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The use of GRADE-CERQual in qualitative evidence synthesis: an evaluation of fidelity and reporting

Wainwright, Megan; Zahroh, Rana Islamiah; Tunçalp, Özge; Booth, Andrew; Bohren, Meghan A.; Noyes, Jane; Cheng, Weilong; Munthe-Kaas, Heather; Lewin, Simon

The use of GRADE-CERQual in qualitative evidence synthesis: an evaluation of fidelity and reporting Thumbnail


Rana Islamiah Zahroh

Özge Tunçalp

Andrew Booth

Meghan A. Bohren

Jane Noyes

Weilong Cheng

Heather Munthe-Kaas

Simon Lewin


GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative Research) is a methodological approach to systematically and transparently assess how much confidence decision makers can place in individual review findings from qualitative evidence syntheses. The number of reviews applying GRADE-CERQual is rapidly expanding in guideline and other decision-making contexts. The objectives of this evaluation were, firstly, to describe the uptake of GRADE-CERQual in qualitative evidence synthesis by review authors and, secondly, to assess both reporting of and fidelity to the approach.

The evaluation had two parts. Part 1 was a citation analysis and descriptive overview of the literature citing GRADE-CERQual. Authors worked together to code and chart the citations, first by title and abstract and second by full text. Part 2 was an assessment and analysis of fidelity to, and reporting of, the GRADE-CERQual approach in included reviews. We developed fidelity and reporting questions and answers based on the most recent guidance for GRADE-CERQual and then used NVivo12 to document assessments in a spreadsheet and code full-text PDF articles for any concerns that had been identified. Our assessments were exported to Excel and we applied count formulae to explore patterns in the data. We employed a qualitative content analysis approach in NVivo12 to sub-coding all the data illustrating concerns for each reporting and fidelity criteria.

233 studies have applied the GRADE-CERQual approach, with most (n = 225, 96.5%) in the field of health research. Many studies (n = 97/233, 41.6%) were excluded from full fidelity and reporting assessment because they demonstrated a serious misapplication of GRADE-CERQual, for example interpreting it as a quality appraisal tool for primary studies or reviews. For the remaining studies that applied GRADE-CERQual to assess confidence in review findings, the main areas of reporting concern involved terminology, labelling and completeness. Fidelity concerns were identified in more than half of all studies assessed.

GRADE-CERQual is being used widely within qualitative evidence syntheses and there are common reporting and fidelity issues. Most of these are avoidable and we highlight these as gaps in knowledge and guidance for applying the GRADE-CERQual approach.


Wainwright, M., Zahroh, R. I., Tunçalp, Ö., Booth, A., Bohren, M. A., Noyes, J., …Lewin, S. (2023). The use of GRADE-CERQual in qualitative evidence synthesis: an evaluation of fidelity and reporting. Health Research Policy and Systems, 21(1), Article 77.

Journal Article Type Article
Acceptance Date May 12, 2023
Online Publication Date Jul 25, 2023
Publication Date 2023
Deposit Date Feb 14, 2024
Publicly Available Date Feb 14, 2024
Journal Health Research Policy and Systems
Publisher BioMed Central
Peer Reviewed Peer Reviewed
Volume 21
Issue 1
Article Number 77
Keywords Health Policy
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© World Health Organization 2023. Open Access The Article is licensed under the terms of the Creative Commons Attribution 3.0 IGO
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medium or format, as long as appropriate credit is given to the IGO, a link is provided to the Creative Commons licence, and any changes
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