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Guideline Summary
Guideline Title
Increasing access to health workers in remote and rural areas through improved retention: global policy recommendations.
Bibliographic Source(s)
World Health Organization (WHO). Increasing access to health workers in remote and rural areas through improved retention. Geneva (Switzerland): World Health Organization (WHO); 2010. 72 p. [105 references]
Guideline Status

This is the current release of the guideline.

Scope

Disease/Condition(s)

Health problems in remote and rural areas

Guideline Category
Management
Prevention
Treatment
Clinical Specialty
Dentistry
Family Practice
Internal Medicine
Nursing
Nutrition
Preventive Medicine
Surgery
Intended Users
Advanced Practice Nurses
Allied Health Personnel
Clinical Laboratory Personnel
Dentists
Health Care Providers
Hospitals
Nurses
Other
Patients
Pharmacists
Physical Therapists
Physician Assistants
Physicians
Public Health Departments
Social Workers
Students
Guideline Objective(s)
  • To provide up-to-date, practical guidance to policy-makers on how to design, implement and evaluate strategies to attract and retain health workers in rural and remote areas
  • To support countries in their efforts to improve health outcomes by strengthening the capacity of health systems to provide quality health care that is accessible, responsive, effective, efficient and equitable
Target Population

Patients living in rural or remote areas

Interventions and Practices Considered
  1. Educational interventions to increase the number of students who will eventually practice in remote and rural areas
  2. Regulatory interventions that will create conditions for rural health workers to do more and train more health workers faster, make the most of compulsory service, and tie education subsidies to mandatory practice
  3. Financial incentives for health professionals who practice in remote or rural areas
  4. Providing personal and professional support for rural health care workers
Major Outcomes Considered

Recruitment and retention rates of health workers for remote and rural areas

Methodology

Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Searches of Unpublished Data
Description of Methods Used to Collect/Select the Evidence

The process to develop these recommendations started off with a literature review conducted by the World Health Organization (WHO) Secretariat in 2008, which formed the basis of the first expert consultation in February 2009. For this review, peer-reviewed publications as well as "grey" literature were examined.

Electronic searches were conducted in August and September 2008 in PubMed, the Cochrane database, EMBASE and LILACS. Reference lists of the retrieved studies were also searched to complement the final list of articles. Further evidence was gathered from experts in the field of human resources for health, hand searches of the journal Human Resources for Health and the Journal of Remote and Rural Health, as well as from grey literature, through searches in Google™, the Human Resources for Health (HRH) Global Resource Centre and various government ministries' websites.

The following subject headings and text words and a combination thereof were used: doctors, nurses, midwives, mid-level health workers, community health workers, health managers, lab technicians, health worker, health professional, human resources for health, health workforce, health technician, clinical engineer, health teams, physician in combination with: rural, remote, underserved, rural/urban imbalances, maldistribution; retention, recruitment, retention, retention strategies/retention strategy, retention scheme; financial incentive, monetary incentive, non-financial incentive, non-monetary incentive, allowances, salaries, benefits; compulsory service, bonding scheme; rural pipeline, professional development, professional support, telemedicine; vacancy rates, motivation, patient satisfaction, utilization of services, duration in service; and evaluation, impact, programme result. Although the main search was conducted in English, substantial efforts were made to gather studies in French, Portuguese, Spanish and Scandinavian languages, with the support of consultants in those regions.

The review included articles that were published between 1995 and September 2008, from both developed and developing countries and covering all types of health workers. The inclusion criteria stated that the study must report on the results/effects of an intervention, have a focus on remote or rural areas, and have a clear description of the study design and methods used. News and editorials were excluded as they did not report on effects of interventions.

A background paper summarizing this initial literature review was presented at the first full expert group meeting in February 2009 and served as a basis for the group to agree on the research questions, to establish the scope of the guidelines, and to identify the research gaps. Based on these gaps and the plan of action agreed upon by the expert group, additional research was commissioned to some of the experts in the group. These are presented in one of the sections in the original guideline document. Subsequent ad hoc searches were conducted through early 2010 to ensure no essential studies were missed during the expert group’s work on the recommendations.

Available/Published Systematic Reviews

Several systematic reviews already available in this field were particularly instrumental in helping collect evidence and complete the Grading of Recommendations Assessment, Development and Evaluation (GRADE) evidence profiles. Further details about the findings of these four reviews are presented in the original guideline document and in the GRADE evidence profiles (Annex 1 of the original guideline document; see the "Availability of Companion Documents" field).

Country Case Studies and Commissioned Reports

Additional research was commissioned by the WHO Secretariat to fill in the evidence gaps identified during the first expert consultation. This included specific systematic reviews and a series of country case studies.

Three reviews were commissioned. One review examined the impact of compulsory service on the recruitment and retention of health workers in rural areas. The second review was a "realistic" evaluation, which applied theory-based methods to the original findings of the World Health Organization (WHO) background paper with the aim of understanding why and how certain interventions worked. Finally, the third review was on the role of outreach support on the recruitment of health workers in remote and rural areas. This review built on and expanded the original review, by providing more examples of outreach support activities in rural areas.

The country case studies were commissioned in order to better understand the contextual elements that influence retention strategies in different situations. They used a common template developed by the expert group, and included the following countries: Australia, China, Ethiopia, the Lao People's Democratic Republic, Mali, Norway, Samoa, Senegal, Vanuatu and Zambia. Some of the case studies are still ongoing, but it is expected that it will be possible to draw comparative lessons from the various contexts of these countries on the planning, implementation and evaluation of different retention strategies.

These country case studies and the three reports mentioned above will all be published as standalone documents and will be accessible online at: http://www.who.int/hrh/resources/ External Web Site Policy.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

The following Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria were used for assessing the quality of the evidence:

Quality of the Evidence Study Design Downgrade the Quality of the Evidence If... Upgrade the Quality of the Evidence If...
High Randomized trial
  • Study limitations
  • Inconsistency
  • Indirectness
  • Imprecision
  • Publication bias
  • Large magnitude of effect
  • Evidence of dose-response
  • All plausible confounding factors accounted for
Moderate
Low
Very low Observational study
Methods Used to Analyze the Evidence
Systematic Review with Evidence Tables
Description of the Methods Used to Analyze the Evidence

Grading of Recommendations, Assessment, Development and Evaluation (GRADE) Evidence Profiles

The GRADE methodology was used in the development of these recommendations. GRADE presents a systematic and transparent way of assessing and grading the quality of the evidence. World Health Organization (WHO) staff from the Health Workforce Retention and Migration Unit were trained and acquired skills in using the GRADE methodology and prepared the GRADE evidence tables, with support from a member of the GRADE working group.

There were certain challenges in using GRADE for these recommendations. For example, GRADE does not allow for consideration of key contextual issues or provide space for the inclusion of adequate descriptions of the characteristics of complex interventions used to recruit and retain health workers. And unlike strictly clinical interventions, using controls or fixing for all variables or confounding factors is extremely challenging and sometimes impossible for complex health policy interventions and is absent in many studies.

The evidence profiles in Annex 1 of the original guideline document present the grading of the evidence for each recommendation and more information on the GRADE methodology. A GRADE evidence profile was prepared for each recommendation with the intention of presenting the highest quality evidence available for that recommendation (additional evidence is captured in the descriptive evidence tables in Annex 2 of the original guideline document). (See the "Availability of Companion Documents" field for the annexes.)

In general, the higher the quality of the evidence, the stronger the recommendations are. However, as noted in Chapters 3 and 6 of the original guideline document, the quality of the evidence was only one of the criteria used to determine the eventual strength of the recommendations. Due to the limitations of using GRADE to assess the quality of the evidence for health policy interventions (as opposed to clinical interventions) equal consideration was given to other criteria such as balance between benefits and risks, values and preferences, and resource use. As a result, there are some strong recommendations associated with low-quality evidence.

Descriptive Evidence Tables

Detailed evidence tables can be found in Annex 2 of the original guideline document (see the "Availability of Companion Documents" field). These were developed at the request of the expert group in order to provide additional evidence to that captured in the GRADE evidence profiles. These descriptive tables present short summaries of approximately 100 studies that were considered in the development of these recommendations. The tables include all the studies that appear in the GRADE evidence profiles, plus additional descriptive studies, papers that analyse the factors that influence health workers' decisions to go to, stay in and leave remote and rural areas, and regional or global literature reviews related to the recruitment and retention of health workers.

Methods Used to Formulate the Recommendations
Balance Sheets
Expert Consensus (Consensus Development Conference)
Description of Methods Used to Formulate the Recommendations

Process for Formulating the Global Recommendations

A background paper was prepared for the first meeting of the expert group in February 2009. In selecting the members, careful consideration was given to achieving a gender balanced group, with representation from all World Health Organization (WHO) regions and relevant constituencies (policy-makers, academics, funders, professional associations and rural health workers).

The WHO background paper provides a comprehensive review of the current thinking and evidence in this area and highlights significant knowledge gaps. The experts used the background paper to agree on the research questions to be addressed by this report, and on the four categories of interventions. During their first meeting, they also finalized a plan of action to further supplement the evidence base, and some of the experts self-selected into a "core" expert group to undertake the additional systematic research needed. Subsequent expert consultations (two of the core group in April and October 2009, and two of the full expert group in June and November 2009) discussed the results of the additional research and proposed draft recommendations. During these consultations, members of the core expert group provided initial text for the recommendations, which were subsequently revised by the WHO Secretariat.

The revised draft recommendations were presented to policy-makers, academics and other stakeholders from 15 Asian countries and eight African countries during a regional workshop in November 2009 in Hanoi, Viet Nam. Participants had the opportunity to discuss their experiences and challenges in improving rural and remote retention and to comment on the draft recommendations.

The experts met for the final time in February 2010 to discuss again the draft recommendations, particularly with a view to rank the recommendations based on the quality of the evidence, benefits, values, and resource use. Balance worksheets were prepared for each recommendation, containing the factors taken into account in ranking the recommendations. Follow-up was done by e-mail with the core group on the final evidence tables and on the revised balance worksheets for each recommendation. The WHO Secretariat incorporated the experts' inputs and finalized the report.

Several papers that informed the development of this report were published in May 2010 in a special theme issue of the Bulletin of the World Health Organization, a peer-reviewed journal. In addition, two experts were commissioned to write reports on compulsory service schemes and outreach services in order to review and analyse available evidence related to these specific recommendations. Another expert conducted a "realist review" of a selection of retention studies with the aim of better understanding the influence of contextual factors and the mechanisms that make interventions work or fail. Comprehensive country case studies were also conducted in Australia, Ethiopia, the Lao People's Democratic Republic, Mali, Norway, Samoa, Senegal, Vanuatu and Zambia in order to understand country specificities and to share lessons learnt. These reports and country case studies were a significant contribution to the evidence base for these recommendations and will all be published as stand-alone documents and will be accessible online at: http://www.who.int/hrh/resources External Web Site Policy/.

All efforts were made to comply with standards for reporting, processing and using evidence in the production of WHO guidelines as required by the Organization's Guidelines Review Committee (GRC). This includes using a system for assessing evidence for interventions known as GRADE (Grading of Recommendations Assessment, Development and Evaluation) and presenting the quality of the evidence in the GRADE format. Because of the richness of the information in this field, particularly with regard to the mechanisms that make interventions work, the expert group felt that a considerable amount of valuable evidence was not being captured by GRADE. As a result, early on in the process of formulating these recommendations the experts decided to supplement the GRADE approach with additional evidence.

Deciding on Strength of the Recommendations

Quality of the evidence as judged by GRADE was only one of the criteria used to decide on the strength of a recommendation. Experiences and opinions of expert group members have further informed the discussions on the evidence as well as on values and preferences, benefits and disadvantages, resource use and feasibility. Policy-makers need to consider all of these criteria when deciding on and implementing the recommendations through wide stakeholder consultation, and within the specific country context. See the "Rating Scheme for the Strength of the Recommendations" field for the definitions and interpretation of the "strong" and "conditional" ratings.

In general, the higher the quality of the evidence, the stronger the recommendations are. However, the quality of the evidence was only one of the criteria used to determine the eventual strength of the recommendations. Due to the limitations of using GRADE to assess the quality of the evidence for health policy interventions (as opposed to clinical interventions) equal consideration was given to other criteria such as balance between benefits and risks, values and preferences, and resource use. As a result, there are some strong recommendations associated with low-quality evidence.

Rating Scheme for the Strength of the Recommendations

Strength of the Recommendations According to Grading of Recommendations Assessment, Development and Evaluation (GRADE)

An intervention with a "strong" recommendation is associated with "moderate" or "low" quality of the evidence in the GRADE tables, general consensus on the absolute magnitude of the effects and benefits, no significant variability in how different stakeholders value the outcomes, and technical prerequisites for implementation that are feasible in most settings. Interventions with a "strong" recommendation are more likely to be successful in a wide variety of settings.

A "conditional" recommendation for an intervention implies "very low" or "low" quality of the evidence, only a small magnitude of effect over a short period of time, significantly more potentially negative effects, wide variability in values among stakeholders, and significant variability between countries in the prerequisites for implementation. A "conditional" recommendation is less likely to be successful in all settings and requires careful consideration of the contextual issues and the prerequisites for implementation.

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation
External Peer Review
Description of Method of Guideline Validation

The revised draft recommendations were presented to policy-makers, academics and other stakeholders from 15 Asian countries and eight African countries during a regional workshop in November 2009 in Hanoi, Viet Nam. Participants had the opportunity to discuss their experiences and challenges in improving rural and remote retention and to comment on the draft recommendations.

Recommendations

Major Recommendations

The definitions for the quality of the evidence (high, moderate, low, very low) and the strength of the recommendations (strong, conditional) are provided at the end of the "Major Recommendations" field.

Education

Get the "Right" Students

Use targeted admission policies to enrol students with a rural background in education programmes for various health disciplines, in order to increase the likelihood of graduates choosing to practice in rural areas. (Quality of the evidence – moderate. Strength of the recommendation – strong)

Train Students Closer to Rural Communities

Locate health professional schools, campuses and family medicine residency programmes outside of capitals and other major cities, as graduates of these schools and programmes are more likely to work in rural areas. (Quality of the evidence – low. Strength of the recommendation – conditional)

Bring Students to Rural Communities

Expose undergraduate students of various health disciplines to rural community experiences and clinical rotations as these can have a positive influence on attracting and recruiting health workers to rural areas. (Quality of the evidence – very low. Strength of the recommendation – conditional)

Match Curricula with Rural Health Needs

Revise undergraduate and postgraduate curricula to include rural health topics so as to enhance the competencies of health professionals working in rural areas, and thereby increase their job satisfaction and retention. (Quality of the evidence – low. Strength of the recommendation – strong)

Facilitate Professional Development

Design continuing education and professional development programmes that meet the needs of rural health workers and that are accessible from where they live and work, so as to support their retention. (Quality of the evidence – low. Strength of the recommendation – conditional)

Regulatory Interventions

Create the Conditions for Rural Health Workers to Do More

Introduce and regulate enhanced scopes of practice in rural and remote areas to increase the potential for job satisfaction, thereby assisting recruitment and retention. (Quality of the evidence – very low. Strength of the recommendation – conditional)

Train More Health Workers Faster to Meet Rural Health Needs

Introduce different types of health workers with appropriate training and regulation for rural practice in order to increase the number of health workers practising in rural and remote areas. (Quality of the evidence – low. Strength of the recommendation – conditional)

Make the Most of Compulsory Service

Ensure compulsory service requirements in rural and remote areas are accompanied with appropriate support and incentives so as to increase recruitment and subsequent retention of health professionals in these areas. (Quality of the evidence – low. Strength of the recommendation – conditional)

Tie Education Subsidies to Mandatory Placements

Provide scholarships, bursaries or other education subsidies with enforceable agreements of return of service in rural or remote areas to increase recruitment of health workers in these areas. (Quality of the evidence – low. Strength of the recommendation – conditional)

Financial Incentives

Make It Worthwhile to Move to a Remote or Rural Area

Use a combination of fiscally sustainable financial incentives such as hardship allowances, grants for housing, free transportation, paid vacations, etc., sufficient enough to outweigh the opportunity costs associated with working in rural areas, as perceived by health workers, to improve rural retention. (Quality of the evidence – low. Strength of the recommendation – conditional)

Personal and Professional Support

Pay Attention to Living Conditions

Improve living conditions for health workers and their families and invest in infrastructure and services (sanitation, electricity, telecommunications, schools etc.) as these factors have a significant influence on a health worker's decision to locate to and remain in rural areas. (Quality of the evidence – low. Strength of the recommendation – strong)

Ensure the Workplace Is Up to an Acceptable Standard

Provide a good and safe working environment, including appropriate equipment and supplies, supportive supervision and mentoring, in order to make these posts professionally attractive, and thereby increase the recruitment and retention of health workers in remote and rural areas. (Quality of the evidence – low. Strength of the recommendation – strong)

Foster Interaction between Urban and Rural Health Workers

Identify and implement appropriate outreach activities to facilitate cooperation between health workers from better served areas and those in underserved areas, and, where feasible, use telehealth to provide additional support to health workers in remote and rural areas. (Quality of the evidence – low. Strength of the recommendation – strong)

Design Career Ladders for Rural Health Workers

Develop and support career development programmes and provide senior posts in rural areas so that health workers can move up the career path as a result of experience, education and training, without necessarily leaving rural areas. (Quality of the evidence – low. Strength of the recommendation – strong)

Facilitate Knowledge Exchange

Support the development of professional networks, rural health professional associations, rural health journals etc. in order to improve the morale and status of rural providers and reduce feelings of professional isolation. (Quality of the evidence – low. Strength of the recommendation – strong)

Raise the Profile of Rural Health Workers

Adopt public recognition measures such as rural health days, awards and titles at local, national and international levels to lift the profile of working in rural areas as these create the conditions to improve intrinsic motivation and thereby contribute to the retention of rural health workers. (Quality of the evidence – low. Strength of the recommendation – strong)

Definitions:

Quality of the Evidence

The following Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria were used for assessing the quality of the evidence:

Quality of the Evidence Study Design Downgrade the Quality of the Evidence If... Upgrade the Quality of the Evidence If...
High Randomized trial
  • Study limitations
  • Inconsistency
  • Indirectness
  • Imprecision
  • Publication bias
  • Large magnitude of effect
  • Evidence of dose-response
  • All plausible confounding factors accounted for
Moderate
Low
Very low Observational study

Strength of the Recommendation

An intervention with a "strong" recommendation is associated with "moderate" or "low" quality of the evidence in the GRADE tables, general consensus on the absolute magnitude of the effects and benefits, no significant variability in how different stakeholders value the outcomes, and technical prerequisites for implementation that are feasible in most settings. Interventions with a "strong" recommendation are more likely to be successful in a wide variety of settings.

A "conditional" recommendation for an intervention implies "very low" or "low" quality of the evidence, only a small magnitude of effect over a short period of time, significantly more potentially negative effects, wide variability in values among stakeholders, and significant variability between countries in the prerequisites for implementation. A "conditional" recommendation is less likely to be successful in all settings and requires careful consideration of the contextual issues and the prerequisites for implementation.

Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for each recommendation (see the "Major Recommendations" field).

Much of the evidence in this field comes from observational studies, rarely from well-designed cohort studies or before-and-after studies.

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Improved health service delivery contributing to improved health status and health outcomes

Potential Harms

Not stated

Qualifying Statements

Qualifying Statements
  • The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.
  • The mention of specific companies or of certain manufacturers' products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters.
  • All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use.

Implementation of the Guideline

Description of Implementation Strategy

The document is available in print, on the World Health Organization (WHO) website and on CD-ROM, and it will be circulated through WHO channels for adaptation and implementation at country level. It will also be translated and subsequently disseminated. Some countries, including the Lao People's Democratic Republic and Mali, are already considering these recommendations to inform the design of their retention strategies, with the WHO Secretariat providing technical assistance, as required. In addition, several members of the expert group are leading a research effort to fill some of the evidence gaps that have emerged through the development of this document.

See also Chapter 4, "Measuring results: how to select, implement and evaluate rural retention policies," in the original guideline document.

Implementation Tools
Quick Reference Guides/Physician Guides
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Staying Healthy
IOM Domain
Effectiveness

Identifying Information and Availability

Bibliographic Source(s)
World Health Organization (WHO). Increasing access to health workers in remote and rural areas through improved retention. Geneva (Switzerland): World Health Organization (WHO); 2010. 72 p. [105 references]
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2010
Guideline Developer(s)
World Health Organization - International Agency
Source(s) of Funding

Financial support for producing these recommendations was received from the United States Agency for International Development and the European Union, and is gratefully acknowledged.

Guideline Committee

World Health Organization Expert Group

Composition of Group That Authored the Guideline

Authors: Carmen Dolea, HMR/HRH; Laura Stormont, HMR/HRH; Joanne McManus, independent consultant, Oxford

Expert Group Members: Ian Couper, University of Witwatersrand, South Africa; Marjolein Dieleman, Royal Tropical Institute, the Netherlands; Gilles Dussault, Instituto de Higiene e Medecina Tropical, Lisbon, Portugal; Jim McCaffery, Training Resources Group and CapacityPlus, USA; Ray Pong, Laurentian University, Canada; Estelle Quain, United States Agency for International Development, USA; Roger Strasser (Northern Ontario Medical School, Canada; Seble Frehywot, George Washington University, USA; Steve Reid, University of Cape Town, South Africa; Christophe Lemière, World Bank, Senegal; Eric de Roodenbeke, International Hospital Federation, France; Marko Vujicic, World Bank, USA; Pascal Zurn, HMR/HRH/WHO; Grace Allen-Young, Independent Consultant, Jamaica; Jim Buchan; Queen Margaret University, United Kingdom; Françoise Jabot, Ecole des hautes études en santé publique, France; Julia Seyer, World Health Professions Alliance, France; Pawit Vanichanon, Langoon Hospital, Thailand; Junhua Zhang, Ministry of Health, China; Kim Webber, Rural Health Workforce Agency, Australia; Dina Balabanova, London School of Hygiene and Tropical Medicine, United Kingdom; Jim Campbell, Integrare, Spain; Laurence Codjia (Global Health Workforce Alliance, Switzerland; Adriana Galan, National Institute of Public Health, Romania; Luis Huicho, Universidad Peruana Cayetano Heredia, Peru; Tim Martineau, Liverpool School of Tropical Medicine, United Kingdom; Mary O'Neil, Management Sciences for Health, USA

Financial Disclosures/Conflicts of Interest

All participants to the consultation meetings signed a declaration of interest. Ten participants declared interest in terms of receiving non-commercial financial support for research and consulting from public bodies interested in retention of health workers. These interests were not considered to be conflicts for the purposes of participation in the guideline development.

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available in Portable Document Format (PDF) from the World Health Organization Web site External Web Site Policy.

Print copies: Available from the WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland; Phone: +41 22 791 3264; Fax: +41 22 791 4857; E-mail: bookorders@who.int.

Availability of Companion Documents

The following are available:

  • Annex 1: GRADE evidence profiles. Geneva (Switzerland): World Health Organization (WHO); 2010. 21 p. Electronic copies: Available in Portable Document Format (PDF) from the World Health Organization (WHO) Web site External Web Site Policy.
  • Annex 2: Descriptive evidence profiles. Geneva (Switzerland): World Health Organization (WHO); 2010. 27 p. Electronic copies: Available in PDF from the WHO Web site External Web Site Policy.
  • WHO handbook for guideline development. Geneva (Switzerland): World Health Organization (WHO); 2008 Mar. 41 p. Electronic copies: Available in PDF from the WHO Web site External Web Site Policy.

An executive summary is available in the original guideline document External Web Site Policy.

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI Institute on August 9, 2012.

Copyright Statement

This NGC summary is based on the original guideline, which may be subject to the guideline developer's copyright restrictions.

Disclaimer

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