Health equity, rights and representation in research: moving towards an action- and justice-oriented approach
By Melissa Murano | @MelissaMurano
In the second half of 2021, Cochrane Australia’s Professor Tari Turner and I joined a team brought together by Dr Doris Chou of the WHO Department of Sexual and Reproductive Health and Research to update clinical recommendations for three induction of labour topics. Our task was to prepare evidence-to-decision documents to inform Guideline Development Group decision-making.
Maternal health care is a clinical area where there is great potential for power and privilege differentials to impact on health care delivery and outcomes. Our team was clear upfront that it was important to have a strong focus on rights and equity in our evidence review. We therefore chose to use the WHO-INTEGRATE evidence-to-decision framework to guide our evidence review of important issues such as equity, human rights, acceptability and feasibility.
We also used the opportunity to reflect on how the methods and processes used to identify, synthesise and integrate this evidence could be improved in a paper recently published in Health Research Policy and Systems (HRPS). Our key findings are outlined in Using the WHO-INTEGRATE evidence-to-decision framework to develop recommendations for induction of labour.
The learnings that arose for me personally during the induction of labour guideline project, in writing the HRPS paper and in the year since aren’t necessarily about methodology (although I have so much more to learn in this department). It’s become clear to me how important it is that as a white researcher living and working in a settler colonial country, I continually inform and challenge myself, and work to develop values- and theory-based positions on concepts such as equity, rights, justice, sovereignty and representation. These aren’t just ‘empty concepts’ that can be left unexamined, but have real and tangible meanings and impacts on people’s lives through the work that we do as evidence reviewers and guideline developers.
For example, part of this ongoing work for me is to interrogate the theories of rights, justice and health equity that evidence-to-decision frameworks draw on. Do I know the history of how these theories came about and where they originated from? Are they fit-for-purpose for the work I am doing and the settings and communities of interest for the guideline? Are there any critiques of these and other competing theories, and if yes, can I articulate how and if they align with my personal and professional values, and/or the values of my organisation and/or guideline group?
As I delve deeper into the social sciences literature, and step outside of academic spaces to listen to and learn from people working in and with communities who are systematically excluded from social and political power (hello Twitter!), I’ve come to understand that the purpose of my work isn’t only to be descriptive and analytical. It is incumbent on me to continually challenge myself so I can begin to realise a more action- and justice-oriented approach in the work I do.
This will mean different things to different people at different times. For example, that might mean stepping aside, rather than stepping up. So for me, the next time I’m given the opportunity to be part of a team reviewing the evidence for a guideline, I’ll be having the conversation about who is best placed to provide the intellectual leadership and who is best placed to provide methodological support.
In particular I’d be advocating for researchers to be leading this work who are from the settings and working with the communities who are most impacted by the structural inequities that result in poorer health outcomes. I’d also love to work in a collaborative interdisciplinary space with social science colleagues who can bring their rich experience and diverse knowledges, theories and approaches to the table (intersectionality anyone?).
There is such a wealth of ways of knowing, skills and experiences that are often overlooked when we ‘stay within our lane’ and don’t move out of our known circles. We can talk about ‘capacity building’ or ‘capacity development’, but I think we can also flip that narrative on its head and think about the many barriers in our institutions, disciplines and spaces that prevent really skilled people who have the critical knowledge and experience from leading and contributing to this work. And most importantly, we can and should work to actively dismantle those barriers, one project at a time.
Are you involved in evidence review for guideline development?
I’d love to hear from other evidence reviewers and guideline developers who are grappling with the critical issues of equity, rights and justice in their work – whether it’s the selection of theories and frameworks used to undertake evidence review for guidelines, the development of values-based positions to inform health equity work, or how you are collaborating across disciplines and settings to elevate and amplify the voices and skills of people outside of the ‘methodology’ community.
Share your thoughts, comments or questions below, reach me via twitter @MelissaMurano or email me at melissa.murano@monash.edu. I welcome your feedback, comments and questions!
Melissa Murano (Senior Research Officer, Cochrane Australia and School of Public Health and Preventive Medicine, Monash University) has a social sciences and public health background, and has contributed to research to increase the uptake and implementation of evidence-informed policy and practice in low-income settings. Tari Turner (Cochrane Australia, Director Australian Living Evidence Consortium, and Professor, School of Public Health and Preventive Medicine, Monash University) is a mixed-methods researcher who has worked in high-, middle- and low-income settings, with a focus on systematic reviews of effectiveness evidence, uptake and implementation of evidence-informed policy and practice, and living evidence.
