J Clin Epidem: Strength of recommendations in WHO guidelines using GRADE was associated with uptake in national policy

‘The results of this study represent a first step in the analysis of the uptake of WHO recommendations at the country level based on the strength of the recommendation.’ Below are the citation, abstract and key findings of a paper in the Journal of Clinical Epidemiology. Unfortunately the full text is restricted-access.

CITATION: Nasser SM, Cooke G, Kranzer K, Norris SL, Olliaro P, Ford N. Strength of recommendations in WHO guidelines using GRADE was associated with uptake in national policy. J Clin Epidemiol. 2015 Jun;68(6):703-7. doi: 10.1016/j.jclinepi.2014.11.006. Epub 2014 Dec 13.


Contact email: fordn@who.int


OBJECTIVES: This study assesses the extent to which the strength of a recommendation in a World Health Organization (WHO) guideline affects uptake of the recommendation in national guidelines.

STUDY DESIGN AND SETTING: The uptake of recommendations included in HIV and TB guidelines issued by WHO from 2009 to 2013 was assessed across guidelines from 20 low- and middle-income countries in Africa and Southeast Asia. Associations between characteristics of recommendations (strength, quality of the evidence, type) and uptake were assessed using logistic regression.

RESULTS: Eight WHO guidelines consisting of 109 strong recommendations and 49 conditional recommendations were included, and uptake assessed across 44 national guidelines (1,255 recommendations) from 20 countries. Uptake of WHO recommendations in national guidelines was 82% for strong recommendations and 61% for conditional recommendations. The odds of uptake comparing strong recommendations and conditional recommendations was 1.9 (95% confidence interval: 1.4, 2.7), after adjustment for quality of evidence. Higher levels of evidence quality were associated with greater uptake, independent of recommendation strength.

CONCLUSION: Guideline developers should be confident that conditional recommendations are frequently adopted. The fact that strong recommendations are more frequently adopted than conditional recommendations underscores the importance of ensuring that such recommendations are justified.

Key findings

– Uptake of World Health Organization recommendations in national guidelines is high and associated with strength of recommendation and evidence quality. A higher level of evidence quality was associated with greater uptake of the recommendation, independent of strength.

What this adds to what was known?

– Conditional recommendations are frequently adopted, although less frequently than strong recommendations.

Best wishes, Neil

Let’s build a future where people are no longer dying for lack of healthcare knowledge – Join HIFA: www.hifa2015.org  

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