How Can We Make Information on Equity in Clinical Guidelines More Usable for Clinicians? A Case Study Methodology of General Practitioners

ABSTRACT

Background

Clinical practice guidelines (CPGs) are moving toward greater consideration of population‐level differences, like health inequities, when creating management recommendations. CPGs have the potential to reduce or perpetuate health inequities. The intrinsic design factors of electronic interfaces that contain CPGs are known barriers to guideline use. There is little existing guidance on supporting the uptake of equity‐specific recommendations within CPGs by end users.

Objective

To investigate (1) How do General Practitioners (GPs) use Therapeutic Guidelines to adapt their clinical management for disadvantaged populations and do they support equity recommendations in this CPG? (2) How could Therapeutic Guidelines embed health equity information into their guidelines?

Methods

The Therapeutic Guidelines was used as a case study as it is the most frequently used CPG in Australian healthcare settings. We employed descriptive qualitative methods, focused on semistructured interviews with 17 eligible GPs. Interviews were structured around four case studies that initially explored the management of a patient from the general population, with their details then changed so they belonged to a disadvantaged population. We used a ‘think aloud’ interview technique to explore the clinician's application of CPGs.

Results

Three themes were developed relating to: (1) GPs agree that health equity information needs to be intentionally included in guidelines and should focus on disadvantaged subgroups to support their clinical decision‐making, (2) GPs want CPGs to include equity information which is relevant to the purpose and use of each guideline, acknowledging that other clinical aids could provide additional information when needed, (3) GPs want clearer signposting of information within guidelines to help navigation of key sections, highlighting the utility of symbols, colours and dropdown functions.

Conclusion

This research extends existing literature by showing that including equity information tailored to the articulated purpose of each CPG, as perceived by end users, may maximise uptake. Our outlined strategies could be used by CPG developers to make equity‐focused management recommendations more accessible. This may increase the implementation of equity‐focused recommendations by clinicians, supporting current primary care strategies in achieving more equitable outcomes.

1. Introduction

Clinical practice guidelines (CPGs) are designed to deliver consistent evidence‐based healthcare through best practice recommendations [1, 2, 3]. CPGs have been defined as ‘systematically developed statements to assist practitioner and patient decisions about appropriate healthcare for specific clinical circumstances’ [1]. However, the rise of CPGs has been accompanied by concerns about their development [2, 3]. A key criticism is that the intended positive impact of standardising patient care can have harmful effects [2, 3, 4]. Standardisation may limit the individualisation of management for each patient whose biological variability [5], degree of co‐morbidity [6, 7] and unique preferences impact treatment outcomes [3, 4, 7, 8, 9]. Therefore, when creating management recommendations CPGs are moving away from prioritising the standard patient and toward considering population‐level differences. The World Health Organisation (WHO) has reflected this change, with a growing focus on developing recommendations for differently resourced settings, with equity being a parameter included in their WHO‐INTEGRATE framework for evidence to decision tables [10].

Health inequities encompass unfair, unjust and avoidable differences in the access to, quality of and outcomes from healthcare [11]. Such differences arise from the influence of social determinants of health—like socioeconomic status, ethnicity, geography and education level—on disadvantaged groups [12, 13]. CPGs have the potential to perpetuate health inequities by discriminatively improving the health of advantaged populations [14, 15, 16, 17]. To counter this, there is increasing consideration of equity within CPG development processes. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) equity frameworks outline how to consider equity in different stages of guideline development. Moreover, a 2023 rapid scoping review provides best practices on health equity considerations for guideline planning, evidence review, guideline development and dissemination [18]. Such resources support guideline developers in critically considering how to provide quality recommendations beyond those that are effective only regarding treatment outcomes and costs. Therefore, the uptake and implementation processes of such recommendations within CPGs are essential.

The design of CPG interfaces are critical in the uptake of recommendations by end users [19, 20, 21]. Intrinsic guideline factors related to ease of use have been shown to positively and negatively affect GPs' use of CPGs within consultations [9, 22]. The clarity [9, 22], complexity [22, 23] and the general format [19] of information are known positive or negative factors influencing the ease of use of CPGs [9]. When positive, these factors help create clear and concise information that is quick to access and can streamline decision‐making [9]. Meanwhile when negative, these same factors can impact ease of use by making information hard to locate, time‐consuming to read and confusing to apply to the patient population in question [9]. Among a group of Dutch GPs, CPG presentation factors acted as a barrier to implementation for 43% of recommendations [22]. Barriers to accessing and implementing equity‐focused recommendations within CPGs have the potential to perpetuate poorer health outcomes within disadvantaged populations and maintaining existing health inequities between disadvantaged and nondisadvantaged groups [14, 15, 16, 17]. At a population level, this is significant [15]. Hence, greater insight into how equity information is presented within CPGs is paramount. However, there is less research and fewer resources that provide equity‐specific guidance on supporting uptake of CPGs recommendations [18] and generally more knowledge is needed about effective website design for CPGs to support end users [24].

Therefore, we aimed to explore how GPs use equity information within a commonly used CPG in Australia and any effect on clinical management. To do this, we used a national Australian clinical guideline known as the Therapeutic Guidelines (TGL) which provides guidance 2500 clinical topics with a focus on prescribing and management. TGLs is a paid subscription platform which is often provided to clinicians by their workplaces, but otherwise an individual subscription must be purchased annually. We aimed to answer the follow research questions:

• 1.How do GPs use TGLs to adapt their clinical management for disadvantaged populations, and do they support equity recommendations in this CPG?
• 2.How could TGLs embed health equity information into their guidelines?

2. Methods

In this research, we employed descriptive qualitative methods, focused on semistructured interviews with GPs, to explore how health equity information may be embedded within clinical guidelines. This research was conducted according to the Standards for Reporting Qualitative Research (Supporting Information S1: Appendix 1) [25].

2.1. Research Context

This research was funded via the RACGP Foundation and the TGL. The grant required that TGL was focused on, therefore, it was selected as the case study for this research. TGL is an Australian independent, nonfor‐profit organisation. They are exclusively funded through subscriptions and receive no industry grants or sponsorships. TGL produces evidence‐based online advice, TGLs, which provides guidance on decision‐making for healthcare providers for over 2500 clinical topics across numerous specialities. Within the guidelines, there is a strong prescribing and management focus and, therefore, TGLs is widely used in Australian primary and secondary care settings. An analysis of 25 Australian GPs, across three states, found that TGLs was the most commonly used CPG [9].

2.2. Participant Recruitment

Between March and June of 2023, GPs from across Australia were recruited to participate. Invitations for participation were disseminated via the research team's twitter account, LinkedIn account and Australian‐specific GP Facebook groups. GPs in RACGP‐specific interest groups were contacted via email and snowballing was encouraged [26]. With each recruitment method, an explanatory statement and the contact details of researchers were provided. Interested participants were asked to complete an online demographic survey via Qualtrics, so eligibility screening could occur. Selection criteria for participants is as follows: (1) Australian GPs, (2) who had been practicing for 1 year or more and (3) in the last 12 months had used TGLs at least ‘infrequently’ (one of the categorical options as per the Qualtrics survey). The authors undertook purposeful sampling strategies to ensure there was a broad mix of participants by gender, age and practice location [26].

Before participation eligible participants were asked to complete a written consent form, however, if they preferred, they could provide verbal consent at the start of the interview.

2.3. Data Collection

All semistructured case‐based interviews, approximately 30–60 min in length, were conducted by ES online via a secure electronic video platform (Zoom). ES is a GP‐researcher (FRACGP) with a PhD in health services research. Interviews were structured around four case studies written by N. M., with E. S. drawing on her clinical expertise to edit these cases. E. S. conducted the interviews using open‐ended questions driven by the research questions and centred on each case study (Supporting Information S2: Appendix 2). Since E. S. was a fellow GP, an iterative approach to asking and elaborating upon questions occurred, potentially allowing greater breadth and depth of interview responses. E. S.'s similar professional background was also intended to provide a safer space to explore each case in depth as the interview subject matter might have invoked a sense of ‘being tested’ for participants. E. S. did not personally or professionally know any of the interviewees outside of this research setting.

In each interview, participants were shown two to three cases and asked to use a ‘think aloud’ technique to verbalise their thought processes around the management of the patient and if and how they might use TGLs to support their clinical decision‐making. For each case, they were provided with TGLs (via a share screen function) and asked to navigate E. S. through what parts of TGLs to click on and what specific information they would use. After discussing the management for a patient from the general population, E. S. then altered some of the details in each case study so that the patient then belonged to a disadvantaged population. The four disadvantaged groups introduced include low English‐speaking skills; frail and elderly; Aboriginal and Torres Strait Islander and unemployed with food and housing insecurity. The participants then continued to use the described ‘think aloud’ technique to explain if and how their management differed for this new patient and if they might use TGLs. They were also asked to comment on whether health equity information in TGLs could be easier to find and use, and if so how. All interviews were video, and audio recorded.

2.4. Team Reflexivity

The research team consisted of early, mid and late‐career researchers with diverse interests in primary care, health inequities and disadvantaged populations. Our team has specific expertise in this topic as E. S. is a clinical GP and researcher, N. M. and A. Y. are senior medical students, N. G. and K. N. are experienced qualitative primary care researchers and S. N. is a pharmacist and researcher with experience in clinical guidelines development. Reflecting on the team perspectives, we acknowledge we are each strongly supportive of equity‐promoting items in CPGs.

2.5. Data Analysis

Otter.ai was used to automatically transcribe interview transcripts verbatim. Following this, the automated transcripts were then double‐checked and deidentified by a research assistant (N. M.).

Data collection and data analysis occurred concurrently to strengthen each process through a continual feedback cycle. Our analysis was informed by our knowledge of the academic literature on equity in CPGs and the best practice recommendations for ensuring CPGs do not worsen health inequalities. Inductive semantic thematic coding of the data was performed using NVivo, and done according to the principles of constant iterative comparison [27]. N. M. was the primary data coder and independently coded interviews in groups of two to three. A total of 50% of all interviews were then double‐coded by another research assistant (A. Y.). First, sections of discourse were coded for themes related to the predefined concepts in our research aims. This included how GPs use the TGLs, perspectives on including equity in guidelines, and the perspectives of how the TGLs could embed equity in their guidelines. Second, to align with rigour in qualitative methods, we were also open to, and specifically looked for, any novel perspectives from GPs that was not centred around these research aims. Sections of conversation in each transcript were analysed and labelled with no predefined categories, enabling the concepts that were significant to the participants' experiences to be identified and highlighted. All codes were included in this analysis as all are relevant to the perspectives of these participants. After the first 10 interviews had been coded the working set of codes were discussed, refined and agreed upon in an entire team analysis meeting. The remaining seven interviews were then conducted, transcribed and analysed. Codes were further refined through this second round of analysis. A series of organised team analysis meetings then took place, where conversations between the broader team of researchers were conducted to finalise the grouping of codes into themes.

2.6. Ethics

Ethical approval for this research project was obtained from the Monash University Human Research Ethics Committee on December 12, 2022 (Project ID 36640) and classified as a low risk. All participants gave voluntary informed consent.

3. Results

Seventeen eligible GPs were interviewed from a total of 88 expressions of interest received. Of these 88 individuals who expressed interest, the majority were ‘imposter respondents’ [28] who were screened as ineligible to participate by either the Qualtrics bot‐detector and or since they were bots having ineligible responses to demographic questions. All respondents who met the selection criteria outlined in participant recruitment (n = 17) were included.

The GP participants were from all states and territories in Australia except Tasmania. Most GPs used TGLs daily and had been practicing for 1–10 years (Table 1).

Table 1.

Demographic characteristics of 17 General Practitioner participants who use Therapeutic Guidelines in their clinical practice (2023).

Participant	Gender	Age	Years practicing	How frequently GPs used Therapeutic Guidelines
P1	Male	35–44	6–10	Daily
P2	Female	45–54	21–30	Infrequently
P3	Female	< 35	1–5	Daily
P4	Male	35–44	11–20	Daily
P5	Female	35–44	1–5	Daily
P6	Female	45–54	6–10	Daily
P7	Female	55–64	6–10	Daily
P8	Prefer not to say	35–44	11–20	Daily
P9	Male	35–44	6–10	Daily
P10	Female	< 35	1–5	Daily
P11	Female	< 35	1–5	Daily
P12	Female	Prefer not to say	11–20	2–3×/week
P13	Female	35–44	6–10	Daily
P14	Female	< 35	1–5	Daily
P15	Male	35–44	1–5	Daily
P16	Female	< 35	1–5	Daily
P17	Female	< 35	6–10	Daily

We developed three themes:

• General Practitioners agree that health equity information needs to be intentionally included in guidelines and should focus on disadvantaged subgroups to support their clinical decision‐making.

• General practitioners want CPGS to include equity information which is relevant to the purpose and use of each guideline, acknowledging that other clinical aids (population‐specific guidelines, manuals, resources) could provide additional information when needed.

• General practitioners want clearer signposting of information within guidelines to aid navigation of key sections, highlighting the utility of symbols, colours and dropdown functions.

3.1. General Practitioners Agree That Health Equity Information Needs to be Intentionally Included in Guidelines and Should Focus on Disadvantaged Subgroups to Support Their Clinical Decision Making

GPs were invited to reflect on whether the TGLs, and clinical guidelines generally, should incorporate information about health equity. All but one GP supported the inclusion of equity, at least in theory, for three main reasons. First, some GPs believe that guidelines have a responsibility to champion change by considering and including evidence‐based advice around health equity issues when this advice would change patient management. Otherwise, they felt guidelines could contribute to perpetuating inequities by prioritising homogenous recommendations, overlooking disadvantaged groups:

We need to think about the people who have been historically left behind by guidance and look deeply at the evidence.

—P13

Other GPs felt that it is reasonable to add in more equity information, as management advice for different subpopulations already exists within CPGs:

I don't think it's too difficult to incorporate [information about patients affected by social determinants of health]…. STI guidelines [already incorporate subheadings about] different subpopulations…. quite well, and we clinicians associate with being able to look for this information.

—P1

Finally, GPs also expressed that for clinicians who work in higher deprivation areas the inclusion of evidence‐based management information for patients with varying disadvantaged backgrounds would provide an authoritative backing. This could help when making management decisions and would lessen the need to predominantly rely on past clinical experiences:

It definitely [would be helpful to have social issues addressed in the guidelines] because I think … having something in a guideline that's very black and white gives you…. one less kind of straining complex decision‐making process that you'd have to go through with the patient. Kind of having the backing or the authority of a guideline to say in your circumstance, this is what we'd recommend.

—P16

The one GP with a contrasting view raised concerns about how including information about equity would impact ease of use. However, they had general issues accessing TGLs as they did not have a subscription. Some GPs who were generally supportive of including equity in CPGs also suggested that CPG recommendations should be for the general population. They felt it is up to the clinician to use their clinical judgement to tailor management for each patient as this is the ‘art of medicine’ (P2). Although these GPs were still supportive of the intentional inclusion of management recommendations for disadvantaged populations, they emphasised the role of clinical judgement:

So…. the guideline … is just for the standard patient, but in the real world there's nobody that can fit exactly to the standardised kind of scenario…. so … you use your clinical judgement. The guideline is only meant to be a general guideline and it does not take precedent over clinical judgement.

—P9

3.2. General Practitioners Want CPGS to Include Equity Information Which Is Relevant to the Purpose and Use of Each Guideline, Acknowledging That Other Clinical Aids (Population‐Specific Guidelines, Manuals, Resources) Could Provide Additional Information When Needed

The GPs' perception of a guideline's purpose influenced what type of equity‐based management advice they sought and expected. Generally, GPs didn't use CPGs to support their clinical decision‐making for the treatment of individuals from disadvantaged populations unless it was for specific information about pharmaceutical management. For example, GPs reported that they viewed TGLs as a ‘prescribing resource’ (P13), and hence they mostly used it to guide pharmacological management decisions.

GPs also explained that when managing patients from disadvantaged backgrounds, they would immediately turn to guidelines tailored to the disadvantaged population in question. This is because of greater trust in the CPG's specialised recommendations, ease of use or clinic‐wide directions on which CPGs to use:

In the Northern Territory there's a lot of remote clinics, they mostly use Central Australian Rural Practitioners Association (CARPA) guidelines for prescribing as well as… remote health manuals. When managing an [Aboriginal and Torres Strait Islander child] I'll probably look at CARPA because that is what my clinic [uses].

—P11

Moreover, GPs did not turn to clinical guidelines for the management of social drivers of disadvantage like unemployment or food and housing insecurity. In these scenarios, GPs were mostly guided by their past clinical experiences and or the assistance of allied health staff. They felt incorporating information about socially driven equity issues and how they may influence clinical decision‐making falls outside the purpose of TGLs. There was a general sentiment that some aspects of the patient's social management cannot be assisted by clinical guidelines, and there are more appropriate resources that GPs could use:

I don't know whether I'd use Therapeutic Guidelines [with an immigrant patient with low English skills trying to quit smoking]. I'd more be looking at whether the QUIT website is available in his language because that would probably be more useful. I don't know how Therapeutic Guidelines would potentially help me with that.

—P4

However, GPs wanted TGLs to include health equity information that impacts pharmacological prescribing recommendations, for example, if the equity issue would change the most appropriate drug type, frequency, dosage or access. This is because they felt this type of information fits within the primary purpose of TGLs:

I would go to the antibiotic regimen [sections for information on differences between non‐Indigenous and Aboriginal and Torre Strait Islander patients]. I would hope that if there was a note around particular groups, that it would be with the prescribing information.

—P13

3.3. General Practitioners Want Clearer Signposting of Information Within Guidelines to Help Navigation of Key Sections, Highlighting the Utility of Symbols, Colours and Navigation Functions

The inclusion of information about health equity in clinical guidelines triggered concerns about the ease of use of the guidelines. The participants stressed that incorporating large amounts of additional information may negatively affect ease of use by making it busier and harder to navigate within the limited timeframe of a consultation. GPs expressed this might deter some clinicians from using CPGs. Others indicated that these practical concerns outweighed their theoretical support for the inclusion of information about equity within guidelines:

Yes I think [it would] be helpful but then [Therapeutic Guidelines] will be more busy, and there will be more words, and yeah sometimes more words might not be good.

—P6

We observed the effect of barriers to accessing information related to equity during the case scenarios. Some GPs turned to TGLs first when considering pharmacological management for individuals from disadvantaged populations. However, if they struggled to locate the information, or the information present was convoluted, they expressed they would then turn to an alternate guideline they were familiar with. GPs reflected that poor usability would be particularly challenging within the time constraints of daily consultations and would deincentivise future use:

I can't see anything else about higher risk on there, unless I'm just not seeing it in front of me….oh me…. oh there you go it was hiding in there [at the bottom] … Okay so it's a separate URL.… and it goes to a guideline that I didn't know existed. That is not usable at all…. I wouldn't even click on the [external] PDF seeing that it was 121 pages long.

—P4

During interviews, GPs suggested helpful ways to embed information about equity into guidelines. They outlined that to support their natural workflow such information about equity would need to sit within the webpage areas of each guideline that are most used in consultations. In the case of the TGLs, for example, GPs suggested including this information in the popular coloured prescribing boxes as GPs often go straight to these:

So, I think include it in the actual antibiotic regime areas. That's the one I tend to click on, because I tend to not necessarily look at those other ones, unless I'm refreshing my knowledge on a particular area. I will typically just go to where the antibiotics guidelines are in this case, so it would have to be in this [blue prescribing box] here particularly.

—P4

There was diversity in the software suggestions for how health equity information could be presented, however GPs emphasised the importance of it being done in a manner that is identifiable and consistent. This would ensure that clinicians would be able to recognise such information has been incorporated in a guideline section, locate it and then use it within the timeframe of a consultation. GPs outlined three key software suggestions for how health equity information could be recognised: through symbol/s, a distinctive coloured box or a separate dropdown section within the relevant pathology:

Yeah like having a star or flag would be okay, it would just need to be…. for only like the really key important stuff. If people just go to the [antibiotic section], which I often do if I know I want to prescribe and I don't want to check anything [else] … then … having a star might be good.

—P11

4. Discussion

4.1. Summary

This study investigated GP perspectives on how information relating to health equity issues could be incorporated into CPGs, employing TGLs—a national Australian general CPG—as a case study. Almost all GPs supported CPGs intentionally including health equity information but emphasised the role of the clinician in tailoring management to the individual patient. GPs highlighted that the most useful type of health equity information included in CPGs might vary by their perception of the CPG's purpose. For example, GPs perceived TGLs to be a management and prescribing‐focused CPG, and, therefore, expected it to include information on making pharmacological management decisions for disadvantaged individuals. However, GPs mostly turned to guidelines tailored to disadvantaged populations, allied health staff, and past clinical experiences to guide management decisions for disadvantaged patient groups. Current literature aligns with how GPs used CPGs for specific management advice related to their perceived purpose and how they encountered intrinsic CPG factors as barriers to uptake of recommendations. This research provides new suggestions relating to content and design that could help end users identify and use equity‐focused recommendations within CPGs, and thereby reducing the risk of perpetuating the inequity gap.

4.2. Comparison With Existing Literature

This study identified that most GPs supported clinical guidelines proactively considering and addressing health inequities within management recommendations. This finding affirms current literature which highlights that CPG developers are increasingly being encouraged to consider equity in all stages of guideline development [14, 15, 16, 18, 29, 30]. Yet the current research has a predominant academic focus, targeted toward guideline developers. Our study adds a newer clinical primary care perspective to this, which is important because clinicians are often the end user of CPGs. Their viewpoint emphases that for guideline developers considering how recommendations may need to be adapted for different population groups not only meets international criteria for high quality CPGs [31, 32], but may better meet the needs of clinicians and their patients.

The clinician perspective on the key purpose of a CPG is important for planning equity inclusion. GPs use CPGs for many reasons including management guidance, reassurance and patient education [9]. In a cohort of Australian GPs, where TGLs was the most commonly used CPG, the principal reason why they turned to CPGs was for prescribing advice [9]. This aligns with our finding that pharmacological management advice was the primary reason why GPs turned to TGLs. In this study, GPs also turned to TGLs for this same reason when managing disadvantaged populations. Our work shows that clinicians may continue to seek out equity‐focused recommendations in nonequity‐focused CPGs. This highlights the importance of including equity information into general CPGs, particularly if that information fits with the articulated purpose of the CPG, as defined by its end users.

GPs' concerns that including equity‐focused management recommendations may add in too many words, complicate navigation and negatively affect CPG use is supported by current research. Commonly cited barriers to using CPGs are factors like the amount of text, ease of navigation, complexity of recommendations and general poor presentation [9, 19, 23]. Interactive CPGs, like TGLs, may have a greater means to address such barriers compared to ‘old school’ CPG documents, through the design flexibility that software development provides [33]. This study modelled how CPG features can be barriers to use when, due to usability challenges, GPs turned from the TGLs to alternate guidelines while seeking equity‐specific management advice. If equity‐focused management recommendations are accessible to clinicians within general guidelines they are more likely to be considered in the management of patients from disadvantaged backgrounds. This may limit the differential rate of improvement in health of advantaged populations compared to disadvantaged populations, supporting existing strategies to reduce health inequities.

Targeting design features to increase usability of CPGs is supported by current literature. Addressing intrinsic factors of CPGs has been shown to be a more cost‐effective method than altering extrinsic factors like time constraints and clinical practice environments, when seeking to increase uptake of CPG recommendations [34]. Our findings align with existing literature on optimise the usability and accessibility of CPGs, particularly that information needs to be presented intuitively and the use of highlighting techniques—either through colour or boxes—can draw readers to key sections [20]. We extend current knowledge in showing that these techniques can be explicitly used for equity‐focused recommendations within CPGs, and not just for CPGs more broadly.

4.3. Strengths and Limitations

This study has several limitations. First, a larger sample size of GPs with greater diversity of gender and ethnicity (which was not recorded in the present study) may increase the transferability of our results. The interviewed participants could have demonstrated some self‐selection bias by being clinicians who work with disadvantage populations and are interested in health equity and guideline usability. The inclusion requirements for this study may have also excluded some study participants who used TGLs frequently in the past but do not use it anymore due to financial limitations or because they are on career break. Finally, the interviews only assessed four case studies of disadvantage and hence our results are not exhaustive about health equity issues within TGLs and the practice implications from this.

The results from this study are strengthened through GP to GP interviewing, which allowed more in‐depth clinical insights to be elicited from participants. The diversity in the geographical practice locations of GP participants, between metropolitan and nonmetropolitan areas, increases the transferability of results because it provided a broader range of clinical experiences with disadvantaged populations and use of CPGs within management. Moreover, because we focused on end‐user experience, we could elicit how general CPG design factors affect usability within clinical consultations, strengthening the practice implications drawn. The daily use of TGLs by 15 of the 17 study participants enhances the credibility of our results and the overall transferability.

4.4. Practice Implications

This study highlights how the perspective of GPs are instrumental in providing insights into how and why a CPG is used, its overall usability, and the implications of these on the uptake of recommendations. For individuals involved in guideline development, first, we propose that they gather a good understanding of why and when end users turn to and away from their CPG. From this, we suggest that it is essential to then prioritise including information about health equity issues that are relevant to the purpose of their specific CPG, and to consider how this relates to other CPGs. We also recommend incorporating health equity information within the natural workflow of end users in a way that is identifiable and consistent, as it is likely to enhance ease of use. Finally, we suggest utilising interviews with end users, once health equity information has been incorporated within a CPG, to review the usability and appropriateness of this information. The inclusion of equity information that is user‐friendly in CPGs is a concrete step toward reducing health inequity in our communities.

Further research that focusses on alternate nonequity‐specific CPGs is needed to corroborate our findings and to expand on what specific intrinsic CPG factors can positively and negatively affect uptake of equity‐focused management recommendations. Specifically, more research is needed to understand if design features differ in how they support uptake of the information between the style of CPG (electronic vs. PDF) and the nature of health equity recommendations. Such research can then inform the development of resources like the GRADE guidelines, to provide specific guidance around design features that positively support the usability and uptake of health equity recommendations in nonequity‐focused CPGs.

5. Conclusion

Overall, this research provides evidence for why it is important to intentionally consider how equity‐focused management recommendations are included within CPGs. GPs supported guidelines intentionally including such information, however encountered existing usability barriers to accessing this within general CPGs. Explicitly considering equity within CPG development is now a somewhat encouraged expectation, but how such recommendations are designed and displayed within general CPGs needs to be the next step. Our identified strategies could be used by CPG developers to make information about health equity issues more accessible for clinicians within consultations. Increasing the convenience of accessing such management advice may increase the uptake and implementation of equity‐focused recommendations by clinicians. Such changes could complement existing approaches within primary care that work to achieve more equitable outcomes for disadvantaged populations.

Conflicts of Interest

All research data collection and analysis were undertaken independently. The work was funded in part by the Therapeutic Guidelines and their software was used as the basis of the case studies. The authors consulted Therapeutic Guidelines on the design of the study, iteratively shared their findings with the organisation to support ongoing quality improvement and considered their suggestions in preparing the final outputs. The research team prepared final outputs.

Supporting information

Supporting information.

Supporting information.

Data Availability Statement

The data underlying this article will be shared on reasonable request to the corresponding author.