Current experience with applying the GRADE approach to public health interventions: an empirical study.

Eva A Rehfuess,Elie A Akl

doi:10.1186/1471-2458-13-9

Abstract

BackgroundThe Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach has been adopted by many national and international organisations as a systematic and transparent framework for evidence-based guideline development. With reference to an ongoing debate in the literature and within public health organisations, this study reviews current experience with the GRADE approach in rating the quality of evidence in the field of public health and identifies challenges encountered.MethodsWe conducted semi-structured interviews with individuals/groups that have applied the GRADE approach in the context of systematic reviews or guidelines in the field of public health, as well as with representatives of groups or organisations that actively decided against its use. We initially contacted potential participants by email. Responses were obtained by telephone interview or email, and written interview summaries were validated with participants. We analysed data across individual interviews to distil common themes and challenges.ResultsBased on 25 responses, we undertook 18 interviews and obtained 15 in-depth responses relating to specific systematic reviews or guideline projects; a majority of the latter were contributed by groups within the World Health Organization. All respondents that have used the GRADE approach appreciated the systematic and transparent process of assessing the quality of the evidence. However, respondents reported a range of minor and major challenges relating to complexity of public health interventions, choice of outcomes and outcome measures, ability to discriminate between different types of observational studies, use of non-epidemiological evidence, GRADE terminology and the GRADE and guideline development process. Respondents’ suggestions to make the approach more applicable to public health interventions included revisiting terminology, offering better guidance on how to apply GRADE to complex interventions and making modifications to the current grading scheme.ConclusionsOur findings suggest that GRADE principles are applicable to public health and well-received but also highlight common challenges. They provide a starting point for exploring options for improvements and, where applicable, testing these across different types of public health interventions. Several public health organisations are currently testing GRADE, and the GRADE Working Group is eager to engage with these groups to find ways to address concerns.

Highlights

The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach has been adopted by many national and international organisations as a systematic and transparent framework for evidence-based guideline development
What are the challenges encountered in applying the GRADE approach to rating evidence for public health interventions? Detailed responses to this question among the individuals/groups who had applied GRADE in one or more systematic review or guideline projects (Additional file 1) can be summarised as GRADE is applied without significant challenges (2 responses), GRADE is applied with minor or major challenges (12 responses) and GRADE is currently being tested (1 response) (Table 1)
Specific challenges related to (i) complexity of public health interventions, (ii) choice of outcomes and outcome measures, (iii) ability to discriminate between different types of observational studies, (iv) use of nonepidemiological evidence, (v) GRADE terminology and (vi) the GRADE and guideline development process

Summary

Introduction

The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach has been adopted by many national and international organisations as a systematic and transparent framework for evidence-based guideline development. Even though many public health approaches are preventive in nature, intervening in people’s lives may do harm as well as good They consume both financial and human resources, and may compromise individual freedom of choice. Public health interventions range from programmatic activities that initiate direct, proximal changes in a specific technology or behaviour to those that bring about more distal changes in multi-sectoral policies with indirect impacts on health [1]. These interventions often combine several approaches that are designed by and delivered through the health sector and/or other sectors [2]. Making the decision-making process explicit and transparent is critical, as is a careful examination of the types of evidence underlying specific judgements and, in particular, the quality of evidence in support of likely benefits and harms

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