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Assessment of health equity consideration in masking/PPE policies to contain COVID-19 using PROGRESS-plus framework: a systematic review

Abstract

Introduction

There is increasing evidence that COVID-19 has unmasked the true magnitude of health inequity worldwide. Policies and guidance for containing the infection and reducing the COVID-19 related deaths have proven to be effective, however the extent to which health inequity factors were considered in these policies is rather unknown. The aim of this study is to measure the extent to which COVID-19 related policies reflect equity considerations by focusing on the global policy landscape around wearing masks and personal protection equipment (PPE).

Methods

A systematic search for published documents on COVID-19 and masks/PPE was conducted across six databases: PubMed, EMBASE, CINAHL, ERIC, ASSIA and Psycinfo. Reviews, policy documents, briefs related to COVID-19 and masks/PPE were included in the review. To assess the extent of incorporation of equity in the policy documents, a guidance framework known as ‘PROGRESS-Plus’: Place of residence, Race/ethnicity, Occupation, Gender/sex, Religion, Education, Socioeconomic status, Social capital, Plus (age, disability etc.) was utilized.

Results

This review included 212 policy documents. Out of 212 policy documents, 190 policy documents (89.62%) included at least one PROGRESS-plus component. Most of the policy documents (n = 163, 85.79%) focused on “occupation” component of the PROGRESS-plus followed by personal characteristics associated with discrimination (n = 4;2.11%), place of residence (n = 2;1.05%) and education (n = 1;0.53%). Subgroup analysis revealed that most of the policy documents (n = 176, 83.01%) were focused on “workers” such as healthcare workers, mortuary workers, school workers, transportation workers, essential workers etc. Of the remaining policy documents, most were targeted towards whole population (n = 30; 14.15%). Contrary to “worker focused” policy documents, most of the ‘whole population focused’ policy documents didn’t have a PROGRESS-plus equity component rendering them equity limiting for the society.

Conclusion

Our review highlights even if policies considered health inequity during the design/implementation, this consideration was often one dimensional in nature. In addition, population wide policies should be carefully designed and implemented after identifying relevant equity related barriers in order to produce better outcomes for the whole society.

Peer Review reports

Introduction

COVID-19 is an infectious disease spread by the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), that first reported in Wuhan, China in 2019 [1]. At the start of the pandemic, SARS-CoV-2 was initially thought to spread mainly through close person to person contact because of production of respiratory droplets formed through a sneeze or cough of an infected person. Later evidence demonstrates that the virus also infects through airborne transmission routes when an infected person ‘exhales, speaks, shouts, sings, sneezes, or coughs’ [2]. SARS-CoV-2 viral particles range from larger respiratory droplets to smaller aerosols [3], making the wearing of high quality and well-fitting masks indoors of particular importance in reducing transmission among the public, and the wearing of additional protective equipment important in reducing transmission among frontline healthcare staff [2]. As of January 5th 2021, 86.2 million cases of COVID-19 have been identified across 218 countries and territories resulting in 1.87 million deaths across the globe [4]. Among the reported cases, 20,551,680 confirmed cases and 349,890 deaths were reported in the USA and (at the time of writing, January 2021) it has become the country with the greatest number of infection and deaths due to COVID-19 [4]. Contrary to US, countries like New Zealand and Vietnam reported 2181 and 1494 cases of COVID-19 resulting into 25 and 35 deaths only respectively [4].

This dire situation demands that everyone has a fair and just opportunity to be as healthy as possible but there is increasing evidence that COVID-19 has unmasked the true magnitude of health inequity worldwide. For example, in US, American Indians or Alaskan natives, African Americans and Hispanic or Latino people have 1.8 times, 1.4 times and 1.7 times higher rate of COVID-19 cases; have 4.0 times, 3.7 times and 4.1 times higher rate of COVID-19 related hospitalizations and 2.6 times, 2.8 times and 2.8 times higher rate of COVID-19 related deaths respectively when compared to their Caucasian counterparts [5]. In addition, elderly people [6], healthcare and frontline workers [7] are at an elevated risk of acquiring COVID-19 and developing severe COVID-19 related outcomes. Thus, to achieve health equity, healthcare policies around COVID-19 should ideally address these inequities so that everyone has a fair opportunity to be as healthy as possible, and the whole society benefits.

Policies and guidance for containing the infection and reducing the COVID-19 related deaths are complex and rapidly evolving. Since no pharmaceutical agents were known to be safe and effective at preventing or treating COVID-19 until recently, only non-pharmaceutical interventions were relied upon for reducing the burden of COVID-19 during the first wave(s) of the pandemic in 2020 [8,9,10,11]. These measures aimed to reduce disease transmission both locally and globally and included bans on public gatherings, compulsory stay-at-home policies, mandating closures of schools and nonessential businesses, face mask ordinances, quarantine and cordon sanitaire, among others. The effectiveness of these interventions to reduce COVID-19 transmission has been demonstrated [8,9,10,11], however the extent to which health inequity factors were considered in these policies is unknown.

Thus, the aim of this study is to measure the extent to which national, regional, institutional and organizational policies reflect equity considerations by focusing on the global policy landscape around wearing masks and personal protection equipment (PPE). Masks/PPE policies were chosen as area of target as these policies affect more people when compared to other interventional policies such as school closure policies, stay at home policies etc. Equity would be assessed using previously developed Cochrane PROGRESS-Plus equity framework. PROGRESS-plus defines the characteristics that stratify health opportunities and outcomes that can mark inequalities. Current masking/PPE policies implemented across world would ideally be expected to reflect equity considerations in order to effectively manage the spread of the disease and to reduce adverse outcomes, although the extent to which this is the case is uncertain. For example, we may expect equity of access to masks/PPE to be considered when policy-makers are designing policies around the need to wear a mask, or for equity to be considered when undertaking health promotion activities in promoting the importance of mask wearing. The understanding of health equity consideration in masking/PPE policies across globe to contain COVID-19 using PROGRESS-Plus framework will help to achieve a better and more sustainable future for all past the barrier of inequity.

Methods

This systematic review was done in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [12,13,14,15,16,17,18,19] (Table S1), following a predetermined published protocol (PROSPERO registration: CRD42021231497).

Search strategy and data sources

We performed a comprehensive search in six electronic databases – PubMed, EMBASE, CINAHL, ERIC, ASSIA and Psycinfo. The search strategy was based on a broad combined search string for COVID-19 and ‘masks or PPE’(Table S2). The searches were conducted to retrieve potentially relevant publications from January 1st, 2020 to July 1st, 2020. Additional literature was identified by searching the reference list of the identified eligible documents.

Inclusion criteria

All identified documents were evaluated for the inclusion based on the following criteria: (1) documents should be related to COVID-19 and (2) documents should have masks or PPE as an intervention/strategy to mitigate COVID-19. Selection criteria were not limited to any specific kind of study design or type of publication thus allowing reviews, policy documents, or research briefs to be included in the systematic review. Systematic reviews focusing on a number of policies were excluded to decrease repetition among the included documents. Selection criteria were not limited to any specific language thus minimizing language bias. Two reviewers (AC and AK) independently undertook the screening of the records (by title and/or abstract) for eligibility and a third reviewer (NC) mediated if contradiction to arrive at an accord occurred. Full text of eligible papers after the first screening was reviewed to confirm that the articles met the inclusion and exclusion criteria. Similar to title/abstract screening, full text screening was also done by two reviewers independently and a third reviewer mediated if contradiction of an accord occurred.

Data extraction

A customized data extraction sheet was constructed to extract relevant data from all documents meeting our inclusion criteria. The data abstracted included: author(s), publication year, the geographical location of data collection, study design, setting, target population, implementation level of policy, equity incorporation, equity component, strength of evidence and key findings. Similar to the screening process, data extraction was conducted by two reviewers (AC and AK) and any contradiction was resolved by a third reviewer (NC).

Assessment of incorporation of equity

To assess the extent of incorporation of equity in policies, we utilized a guidance framework known as ‘PROGRESS-Plus’ [20, 21]. This assessment was conducted in order to analyze the extent to which equity has been incorporated in PPE or masking policies and implementation of these policies around the globe. PROGRESS-plus equity framework is aimed at warranting the consideration of various health inequity inducing factors such as place of residence, race/ethnicity, occupation, gender, religion, education, socioeconomic status and personal characteristics when devising policies and/or guidelines. Additional details about the framework can be found elsewhere [20, 21]. The data from included documents were analyzed to determine whether a study has considered equity component. If the included policy had any of the above-mentioned PROGRESS-Plus components it was determined that the study had incorporated an equity component. Where a measure was classifiable under more than one PROGRESS-Plus factor (e.g. an indicator of employment status is relevant to ‘occupation’ but also to ‘socio-economic status’ (SES)), we included it under the factor deemed more appropriate. It is important to note that utilization of PROGRESS-plus framework for this research is context specific and findings are limited to COVID-19 for most part. For instance, population types such as healthcare workers, essential workers are not usually considered vulnerable in society but in the context of COVID-19, increased risk of transmission of COVID-19 puts them at a disadvantage compared to the general population. Thus, findings of the research work should be interpreted within aforementioned scope.

Second, the provision and strength of the rationale to support inclusion of “PROGRESS-plus” factor in a policy was analyzed. The aim of this analysis was to ascertain whether policies have included an equity component following the empirical evidence or not. The documents were divided into two groups: explicit rationale or implicit rationale. If a study/policy provided the empirical evidence for inclusion of PROGRESS-plus component, the study was deemed to have an ‘explicit rationale’. The study/policy was deemed to have an ‘implicit rationale’ if no empirical evidence was provided for the inclusion of PROGRESS-plus component.

Third, “indication level of equity” in documents was assessed. The aim of this analysis was to ascertain whether “equitable health” was a primary factor while framing the policies (defined as high level) or documents were focused on a certain group or subpopulation thus having “equitable health” as a latent factor (defined as low level). The major difference between these two categories is that ‘high level’ documents acknowledge ‘health equity’ related issues, as opposed to ‘low level’ documents which fail to mention them. For example, if a study/policy was targeted at use of face masks among healthcare workers without any mention of ‘equity’, ‘inequity’, ‘health disparities’ in aims, objectives or discussion, it was deemed to be ‘low level’. On the contrary if a study/policy was targeted at use of face masks among healthcare workers with the mention of ‘equity’, ‘inequity’, ‘health disparities’ in aims, objectives or discussion, it was deemed to be ‘high level’.

Data analysis

A narrative synthesis of data was conducted as most of the included documents were policies and lacked statistical results. We presented the data in the two distinct sections. The first section aimed at outlining the included policies in the review and second section aimed at explaining the equity component in the eligible documents. The results are presented in a descriptive manner using frequencies, percentages and pie charts. EPPI-reviewer [22] was utilized for the management and analysis of the data . In addition, due to subjective nature of the extracted policy documents, no ‘strength of evidence’ analysis was performed.

Results

The search strategy yielded 2177 articles that were focused on COVID-19. Out of these 2177 articles 125 duplicates were removed. Of the remaining 2051 articles only 191 met the inclusion criteria and were retrieved to be reviewed in full-text. In addition, 42 policy documents retrieved from references of these included articles were added to be reviewed in full text. During the full-text screening, further 21 articles were excluded due to following reasons; duplicate (n = 6), and irrelevant/non mask/PPE policy (n = 15). This resulted in a total of 212 [23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70,71,72,73,74,75,76,77,78,79,80,81,82,83,84,85,86,87,88,89,90,91,92,93,94,95,96,97,98,99,100,101,102,103,104,105,106,107,108,109,110,111,112,113,114,115,116,117,118,119,120,121,122,123,124,125,126,127,128,129,130,131,132,133,134,135,136,137,138,139,140,141,142,143,144,145,146,147,148,149,150,151,152,153,154,155,156,157,158,159,160,161,162,163,164,165,166,167,168,169,170,171,172,173,174,175,176,177,178,179,180,181,182,183,184,185,186,187,188,189,190,191,192,193,194,195,196,197,198,199,200,201,202,203,204,205,206,207,208,209,210,211,212,213,214,215,216,217,218,219,220,221,222,223,224,225,226,227,228,229,230,231,232,233,234] relevant articles to be included in this systematic review (Fig. 1). The screening yielded two types of documents: original policies and policy recommendations. Original policies were the documents issued by government agencies such as CDC, WHO or alike whereas policy recommendations consisted of documents that were not policies themselves but contained different recommendations for the policy. Both original policies and policy recommendations will be referred to as “policy documents” from here on in the review.

Fig. 1
figure1

PRISMA Flow for Selection of the Included Policy Documents

General study characteristics

General characteristics of the included policy documents are summarized in Table 1. Masks/PPE as a mitigation strategy against COVID-19 was implemented across different regions ranging from USA to Australia to Russia (Table 1 and Fig. 2). There were no policy documents identified from Eastern Europe, Africa and Middle Eastern regions in this review. There were 29 policy documents [25, 34, 41, 59, 75, 125, 126, 133, 134, 140, 141, 146, 155, 157, 166, 177, 178, 208,209,210,211,212,213,214,215,216,217,218,219] that were not targeted towards a specific nation or region but were global in nature.

Table 1 Characteristics of The Included Policy Documents
Fig. 2
figure2

Number of Included Policy Documents Categorized by Nation*

The origin/target of policy documents was analyzed on an income level scale (Table 1) as a growing body of literature suggests that there is significant heterogeneity, both in the direction and magnitude, of association between factors such as socioeconomic status, income inequality and health outcomes. Most policy documents were from high income countries (HIC) such as USA, Italy, Canada and UK. Specifically, 136 policy documents (64.15%) were from HIC [26, 28,29,30,31,32,33, 37,38,39,40, 42,43,44,45,46, 48,49,50,51,52,53,54,55,56,57,58, 60, 61, 63, 71,72,73,74, 76, 77, 79,80,81,82, 85,86,87,88,89,90,91,92,93,94, 99,100,101,102,103,104,105,106,107, 110, 112, 113, 116, 117, 119, 121,122,123,124, 127, 129, 130, 132, 135, 137,138,139, 143,144,145, 147,148,149,150,151,152,153,154, 156, 158, 159, 161, 163,164,165, 167,168,169,170,171,172, 174,175,176, 179,180,181,182, 184, 185, 188,189,190,191,192,193,194,195,196,197,198,199,200,201,202,203,204, 206, 207, 220, 222, 223, 226, 228, 229, 233], 39 policy documents (18.40%) were from lower middle income countries (LMIC) [23, 24, 27, 35, 36, 47, 62, 64, 65, 67,68,69,70, 78, 83, 84, 108, 111, 114, 115, 118, 128, 136, 142, 160, 162, 173, 183, 186, 187, 205, 221, 224, 225, 227, 230,231,232, 234] and 37 policy documents (17.45%) were from HIC and LMIC [25, 34, 41, 59, 66, 75, 95,96,97,98, 109, 120, 125, 126, 131, 133, 134, 140, 141, 146, 155, 157, 166, 177, 178, 208,209,210,211,212,213,214,215,216,217,218,219] (Table 1).

Mask/PPE policy documents were analyzed for the scale upon which they were implemented (Table 1). The scale was divided into categories: institutional, national and global. Institutional policies were defined as the strategies that were implemented at a unit/institution level such as an ophthalmology center or were targeted towards a specific group that work at an institutional level such as an ophthalmologist. National policies were defined as the strategies that were implemented or intended to be implemented at a national level and included all the population of that nation. Policies from country specific agencies such as CDC, Ministero della Salute etc. were considered national policies. Global policies were defined as the policies that were implemented or intended to be implemented at global level and included everyone across globe. Policies from WHO and any other international agencies were included in this category. Our analysis found that most of the policy documents were implemented at an institutional level. Specifically, 148 policy documents (69.81%) were implemented at institutional level [25, 27,28,29, 31, 32, 34,35,36,37,38, 40, 42,43,44,45,46, 48, 49, 51, 53, 58, 61,62,63,64,65,66, 71, 73, 74, 76,77,78, 80,81,82, 85, 86, 88,89,90,91, 93, 96, 99,100,101,102,103,104,105,106,107,108,109,110, 112,113,114,115, 117, 120,121,122,123,124,125,126, 128, 130,131,132,133,134,135,136,137,138,139, 142,143,144,145,146,147,148,149,150,151,152,153, 155,156,157,158,159,160,161,162,163,164, 166,167,168, 171, 173,174,175,176,177,178,179,180,181,182,183,184, 186, 188,189,190, 192, 193, 197, 199,200,201,202,203,204, 206, 207, 210, 211, 213, 220,221,222,223, 225,226,227,228, 230, 231, 233, 234] whereas 42 policy documents (19.81%) were implemented at national level [23, 24, 26, 30, 33, 39, 47, 50, 52, 55,56,57, 67,68,69,70, 72, 79, 83, 84, 87, 92, 94, 97, 98, 111, 119, 129, 154, 165, 169, 170, 187, 191, 194,195,196, 198, 205, 224, 229, 232] and only 22 policy documents (10.38%) were implemented at the global level [41, 54, 59, 60, 75, 95, 116, 118, 127, 140, 141, 172, 185, 208, 209, 212, 214,215,216,217,218,219] (Table 1).

In addition, the target population for the policy documents was also assessed (Table 1). Specifically, 141 policy documents (66.51%) were targeted towards healthcare workers [23, 25,26,27,28, 30, 32, 35,36,37,38,39,40,41,42, 44,45,46,47,48,49, 51, 53, 54, 57, 60,61,62,63,64,65,66, 70,71,72,73, 76,77,78,79,80, 83, 86,87,88, 90, 91, 93, 96, 98, 99, 101,102,103,104,105, 107,108,109,110, 112, 113, 115,116,117, 119,120,121,122,123,124,125,126,127, 130, 133,134,135,136, 138, 139, 142,143,144,145,146,147,148,149,150, 152, 155,156,157,158,159,160,161,162,163,164, 166, 167, 169,170,171, 173, 174, 176,177,178,179,180,181, 183, 186,187,188,189,190, 193, 194, 197,198,199,200,201, 203, 204, 206, 218, 220,221,222,223, 225, 228, 230, 231, 233, 234]; 5 policy documents (2.36%) were targeted towards other workers (mortuary workers, transportation workers, essential workers etc.) [67, 68, 92, 185, 202]; 6 policy documents (2.83%) were targeted towards patients across different disease groups [55, 56, 94, 100, 132, 217]; 30 policy documents (14.15%) were targeted for the general population [24, 33, 50, 52, 59, 75, 84, 89, 95, 111, 114, 118, 129, 140, 141, 154, 165, 172, 191, 196, 205, 208, 209, 212, 214,215,216, 224, 229, 232] and 30 policy documents (14.15%) had multiple defined target groups [29, 31, 34, 43, 58, 69, 74, 81, 82, 85, 97, 106, 128, 131, 137, 151, 153, 168, 175, 182, 184, 192, 195, 207, 210, 211, 213, 219, 226, 227] (Table 1). Examples of policy documents having multiple target groups were policy documents targeting both patients and healthcare workers; policy documents targeting frontline healthcare workers and hospital administrators and policy documents targeting healthcare workers, staff of mortuaries and public health officials (Table 1).

Equity incorporation

Out of 212 policy documents, 190 policy documents (89.62%) included at least one PROGRESS-plus component [23, 25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49, 51,52,53,54, 56,57,58,59,60,61,62,63,64,65,66,67,68,69,70,71,72,73,74,75,76,77,78,79,80,81,82,83, 85,86,87,88, 90,91,92,93, 96,97,98,99, 101,102,103,104,105,106,107,108,109,110,111,112,113,114,115,116,117, 119,120,121,122,123,124,125,126,127,128, 130, 131, 133,134,135,136,137,138,139, 142,143,144,145,146,147,148,149,150,151,152,153,154,155,156,157,158,159,160,161,162,163,164, 166,167,168,169,170,171, 173,174,175,176,177,178,179,180,181,182,183,184,185,186,187,188,189,190, 192,193,194,195, 197,198,199,200,201,202,203,204, 206,207,208,209,210,211, 213, 215,216,217,218,219,220,221,222,223, 225,226,227,228,229,230,231, 233, 234] (Fig. 3). The policy documents (n = 190) were then categorized in different strata based on the included ‘PROGRESS-Plus” component (Fig. 4). Most of the policy documents focused on “occupation” component of the PROGRESS-plus and included populations at higher risk of contracting COVID-19 such as healthcare workers, essential workers, transportation workers etc. Specifically, 85.79% (n = 163) of the included policy documents had “occupation” as an equity component [23, 25,26,27, 29,30,31,32, 34,35,36,37, 40, 42,43,44,45,46, 48, 49, 51, 53, 54, 58, 60, 62,63,64,65,66,67,68, 70,71,72,73,74, 76,77,78,79,80,81, 83, 85,86,87,88, 90, 91, 93, 96,97,98,99, 101,102,103,104,105,106,107,108,109, 112, 113, 115,116,117, 119,120,121, 123,124,125,126, 128, 130, 131, 133,134,135,136, 138, 139, 142,143,144,145,146,147,148,149,150,151,152,153,154,155,156,157,158,159,160,161,162,163,164, 166,167,168,169,170,171, 173,174,175,176,177,178,179,180,181,182,183,184, 186,187,188,189,190, 192,193,194,195, 197,198,199,200,201,202,203,204, 206, 207, 210, 211, 213, 215, 217,218,219,220,221,222,223, 225,226,227,228, 230, 231, 234] followed by personal characteristics associated with discrimination (n = 4; 2.11%) [33, 56, 216, 229], place of residence (n = 2; 1.05%) [75, 114] and education (n = 1; 0.53%) [69]. Several policy documents had mentioned multiple PROGRESS-Plus components. Specifically, 17 policy documents (8.95%) mentioned two components of PROGRESS-Plus [28, 38, 39, 41, 47, 52, 57, 59, 82, 92, 110, 111, 122, 127, 137, 185, 233] and 3 policy documents (1.58%) mentioned more than two components of the PROGRESS-plus framework [61, 208, 209] (Fig. 4).

Fig. 3
figure3

Equity Incorporation (PROGRESS+) Assessment for Included Policy Documents

Fig. 4
figure4

Equity Components (PROGRESS+) For Included Policy Documents

Second, the strength of rationale to support inclusion of “PROGRESS-plus” factor in a policy document was analyzed. Of all the policy documents having equity component, 71 policy documents (37.37%) explicitly provided the evidence for inclusion of PROGRESS-Plus component [25, 27, 28, 34, 36,37,38, 41, 42, 49, 58,59,60,61, 63, 64, 66, 71, 74,75,76,77, 82, 86, 91,92,93, 104,105,106, 111, 112, 114, 121, 122, 124, 126, 127, 130, 131, 134,135,136,137, 144, 146, 148, 155, 159, 160, 166, 167, 171, 176, 177, 180, 182, 185, 190, 192, 193, 197, 201, 206,207,208, 226, 227, 231, 233, 234] whereas rest did not provide any rationale for inclusion of PROGRESS-Plus component [23, 26, 29,30,31,32,33, 35, 39, 40, 43,44,45,46,47,48, 51,52,53,54, 56, 57, 62, 65, 67,68,69,70, 72, 73, 78,79,80,81, 83, 85, 87, 88, 90, 96,97,98,99, 101,102,103, 107,108,109,110, 113, 115,116,117, 119, 120, 123, 125, 128, 133, 138, 139, 142, 143, 145, 147, 149,150,151,152,153,154, 156,157,158, 161,162,163,164, 168,169,170, 173,174,175, 178, 179, 181, 183, 184, 186,187,188,189, 194, 195, 198,199,200, 202,203,204, 209,210,211, 213, 215,216,217,218,219,220,221,222,223, 225, 228,229,230] (Fig. 5). Among these 71 policy documents, 47 were conducted in HIC [28, 37, 38, 42, 49, 58, 60, 61, 63, 71, 74, 76, 77, 82, 86, 91,92,93, 104,105,106, 112, 121, 122, 124, 127, 130, 135, 137, 144, 148, 159, 167, 171, 176, 180, 182, 185, 190, 192, 193, 197, 201, 206, 207, 226, 233], 10 were conducted in LMIC [27, 36, 64, 111, 114, 136, 160, 227, 231, 234] and 14 were conducted in both HIC and LMIC [25, 34, 41, 59, 66, 75, 126, 131, 134, 146, 155, 166, 177, 208]. In addition, most of these policy documents were targeted at workers (n = 66; 92.96%) [25, 27, 28, 34, 36,37,38, 41, 42, 49, 58, 60, 61, 63, 64, 66, 71, 74, 76, 77, 82, 86, 91,92,93, 104,105,106, 112, 121, 122, 124, 126, 127, 130, 131, 134,135,136,137, 144, 146, 148, 155, 159, 160, 166, 167, 171, 176, 177, 180, 182, 185, 190, 192, 193, 197, 201, 206, 207, 226, 227, 231, 233, 234] and were implemented at institutional level (n = 62; 87.32%) [25, 27, 28, 34, 36,37,38, 42, 49, 58, 61, 63, 64, 66, 71, 74, 76, 77, 82, 86, 91, 93, 104,105,106, 112, 114, 121, 122, 124, 126, 130, 131, 134,135,136,137, 144, 146, 148, 155, 159, 160, 166, 167, 171, 176, 177, 180, 182, 190, 192, 193, 197, 201, 206, 207, 226, 227, 231, 233, 234].

Fig. 5
figure5

Rationale of Evidence for Justification of Inclusion of PROGRESS-Plus Components in Policy Documents

Third, “indication level of equity” in policy documents was assessed. Our analysis found that only 2 policy documents (1.05%) [75, 209] had included terms related to equity and thus were deemed ‘high level’ whereas rest were considered to be of ‘low level’.

Subgroup analysis

For further analysis, policy documents were subdivided into two groups: policy documents targeted towards workers (n = 176; 83.01%) [23, 25,26,27,28,29,30,31,32, 34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49, 51, 53, 54, 57, 58, 60,61,62,63,64,65,66,67,68,69,70,71,72,73,74, 76,77,78,79,80,81,82,83, 85,86,87,88, 90,91,92,93, 96,97,98,99, 101,102,103,104,105,106,107,108,109,110, 112, 113, 115,116,117, 119,120,121,122,123,124,125,126,127,128, 130, 131, 133,134,135,136,137,138,139, 142,143,144,145,146,147,148,149,150,151,152,153, 155,156,157,158,159,160,161,162,163,164, 166,167,168,169,170,171, 173,174,175,176,177,178,179,180,181,182,183,184,185,186,187,188,189,190, 192,193,194,195, 197,198,199,200,201,202,203,204, 206, 207, 210, 211, 213, 218,219,220,221,222,223, 225,226,227,228, 230, 231, 233, 234] and policy documents targeted towards everyone else (n = 36; 16.98%) [24, 33, 50, 52, 55, 56, 59, 75, 84, 89, 94, 95, 100, 111, 114, 118, 129, 132, 140, 141, 154, 165, 172, 191, 196, 205, 208, 209, 212, 214,215,216,217, 224, 229, 232]. The policy documents were divided as such because workers are usually provided masks/PPE as a part of safety protocol across different working environments such as healthcare setting, shopping centers, transportation centers etc. Among policy documents that were not targeted at workers, the target groups were: “patients” (n = 6; 2.80%) [55, 56, 94, 100, 132, 217] and “population wide” (n = 30; 14.15%) [24, 33, 50, 52, 59, 75, 84, 89, 95, 111, 114, 118, 129, 140, 141, 154, 165, 172, 191, 196, 205, 208, 209, 212, 214,215,216, 224, 229, 232].

As expected, all of the policy documents that were targeted towards workers had at least “occupation” component of the PROGRESS-Plus framework. Among policy documents that were not targeted at workers, 16 documents were conducted in HIC [33, 50, 52, 55, 56, 89, 94,