# Development of the Kunonga framework for operationalising approaches to health inequality and/or inequity evidence syntheses

## TL;DR

The Kunonga framework helps researchers study health inequalities by integrating intersectionality and life-course perspectives into evidence synthesis methods.

## Contribution

The paper introduces the Kunonga framework, a novel methodological tool for incorporating intersectionality and life-course analysis into health inequality evidence syntheses.

## Key findings

- The framework includes practical tools like logic models and intersectionality-informed templates for data extraction.
- A case study demonstrated the framework's feasibility in analyzing ethnic inequalities in palliative care prescribing.
- The framework enhances analytical depth and policy relevance by addressing social complexity and temporal change.

## Abstract

Health inequalities and inequities are shaped by intersecting social determinants and cumulative life-course experiences. However, conventional evidence synthesis methods often lack the conceptual and analytical tools to capture this complexity. This limits their ability to inform inequality and/or inequity-sensitive policy and practice. In response, we developed a methodological framework to support the systematic integration of intersectionality and life-course perspectives into evidence synthesis.

Framework development followed a three-phase process. First, a systematic review identified conceptual and operational limitations in existing synthesis methods that seek to address health inequality and/or inequity. Second, semi-structured discussions were conducted with eight experts in health inequalities and evidence synthesis to elicit practice-relevant insights aimed at addressing these gaps. Third, findings from both phases were synthesised using a modified framework analysis to construct a structured thematic model aligned with key stages of evidence syntheses (protocol development, data extraction, analysis and synthesis), informing the design of the methodological framework.

The Kunonga Framework offers practical tools and methodological guidance for integrating inequality and/or inequity considerations across protocol development, data extraction, analysis, and synthesis stages. It is underpinned by three core principles: (1) distinguishing between health inequality and health inequity to improve conceptual clarity; (2) applying intersectionality to examine how overlapping social disadvantages shape health outcomes; and (3) adopting a life-course perspective to assess how inequalities and inequities emerge, accumulate and evolve over time. The framework provides practical tools, including logic models, intersectionality-informed extraction template and life-stage mapping, to support implementation. A case study on ethnic inequalities in palliative care prescribing illustrated the framework’s feasibility and highlighted its potential to enhance analytical depth and policy relevance.

The Kunonga Framework advances review methodology by translating intersectionality and life-course theory into practical guidance across protocol development, data extraction, analysis, and synthesis. It helps reviewers consider social complexity and change over time to understand for whom, how, and in what contexts interventions work. Although developed for inequality-focused reviews, future work should test the framework across different review types and methods and extend its principles of intersectionality and life-course to earlier stages, including searching and screening.

The online version contains supplementary material available at 10.1186/s12889-025-25688-4.