New GRADE concept paper identifies challenges and solutions to use of GRADE in public health contexts

The GRADE framework can be applied across a variety of different fields, not the least of which is public health. Public health, as the authors of a new GRADE concept paper define it, is concerned with "preventing disease, prolonging life, and promoting health through the organized efforts of society" and comprises three key domains: health protection, health services, and health improvement. However, the field of public health also has unique challenges in the application of GRADE that require addressing. 

To dig deeper into these challenges and design a plan of action for solutions and guidance, the GRADE Public Health group conducted a scoping review to better understand published accounts of the barriers, challenges, and facilitators to the adoption and application of GRADE in public health contexts, presenting the results of nine identified articles. Of these, five major challenges were identified:

• Incorporating diverse perspectives 
• Selecting and prioritizing outcomes
• Interpreting outcomes and identifying a threshold for decision-making
• Assessing certainty of evidence from diverse sources (e.g., nonrandomized studies)
• Addressing implications for decision-makers, including concerns about conditional recommendations

The article then discusses proposed solutions and a work plan to address these key challenges.

Forthcoming GRADE public health guidance articles, collaborations with the GRADE Evidence-to-Decision working group, and the adaptation of GRADE training materials to nonhealth and policy audiences will help guide those in public health contexts in meeting the unique needs presented for rigorous guideline development. Additional promotion of existing GRADE guidance, such as the consideration of equity in the evidence-to-decision process, may help guideline developers within specific challenges related to selecting and prioritizing outcomes or identifying thresholds for decision-making. Ongoing guidance from the GRADE group for Non-Randomizes Studies and the use of ROBINS-I may further improve the application of GRADE in settings where observational evidence is dominant. 

Hilton Boon, M., Thomson, H., Shaw, B., et al. (2021). Challenges in applying the GRADE approach in public health guidelines and systematic reviews: A concept article from the GRADE public health group. J Clin Epidemol 135:42-53.

Article available at the publisher's website here.