Development Of Health Guidelines Research Articles

Using a priority setting exercise to identify priorities for guidelines on newborn and child health in South Africa, Malawi, and Nigeria

BackgroundSub-Saharan Africa is the region with the highest under-five mortality rate globally. Child healthcare decisions should be based on rigorously developed evidence-informed guidelines. The Global Evidence, Local Adaptation (GELA) project is enhancing capacity to use global research to develop locally relevant guidelines for newborn and child health in South Africa (SA), Malawi, and Nigeria. The first step in this process was to identify national priorities for newborn and child health guideline development, and this paper describes our approach.MethodsWe followed a good practice method for priority setting, including stakeholder engagement, online priority setting surveys and consensus meetings, conducted separately in South Africa, Malawi and Nigeria. We established national Steering Groups (SG), comprising 10–13 members representing government, academia, and other stakeholders, identified through existing contacts and references, who helped prioritise initial topics identified by research teams and oversaw the process. Various stakeholders were consulted via online surveys to rate the importance of topics, with results informing consensus meetings with SGs where final priority topics were agreed.ResultsBased on survey results, nine, 10 and 11 topics were identified in SA, Malawi, and Nigeria respectively, which informed consensus meetings. Through voting and discussion within meetings, and further engagement after the meetings, the top three priority topics were identified in each country. In SA, the topics concerned anemia prevention in infants and young children and post-discharge support for caregivers of preterm and LBW babies. In Malawi, they focused on enteral nutrition in critically ill children, diagnosis of childhood cancers in the community, and caring for neonates. In Nigeria, the topics focused on identifying pre-eclampsia in the community, hand hygiene compliance to prevent infections, and enteral nutrition for LBW and preterm infants.ConclusionsThrough dynamic and iterative stakeholder engagement, we identified three priority topics for guideline development on newborn and child health in SA, Malawi and Nigeria. Topics were specific to contexts, with no overlap, which highlights the importance of contextualised priority setting as well as of the relationships with key decisionmakers who help define the priorities.

Assessment of potential transthyretin amyloid cardiomyopathy cases in the Brazilian public health system using a machine learning model.

To identify and describe the profile of potential transthyretin cardiac amyloidosis (ATTR-CM) cases in the Brazilian public health system (SUS), using a predictive machine learning (ML) model. This was a retrospective descriptive database study that aimed to estimate the frequency of potential ATTR-CM cases in the Brazilian public health system using a supervised ML model, from January 2015 to December 2021. To build the model, a list of ICD-10 codes and procedures potentially related with ATTR-CM was created based on literature review and validated by experts. From 2015 to 2021, the ML model classified 262 hereditary ATTR-CM (hATTR-CM) and 1,581 wild-type ATTR-CM (wtATTR-CM) potential cases. Overall, the median age of hATTR-CM and wtATTR-CM patients was 66.8 and 59.9 years, respectively. The ICD-10 codes most presented as hATTR-CM and wtATTR-CM were related to heart failure and arrythmias. Regarding the therapeutic itinerary, 13% and 5% of hATTR-CM and wtATTR-CM received treatment with tafamidis meglumine, respectively, while 0% and 29% of hATTR-CM and wtATTR-CM were referred to heart transplant. Our findings may be useful to support the development of health guidelines and policies to improve diagnosis, treatment, and to cover unmet medical needs of patients with ATTR-CM in Brazil.

Capturing Emerging Experiential Knowledge for Vaccination Guidelines Through Natural Language Processing: Proof-of-Concept Study.

Experience-based knowledge and value considerations of health professionals, citizens, and patients are essential to formulate public health and clinical guidelines that are relevant and applicable to medical practice. Conventional methods for incorporating such knowledge into guideline development often involve a limited number of representatives and are considered to be time-consuming. Including experiential knowledge can be crucial during rapid guidance production in response to a pandemic but it is difficult to accomplish. This proof-of-concept study explored the potential of artificial intelligence (AI)-based methods to capture experiential knowledge and value considerations from existing data channels to make these insights available for public health guideline development. We developed and examined AI-based methods in relation to the COVID-19 vaccination guideline development in the Netherlands. We analyzed Dutch messages shared between December 2020 and June 2021 on social media and on 2 databases from the Dutch National Institute for Public Health and the Environment (RIVM), where experiences and questions regarding COVID-19 vaccination are reported. First, natural language processing (NLP) filtering techniques and an initial supervised machine learning model were developed to identify this type of knowledge in a large data set. Subsequently, structural topic modeling was performed to discern thematic patterns related to experiences with COVID-19 vaccination. NLP methods proved to be able to identify and analyze experience-based knowledge and value considerations in large data sets. They provide insights into a variety of experiential knowledge that is difficult to obtain otherwise for rapid guideline development. Some topics addressed by citizens, patients, and professionals can serve as direct feedback to recommendations in the guideline. For example, a topic pointed out that although travel was not considered as a reason warranting prioritization for vaccination in the national vaccination campaign, there was a considerable need for vaccines for indispensable travel, such as cross-border informal caregiving, work or study, or accessing specialized care abroad. Another example is the ambiguity regarding the definition of medical risk groups prioritized for vaccination, with many citizens not meeting the formal priority criteria while being equally at risk. Such experiential knowledge may help the early identification of problems with the guideline's application and point to frequently occurring exceptions that might initiate a revision of the guideline text. This proof-of-concept study presents NLP methods as viable tools to access and use experience-based knowledge and value considerations, possibly contributing to robust, equitable, and applicable guidelines. They offer a way for guideline developers to gain insights into health professionals, citizens, and patients' experience-based knowledge, especially when conventional methods are difficult to implement. AI-based methods can thus broaden the evidence and knowledge base available for rapid guideline development and may therefore be considered as an important addition to the toolbox of pandemic preparedness.

Economic evaluations of maternal health interventions: a scoping review

Background Evidence on the affordability and cost-effectiveness of interventions is critical to decision-making for clinical practice guidelines and development of national health policies. This study aimed to develop a repository of primary economic evaluations to support global maternal health guideline development and provide insights into the body of research conducted in this field. Methods A scoping review was conducted to identify and map available economic evaluations of maternal health interventions. We searched six databases (NHS Economic Evaluation Database, EconLit, PubMed, Embase, CINAHL and PsycInfo) on 20 November 2020 with no date, setting or language restrictions. Two authors assessed eligibility and extracted data independently. Included studies were categorised by subpopulation of women, level of care, intervention type, mechanism, and period, economic evaluation type and perspective, and whether the intervention is currently recommended by the World Health Organization. Frequency analysis was used to determine prevalence of parameters. Results In total 923 studies conducted in 72 countries were included. Most studies were conducted in high-income country settings (71.8%). Over half pertained to a general population of pregnant women, with the remainder focused on specific subgroups, such as women with preterm birth (6.2%) or those undergoing caesarean section (5.5%). The most common interventions of interest related to non-obstetric infections (23.9%), labour and childbirth care (17.0%), and obstetric complications (15.7%). Few studies addressed the major causes of maternal deaths globally. Over a third (36.5%) of studies were cost-utility analyses, 1.4% were cost-benefit analyses and the remainder were cost-effectiveness analyses. Conclusions This review provides a navigable, consolidated resource of economic evaluations in maternal health. We identified a clear evidence gap regarding economic evaluations of maternal health interventions in low- and middle-income countries. Future economic research should focus on interventions to address major drivers of maternal morbidity and mortality in these settings.

European Society for Vascular Surgery Clinical Practice Guideline Development Scheme: An Overview of Evidence Quality Assessment Methods, Evidence to Decision Frameworks, and Reporting Standards in Guideline Development

A structured and transparent approach is instrumental in translating research evidence to health recommendations and evidence informed clinical decisions. The aim was to conduct an overview and analysis of principles and methodologies for health guideline development. A literature review on methodologies, strategies, and fundamental steps in the process of guideline development was performed. The clinical practice guideline development process and methodology adopted by the European Society for Vascular Surgery are also presented. Sophisticated methodologies for health guideline development are being applied increasingly by national and international organisations. Their overarching principle is a systematic, structured, transparent, and iterative process that is aimed at making well informed healthcare choices. Critical steps in guideline development include the assessment of the certainty of the body of evidence; evidence to decision frameworks; and guideline reporting. The goal of strength of evidence assessments is to provide well reasoned judgements about the guideline developers’ confidence in study findings, and several evidence hierarchy schemes and evidence rating systems have been described for this purpose. Evidence to decision frameworks help guideline developers and users conceptualise and interpret the construct of the quality of the body of evidence. The most widely used evidence to decision frameworks are those developed by the GRADE Working Group and the WHO-INTEGRATE, and are structured into three distinct components: background; assessment; and conclusions. Health guideline reporting tools are employed to ensure methodological rigour and transparency in guideline development. Such reporting instruments include the AGREE II and RIGHT, with the former being used for guideline development and appraisal, as well as reporting. This guide will help guideline developers/expert panels enhance their methodology, and patients/clinicians/policymakers interpret guideline recommendations and put them in context. This document may be a useful methodological summary for health guideline development by other societies and organisations.

PROTOCOL: Guidance for stakeholder engagement in guideline development: A systematic review.

This is the protocol for a Campbell systematic review.The objectives are as follows:to identify, describe, and summarize existing guidance and methods for multistakeholder engagement throughout the health guideline development process.

PROTOCOL: Barriers and facilitators to stakeholder engagement in health guideline development: A qualitative evidence synthesis.

There is a need for the development of comprehensive, global, evidence-based guidance for stakeholder engagement in guideline development. Stakeholders are any individual or group who is responsible for or affected by health- and healthcare-related decisions. This includes patients, the public, providers of health care and policymakers for example. As part of the guidance development process, Multi-Stakeholder Engagement (MuSE) Consortium set out to conduct four concurrent systematic reviews to summarise the evidence on: (1) existing guidance for stakeholder engagement in guideline development, (2) barriers and facilitators to stakeholder engagement in guideline development, (3) managing conflicts of interest in stakeholder engagement in guideline development and (4) measuring the impact of stakeholder engagement in guideline development. This protocol addresses the second systematic review in the series. The objective of this review is to identify and synthesise the existing evidence on barriers and facilitators to stakeholder engagement in health guideline development. We will address this objective through two research questions: (1) What are the barriers to multi-stakeholder engagement in health guideline development across any of the 18 steps of the GIN-McMaster checklist? (2) What are the facilitators to multi-stakeholder engagement in health guideline development across any of the 18 steps of the GIN-McMaster checklist? A comprehensive search strategy will be developed and peer-reviewed in consultation with a medical librarian. We will search the following databases: MEDLINE, Cumulative Index to Nursing & Allied Health Literature (CINAHL), EMBASE, PsycInfo, Scopus, and Sociological Abstracts. To identify grey literature, we will search the websites of agencies who actively engage stakeholder groups such as the AHRQ, Canadian Institutes of Health Research (CIHR) Strategy for Patient-Oriented Research (SPOR), INVOLVE, the National Institute for Health and Care Excellence (NICE) and the PCORI. We will also search the websites of guideline-producing agencies, such as the American Academy of Pediatrics, Australia's National Health Medical Research Council (NHMRC) and the WHO. We will invite members of the team to suggest grey literature sources and we plan to broaden the search by soliciting suggestions via social media, such as Twitter. We will include empirical qualitative and mixed-method primary research studies which qualitatively report on the barriers or facilitators to stakeholder engagement in health guideline development. The population of interest is stakeholders in health guideline development. Building on previous work, we have identified 13 types of stakeholders whose input can enhance the relevance and uptake of guidelines: Patients, caregivers and patient advocates; Public; Providers of health care; Payers of health services; Payers of research; Policy makers; Program managers; Product makers; Purchasers; Principal investigators and their research teams; and Peer-review editors/publishers. Eligible studies must describe stakeholder engagement at any of the following steps of the GIN-McMaster Checklist for Guideline Development. All identified citations from electronic databases will be imported into Covidence software for screening and selection. Documents identified through our grey literature search will be managed and screened using an Excel spreadsheet. A two-part study selection process will be used for all identified citations: (1) a title and abstract review and (2) full-text review. At each stage, teams of two review authors will independently assess all potential studies in duplicate using a priori inclusion and exclusion criteria. Data will be extracted by two review authors independently and in duplicate according to a standardised data extraction form. The results of this review will be used to inform the development of guidance for multi-stakeholder engagement in guideline development and implementation. This guidance will be official GRADE (Grading of Recommendations Assessment, Development and Evaluation) Working Group guidance. The GRADE system is internationally recognised as a standard for guideline development. The findings of this review will assist organisations who develop healthcare, public health and health policy guidelines, such as the World Health Organization, to involve multiple stakeholders in the guideline development process to ensure the development of relevant, high quality and transparent guidelines.

Economic evaluations of maternal health interventions: a scoping review

Background Evidence on the affordability and cost-effectiveness of interventions is critical to decision-making for clinical practice guidelines and development of national health policies. This study aimed to develop a repository of primary economic evaluations to support global maternal health guideline development and provide insights into the body of research conducted in this field. Methods A scoping review was conducted to identify and map available economic evaluations of maternal health interventions. We searched six databases (NHS Economic Evaluation Database, EconLit, PubMed, Embase, CINAHL and PsycInfo) on 20 November 2020 with no date, setting or language restrictions. Two authors assessed eligibility and extracted data independently. Included studies were categorised by subpopulation of women, level of care, intervention type, mechanism, and period, economic evaluation type and perspective, and whether the intervention is currently recommended by the World Health Organization. Frequency analysis was used to determine prevalence of parameters. Results In total 923 studies conducted in 72 countries were included. Most studies were conducted in high-income country settings (71.8%). Over half pertained to a general population of pregnant women, with the remainder focused on specific subgroups, such as women with preterm birth (6.2%) or those undergoing caesarean section (5.5%). The most common interventions of interest related to non-obstetric infections (23.9%), labour and childbirth care (17.0%), and obstetric complications (15.7%). Few studies addressed the major causes of maternal deaths globally. Over a third (36.5%) of studies were cost-utility analyses, 1.4% were cost-benefit analyses and the remainder were cost-effectiveness analyses. Conclusions This review provides a navigable, consolidated resource of economic evaluations in maternal health. We identified a clear evidence gap regarding economic evaluations of maternal health interventions in low- and middle-income countries. Future economic research should focus on interventions to address major drivers of maternal morbidity and mortality in these settings.

Systematic review of the methodological literature for integrating qualitative evidence syntheses into health guideline development.

Guidelines produced by local, national and international bodies underpin clinical practice and healthcare services worldwide. For guidelines to be based on the best available evidence, it is critical that syntheses of both qualitative and quantitative evidence are used to inform decision-making. As methods for qualitative evidence syntheses (QES) develop, they are increasingly able to inform health guideline production. However, the process whereby this form of evidence is considered and incorporated tends to be unclear. This systematic review synthesized existing guidance concerning the use of QES in guideline development. Sources published in English that described or prescribed methods for incorporating QES into evidence-based health guidelines were eligible for inclusion. Seventeen relevant papers were identified. The literature indicates that there is a reasonable consensus about many stages of conducting a QES to inform guideline development. Areas needing further exploration include: the way that committees engage with QES; the usefulness of different QES methodologies; and understanding of how expert committees use evidence. Methods for producing QES for guideline committees tend to be similar to quantitative systematic review methods in terms of searching, quality appraisal, systematic management of data, and presentation of results. While this allows transparency and accountability, it could be argued that it is less "true" to the principles of being led by the data, which are fundamental to most qualitative research. Understanding the process of using QES to produce guidelines is critical to determining their validity and applicability, and to ensure that healthcare provision is based on the best available evidence.

Challenges in applying the GRADE approach in public health guidelines and systematic reviews: a concept article from the GRADE Public Health Group

Background and ObjectiveThis article explores the need for conceptual advances and practical guidance in the application of the GRADE approach within public health contexts. MethodsWe convened an expert workshop and conducted a scoping review to identify challenges experienced by GRADE users in public health contexts. We developed this concept article through thematic analysis and an iterative process of consultation and discussion conducted with members electronically and at three GRADE Working Group meetings. ResultsFive priority issues can pose challenges for public health guideline developers and systematic reviewers when applying GRADE: (1) incorporating the perspectives of diverse stakeholders; (2) selecting and prioritizing health and “nonhealth” outcomes; (3) interpreting outcomes and identifying a threshold for decision-making; (4) assessing certainty of evidence from diverse sources, including nonrandomized studies; and (5) addressing implications for decision makers, including concerns about conditional recommendations. We illustrate these challenges with examples from public health guidelines and systematic reviews, identifying gaps where conceptual advances may facilitate the consistent application or further development of the methodology and provide solutions. ConclusionThe GRADE Public Health Group will respond to these challenges with solutions that are coherent with existing guidance and can be consistently implemented across public health decision-making contexts.

Managing conflicts of interest in the development of health guidelines.

KEY POINTS Public awareness regarding the importance of disclosing and managing conflicts of interest (COIs) during the development of clinical practice and public health guidelines is growing, owing to recent high-profile news stories within and outside Canada.[1][1]–[9][2] Despite the existence

The views of health guideline developers on the use of automation in health evidence synthesis

BackgroundThe increasingly rapid rate of evidence publication has made it difficult for evidence synthesis—systematic reviews and health guidelines—to be continually kept up to date. One proposed solution for this is the use of automation in health evidence synthesis. Guideline developers are key gatekeepers in the acceptance and use of evidence, and therefore, their opinions on the potential use of automation are crucial.MethodsThe objective of this study was to analyze the attitudes of guideline developers towards the use of automation in health evidence synthesis. The Diffusion of Innovations framework was chosen as an initial analytical framework because it encapsulates some of the core issues which are thought to affect the adoption of new innovations in practice. This well-established theory posits five dimensions which affect the adoption of novel technologies: Relative Advantage, Compatibility, Complexity, Trialability, and Observability. Eighteen interviews were conducted with individuals who were currently working, or had previously worked, in guideline development. After transcription, a multiphase mixed deductive and grounded approach was used to analyze the data. First, transcripts were coded with a deductive approach using Rogers’ Diffusion of Innovation as the top-level themes. Second, sub-themes within the framework were identified using a grounded approach.ResultsParticipants were consistently most concerned with the extent to which an innovation is in line with current values and practices (i.e., Compatibility in the Diffusion of Innovations framework). Participants were also concerned with Relative Advantage and Observability, which were discussed in approximately equal amounts. For the latter, participants expressed a desire for transparency in the methodology of automation software. Participants were noticeably less interested in Complexity and Trialability, which were discussed infrequently. These results were reasonably consistent across all participants.ConclusionsIf machine learning and other automation technologies are to be used more widely and to their full potential in systematic reviews and guideline development, it is crucial to ensure new technologies are in line with current values and practice. It will also be important to maximize the transparency of the methods of these technologies to address the concerns of guideline developers.

Supporting effective participation in health guideline development groups: The Guideline Participant Tool

ObjectivesHealth guidelines are a key knowledge translation tool produced and used by numerous stakeholders worldwide. Effective participation in guideline development groups or development groups is crucial for guideline success, yet little guidance exists for members of these groups. In this study, we present the Guideline Participant Tool (GPT) to support effective participation in guideline groups, in particular those using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. Study Design and SettingWe used a mixed methods and iterative approach to develop a tool to support guideline participation. We used the findings of a published systematic review to develop an initial list of items for considerations for guideline participants. Then, we refined this list through key informant interviews with guideline chairs, sponsors, and participants. Finally, we validated the GPT in three guideline groups with 26 guideline group members. ResultsThe initial list of items based on 37 articles from the existing systematic review included 15 themes and 61 items for a draft tool. Ten key informant interviews helped us refine the list to include the following themes: selection of participants, guideline group process, and tool format. 26 respondents completed the validation survey from three guideline groups. Refinement of the tool ultimately generated a GPT with 33 items for participant consideration before, during, and in follow-up to guideline group meetings. ConclusionThe GPT contains helpful guidance for all guideline participants, particularly those without previous guideline experience. Future research should further explore the need for additional tools to support guideline participants and identify and develop strategies for improving guideline members’ participation in guideline groups. This work will be incorporated into INGUIDE.org guideline training and credentialing efforts by the Guidelines International Network and McMaster University.

"It's Not Smooth Sailing": Bridging the Gap Between Methods and Content Expertise in Public Health Guideline Development.

Background: The development of reliable, high quality health-related guidelines depends on explicit and transparent processes, methods aimed at minimising risks of bias and the inclusion of all relevant expertise and perspectives. While the methodological aspects of guidelines have been a focus to improve their quality, less is known about the social processes involved, for example, how guideline group members interact and communicate with one another, and how the evidence is considered in informing recommendations. With this in in mind, we aimed to empirically examine the perspectives and experiences of the key participants involved in developing public health guidelines for the Australian National Health and Medical Research Council (NHMRC). Design: This study was conducted using constructivist grounded theory as described by Charmaz, which informed our sampling, data collection, coding and analysis of interviews with key participants involved in developing public health guidelines. Setting: Australian public health guidelines commissioned by the NHMRC. Participants: Twenty experts that were involved in Australian NHMRC public health guideline development, including working committee members with content topic expertise (n=16) and members of evidence review groups responsible for evaluating the evidence (n=4). Results: Public health guideline development in Australia is a divided process. The division is driven by 3 related factors: the divergent disciplinary background and expertise that each group brings to the process; the methodological limitations of the framework, inherited from clinical medicine, that is used to assess the evidence; and barriers to communication between content experts and evidence reviewers around respective roles and methodological limitations. Conclusion: Our findings suggest several improvements for a more functional and unified guideline development process: greater education of the working committee on the methodological process employed to evaluate evidence, improved communication on the role of the evidence review groups and better facilitation of the process so that the evidence review groups feel their contribution is valued.

Antidepressants in the Postpartum Period: Additional Considerations

Back to table of contents Previous article Next article Letters to the EditorFull AccessAntidepressants in the Postpartum Period: Additional ConsiderationsRACHEL BURBECK M.Sc.STEPHEN PILLING M.Sc.DAVE TOMSON M.D.LIZ McDONALD M.D.,RACHEL BURBECK M.Sc.Search for more papers by this authorSTEPHEN PILLING M.Sc.Search for more papers by this authorDAVE TOMSON M.D.Search for more papers by this authorLIZ McDONALD M.D.Search for more papers by this author,Published Online:1 Feb 2008https://doi.org/10.1176/appi.ajp.2007.07091462AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail To The Editor: We read with interest the article by Jennifer L. Payne, M.D., published in the September 2007 issue of the Journal , on practical considerations of antidepressant use postnatally (1) . However, as developers of the United Kingdom National Clinical Guideline on Antenatal and Postnatal Mental Health (2) , we found the article to be inaccurate in several respects. We agree that maintaining drugs started during pregnancy in the postnatal period is appropriate but feel that this means that paroxetine, although virtually undetectable in breast milk, should not be given to a woman who wishes to breast-feed, given the concern over its safety in pregnancy (3 , 4) and the possible difficulties on withdrawal. While monitoring a breastfed infant is important, the additional point should be made that neonates whose mothers took antidepressants during pregnancy should also be monitored both for symptoms of withdrawal from the drug and for serotonergic toxicity syndrome (the symptoms are similar) (2 , 5) . After a careful review of the available data, we concluded that “indicated” prevention may benefit women with subthreshold symptoms of depression or anxiety, although the Cochrane review on the prevention of postnatal depression concluded that this is not effective (6) . Evidence on the risk to the fetus of chronic subthreshold anxiety during pregnancy influenced our decision (7) . Dr. Payne gives only limited consideration of psychological therapies, but these are equally effective and safer than medication, particularly in less severe depression (8) . We recommended that psychological treatments should be offered without delay in order to avoid the risks associated with antidepressants where this is appropriate (2) . The considerable reluctance of many pregnant women to take medication influenced this decision. Finally, antidepressants are used to treat a range of disorders in addition to depression, particularly anxiety disorders. Psychological treatments are often appropriate in these disorders and should be offered in place of antidepressants where appropriate (2) . London, United KingdomMr. Pilling receives funding from the National Institute for Clinical Excellence for the development of clinical guidelines in mental health. Dr. Tomson has served as chairperson of the Antenatal and Postnatal Mental Health Guideline Development Group, of which Dr. McDonald was a member and to which Ms. Burbeck has provided technical support. Dr. McDonald has received speaker’s honorarium from Janssen-Cilag.This letter (doi: 10.1176/appi.ajp.2007.07091462) was accepted for publication in October 2007.

Lagoons and ponds

Lagoons and ponds

The Development of Health Guidelines for Wastewater Reclamation

Wastewater reclamation has multiple benefits including water conservation and supplementing available water resources, while providing valuable nutrients to the soil. It also contributes to the reduction of environmental pollution, by reducing wastewater discharges to surface and underground water sources. However, potential health problems associated with reuse of wastewater must be carefully assessed and health guidelines developed which effectively reduce health risks and allow for the full social and economic benefits of wastewater reuse to be achieved. This paper reviews the major findings of a World Bank/United Nations Development Program study aimed at evaluating health guidelines for wastewater reuse in agricultural irrigation. This study concludes that early guidelines were often unjustifiably conservative and recommends for unrestricted irrigation of all crops including edible vegetable crops, a microbial quality of the effluent of 1000 fecal coliforms/100 ml and l or less helminth eggs/litre. This microbial standard can be achieved in well designed multi-celled stabilization pond systems which are low cost, robust and simple to operate and are particularly suited to developing countries in warm climates. Alternative advanced treatment technologies can also meet these guidelines. The World Health Organization has recently provided a new impetus to wastewater reclamation in agriculture throughout the world with its official approval of these guidelines.