The Guideline Uptake in Digital Ecosystems (GUIDE) study: protocol for implementation research on the impact of WHO SMART guidelines digital adaptation kits to improve quality of care

ObjectivesDigital tools for decision-support and health records can address the protracted process of guideline adoption at local levels and accelerate countries’ implementation of new health policies and programmes. World Health Organization (WHO) launched the SMART Guidelines approach to support the uptake of clinical, public health, and data recommendations within digital systems. SMART guidelines are a package of tools that include Digital Adaptation Kits (DAKs), which distill WHO guidelines into a format that facilitates translation into digital systems. SMART Guidelines also include reference software applications known as digital modules.MethodsThis paper details the structured process to inform the adaptation of the WHO antenatal care (ANC) digital module to align with country-specific ANC packages for Zambia and Rwanda using the DAK. Digital landscape assessments were conducted to determine potential integrations between the ANC digital module and existing systems. A multi-stakeholder team consisting of Ministry of Health technical officers representing maternal health, HIV, digital health, and monitoring and evaluation at district and national levels was assembled to review existing guidelines to adapt the DAK.ResultsThe landscape analysis resulted in considerations for integrating the ANC module into the broader digital ecosystems of both countries. Adaptations to the DAK included adding national services not reflected in the generic DAK and modification of decision support logic and indicators. Over 80% of the generic DAK content was consistent with processes for both countries. The adapted DAK will inform the customization of country-specific ANC digital modules.ConclusionBoth countries found that coordination between maternal and digital health leads was critical to ensuring requirements were accurately reflected within the ANC digital module. Additionally, DAKs provided a structured process for gathering requirements, reviewing and addressing gaps within existing systems, and aligning clinical content.

BackgroundCoronavirus disease 2019 (COVID‐19) began in 2019 with several unknown factors. The World Health Organization (WHO) subsequently developed COVID‐19 occupational safety and health (OSH) guidelines to reduce occupational COVID‐19 transmission. Many countries also developed their own COVID‐19 OSH guidelines, but whether these guidelines included WHO's guidelines and whether including WHO's guidelines in countries' COVID‐19 OSH guidelines reduced COVID‐19 transmission is unknown.ObjectivesThe objectives of our study were to (1) compare the COVID‐19 OSH guidelines of several countries to WHO's OSH guidelines, (2) estimate associations between characteristics of countries and their OSH guidelines and the number of WHO's OSH guidelines included in countries' OSH guidelines, and (3) estimate associations between WHO's OSH guidelines included in countries' OSH guidelines and COVID‐19 risk, death risk, and case‐fatality proportion.MethodsThis study represents international, ecological research of 36 countries from all six world health regions. Countries' COVID‐19 OSH guidelines were compared with WHO's OSH guidelines. Linear regression models adjusted for potential confounders were used to estimate associations of interest.ResultsThe median number of WHO's 15 COVID‐19 OSH guidelines included in countries' COVID‐19 OSH guidelines was eight. Countries' COVID‐19 OSH guidelines focused on workers included significantly more of WHO's COVID‐19 OSH guidelines than countries' COVID‐19 OSH guidelines focused on general populations. Including “provide personal protective equipment for workers” and “create workplace policy for wearing personal protective equipment” in countries' COVID‐19 OSH guidelines were significantly related to decreased COVID‐19 risk, death risk, and/or case‐fatality proportion.ConclusionsCountries' COVID‐19 OSH guidelines should include WHO's guidelines, focus on workers, and include “provide personal protective equipment for workers” and “create workplace policy for wearing personal protective equipment.”

In disasters and emergency situations, a lot of drug and medical supplies comes to the affected area from local or international donors. But, those donations often generate more problems for the recipients. The WHO and major humanitarian organisations developed WHO Guidelines for Drug Donations in 1996. The guidelines based on four core principles which are all donation should benefit the recipient, respect for wishes and authority of the recipient, there should not be a double standard in quality, and effective communication between donor and recipient. The guidelines influenced positively to drug donation practices for several years until 2004. The drug donation practices during 2004 tsunami relief in Sri Lanka and Aceh (Indonesia) showed that the compliance with WHO Guidelines for Drug Donations was low. This study aim was to strengthen the effectiveness of WHO Guidelines for Drug Donations in disaster and emergency situations. While the objectives are to explore the strength and weakness of the WHO Guidelines for Drug Donations and to recommend how to improve the effectiveness of drug donations. In this study, the WHO Guidelines for Drug Donations were analysed using the model of health policy analysis from Walt and Gilson, which is specifically used for analysing health policies. The framework is viewed as a tool to describe the interactions and interconnections systems between content, context, process and groups of actors. The author concludes that presence of donation operator team for drug donations is needed during the emergency situations and it should be stated in the WHO Guidelines for Drug Donations. The WHO needs to encourage donors and recipients to refer to WHO Guidelines for Drug Donations when they are making their own guidelines. The guidelines can be strengthened at country level and adjusted to regulations in the countries. The WHO Guidelines for Drug Donations should state that donations are preferred in form of New Emergency Health Kit (NEHK) or cash donations, and the necessity of information and communication centre in the WHO Guidelines for Drug Donations.

Background: Animal bites are one of the leading causes of visits to an emergency room (ER) in Thailand. Rabies is an almost invariably fatal disease. Objectives: We evaluated the appropriateness of rabies vaccination in clinical practice following the World Health Organization (WHO) guidelines. Methods: All patients who visited the ER at Ramathibodi Hospital of Mahidol University because of mammal bites and received rabies vaccination by the WHO rabies postexposure regimen were enrolled. Data were retrievedfrom medical records. Wound categories were classified by WHO guidelines both in real practice and by the investigators on subsequent investigation. Results: The agreement between clinical practice and the WHO guidelines was calculated and reported as kappa statistics. There were 372 eligible patients. The mean age was 36 years and 172 patients were male.The agreement between clinical practice and the WHO guidelines was a disturbing 26.9% with a kappa statistic of -0.02, P = 0.56. Conclusion: Even in a referral and teaching hospital, rabies postexposure vaccination in Thailand was not appropriate according to WHO guidelines. Keywords: Postexposure, pragmatic study, rabies, vaccination, WHO guideline

Poor adherence to guidelines during empirical antibiotic prescription in low-income countries could increase antimicrobial resistance without improving outcomes. Revised World Health Organization (WHO) guidelines published in 2014 on childhood (2-59 months) pneumonia re-defined the classification of severe pneumonia and changed the first-line treatment. The adherence to WHO guidelines in southern Ethiopia at the hospital level is unknown. We sought to determine the adherence to WHO guidelines on severe pneumonia first-line treatment in children in an Ethiopian referral hospital and assess the impact of non-adherence on patient outcomes. An observational study was conducted on all children (2-59 months) clinically diagnosed with severe pneumonia and admitted to the Pediatric Ward of Jinka Hospital from 1 June 2021 to 31 May 2022. Exclusion criteria included a known HIV infection, ongoing antibiotic treatment before the event not related to acute pneumonia, or any other severe bacterial infection, confirmed or suspected. Adherence to guidelines was defined as first-line treatment with ampicillin or benzylpenicillin and gentamicin at the recommended dose. We compared the patients treated adherently vs. non-adherently. For categorical variables, the chi-square or Fisher's exact test was used, while for continuous variables, the Mann-Whitney U-test was used. Multivariate logistic regression was used to evaluate the association between adherence and demographic and clinical characteristics. During the observational period, 266 patients were registered as having severe pneumonia with an age between 2 and 59 months. After excluding 114 patients due to missing charts or other exclusion criteria, a total of 152 patients were included in the analysis. Of these, 78 (51%) were girls with a median age of 10 months (IQR 7-14). Overall, 75 (49%) patients received therapy according to the WHO guidelines. Compared to patients treated adherently to the guidelines, patients not treated adherently had similar outcomes [median length of stay of 3 (IQR 3-5) and 4 (IQR 3-6) days], median duration of oxygen therapy of 2 (IQR 1-3) for both the groups, and self-discharge rates of 5% and 6.5%, respectively). Adherence to the revised WHO guideline was limited and not associated with outcomes. Efforts should focus on reducing the gap between theory and practice.

Mathematical modeling studies are frequently conducted to guide policy in global health. However, the contribution of mathematical modeling studies to World Health Organization (WHO) guideline recommendations, and the quality of evidence contributed by these studies remains unknown. We conducted a systematic review of the WHO Guidelines Review Committee database to identify guideline recommendations that included evidence from mathematical modeling studies since inception of the Guidelines Review Committee on 1 December, 2007. We included WHO guideline recommendations citing a mathematical modeling study in the primary evidence base. We defined a mathematical model as a framework that predicted epidemiologic, health or economic impact of an intervention or decision in the clinical or public health context. The primary outcome was inclusion of evidence from mathematical modeling studies in a guideline recommendation. We evaluated each unique modeling study across multiple domains of quality. Between 1 December 2007 and 1 April 2019, the WHO Guidelines Review Committee approved 154 guidelines providing 1619 guideline recommendations. Mathematical modeling studies informed 46 WHO guidelines (29.9%) and 101 unique guideline recommendations (6.2%). Modeling evidence addressed topics related to infectious diseases in 38 guidelines (82.6%) and 81 recommendations (80.2%), most commonly for HIV and tuberculosis. Evidence from modeling studies was assessed in the GRADE evidence profile for 12 recommendations (12.9%) and GRADE evidence-to-decision framework for 45 recommendations (44.6%). Modeling-informed recommendations were more likely than other recommendations within the same guidelines to be issued with a “conditional” rather than “strong” strength of recommendation (53.5% versus 37.8%), and the evidence underlying modeling-informed recommendations was more likely to be assessed as very low quality (41.6% versus 24.1%). Upon review of individual modeling studies, we estimated that 33.8% of models performed a calibration, 29.4% of models performed a validation of results, and 20.6% of models reported a change in the study conclusion in the sensitivity analysis. While policy recommendations in WHO guidelines are informed by evidence from modeling studies, the validity of modeling studies included in guidelines development is heterogeneous. Quality assessment is needed to support the evaluation and incorporation of evidence from mathematical modeling studies in guidelines development.

Background: Cotrimoxazole prophylactic therapy (CPT) is a feasible, cost-effective, and safe way of using cotrimoxazole intervention to reduce HIV/AIDS related morbidities and mortalities associated with opportunistic infections. Despite its effectiveness in reducing the incidence of opportunistic infections, the actual drug utilization process has been shown to deviate from World Health Organization (WHO) guideline in Ethiopia. This study, therefore, aims to evaluate CPT among HIV/AIDS patients in Jugel Hospital (JH), Harar and Dilchora Referral Hospital (DRH), Dire Dawa, Eastern Ethiopia.Methods: A cross sectional study was conducted to evaluate the use of cotrimoxazole as prophylactic therapy. In this study, 556 medical records (305 in JH and 251 in DRH) of HIV/AIDS patients who had been taking CPT within September 2015–August 2016 were reviewed. Systematic random sampling was employed to obtain medical records from the sampling frame. Data were abstracted from the patient medical records using structured checklist customized from the WHO guideline. The data were entered into Epi-data 3.1 and exported to and analyzed with statistical Package for Social Sciences (SPSS) version 20. The finding was evaluated against the WHO guideline on the use of cotrimoxazole prophylaxis in HIV/AIDS patients. Descriptive statistics was used to present the data in tables, figures and pie chart.Results: Majority of the HIV/AIDS patients who had been taking CPT were adults (95.9%), female (61.2%), married (43.7%), Orthodox Christian (54.3%), and attended primary school (40.1%). At the initiation of CPT, most of the patients were at WHO clinical stage III (40.8%). The major comorbid illnesses identified were tuberculosis and pneumocystis-jiroveci pneumonia. Initially, majority of the patients were at CD4 count of less than 350 cells/mm3 (n = 504, 90.6%). Greater proportion of patients started CPT prior to initiating antiretroviral therapy (ART). Most of the patients took CPT for greater than 6 months. The primary reasons for premature discontinuation of CPT were CD4 greater than 350 cells/mm3, severe sulfa allergy and first trimester of pregnancy. Generally, the use of cotrimoxazole prophylaxis was consistent with the WHO guideline for indication to start (n = 519, 93.3%) and dose (n = 552, 99.28%), despite the presence of contraindication in 6.65% patients.Conclusion: In reference to the WHO guideline, the use of CPT was found to be fully appropriate in nearly two-thirds of HIV/AIDS patients. For the rest patients, inappropriate use of cotrimoxazole was observed based on the WHO criteria for initiation, discontinuation, continuation and dose with rate of discontinuation being the dominant one. Such practice may lead to adverse health outcomes including adverse drug reactions and negative treatment outcome.

Background: Animal bites are one of the leading causes of visits to an emergency room (ER) in Thailand. Rabies is an almost invariably fatal disease. Objectives: We evaluated the appropriateness of rabies vaccination in clinical practice following the World Health Organization (WHO) guidelines. Methods: All patients who visited the ER at Ramathibodi Hospital of Mahidol University because of mammal bites and received rabies vaccination by the WHO rabies postexposure regimen were enrolled. Data were retrieved from medical records. Wound categories were classified by WHO guidelines both in real practice and by the investigators on subsequent investigation. Results: The agreement between clinical practice and the WHO guidelines was calculated and reported as kappa statistics. There were 372 eligible patients. The mean age was 36 years and 172 patients were male. The agreement between clinical practice and the WHO guidelines was a disturbing 26.9% with a kappa statistic of -0.02, P = 0.56. Conclusion: Even in a referral and teaching hospital, rabies postexposure vaccination in Thailand was not appropriate according to WHO guidelines.

BackgroundThe 2021 World Health Organization (WHO) guidelines on cervical cancer screening and treatment provide countries with evidence-based recommendations to accelerate disease elimination. However, evidence shows that health providers’ adherence to screening guidelines is low. We conducted a study in Argentina to analyze health providers’ knowledge and perceptions regarding the 2021 WHO Guidelines.MethodsA qualitative study was conducted based on individual, semi-structured interviews with health providers specializing in gynecology (n = 15). The themes explored were selected and analyzed using domains and constructs of the Consolidated Framework for Implementation Research.ResultsAlthough health providers perceive WHO as a reliable institution, they do not know the 2021 guidelines, its supporting evidence, and its elaboration process. Their clinical practice is mainly guided by local recommendations developed by national professional medical associations (PMAs). For interviewees, WHO guidelines should be disseminated through health authorities and national PMAs, mainly through in-service training. Health providers had a positive assessment regarding WHO Recommendation 1 (screen, triage, and treatment for women aged 30 + with HPV-testing every 5 to 10 years) and perceived a favorable climate for its implementation. HPV-testing followed by triage was considered a low-complexity practice, enabling a better detection of HPV, a better selection of the patients who will need diagnosis and treatment, and a more efficient use of health system resources. However, they suggested adapting this recommendation by removing screening interval beyond 5 years. WHO Recommendation 2 (screen-and-treat approach with HPV-testing for women aged 30 + every 5 to 10 years) was predominantly rejected by interviewees, was considered an algorithm that did not respond to women’s needs, and was not adequate for the Argentinean context. Regarding the HPV-test modality, clinician-collected tests were the preferred mode. Health providers considered that HPV self-collection should be used primarily among socially vulnerable women to increase screening coverage.ConclusionWHO guidelines should be widely disseminated among health providers, especially in settings that could benefit from a screen-and-treat approach. Identifying areas of partnership and collaboration with PMAs in implementing WHO guidelines is essential.

Digital health innovations represent unique opportunities to address maternal, newborn, and child health challenges in Sub-Saharan Africa. In 2021, the World Health Organization (WHO) launched the Digital Adaptation Kits (DAKs) for antenatal care (ANC) as part of its Standards-Based, Machine-Readable, Adaptive, Requirements-Based, and Testable (SMART) guidelines approach. DAKs are operational and software-neutral mechanisms that convert WHO guidelines into standardized formats that can be easily integrated into digital systems by various countries. This article outlines the methodology for updating and integrating WHO DAK content into the BornFyne-prenatal management system (PNMS) version 2.0. This study, which employs a participatory action research approach, is part of a larger research study for the BornFyne-PNMS project. A review of the ANC DAK operational document and data dictionaries was conducted to identify elements that were present in BornFyne-PNMS version 1.0. This was followed by a series of consultations and stakeholder meetings. Five stakeholder meetings were held to engage stakeholders across Cameroon. Some of the registration elements, among other DAK aspects of ANC service provision, were identified in BornFyne version 1.0 but required reorganizing, remodeling, and reanalyzing to align with the International Classification of Diseases codes and DAK data content as part of the expansion for BornFyne version 2.0. Up to 40% of the DAK dictionary data content existed within the BornFyne-PNMS version 1.0, including additional DAK content adapted to update BornFyne-PNMS version 2.0. The digital health ecosystem in Cameroon is in an emerging phase with an increasing demand for digital health technologies, especially in the areas of reproductive, maternal, newborn, child, and adolescent health. The digital health ecosystem in Cameroon is in an emerging phase with an increasing demand for digital health technologies, especially in the area of reproductive, maternal, newborn, child, and adolescent health. This article describes and documents the steps in operationalization of the ANC DAK content into the BornFyne-PNMS content, highlighting the DAK as an important tool for guiding and facilitating software engineers in developing and integrating recommended ANC guidelines into digital platforms to facilitate interoperability, going by the structure of the document, its workflow processes, and content mapping elements.

BackgroundStrengthening contraceptive services in sub Saharan Africa is critical to achieve the FP 2020 goal of enabling 120 million more women and girls to access and use contraceptives by 2020 and the Sustainable Development Goals (SDG) targets of universal access to sexual and reproductive health (SRH) services including family planning by 2030.MethodThe World Health Organization (WHO) and partners have designed a multifaceted project to strengthen health systems to reduce the unmet need of contraceptive and family planning services in sub Saharan Africa. The plan leverages global, regional and national partnerships to facilitate and increase the use of evidence based WHO guidelines with a specific focus on postpartum family planning. The four key approaches undertaken are i) making WHO Guidelines adaptable & appropriate for country use ii) building capacity of WHO regional/country staff iii) providing technical support to countries and iv) strengthening partnerships for introduction and implementation of WHO guidelines. This paper describes the project design and elaborates the multifaceted approaches required in initial implementation to strengthen contraceptive services.ConclusionThe initial results from this project reflect that simultaneous application these approaches may strengthen contraceptive services in Sub Saharan Africa and ensure sustainability of the efforts. The lessons learned may be used to scale up and expand services in other countries.

BackgroundAntenatal health care utilization has the potential to influence maternal and new-born health. In this study, we assessed compliance of antenatal care utilization with national and World Health Organization (WHO) guidelines. We also examined association of antenatal care utilization with adverse pregnancy outcomes as secondary outcome.MethodsThis was a community-based cross sectional study conducted from July 2016 to November 2017 in rural south-central Ethiopia. We described antenatal care received by pregnant women, whom we followed at three prescheduled visits during pregnancy and collected birth data at time of delivery. Extent of antenatal care content received, timing of antenatal care, place of antenatal care and place and mode of delivery were obtained and computed in accordance with national and WHO guidelines. For adverse pregnancy outcomes, computed as sum of low birth weight, preterm birth, intrauterine foetal death, and stillbirth, the exposure variable used was antenatal care utilization.ResultsSeven hundred and four (704) women participated in the study, and 536 (76.1%) had attended at least one antenatal care visit. Among women who attended antenatal care visit, majority, 421 (79.3%), had done so at health centres and hospitals, while 110 (20.7%) attended at health post. Average number of antenatal care visits was 2.5, which is less than that recommended in national and WHO guidelines. Only 18 (2.6%) women had attended antenatal care in their first trimester, which is low in contrast to the expected 100% specified in the guidelines. Less than half (47%) of the women delivered in a health facility. This is in contrast to the 100% expected health institution deliveries. Low birth weight was 7.9% (n = 48), and preterm birth was 4.9% (n = 31). There were 12 twin pregnancies, three stillbirths, 11 spontaneous abortions, and two intrauterine foetal deaths. We did not find significant association between adverse pregnancy outcomes and antenatal care utilization (COR = 1.07, 95% CI 0.62, 1.86).ConclusionThis study showed that antenatal care service utilization in the study area was markedly low compared to that recommended in national and WHO guidelines. The obtained antenatal health care utilization was not associated with the registered adverse pregnancy outcomes.

It has been reported that pain relief for patients with cancer is suboptimal in Japan. This has been mainly attributed to inadequate dissemination of the World Health Organization (WHO) guidelines for cancer pain management. To better understand this problem, we reviewed how 6 hospital palliative care teams (HPCTs) used the WHO guidelines for unrelieved pain in a 1-year audit that included 534 patients. The HPCT interventions were classified according to the contents of the WHO guidelines. In our study, HPCT interventions involved opioid prescriptions in >80% of referred patients, and "For the Individual" and "Attention to Detail" were the 2 most important principles. Our study indicates which parts of the WHO guidelines should be most heavily emphasized, when disseminating them in Japan.

Drinking water quality assessment based on index values incorporating WHO guidelines and Bangladesh standards

Over half of the WHO guidelines published from 2014 to 2019 explicitly considered health equity issues: a cross-sectional survey