Ani Movsisyan (American University of Armenia, Master of Public Health 2013), supervised by Dr. G.J. Melendez-Torres and Professor Paul Montgomery, published an article titled “Users identified challenges in applying GRADE to complex interventions and suggested an extension to GRADE” from the Centre for Evidence-Based Intervention (CEBI), University of Oxford. She published the article in the Journal of Clinical Epidemiology – an international peer-reviewed journal that aims to promote high quality clinical and patient-oriented health care research through the advancement and application of innovative methods.
The article investigates experiences of using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach in Cochrane systematic reviews of complex interventions, including public health interventions. The GRADE approach is currently considered as the world-leading system to rate the quality of evidence and the strength of recommendations, and inform practice guideline development. It has been endorsed by more than 80 organizations, including the World Health Organization. However, developed and validated in the context of biomedical and clinical treatments, there have been contentions on the applicability of GRADE for guiding decisions in social interventions. These interventions are often complex: that is they may employ a number of interacting components, target multiple health and social outcomes and operate via psychosocial and behavioral change mechanisms in contrast to biological processes. This, in turn, challenges the evaluation of these intervention, which often need to deviate from traditional approaches and evidence hierarchies, used in the field of biomedicine, to capture the broad range of evidence types, including evidence on intervention implementation, context and mechanisms.
This study identified specific challenges in applying GRADE to reviews of complex interventions. These were related to the assessment of non-randomized studies and performance bias in GRADE. Authors of systematic reviews perceived these challenges to contribute to frequent downgrading of the “best evidence possible” for complex interventions. Meanwhile, GRADE was found to lack an analytic approach to enable adequate evidence synthesis and assessment of intervention implementation elements. This investigation speaks to the need for extending, i.e. adapting the GRADE approach to address specific considerations of complex social interventions. The DPhil (doctoral dissertation) project of Ani Movsisyan at the Department of Social Policy and Intervention, University of Oxford, aims to develop such an extension to the GRADE approach, using a consensus-based methodology.
Ani Movsisyan has been awarded Barnett Scholarship from the Department of Social Policy and Intervention at the University of Oxford to pursue her research interest as a Doctor of Philosophy candidate from 2014 to 2017. Movsisyan finished her Master of Science degree in Evidence-based Social Intervention at the University of Oxford in fall 2014. She was awarded Open Society Foundations Scholarship to realize this endeavor. Movsisyan received her Master of Public Health (MPH) degree from the American University of Armenia (AUA) School of Public Health (SPH) in 2013. During her studies at AUA she was granted a full merit-based scholarship from AUA and the Ministry of Education and Science of the Republic of Armenia. She also holds a bachelor degree in Psychology from Yerevan State University. From 2012 to 2013, Ani Movsisyan was involved in a working group to develop a comprehensive mental health strategy for the Republic of Armenia in collaboration with the Ministry of Health and Open Society Foundations – Armenia. She has also contributed to research activities at the SPH Center for Health Services Research and Development.
The AUA School of Public Health works actively to improve population health and health services in Armenia and the region through interdisciplinary education and development of public health professionals to be leaders in public health, health services research and evaluation, and health care delivery and management.