Promoting equitable inclusion in a multi-centre randomized controlled trial on palliative rehabilitation for advanced cancer in Europe: a collaborative synthesis using a ‘world café’ approach

Equity is receiving increasing attention in palliative care. In particular, access to palliative care services and research is a significant challenge for some populations, including ethnic minorities, migrants, socioeconomically disadvantaged groups, and people with disabilities. This study concerns equitable inclusion in a multi-national palliative care trial. A special focus is directed towards collaborative learning and the development of actionable recommendations, including how actionable insights may underpin equitable inclusion in future clinical trials. A novel three-step participatory approach was used to co-create knowledge and foster ongoing reflection within a multinational research consortium to improve the inclusion of underserved groups in clinical research. This included identification of barriers, development of tailored equitable inclusion plans, and a ‘world café’ to map areas for future focus. Data collected were subjected to reflexive thematic analysis informed by pragmatism, with findings iteratively refined through collaboration with consortium partners to ensure agreement. Several factors were identified as essential for advancing equitable inclusion. First, effective planning requires a nuanced understanding of local contexts, which highlights the importance of tailored, site-specific strategies over generic approaches that ignore context. Second, collaboration with clinicians and patient representatives emerged as critical, along with language adaptation (both written and verbal) and geographical accessibility. Third, cultivating an inclusive culture requires attention to unconscious bias among clinical staff, ongoing training, and clear communication of goals. Importantly, time and effort must be allocated to devise and exercise inclusive practices to address structural barriers posed by institutional governance. Case stories from the recruitment sites suggest that the collaborative production of equitable inclusion plans led to more inclusive practices across the research consortium. Equitable inclusion may be facilitated by tailoring services to individual contexts and needs. Successful facilitation requires cultivation of an inclusive culture. The novel participatory approach presented in this study and the resulting findings may inspire other research communities and collaborations to prioritize equitable inclusion.