Call for authors – Qualitative evidence synthesis and resource use reviews for prevention and treatment of wasting

Background

World Health Organization (WHO) has begun the guideline development process for prevention and treatment of wasting. The guideline will include four overlapping areas of focus including growth faltering/failure in infants younger than six months; moderate wasting in infants and children aged six months and older; severe wasting and oedema in infants and children aged six months and older; and prevention of wasting.

Growth faltering/failure in infants younger than six months

The 2013 WHO guidelines for severe acute malnutrition (severe wasting and oedema) included a limited number of recommendations for infants under six months of age. There is a key care gap in the treatment of infants with growth faltering/failure more broadly, which includes but is not limited to severe wasting or oedema.

Moderate wasting in infants and children aged six months and older

There are currently no WHO guidelines focusing specifically on the treatment of moderate wasting, including clinical and nutritional management. While certain treatment approaches for severe wasting may be applicable for children with moderate wasting, it is possible that differentiated treatment approaches are needed because of different physiological thresholds in children with moderate wasting.

Severe wasting and oedema in infants and children aged six months and older

The most recent WHO guideline updates for treatment of severe wasting and oedematous malnutrition were published in 2013, and therefore the new recommendations will build on this existing guidance. Many of the remaining key care gaps relate to clinical management of children with severe wasting or oedema, as mortality remains high particularly in inpatient settings and following discharge.

Prevention of wasting

Prevention is a new area for WHO guideline development around wasting in infants and children. It can include prevention of wasting incidence, or of progression from moderate to severe wasting for instance. Importantly, appropriateness and effectiveness of prevention, approaches may differ by setting, context, and other factors which will be considered for this guideline.

Scope

To inform the guideline on prevention and treatment of wasting, WHO will commission systematic reviews relating to values and preferences, resource use and cost-effectiveness, equity, acceptability, and feasibility of interventions for prevention and treatment of wasting. These qualitative evidence synthesis (QES) and systematic reviews of economic evidence will accompany and complement a series of quantitative systematic reviews for the guideline ( Call for authors – systematic reviews on prevention and treatment of wasting). Interventions and outcomes defined for the QES and reviews of economic evidence are derived from and have been drafted to complement the series of quantitative systematic review questions that will inform the WHO guideline. 

The QES domains, topics/lines of enquiry, and questions are the following:

1. Values and preferences

What would the impact of the treatment decisions be on health equity? How acceptable are the treatment decisions to key stakeholders (i.e. parents/caregivers, health workers, government and policy makers)? How feasible are the treatment decisions to implement? (1 qualitative evidence synthesis)

• Initiation of treatment in an outpatient/community setting
• Referral to treatment in an inpatient setting
• Transfer to outpatient/community treatment
• Discharge from outpatient/community treatment (e.g. duration of stay, timing of discharge)

3. Equity, acceptability, and feasibility: Clinical and nutritional interventions

What would the impact of the clinical and nutritional interventions be on health equity? How acceptable are the clinical and nutritional interventions to key stakeholders (i.e. parents/caregivers, health workers, government and policymakers)? How feasible are the clinical and nutritional interventions to implement? (1 qualitative evidence synthesis)

Subcategories of clinical and nutritional interventions:

• Clinical interventions (e.g. standard WHO low-osmolarity ORS vs ReSoMal)
• Therapeutic feeds and formulas (e.g. hydrolyzed or lactose-free formulas vs F-75/F-100)
• Dietary interventions (e.g. varying quantity or duration of RUTF)
• Maternal-directed and post-discharge interventions (e.g. management of difficulties with breastfeeding/lactation)

Specific clinical and nutritional interventions are available upon request to nutrition@who.int.

4. Equity, acceptability, and feasibility: Community and population interventions

What would the impact of the community and population interventions be on health equity? How acceptable are the community and population interventions to key stakeholders (i.e. parents/caregivers, health workers, government and policy makers)? How feasible are the community and population nutritional interventions to implement? (1 qualitative evidence synthesis)

• Identification and treatment of wasting by community health workers (in community settings)
• Community prevention interventions including nutritional supplementation, nutritional counselling, etc.
• Population-based interventions including blanket supplementary feeding programs, nutritional supplementation programs, and cash transfers

Note: Applicants may select any or all of the above 3 systematic reviews.

The questions for the systematic reviews of economic evidence are:

5. Resource use and cost-effective: Treatment decisions (where to treat)

How large are the resource requirements related to treatment decisions (costs)? What is the certainty of this evidence of resource requirements (costs)? Does the cost-effectiveness favour the intervention or the comparison? (1 systematic review of economic evidence)

• Initiation of treatment in an outpatient/community setting
• Referral to treatment in an inpatient setting
• Transfer to outpatient/community treatment
• Discharge from outpatient/community treatment (e.g. duration of stay, timing of discharge)

6. Resource use and cost-effective: Clinical and nutritional interventions

How large are the resource requirements related to clinical and nutrition interventions (costs)? What is the certainty of this evidence of resource requirements (costs)? Does the cost-effectiveness favour the intervention or the comparison? (1 systematic review of economic evidence)

Subcategories of clinical and nutritional interventions:

• Clinical interventions (e.g. standard WHO low-osmolarity ORS vs ReSoMal)
• Therapeutic feeds and formulas (e.g. hydrolyzed or lactose-free formulas vs F-75/F-100)
• Dietary interventions (e.g. varying quantity or duration of RUTF)
• Maternal-directed and post-discharge interventions (e.g. management of difficulties with breastfeeding/lactation)

Specific clinical and nutritional interventions are available upon request to nutrition@who.int.

7. Resource use and cost-effective: Community and population interventions

How large are the resource requirements related to community and population interventions (costs)? What is the certainty of this evidence of resource requirements (costs)? Does the cost-effectiveness favour the intervention or the comparison? (1 systematic review of economic evidence)

• Identification and treatment of wasting by community health workers (in community settings)
• Community prevention interventions including nutritional supplementation, nutritional counselling, etc.
• Population-based interventions including blanket supplementary feeding programs, nutritional supplementation programs, and cash transfers

Note: Applicants may select any or all of the above 3 systematic reviews.

For further details of any of the above reviews please contact nutrition@who.int. Responses will be posted to a living document linked to this page.

Concept note and budget

Interested author(s)/teams are invited to submit a concept note (5-6 pages) by sending an email to WHO at nutrition@who.int no later than 20 August 2021. The subject heading of the email should read as, “QES and resource use reviews for prevention and treatment of wasting” plus the question number(s) of the review(s) being proposed.

The concept note should include a proposal containing (in a single document) the following:

• The question number(s) and title(s) of the review(s) being proposed, lead author and host institution with overall responsibility for the review, and contributors. Please note that authors/teams may choose to apply for one or multiple reviews.
• The specific competencies and contributions of each author or team member should be explicitly stated. Interested author(s)/teams must have experience with conducting complex reviews and should provide references of reviews that they have published in peer-reviewed journals. Interested author(s)/teams should have members with complementary skills and competencies including knowledge of the technical area, qualitative analysis and synthesis and excellent writing capabilities. Interested authors/teams should also have experience with assessing risk of bias of qualitative evidence, for example using CASP or GRADE-CERQual.
• Proposed question(s) to be addressed through the review(s), outlining the background and justification for the review, the search strategy and databases to be searched, the definition of inclusion/exclusion criteria, the process of data extraction and analytical approach. This description should reflect the scope of work described below. Author(s) teams may undertake one or more reviews. However, they need to demonstrate capacity to conduct the review(s) within the timeline below. Successful authors will be required to submit a protocol prior to performing the review. They will also be required to engage with WHO in finalizing the required outputs in preparation for the guideline development meetings.
• Final questions for the QES should be formulated/refined using well-known qualitative question frameworks or notations (e.g. SPICE, SPIDER). Assessment of the certainty of the qualitative and the economic evidence using an appropriate approach/system (e.g. GRADE-CERQual, GRADE for modelled evidence) would be advantageous.  
• Budget (US $). This should outline the total amount for the review including an approximate breakdown of personnel vs. institutional/other costs. If the author/team proposes to undertake multiple reviews, the budget should specify costs for each separate review as well as the total for the package of reviews since savings may be possible when conducting multiple reviews jointly. It is expected that WHO will provide technical input on the final protocols that will govern the reviews. For the purpose of the concept note, it is not necessary to describe every detail of the review.

Timeline

20 August 2021 – Interested authors or teams submit concept notes and budget to WHO

WHO review of proposals complete and authors/teams contacted and contracts agreed (subject to WHO conditions including review of declarations of interest to members of the review teams) in August 2021

10 September 2021 – Protocols submitted to PROSPERO

11 November 2021 – Draft reviews submitted to WHO

1 December 2021 – Final reviews submitted to WHO (with GRADE CERQual tables)