Table 1

Enablers and challenges to COVID-19 guidelines development

Enablers
Leadership guided by flexibility and empowerment‘I cannot achieve this without input from different team members. I think my role was much overarching the project, for example, I think one of the roles is that I need to identify the different areas we have to work, and then to add the people who can work in this area.’
‘Looking back, it was a hard time for anyone to be writing guidelines…I reached out to [clinical colleague] who has a lot of clinical experience, she’s really busy looking after the running all of our health programs…but she had insight into system here and her own resources and her own networks which were helpful.’
Shared responsibility through equitable ownership‘I think there is an amalgamation of work of different projects, so the documents weren’t fully developed, and are in the draft form so going back and forth with team members to finalise either the wording or doing copy edits of the guidelines themselves…That was the process going back and forth.’
‘When each team member had the guidelines, it was like it was their responsibility, to check and double check everything and work together to confirm the contents. There was hesitation by some non-clinical team members but ultimately, by each team member from their unique disciplinary perspective and experience taking responsibility and flagging issues or asking questions, it created this shared ownership.’
‘I think one of the tricky things about the nature of guidelines is you’re giving advice to doctors and nurses and it’s also guidelines in the middle of an international crisis when the evidence is unclear, so I think what was hard was as I pass this ‘hot potato’ around, who has the authority to have the final say on this? If I imply something wrong, then what happens?’
Interdisciplinary team and collaboration with local experts‘We had connections with the Ministry of Health, pandemic management team, all public health networks because [team member] worked for them. We had a whole lot of connections there. That was very useful, knowing the system helped us to translate and modify it.’
‘I feel you have to speak to the ground level because the upper national level guideline is different. The activity at ground level is different from country to country so you have to take the inputs from the grassroot level then adapt it to your structure…It’ll be easier or productive, or else, the documents we make will not be practiced in the field.’
‘And I think for a few on the team they really wanted to help and had a lot of skills to offer but there was that removed feeling if you were non-clinical, there was a feeling of being an ‘outsider’ to the medical field’
Challenges
Interpreting and incorporating context‘I was looking at the WHO interim guidelines…I was looking at some CDC guidelines as well…It’s a bit different when you apply it to a low-income country context, there’s not as many supplies, there’s more challenges that you have to think about…A lot of the guidelines were coming from high-income countries like the UK or USA. Even though we had local input, I wonder if we are missing guidelines from elsewhere because they are harder [for us] to access.’
‘The China guideline said that even if they are negative on PCR, they may still have the disease so do a CT scan, which was part of the guidelines for them. That was questioned by Sri Lanka, why we have to do that?’
‘The most challenging thing was that I knew little of the local context and local practice of relevant staff. What I could do was to organise the [existing] contents based on my previous experience in China and developed a first draft for further revision by local partners. During the process, I also added some sections suggested by the local partners during regular meetings, (mental health support and corpse disposal) and updated sections according to latest national guidelines…We can’t just cut and paste under different situations. So you need to speak to the ground level people, then according to that, amend the guideline.’
Tensions between the ideal guidelines versus timeliness and usability‘I felt that I was going at a snail’s pace with the transcript because I kept finding things in the documents and the documents were pretty large…I wanted to defer to the health experts on the content. Knowing that it needs to get into a published form… was probably the biggest challenge I faced at that time.’
‘A large part was taking a huge amount of information…and diluting it down, making it readable and digestible and also creating desk guides from that as well to make it more digestible. It was big but, a lot of it was taking something from larger and abstract and make it more relevant and narrowing it down and digestible for people to use on a daily basis.’
‘When you write guidelines, you should be open and honest at that moment, and clearly state that when things change, we will update the guidelines.’
‘We went into the process thinking this would be a very positivist exercise, but it’s much more constructivist. Things are evolving and emerging – the evidence, the situation on the ground, the virus itself. Developing comprehensive guidelines in this situation requires a bit of a mindset shift towards the ‘good enough’ model where you get something out that’s good enough given all known information and best clinical practices and are clear with each other and with your end users that it will be updated pending new evidence.’
Updating and adapting with evolving information‘The frequently updated local national guidelines made the guideline development process more complicated as one minor update might influence several sections.’
‘We had already printed [the guidelines] and then there are changes…I guess that the fluidity [to update the guidelines] was kind of lost. I like a real-time sense of where we were in training vs updating the guideline. And which is also understandable with things coming out at different times so, I don't see that as a fault. But content evolving, I think that was [a challenge]. Just getting it in before the next training, needing to know [any changes].’
The impact of the pandemic‘In a pandemic, our ability to push forward the work is really hindered by the emergencies. There have been a number of emergencies in Philippines and Sri Lanka which has delayed our project. So I don’t think that we can specifically prepare something for that.’
‘It felt like there were limited staff and a lot of volatility during the initial phase… there were all of these intense situations happening that were underlying the process…so it was good that we had a bigger team, the intensity of the situation made us work together well and support each other better and have a lot of conversations’