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

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. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-021-11688-7.

Specify the methods used to decide whether a study met the inclusion criteria of the review, including how many reviewers screened each record and each report retrieved, whether they worked independently, and if applicable, details of automation tools used in the process.

Data collection process 9
Specify the methods used to collect data from reports, including how many reviewers collected data from each report, whether they worked independently, any processes for obtaining or confirming data from study investigators, and if applicable, details of automation tools used in the process.

Data items 10a
List and define all outcomes for which data were sought. Specify whether all results that were compatible with each outcome domain in each study were sought (e.g. for all measures, time points, analyses), and if not, the methods used to decide which results to collect.

✔ 10b
List and define all other variables for which data were sought (e.g. participant and intervention characteristics, funding sources). Describe any assumptions made about any missing or unclear information. ✔

Study risk of bias assessment 11
Specify the methods used to assess risk of bias in the included studies, including details of the tool(s) used, how many reviewers assessed each study and whether they worked independently, and if applicable, details of automation tools used in the process.

Not Applicable
Effect measures 12 Specify for each outcome the effect measure(s) (e.g. risk ratio, mean difference) used in the synthesis or presentation of results. Not Applicable Synthesis methods 13a Describe the processes used to decide which studies were eligible for each synthesis (e.g. tabulating the study intervention characteristics and comparing against the planned groups for each synthesis (item #5)). ✔ 13b Describe any methods required to prepare the data for presentation or synthesis, such as handling of missing summary statistics, or data conversions. ✔ 13c Describe any methods used to tabulate or visually display results of individual studies and syntheses. ✔ 13d Describe any methods used to synthesize results and provide a rationale for the choice(s). If meta-analysis was performed, describe the model(s), method(s) to identify the presence and extent of statistical heterogeneity, and software package(s) used.

✔ 13e
Describe any methods used to explore possible causes of heterogeneity among study results (e.g. subgroup analysis, metaregression). Not Applicable 13f Describe any sensitivity analyses conducted to assess robustness of the synthesized results. Not Applicable Reporting bias assessment 14 Describe any methods used to assess risk of bias due to missing results in a synthesis (arising from reporting biases). Not Applicable Certainty assessment 15 Describe any methods used to assess certainty (or confidence) in the body of evidence for an outcome. Not Applicable

Study selection 16a
Describe the results of the search and selection process, from the number of records identified in the search to the number of studies included in the review, ideally using a flow diagram. ✔

16b
Cite studies that might appear to meet the inclusion criteria, but which were excluded, and explain why they were excluded.

Discussion 23a
Provide a general interpretation of the results in the context of other evidence. ✔ 23b Discuss any limitations of the evidence included in the review. ✔ 23c Discuss any limitations of the review processes used. ✔ 23d Discuss implications of the results for practice, policy, and future research. ✔

Registration and protocol 24a
Provide registration information for the review, including register name and registration number, or state that the review was not registered. ✔ 24b Indicate where the review protocol can be accessed, or state that a protocol was not prepared. ✔ 24c Describe and explain any amendments to information provided at registration or in the protocol. ✔ Support 25 Describe sources of financial or non-financial support for the review, and the role of the funders or sponsors in the review. ✔

Competing interests 26
Declare any competing interests of review authors. ✔

Availability of data, code and other materials 27
Report which of the following are publicly available and where they can be found: template data collection forms; data extracted from included studies; data used for all analyses; analytic code; any other materials used in the review. ✔