Understanding fragility: implications for global health research and practice

Abstract Advances in population health outcomes risk being slowed—and potentially reversed—by a range of threats increasingly presented as ‘fragility’. Widely used and critiqued within the development arena, the concept is increasingly used in the field of global health, where its relationship to population health, health service delivery, access and utilization is poorly specified. We present the first scoping review seeking to clarify the meaning, definitions and applications of the term in the global health literature. Adopting the theoretical framework of concept analysis, 10 bibliographic and grey literature sources, and five key journals, were searched to retrieve documents relating to fragility and health. Reviewers screened titles and abstracts and retained documents applying the term fragility in relation to health systems, services, health outcomes and population or community health. Data were extracted according to the protocol; all documents underwent bibliometric analysis. Narrative synthesis was then used to identify defining attributes of the concept in the field of global health. A total of 377 documents met inclusion criteria. There has been an exponential increase in applications of the concept in published literature over the last 10 years. Formal definitions of the term continue to be focused on the characteristics of ‘fragile and conflict-affected states’. However, synthesis indicates diverse use of the concept with respect to: level of application (e.g. from state to local community); emphasis on particular antecedent stressors (including factors beyond conflict and weak governance); and focus on health system or community resources (with an increasing tendency to focus on the interface between two). Amongst several themes identified, trust is noted as a key locus of fragility at this interface, with critical implications for health seeking, service utilization and health system and community resilience.

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The impact of economic sanctions on health and health systems in low- and middle-income countries

European Journal of Public Health ◽

10.1093/eurpub/ckaa165.912 ◽

2020 ◽

Vol 30 (Supplement_5) ◽

Author(s):

M Suhrcke ◽

M Pinna Pintor ◽

C Hamelmann

Keyword(s):

Health Outcomes ◽

Health System ◽

Health Systems ◽

Grey Literature ◽

Economic Sanctions ◽

Political Crisis ◽

Middle Income ◽

Financial Flows ◽

Adverse Health ◽

The Impact

Abstract Background Economic sanctions, understood as measures taken by one state or a group of states to coerce another into a desired conduct (eg by restricting trade and financial flows) do not primarily seek to adversely affect the health or health system of the target country's population. Yet, there may be indirect or unintended health and health system consequences that ought to be borne in mind when assessing the full set of effects of sanctions. We take stock of the evidence to date in terms of whether - and if so, how - economic sanctions impact health and health systems in LMICs. Methods We undertook a structured literature review (using MEDLINE and Google Scholar), covering the peer-reviewed and grey literature published from 1970-2019, with a specific focus on quantitative assessments. Results Most studies (23/27) that met our inclusion criteria focus on the relationship between sanctions and health outcomes, ranging from infant or child mortality as the most frequent case over viral hepatitis to diabetes and HIV, among others. Fewer studies (9/27) examined health system related indicators, either as a sole focus or jointly with health outcomes. A minority of studies explicitly addressed some of the methodological challenges, incl. control for relevant confounders and the endogeneity of sanctions. Taking the results at face value, the evidence is almost unanimous in highlighting the adverse health and health system effects of economic sanctions. Conclusions Quantitatively assessing the impact of economic sanctions on health or health systems is a challenging task, not least as it is persistently difficult to disentangle the effect of sanctions from many other, potentially major factors at work that matter for health (as, for instance, war). In addition, in times of severe economic and political crisis (which often coincide with sanctions), the collection of accurate and comprehensive data that could allow appropriate measurement is typically not a priority. Key messages The existing evidence is almost unanimous in highlighting the adverse health and health system effects of economic sanctions. There is preciously little good quality evidence on the health (system) impact of economic sanctions.

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Artificial intelligence for good health: a scoping review of the ethics literature

BMC Medical Ethics ◽

10.1186/s12910-021-00577-8 ◽

2021 ◽

Vol 22 (1) ◽

Author(s):

Kathleen Murphy ◽

Erica Di Ruggiero ◽

Ross Upshur ◽

Donald J. Willison ◽

Neha Malhotra ◽

...

Keyword(s):

Public Health ◽

Artificial Intelligence ◽

Global Health ◽

Population Health ◽

Health Systems ◽

Scoping Review ◽

Industrial Revolution ◽

Ethical Issues ◽

Grey Literature ◽

Ethical Implications

Abstract Background Artificial intelligence (AI) has been described as the “fourth industrial revolution” with transformative and global implications, including in healthcare, public health, and global health. AI approaches hold promise for improving health systems worldwide, as well as individual and population health outcomes. While AI may have potential for advancing health equity within and between countries, we must consider the ethical implications of its deployment in order to mitigate its potential harms, particularly for the most vulnerable. This scoping review addresses the following question: What ethical issues have been identified in relation to AI in the field of health, including from a global health perspective? Methods Eight electronic databases were searched for peer reviewed and grey literature published before April 2018 using the concepts of health, ethics, and AI, and their related terms. Records were independently screened by two reviewers and were included if they reported on AI in relation to health and ethics and were written in the English language. Data was charted on a piloted data charting form, and a descriptive and thematic analysis was performed. Results Upon reviewing 12,722 articles, 103 met the predetermined inclusion criteria. The literature was primarily focused on the ethics of AI in health care, particularly on carer robots, diagnostics, and precision medicine, but was largely silent on ethics of AI in public and population health. The literature highlighted a number of common ethical concerns related to privacy, trust, accountability and responsibility, and bias. Largely missing from the literature was the ethics of AI in global health, particularly in the context of low- and middle-income countries (LMICs). Conclusions The ethical issues surrounding AI in the field of health are both vast and complex. While AI holds the potential to improve health and health systems, our analysis suggests that its introduction should be approached with cautious optimism. The dearth of literature on the ethics of AI within LMICs, as well as in public health, also points to a critical need for further research into the ethical implications of AI within both global and public health, to ensure that its development and implementation is ethical for everyone, everywhere.

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Impact of a health system strengthening intervention on maternal and child health outputs and outcomes in rural Rwanda 2005–2010

BMJ Global Health ◽

10.1136/bmjgh-2017-000674 ◽

2018 ◽

Vol 3 (2) ◽

pp. e000674 ◽

Cited By ~ 6

Author(s):

Dana R Thomson ◽

Cheryl Amoroso ◽

Sidney Atwood ◽

Matthew H Bonds ◽

Felix Cyamatare Rwabukwisi ◽

...

Keyword(s):

Child Health ◽

Health Outcomes ◽

Health System ◽

Population Health ◽

Maternal And Child Health ◽

Rural Areas ◽

Health System Strengthening ◽

Live Births ◽

Intervention Area ◽

And Child Health

IntroductionAlthough Rwanda’s health system underwent major reforms and improvements after the 1994 Genocide, the health system and population health in the southeast lagged behind other areas. In 2005, Partners In Health and the Rwandan Ministry of Health began a health system strengthening intervention in this region. We evaluate potential impacts of the intervention on maternal and child health indicators.MethodsCombining results from the 2005 and 2010 Demographic and Health Surveys with those from a supplemental 2010 survey, we compared changes in health system output indicators and population health outcomes between 2005 and 2010 as reported by women living in the intervention area with those reported by the pooled population of women from all other rural areas of the country, controlling for potential confounding by economic and demographic variables.ResultsOverall health system coverage improved similarly in the comparison groups between 2005 and 2010, with an indicator of composite coverage of child health interventions increasing from 57.9% to 75.0% in the intervention area and from 58.7% to 73.8% in the other rural areas. Under-five mortality declined by an annual rate of 12.8% in the intervention area, from 229.8 to 83.2 deaths per 1000 live births, and by 8.9% in other rural areas, from 157.7 to 75.8 deaths per 1000 live births. Improvements were most marked among the poorest households.ConclusionWe observed dramatic improvements in population health outcomes including under-five mortality between 2005 and 2010 in rural Rwanda generally and in the intervention area specifically.

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Artificial intelligence (AI) and global health: how can AI contribute to health in resource-poor settings?

BMJ Global Health ◽

10.1136/bmjgh-2018-000798 ◽

2018 ◽

Vol 3 (4) ◽

pp. e000798 ◽

Cited By ~ 62

Author(s):

Brian Wahl ◽

Aline Cossy-Gantner ◽

Stefan Germann ◽

Nina R Schwalbe

Keyword(s):

Artificial Intelligence ◽

Patient Safety ◽

Global Health ◽

Health Outcomes ◽

Health System ◽

Healthcare Services ◽

Full Potential ◽

High Profile ◽

Resource Poor ◽

Improve Health

The field of artificial intelligence (AI) has evolved considerably in the last 60 years. While there are now many AI applications that have been deployed in high-income country contexts, use in resource-poor settings remains relatively nascent. With a few notable exceptions, there are limited examples of AI being used in such settings. However, there are signs that this is changing. Several high-profile meetings have been convened in recent years to discuss the development and deployment of AI applications to reduce poverty and deliver a broad range of critical public services. We provide a general overview of AI and how it can be used to improve health outcomes in resource-poor settings. We also describe some of the current ethical debates around patient safety and privacy. Despite current challenges, AI holds tremendous promise for transforming the provision of healthcare services in resource-poor settings. Many health system hurdles in such settings could be overcome with the use of AI and other complementary emerging technologies. Further research and investments in the development of AI tools tailored to resource-poor settings will accelerate realising of the full potential of AI for improving global health.

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Artificial Intelligence for Good Health: A Scoping Review of the Ethics Literature

10.21203/rs.3.rs-29373/v1 ◽

2020 ◽

Author(s):

Kathleen Murphy ◽

Erica Di Ruggiero ◽

Ross Upshur ◽

Donald J. Willison ◽

Neha Malhotra ◽

...

Keyword(s):

Public Health ◽

Artificial Intelligence ◽

Global Health ◽

Population Health ◽

Health Systems ◽

Scoping Review ◽

Industrial Revolution ◽

Ethical Issues ◽

Grey Literature ◽

Ethical Implications

Abstract Background Artificial intelligence (AI) has been described as the “fourth industrial revolution” with transformative and global implications, including in healthcare, public health, and global health. AI approaches hold promise for improving health systems worldwide, as well as individual and population health outcomes. While AI may have the potential to advance health equity within and between countries, we must consider the ethical implications of its deployment in order to mitigate its potential harms, particularly for the most vulnerable. This scoping review addresses the following question: What ethical issues have been identified in relation to AI in the field of health, including from a global health perspective? Methods Eight electronic databases were searched for peer reviewed and grey literature using the overarching concepts of health, ethics, and AI, and their related terms. Records were independently screened by two reviewers and were included if they reported on AI in relation to health and ethics and were written in the English language. Data was charted on a piloted data abstraction form, and a descriptive and thematic analysis was performed. Results Upon reviewing 12,722 articles, 103 met the predetermined inclusion criteria. The literature was primarily focused on the ethics of AI in health care, particularly on carer robots, diagnostics, and precision medicine, but was largely silent on ethics of AI in public and population health. The literature highlighted a number of common ethical concerns related to privacy, trust, accountability, and bias. Largely missing from the reviewed literature was the ethics of AI in global health, particularly in the context of low- and middle-income countries (LMICs). Conclusions The ethical issues surrounding AI in the field of health are both vast and complex. While AI holds the potential to improve health and health systems, our analysis suggests that its introduction should be approached with cautious optimism. The dearth of literature on the ethics of AI within LMICs, as well as in public health, also points to a critical need for further research into the ethical implications of AI within both global and public health, to ensure that its development and implementation is ethical for everyone, everywhere.

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Artificial Intelligence for Good Health: A Scoping Review of the Ethics Literature

10.21203/rs.3.rs-29373/v3 ◽

2021 ◽

Author(s):

Kathleen Murphy ◽

Erica Di Ruggiero ◽

Ross Upshur ◽

Donald J. Willison ◽

Neha Malhotra ◽

...

Keyword(s):

Public Health ◽

Artificial Intelligence ◽

Global Health ◽

Population Health ◽

Health Systems ◽

Scoping Review ◽

Industrial Revolution ◽

Ethical Issues ◽

Grey Literature ◽

Ethical Implications

Abstract Background: Artificial intelligence (AI) has been described as the “fourth industrial revolution” with transformative and global implications, including in healthcare, public health, and global health. AI approaches hold promise for improving health systems worldwide, as well as individual and population health outcomes. While AI may have potential for advancing health equity within and between countries, we must consider the ethical implications of its deployment in order to mitigate its potential harms, particularly for the most vulnerable. This scoping review addresses the following question: What ethical issues have been identified in relation to AI in the field of health, including from a global health perspective? Methods: Eight electronic databases were searched for peer reviewed and grey literature published before April 2018 using the concepts of health, ethics, and AI, and their related terms. Records were independently screened by two reviewers and were included if they reported on AI in relation to health and ethics and were written in the English language. Data was charted on a piloted data charting form, and a descriptive and thematic analysis was performed. Results: Upon reviewing 12,722 articles, 103 met the predetermined inclusion criteria. The literature was primarily focused on the ethics of AI in health care, particularly on carer robots, diagnostics, and precision medicine, but was largely silent on ethics of AI in public and population health. The literature highlighted a number of common ethical concerns related to privacy, trust, accountability and responsibility, and bias. Largely missing from the literature was the ethics of AI in global health, particularly in the context of low- and middle-income countries (LMICs). Conclusions: The ethical issues surrounding AI in the field of health are both vast and complex. While AI holds the potential to improve health and health systems, our analysis suggests that its introduction should be approached with cautious optimism. The dearth of literature on the ethics of AI within LMICs, as well as in public health, also points to a critical need for further research into the ethical implications of AI within both global and public health, to ensure that its development and implementation is ethical for everyone, everywhere.

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Just Moments: A Letter to Dr Peter Erickson

American Journal of Health Promotion ◽

10.1177/0890117119874244 ◽

2019 ◽

Vol 33 (8) ◽

pp. 1104-1106

Author(s):

Paul E. Terry

Keyword(s):

Health Outcomes ◽

Health System ◽

Population Health ◽

Self Care ◽

Well Being ◽

Improve Population Health ◽

Care Practices ◽

The Moment ◽

Individual Self

Practicing mindfulness is usually characterized as being “in the moment” and is most often associated with an effort to manage individual illness, stress, or well-being. This editorial memorializes my dear friend Pete Erickson who was an exemplar to making every moment count. But more importantly, moments he made with others were “just moments” in service to his community, moments that made others experience their community and their health system as more just places. In defining “just moments,” I cite the paper “Collective Well-being to Improve Population Health Outcomes” where the authors argued that well-being is a function of a group and that domains such as “connectedness” and “contribution” may have as much to do with well-being as does our usual focus on individual self-care practices.

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Senegal Health System Analysis and Its Implications to Global Health Cooperation

10.21203/rs.3.rs-585164/v1 ◽

2021 ◽

Author(s):

Yue Zhang ◽

Jingyi Chen ◽

Chunfeng Zhang ◽

Lucy Chen

Keyword(s):

Global Health ◽

Human Resources ◽

Health System ◽

International Development ◽

Population Health ◽

Urban Areas ◽

System Analysis ◽

Health Workers ◽

Health Human Resources ◽

Health Cooperation

Abstract As an active participant of global health cooperation in west Africa, the Republic of Senegal is one of the major recipients of international development assistance. Yet, funding and actions from different donors and implementing organizations are fragmented, which is one of the reasons that Senegal is failing to outstand its health performance disproportionally. This report provides an overview of Senegal’s population health status and health system performance and pinpoint areas that should be prioritized for focused global health assistance. Undernutrition and neonatal disorders were found to have posed the highest and most urgent risks on the public health of Senegal. This is intensified by the severe shortage of health human resources, vast disparity of resources between rural and urban areas, and unsatisfactory health financing mechanism. Based on the situation analysis of Senegal’s population health and health system, this report recommends (1) the Senegal MSAS to take the lead of integrating and coordinating public, private, and international health programs to reduce fragmentation with a focus on financing rural health human resources; (2) to research the root causes of undernutrition and neonatal disorders in Senegal and construct nutrition and maternal health interventions based on evidence generated; and (3) to conduct continued training of doctors, nurses, midwives, community health workers with strong focus in Kedougou and Kolda.

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Incorporating Concepts of Population Health within the Nursing Curriculum

Journal of Nursing & Healthcare ◽

10.33140/jnh/01/01/00005 ◽

2016 ◽

Vol 1 (1) ◽

Keyword(s):

Nursing Students ◽

Health Outcomes ◽

Population Health ◽

Best Practice ◽

Local Community ◽

Population Level ◽

Well Being ◽

Learning Objects ◽

Lessons Learned ◽

Health And Wellness

The goal of Population Health is to improve health and wellness in patient populations. Disparities can negatively impact individual/family or community subsets that have experienced access, resource or socioeconomic obstacles to health and wellness. As such, it is important to understand the determinants that impact health outcomes at the population level. Family centric nursing in both the educational and practice arena can broaden its impact through incorporating concepts from population health to enhance the well-being of persons across the lifespan in local community and broader global settings. The Department of Nursing at one state college has made an effort to incorporate Population Health and its tenets into the curriculum. Grant funding has supported strategies utilized in the transition. The strategies include, but are not limited to; educating faculty, students, and affiliated clinical settings and their providers about issues involved in determining population health; utilizing existing research evidence or best practice interventions in the planning and delivery of care; increasing inter professional collaboration; mobilizing existing community resources to achieve better health outcomes; and the use of informatics and technology. Lessons learned in developing knowledge, establishing learning objects, and offering clinical experiences that promote competencies in population-based health care will be shared. Highlights will include a discussion of learning experiences of nursing students involved in an academic-practice partnership within an underserved urban area and a global health medical mission with a NGO to address population health disparities in a resource poor environment.

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Commissioning services and Primary Health Networks

Australian Journal of Primary Health ◽

10.1071/py15167 ◽

2016 ◽

Vol 22 (1) ◽

pp. 3 ◽

Cited By ~ 2

Author(s):

Mark Booth ◽

Anne-marie Boxall

Keyword(s):

Health Outcomes ◽

Health System ◽

Population Health ◽

International Experience ◽

Health Networks ◽

Hospital Sector ◽

Australian Health ◽

Primary Health ◽

International Experiences ◽

Australian Hospital

Commissioning is set to become a stronger feature in the Australian health system as Primary Health Networks embrace it as a tool for improving population health outcomes. International experience shows that developing into a commissioning organisation is not always easy. Drawing on international experiences of commissioning, as well as those from the Australian hospital sector, will help smooth the path for Primary Health Networks.

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