June 2015


Confidence in the Evidence from Reviews of Qualitative Research

The CERQual approach aims to provide a systematic and explicit method for assessing and describing how much confidence to place in findings from qualitative evidence syntheses. 

CERQual Website goes live!

CERQual is now a project group within the wider GRADE Working Group. As a GRADE Project Group, CERQual shares GRADE’s overall aim of providing a systematic and explicit approach to making judgments about confidence in research evidence, with the ultimate goal of supporting informed decisions in health care. You are invited to read and comment on the Terms of Reference found herePlease send feedback by 9th of July.

Mailing List or Project Group?
We kindly request you to take a minute and click here to confirm whether you would like to be part of the GRADE-CERQual project group, or simply be on our mailing list to receive newsletters and other updates. The CERQual Project Group is an open group and we welcome the involvement of methodologists, researchers, review authors, guideline developers and other end-users in developing the approach. CERQual Project Group Members will be asked for their input on new developments and publications.

What led to the development of the CERQual approach?
Our first version of the CERQual approach was developed alongsidthe WHO OptimizeMNH guideline ( 

    The recommendations in this guideline focused on the shifting of maternal and newborn healthcare tasks from higher-level health worker groups to health worker groups with less training. Health systems interventions such as these are complex, and it quickly became clear to us that issues of acceptability and feasibility were likely to be as important as issues of effectiveness. The WHO therefore made the innovative decision to use evidence from qualitative research to address questions of acceptability and feasibility, in addition to using evidence of effectiveness to inform the recommendations. Like many guideline producers, the WHO uses the GRADE approach to indicate to the guideline panel how certain we are of the evidence of intervention effectiveness. When presenting evidence from systematic reviews of qualitative research, we realised that we needed to give similar information to the panel about our certainty, or confidence, in this evidence. As existing GRADE tools were not appropriate for qualitative research findings and we were unable to identify other appropriate tools, we set about developing the CERQual approach. 

How has the CERQual approach evolved?
The CERQual approach has evolved considerable since its first use in 2012 and now includes four components.
 In the first version of CERQual, an assessment of confidence in the evidence was based on two components: methodological limitations and coherence of the data. The approach was later revised through the important contributions of Project Group members and piloting in several qualitative evidence syntheses. The current version includes four components: methodological limitations, coherence, relevance, and adequacy of data. A paper describing the CERQual approach has been submitted to a journal and we hope that this will be published later in 2015. Further information is also available on our website

What is the focus of CERQual work now?
Our work now focuses on how to operationalize each component of the CERQual approach, and a meeting in Oslo in 2015 was fruitful in this regard. We are also exploring 'publication (or dissemination) bias' in qualitative research and have set up a sub-group to take this work forward.

CERQual meeting, Oslo, June 2015
A very productive GRADE-CERQual Meeting was held recently in Oslo.
The Norwegian Knowledge Centre for the Health Services hosted a GRADE-CERQual meeting in Oslo on the 3rd and 4th of June 2015. Sixteen experts in the fields of qualitative research and evidence synthesis were invited to participate in this two-day workshop which provided in-depth and constructive feedback on how the four components of CERQual should be operationalised and on carrying out an overall CERQual assessment of confidence in a finding from a qualitative evidence synthesis. These discussions will contribute to the development of a series of papers on the CERQual approach, to be published in 2016. We thank all who contributed as well as our funders listed in this newsletter.  

Where has CERQual been used to date?
The first version of the CERQual approach was used in three reviews that were developed for the World Health Organization OptimizeMNH guidelines (Colvin 2013, Glenton 2013, Rashidian 2013). One of these reviews (Glenton 2013) was later published in the Cochrane Library, and was the first Cochrane Review to be based solely on qualitative research. The first version of the CERQual approach was also used in a review developed for the Norwegian government to support decisions regarding care in residential childcare institutions (Munthe-Kaas 2013), in a review developed as part of WHO activities on facility-based childbirth delivery rates (Bohren 2014) and in a review of intervention effectiveness for eliminating repeat pregnancies (Whitaker, 2014)
So far, the second version of the approach has been used in one review that has been accepted for publication (Bohren 2015), and is currently being used in a further ten Cochrane and non-Cochrane reviews, at least half of which are being produced to support WHO guidance.