following orthopaedic outcomes, mul.ple or non-‐specific injuries featured frequently (n = 9), as did the medical and/or surgical response to crush injuries or renal failure (n = 7). Craniofacial injuries, and the repair of abdominal and thoracic injuries, were each the subject of five papers. Twenty-‐one studies described a range of non-‐specific surgical interven.ons. Seven papers looked at surgical external or internal fixa.on techniques in par.cular. This type of opera.on was the focal point of published research more frequently than any other complex surgical technique. Seven papers described different forms of renal therapy, and/or fasciotomy.
Methods A systema.c review explored the available evidence for injury and physical rehabilita.on interven.ons in crisis contexts. This review offers a thorough assessment of the quan.ty and quality of published evidence that informs humanitarian health programming in this field. An extensive selec.on of peer-‐reviewed and grey literature sources were evaluated following consulta.on with sector experts. Papers published between January 1st 1980 and April 30th 2013 were selected for inclusion if they were primary research studies that documented either primary or secondary health outcomes during an acute crisis in a low-‐ or middle-‐income country. Study quality was assessed using criteria dis.lled from an adapted version of the Strengthening the Repor.ng of Observa.onal Studies in Epidemiology (STROBE) protocol.
Results 4798 studies were iden.fied following a search of the peer-‐reviewed literature. One grey literature study was included. A total of 46 studies met the criteria for inclusion in this review. Both the quan.ty and the quality of papers have increased over the course of the last 33 years. Of the 46 studies, 58.7% (n = 27) were published between the year 2000 and 2015. 79% (n = 15) of the higher quality studies were published in the same .me period (Fig. 1). Only 2 papers were considered of a high quality. A further 17 papers were of a moderate quality, while the remaining 27 papers were deemed of a low quality. None of the papers met the full quality criteria, as sample size calcula.ons were consistently absent. 4 3 LOW MODERATE HIGH
2
1
0 1985
1990
1995
2000
2005
2010
2015
Figure 1: study quality by year
Acknowledgements We would like to thank the Wellcome Trust and the UK Department for Interna.onal Development (DfiD) for funding the original evidence review, which featured a review of injury and physical rehabilita.on interven.ons alongside the review of a number of other health topics and contextual factors. We would also like to thank Enhancing Learning and Research in Humanitarian Assistance (ELHRA) for its managerial oversight of the original review. The Wellcome Trust and the DfID funded a mul.-‐topic evidence review as a preliminary to the Research for Health in Humanitarian Crises Ini.a.ve. This review featured in a condensed format alongside a number of other health topic reviews. The study funders had no role in the design of this study, or the produc.on of the final review.
Improving health worldwide
Study characteris;cs Geographical Region Asia Eastern Europe Middle East Africa Caribbean/La.n America Mul.-‐Region Crisis Context Yugoslav wars (1991–1999) Sichuan earthquake, China (2008) Iran–Iraq war (1980–1988) Iraq war (2003–2011) Soviet war in Afghanistan (1979–1989) Other Crisis Type Armed conflict Environmental disaster Popula;on Type General popula.on Refugee Crisis Loca;on Urban Rural Mixed Crisis Phase Acute crisis Early recovery Stabilisa.on Study Methodology Cross-‐sec.onal Longitudinal Non-‐random trial Economic
%
n
34.8 30.4 26.1 4.3 2.2 2.2
16 14 12 2 1 1
30.4 21.7 6.5 6.5 6.5 28.3
14 10 3 3 3 13
63.0 37.0
29 17
97.8 2.2
45 1
8.7 19.6 71.7
4 9 33
82.6 8.7 8.7
38 4 4
67.4 21.7 8.7 2.2
31 10 4 1
Table 1: breakdown of study loca5on, crisis type and phase, popula5on type, and study methodology
Conclusions This review is the first of its kind to examine the quan.ty and quality of evidence for injury and physical rehabilita.on interven.ons in humanitarian crises. While the evidence base has increased in recent years, inadequate aPen.on has been paid to research in humanitarian seQngs as the number of humanitarian actors, and the budget allocated to humanitarian opera.ons, con.nues to grow. Humanitarian ac.on can benefit from the improved applica.on of rigorously tested and context-‐appropriate research that iden.fies not only what works, but why. However, it is important not only to improve the quality of available evidence, but also to bridge the gap between the academic and opera.onal communi.es. This will require a long-‐term vision, an itera.ve research process that is firmly embedded within new and exis.ng systems for monitoring and evalua.on, and a con.nuous dialogue between mul.ple stakeholders invested in the humanitarian endeavour.
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