PRISMA-Equity 2012 Extension

What it is

PRISMA-Equity 2012 is the official PRISMA extension for equity-focused systematic reviews — reviews whose primary question is not only "does the intervention work?" but "for whom, and does it widen or narrow health inequities?" It was developed by the Campbell and Cochrane Equity Methods Group (Welch, Petticrew, Tugwell and colleagues) through a Bellagio consensus process and is hosted by the EQUATOR Network alongside the PRISMA family. It supplements the PRISMA checklist with equity-specific reporting items and is organized around the PROGRESS-Plus framework of socially stratifying factors: Place of residence, Race/ethnicity/culture/language, Occupation, Gender/sex, Religion, Education, Socioeconomic status, Social capital — plus context-relevant additions such as age, disability, sexual orientation, and other circumstances tied to discrimination or vulnerability. PRISMA-Equity is a reporting guideline: it tells authors what to disclose so a reader (or HTA committee) can judge whether the review's equity claims are trustworthy. It is not a search strategy, a risk-of-bias tool, or a quality score.

When to use

Use PRISMA-Equity when health equity is an a priori focus of a systematic review or meta-analysis — the protocol asks whether effects differ across PROGRESS-Plus strata, or whether the intervention is differentially effective/accessible in disadvantaged populations. Typical decision contexts: a peer-reviewed equity review or health-disparities synthesis; an HTA/payer evidence package where the appraisal body (e.g., NICE health-inequalities guidance, CADTH equity considerations, ICER's contextual considerations) asks how the evidence base bears on disadvantaged groups; a guideline-development synthesis with an explicit equity remit. Decision rule for which PRISMA document applies: use base PRISMA 2020 for any systematic review; layer PRISMA-Equity on top only when equity is a stated review objective. For a protocol of such a review, register with PRISMA-P and flag the equity aim there. PRISMA-Equity sits alongside — not instead of — PRISMA 2020; it adds equity items to, and does not replace, the base checklist.

What it requires

PRISMA-Equity enforces equity-specific transparency at each review stage: (1) frame the equity question — name the PROGRESS-Plus factors of interest and the populations expected to be disadvantaged, with the logic model linking the intervention to the equity outcome; (2) eligibility and search — report whether study selection and search terms were designed to capture disadvantaged populations and equity-relevant settings (e.g., low-/middle-income settings, grey literature); (3) data items — pre-specify which PROGRESS-Plus stratifiers were extracted and how subgroup/effect-modification analyses were planned; (4) synthesis — report effects within and across equity strata, gradients (not just present/absent), and whether differential effects were tested rather than assumed; (5) interpretation — discuss how findings affect the equity gap and the applicability of evidence to disadvantaged groups, including the limits imposed by under-representation. Because the included studies are frequently real-world observational designs drawn from claims, EHR, or registry data, PRISMA-Equity reporting forces a reviewer to confront whether equity variables were even measurable in the source data — race/ethnicity, language, income, and place are commonly absent, incomplete, or differentially missing in administrative data, and the review must say so rather than silently dropping strata.

When NOT to use — limitations and common misapplications

- It is a reporting checklist, not a risk-of-bias or quality instrument. A complete PRISMA-Equity checklist tells you the review disclosed its equity methods; it does not certify that those methods were sound. Critical appraisal of the included studies still requires ROBINS-I / RoB 2 (and equity-specific appraisal of differential bias), and confidence in the synthesis still requires GRADE. Treating a filled checklist as evidence of quality is the checklist-as-theater failure mode. - Completing it does not make differential effects causal. Reporting a subgroup gradient across PROGRESS-Plus strata is descriptive transparency; whether the gradient reflects effect modification rather than confounding or differential measurement is a separate analytic question. - Wrong scope. Do not bolt PRISMA-Equity onto a review that was never designed around equity, merely to appear thorough — the extension presumes equity is an a priori objective, and retrofitting it produces post-hoc subgroup fishing dressed up as equity reporting. Conversely, do not use base PRISMA-only reporting when equity was the review's purpose. - Version mismatch. PRISMA-Equity 2012 was written against PRISMA 2009; when used today it must be paired with the current PRISMA 2020 base checklist (item numbering differs), not the obsolete 2009 wording. - Not a substitute for equity reporting in primary studies. For a single observational RWE study, equity reporting belongs in STROBE/RECORD plus subgroup pre-specification, not in a systematic-review extension.

How it maps to this catalog

PRISMA-Equity governs reporting of an equity-focused synthesis; the substantive RWE concepts that implement each requirement live elsewhere in this catalog. The PROGRESS-Plus stratifiers are operationally the social determinants captured (or not) in real-world data — see `sdoh-social-determinants-of-health` for how Place, race/ethnicity, and SES are measured and where they are missing in claims/EHR. The "for whom does the evidence apply" question is generalizability/applicability — see `generalizability-transportability-external-validity-rwe` and `special-populations-rwe-methods`. Differential inclusion of disadvantaged groups across primary studies is a selection problem — see `selection-bias-sensitivity-analysis-rwe`. Because equity variables are systematically incomplete in administrative data, the honest reporting of which strata could be analyzed depends on `missing-data-pattern-table-rwe`. The review's population and equity strata are specified through the P (and the equity lens on every element) of `picots-framework-rwe`. The reviews themselves are `systematic-review` and `meta-analysis-obs`. Applied note for claims/EHR/registry RWE: when the included evidence is administrative-data RWE, PRISMA-Equity's value is forcing the reviewer to state plainly that race/ethnicity may be imputed, that income and education are usually proxied by area-level measures, and that disadvantaged populations are often under-enrolled or differentially censored — so an apparent "no difference across strata" may reflect measurement and representation gaps rather than equitable effects.