Health equity considerations in guideline development: a rapid scoping review

Prioritize key questions that are of the greatest concern and interest to disadvantaged groups (41)^, (50)

PROGRESS-Plus (60) may help developers systematically consider and prioritize populations for whom the health care topic is particularly relevant (27)^, (28)^, (41)^, (56)

Consider dedicating a part of or a whole guideline to the care of disadvantaged groups (41)

Examine any health issue through the lens of equity, human rights, gender and the influence of social determinants if adapting or adopting an existing guideline (28)^, (46)

Consider other variables that might constitute potential barriers to the desired outcomes, such as legal and policy frameworks that could marginalize or exclude certain populations (46)

May help to better understand the needs and gaps to be addressed and may lead to interventions that are more effective in the longer term and that will evoke a feeling of “ownership” in the targeted group or community

PROGRESS-Plus (60)

INCLEN equity lens (18)

Disadvantaged groups should be considered when identifying the target audience of a proposed guideline (55)

Planned guidelines should not only focus on the average level of health, but how health is distributed within populations and across groups (46)

Representatives of disadvantaged groups may help to identify target audiences for guidelines (41)

Include representatives of disadvantaged population groups in the guideline group (20)^, (41)^, (44)^, (49)^, (50)

Include representatives throughout the entire guideline development process, from selecting topics to implementation (44)

Listen to challenges experienced by guideline members from disadvantaged population groups and create and implement an action plan to eliminate identified challenges (49)

Consider creating an independent subgroup for disadvantaged populations (50)

Promote transparency and objective criteria for the guideline group selection process (49)^, (59)

Recruit and select individuals who understand how to take health equity, human rights, gender and social determinants into account in efforts to promote better health (41)^, (46)

Ensure that the chair of the voting panel is familiar with health equity (41)

Include EDI considerations in leadership and chair appointments (49)^, (59)

Give explicit attention to conflicts of interest that can lead to a weakened stance on equity, human rights, gender and social determinants in the final guideline (46)

May lend a clear voice to discussions

Not resource intensive

Representatives from professional organizations may help bring the weight of their organizations with them

One individual may feel pressure to represent the views of the population

A single voice may not be heard by the group

A health professional from a disadvantaged population may have extra demands, making it difficult for them to commit the time necessary for guideline development

Only hearing 1 individual perspective

Safe and open environment to discuss culturally specific needs related to the guideline

May ensure more equitable participation

Outcomes may be more relevant to the community that they represent

Resource intensive

No guarantee that subgroup will lead to any additional recommendations

A subgroup separate from the rest of the guideline team may appear exclusionary

Create a plan to recruit, involve and support representatives of disadvantaged populations (15)^, (20)^, (28)^, (51)

Consult experts in engaging representatives and stakeholders (41)

Train stakeholders in the guideline content and development process (41)

Use a structured format to facilitate active participation and feedback (41)

Conduct systematic reviews of qualitative studies, conduct electronic surveys, or conduct in-person semistructured interviews to collect guideline perspectives from underserved or disadvantaged populations (45)

Use existing tools (e.g., GRADE-FACE) to create an interview guide with language appropriate to specific disadvantaged populations (45)

Supply a feedback form when writing to stakeholders (51)

In-person interviews may be better suited to collect perspectives from some underserved populations than electronic surveys

May reveal previously unknown priorities for certain subgroups (45)

Consultation may become tokenistic if stakeholders are unable to fully participate (41)

Additional resources, planning and effort may be required (15)^, (28)

Provides a transparent and evidence- informed strategy that is supported by validity and reliability measures, user reported usability, and rating scales

GRADE-FACE (45)^, (58)

Conduct a literature review to inform the scope of the guideline and question development (50)^, (51)^, (56)

Create a report combining results of formal searches and stakeholder discussions (50)

Develop a logic model to assess relations between interventions, outcomes, effect modifiers and the social determinants of health (56)

Evaluate health equity at each stage of the PICO framework (41)

Consider population subgroups who are likely to be particularly affected by changes in health care related to the guideline topic (28)^, (41)^, (51)

Create a key question to seek interventions that may reduce disparities in health outcomes (50)^, (56)

Include health equity as an outcome in the PICO questions, analytic framework and SoF table (42)

Address human rights in questions and other issues related to laws, policies, standards, protocols and guidelines (46)

Provides an opportunity to discuss equity related actions regarding previous gaps in evidence (50)

Potential difficulty finding data relevant to disadvantaged populations/health equity (50)

May need to exclude other important patient outcomes, as the recommended number of outcomes in a GRADE table is seven (42)

Kunst and Mackenbach inequality evaluation (61)

Oxman prompts to consider equity in key questions (16)

Involve representatives of disadvantaged populations to rate interventions and outcomes (28)^, (41)^, (42)

Search relevant databases for outcomes or interventions rated important by disadvantaged populations (41)

It may be challenging to balance the benefits and harms for recommendations when care provider values differ from stakeholder values (28)

Databases for information on patient views: UK DUETs and COMET (41)

Include non-English studies in the search strategy (41)

Use special filters for guideline questions related to specific geographic locations (e.g., LMIC) (41)

Consider including qualitative and observational studies (28)^, (50)

Consider evidence from fields outside of health (e.g., social science, economics) (41)

NHMRC Guidelines for Guidelines Handbook (62)

Informit Indigenous Collection (63)

Aboriginal and Torres Strait Islander Health Bibliography (64)

The Cochrane Health Equity Checklist for Systematic Reviews (65)

Include health equity within the PICO question as an outcome in the SoF table (42)

Present the baseline risks and risk differences for each relevant population group with supporting evidence in a SoF table (17)

Assess differences in the magnitude of effect in relative terms between disadvantaged and more advantaged populations (42)

Assess subgroup effects and the credibility of the apparent effect (42)

Lack of evidence surrounding a critical health equity outcome should not be a reason to omit from the SoF table (41)

Easier for guideline panels to find the information on health equity during the EtD process (42)

May need to exclude other important patient outcomes, as the recommended number of outcomes in a GRADE table is seven (42)

Checklist for assessing credibility of subgroup analyses (66)

PRISMA-Equity extension (67)

Consider any potential sources of bias that may relate to disadvantaged groups because the quality appraisal of RCTs tend to be generalized across different population groups (50)

Assess indirectness of evidence using the GRADE approach to disadvantaged groups and/or settings (42)^, (43)^, (68)

Provide higher quality ratings for outcomes in the equity analysis under certain conditions, using the GRADE approach (56)

There may be limitations in the evidence base making it difficult to assess indirectness and rate the overall certainty of evidence (41)^, (42)

The Cochrane Health Equity Checklist for Systematic Reviews (65)

Balance the harms and benefits of interventions for disadvantaged populations (27)^, (43)

Formulate equitable recommendations by, for example, considering barriers and facilitators of interventions (50)^– (52)^, (55)

Develop an “equity-strategy” that aims to overcome identified barriers for disadvantaged populations (44)

Consider the 6 criteria of the WHO-INTEGRATE framework that are relevant to health decision-making and the formulation of recommendations: balance of health benefits and harms, human rights and sociocultural acceptability, health equity, equality and nondiscrimination, societal implications, financial and economic considerations, and feasibility and health system considerations (29)

Consider using an equity EtD framework when formulating recommendations (54)

There may not be one approach to mitigate harms on health equity due to the heterogeneity of disadvantaged populations (43)

A comprehensive EtD framework that key informants found value in adding the criterion assessing societal implications, as well as human rights and sociocultural acceptability, health equity, equality and nondiscrimination

Key informants expressed concerns with the workload that the use of the framework might add to the guideline development process

Health Equity Assessment Tool (50)

WHO-INTEGRATE framework (29)

Recommendations should be worded as clear and actionable statements with respect to equity, human rights, gender and social determinants (41)^, (46)

Be specific when defining disadvantaged populations (41)

Use language carefully so as to not further stigmatize disadvantaged populations (44)

To determine how well guidelines address equity, use the INCLEN equity lens (18)

Use the EEFA framework when creating and evaluating equity in vaccine guidelines (69)

Evaluation and monitoring of the impact of recommendations that potentially affect inequities are also critically important and should be articulated in the guideline document (46)

Transparent and reproducible evaluation (20)

Reflects the care provider perspective (52)

Broadly applicable to many guidelines (52)

Can be used during development or retrospectively (52)

Focuses on biomedical considerations and may miss population-level inequities related to broader sociocultural factors (52)

Ensures that recommendations are appropriate and comprehensive

Will help committees to balance the benefits and harms of evidence when creating recommendations

INCLEN equity lens (18)

EEFA Framework (69)

Develop methods to ensure the rigorous and systematic reporting of evidence related to equity-based recommendations (2)

Monitor the guideline impact and uptake in subgroups (27)^, (41)^, (44)^, (56)

Decide on implementation strategies and indicators before guideline publication (56)

Use indicators that are stratified by equity factors to monitor disparities (44) or measure implementation within subgroups (41)

Obtain surveillance data to monitor relevant health outcomes or indicators (41)

Consult relevant community advisory committees and stakeholders for disadvantaged populations to obtain implementation feedback (47)^, (52)

Consider the impact of the guideline recommendations on disadvantaged populations to help inform decisions on guideline revisions (51)