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Abstract

BACKGROUND

Environmental and occupational health (EOH) assessments increasingly utilize systematic review methods and structured frameworks for evaluating evidence about the human health effects of exposures. However, there is no prevailing approach for how to integrate this evidence into decisions or recommendations. Grading of Recommendations Assessment, Development and Evaluation (GRADE) evidence-to-decision (EtD) frameworks provide a structure to support standardized and transparent consideration of relevant criteria to inform health decisions. This study identifies and synthesizes available EOH decision frameworks and evaluates the applicability and usability of an existing GRADE EtD perspective to advance the development of a tailored EOH EtD framework.

METHODS

We performed a systematic review of MEDLINE, EMBASE, and Cochrane Library, and a manual search of gray literature to identify frameworks that inform decision-making about EOH exposures from the years 2011 to 2021. We abstracted and analyzed decision considerations from each framework through narrative synthesis. Next, we conducted a two-round Delphi process, engaging stakeholders from the following perspectives within environmental and occupational health: risk assessment and management, nutrition and food safety, cancer, and socio-economic analysis. Panelists rated the relevance and wording of each consideration on a 7-point Likert scale and provided free-text comments during both phases. Considerations that did not meet predetermined thresholds were excluded.

RESULTS

Out of 5,196 unique references, we identified 22 published reports of EOH decision frameworks. We identified another 16 frameworks in a search of gray literature, totaling 38 source frameworks. We abstracted 560 individual decision considerations from these frameworks, 104 of which may contribute additional information to the guidance, scope, context, or assessment criteria of the GRADE EtD framework. In round 1 of the Delphi study, 50 decision considerations were aggregated or removed, and 9 were aggregated or removed after round 2, for a final total of 47. No new decision considerations were added in either round. We identified several differences between decision criteria that are applied in EOH and the GRADE EtD framework, including vocabulary that is specific to EOH (e.g., toxicity, the precautionary principle), and granularity of the EOH decision considerations (e.g., detailed signaling questions to assess feasibility and resources required). However, this study did not identify any EOH decision criteria that are completely distinct from the GRADE EtD framework.

CONCLUSIONS

Findings of this mixed-methods study comprise a foundation for a GRADE EtD that is applicable for use in EOH decision-making, with implications for approaches to regulation of environmental and occupational exposures and the formulation of recommendations for interventions to prevent or mitigate undesirable health and other consequences.

摘要

背景

环境与职业健康（EOH）评估越来越多地采用系统评价方法和结构化框架来评估有关暴露对人类健康影响的证据。然而，对于如何将这些证据整合到决策或建议中，尚无普遍适用的方法。推荐分级评估、制定与评价（GRADE）证据到决策（EtD）框架提供了一种结构，以支持对相关标准进行标准化和透明的考量，从而为健康决策提供依据。本研究识别并综合了现有的EOH决策框架，并评估了现有GRADE EtD视角的适用性和可用性，以推进量身定制的EOH EtD框架的开发。

方法

我们对MEDLINE、EMBASE和Cochrane图书馆进行了系统评价，并对手稿文献进行了人工检索，以识别2011年至2021年间为EOH暴露决策提供依据的框架。我们通过叙述性综合从每个框架中提取并分析决策考量因素。接下来，我们进行了两轮德尔菲法，邀请了环境与职业健康领域以下视角的利益相关者参与：风险评估与管理、营养与食品安全、癌症以及社会经济分析。小组成员在7点李克特量表上对每个考量因素的相关性和措辞进行评分，并在两个阶段都提供了自由文本评论。未达到预定阈值的考量因素被排除。

结果

在5196篇独特参考文献中，我们识别出22篇已发表的EOH决策框架报告。在对手稿文献的检索中，我们又识别出16个框架，共计38个来源框架。我们从这些框架中提取了560个单独的决策考量因素，其中104个可能会为GRADE EtD框架的指南、范围、背景或评估标准提供额外信息。在德尔菲研究的第一轮中，50个决策考量因素被汇总或删除，第二轮后又有9个被汇总或删除，最终总计47个。两轮中均未添加新的决策考量因素。我们发现EOH中应用的决策标准与GRADE EtD框架之间存在一些差异，包括EOH特有的词汇（如毒性、预防原则）以及EOH决策考量因素的粒度（如用于评估可行性和所需资源的详细信号问题）。然而，本研究未发现任何与GRADE EtD框架完全不同的EOH决策标准。