All people should have a fair opportunity to attain their full health potential, and no one should be disadvantaged in achieving this potential if it can be avoided
Watch Dr Leena Gupta from the New South Wales Government Sydney Local Health District as she takes us through some ways that guideline developers can address inequity in guideline development.
Health inequity is defined as differences in health that are avoidable and also considered unfair or unjust (Welch, Akl et al. 2017a). Issues of equity can impact on health in a number of ways, including socially or economically disadvantaged groups who experience different prevalence of disease or poorer health outcomes (Marmot 2018), groups who have different levels of access to health interventions (e.g. due to geographic distance, economic barriers or discrimination), and groups who may respond differently to interventions (such as children). The moral principle of distributive justice requires that guidelines consider how their recommendations can impact on or improve equity (Welch, Akl et al. 2017a).
There are practical steps that can be taken to consider equity in the development of guidelines. By considering equity, guidelines can ensure that different outcomes and recommendations for specific populations are considered. Guidelines can potentially help practitioners to address inequitable variations in health care and the allocation of services which might result in health disparities. Guidelines can provide a framework for health professionals and service providers to consider equity in their practice (Aldrich, Kemp et al. 2003), identify points in the decision-making process where equity considerations are important and avoid decisions that make inequities worse.
Where equity factors are not considered appropriately during their development, it is possible for guidelines to unintentionally cause or exacerbate inequity by not sufficiently addressing the needs of disadvantaged groups and therefore widening both health disparities and inequity. Guideline recommendations often do not take socioeconomic position into account despite evidence showing that the quality of care received by people from lower socioeconomic conditions is different (Aldrich, Kemp et al. 2003).
In Australia, much of the focus of work around equity has been on the health needs of Aboriginal and Torres Strait Islander peoples, for whom there is a documented gap in health status, outcomes and access to services compared to non-Indigenous Australians (Australian Institute of Health and Welfare 2016). Other communities in which equity considerations are particularly important include people with poor mental health, people with disabilities, refugees, people from culturally and linguistically diverse backgrounds, people with low socioeconomic status and people living outside major cities (Australian Institute of Health and Welfare 2016).
What to do
1. Identify equity issues relevant to the guideline
While scoping the guideline, the guideline development group should explicitly consider how equity issues may arise for the population and interventions to be considered and document the decision-making process.
Oxman and colleagues suggest four prompts to help assess whether a question is sensitive to health equity (Oxman, Schünemann et al. 2006):
- Are there groups or settings that might be disadvantaged in relation to the problem or intervention of interest?
- Are there plausible reasons for anticipating differences in the relative effectiveness of the interventions for disadvantaged groups or settings?
- Are there different baseline conditions across groups or settings that affect the absolute impact of the intervention or the importance of the problem for disadvantaged groups or settings?
- Are there important considerations that people implementing the intervention should consider to ensure that inequities are reduced, if possible, and that they are not increased?
Guideline developers may also find it useful to consider equity in the conceptual frameworks or logic models underpinning the purpose and scope of the guideline (see Considering purpose and context).
It can be helpful to use a structured tool to think through the different dimensions of equity that may be affected by a planned guideline. A commonly used framework is the PROGRESS Plus acronym (Evans and Brown 2003; Oliver, Kavanagh et al. 2008; O'Neill, Tabish et al. 2014), designed to assist researchers to think through factors such as place of residence, race, occupation, gender, socioeconomic status and other factors, which is recommended by the GRADE Working Group (Welch, Akl et al. 2017a).
In Australia, reports published by the
2. Engage with communities affected by inequity
Consultation with consumer groups and stakeholders can provide insight into groups experiencing poorer health outcomes or specific barriers to the implementation of health interventions that should be considered within the guideline. For Australian guidelines, developers will be expected to consider whether Aboriginal and Torres Strait Islander peoples are considered disadvantaged in relation to the guideline topic. Early consultation with broad groups may identify key representatives of affected populations who can remain engaged throughout the guideline development process
It is important to make sure the right people and communities are consulted throughout the guideline development process to ensure that the critical contextual factors, barriers and facilitators to implementation and outcomes are considered. This will often require additional planning and effort, such as travelling to meet stakeholders ‘on country’, using interpreter services, engaging with the justice system or social services, learning new cultural norms, or seeking information about illegal or challenging behaviours. Getting the views of key informants is a critical step for prioritising guideline outcomes and ensuring that the values and preferences of disadvantaged communities are considered when recommendations are made, and that their voices are heard.
The Engaging stakeholders, Consumer involvement, Public consultation and Guideline Development Group modules discuss in more detail how you can include the views of groups affected by guideline recommendations at all stages of the development process.
3. Ensure appropriate evidence is sought, identified and considered
Where a new search for evidence is needed, search strategies should be constructed so they are sensitive to research on disadvantaged populations where this is relevant (see Identifying the evidence). Guidelines focusing on equity will often need to incorporate a wider range of evidence, including different study designs and sources, than straightforward clinical questions (Welch, Petticrew et al. 2013). Databases relevant to these groups should be identified and searched, such as the
When planning the protocol for a systematic review, any analysis planned to investigate differential effects for specific populations should be clearly pre-specified. These analyses should be conducted carefully and interpreted with caution to avoid spurious findings (Deeks, Higgins et al. 2011) (see Synthesising the evidence and Assessing certainty of evidence).
The GRADE Working Group has also published advice on how to use health equity considerations in rating the certainty of synthesised evidence (Welch, Akl et al. 2017b). In common with other elements of the GRADE approach, they emphasise the need for transparent reporting of how judgements relating to equity are made.
The Cochrane and Campbell Collaborations have developed an extension to the PRISMA systematic review reporting tool, the
Adopting or adapting a guideline: An ‘equity lens’, a series of structured questions focusing on the visibility of equity, inequity and socioeconomic determinants, can be used to assess whether existing guidelines have explicitly considered the needs and values of disadvantaged populations. Dans and colleagues from the International Clinical Epidemiology Network (INCLEN) have developed a short equity lens to help users of guidelines consider whether they have addressed inequities appropriately (Dans, Dans et al. 2007). While this lens has limitations and is mainly focused on clinical practice guidelines, it is nevertheless one of the few developed with end users of guidelines in mind.
4. Understand the impact of guideline recommendations on disadvantaged populations
Guideline recommendations can have significant impact on disadvantaged populations. Guidelines may further exacerbate disadvantage, so the potential for recommendations to have unwanted effects on equity should be carefully considered. Context may determine whether an individual can benefit from the interventions recommended by a guideline and which outcomes may be affected (e.g. children in areas where fluoridation has been rejected by the community, or in families who decline vaccination, where they may also be unable to access early childhood education). Guidelines may sometimes need to explicitly offer alternative recommendations to best practice in these situations, or propose mitigating strategies to reduce their impact.
The values and preferences of disadvantaged communities should also be considered to confirm that recommendations are likely to be acceptable to the community and feasible to implement.
5. Identify areas where research is needed about equity and disadvantaged populations
Many guidelines targeting disadvantaged populations will identify areas where further research is needed. For example
The lack of good quality research evidence may require the use of conditional recommendations.
Guidelines approved by NHMRC must meet all requirements outlined in the
- A.4.1 (desirable) The guideline development process includes participation by representatives of Aboriginal and Torres Strait Islander peoples and culturally and linguistically diverse communities (as appropriate to the clinical need and context), and the process employed to recruit, involve and support these participants are described.
- B.4 The population to which the guideline recommendations will apply is defined (e.g. children, adolescents, adults or older adults) and population subgroups for which information is required are identified and described.
- B.5 Issues relevant to Aboriginal and Torres Strait Islander peoples (such as particular risks, treatment considerations or sociocultural considerations) are identified and described.
- B.5.1 (desirable) Issues relevant to special-needs groups such as culturally and linguistically diverse communities or groups with low socioeconomic status (e.g. particular risks, treatment considerations or sociocultural considerations) are identified and described.
- C.3 The population groups identified in the search strategy include Aboriginal and Torres Strait Islander peoples and any population subgroups that have been identified.
- C.3.1 (desirable) The population groups specified in the search strategy include groups such as culturally and linguistically diverse communities or other groups for whom specific sociocultural factors (including ethnicity, gender, age, disability, socioeconomic status and location) in treatment or prevention outcomes should be considered.
- C3.4 (desirable) Search strategies include search terms to identify evidence related to cost effectiveness and resource implications of practice.
- D9.2 (desirable) The resource implications and cost effectiveness of any recommended practice, compared with current or established practice, are explicitly stated in the guideline text.
- D11. Where evidence is identified showing that Aboriginal and Torres Strait Islander peoples or other population groups have specific treatment or prevention outcomes, this evidence is clearly identified and considered in the formulation of recommendations.
- D11.1 (desirable) Where evidence is identified showing that sociocultural factors (including ethnicity, gender, age, disability, socioeconomic status and location) affect treatment or prevention outcomes, this evidence is clearly identified and considered in the formulation of recommendations.
- D13.1 (desirable) Ethical issues are considered when formulating the recommendations and any such issues are identified and described.
- G2. Key recommendations that are most likely to lead to improvement in health outcomes are highlighted for consideration of implementation.
The following of the NHMRC Standards apply to the Equity module:
5. To be focused on health and related outcomes guidelines will:
5.1 Clearly define the outcomes considered to be important to the person/s who will be affected by the decision, and prioritise these outcomes.
6. To be evidence informed guidelines will:
6.2. Consider the body of evidence for each outcome (including the quality of that evidence) and other factors that influence the process of making recommendations including benefits and harms, values and preferences, resource use and acceptability.
Deeks, J. J., Higgins, J. P. T., et al. (2011). Chapter 9: Analysing data and undertaking meta-analyses. Cochrane Handbook for Systematic Reviews of Interventions. J. P. T. Higgins and S. Green, The Cochrane Collaboration. Version 5.1.0 (updated March 2011).
O'Neill, J., Tabish, H., et al. (2014). Applying an equity lens to interventions: using PROGRESS ensures consideration of socially stratifying factors to illuminate inequities in health. Journal of Clinical Epidemiology 67(1): 56-64.
Oxman, A. D., Schünemann, H. J., et al. (2006). Improving the use of research evidence in guideline development: 12. Incorporating considerations of equity. Health Research Policy and Systems 4(1): 24.
NHMRC would like to acknowledge and thank Doctor Leena Gupta from the New South Wales Government Sydney Local Health District for her contribution to this module as editor. Doctor Gupta’s contribution to this module was also informed by her Doctor of Public Health thesis: Gupta, Leena. The visibility of equity in Australian clinical practice guidelines. Doctor of Public Health Thesis, 2017, Flinders University. Supervisors: Professor Paul Ward, Professor Jeanette Ward.
Version 5.0. Last Updated 23/11/2018.
Suggested citation: NHMRC. Guidelines for Guidelines: Equity. https://nhmrc.gov.au/guidelinesforguidelines/plan/equity. Last published 23/11/2018.