1. Approach to guideline development
WHO guidelines on health policy and system support to optimize community health worker programmes 1st meeting of Guideline Development Group Geneva, Switzerland, October 2016
Approach to guideline development
Elie Akl, MD, MPH, PhD
American University of Beirut, Lebanon

2. Disclosures
Member of the GRADE working group and of the GRADE Guidance Group
Consult for groups applying GRADE
No other intellectual or financial COI

3. On my way to Geneva

4. Outline Describing our task Defining the strength of recommendation
Factors that affect the grading of the strength of recommendation

5. Outline Describing our task Defining the strength of recommendation
Factors that affect the grading of the strength of recommendation

6. The guideline

8. The recommendation

9. The recommendation

10. The recommendations
Guidelines should provide answers to the questions raised by the target users
A recommendation is a direct answer to a specific policy question
The starting point is a policy question addressing different options

11. The question
Policy question: Should LAY HEALTH WORKERS distribute oral supplements to pregnant women?

12. The question
Population/Problem: Poor access to oral supplements for pregnant women
Intervention: LHWs distribution of oral supplements
Control: No care delivered
Outcomes:
Use of supplements by pregnant
Adverse effects related to use of supplements

13. The question
Population/Problem: Poor access to oral supplements for pregnant women
Intervention: LHWs distribution of oral supplements
Control: No care delivered
Outcomes:
Use of supplements by pregnant
Adverse effects related to use of supplements

14. The overall process

16. Grades of Recommendation Assessment, Development and Evaluation
2008 BMJ series
2011 JCE series

17. Adopted by more than 90 organizations

18. GRADE framework Emphasizes: Uses standardized tables to present:
Systematic approach
Explicitness
Transparency
Uses standardized tables to present:
Summary of evidence (evidence profile)
The factors that affect the final recommendation (Evidence to Decision (EtD) table)

19. Outline Describing our task Defining the strength of recommendation
Factors that affect the grading of the strength of recommendation

20. Strength of recommendation
The extent to which we can be confident that the desirable effects of an intervention outweigh the undesirable effects.

21. Strength of recommendation
A recommendation can have one of 2 strength:
Strong : panel is confident that the desirable effects of adherence to the recommendation outweigh the undesirable effects (or vice versa).
Conditional : panel concludes that the desirable effects of adherence to the recommendation probably outweigh the undesirable effects (or vice versa), but is not confident.

22. Implications of strong and conditional recommendations
Strong recommendation
Conditional recommendation
Patients
Most people in your situation would want the recommended course of action and only a small proportion would not
The majority of people in your situation would want the recommended course of action, but many would not
Clinicians
Policy makers

23. Implications of strong and conditional recommendations
Strong recommendation
Conditional recommendation
Patients
Most people in your situation would want the recommended course of action and only a small proportion would not
The majority of people in your situation would want the recommended course of action, but many would not
Clinicians
Most patients should receive the recommended course of action
Be prepared to help patients to make a decision that is consistent with their own values
Policy makers

24. Implications of strong and conditional recommendations
Strong recommendation
Conditional recommendation
Patients
Most people in your situation would want the recommended course of action and only a small proportion would not
The majority of people in your situation would want the recommended course of action, but many would not
Clinicians
Most patients should receive the recommended course of action
Be prepared to help patients to make a decision that is consistent with their own values
Policy makers
The recommendation can be adapted as a policy in most situations
There is a need for substantial debate and involvement of stakeholders

25. Outline Describing our task Defining the strength of recommendation
Factors that affect the grading of the strength of recommendation

26. Factors affecting recommendation
GRADE framework
Factors affecting recommendation
Clinical guidelines
PH guidelines 1.0
PH guidelines 2.0
Extent of the problem
Quality of evidence
Balance benefits/harms
Values and preferences
Acceptability
Resource use
Feasibility
Equity

27. Determining strength of recommendation
Priority of the problem
Quality of evidence
Balance of benefits and harms
Values and preferences
Resource use
Equity
Feasibility
Acceptability

28. Evidence to Decision table
Tool we will be using to move draft the recommendations

29. Evidence to Decision table

30. Evidence to Decision table

31. Evidence to Decision table

32. Evidence to Decision table

33. Evidence to Decision table

34. Evidence to Decision table

35. Evidence to Recommendation table
The table helps with:
Using a systematic and explicit approach to making recommendations
Making transparent the judgments about the factors affecting the recommendation
Providing supporting evidence to judgments

36. Thank you Questions?

43. Determinants of quality