When is a randomised controlled trial health equity relevant? Development and validation of a conceptual framework

Reporting of health equity considerations in vaccine trials for COVID-19: a methodological review

BACKGROUND AND OBJECTIVES

An emerging body of randomized controlled trials (RCTs) on COVID-19 vaccines has served as the evidence base for public health decision-making. While it is recommended that RCTs report results by health equity stratifiers to reduce bias in health care and gaps in research, it is unknown whether this was done in COVID-19 vaccine trials. To critically examine the use of health equity stratifiers in COVID-19 vaccine trials.

STUDY DESIGN AND SETTING

We conducted a methodological review of published COVID-19 vaccine trials available in the COVID-19 living Network Meta-Analysis systematic review database through February 8, 2023. Based on the PROGRESS-Plus framework, we examined the following health equity stratifiers: place of residence, race/ethnicity, occupation, gender/sex, religion, education, socio-economic status, social capital, age, disability, features of relationships, and temporary situations. We assessed each study in duplicate according to three criteria for comprehensive health-equity reporting: 1) describing participants, 2) reporting equity-relevant results, and 3) discussing equity-relevant implications of trial findings.

RESULTS

We reviewed 144 trial manuscripts. The most frequently used PROGRESS-Plus stratifiers to describe participants were age (100%), place of residence (100%), gender/sex (99%), and race/ethnicity (64%). Age was most often used to disaggregate or adjust results (67%), followed by gender or sex (35%). Discussions of equity-relevant implications often indicated limited generalizability of results concerning age (40% of studies). Half (47%) of the studies considered at least one health equity stratifier for all three criteria. No trials included stratifiers related to religion, socioeconomic status, sexual orientation, or features of relationships.

CONCLUSION

COVID-19 vaccine trials provided a limited description of health equity stratifiers as defined by PROGRESS-Plus and infrequently disaggregated results or discussed the study implications as they related to health equity. Considering the health disparities exacerbated during the pandemic, increased uptake of PROGRESS-Plus in RCTs would support a more nuanced understanding of health disparities and better inform actions to improve health equity.

Motivations for investigating health inequities in observational epidemiology: a content analysis of 320 studies

OBJECTIVES

To enhance equity in clinical and epidemiological research, it is crucial to understand researcher motivations for conducting equity-relevant studies. Therefore, we evaluated author motivations in a randomly selected sample of equity-relevant observational studies published during the COVID-19 pandemic.

STUDY DESIGN AND SETTING

We searched MEDLINE for studies from 2020 to 2022, resulting in 16,828 references. We randomly selected 320 studies purposefully sampled across income setting (high vs low-middle-income), COVID-19 topic (vs non-COVID-19), and focus on populations experiencing inequities. Of those, 206 explicitly mentioned motivations which we analyzed thematically. We used discourse analysis to investigate the reasons behind emerging motivations.

RESULTS

We identified the following motivations: (1) examining health disparities, (2) tackling social determinants to improve access, and (3) addressing knowledge gaps in health equity. Discourse analysis showed motivations stem from commitments to social justice and recognizing the importance of highlighting it in research. Other discourses included aspiring to improve health-care efficiency, wanting to understand cause-effect relationships, and seeking to contribute to an equitable evidence base.

CONCLUSION

Understanding researchers' motivations for assessing health equity can aid in developing guidance that tailors to their needs. We will consider these motivations in developing and sharing equity guidance to better meet researchers' needs.

Reporting of equity in observational epidemiology: A methodological review

Background

Observational studies can inform how we understand and address persisting health inequities through the collection, reporting and analysis of health equity factors. However, the extent to which the analysis and reporting of equity-relevant aspects in observational research are generally unknown. Thus, we aimed to systematically evaluate how equity-relevant observational studies reported equity considerations in the study design and analyses.

Methods

We searched MEDLINE for health equity-relevant observational studies from January 2020 to March 2022, resulting in 16 828 articles. We randomly selected 320 studies, ensuring a balance in focus on populations experiencing inequities, country income settings, and coronavirus disease 2019 (COVID-19) topic. We extracted information on study design and analysis methods.

Results

The bulk of the studies were conducted in North America (n = 95, 30%), followed by Europe and Central Asia (n = 55, 17%). Half of the studies (n = 171, 53%) addressed general health and well-being, while 49 (15%) focused on mental health conditions. Two-thirds of the studies (n = 220, 69%) were cross-sectional. Eight (3%) engaged with populations experiencing inequities, while 22 (29%) adapted recruitment methods to reach these populations. Further, 67 studies (21%) examined interaction effects primarily related to race or ethnicity (48%). Two-thirds of the studies (72%) adjusted for characteristics associated with inequities, and 18 studies (6%) used flow diagrams to depict how populations experiencing inequities progressed throughout the studies.

Conclusions

Despite over 80% of the equity-focused observational studies providing a rationale for a focus on health equity, reporting of study design features relevant to health equity ranged from 0-95%, with over half of the items reported by less than one-quarter of studies. This methodological study is a baseline assessment to inform the development of an equity-focussed reporting guideline for observational studies as an extension of the well-known Strengthening Reporting of Observational Studies in Epidemiology (STROBE) guideline.

Using administrative data to evaluate national policy impacts on child and maternal health: a research framework from the Maternal and Child Health Network (MatCHNet)

Reducing health inequalities by addressing the social circumstances in which children are conceived and raised is a societal priority. Early interventions are key to improving outcomes in childhood and long-term into adulthood. Across the UK nations, there is strong political commitment to invest in the early years. National policy interventions aim to tackle health inequalities and deliver health equity for all children. Evidence to determine the effectiveness of socio-structural policies on child health outcomes is especially pressing given the current social and economic challenges facing policy-makers and families with children. As an alternative to clinical trials or evaluating local interventions, we propose a research framework that supports evaluating the impact of whole country policies on child health outcomes. Three key research challenges must be addressed to enable such evaluations and improve policy for child health: (1) policy prioritisation, (2) identification of comparable data and (3) application of robust methods.

Distributional Cost-Effectiveness Analysis of Health Technologies: Data Requirements and Challenges

Governments and health technology assessment agencies are putting greater focus on and efforts in understanding and addressing health inequities. Cost-effectiveness analyses are used to evaluate the costs and health gains of different interventions to inform the decision-making process on funding of new treatments. Distributional cost-effectiveness analysis (DCEA) is an extension of cost-effectiveness analysis that quantifies the equity impact of funding new treatments. Key challenges for the routine and consistent implementation of DCEA are the lack of clearly defined equity concerns from decision makers and endorsed measures to define equity subgroups and the availability of evidence that allows analysis of differences in data inputs associated with the equity characteristics of interest. In this article, we detail the data gaps and challenges to build robust DCEA analysis routinely in health technology assessment and suggest actions to overcome these hurdles.

Equitable implementation of S.A.F.E. Firearm: A multi-method pilot study

Attention to health equity is critical in the implementation of firearm safety efforts. We present our operationalization of equity-oriented recommendations in preparation for launch of a hybrid effectiveness-implementation trial focused on firearm safety promotion in pediatric primary care as a universal suicide prevention strategy. In Step 1 of our process, pre-trial engagement with clinican partners and literature review alerted us that delivery of a firearm safety program may vary by patients' medical complexity, race, and ethnicity. In Step 2, we selected the Health Equity Implementation Framework to inform our understanding of contextual determinants (i.e., barriers and facilitators). In Step 3, we leveraged an implementation pilot across 5 pediatric primary care clinics in 2 health system sites to study signals of inequities. Eligible well-child visits for 694 patients and 47 clinicians were included. Our results suggested that medical complexity was not associated with program delivery. We did see potential signals of inequities by race and ethnicity but must interpret with caution. Though we did not initially plan to examine differences by sex assigned at birth, we discovered that clinicians may be more likely to deliver the program to parents of male than female patients. Seven qualitative interviews with clinicians provided additional context. In Step 4, we interrogated equity considerations (e.g., why and how do these inequities exist). In Step 5, we will develop a plan to probe potential inequities related to race, ethnicity, and sex in the fully powered trial. Our process highlights that prospective, rigorous, exploratory work is vital for equity-informed implementation trials.

Advancing Health Equity Efforts to Reduce Obesity: Changing the Course

Population-based solutions are needed to stabilize and then reverse the continued upward trends in obesity prevalence in the US population and worldwide. This review focuses on the related, urgent issue of disparities in obesity prevalence affecting US racial/ethnic minority and other socially marginalized populations. The review provides background on these disparities from a health equity perspective and highlights evidence of progress in equity-focused obesity efforts. Five recommendations for advancing equity efforts are offered as potential approaches to build on progress to date: (a) give equity issues higher priority, (b) adopt a health equity lens, (c) strengthen approaches by using health equity frameworks, (d) broaden the types of policies considered, and (e) emphasize implementation science concepts and tools. Potential challenges and opportunities are identified, including the prospect of longer-term, transformative solutions that integrate global and national initiatives to address obesity, undernutrition, and climate change.

Reporting of health equity considerations in equity-relevant observational studies: Protocol for a systematic assessment

Background: The mitigation of unfair and avoidable differences in health is an increasing global priority. Observational studies including cohort, cross-sectional and case-control studies tend to report social determinants of health which could inform evidence syntheses on health equity and social justice. However, the extent of reporting and analysis of equity in equity-relevant observational studies is unknown. Methods: We define studies which report outcomes for populations at risk of experiencing inequities as “equity-relevant”. Using a random sampling technique we will identify 320 equity-relevant observational studies published between 1 January 2020 to 27 April 2022 by searching the MEDLINE database. We will stratify sampling by 1) studies in high-income countries (HIC) and low- and middle-income countries (LMIC) according to the World Bank classification, 2) studies focused on COVID and those which are not, 3) studies focused on populations at risk of experiencing inequities and those on general populations that stratify their analyses. We will use the PROGRESS framework which stands for place of residence, race or ethnicity, occupation, gender or sex, religion, education, socioeconomic status, social capital, to identify dimensions where inequities may exist. Using a previously developed data extraction form we will pilot-test on eligible studies and revise as applicable. Conclusions: The proposed methodological assessment of reporting will allow us to systematically understand the current reporting and analysis practices for health equity in observational studies. The findings of this study will help inform the development of the equity extension for the STROBE (Strengthening the Reporting of Observational studies in Epidemiology) reporting guidelines.

What Makes an Intervention a Life Course Intervention?

OBJECTIVES

To develop an initial list of characteristics of life course interventions to inform the emerging discipline of life course intervention research.

METHODS

The Life Course Intervention Research Network, a collaborative national network of >75 researchers, service providers, community representatives, and thought leaders, considered the principles, characteristics, and utility of life course interventions. After an in-person launch meeting in 2019, the steering committee collaboratively and iteratively developed a list of life course intervention characteristics, incorporating a modified Delphi review process.

RESULTS

The Life Course Intervention Research Network identified 12 characteristics of life course interventions. These interventions (1) are aimed at optimizing health trajectories; (2) are developmentally focused, (3) longitudinally focused, and (4) strategically timed; and are (5) designed to address multiple levels of the ecosystem where children are born, live, learn, and grow and (6) vertically, horizontally, and longitudinally integrated to produce a seamless, forward-leaning, health optimizing system. Interventions are designed to (7) support emerging health development capabilities; are (8) collaboratively codesigned by transdisciplinary research teams, including stakeholders; and incorporate (9) family-centered, (10) strengths-based, and (11) antiracist approaches with (12) a focus on health equity.

CONCLUSIONS

The intention for this list of characteristics of life course interventions is to provide a starting point for wider discussion and to guide research development. Incorporation of these characteristics into intervention designs may improve emerging health trajectories and move critical developmental processes and pathways back on track, even optimizing them to prevent or reduce adverse outcomes.

Health equity impact of community-initiated kangaroo mother care: a randomized controlled trial

Background

Kangaroo mother care (KMC) can substantially enhance overall survival of low birthweight babies. In a large randomized controlled trial, we recently showed that supporting mothers to provide community initiated KMC (ciKMC) can reduce mortality among infants up to 180 days of life by 25% (hazard ratio (HR) 0.75). With the current analysis, we aimed to explore if ciKMC promotion leads to increased inequity in survival.

Methods

In the trial we randomized 8402 low birthweight babies to a ciKMC (4480 babies) and a control (3922 babies) arm, between 2015 and 2018 in Haryana, India. We estimated the difference in concentration indices, which measure inequality, between babies in the ciKMC and control arms for survival until 180 days of life. Further, we compared the effect of ciKMC promotion across subgroups defined by socioeconomic status, caste, maternal literacy, infant’s sex, and religion.

Results

Our intervention did not increase survival inequity, as the concentration index in the ciKMC arm of the trial was 0.05 (95% CI -0.07 to 0.17) lower than in the control arm. Survival impact was higher among those belonging to the lower two wealth quintiles, those born to illiterate mothers and those belonging to religions other than Hindu.

Conclusions

We found that ciKMC promotion did not increase inequity in survival associated with wealth. The beneficial impact of ciKMC tended to be larger among vulnerable groups. Supporting mothers to provide KMC at home to low birthweight babies will not increase and could indeed reduce inequities in infant survival.

Trial registration

ClinicalTrials.gov, NCT02653534. Registered January 12, 2016—Retrospectively registered.

Enrollment, retention, and strategies for including disadvantaged populations in randomized controlled trials: a systematic review protocol

BACKGROUND

Many randomized controlled trials fail to reach their target sample size. When coupled with the omission and underrepresentation of disadvantaged groups in randomized controlled trials, many trials fail to obtain data that accurately represents the true diversity of their target population. Policies and practices have been implemented to increase representation of disadvantaged groups in many randomized controlled trials, with some trials specifically targeting such groups. To our knowledge, no systematic review has quantified the enrollment metrics and effectiveness of inclusion and retention strategies in randomized controlled trials focused on disadvantaged populations specifically.

METHODS

We will conduct a systematic search across EMBASE, MEDLINE, Web of Science, and CINAHL as well as grey literature, conference proceedings, research monographs, and Google Scholar from inception onwards. We will include randomized controlled trials where at least 50% of enrolled participants are considered to be disadvantaged, as per the RCT authors' definition and in line with our inclusion criteria. Two independent researchers per article will conduct preliminary title and abstract screening, subsequent full text review, and data extraction for the selected trials, with a third reviewer available to resolve conflicts. We will assess the quality of all included studies using specific criteria regarding data reporting, external validity, and internal validity. We will combine all selected studies and conduct a narrative synthesis to assess enrollment metrics. If there is sufficient homogeneity and sufficient trials comparing recruitment strategies within disadvantaged populations, we will conduct a random effects meta-analysis to evaluate the effectiveness of strategies designed to maximize the inclusion of disadvantaged populations in randomized controlled trials.

DISCUSSION

The findings of this systematic review will establish baseline recruitment and enrollment metrics of trials targeting disadvantaged populations to elucidate the scope of the challenge of recruiting such populations. We hope that our findings will promote future research on the distinct barriers that may prevent disadvantaged populations from participating in health intervention research, will encourage more trials exploring effective, tailored recruitment strategies, and will establish a foundation to track future progress in the recruitment of disadvantaged populations.

TRIAL REGISTRATIONS

PROSPERO ID: CRD42020152814.

Implementation science should give higher priority to health equity

Background

There is growing urgency to tackle issues of equity and justice in the USA and worldwide. Health equity, a framing that moves away from a deficit mindset of what society is doing poorly (disparities) to one that is positive about what society can achieve, is becoming more prominent in health research that uses implementation science approaches. Equity begins with justice—health differences often reflect societal injustices. Applying the perspectives and tools of implementation science has potential for immediate impact to improve health equity.

Main text

We propose a vision and set of action steps for making health equity a more prominent and central aim of implementation science, thus committing to conduct implementation science through equity-focused principles to achieve this vision in U.S. research and practice. We identify and discuss challenges in current health disparities approaches that do not fully consider social determinants. Implementation research challenges are outlined in three areas: limitations of the evidence base, underdeveloped measures and methods, and inadequate attention to context. To address these challenges, we offer recommendations that seek to (1) link social determinants with health outcomes, (2) build equity into all policies, (3) use equity-relevant metrics, (4) study what is already happening, (5) integrate equity into implementation models, (6) design and tailor implementation strategies, (7) connect to systems and sectors outside of health, (8) engage organizations in internal and external equity efforts, (9) build capacity for equity in implementation science, and (10) focus on equity in dissemination efforts.

Conclusions

Every project in implementation science should include an equity focus. For some studies, equity is the main goal of the project and a central feature of all aspects of the project. In other studies, equity is part of a project but not the singular focus. In these studies, we should, at a minimum, ensure that we “leave no one behind” and that existing disparities are not widened. With a stronger commitment to health equity from funders, researchers, practitioners, advocates, evaluators, and policy makers, we can harvest the rewards of the resources being invested in health-related research to eliminate disparities, resulting in health equity.

Count me in: using a patient portal to minimize implicit bias in clinical research recruitment

OBJECTIVE

Determine whether women and men differ in volunteering to join a Research Recruitment Registry when invited to participate via an electronic patient portal without human bias.

MATERIALS AND METHODS

Under-representation of women and other demographic groups in clinical research studies could be due either to invitation bias (explicit or implicit) during screening and recruitment or by lower rates of deciding to participate when offered. By making an invitation to participate in a Research Recruitment Registry available to all patients accessing our patient portal, regardless of demographics, we sought to remove implicit bias in offering participation and thus independently assess agreement rates.

RESULTS

Women were represented in the Research Recruitment Registry slightly more than their proportion of all portal users (n = 194 775). Controlling for age, race, ethnicity, portal use, chronic disease burden, and other questionnaire use, women were statistically more likely to agree to join the Registry than men (odds ratio 1.17, 95% CI, 1.12-1.21). In contrast, Black males, Hispanics (of both sexes), and particularly Asians (both sexes) had low participation-to-population ratios; this under-representation persisted in the multivariable regression model.

DISCUSSION

This supports the view that historical under-representation of women in clinical studies is likely due, at least in part, to implicit bias in offering participation. Distinguishing the mechanism for under-representation could help in designing strategies to improve study representation, leading to more effective evidence-based recommendations.

CONCLUSION

Patient portals offer an attractive option for minimizing bias and encouraging broader, more representative participation in clinical research.

Identifying vulnerable older adult populations by contextualizing geriatric syndrome information in clinical notes of electronic health records

OBJECTIVE

Geriatric syndromes such as functional disability and lack of social support are often not encoded in electronic health records (EHRs), thus obscuring the identification of vulnerable older adults in need of additional medical and social services. In this study, we automatically identify vulnerable older adult patients with geriatric syndrome based on clinical notes extracted from an EHR system, and demonstrate how contextual information can improve the process.

MATERIALS AND METHODS

We propose a novel end-to-end neural architecture to identify sentences that contain geriatric syndromes. Our model learns a representation of the sentence and augments it with contextual information: surrounding sentences, the entire clinical document, and the diagnosis codes associated with the document. We trained our system on annotated notes from 85 patients, tuned the model on another 50 patients, and evaluated its performance on the rest, 50 patients.

RESULTS

Contextual information improved classification, with the most effective context coming from the surrounding sentences. At sentence level, our best performing model achieved a micro-F1 of 0.605, significantly outperforming context-free baselines. At patient level, our best model achieved a micro-F1 of 0.843.

DISCUSSION

Our solution can be used to expand the identification of vulnerable older adults with geriatric syndromes. Since functional and social factors are often not captured by diagnosis codes in EHRs, the automatic identification of the geriatric syndrome can reduce disparities by ensuring consistent care across the older adult population.

CONCLUSION

EHR free-text can be used to identify vulnerable older adults with a range of geriatric syndromes.

How health inequalities accumulate and combine to affect treatment value: A distributional cost-effectiveness analysis of smoking cessation interventions

INTRODUCTION

Reduction of health inequality is a goal in health policy, but commissioners lack information on how policies change health inequality. This study illustrates how decision models can be readily extended to produce information on health inequality impacts as well as for population health, using the example of smoking cessation therapies.

METHODS

We retrospectively adapt a model developed for public health guidance to undertake distributional cost effectiveness analysis. We identify and incorporate evidence on how inputs vary by area-level deprivation. Therapies are evaluated in terms of total population health, extent of inequality, and a summary measure of equally distributed equivalent health based on a societal value for inequality aversion. Last, we examine how accounting for social variation in different sets of parameters affects our results.

RESULTS

All interventions increase population health and increase the slope index ofinequality. At estimated levels of health inequality aversion for England, our resultsindicate that the increases in inequality are compensated by the health gains.

DISCUSSION

The inequality impacts are driven by higher benefits of quitting and higher intervention uptake amongst advantaged groups, despite the greater proportion of smokers in disadvantaged groups. Failure to account for differential effects between groups leadsto different conclusions about health inequality impact but does not alter conclusionsabout value for money.

A protocol for a scoping review of equity measurement in mental health care for children and youth

BACKGROUND

Mental health (MH) problems are among the most important causes of morbidity and mortality for children and youth. Problems of lack of equity in child and youth MH services (CYMHS)-including, but not limited to, problems in inaccessibility and quality of services-are widespread. Characterizing the nature of equity in CYMHS is an ongoing challenge because the field lacks a consistent approach to conceptualizing equity. We will conduct a scoping review of how equity in MH services for children and youth has been defined, operationalized, and measured. Our objectives are to discover: (1) What conceptual definitions of equity are used by observational studies of CYMHS?; (2) What service characteristics of CYMHS care do indices of equity cover?; (3) What population dimensions have been used to operationalize equity?; (4) What statistical constructs have been used in indices that measure CYMHS equity?; and (5) What were the numerical values of those indices?

METHODS

The following databases will be searched: Medline, Embase, PsycINFO, Cochrane Controlled Register of Trials, CINAHL, EconLit, and Sociological Abstracts. Searches will be conducted from the date of inception to the end of the last full calendar year (December 2019). Studies will be included if they include an evaluation of a mental health service for children or youth (defined as those under 19 years of age) and which quantify variation in some aspect of child or youth mental health services (e.g., accessibility, volume, duration, or quality) as a function of socio-demographic and/or geographic variables. Study selection will occur over two stages. Stage one will select articles based on title and abstract using the liberal-accelerated method. Stage two will review the full texts of selected titles. Two reviewers will work independently on full-text reviewing, with each study screened twice using pre-specified eligibility criteria. One reviewer will chart study characteristics and indices to be verified by a second reviewer. Reviewers will resolve full-text screening and data extraction disagreements through discussion. Synthesis of the collected data will focus on compiling and mapping the types and characteristics of the indices used to evaluate MH services equity.

DISCUSSION

The planned, systematic scoping review will survey the literature regarding how equity in MH services for children and youth has been operationalized and help inform future studies of equity in CYMHS.

SYSTEMATIC REVIEW REGISTRATION

Open Science Foundation ID SYSR-D-19-00371, https://osf.io/58srv/ .

Recruiting men from across the socioeconomic spectrum via GP registers and community outreach to a weight management feasibility randomised controlled trial

Background

Men, particularly those living in disadvantaged areas, are less likely to participate in weight management programmes than women despite similar levels of excess weight. Little is known about how best to recruit men to weight management interventions. This paper describes patient and public involvement in pre-trial decisions relevant to recruitment and aims to report on recruitment to the subsequent men-only weight management feasibility trial, including the: i) acceptability and feasibility of recruitment; and ii) baseline sample characteristics by recruitment strategy.

Methods

Men with BMI ≥30 kg/m² and/or waist circumference ≥ 40 in. were recruited to the feasibility trial via two strategies; community outreach (venue information stands and word of mouth) and GP letters, targeting disadvantaged areas. Recruitment activities (e.g. letters sent, researcher venue hours) were recorded systematically, and baseline characteristics questionnaire data collated. Qualitative interviews (n = 50) were conducted three months post-recruitment. Analyses and reporting followed a complementary mixed methods approach.

Results

105 men were recruited within four months (community n = 60, GP letter n = 45). Community outreach took 2.3 recruiter hours per participant and GP letters had an opt-in rate of 10.2% (n = 90/879). More men were interested than could be accommodated. Most participants (60%) lived in more disadvantaged areas. Compared to community outreach, men recruited via GP letters were older (mean = 57 vs 48 years); more likely to report an obesity-related co-morbidity (87% vs 44%); and less educated (no formal qualifications, 32% vs 10%, degree educated 11% vs 41%). Recruitment strategies were acceptable, a sensitive approach and trusting relationships with recruiters valued, and the ‘catchy’ study name drew attention.

Conclusions

Targeted community outreach and GP letters were acceptable strategies that successfully recruited participants to a men-only weight management feasibility trial. Both strategies engaged men from disadvantaged areas, a typically underserved population. Using two recruitment strategies produced samples with different health risk profiles, which could add value to research where either primary or secondary prevention is of interest. Further work is required to examine how these strategies could be implemented and sustained in practice.

Trial registration

ClinicalTrials.gov: NCT03040518, 2nd February 2017.

Reporting of health equity considerations in cluster and individually randomized trials

Background

The randomized controlled trial (RCT) is considered the gold standard study design to inform decisions about the effectiveness of interventions. However, a common limitation is inadequate reporting of the applicability of the intervention and trial results for people who are “socially disadvantaged” and this can affect policy-makers’ decisions. We previously developed a framework for identifying health-equity-relevant trials, along with a reporting guideline for transparent reporting. In this study, we provide a descriptive assessment of health-equity considerations in 200 randomly sampled equity-relevant trials.

Methods

We developed a search strategy to identify health-equity-relevant trials published between 2013 and 2015. We randomly sorted the 4316 records identified by the search and screened studies until 100 individually randomized (RCTs) and 100 cluster randomized controlled trials (CRTs) were identified. We developed and pilot-tested a data extraction form based on our initial work, to inform the development of our reporting guideline for equity-relevant randomized trials.

Results

In total, 39 trials (20%) were conducted in a low- and middle-income country and 157 trials (79%) in a high-income country focused on socially disadvantaged populations (78% CRTs, 79% RCTs). Seventy-four trials (37%) reported a subgroup analysis across a population characteristic associated with disadvantage (25% CRT, 49% RCTs), with 19% of included studies reporting subgroup analyses across sex, 9% across race/ethnicity/culture, and 4% across socioeconomic status. No subgroup analyses were reported for place of residence, occupation, religion, education, or social capital. One hundred and forty-one trials (71%) discussed the applicability of their results to one or more socially disadvantaged populations (68% of CRT, 73% of RCT).

Discussion

In this set of trials, selected for their relevance to health equity, data that were disaggregated for socially disadvantaged populations were rarely reported. We found that even when the data are available, opportunities to analyze health-equity considerations are frequently missed. The recently published equity extension of the Consolidated Reporting Standards for Randomized Trials (CONSORT-Equity) may help improve delineation of hypotheses related to socially disadvantaged populations, and transparency and completeness of reporting of health-equity considerations in RCTs. This study can serve as a baseline assessment of the reporting of equity considerations.

Sex/gender and additional equity characteristics of providers and patients in perioperative anesthesia trials: a cross-sectional analysis of the literature

Sex and gender, among other equity-related characteristics, influence the process of care and patients’ outcomes. Currently, the extent to which these characteristics are considered in the anesthesia literature remains unknown. This study assesses their incorporation in randomized controlled trials (RCTs) on anesthesia-related interventions, for both patients and healthcare providers. This is a cross-sectional analysis using an existing dataset derived from the anesthesia literature. The dataset originated from a scoping review searching MEDLINE, Embase, CINAHL, CENTRAL, and the Cochrane Database of Systematic reviews. RCTs investigating the effect of anesthesia-related interventions on mortality for adults undergoing surgery were included. Equity outcome measures were recorded for both patients and providers and assessed for inclusion in the study design, reporting of results, and analysis of intervention effects. Three-hundred sixty-one RCTs (n = 144,674) were included. Most RCTs (91%) reported patient sex/gender, with 58% of patients identified as male. There were 139 studies (39%), where 70% or more of the sample was male, compared to just 14 studies (4%), where 70% or more of the sample was female. Only 10 studies (3%) analyzed results by patient sex/gender, with one reporting a significant effect. There was substantial variation in how age was reported, although nearly all studies (98%) reported some measure of age. For healthcare providers, equity-related information was never available. Better consideration of sex/gender and additional health equity parameters for both patients and providers in RCTs is needed to improve evidence quality, and ultimately, patient care and outcome.

Taking an integrated knowledge translation approach in research to develop the CONSORT-Equity 2017 reporting guideline: an observational study

OBJECTIVE

We describe the use of an integrated knowledge translation (KT) approach in the development of the CONsolidated Standards Of Reporting Trials extension for equity ('CONSORT-Equity 2017'), and advisory board-research team members' ('the team') perceptions of the integrated KT process.

DESIGN

This is an observational study to describe team processes and experience with a structured integrated KT approach to develop CONSORT-Equity 2017. Participant observation to describe team processes and a survey were used with the 38 team members.

SETTING

Use of the CONSORT health research reporting guideline contributes to an evidence base for health systems decision-making, and CONSORT-Equity 2017 may improve reporting about health equity-relevant evidence. An integrated KT research approach engages knowledge users (those for whom the research is meant to be useful) with researchers to co-develop research evidence and is more likely to produce findings that are applied in practice or policy.

PARTICIPANTS

Researchers adopted an integrated KT approach and invited knowledge users to form a team.

RESULTS

An integrated KT approach was used in the development of CONSORT-Equity 2017 and structured replicable steps. The process for co-developing the reporting guideline involved two stages: (1) establishing guiding features for co-development and (2) research actions that supported the co-development of the reporting guideline. Stage 1 consisted of four steps: finding common ground, forming an advisory board, committing to ethical guidance and clarifying theoretical research assumptions. Bound by the stage 1 guiding features of an integrated KT approach, stage 2 consisted of five steps during which studies for consensus-based reporting guidelines were conducted. Of 38 team members, 25 (67.5%) completed a survey about their perceptions of the integrated KT approach.

CONCLUSIONS

An integrated KT approach can be used to engage a team to co-develop reporting guidelines. Further study is needed to understand the use of an integrated KT approach in the development of reporting guidelines.

Rights to social determinants of flourishing? A paradigm for disability and public health research and policy

Background

The term evidence based medicine was introduced in the early 1990s in clinical medicine to educate clinicians about how to assess the ‘credibility’ of research to ensure best treatments for their patients. The evidence based medicine paradigm has become more diffuse in times of austerity and randomised controlled designs are being used to address complex issues in public health and disability research. This research is not addressing inequalities in terms of disability nor how people can live well with disabilities.

Main text

We argue that there are four ways that public health research needs to change if it wants to address inequalities linked to disability: 1) rethinking theoretical connections between public health and disability; 2) building ethics and equity into interventions through a human rights approach; 3) ensuring ethical inclusion through intersectionality; and 4) evaluating policy and other social impacts to ensure they capture diversity. We argue that these are key issues to building a social determinants of flourishing.

Conclusions

We need to understand how disability might have an accumulative impact across the life course, as well as how to ensure equity for people living with disabilities. This means conceptualising a social determinants of flourishing where we evaluate how exactly randomised controlled trials and public health interventions, not only lead to greater equality but also ensure rights to health and wellbeing.

Towards theoretically robust evidence on health equity: a systematic approach to contextualising equity-relevant randomised controlled trials

Reducing inequalities in health and the determinants of health is a widely acknowledged health policy goal, and methods for measuring inequalities and inequities in health are well developed. Yet, the evidence base is weak for how to achieve these goals. There is a lack of high-quality randomised controlled trials (RCTs) reporting impact on the distribution of health and non-health benefits and lack of methodological rigour in how to design, power, measure, analyse and interpret distributional impact in RCTs. Our overarching aim in this paper is to contribute to the emerging effort to improve transparency and coherence in the theoretical and conceptual basis for RCTs on effective interventions to reduce health inequity. We endeavour to achieve this aim by pursuing two more specific objectives. First, we propose an overview of three broader health equity frameworks and clarify their implications for the measurement of health inequality in RCTs. Second, we seek to clarify the relationship between theory and translational challenges that researchers would need to attend to, in order to ensure that equity-relevant RCTs are coherently grounded in theory.

Engaging knowledge users in development of the CONSORT-Equity 2017 reporting guideline: a qualitative study using in-depth interviews

BACKGROUND

Randomized controlled trials ("randomized trials") can provide evidence to assess the equity impact of an intervention. Decision makers need to know about equity impacts of healthcare interventions so that people get healthcare that is best for them. To better understand the equity impacts of healthcare interventions, a range of people who were potentially the ultimate users of research results were involved in a six-phase project to extend the CONsolidated Standards Of Reporting Trials Statement for health equity ("CONSORT-Equity 2017"). We identified these "knowledge users" as: patients and healthcare researchers, decision makers and providers. This paper reports on one project phase: specifically, a qualitative study designed to integrate the expertise of knowledge users. The experiences and perspectives of knowledge users provided many insights about the reporting of health equity issues in randomized trials. This paper describes key informant interviews with knowledge users that contribute to a better understanding of the effects of an intervention on health equity. Additionally, the paper shows how these insights were used to develop CONSORT-Equity 2017.

METHODS

A qualitative study that used the framework analysis method was conducted in collaboration with an international study executive and advisory board team. In-depth semi-structured interviews were conducted with a purposive sample of key informants who: consider the research ethics of, fund, conduct, participate in, publish, or use research evidence generated in randomized trials. Transcripts were coded and analyzed using the seven-stage framework analysis method, and data reported to reflect knowledge user suggestions to develop CONSORT-Equity 2017.

RESULTS

Thirteen key informants, of which three were patients, chose to participate in interviews. Seven themes emerged: "Differentiate the type of trial", "Prompts for health equity", "Ethics matter", "Describe unique research strategies", "Clarity of reporting", "Implications of equity for sampling and analysis", "Think beyond the immediate trial". The interviews provided direction for the extension of 16 CONSORT-Equity 2017 items.

CONCLUSIONS

Key informant interviews were used to identify new concepts that were not generated in our other studies and to develop CONSORT-Equity 2017. We encourage the use of key informant interviews in guideline development to obtain and include the real-life expertise of knowledge users.