. 2021 Jul:135:42-53.

doi: 10.1016/j.jclinepi.2021.01.001. Epub 2021 Jan 18.

Challenges in applying the GRADE approach in public health guidelines and systematic reviews: a concept article from the GRADE Public Health Group

Michele Hilton Boon¹, Hilary Thomson², Beth Shaw³, Elie A Akl⁴, Stefan K Lhachimi⁵, Jesús López-Alcalde⁶, Miloslav Klugar⁷, Leslie Choi⁸, Zuleika Saz-Parkinson⁹, Reem A Mustafa¹⁰, Miranda W Langendam¹¹, Olivia Crane¹², Rebecca L Morgan¹³, Eva Rehfuess¹⁴, Bradley C Johnston¹⁵, Lee Yee Chong¹⁶, Gordon H Guyatt¹³, Holger J Schünemann¹⁷, Srinivasa Vittal Katikireddi²; GRADE Working Group

Affiliations

¹ MRC/CSO Social and Public Health Sciences Unit, Berkeley Square, 99 Berkeley Street, University of Glasgow, Glasgow G3 7HR, UK. Electronic address: michele.hiltonboon@glasgow.ac.uk.
² MRC/CSO Social and Public Health Sciences Unit, Berkeley Square, 99 Berkeley Street, University of Glasgow, Glasgow G3 7HR, UK.
³ Center for Evidence-based Policy, Oregon Health & Science University, Portland, OR 97201 USA.
⁴ Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main Street W, Hamilton, Ontario L8S 4K1, Canada; Department of Internal Medicine, American University of Beirut, Beirut, Lebanon.
⁵ Department for Health Services Research, Institute of Public Health and Nursing Research, University of Bremen, Grazer Straße 4, 28359 Bremen, Germany; Health Sciences Bremen, University of Bremen, 28359 Bremen, Germany.
⁶ Department of Paediatrics, Obstetrics & Gynaecology and Preventative Medicine, Universitat Autònoma de Barcelona; Faculty of Health Sciences, Universidad Francisco de Vitoria (UFV)-Madrid; Clinical Biostatistics Unit, Hospital Universitario Ramón y Cajal (IRYCIS); CIBER Epidemiology and Public Health; Cochrane Associate Centre of Madrid, Madrid, Spain.
⁷ Faculty of Medicine, Czech National Centre for Evidence-Based Healthcare and Knowledge Translation (Cochrane Czech Republic, The Czech Republic Centre for Evidence-Based Healthcare; JBI Centre of Excellence, Masaryk University GRADE Centre), Institute of Biostatistics and Analyses, Masaryk University, 625 00 Brno, Czechia.
⁸ The Department of Vector Biology, Partnership for Increasing the Impact of Vector Control, Liverpool School of Tropical Medicine, Liverpool, UK.
⁹ European Commission, Joint Research Centre, Ispra, Italy.
¹⁰ Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main Street W, Hamilton, Ontario L8S 4K1, Canada; Departments of Medicine and Biomedical & Health Informatics, University of Missouri-Kansas City, Kansas City, MO 66160 USA.
¹¹ Department of Clinical Epidemiology, Amsterdam University Medical Centres, University of Amsterdam, Biostatistics and Bioinformatics, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands.
¹² National Institute for Health and Care Excellence (NICE), Level 1A, City Tower, Piccadilly Plaza, Manchester M1 4BT, UK.
¹³ Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main Street W, Hamilton, Ontario L8S 4K1, Canada.
¹⁴ Institute for Medical Informatics, Biometry and Epidemiology, Pettenkofer School of Public Health, LMU Munich, Munich, Germany.
¹⁵ Department of Nutrition, Texas A&M University, College Station, TX, USA.
¹⁶ Cochrane Public Health and Health Systems Network, University of Oxford, Oxford, UK.
¹⁷ Department of Health Research Methods, Michael G DeGroote Cochrane Canada and McMaster GRADE Centres, and WHO Collaborating Centre for Infectious Diseases, Research Methods and Recommendations, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.

PMID: 33476768
PMCID: PMC8352629
DOI: 10.1016/j.jclinepi.2021.01.001

Challenges in applying the GRADE approach in public health guidelines and systematic reviews: a concept article from the GRADE Public Health Group

Michele Hilton Boon et al. J Clin Epidemiol. 2021 Jul.

. 2021 Jul:135:42-53.

doi: 10.1016/j.jclinepi.2021.01.001. Epub 2021 Jan 18.

Authors

Affiliations

¹ MRC/CSO Social and Public Health Sciences Unit, Berkeley Square, 99 Berkeley Street, University of Glasgow, Glasgow G3 7HR, UK. Electronic address: michele.hiltonboon@glasgow.ac.uk.
² MRC/CSO Social and Public Health Sciences Unit, Berkeley Square, 99 Berkeley Street, University of Glasgow, Glasgow G3 7HR, UK.
³ Center for Evidence-based Policy, Oregon Health & Science University, Portland, OR 97201 USA.
⁴ Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main Street W, Hamilton, Ontario L8S 4K1, Canada; Department of Internal Medicine, American University of Beirut, Beirut, Lebanon.
⁵ Department for Health Services Research, Institute of Public Health and Nursing Research, University of Bremen, Grazer Straße 4, 28359 Bremen, Germany; Health Sciences Bremen, University of Bremen, 28359 Bremen, Germany.
⁶ Department of Paediatrics, Obstetrics & Gynaecology and Preventative Medicine, Universitat Autònoma de Barcelona; Faculty of Health Sciences, Universidad Francisco de Vitoria (UFV)-Madrid; Clinical Biostatistics Unit, Hospital Universitario Ramón y Cajal (IRYCIS); CIBER Epidemiology and Public Health; Cochrane Associate Centre of Madrid, Madrid, Spain.
⁷ Faculty of Medicine, Czech National Centre for Evidence-Based Healthcare and Knowledge Translation (Cochrane Czech Republic, The Czech Republic Centre for Evidence-Based Healthcare; JBI Centre of Excellence, Masaryk University GRADE Centre), Institute of Biostatistics and Analyses, Masaryk University, 625 00 Brno, Czechia.
⁸ The Department of Vector Biology, Partnership for Increasing the Impact of Vector Control, Liverpool School of Tropical Medicine, Liverpool, UK.
⁹ European Commission, Joint Research Centre, Ispra, Italy.
¹⁰ Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main Street W, Hamilton, Ontario L8S 4K1, Canada; Departments of Medicine and Biomedical & Health Informatics, University of Missouri-Kansas City, Kansas City, MO 66160 USA.
¹¹ Department of Clinical Epidemiology, Amsterdam University Medical Centres, University of Amsterdam, Biostatistics and Bioinformatics, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands.
¹² National Institute for Health and Care Excellence (NICE), Level 1A, City Tower, Piccadilly Plaza, Manchester M1 4BT, UK.
¹³ Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main Street W, Hamilton, Ontario L8S 4K1, Canada.
¹⁴ Institute for Medical Informatics, Biometry and Epidemiology, Pettenkofer School of Public Health, LMU Munich, Munich, Germany.
¹⁵ Department of Nutrition, Texas A&M University, College Station, TX, USA.
¹⁶ Cochrane Public Health and Health Systems Network, University of Oxford, Oxford, UK.
¹⁷ Department of Health Research Methods, Michael G DeGroote Cochrane Canada and McMaster GRADE Centres, and WHO Collaborating Centre for Infectious Diseases, Research Methods and Recommendations, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.

PMID: 33476768
PMCID: PMC8352629
DOI: 10.1016/j.jclinepi.2021.01.001

Abstract

Background and objective: This article explores the need for conceptual advances and practical guidance in the application of the GRADE approach within public health contexts.

Methods: We convened an expert workshop and conducted a scoping review to identify challenges experienced by GRADE users in public health contexts. We developed this concept article through thematic analysis and an iterative process of consultation and discussion conducted with members electronically and at three GRADE Working Group meetings.

Results: Five priority issues can pose challenges for public health guideline developers and systematic reviewers when applying GRADE: (1) incorporating the perspectives of diverse stakeholders; (2) selecting and prioritizing health and "nonhealth" outcomes; (3) interpreting outcomes and identifying a threshold for decision-making; (4) assessing certainty of evidence from diverse sources, including nonrandomized studies; and (5) addressing implications for decision makers, including concerns about conditional recommendations. We illustrate these challenges with examples from public health guidelines and systematic reviews, identifying gaps where conceptual advances may facilitate the consistent application or further development of the methodology and provide solutions.

Conclusion: The GRADE Public Health Group will respond to these challenges with solutions that are coherent with existing guidance and can be consistently implemented across public health decision-making contexts.

Keywords: GRADE; Guidelines; Health policy; Nonrandomized studies; Public health; Social determinants.

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Figures

**Fig. 1**
Process of developing the scope and priorities of the GRADE Public Health Group.

See this image and copyright information in PMC

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Challenges in applying the GRADE approach in public health guidelines and systematic reviews: a concept article from the GRADE Public Health Group

Affiliations

Challenges in applying the GRADE approach in public health guidelines and systematic reviews: a concept article from the GRADE Public Health Group

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