Grade Equity Guidelines 2: Considering Health Equity in Grade Guideline Development: Equity Extension of the Guideline Development Checklist

Akl EA, Welch V, Pottie K, Eslava-Schmalbach J, Darzi A, Sola I, Katikireddi SV, Singh J, Murad MH, Meerpohl J, Stanev R, Lang E, Matovinovic E, Shea B, Agoritsas T, Alexander PE, Snellman A, Brignardello-Petersen R, Gloss D, Thabane L, Shi C, Stein AT, et al
Source: J Clin Epidemiol
Publication Year: 2017
Population Focus: Vulnerable/disadvantaged
Intervention Type: Best practices
Study Design: Other Study Design
Type of Literature: White

To provide guidance for guideline developers on how to consider health equity at key stages of the guideline development process.

Literature review followed by group discussions and consensus building.

The key stages at which guideline developers could consider equity include setting priorities, guideline group membership, identifying the target audience(s), generating the guideline questions, considering the importance of outcomes and interventions, deciding what evidence to include and searching for evidence, summarizing the evidence and considering additional information, wording of recommendations, and evaluation and use. We provide examples of how guidelines have actually considered equity at each of these stages.

Guideline projects should consider the aforementioned suggestions for recommendations that are equity sensitive.

Insights Results

Overview of article

  • This paper is the second in a 4-part series about considering equity in the Grading Recommendations Assessment and Development Evidence (GRADE) guideline development process. Specifically, this paper outlines 9 steps and specific suggestions associated with each step in the guideline development process where health equity could be incorporated

Methods of article

  • The identification of these 9 steps was informed by a literature review, group discussions and consensus building


  • The 9 steps and specific suggestions are:
    1) Setting priorities – Consider dedicating part of or a whole guideline (as opposed to no part) to the care of disadvantaged populations;
    2) Guideline group membership – Include representatives of the disadvantaged populations in the different guideline groups, particularly the voting panel, ensure the method for recruitment of group members considers representatives of all relevant disadvantaged populations, recruit a methodologist who is familiar with and mindful of equity issues, and ensure the chair of the voting panel is familiar with equity issues;
    3) Identifying the target audience – Specify relevant disadvantaged populations when identifying the target audience(s), and involve representatives of disadvantaged populations when identifying the target audience(s);
    4) Generating the guideline questions – Consider equity when specifying elements of the Patient/Population/Problem, Intervention, Comparison, Outcome (PICO) questions, and consider ‘good-practice statements’ that could help address equity issues;
    5) Considering the importance of outcomes and interventions – Involve representatives of disadvantaged populations in rating the importance of interventions and outcomes, search selected databases for outcomes rated as important by disadvantaged populations, and consider separate recommendations for disadvantaged populations if their values and preferences are thought to differ substantively to the point of affecting the strength and/or direction of recommendation;
    6) Deciding what evidence to include and searching for evidence – Seek evidence specific to disadvantaged populations, consider including evidence derived from fields other than health (e.g., social science) that address disadvantaged populations, and search literature published in the language relevant to the disadvantaged population;
    7) Summarizing the evidence and considering additional information – Consider the PROGRESS-Plus elements when synthesizing the evidence, follow the PRISMA-Equity statement when reporting the systematic reviews, and consider information on resource use, cost, effect on equity, feasibility and acceptability from the perspective of disadvantaged populations. PROGRESS-Plus stands for Place of residence, Race/ethnicity/culture/language, Occupation, Gender/sex, Religion, Education, Socioeconomic status, Social capital. Plus stands for other characteristics not included in PROGRESS (e.g., age, disability);
    8) Wording of recommendations – Be as specific as possible in defining the population in order to maximize the understanding that it applies to a disadvantaged populations (when applicable), include the necessary remarks following the recommendation to ensure its appropriate implementation in disadvantaged populations; and ensure that language is used carefully so that the recommendation does not stigmatize already disadvantaged populations; and
    9) Evaluation and use – Produce tools to facilitate implementation and use among disadvantaged populations, and monitor and audit implementation and use among disadvantaged populations

Key takeaways/implications

  • Considerations and potential challenges in integrating health equity at one of these steps may include availability of relevant evidence, logistical challenges, and lack of engagement by representatives of disadvantaged populations
  • It is important to maintain transparency and systematic approaches throughout the guideline development
  • Future areas of research should focus on evaluating the extent to which guideline development are considering equity at the different stages in their processes. Most importantly, studies should assess the extent that equity considerations during guideline development actually impact health equity at the population level