Table 5 Challenges faced and proposed solutions

Resources

• Suboptimal original data from Pakistan^a

• Make use of regional literature

• Judicious use of grey-literature

• Structuring the GRADE-ADOLOPMENT process to the resource-constrained context of Pakistan (revise through experience, highlight resource gap)^b

• Conduct a thorough, realistic resource assessment, and highlight resource gaps

• Revise process accordingly through experience

• Inadequate manpower/size of workforce^a

• Involve students and trainees on a volunteer basis

Stakeholder Support & Involvement

• Suboptimal departmental support^b

• 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

• Collaborate with patient advocacy groups

• Community outreach and education

• Involve Medical Societies for review of guidelines

• Invite external topic specialists

• Suboptimal provincial/federal government involvement^a

• Suboptimal involvement of external societies or organizations^a

• Absence of patients’ perspective^a

• Absence of general practitioners’ perspective^a

• Absence of the allied health perspective^a

Resistance to Change

• Experts’ doubts regarding need for local EBCPGs^b

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

• Experts’ exercising caution/opting for middle-ground with regards to decision-making in ETD table^b

• Emphasize the anonymity of the ETD process

• Emphasize importance of incorporating varying schools of thought in the adaptation process

• Experts’ doubts regarding nationwide implementation of local guidelines^a

• Involve decision-makers from other institutions across the country and ensure buy-in to the newly adoloped EBCPGs

Methodological Limitations

• Individual-level biases from experts^b

• Increase the number and diversity of experts

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

• Group-level biases from experts^b

• Suboptimal generalizability of consensus opinion based on 5 experts^b

• Expert opinion is no substitute for the lack of scientific evidence^a

• Supplement the expert opinion with as much auxiliary evidence as possible

• Plan future studies to answer specific questions that arise during the GRADE-ADOLOPMENT process