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

  • Glover, Rebecca E1
  • van Schalkwyk, May C I2
  • Akl, Elie A3
  • Kristjannson, Elizabeth4
  • Lotfi, Tamara5
  • Petkovic, Jennifer6
  • Petticrew, Mark P2
  • Pottie, Kevin7
  • Tugwell, Peter8
  • Welch, Vivian9
  • 1 London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH. Electronic address: [email protected]
  • 2 London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH.
  • 3 Department of Epidemiology and Population Health, American University of Beirut, Beirut, Lebanon. , (Lebanon)
  • 4 School of Psychology, Faculty of Social Sciences, University of Ottawa, Ottawa, Ontario L8S 4L8, Canada. , (Canada)
  • 5 Department of Health Research Methods, Evidence & Impact, McMaster University, 1280 Main St W, Hamilton, Ontario L8S 4L8, Canada. , (Canada)
  • 6 Bruyere Research Institute, Ottawa, Canada. , (Canada)
  • 7 Department of Family Medicine, Bruyere Research Institute, University of Ottawa, Ottawa, Ontario L8S 4L8, Canada. , (Canada)
  • 8 Department of Medicine, Bruyere Research Institute, University of Ottawa, Ottawa, Ontario L8S 4L8, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario L8S 4L8, Canada. , (Canada)
  • 9 Bruyere Research Institute, Ottawa, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario L8S 4L8, Canada. , (Canada)
Published Article
Journal of clinical epidemiology
Publication Date
Dec 01, 2020
DOI: 10.1016/j.jclinepi.2020.06.004
PMID: 32526461


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. 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). 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. 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. Copyright © 2020 Elsevier Inc. All rights reserved.

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