Insight and equality: A systematic review and meta-analysis of socio-demographic associations.
Abstract BACKGROUNDInsight is often used in clinical and legal contexts e.g. as evidence of decision-making capacity. However, it is unclear whether this disadvantages certain groups protected under equality legislation. To our knowledge, this question has yet to be addressed systematically. Therefore, the present study reviews empirical studies that look at the relationship between insight and sociodemographic variables. METHODSA systematic search of six bibliographic databases (CENTRAL, CINAHL, Cochrane Library of Systematic Reviews, EMBASE, MEDLINE and PsycINFO) was conducted, which yielded 6192 results. Study characteristics and outcomes (associations between insight and socio-demographic variables) were then extracted from 207 eligible studies. This included protected characteristics under the Equality Act (2010): age, sex, ethnicity, marital status and religion. Weighted confidence estimates were calculated and relevant moderators included in a random effects meta-analysis. A study protocol was registered prospectively on PROSPERO, ID: CRD42019120117. RESULTSInsight was not strongly associated with age, gender or ethnicity. Better insight was weakly but significantly associated with white ethnicity, being employed, younger age and more years of education. The age associations were mostly explained relevant moderating variables. Cultural context (studies done in individualistic versus collectivist countries) did not moderate associations. For people with schizophrenia, the associations between sociodemographic variables and insight were comparable to associations with decision making capacity. CONCLUSIONSOur results moderate some concerns over whether insight is discriminatory if used as evidence in mental capacity assessment. We have identified specific subgroups where further research is needed to clarify potential associations.