Newborn and child health national and provincial clinical practice guidelines in South Africa, Nigeria and Malawi: a scoping review

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Clinical practice guidelines (CPGs) are essential policy tools in supporting implementation of effective, safe, and cost-effective healthcare. High-quality evidence-based CPGs play a key role in improving clinical management aiming to impact child mortality. We aimed to identify and assess the quality of CPGs for newborn and child health published in South Africa, Nigeria and Malawi. Methods We searched relevant websites (June–July 2022), for publicly available national and subnational de novo or adapted CPGs, addressing newborn and child health in the three countries. Pairs of reviewers independently extracted information from eligible CPGs (scope, topic, target population and users, responsible developers, stakeholder consultation process, adaptation description, assessment of evidence certainty). We appraised CPG quality using the Appraisal of Guidelines for Research & Evaluation (AGREE II) instrument. Results We identified 40 CPGs from the three countries. Of these, 8/40 reported being adopted from a parent CPG. More CPGs (n = 19) provided guidance on communicable diseases than on non-communicable diseases (n = 8). CPGs were most often developed by national health ministries and professional societies. Eighteen CPGs reported on stakeholder consultation; with Nigeria (10/11) and Malawi (3/6) faring better than South Africa (5/23) in reporting this activity. GRADE was used in 1/7 CPGs that reported assessing certainty of evidence. Overall CPGs scored well on two AGREE II domains: scope and purpose median (IQR) score 68% (IQR 47–83), and clarity of presentation 81% (67–94). Domains critical for ensuring credible guidance scored below 20%: rigour of development 11% ( 4 – 32 ) and editorial independence 6% (0–27). Conclusion Topics covered by the identified CPGs did not always match country level burden of disease likely representing substantial gaps in available guidance for healthcare providers, parents, caregivers, and patients. Our study found low AGREE II scores for CPG development processes, possibly undermining the credibility of the available CPGs to provide evidence-informed care. Our findings highlight the importance of ongoing efforts to strengthen capacity and support CPG development with collaboration between policymakers, researchers and the public. Clinical practice guidelines Newborn and child health Nigeria South Africa Malawi scoping review quality appraisal GRADE Figures Figure 1 Figure 2 Figure 3 Introduction Despite global progress in reducing infant and child mortality, most low- and middle-income countries (LMICs) remain disproportionately affected by high rates of childhood mortality ( 1 ). About 80% of the five million deaths that occurred in children under five in 2020 occurred in sub-Saharan Africa (SSA) and South Asia ( 1 ). Children born in SSA are 14 times more likely to die before reaching the age of five compared to children in high-income regions such as Europe and North America ( 1 ). Mortality rates in SSA are predominantly driven by factors such as health inequity, poverty, poor health systems and poor nutrition ( 2 , 3 ). Furthermore, negative economic and health system impacts of the coronavirus 2019 (COVID-19) pandemic have skewed child mortality further towards poor and vulnerable populations ( 1 , 4 ). Poverty-related diseases including human immunodeficiency virus (HIV), pneumonia, diarrhoea, and malaria remain among the leading causes of death in children under five years in LMICs ( 1 ). Most SSA countries are at risk of not meeting the Sustainable Development Goals (SDG) targets of reducing neonatal and under-five mortality rates to 12 per 1000 live births and 25 per 1000, respectively, by 2030 ( 5 ). However, steady declines in under-five mortality have been witnessed in the last decade (2009–2020) in some SSA countries, including South Africa (79.2 to 32.2 deaths per 1000 live births), Nigeria (138.3 to 113.8 deaths per 1000 live births), and Malawi (89.41 to 38.6 deaths per 1000 live births) ( 6 – 8 ). This decline has been partly due to the successful implementation of antiretroviral therapy (ART) programmes ( 8 , 9 ). Despite this progress, child mortality due to preventable conditions which could be effectively managed through feasible implementation interventions remains unacceptably high ( 8 , 10 ). Newborn and child survival is often associated with high standards of healthcare including neonatal and obstetric care, as well as the socio-economic development of populations ( 11 , 12 ). However, in countries where inequity is high, or in those with fragmented health systems, the survival scale is often tipped in favour of well-off individuals with the capacity to sustain out-of-pocket expenses and private health insurance ( 12 ). Hence, most SSA countries acknowledge the significance and role of Universal Health Care (UHC) in reaching the health SDG targets. The World Health Organization (WHO) maintains that health systems in low-resource settings where laboratory and radiology diagnostic services are limited or non-existent may benefit from using evidence-based algorithms and clinical practice guidelines (CPGs) to determine the course of management for certain conditions ( 10 ). Furthermore, clinical practice guidelines (CPGs) may be instrumental for countries in the quest to achieve UHC the use of appropriate and effective limited health services and resources ( 13 ). CPGs are “statements that include recommendations intended to optimise patient care that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options” ( 14 ). Therefore, CPGs bridge the gap between research evidence and clinical practice, allowing the integration of the best scientific evidence with clinical expertise when making healthcare decisions- one of the core competencies in healthcare practice ( 15 ). Well-formulated CPGs are essential in standardising clinical decision-making, minimising error and wastage of health resources, and informing quality of care and funding decisions ( 14 ). Key aspects of best-practice CPG development methods include transparency and good governance, use of rigorously collected and synthesised research evidence, contextualisation, and appropriate methods for assessing certainty of evidence such as Grading of Recommendations Assessment, Development and Evaluation (GRADE) for reviews and guidelines ( 14 , 16 ). International organisations including the WHO, the Guideline International Network (GIN), the Institute of Medicine (IOM) and the National Institute for Health and Care Excellence (NICE) have published standards for high-quality de novo (new) CPG development, adaptation, and implementation ( 17 – 19 ). However, these resources are not consistently adopted by CPG developers, leading to the development in some settings of CPGs that do not meet international methodological standards. This aligns with the findings of a recent study which reported that 66% of the randomly sampled and assessed global CPGs (for any condition) were developed using non-systematic approaches to evidence synthesis ( 20 ). It is widely accepted that de novo (new) CPG development is resource intensive, requiring adequate funding, technical expertise, and sufficient time. Hence, countries are embracing methods for adopting and adapting CPGs with contextualization of recommendations in existing high-quality global guidelines to the needs of local settings or countries. The methods for adoption and adaptation aim for transparency while minimising resource waste and duplication of efforts ( 21 ). The WHO develops high-quality, global-level CPGs which cover most of the key disease conditions to which most deaths are attributed. However, these CPGs have not consistently been adopted, or adapted in countries in SSA and other low-resource settings ( 22 ). Furthermore, lack of transparency in adaptation methods may cast doubts on the credibility of the adapted CPGs and their recommendations. To understand the landscape of newborn and child health CPGs in South Africa, Nigeria, and Malawi, this scoping review aimed to i) identify publicly available national and subnational CPGs for newborn and child health, ii) describe the scope of these CPGs, including methods used, and iii) appraise the quality and reporting standards of these CPGs. This study is part of a larger project, Global Evidence – Local Adaptation (GELA) ( 23 ), which aims to increase researchers and decision makers’ capacity to use global research evidence to develop locally relevant CPGs for newborn and child health. The GELA project aims to support decision makers in South Africa, Nigeria, and Malawi, and to build on and add value to the large-scale programme of global child health CPG development led by the WHO with adaptation and implementation led by the WHO Regional Office for Africa (Afro) and national ministries. Methods We conducted a scoping review using a pre-defined protocol in accordance with the Arksey and O’Malley methodological approach ( 24 ) reported the results according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist ( 24 ). The protocol was developed by authors from South Africa, Nigeria, and Malawi, and implemented with teams in each country. The data from each country were then compiled to create overall findings. Eligibility Criteria We included publicly available national and subnational level de novo , adapted and adopted CPGs, published between 2017 and 2022 in English or local languages of the respective countries. CPGs were defined as documents that provide evidence-based clinical guidance and actionable recommendations for individual care. CPGs were considered eligible if they provided guidance and recommendations for newborn and child health from birth to 12 years of age. CPGs were excluded if they included adolescents and adults only, were published before 2017, were not developed for South Africa, Nigeria, and Malawi, provided recommendations for population, school-based, community-based or policy-level interventions or strategies, or had been replaced by newer or updated versions. Identification Of Cpgs Search terms and information sources are presented in Supplementary file 1 (S1). Searches were conducted between June and July 2022 with no language restrictions. Each country team searched various sources including Google, Google scholar, respective Ministry of Health websites and policy document repositories, paediatric association websites, guideline clearing houses, GIN Library, Emergency Care Research Institute (ECRI), BIGG (International Database of GRADE Guidelines)], and relevant journals using predefined and relevant key terms. We also contacted experts, including Ministry of Health representatives and clinicians, in each country to identity eligible up-to-date CPGs not found or published online. Cpg Selection Pairs of authors independently screened titles and abstracts, and then full texts of retrieved documents, against the eligibility criteria. Any discrepancies were resolved through discussion or by involving a third author, if needed. Data Extraction One author independently extracted data from the included CPGs using a piloted Microsoft Excel data extraction sheet, with a second author verifying the data. Discrepancies were resolved through discussion. We extracted the following data: title; year of publication; topic or condition addressed by CPG; health care scope (e.g., prevention, treatment, diagnosis); target population; and target users. We also extracted data on whether stakeholders were consulted, whether the CPG was externally reviewed, and whether certainty of evidence was assessed; as well as descriptions of methods for CPG adaptation or adoption, and for assessing CPG applicability (costs associated with implementation, feasibility etc). Critical Appraisal: Agree Instrument Pairs of reviewers independently assessed the quality and reporting standards of included CPGs using the online Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument ( 25 – 27 ). This instrument contains 23 items organized into six domains: scope and purpose, stakeholder involvement, rigor of development, clarity of presentation, applicability, and editorial independence. Each item was rated on a 7-point scale (1- strongly disagree to 7-strongly agree). The online AGREE II instrument automatically generates scores at the end of the CPG appraisal ( 27 ). The standardized scores for individual AGREE domains range from 0 to 100% and are calculated using the following formula: (Obtained score – Minimum possible score) / (Maximum possible score – Minimum possible score) ∗ 100%. The overall score was generated by making a judgement on the overall quality of the CPG while taking into account the domain scores. Any discrepancies in scoring were resolved by consensus or through consulting a third reviewer, where necessary. If a CPG explicitly stated that it was adopted or adapted, the quality of the parent CPG was appraised to understand the methods used. Data analysis We analysed data using descriptive statistics, such as counts and proportions of characteristics of CPGs, using STATA 17 (StataCorp LLC, USA) and Microsoft Excel 2018. AGREE II scores were assessed for normality using the Shapiro-Wilk test and through visual inspection of box plots. As data were non-normally distributed, we reported medians with interquartile ranges. Extracted data were presented as counts and proportions. Results Results of the search The searches retrieved 1047 records across the three countries (Fig. 1 ). After deduplication, we screened the titles and abstracts of 1038 records. Of these, 892 were excluded and a total of 146 potentially eligible full texts were screened. After screening, we excluded 106 records that included CPGs published before 2017 (74), international CPGs ( 6 ), focused on adults ( 1 ), irrelevant settings ( 4 ), and did not fit the description of a CPG ( 18 ). Overall, 40 CPGs met our inclusion criteria. Figure 1 : PRISMA flowchart of study selection Characteristics Of Included Cpgs We included 40 CPGs of which 58% (n = 23) were from South Africa, 28% (n = 11) from Nigeria and 15% (n = 6) from Malawi. Of the 40 CPGs, 20% (n = 8) specifically stated that they were adopted from other CPGs, and thus the remaining 80% (n = 32) were presumed de novo . The leading CPG developers in all three countries were ministries of health and professional associations. Of the 40 CPGs, two from South Africa were developed at the subnational level. Figure 2 : Characteristics of included CPGs Scope or aspects of healthcare covered by CPGs were treatment 87% (n = 35), prevention 75% (n = 30), screening 60% (n = 24), diagnosis 78% (n = 31) and rehabilitation 13% (n = 5) (Fig. 2 A). Target populations of the CPGs were children 90% (n = 36) and infants 78% (n = 31) (Fig. 2 B). Fewer CPGs targeted prenatal care 38% (n = 15). CPGs predominantly provided guidance on communicable diseases 48% (n = 19); with fewer providing guidance on non-communicable diseases (NCDs) 18% (n = 8). Other CPGs did not address a specific disease 35% (n = 14) but focused on integrated healthcare of children as well as pharmaceutical management and treatment of a wide array of diseases. These CPGs included the integrated management of childhood illnesses (IMCI) (n = 2), kangaroo mother care (n = 1), care and management of newborns (n = 3), and primary healthcare or hospital level standard treatment guidelines and essential medicine lists (n = 2) (Table 1). Across the three countries, common conditions covered by CPGs focusing on specific health issues were HIV (all countries), as well as COVID-19 and tuberculosis (TB) (Nigeria and South Africa) (Table 1). The target audience for the CPGs was mostly health professionals 93% (n = 37), with only a small number of CPGs considering parents / caregivers 15% (n = 6) as part of their target audience. Overall, 45% of the CPGs (n = 18) described stakeholder consultation processes, with CPGs developed in Nigeria (10 of 11, 91%) and Malawi (3 of 6, 50%) showing better stakeholder involvement compared to CPGs developed in South Africa (5 of 23, 22%). Overall, systematic methods for assessing certainty of evidence were described in 18% (n = 7) of the CPGs, with one CPG (from South Africa) reporting use of GRADE. CPG external review processes were described in 15% of the CPGs (n = 6), while methods of assessing CPG applicability (i.e., barriers and facilitators to implementation, as well as costs and resources associated with CPG implementation) were described in 13% of the CPGs (n = 5). About 65% of the CPGs (n = 26) provided a list of the guideline development group, with Nigeria (10 of 11, 91%) and South Africa (13 of 23, 57%) showing better reporting processes for participants involved in the CPG development compared with Malawi (3 of 6, 50%). Table 1: Topics / conditions covered by CPGs Conditions South Africa (n) Nigeria (n) Malawi (n) Communicable Diseases 14 4 1 HIV /AIDS 3 2 1 Tuberculosis 2 1 - COVID-19 2 1 - Pertussis 1 - - Candida Auris 1 - - Diphtheria 1 - - Listeriosis 1 - - Malaria 2 - - Pneumonia 1 - - Non-Communicable diseases 4 4 0 Asthma 1 - - Cystic fibrosis 1 - - Enuresis 1 - - Diabetes - 1 - Chronic pain - 1 - Eye health 1 1 - Substance use disorders - 1 - Other 6 3 5 Primary healthcare STG 1 - - Hospital level paediatric STG 1 - - IMCI 1 - 1 Determination of death 1 - - Neonatal skincare 1 - - Cochlear implant quality standards 1 - - Care for infant and newborn - - 1 Infant and youth nutrition policy - - 1 Kangaroo mother care - 1 - Newborn management /care - 2 1 Baby friendly hospital initiative - - 1 Abbreviations: AIDS, acquired immunodeficiency syndrome; COVID-19, coronavirus disease 2019; HIV, human immunodeficiency virus; IMCI, integrated management of childhood illness; STG, standard treatment guidelines CPG quality and reporting methods The domains with the lowest median scores were editorial independence 6% (0 – 27), rigour of development 11% (4 – 32), and applicability 32% (12 – 50) (Table 2 and Figure 2). The domains with highest median scores were clarity of presentation 81 % (67 – 94), and scope and purpose 68% (47 – 83). When stratified by country, similar trends in domain scores across CPGs from South Africa, Nigeria and Malawi were observed. Each country exhibited very low editorial independence median domain scores ranging from 0 to 8%; low rigour domain median scores ranging 6 to 15%; and low applicability domain median scores ranging from 29 to 35%. Table 2: Summary of AGREE II domain scores (%) for CPGs in South Africa, Nigeria, and Malawi Domains Median scores (IQR) South Africa N = 23 Nigeria N = 11 Malawi N = 6 All countries N = 40 Scope and purpose 61 (39 – 78) 83 (64 – 94) 74 (56 – 75) 68 (47 – 83) Stakeholder involvement 39 (11 – 56) 56 (50 – 89) 60 (31 – 75) 52 (25 – 66) Rigor of development 15 (6 – 38) 6 (2 – 26) 11 (10 – 38) 11 (4 – 32) Clarity of presentation 92 (69 – 97) 81 (72 – 92) 64 (47 – 75) 81 (67 – 94) Applicability 31 (6 – 50) 29 (17 – 50) 36 (27 – 42) 32 (12 – 50) Editorial independence 4 (0 – 38) 8 (8 – 8) 0 (0 – 0) 6 (0 – 27) Overall 42 (33 – 50) 33 (33 – 50) 50 (42 – 67) 42 (33 – 54) Discussion We conducted a scoping review to describe the landscape and reporting quality of locally produced newborn and child health-related CPGs in South Africa, Nigeria, and Malawi. Overall, we identified 40 CPGs that provide recommendations for various aspects of health care (treatment, screening, prevention, diagnosis, and rehabilitation) for infants and children from birth up to 12 years old. Most CPGs provided guidance on the management of communicable diseases, which aligns with burden of disease in the region where poverty-related infectious diseases are often associated with under-five child mortality in SSA (28). Our main findings highlighted similar issues across the three countries regarding the poor methodological quality and reporting methods of CPGs. Although they scored well for the clarity of presentation and scope and purpose domains in AGREE II, most CPGs scored very poorly on rigor of development and did not adequately describe their methods for identifying, selecting, and assessing certainty of evidence. The lack of appropriate methodological reporting may undermine on the credibility of recommendations. Furthermore, grading the strength of recommendations and distinguishing expert opinion from evidence-based statements becomes an impossible task if appropriate links to evidence are not apparent; this is critical for transparency and CPG adaptation. Our findings further highlighted gaps in transparent reporting of funding disclosures and management of interests of members in CPG panels, as well as in considering factors such as feasibility, acceptability and equity to inform recommendations prior to CPG implementation. Similar trends in CPG quality and reporting methods were observed across the three countries, which may reflect the overall challenges faced by LMICs in CPG development and implementation. The extensive resources, including capacity, skills, time, and funding, needed for d e novo CPG development and implementation are often limited in LMICs. Using WHO guidance documents which are developed for adoption or adaptation by LMICs may therefore be a good option for these settings. However, the responsibility of appropriately assessing and considering local and contextual factors during CPG adoption / adaptation remain that of the individual countries, and the methods used for doing this are often unclear and implicit. For example, the South African and Malawian IMCI CPGs as well as the Malawian guideline on implementing the baby-friendly hospital initiative allude to the involvement of organisations such WHO, UNICEF or USAID through inclusion of their logos in the CPG documents, but without any explicit description of their role or involvement or adoption of recommendations. Scant local evidence may further complicate the CPG adoption/adaptation processes. Overall, this highlights lack of emphasis on reporting transparency with regards to guideline adaptation methods and processes to ensure that a guideline is trustworthy as well as clear linking of evidence to recommendations local evidence. The challenges in CPG quality and reporting methods may also reflect issues with expert or stakeholder representation and the failure to include a methodologist in CPG development groups. The CPGs included in this review highlighted some collaborative effort between ministries of health and professional associations in the respective countries, with ministries of health being the major drivers, especially in Nigeria and Malawi. Health ministries and professional associations are often led and represented by a diverse group of front-line health professionals and clinical experts with a common goal of enhancing efficiency in resource-constrained and often understaffed health systems. Hence, CPG development and implementation may be more focused on a front-line user-centred approach with a primary goal of enhancing clarity and dissemination of recommendations for easier use, while providing little to no detail on the development process. This was reflected in the very low ‘rigor of development’ and high ‘clarity of presentation’ domain score across the three countries in our findings. Given the stark impact of financial and time constraints of developing CPGs de novo , and the heavily burdened health systems in LMICs, it may seem justifiable to front-line clinicians to publish some clinical guidance as protocols and algorithms, as reflected by documents such as the IMCI. Although most of the included CPGs provided a list of the respective CPG development groups, it was difficult to ascertain whether these groups included all relevant stakeholders as affiliations and individual roles in CPG development were often not described. For example, the observed gaps in considering health economic evidence as shown by the low scores of CPGs in the applicability domain, may potentially reflect underrepresentation of expertise such as health economics in CPG development efforts. Unlike high-income regions, SSA has thus far experienced less success in reaching the SDG goal of reducing childhood mortality. Strengthened evidence-based interventions such as CPGs addressing country specific disease burdens may play a catalytic role in these efforts. De novo CPG development processes, such as priority setting and CPG group convening, may be out of reach for most LICs and may often not be necessary if good quality up-to-date guidance from other settings is available for for adoption or adaptation. However, complete reliance on international guidance may lead to missed opportunities in addressing country-specific gaps in relation to the local disease burden. Our findings revealed potential gaps in CPGs considering locally relevant evidence when making recommendations and in addressing key conditions associated with newborn and childhood morbidity and mortality in those countries. For example, malnutrition, gastroenteritis and neonatal disorders contribute to the burden of disease of all three countries, yet guidance for them is often included in other documents, such as the IMCI and standard treatment CPGs. In a region where poverty is often the major driver of the disease burden and child mortality and where a consistent pattern of malnutrition is observed, it would seem logical to have individual CPGs dedicated to diagnosis and management of malnutrition. Furthermore, it may be crucial to consider the emerging epidemics such as NCDs, including mental health, in children and preadolescents. For example, violence and intentional or unintentional injuries disproportionately affect LMICs (29), and hence CPGs for addressing trauma and associated mental impact may be a crucial piece of the puzzle in ensuring child health and development. As countries gear up towards implementing national health insurance schemes, there has been substantial advancement in the CPG landscape in some SSA countries. For example, the standard treatment guideline (STG) and EML first published in 1996 in South Africa to ensure rational and equitable access to medicines has evolved to include established terms of reference for guideline committee governance, evidence review and synthesis, as well as management of interests while fostering relationships with relevant experts and methodologists in the field of evidence synthesis (30). Furthermore, projects dedicated to strengthening capacity for development and implementation of CPGs such as the South African Guidelines Excellence (SAGE) and higher education on CPG training have been established (31-33). In this study we identified the paediatric hospital (2017) (34) and primary healthcare level (2020) (35) STGs from South Africa, with the latter showing improvement in domain scores such as such stakeholder involvement, applicability, and editorial independence. However, scores were still low for rigour of development, possibly due to lack of easy access to the methods guides that underpin the decision-processes. Given the size of the STG documents (often ± 600 pages), some methods sections may be omitted to accommodate the recommendation sections for included various conditions. Limitations of the study The lack of regional or national central CPG repositories makes it challenging to identify CPGs and it is therefore possible that we may have missed relevant CPGs in the field of newborn and child health. Our search was limited to CPGs developed in the last five years and it is possible that some of the older CPGs excluded by this limitation may be in the process of being updated. Some CPGs may have followed rigorous methods, but due to limited sharing of their methods in public websites or accessible repositories, this may not be well captured in the methods. AGREE II only appraises reporting of methods but does not cover the content of the CPGs; the recommendations may thus be appropriate even if the methods are not adequately reported. Implications for practice and policy This study highlights the need for involving guideline methodologists when developing CPGs to support transparent and trustworthy guidelines and use of adaptation/adoption methods for high-quality CPGs. CPGs that focus on high priority newborn and child health issues in specific country settings are needed. End-users of CPGs including policymakers may lack the skills to assess the quality of CPGs, leading to adoption of poor-quality CPGs in SSA countries. CPGs that don't adequately address country level contextual factors may face implementation challenges if the recommendations are appropriate to country settings. Conclusion There is considerable CPG production in the three countries which demonstrates both strengths and weakness on AGREE domains.The findings of this study highlight the importance of ongoing efforts to strengthen capacity and support CPG development with collaboration between policymakers, researchers and all relevant stakeholders. including the public, to improve and standardise CPG quality and reporting methods. This study also highlights gaps in current CPGs for conditions that contribute to the burden of diseases in newborn and child health in each country, including malnutrition, neonatal and congenital disorders, as well as comorbidities. Abbreviations AGREE Appraisal of Guidelines for Research and Evaluation AIDS Acquired immunodeficiency syndrome ART Antiretroviral therapy BIGG International Database of GRADE Guidelines COVID-19 Coronavirus 2019 CPG Clinical Practice Guideline ECRI Emergency Care Research Institute EML Essential medicine list GDG Guideline Development Group GIN Guideline international network GRADE Grading of Recommendations Assessment, Development and Evaluation HIV Human immunodeficiency virus IMCI Integrated Management of Childhood Illnesses IOM Institute of Medicine LMIC Lower middle-income countries NCD Non-communicable disease NICE National Institute for Health and Care Excellence SDG Sustainable Development Goals SSA Sub-Saharan Africa STGs Standard treatment guidelines TB Tuberculosis UHC Universal Health Care WHO World Health Organisation Declarations Supplementary information Supplementary file 1 – search terms Acknowledgements We acknowledge the GELA project consortium involving South Africa, Nigeria and Malawi, for the conceptualization of the project and contributions to the study. Author contributions Conceptualisation / design: TK, NMM, EE, MM, MMc, SD, SLe, PoV, RC, CN, MMe Data acquisition /analysis / Interpretation: TK, MM, NB, DM, TL, AB, IK, RC, SD, SLe, GK, EE, NMM, MC, EEs, CN, PoV, DA, MMc, MMe, PoV. MM and TK wrote the first draft of the manuscript, MM revised all drafts with input from all authors. All authors approved the final version of the manuscript. Funding GELA project is funded as part of the EDCTP2 programme supported by the European Union (grant number RIA2020S-3303-GELA). Availability of data and materials All data generated or analysed during this study are included in this manuscript (and its supplementary information files). Ethics approval and consent to participate Not applicable Consent for publication Not applicable Competing interests Tamara Kredo is a member of the GRADE working group and co-Director of South African GRADE Network, and a member of National Essential Medicines List Committee in South Africa, reviewing and ratifying national standard treatment guidelines. Other authors do not have any competing interest. References UNICEF-IGME. Levels & Trends in Child Mortality 2021 [Available from: https://data.unicef.org/resources/levels-and-trends-in-child-mortality/. Van Malderen C, Amouzou A, Barros AJD, Masquelier B, Van Oyen H, Speybroeck N. Socioeconomic factors contributing to under-five mortality in sub-Saharan Africa: a decomposition analysis. BMC Public Health. 2019;19(1):760. Amegah AK. Improving Child Survival in Sub-Saharan Africa: Key Environmental and Nutritional Interventions. Annals of global health. 2020;86(1):73. Headey D, Heidkamp R, Osendarp S, Ruel M, Scott N, Black R, et al. 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Available from: https://www.who.int/publications/i/item/9789241548960. NICE. Developing NICE guidelines: the manual | Guidance and guidelines | NICE. 2014. Lunny C, Ramasubbu C, Puil L, Liu T, Gerrish S, Salzwedel DM, et al. Over half of clinical practice guidelines use non-systematic methods to inform recommendations: A methods study. PLOS ONE. 2021;16(4):e0250356. McCaul M, Tovey D, Young T, Welch V, Dewidar O, Goetghebeur M, et al. Resources supporting trustworthy, rapid and equitable evidence synthesis and guideline development: results from the COVID-19 evidence network to support decision-making (COVID-END). Journal of clinical epidemiology. 2022;151:88-95. Dizon JM, Machingaidze S, Grimmer K. To adopt, to adapt, or to contextualise? The big question in clinical practice guideline development. BMC research notes. 2016;9(1):442. Cochrane Africa. Global Evidence - Local Adaptation (GELA): Grant to enhance evidence-informed guideline recommendations for newborn and young child health in three sub-Saharan African countries 2023 [Available from: https://africa.cochrane.org/projects/GELA. Tricco AC, Lillie E, Zarin W, O'Brien KK, Colquhoun H, Levac D, et al. PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation. Annals of Internal Medicine. 2018;169(7):467-73. Kredo T, Wiseman R, Gray A, Parrish A, Miot J, Cohen K. How good are our guidelines? Four years of experience with the SAMJ's AGREE II review of submitted clinical practice guidelines. SAMJ: South African Medical Journal. 2018;108:833-85. Brouwers MC, Kerkvliet K, Spithoff K. The AGREE Reporting Checklist: a tool to improve reporting of clinical practice guidelines. BMJ (Clinical research ed). 2016;352:i1152. Brouwers MC, Kho ME, Browman GP, Burgers JS, Cluzeau F, Feder G, et al. AGREE II: advancing guideline development, reporting and evaluation in health care. CMAJ. 2010;182(18):E839-E42. United-Nations. Levels and trends in child mortality: report 2020. Estimates developed by the UN Inter-agency Group for Child Mortality Estimation: UNICEF; 2020 [Available from: https://www.unicef.org/media/79371/file/UN-IGME-child-mortality-report-2020.pdf.pdf. Aboagye RG, Mireku DO, Nsiah JJ, Ahinkorah BO, Frimpong JB, Hagan JE, et al. Prevalence and psychosocial factors associated with serious injuries among in-school adolescents in eight sub-Saharan African countries. BMC Public Health. 2022;22(1):853. Perumal-Pillay VA, Suleman F. Selection of essential medicines for South Africa - an analysis of in-depth interviews with national essential medicines list committee members. BMC Health Services Research. 2017;17(1):17. Louw Q, Dizon JM, Grimmer K, McCaul M, Kredo T, Young T. Building capacity for development and implementation of clinical practice guidelines. SAMJ: South African Medical Journal. 2017;107:745-6. Taryn Y, Janine D, Tamara K, Michael M, Eleanor O, Karen G, et al. Enhancing capacity for clinical practice guidelines in South Africa. PAMJ. 2020;36(18). McCaul M, Durao S, Kredo T, Garner P, Young T, Rohwer A. Evidence synthesis workshops: moving from face-to-face to online learning. BMJ Evidence-Based Medicine. 2021;26(5):255. National Department of Health. Hospital Level (Paediatrics) Standard Treatment Guidelines and Essential Medicines List for South Africa 4th Edition 2017 [Available from: https://www.knowledgehub.org.za/elibrary/hospital-level-paediatrics-standard-treatment-guidelines-and-essential-medicines-list. National Department of Health. Primary Healthcare (PHC) Standard Treatment Guidelines and Essential Medicines List for South Africa 2020 [Available from: https://www.knowledgehub.org.za/elibrary/primary-healthcare-phc-standard-treatment-guidelines-and-essential-medicines-list-south. Additional Declarations Competing interest reported. Tamara Kredo is a member of the GRADE working group and co-Director of South African GRADE Network, and a member of National Essential Medicines List Committee in South Africa, reviewing and ratifying national standard treatment guidelines. Other authors do not have any competing interest. Supplementary Files Supplementaryfile.docx Cite Share Download PDF Status: Published Journal Publication published 19 Feb, 2024 Read the published version in BMC Health Services Research → Version 1 posted Editorial decision: Major revision 06 Jul, 2023 Reviews received at journal 03 Jul, 2023 Reviews received at journal 28 Apr, 2023 Reviewers agreed at journal 19 Apr, 2023 Reviewers agreed at journal 19 Apr, 2023 Reviewers invited by journal 16 Apr, 2023 Editor assigned by journal 16 Apr, 2023 Editor invited by journal 16 Apr, 2023 Submission checks completed at journal 16 Apr, 2023 First submitted to journal 26 Mar, 2023 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-2737679","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":192232202,"identity":"7a8bb919-8b58-4b1d-837b-c2ac3f6ff514","order_by":0,"name":"Mashudu Mthethwa","email":"","orcid":"","institution":"Cochrane South Africa, South African Medical Research Council","correspondingAuthor":false,"prefix":"","firstName":"Mashudu","middleName":"","lastName":"Mthethwa","suffix":""},{"id":192232204,"identity":"d17c1f68-358b-4118-ba13-84b3078d89a7","order_by":1,"name":"Nyanyiwe Masingi Mbeye","email":"","orcid":"","institution":"Evidence Informed Decision-making Centre, Department of Community and Environmental Health, School of Global and Public Health, Kamuzu University of Health Sciences","correspondingAuthor":false,"prefix":"","firstName":"Nyanyiwe","middleName":"Masingi","lastName":"Mbeye","suffix":""},{"id":192232207,"identity":"349bf788-099e-438f-9f18-ae99656c293c","order_by":2,"name":"Emmanuel Effa","email":"","orcid":"","institution":"Cochrane Nigeria, University of Calabar","correspondingAuthor":false,"prefix":"","firstName":"Emmanuel","middleName":"","lastName":"Effa","suffix":""},{"id":192232208,"identity":"e2ce17b9-6cca-4e41-bf2d-9c77a5b46c9f","order_by":3,"name":"Dachi Arikpo","email":"","orcid":"","institution":"Cochrane Nigeria, University of Calabar","correspondingAuthor":false,"prefix":"","firstName":"Dachi","middleName":"","lastName":"Arikpo","suffix":""},{"id":192232210,"identity":"c71478dd-b20f-4f0f-b81a-9c568c528480","order_by":4,"name":"Ntombifuthi 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09:59:22","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-2737679/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-2737679/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12913-024-10682-0","type":"published","date":"2024-02-19T15:02:01+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":35955424,"identity":"9ec3c5e5-b0c6-4cba-a646-2979db0a32fe","added_by":"auto","created_at":"2023-04-18 18:39:03","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":32129,"visible":true,"origin":"","legend":"\u003cp\u003ePRISMA flowchart of study selection\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-2737679/v1/6b72af52afa69468fe0122cc.png"},{"id":35955119,"identity":"4aedb4a1-3d00-4e37-b39c-547f8ad5d2f0","added_by":"auto","created_at":"2023-04-18 18:31:03","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":22728,"visible":true,"origin":"","legend":"\u003cp\u003echaracteristics of included CPGs\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-2737679/v1/ec761ac2a7a7cd72c9912c21.png"},{"id":35955117,"identity":"081469aa-6e9d-4494-8c46-051ca45bbfa4","added_by":"auto","created_at":"2023-04-18 18:31:03","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":16442,"visible":true,"origin":"","legend":"\u003cp\u003eGraphical representation of AGREE II scores\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-2737679/v1/b8926962f2f5bb77d4b51d4b.png"},{"id":51648467,"identity":"58bf2198-683b-41ca-a5ea-cf9aad9c1e27","added_by":"auto","created_at":"2024-02-26 15:13:36","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":589534,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-2737679/v1/d3559658-c99d-449c-bae1-0ea1db387cda.pdf"},{"id":35955425,"identity":"1c27b933-7e75-41cf-9053-4a33df743b9b","added_by":"auto","created_at":"2023-04-18 18:39:03","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":16963,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementaryfile.docx","url":"https://assets-eu.researchsquare.com/files/rs-2737679/v1/a4e1231bb34aef0977e69ca3.docx"}],"financialInterests":"Competing interest reported. Tamara Kredo is a member of the GRADE working group and co-Director of South African GRADE Network, and a member of National Essential Medicines List Committee in South Africa, reviewing and ratifying national standard treatment guidelines.\nOther authors do not have any competing interest.","formattedTitle":"Newborn and child health national and provincial clinical practice guidelines in South Africa, Nigeria and Malawi: a scoping review","fulltext":[{"header":"Introduction","content":"\u003cp\u003eDespite global progress in reducing infant and child mortality, most low- and middle-income countries (LMICs) remain disproportionately affected by high rates of childhood mortality (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). About 80% of the five million deaths that occurred in children under five in 2020 occurred in sub-Saharan Africa (SSA) and South Asia (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Children born in SSA are 14 times more likely to die before reaching the age of five compared to children in high-income regions such as Europe and North America (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Mortality rates in SSA are predominantly driven by factors such as health inequity, poverty, poor health systems and poor nutrition (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Furthermore, negative economic and health system impacts of the coronavirus 2019 (COVID-19) pandemic have skewed child mortality further towards poor and vulnerable populations (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Poverty-related diseases including human immunodeficiency virus (HIV), pneumonia, diarrhoea, and malaria remain among the leading causes of death in children under five years in LMICs (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Most SSA countries are at risk of not meeting the Sustainable Development Goals (SDG) targets of reducing neonatal and under-five mortality rates to 12 per 1000 live births and 25 per 1000, respectively, by 2030 (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). However, steady declines in under-five mortality have been witnessed in the last decade (2009\u0026ndash;2020) in some SSA countries, including South Africa (79.2 to 32.2 deaths per 1000 live births), Nigeria (138.3 to 113.8 deaths per 1000 live births), and Malawi (89.41 to 38.6 deaths per 1000 live births) (\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). This decline has been partly due to the successful implementation of antiretroviral therapy (ART) programmes (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Despite this progress, child mortality due to preventable conditions which could be effectively managed through feasible implementation interventions remains unacceptably high (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eNewborn and child survival is often associated with high standards of healthcare including neonatal and obstetric care, as well as the socio-economic development of populations (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). However, in countries where inequity is high, or in those with fragmented health systems, the survival scale is often tipped in favour of well-off individuals with the capacity to sustain out-of-pocket expenses and private health insurance (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Hence, most SSA countries acknowledge the significance and role of Universal Health Care (UHC) in reaching the health SDG targets. The World Health Organization (WHO) maintains that health systems in low-resource settings where laboratory and radiology diagnostic services are limited or non-existent may benefit from using evidence-based algorithms and clinical practice guidelines (CPGs) to determine the course of management for certain conditions (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Furthermore, clinical practice guidelines (CPGs) may be instrumental for countries in the quest to achieve UHC the use of appropriate and effective limited health services and resources (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eCPGs are \u0026ldquo;statements that include recommendations intended to optimise patient care that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options\u0026rdquo; (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Therefore, CPGs bridge the gap between research evidence and clinical practice, allowing the integration of the best scientific evidence with clinical expertise when making healthcare decisions- one of the core competencies in healthcare practice (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Well-formulated CPGs are essential in standardising clinical decision-making, minimising error and wastage of health resources, and informing quality of care and funding decisions (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eKey aspects of best-practice CPG development methods include transparency and good governance, use of rigorously collected and synthesised research evidence, contextualisation, and appropriate methods for assessing certainty of evidence such as Grading of Recommendations Assessment, Development and Evaluation (GRADE) for reviews and guidelines (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). International organisations including the WHO, the Guideline International Network (GIN), the Institute of Medicine (IOM) and the National Institute for Health and Care Excellence (NICE) have published standards for high-quality \u003cem\u003ede novo\u003c/em\u003e (new) CPG development, adaptation, and implementation (\u003cspan additionalcitationids=\"CR18\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). However, these resources are not consistently adopted by CPG developers, leading to the development in some settings of CPGs that do not meet international methodological standards. This aligns with the findings of a recent study which reported that 66% of the randomly sampled and assessed global CPGs (for any condition) were developed using non-systematic approaches to evidence synthesis (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIt is widely accepted that \u003cem\u003ede novo\u003c/em\u003e (new) CPG development is resource intensive, requiring adequate funding, technical expertise, and sufficient time. Hence, countries are embracing methods for adopting and adapting CPGs with contextualization of recommendations in existing high-quality global guidelines to the needs of local settings or countries. The methods for adoption and adaptation aim for transparency while minimising resource waste and duplication of efforts (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). The WHO develops high-quality, global-level CPGs which cover most of the key disease conditions to which most deaths are attributed. However, these CPGs have not consistently been adopted, or adapted in countries in SSA and other low-resource settings (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Furthermore, lack of transparency in adaptation methods may cast doubts on the credibility of the adapted CPGs and their recommendations.\u003c/p\u003e \u003cp\u003eTo understand the landscape of newborn and child health CPGs in South Africa, Nigeria, and Malawi, this scoping review aimed to i) identify publicly available national and subnational CPGs for newborn and child health, ii) describe the scope of these CPGs, including methods used, and iii) appraise the quality and reporting standards of these CPGs. This study is part of a larger project, Global Evidence \u0026ndash; Local Adaptation (GELA) (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e), which aims to increase researchers and decision makers\u0026rsquo; capacity to use global research evidence to develop locally relevant CPGs for newborn and child health. The GELA project aims to support decision makers in South Africa, Nigeria, and Malawi, and to build on and add value to the large-scale programme of global child health CPG development led by the WHO with adaptation and implementation led by the WHO Regional Office for Africa (Afro) and national ministries.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eWe conducted a scoping review using a pre-defined protocol in accordance with the Arksey and O\u0026rsquo;Malley methodological approach (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e) reported the results according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). The protocol was developed by authors from South Africa, Nigeria, and Malawi, and implemented with teams in each country. The data from each country were then compiled to create overall findings.\u003c/p\u003e\n\u003ch3\u003eEligibility Criteria\u003c/h3\u003e\n\u003cp\u003eWe included publicly available national and subnational level \u003cem\u003ede novo\u003c/em\u003e, adapted and adopted CPGs, published between 2017 and 2022 in English or local languages of the respective countries. CPGs were defined as documents that provide evidence-based clinical guidance and actionable recommendations for individual care. CPGs were considered eligible if they provided guidance and recommendations for newborn and child health from birth to 12 years of age.\u003c/p\u003e \u003cp\u003eCPGs were excluded if they included adolescents and adults only, were published before 2017, were not developed for South Africa, Nigeria, and Malawi, provided recommendations for population, school-based, community-based or policy-level interventions or strategies, or had been replaced by newer or updated versions.\u003c/p\u003e\n\u003ch3\u003eIdentification Of Cpgs\u003c/h3\u003e\n\u003cp\u003eSearch terms and information sources are presented in Supplementary file 1 (S1). Searches were conducted between June and July 2022 with no language restrictions. Each country team searched various sources including Google, Google scholar, respective Ministry of Health websites and policy document repositories, paediatric association websites, guideline clearing houses, GIN Library, Emergency Care Research Institute (ECRI), BIGG (International Database of GRADE Guidelines)], and relevant journals using predefined and relevant key terms. We also contacted experts, including Ministry of Health representatives and clinicians, in each country to identity eligible up-to-date CPGs not found or published online.\u003c/p\u003e\n\u003ch3\u003eCpg Selection\u003c/h3\u003e\n\u003cp\u003ePairs of authors independently screened titles and abstracts, and then full texts of retrieved documents, against the eligibility criteria. Any discrepancies were resolved through discussion or by involving a third author, if needed.\u003c/p\u003e\n\u003ch3\u003eData Extraction\u003c/h3\u003e\n\u003cp\u003eOne author independently extracted data from the included CPGs using a piloted Microsoft Excel data extraction sheet, with a second author verifying the data. Discrepancies were resolved through discussion. We extracted the following data: title; year of publication; topic or condition addressed by CPG; health care scope (e.g., prevention, treatment, diagnosis); target population; and target users. We also extracted data on whether stakeholders were consulted, whether the CPG was externally reviewed, and whether certainty of evidence was assessed; as well as descriptions of methods for CPG adaptation or adoption, and for assessing CPG applicability (costs associated with implementation, feasibility etc).\u003c/p\u003e\n\u003ch3\u003eCritical Appraisal: Agree Instrument\u003c/h3\u003e\n\u003cp\u003ePairs of reviewers independently assessed the quality and reporting standards of included CPGs using the online Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument (\u003cspan additionalcitationids=\"CR26\" citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). This instrument contains 23 items organized into six domains: scope and purpose, stakeholder involvement, rigor of development, clarity of presentation, applicability, and editorial independence. Each item was rated on a 7-point scale (1- strongly disagree to 7-strongly agree). The online AGREE II instrument automatically generates scores at the end of the CPG appraisal (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). The standardized scores for individual AGREE domains range from 0 to 100% and are calculated using the following formula: (Obtained score \u0026ndash; Minimum possible score) / (Maximum possible score \u0026ndash; Minimum possible score) \u0026lowast; 100%. The overall score was generated by making a judgement on the overall quality of the CPG while taking into account the domain scores. Any discrepancies in scoring were resolved by consensus or through consulting a third reviewer, where necessary. If a CPG explicitly stated that it was adopted or adapted, the quality of the parent CPG was appraised to understand the methods used.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eWe analysed data using descriptive statistics, such as counts and proportions of characteristics of CPGs, using STATA 17 (StataCorp LLC, USA) and Microsoft Excel 2018. AGREE II scores were assessed for normality using the Shapiro-Wilk test and through visual inspection of box plots. As data were non-normally distributed, we reported medians with interquartile ranges. Extracted data were presented as counts and proportions.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eResults of the search\u003c/h2\u003e \u003cp\u003eThe searches retrieved 1047 records across the three countries (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003e). After deduplication, we screened the titles and abstracts of 1038 records. Of these, 892 were excluded and a total of 146 potentially eligible full texts were screened. After screening, we excluded 106 records that included CPGs published before 2017 (74), international CPGs (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e), focused on adults (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e), irrelevant settings (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e), and did not fit the description of a CPG (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Overall, 40 CPGs met our inclusion criteria.\u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003e: \u003cb\u003ePRISMA flowchart of study selection\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eCharacteristics Of Included Cpgs\u003c/h3\u003e\n\u003cp\u003eWe included 40 CPGs of which 58% (n\u0026thinsp;=\u0026thinsp;23) were from South Africa, 28% (n\u0026thinsp;=\u0026thinsp;11) from Nigeria and 15% (n\u0026thinsp;=\u0026thinsp;6) from Malawi. Of the 40 CPGs, 20% (n\u0026thinsp;=\u0026thinsp;8) specifically stated that they were adopted from other CPGs, and thus the remaining 80% (n\u0026thinsp;=\u0026thinsp;32) were presumed \u003cem\u003ede novo\u003c/em\u003e. The leading CPG developers in all three countries were ministries of health and professional associations. Of the 40 CPGs, two from South Africa were developed at the subnational level.\u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e2\u003c/span\u003e: \u003cb\u003eCharacteristics of included CPGs\u003c/b\u003e\u003c/p\u003e \u003cp\u003eScope or aspects of healthcare covered by CPGs were treatment 87% (n\u0026thinsp;=\u0026thinsp;35), prevention 75% (n\u0026thinsp;=\u0026thinsp;30), screening 60% (n\u0026thinsp;=\u0026thinsp;24), diagnosis 78% (n\u0026thinsp;=\u0026thinsp;31) and rehabilitation 13% (n\u0026thinsp;=\u0026thinsp;5) (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e2\u003c/span\u003eA). Target populations of the CPGs were children 90% (n\u0026thinsp;=\u0026thinsp;36) and infants 78% (n\u0026thinsp;=\u0026thinsp;31) (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e2\u003c/span\u003eB). Fewer CPGs targeted prenatal care 38% (n\u0026thinsp;=\u0026thinsp;15). CPGs predominantly provided guidance on communicable diseases 48% (n\u0026thinsp;=\u0026thinsp;19); with fewer providing guidance on non-communicable diseases (NCDs) 18% (n\u0026thinsp;=\u0026thinsp;8). Other CPGs did not address a specific disease 35% (n\u0026thinsp;=\u0026thinsp;14) but focused on integrated healthcare of children as well as pharmaceutical management and treatment of a wide array of diseases. These CPGs included the integrated management of childhood illnesses (IMCI) (n\u0026thinsp;=\u0026thinsp;2), kangaroo mother care (n\u0026thinsp;=\u0026thinsp;1), care and management of newborns (n\u0026thinsp;=\u0026thinsp;3), and primary healthcare or hospital level standard treatment guidelines and essential medicine lists (n\u0026thinsp;=\u0026thinsp;2) (Table\u0026nbsp;1). Across the three countries, common conditions covered by CPGs focusing on specific health issues were HIV (all countries), as well as COVID-19 and tuberculosis (TB) (Nigeria and South Africa) (Table\u0026nbsp;1). The target audience for the CPGs was mostly health professionals 93% (n\u0026thinsp;=\u0026thinsp;37), with only a small number of CPGs considering parents / caregivers 15% (n\u0026thinsp;=\u0026thinsp;6) as part of their target audience.\u003c/p\u003e \u003cp\u003eOverall, 45% of the CPGs (n\u0026thinsp;=\u0026thinsp;18) described stakeholder consultation processes, with CPGs developed in Nigeria (10 of 11, 91%) and Malawi (3 of 6, 50%) showing better stakeholder involvement compared to CPGs developed in South Africa (5 of 23, 22%). Overall, systematic methods for assessing certainty of evidence were described in 18% (n\u0026thinsp;=\u0026thinsp;7) of the CPGs, with one CPG (from South Africa) reporting use of GRADE. CPG external review processes were described in 15% of the CPGs (n\u0026thinsp;=\u0026thinsp;6), while methods of assessing CPG applicability (i.e., barriers and facilitators to implementation, as well as costs and resources associated with CPG implementation) were described in 13% of the CPGs (n\u0026thinsp;=\u0026thinsp;5). About 65% of the CPGs (n\u0026thinsp;=\u0026thinsp;26) provided a list of the guideline development group, with Nigeria (10 of 11, 91%) and South Africa (13 of 23, 57%) showing better reporting processes for participants involved in the CPG development compared with Malawi (3 of 6, 50%).\u003c/p\u003e \u003cp\u003e \u003cb\u003eTable\u0026nbsp;1: Topics / conditions covered by CPGs\u003c/b\u003e \u003c/p\u003e\u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\" width=\"576\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.75%\"\u003e\n \u003cp\u003e\u003cstrong\u003eConditions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.791666666666668%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSouth Africa (n)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\n \u003cp\u003e\u003cstrong\u003eNigeria (n)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.791666666666668%\"\u003e\n \u003cp\u003e\u003cstrong\u003eMalawi (n)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.75%\"\u003e\n \u003cp\u003e\u003cstrong\u003eCommunicable Diseases\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.791666666666668%\"\u003e\n \u003cp\u003e\u003cstrong\u003e14\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\n \u003cp\u003e\u003cstrong\u003e4\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.791666666666668%\"\u003e\n \u003cp\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.75%\"\u003e\n \u003cp\u003eHIV\u0026nbsp;/AIDS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.791666666666668%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.791666666666668%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.75%\"\u003e\n \u003cp\u003eTuberculosis\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.791666666666668%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.791666666666668%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.75%\"\u003e\n \u003cp\u003eCOVID-19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.791666666666668%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.791666666666668%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.75%\"\u003e\n \u003cp\u003ePertussis\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.791666666666668%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.791666666666668%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.75%\"\u003e\n \u003cp\u003eCandida Auris\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.791666666666668%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.791666666666668%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.75%\"\u003e\n \u003cp\u003eDiphtheria\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.791666666666668%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.791666666666668%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.75%\"\u003e\n \u003cp\u003eListeriosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.791666666666668%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.791666666666668%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.75%\"\u003e\n \u003cp\u003eMalaria\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.791666666666668%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.791666666666668%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.75%\"\u003e\n \u003cp\u003ePneumonia\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.791666666666668%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.791666666666668%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.75%\"\u003e\n \u003cp\u003e\u003cstrong\u003eNon-Communicable diseases\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.791666666666668%\"\u003e\n \u003cp\u003e\u003cstrong\u003e4\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\n \u003cp\u003e\u003cstrong\u003e4\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.791666666666668%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.75%\"\u003e\n \u003cp\u003eAsthma\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.791666666666668%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.791666666666668%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.75%\"\u003e\n \u003cp\u003eCystic fibrosis\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.791666666666668%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.791666666666668%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.75%\"\u003e\n \u003cp\u003eEnuresis\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.791666666666668%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.791666666666668%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.75%\"\u003e\n \u003cp\u003eDiabetes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.791666666666668%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.791666666666668%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.75%\"\u003e\n \u003cp\u003eChronic pain\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.791666666666668%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.791666666666668%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.75%\"\u003e\n \u003cp\u003eEye health\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.791666666666668%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.791666666666668%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.75%\"\u003e\n \u003cp\u003eSubstance use disorders\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.791666666666668%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.791666666666668%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.75%\"\u003e\n \u003cp\u003e\u003cstrong\u003eOther\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.791666666666668%\"\u003e\n \u003cp\u003e\u003cstrong\u003e6\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\n \u003cp\u003e\u003cstrong\u003e3\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.791666666666668%\"\u003e\n \u003cp\u003e\u003cstrong\u003e5\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.75%\"\u003e\n \u003cp\u003ePrimary healthcare STG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.791666666666668%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.791666666666668%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.75%\"\u003e\n \u003cp\u003eHospital level paediatric STG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.791666666666668%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.791666666666668%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.75%\"\u003e\n \u003cp\u003eIMCI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.791666666666668%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.791666666666668%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.75%\"\u003e\n \u003cp\u003eDetermination of death\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.791666666666668%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.791666666666668%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.75%\"\u003e\n \u003cp\u003eNeonatal\u0026nbsp;skincare\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.791666666666668%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.791666666666668%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.75%\"\u003e\n \u003cp\u003eCochlear implant quality\u0026nbsp;standards\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.791666666666668%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.791666666666668%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.75%\"\u003e\n \u003cp\u003eCare for infant and newborn\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.791666666666668%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.791666666666668%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.75%\"\u003e\n \u003cp\u003eInfant and youth nutrition policy\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.791666666666668%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.791666666666668%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.75%\"\u003e\n \u003cp\u003eKangaroo mother care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.791666666666668%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.791666666666668%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.75%\"\u003e\n \u003cp\u003eNewborn management\u0026nbsp;/care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.791666666666668%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.791666666666668%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"43.75%\"\u003e\n \u003cp\u003eBaby friendly hospital initiative\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.791666666666668%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.791666666666668%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAbbreviations: AIDS, acquired immunodeficiency syndrome; COVID-19, coronavirus disease 2019; HIV, human immunodeficiency virus; IMCI, integrated management of childhood illness; STG, standard treatment guidelines\u003c/p\u003e\n\u003ch2\u003eCPG quality and reporting methods\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eThe domains with the lowest median scores were editorial independence 6% (0 \u0026ndash; 27), rigour of development 11% (4 \u0026ndash; 32), and applicability 32% (12 \u0026ndash; 50) (Table 2 and Figure 2). \u0026nbsp;The domains with highest median scores were clarity of presentation 81 % (67 \u0026ndash; 94), and scope and purpose 68% (47 \u0026ndash; 83). When stratified by country, similar trends in domain scores across CPGs from South Africa, Nigeria and Malawi were observed. Each country exhibited very low editorial independence median domain scores ranging from 0 to 8%; low rigour domain median scores ranging 6 to 15%; and low applicability domain median scores ranging from 29 to 35%.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2: Summary of AGREE II domain scores (%) for CPGs in South Africa, Nigeria, and Malawi\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\" width=\"633\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"27.330173775671405%\"\u003e\n \u003cp\u003e\u003cstrong\u003eDomains\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"top\" width=\"72.66982622432859%\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedian scores (IQR)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"25.49019607843137%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSouth Africa\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eN = 23\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"24.18300653594771%\"\u003e\n \u003cp\u003e\u003cstrong\u003eNigeria\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eN = 11\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"24.18300653594771%\"\u003e\n \u003cp\u003e\u003cstrong\u003eMalawi\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eN = 6\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"26.143790849673202%\"\u003e\n \u003cp\u003e\u003cstrong\u003eAll countries\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eN = 40\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.373417721518987%\"\u003e\n \u003cp\u003e\u003cstrong\u003eScope and purpose\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.5126582278481%\"\u003e\n \u003cp\u003e61 (39 \u0026ndash; 78)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.563291139240505%\"\u003e\n \u003cp\u003e83 (64 \u0026ndash; 94)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.563291139240505%\"\u003e\n \u003cp\u003e74 (56 \u0026ndash; 75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.9873417721519%\"\u003e\n \u003cp\u003e68 (47 \u0026ndash; 83)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.373417721518987%\"\u003e\n \u003cp\u003e\u003cstrong\u003eStakeholder involvement\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.5126582278481%\"\u003e\n \u003cp\u003e39 (11 \u0026ndash; 56)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.563291139240505%\"\u003e\n \u003cp\u003e56 (50 \u0026ndash; 89)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.563291139240505%\"\u003e\n \u003cp\u003e60 (31 \u0026ndash; 75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.9873417721519%\"\u003e\n \u003cp\u003e52 (25 \u0026ndash; 66)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.373417721518987%\"\u003e\n \u003cp\u003e\u003cstrong\u003eRigor of development\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.5126582278481%\"\u003e\n \u003cp\u003e15 (6 \u0026ndash; 38)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.563291139240505%\"\u003e\n \u003cp\u003e6 (2 \u0026ndash; 26)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.563291139240505%\"\u003e\n \u003cp\u003e11 (10 \u0026ndash; 38)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.9873417721519%\"\u003e\n \u003cp\u003e11 (4 \u0026ndash; 32)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.373417721518987%\"\u003e\n \u003cp\u003e\u003cstrong\u003eClarity of presentation\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.5126582278481%\"\u003e\n \u003cp\u003e92 (69 \u0026ndash; 97)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.563291139240505%\"\u003e\n \u003cp\u003e81 (72 \u0026ndash; 92)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.563291139240505%\"\u003e\n \u003cp\u003e64 (47 \u0026ndash; 75)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.9873417721519%\"\u003e\n \u003cp\u003e81 (67 \u0026ndash; 94)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.373417721518987%\"\u003e\n \u003cp\u003e\u003cstrong\u003eApplicability\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.5126582278481%\"\u003e\n \u003cp\u003e31 (6 \u0026ndash; 50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.563291139240505%\"\u003e\n \u003cp\u003e29 (17 \u0026ndash; 50)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.563291139240505%\"\u003e\n \u003cp\u003e36 (27 \u0026ndash; 42)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.9873417721519%\"\u003e\n \u003cp\u003e32 (12 \u0026ndash; 50)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.373417721518987%\"\u003e\n \u003cp\u003e\u003cstrong\u003eEditorial independence\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.5126582278481%\"\u003e\n \u003cp\u003e4 (0 \u0026ndash; 38)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.563291139240505%\"\u003e\n \u003cp\u003e8 (8 \u0026ndash; 8)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.563291139240505%\"\u003e\n \u003cp\u003e0 (0 \u0026ndash; 0)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.9873417721519%\"\u003e\n \u003cp\u003e6 (0 \u0026ndash; 27)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.373417721518987%\"\u003e\n \u003cp\u003e\u003cstrong\u003eOverall\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.5126582278481%\"\u003e\n \u003cp\u003e42 (33 \u0026ndash; 50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.563291139240505%\"\u003e\n \u003cp\u003e33 (33 \u0026ndash; 50)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.563291139240505%\"\u003e\n \u003cp\u003e50 (42 \u0026ndash; 67)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.9873417721519%\"\u003e\n \u003cp\u003e42 (33 \u0026ndash; 54)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003ch1\u003e\u0026nbsp;\u003c/h1\u003e"},{"header":"Discussion","content":"\u003cp\u003eWe conducted a scoping review to describe the landscape and reporting quality of locally produced newborn and child health-related CPGs in South Africa, Nigeria, and Malawi. Overall, we identified 40 CPGs that provide recommendations for various aspects of health care (treatment, screening, prevention, diagnosis, and rehabilitation) for infants and children from birth up to 12 years old. Most CPGs provided guidance on the management of communicable diseases, which aligns with burden of disease in the region where poverty-related infectious diseases are often associated with under-five child mortality in SSA\u0026nbsp;(28). Our main findings highlighted similar issues across the three countries regarding the poor methodological quality and reporting methods of CPGs. Although they scored well for the clarity of presentation and scope and purpose domains in AGREE II, most CPGs scored very poorly on rigor of development and did not adequately describe their methods for identifying, selecting, and assessing certainty of evidence. The lack of appropriate methodological reporting may undermine on the credibility of recommendations. Furthermore, grading the strength of recommendations and distinguishing expert opinion from evidence-based statements becomes an impossible task if appropriate links to evidence are not apparent; this is critical for transparency and CPG adaptation. Our findings further highlighted gaps in transparent reporting of funding disclosures and management of interests of members in CPG panels, as well as in considering factors such as feasibility, acceptability and equity to inform recommendations prior to CPG implementation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSimilar trends in CPG quality and reporting methods were observed across the three countries, which may reflect the overall challenges faced by LMICs in CPG development and implementation. The extensive resources, including capacity, skills, time, and funding, needed for d\u003cem\u003ee novo\u003c/em\u003e CPG development and implementation are often limited in LMICs. Using WHO guidance documents which are developed for adoption or adaptation by LMICs may therefore be a good option for these settings. However, the responsibility of appropriately assessing and considering local and contextual factors during CPG adoption / adaptation remain that of the individual countries, and the methods used for doing this are often unclear and implicit. For example, the South African and Malawian IMCI CPGs as well as the Malawian guideline on implementing the baby-friendly hospital initiative allude to the involvement of organisations such WHO, UNICEF or USAID through inclusion of their logos in the CPG documents, but without any explicit description of their role or involvement or adoption of recommendations. Scant local evidence may further complicate the CPG adoption/adaptation processes. Overall, this highlights lack of emphasis on reporting transparency with regards to guideline adaptation methods and processes to ensure that a guideline is trustworthy as well as clear linking of evidence to recommendations local evidence.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe challenges in CPG quality and reporting methods may also reflect issues with expert or stakeholder representation and the failure to include a methodologist in CPG development groups. The CPGs included in this review highlighted some collaborative effort between ministries of health and professional associations in the respective countries, with ministries of health being the major drivers, especially in Nigeria and Malawi. Health ministries and professional associations are often led and represented by a diverse group of front-line health professionals and clinical experts with a common goal of enhancing efficiency in resource-constrained and often understaffed health systems. Hence, CPG development and implementation may be more focused on a front-line user-centred approach with a primary goal of enhancing clarity and dissemination of recommendations for easier use, while providing little to no detail on the development process. This was reflected in the very low \u0026lsquo;rigor of development\u0026rsquo; and high \u0026lsquo;clarity of presentation\u0026rsquo; domain score across the three countries in our findings. Given the stark impact of financial and time constraints of developing CPGs \u003cem\u003ede novo\u003c/em\u003e, and the heavily burdened health systems in LMICs, it may seem justifiable to front-line clinicians to publish some clinical guidance as protocols and algorithms, as reflected by documents such as the IMCI. Although most of the included CPGs provided a list of the respective CPG development groups, it was difficult to ascertain whether these groups included all relevant stakeholders as affiliations and individual roles in CPG development were often not described. For example, the observed gaps in considering health economic evidence as shown by the low scores of CPGs in the applicability domain, may potentially reflect underrepresentation of expertise such as health economics in CPG development efforts.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eUnlike high-income regions, SSA has thus far experienced less success in reaching the SDG goal of reducing childhood mortality. \u0026nbsp;Strengthened evidence-based interventions such as CPGs addressing country specific disease burdens may play a catalytic role in these efforts. \u0026nbsp;\u003cem\u003eDe novo\u003c/em\u003e CPG development processes, such as priority setting and CPG group convening, may be out of reach for most LICs and may often not be necessary if good quality up-to-date guidance from other settings is available for for adoption or adaptation. However, complete reliance on international guidance may lead to missed opportunities in addressing country-specific gaps in relation to the local disease burden. Our findings revealed potential gaps in CPGs considering locally relevant evidence when making recommendations and in addressing key conditions associated with newborn and childhood morbidity and mortality in those countries. For example, malnutrition, gastroenteritis and neonatal disorders contribute to the burden of disease of all three countries, yet guidance for them is often included in other documents, such as the IMCI and standard treatment CPGs. In a region where poverty is often the major driver of the disease burden and child mortality and where a consistent pattern of malnutrition is observed, it would seem logical to have individual CPGs dedicated to diagnosis and management of malnutrition. Furthermore, it may be crucial to consider the emerging epidemics such as NCDs, including mental health, in children and preadolescents. For example, violence and intentional or unintentional injuries disproportionately affect LMICs\u0026nbsp;(29), and hence CPGs for addressing trauma and associated mental impact may be a crucial piece of the puzzle in ensuring child health and development.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAs countries gear up towards implementing national health insurance schemes, there has been substantial advancement in the CPG landscape in some SSA countries. For example, the standard treatment guideline (STG) and EML first published in 1996 in South Africa to ensure rational and equitable access to medicines has evolved to include established terms of reference for guideline committee governance, evidence review and synthesis, as well as management of interests while fostering relationships with relevant experts and methodologists in the field of evidence synthesis\u0026nbsp;(30). Furthermore, projects dedicated to strengthening capacity for development and implementation of CPGs such as the South African Guidelines Excellence (SAGE) and higher education on CPG training have been established\u0026nbsp;(31-33).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn this study we identified the paediatric hospital (2017)\u0026nbsp;(34)\u0026nbsp;and primary healthcare level (2020)\u0026nbsp;(35)\u0026nbsp;STGs from South Africa, with the latter showing improvement in domain scores such as such stakeholder involvement, applicability, and editorial independence. However, scores were still low for rigour of development, possibly due to lack of easy access to the methods guides that underpin the decision-processes. \u0026nbsp;Given the size of the STG documents (often \u0026plusmn; 600 pages), some methods sections may be omitted to accommodate the recommendation sections for included various conditions.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eLimitations of the study\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eThe lack of regional or national central CPG repositories makes it challenging to identify CPGs and it is therefore possible that we may have missed relevant CPGs in the field of newborn and child health. Our search was limited to CPGs developed in the last five years and it is possible that some of the older CPGs excluded by this limitation may be in the process of being updated. Some CPGs may have followed rigorous methods, but due to limited sharing of their methods in public websites or accessible repositories, this may not be well captured in the methods. AGREE II only appraises reporting of methods but does not cover the content of the CPGs; the recommendations may thus be appropriate even if the methods are not adequately reported.\u003c/p\u003e\n\u003ch1\u003eImplications for practice and policy\u0026nbsp;\u003c/h1\u003e\n\u003cul\u003e\n \u003cli\u003eThis study highlights the need for involving guideline methodologists when developing CPGs to support transparent and trustworthy guidelines and use of adaptation/adoption methods for high-quality CPGs.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eCPGs that focus on high priority newborn and child health issues in specific country settings are needed.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eEnd-users of CPGs including policymakers may lack the skills to assess the quality of CPGs, leading to adoption of poor-quality CPGs in SSA countries.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eCPGs that don\u0026apos;t adequately address country level contextual factors may face implementation challenges if the recommendations are appropriate to country settings.\u0026nbsp;\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThere is considerable CPG production in the three countries which demonstrates both strengths and weakness on AGREE domains.The findings of this study highlight the importance of ongoing efforts to strengthen capacity and support CPG development with collaboration between policymakers, researchers and all relevant stakeholders. including the public, to improve and standardise CPG quality and reporting methods. This study also highlights gaps in current CPGs for conditions that contribute to the burden of diseases in newborn and child health in each country, including malnutrition, neonatal and congenital disorders, as well as comorbidities.\u0026nbsp;\u003c/p\u003e\n"},{"header":"Abbreviations","content":"\u003ctable border=\"0\" cellpadding=\"0\" cellspacing=\"0\" width=\"634\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"16.08832807570978%\"\u003e\n \u003cp\u003e\u003cstrong\u003eAGREE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"83.91167192429022%\"\u003e\n \u003cp\u003eAppraisal of Guidelines for Research and Evaluation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"16.08832807570978%\"\u003e\n \u003cp\u003e\u003cstrong\u003eAIDS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"83.91167192429022%\"\u003e\n \u003cp\u003eAcquired immunodeficiency syndrome\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"16.08832807570978%\"\u003e\n \u003cp\u003e\u003cstrong\u003eART\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"83.91167192429022%\"\u003e\n \u003cp\u003eAntiretroviral therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"16.08832807570978%\"\u003e\n \u003cp\u003e\u003cstrong\u003eBIGG\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"83.91167192429022%\"\u003e\n \u003cp\u003eInternational Database of GRADE Guidelines\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"16.08832807570978%\"\u003e\n \u003cp\u003e\u003cstrong\u003eCOVID-19\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"83.91167192429022%\"\u003e\n \u003cp\u003eCoronavirus 2019\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"16.08832807570978%\"\u003e\n \u003cp\u003e\u003cstrong\u003eCPG\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"83.91167192429022%\"\u003e\n \u003cp\u003eClinical Practice Guideline\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"16.08832807570978%\"\u003e\n \u003cp\u003e\u003cstrong\u003eECRI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"83.91167192429022%\"\u003e\n \u003cp\u003eEmergency Care Research Institute\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"16.08832807570978%\"\u003e\n \u003cp\u003e\u003cstrong\u003eEML\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"83.91167192429022%\"\u003e\n \u003cp\u003eEssential medicine list\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"16.08832807570978%\"\u003e\n \u003cp\u003e\u003cstrong\u003eGDG\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"83.91167192429022%\"\u003e\n \u003cp\u003eGuideline Development Group\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"16.08832807570978%\"\u003e\n \u003cp\u003e\u003cstrong\u003eGIN\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"83.91167192429022%\"\u003e\n \u003cp\u003eGuideline international network\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"16.08832807570978%\"\u003e\n \u003cp\u003e\u003cstrong\u003eGRADE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"83.91167192429022%\"\u003e\n \u003cp\u003eGrading of Recommendations Assessment, Development and Evaluation\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"16.08832807570978%\"\u003e\n \u003cp\u003e\u003cstrong\u003eHIV\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"83.91167192429022%\"\u003e\n \u003cp\u003eHuman immunodeficiency virus\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"16.08832807570978%\"\u003e\n \u003cp\u003e\u003cstrong\u003eIMCI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"83.91167192429022%\"\u003e\n \u003cp\u003eIntegrated Management of Childhood Illnesses\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"16.08832807570978%\"\u003e\n \u003cp\u003e\u003cstrong\u003eIOM\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"83.91167192429022%\"\u003e\n \u003cp\u003eInstitute of Medicine\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"16.08832807570978%\"\u003e\n \u003cp\u003e\u003cstrong\u003eLMIC\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"83.91167192429022%\"\u003e\n \u003cp\u003eLower middle-income countries\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"16.08832807570978%\"\u003e\n \u003cp\u003e\u003cstrong\u003eNCD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"83.91167192429022%\"\u003e\n \u003cp\u003eNon-communicable disease\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"16.08832807570978%\"\u003e\n \u003cp\u003e\u003cstrong\u003eNICE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"83.91167192429022%\"\u003e\n \u003cp\u003eNational Institute for Health and Care Excellence\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"16.08832807570978%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSDG\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"83.91167192429022%\"\u003e\n \u003cp\u003eSustainable Development Goals\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"16.08832807570978%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSSA\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"83.91167192429022%\"\u003e\n \u003cp\u003eSub-Saharan Africa\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"16.08832807570978%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSTGs\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"83.91167192429022%\"\u003e\n \u003cp\u003eStandard treatment guidelines\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"16.08832807570978%\"\u003e\n \u003cp\u003e\u003cstrong\u003eTB\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"83.91167192429022%\"\u003e\n \u003cp\u003eTuberculosis\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"16.08832807570978%\"\u003e\n \u003cp\u003e\u003cstrong\u003eUHC\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"83.91167192429022%\"\u003e\n \u003cp\u003eUniversal Health Care\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"16.08832807570978%\"\u003e\n \u003cp\u003e\u003cstrong\u003eWHO\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"83.91167192429022%\"\u003e\n \u003cp\u003eWorld Health Organisation\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eSupplementary information\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSupplementary file 1 \u0026ndash; search terms\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe acknowledge the GELA project consortium involving South Africa, Nigeria and Malawi, for the conceptualization of the project and contributions to the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConceptualisation / design: TK, NMM, EE, MM, MMc, SD, SLe, PoV, RC, CN, MMe\u003c/p\u003e\n\u003cp\u003eData acquisition /analysis / Interpretation: TK, MM, NB, DM, TL, AB, IK, RC, SD, SLe, GK, EE, NMM, MC, EEs, CN, PoV, DA, MMc, MMe, PoV.\u003c/p\u003e\n\u003cp\u003eMM and TK wrote the first draft of the manuscript, MM revised all drafts with input from all authors. All authors approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGELA project is funded as part of the EDCTP2 programme supported by the European Union (grant number RIA2020S-3303-GELA).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analysed during this study are included in this manuscript (and its supplementary information files).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTamara Kredo is a member of the GRADE working group and co-Director of South African GRADE Network, and a member of National Essential Medicines List Committee in South Africa, reviewing and ratifying national standard treatment guidelines.\u003c/p\u003e\n\u003cp\u003eOther authors do not have any competing interest.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eUNICEF-IGME. Levels \u0026amp; Trends in Child Mortality 2021 [Available from: https://data.unicef.org/resources/levels-and-trends-in-child-mortality/.\u003c/li\u003e\n\u003cli\u003eVan Malderen C, Amouzou A, Barros AJD, Masquelier B, Van Oyen H, Speybroeck N. Socioeconomic factors contributing to under-five mortality in sub-Saharan Africa: a decomposition analysis. BMC Public Health. 2019;19(1):760.\u003c/li\u003e\n\u003cli\u003eAmegah AK. Improving Child Survival in Sub-Saharan Africa: Key Environmental and Nutritional Interventions. Annals of global health. 2020;86(1):73.\u003c/li\u003e\n\u003cli\u003eHeadey D, Heidkamp R, Osendarp S, Ruel M, Scott N, Black R, et al. Impacts of COVID-19 on childhood malnutrition and nutrition-related mortality. The Lancet. 2020;396(10250):519-21.\u003c/li\u003e\n\u003cli\u003eWHO. 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Integrated management of childhood illness: World Health Organizations 2022 [Available from: https://www.who.int/teams/maternal-newborn-child-adolescent-health-and-ageing/child-health/integrated-management-of-childhood-illness.\u003c/li\u003e\n\u003cli\u003eRoder-DeWan S, Nimako K, Twum-Danso NAY, Amatya A, Langer A, Kruk M. Health system redesign for maternal and newborn survival: rethinking care models to close the global equity gap. BMJ Global Health. 2020;5(10):e002539.\u003c/li\u003e\n\u003cli\u003ePeven K, Mallick L, Taylor C, Bick D, Day LT, Kadzem L, et al. Equity in newborn care, evidence from national surveys in low- and middle-income countries. International Journal for Equity in Health. 2021;20(1):132.\u003c/li\u003e\n\u003cli\u003eWilkinson M, Wilkinson T, Kredo T, MacQuilkan K, Mudara C, Winch A, et al. South African clinical practice guidelines: A landscape analysis. S Afr Med J. 2017;108(1):23-7.\u003c/li\u003e\n\u003cli\u003eInstitute of Medicine Committee on Standards for Developing Trustworthy Clinical Practice G. In: Graham R, Mancher M, Miller Wolman D, Greenfield S, Steinberg E, editors. Clinical Practice Guidelines We Can Trust. Washington (DC): National Academies Press (US) Copyright 2011 by the National Academy of Sciences. All rights reserved.; 2011.\u003c/li\u003e\n\u003cli\u003eInstitute of Medicine (US) Committee on the Health Professions Education Summit. The Core Competencies Needed for Health Care Professionals. Health Professions Education: A Bridge to Quality Washington (DC): National Academies Press (US); 2003.\u003c/li\u003e\n\u003cli\u003eGranholm A, Alhazzani W, M\u0026oslash;ller MH. Use of the GRADE approach in systematic reviews and guidelines. British Journal of Anaesthesia. 2019;123(5):554-9.\u003c/li\u003e\n\u003cli\u003eSch\u0026uuml;nemann HJ, Wiercioch W, Etxeandia I, Falavigna M, Santesso N, Mustafa R, et al. Guidelines 2.0: systematic development of a comprehensive checklist for a successful guideline enterprise. Canadian Medical Association Journal. 2014;186(3):E123.\u003c/li\u003e\n\u003cli\u003eWHO. WHO handbook for guideline development 2014. Available from: https://www.who.int/publications/i/item/9789241548960.\u003c/li\u003e\n\u003cli\u003eNICE. Developing NICE guidelines: the manual | Guidance and guidelines | NICE. 2014.\u003c/li\u003e\n\u003cli\u003eLunny C, Ramasubbu C, Puil L, Liu T, Gerrish S, Salzwedel DM, et al. Over half of clinical practice guidelines use non-systematic methods to inform recommendations: A methods study. PLOS ONE. 2021;16(4):e0250356.\u003c/li\u003e\n\u003cli\u003eMcCaul M, Tovey D, Young T, Welch V, Dewidar O, Goetghebeur M, et al. Resources supporting trustworthy, rapid and equitable evidence synthesis and guideline development: results from the COVID-19 evidence network to support decision-making (COVID-END). Journal of clinical epidemiology. 2022;151:88-95.\u003c/li\u003e\n\u003cli\u003eDizon JM, Machingaidze S, Grimmer K. To adopt, to adapt, or to contextualise? The big question in clinical practice guideline development. BMC research notes. 2016;9(1):442.\u003c/li\u003e\n\u003cli\u003eCochrane Africa. Global Evidence - Local Adaptation (GELA): Grant to enhance evidence-informed guideline recommendations for newborn and young child health in three sub-Saharan African countries 2023 [Available from: https://africa.cochrane.org/projects/GELA.\u003c/li\u003e\n\u003cli\u003eTricco AC, Lillie E, Zarin W, O\u0026apos;Brien KK, Colquhoun H, Levac D, et al. PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation. Annals of Internal Medicine. 2018;169(7):467-73.\u003c/li\u003e\n\u003cli\u003eKredo T, Wiseman R, Gray A, Parrish A, Miot J, Cohen K. How good are our guidelines? Four years of experience with the SAMJ\u0026apos;s AGREE II review of submitted clinical practice guidelines. SAMJ: South African Medical Journal. 2018;108:833-85.\u003c/li\u003e\n\u003cli\u003eBrouwers MC, Kerkvliet K, Spithoff K. The AGREE Reporting Checklist: a tool to improve reporting of clinical practice guidelines. BMJ (Clinical research ed). 2016;352:i1152.\u003c/li\u003e\n\u003cli\u003eBrouwers MC, Kho ME, Browman GP, Burgers JS, Cluzeau F, Feder G, et al. AGREE II: advancing guideline development, reporting and evaluation in health care. CMAJ. 2010;182(18):E839-E42.\u003c/li\u003e\n\u003cli\u003eUnited-Nations. Levels and trends in child mortality: report 2020. Estimates developed by the UN Inter-agency Group for Child Mortality Estimation: UNICEF; 2020 [Available from: https://www.unicef.org/media/79371/file/UN-IGME-child-mortality-report-2020.pdf.pdf.\u003c/li\u003e\n\u003cli\u003eAboagye RG, Mireku DO, Nsiah JJ, Ahinkorah BO, Frimpong JB, Hagan JE, et al. Prevalence and psychosocial factors associated with serious injuries among in-school adolescents in eight sub-Saharan African countries. BMC Public Health. 2022;22(1):853.\u003c/li\u003e\n\u003cli\u003ePerumal-Pillay VA, Suleman F. Selection of essential medicines for South Africa - an analysis of in-depth interviews with national essential medicines list committee members. BMC Health Services Research. 2017;17(1):17.\u003c/li\u003e\n\u003cli\u003eLouw Q, Dizon JM, Grimmer K, McCaul M, Kredo T, Young T. Building capacity for development and implementation of clinical practice guidelines. SAMJ: South African Medical Journal. 2017;107:745-6.\u003c/li\u003e\n\u003cli\u003eTaryn Y, Janine D, Tamara K, Michael M, Eleanor O, Karen G, et al. Enhancing capacity for clinical practice guidelines in South Africa. PAMJ. 2020;36(18).\u003c/li\u003e\n\u003cli\u003eMcCaul M, Durao S, Kredo T, Garner P, Young T, Rohwer A. Evidence synthesis workshops: moving from face-to-face to online learning. BMJ Evidence-Based Medicine. 2021;26(5):255.\u003c/li\u003e\n\u003cli\u003eNational Department of Health. Hospital Level (Paediatrics) Standard Treatment Guidelines and Essential Medicines List for South Africa 4th Edition 2017 [Available from: https://www.knowledgehub.org.za/elibrary/hospital-level-paediatrics-standard-treatment-guidelines-and-essential-medicines-list.\u003c/li\u003e\n\u003cli\u003eNational Department of Health. Primary Healthcare (PHC) Standard Treatment Guidelines and Essential Medicines List for South Africa 2020 [Available from: https://www.knowledgehub.org.za/elibrary/primary-healthcare-phc-standard-treatment-guidelines-and-essential-medicines-list-south.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Clinical practice guidelines, Newborn and child health, Nigeria, South Africa, Malawi, scoping review, quality appraisal, GRADE ","lastPublishedDoi":"10.21203/rs.3.rs-2737679/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-2737679/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e \u003cp\u003eLow and middle-income countries remain disproportionately affected by high rates of childhood mortality, often caused by preventable conditions. Clinical practice guidelines (CPGs) are essential policy tools in supporting implementation of effective, safe, and cost-effective healthcare. High-quality evidence-based CPGs play a key role in improving clinical management aiming to impact child mortality. We aimed to identify and assess the quality of CPGs for newborn and child health published in South Africa, Nigeria and Malawi.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e \u003cp\u003eWe searched relevant websites (June\u0026ndash;July 2022), for publicly available national and subnational \u003cem\u003ede novo\u003c/em\u003e or adapted CPGs, addressing newborn and child health in the three countries. Pairs of reviewers independently extracted information from eligible CPGs (scope, topic, target population and users, responsible developers, stakeholder consultation process, adaptation description, assessment of evidence certainty). We appraised CPG quality using the Appraisal of Guidelines for Research \u0026amp; Evaluation (AGREE II) instrument.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003eWe identified 40 CPGs from the three countries. Of these, 8/40 reported being adopted from a parent CPG. More CPGs (n\u0026thinsp;=\u0026thinsp;19) provided guidance on communicable diseases than on non-communicable diseases (n\u0026thinsp;=\u0026thinsp;8). CPGs were most often developed by national health ministries and professional societies. Eighteen CPGs reported on stakeholder consultation; with Nigeria (10/11) and Malawi (3/6) faring better than South Africa (5/23) in reporting this activity. GRADE was used in 1/7 CPGs that reported assessing certainty of evidence. Overall CPGs scored well on two AGREE II domains: scope and purpose median (IQR) score 68% (IQR 47\u0026ndash;83), and clarity of presentation 81% (67\u0026ndash;94). Domains critical for ensuring credible guidance scored below 20%: rigour of development 11% (\u003cspan additionalcitationids=\"CR5 CR6 CR7 CR8 CR9 CR10 CR11 CR12 CR13 CR14 CR15 CR16 CR17 CR18 CR19 CR20 CR21 CR22 CR23 CR24 CR25 CR26 CR27 CR28 CR29 CR30 CR31\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e) and editorial independence 6% (0\u0026ndash;27).\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion\u003c/b\u003e\u003c/p\u003e \u003cp\u003eTopics covered by the identified CPGs did not always match country level burden of disease likely representing substantial gaps in available guidance for healthcare providers, parents, caregivers, and patients. Our study found low AGREE II scores for CPG development processes, possibly undermining the credibility of the available CPGs to provide evidence-informed care. Our findings highlight the importance of ongoing efforts to strengthen capacity and support CPG development with collaboration between policymakers, researchers and the public.\u003c/p\u003e","manuscriptTitle":"Newborn and child health national and provincial clinical practice guidelines in South Africa, Nigeria and Malawi: a scoping review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-04-18 18:30:58","doi":"10.21203/rs.3.rs-2737679/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2023-07-06T04:39:16+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2023-07-03T09:53:30+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2023-04-28T21:44:15+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"440e8dbe-dde5-4517-b2e7-651d5cc6417e","date":"2023-04-19T17:48:47+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"8ba062b3-ec18-4549-8f13-bb5a960f450f","date":"2023-04-19T13:23:33+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2023-04-16T12:30:47+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2023-04-16T12:28:54+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2023-04-16T08:03:40+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2023-04-16T07:51:46+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2023-03-26T09:56:02+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"2f077376-560e-4eb3-a7f3-014ab3f437a0","owner":[],"postedDate":"April 18th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-02-26T15:08:17+00:00","versionOfRecord":{"articleIdentity":"rs-2737679","link":"https://doi.org/10.1186/s12913-024-10682-0","journal":{"identity":"bmc-health-services-research","isVorOnly":false,"title":"BMC Health Services Research"},"publishedOn":"2024-02-19 15:02:01","publishedOnDateReadable":"February 19th, 2024"},"versionCreatedAt":"2023-04-18 18:30:58","video":"","vorDoi":"10.1186/s12913-024-10682-0","vorDoiUrl":"https://doi.org/10.1186/s12913-024-10682-0","workflowStages":[]},"version":"v1","identity":"rs-2737679","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-2737679","identity":"rs-2737679","version":["v1"]},"buildId":"_2-kVJe1T_tPrBINL-cwx","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}