Developing the INCLUDE Ethnicity Framework: a tool to help trialists design trials that better reflect the communities they serve

Shaun Treweek* (Corresponding Author), Katie Banister, Peter Bower, Seonaidh Cotton, Declan Devane, Heidi Gardner, Talia Isaacs, Gary Nestor, Adepeju Oshisanya, Adwoa Parker, Lynn Rochester, Irene Soulsby, Hywel C Williams, Miles D Witham

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

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Ensuring that a trial is designed so that its participants reflect those who might benefit from the results, or be spared harms, is key to the potential benefits of the trial reaching all they should. This paper describes the process, facilitated by Trial Forge, that was used between July 2019 and October 2020 to develop the INCLUDE Ethnicity Framework, part of the wider INCLUDE initiative from the National Institute for Health Research to improve inclusion of under-served groups in clinical research studies.

Development of the Framework was done in seven phases: (1) outline, (2) initial draft, (3) stakeholder meeting, (4) modify draft, (5) Stakeholder feedback, (6) applying the Framework and (7) packaging. Phases 2 and 3 were face-to-face meetings. Consultation with stakeholders was iterative, especially phases 4 to 6. Movement to the next phase was done once all or most stakeholders were comfortable with the results of the current phase. When there was a version of the Framework that could be considered final, the Framework was applied to six trials to create a set of examples (phase 6). Finally, the Framework, guidance and examples were packaged ready for dissemination (phase 7).

A total of 40 people from stakeholder groups including patient and public partners, clinicians, funders, academics working with various ethnic groups, trial managers and methodologists contributed to the seven phases of development. The Framework comprises two parts. The first part is a list of four key questions:

Who should my trial apply to?

Are the groups identified likely to respond in different ways?

Will my study intervention make it harder for some groups to engage?

Will the way I have designed the study make it harder for some groups to engage?

The second part is a set of worksheets to help trial teams address these questions. The Framework can be used for any stage of trial, for a healthcare intervention in any disease area. The Framework was launched on 1st October 2020 and is available open access at the Trial Forge website:

Thinking about the number of people in our trials is not enough: we need to start thinking more carefully about who our participants are.
Original languageEnglish
Article number337
Number of pages12
Early online date10 May 2021
Publication statusPublished - 2021

Bibliographical note

The Health Services Research Unit at the University of Aberdeen receives core funding from the Chief Scientist Office of the Scottish Government Health Directorates.

This work has received funding from the National Institute for Health Research (NIHR) INCLUDE initiative led from the Newcastle University CRN Cluster Office, NIHR Senior Investigator funding provided to PB and the UK Research Innovation-Medical Research Council COVID-19 Rapid Response funding (grant MR/V020544/1). MDW acknowledges support from the NIHR Newcastle Biomedical Research Centre.


  • Ethnicity
  • External validity
  • Inclusion
  • Randomised controlled trials
  • Methodology


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