Consensus guidelines are useful to improve clinical decision making. Therefore, the methodological evaluation of these guidelines is of paramount importance. Low quality information may guide to inadequate or harmful clinical decisions.To evaluate the methodological quality of consensus guidelines published in implant dentistry using a validated methodological instrument.The six implant dentistry journals with impact factors were scrutinised for consensus guidelines related to implant dentistry. Two assessors independently selected consensus guidelines, and four assessors independently evaluated their methodological quality using the Appraisal of Guidelines for Research & Evaluation (AGREE) II instrument. Disagreements in the selection and evaluation of guidelines were resolved by consensus. First, the consensus guidelines were analysed alone. Then, systematic reviews conducted to support the guidelines were included in the analysis. Non-parametric statistics for dependent variables (Wilcoxon signed rank test) was used to compare both groups.p < 0.05).Of 258 initially retrieved articles, 27 consensus guidelines were selected. Median scores in four domains , expressed as percentages of maximum possible domain scores, were below 50% . The consensus guidelines and consensus guidelines + systematic reviews data sets could be compared for 19 guidelines, and the results showed significant improvements in all domain scores (Methodological improvement of consensus guidelines published in major implant dentistry journals is needed. The findings of the present study may help researchers to better develop consensus guidelines in implant dentistry, which will improve the quality and trust of information needed to make proper clinical decisions. Consensus guidelines are important tools that help clinicians make appropriate decisions in the treatment of their patients. The developers of these guidelines suggest recommendations for clinical practice based on the best available evidence from, for example, well-conducted systematic reviews . Consenshttp://community-archive.cochrane.org/glossary/]. Thus, although one can argue that might have slight methodological differences between a consensus and a “classic” guideline, the objective of both guidelines is exactly the same: the improvement of health care of our patients. Therefore, both documents require to be scrutinized for their quality.Consensus guidelines are usually planned and developed by leading experts in the respective field who personally meet to discuss recommendations for clinical practice. As the name suggests, there is always an attempt for reaching consensus in generating clinical recommendations. This approach does not vary too much from the development of so-called “classic guidelines” which are also produced by specialists in the field of the respective guideline. For example, the Cochrane Collaboration defines a clinical guideline as “a systematically developed statement for practitioners and participants about appropriate health care for specific clinical circumstances” [The Appraisal of Guidelines Research and Evaluation (AGREE) tool is a validated instrument used to evaluate the methodological quality and transparency of development of clinical guidelines. This tool was first published in 2003  has beenThe main objective of this study was to evaluate the methodological quality of consensus guidelines published in highly ranked implant dentistry journals using the AGREE II tool. A secondary objective was to evaluate whether the inclusion of systematic reviews conducted to support the consensus guidelines improved the methodological quality of the consensus guidelines.This methodological study was performed to answer the question, “Do consensus guidelines published in highly ranked implant dentistry journals meet the requirements proposed in the AGREE II instrument?”Consensus guidelines on implant dentistry published since 2009 (with the respective consensus conference held after May 2009) in the six major implant dentistry journals (listed below) were included. Other types of document, such as those related to primary and secondary research, were excluded. Data from systematic reviews conducted to support the consensus guidelines were also included in the second part of the assessment.http://ipscience.thomsonreuters.com/product/journal-citation-reports/?utm_source=false&utm_medium=false&utm_campaign=false): Clinical Oral Implants Research (COIR), Clinical Implant Dentistry and Related Research (CIDRR), European Journal of Oral Implants (EJOI), The International Journal of Oral and Maxillofacial Implants (JOMI), Journal of Oral Implantology, and Implant Dentistry. Searches were limited to guidelines published between May 2009 and February 2016. The Medline database was also searched (via PubMed), using the following key words and Boolean operators: ‘guidelines’ OR ‘consensus’ OR ‘position paper’ OR ‘workshop’ OR ‘proceeding’ OR ‘conference’ in combination (AND) with each of the six journal titles. This second search was conducted to provide a detailed pathway for reporting of the literature search process.Two authors  independently searched for consensus guidelines in the six implant dentistry journals with impact factors (2014) assigned by Journal Citation Reports  evaluated the titles and abstracts of reports to determine eligibility for initial inclusion. Then, they scrutinised full texts of papers to determine whether the studies met the inclusion criteria. The authors documented excluded articles, with corresponding reasons for exclusion. The two authors performed study selection independently and in duplicate, and discussed any disagreement regarding the inclusion or exclusion of papers until consensus was achieved.The AGREE II tool is an updated version of the seminal AGREE tool developed by the AGREE Collaboration , a groupFour authors  independently applied the AGREE II tool, first to consensus guidelines only, and then with the inclusion of systematic reviews conducted to support the guidelines. The latter assessment was performed to understand the amount of information added to clinical recommendations by the consideration of systematic reviews as supporting material. Disagreements on data evaluation were resolved by discussion among the four authors until consensus was achieved.A standardised form containing the 23 AGREE II items was produced for data extraction/evaluation. After carefully reading the AGREE handbook, the four assessors applied the tool to evaluate the methodology of consensus guidelines not included in the present study, recording data in the form. Between rounds of data evaluation, assessors discussed the outcomes comprehensively to improve the homogeneity of assessment.p = 0.05. Statistical analyses were performed with the SigmaPlot software .Domains scores were presented as medians of percentages of maximum possible scores with their respective interquartile range (IQR). Domain scores from the two data sets (consensus guidelines and consensus guidelines plus supporting systematic reviews) were compared using non-parametric statistics for dependent variables (Wilcoxon signed rank test), with the level of significance set at We initially identified 258 publications. After the assessment of titles and abstracts, 213 publications were excluded. Full text evaluation led to the exclusion of 45 additional publications. Hence, 27 consensus guidelines were included. The literature search process is illustrated in n = 12), JOMI (n = 7), EJOI (n = 6), CIDRR (n = 1), and Implant Dentistry (n = 1). Twenty-six guidelines were developed after meetings held in European countries. The number of authors of the consensus guidelines ranged from 2 to 27 . The European Association for Osseointegration was the organisation that most frequently supported the meetings and development of consensus guidelines (n = 9). Consensus guidelines were published in five of the six journals searched: COIR (The score for domain 4 (clarity of presentation) was highest , followed by the score for domain 1 . Median scores for domains 2 (stakeholder involvement) and 6  were both 41.70 . Scores for domains 3 (rigour of development) and 5 (applicability) were lowest .When systematic reviews were included in the sample, the score for domain 1 was highest . The median score for domain 6 was second highest , but this score showed the greatest variability among guidelines. The third highest score was for domain 4 , followed by the scores for domains 3 and 2 . The score for domain 5 was lowest . Tables in p < 0.05; Domain scores could be compared between data sets for 19 of the 27 consensus guidelines Table in . Scores In this sample of 27 consensus guidelines in implant dentistry, median scores for four AGREE II domains  were less than 50. However, the inclusion of supporting systematic reviews significantly improved all domain scores. Great variability was found among consensus guidelines, as reflected by large IQRs for some domains.The present findings have important consequences for the further development of consensus guidelines in implant dentistry. First, they provide a measurement of the methodological quality of these guidelines that may greatly impact clinicians’ decisions. Consensus guidelines in the present sample were supported by reputable implant dentistry organisations, and were published in highly ranked implant dentistry journals, which are reliable sources of information for clinicians working with dental implants. Second, the findings provide comprehensive information about which domains should be prioritised in the development of future guidelines in this field. Third, this study demonstrated that the AGREE II tool can serve as a reference for the development of future consensus guidelines in implant dentistry.In the present study, scores for domain 5 (applicability) were lowest. These results show that a gap currently exists between the evidence provided and its applicability in the clinical setting. Scores for domain 3 (rigour of development), which more directly reflects the methodological aspects of the guidelines, were second lowest. Importantly, scores for domain 2 (stakeholder involvement) were also low. For example, the sub-item ‘the views and preferences of the target population  have been sought’ was poorly addressed in all consensus guidelines. Patients’ views are pivotal in gaining an understanding of their needs, and future guidelines in implant dentistry should include more information from patients’ perspectives. One approach would be to select patients to attend or participate in consensus meetings.The significant improvement in all domain scores achieved by the inclusion of systematic reviews suggests that these reviews contain much important information needed to evaluate the methodological quality of consensus guidelines. We thus recommend that users examine both types of material to more fully understand the quality of guidelines. Ideally, systematic reviews and guidelines are produced at the highest methodological level possible and published separately, with the reviews serving as the source for guideline development .Few publications describe the use of the AGREE II tool to evaluate clinical guidelines in dentistry. Horner et al.  recentlyTo our knowledge, this study is the first to evaluate the methodological quality of consensus guidelines published in highly ranked implant dentistry journals using a validated tool. The AGREE II instrument represents improvement over the original AGREE tool, enabling more in-depth evaluation of the strengths and weaknesses of guidelines, and it has shown validity and reliability ,16. ThusOne may argue that AGREE II instrument is an inadequate methodology for assessing consensus guidelines. The idea is that consensus guidelines are developed by experts attending workshops and they do not fulfil the requirements of a quality instrument. But, this is the main reason for applying an instrument such as AGREE II. The question here is: what is the validity of a document that does not allow audit and quality evaluation? Therefore, we understand this approach is appropriate for several reasons. Firstly, guidelines included in the study fall within the Cochrane Collaboration’s definition of a clinical guideline as ‘a systematically developed statement for practitioners and participants about appropriate health care for specific clinical circumstances’ . Secondlp values, which might generate misleading assumptions [We statistically compared evaluations performed with and without additional information from systematic reviews supporting the consensus guidelines. However, some limitations should be kept in mind when interpreting these results. Firstly, adequate sample size was difficult to determine, and our sample of guidelines is arguably small. Nevertheless, AGREE II domain scores showed robust and significant improvement with the inclusion of data from systematic reviews, and similar results would likely be obtained with a larger sample. Secondly, comparison is ideally performed between two independent groups. However, the identification of two sets of similar guidelines (in terms of structure and objectives) for a comparison like that performed in this study would be challenging. Although limited, this comparison is relevant because it provides quantitative evidence for the amount of information that supporting systematic reviews can add to consensus guidelines. In other words, the reader can understand these two different scenarios (guidelines with and without systematic review). More than focusing on umptions , readersIn the present study, we did not attempt to determine which consensus guidelines are recommended for clinical practice and which are not. As reported in the AGREE II user’s manual (AGREE II instrument), the AGREE Collaboration does not recommend the application of any score threshold to differentiate between high-quality and poor-quality guidelines. They recommend that decisions about the use of guidelines be made by users, oriented by the context in which the AGREE II instrument is applied.The consensus guidelines included in the present study were produced by key opinion leaders in the field of implant dentistry. We understand that the involvement of authorities, researchers, and clinicians in the development of such guidelines is important, as it represents integration between research foundation and clinical relevance. However, guidelines should be produced to the highest methodological quality possible, to give users more accurate information about the level and quality of evidence they intend to apply in the clinical setting.Implant dentistry has reached a level of excellence in the conducting of systematic reviews. Now, it is time to move forward to improve the quality of clinical guidelines, which can provide a bridge between evidence and its applicability. The concept of developing consensus guidelines without a robust methodology is a remnant from the “pre–evidence-based” era. Hence, this methodological gap between well-developed systematic reviews and clinical practice guidelines should be reduced.The so-called “classic” guidelines should also be scrutinized for quality with the AGREE II instrument. In the implant dentistry field they may also be available. For example, we searched Medline (via PubMed) for such guidelines , and found 14 potential “non-consensus” implant dentistry guidelines. Although it is not in the scope of the present study to evaluate these guidelines, it would be also important to evaluate them in a future project.There is room to improve the quality of consensus guidelines published in highly ranked implant dentistry journals. Clinicians’ and researchers’ development of consensus guidelines to improve clinical treatment with dental implants is laudable. However, as for primary and secondary research, these guidelines should adhere to high and transparent standards. The AGREE II instrument can be used as a reference for the development of high-quality guidelines to provide unbiased and adequate clinical recommendations to clinicians working with dental implants.S1 PRISMA Checklist(DOC)Click here for additional data file.S1 Appendix(DOCX)Click here for additional data file.S2 Appendix(DOCX)Click here for additional data file.S1 Table(DOCX)Click here for additional data file.S2 Table(DOCX)Click here for additional data file.S3 TableIQR: interquartile range. CG: consensus guideline; CGSR: consensus guideline + systematic review.(DOCX)Click here for additional data file.S4 Table(DOCX)Click here for additional data file.


Clinicians and researchers require sound neurological tests to measure changes in neurological impairments necessary for clinical decision-making. Little evidence-based guidance exists for selecting and interpreting an appropriate, paediatric-specific lower limb neurological test aimed at the impairment level.To determine the clinimetric evidence underpinning neurological impairment tests currently used in paediatric rehabilitation to evaluate muscle strength, tactile sensitivity, and deep tendon reflexes of the lower limb in children and young people with a neurological condition.Thirteen databases were systematically searched in two phases, from the date of database inception to 16 February 2017. Lower limb neurological impairment tests were first identified which evaluated muscle strength, tactile sensitivity or deep tendon reflexes in children or young people under 18 years of age with a neurological condition. Papers containing clinimetric evidence of these tests were then identified. The methodological quality of each paper was critically appraised using standardised tools and clinimetric evidence synthesised for each test.Thirteen papers were identified, which provided clinimetric evidence on six neurological tests. Muscle strength tests had the greatest volume of clinimetric evidence, however this evidence focused on reliability. Studies were variable in quality with inconsistent results. Clinimetric evidence for tactile sensitivity impairment tests was conflicting and difficult to extrapolate. No clinimetric evidence was found for impairment tests of deep tendon reflexes.Limited high-quality clinimetric evidence exists for lower limb neurological impairment tests in children and young people with a neurological condition. Results of currently used neurological tests, therefore, should be interpreted with caution. Robust clinimetric evidence on these tests is required for clinicians and researchers to effectively select and evaluate rehabilitation interventions. Paediatric neurological examinations are a fundamental component for planning and adjusting rehabilitation interventions, monitoring the course of a neurological condition, and evaluating the effectiveness of an intervention, –3 in botClinicians may structure their physical assessment with an initial screen of neurological integrity in conjunction with the history, or subjective examination, providing information on activity limitations or participation restrictions from the child, young person or parent. Due to the increasing numbers of neurological impairment tests available, ,6–11 selAlthough adult neurological tests have frequently been modified for use in paediatric populations, the clinimetric properties of adult tests are not inherently transferrable to children and young people. ,17 AdultClinimetric properties of tests for typically developing children are also not necessarily transferable to children with a lower limb neurological condition. ,13,17–19There is little evidence-based guidance on how to assist clinicians and researchers select and interpret an appropriate, paediatric-specific lower limb neurological test for children and young people with a neurological disorder. ,20,21 WhIdentify neurological impairment tests currently used to evaluate the lower limb neural integrity of muscle strength, tactile sensitivity, and deep tendon reflexes in children and young people with a neurological conditionIdentify clinimetric evidence for neurological impairment tests used in children and young people with a wide range of neurological conditionsCritically appraise and synthesise the clinimetric evidence underpinning the lower limb neurological testsMake recommendations regarding their use in clinical practice and research settings.This study was undertaken in two phases based on the works by Bialocerkowski and colleagues. ,24 The fSearch terms, identifying lower limb neurological impairment tests for children (aged 2–18 years) with a neurological condition, were generated from previous search strategies. ,27 MedicDuplicates were removed from identified papers, before two researchers (RC and BH) independently evaluated them for the following inclusion criteria:Paediatric participants had an average age greater than two years and less than 18 years, as the focus of the paper was on children and young people less than 18 years. ,28–30Participants with a neurological condition affecting the lower limb. These conditions included diseases of the nervous system, musculoskeletal system and connective tissue, injuries to the head or unspecified part of trunk and certain other consequences of external causes, certain conditions originating in the perinatal period, congenital malformations, deformations and chromosomal abnormalities that effect the central or peripheral nervous system including the spinal cord, peripheral nerves, nerve roots, autonomic nervous system and muscles. Papers reported using a neurological impairment test that measured or evaluated muscle strength (b730), and/or tactile sensitivity (b270), and/or deep tendon reflexes (b750) at the “body functions and structures” level of the ICF-CY. Neurological impairment tests were suitable for use within the clinical setting, using equipment that was typically available, inexpensive and portable. ,31Quantitative studies with a level of evidence rated I-IV   to optimise clinical care. Papers were excluded if:The average age for participants could not be determined or the average age of participants was younger than 2 years of age or older than 18 years of age.Participants were diagnosed with conditions limited to metabolic, orthopaedic or cardiovascular conditions .Neurological tests were classified as activity or participation measures, as these measures represented a different ICF-CY construct. Papers reported only spasticity or primitive reflexes, as these were not the focus of this study. –30Neurological impairment tests with a low level of clinical utility due to expense or limited transportability of equipment (e.g. isokinetic dynamometer) or the specialised diagnostic nature of testing (e.g. electromyography or nerve conduction studies). Papers were editorials or opinion pieces, as they are not quantitative studies. If eligibility was unclear, the two researchers (RC and BH) undertook a review of the full text article. A third reviewer (AB) was consulted to reach consensus in cases of continued disagreement. Included papers were reviewed in full text and the names of all relevant neurological tests were extracted by the same two researchers (RC and BH) and compared for agreement. If required, the third reviewer (AB) determined consensus.Neurological impairment tests identified in Phase 1 were systematically searched for their clinimetric properties from their date of inception to 16 February 2017 using four health databases, CINAHL, EMBASE, Medline, Scopus.  By transa neurological test search, to identify measures of muscle strength, or tactile sensitivity, or deep tendon reflexes limited to the lower limb;a population search, including paediatric participants aged less than 18 years;a neurological test search, derived from the neurological impairment test names identified in Phase 1 and;filtering for measurement properties, as outlined by Terwee, et al. Papers were included if:all paediatric participants were aged less than 18 years, as clinimetric properties are population specific. participants had a neurological condition affecting the lower limb. Neurological conditions were defined using the International Classification of Diseases (ICD-10) as per Phase 1.papers contained clinimetric evidence on a lower limb neurological impairment test that evaluated muscle strength, tactile sensitivity and/or deep tendon reflexes in the lower limb as per the ICF-CY framework outlined in Phase 1.quantitative studies with a level of evidence rated II-IV   was reached using the same method as Phase 1. Papers that contained additional evidence outside the scope of this paper were included only if data could be extrapolated that met the inclusion criteria. Systematic reviews (level I evidence) identified in this process were searched for primary papers that met the inclusion criteria through secondary searching. Additional primary papers that met the inclusion criteria were identified through secondary searching by hand through the reference lists of included papers and identified systematic reviews.The methodological quality of the included clinimetric papers was evaluated independently by two reviewers (RC and BH) using two critical appraisal tools: Brink and Louw critical appraisal tool  and the Additional data were extracted from each study, including the name of the authors, date of publication, name of the neurological test, type of clinimetric property evaluated, participant characteristics, rater characteristics, measurement characteristics, results of the clinimetric evaluation and information on the clinical utility of the test. Clinical utility was described based on information contained within the included papers on the portability, cost, and feasibility of using the equipment on children and young people with a neurological condition in a clinical setting. Evidence on each clinimetric property for each neurological test within primary papers was narratively synthesised and interpreted in combination with the methodological quality of the primary paper. Reliability correlation coefficients from the primary papers were interpreted using guidelines from Katz et al.,  low = <0The Phase 1 search strategy identified 77 papers that met the inclusion criteria. Thirteen papers –57 met tThere was high agreement  between reviewers when scoring the methodological quality of included papers. The most prevalent quality limitations identified using the Brink and Louw critical appraisal tool  Table 3Table 3. The 13 primary papers provided clinimetric evidence for six neurological tests: American Spinal Impairment Association) ASIA impairment scale,  Charcot-Hand held dynamometry had the largest body of evidence, with nine papers –54 repor and a lack of reported patient stability between testing sessions  ,55,56 fosessions . [56] MMsessions . Escolarsessions . Body posessions . Body posessions . The MMTThe Charcot-Marie-Tooth Pediatric Scale (CMTPedS) was evaluated in one paper with children and young people with Charcot-Marie-Tooth , Table 4The International Standards for Neurological Classification of Spinal Cord Injury American Spinal Injury Association (ASIA) scale was evaluated in one paper with children and young people with spinal cord injury , Table 4Clinimetric evidence for the Richmond Quantitative Measurement System was identified in one paper in children and young people with cerebral palsy , Table 4One study provided evidence on the reliability of the Standing Heel Rise  in childA best evidence synthesis for each of the six neurological tests showed HHD had conflicting evidence on reliability for children with cerebral palsy, moderate inter-rater reliability for children with spina bifida and moderate intra-rater reliability for children with Duchenne’s muscular dystrophy . MMT hadThis is the first study to systematically identify clinimetric evidence on lower limb neurological impairment tests used on children and young people across a range of neurological disorders. Evidence of reliability was the only identified clinimetric property for six of the identified 21 neurological tests, demonstrating the paucity of evidence for neurological impairment testing. Clinimetric evidence for tactile sensitivity was identified in two primary papers ,57 contapoor quality’ due to small sample sizes (less than 30). ,6316,63]Results of this study indicate that the same clinician should perform each neurological test due to consistently higher intra-rater reliability coefficients compared to inter-rater reliability coefficients . All cliManual muscle testing is typically recommended in weaker muscles, with equal or less than gravity strength, ,64 yet tInconsistent muscle strength testing methods between the primary papers confirms that a standardised test protocol for muscle strength testing does not exist. There is also wide variability in grading scales when using MMT, with four different scales reported in the three MMT papers ,55,56 wiReliability is only one of many clinimetric properties, which include validity, responsiveness and clinical utility, ,14 The CCurrently there is no universally accepted definition of the upper age limits  for a paIn contrast to previous reviews ,30,31,41This study was limited to three components of a neurological examination at the ‘body function and structures’ level of the ICF-CY as other neurological impairment tests such as spasticity are dependent on the diagnosis of the child.  For a coSynthesising best evidence, through combining a consistent body of clinimetric evidence with robust methodological qualities, can guide clinicians and researchers to select appropriate paediatric-specific lower limb neurological tests. ,31 GuidaThere is a lack of robust clinimetric evidence on neurological impairment tests to use on children and young people with a lower limb neurological condition. Clinimetric evidence was only found on the reliability of neurological impairment tests evaluating muscle strength. Performing standardised testing protocols, such as the make method, with manual or belt stabilisation in a stable population-specific group, are recommended as a starting point for further clinimetric studies. In the absence of clinimetrically-sound neurological tests, clinicians should use the best available evidence. Without clinimetrically-sound neurological tests it is difficult for clinicians and researchers to select and perform a test in clinical practice, which becomes increasingly complex when requiring a combination of these tests for a thorough neurological examination. High quality, population-specific studies are required to provide a strong body of clinimetric evidence for clinicians and researchers to make future recommendations for use of a neurological examination in clinical practice and research.S1 Table(DOCX)Click here for additional data file.S2 Table(DOCX)Click here for additional data file.S3 Table(DOCX)Click here for additional data file.S4 Table(DOCX)Click here for additional data file.S5 Table(DOC)Click here for additional data file.


Children with disabilities (CWDs) are at a higher risk of being maltreated than are typical children. The evidence base on the abuse of children with disabilities living in low- and middle-income countries is extremely limited but the problem is particularly acute in East Africa. We don’t know the types of evidence that exist on this topic. This problem is compounded by the fact that key indicators of disability, such as reliable prevalence rates, are not available currently. This paper addresses this serious problem by mapping the existing evidence-base to document the coverage, patterns, and gaps in existing research on the abuse of children with disabilities in East Africa. An evidence map, following systematic review guidelines, was conducted and included a systematic search, transparent and structured data extraction, and critical appraisal. Health and social science databases  were systematically searched for relevant studies. A substantive grey literature search was also conducted. All empirical research on the abuse of CWDs in East Africa was eligible for inclusion: Data on abuse was systematically extracted and the research evidence, following critical appraisal, mapped according to the type of abuse and disability condition, highlighting gaps and patterns in the evidence-base. 6005 studies were identified and screened, of which 177 received a full-text assessment. Of these, 41 studies matched the inclusion criteria. By mapping the available data and reports and systematically assessing their trustworthiness and relevance, we highlight significant gaps in the available evidence base. Clear patterns emerge that show a major data gap and lack of research on sexual abuse of children with disabilities and an identifiable lack of methodological quality in many relevant studies. These make the development of a concerted and targeted research effort to tackle the abuse of children with disabilities in East Africa extremely difficult. This needs to be addressed urgently if the abuse of children with disabilities is to be prioritised by the global health community. This may be because many CWDs in East Africa often receive limited education or no schooling at all and most surveys on child abuse are conducted at university or secondary school level [Child maltreatment and abuse, which “includes all forms of physical and emotional ill-treatment, sexual abuse, neglect, and exploitation that results in actual or potential harm to the child’s health, development or dignity” , continuol level –21. WhatIn this paper, we systematically review, categorise, and map studies on the physical, psychological, sexual and systemic abuse of CWDs in East Africa. We develop a systematic evidence map of the available evidence base that explicitly shows which areas and relationships have received attention and which have not. This work contributes to the field primarily by identifying an evidence gap and presenting the need for it to be taken forward to support the prioritisation of new research in this neglected area.Evidence mapping is a rigorous method of research synthesis, which transparently assesses and structures the type of research conducted in relation to a specific research question, to identify and visualize patterns and gaps in the existing evidence base –24. EvidWe opted to conduct an evidence map rather than a full systematic review as our research was concerned with providing an overview of the patterns and characteristics of the available evidence base. A systematic review would have allowed us to answer detailed individual questions such as what interventions work to protect children from abuse or why certain types of abuse are more prevalent than other. However, in this evidence map we are more concerned with the higher-level patterns in the evidence-base itself; for example, what research gaps and research clusters exists, and what are their characteristics?i) what we know about the relationship between different conditions and the events of abuse; and ii) for which conditions and types of abuse there is a lack of research evidence currently. A review protocol was not published and the study was not registered with PROSPERO because these mechanisms do not cater for evidence maps at present.As a result, we conducted a systematic evidence map of all available research investigating the abuse of children with disabilities in East Africa see . We systEast African Medical Journal were conducted too to ensure the sensitivity of the applied search strategy. An exhaustive record of the full search strategy including key words is provided in The search strategy to identify relevant studies for the map targeted both academic and grey literature sources to provide an exhaustive account of the evidence base. Academic database searches included health as well as social sciences sources: Medline, EMBASE, PsychInfo, Taylor&Francis, Web of Science, and SAGE. The cut-off date for searches was 1980 and database specific filters (e.g. country filter) were used where applicable. Grey literature sources comprised international and NGO websites , government publications, as well as Google and Google Scholar searches. The applied search terms combined terms related to (i) disability; (ii) abuse; and (iii) East Africa using the ‘AND’ boolean operator. Searches were run between August and September 2015. We further applied forward and backward citation searches of all identified studies and screened the reference lists of existing reviews . Hand-seA pre-defined set of inclusion criteria was used to identify relevant studies eligible for inclusion in the evidence map. To be included a study had to meet all of the following:Studies eligible for inclusion either had to focus on children with disabilities or the caregivers of children with disabilities. The age definition of “child” adopted by this evidence map follows the UN Convention on the Rights of the Child (CRC) definition . DefinitOnly studies conducted in East Africa were eligible for inclusion in this evidence map. East Africa was defined as the countries belonging to the East African Community: Ethiopia, Kenya, Tanzania, Burundi, Uganda and Rwanda See .Acknowledging that child maltreatment and abuse can have different definitions across different cultures and societies, the WHO definition of maltreatment (quoted in the introduction) was adopted for this map.To be included, studies had to present empirical qualitative or quantitative research evidence. Commentary, opinion, advocacy, and theory papers, which were not based on empirical data were excluded. The inclusion threshold of empirical research was met if the research objective, method, population, data, and analysis were described. Eligible study designs can be differentiated into three categories of research: (i) descriptive qualitative and quantitative studies reporting on the abuse/prevention of abuse; (ii) quantitative and qualitative process and impact evaluations of programmes aiming to protect children with disabilities from abuse; (iii) systematic reviews and meta-analyses on (i) or (ii).Citations identified in the exhaustive search were imported into Endnote and screened on title and abstract for eligibility. Two reviewers conducted the screening and a subset of ten percent of the studies was double-screened to test inter-reviewer reliability. Full-texts of relevant citations were then sought and further assessed against the inclusion criteria following the same test for inter-reviewer reliability. Studies for which the two reviewers could not reach agreement were deferred to a third reviewer, who acted as an arbitrator.Structured data extraction was conducted using a detailed pre-defined coding tool provided in and the relevance of the research to the reviews question of enquiry. Assessing the contribution of a study to the review, therefore, depended on its ability to produce unbiased research findings as much as its overlap with the review question and context. This critical appraisal approach is widely used in reviews of social research because of its ability to incorporate contextual factors into the critical appraisal process [Included full-texts were then critically appraised regarding their methodological quality and relevance to the research question. For this purpose, a weight of evidence appraisal tool was developed based on a standard tool designed by Gough  and appl process –32. It aHeatmap software in MS Excel was used to generate a visual representation of the identified evidence-base. The binary codes recording instances of abuse served as a data input, with the overall categories of disabilities and abuse presenting the framework for the evidence map. The resulting evidence map , 24 were qualitative, five quantitative, eight contained both quantitative and qualitative elements, and four resembled empirical policy analyses. The included studies could be clearly divided into research-based advocacy reports by non-governmental organisations (n = 11) and peer-reviewed academic studies (n = 30). The types of maltreatment and abuse of children with disabilities that emerged from the coding of the studies were clustered into four overarching categories: physical, psychological, sexual and systemic maltreatment and abuse.http://tinyurl.com/ace-evidencemap.) This evidence base is divided into four categories  of abuse and maltreatment for eight disabilities , presented in a matrix of 32 cells. The number of each cell represents the research evidence reporting instances of abuse or maltreatment for that cell.homogenous condition; in many cases data is not disaggregated by condition or conditions are clustered together when discussed. This is particularly true when discussing blindness and deafness; in some cases they are clustered under disability more generally Click here for additional data file.S2 Appendix(XLSX)Click here for additional data file.S3 Appendix(XLSX)Click here for additional data file.S4 Appendix(DOC)Click here for additional data file.


Evidence from the field of Developmental Origins of Health and Disease (DOHaD) demonstrates that early life environmental exposures impact later-life risk of non-communicable diseases (NCDs). This has revealed the transgenerational nature of NCD risk, thus demonstrating that interventions to improve environmental exposures during early life offer important potential for primary prevention of DOHaD-related NCDs. Based on this evidence, the prospect of multi-sectoral approaches to enable primary NCD risk reduction has been highlighted in major international reports. It is agreed that pregnancy, lactation and early childhood offer significant intervention opportunities. However, the importance of interventions that establish positive behaviors impacting nutritional and non-nutritional environmental exposures in the pre-conceptual period in both males and females, thus capturing the full potential of DOHaD, must not be overlooked. Adolescence, a period where life-long health-related behaviors are established, is therefore an important life-stage for DOHaD-informed intervention. DOHaD evidence underpinning this potential is well documented. However, there is a gap in the literature with respect to combined application of theoretical evidence from science, education and public health to inform intervention design. This paper addresses this gap, presenting a review of evidence informing theoretical frameworks for adolescent DOHaD interventions that is accessible collectively to all relevant sectors. Escalating rates of obesity and associated avoidable noncommunicable diseases (NCDs) have increased global attention on impacts, prevention, and control. NCDs, primarily cardiovascular diseases, cancers, chronic respiratory diseases and type 2 diabetes mellitus, are responsible for 68% of global deaths, with 40% occurring prematurely (before age 70). Low- and middle-income nations bear 75% of all, and 82% of premature, NCD deaths . The Wora world free of the avoidable burden of NCDs”, propose multi-sectoral, empowerment-based knowledge-translation strategies, including life-course approaches to prevention and control [Principles and approaches guiding fulfillment of the vision, “ control . Life-co control , and tha control .Pregnancy, lactation and infancy were rapidly identified as life-stages appropriate for DOHaD-informed interventions ,6. HowevAdolescence is a determining point for nutritional, physical activity, and cognitive behaviors that persist into adulthood ,8 and inReports recommending inclusion of adolescent interventions within prevention strategies suggest multi-sectoral approaches, highlighting the potential of schools as intervention settings ,11,12. Rmulti-sectoral perspective. It is intended as an enabling tool supporting participating sectors to recognize sectoral-specific perspectives. From this collaborators may gain understanding of evidence and drivers from partner sectors, and consider how evidence and practice can be integrated to achieve the potential of transgenerational NCD risk reduction offered within adolescence.Having led the development of multi-sectoral education–science–health adolescent intervention partnerships in Oceania ,14, and Multi-sectoral partnerships are recommended where complexity determines that no single sector has the required expertise or resources to bring about change . It has Multiple social structures offer settings for DOHaD-driven interventions aiming to empower adolescents to engage in evidence-based preventive actions. Settings need to enable individuals and/or communities to examine evidence , identify the significance of this evidence for their context, and identify and engage in evidence-based risk-reducing actions. To facilitate the potential of positive health-behaviors prior to parenting, intervention settings should engage adolescents before and within the reproductive years. Participation should be sustained for long enough to allow in-depth interaction and effect learning and development that leads to evidence-based actions. Intervention settings sit within and are impacted by the social, environmental and political context of the community. This influences resourcing (available and required) to support adolescent empowerment, the type of actions adolescents will identify as opportunities for change, and the manner in which adolescents may approach empowerment-based social disruption to bring about change in the health status of their families and communities.Schools offer established social networks wherein education can facilitate development of competencies  that empower adolescent-led evidence-based actions within the socio-ecological context of the individual and their community . HoweverShared vision is the most significant critical success factor for multi-sectoral partnerships . Also reWithin multi-sectoral partnerships it is known that differing goals lead to devaluing of others’ strategies by partners, and that this limits success . In schoThe science and health sectors share goals related to improving nutrition and associated factors in childhood and adolescence, promoting transgenerational NCD risk reduction ,11,12. WAchieving shared vision requires investment in partnership development, including recognition and respect for sector-specific goals . The impEducation, often seen as a panacea for multiple social ills, may react skeptically when yet another issue to be addressed in schools is identified. While science/health has recognized adolescence as a valid point to disrupt transgenerational obesity/NCD cycles, this is not core business for education. To accept and sustain the invitation to lead intervention design and facilitation, the education sector (both leaders and teachers) needs to examine the relevant scientific and health evidence in depth, and consider the potential for the NCD/DOHaD context to support educational goals. We intentionally define education as the leader of intervention design. Health and education leaders within our DOHaD translation partnership programs believe that inviting education to lead intervention design has achieved significantly more than when health develop and offer interventions to schools , which i“primarily about the transmission of subject matter from teacher to student” [Non-educators involved in partnerships need to appreciate modern pedagogy and practice. Shifts in understanding of the nature of knowledge (epistemology) in the past 20 years have seen a move from positivism towards constructivism, promoting learner-centered classrooms .  and system agents contributing to the determination of NCD risk by participating adolescents, leading to evidence-based decision-making.Reductionist thinking, promoting individual responsibility or blame over understanding of complex social and biological determinants of risk, is frequently used in relation to NCDs/DOHaD, particularly at the level of public communication. Legitimate in the context of defined best-practice, where cause and effect relationships are, or can be, made evident to everyone, this perspective is inadequate in relation to causality of NCD risk. Application of the Cynefin sense-making approach to inform health promotion strategies addressing complex issues  issues” . In relaThe rationale for primary and transgenerational prevention of NCD risk via adolescent intervention, outlined briefly in the introduction, emerges from the field of DOHaD. This evidence must be made accessible to all partners in a manner that enables it to be understood and contextually interpreted by program facilitators.contribute towards adverse long-term outcomes [In animal models, under-nutrition and obesogenic early life environments result in offspring with a propensity towards subsequent development of metabolic or cardiovascular diseases . Evidencoutcomes ,40. Longoutcomes ,42,43. IEvidence of mechanisms underpinning the impact of early life environmental exposures on later-life health has demonstrated that during critical life-course periods, developmental plasticity creates the potential for environmental exposures to influence regulatory pathways by altering gene expression in response to favorable or unfavorable conditions. The latent phenotypic influences resulting from developmental plasticity may be associated with increased neuro-cognitive developmental challenges ,45, earlCollectively, these data suggest that two forms of preventive intervention are theoretically possible. First, by improving adverse nutritional and environmental exposures before and during pregnancy, predictive adaptive or conditional responses that lead to phenotypic vulnerabilities such as increased later-life NCD risk could be minimized, share in scientific advancement and its benefits” [DOHaD research evidence has reached a point where, if applied in community settings, it has the potential to improve health and wellbeing . This does not mean that new evidence will not continue to emerge, but does mean that the right of every human to “enefits”  must be Core to this science communication/translation process is the concept that programs must facilitate contextual interpretation of evidence within communities for whom it has relevance, so that individuals and/or groups can decide how to use (or not use) the evidence. Hence, we need to examine the concept of science communication, and how this is interpreted by sectoral partners within intervention design to enable individuals and communities  to decide on contextually relevant evidence-based actions.Traditional views of science communication, defined by positivist epistemology, identify knowledge as descriptions of phenomena that can be observed, measured and absolute. This leads to the belief that knowledge can be transmitted from expert to public, creating an informed society that uses scientific evidence in decision-making . EstabliKnowledge is a multi-dimensional concept that encompasses more than a collection of facts. It can be categorized as declarative (or content), procedural, and epistemic. The ability to use knowledge in decision-making is influenced by attitudes, competencies and context. In modern schooling, rather than transmitting declarative knowledge, teachers facilitate learning experiences that allow students to examine, question, challenge, and formulate their own ideas, opinions, and conclusions . As wellWhen research evidence is explored in open, non-linear learning environments that present multiple perspectives on an issue alongside core scientific and sociological concepts, development of understanding that leads to conscious decision-making initiated by adolescents is possible . This trTransactional, learner-centered programs that facilitate construction of meaningful understanding of evidence from which decision-making can emerge differ significantly from transmission-based science communication, such as that used to facilitate mass public awareness. Campaigns such as “5+ a day” transmit declarative knowledge via mass media, pamphlets, posters etc. without the opportunity to enable the public to engage with evidence that has led to the knowledge. Furthermore in such programs little opportunity exists for collaborative construction of contextual understanding of this knowledge. Thus, it is not surprising that such programs are known to improve awareness but not change behaviors . While oextremely broad profiles of NCDs as a disease cluster;latency between environmental exposure and potential identification of risk;extended time over which risk and morbidity develops;breadth of physiological systems that may be impacted; and○the double burden of maternal and child malnutrition alongside child and/or adult overweight, obesity and NCDs found in low- and middle-income countries and socially/economically disadvantaged populations, and○impacts emerging from climate change, nutritional transitions, and food insecurity.complex interaction of sociological, environmental, genetic and epigenetic factors that contribute to NCD risk profiles for individuals, families, and populations, includingThe complexity of NCD cause and effect must underpin intervention design. This complexity, while challenging, presents significant educational opportunity with respect to development of competencies enabling critical engagement in open-ended social issues , validatDOHaD evidence is a component of this complexity. The impact of early life exposures on later-life NCD risk is neither isolated nor absolute, but resides within a life-course approach to understanding NCD risk, disease and prevention . FurtherThis matrix of interacting factors impacting NCD risk creates multiple rich contexts for learning that is designed to facilitate development of capabilities required for critical engaged citizenship. Intervention design should enable age-appropriate exploration of current and historical influences on and beliefs about NCD risk, facilitating students to identify and challenge beliefs and assumptions  and negotiate concepts of: association rather than determination; transgenerational risk; and interaction between environmental and biological factors within a broader societal context. Learning such as this supports competency development, and empowers evidence-based actions.Initiated by the 1970s Science, Technology and Society movement, examination of socio-scientific issues is a universally agreed component of schooling ,79. Desplead an overall successful and responsible life and for contemporary society to face present and future challenges” [interactive use of tools ;interactions within heterogeneous groups ; andthe ability to act autonomously  .In response to challenges of increasing social complexity, the education sector, via the Development and Selection of Competencies (DeSeCo) program, defined competencies required for individuals  to “llenges” . They siIn the context of NCDs, these competencies contribute to the ability of adolescents to engage with evidence  and decide how individual, community and societal actions may be beneficial. Capabilities associated with knowledge and understanding of science and health are also required.Health literacy implies the achievement of a level of knowledge, personal skills and confidence to take action to improve personal and community health by changing personal lifestyles and living conditions. Thus, health literacy means more than being able to read pamphlets and make appointments. By improving people’s access to health information, and their capacity to use it effectively, health literacy is critical to empowerment.” [Health literacy describes a set of capabilities supporting and enabling evidence-based decision-making related to wellbeing and health at personal, community and societal levels and is therefore an important aspect of intervention design. While definitions are variable and at times confined to health-service literacy, the asset model of health literacy proposed by Nutbeam considers the capabilities required to enable critical informed engagement in decision-making. “erment.” .Nutbeam’s ongoing refinement of this model presents the capabilities within a frame of increasing cognitive demand. Useful from an educational perspective, it moves from basic/functional literacy, associated with skills for daily living, towards communicative/interactive literacy, and finally critical literacy, associated with capabilities required for decision-making within complex contexts . Importaexplain natural and technical phenomena;evaluate and design scientific enquiry; andinterpret data and evidence scientifically .Scientific literacy is associated with the ability to use scientific knowledge and understanding in decision-making at personal, community and societal levels . TherefoThis recognizes that attitudes associated with interest and engagement in the role of science, and use of scientific knowledge within society are components of scientific literacy . It idenIntervention design should support development of capabilities associated with scientific literacy within three increasingly complex levels of engagement: personal/family, community, and societal . They are moderated by development of attitudes and dispositions promoting engagement in social issues. As such, scientific literacy contributes to the matrix of capabilities required for critical, informed, and responsible citizenship  requiredThe matrix of capabilities described above contributes to individuals or groups engaging with and acting upon scientific and sociological evidence. The extent to which intention leads to sustained action is impacted by self-efficacy and the social/emotional environment. Self-efficacy is the extent to which individuals or communities believe they have the capacity to accomplish a task. Self-efficacy may fluctuate. It is influenced by past experiences, vicarious experiences (modeling from significant others), verbal persuasion, and physiological feedback . Self-efTeacher quality, preparation, beliefs, and commitment are significant controllable factors that enable educational change and influence student learning ,94. HealWithin multi-sectoral partnerships, lead providers are likely to develop intervention frameworks and core resources, enabling schools to lead intervention adaptation to create contextually appropriate programs contributing towards educational and health goals in each community. Participatory teacher research, a collaborative process whereby teachers, via critical analysis, develop, implement, and evaluate education interventions, is an effective form of PLD to facilitate change . This reThrough PLD processes, teachers will adapt programs to ensure they are supportive of learning for and within school communities. This addresses the ever-present challenge of diversity within and between schools, suggested as a reason why evidence-informed health policies and practice applied to school-based health promotion do not always yield similar outcomes .retrieving, organizing and applying professional knowledge in light of the challenges and needs presented by the students they are teaching” [Schools are constantly challenged by change and the need to respond to change . Diversieaching” . This reeaching” , promotieaching” . DifficuBiological and sociological evidence points to the potential of schools as a setting for interventions that support transgenerational interruption of the NCD/obesity cycle; however, historically, school-based health interventions have been problematic. Recognition of evidence from multiple sectors and disciplines offers the opportunity to address these historical challenges, which may have occurred due to lack of true partnerships demonstrating mutual respect within multi-sectoral engagement.On investigation, educators identify in NCD/DOHaD socio-scientific issues of relevance to multiple communities with significant potential as contexts to facilitate learning. When the breadth of later-life health issues impacted by early life environment is linked to social determinants such as poverty, food security, sustainable energy, climate change and technologies, the potential of the context across learning areas ranging from science and health to humanities, arts and languages is identified. This breadth enables multiple exposures via related learning experiences, increasing intervention dose and strength.Educators need to create the conditions in which adolescents can be empowered as agents of change with respect to obesity, NCDs and socio-ecological impacts. This can only occur when educators are themselves empowered as facilitators of this change, a process that requires transactional engagement between education, health and science communities so that collectively the opportunities can be recognized and enabled.support educational and health goals in equal measure;be underpinned by appropriate pedagogies utilizing constructs such as student-centered learning, constructivist and inquiry-based epistemologies and epistemic thinking;support fulfillment of national-level curriculum, assessment and pastoral care policies and objectives;enable integration into school-level curriculum and policies , and support strategic development goals;provide resources that are designed to be adapted by teachers to meet social, cultural, pastoral and academic needs within their school community and classes, thus supporting development for all learners;be evaluated via protocols that are inclusive of the school community and the sectoral partners; andacknowledge that learning environments, scientific and health evidence are dynamic constructs, and that programs should evolve over time.In effective school-based partnerships, intervention design, while co-constructed, will be led by educators, ensuring links to the core mission of schools. Interventions should:There are currently some programs addressing the potential for DOHaD informed adolescent interventions based on the principles described in this paper occurring in a range of socio-cultural settings. Evidence is emerging, but needs to be developed. The complexity of the school setting, and NCD risk is challenging, and there is room for further exploration of interactions such as those between the school, the adolescent, the family and the community. Research into how such partnerships are developed and maintained should be prioritized, as should publication of evidence that is inclusive of education perspectives. Examination of the impact of program initiation at different phases of child development (for example pre vs. post pubescent), the impact of ongoing program engagement from childhood into adolescence, and the potential for family-involvement should be explored in greater depth. Detailed analysis of intervention tools and empirical evidence relating to education and health, including case studies from a range of contexts and eventually prospective studies, are required.


Quality indicators (QIs) are used in assessing the quality of healthcare. Evidence-based clinical practice guidelines (CPGs) are relevant sources for generating QIs. In this context, QIs are important tools to assess the implementation of guideline recommendations. However, the methodological approaches to guideline-based QI development vary considerably.In Germany, the guideline classification scheme of the AWMF  differentiates between S1-, S2k-, S2e-, and S3-CPGs depending on the methodological approach. Thus, S3-CPGs are consensus- and evidence-based CPGs and have the highest methodological standard in Germany. An analysis of the status quo of reported QIs in S3-CPGs found 35 current S3-CPGs, which report 372 different QIs.Currently, there is no gold standard for the development of guideline-based QIs. To our knowledge, no studies have investigated to what extent guideline-based QIs from different CPGs that are related to the same topic are consistent. The objective of this study is to compare guideline-based QIs and their underlying methodological approaches of German S3-CPGs with those of topic-related international CPGs.n = 35), which report quality indicators, we will conduct systematic searches in the guidelines databases of G-I-N  and NGC  to identify international CPGs matching the topics of the S3-CPGs. If necessary, we will search additionally the websites of the particular CPG providers for separate documents with regard to QIs. We will include evidence-based CPGs which report QIs. Reported QIs as well as methods of development and the rationale for QIs will be extracted and compared with those of the S3-CPGs.Based on the previous identified German S3-CPGs . The results of this analysis will feed into a subsequent qualitative study, which will consist of structured interviews with developers of international CPGs. Further, the results will be considered in a consensus study on standards of the translation of guideline recommendations into quality indicators in Germany.The online version of this article (10.1186/s13643-017-0669-2) contains supplementary material, which is available to authorized users. Quality measurement and improvement play an important role in healthcare. For this purpose, quality indicators (QIs) can be used. There is no clear-cut definition of a QI. According to Lawrence and Frede, a QI is a “measurable element of practice performance for which there is evidence or consensus that it can be used to assess the quality, and hence change in the quality, of care provided” . The JoiAs evidence-based clinical practice guidelines (CPGs) are designed to reflect current best practice, they are relevant sources for generating QIs , 9. The In Germany, the AWMF  provides the methodological framework for the development of CPGs by the scientific medical societies. The guideline classification scheme of the AWMF differentiates between S1-, S2k-, S2e-, and S3-CPGs depending on the methodological approach . Thus, SAlthough a working group of the Guidelines International Network (G-I-N) recently proposed a set of reporting standards for guideline-based performance measures , there iThe objective of this study is to compare guideline-based QIs and their underlying methodological approaches of the 35 previously identified German S3-CPGs with those of topic-related international CPGs.Our study is not registered with PROSPERO as we will not report health-related outcomes.QIs are reportedThe CPG is an evidence-based CPGThe topic and recommendations have to be comparable with those of at least one of the 35 previous identified S3-CPGs  and/or a level of evidence (LoE)Explicitly or implicitly linked to the references of the underlying evidenceIf QIs are solely reported in a separate document, which is not a supplement to the CPG , they have to be explicitly linked with the particular CPG. Otherwise, we will assume that these QIs are not guideline-based, and we will exclude the guideline. An example for such a separate document that contains guideline-based QIs is a document from the website of the National Institute for Health and Care Excellence (NICE): “NICE menu of general practice and clinical commissioning group indicators” . The menBased on the previously identified S3-CPGs which report QIs, we will conduct systematic searches in the guidelines databases of G-I-N and NGC  to identify international CPGs matching the topics of the S3-CPGs. The search strategies will include suitable keywords relating to the clinical topics and as appropriate truncations as well as Boolean operators. In cases where we cannot identify topical eligible guidelines, we will screen the websites of CPG providers additionally, whereby the searches will be tailored to the structure and capabilities of the websites. Furthermore, we will crosscheck the reference lists of the S3-CPGs and the international CPGs eligible for inclusion in the analysis.In cases where topical eligible CPGs comprise neither QIs nor links to QIs, we will search the websites of the particular CPG providers for separate documents with regard to QIs that are explicitly linked with the particular CPG.One reviewer will screen the titles of records, and the full texts of those deemed eligible for inclusion will be retrieved. In the next step, the screening of full texts will be conducted by one reviewer and checked by another. The reasons for exclusion will be documented, and any disagreements will be resolved through discussion and consensus.The records will be uploaded and managed using Microsoft Excel.In cases where no eligible CPG matching the topic of a S3-CPG can be found, we will exclude the particular CPG from analysis.Information on QI-development group Labeling of the measure of quality, e.g., QI, quality criteria, performance measureCategorization of QI in structure, process, outcome indicator according to the definition of Donabedian   × 7 (items) × 2 (appraisers)) .Reviewers who have been involved in the development of the included CPGs will not participate in their quality assessment.Data synthesis will contain a descriptive analysis and a tabular comparison of the QIs of the included CPGs and those of the S3-CPGs for each clinical topic and when applicable for each underlying recommendation. We will collect the number of CPGs that give information to the QI-development group, the methods of QI-development, as well as the rationale and intended purpose of QI. On the basis of reported QIs, we will collect the number of QI for which quality objectives and measurement properties are reported as well as the number of QI that are explicitly or implicitly based on guideline recommendations.For each matched pair of CPGs, we will compare the suggested QIs and assess if the QIs agree, disagree, or if they are not comparable. We will assign QIs on the same topic either to the category “not different/slightly different” or “different.” QIs that are not comparable will be extracted under the category “QI only defined in the international respectively the S3-CPG. For each category, we will collect the number of QIs respectively QI-pairs. Furthermore, the methods for QI-development will be summarized narratively.This study will be part of the project “Systematic analysis of the translation of guideline recommendations into quality indicators and development of an evidence- and consensus-based standard,” supported by the German Research Association (DFG). It will be the second systematic analysis in the overall project. The results of this analysis will feed into a subsequent qualitative study which will consist of structured interviews with developers, methodologists, and users of international guidelines. Both studies intend to deliver additional information to existing research on methods for the development of guideline-based QIs , 18. ForAn overview of the overall project is shown in Fig. This protocol adheres to the “Preferred Reporting Items for Systematic Review and Meta-Analysis-Protocols (PRISMA-P)” . As PRISThe results of our study will be considered in the last phases of the overall project, namely a consensus-study on standards of the translation of guideline recommendations into quality indicators.Additional file 1:S3-CPGs which report QIs. (DOCX 25 kb)Additional file 2:PRISMA-P 2015 Checklist. (DOCX 35 kb)