Glenton Claire, Lewin Simon, Gülmezoglu Ahmet Metin
Global Health Unit, Knowledge Centre for the Health Services, Norwegian Institute of Public Health, Oslo, Norway.
Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa.
Implement Sci. 2016 Jul 18;11:98. doi: 10.1186/s13012-016-0470-y.
In 2012, the World Health Organization (WHO) published recommendations on the use of optimization or "task-shifting" strategies for key, effective maternal and newborn interventions (the OptimizeMNH guidance). When making recommendations about complex health system interventions such as task-shifting, information about the feasibility and acceptability of interventions can be as important as information about their effectiveness. However, these issues are usually not addressed with the same rigour. This paper describes our use of several innovative strategies to broaden the range of evidence used to develop the OptimizeMNH guidance. In this guidance, we systematically included evidence regarding the acceptability and feasibility of relevant task-shifting interventions, primarily using qualitative evidence syntheses and multi-country case study syntheses; we used an approach to assess confidence in findings from qualitative evidence syntheses (the Grading of Recommendations, Assessment, Development and Evaluation-Confidence in Evidence from Reviews of Qualitative Research (GRADE-CERQual) approach); we used a structured evidence-to-decision framework for health systems (the DECIDE framework) to help the guidance panel members move from the different types of evidence to recommendations.
The systematic inclusion of a broader range of evidence, and the use of new guideline development tools, had a number of impacts. Firstly, this broader range of evidence provided relevant information about the feasibility and acceptability of interventions considered in the guidance as well as information about key implementation considerations. However, inclusion of this evidence required more time, resources and skills. Secondly, the GRADE-CERQual approach provided a method for indicating to panel members how much confidence they should place in the findings from the qualitative evidence syntheses and so helped panel members to use this qualitative evidence appropriately. Thirdly, the DECIDE framework gave us a structured format in which we could present a large and complex body of evidence to panel members and end users. The framework also prompted the panel to justify their recommendations, giving end users a record of how these decisions were made.
By expanding the range of evidence assessed in a guideline process, we increase the amount of time and resources required. Nevertheless, the WHO has assessed the outputs of this process to be valuable and is currently repeating the approach used in OptimizeMNH in other guidance processes.
2012年，世界卫生组织（WHO）发布了关于在关键、有效的孕产妇和新生儿干预措施中使用优化或“任务转移”策略的建议（《优化孕产妇和新生儿保健指南》）。在就诸如任务转移等复杂的卫生系统干预措施提出建议时，有关干预措施可行性和可接受性的信息与有关其有效性的信息同样重要。然而，这些问题通常没有得到同等严格的处理。本文描述了我们如何运用多种创新策略来拓宽用于制定《优化孕产妇和新生儿保健指南》的证据范围。在本指南中，我们系统地纳入了有关相关任务转移干预措施的可接受性和可行性的证据，主要采用定性证据综合分析和多国案例研究综合分析；我们采用了一种方法来评估定性证据综合分析结果的可信度（推荐分级、评估、制定与评价——定性研究综述证据的可信度（GRADE-CERQual）方法）；我们使用了一个针对卫生系统的结构化证据到决策框架（DECIDE框架）来帮助指南制定小组的成员从不同类型的证据得出建议。
系统地纳入更广泛的证据范围以及使用新的指南制定工具产生了多方面的影响。首先，这一更广泛的证据范围提供了有关指南中所考虑干预措施的可行性和可接受性的相关信息以及有关关键实施考量的信息。然而，纳入这些证据需要更多的时间、资源和技能。其次，GRADE-CERQual方法提供了一种向小组成员表明他们应对定性证据综合分析结果抱有多大信心的方法，从而帮助小组成员恰当地使用这些定性证据。第三，DECIDE框架为我们提供了一种结构化的形式，我们可以用这种形式向小组成员和最终用户展示大量复杂的证据。该框架还促使小组为其建议提供理由，为最终用户提供这些决策是如何做出的记录。
通过在指南制定过程中扩大评估的证据范围，我们增加了所需的时间和资源量。尽管如此，WHO已评估该过程的产出具有价值，并且目前正在其他指南制定过程中重复《优化孕产妇和新生儿保健指南》中使用的方法。
