BACKGROUND: WHO has recognised the need to improve its guideline methodology to ensure that guideline decision-making processes are transparent and evidence based, and that the resulting recommendations are relevant and applicable. To help achieve this, WHO guidelines now typically enhance intervention effectiveness data with evidence on a wider range of decision-making criteria, including how stakeholders value different outcomes, equity, gender and human rights impacts, and the acceptability and feasibility of interventions. Qualitative evidence syntheses (QES) are increasingly used to provide evidence on this wider range of issues. In this paper, we describe and discuss how to use the findings from QES to populate decision-making criteria in evidence-to-decision (EtD) frameworks. This is the second in a series of three papers that examines the use of QES in developing clinical and health system guidelines.
METHODS: WHO convened a writing group drawn from the technical teams involved in its recent (2010-2018) guidelines employing QES. Using a pragmatic and iterative approach that included feedback from WHO staff and other stakeholders, the group reflected on, discussed and identified key methods and research implications from designing QES and using the resulting findings in guideline development.
RESULTS: We describe a step-wise approach to populating EtD frameworks with QES findings. This involves allocating findings to the different EtD criteria (how stakeholders value different outcomes, equity, acceptability and feasibility, etc.), weaving the findings into a short narrative relevant to each criterion, and inserting this summary narrative into the corresponding \'research evidence\' sections of the EtD. We also identify areas for further methodological research, including how best to summarise and present qualitative data to groups developing guidelines, how these groups draw on different types of evidence in their decisions, and the extent to which our experiences are relevant to decision-making processes in fields other than health.
CONCLUSIONS: This paper shows the value of incorporating QES within a guideline development process, and the roles that qualitative evidence can play in integrating the views and experiences of relevant stakeholders, including groups who may not be otherwise represented in the decision-making process.

BACKGROUND: This is the third in a series of three papers describing the use of qualitative evidence syntheses (QES) to inform the development of clinical and health systems guidelines. WHO has recognised the need to improve its guideline methodology to ensure that decision-making processes are transparent and evidence based, and that the resulting recommendations are relevant and applicable to end users. In addition to the standard data on effectiveness, WHO guidelines increasingly use evidence derived from QES to provide information on acceptability and feasibility and to develop important implementation considerations.
METHODS: WHO convened a group drawn from the technical teams involved in formulating recent (2010-2018) guidelines employing QES. Using a pragmatic and iterative approach that included feedback from WHO staff and other stakeholders, the group reflected on, discussed and identified key methods and research implications from designing QES and using the resulting findings in guideline development. As members of WHO guideline technical teams, our aim in this paper is to explore how we have used findings from QES to develop implementation considerations for these guidelines.
RESULTS: For each guideline, in addition to using systematic reviews of effectiveness, the technical teams used QES to gather evidence of the acceptability and feasibility of interventions and, in some cases, equity issues and the value people place on different outcomes. This evidence was synthesised using standardised processes. The teams then used the QES to identify implementation considerations combined with other sources of information and input from experts.
CONCLUSIONS: QES were useful sources of information for implementation considerations. However, several issues for further development remain, including whether researchers should use existing health systems frameworks when developing implementation considerations; whether researchers should take confidence in the evidence into account when developing implementation considerations; whether qualitative evidence that reveals implementation challenges should lead guideline panels to make conditional recommendations or only point to implementation considerations; and whether guideline users find it helpful to have challenges pointed out to them or whether they also need solutions. Finally, we need to explore how QES findings can be incorporated into derivative products to aid implementation.

BACKGROUND: WHO has recognised the need to ensure that guideline processes are transparent and evidence based, and that the resulting recommendations are relevant and applicable. Along with decision-making criteria that require findings from effectiveness reviews, WHO is increasingly using evidence derived from qualitative evidence syntheses (QES) to inform the values, acceptability, equity and feasibility implications of its recommendations. This is the first in a series of three papers examining the use of QES in developing clinical and health systems guidelines.
METHODS: WHO convened a group of methodologists involved in developing recent (2010-2018) guidelines that were informed by QES. Using a pragmatic and iterative approach that included feedback from WHO staff and other stakeholders, the group reflected on, discussed and identified key methods and research implications from designing QES and using the resulting findings in guideline development. Our aim in this paper is to (1) describe and discuss how the findings of QES can inform the scope of a guideline and (2) develop findings for key guideline decision-making criteria.
RESULTS: QES resulted in the addition of new outcomes that are directly relevant to service users, a stronger evidence base for decisions about how much effective interventions and related outcomes are valued by stakeholders in a range of contexts, and a more complete database of summary evidence for guideline panels to consider, linked to decisions about values, acceptability, feasibility and equity.
CONCLUSIONS: Rigorously conducted QES can be a powerful means of improving the relevance of guidelines, and of ensuring that the concerns of stakeholders, at all levels of the healthcare system and from a wide range of settings, are taken into account at all stages of the process.

BACKGROUND: Measuring care processes is an important component of any effort to improve care quality, however knowing the appropriate metrics to measure is a challenge both in Ireland and other countries. Quality of midwifery care depends on the expert knowledge of the midwife and her/his contribution to women and their babies\' safety in the healthcare environment. Therefore midwives need to be able to clearly articulate and measure what it is that they do, the dimensions of their professional practice frequently referred to as midwifery care processes. The objective of this paper is to report on the development and prioritisation of a national suite of Quality Care Metrics (QCM), and their associated indicators, for midwifery care processes in Ireland.
METHODS: The study involved four discrete, yet complimentary, phases; i) a systematic literature review to identify midwifery care process metrics and their associated measurement indicators; ii) a two-round, online Delphi survey of midwives to develop consensus on the set of midwifery care process metrics to be measured; iii) a two-round online Delphi survey of midwives to develop consensus on the indicators that will be used to measure prioritised metrics; and iv) a face-to-face consensus meeting with midwives to review the findings and achieve consensus on the final suite of metrics and indicators.
RESULTS: Following the consensus meeting, 18 metrics and 93 indicators were prioritised for inclusion in the suite of QCM Midwifery Metrics. These metrics span the pregnancy, birth and postpartum periods.
CONCLUSIONS: The development of this suite of process metrics and indicators for midwifery care provides an opportunity for measuring the safety and quality of midwifery care in Ireland and for adapting internationally. This initial work should be followed by a rigorous evaluation of the impact of the new suite of metrics on midwifery care processes.

Assessing gaps in antenatal pertussis vaccination to increase coverage.
Antenatal pertussis vaccination has been proven effective in reducing pertussis disease in infants. Current guidelines recommend maternal pertussis vaccination from 28 weeks gestation. The aim of this study is to determine antenatal pertussis vaccination coverage in the Northern Territory and potential socio-demographic factors affecting uptake, using validated birth and immunisation data.
Cross-sectional population study including all viable births (from 24 weeks gestation) in Northern Territory public hospitals in 2016.
There were 3392 viable delivery episodes in 2016 with 48.9% coverage against maternal pertussis based on current guidelines. Mothers <35 years old were more likely to receive antenatal vaccination (adjusted odds ratio (aOR) = 1.26, CI 1.035-1.52, P = 0.021). Pertussis vaccination coverage for preterm births was low at 0% for extreme, 18.86% for very preterm and 39.8% for moderate preterm births, with an overall coverage of 33.5% for all preterm births. Term births were two times more likely than preterm births to have had mothers receive an antenatal diphtheria toxoid, tetanus toxoid and acellular pertussis vaccine (aOR = 1.957, CI 1.53-2.50, P < 0.001).
A significant proportion (66.5%) of preterm babies are not benefiting from protection against pertussis with the current pertussis vaccination policy from 28 weeks gestation. As timing of birth cannot be predetermined, a review of safety and acceptability of pertussis vaccine administration in the second trimester is needed. Implementation of pertussis vaccination from 20 weeks gestation will provide a wider vaccination period and maximise the protection of all infants including pre-term infants from pertussis.

Individual supervision of home-visiting professionals has proved to be a key element for perinatal home-visiting programs. Although studies have been published concerning quality criteria for supervision in North American contexts, little is known about this subject in other national settings. In the context of the CAPEDP program (Compétences parentales et Attachement dans la Petite Enfance: Diminution des risques liés aux troubles de santé mentale et Promotion de la résilience; Parental Skills and Attachment in Early Childhood: Reducing Mental Health Risks and Promoting Resilience), the first randomized controlled perinatal mental health promotion research program to take place in France, this article describes the results of a study using the Delphi consensus method to identify the program supervisors\' points of view concerning best practice for the individual supervision of home visitors involved in such programs. The final 18 recommendations could be grouped into four general themes: the organization and setting of supervision sessions; supervisor competencies; relationship between supervisor and supervisee; and supervisor intervention strategies within the supervision process. The quality criteria identified in this perinatal home-visiting program in the French cultural context underline the importance of clinical supervision and not just reflective supervision when working with families with multiple, highly complex needs.

Information, education, and communication (IEC) guidelines for implementing the IEC component of the maternal and child health(MCH)/family planning(FP) project (MON/93/P01) of the Ministry of Health of Mongolia (the result of a mission by the CST for the East and South East Asia Adviser on Population Communication) target 3 groups: all women of reproductive age; adolescents and young adults aged 15-34 (36.7% of the total population); and children under 14 (41% of the total population). Government policy makers, legislators, administrators, school teachers, media practitioners, and health educators will receive IEC messages. Initial efforts will be in urban areas. The messages will cover reproductive health and hygiene, responsible sex, family life education, delaying marriage and first pregnancy, dangers of abortion, sexually transmitted disease (STD), safe motherhood, breastfeeding, child care, contraceptive methods, and misconceptions about family planning. Specific messages will be used for 5 high risk groups of women (those aged 20 or less; those older than 35; those with 4 or more children; those with children less than 2 years apart; and those 15-34 years of age). Messages will first be broadcast over radio and television and then confirmed, supported, and reinforced through use of print materials and face to face interactions with service providers. The proposed workplan includes activities on audience research; training on communication design; production of IEC materials, and planning and implementing IEC campaigns; IEC materials development and FP counseling workshops; newsletter production; and establishment of a Documentation Centre.

This paper examines the role of the Program for International Training in Health (INTRAH) in the development of national family planning service guidelines throughout sub-Saharan Africa. INTRAH noted that the service managers, trainers and service providers lacked a common set of references to guide family planning service development, provision, training and evaluation. This was evident from the great variations in family planning service delivery practices and procedures and working conditions, and considerable confusion about what constituted an acceptable level of family planning service coverage and quality. In response to this problem, INTRAH conducted a series of technical assistance program in Botswana, which resulted in two ministry-sanctioned service and training-directed guidance documents. These documents include a national family planning service policy and a set of standards to accompany the policy statements, and a set of family planning service guideline that operates the policy and standards. These documents are available at all government-sponsored family planning service sites, and service providers are expected to use them as references for service planning, provision and evaluation. In addition, INTRAH assists ministries of health to organize for and prepare drafts of country-appropriate service guides and guidelines with an emphasis on in-country working groups.

In these guidelines for improvement in the Indian Family Welfare Programme the Auxiliary Nurse Midwife (ANM) comes under scrutiny, especially in relation to other family planning personnel. The ANM is expected to provide maternal child care, family planning, recordkeeping, training and supervision of local midwives in maternal-child health services. Field observations show that the ANM has not been as effective as expected. Reasons offered include: lack of trust and understanding between the ANM and the villagers, location of subcenter, lack of supplies, and inadequate services. The author believes support and supervision by family planning personnel could improve the efficiency of the ANM. A 3 tier supervisional structure is proposed including; a) supervision by state headquarters, b) supervision by district level staff, c) supervision by primary health center staff. A sample of personnel involved and projected supervisional duties is described. The author feels that implementation of such needed improvements as undefined work areas and duties; poor followup; limited use of available literature; lack of scheduling; poor supplies and attitudes on part of the workers can succeed with the 3 tier system.

Guidelines for the integrated management of childhood illness (IMCI) in peripheral health facilities have been developed by WHO and UNICEF to improve the recognition and treatment of common causes of childhood death. To evaluate the impact of the guidelines on treatment costs, we compared the cost of drugs actually prescribed to a sample of 747 sick children aged 2-59 months in rural health facilities in western Kenya with the cost of drugs had the children been managed using the IMCI guidelines. The average cost of drugs actually prescribed per child was US$ 0.44 (1996 US$). Antibiotics were the most costly component, with phenoxymethylpenicillin syrup accounting for 59% of the cost of all the drugs prescribed. Of the 295 prescriptions for phenoxymethylpenicillin syrup, 223 (76%) were for treatment of colds or cough. The cost of drugs that would have been prescribed had the same children been managed with the IMCI guidelines ranged from US$ 0.16 per patient (based on a formulary of larger-dose tablets and a home remedy for cough) to US$ 0.39 per patient (based on a formulary of syrups or paediatric-dose tablets and a commercial cough preparation). Treatment of coughs and colds with antibiotics is not recommended in the Kenyan or in the IMCI guidelines. Compliance with existing treatment guidelines for the management of acute respiratory infections would have halved the cost of the drugs prescribed. The estimated cost of the drugs needed to treat children using the IMCI guidelines was less than the cost of the drugs actually prescribed, but varied considerably depending on the dosage forms and whether a commercial cough preparation was used.
This study evaluated the impact of the integrated management guidelines of childhood illness (IMCI) developed by the WHO and UN Children\'s Fund on the treatment cost in Kenya. To determine the impact of the guidelines, a comparison was made of the cost of drugs actually prescribed to 747 sick children aged 2-59 months in rural facilities with the treatment cost had the children been managed following the IMCI guidelines. The study found that the estimated cost of drugs required to treat children following the IMCI guidelines was lower than the cost of the drugs actually prescribed in ill children. The average cost of drugs actually prescribed for every sick child was US$0.44. Antibiotics were the most expensive component, with phenoxymethylpenicillin syrup responsible for 59% of the total cost of prescribed drugs. The cost of medications that would have been prescribed had the children been treated using the guidelines ranges from US$0.16 to US$0.39 per patient. Managing cough and colds with antibiotics is not recommended in the IMCI guidelines, thus, compliance to guidelines would have reduced the treatment cost to one half the cost of drugs actually prescribed.