Helena Lagerlöf, Teun Zuiderent-Jerak and Morten Sager
This blog post is based on the Evidence & Policy article ‘Epistemological deliberation: the challenges of producing evidence-based guidelines on lifestyle habits‘
Drafting recommendations is an art that requires more attention to the choices between different views of knowledge, formats and standards and their ramifications.
Most people would agree with the general statement that decisions in healthcare should be based on the best available knowledge, which is also the overall purpose of evidence-based practice (EBP). However, the application of EBP has proved to be a not so straightforward process in many contexts. The challenges include considerations of trustworthiness and relevance of different kinds of knowledge claims, and what to do when different knowledge and different forms of knowledge point in various and sometimes opposite directions. These conflicts are at the core in current national and international debates, e.g. surrounding interventions to mitigate the spread of the COVID-19.
The procedures for gathering and compiling knowledge have been standardised within governmental and other central agencies tasked with drafting recommendations, i.e. guidelines, for health care practices. These standards of how guidelines are produced can conflict with knowledge claims not fitting such standards, specifically when those standards are extrapolated beyond the areas where they were initially developed. For almost 20 years, the Swedish National Board of Health and Welfare (NBHW) has standardised the production of guidelines under the label National Guidelines with the aim of producing evidence-based guidelines with scientific rigor and relevance for clinical practice. Trust in the results of randomised controlled trials (RCTs) has been central, which is fitting when testing medicines, but harder to use in public health interventions.
In our Evidence & Policy article, ‘Epistemological deliberation: the challenges of producing evidence-based guidelines on lifestyle habits’, we describe three ways of managing different views when format of National Guidelines was in conflict with relevant public health knowledge:
- The guideline format and its focus on RCTs may win: The format of National Guidelines favours RCT-knowledge whereas public health knowledge takes many forms. The NBHW decided to go for RCT knowledge as the basis for evaluation of effectiveness of health promotion interventions.
- The public health knowledge may win: Priorities of interventions in Swedish healthcare should, according to the Health and Medical Services Act, be based primarily on the severity of the conditions. But how can severity of an unhealthy lifestyle be assessed? An unhealthy lifestyle is hardly a severe condition like a disease. However, there is knowledge that unhealthy lifestyles increase the risk of future diseases. The NBHW decided to include risk of future disease and thus unhealthy lifestyles could be classified as severe conditions.
- Both the format and public health knowledge may win: Health dialogues is a package of health screenings and a counselling session offered to all people of a certain age with the aim to promote healthy lifestyle habits for the whole population, including those that have healthy lifestyle habits. This means, however, that the condition of the population is not sufficiently severe to fit the guideline format. In this case, health dialogues were included anyway, not in the standardized recommendations of the guidelines, but in the discussion sections of the guideline.
When different perspectives point in opposing directions and there is more than one way to view the evidence, the very art of making guidelines is probably most important, but also most difficult. This is also clear in the case of the COVID-19 pandemic. For improvement of this art we propose that it is worth reflecting more on how different views and formats of knowledge are negotiated in guideline production. Clearly there are no unequivocally correct answers for how to do it, but wise deliberations are needed. That is why the discussion must be kept alive.
Helena Lagerlöf, MSc, MA, Regional Primary Care Coordinating Officer and Doctoral student in Theory of science, Region Västmanland and University of Gothenburg
Teun Zuiderent-Jerak, MA, MA, PhD, Associate Professor of Transdisciplinary Science & Technology Studies, Athena Institute, Vrije Universiteit Amsterdam
Morten Sager, Associate Professor in Theory of Science and Director of Master’s Program in Evidence-Basing, Department of Philosophy, Linguistics and Theory of Science at the University of Gothenburg
You can read the original research in Evidence & Policy:
Lagerlöf, Helena; Zuiderent-Jerak, Teun; and Sager, Morten. (2021). Epistemological deliberation: the challenges of producing evidence-based guidelines on lifestyle habits. Evidence & Policy, DOI: 10.1332/174426421X16149619907286.
Image credit: Photo by Photo by h.Koppdelaney CC BY-ND 2.0