BackgroundThe implementation of evidence-based guidelines can improve clinical and public health outcomes by helping health professionals practice in the most effective manner, as well as assisting policy-makers in designing optimal programs. Adaptation of a guideline to suit the context in which it is intended to be applied can be a key step in the implementation process. Without taking the local context into account, certain interventions recommended in evidence-based guidelines may be infeasible under local conditions. Guideline adaptation frameworks provide a systematic way of approaching adaptation, and their use may increase transparency, methodological rigor, and the quality of the adapted guideline.This paper presents a number of adaptation frameworks that are currently available. We aim to compare the advantages and limitations of their processes, methods, and resource implications. These insights into adaptation frameworks can inform the future development of guidelines and systematic methods to optimize their adaptation.AnalysisRecent adaptation frameworks show an evolution from adapting entire existing guidelines, to adapting specific recommendations extracted from an existing guideline, to constructing evidence tables for each recommendation that needs to be adapted. This is a move towards more recommendation-focused, context-specific processes and considerations. There are still many gaps in knowledge about guideline adaptation. Most of the frameworks reviewed lack any evaluation of the adaptation process and outcomes, including user satisfaction and resources expended. The validity, usability, and health impact of guidelines developed via an adaptation process have not been studied. Lastly, adaptation frameworks have not been evaluated for use in low-income countries.ConclusionDespite the limitations in frameworks, a more systematic approach to adaptation based on a framework is valuable, as it helps to ensure that the recommendations stay true to the evidence while taking local needs into account. The utilization of frameworks in the guideline implementation process can be optimized by increasing the understanding and upfront estimation of resource and time needed, capacity building in adaptation methods, and increasing the adaptability of the source recommendation document.Electronic supplementary materialThe online version of this article (10.1186/s13012-018-0763-4) contains supplementary material, which is available to authorized users.

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BackgroundThe implementation of high-quality guidelines is essential to improve clinical practice and public health. The World Health Organisation (WHO) develops evidence-based public health and other guidelines that are used or adapted by countries around the world. Detailed implementation plans are often necessary for local policymakers to properly use the guidelines developed by WHO. This paper describes the plans for guideline implementation reported in WHO guidelines and indicates which of these plans are evidence-based.MethodsWe conducted a content analysis of the implementation sections of WHO guidelines approved by the WHO guideline review committee between December 2007 and May 2015. The implementation techniques reported in each guideline were coded according to the Cochrane Collaboration’s Effective Practice and Organisation of Care (EPOC) taxonomy and classified as passive, active or policy strategies. The frequencies of implementation techniques are reported.ResultsThe WHO guidelines (n = 123) analysed mentioned implementation techniques 800 times, although most mentioned implementation techniques very briefly, if at all. Passive strategies (21 %, 167/800) and general policy strategies (62 %, 496/800) occurred most often. Evidence-based active implementation methods were generally neglected with no guideline mentioning reminders (computerised or paper) and only one mentioning a multifaceted approach. Many guidelines contained implementation sections that were identical to those used in older guidelines produced by the same WHO technical unit.ConclusionsThe prevalence of passive and policy-based implementation techniques as opposed to evidence-based active techniques suggests that WHO guidelines should contain stronger guidance for implementation. This could include structured and increased detail on implementation considerations, accompanying or linked documents that provide information on what is needed to contextualise or adapt a guideline and specific options from among evidence-based implementation strategies.

This review is, in press, to be published in the Australian National Health and Medical Research Council’s (NHMRC) Guidelines for Guidelines. Background: Observational studies are the primary human study type for evaluating potential harm from environmental exposures, and therefore critical for developing public health guidance. Although there are tools for assessing methodological quality in observational studies, there is no consensus on optimal tools or key elements to include when assessing quality. This study aims to help decision makers in selecting tools to assess risk of bias in observational studies of exposures. Objective: To identify, describe, categorize elements into domains, and evaluate published tools designed to assess methodological quality or risk of bias in observational human studies assessing the effects of exposures. Study appraisal and synthesis: Data was extracted on the characteristics, development and testing of each tool. The categories of items were classified into 9 domains informed by the literature. Results: We identified 62 tools with 17 categories of similar or overlapping items. Conclusions: Our review highlights the need for a common tool for assessing risk of bias in human observational studies of exposures. Absent that common tool, this review provides a clear cross-walk across available tools and identifies four main take home messages: (1) the tool should have clear definitions for each item and be transparent regarding the empirical or theoretical basis for each domain, (2) tools should include questions addressing 9 domains: Selection, Exposure, Outcome assessment, Confounding, Loss to follow-up, Analysis, Selective reporting, Conflicts of interest and Other, (3) the ratings for each domain should be reported, rather than an overall score, (4) the tool should be rigorously and independently tested for usability and reliability. Systematic Review Registration: PROSPERO: CRD42018094173

Background The World Health Organisation (WHO) publishes a large number of clinical practice and public health guidelines to promote evidence-based practice across the world. Due to the variety of health system capacities and contextual issues in different regions and countries, adapting the recommendations in the guidelines to the local situation is vital for the success of their implementation. We aim to understand the range of experiences with guideline adaptation from the perspectives of those working in WHO regional and country offices. Our findings will inform development of guidance on how to improve adaptability of WHO guidelines. Methods A grounded theory-informed, qualitative study was carried out between March 2018 and December 2018. Seventeen semi-structured interviews were conducted with participants who included WHO guideline developers and staff in the headquarters, regional and country offices recruited from a sample of published WHO guidelines. Participants were eligible for recruitment if they had recent experience in clinical practice or public health guideline implementation. Deidentified transcripts of these interview were analysed through three cycles of coding. Results We categorised the adaptation processes described by the participants into two dominant models along a spectrum of guideline adaptation processes. First, the Copy or Customise Model is a pragmatic approach of either copying or customising WHO guidelines to suit local needs. This is done by local health authorities and/or clinicians directly through consultations with WHO staff. Selections and adjustments of guideline recommendations are made according to what the implementers deemed important, feasible and applicable through the consensus discussions. Second, the Capacity Building Model focuses on WHO building local capacity in evidence synthesis methods and adaptation frameworks to support local development of a national guideline informed by international guidelines. Conclusions In comparing and contrasting these two models of guideline adaptation, we outline the different kinds of support from WHO that may be necessary to improve the effectiveness and efficiency of the respective models. We also suggest clarifications in the descriptions of the process of guideline adaptation in WHO and academic literature, to help guideline adaptors and implementers decide on the appropriate course of action according to their specific circumstances. Ethics This project was conducted with ethics approval from The University of Sydney (Project number: 2017/723) and WHO (Protocol ID: 00001).