Table 1 Strengths of the CERQual approach

Strengths related to how the approach was developed:

 • Developed by a diverse group of international methodologists, qualitative researchers, systematic review authors and guideline developers. A few members of the group were also involved in health care decision making

 • Refined over several years through testing on a substantial number of qualitative evidence syntheses and through several rounds of consultations with academics and users in relevant fields

Strengths related to the design of the approach:

 • Uses terminology, concepts and theoretical underpinnings that are sensitive to qualitative research

 • Provides explicit guidance on which concerns/threats to consider that may lead users to lower their confidence in the evidence

 • Makes judgements about confidence in qualitative evidence more transparent

 • The approach is independent of specific primary qualitative research methods and methods of synthesis

 • Assessments of confidence are based on multiple interdependent components

Strengths related to the uses of the approach:

 • Assessments can be used within diverse decision making processes, including guideline development and health technology assessments, alongside GRADE assessments for other forms of evidence

 • The approach is congruent with other GRADE approaches for other types of evidence, and so can be easily integrated with these other approaches in decision making

 • The approach is well received and understood by stakeholders, when used in decision making processes including guideline development

 • Within decision making processes, CERQual may facilitate the use of qualitative evidence to address a range of issues. These include which outcomes are important to stakeholders; the acceptability and feasibility of interventions, including differences in views across different stakeholder groups; considerations regarding implementation; and the unintended consequences of interventions