A Meta-epidemiological study of the Diversity, Transparency and Accessibility of PRISMA extension development

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines are widely perceived as the gold standard for reporting evidence syntheses. However, the diversity of contributors, transparency of development processes, and accessibility of PRISMA checklists have not been systematically examined. We conducted a meta-epidemiological analysis of 21 guidelines identified as PRISMA or PRISMA extensions, assessing equity, diversity, and inclusion (EDI) measures; transparency in guideline development; and the implementability and accessibility of checklists. Women were well represented among authors (47%), but geographic representation was limited: only 11% of authors were affiliated with institutions in the Global South (0.01% excluding China), and 62% of extensions had no contributors from these regions. Transparency varied: most extensions (72%) reported following established methodological frameworks and 62% sought external feedback, yet only 24% provided summaries of consensus meetings and none reported repeatability or inter-rater reliability testing. Accessibility was similarly inconsistent: while 86% provided a reporting checklist, only 10% offered open-access, editable formats. We provide practical recommendations to address these gaps and introduce an open-source reporting template. Our findings highlight the need for reform in the development of widely adopted reporting standards that underpin evidence synthesis and inform global decision-making.