Context is the new keyword to describe the conditions present in the environment when an intervention is carried out to improve healthcare. It is usually excluded from controlled experimental studies, so that the treatment effect can be attributed to the intervention. However, while it might be easy to understand the pathophysiology of certain drugs that are shown to be more effective than others, a good RCT can only tell you that a treatment is effective, not why, or in what conditions it is more effective.
As an example, in a drug trial, we assume that people take the tablets (which specify the dose) when required; and mostly this does happen because it is easy to do, and many people connect the drug taking with their health improvement. However, when something like a healthy diet and regular exercise are substituted for a drug, we recognise that these recommendations are more complex and they require additional adjustments in daily life. The daily life adjustments are what we call the context for this intervention. So while there is research evidence to support regular exercise for improving physical fitness and quality of life for adults with chronic kidney disease, and a summary recommendation for 4-6 months of supervised sessions held 3 times a week, using high intensity mixed cardiovascular and resistance training for 30 to 90 minutes, we still don’t know what aspects of individuals’ personal and family lives and their physical environment makes this more achievable.
When we look at research about these complex interventions, that include one or more components, it is important to identify which conditions in the environment surrounding the delivery of that intervention are more inclined to support its success. Evidence is emerging about which aspects of context are critical for some interventions that are designed to improve quality of care. However, there are often several strategies that can achieve this intervention improvement. Some interventions are more sensitive to context than others, and these might be different at different stages and levels of implementation. There is also little guidance about which aspects of context will facilitate or hinder the intervention. It seems that there is both an art and science to identifying the important contextual aspects to support change.
To fully understand context, many business consultants, managers and academics will recommend a detailed organisational analysis; perhaps a stakeholder or root cause analysis. There are a range of tools and strategies to help understand who and what are the most important aspects of the context, in relation to the planned intervention. Then it is important to look for empirical research evidence about the role of context in supporting clinical interventions, to identify what conditions support or hinder an intervention. Most often, we can find some evidence about barriers in relation to knowledge, attitudes or behaviour.
However, it is often difficult to determine the actual intervention from a published research paper, and it is very uncommon to find suggestions for how to implement it in different environments. There is a need for those of us interested in this area to document both the actual success and replicability of the intervention, through a detailed description of the context that supported and hindered its implementation. Then a systematic comparison between what worked (and didn’t work) in different environments may lead to the identification of contextual factors that are necessary or sufficient for that particular intervention, together with some key facilitators and barriers.