Guideline Contextualisation: A Handbook Summary

Guideline Contextualisation: A Handbook Summary

Developing and adapting guidelines based on solid evidence is crucial for achieving reliable and effective outcomes. The WHO's Strengthening Countries' Capacities to Adopt and Adapt Evidence-Based Guidelines: A Handbook for Guideline Contextualization, a valuable resource recently published, is designed to empower research teams. It outlines the core principles and methods for developing and contextualising guidelines, introducing a 15-step process for using GRADE-ADOLOPMENT to create recommendations tailored to local needs. By drawing from existing guidelines and relevant local evidence, this handbook equips you with the tools to ensure the guidelines are effectively applied and maintained, enhancing the team's ability to make a difference in the local healthcare system.

Disclaimer: This blog post summarises the key insights from the WHO handbook, particularly the section Detailed Process & Steps for Contextualization and is not officially endorsed by the World Health Organization (WHO). While we aim to provide a clear and informative summary, this post does not capture the full depth and detail of the handbook. We strongly encourage teams and individuals to refer directly to the original document for a complete and thorough understanding of the principles, methods, and steps involved in the guideline development and contextualisation process.

Strengthening countries' capacities to adopt and adapt evidence-based guidelines a handbook for guideline contextualization 

As technology advances, healthcare teams worldwide have more innovative tools at their disposal for conducting research and crafting guidelines. It's easy for multiple guidelines on the same topic to emerge without realising that a similar guideline already exists in a different context. The WHO's handbook offers a systematic approach, GRADE-ADOLOPMENT, which enables the customisation of evidence-based recommendations to fit specific regional or national settings. This process ensures that guidelines address local populations' unique needs and challenges and promote the efficient use of resources by avoiding duplicated efforts. With its comprehensive guidance and iterative development, the handbook equips decision-makers with the necessary tools to tailor guidelines effectively, ultimately enhancing the implementation of evidence-based practices and improving healthcare outcomes.

The adolopment process is explained as a systematic approach to adopting, adapting, or creating new recommendations from existing guidelines. The method ensures that each recommendation, whether adopted as-is, adapted for specific contexts, or developed anew, is equally valuable and relevant. The goal of the handbook is to promote the use of global guidelines locally, improving public health and clinical practices efficiently. Multiple key terms and definitions, from contextualisation to Evidence to Decision (EtD) Frameworks, are provided for developing guidelines. For a complete list and comprehensive understanding of these terms, please refer to pages 15 to 20 of the handbook. 

Creating effective health guidelines requires transparency, meticulous planning, and collaboration with diverse stakeholders, including health professionals, policymakers, and the public. The process involves setting priorities, updating information, documenting methodologies, and managing conflicts of interest. An oversight committee, guideline panel, and working groups work together to develop and validate recommendations using systematic reviews and contextual evidence. The effort continues beyond publication; it includes dissemination, evaluation, and a robust implementation plan.  Contextualisation and implementation are inseparable, ensuring that guidelines are relevant and actionable in specific settings. The GRADE-ADOLOPMENT process involves 15 detailed steps for contextualising guidelines: 

Step 1: Selection of a guideline topic

Step 1 involves identifying and prioritising guideline topics through stakeholder input and existing evidence, conducting a scoping exercise to refine the topic, and establishing an organisational framework, including selecting a multidisciplinary guideline group.

Step 2: Prioritisation of questions

Selecting and ranking questions based on local needs and priorities, particularly in areas of controversy or required policy changes, is essential for this step. This process includes reviewing existing guidelines, evidence syntheses, and stakeholder input, with guideline panel members rating the importance of these questions to ensure the recommendations are relevant and comprehensive for the specific context.

Step 3: Identification of appropriate source guidelines or systematic reviews

This step involves conducting a thorough search for potential source guidelines with the help of an information retrieval expert. These guidelines are evaluated to ensure they address priority questions, are credible, recent, and ideally based on the GRADE methodology. If no suitable guidelines are found, systematic reviews are sought to build an EtD framework, ensuring all recommendations are well-supported.

Step 4: Matching source guideline recommendations to each prioritised question

Step 4 entails matching prioritised questions with recommendations from existing guidelines, using the PICO domains (population, intervention, comparison and outcomes) to ensure relevance. This step may involve multiple guidelines or, if none match, creating new recommendations. Unlike traditional adaptation, GRADE-ADOLOPMENT focuses on local priorities and may require contacting original guideline developers for additional materials or permissions.

Step 5: Does a matching recommendation exist?

Step 5 involves determining if a recommendation in the source guidelines aligns with the prioritised question. If it does, the original guideline creators should be contacted to request adolopment, provided the guidelines meet the necessary quality criteria. A new recommendation must be developed if no matching recommendation exists, potentially using existing evidence syntheses.

Step 6: Update systematic review(s) (as needed)

Step 6 assesses whether existing systematic reviews need updating or if new reviews are required, especially to include local contextual evidence. This step ensures that the evidence is current, includes all relevant outcomes, and considers local factors such as values, feasibility, and resource use. Summary of Findings (SoFs) and EtD frameworks must also be revised or created if updates are needed.

Step 7: EtD from source guideline

Determine if the source guideline includes a complete EtD framework. If not, a new EtD should be developed in the next step. If an EtD exists, it must be reviewed for its original judgments and integrated with contextual evidence, considering which EtD criteria are most relevant for the new setting.

Step 8: Develop an EtD

Based on the previous step, step 8 involves creating an EtD framework if one does not exist in the source guideline. Step 8 requires extracting information from the source guideline to justify the recommendation and may involve seeking additional evidence to complete the framework. It's vital to base contextualisation on local evidence rather than current practices to allow for new recommendations based on existing circumstances.

Step 9: Reassess EtD judgements

Step 9 involves convening a guideline panel meeting, where the existing or developed EtDs are checked for completeness and judgments are reviewed. This process may result in agreeing with the original judgments or making adjustments based on new evidence or contextual factors, with options ranging from maintaining the original judgments to re-evaluating them entirely. 

Step 10: Develop recommendations

Similarly, step 10 involves a guideline panel meeting to discuss, judge, and agree upon recommendations based on completed and contextualised EtDs. During this process, research gaps, implementation considerations, and monitoring and evaluation aspects are documented to inform the drafting of the implementation plan.

Step 11: Adoloped recommendation similar to the source

Step 11 involves categorising the recommendation based on whether it aligns with the source recommendation and EtD judgments. If the recommendation remains unchanged, it is adopted; if it is altered due to updated evidence or changes in judgment, it is adapted.

Step 12: Adopted recommendation

In step 12, the recommendation is identified as adopted from the source guideline, referencing it accordingly and maintaining it without alteration, except for possible translation or attribution to the adapting organisation.

Step 13: Adapted recommendation

As with step 12, step 13 involves referencing the source guideline and expressing any changes to the recommendation in the adapted version.

Step 14: De novo development

Step 14 entails initiating a complete recommendation development process if no source recommendation exists, following step 15 to ensure guideline quality. This may involve using existing evidence syntheses and developing an EtD for the new recommendation.

Step 15: New recommendation

Finally, step 15 involves implementing reliable recommendation development processes to create a new recommendation, ensuring thorough documentation and appropriate reporting. 

Following the adolopment process enhances the credibility of the resulting guideline. The handbook recognises the challenges of adhering to every step but emphasises the importance of transparent documentation. Likewise, dissemination and implementation are critical aspects of guideline utilisation that require a systematic approach with clearly assigned responsibilities.

An implementation plan, developed collaboratively with stakeholders, ensures effective dissemination and addresses potential barriers to implementation. Essentials include assessing resource needs, setting milestones, providing necessary training, and utilising existing networks for implementation. Quality assurance measures such as checklist completion, adherence to reporting standards, evaluation of group processes, and external peer review ensure the reliability and credibility of adoloped recommendations. 

While the process is complicated and detailed, the handbook outlines several tools and checklists that aid in contextualising guidelines:

  • GRADEpro: This multifaceted software facilitates the entire guideline development process. The handbook specifically mentions GRADEpro for the Evidence to Decision Frameworks, Summary of Findings table, the incorporation of the GRADE Handbook and the GIN Checklist and finally, a guidelines database.
  • BIGG: An international database of GRADE guidelines.
  • Appraisal of Guidelines for Research and Evaluation (AGREE) tool: A guideline evaluation tool that helps to identify if the scoping exercises and systematic searches address the prioritised questions. 
  • The United States Agency for Healthcare Research and Quality’s National Guideline Clearinghouse Extent of Adherence to Trustworthy Standards instrument: A tool that assists in evaluating a guideline’s trustworthiness.
  • The GIN–McMaster Guideline Development Checklist: facilitates the guideline development process.
  • International Prospective Register of Systematic Reviews (PROSPERO): aids in registering and identifying registered evidence syntheses. 

Regular evaluation and updating of guidelines are imperative to maintain their relevance and effectiveness in guiding healthcare practices. The WHO handbook encapsulates a well-detailed process of contextualising guidelines to improve public health and clinical practises. For a comprehensive dive into the process, we strongly recommend reading the handbook:

Strengthening countries' capacities to adopt and adapt evidence-based guidelines a handbook for guideline contextualization


World Health Organization. Regional Office for Europe. (‎2023)‎. Strengthening countries’ capacities to adopt and adapt evidence-based guidelines: a handbook for guideline contextualization. World Health Organization. Regional Office for Europe. License: CC BY-NC-SA 3.0 IGO