Applying GRADE-CERQual to Interpretive Review Findings: Reflections from a Cochrane Meta-ethnography on Childhood Vaccination Acceptance

"...believe in the transformative potential of strategies - inevitably precarious- that seek to enlarge the kinds of qualitative knowledge that might contribute to decision-making processes."

There has been growing recognition of the potential contribution of qualitative evidence within global health and social care decision-making. Those working in these arenas increasingly seek evidence beyond the effects of interventions, to wider questions about local norms and preferences, equity and human rights issues, acceptability and feasibility of interventions, implementation processes, and the impact of socio-political and cultural contexts. GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) was developed to support the use of evidence from qualitative reviews within policy- and decision-making. This paper reflects on experiences with applying GRADE-CERQual to findings that emerged from a 2021 Cochrane meta-ethnography on childhood vaccination.

In summary, the earlier Cochrane review sought to develop a conceptual understanding of what and how different factors interact to influence parental views and practices around routine childhood vaccination. The researchers used a meta-ethnographic approach, which translates and synthesises conceptual data from included studies to produce more interpretive or higher-level understandings.

The researchers reflect on our experience of operationalising GRADE-CERQual, including developing a summary of findings and applying each of the four components of the approach: methodological limitations, coherence, relevance, and adequacy. In particular, the article outlines both the similarities as well as the differences, challenges and dilemmas the researchers faced when applying GRADE-CERQual. Tables 1 and 2 provide examples from the review of: a finding, summary of finding, and GRADE-CERQual assessments. One of the findings indicates that many parents held a worldview informed by neoliberal discourses. These discourses understand health as individualised, and health-related risks and decisions as matters of individual choice and responsibility. Some parents experienced this worldview as in conflict with vaccination promotion messages, which tend to emphasise generalised risk and safety statistics, claim that "doctor knows best", ask people to trust authorities and follow what they promote, and advocate for social responsibility and the health of the community. Parents' perceived tension between the discourses informing their own worldview and those of vaccination promotion messages led some to resist these messages and be less accepting of vaccination.

In unearthing how they applied the core criteria and principles of GRADE-CERQual to this and other examples, the researchers contend that they could do so in ways that were congruent with the methodologies and epistemologies of a meta-ethnography and its findings. They also found that the practical application processes were similar across review finding types. The main differences related to the level of demand placed on the evidence and the level of complexity involved with the decisions. Compared to more descriptive findings, more interpretive findings required evidence that was richer, thicker, more contextually situated and methodologically stronger for them to have the same level of confidence in them. Making the assessments for these findings also involved more complicated forms of judgment.

The researchers also highlight areas requiring further discussion in the hope of offering a platform for engagement and the potential future refinement of the approach. 

In conclusion, the researchers content that GRADE-CERQual "provides a way of bringing to the table rich insights and theoretical frameworks of experience and context that could potentially unsettle and expand simplistic or one-dimensional concepts that often dominate decision-making interactions.... It affords a possible mechanism for broadening the kinds of issues qualitative research is typically sought for - such as 'acceptability' and 'feasibility' - to more critical conversations about 'power', 'ideology', 'structure' and 'justice'.... Ultimately, it offers potential openings and opportunities for expanding the kinds of knowledges and ways of knowing that count within health and social care decision-making."