GRADE: Assessing the quality of evidence in environmental and occupational health |
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| Institution: | 1. Department of Clinical Epidemiology & Biostatistics, McMaster University, Health Sciences Centre, Room 2C14, 1280 Main Street West, Hamilton, ON L8S 4K1, Canada;2. Division of the National Toxicology Program, National Institute of Environmental Health Sciences, National Institutes of Health, Department of Health and Human Services, P.O. Box 12233, Mail Drop K2-02, Research Triangle Park, NC 27709, USA;3. Charles Perkins Centre, The University of Sydney, D17, The Hub, 6th floor, New South Wales, 2006, Australia;4. Department of Public Health and Policy, University of Liverpool, L69 3GB, United Kingdom;5. Division of Gastroenterology, Case Western Reserve University and Louis Stokes VA Medical Center, 10701 East Blvd., Cleveland, OH 44106, USA;6. Sydney Medical School, University of Sydney, New South Wales 2006, Australia;7. National Health and Medical Research Council, 16 Marcus Clarke Street, Canberra City, ACT 2601, Australia;8. Departments of SYRCLE and Anesthesiology, Radboud University Medical Centre, Geert Grooteplein-Noord 29, Route 231, 6525 GA Nijmegen, The Netherlands;9. Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Center, University of Amsterdam, Room J1B-211, P.O. Box 22660, 1100 DD Amsterdam, The Netherlands;10. Cesare Maltoni Cancer Research Center, Ramazzini Institute, Via Saliceto 3, Bentivoglio, Bologna, P.O. Box 40133, Italy;11. Departments of Medicine/Nephrology and Biomedical & Health Informatics, University of Missouri-Kansas City, School of Medicine, M4-303, 2411 Holmes St., Kansas City, Missouri 64108-2792, USA;12. Institute for Medical Informatics, Biometry and Epidemiology, University of Munich, Marchioninistr. 15, 81377 Munich, Germany;13. Bruyere Research Institute and Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada;14. Department of Environmental Health Sciences, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, E6644, Baltimore, MD 21205, USA;15. Program on Reproductive Health and the Environment, University of California-San Francisco, 550 16th Street, San Francisco, CA 94143, USA;p. Finnish Institute of Occupational Health, Cochrane Work, PO Box 310, 70101 Kuopio, Finland;q. Department of Obstetrics and Gynecology, McMaster University, Health Sciences Centre, Room 3N52A, 1280 Main Street West, Hamilton, ON L8S 4K1, Canada;r. Department of Medicine, McMaster University, Health Sciences Centre, Room 2C14, 1280 Main Street West, Hamilton, ON L8S 4K1, Canada;1. Institute of Occupational, Social and Environmental Medicine, Centre for Health and Society, Faculty of Medicine, University of Düsseldorf, Universitätsstraße 1, Düsseldorf 40225, Germany;2. Centre de Recherche du CHU de Québec, Université Laval, 1050 Chemin Ste-Foy, Quebec City, G1S 4L8, Quebec, Canada;3. Department of Public Health, Ghent University, Campus University Hospital, 4K3, De Pintelaan 185, B-9000 Ghent, Belgium;4. Research Centre EPIMED, University of Insubria, Via O Rossi 9, 21100 Varese, Italy;5. Department of Public Health, Environmental and Social Determinants of Health, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland;6. State University of New York-Downstate School of Public Health, 450 Clarkson Ave., Brooklyn, NY 11238, United States of America;7. Labour Administration, Labour Inspection and Occupational Safety and Health Branch, International Labour Organization, Route des Morillons 4, 1211 Geneva, Switzerland;8. Institute of Epidemiology and Health Care, University College London, 1-19 Torrington Place, London WC1E 6BT, United Kingdom;9. National Research Centre for the Working Environment, Lersø Parkallé 105, DK-2100 Copenhagen, Denmark;10. Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, DK-1014 Copenhagen, Denmark;11. Department of Psychology, University of Copenhagen, Øster Farimagsgade 2A, DK-1353 Copenhagen, Denmark;12. Center for Occupational and Environmental Health, University of California-Irvine, 100 Theory Way, Irvine, CA, United States of America;13. Department of Information, Evidence and Research, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland;14. Department of Public Health, School of Medicine, Kitasato University, 1-15-1 Kitasato, Minami, Sagamihara 252-0374, Japan;15. Life Science Centre, University of Düsseldorf, Merowingerplatz 1a, Düsseldorf 40225, Germany;1. University of California San Francisco, Program on Reproductive Health and the Environment, Oakland, CA, USA;2. ORISE Post-doctoral Fellowship, U.S. Environmental Protection Agency, Office of Policy, National Center for Environmental Economics, Washington, D.C., USA;3. Office of Environmental Health Hazard Assessment, California Environmental Protection Agency, CA, USA;4. University of California San Francisco, Department of Epidemiology and Biostatistics, San Francisco, CA, USA;5. University of California San Francisco, Department of Clinical Pharmacy, San Francisco, CA, USA |
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| Abstract: | There is high demand in environmental health for adoption of a structured process that evaluates and integrates evidence while making decisions and recommendations transparent. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework holds promise to address this demand. For over a decade, GRADE has been applied successfully to areas of clinical medicine, public health, and health policy, but experience with GRADE in environmental and occupational health is just beginning. Environmental and occupational health questions focus on understanding whether an exposure is a potential health hazard or risk, assessing the exposure to understand the extent and magnitude of risk, and exploring interventions to mitigate exposure or risk. Although GRADE offers many advantages, including its flexibility and methodological rigor, there are features of the different sources of evidence used in environmental and occupational health that will require further consideration to assess the need for method refinement. An issue that requires particular attention is the evaluation and integration of evidence from human, animal, in vitro, and in silico (computer modeling) studies when determining whether an environmental factor represents a potential health hazard or risk. Assessment of the hazard of exposures can produce analyses for use in the GRADE evidence-to-decision (EtD) framework to inform risk-management decisions about removing harmful exposures or mitigating risks. The EtD framework allows for grading the strength of the recommendations based on judgments of the certainty in the evidence (also known as quality of the evidence), as well as other factors that inform recommendations such as social values and preferences, resource implications, and benefits. GRADE represents an untapped opportunity for environmental and occupational health to make evidence-based recommendations in a systematic and transparent manner. The objectives of this article are to provide an overview of GRADE, discuss GRADE's applicability to environmental health, and identify priority areas for method assessment and development. |
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