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

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: Adverse effects; COVID-19; Equity; Impact assessment; Inequity; Public health.

Fig. 1

The pandemic exacerbates existing inequities, which can in turn exacerbate the pandemic, for example, low SES individuals need to work rather than remain in lockdown. Policy responses have the ability to reduce the peak of the pandemic, or, if poorly designed or implemented, increase it. They also have the potential to increase or reduce inequities. Mitigation strategies can be implemented at the review stage leading to a change in the policy design to prevent or reduce the risk of inequitable harms, or be implemented alongside the lockdown policies to counter or reduce the anticipated impacts on inequities. Both approaches may be taken; this may introduce a feedback loop that targets reductions in the pandemic itself, and health and societal inequities.