Translating research into prevention of high-risk behaviors in the presence of complex systems: definitions and systems frameworks

What is context in knowledge translation? Results of a systematic scoping review

Knowledge Translation (KT) aims to convey novel ideas to relevant stakeholders, motivating their response or action to improve people's health. Initially, the KT literature focused on evidence-based medicine, applying findings from laboratory and clinical research to disease diagnosis and treatment. Since the early 2000s, the scope of KT has expanded to include decision-making with health policy implications.This systematic scoping review aims to assess the evolving knowledge-to-policy concepts, that is, macro-level KT theories, models and frameworks (KT TMFs). While significant attention has been devoted to transferring knowledge to healthcare settings (i.e. implementing health policies, programmes or measures at the meso-level), the definition of 'context' in the realm of health policymaking at the macro-level remains underexplored in the KT literature. This study aims to close the gap.A total of 32 macro-level KT TMFs were identified, with only a limited subset of them offering detailed insights into contextual factors that matter in health policymaking. Notably, the majority of these studies prompt policy changes in low- and middle-income countries and received support from international organisations, the European Union, development agencies or philanthropic entities.

System dynamics modeling for cancer prevention and control: A systematic review

Cancer prevention and control requires consideration of complex interactions between multilevel factors. System dynamics modeling, which consists of diagramming and simulation approaches for understanding and managing such complexity, is being increasingly applied to cancer prevention and control, but the breadth, characteristics, and quality of these studies is not known. We searched PubMed, Scopus, APA PsycInfo, and eight peer-reviewed journals to identify cancer-related studies that used system dynamics modeling. A dual review process was used to determine eligibility. Included studies were assessed using quality criteria adapted from prior literature and mapped onto the cancer control continuum. Characteristics of studies and models were abstracted and qualitatively synthesized. 32 studies met our inclusion criteria. A mix of simulation and diagramming approaches were used to address diverse topics, including chemotherapy treatments (16%), interventions to reduce tobacco or e-cigarettes use (16%), and cancer risk from environmental contamination (13%). Models spanned all focus areas of the cancer control continuum, with treatment (44%), prevention (34%), and detection (31%) being the most common. The quality assessment of studies was low, particularly for simulation approaches. Diagramming-only studies more often used participatory approaches. Involvement of participants, description of model development processes, and proper calibration and validation of models showed the greatest room for improvement. System dynamics modeling can illustrate complex interactions and help identify potential interventions across the cancer control continuum. Prior efforts have been hampered by a lack of rigor and transparency regarding model development and testing. Supportive infrastructure for increasing awareness, accessibility, and further development of best practices of system dynamics for multidisciplinary cancer research is needed.

Using systems science to advance health equity in tobacco control: a causal loop diagram of smoking

OBJECTIVES

Develop and use a causal loop diagram (CLD) of smoking among racial/ethnic minority and lower-income groups to anticipate the intended and unintended effects of tobacco control policies.

METHODS

We developed a CLD to elucidate connections between individual, environmental and structural causes of racial/ethnic and socioeconomic disparities in smoking. The CLD was informed by a review of conceptual and empirical models of smoking, fundamental cause and social stress theories and 19 qualitative interviews with tobacco control stakeholders. The CLD was then used to examine the potential impacts of three tobacco control policies.

RESULTS

The CLD includes 24 constructs encompassing individual (eg, risk perceptions), environmental (eg, marketing) and structural (eg, systemic racism) factors associated with smoking. Evaluations of tobacco control policies using the CLD identified potential unintended consequences that may maintain smoking disparities. For example, the intent of a smoke-free policy for public housing is to reduce smoking among residents. Our CLD suggests that the policy may reduce smoking among residents by reducing smoking among family/friends, which subsequently reduces pro-smoking norms and perceptions of tobacco use as low risk. On the other hand, some residents who smoke may violate the policy. Policy violations may result in financial strain and/or housing instability, which increases stress and reduces feelings of control, thus having the unintended consequence of increasing smoking.

CONCLUSIONS

The CLD may be used to support stakeholder engagement in action planning and to identify non-traditional partners and approaches for tobacco control.

Aligning clinical research ethics with community-engaged and participatory research in the United States

The professional role in ethical review of research in which boards review proposed research involving human beings continues to evolve. The scholarly literature on institutional review boards in academic centers of the United States, at which a majority of the community engaged and participatory research emanates and is reviewed, suggests the need to implement changes in board education, the infrastructure supporting review, and the accountability of review. The recommendations for change advanced in this perspective involve enhancing reviewer knowledge of local community contexts and developing an infrastructure that supports engagement in and dialogue among individuals involved in community-academic research to inform ethical review and the assessment of review outcomes. Additionally, recommendations regarding putting an institutional infrastructure in place are advanced in order to sustain community engaged and participatory research. The infrastructure can also support the collection and review of outcome data as the foundation of accountability. The recommendations outlined intend to improve clinical research ethics reviews of community-engaged and participatory research.

Using decision analysis to support implementation planning in research and practice

BACKGROUND

The process of implementing evidence-based interventions, programs, and policies is difficult and complex. Planning for implementation is critical and likely plays a key role in the long-term impact and sustainability of interventions in practice. However, implementation planning is also difficult. Implementors must choose what to implement and how best to implement it, and each choice has costs and consequences to consider. As a step towards supporting structured and organized implementation planning, we advocate for increased use of decision analysis.

MAIN TEXT

When applied to implementation planning, decision analysis guides users to explicitly define the problem of interest, outline different plans (e.g., interventions/actions, implementation strategies, timelines), and assess the potential outcomes under each alternative in their context. We ground our discussion of decision analysis in the PROACTIVE framework, which guides teams through key steps in decision analyses. This framework includes three phases: (1) definition of the decision problems and overall objectives with purposeful stakeholder engagement, (2) identification and comparison of different alternatives, and (3) synthesis of information on each alternative, incorporating uncertainty. We present three examples to illustrate the breadth of relevant decision analysis approaches to implementation planning.

CONCLUSION

To further the use of decision analysis for implementation planning, we suggest areas for future research and practice: embrace model thinking; build the business case for decision analysis; identify when, how, and for whom decision analysis is more or less useful; improve reporting and transparency of cost data; and increase collaborative opportunities and training.

Critical factors that affect the functioning of a research and evaluation capacity building partnership: A causal loop diagram

Introduction

Public health policy and practice is strengthened by the application of quality evidence to decision making. However, there is limited understanding of how initiatives that support the generation and use of evidence in public health are operationalised. This study examines factors that support the internal functioning of a partnership, the Western Australian Sexual Health and Blood-borne Virus Applied Research and Evaluation Network (SiREN). SiREN aims to build research and evaluation capacity and increase evidence-informed decision making in a public health context.

Methods

This study was informed by systems concepts. It developed a causal loop diagram, a type of qualitative system model that illustrated the factors that influence the internal operation of SiREN. The causal loop diagram was developed through an iterative and participatory process with SiREN staff and management (n = 9) via in-depth semi-structured interviews (n = 4), workshops (n = 2), and meetings (n = 6).

Results

Findings identified critical factors that affected the functioning of SiREN. Central to SiREN’s ability to meet its aims was its capacity to adapt within a dynamic system. Adaptation was facilitated by the flow of knowledge between SiREN and system stakeholders and the expertise of the team. SiREN demonstrated credibility and capability, supporting development of new, and strengthening existing, partnerships. This improved SiREN’s ability to be awarded new funding and enhanced its sustainability and growth. SiREN actively balanced divergent stakeholder interests to increase sustainability.

Conclusion

The collaborative development of the diagram facilitated a shared understanding of SiREN. Adaptability was central to SiREN achieving its aims. Monitoring the ability of public health programs to adapt to the needs of the systems in which they work is important to evaluate effectiveness. The detailed analysis of the structure of SiREN and how this affects its operation provide practical insights for those interested in establishing a similar project.

Insights from system dynamics applications in addiction research: A scoping review

BACKGROUND AND AIMS

Substance misuse and use disorders are dynamic and complex problems, situated within systems of interacting social, environmental, and neurobiological factors. System dynamics (SD) methods broaden, test, and improve understanding of complex systems and can help inform effective action. We sought to systematically review the use of SD tools in addiction-related research.

METHODS

Following PRISMA guidelines, we searched several databases from 1958 to 2019. We included studies focused on addiction-related screening and diagnosis, treatment, and return to use, as well as studies focused on earlier stages that may begin a path to addiction (e.g., experimentation, misuse onset).

RESULTS

We extracted information from 59 articles with a median publication year of 2014. In addition to using SD to understand the underlying complexity driving addiction-related trends, other commonly cited reasons for use of SD included assessing impacts of potential actions (n = 35), predicting future trends (n = 28), and supporting strategic planning processes (n = 22). Most studies included simulation models (n = 43); however, some presented insights from qualitative SD diagrams (n = 9) and concept models (n = 6). The majority of studies focused on stages leading to potential addiction: initiation/ experimentation (n = 42) and misuse onset (n = 38). One-third (n = 20) engaged persons with lived experience or other stakeholders during the modeling process.

CONCLUSIONS

Addiction-related SD research has increased over the last few decades with applications varying in several ways, from model purpose and types of data used to stakeholder involvement. Future applications should consider the benefits of stakeholder engagement throughout the modeling process and expanding models to include concomitant substance use.

The United Nations Office on Drugs and Crime's Efforts to Strengthen a Culture of Prevention in Low- and Middle-Income Countries

This article discusses how decision-makers can be supported to strengthen a culture of prevention. This article presents an example of the United Nations Office on Drugs and Crime’s (UNODC) work to engage with decision-makers to create readiness, demand, and capacity for evidence-based prevention programming among them, particularly in low- and middle-income countries. First, we utilized two of the UNODC’s data sources to describe the context where the UNODC’s prevention efforts take place. Analysis of the first dataset on prevention activities implemented globally revealed a gap in translating evidence into practice on a global scale. The second dataset consisted of UNODC policy documents mandating and guiding global action to address substance use. The analysis showed that at the level of political frameworks, prevention is gradually gaining more attention but is still frequently left in the shadow of health- and law enforcement-related issues. In addition, these guiding documents did not reflect fully the current scientific understanding of what constitutes an effective prevention response. Against this background, the feasibility of the UNODC’s efforts to bridge the science–practice gap in the field of prevention was discussed by presenting the results from the UNODC’s regional capacity-building seminars focused on the role of monitoring and evaluation in prevention programming. The results showed potential of this capacity building to affect the attitudes and knowledge of targeted decision-makers. Such efforts to increase decision-makers’ readiness and ultimately their endorsement, adoption, and ongoing support of evidence-based preventive interventions should be continued and intensified.

Examining the sustainability potential of a multisite pilot to integrate alcohol screening and brief intervention within three primary care systems

The U.S. Preventive Services Task Force recommends that clinicians adopt universal alcohol screening and brief intervention as a routine preventive service for adults, and efforts are underway to support its widespread dissemination. The likelihood that healthcare systems will sustain this change, once implemented, is under-reported in the literature. This article identifies factors that were important to postimplementation sustainability of an evidence-based practice change to address alcohol misuse that was piloted within three diverse primary care organizations. The Centers for Disease Control and Prevention funded three academic teams to pilot and evaluate implementation of alcohol screening and brief intervention within multiclinic healthcare systems in their respective regions. Following the completion of the pilots, teams used the Program Sustainability Assessment Tool to retrospectively describe and compare differences across eight sustainability domains, identify strengths and potential threats to sustainability, and make recommendations for improvement. Health systems varied across all domains, with greatest differences noted for Program Evaluation, Strategic Planning, and Funding Stability. Lack of funding to sustain practice change, or data monitoring to promote fit and fidelity, was an indication of diminished Organizational Capacity in systems that discontinued the service after the pilot. Early assessment of sustainability factors may identify potential threats that could be addressed prior to, or during implementation to enhance Organizational Capacity. Although this study provides a retrospective assessment conducted by external academic teams, it identifies factors that may be relevant for translating evidence-based behavioral interventions in a way that assures that they are sustained within healthcare systems.

Translational science matters: forging partnerships between biomedical and behavioral science to advance the public's health

The prevention and effective treatment of many chronic diseases such as cardiovascular disease, cancer and diabetes are dependent on behaviors such as not smoking, adopting a physically-active lifestyle, eating a healthy diet, and adhering to prescribed medical and behavioral regimens. Yet adoption and maintenance of these behaviors pose major challenges for individuals, their families and communities, as well as clinicians and health care systems. These challenges can best be met through the integration of the biomedical and behavioral sciences that is achieved by the formation of strategic partnerships between researchers and practitioners in these disciplines to address pressing clinical and public health problems. The National Institutes of Health has supported a number of clinical trials and research initiatives that demonstrate the value of biomedical and behavioral science partnerships in translating fundamental discoveries into significant improvements in health outcomes. We review several such examples of collaborations between biomedical and behavioral researchers, describe key initiatives focused on advancing a transdisciplinary translational perspective, and outline areas which require insights, tools and findings from both the biomedical and behavioral sciences to advance the public's health.

Interactions among poverty, gender, and health systems affect women's participation in services to prevent HIV transmission from mother to child: A causal loop analysis

Retention in care remains an important issue for prevention of mother-to-child transmission (PMTCT) programs according to WHO guidelines, formerly called the “Option B+” approach. The objective of this study was to examine how poverty, gender, and health system factors interact to influence women’s participation in PMTCT services. We used qualitative research, literature, and hypothesized variable connections to diagram causes and effects in causal loop models. We found that many factors, including antiretroviral therapy (ART) use, service design and quality, stigma, disclosure, spouse/partner influence, decision-making autonomy, and knowledge about PMTCT, influence psychosocial health, which in turn affects women’s participation in PMTCT services. Thus, interventions to improve psychosocial health need to address many factors to be successful. We also found that the design of PMTCT services, a modifiable factor, is important because it affects several other factors. We identified 66 feedback loops that may contribute to policy resistance—that is, a policy’s failure to have its intended effect. Our findings point to the need for a multipronged intervention to encourage women’s continued participation in PMTCT services and for longitudinal research to quantify and test our causal loop model.

Extending systems thinking in planning and evaluation using group concept mapping and system dynamics to tackle complex problems

Group concept mapping (GCM) has been successfully employed in program planning and evaluation for over 25 years. The broader set of systems thinking methodologies (of which GCM is one), have only recently found their way into the field. We present an overview of systems thinking emerging from a system dynamics (SD) perspective, and illustrate the potential synergy between GCM and SD. As with GCM, participatory processes are frequently employed when building SD models; however, it can be challenging to engage a large and diverse group of stakeholders in the iterative cycles of divergent thinking and consensus building required, while maintaining a broad perspective on the issue being studied. GCM provides a compelling resource for overcoming this challenge, by richly engaging a diverse set of stakeholders in broad exploration, structuring, and prioritization. SD provides an opportunity to extend GCM findings by embedding constructs in a testable hypothesis (SD model) describing how system structure and changes in constructs affect outcomes over time. SD can be used to simulate the hypothesized dynamics inherent in GCM concept maps. We illustrate the potential of the marriage of these methodologies in a case study of BECOMING, a federally-funded program aimed at strengthening the cross-sector system of care for youth with severe emotional disturbances.

Flavoured tobacco products and the public's health: lessons from the TPSAC menthol report

The menthol report developed by the Tobacco Products Scientific Advisory Committee (TPSAC) of the Center for Tobacco Products elaborated a methodology for considering the public health impact of menthol in cigarettes that has relevance to flavourings generally. The TPSAC report was based on a conceptual framework on how menthol in cigarettes has public health impact results of evidence from related systematic reviews, and an evidence-based statistical model. In extending this approach to flavourings generally, consideration will need to be given to the existence of multiple flavourings, a very dynamic market place and regulatory interventions and industry activities. Now is the time to begin to develop the research strategies and models needed to extend the TPSAC approach to flavoured tobacco products generally.

The full translational spectrum of prevention science: facilitating the transfer of knowledge to practices and policies that prevent behavioral health problems

A broad-span, six-stage translational prevention model is presented, extending from the basic sciences-taking a multi-level systems approach, including the neurobiological sciences-through to globalization. The application of a very wide perspective of translation research from basic scientific discovery to international policy change promises to elicit sustainable, population-level reductions in behavioral health disorders. To illustrate the conceptualization and actualization of a program of translational prevention research, we walk through each stage of research to practice and policy using an exemplar, callous-unemotional (CU) traits. Basic science has identified neurobiological, psychophysiological, behavioral, contextual, and experiential differences in this subgroup, and yet, these findings have not been applied to the development of more targeted intervention. As a result, there are currently no programs considered especially effective for CU traits, likely because they do not specifically target underlying mechanisms. To prevent/reduce the prevalence of conduct disorder, it is critical that we transfer existing knowledge to subsequent translational stages, including intervention development, implementation, and scaling. And eventually, once resulting programs have been rigorously evaluated, replicated, and adapted across cultural, ethnic, and gender groups, there is potential to institutionalize them as well as call attention to the special needs of this population. In this paper, we begin to consider what resources and changes in research perspectives are needed to move along this translational spectrum.

Transforming community prevention systems for sustained impact: embedding active implementation and scaling functions

Traditional efforts to translate evidence-based prevention strategies to communities, at scale, have not often produced socially significant outcomes or the local capacity needed to sustain them. A key gap in many efforts is the transformation of community prevention systems to support and sustain local infrastructure for the active implementation, scaling, and continuous improvement of effective prevention strategies. In this paper, we discuss (1) the emergence of applied implementation science as an important type 3-5 translational extension of traditional type 2 translational prevention science, (2) active implementation and scaling functions to support the full and effective use of evidence-based prevention strategies in practice, (3) the organization and alignment of local infrastructure to embed active implementation and scaling functions within community prevention systems, and (4) policy and practice implications for greater social impact and sustainable use of effective prevention strategies.