Various standards for how to present recommendations advise that the strength of the recommendation and the level of evidence be presented separately (for example, a strong recommendation based on moderate quality evidence). The quality of evidence does, of course, affect the strength of the recommendation.

To enable patients to understand the strength of recommendations in patient versions, we suggest using several strategies, for example, using words and symbols. Some work has also indicated that people want to know why a recommendation is strong or not. Therefore, providing the reasons for a recommendation and what to consider may help.

Conveying the strength of the recommendation in words

Typically, guideline producers will use qualitative text to convey the strength of a recommendation in the original guideline document. For example, strong recommendations may be ‘recommended’ and weaker recommendations may be ‘suggested’. Different guideline producers may use different labels to convey the strength of the recommendation. When using the GRADE approach, recommendations are labelled as ‘strong’, ‘weak’ or ‘conditional’ (Guyatt et al. 2008). It may be helpful, regardless of the system being used, to include a legend in the patient version for the definitions of the terms used (Ottawa Hospital Research Institute 2020).

Research, in particular with healthcare professionals, has indicated that words are interpreted differently (Nast et al. 2013). To minimise misunderstanding, guideline developers should include symbols, other labels and or reasons for the strength of the recommendation. The reasons may be based on the certainty of the evidence, the differences in people’s preferences, resources or other issues, such as feasibility, accessibility or equity.

Using symbols to convey the strength of recommendations

Symbols were used in the WHO’s guideline on health worker roles in maternal and newborn health (see figure 3). The guideline was aimed at a range of stakeholders (although not the public). The symbols were well received.

Figure 3 Symbols in WHO’s guideline on health worker roles in maternal and newborn health that were tested with the target audience

The solid green ticks are strong recommendations in favour of the intervention, and solid red crosses are strong recommendations against the intervention. The dotted ticks and crosses are weak recommendations for and against the intervention, respectively.

Having learned from work with patients and the public (Ottawa Hospital Research Institute 2020), SIGN uses a system of icons with text to flag recommendations and their evidence level. The symbols in figure 4 were adopted for SIGN’s autism booklet for patients, carers and families of children and young people, which is the public version of the autism guideline.

Figure 4 symbols tested with parents and carers for SIGN’s autism booklet

Use of symbols to express strength of evidence needs to be tested with the target audience. For example, parents and carers taking part in user testing of the symbols in figure 4, found the thumbs up, tick and question mark symbols clear and easy to understand. However, the response to the underlying 4 levels of evidence was mixed. Some parents appreciated the level of detail offered by the grades of evidence and recommendations, and others thought it would be sufficient simply to know that SIGN recommended an intervention (DECIDE patients and public). The parents understood the essential message of the evidence levels, which is that one intervention is strongly recommended and another one less strongly recommended. But most did not understand why it is necessary to have these different levels of recommendation. Similarly parents found the not enough evidence icon disconcerting. Although they understood that the question mark and text was meant to convey uncertainty, they did not like this message, or understand why guideline producers would need to use it (DECIDE patients and public).