1. Guideline planning |
a) Priority setting |
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)
| Practice: Examine any health issue through the lens of equity, human rights, gender and the influence of social determinants Advantages: (46)
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PROGRESS-Plus (60) INCLEN equity lens (18)
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b) Identifying target audience and topic selection |
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)
| None identified | None identified |
c) Guideline group membership |
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)
| Practice: Include representatives of disadvantaged population groups in the guideline group Advantages: (50)
Disadvantages: (50)
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 Practice: Create an independent subgroup Advantages: (24)
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 Disadvantages: (50)
| None identified |
d) Stakeholder involvement |
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)
| Practice: Conduct in-person semistructured interviews to collect guideline perspectives from underserved or disadvantaged populations (45) Advantages:
Practice: Consult disadvantaged populations or stakeholders Advantages:
Disadvantages:
Consultation may become tokenistic if stakeholders are unable to fully participate (41) Additional resources, planning and effort may be required (15), (28) Practice: Use the GRADE-FACE approach to collect stakeholder feedback (45) Advantages:
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e) Scoping questions |
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)
| Practice: Conduct a literature review Advantages:
Disadvantages:
Practice: Include heath equity as an outcome in the PICO questions, analytic framework and SoF table Disadvantages:
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f) Considering the importance of outcomes and interventions, values, preferences and utilities |
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)
| Practice: Involve representatives to rate interventions and outcomes Disadvantages:
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2. Evidence review |
a) Searching for relevant evidence |
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)
| None identified |
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)
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b) Summarizing the evidence |
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)
| Practice: Include health equity as an outcome in the SoF table Advantages:
Disadvantages:
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c) Quality appraisal |
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)
| Practice: Consider indirectness when evaluating evidence for disadvantaged groups using the GRADE approach Disadvantages:
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3. Guideline development |
a) Formulating recommendations |
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)
| Practice: Develop an equity strategy to overcome identified barriers Disadvantages:
Practice: Consider the 6 criteria of the WHO-INTEGRATE framework Advantages:
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 Disadvantages:
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b) Wording of recommendations |
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)
| None identified | None identified |
c) Assessing equity within guidelines |
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)
| Practice: Use the INCLEN equity lens to assess equity in guidelines Advantages:
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) Disadvantages:
Practice: Use the EEFA framework when creating and evaluating equity in vaccine guidelines Advantages:
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INCLEN equity lens (18) EEFA Framework (69)
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d) Review and reporting |
| None identified | None identified |
4. Dissemination |
a) Monitoring implementation and evaluating use |
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)
| None identified | |
b) Updating |
| None identified | None identified |