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Implement Sci. 2018 Jan 25;13(Suppl 1):12. doi: 10.1186/s13012-017-0694-5.

Applying GRADE-CERQual to qualitative evidence synthesis findings-paper 7: understanding the potential impacts of dissemination bias.

Author information

School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK.
Norwegian Institute of Public Health, Oslo, Norway.
Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa.
Norwegian Institute of Public Health, Oslo, Norway.
Unit for Social Welfare Research, Norwegian Institute of Public Health, Oslo, Norway.
Cochrane Germany, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
School of Social Sciences, Bangor University, Bangor, UK.
Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran.
Department of Information, Evidence and Research Department, Eastern Mediterranean Regional Office, World Health Organization, Cairo, Egypt.
Department of Community Medicine, University of Tromsø, Tromsø, Norway.
Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK.
Centre de Recherche Épidémiologie et Statistique Sorbonne Paris Cité - U1153, Inserm/Université Paris Descartes, Cochrane France, Hôpital Hôtel-Dieu, 1 place du Parvis Notre Dame, 75181, Paris, Cedex 04, France.



The GRADE-CERQual (Confidence in Evidence from Reviews of Qualitative research) approach has been developed by the GRADE (Grading of Recommendations Assessment, Development and Evaluation) Working Group. The approach has been developed to support the use of findings from qualitative evidence syntheses in decision-making, including guideline development and policy formulation. CERQual includes four components for assessing how much confidence to place in findings from reviews of qualitative research (also referred to as qualitative evidence syntheses): (1) methodological limitations, (2) coherence, (3) adequacy of data and (4) relevance. This paper is part of a series providing guidance on how to apply CERQual and focuses on a probable fifth component, dissemination bias. Given its exploratory nature, we are not yet able to provide guidance on applying this potential component of the CERQual approach. Instead, we focus on how dissemination bias might be conceptualised in the context of qualitative research and the potential impact dissemination bias might have on an overall assessment of confidence in a review finding. We also set out a proposed research agenda in this area.


We developed this paper by gathering feedback from relevant research communities, searching MEDLINE and Web of Science to identify and characterise the existing literature discussing or assessing dissemination bias in qualitative research and its wider implications, developing consensus through project group meetings, and conducting an online survey of the extent, awareness and perceptions of dissemination bias in qualitative research.


We have defined dissemination bias in qualitative research as a systematic distortion of the phenomenon of interest due to selective dissemination of studies or individual study findings. Dissemination bias is important for qualitative evidence syntheses as the selective dissemination of qualitative studies and/or study findings may distort our understanding of the phenomena that these syntheses aim to explore and thereby undermine our confidence in these findings. Dissemination bias has been extensively examined in the context of randomised controlled trials and systematic reviews of such studies. The effects of potential dissemination bias are formally considered, as publication bias, within the GRADE approach. However, the issue has received almost no attention in the context of qualitative research. Because of very limited understanding of dissemination bias and its potential impact on review findings in the context of qualitative evidence syntheses, this component is currently not included in the GRADE-CERQual approach.


Further research is needed to establish the extent and impacts of dissemination bias in qualitative research and the extent to which dissemination bias needs to be taken into account when we assess how much confidence we have in findings from qualitative evidence syntheses.


Confidence; Dissemination bias; Evidence-based practice; GRADE; Methodology; Publication bias; Qualitative evidence synthesis; Qualitative research; Research design; Systematic review methodology

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