Elsevier

Journal of Clinical Epidemiology

Volume 127, November 2020, Pages 125-133
Journal of Clinical Epidemiology

Original Article
Over half of the WHO guidelines published from 2014 to 2019 explicitly considered health equity issues: a cross-sectional survey

https://doi.org/10.1016/j.jclinepi.2020.07.012Get rights and content

Abstract

Objective

To evaluate how and to what extent health equity considerations are assessed in World Health Organization (WHO) guidelines.

Study Design and Setting

We evaluated WHO guidelines published between January 2014 and May 2019. Health equity considerations were assessed in relation to differences in baseline risk, importance of outcomes for socially disadvantaged populations, inclusion of health inequity as an outcome, equity-related subgroup analysis, and indirectness in each recommendation.

Results

We identified 111 WHO guidelines, and 54% (60 of 111) of these used the Evidence to Decision (EtD) framework. For the 60 guidelines using an EtD framework, the likely impact on health equity was supported by research evidence in 28% of the recommendations (94 of 332). Research evidence was mostly provided as differences in baseline risk (23%, 78/332). Research evidence less frequently addressed the importance of outcomes for socially disadvantaged populations (11%, 36/332), considered indirectness of the evidence for socially disadvantaged populations (2%, 5/332), considered health inequities as an outcome (2%, 5/332) and considered differences in the magnitude of effect in relative terms between disadvantaged and more advantaged populations (1%, 3/332).

Conclusion

The provision of research evidence to support equity judgements in WHO guidelines is still suboptimal, suggesting the need for better guidance and more training.

Introduction

Health inequity has been defined as differences in health that are avoidable and also considered unfair or unjust [1]. Health inequities are present both between and within countries for many health-related issues, such as noncommunicable diseases, communicable diseases, and injuries [[2], [3], [4]]. Those differences are related to social dimensions that condition these health-related issues [5]. This has led to health equity being increasingly considered as a fundamental principle in clinical practice, public health, and health policy making [[6], [7], [8], [9]]. The World Health Organization (WHO) is an autonomous organization that works with the United Nations in addressing international public health matters. The WHO recognizes the importance of reducing health inequities as health is a fundamental human right [10]. Similarly, many global organizations have pledged to address health inequities [[11], [12], [13]].

One way WHO contributes to public health is through the production of guidelines that play a role in the formulation of public health policies in many countries. As in other health guidelines, WHO guidelines provide population level recommendations that can impact health equity at the individual patient level [14]. In addition, WHO produces manuals and technical handbooks to provide technical and procedural guidance for developing WHO guidelines. The WHO was first advised to include consideration about equity in 2006 by its Advisory Committee on Health Research [15]. The official technical handbook of WHO, published in 2014, includes a specific chapter on integrating health equity into guidelines [16]. This emphasis reflects WHO's goal of reducing health inequities while improving population health.

Since 2003, the WHO has used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach to develop its guidelines and the GRADE summary of findings (SoF) to evaluate the quality of evidence, and grade the strength of recommendations [17,18]. In 2016, the GRADE working group published its Evidence to Decision (EtD) frameworks, which provide a set of transparent and structured approaches for panels to consider when deciding on the strength and direction of recommendations [19]. The frameworks can be used to inform different types of decisions (e.g., public health or coverage), including clinical recommendations [20,21].

The EtD frameworks include health equity as one of the core criteria to consider for deciding on the strength and direction of recommendations. The criterion assesses the impact on health equity (“What would be the impact on health equity?”) and the judgment needs to be made based on identifying and estimating the effect in disadvantaged groups in relation to the problem or intervention, anticipating differences in relative or absolute effectiveness of the intervention between groups, and determining intervention implementation considerations to reduce health inequities [19].

In 2017, the GRADE Equity project group developed further guidance to consider health equity throughout the guideline development process, including the following five aspects that need to be assessed: (1) differences in baseline risk, (2) differential effects, (3) valuation of outcomes, (4) assessing population-level inequalities, and (5) assessing indirectness [14,[22], [23], [24]]. In addition, panels may consider health equity at different steps in the guideline development process, such as when assembling a guideline panel, including populations that experience health inequities or practitioners who work with those communities [22]. Furthermore, health equity consideration may apply for other EtD criteria, such as acceptability and feasibility [24].

The purpose of this project is to evaluate how and to what extent health equity considerations are assessed in WHO guidelines.

Section snippets

Search

We evaluated WHO Guideline Review Committee (GRC)–approved guidelines published from January 1, 2014, to May 1, 2019, and available at the WHO web site [25]. To verify that we obtained all the GRC-approved guidelines, we contacted WHO staff and obtained a confirmed list of published guidelines. We used both sources to develop a final list (Appendix 1).

Eligibility of guidelines

We included all WHO guideline documents, irrespective of the topic, that provided one or more recommendations or guidance for a health-related

Characteristics of included guidelines

A total of 119 guidelines were identified. After excluding a summary of rapid advice guideline [27], a policy brief [28], a rapid advice guideline [29], a compilation guideline [30], and four duplicates, 111 guidelines were included (Fig. 1).

A total of 51 of 111 guidelines (46%) were developed without using the EtD framework, whereas 60 of 111 guidelines (54%) were developed using the EtD framework. Of these 60 guidelines, two guidelines were excluded because they were inaccessible (i.e., web

Discussion

Our evaluation of WHO guidelines published since 2014 shows that gradually more guidelines are incorporating health equity. Despite this, we found that almost two-thirds of the recommendations provided no supporting evidence for their health equity–related judgments. Similarly, we also observed an increase in the use of the EtD frameworks by the WHO, a change that could partially explain the change observed in relation to the incorporation of equity.

CRediT authorship contribution statement

Omar Dewidar: Methodology, Formal analysis, Investigation, Data curation, Writing - original draft, Visualization, Project administration. Phillip Tsang: Methodology, Investigation, Data curation. Montserrat León-García: Investigation, Writing - review & editing. Christine Mathew: Investigation. Alba Antequera: Investigation, Writing - review & editing. Tejan Baldeh: Investigation. Elie A. Akl: Conceptualization, Methodology, Writing - review & editing. Pablo Alonso-Coello: Conceptualization,

Acknowledgments

The authors gratefully acknowledge the WHO for their support in this project and Olympe Perez for assisting in obtaining the list of GRC-approved guidelines. They also would like to thank Astha Saxena for reviewing and verifying the recommendations of the guidelines that used the EtD frameworks.

Patient and public involvement: No patients or public were involved in the conduction or the design of this project.

Data sharing: Data sets are available on request.

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    Transparency declaration: The manuscript's guarantor (O.D.) affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

    Funding: The authors received no financial support for the research or the publication of this article.

    Ethics approval: Not required.

    Competing interest statement: All authors have completed the ICMJE uniform disclosure format http://www.icmje.org/coi_disclosure.pdf and declare: no support from any organization for the submitted work; Peter Tugwell recused himself from the entire editorial process. Holger Schunemann is the co-chair of the GRADE working group and reports no financial conflict of interest, Peter Tugwell is the recipient of Canada Research Chair in Health Equity (Tier 1d2016 to 2024) from the Canadian Institutes of Health Research, Vivian Welch reports grants from World Health Organization, outside the submitted work; no other relationships or activities could have influenced this work.

    Contribution: V.W., Peter Tugwell, E.A., P.C., K.P., and H.S. conceived the study. O.D., V.W., Philip Tsang, J.P., and T.P. developed the screening and data extraction forms. O.D., Philip Tsang, M.L., C.M., A.A., and T.B. screened the reviews and extracted data. O.D. conducted data quality check, analyzed the data, and wrote the first draft of the manuscript. V.W., Peter Tugwell, E.A., P.C., K.P., H.S., A.A., M.L., and T.P. suggested revisions to the manuscript. All authors approved the final version of the manuscript.

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