Advancing the WHO-INTEGRATE Framework as a Tool for Evidence-Informed, Deliberative Decision-Making Processes: Exploring the Views of Developers and Users of WHO Guidelines.

Jan M Stratil,Eva A Rehfuess,Manfred Wildner,Deepak Paudel,Carlos E Menezes De Rezende,Aline A Monroe,Jimmy Osuret,Inger B Scheel,Karen E Setty

doi:10.34172/ijhpm.2020.193

Abstract

Background: Decision-making on matters of public health and health policy is a deeply value-laden process. The World Health Organization (WHO)-INTEGRATE framework was proposed as a new evidence-to-decision (EtD) framework to support guideline development from a complexity perspective, notably in relation to public health and health system interventions, and with a foundation in WHO norms and values. This study was conducted as part of the development of the framework to assess its comprehensiveness and usefulness for public health and health policy decision-making. Methods: We conducted a qualitative study comprising nine key informant interviews (KIIs) with experts involved in WHO guideline development and four focus group discussions (FGDs) with a total of forty health decision-makers from Brazil, Germany, Nepal and Uganda. Transcripts were analyzed using MAXQDA12 and qualitative content analysis. Results: Most key informants and participants in the FGDs appreciated the framework for its relevance to real-world decision-making on four widely differing health topics. They praised its broad perspective and comprehensiveness with respect to new or expanded criteria, notably regarding societal implications, equity considerations, and acceptability. Some guideline developers questioned the value of the framework beyond current practice and were concerned with the complexity of applying such a broad range of criteria in guideline development processes. Participants made concrete suggestions for improving the wording and definitions of criteria as well as their grouping, for covering missing aspects, and for addressing overlap between criteria.Conclusion: The framework was well-received by health decision-makers as well as the developers of WHO guidelines and appears to capture all relevant considerations discussed in four distinct real-world decision processes that took place on four different continents. Guidance is needed on how to apply the framework in guideline processes that are both transparent and participatory. A set of suggestions for improvement provides a valuable starting point for advancing the framework towards version 2.0.

Highlights

Making evidence-informed decisions about public health and health system interventions and policies is complex.[1,2,3] On the one hand, producing and assessing evidence eg, on the effectiveness of public health and health policy interventions is challenging due to the complexity of the interventions themselves.[4]
We conducted nine key informant interviews (KIIs) with experts involved in World Health Organization (WHO) guideline development on an international level as well as four focus group discussions (FGDs) with health decision-makers in Brazil, Germany, Nepal, and Uganda
Our study suggests that the WHO-INTEGRATE framework can be a valuable resource for better-informed public health and health systems decisions

Summary

Introduction

Making evidence-informed decisions about public health and health system interventions and policies is complex.[1,2,3] On the one hand, producing and assessing evidence eg, on the effectiveness of public health and health policy interventions is challenging due to the complexity of the interventions themselves (eg, the number of components, or the pathway leading to multiple outcomes).[4] due to interactions with the system in which these are implemented (eg, system changes due to emergent properties, adaptivity, or feedback mechanisms) as well as due to the high contextdependency of the effects of the intervention.[2,5] On the other hand, producing more and stronger evidence eg, on the efficacy or cost-effectiveness of an intervention is in itself not sufficient to make better choices, as evidenceinformed decision-making is a deeply value-laden process.[6,7,8] Decision-makers must balance numerous and often conflicting normative and technical aspects for a decisionmaking process,[9,10,11] which represents an additional source of complexity (eg, which criteria should be considered and how should these be weighed against each other)?

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Conclusion