Barriers to and facilitators of living guidelines use in low-income and middle-income countries: a scoping review


  • A priori registration of the full protocol in the Open Science Framework journal.

  • Comprehensive search of quantitative, qualitative and grey literature.

  • Followed rigorous methodological and reporting guidelines.

  • Identifying living guidelines in the grey literature is challenging, and it is possible that we missed some unindexed records.

  • The review does not assess the risk of bias of the included studies.


The development and implementation of trustworthy guidelines can aid evidence-based clinical decision-making. However, to do so, guidelines must be of a high methodological standard and up to date.1 2 Implementing evidence-based recommendations included in guidelines may result in improved patient outcomes, reduced hospital stays, increased resource efficiency, higher-quality care and an overall improvement in the healthcare delivery system.3–6

Guidelines should ideally be reviewed and updated as soon as new information becomes available in order to maintain their currency.7 8 However, the most common approach to updating clinical practice guideline recommendations is to update the whole guideline after a certain period of time (often 3–5 years).9 This strategy has two significant drawbacks. First, some recommendations become outdated within a brief amount of time as new evidence emerges. Second, resources may be wasted on recommendations that do not require updating, reducing the efficiency of the guideline development process.9 Both of these drawbacks can be addressed through a living evidence synthesis approach, including living systematic reviews and living guidelines.10

Living guidelines are designed to hasten the development and updating processes so that each recommendation can be updated as soon as new evidence becomes available.11 The following criteria should be assessed to identify evidence-based guidelines that are suitable for living guideline approaches: (1) They address a high-priority clinical question (or questions); (2) There is uncertainty regarding the available evidence and (3) The availability of new or anticipated evidence.12 As illustrated in figure 1, the development of living guidelines is not a sequential process but rather an adaptive and iterative one.11 12

Figure 1
Figure 1

The spinning wheel of living guidelines.12 RCT, randomised controlled trial; SR, systematic review.

Living guidelines are developed using a defined methodology and consider individual recommendations separately rather than changing the entire guideline at once.13 14 During COVID-19, living guideline methods have been advanced and applied in a number of high-income countries. For example, the American Society of Haematology published a living recommendation for anticoagulant medications,15 and the European COVID-19 living guideline group has made conditional recommendations against the use of individual therapeutic drugs.16 In Australia, the National COVID-19 Clinical Evidence Taskforce developed and maintained a comprehensive living guideline for the management of COVID-19. Living guidelines have also been developed to inform management of various medical conditions such as stroke, maternal health, prenatal health, arthritis and diabetes.14 17–19 However, little is known about the usefulness and feasibility of living guidelines in low-income and middle-income countries (LMICs). Identifying opportunities for, and barriers to, the development and use of living guidelines in LMICs may be valuable for informing methods for developing living guidelines in these settings and exploring their potential. This scoping review set out to explore what is currently known about how living guidelines were developed, used and applied in LMICs, as well as what opportunities and challenges there are for doing so.

Objectives of the review

  • To examine current literature from a variety of disciplines and locations in order to better understand how living guidelines are being used in low-income and middle-income settings.

  • To synthesise available evidence about opportunities for and impediments to following a living guideline development approach in LMIC contexts.

  • To inform and generate suggestions for future research and actions with a focus on living guidelines in LMICs.

Materials and methods

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews extension (PRISMA checklist) was followed in reporting the findings of this review and is supplied as online supplemental additional file 1. The protocol for this review was registered in the Open Science Framework journal and is accessible at

Supplemental material

Study eligibility criteria

Inclusion criteria

  • Study definition: The study reported on a ‘living guideline,’ defined as an enhancement to guideline production in which guideline recommendations are continually updated as new information emerges.

  • Study design: Any form of study design describing or reflecting on living guideline activities and their implementation, whether qualitative, quantitative or mixed-method studies.

  • Date of publication: Studies conducted in the last 10 years (2012–2022) were included, as this is the period in which living guidelines have been developed.

  • Document type: All types of documents describing living guidelines, whether published or unpublished (clinical practice guidelines, articles and grey literature sources).

  • Population/setting: LMICs according to the World Bank’s 2022 list. WHO Living Guidelines were also included because they are typically the main source of evidence for clinical practice in LMICs.

  • Content: Studies that described living guideline activities or contained pertinent information about opportunities for or barriers to living guideline development.

  • Language: English or original articles translated into English.

Exclusion criteria

Abstracts, promotional brochures, blogs, news items and conference proceedings were excluded because they lacked complete information.

Information sources

To identify potentially eligible articles, four databases (Medline, Cochrane Library, Embase and Global Health) were searched using key terms to access indexed articles developed with advice from a librarian and an expert in living evidence synthesis. Global Health is a less popular database that catalogues public health and medical research literature, especially that which other databases have unindexed.20 Google Scholar and WHO websites were searched for unindexed articles. Reference lists of included articles were examined for any additional relevant studies.

Search strategy

The search terms were developed based on those of a related study on Living Guidelines.21 Separate key terms were prepared for Embase. Databases were searched on 8 August 2022. On 9 August 2022, we searched the grey literature, using the search terms ‘living’ and ‘guidelines’.

Study selection

The first author (BTM) uploaded search results to Covidence software. Each step of the screening and selection process was managed using Covidence22 and reported in the form of a PRISMA flow chart.23 First, titles and abstracts were screened, and then the full texts of the retrieved articles were reviewed. The screening and review processes were conducted independently by two reviewers (BTM and MQ). Disagreements were resolved through discussion with a third reviewer (TT). Abstracts and full texts of studies authored in languages other than English were translated into English using Google Translate.

Data extraction and synthesis

A structured data extraction form was developed to capture necessary study information, such as the study’s design, setting, clinical topic focus, date of publication, search date (ie, the time when new evidence was sought to update clinical recommendations in the context of the Living Guidelines), search frequency (ie, how frequently new evidence was looked for and considered for inclusion in the guideline), type of study, language, and barriers to and opportunities for developing and implementing living guidelines. Three researchers discussed and evaluated the data extraction format prior to data retrieval (BTM, SEG and TT). The lead researcher (BTM) gathered data from the included studies, which were later reviewed by two additional researchers (TT and SEG). Any ambiguities or contradictions were discussed by the full research team. A risk of bias assessment was not carried out in the review, consistent with approaches to scoping reviews.23 Overall, the characteristics and key findings of the included studies were summarised in both narrative and tabular form.

Patient and public involvement



We identified 2582 studies for screening and review. Among these, 2571 studies were found in publication databases, 8 studies on Google Scholar and 3 studies on the WHO website. After removing 763 duplicate studies, 1819 articles underwent title and abstract eligibility screening. A total of 1790 studies were excluded. Full-text eligibility assessment was performed on 29 studies, which resulted in the exclusion of 8 further studies. Finally, 21 studies met the inclusion criteria, as shown in figure 2.

Figure 2
Figure 2

PRISMA flow chart displaying search results and study screening. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses. *Medline, Cochrane Library, Embase and Global Health.

The three key reasons for exclusion were as follows:

  • Abstract with no complete information.

  • Guidelines did not meet the definition of living guidelines.

  • Study setting was not a LMIC.

Characteristics of the included studies

The majority of the studies reported living guideline activities conducted by the WHO (15, 71.4%),14 19 24–35 followed by China (4, 19%),36–39 Chile (1, 4.8%)40 and Lebanon (1, 4.8%).41 All studies included in this review were published between 2019 and 2022.

Descriptive details of the included studies are presented in table 1.

Table 1

Retrieved data from included studies on living guideline activities in low-income and middle-income countries

Outcomes of the review

Outcome objective 1: how living guidelines are being used in low-income and middle-income settings

Studies in China focused on COVID-19 therapeutic medicines as well as methods for developing living guidelines. The remaining two studies, from Chile and Lebanon, described the establishment of living guidelines. Among the four China-based studies, one reported the medications used to treat mild to moderate COVID-19 illness,42 one described the development of living Chinese medicine guidelines for treating COVID-19 patients,43 one covered a broad appraisal of the development of the living guidelines,37 and one looked at the development of a proposal for living, evidence-based guidelines on the integration of conventional Chinese medicine and Western medicine.39 The study from Lebanon showed how a framework for developing living recommendations for healthcare was produced, and the study from Chile emphasised the significance of thresholds for developing the living recommendations that are defined for the treatment of COVID-19.40

Outcome objective 2: opportunities for and impediments to following a living guideline development approach in LMIC contexts

We were unable to describe the second stated objective since none of the included studies addressed the opportunities and barriers of adapting, developing and using living guidelines in LMICs (table 1).

Outcome objective 3: inform and generate suggestions for future research and actions with a focus on living guidelines in LMICs

Similarly, the third objective, to inform and provide recommendations for future research and action with a focus on living guidelines in LMICs, could not be met due to the scarcity of information provided in the included studies (table 1).


To the best of the authors’ knowledge, this scoping review is the first attempt to comprehensively document the available information on the development and use of living guidelines in LMICs. Most of the studies included in this review were WHO-reported studies that focused on the management of COVID-19. This could be due to the WHO’s role as the primary United Nations organisation responsible for preserving global health, developing guidelines, disseminating them internationally and serving as the key health information source for the world.44 Little information was available to determine whether or how living guidelines are being developed, adapted and used in LMICS or the barriers and enablers of this.

The implementation of living guidelines and associated living recommendations has aided in the generation of timely evidence to guide clinical practice in the care of patients with COVID-19.42 45 In theory, the value of living guidelines in LMICs could be consistent with that demonstrated in a high-income country. One study has shown that it is possible and acceptable to implement living COVID-19 guidelines in Australian healthcare settings.46 Likewise, a study on living clinical guidelines for the treatment of stroke found them to be feasible, though more research is needed to fully understand impact.47

At this early stage in the development of living guidelines, this review found that, when compared with high-income countries,14 17 18 the scope of living guidelines currently available in LMICs covered a narrower range of health issues, focusing mostly on COVID-19. In addition, unlike studies conducted in Australia,11 none of the studies we identified reported facilitators and barriers associated with developing living guidelines in low-income and middle-income nations. The scarcity of literature may be due to the concept of living guidelines being relatively new, particularly in LMIC, and more effort is needed to understand the challenges and opportunities involved in developing, adapting and implementing living guidelines outside of high-income contexts.


This review could not present detailed evidence for each stated objective (objectives 2 and 3) because the included studies did not report key information on overall activities related to living guidelines, highlighting an important research gap. We were unable to compare these findings to those of similar studies because, to our knowledge, no similar review articles on the topic have been published.

The search was largely restricted to published studies. As a result, we may have missed some unpublished reports.


In this scoping review, 21 studies were identified to assess the activities, opportunities and barriers to living guidelines in LMICs. Most of the studies included in this review were WHO-reported studies that focused solely on COVID-19 disease treatment living guidelines. There was no clear explanation of how living guidelines were used or information on the prospects for and obstacles to development and use of living guidelines in LMICs. Given the growing demand for living guidelines, it is clear that more research is needed to answer these questions.

Data availability statement

All data relevant to the study are included in the article or uploaded as online supplemental information.

Ethics statements

Patient consent for publication


We would like to thank Steve McDonald, codirector and senior information expert at Cochrane Australia at Monash University, for his help in developing the search terms. We would also like to thank Romero Lorena, librarian at Alfred Hospital, Monash University, who assisted us in developing database search terms.

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