Lessons Learned from Systematic Reviews of Qualitative Data in Global Health

The summer before I started medical school in 2009, I received a UCSF medical student training program grant to support a summer internship at the World Health Organization (WHO) headquarters in Geneva, Switzerland. At the time, there was a big push to conduct systematic reviews and use evidence-based guidance for program recommendations.

Jason Nagata, MD, MSc

However, a critical gap in the evidence base remained for research questions without purely quantitative outcomes, such as research on the social determinants of health or on implementation science. I had just completed a master’s degree in medical anthropology, receiving training in qualitative research methods, and would use a novel methodology for systematic reviews of qualitative data, called meta-ethnography.

During my internship, I worked on a systematic review of the social determinants of health related to iron supplementation in women of reproductive age with the WHO Department of Nutrition for Health and Development, which was later published in Maternal and Child Nutrition. The internship was a great opportunity to meet global health leaders from around the world, learn about the process by which WHO guidelines and recommendations are made, and experience the idyllic European summer.

Having learned the methodology to conduct systematic reviews during my internship, I have been able to apply these skills to diverse global health topics. I subsequently worked on other systematic reviews with WHO on social determinants of influenza vaccination, cotrimoxizole prophylaxis in HIV and performance-based financing for HIV/AIDS service delivery.

My most recent collaboration, “Lessons learnt from implementation of the International Health Regulations: a systematic review,” is published in the February 2018 issue of the Bulletin of the World Health Organization and is my first review as senior author. This special issue on emerging infectious diseases includes an editorial by WHO Director-General Tedros Adhanom Ghebreyesus.

The International Health Regulations (IHR) were first introduced in 1969 as global legislation requiring countries to link and coordinate specific actions related to the control of infectious diseases such as cholera, plague, yellow fever and smallpox. However, the regulations were revised in 2005, given the need to expand the scope to include new epidemics and to improve global coordination. IHR (2005) requires countries to notify the WHO of all events that may constitute a public health emergency of international concern, such as Ebola virus, Zika virus and H1N1 pandemic influenza.

In addition, IHR (2005) requires countries to develop, strengthen and maintain eight core public health capacities: (1) national legislation, policy and financing, (2) coordination and National Focal Point communications, (3) surveillance, (4) response, (5) preparedness, (6) risk communication, (7) human resources and (8) laboratory. Although substantial progress has been made in some areas, by the end of 2015, two-thirds of countries had not met all IHR (2005) core capacity requirements.

The review included 51 articles from 77 countries representing all WHO regions describing lessons learnt from the implementation of IHR (2005). Major themes included the need to mobilize and sustain political commitment; the adaptation of global requirements based on local sociocultural, epidemiological, health system, and economic contexts; and the conducting of baseline and follow-up assessments to monitor the status of IHR (2005) implementation. Specific lessons learned are listed for each of the eight core capacities.

Given the recent outbreaks of Ebola virus and Zika virus and the continued threats of future epidemics, I hope that this systematic review of qualitative data will provide useful lessons learned for countries still implementing the International Health Regulations.

Jason Nagata is a second-year physician fellow in the Division of Adolescent & Young Adult Medicine in the UCSF Department of Pediatrics.