Elsevier

Journal of Clinical Epidemiology

Volume 128, December 2020, Pages 35-48
Journal of Clinical Epidemiology

COVID-19 Series
A framework for identifying and mitigating the equity harms of COVID-19 policy interventions

https://doi.org/10.1016/j.jclinepi.2020.06.004Get rights and content

Abstract

Background

Coronavirus disease 2019 (COVID-19) is a global pandemic. Governments have implemented combinations of “lockdown” measures of various stringencies, including school and workplace closures, cancellations of public events, and restrictions on internal and external movements. These policy interventions are an attempt to shield high-risk individuals and to prevent overwhelming countries' healthcare systems, or, colloquially, “flatten the curve.” However, these policy interventions may come with physical and psychological health harms, group and social harms, and opportunity costs. These policies may particularly affect vulnerable populations and not only exacerbate pre-existing inequities but also generate new ones.

Methods

We developed a conceptual framework to identify and categorize adverse effects of COVID-19 lockdown measures. We based our framework on Lorenc and Oliver's framework for the adverse effects of public health interventions and the PROGRESS-Plus equity framework. To test its application, we purposively sampled COVID-19 policy examples from around the world and evaluated them for the potential physical, psychological, and social harms, as well as opportunity costs, in each of the PROGRESS-Plus equity domains: Place of residence, Race/ethnicity, Occupation, Gender/sex, Religion, Education, Socioeconomic status, Social capital, Plus (age, and disability).

Results

We found examples of inequitably distributed adverse effects for each COVID-19 lockdown policy example, stratified by a low- or middle-income country and high-income country, in every PROGRESS-Plus equity domain. We identified the known policy interventions intended to mitigate some of these adverse effects. The same harms (anxiety, depression, food insecurity, loneliness, stigma, violence) appear to be repeated across many groups and are exacerbated by several COVID-19 policy interventions.

Conclusion

Our conceptual framework highlights the fact that COVID-19 policy interventions can generate or exacerbate interactive and multiplicative equity harms. Applying this framework can help in three ways: (1) identifying the areas where a policy intervention may generate inequitable adverse effects; (2) mitigating the policy and practice interventions by facilitating the systematic examination of relevant evidence; and (3) planning for lifting COVID-19 lockdowns and policy interventions around the world.

Keywords

COVID-19
Equity
Inequity
Adverse effects
Public health
Impact assessment

Cited by (0)

Funding sources: This study was funded by the NIHR Policy Research Program through its core support to the Policy Innovation and Evaluation Research Unit (Project No: PR-PRU-1217-20602). The views expressed are those of the author(s) and are not necessarily those of the NIHR or the Department of Health and Social Care.

Conflicts of interest: All authors declare no conflicts of interest.

Declaration of interests: All authors declared no competing interests.

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