EBBP Process Module


  • Authors:

    Bonnie Spring, Ph.D., ABPP
    Ana M. Abrantes, Ph.D.
    Jennifer M. Kreslake, M.P.H.
    Kristin Hitchcock, M.S.I.

  • Acknowledgments to:

    Barbara Walker, Ph.D.
    NogginLabs, Inc.
    Kemi Jona, Ph.D.

  • Supported by NIH OBSSR contract


Evidence Based Behavioral Practice (EBBP)

Evidence-based behavioral practice entails making decisions about how to promote healthful behaviors by integrating the best available evidence with practitioner expertise and other resources, and with the characteristics, state, needs, values and preferences of those who will be affected. This is done in a manner that is compatible with the environmental and organizational context.

  • EBBP is a framework to guide decision-making about behavioral interventions
  • EBBP is used to work with individuals and populations
  • EBBP draws on the best available research
  • EBBP examines resources, including practitioner expertise
  • EBBP is a context specific approach to behavioral health practice

EBBP is a framework to guide decision making about behavioral health intervention for individuals and populations. EBBP integrates:

  • Best available research
  • Client/Population characteristics including preferences
  • Resources including practitioner expertise
  • And does so in a context-sensitive manner

Misconceptions of EBBP

  • EBBP is just a pretense to justify cost-cutting
  • EBBP relies on irrelevant research
  • EBBP is a nice idea but not practical in a busy practice
  • EBBP forces adherence to “cookbook” intervention manuals

The EBBP Process

The EBBP process is an iterative one, but in general, the five steps, which are initiated by an encounter by a client/community, are:

  • ASK client oriented, relevant, answerable questions about the health status, context and care of individuals, communities or populations.
  • ACQUIRE the best available evidence to answer the question.
  • APPRAISE the evidence critically for validity and applicability to the problem at hand.
  • APPLY the evidence by engaging in collaborative health decision making with the affected individual(s) and/or group(s). Implement the health practice. Appropriate decision-making integrates the context, values and preferences of the recipient of the health intervention, as well as available resources, including practitioner expertise.
  • ANALYZE the new health practice and ADJUST practice accordingly. Evaluate implications for future decision-making, disseminate the results and identify needed evidence.

EBBP demands explicit attention to client/population characteristics at each step:

  • You ASK questions specific to the client/population condition and context
  • You ACQUIRE evidence that is relevant to the client/population condition and characteristics
  • You APPRAISE the evidence based on whether it is generalizable to the client/population
  • You APPLY the evidence in light of client/population characteristics including preferences
  • You ANALYZE & ADJUST practice based on how the client/population responds to the intervention

The possible outcomes of adopting EBBP involve:

  • Bridging the gap between research and practice
  • Encouraging the use of Empirically-Supported Treatments (ESTs)
  • Elevating client preferences and population data in the decision-making process
  • Increased case study research
  • I’m already doing EBBP

To practice applying the EBBP process in working with both an individual and community example, please visit the EBBP Process Training Module.

Question Formulation

Formulate Background Questions

Background questions ask about general knowledge about a condition, rather than specific knowledge about a particular case. A well-formulated background question has two components:

  • A question root (Who, What, How, etc.) including a verb
  • A disorder, treatment or other health issue

EBBP demands explicit attention to client/population characteristics at each step:

  • Assessment – Questions that address ways of measuring, describing or diagnosing the problem
  • Treatment – Questions that address interventions to prevent, contain or improve a health problem
  • Etiology – Questions that concern influences that cause or contribute to the onset of a health problem
  • Prognosis – Questions that pertain to the probable course and outcome of a health condition
  • Harm – Questions that address potential adverse effects of interventions
  • Cost-Effectiveness – Questions that express the consequences of a health procedure in common units (e.g. cost per quality-adjusted life year)

Background question example: What are the most effective interventions for smoking cessation?

Formulate Foreground Questions

Foreground questions ask about specific choices among different action options that fit the context of available resources and the client’s characteristics

  • PICO
  • Patient/Population
  • Intervention
  • Comparison
  • Outcome

Foreground question example: In an adult motivated smoker, would 8 or 16 sessions of behavioral counseling, compared to one session be more likely to result in smoking cessation?

Additional Resources

Hierarchy of Evidence

Pyramid of Evidence Resources

Client Characteristics and Resources – Individual

When gathering data for the Client Characteristics and Resources circles, consider each of the following categories.

Client Characteristics

  • Personal attributes and relevant history

  • Health status and current needs

  • Cultural beliefs and values

  • Treatment preferences


  • Insurance coverage

  • Financial resources

  • Available, accessible interventionist trained to deliver the behavioral treatment

  • Accessible provider willing to prescribe medications if appropriate

Population Characteristics and Resources – Community

When gathering data for the Population Characteristics and Resources circles, consider each of the following categories.

Population Characteristics

  • Prevalence and incidence of condition

  • Social norms related to the condition and intervention options

  • Identification of high-risk subpopulations


  • Government Funding

  • Volunteers and Grassroots Efforts

  • Product Taxes and Set-asides

  • Public Health Staffing and Infrastructure

The Cochrane Collaboration