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Abstract
Introduction Recent decades have seen a growth in multisectoral and transdisciplinary approaches to improving global health, particularly across human, animal and environmental health-related sciences that advocate for participatory, systems-based perspectives to understanding and promoting health and well-being in the context of social and ecological interactions. For several issues, including human health, animal health and food security, researchers have highlighted the need for transdisciplinary One Health approaches to assess the sustainability of interventions. To understand the current thinking and conceptualisation of sustainability across One Health disciplines, we present a protocol paper for an umbrella systematic review study planned in 2024.
Methods and analysis A search strategy based on Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines was developed. The Medline, Embase, Global Health and Web of Science Core Collection were the four databases interrogated through the search strategy and included all articles found in the English language up to 14 April 2024. Meta-analyses, systematic, structured literature reviews and narrative reviews on sustainability will be included and a full-text review of all articles will be undertaken. The articles will be quality appraised using the AMSTAR 2 tool. Data that cover proposed factors influencing and characterising sustainability will be extracted across One Health disciplines including similarities and differences, and a summative content analysis will be completed to identify any emerging themes and develop an analytical framework. The conceptualisation of sustainability in the context of One Health multisectoral approaches will be summarised, a definition of sustainability proposed and include an identification of tools for measuring and assessing sustainability.
Ethics and dissemination No primary data will be collected; therefore, ethical approval will not be required. The results will be disseminated in peer-reviewed literature and conference presentations. The findings will also be directly disseminated to the Quadripartite agencies.
Prospero registration number CRD42018094031
- Health
- Review
- Public health
- PREVENTIVE MEDICINE
- Systematic Review
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STRENGTH AND LIMITATIONS OF THIS STUDY
To our knowledge, our proposed protocol is for the first-ever umbrella systematic review of conceptual and analytical approaches to sustainability applied across the One Health spectrum of human, animal and environmental health disciplines.
This protocol provides a systematic methodology for conducting an umbrella systematic review of review studies of conceptual approaches to sustainability and the planned search strategy and data synthesis following Preferred Reporting Items of Systematic Reviews and Meta-Analyses guidelines.
A quality appraisal using the AMSTAR 2 tool will be conducted of the included review studies identified through this umbrella review.
This umbrella review will only include studies published in the English language, and so may miss some important reviews and perspectives on sustainability across the human, animal and environmental health sectors published in other languages.
Introduction
Recent decades have seen a growth in multisectoral and transdisciplinary approaches1 to improving global health, particularly across human, animal and environmental health-related sciences. These approaches advocate for participatory, systems-based perspectives to understanding and promoting health and well-being in the context of social and ecological interactions. One Health, EcoHealth and Planetary Health are all examples of conceptual approaches that have gained prominence in academic and policy discourse to support efforts to tackle global issues such as climate change, emerging and zoonotic infections, food and water security, antimicrobial resistance (AMR), expanding human populations, and disaster preparedness and response.1–3 Across the health security spectrum of emerging epidemic prone infections, endemic and neglected diseases, food-borne illnesses, and other disasters and emergencies affecting human populations, a growing evidence base now exists of the utility and policy implications of such multisectoral approaches.4 5
Of the three approaches, One Health has, to date, received the most attention and gained the most traction with national governments, United Nations (UN) agencies,6 funders,7 global health and development institutions, and national governments. Recent global health challenges, in particular the Ebola outbreak in West Africa, the growing threat of AMR and the COVID-19 pandemic have been particular catalysts for the adoption of the approach.8 Having evolved from the narrower concept of ‘One Medicine’ that sought to combine human health and veterinary sciences, One Health now represents a wider holistic approach with a clear definition and a set of guiding principles, that examines the interface between, ecology, veterinary medicine, public health, human medicine, molecular biology and microbiology, as well as social sciences, economics, security and trade.9 10 While this broader conceptualisation has allowed the approach to be adopted by a more diverse array of organisations and stakeholders, it has made governance and operationalisation problematic at times, with the boundaries as to what does and does not constitute a One Health initiative or programme open to wide interpretation. To support programme development for UN member states, the Quadripartite-led global initiative, the One Health Joint Plan of Action (2022–2026) provides a theory of change and operational framework to help guide countries with their One Health focused activities.8 The substantial increase in One Health activities around the world and the acceleration of specific initiatives for building health security capacities such as the World Bank Pandemic Fund that have adopted the approach,7 necessitate the development of monitoring and evaluation (M&E) frameworks to measure the progress of these initiatives and assess their effectiveness—both in terms of impact and sustainability. Since the publication of the UN Brundtland report ‘Our Common Future’ in 198711 the term ‘sustainable development’ has gained significant prominence in international development and global health discourse. Defined at the time as ‘development that meets the needs of the present without compromising the ability of future generations to meet their own needs’, the concept has continued to evolve globally, accelerating with the worldwide adoption of the UN sustainable development goals (SDGs) in 2015 which aim to ‘end poverty, protect the planet and ensure prosperity for all’.12 While the SDGs have framed sustainability around three core pillars namely, environment, economy and societal well-being, there has been a wide variety of definitions and conceptual approaches to the term, originating not only from public health research but also disciplines such as animal health, environmental sciences, management and international development. With wide interest in the topic, there are a multitude of empirical and review studies that have been carried out examining sustainability in the human, animal and environmental health sciences, though the majority of these have focused on the human health sector in particular. Several of these reviews have concluded that sustainability is still poorly defined and conceptualised and that further empirical research about its determinants is necessary to make progress on improving the M&E of health programmes and interventions across these disciplines.13–16 For several issues, including human health, animal health and food security, researchers have highlighted the need for transdisciplinary One Health approaches to assess the sustainability of interventions.17 However, recent reviews also suggest a deficit in using theoretical frameworks to underpin assessment of sustainability, or, that frameworks are inconsistently applied, often at the evaluation stage rather than during the development of programmes and interventions.18 This demonstrates the limited application of frameworks and a lack of consensus regarding the conceptualisation of sustainability for One Health interventions and other transdisciplinary complex systems and initiatives. It also highlights the need to identify interdisciplinary determinants of sustainability and build evidence-based analytical frameworks for the M&E of One Health programmes and ultimately support sustainable development.
Objective
We propose an umbrella review of previous systematic and other review studies to help us describe and explore conceptual and analytical approaches to sustainability across human, animal and environmental health disciplines. This review of review studies will be used to develop an analytical framework for assessing sustainability in the context of One Health initiatives, interventions and programmes. Here, we provide a study protocol that sets out our approach and methodology.
Research questions
As our objective is to understand conceptual approaches to sustainability across One Health disciplines and develop an analytical framework for assessing it, we have laid out a number of guiding research questions to frame our umbrella systematic review analysis.
What existing definitions and/or conceptualisations of sustainability are being most used and applied across the human, animal and environmental/ecosystem health sectors?
What are the elements or capabilities that are characterised as attributes of a sustainable human, animal or environmental health programme (organisation or collaboration)?
Are these characteristics of sustainability applied or assessed across programmes or collaborations involving multiple sectors (human, animal and environmental)?
What are the main conceptual differences and similarities in approaches to sustainability across the human, animal and environmental/ecosystem health sectors?
What tools, indicators and/or analytical frameworks have been developed to measure or evaluate sustainability in a multisectoral context?
Methods and analysis
Rationale
The primary aim of this study is to develop a conceptual approach to and a framework for analysing sustainability in the context of multisectoral1 ‘One Health’ collaborations. An initial scoping of the literature identified several systematic and other review studies examining similar themes—but often—with the important caveat that the research questions would be limited to or focus largely on one sector or discipline relevant to a ‘One Health’ approach, that is, human health or animal health or environmental/ecosystem health.
Search strategy
The researchers searched four databases; Medline, Embase, Global Health and Web of Science Core Collection for peer-reviewed papers. All databases were searched from their inception to 14 April 2024. Table 1 presents the search strategy that was used for the selected electronic databases. The selected search terms were developed through an analysis of previous systematic reviews14–16 and built on further work by Lennox and colleagues, and Zurynski et al.19 20 The search strategy included key terms related to the concept of sustainability with truncation applied where appropriate. A search of titles and abstracts was conducted for all columns, and MeSH and Emtree headings were applied for terms in columns: A, B and C where relevant (see online supplemental appendix A for example searches in each database).
Supplemental material
Search strategy
The literature searches of peer-reviewed publications were supplemented by reviewing the reference lists of relevant studies and systematic reviews. Two experts knowledgeable in the One Health and sustainability fields were consulted to identify and further review articles of relevance.
Eligibility criteria
Reviews were deemed relevant if they explicitly addressed definitions, conceptual frameworks or analytical frameworks of sustainability across the human, ecosystem or environmental health sectors and where sustainability and its main characteristics were the main focus of the review. Reviews that presented evaluations of sustainability of human and/or animal and/or environmental health and/or ecosystem health interventions, health programmes, health services, health organisations (eg, governmental agencies, international non-governmental organisations (NGOs) or consortia working on health issues) or health systems as a primary outcome were also included; however, this was for a more limited analysis to assess what types of sustainability frameworks were being used for evaluation currently. This allowed the researchers to include all relevant papers from both sector specific as well as multisectoral ‘One Health’ approaches to sustainability.
Our inclusion criteria for papers to be part of this review were:
Systematic±meta-analysis or structured literature reviews of empirical studies on sustainability and the health of humans and/or animals and/or ecosystems.
Scoping or narrative literature reviews of theoretical, conceptual or analytical frameworks or methodological approaches to sustainability and the health of humans and/or animals and/or ecosystems.
Articles were excluded if they:
Mention sustainability only in passing and where it was not a central theme of the review or a defined primary outcome measure.
Do not make a central or specific reference to the health of the ecosystem/environment or human or animal population.
The article was an expert opinion piece without any formal literature review
Articles where sustainability is used as a synonym for the concept of environmental sustainability alone or for food security alone without a focused reference to the health of humans, animals or ecosystems.
Reviews focused on community or population resilience alone without explicit reference to sustainability and health.
Publications where the full text was not available electronically in the English language.
Study selection, data extraction and synthesis
We will use the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines as an overarching framework for screening and selection of documents (see online supplemental appendix B). A PRISMA flow chart detailing document identification, screening and inclusion will be produced. Results from the electronic databases will be combined and imported into the Covidence21 or Rayyan22 tool. Duplicates will be removed. The search results will first be screened by title and abstract to identify papers for inclusion by the reviewers independently. The research team will meet to discuss the inclusion and exclusion criteria to ensure a common understanding and interpretation of the criteria. Discrepancies will be discussed among the review team until a consensus is reached.
A full-text review of all included articles will be undertaken. The reviewers will meet prior to undertaking the full-text review to discuss the definitions and scope of data elements to be extracted to ensure a common understanding. The reviewers also will meet on a regular basis during the full-text review phase to discuss any discrepancies in interpretation. A data extraction form has been developed in Microsoft Excel (Office365) to systematically extract data elements as outlined in Box 1.
Data extraction form for selected papers
Author, title, journal, year of publication
Does paper address sustainability of
Human health
Animal health
Environmental health
Multi sectoral health initiatives/programmes/collaborations
health interventions
health services/ health organizations
health systems
Type of paper
Conceptual or analytical framework as part of a review
Systematic literature review +/- meta analysis
Narrative or scoping literature review
Assessment of frameworks
Theoretical framework or background (literature review or other)
Definition of sustainability
Context (i.e. setting, country, region)
Unit of analysis (as defined by authors)
Intervention
Programme
Health organization (including NGOs, networks, coalitions)
Human health system
Agriculture/aquaculture/wildlife
Environment/ecosystem
Multi-sectoral
Specific research area (e.g. target group, population health, chronic diseases, communicable diseases, water security, food security, disease prevention, disease control, emergency response)
Factors hypothesised/assumed to influence, namely barriers and promotors, or to determine sustainability (or what are attributes of sustainability, characteristics of a sustainable programme/intervention)
How are One Health multi-sectoral collaborations being conceptualised, defined or acknowledged
How economic, political, epidemiological (other) environments are conceptualised, defined or acknowledged
Assessment of review studies
What is the research question, study aim, hypothesis or general line of inquiry?
Context (i.e. setting, country, region)
Unit of analysis (as defined by authors)
Intervention
Programme
Health organizations (including NGOs, networks, coalitions)
Human health system
Agriculture/aquaculture
Wildlife
Environment/ecosystem
Multi-sectoral
Specific research area (e.g. target group, population health, chronic diseases, communicable diseases, water security, food security, disease prevention, disease control, emergency response)
Review study design or research approach:
Systematic +/- meta analysis
Non systematic
Definition of sustainability
How sustainability is defined, or what is meant by sustainability
Theoretical or conceptual underpinning of the study
Methods
data collection, data analysisif/how the time factor is articulated (i.e. when and what is being assessed/measured)
Results
Main findings
Factors identified as influencing (including barriers and promotors)/critical for sustainability; if/how these actual factors relate to assumed/hypothesised factors (as identified by authors)
Limitations/reflections, as identified by authors, in measuring sustainability or overall methodological approach
Quality appraisal
Extracted data will be reviewed within the Covidence21 and Rayyan22 tools and review studies will be quality appraised using the AMSTAR 2 tool.23 Key domains identified in the AMSTAR 2 tool include: establishing the research question and inclusion criteria before conduct of the review, data extraction by at least two independent data extractors, comprehensive literature review with searching of at least two databases, keyword identification, expert consultation and limits applied, detailed list of included/excluded studies and study characteristics, quality assessment of included studies and consideration of quality assessments in analysis and conclusions, appropriate assessment of homogeneity where relevant, assessment of publication bias and a statement of any conflict of interest.
Data synthesis
Due to the heterogeneity, conceptual nature and largely qualitative focus of the review studies, a thematic synthesis will be applied using established principles for analysis of qualitative data24–26 to infer relevant characteristics and capabilities characterising sustainability, propose factors influencing it and develop a conceptual framework. At the initial stage, a coding scheme will be developed based on constructs identified in previous conceptualisations of sustainability.14 19Identified frameworks for defining, conceptualising and analysing sustainability will be assessed through question probes which will be used to guide the initial screening and thematic analysis.
Researchers will extract section/s of included papers that proposed factors influencing and characterising sustainability. Extracted sections will be coded line-by-line. Additional codes will be generated deductively if a construct or process identified in the literature is not represented in the initial coding scheme. Codes will be compared, refined and grouped into emerging themes. The initial grouping of emerging themes will be described according to the level of a human and/or animal and/or environmental health system (an intervention, service, organisation, health system or broader multisectoral context). Researchers will complete summative content analysis of the coded data and will identify emerging themes and potential factors both influencing and characterising sustainability. Similarities and differences identified in conceptualisations between human, animal and environmental health disciplines will also be described and the review will include applying Morse and colleagues concept analysis approach which examines a concept’s definitions, characteristics, influencing factors or preconditions, outcomes, boundaries and maturity.27 This will allow the authors to capture analysis from existing reviews while examining important similarities, differences and sector-specific issues including trade-offs between determinants or domains in relation to the conceptualisation and framing of sustainability. The conceptualisation of a One Health multisectoral approach and its context-specific application to date will be summarised and include identification and categorisation of tools and indicators for measuring sustainability. The interpretation of results will be supplemented and strengthened by consultation with known experts in One Health and sustainability in the different sectors.
Patient and public involvement
Patients and the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Ethics and dissemination
This study does not require ethical approval. The completed review will be published in an open-access peer-reviewed journal and the results will be presented at relevant international conferences. The findings will also be directly disseminated to the Quadripartite agencies and will provide a comprehensive and up-to-date understanding of conceptual approaches to sustainability across human, animal and environmental health.
Conclusion
Given the growing global focus and investment in One Health approaches to health security as well as other areas of multisectoral collaboration on health, there is a clear need for developing appropriate analytical frameworks for assessing the effectiveness of these initiatives in terms of sustainability. However, there has been a wide variety of definitions and conceptual approaches to ‘sustainability’. This umbrella systematic review will describe the attributes of sustainability in the context of multisectoral One Health initiatives and provide an analytical framework for assessing it.
This protocol paper provides a detailed methodology for the identification, selection, quality appraisal, data extraction and analysis of review studies that aim to understand and conceptualise sustainability when applied across sectors to the health of humans, animals or the environment. The protocol can be used to inform similar future umbrella systematic reviews undertaken by researchers across One Health disciplines.
Ethics statements
Patient consent for publication
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Contributors OAD conceptualised the study and led the team. OAD developed the overarching rationale, methodology and drafted the protocol with HN. OAD and MA developed the initial search strategy and data extraction tool. OAD, MA and HN refined the selection criteria and all authors contributed to the data extraction and analysis plan. All authors had an opportunity to comment on and contribute to the final manuscript text and approve submission. OAD is responsible for overall content as guarantor.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.