The COVID-19 pandemic has thrust a spotlight on the reality that pediatricians have long understood: Children from disadvantaged groups, including children of color and those living in poverty, experience worse health outcomes relative to their more privileged peers.1–3 This is the very definition of health inequity.4 Health inequity is largely attributed to differences in a child’s psychosocial, physical, and economic environments or to social determinants. However, these differences and subsequent health inequities are not chance events, but are deeply rooted in societal and health care structures characterized by systemic racism.5 Health systems have a substantial impact on health equity, largely through access to services, clinicians’ decisions, and quality of care.6 Decision support tools based on clinical practice guidelines (CPGs) can reduce cognitive load for clinicians, standardize care, and improve outcomes.7 When we consider equity and implementation principles from the outset, CPGs can reduce inequities.8 Conversely, CPGs can paradoxically exacerbate inequities through differential access and uptake or by providing greater benefit to advantaged (lower-risk) groups relative to disadvantaged (higher-risk) groups.8 For example, after publication of a CPG for attention-deficit/hyperactivity disorder,9 African American and Hispanic children were more likely to stop medication and disengage from treatment all together, possibly reflecting suboptimal communication related to addressing concerns of the parent and/or child about taking medications.10 Another example is the American Academy of Pediatrics (AAP) CPG for urinary tract infections, which included race as a risk factor for urinary tract infections and suggested differential race-based evaluation and management.11,12 Published in 2011 and reaffirmed in 2016, this CPG was retired in May 2021.13 CPGs endorsed and/or developed by the AAP are particularly important because they often become the standard of practice, informing clinical decision-making for pediatricians and child health providers throughout the United States and the world.14
In 2010, the AAP published the policy statement Health Equity and Children’s Rights, laying a foundation for pediatricians to consider social determinants of health and helping every child to achieve their fullest potential through advocacy and community engagement.15 This policy statement recommended the integration of child health equity principles into clinical practice but did not explicitly describe how to do so. Now is the time to build on this policy statement and formally apply an equity lens to CPGs, clinical reports, and clinical decision-making, thereby helping all children to attain optimal physical, mental, and social health and well-being. In this perspective, we compare traditional CPG development with an equity-based approach, discuss implications of using an equity lens to inform clinical-decision making, and provide recommendations to integrate equity principles into future CPGs.
Traditional Versus Equity-Based Approaches
Traditionally, professional societies and institutions use rigorous processes and the best available evidence to develop CPGs and clinical reports that inform clinical decision-making.16 Objectives include reducing inappropriate variation, optimizing outcomes, minimizing harm, and promoting cost-effective practices.14 CPGs address specific questions and collect, summarize, and assess evidence, including important aspects of the study design, anticipated benefits and harms, risk of bias, and magnitude of effect.14,16 Although the process prioritizes transparency to ensure credibility and acceptability,16,17 implementation barriers often limit clinical adoption.18,19
An equity-based approach maintains this foundational structure, but also explicitly includes equity principles. Eslava-Schmalbach et al8 proposed 9 equity-focused steps to develop and implement CPGs (Table 1). Integrated with the traditional approach, these steps fundamentally restructure CPG development by (1) explicitly embedding equity principles and (2) viewing development and implementation as 2 equally important phases considered in concert at the outset. For example, by identifying disadvantaged groups and quantifying current health inequities in the development phase, CPG authors can send a clear signal that disease burden is not uniformly distributed, endorsing recommendations that reflect these differences. CPG workgroups can use the PROGRESS acronym (place of residence, race/ethnicity/culture/language, occupation, gender/sex, religion, education, socioeconomic status, and social capital) to define disadvantaged populations.20,21 The implementation phase underscores the need to identify implementation barriers in different settings, design strategies to overcome these challenges, and plan approaches to monitor and evaluate effects of recommendations in disadvantaged and privileged populations. This equity-based approach may be applied to all CPGs, ranging from those focusing specifically on equity issues to those with broader relevance to the general population in which a subset of recommendations would target disadvantaged populations and inequities.8
Steps in Consideration of Equity for CPG Development and Implementation
| Phase . | Steps . |
|---|---|
| Development | Identify disadvantaged groups |
| Quantify current health inequities | |
| Develop or identify equity-sensitive recommendations | |
| Implementation | Identify key actors for implementing equity-focused recommendations |
| Identify barriers and facilitators to implementation | |
| Design strategies to overcome the identified barriers | |
| Define resources and incentives | |
| Design a communication strategy with an equity focus | |
| Define the monitoring and evaluation strategies |
| Phase . | Steps . |
|---|---|
| Development | Identify disadvantaged groups |
| Quantify current health inequities | |
| Develop or identify equity-sensitive recommendations | |
| Implementation | Identify key actors for implementing equity-focused recommendations |
| Identify barriers and facilitators to implementation | |
| Design strategies to overcome the identified barriers | |
| Define resources and incentives | |
| Design a communication strategy with an equity focus | |
| Define the monitoring and evaluation strategies |
Implications
The implications of an equity-based approach to CPG development are profound. First, unanticipated barriers (ie, money, time, pain, stress), typically related to obtaining important predictors such as biomarkers, often limit clinical adoption of CPGs and decision support aids.22,23 An equity-based approach that considers implementation barriers in the initial stages of CPG development may lead to increased clinical adoption. Second, although it is likely unrealistic to account for every scenario in which a CPG may be used, an equity-based approach would inherently consider contextual factors related to the diverse array and combinations of clinic and practice types (eg, hospital-based, private, rural practice) and patient/caregiver access barriers and preferences. Thus, scarce and finite institution- and practice-level resources, previously reserved to enhance CPG implementation, may now be directed toward other high-priority initiatives. Additionally, by considering patient/caregiver preferences, the CPG could lay a path toward shared decision-making. Third, by applying the standard tenets of high-quality critical appraisals of the literature to equity-related outcomes, CPGs would inherently identify gaps in knowledge. Therefore, CPGs can serve an additional role of helping to establish an agenda for child health equity research. Finally, building equity into CGPs aligns practice with the AAP’s position on diversity, inclusion, and health equity and its Equity Agenda.24,25
Call to Action
It is essential to retain stringent and rigorous processes to develop CPGs, identifying and qualifying evidence while summarizing limitations. Additionally, to ensure that clinical decisions improve outcomes for all children, CPG and clinical report recommendations should also identify equity as an important outcome and consider implementation barriers in different settings. We propose a call to action with the following recommendations to the AAP as starting points in achieving child health equity. First, CPG development should be grounded in an equity-based approach, integrating development and implementation phases. Second, authors and workgroup members of CPGs and clinical reports should reflect the diversity of the children affected by the guideline in terms of race, ethnicity, disability, and so forth. Content experts and organizational liaisons are essential, but so are context experts who understand the perspectives of individuals affected by clinical decisions and subsequent consequences. The AAP should ensure that members of its Committee on Native American Child Health; the Section on Minority Health, Equity, and Inclusion; the Council on Community Pediatrics; and the Council on Immigrant Child and Family Health participate in developing CPGs and clinical reports. Additionally, caregivers, school representatives, providers from federally qualified health centers and America’s Essential Hospitals,26 a Family Voices representative,27 and community-based organizations should also be included. This diverse network of individuals would be well equipped to inform an equity-based approach while maintaining the scientific rigor expected by pediatricians. Third, members of the AAP Partnership for Policy Implementation group, who collaborate with CPG workgroups to produce clear recommendations and facilitate implementation efforts, should also embrace an equity-based approach. Finally, a formalized task force charged with monitoring outcomes and implementation challenges, particularly in disadvantaged groups, should assess each CPG and report findings to drive future research and inform revisions.
To address child health equity in the 21st century, we need a bold and multifaceted approach. By using an equity-based approach to develop and implement CPGs, pediatricians will gain one more tool to help reduce inequities and improve outcomes for all children.
Dr Yaeger conceptualized and designed the manuscript, drafted the initial manuscript, and revised the manuscript; Drs Alio and Fiscella helped to refine the concept for the manuscript and reviewed and revised the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
FUNDING: No external funding.
References
Competing Interests
FINANCIAL DISCLOSURES: The authors have indicated they have no financial relationships relevant to this article to disclose.
POTENTIAL CONFLICTS OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
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