Table 5 Challenges faced and proposed solutions

Resources

• Inadequate expertise & experience with guideline development *: Our team was the first to implement GRADE-ADOLOPMENT of any guidelines in Pakistan in collaboration with the GRADE-USA working group.

• Collaborate with personnel with requisite experience and expertise

• Conduct comprehensive, standardized training modules for all personnel involved in the “adolopment”

• Inadequate manpower/size of workforce *: Our team consisted of 4–5 personnel, which limited pace of work.

• Involve students and trainees on a volunteer basis

Stakeholder Support & Involvement

• Suboptimal provincial/federal government involvement * ⁺: As we expected delays stemming from external stakeholder involvement, we decided to proceed without provincial/federal government involvement in this first iteration of GRADE-ADOLOPMENT. This may have led to possible public health and large-scale implementation perspectives missing from this effort.

• Involve all stakeholders from the start

• Emphasize and reiterate mutual interests

• Design specific curricula for all stakeholders involved

• Tailor and deliver presentations to all stakeholders involved and invite stakeholders to participate in the GRADE-ADOLOPMENT process.

• Suboptimal involvement of external societies or organizations * ⁺: As we expected delays and conflicts of interest stemming from involvement of external societies, we decided to proceed without their involvement in this first iteration of GRADE-ADOLOPMENT. This may lead to a possible future lack of buy-in from these organizations regarding the newly developed local EBCPGs.

• Absence of patients’ perspective in the “adolopment” process * ⁺: As we expected it nigh impossible to secure a patient sample sufficiently representative of the diverse sociodemographic and cultural population in Pakistan, we elected to consider the perspective of the experts as a surrogate for patients’. Nevertheless, this may lead to some socioeconomic and cultural considerations missing in our effort.

Resistance to Change

• Rigorousness of the GRADE-ADOLOPMENT process may discourage the process of adaptation *: Given that the subject experts did not deem adaptation of any of the recommendations necessary, it is possible they were dissuaded from adaptation by the rigorousness of the process.

• Initial presentation to emphasize need for local EBCPGs, robustness of the GRADE-ADOLOPMENT process, and the importance of strict adherence to the rigorous GRADE-ADOLOPMENT processes in order to produce valid and credible guidelines.

Methodological Limitations

• Individual-level biases from experts **: Given unavoidable differences in each expert’s clinical practice, it is possible that individual-level biases affected the GRADE-ADOLOPMENT process.

• Increase the number and diversity of experts

• Gauge acceptability and validity of any revisions made by getting feedback from experts from external institutes

• Group-level biases from experts **: Given that all the experts were from a single institution, it is possible that group-level biases affected the GRADE-ADOLOPMENT process.