OBJECTIVE: To provide guidance for the use of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Evidence-to-Decision (EtD) framework for environmental and occupational health (EOH). STUDY DESIGN AND SETTING: We conducted a systematic review and narrative synthesis of published and public EOH decision frameworks, followed by a modified Delphi process leading to development of a draft GRADE EtD framework for EOH. We pilot tested the provisional framework through a virtual workshop series, which further informed guidance for the framework's application. We presented a summary of the results to all attendees of the GRADE Working Group meeting for feedback in July 2022 and November 2022, and for approval in May 2023. RESULTS: Consistent with existing GRADE EtD frameworks, the EtD framework for EOH includes a scoping and contextualization process and twelve assessment criteria. Modifications to the existing EtD frameworks include: consideration of the socio-political context when making judgments about the priority of the problem and feasibility of different alternatives
the addition of timing when making judgments about benefits and harms, the balance of effects, and feasibility
broadening of the equity criterion to include considerations beyond health equity
and more explicit accommodation of variable or conflicting stakeholder views when considering values and acceptability. The new EtD framework is also accompanied by a user guide intended to support its implementation in the EOH context. CONCLUSION: Policymakers, regulators, and other stakeholders may use this GRADE EtD framework to approach decision-making about environmental and occupational exposures and interventions.