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Abstract
Background: The World Health Organization (WHO) supports the UN to deliver the 2030 Agenda for Sustainable Development Goals (SDG), which primarily calls for ending poverty, protecting the planet and reducing health inequities, through the development of health guidelines. These guidelines are developed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to ensure that high quality of evidence is used. The GRADE group developed a series of Evidence to Decision (EtD) frameworks in 2016 which builds on the GRADE approach while providing a set of expanded criteria, including impact on health equity, to explicitly collect details on factors that influence the strength and direction of recommendations. To present the WHO’s principles of guideline development, the WHO released their 2nd edition for technical handbook on guideline development in 2014, which included a chapter on integrating gender, equity and human rights into guidelines.
Objectives: To evaluate how and to what extent health equity considerations are assessed in WHO guidelines.
Methods: We conducted a cross-sectional survey on guidelines approved by the WHO guideline review committee (GRC) published between Jan 2014 to May 2019. Guidelines were assessed for health equity considerations using the PROGRESS (Place, Race, Occupation, Gender, Religion, Education, Socioeconomic Status, Social Capital) framework. We also assessed how likely impact on health equity was assessed in the research evidence section of each recommendation of these guidelines using criteria based on differences in baseline risk, value of outcomes for socially disadvantaged populations, health inequity as an outcome, equity related subgroup analysis, and applicability.
Results: We identified 111 WHO guidelines published in this time period and 91% (101/111) of them were focused on socially disadvantaged populations. The use of the EtD frameworks progressively increased from 10% (2/20) in 2014, to 100% (8/8) in 2019. Mention of health equity anywhere in the guideline increased from 55% (11/20) in 2014 to 100% (8/8) in 2019. For the 40 guidelines that reported using and published their EtD frameworks, likely impact on health equity was supported by evidence statements in 28% (94/332) of the recommendations. The most common evidence provided was differences in baseline risk of outcomes (23%; 78/332 recommendations), and the least frequently reported as differences in the magnitude of effect (0.9%, 3/332).
Conclusion: Consideration of the importance of health equity in WHO guidelines has increased since the adoption of the EtD framework. However, there is a lack of evidence provided to support judgements for likely impact on health equity. For the united nation’s global agenda to succeed, high quality medical research is needed in conjunction with informed decision. Better harnessing these characteristics of rapid learning health systems would eventually lead to an improvement in individual experience and health outcomes.
Patient or healthcare consumer involvement: no
Objectives: To evaluate how and to what extent health equity considerations are assessed in WHO guidelines.
Methods: We conducted a cross-sectional survey on guidelines approved by the WHO guideline review committee (GRC) published between Jan 2014 to May 2019. Guidelines were assessed for health equity considerations using the PROGRESS (Place, Race, Occupation, Gender, Religion, Education, Socioeconomic Status, Social Capital) framework. We also assessed how likely impact on health equity was assessed in the research evidence section of each recommendation of these guidelines using criteria based on differences in baseline risk, value of outcomes for socially disadvantaged populations, health inequity as an outcome, equity related subgroup analysis, and applicability.
Results: We identified 111 WHO guidelines published in this time period and 91% (101/111) of them were focused on socially disadvantaged populations. The use of the EtD frameworks progressively increased from 10% (2/20) in 2014, to 100% (8/8) in 2019. Mention of health equity anywhere in the guideline increased from 55% (11/20) in 2014 to 100% (8/8) in 2019. For the 40 guidelines that reported using and published their EtD frameworks, likely impact on health equity was supported by evidence statements in 28% (94/332) of the recommendations. The most common evidence provided was differences in baseline risk of outcomes (23%; 78/332 recommendations), and the least frequently reported as differences in the magnitude of effect (0.9%, 3/332).
Conclusion: Consideration of the importance of health equity in WHO guidelines has increased since the adoption of the EtD framework. However, there is a lack of evidence provided to support judgements for likely impact on health equity. For the united nation’s global agenda to succeed, high quality medical research is needed in conjunction with informed decision. Better harnessing these characteristics of rapid learning health systems would eventually lead to an improvement in individual experience and health outcomes.
Patient or healthcare consumer involvement: no