title: Users identified challenges in applying GRADE to complex interventions and suggested an extension to GRADE.
abstract: OBJECTIVE
  To explore user perspectives on applying the Grading of Recommendations Assessment, Development and Evaluation (GRADE) to systematic reviews of complex interventions.
  
  
  METHODS
  Thirty-three authors of recent (2013 onward) systematic reviews were contacted regarding their perspectives on using GRADE from three Cochrane review groups: Cochrane Developmental, Psychosocial, and Learning Problems Group; Cochrane Public Health Group; and Cochrane Depression, Anxiety, and Neurosis Group. Framework Analysis was applied to the data to identify the challenges in applying GRADE and suggestions for its extension, that is, adaptation. These two themes were cross-compared between the groups of answers from "simple" vs. "complex" intervention review authors to identify the specific perspectives on using GRADE in reviews of complex interventions.
  
  
  RESULTS
  Specific challenges were identified in applying GRADE to reviews of complex interventions. These were related to the assessment of nonrandomized studies and performance bias in GRADE. Authors perceived these challenges to contribute to frequent downgrading of the "best evidence possible" for complex interventions. Meanwhile, GRADE was found to lack an analytic approach to enable adequate evidence synthesis and assessment of intervention implementation elements.
  
  
  CONCLUSIONS
  Users suggest that the GRADE guidance be extended to address-specific considerations for complex interventions.
authors.affiliation: Centre for Evidence Based Intervention, Department of Social Policy and Intervention, University of Oxford, Barnett House, 32 Wellington Square, Oxford OX1 2ER, UK. Electronic address: ani.movsisyan@spi.ox.ac.uk.
authors.forename: Ani
authors.initials: A
authors.lastname: Movsisyan
authors.affiliation: Centre for Evidence Based Intervention, Department of Social Policy and Intervention, University of Oxford, Barnett House, 32 Wellington Square, Oxford OX1 2ER, UK.
authors.forename: G J
authors.initials: GJ
authors.lastname: Melendez-Torres
authors.affiliation: Centre for Evidence Based Intervention, Department of Social Policy and Intervention, University of Oxford, Barnett House, 32 Wellington Square, Oxford OX1 2ER, UK.
authors.forename: Paul
authors.initials: P
authors.lastname: Montgomery
mesh_terms: D055317:Evidence-Based Practice / Q000592:standards*; D006801:Humans; D036301:Qualitative Research; D011785:Quality Assurance, Health Care; D012107:Research Design; D012196:Review Literature as Topic
keywords: Complex interventions; GRADE; Qualitative research methods; Quality of evidence; Systematic reviews; User perspectives