Understanding fragility: Implications for global health research and practice
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Date
2019-12-10Author
Diaconu, Karin
Falconer, Jennifer
Vidal, Nicole L.
O'May, Fiona
Azasi, Esther
Elimian, Kelly
Bou-Orm, Ibrahim
Sarb, Cristina
Witter, Sophie
Ager, Alastair
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Diaconu, K., Falconer, J., Vidal, N., O’May, F., Azasi, E., Elimian, K., Bou-Orm, I., Sarb, C., Witter, S. and Ager, A. (2020) ‘Understanding fragility: implications for global health research and practice’, Health Policy and Planning, 35(2), pp. 235–243. Available at: https://doi.org/10.1093/heapol/czz142.
Abstract
Advances in population health outcomes risk being slowed—and potentially reversed—by a range
of threats increasingly presented as ‘fragility’. Widely used and critiqued within the development
arena, the concept is increasingly used in the field of global health, where its relationship to population health, health service delivery, access and utilization is poorly specified. We present the first
scoping review seeking to clarify the meaning, definitions and applications of the term in the global
health literature. Adopting the theoretical framework of concept analysis, 10 bibliographic and grey
literature sources, and five key journals, were searched to retrieve documents relating to fragility
and health. Reviewers screened titles and abstracts and retained documents applying the term fragility in relation to health systems, services, health outcomes and population or community health.
Data were extracted according to the protocol; all documents underwent bibliometric analysis.
Narrative synthesis was then used to identify defining attributes of the concept in the field of global
health. A total of 377 documents met inclusion criteria. There has been an exponential increase in
applications of the concept in published literature over the last 10 years. Formal definitions of the
term continue to be focused on the characteristics of ‘fragile and conflict-affected states’. However,
synthesis indicates diverse use of the concept with respect to: level of application (e.g. from state
to local community); emphasis on particular antecedent stressors (including factors beyond
conflict and weak governance); and focus on health system or community resources (with an
increasing tendency to focus on the interface between two). Amongst several themes identified,
trust is noted as a key locus of fragility at this interface, with critical implications for health seeking,
service utilization and health system and community resilience.