Assessing evidence: quality and recommendations

GRADE stands for ‘Grading of Recommendations Assessment, Development and Evaluation’. It was developed for health systems interventions. The GRADE approach separates two issues: “the quality of the evidence and the strength of recommendations. Quality of evidence is only one of several factors considered when assessing the strength of recommendations.” The intention of the GRADE approach is that the judgements (often by panels or policy makers) made in the assessments are systematic and transparent. For quality of the evidence: “The degree of confidence is a continuum but, for practical purposes, it is categorised into high, moderate, low, and very low quality…”.

In terms of the strength of recommendations, GRADE includes factors such as:

  • “Whether there is uncertainty about the balance of benefits versus harms and burdens
  • The quality of the evidence from the systematic review (very low, low, moderate, high)
  • Whether there is uncertainty or variability in values and preferences among stakeholders
  • Whether there is uncertainty about whether the net benefits are worth the costs or about resource use
  • Whether there is uncertainty about the feasibility of the intervention (or about local factors that influence the translation of evidence into practice, including equity issues)…
  • Ease of implementation at the systems level, including governance arrangements (e.g., changes needed in regulations), financial arrangements (e.g., the extent to which the options fit with financing models within settings), and implementation strategies (e.g., how to provide the skills and experience needed among implementers or facilitators)
  • Socio-political considerations, e.g., how the proposed options relate to existing policies, values within the political system in relation to issues such as equity or privatisation, and economic changes” (p.5).

Illustrated outputs of GRADE assessments are provided via the PLOS website at:

  1. (PDF 27KB); and,
  2. (PDF 30KB).

Reference: Lewin, Simon., Bosch-Capblanch, Xavier., Oliver, Sandy., Akl, Elie A., Vist, Gunn E., Lavis, John N., Ghersi, Davina., Røttingen, John-Arne., Steinmann, Peter., Gulmezoglu, Metin., Tugwell, Peter., El-Jardali, Fadi., and, Haines, Andy. (2012). Guidance for Evidence-Informed Policies about Health Systems: Assessing How Much Confidence to Place in the Research Evidence. PLOS Medicine, 9, 3, e1001187. Article online at:; DOI: 10.1371/journal.pmed.1001187).

Posted: January 2013
Last modified: February 2016