title: GRADE: Assessing the quality of evidence in environmental and occupational health.
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.
authors.affiliation: Department of Clinical Epidemiology & Biostatistics, McMaster University, Health Sciences Centre, Room 2C14, 1280 Main Street West, Hamilton, ON L8S 4K1, Canada. Electronic address: morganrl@mcmaster.ca.
authors.forename: Rebecca L
authors.initials: RL
authors.lastname: Morgan
authors.affiliation: 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. Electronic address: thayer@niehs.nih.gov.
authors.forename: Kristina A
authors.initials: KA
authors.lastname: Thayer
authors.affiliation: Charles Perkins Centre, The University of Sydney, D17, The Hub, 6th floor, New South Wales, 2006, Australia. Electronic address: lisa.bero@sydney.edu.au.
authors.forename: Lisa
authors.initials: L
authors.lastname: Bero
authors.affiliation: Department of Public Health and Policy, University of Liverpool, L69 3GB, United Kingdom. Electronic address: ngb@liv.ac.uk.
authors.forename: Nigel
authors.initials: N
authors.lastname: Bruce
authors.affiliation: Division of Gastroenterology, Case Western Reserve University and Louis Stokes VA Medical Center, 10701 East Blvd., Cleveland, OH 44106, USA. Electronic address: Yngve.Falck-Ytter@case.edu.
authors.forename: Yngve
authors.initials: Y
authors.lastname: Falck-Ytter
authors.affiliation: Sydney Medical School, University of Sydney, New South Wales 2006, Australia; National Health and Medical Research Council, 16 Marcus Clarke Street, Canberra City, ACT 2601, Australia. Electronic address: davina.ghersi@nhmrc.gov.au.
authors.forename: Davina
authors.initials: D
authors.lastname: Ghersi
authors.affiliation: Department of Clinical Epidemiology & Biostatistics, McMaster University, Health Sciences Centre, Room 2C14, 1280 Main Street West, Hamilton, ON L8S 4K1, Canada. Electronic address: guyatt@mcmaster.ca.
authors.forename: Gordon
authors.initials: G
authors.lastname: Guyatt
authors.affiliation: Departments of SYRCLE and Anesthesiology, Radboud University Medical Centre, Geert Grooteplein-Noord 29, Route 231, 6525 GA Nijmegen, The Netherlands. Electronic address: Carlijn.Hooijmans@radboudumc.nl.
authors.forename: Carlijn
authors.initials: C
authors.lastname: Hooijmans
authors.affiliation: 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. Electronic address: m.w.langendam@amc.uva.nl.
authors.forename: Miranda
authors.initials: M
authors.lastname: Langendam
authors.affiliation: Cesare Maltoni Cancer Research Center, Ramazzini Institute, Via Saliceto 3, Bentivoglio, Bologna, P.O. Box 40133, Italy. Electronic address: mandriolid@ramazzini.it.
authors.forename: Daniele
authors.initials: D
authors.lastname: Mandrioli
authors.affiliation: Department of Clinical Epidemiology & Biostatistics, McMaster University, Health Sciences Centre, Room 2C14, 1280 Main Street West, Hamilton, ON L8S 4K1, Canada; 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. Electronic address: ramustafa@gmail.com.
authors.forename: Reem A
authors.initials: RA
authors.lastname: Mustafa
authors.affiliation: Institute for Medical Informatics, Biometry and Epidemiology, University of Munich, Marchioninistr. 15, 81377 Munich, Germany. Electronic address: rehfuess@ibe.med.uni-muenchen.de.
authors.forename: Eva A
authors.initials: EA
authors.lastname: Rehfuess
authors.affiliation: 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. Electronic address: andrew.rooney@nih.gov.
authors.forename: Andrew A
authors.initials: AA
authors.lastname: Rooney
authors.affiliation: Bruyere Research Institute and Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada. Electronic address: bevshea@uottawa.ca.
authors.forename: Beverley
authors.initials: B
authors.lastname: Shea
authors.affiliation: Department of Environmental Health Sciences, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, E6644, Baltimore, MD 21205, USA. Electronic address: esilber2@jhu.edu.
authors.forename: Ellen K
authors.initials: EK
authors.lastname: Silbergeld
authors.affiliation: Program on Reproductive Health and the Environment, University of California-San Francisco, 550 16th Street, San Francisco, CA 94143, USA. Electronic address: patrice.sutton@ucsf.edu.
authors.forename: Patrice
authors.initials: P
authors.lastname: Sutton
authors.affiliation: 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. Electronic address: wolfe@niehs.nih.gov.
authors.forename: Mary S
authors.initials: MS
authors.lastname: Wolfe
authors.affiliation: Program on Reproductive Health and the Environment, University of California-San Francisco, 550 16th Street, San Francisco, CA 94143, USA. Electronic address: tracey.woodrfuff@ucsf.edu.
authors.forename: Tracey J
authors.initials: TJ
authors.lastname: Woodruff
authors.affiliation: Finnish Institute of Occupational Health, Cochrane Work, PO Box 310, 70101 Kuopio, Finland. Electronic address: Jos.Verbeek@ttl.fi.
authors.forename: Jos H
authors.initials: JH
authors.lastname: Verbeek
authors.affiliation: Department of Obstetrics and Gynecology, McMaster University, Health Sciences Centre, Room 3N52A, 1280 Main Street West, Hamilton, ON L8S 4K1, Canada. Electronic address: hollow@mcmaster.ca.
authors.forename: Alison C
authors.initials: AC
authors.lastname: Holloway
authors.affiliation: Department of Clinical Epidemiology & Biostatistics, McMaster University, Health Sciences Centre, Room 2C14, 1280 Main Street West, Hamilton, ON L8S 4K1, Canada. Electronic address: santesna@mcmaster.ca.
authors.forename: Nancy
authors.initials: N
authors.lastname: Santesso
authors.affiliation: Department of Clinical Epidemiology & Biostatistics, McMaster University, Health Sciences Centre, Room 2C14, 1280 Main Street West, Hamilton, ON L8S 4K1, Canada; Department of Medicine, McMaster University, Health Sciences Centre, Room 2C14, 1280 Main Street West, Hamilton, ON L8S 4K1, Canada. Electronic address: schuneha@mcmaster.ca.
authors.forename: Holger J
authors.initials: HJ
authors.lastname: Schünemann
mesh_terms: D004782:Environmental Health; D015340:Epidemiologic Research Design; D019317:Evidence-Based Medicine / Q000592:standards* / Q000706:statistics & numerical data*; D006801:Humans; D016272:Occupational Health; D015203:Reproducibility of Results; D012196:Review Literature as Topic
keywords: Environmental health; Evidence-based; GRADE; Recommendations; Risk assessment; Risk of bias
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