This article describes how the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to grading the quality of evidence and strength of recommendations considers the Bradford Hill criteria for causation and how GRADE may relate to questions in public health. A primary concern in public health is that evidence from non-randomised studies may provide a more adequate or best available measure of a public health strategy's impact, but that such evidence might be graded as lower quality in the GRADE framework. GRADE, however, presents a framework that describes both criteria for assessing the quality of research evidence and the strength of recommendations that includes considerations arising from the Bradford Hill criteria. GRADE places emphasis on recommendations and in assessing quality of evidence; GRADE notes that randomisation is only one of many relevant factors. This article describes how causation may relate to developing recommendations and how the Bradford Hill criteria are considered in GRADE, using examples from the public health literature with a focus on immunisation.
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Competing interests HJS is co-chair of the GRADE working group; he supports the implementation of the GRADE approach worldwide. From non-profit organisations he has accepted honoraria and consulting fees for activities in which his work with GRADE may be relevant. SH is a staff member of the WHO. The authors alone are responsible for the views expressed in this publication and they do not necessarily represent the decisions, policy or views of the WHO or other organisations. The conclusions in this article are those of the authors and do not necessarily represent the official position of the US Centers for Disease Control and Prevention. GG is co-chair of the GRADE working; he supports the implementation of the GRADE approach worldwide. On behalf of McMaster University, he has accepted honoraria and consulting fees for activities in which his work with GRADE is relevant.
Provenance and peer review Not commissioned; not externally peer reviewed.