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SAMJ: South African Medical Journal

versão On-line ISSN 2078-5135
versão impressa ISSN 0256-9574

SAMJ, S. Afr. med. j. vol.106 no.12 Pretoria Dez. 2016 



South African Guidelines Excellence (SAGE): Adopt, adapt, or contextualise?



J M DizonI, II; K GrimmerIII, IV; Q LouwV;T KredoVI; T YoungVII, VIII; S MachingaidzeIX, X

IPhD, MSPT, BSPT;Centre for Evidence-Based Health Care, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
IIPhD, MSPT, BSPT; Center for Health Research and Movement Science, University of Santo Tomas, Manila, Philippines
IIIPhD, MMedSc, LMusA, BPt, Cert Health Economics; International Centre for Allied Health Evidence, City East Campus, University of South Australia, Adelaide, Australia
IVPhD, MMedSc, LMusA, BPt, Cert Health Economics; Department of Physiotherapy, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
VPhD, MASP, BSc (Physio); Department of Physiotherapy, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
VIMMed (Clin Pharm), MB ChB, Dip HIV Man; Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa
VIIPhD, MMed, FCPHM, MB ChB; Centre for Evidence-Based Health Care, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
VIIIPhD, MMed, FCPHM, MB ChB; Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa
IXMPH, BSc Hons, BSc; Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa
XMPH, BSc Hons, BSc; European and Developing Countries Clinical Trial Partnership, Cape Town, South Africa





Clinical practice guideline (CPG) activities must be planned carefully for efficient use of available resources and evidence-based implementation. De novo development of CPGs may sometimes 'recreate the wheel' and delay implementation. Three innovative alternatives to de novo CPG development (adopt, contextualise or adapt) are outlined, which have greater potential than de novo development to best use the limited available resources, personnel and time in settings such as South Africa.



Clinical practice guidelines (CPGs) assist policymakers, managers, clinicians and patients to make evidence-informed healthcare decisions.[1] Most CPGs have been developed by reputable internationally recognised groups with established methods, and experienced multidisciplinary teams (method-ologists and content experts).[2-5] They are generally based in higher-income countries and focus on their healthcare priorities and systems.[6]

As more low- and middle-income countries (LMICs) use CPGs to improve healthcare practices, policymakers, managers and clinicians can draw on existing CPGs. However, these may be of questionable relevance to local settings (nature of practice, resources available, etc.) and local health priorities (country-specific priorities such as HIV or TB in Africa). Consequently, CPG groups in these countries may opt to develop de novo locally relevant CPGs, rather than considering how they could efficiently 'localise' existing CPGs.

Developing de novo guidelines is expensive and time-consuming and requires CPG knowledge, skills and expertise, which are limited in LMICs, including South Africa (SA).[7] The need tor evidence-informed and cost-efficient healthcare is urgent, and CPGs produced for local needs in these countries may have compromised quality and credibility and fail to meet international reporting standards for CPGs.[8] We have previously examined critical components of good-quality CPGs,[9] the potential of dedicated projects

such as South African Guidelines Excellence (SAGE) to better understand the development, implementation and use of CPGs in SA primary care settings,[10] and the construction and management of effective, efficient and outcome-focused CPG teams.[11] An alternative approach to CPG development is proposed that involves adopting, contextualising or adapting existing CPGs to suit local purposes. We outline four steps for determining the need for developing de novo CPGs, or identifying an alternative (Fig. 1).



Step 1. Establish the CPG condition, target patient group and end-users

Identify the condition, and the characteristics of patients for whom guidance is needed and who will use the CPG.


Step 2. Identify existing CPGs

Search reputable guideline sources for relevant CPGs. Several guideline sites allow free access to full CPGs developed for a range of conditions. Useful CPG resources can be accessed at


Step 3. Screen the CPGs and decide whether de novo development is necessary

Check whether the CPG was published within the past 5 years and is of good quality using standardised tools'12131 such as AGREE II[14] or the iCAHE tool.[15]

(a) If a CPG is outdated or of poor quality, an update is recommended using formal de novo methods.[1, 16]

(b) If a CPG is current and of good quality, it is justifiable to use it and decide whether to adopt, contextualise or adapt the recommendations.


Step 4. Consider whether to adopt, adapt or contextualise

Step 4.1 Adopt

Decide to adopt if the CPG has recommendations that are relevant and applicable to local needs and settings. CPG adoption is a method where CPGs produced elsewhere are used as is, and directly implemented into practiced Countries with the same patient types, health systems and resources should be able to adopt and implement such CPG recommendations.

Step 4.2 Contextualise

Decide to contextualise if the CPG has recommendations relevant to local needs; however, consideration of local context issues is required prior to implementation. CPG contextualisation is a method where recommendations from CPGs produced elsewhere can be adopted; however, additional information is required to address local contexts.[17, 18]

Current good-quality CPGs for many conditions, such as chronic pain, should be applicable to patients in most settings. The challenge is to contextualise (localise the evidence to fit local contexts),[19] e.g. high-quality CPGs for chronic pain commonly recommend that patients should participate in individualised exercise programmes to improve function,[18-20] which is relevant to chronic pain patients internationally. However, this may be difficult to implement in many SA communities, as trained exercise instructors, exercise equipment or safe exercise spaces may not be available. To implement this CPG recommendation, contextualisation is therefore required (find a secure community space, and use mats, towels, and kitchen items for weights), and regular group/community exercise programmes may be implemented as alternative strategies.

Step 4.3 Adapt

Decide to adapt if CPG recommendations are unachievable in local circumstances, and new evidence must be added to make them relevant to local conditions and therefore implementable. CPG adaptation is a method where recommendations are taken from CPGs produced elsewhere but amended to include local research evidence and expert group consensus.[15]In adapting, a process of layering the evidence underpinning recommendations from existing CPGs with additional local evidence is used. For example, if drug A, which is recommended in high-quality CPGs for patients with acute stroke, is not available in a country (not registered, too expensive, cannot be safely stored, etc.) and instead drug Β is locally available, affordable, with locally tested evidence and with equivalent benefits to drug A, the CPG recommendation could be adapted to suggest that drug Β could be used.

Acknowledgements. We thank Dawn Ernstzen, Division of Physiotherapy Stellenbosch University for her contextualisation work for chronic pain management in SA used in the example in this article, and Michelle Galloway for her support in finalising the submission on behalf of the author team.

Funding. The authors were funded, partially or in full, by the SAGE project, a 3-year (2014 - 2017) Flagship Grant from the South African Medical Research Council. The Flagship Grant programme was not involved in the conceptualisation or conduct of this study.



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J.M Dizon

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