key: cord-0724642-154amdh9 authors: Glover, Rebecca E.; van Schalkwyk, May CI.; Akl, Elie A.; Kristjannson, Elizabeth; Lotfi, Tamara; Petkovic, Jennifer; Petticrew, Mark P.; Pottie, Kevin; Tugwell, Peter; Welch, Vivian title: A framework for identifying and mitigating the equity harms of COVID-19 policy interventions date: 2020-06-09 journal: J Clin Epidemiol DOI: 10.1016/j.jclinepi.2020.06.004 sha: 0333b149fa1bad7b40013227fa125d7a90745265 doc_id: 724642 cord_uid: 154amdh9 Abstract: Introduction 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 categorise 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 LMIC and HIC, in every PROGRESS-Plus equity domain. We identified 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 areas where a policy intervention may generate inequitable adverse effects; (2) mitigating 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. The World Health Organization (WHO) declared the coronavirus disease 2019 , caused by the novel viral zoonosis Severe Acute Respiratory Syndrome Coronavirus 2, a pandemic on 11 March 2020. (1) Countries have reacted to the virus by putting in place different public health interventions. These interventions are intended to reduce morbidity and mortality associated with COVID-19, while also mitigating the potentially disastrous impact on health systems. Each country is choosing different combinations of policy interventions, some of which are more or less stringent. (2) The menu of policy options includes: school closures; workplace closures; public event cancellations; public transport closure; restriction on internal movement; and international travel controls. Combinations of these policy options are colloquially being referred to as 'lockdown'. The benefits of these policy options with respect to reducing transmission and flattening the COVID-19 epidemic curve have been enumerated elsewhere. (3) However, some of the adopted interventions risk generating or exacerbating inequities.(4) There is evidence for both the inequitable distribution of harms accrued due to pandemics, and due to the policy interventions in response to them; there is thus a need for pandemic preparedness and responses to adopt an equity and social justice lens. (5) (6) (7) (8) (9) (10) In their comment in Nature Medicine on 26th March 2020, Wang and Tang stated "Solid evidence for tackling health inequities during the COVID-19 outbreak is in urgent need. The scarcity of health-equity assessment during the current outbreak will halve the disease-control efforts." (5) While there have been analyses of the wider impacts of the pandemic, (11) there is a lack of evidence-informed tools for detailed and systematic analysis of the type and extent of inequities that may be created or deepened as a result of the actions taken to address the pandemic. Such tools are needed to identify and implement mitigation strategies and to inform an equitable pandemic response. The aim of this study was to develop a conceptual framework to help various policy actors, including national and local governments, public health professionals, non-governmental organisations, and researchers, systematically to analyse the health, psychological, social, and opportunity cost harms of COVID-19 policies according to the Cochrane PROGRESS-Plus equity algorithm. We worked through specific COVID- 19 policy examples for each of the PROGRESS-Plus equity domains in order to demonstrate how the conceptual framework could be used. We identified areas where there may be an inequitably distributed burden of adverse effects caused by COVID-19 public health interventions, or where COVID-19 interventions may widen pre-existing inequities. (12) We built on two previously developed frameworks for assessing the adverse and inequitable effects of public health interventions. (4, 9) The Lorenc and Oliver framework describes five categories of harms that may occur when implementing public health interventions without mitigation strategies: direct health harms, psychological harms, equity harms, group and social harms, and opportunity costs.(9) We expanded on this by subdividing the concept of 'equity harms' into the domains specified by the Construction and application of the framework demonstrated that each adverse effect, and each equity domain, can interact with, worsen, and be worsened by others. For example, equity factors such as age, place of residence, SES, ethnicity and occupation may all contribute to physical risk of Covid-19 but also be risk factors for disproportionately feeling the effects of certain policy interventions. (Figure 1 ) comprise the framework and are used in Table 1 . We used examples of specific policies adopted in response to the COVID-19 pandemic to demonstrate the types of evidence that may support identification of a range of equity issues and associated harms. We chose a real-world policy response to the COVID-19 pandemic which has relevance to each of the PROGRESS-Plus categories, including a High Income Country (HIC) and a Low or Middle Income Country (LMIC) policy example. We also identified examples of mitigating interventions that have been attempted so far in the COVID-19 response. Not all mitigating strategies will be effective, and these proposed mitigating strategies may themselves generate a range of adverse effects that are also likely to be distributed inequitably, with many yet to be evaluated. While each policy example and associated equity considerations provide important insights for policy design and implementation, important observations are made from examining trends across the table as a whole. For example, the same harms (food insecurity; violence; loneliness; depression; anxiety; stigma) are repeated across many groups, and are exacerbated by many COVID-19 policy interventions. This is crucial; it shows that inequitable policy options may generate interactive and multiplicative harms. (11, 17, 18) For example, poorer women living in poorer communities are at higher risk of acquiring COVID-19 due to the need to continue working, and to crowded working and living conditions. Also, if they become infected, they are at higher risk of poor health outcome considering lower access to, and lower quality of healthcare services. On the other hand, lockdown measures put them at higher risks of physical and mental health risks of inactivity, domestic abuse, and lost earnings. Table 1 also demonstrates that certain mitigation strategies may be implemented in response to more than one equity issue, and that certain lockdown policies may act upon multiple equity domains. Most countries have implemented a 'package' of lockdown policies and Table 1 demonstrates the need to conduct such an assessment on each component of the package, to help consider and identify how policies may interact in a way that worsens inequities to a greater extent than had any one component been implemented in isolation. The absence of avoidable and unfair differences in a particular condition or state between different groups of people. For example, health equity is the absence of avoidable and unfair differences in health outcomes. (19) Adverse effects (adapted from Lorenc and Oliver)(9) Physical health Direct or indirect harms that accrue across all spheres of physical health. Direct or indirect harms that accrue across the range of mental health areas, including but not limited to depression, anxiety, stress, and psychosis. Group or social Direct or indirect harms that accrue by targeting social interventions at particular groups or parts of society, thereby worsening the experience of subsets of people within a population. The loss of one or more option, course of action, or outcome that is incurred by selecting an alternative one. Place of residence can mean type of dwelling (house with garden, flat, house of multiple occupancy, informal settlement, prison), location of dwelling (urban, suburban, rural), specialist dwelling (assisted living, care homes, hospice) or lack of dwelling (people who experience homelessness). It is linked to socio-economic status and access to: outside space, public transit, infrastructure, livelihoods, and other services (e.g. health care), social cohesion, and environmental exposures.(20) There are many health outcomes that accrue inequitably due to race, ethnicity, culture, and language. Health risks and outcomes are often stratified between ethnic groups, with worse health outcomes often observed in Black, Asian, and Minority Ethnic (BAME) populations. This may reflect inequities in the burdens of wider determinants of health such as employment and environmental exposures, discrimination, education, or diet. However, concepts such as inherent or biological susceptibility can be invoked to further discriminate against such groups, leading to further physical and psychological harms. Occupation may refer to the status of employment-such as unemployed, part-time, 'zero-hours' contract or full-time employment -or type of employment. These have implications for health equity, with some professions or exposures being more high risk than others. Job security and the type of labour protections in place are important, particularly during times of crisis. Gender-based and biological differences can lead to unequal distribution of disease risks, incidence and outcomes, as well as healthcare service needs. Other differences can be due to inequitable exposure to risk or protections based on sex or gender, such as through sector of employment or legal rights, or discrimination, barriers to services, or the type and quality of service provision that is received. Religious affiliation, or lack thereof, can lead to inequitably exposure to harms and/or opportunities. For example religious status may affect access to health services or the appropriateness of the health service offered and received. Certain religious affiliations may experience discrimination, stigma, or even violence. Education is known to impact on health status due to its relationship with employment, and consequently, income, but also due to the co-location and embedding of other health interventions (e.g. counseling; meal programmes) into educational settings. Education is a fundamental determinant of health and also an effective means of reducing health inequities. Conversely, disruption to education is an adverse mechanism for potentially increasing inequalities; partly by withdrawing the intervention from poorer families, but also because better off families are better able to fill the gap with supplemental homeschooling. Higher SES is associated with longer life expectancy and fewer years of poor health due to a constellation of effects including access to clean water, food security, better housing conditions, education, access to healthcare, health and communication literacy, and lower rates of stress. The original PROGRESS definitions included social capital, which was defined as: "social relationships and networks. It includes interpersonal trust between members of a community, civic participation, and the willingness of members of a community to assist each other and facilitate the realization of collective community goals and the strength of their political connections, which can facilitate access to services." (4) Social capital can act as a determinant of health and also a social buffer, particularly in times of individual or population-level crisis. It can act via psychosocial pathways, it can enhance financial support, or access to resources. (21) Social capital is closely related to socioeconomic inequalities; it is important not to view social capital, which often has an individualistic focus, as an alternative to effective health, social and economic policies to reduce or even prevent inequities. (22) Other relevant domains: The PROGRESS domains include a 'Plus' feature, which allows for the addition of specific time-dependent or condition-dependent domains. These can vary across contexts. We chose to include age and disability due to their relevance to COVID-19 outcomes.(4) While age is itself an unavoidable risk factor for many diseases, certain age groups can often be inequitably impacted by avoidable differences in access to services and technology, vulnerability to exploitation and to the impacts of termination or suspension of certain services such as routine healthcare services or education. Some age groups may have greater resilience or adaptability during times of crisis. Disability reduces access to health services.(23) These reductions in access may be exacerbated by closures, uncertainties, and reduced availability of primary care clinicians or other forms of routine care. Uncertainty in access to services can lead to psychological harms for those most dependent on them. (24) We have developed a framework tool systematically to analyse the types of harms potentially induced by COVID-19 policies across different equity domains. The tool also allows for the identification of mitigation strategies. Many of the included policies, while providing benefits in addressing the pandemic, are simultaneously likely to be generating new inequities and worsening pre-existing ones. Systematically adopting the proposed framework may help to identify inequitably distributed adverse effects, thereby aiding in the development of mitigating policy options in these areas. It may also help with considering the beneficial or harmful impacts of partially or wholly lifting lockdowns, as well as the impacts of the economic recession that will follow the acute response to the pandemic. In the future, it might also provide an input into decisions about when and how to return to lockdown in a second or third pandemic wave. Ideally this exercise could be undertaken using systematically identified, relevant academic evidence, and would have been undertaken as lockdown policies were being planned and implemented. (Table 3 ). This view is consistent with that of others working to develop COVID-19 policy recommendations using the precautionary principle to protect groups likely to be disproportionately affected.(28,29) Table 3 lists resources that could help in rapidly assessing COVID-19 emerging literature for local, regional, and national contexts, across multiple topics. These sources are live at the time of writing. Some governments, once they have been made aware of inequities, have attempted to marshal the fastmoving COVID-19 response in order to mitigate them. In the UK, the government has recently made methadone available at pharmacies without a prescription.(30) After initially banning alcohol sales, a French local authority changed their policy after fears that alcohol-dependency meant dangerous detoxification alone during the pandemic.(31) The Swedish government found that multigenerational housing combined with risk groups was causing increased rates of COVID-19 in the Swedish-Somali community, and so made housing available for high risk members of the Swedish-Somali community.(32) In Spain, universal basic income is being considered as an effort to avert coronavirus economic disaster.(33) However, more can always be done; domestic abuse is increasing due to lockdown requirements for victims to stay home with their abusers, (34) and, in Canada, asylum seekers are being turned away due to international travel restrictions.(35) For every example of a mitigating policy intervention, there seem to be many more groups whose needs have been neglected. The goals, timing, and outcome prioritisation of COVID-19 policy interventions reflect political considerations. For example, political orientation may be reflected in an emphasis on personal responsibility and individual-level behaviour change interventions (e.g. an exclusive focus on individual hygiene behaviours) as opposed to population level measures. Similarly governments with neoliberal orientations may prioritise interventions which preserve the economy. This may manifest itself in political choices to have less stringent or shorter lockdown policies, or in how long it took to lock down in the first instance. Some of these market-oriented decisions may encourage inequities. Even choices aiming to protect health services may inadvertently increase existing inequities in care seeking and health care use. (36) The framework presented here may also serve as a tool to advocate for more attention to be given to equity issues in contexts where they receive less political priority, by exposing unfair and unjust harms. The nature of inequities is that they co-exist across different levels of society, and can incur interactive and multiplicative effects among the most disadvantaged. (37) This can be shown by the repetition of inequities across Table 1 . For example, inequitable distributions of education disruptions were highlighted in the gender category in LMICs, and also in the education category in LMICs and HICs. The impact of loneliness occurs multiple times as well. The pandemic will likely exacerbate these inequities, tipping those groups already on the margins of society, economic viability, and survival, over a cliff-edge of uncertainty and life-changing adverse effects. There is a serious risk in the COVID-19 pandemic of LMICs bowing to international pressure to make the same policy choices as HICs. This may not be appropriate in all contexts because of variations in baseline risk, resources, health and other system-level factors. (38) Adopting many of the same policy options, such as 'staying at home' is effectively impossible in many contexts, such as informal settlements, crowded dwellings, and those without access to potable water or latrines. The country context will strongly mediate the effects of COVID-19 policy options; the same policies may generate different burdens, and patterns, of inequities in different countries because of contextual and other variations. (39) In considering this, a wide definition of context should be adopted, which could include the socio-economic characteristics of populations, culture, ethnicity, geography, legal environments, health and other systems, social norms, community support mechanisms, and many other considerations which may affect the implementation and effectiveness of interventions. (39) Policymakers should be actively taking these equity groups into account when choosing their COVID-19 policy packages and how they are implemented. When making decisions about COVID-19 policy options, governments should adopt an approach that considers both the benefits gained in transmission reduction as well as the harms accrued (and to whom). When the first and subsequent waves of COVID-19 are dealt with in a reactionary way, this framework can inform the strengthening of pandemic preparedness plans proactively in the future. These decisions could be informed by decision analytic approaches to encourage costs and benefits options to be compared across multiple domains. (40) There are several limitations of this conceptual framework. First, any effort to mitigate inequities risks incurring them. It may also be difficult to operationalise an equity lens for those populations or groups that fall between or among categories. One way to consider particularly vulnerable groups would be to conduct this exercise for a single vulnerable population, such as displaced persons, and work through the entire table for that specific population. It must also be remembered that the potential inequitable effects of policies that we identify, and inequities in outcomes, in general reflect underlying structural inequities, which the pandemic has brought into sharper relief. Addressing the underlying social determinants of inequity in parallel is itself an essential intervention to mitigate the effects of this and future pandemics. (41) Though this framework represents an approach to assessing potential equity concerns, it does not enumerate all, or even most, areas in which equity concerns may exist. Rather, it is a starting point to encourage others to work toward cataloguing unintended consequences of COVID-19 using an equity lens. While our approach is in no way comprehensive, it may be a helpful tool to use in different settings. It may also be helpful as a way of considering the applicability of COVID-19 policies and other interventions across different contexts. This framework is also not COVID-19 specific. We would encourage the thoughtful and deliberate consideration of inequities as best practice in policy-making, even -or indeed especially -in a global crisis. Economic loss; unemployment (7, 8) Topping up child support grants (9) HIC Closure of green spaces. (10, 11) Child injuries (12) Mental health (13, 14) Homeless (15) Inactivity (16, 17) Parks (10) Backsliding; stress (126, 128) Regressions in skills (129) Access to information (130) Involve affected groups (127) WHO Director-General's opening remarks at the media briefing on COVID-19 -11 Coronavirus Government Response Tracker Impact of non-pharmaceutical interventions (NPIs) to reduce COVID-19 mortality and healthcare demand Applying an equity lens to interventions: using PROGRESS ensures consideration of socially stratifying factors to illuminate inequities in health Combating COVID-19: health equity matters Pandemic influenza planning in the United States from a health disparities perspective. Emerg Infect Dis Planning for an influenza pandemic: social justice and disadvantaged groups Social justice in pandemic preparedness Adverse effects of public health interventions: a conceptual framework Unprecedented disruption of lives and work: Health, distress and life satisfaction of working adults in China one month into the COVID-19 outbreak Mitigating the wider health effects of covid-19 pandemic response What types of interventions generate inequalities? Evidence from systematic reviews Building a Conceptual Framework: Philosophy, Definitions, and Procedure Essentials of Nursing Research: Appraising Evidence for Nursing Practice Health equity impact assessment. Health Promot Int Use of health impact assessment in incorporating health considerations in decision making Deprivation amplification revisited; or, is it always true that poorer places have poorer access to resources for healthy diets and physical activity? Deprivation amplification and health promoting resources in the context of a poor country The concepts and principles of equity and health Socioeconomic inequalities in children's exposure to tobacco retailing based on individual-level GPS data in Scotland A systematic review of the relationships between social capital and socioeconomic inequalities in health: a contribution to understanding the psychosocial pathway of health inequalities Is social capital the key to inequalities in health? Primary care of adults with intellectual and developmental disabilities Fierce Enforcement of Coronavirus Lockdowns Is Stirring Resentment. The Wall Street Journal Inequalities in health and health risk factors in the Southern African Development Community: evidence from World Health Surveys Overcrowding and health in two impoverished suburbs of Johannesburg, South Africa. BMC Public Health A Systematised Review of the Health Impact of Urban Informal Settlements and Implications for Upgrading Interventions in South Africa, a Rapidly Urbanising Middle-Income Country Street Vendors and invormal trading: struggling for the right to trade COVID-19 lockdowns threaten Africa's vital informal urban food trade People experiencing homelessness: Their potential exposure to COVID-19 Slum Health: Arresting COVID-19 and Improving Well-Being in Urban Informal Settlements South Africa can -and should -top up child support grants to avoid a humanitarian crisis The case for reopening America's parks The psychological impact of quarantine and how to reduce it: rapid review of the evidence Housing, income inequality and child injury mortality in Europe: a cross-sectional study. Child Care Health Dev Increasing incidence of serious infectious diseases and inequalities in New Zealand: a national epidemiological study Promoting Mental Health: concepts, emerging evidence, practice The impact of the COVID-19 crisis on homelessness European Public Health Alliance Associations between greenspace and mortality vary across contexts of community change: a longitudinal ecological study Nature and mental health: An ecosystem service perspective London's rough sleepers to be offered hotel beds to self isolate [Internet]. Mayor of London Lebanon faces coronavirus, poverty, hunger. DW [Internet How COVID-19 is limiting healthcare access for refugees in Lebanon Post-traumatic stress disorder in a sample of Syrian refugees in Lebanon Health status and use of medication and their association with migration related exposures among Syrian refugees in Lebanon and Norway: a cross-sectional study Lebanon municipalities "discriminate" against refugees Coronavirus and aid: What we're watching United Nations Response to COVID-19 Outbreak in Lebanon When Religion and Culture Kill: COVID-19 in the Somali Diaspora Communities in Sweden Sweden is making a dangerous bet on a "cultural cure" to COVID-19 The Hidden Flaw in Sweden's Anti-Lockdown Strategy [Internet]. Foreign Policy Damned if you do, damned if you don't: subgroup analysis and equity We don't work, we don't eat': Informal workers face stark choices as Africa's largest megacity shuts down protect most vulnerable in COVID-19 COVID-19 is exacerbating food shortages in Africa The impact of the COVID-19 on the informal economy in Africa and the related policy responses International Labour Organization Understanding the impact of the COVID-19 outbreak on the Nigerian economy The Front Line: Visualizing the Occupations with the Highest COVID-19 Risk COVID-19) in the EU/EEA and the UK -eighth update. European Centre for Disease Prevention and Control Managing mental health challenges faced by healthcare workers during covid-19 pandemic NHS paramedic evicted from home for fear he would spread COVID-19 [Internet]. The Guardian The Untold Toll -The Pandemic's Effects on Patients without Covid-19 European Centre for Disease Prevention and Control. Considerations relating to social distancing measures in response to COVID-19 -second update COVID-19: the gendered impacts of the outbreak. The Lancet Global Education Coalition Structural determinants of gender inequality: why they matter for adolescent girls' sexual and reproductive health Child marriage and psychological well-being in Niger and Ethiopia Mapping disparities in education across low-and middle-income countries Education in crisis: why girls will pay the highest price in the COVID-19 pandemic The Telegraph. 2020 Gender and education Gender, equity, and human rights [Internet]. World Health Organization Calamitous": domestic violence set to soar by 20% during global lockdown. The Guardian Revealed: surge in domestic violence during COVID-19 crisis. The Observer Refuges from domestic violence running out of space, MPs hear. The Guardian Intimate partner violence and Hurricane Katrina: predictors and associated mental health outcomes Labour calls for end to migrant benefit block during lockdown. The Guardian Domestic abuse victim charactieristics, England and Wales: year ending The economic and social costs of domestic abuse COVID-19): support for victims of domestic abuse indoneisa bans Ramadan exodus amid coronavirus fears. The Guardian Media Statement: Knowing the risks for COVID-19 World Health Organization Wuhan Virus Boosts Indonesian Anti-Chinese Conspiracies [Internet]. Foreign Policy Coronavirus, fear, and misinformation Kantar Indonesia. COVID19 Impact on Indonesian Attitudes & Behaviours: Learning for brands Transcript of PM earnings conference call Earnings conference call presented at Hussain S. NHS officials told me Muslim households are particularly vulnerable to coronavirus -it's important to understand why Police investigate UK far-right groups over anti-Muslim coronavirus claims. The Guardian Jewish leaders fear ultra-Orthodox Jews have missed isolation message. The Guardian Faith and Global Health Practice in Ebola and HIV Emergencies Spirituality and Faith-Based Interventions: Pathways to Disaster Resilience for African American Hurricane Katrina Survivors COVID-19 Educational Disruption and Response How are we compensating for the missing daily meal? WFP Mental health effects of school closures during COVID-19. Lancet Child Adolesc Health Africa: Virtual Learning During COVID-19, Who is Left Behind? 44 states have ordered or recommended that schools don't reopen this academic year Closure of schools during an influenza pandemic Impact of school closures for COVID-19 on the US health-care workforce and net mortality: a modelling study The Families First Coronavirus Response Act: Summary of Key Provisions Coronavirus compounds Lebanon's woes, many struggle for food. Reuters Informal workers in Arab world hit hardest by coronavirus, unlikely to get help. Al Arabiya Can Lebanon afford a coronavirus shut-down? Education Public Expenditure Review World Bank Group Lebanon shuts schools after fourth coronavirus case. Arab News Lebanon: Direct COVID-19 Assistance to Hardest Hit -Inadequate Government Response Creates Risk of Hunger for Many Informal politics and inequity of access to health care in Lebanon Why New Zealand's Coronavirus Elimination Strategy Is Unlikely to Work in Most Other Places Covid-19 deadlier for Māori, Pasifika -modelling predicts The Gap in the Subjective Wellbeing of Māori and New Zealand Europeans Widened Between Effects of self-reported racial discrimination and deprivation on Māori health and inequalities in New Zealand: cross-sectional study. The Lancet Why inequality could spread COVID-19. Lancet Public Health COVID-19 and mitigating impact on health inequalities Royal College of Physicians The role of social capital in successful adherence to antiretroviral therapy in Africa Adversity, social capital, and mental distress among mothers of small children: A cross-sectional study in three low and middleincome countries Measurement of social capital in relation to health in low and middle income countries (LMIC): A systematic review A systematic review of the relationships between social capital and socioeconomic inequalities in health: a contribution to understanding the psychosocial pathway of health inequalities Governance and Social Capital in Urban Regeneration: A Comparison between Bristol and Naples. Urban Stud Protecting workers aged 60-69 years from COVID-19 snitch lines: Crackdown on coronavirus rule breakers could have consequences City of Ottawa's tough COVID-19 crackdown measures could backfire. Ottawa Citizen Barriers to cancer symptom presentation among people from low socioeconomic groups: a qualitative study The association between social capital and loneliness in different age groups: a population-based study in Western Finland. BMC Public Health Joint Call for Human Rights Oversight of Government Responses to the COVID-19 Pandemic British Columbia Civil Liberties Association Suspension of vaccination due to COVID-19 increases the risk of infectious diseases outbreaks -UNICEF and WHO Vaccination and all-cause child mortality from 1985 to 2011: global evidence from the Demographic and Health Surveys Anthropometric, cognitive, and schooling benefits of measles vaccination: Longitudinal cohort analysis in Ethiopia Strengthened EU cooperation against vaccine preventable diseases The effects of public health policies on health inequalities in high-income countries: an umbrella review What types of interventions generate inequalities? Evidence from systematic reviews Why Are Some Population Interventions for Diet and Obesity More Equitable and Effective Than Others? The Role of Individual Agency The Coronavirus and the Risks to the Elderly in Long-Term Care Older adults reporting social isolation or loneliness show poorer cognitive function 4 years later. Evid Based Nurs Social isolation should be a public health priority [Internet]. The Guardian Governments Are Weighing How to Ease Coronavirus Lockdowns ALONE launch a COVID-19 support line for older people Working in collaboration with the Department of Health and the HSE Older people are at highest risk from COVID-19, but all must act to prevent community spread Statement presented at: WHO regional office for Europe Prisons worldwide risk becoming incubators of covid-19. The Economist Determinants of Intercountry Prison Incarceration Rates and Overcrowding in Latin America and the Caribbean. Int Crim Justice Rev An Epidemic of Pneumococcal Disease in an Overcrowded, Inadequately Ventilated Jail The Effects of Prison Visits From Family Members on Prisoners' Well-Being, Prison Rule Breaking, and Recidivism: A Review of Research Since 1991. Trauma Violence Abuse Anticipated Stigma and Stigma Management Among Those to be Labeled "Ex-con Association for the prevention of torture COVID-19 pandemic taking harder toll on parents, families taking care of children living with autism Disability considerations during the COVID-19 outbreak [Internet]. World Health Organization Autism Spectrum Disorder: Primary Care Principles The Pandemic is a crisis for students with special needs. The Atlantic Retrofitting accessibility: the legal ineqality of after-the-fact online access for persons with disabilities in the United states Backgrounder : COVID-19 Disability Advisory Group • COVID-19 lockdown policies particularly affect vulnerable populations, exacerbating pre-existing inequities, and generating new ones. • We developed a conceptual framework for identifying the equity harms of COVID-19 policy interventions • We found examples of inequitably distributed adverse effects for each COVID-19 lockdown policy example, stratified by LMIC and HIC, in every equity domain.• Systematically applying this framework can help to identify areas where a policy intervention may generate inequitable adverse effects; mitigate policy and practice interventions by facilitating the systematic examination of relevant evidence; and plan for lifting COVID-19 lockdowns around the world.