Elsevier

The Lancet

Volume 390, Issue 10109, 18–24 November 2017, Pages 2297-2313
The Lancet

Series
Public health information in crisis-affected populations: a review of methods and their use for advocacy and action

https://doi.org/10.1016/S0140-6736(17)30702-XGet rights and content

Summary

Valid and timely information about various domains of public health underpins the effectiveness of humanitarian public health interventions in crises. However, obstacles including insecurity, insufficient resources and skills for data collection and analysis, and absence of validated methods combine to hamper the quantity and quality of public health information available to humanitarian responders. This paper, the second in a Series of four papers, reviews available methods to collect public health data pertaining to different domains of health and health services in crisis settings, including population size and composition, exposure to armed attacks, sexual and gender-based violence, food security and feeding practices, nutritional status, physical and mental health outcomes, public health service availability, coverage and effectiveness, and mortality. The paper also quantifies the availability of a minimal essential set of information in large armed conflict and natural disaster crises since 2010: we show that information was available and timely only in a small minority of cases. On the basis of this observation, we propose an agenda for methodological research and steps required to improve on the current use of available methods. This proposition includes setting up a dedicated interagency service for public health information and epidemiology in crises.

Introduction

Between 2005 and 2014, an annual mean of 35 (range 31–40) armed conflicts occurred, of which six (four to 11) major conflicts (>1000 people killed annually) were active globally,1 directly affecting about 172 million people in 2012, the sole year for which global estimates including displaced and affected non-displaced people were available.2 Between 2006 and 2015, an annual mean of 393 (range 341–462) natural disasters (geological and hydrometeorological hazards only) occurred, affecting a mean of 169 (97–260) million people annually.3

In these crises, robust and timely public health information is crucial to rapidly establish public health needs and priorities, and thus an appropriate package of public health services; quantify and mobilise funds and resources required to deliver this package, given the population in need and the required intensity of support to the local disrupted health system; and monitor the performance of the humanitarian response, by identifying and reacting in real time to substandard quality of health services, new threats (eg, an epidemic), gaps in service availability, and other changes (eg, improvements in food security or reduced use of health services). A secondary function of public health information is to enable advocacy and documentation of the crisis' impact (including for legal purposes).4

War and disasters, however, disproportionately occur in countries where public health information systems are already weak. Crises compound these weaknesses by further disrupting government services. Other challenges specific to crises include the short timeframe and high frequency (days or weeks) within which data should be generated so as to monitor fast-developing health events such as epidemics or detect deteriorations in malnutrition and mortality, practical or statistical constraints of data collection methods in displacement situations, paucity of readily available expertise and resources for robust data collection, and security constraints, particularly where data collection or publication are perceived as threatening by combatants.

Epidemiologists and demographers have partially developed adapted methods5 to respond to these challenges, but it is unclear to what extent these methods are used consistently, and major methodological evidence gaps remain. In this paper, we distinguish the different domains of public health information in crisis settings, map existing methods against each of these domains and review the evidence supporting their use, suggest a minimum set of public health information products during the acute phase of the crisis and investigate their actual availability in recent crises, and, lastly, we propose an agenda for methods development and systemic measures to make accurate, timely public health information more consistently available in future crises.

Key messages

  • Timely robust public health information is essential to guide an effective response to crises (armed conflicts and natural disasters). This response encompasses establishing needs and priorities, strategic planning and deciding on appropriate service packages, and reacting in real time to insufficient health service performance or new public health threats. Public health information is also important for advocacy and documentation purposes.

  • Various methods exist to measure relevant aspects of demographics, public health risks, and status and services in crisis settings; however, many of these methods are not strongly evidence based.

  • Actual, timely application of existing methods has been inadequate in recent large crises, even when considering a minimal set of essential public health information services.

  • Far greater investment and institutional buy-in are required to make an advancement from the present unsatisfactory baseline. We propose that a dedicated body might need to be established to do core functions of public health information generation and analysis in crisis settings.

  • The research agenda for development of more robust methods needs to be consolidated, and priorities tackled collaboratively across academic and operational agencies.

For the purpose of this paper, our definition of crisis encompasses sudden unplanned displacement, direct exposure to armed conflict resulting in heightened public health risks or reduced public health services (or both), sudden deterioration in nutritional status (as opposed to trends over multiple years), natural or industrial disaster, or a sudden breakdown of key administrative and management functions in a country (appendix p 13). We consider both the acute and protracted phases of a crisis in this review. We omit large epidemics or pandemics, because they have very specific public health information requirements that, moreover, largely depend on the pathogen and context.

Section snippets

Domains of public health information

The figure summarises the main domains of public health information that could be relevant in a crisis. A necessary starting point is quantifying the affected population and vulnerable subgroups of interest. The figure shows the main public health risk factors that emerge in crises, and how these factors act upon each other and key public health outcomes (nutritional status, morbidity) and impacts (mental health, disability, mortality). Lastly, humanitarian public health (water, sanitation, and

Affected population size and composition

Table 1 summarises available methods pertaining to the public health information domains, and the appendix (p 2) shows the search strategy of this methodological review.

Prospective demographic surveillance, consisting of initial census and ongoing (weekly or monthly) updates by community health workers, is an established approach for tracking population size and mortality, but is mainly done in camps. In the camps of internally displaced people in the eastern Democratic Republic of the Congo,

What minimal information is needed to start responding?

Not all information is required before launching humanitarian interventions. Humanitarian decision making needs to emphasise speed of response, with a no-regrets attitude. For most plausible scenarios, initial priority interventions can be predicated based on the evidence base collected in previous crises and codified in various guidelines, and on the desk-based public health situation analysis relying on pre-crisis secondary data, circumstantial information, and epidemiologically plausible

Development of better methods

Numerous areas for improvement of current methods and development of new ones exist. We suggest key priorities in table 3. Moving forward, methods development will require field agencies and academics to agree on a common research agenda and plan multisite validation studies to ensure findings have wide applicability.157 The current gaps of evidence also result from funding neglect. Dedicated funds, such as the current Wellcome Trust and UK Department for International Development funded

Conclusion

Timely collection of quality public health information in crisis-affected populations is an ethical and deontological responsibility of the humanitarian response system, and a prerequisite for full accountability to beneficiaries and donors. Without information, public health actions risk being inappropriate, inefficient, ineffective, and impossible to evaluate.

Our review highlights areas requiring methodological advancement that warrant a focused, globally coordinated programme of research.

References (161)

  • H Spirer et al.

    Obtaining evidence for the international criminal court using data and quantitative analysis

  • J Leaning et al.

    Natural disasters, armed conflict, and public health

    N Engl J Med

    (2013)
  • TK Mackey et al.

    Responding to the public health consequences of the Ukraine crisis: an opportunity for global health diplomacy

    J Int AIDS Soc

    (2015)
  • P Moszynski

    Excessive mortality in Central African Republic is out of control, warns charity

    BMJ

    (2011)
  • C Robinson et al.

    Demographic methods in emergency assessment. a guide for practitioners

    (2003)
  • RM Coupland et al.

    Mortality associated with use of weapons in armed conflicts, wartime atrocities, and civilian mass shootings: literature review

    BMJ

    (1999)
  • A Vu et al.

    The prevalence of sexual violence among female refugees in complex humanitarian emergencies: a systematic review and meta-analysis

    PLoS Curr

    (2014)
  • Z Steel et al.

    Association of torture and other potentially traumatic events with mental health outcomes among populations exposed to mass conflict and displacement: a systematic review and meta-analysis

    JAMA

    (2009)
  • R Asgary et al.

    Systematic review of prevention and management strategies for the consequences of gender-based violence in refugee settings

    Int Health

    (2013)
  • P Heudtlass et al.

    Excess mortality in refugees, internally displaced persons and resident populations in complex humanitarian emergencies (1998–2012)—insights from operational data

    Confl Health

    (2016)
  • B Roberts et al.

    Why are we not doing more for alcohol use disorder among conflict-affected populations?

    Addiction

    (2015)
  • L Roberts et al.

    Assessing the impact of humanitarian assistance in the health sector

    Emerg Themes Epidemiol

    (2004)
  • K Johnson et al.

    Association of sexual violence and human rights violations with physical and mental health in territories of the Eastern Democratic Republic of the Congo

    JAMA

    (2010)
  • MJ Toole et al.

    The association between inadequate rations, undernutrition prevalence, and mortality in refugee camps: case studies of refugee populations in eastern Thailand, 1979–1980, and eastern Sudan, 1984–1985

    J Trop Pediatr

    (1988)
  • Measuring mortality, nutritional status, and food security in crisis situations: SMART methodology, version 1

  • H Young et al.

    HPN network paper 56: the meaning and measurement of acute malnutrition in emergencies: a primer for decision-makers

    (2006)
  • UE Schaible et al.

    Malnutrition and infection: complex mechanisms and global impacts

    PLoS Med

    (2007)
  • CS Grijalva-Eternod et al.

    The double burden of obesity and malnutrition in a protracted emergency setting: a cross-sectional study of western Sahara refugees

    PLoS Med

    (2012)
  • SL Zeger et al.

    Estimating excess deaths in Iraq since the US-British-led invasion

    Significance

    (2007)
  • F Checchi et al.

    Documenting mortality in crises: what keeps us from doing better

    PLoS Med

    (2008)
  • ON Thoms et al.

    Public health, conflict and human rights: toward a collaborative research agenda

    Confl Health

    (2007)
  • The human security report 2005. War and peace in the 21st century

    (2005)
  • LJ Church

    The data centre for IDPs in North Kivu

  • GM Caleo et al.

    Sentinel site community surveillance of mortality and nutritional status in southwestern Central African Republic, 2010

    Popul Health Metr

    (2012)
  • Tools and methods for estimating populations at risk from natural disasters and complex humanitarian crises

    (2007)
  • A Koedam

    Rapid estimation of affected population figures: desk review

    (2012)
  • F Checchi et al.

    Validity and feasibility of a satellite imagery-based method for rapid estimation of displaced populations

    Int J Health Geogr

    (2013)
  • RF Grais et al.

    Are rapid population estimates accurate? A field trial of two different assessment methods

    Disasters

    (2006)
  • A Pinto et al.

    Estimating population size using spatial analysis methods

  • J Telford et al.

    Counting and identification of beneficiary populations in emergency operations: registration and its alternatives

    (1997)
  • A Henderson

    Using the Delphi method to estimate population size and demographics in emergency food security assessments. Emergency Food Security Assessments (EFSAs) technical guidance sheet no 10

    (2009)
  • Desk review: estimating population size in emergencies

    (2006)
  • L Bengtsson et al.

    Improved response to disasters and outbreaks by tracking population movements with mobile phone network data: a post-earthquake geospatial study in Haiti

    PLoS Med

    (2011)
  • V Treacy-Wong

    Population estimation methods used in complex emergency settings

    (2011)
  • B Harrell-Bond et al.

    Counting the refugees: gifts, givers, patrons and clients

    J Refug Stud

    (1992)
  • R Sollom et al.

    Health and human rights in Chin State, Western Burma: a population-based assessment using multistaged household cluster sampling

    PLoS Med

    (2011)
  • K Johnson et al.

    A national population-based assessment of 2007–2008 election-related violence in Kenya

    Confl Health

    (2014)
  • MH Hicks et al.

    Violent deaths of Iraqi civilians, 2003–2008: analysis by perpetrator, weapon, time, and location

    PLoS Med

    (2011)
  • R Sundberg et al.

    Systematic data collection: experiences from the Uppsala Conflict Data Program

  • M Price et al.

    Updated statistical analysis of documentation of killings in the Syrian Arab Republic

    (2014)
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