Introduction

COVID-19 is an infectious disease spread by the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), that first reported in Wuhan, China in 2019 [1]. At the start of the pandemic, SARS-CoV-2 was initially thought to spread mainly through close person to person contact because of production of respiratory droplets formed through a sneeze or cough of an infected person. Later evidence demonstrates that the virus also infects through airborne transmission routes when an infected person ‘exhales, speaks, shouts, sings, sneezes, or coughs’ [2]. SARS-CoV-2 viral particles range from larger respiratory droplets to smaller aerosols [3], making the wearing of high quality and well-fitting masks indoors of particular importance in reducing transmission among the public, and the wearing of additional protective equipment important in reducing transmission among frontline healthcare staff [2]. As of January 5th 2021, 86.2 million cases of COVID-19 have been identified across 218 countries and territories resulting in 1.87 million deaths across the globe [4]. Among the reported cases, 20,551,680 confirmed cases and 349,890 deaths were reported in the USA and (at the time of writing, January 2021) it has become the country with the greatest number of infection and deaths due to COVID-19 [4]. Contrary to US, countries like New Zealand and Vietnam reported 2181 and 1494 cases of COVID-19 resulting into 25 and 35 deaths only respectively [4].

This dire situation demands that everyone has a fair and just opportunity to be as healthy as possible but there is increasing evidence that COVID-19 has unmasked the true magnitude of health inequity worldwide. For example, in US, American Indians or Alaskan natives, African Americans and Hispanic or Latino people have 1.8 times, 1.4 times and 1.7 times higher rate of COVID-19 cases; have 4.0 times, 3.7 times and 4.1 times higher rate of COVID-19 related hospitalizations and 2.6 times, 2.8 times and 2.8 times higher rate of COVID-19 related deaths respectively when compared to their Caucasian counterparts [5]. In addition, elderly people [6], healthcare and frontline workers [7] are at an elevated risk of acquiring COVID-19 and developing severe COVID-19 related outcomes. Thus, to achieve health equity, healthcare policies around COVID-19 should ideally address these inequities so that everyone has a fair opportunity to be as healthy as possible, and the whole society benefits.

Policies and guidance for containing the infection and reducing the COVID-19 related deaths are complex and rapidly evolving. Since no pharmaceutical agents were known to be safe and effective at preventing or treating COVID-19 until recently, only non-pharmaceutical interventions were relied upon for reducing the burden of COVID-19 during the first wave(s) of the pandemic in 2020 [8,9,10,11]. These measures aimed to reduce disease transmission both locally and globally and included bans on public gatherings, compulsory stay-at-home policies, mandating closures of schools and nonessential businesses, face mask ordinances, quarantine and cordon sanitaire, among others. The effectiveness of these interventions to reduce COVID-19 transmission has been demonstrated [8,9,10,11], however the extent to which health inequity factors were considered in these policies is unknown.

Thus, the aim of this study is to measure the extent to which national, regional, institutional and organizational policies reflect equity considerations by focusing on the global policy landscape around wearing masks and personal protection equipment (PPE). Masks/PPE policies were chosen as area of target as these policies affect more people when compared to other interventional policies such as school closure policies, stay at home policies etc. Equity would be assessed using previously developed Cochrane PROGRESS-Plus equity framework. PROGRESS-plus defines the characteristics that stratify health opportunities and outcomes that can mark inequalities. Current masking/PPE policies implemented across world would ideally be expected to reflect equity considerations in order to effectively manage the spread of the disease and to reduce adverse outcomes, although the extent to which this is the case is uncertain. For example, we may expect equity of access to masks/PPE to be considered when policy-makers are designing policies around the need to wear a mask, or for equity to be considered when undertaking health promotion activities in promoting the importance of mask wearing. The understanding of health equity consideration in masking/PPE policies across globe to contain COVID-19 using PROGRESS-Plus framework will help to achieve a better and more sustainable future for all past the barrier of inequity.

Methods

This systematic review was done in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [12,13,14,15,16,17,18,19] (Table S1), following a predetermined published protocol (PROSPERO registration: CRD42021231497).

Search strategy and data sources

We performed a comprehensive search in six electronic databases – PubMed, EMBASE, CINAHL, ERIC, ASSIA and Psycinfo. The search strategy was based on a broad combined search string for COVID-19 and ‘masks or PPE’(Table S2). The searches were conducted to retrieve potentially relevant publications from January 1st, 2020 to July 1st, 2020. Additional literature was identified by searching the reference list of the identified eligible documents.

Inclusion criteria

All identified documents were evaluated for the inclusion based on the following criteria: (1) documents should be related to COVID-19 and (2) documents should have masks or PPE as an intervention/strategy to mitigate COVID-19. Selection criteria were not limited to any specific kind of study design or type of publication thus allowing reviews, policy documents, or research briefs to be included in the systematic review. Systematic reviews focusing on a number of policies were excluded to decrease repetition among the included documents. Selection criteria were not limited to any specific language thus minimizing language bias. Two reviewers (AC and AK) independently undertook the screening of the records (by title and/or abstract) for eligibility and a third reviewer (NC) mediated if contradiction to arrive at an accord occurred. Full text of eligible papers after the first screening was reviewed to confirm that the articles met the inclusion and exclusion criteria. Similar to title/abstract screening, full text screening was also done by two reviewers independently and a third reviewer mediated if contradiction of an accord occurred.

Data extraction

A customized data extraction sheet was constructed to extract relevant data from all documents meeting our inclusion criteria. The data abstracted included: author(s), publication year, the geographical location of data collection, study design, setting, target population, implementation level of policy, equity incorporation, equity component, strength of evidence and key findings. Similar to the screening process, data extraction was conducted by two reviewers (AC and AK) and any contradiction was resolved by a third reviewer (NC).

Assessment of incorporation of equity

To assess the extent of incorporation of equity in policies, we utilized a guidance framework known as ‘PROGRESS-Plus’ [20, 21]. This assessment was conducted in order to analyze the extent to which equity has been incorporated in PPE or masking policies and implementation of these policies around the globe. PROGRESS-plus equity framework is aimed at warranting the consideration of various health inequity inducing factors such as place of residence, race/ethnicity, occupation, gender, religion, education, socioeconomic status and personal characteristics when devising policies and/or guidelines. Additional details about the framework can be found elsewhere [20, 21]. The data from included documents were analyzed to determine whether a study has considered equity component. If the included policy had any of the above-mentioned PROGRESS-Plus components it was determined that the study had incorporated an equity component. Where a measure was classifiable under more than one PROGRESS-Plus factor (e.g. an indicator of employment status is relevant to ‘occupation’ but also to ‘socio-economic status’ (SES)), we included it under the factor deemed more appropriate. It is important to note that utilization of PROGRESS-plus framework for this research is context specific and findings are limited to COVID-19 for most part. For instance, population types such as healthcare workers, essential workers are not usually considered vulnerable in society but in the context of COVID-19, increased risk of transmission of COVID-19 puts them at a disadvantage compared to the general population. Thus, findings of the research work should be interpreted within aforementioned scope.

Second, the provision and strength of the rationale to support inclusion of “PROGRESS-plus” factor in a policy was analyzed. The aim of this analysis was to ascertain whether policies have included an equity component following the empirical evidence or not. The documents were divided into two groups: explicit rationale or implicit rationale. If a study/policy provided the empirical evidence for inclusion of PROGRESS-plus component, the study was deemed to have an ‘explicit rationale’. The study/policy was deemed to have an ‘implicit rationale’ if no empirical evidence was provided for the inclusion of PROGRESS-plus component.

Third, “indication level of equity” in documents was assessed. The aim of this analysis was to ascertain whether “equitable health” was a primary factor while framing the policies (defined as high level) or documents were focused on a certain group or subpopulation thus having “equitable health” as a latent factor (defined as low level). The major difference between these two categories is that ‘high level’ documents acknowledge ‘health equity’ related issues, as opposed to ‘low level’ documents which fail to mention them. For example, if a study/policy was targeted at use of face masks among healthcare workers without any mention of ‘equity’, ‘inequity’, ‘health disparities’ in aims, objectives or discussion, it was deemed to be ‘low level’. On the contrary if a study/policy was targeted at use of face masks among healthcare workers with the mention of ‘equity’, ‘inequity’, ‘health disparities’ in aims, objectives or discussion, it was deemed to be ‘high level’.

Data analysis

A narrative synthesis of data was conducted as most of the included documents were policies and lacked statistical results. We presented the data in the two distinct sections. The first section aimed at outlining the included policies in the review and second section aimed at explaining the equity component in the eligible documents. The results are presented in a descriptive manner using frequencies, percentages and pie charts. EPPI-reviewer [22] was utilized for the management and analysis of the data . In addition, due to subjective nature of the extracted policy documents, no ‘strength of evidence’ analysis was performed.

Results

The search strategy yielded 2177 articles that were focused on COVID-19. Out of these 2177 articles 125 duplicates were removed. Of the remaining 2051 articles only 191 met the inclusion criteria and were retrieved to be reviewed in full-text. In addition, 42 policy documents retrieved from references of these included articles were added to be reviewed in full text. During the full-text screening, further 21 articles were excluded due to following reasons; duplicate (n = 6), and irrelevant/non mask/PPE policy (n = 15). This resulted in a total of 212 [23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70,71,72,73,74,75,76,77,78,79,80,81,82,83,84,85,86,87,88,89,90,91,92,93,94,95,96,97,98,99,100,101,102,103,104,105,106,107,108,109,110,111,112,113,114,115,116,117,118,119,120,121,122,123,124,125,126,127,128,129,130,131,132,133,134,135,136,137,138,139,140,141,142,143,144,145,146,147,148,149,150,151,152,153,154,155,156,157,158,159,160,161,162,163,164,165,166,167,168,169,170,171,172,173,174,175,176,177,178,179,180,181,182,183,184,185,186,187,188,189,190,191,192,193,194,195,196,197,198,199,200,201,202,203,204,205,206,207,208,209,210,211,212,213,214,215,216,217,218,219,220,221,222,223,224,225,226,227,228,229,230,231,232,233,234] relevant articles to be included in this systematic review (Fig. 1). The screening yielded two types of documents: original policies and policy recommendations. Original policies were the documents issued by government agencies such as CDC, WHO or alike whereas policy recommendations consisted of documents that were not policies themselves but contained different recommendations for the policy. Both original policies and policy recommendations will be referred to as “policy documents” from here on in the review.

Fig. 1
figure 1

PRISMA Flow for Selection of the Included Policy Documents

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General study characteristics

General characteristics of the included policy documents are summarized in Table 1. Masks/PPE as a mitigation strategy against COVID-19 was implemented across different regions ranging from USA to Australia to Russia (Table 1 and Fig. 2). There were no policy documents identified from Eastern Europe, Africa and Middle Eastern regions in this review. There were 29 policy documents [25, 34, 41, 59, 75, 125, 126, 133, 134, 140, 141, 146, 155, 157, 166, 177, 178, 208,209,210,211,212,213,214,215,216,217,218,219] that were not targeted towards a specific nation or region but were global in nature.

Table 1 Characteristics of The Included Policy Documents
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Fig. 2
figure 2

Number of Included Policy Documents Categorized by Nation*

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The origin/target of policy documents was analyzed on an income level scale (Table 1) as a growing body of literature suggests that there is significant heterogeneity, both in the direction and magnitude, of association between factors such as socioeconomic status, income inequality and health outcomes. Most policy documents were from high income countries (HIC) such as USA, Italy, Canada and UK. Specifically, 136 policy documents (64.15%) were from HIC [26, 28,29,30,31,32,33, 37,38,39,40, 42,43,44,45,46, 48,49,50,51,52,53,54,55,56,57,58, 60, 61, 63, 71,72,73,74, 76, 77, 79,80,81,82, 85,86,87,88,89,90,91,92,93,94, 99,100,101,102,103,104,105,106,107, 110, 112, 113, 116, 117, 119, 121,122,123,124, 127, 129, 130, 132, 135, 137,138,139, 143,144,145, 147,148,149,150,151,152,153,154, 156, 158, 159, 161, 163,164,165, 167,168,169,170,171,172, 174,175,176, 179,180,181,182, 184, 185, 188,189,190,191,192,193,194,195,196,197,198,199,200,201,202,203,204, 206, 207, 220, 222, 223, 226, 228, 229, 233], 39 policy documents (18.40%) were from lower middle income countries (LMIC) [23, 24, 27, 35, 36, 47, 62, 64, 65, 67,68,69,70, 78, 83, 84, 108, 111, 114, 115, 118, 128, 136, 142, 160, 162, 173, 183, 186, 187, 205, 221, 224, 225, 227, 230,231,232, 234] and 37 policy documents (17.45%) were from HIC and LMIC [25, 34, 41, 59, 66, 75, 95,96,97,98, 109, 120, 125, 126, 131, 133, 134, 140, 141, 146, 155, 157, 166, 177, 178, 208,209,210,211,212,213,214,215,216,217,218,219] (Table 1).

Mask/PPE policy documents were analyzed for the scale upon which they were implemented (Table 1). The scale was divided into categories: institutional, national and global. Institutional policies were defined as the strategies that were implemented at a unit/institution level such as an ophthalmology center or were targeted towards a specific group that work at an institutional level such as an ophthalmologist. National policies were defined as the strategies that were implemented or intended to be implemented at a national level and included all the population of that nation. Policies from country specific agencies such as CDC, Ministero della Salute etc. were considered national policies. Global policies were defined as the policies that were implemented or intended to be implemented at global level and included everyone across globe. Policies from WHO and any other international agencies were included in this category. Our analysis found that most of the policy documents were implemented at an institutional level. Specifically, 148 policy documents (69.81%) were implemented at institutional level [25, 27,28,29, 31, 32, 34,35,36,37,38, 40, 42,43,44,45,46, 48, 49, 51, 53, 58, 61,62,63,64,65,66, 71, 73, 74, 76,77,78, 80,81,82, 85, 86, 88,89,90,91, 93, 96, 99,100,101,102,103,104,105,106,107,108,109,110, 112,113,114,115, 117, 120,121,122,123,124,125,126, 128, 130,131,132,133,134,135,136,137,138,139, 142,143,144,145,146,147,148,149,150,151,152,153, 155,156,157,158,159,160,161,162,163,164, 166,167,168, 171, 173,174,175,176,177,178,179,180,181,182,183,184, 186, 188,189,190, 192, 193, 197, 199,200,201,202,203,204, 206, 207, 210, 211, 213, 220,221,222,223, 225,226,227,228, 230, 231, 233, 234] whereas 42 policy documents (19.81%) were implemented at national level [23, 24, 26, 30, 33, 39, 47, 50, 52, 55,56,57, 67,68,69,70, 72, 79, 83, 84, 87, 92, 94, 97, 98, 111, 119, 129, 154, 165, 169, 170, 187, 191, 194,195,196, 198, 205, 224, 229, 232] and only 22 policy documents (10.38%) were implemented at the global level [41, 54, 59, 60, 75, 95, 116, 118, 127, 140, 141, 172, 185, 208, 209, 212, 214,215,216,217,218,219] (Table 1).

In addition, the target population for the policy documents was also assessed (Table 1). Specifically, 141 policy documents (66.51%) were targeted towards healthcare workers [23, 25,26,27,28, 30, 32, 35,36,37,38,39,40,41,42, 44,45,46,47,48,49, 51, 53, 54, 57, 60,61,62,63,64,65,66, 70,71,72,73, 76,77,78,79,80, 83, 86,87,88, 90, 91, 93, 96, 98, 99, 101,102,103,104,105, 107,108,109,110, 112, 113, 115,116,117, 119,120,121,122,123,124,125,126,127, 130, 133,134,135,136, 138, 139, 142,143,144,145,146,147,148,149,150, 152, 155,156,157,158,159,160,161,162,163,164, 166, 167, 169,170,171, 173, 174, 176,177,178,179,180,181, 183, 186,187,188,189,190, 193, 194, 197,198,199,200,201, 203, 204, 206, 218, 220,221,222,223, 225, 228, 230, 231, 233, 234]; 5 policy documents (2.36%) were targeted towards other workers (mortuary workers, transportation workers, essential workers etc.) [67, 68, 92, 185, 202]; 6 policy documents (2.83%) were targeted towards patients across different disease groups [55, 56, 94, 100, 132, 217]; 30 policy documents (14.15%) were targeted for the general population [24, 33, 50, 52, 59, 75, 84, 89, 95, 111, 114, 118, 129, 140, 141, 154, 165, 172, 191, 196, 205, 208, 209, 212, 214,215,216, 224, 229, 232] and 30 policy documents (14.15%) had multiple defined target groups [29, 31, 34, 43, 58, 69, 74, 81, 82, 85, 97, 106, 128, 131, 137, 151, 153, 168, 175, 182, 184, 192, 195, 207, 210, 211, 213, 219, 226, 227] (Table 1). Examples of policy documents having multiple target groups were policy documents targeting both patients and healthcare workers; policy documents targeting frontline healthcare workers and hospital administrators and policy documents targeting healthcare workers, staff of mortuaries and public health officials (Table 1).

Equity incorporation

Out of 212 policy documents, 190 policy documents (89.62%) included at least one PROGRESS-plus component [23, 25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49, 51,52,53,54, 56,57,58,59,60,61,62,63,64,65,66,67,68,69,70,71,72,73,74,75,76,77,78,79,80,81,82,83, 85,86,87,88, 90,91,92,93, 96,97,98,99, 101,102,103,104,105,106,107,108,109,110,111,112,113,114,115,116,117, 119,120,121,122,123,124,125,126,127,128, 130, 131, 133,134,135,136,137,138,139, 142,143,144,145,146,147,148,149,150,151,152,153,154,155,156,157,158,159,160,161,162,163,164, 166,167,168,169,170,171, 173,174,175,176,177,178,179,180,181,182,183,184,185,186,187,188,189,190, 192,193,194,195, 197,198,199,200,201,202,203,204, 206,207,208,209,210,211, 213, 215,216,217,218,219,220,221,222,223, 225,226,227,228,229,230,231, 233, 234] (Fig. 3). The policy documents (n = 190) were then categorized in different strata based on the included ‘PROGRESS-Plus” component (Fig. 4). Most of the policy documents focused on “occupation” component of the PROGRESS-plus and included populations at higher risk of contracting COVID-19 such as healthcare workers, essential workers, transportation workers etc. Specifically, 85.79% (n = 163) of the included policy documents had “occupation” as an equity component [23, 25,26,27, 29,30,31,32, 34,35,36,37, 40, 42,43,44,45,46, 48, 49, 51, 53, 54, 58, 60, 62,63,64,65,66,67,68, 70,71,72,73,74, 76,77,78,79,80,81, 83, 85,86,87,88, 90, 91, 93, 96,97,98,99, 101,102,103,104,105,106,107,108,109, 112, 113, 115,116,117, 119,120,121, 123,124,125,126, 128, 130, 131, 133,134,135,136, 138, 139, 142,143,144,145,146,147,148,149,150,151,152,153,154,155,156,157,158,159,160,161,162,163,164, 166,167,168,169,170,171, 173,174,175,176,177,178,179,180,181,182,183,184, 186,187,188,189,190, 192,193,194,195, 197,198,199,200,201,202,203,204, 206, 207, 210, 211, 213, 215, 217,218,219,220,221,222,223, 225,226,227,228, 230, 231, 234] followed by personal characteristics associated with discrimination (n = 4; 2.11%) [33, 56, 216, 229], place of residence (n = 2; 1.05%) [75, 114] and education (n = 1; 0.53%) [69]. Several policy documents had mentioned multiple PROGRESS-Plus components. Specifically, 17 policy documents (8.95%) mentioned two components of PROGRESS-Plus [28, 38, 39, 41, 47, 52, 57, 59, 82, 92, 110, 111, 122, 127, 137, 185, 233] and 3 policy documents (1.58%) mentioned more than two components of the PROGRESS-plus framework [61, 208, 209] (Fig. 4).

Fig. 3
figure 3

Equity Incorporation (PROGRESS+) Assessment for Included Policy Documents

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Fig. 4
figure 4

Equity Components (PROGRESS+) For Included Policy Documents

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Second, the strength of rationale to support inclusion of “PROGRESS-plus” factor in a policy document was analyzed. Of all the policy documents having equity component, 71 policy documents (37.37%) explicitly provided the evidence for inclusion of PROGRESS-Plus component [25, 27, 28, 34, 36,37,38, 41, 42, 49, 58,59,60,61, 63, 64, 66, 71, 74,75,76,77, 82, 86, 91,92,93, 104,105,106, 111, 112, 114, 121, 122, 124, 126, 127, 130, 131, 134,135,136,137, 144, 146, 148, 155, 159, 160, 166, 167, 171, 176, 177, 180, 182, 185, 190, 192, 193, 197, 201, 206,207,208, 226, 227, 231, 233, 234] whereas rest did not provide any rationale for inclusion of PROGRESS-Plus component [23, 26, 29,30,31,32,33, 35, 39, 40, 43,44,45,46,47,48, 51,52,53,54, 56, 57, 62, 65, 67,68,69,70, 72, 73, 78,79,80,81, 83, 85, 87, 88, 90, 96,97,98,99, 101,102,103, 107,108,109,110, 113, 115,116,117, 119, 120, 123, 125, 128, 133, 138, 139, 142, 143, 145, 147, 149,150,151,152,153,154, 156,157,158, 161,162,163,164, 168,169,170, 173,174,175, 178, 179, 181, 183, 184, 186,187,188,189, 194, 195, 198,199,200, 202,203,204, 209,210,211, 213, 215,216,217,218,219,220,221,222,223, 225, 228,229,230] (Fig. 5). Among these 71 policy documents, 47 were conducted in HIC [28, 37, 38, 42, 49, 58, 60, 61, 63, 71, 74, 76, 77, 82, 86, 91,92,93, 104,105,106, 112, 121, 122, 124, 127, 130, 135, 137, 144, 148, 159, 167, 171, 176, 180, 182, 185, 190, 192, 193, 197, 201, 206, 207, 226, 233], 10 were conducted in LMIC [27, 36, 64, 111, 114, 136, 160, 227, 231, 234] and 14 were conducted in both HIC and LMIC [25, 34, 41, 59, 66, 75, 126, 131, 134, 146, 155, 166, 177, 208]. In addition, most of these policy documents were targeted at workers (n = 66; 92.96%) [25, 27, 28, 34, 36,37,38, 41, 42, 49, 58, 60, 61, 63, 64, 66, 71, 74, 76, 77, 82, 86, 91,92,93, 104,105,106, 112, 121, 122, 124, 126, 127, 130, 131, 134,135,136,137, 144, 146, 148, 155, 159, 160, 166, 167, 171, 176, 177, 180, 182, 185, 190, 192, 193, 197, 201, 206, 207, 226, 227, 231, 233, 234] and were implemented at institutional level (n = 62; 87.32%) [25, 27, 28, 34, 36,37,38, 42, 49, 58, 61, 63, 64, 66, 71, 74, 76, 77, 82, 86, 91, 93, 104,105,106, 112, 114, 121, 122, 124, 126, 130, 131, 134,135,136,137, 144, 146, 148, 155, 159, 160, 166, 167, 171, 176, 177, 180, 182, 190, 192, 193, 197, 201, 206, 207, 226, 227, 231, 233, 234].

Fig. 5
figure 5

Rationale of Evidence for Justification of Inclusion of PROGRESS-Plus Components in Policy Documents

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Third, “indication level of equity” in policy documents was assessed. Our analysis found that only 2 policy documents (1.05%) [75, 209] had included terms related to equity and thus were deemed ‘high level’ whereas rest were considered to be of ‘low level’.

Subgroup analysis

For further analysis, policy documents were subdivided into two groups: policy documents targeted towards workers (n = 176; 83.01%) [23, 25,26,27,28,29,30,31,32, 34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49, 51, 53, 54, 57, 58, 60,61,62,63,64,65,66,67,68,69,70,71,72,73,74, 76,77,78,79,80,81,82,83, 85,86,87,88, 90,91,92,93, 96,97,98,99, 101,102,103,104,105,106,107,108,109,110, 112, 113, 115,116,117, 119,120,121,122,123,124,125,126,127,128, 130, 131, 133,134,135,136,137,138,139, 142,143,144,145,146,147,148,149,150,151,152,153, 155,156,157,158,159,160,161,162,163,164, 166,167,168,169,170,171, 173,174,175,176,177,178,179,180,181,182,183,184,185,186,187,188,189,190, 192,193,194,195, 197,198,199,200,201,202,203,204, 206, 207, 210, 211, 213, 218,219,220,221,222,223, 225,226,227,228, 230, 231, 233, 234] and policy documents targeted towards everyone else (n = 36; 16.98%) [24, 33, 50, 52, 55, 56, 59, 75, 84, 89, 94, 95, 100, 111, 114, 118, 129, 132, 140, 141, 154, 165, 172, 191, 196, 205, 208, 209, 212, 214,215,216,217, 224, 229, 232]. The policy documents were divided as such because workers are usually provided masks/PPE as a part of safety protocol across different working environments such as healthcare setting, shopping centers, transportation centers etc. Among policy documents that were not targeted at workers, the target groups were: “patients” (n = 6; 2.80%) [55, 56, 94, 100, 132, 217] and “population wide” (n = 30; 14.15%) [24, 33, 50, 52, 59, 75, 84, 89, 95, 111, 114, 118, 129, 140, 141, 154, 165, 172, 191, 196, 205, 208, 209, 212, 214,215,216, 224, 229, 232].

As expected, all of the policy documents that were targeted towards workers had at least “occupation” component of the PROGRESS-Plus framework. Among policy documents that were not targeted at workers, 16 documents were conducted in HIC [33, 50, 52, 55, 56, 89, 94, 100, 129, 132, 154, 165, 172, 191, 196, 229], 8 were conducted in LMIC [24, 84, 111, 114, 118, 205, 224, 232] and rest were conducted in HIC and LMIC [59, 75, 95, 140, 141, 208, 209, 212, 214,215,216,217]. In addition, most of these policy documents were implemented at national level [24, 33, 50, 52, 55, 56, 84, 94, 111, 129, 154, 165, 191, 196, 205, 224, 229, 232]. As opposed to ‘workers related’ policy documents most of these remaining policy documents didn’t have a PROGRESS-Plus equity component rendering them equity limiting. Specifically, 14 policy documents included consideration of a PROGRESS-Plus component [33, 52, 56, 59, 75, 111, 114, 154, 208, 209, 215,216,217, 229] whereas 22 policy documents didn’t have a PROGRESS-plus component [24, 50, 55, 84, 89, 94, 95, 100, 118, 129, 132, 140, 141, 165, 172, 191, 196, 205, 212, 214, 224, 232]. Specifically, 4 policy documents had ‘personal characteristics associated with discrimination’ as a component [33, 56, 216, 229], 2 policy documents had ‘place of residence’ as a component [75, 114]; 3 policy documents had ‘two components’ [52, 59, 111]; and 2 policy documents had ‘more than two components [208, 209]. Out of 14 policy documents that included a PROGRESS-Plus component [33, 52, 56, 59, 75, 111, 114, 154, 208, 209, 215,216,217, 229], only 5 policy documents explicitly mentioned the reason to include PROGRESS-plus component [59, 75, 111, 114, 208].

Discussion

To our knowledge, this is the first systematic review trying to ascertain the extent to which national, regional, institutional and organizational policies reflect equity considerations by focusing specifically on masks and personal protection equipment related policies. We have described the characteristics of the included policy documents including target population and implementation level among others. Most importantly, we have reported the equity factors considered within these policy documents using PROGRESS-plus equity framework. It is important to note that utilization of PROGRESS-plus framework for this research work is context specific and findings are limited to COVID-19 for most part. For instance, population types such as healthcare workers, essential workers are not usually considered vulnerable in society but in the context of COVID-19, increased risk of transmission of COVID-19 puts them at a disadvantage compared to the general population. Thus, findings of the research work should be interpreted within above mentioned scope.

Our review revealed that most of the included policy documents were from HIC. Specifically, we found that 64.15% policy documents were conducted/targeted towards HIC [26, 28,29,30,31,32,33, 37,38,39,40, 42,43,44,45,46, 48,49,50,51,52,53,54,55,56,57,58, 60, 61, 63, 71,72,73,74, 76, 77, 79,80,81,82, 85,86,87,88,89,90,91,92,93,94, 99,100,101,102,103,104,105,106,107, 110, 112, 113, 116, 117, 119, 121,122,123,124, 127, 129, 130, 132, 135, 137,138,139, 143,144,145, 147,148,149,150,151,152,153,154, 156, 158, 159, 161, 163,164,165, 167,168,169,170,171,172, 174,175,176, 179,180,181,182, 184, 185, 188,189,190,191,192,193,194,195,196,197,198,199,200,201,202,203,204, 206, 207, 220, 222, 223, 226, 228, 229, 233]; 18.40% were conducted/targeted towards LMIC [23, 24, 27, 35, 36, 47, 62, 64, 65, 67,68,69,70, 78, 83, 84, 108, 111, 114, 115, 118, 128, 136, 142, 160, 162, 173, 183, 186, 187, 205, 221, 224, 225, 227, 230,231,232, 234] and 17.45% were conducted/targeted towards both HIC and LMIC countries [25, 34, 41, 59, 66, 75, 95,96,97,98, 109, 120, 125, 126, 131, 133, 134, 140, 141, 146, 155, 157, 166, 177, 178, 208,209,210,211,212,213,214,215,216,217,218,219]. In addition, our analysis found that most of the policy documents were implemented at an institutional level. Specifically, 69.81% of the policy documents were implemented at institutional level [25, 27,28,29, 31, 32, 34,35,36,37,38, 40, 42,43,44,45,46, 48, 49, 51, 53, 58, 61,62,63,64,65,66, 71, 73, 74, 76,77,78, 80,81,82, 85, 86, 88,89,90,91, 93, 96, 99,100,101,102,103,104,105,106,107,108,109,110, 112,113,114,115, 117, 120,121,122,123,124,125,126, 128, 130,131,132,133,134,135,136,137,138,139, 142,143,144,145,146,147,148,149,150,151,152,153, 155,156,157,158,159,160,161,162,163,164, 166,167,168, 171, 173,174,175,176,177,178,179,180,181,182,183,184, 186, 188,189,190, 192, 193, 197, 199,200,201,202,203,204, 206, 207, 210, 211, 213, 220,221,222,223, 225,226,227,228, 230, 231, 233, 234] whereas 19.81% were implemented at national [23, 24, 26, 30, 33, 39, 47, 50, 52, 55,56,57, 67,68,69,70, 72, 79, 83, 84, 87, 92, 94, 97, 98, 111, 119, 129, 154, 165, 169, 170, 187, 191, 194,195,196, 198, 205, 224, 229, 232] and only 10.38% were implemented at global level [41, 54, 59, 60, 75, 95, 116, 118, 127, 140, 141, 172, 185, 208, 209, 212, 214,215,216,217,218,219]. These differences might be the result of variations in baseline risk, resources, health, and other system-level factors whether be at institutional or national level that hinder successful implementation of certain policies. For example, guidelines arising from HICs recommending the immediate upscaling of hospital care were not likely to be directly applicable to LMICs such as India because of an already overstretched medical system. In addition, mask mandates enacted in HICs were unlikely to be directly applicable to LMICs due to poverty related issues. Thus, policy makers should consider factors such as socioeconomic status, resource availability, place of residence while designing /implementing the policies. For example, Casola and colleagues [235] highlight that with 12% of US households living under the poverty line, many households may not have been able to purchase an adequate supply of masks for everyone in the household, or have the privilege of isolating at home while an adequate supply is delivered.

Equity assessment analysis revealed that most of the policy documents included only a single PROGRESS-Plus equity component (89.47%) [23, 25,26,27, 29,30,31,32,33,34,35,36,37, 40, 42,43,44,45,46, 48, 49, 51, 53, 54, 56, 58, 60, 62,63,64,65,66,67,68,69,70,71,72,73,74,75,76,77,78,79,80,81, 83, 85,86,87,88, 90, 91, 93, 96,97,98,99, 101,102,103,104,105,106,107,108,109, 112,113,114,115,116,117, 119,120,121, 123,124,125,126, 128, 130, 131, 133,134,135,136, 138, 139, 142,143,144,145,146,147,148,149,150,151,152,153,154,155,156,157,158,159,160,161,162,163,164, 166,167,168,169,170,171, 173,174,175,176,177,178,179,180,181,182,183,184, 186,187,188,189,190, 192,193,194,195, 197,198,199,200,201,202,203,204, 206, 207, 210, 211, 213, 215,216,217,218,219,220,221,222,223, 225,226,227,228,229,230,231, 234]. This finding reflects that even if policy documents considered health inequity during the design/implementation, this consideration was very one dimensional in nature. There is significant evidence that determinants of health or health equity related factors coexist across different levels of society and can incur interactive and multiplicative effects among the most disadvantaged subpopulations [236, 237]. People from some racial and ethnic minority groups are more likely to be uninsured than non-Hispanic whites [238]. Healthcare access can also be limited for these groups by many other factors, such as lack of transportation, child care, or ability to take time off of work; communication and language barriers; cultural differences between patients and providers; and historical and current discrimination in healthcare systems. Furthermore, inequities in access to high-quality education for some racial and ethnic minority groups can lead to lower high school completion rates and barriers to college entrance [239]. This may limit future job options and lead to lower paying or less stable jobs. These factors interacting together can not only increase the risk of these subpopulations to contract COVID-19 but also limit their ability to access good medical care. For instance, a poor (socioeconomic status) essential worker (occupation) in LMIC (place of residence) would be at a severe disadvantage of buying PPE/masks and protecting themselves from the transmission of COVID-19, and if contracted would be limited in getting treatment as well. Thus, policy makers should not only consider the presence of different equity related factors but also should consider the possible intersections between them while designing/implementing the policy.

Our review also revealed that very few policy documents acknowledged ‘health equity’ related issues in their text which illustrates that health equity was not a primary factor when these documents were being designed or implemented. Specifically, only 2 policy documents were found to have equity or inequity or health disparities in the aims, objectives or discussion. In addition, our assessment showed that, out of the selected documents, more than 10% of the policy documents [24, 50, 55, 84, 89, 94, 95, 100, 118, 129, 132, 140, 141, 165, 172, 191, 196, 205, 212, 214, 224, 232] had no PROGRESS-plus component mentioned or included in the policy. These findings indicate that significant proportion of policies were enacted with little to no emphasis on the ‘health equity’ mechanisms; which if enacted properly could have further improved the health outcomes for the society as whole.

Lastly, we analyzed the target population for the policies as well. Policy documents were subdivided into two groups: documents targeted towards workers. Our analysis found that majority of policy documents (n = 176; 83.01%) were targeted towards workers which was expected as they were at increased risk of contracting COVID-19 when compared to the general population. These targeted policies are usually equity enabling as workers are usually provided masks/PPE as a part of safety protocols across different working environments such as healthcare setting, shopping centers, transportation centers etc. and hence improve COVID-19 related health outcomes. Of the remaining 36 policy documents (16.98%), most were targeted towards whole population (n = 30; 14.15%) [24, 33, 50, 52, 59, 75, 84, 89, 95, 111, 114, 118, 129, 140, 141, 154, 165, 172, 191, 196, 205, 208, 209, 212, 214,215,216, 224, 229, 232]. Most of these policy documents did not include a PROGRESS-Plus equity component rendering them equity limiting for the society. These ‘whole population’ targeted policies should have considered equity as their success in improving COVID-19 related outcomes at a macro scale depends on a number of equity related factors such as education, gender, occupation, place of residence, socioeconomic status among others. Policy makers should identify relevant barriers to successful implementation of population wide policies while formulating such policies.

This study has several limitations that deserve mention. First, our search strategy was limited mainly to biomedical databases such as PubMed, EMBASE, CINAHL and Psycinfo with exceptions of ERIC and ASSIA. The search across a greater number of databases would have led to a substantial increase in the number of retrieved articles thus limiting the feasibility of the process.

In order to address this limitation, we supplemented our search with the documents that were identified by searching the reference list of the documents. Second, it was beyond the remit of this study to assess the potential generalizability of a specific policy, although our analyses of PROGRESS-Plus characteristics indicates that this would have been challenging given that there was little consideration about equity in implementation and impacts within settings, let alone consideration about implementation across different settings. Third, the narrative nature of the findings did not allow us to perform a pooled analysis of any kind (e.g. on the implementation of PPE/masking policies or their impact across different PROGRESS-Plus groups). Although such an analysis would be interesting for future research, this study addressed a different question around the consideration of health equity and inequity in COVID-19 policy and guideline development.

Conclusion

Policy makers should identify the importance of considering equity via PROGRESS-Plus components while devising guidelines for COVID-19 as these components affect both, risk of acquiring COVID-19 and the COVID-19 associated outcomes. Our review via focus on the masks/PPE policies across the globe highlights that the consideration of equity if present is very, 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. It is now clear that COVID-19 has disproportionately impacted minoritised and disadvantaged groups and the pandemic has been characterised as killing unequally, with mitigation measures being experienced unequally, and will further impoverish unequally [240]. Our analysis here indicates some of the most important set of policies designed to limit the spread of the pandemic – policies around limiting the pandemic through masking and PPE - were all too frequently devised without equity considerations, and suggests that pandemic response measures were designed from a particular lens (high income country, white, and middle class). In contrast, advancing progress towards equity will generate social, cultural, economic, and environmental wellbeing for the whole society.