title: Strength of recommendations in WHO guidelines using GRADE was associated with uptake in national policy.
abstract: OBJECTIVE
  This study assesses the extent to which the strength of a recommendation in a World Health Organization (WHO) guideline affects uptake of the recommendation in national guidelines.
  
  
  METHODS
  The uptake of recommendations included in HIV and TB guidelines issued by WHO from 2009 to 2013 was assessed across guidelines from 20 low- and middle-income countries in Africa and Southeast Asia. Associations between characteristics of recommendations (strength, quality of the evidence, type) and uptake were assessed using logistic regression.
  
  
  RESULTS
  Eight WHO guidelines consisting of 109 strong recommendations and 49 conditional recommendations were included, and uptake assessed across 44 national guidelines (1,255 recommendations) from 20 countries. Uptake of WHO recommendations in national guidelines was 82% for strong recommendations and 61% for conditional recommendations. The odds of uptake comparing strong recommendations and conditional recommendations was 1.9 (95% confidence interval: 1.4, 2.7), after adjustment for quality of evidence. Higher levels of evidence quality were associated with greater uptake, independent of recommendation strength.
  
  
  CONCLUSIONS
  Guideline developers should be confident that conditional recommendations are frequently adopted. The fact that strong recommendations are more frequently adopted than conditional recommendations underscores the importance of ensuring that such recommendations are justified.
authors.affiliation: Division of Infectious Diseases, St Mary's Campus, Imperial College London, Paddington, London, United Kingdom.
authors.forename: Syed Muhammad Umar
authors.initials: SM
authors.lastname: Nasser
authors.affiliation: Division of Infectious Diseases, St Mary's Campus, Imperial College London, Paddington, London, United Kingdom.
authors.forename: Graham
authors.initials: G
authors.lastname: Cooke
authors.affiliation: Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom.
authors.forename: Katharina
authors.initials: K
authors.lastname: Kranzer
authors.affiliation: Guidelines Review Committee Secretariat, World Health Organization, Avenue Appia 20, 1202 Geneva, Switzerland.
authors.forename: Susan L
authors.initials: SL
authors.lastname: Norris
authors.affiliation: UNICEF/UNDP/World Bank/WHO Special Programme on Research & Training in Tropical Diseases (TDR), World Health Organization, Avenue Appia 20, 1202 Geneva, Switzerland; Centre for Tropical Medicine, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom.
authors.forename: Piero
authors.initials: P
authors.lastname: Olliaro
authors.affiliation: Department of HIV/AIDS, World Health Organization, Avenue Appia 20, 1202 Geneva, Switzerland. Electronic address: fordn@who.int.
authors.forename: Nathan
authors.initials: N
authors.lastname: Ford
mesh_terms: D019317:Evidence-Based Medicine; D019983:Guideline Adherence / Q000458:organization & administration* / Q000706:statistics & numerical data*; D006291:Health Policy; D006801:Humans; D016015:Logistic Models; D017410:Practice Guidelines as Topic; D014944:World Health Organization
keywords: GRADE; Guidelines; Quality; Strength; Uptake; World Health Organization