1 Approach to guideline developmentWHO 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 recommendationFactors that affect the grading of the strength of recommendation

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

6 The guideline

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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

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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 recommendationFactors that affect the grading of the strength of recommendation

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

21 Strength of recommendationA 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 recommendationsStrong 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 recommendationsStrong 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 recommendationsStrong 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 recommendationFactors that affect the grading of the strength of recommendation

26 Factors affecting recommendationGRADE 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 recommendationPriority of the problem Quality of evidence Balance of benefits and harms Values and preferences Resource use Equity Feasibility Acceptability

28 Evidence to Decision tableTool 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 tableThe 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?

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43 Determinants of quality

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