Challenges in applying the GRADE approach in public health guidelines and systematic reviews: A concept paper from the GRADE Public Health Group.

Abstract Objective This paper explores the need for conceptual advances and practical guidance in the application of the GRADE approach within public health contexts. Study Design and Setting 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 paper 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 prioritising health and ‘non-health’ outcomes; (3) interpreting outcomes and identifying a threshold for decision-making; (4) assessing certainty of evidence from diverse sources, including non-randomised 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.