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Expanding the evidence within evidence-based healthcare: thinking about the context, acceptability and feasibility of interventions
  1. Rachel L Shaw1,
  2. Michael Larkin2,
  3. Paul Flowers3
  1. 1School of Life and Health Sciences, Aston University, Birmingham, West Midlands, UK
  2. 2School of Psychology, University of Birmingham, Edgbaston, Birmingham, West Midlands, UK
  3. 3Institute for Applied Health Research, Glasgow Caledonian University, Glasgow, UK
  1. Correspondence to: Dr Rachel L Shaw
    , School of Life and Health Sciences, Aston University, Birmingham, WM B4 7ET, UK; r.l.shaw{at}aston.ac.uk.

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Delivering evidence-based healthcare is a complex interpersonal process

Evidence-based healthcare (EBHC) depends on collating research evidence, communicating findings and translating findings into best-practice guidance that can be implemented in real-world practice. Cochrane's definition of EBHC highlights the centrality of the clinician–evidence relationship to bridge the gap between research and practice (see: http://www.cochrane.org/about-us/evidence-based-health-care#REF1). How clinicians feel about evidence can have an impact on the degree of fidelity with which healthcare interventions are implemented.1 As such there are critical differences between evidence of efficacy and effectiveness. All evidence-based interventions, whether biomedical, social or structural, involve interpersonal processes and are “delivered in the context of an encounter between a health professional and a patient, making healthcare professional clinical behaviours an important proximal determinant of the quality of care that patients receive.”2

Thus, interpersonal relationships and communication are fundamental to implementation science. This jars with most understandings of the role of evidence within guideline formation, which disproportionately privileges large-scale population-based studies. Such studies are vital tests of efficacy and cost-effectiveness, yet poor at understanding implementation. The current evidence hierarchy used to help shape guidance production (eg, by National Institute for Health and Care Excellence (NICE) and the Scottish Intercollegiate Guideline Network (SIGN)) struggles to incorporate qualitative and mixed methods research, and thus lacks systematic analyses of the context and experience of implementing interventions. Clinicians and commissionersi need to understand the interactions, relationships and sociocultural contexts that shape the acceptability and meaningfulness of healthcare interventions. To complete the cycle of translating findings into ‘practice-ready’ guidance it is necessary to consider the human systems within which an intervention is to be implemented. This is an iterative process, as described in the Medical Research Council's (MRC) framework for developing complex behavioural interventions (see: http://www.mrc.ac.uk/Utilities/Documentrecord/index.htm?d=MRC004871).

A complete evidence base must inform healthcare guidance. This should develop from a pluralistic model of …

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