Clinical practice guidelines (CPGs) have been defined as:

In addition to considering benefits and harms, other factors such as costs, acceptability, feasibility and equity implications of alternative care options need to be assessed.

Globally, the value of CPGs is increasingly being recognised. This has, firstly, led to a rise in the number of CPGs being produced.² For example, the World Health Organization (WHO) has developed CPGs for all major infectious conditions and for more and more non-communicable conditions. Secondly, the evidence base on CPG methods and processes is growing, with published guidance on CPG development, adaptation, contextualisation, implementation and evaluation. The WHO, the GRADE working group (https://www.gradeworkinggroup.org/) and the Guidelines International Network (https://g-i-n.net/home) are recognised as knowledge leaders in this field and have set international standards for developing guidelines from scratch (‘de novo’ guidelines) and for adapting existing guidelines to other settings.³

Given the advancements and increase in complexity in CPG methods, it is vital that the skills, knowledge and experience of those developing CPGs keep pace.⁴ However, reviews of CPGs in sub-Saharan Africa (SSA) and globally indicate that many of these do not meet standards, for example, they perform poorly on reporting on how they were developed and how editorial independence was maintained.^5,6,7 Given the substantial potential impact of CPGs, there is a strong rationale for investing in training and capacity building for managing and participating in guideline development and evidence-informed decision-making, comprising aspects linked to convening the CPG group, moving stepwise through a rigorous process and ensuring that resource-efficient methods are used.

Against this backdrop, the Global Evidence, Local Adaptation (GELA) project aimed to maximise the impact of research on poverty-related diseases through enhancing researchers’ and decision makers’ capacity to use research evidence to develop locally relevant CPGs for newborn and child health in Malawi, Nigeria and South Africa (https://africa.cochrane.org/projects/GELA).

The project was implemented over a 3-year period (2022–2025) in Malawi, Nigeria and South Africa, through a multifaceted, multidisciplinary research approach that used primary and secondary research, guideline adaptation methodology, and digital platforms to support dynamic guideline development. Guideline development and adaptation within the project were informed by the GRADE approach, including the use of evidence-to-decision (EtD) frameworks to present evidence within a guideline process, and to facilitate systematic and transparent judgements about the evidence.⁸ This was supported by a capacity building programme, specifically for decision makers such as the guideline development group (GDG) and steering group (SG) committee members (those involved in steering and developing the guidelines), GELA staff members and researchers in the respective countries. Throughout the project, we introduced innovations⁹ in the tools we were using to meet the constraints and needs of the CPG processes in each country, accompanied by a comprehensive evaluation of key aspects of the research, research uptake into policy, and capacity building.

This article aimed to evaluate capacity development of GDG and SG committee members GELA. Capacity building activities included formal short courses, webinars, in-person guideline simulation workshops and an online community of practice. Our needs assessment (baseline survey) at the beginning of the project highlighted learning needs across all evidence synthesis and guideline development domains. Table 7 provides a summary of our findings according to the four levels of Kirkpatrick’s model to evaluate training.

The survey found that participants’ confidence in skills required for CPG development increased, and their self-reported behaviours linked to CPG development changed through GELA activities. However, it is likely that the change in knowledge, skills and behaviour over the course of GELA was not only because of capacity development activities but also as a result of learning by doing, as many respondents indicated that they did not attend courses but participated in the GELA guideline development process in their respective countries. Therefore, apart from the planned activities within GELA,¹⁴ capacity development also occurred implicitly during the ‘actual’ priority setting and guideline development meetings, and associated team discussions. Here, they received hands-on experience in priority setting, using evidence and participating in the guideline development process. For some, this would have provided them with opportunities to apply and potentially extend the knowledge and skills they had obtained from the formal capacity building activities in real-world settings.

The interviews complemented the key survey findings, which subsequently shaped the team’s reflections on the importance of tailoring activities that are underpinned by appropriate educational pedagogy, such as adult learning principles and experiential learning theory.^25,26 For example, we used simulation as a teaching event, mimicking a guideline development panel meeting with elements of role play. The simulation provided an authentic experiential opportunity, allowing participants to put into practice various evidence-informed decision-making competencies, including a practical application of GRADE for guidelines⁸ in making a recommendation, and an appreciation for both qualitative and quantitative evidence. A similar guideline simulation workshop has been developed and implemented in Norway by the Norwegian project partners, and a recent evaluation thereof highlights the potential value in increasing active participation in a real guideline development process.²⁷ In GELA, we found that teaching and learning activities, such as the simulation, contributed to the increased confidence of participants in guideline development processes and decision-making spaces (especially those new to the process). Indeed, other studies have also emphasised the value of authentic learning environments for CPG training. One study reported on guideline development training of European Neurology Residents and found that exercises mimicking the guideline development process were effective to enhance understanding and raise awareness of guideline development.²⁸ Another study from the USA, reporting on CPG training for patient representatives, also found that experiential learning and roleplay were key in learning about the guideline development process.²⁹

Furthermore, self-reported behaviour changes were seen in the guideline development activities, such as the formulation of clinical and/or public health practice guideline questions, searching for research evidence to answer healthcare questions and participating in the critical appraisal of individual research studies to determine their validity and applicability to healthcare practice. Many participants were also positive about how the process enhanced their collaboration with in-country colleagues in similar research interests. Drawing on the views and experiences of GDG and SG committee members regarding the positive impact of GELA activities, it was not surprising to see that many suggested ways to provide more training, as well as sustain the skills gained from the GELA project and/or institutionalise these guidelines development processes.

Indeed, capacity development is likely a cross-cutting and necessary principle in guideline development, not an optional extra. Without sound training in evidence-informed decision-making and guideline processes, or if those making the decisions (such as clinicians and policymakers) lack this training, we undermine the credibility of recommendations and trust in the outputs, and risk harmful recommendations.³⁰ The ongoing shifts and evolution in guideline development methods often place considerable pressure on guideline panels and steering committees, such as seen in living and rapid guideline methods.^31,32,33 Thus, as the complexity of guideline development increases, we must sufficiently equip those involved. This includes emphasising exposing GDGs to different streams of evidence, such as qualitative and economic evidence, beyond the usual focus on effectiveness evidence and interpretation thereof. A recent survey conducted among guideline developers in the Netherlands also highlighted the importance of training for CPG development and incorporating aspects linked to economic and qualitative evidence.³⁴

Our findings are based on a document analysis, an online survey, individual, in-depth interviews and a structured reflection. We thus provide a holistic picture of our experience with strengthening capacity in CPG development of GDG and SG members from South Africa, Malawi and Nigeria. As far as we know, this is the first study to report on CPG capacity development for GDG and SG members in SSA. All authors were involved in the implementation of GELA, and were thus able to critically reflect on capacity development activities and understand the context within which these were implemented. These reflections, together with findings from in-depth interviews, led to rich discussions on lessons learned. However, we are aware that our involvement with GELA has the potential to shape our interpretation of data.

Although we invited all GDG and SG members to attend various capacity development activities, participation varied across countries, with good representation from Nigeria, and less so from South Africa and Malawi. Similarly, most respondents to both surveys were from Nigeria. Presumably, the higher participation by Nigerian participants was because of ongoing involvement as members of guideline committees of professional groups and the desire to upskill for subsequent independence in those positions. It may also be related to the use of different reminder approaches to encourage participation. Furthermore, GDG and SG members in Malawi preferred in-person rather than online training, which probably also impacted participation in activities. We therefore acknowledge that the findings may not be a good representation of the full range of views of participants from South Africa and Malawi.

Overall, the response rate to the surveys, particularly the mid-term survey, was low despite numerous reminder emails. We did not collect information on reasons for not responding to the survey. Guideline development group and SG members were busy clinicians, who participated in the GELA project in addition to their full-time jobs, and were not compensated for their time. It is also possible that there were too many requests over the course of the project, and initial enthusiasm might have decreased by the time of the evaluation. Lastly, respondents might have been hesitant to respond honestly and therefore preferred not to respond. We acknowledge that the sample of respondents (specifically to the mid-term survey) may have biased the results. In the mid-term survey, most respondents indicated that they did not participate in the capacity development activities.

Our survey tool was adapted from two existing tools.¹⁴ We used the competencies (for novices and advanced beginners) proposed in the work by Sultan et al.¹⁵ as a basis for questions on confidence in guideline development knowledge and skills in the survey, but not to develop learning activities. Even though there might have been a slight disconnect between what participants learned and the questions in the survey, we are confident that we covered most competencies through the various activities and participation in GELA.

Although we asked GDG and SG members to rate their confidence in their knowledge and skills at the beginning of the project, we did not include a question on behaviour in the baseline survey. Instead, we asked respondents of the mid-term survey to rate their behaviour before GELA retrospectively. Recollection bias may have led to an inaccurate assessment of behaviour frequency at baseline.

Future research should build on our experience to explore how capacity in evidence-informed decision-making and CPG development can be strengthened in a sustainable way and integrated into routine training. This includes exploring barriers to engaging in capacity development activities, learner preferences in terms of the format of activities, and the role of mentorship between experienced and novice GDG members. Training should be based on learners’ needs and baseline skills. In our sample, self-perceived confidence in finding and interpreting qualitative research evidence, as well as methods to adapt guidelines remained low.

Similarly, behaviour linked to synthesising and interpreting effectiveness, qualitative and economic evidence for guideline development remained low. While GDG members wouldn’t be expected to carry out all these tasks themselves, they need a good understanding of how each of these steps is performed to make informed decisions based on the evidence presented to them. Further learning opportunities should address these needs. Further exploration of simulation-based learning (such as guideline panel simulations) and its impact on participants’ confidence and competence, not only for guideline panellists but also for those facilitating the process, should be further explored. Simulation could thus act as a valuable ‘play-ground’ for both prospective panellists and methodologists to hone their skills for the real-world setting, however, research on the impact of simulation for guideline panels remains sparse. Lastly, there is a need to explore how guideline processes can be institutionalised within national borders and across, where knowledge, process and systems sharing is paramount.

The GELA project was an important opportunity for GDG and SG members in South Africa, Malawi and Nigeria to learn about and participate in a rigorous guideline development process. The multifaceted approach comprising formal courses, experiential learning and networking was seen by participants to facilitate capacity development in evidence-informed decision-making. The sustainability of training initiatives and the institutionalisation of rigorous guideline development processes remain challenging in the study settings, as these require time and resources, including experienced guideline methodologists. Continuing to support networking and collaboration between evidence producers, evidence users and guideline methodologists is important, including through both formal and informal initiatives.