Bulletin of the World Health Organization最新文献

A toolkit for emergency care is being adapted for use across a wide range of countries and is having a significant impact on outcomes. Gary Humphreys reports.

The World Health Organization (WHO) plays an important role in developing evidence-based and ethically sound guidelines to assist health workers, programme managers and policy-makers, particularly in countries with limited capacities to create their own. While the development of these guidelines follows rigorous methods, contextualizing recommendations is often necessary to ensure their applicability, feasibility and acceptability at the country level. The adaptation and adoption of global guidelines should happen in a transparent, systematic and participatory manner to maintain credibility while ensuring the ownership necessary for implementation. Here, we present an example from Estonia that showcases the process, requirements and outcomes of implementing WHO guidelines through effective contextualization. The work in Estonia showed that contextualization can shorten guideline development time and reduce costs. To support countries in contextualizing guidelines, including those developed by WHO, to local contexts while maintaining trustworthiness and relevance, the WHO Regional Office for Europe has developed a handbook based on the GRADE-Adolopment approach to guide this process. Furthermore, a rapid assessment of 21 of the 53 Member States in the WHO European Region revealed that many countries need guidance and support to build capacity for contextualizing guidelines. To address the capacity gaps, we suggest a way forward that encompasses four areas of further work: standardizing methods; institutionalizing guideline programmes and initiatives; promoting continuous and shared learning; and providing support and identifying resources. Strengthening countries' capacities to contextualize global guidelines is crucial and will become especially relevant during future health threats, such as pandemics, climate change and conflict situations.

Problem: At the beginning of the coronavirus disease 2019 (COVID-19) pandemic, reliable, globally applicable recommendations for safe and continuous school operations were lacking.

Approach: In October 2020, the German Association of Scientific Medical Societies' task force for COVID-19 guidelines and public health researchers at Ludwig-Maximilians-Universität München initiated the rapid development of a living evidence- and consensus-based guideline to reduce severe acute respiratory syndrome coronavirus 2 transmission in schools. To facilitate transparent, structured and comprehensive decision-making with a whole-of-society perspective, they applied the WHO-INTEGRATE evidence-to-decision framework. This framework supported a broad, multisectoral composition of the guideline panel. The panel used newly synthesized evidence on nine school measures. Participating medical societies or the guideline secretariat completed evidence-to-decision tables. They also drafted recommendations for the guideline panel, who discussed and revised them during moderated consensus conferences.

Local setting: In Germany, each state is responsible for organizing schooling. The German Association of Scientific Medical Societies coordinates development of evidence- and consensus-based guidelines.

Relevant changes: The first version of the guideline was published in February 2021, and the guideline dissemination created much media attention. Of the 16 state education ministries, almost all knew about the guideline, nine recognized it as a relevant source of information and five used it to check existing directives.

Lessons learnt: The WHO-INTEGRATE framework facilitated a comprehensive assessment of school measures from the start of guideline development, considering the broad societal impact of the measures. Using the framework in rapid mode was feasible, but it fell short of its potential.

Problem: The Malaita and Western provinces in Solomon Islands had low routine immunization coverage due to disruptions in health services caused by the coronavirus disease 2019 pandemic in early 2022.

Approach: The country introduced the World Health Organization (WHO) Reaching Every District (RED) approach in 2002. Between July and September 2022, we strengthened supportive supervision, monitoring and use of data for decision-making, especially for microplanning and re-establishing outreach to prioritized areas. Health workers were supported to identify key concerns and develop strategies to improve performance. Monthly updates of reported immunization coverage, reporting completeness and fieldwork findings were widely disseminated.

Local setting: Solomon Islands' population is 748 606 people, of whom 165 345 reside in Malaita and 105 367 in Western Province.

Relevant changes: In Malaita Province, reported coverage of third dose of pentavalent vaccine and first dose of measles-rubella vaccine increased from 40% (757/1892) of eligible children to 121% (1144/946) and from 30% (568/1892) to 159% (1504/946), respectively; and in Western Province reported coverage increased from 38% (443/1165) to 191% (1113/583) and from 44% (513/1165) to 149% (868/583), respectively. Reported coverage for the remaining provinces increased from 64% (3380/5282) to 88% (2325/2641) and from 59% (3116/5282) to 137% (3619/2641), respectively. These findings led the programme on immunization to re-expand the WHO RED approach nationwide.

Lessons learnt: Supportive supervision, systematic monitoring and use of data for decision-making helped restoring reported immunization coverage in two low-coverage provinces. However, sustaining these results at a national level is necessary. The WHO RED approach remains relevant, even during a pandemic.

The normative role of the World Health Organization (WHO) involves creating evidence-based, principled guidelines to guide its Member States in making well-informed public health decisions. While these guidelines often need to be adapted to ensure contextual relevance, foster better implementation and adherence, adapting existing guidelines is more efficient than creating new ones. Here we describe the adaptation of the WHO coronavirus disease 2019 (COVID-19) living guideline on pharmacological interventions for the Caribbean using the grading of recommendations, assessment, development and evaluation (GRADE)-ADOLOPMENT method. The Caribbean Public Health Agency and the Pan American Health Organization led the effort, assembling a diverse panel of 16 experts from seven Caribbean countries and territories. The adaptation process, involving 15 steps, was guided by an experienced methodologist and included selecting relevant clinical questions and prioritizing them based on regional needs. The panel evaluated the latest WHO guidelines and integrated additional local data. They adjusted the direction and strength of several recommendations to better fit the Caribbean context, considering local values and preferences, resources, accessibility, feasibility and impact on health equity. Ultimately, we changed the direction of two recommendations and the strength of five, tailoring them to regional realities. This effort highlights the importance of adapting global guidelines to local settings, improving their applicability and effectiveness. The adaptation process also serves as a valuable opportunity for skill transfer and capacity-building in guideline development. Continued research is needed to assess the impact of these adaptations on health-care outcomes in the Caribbean.

Problem: Violence against women is a global health problem. Effectively preventing such violence requires locally adapted strategies.

Approach: The World Health Organization in Indonesia, in collaboration with United Nations (UN) Population Fund, UN Women, United Nations Children's Fund, United Nations Development Programme and Joint United Nations Programme on HIV/AIDS, launched capacity-building initiatives to introduce RESPECT as an evidence-based framework to address violence against women. The initiatives included stakeholder engagement, module development, sensitization training, a workshop and evaluation sessions. These sessions introduced RESPECT strategies to government officials, UN officers and community representatives, mapped best practices and developed action plans.

Local setting: Indonesia has a substantial burden of violence against women, despite numerous laws and policies to combat it. The 2021 Indonesian violence against women survey showed that 26.1% (3341/12 800) of women aged 15-64 years had experienced violence in their lifetime, with 8.7% (1114/12 800) experiencing violence in the past year.

Relevant changes: The initiatives to introduce RESPECT led to securing government support, and verbal commitment was given by the Director for the Protection of Women's Rights against Domestic Violence and Vulnerability to integrate RESPECT into the 2025-2029 National Development Plan and National Strategy for Reducing Violence Against Women.

Lessons learnt: RESPECT can be adapted to local contexts through customization and capacity-building and by ensuring initial government support, dedicated personnel, resource allocation and use of established relationships with key stakeholders. Improved research, monitoring and evaluation are vital to promote evidence-informed decision-making, together with community engagement and multistakeholder collaboration. The UN can facilitate these efforts.