“How” Questions

The potential effects of an intervention can be realized only if it is delivered appropriately in a particular setting. Answers to “How” questions help decision makers determine how to meet this need. Table 5-3 lists some examples of areas of concern addressed by “How” questions and the corresponding evidence that might be gathered.

To answer “How” questions, decision makers require evidence about the population, setting, and time frame at hand. Answers to “How” questions may feed back to “Why” and “What” questions by helping decision makers determine how plans and expectations should be adjusted to their context, what resources are needed to

TABLE 5-3 Areas of Concern and Examples of Evidence Needed: “How” Questions

Area of Concern

Examples of Evidence Needed

Relevance of the intervention on a large scale


• Generalizability

Likelihood of achieving the expected outcomes in different demographic groups and in different communities/regions

• Sustainability

Likelihood that the intervention effect will last more than 1 to 5 years in the various groups

• Stakeholder acceptance

Likelihood that the intervention be well received by the target population/community and program delivery personnel

Costs and benefits of large-scale implementation


• Cost-effectiveness

Costs of the intervention versus measured effects on the outcomes of interest (e.g., premature deaths averted, years of life saved, pounds lost) compared with other competitive interventions

• Cost/benefit

Value of health benefits versus the costs of implementation compared with other competitive interventions

• Cost feasibility

Costs of implementing the intervention on a communitywide scale compared with other competitive interventions

• Cost minimization

Costs of implementing the intervention in a hospital compared with costs of implementing a competitive intervention in a community clinic and achieving the same outcome

• Cost utility

Stakeholder preferences versus implementation costs compared with other competitive interventions

Political and practical concerns


• Implementation priorities

Fit of the intervention with community or policy priorities; basis for giving this intervention high priority

• Portfolio balance

Fit within an overall set of interventions if considerations of feasibility, size of impact, and certainty of effect are combined

• Strategic planning

Strategies and tactics that can be used to mount this intervention

• Potential challenges

Implementation challenges that can be anticipated and evidence on how to overcome them

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