PRISMA-E is the equity-focused extension of the PRISMA statement, designed for systematic reviews that examine how an intervention affects health equity across disadvantaged populations. It does not introduce a different flow diagram; the figure remains the standard PRISMA 2020 diagram with identification, screening, eligibility, and inclusion phases. What PRISMA-E adds is a set of reporting items that ask you to make equity considerations visible throughout the review, including how equity-relevant characteristics shaped your eligibility criteria and what populations the included studies actually covered. You can build the selection figure in our free PRISMA 2020 flow diagram generator and layer the equity reporting on top of it.
The motivation for the extension is that many reviews quietly average results across whole populations and lose sight of who benefits and who is left behind. PRISMA-E exists to keep that question in view from the protocol to the final synthesis.
Why an Equity Lens Changes What You Report
A standard review asks whether an intervention works. An equity-focused review asks whether it works for the people who most need it, and whether it might widen or narrow existing health gaps. That reframing does not alter the mechanics of study selection, but it changes the criteria you screen against and the data you extract.
PRISMA-E organises equity-relevant characteristics using the PROGRESS-Plus framework, which covers place of residence, race and ethnicity, occupation, gender and sex, religion, education, socioeconomic status, and social capital, plus additional factors such as age and disability. When equity is the lens, these characteristics become part of your eligibility and extraction plan, and the review must report how each was handled. Our walkthrough of the PRISMA 2020 checklist items covers the base reporting that PRISMA-E builds on.
Because the equity lens shapes the eligibility criteria and the PROGRESS-Plus data you extract, those decisions belong in the protocol rather than being improvised mid-review. Specifying the disadvantaged populations and the equity characteristics in advance, ideally by writing the equity criteria into your protocol from the outset, keeps the screening consistent and protects the review from the charge that equity was considered only after the results were known.
What PRISMA-E Adds to the Checklist
PRISMA-E keeps the full PRISMA checklist and adds equity-specific guidance at several points. The additions ask authors to:
- State in the title and abstract that the review has an equity focus.
- Define the disadvantaged populations of interest in the objectives and eligibility criteria.
- Describe how equity characteristics were considered during screening and data extraction.
- Report the populations actually represented in the included studies, including any equity gaps.
- Discuss the implications of the findings for health equity, not just average effect.
These items live mostly in the methods, results, and discussion text. The flow diagram still simply counts records and studies, but the criteria those counts reflect now explicitly include equity dimensions. Mapping each new item to a manuscript section is the same discipline a thorough review applies across the board, as our guide on how to conduct a systematic review describes.
How Equity Criteria Touch the Flow Diagram
The flow diagram is unchanged in shape but informed by equity decisions in two concrete ways. First, your eligibility criteria may require that studies report outcomes for a defined disadvantaged group, which means some full texts are excluded specifically for lacking equity-relevant data. Those exclusions are recorded at the full-text stage with a clear reason, exactly as any other exclusion.
Second, the included count at the bottom of the diagram represents studies that met the equity-aware criteria. The figure therefore documents not only that the search was thorough but that screening applied the equity lens consistently. The arithmetic still has to reconcile: full-text exclusions, including any for missing equity data, must sum to the total excluded. Our explainer on what goes in each PRISMA box sets out that top-to-bottom reconciliation in detail.
Reporting the Equity Gaps You Find
One of the most valuable outputs of a PRISMA-E review is an honest map of where evidence is missing. If your included studies overwhelmingly enrolled high-income, urban, or majority-population participants, that is a finding worth stating plainly. The flow diagram shows how many studies were included; the results text then characterises who those studies represented and which PROGRESS-Plus dimensions went unexamined. Framing those gaps as a priority for future primary research turns a limitation into a contribution, much as a well-documented review of any kind does.
Frequently Asked Questions
What is PRISMA-E?
PRISMA-E is the official equity extension of the PRISMA statement. It guides the reporting of systematic reviews that focus on health equity, adding items about disadvantaged populations and equity characteristics while keeping the full base PRISMA checklist and the standard flow diagram.
Does PRISMA-E change the flow diagram?
No. The flow diagram keeps the same identification, screening, eligibility, and inclusion phases. PRISMA-E changes the criteria those phases reflect and adds reporting items in the text, but the figure itself is the standard PRISMA 2020 diagram.
What is PROGRESS-Plus?
PROGRESS-Plus is a framework of equity-relevant characteristics: place of residence, race and ethnicity, occupation, gender and sex, religion, education, socioeconomic status, and social capital, plus factors such as age and disability. PRISMA-E uses it to structure how equity is considered across a review.
When should I use PRISMA-E instead of PRISMA 2020?
Use PRISMA-E when health equity is an explicit focus of the review, for example when you want to know whether an intervention narrows or widens health gaps across disadvantaged groups. It supplements PRISMA 2020 rather than replacing it.
How do I report equity gaps in the included studies?
Use the flow diagram for the counts, then describe in the results which populations the included studies actually enrolled and which PROGRESS-Plus dimensions were not examined. Presenting these gaps as priorities for future research is a core aim of the equity extension.