Knowledge integration: conceptualizing communications in cancer control systems

A scoping review of social and behavioral science research to translate genomic discoveries into population health impact

Since the completion of the Human Genome Project, progress toward translating genomic research discoveries to address population health issues has been limited. Several meetings of social and behavioral scientists have outlined priority research areas where advancement of translational research could increase population health benefits of genomic discoveries. In this review, we track the pace of progress, study size and design, and focus of genomics translational research from 2012 to 2018 and its concordance with five social and behavioral science recommended priorities. We conducted a review of the literature following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Guidelines for Scoping Reviews. Steps involved completing a search in five databases and a hand search of bibliographies of relevant literature. Our search (from 2012 to 2018) yielded 4,538 unique studies; 117 were included in the final analyses. Two coders extracted data including items from the PICOTS framework. Analysis included descriptive statistics to help identify trends in pace, study size and design, and translational priority area. Among the 117 studies included in our final sample, nearly half focused on genomics applications that have evidence to support translation or implementation into practice (Centers for Disease Control and Prevention Tier 1 applications). Common study designs were cross-sectional (40.2%) and qualitative (24.8%), with average sample sizes of 716 across all studies. Most often, studies addressed public understanding of genetics and genomics (33.3%), risk communication (29.1%), and intervention development and testing of interventions to promote behavior change (19.7%). The number of studies that address social and behavioral science priority areas is extremely limited and the pace of this research continues to lag behind basic science advances. Much of the research identified in this review is descriptive and related to public understanding, risk communication, and intervention development and testing of interventions to promote behavior change. The field has been slow to develop and evaluate public health-friendly interventions and test implementation approaches that could enable health benefits and equitable access to genomic discoveries. As the completion of the human genome approaches its 20th anniversary, full engagement of transdisciplinary efforts to address translation challenges will be required to close this gap.

Challenges and Opportunities for Communication about the Role of Genomics in Public Health

Despite growing awareness about the potential for genomic information to improve population health, lingering communication challenges remain in describing the role of genomics in public health programs. Identifying and addressing these challenges provide an important opportunity for appropriate communication to ensure the translation of genomic discoveries for public health benefits. In this commentary, we describe 5 common communication challenges encountered by the Centers for Disease Control and Prevention's Office of Genomics and Precision Public Health based on over 20 years of experience in the field. These include (1) communicating that using genomics to assess rare diseases can have an impact on public health; (2) providing evidence that genetic factors can add important information to environmental, behavioral, and social determinants of health; (3) communicating that although genetic factors are nonmodifiable, they can increase the impact of public health programs and communication strategies; (4) addressing the concern that genomics is not ready for clinical practice; and (5) communicating that genomics is valuable beyond the domain of health care and can be integrated as part of public health programs. We discuss opportunities for addressing these communication challenges and provide examples of ongoing approaches to communication about the role of genomics in public health to the public, researchers, and practitioners.

Applying systems thinking to knowledge mobilisation in public health

CONTEXT

Knowledge mobilisation (KM) is a vital strategy in efforts to improve public health policy and practice. Linear models describing knowledge transfer and translation have moved towards multi-directional and complexity-attuned approaches where knowledge is produced and becomes meaningful through social processes. There are calls for systems approaches to KM but little guidance on how this can be operationalised. This paper describes the contribution that systems thinking can make to KM and provides guidance about how to put it into action.

METHODS

We apply a model of systems thinking (which focuses on leveraging change in complex systems) to eight KM practices empirically identified by others. We describe how these models interact and draw out some key learnings for applying systems thinking practically to KM in public health policy and practice. Examples of empirical studies, tools and targeted strategies are provided.

FINDINGS

Systems thinking can enhance and fundamentally transform KM. It upholds a pluralistic view of knowledge as informed by multiple parts of the system and reconstituted through use. Mobilisation is conceived as a situated, non-prescriptive and potentially destabilising practice, no longer conceptualised as a discrete piece of work within wider efforts to strengthen public health but as integral to and in continual dialogue with those efforts. A systems approach to KM relies on contextual understanding, collaborative practices, addressing power imbalances and adaptive learning that responds to changing interactions between mobilisation activities and context.

CONCLUSION

Systems thinking offers valuable perspectives, tools and strategies to better understand complex problems in their settings and for strengthening KM practice. We make four suggestions for further developing empirical evidence and debate about how systems thinking can enhance our capacity to mobilise knowledge for solving complex problems - (1) be specific about what is meant by 'systems thinking', (2) describe counterfactual KM scenarios so the added value of systems thinking is clearer, (3) widen conceptualisations of impact when evaluating KM, and (4) use methods that can track how and where knowledge is mobilised in complex systems.

Nutrition and Cancer Prevention: Why is the Evidence Lost in Translation?

With the high burden of cancer worldwide, primary prevention has been identified as a key cancer control strategy to reduce this burden. Diet and nutrition are important modifiable factors that may alter the risk of developing cancer, because several dietary components including alcohol consumption, fruit and vegetable intake, and dietary fiber have been shown to significantly impact cancer risk. Consequently, a number of organizations have developed cancer prevention guidelines that highlight the importance of nutrition (and related factors including body size and physical activity) to reduce the risk of cancer. However, there are barriers to the uptake of these guidelines, particularly with respect to diet and nutrition including awareness, communication, and other factors that influence eating behavior. Improved knowledge translation (KT) of recommendations may help facilitate uptake. The purposes of this narrative review are: 1) to examine issues and challenges related to KT of diet and nutrition evidence in the context of cancer prevention, including public awareness and attitudes towards cancer prevention, engagement in cancer prevention strategies, and effects of KT on diet-cancer preventive behaviors; 2) to discuss examples of effective and ineffective KT of diet and nutrition evidence; and 3) to provide recommendations for improving KT to help move the field of diet, nutrition, and cancer prevention forward. Evidence shows that adherence to nutrition recommendations for cancer prevention significantly reduces the risk of cancer; however, engagement in nutrition-based preventative behaviors is low. Skepticism and confusion around evidence linking diet and nutrition with cancer may arise, in part, through ineffective media KT; the primary source of health information for many people. Simple, tailored, targeted KT communication strategies aimed at increasing the general public's awareness, attitudes, and engagement in cancer preventive behavior should be emphasized to encourage cancer control.

Participatory development and pilot testing of iChoose: an adaptation of an evidence-based paediatric weight management program for community implementation

BACKGROUND

To describe the identification, adaptation, and testing of an evidence-based pediatric weight management program for a health disparate community.

METHODS

A community advisory board (CAB) of decision-makers and staff from local health care, public health, and recreation organizations engaged with academic partners to select an evidence-based program (EBP) for local implementation. Three EBPs were identified (Traffic Light, Bright Bodies, Golan and colleagues Home Environmental Model) and each EBP was rated on program characteristics, implementation and adaptation, and adoptability. Following selection of the EBP that was rated highest, the POPS-CAB made adaptations based on the program principles described in peer-reviewed publications. The adapted intervention, iChoose, was then pilot tested in 3 iterative phases delivered initially by research partners, then co-delivered by research and community partners, then delivered by community partners. The RE-AIM framework was used to plan and evaluate the iChoose intervention across all waves with assessments at baseline, post program (3 months), and follow-up (6 months).

RESULTS

Bright Bodies rated highest on program characteristics and adoptability (p's < 0.05), while Home Environmental Model rated highest on implementation factors (p < 0.05). Qualitatively, the selection focused on important program characteristics and on matching those characteristics to the potential to fit within the community partner services. The adapted program-iChoose-had 18% reach and with participants that were representative of the target population on age, gender, ethnicity, and race. Effectiveness was demonstrated by modest, but significant reductions in BMI z-scores at post-program compared to baseline (MΔ = - 0.047; t = - 2.11, p = 0.046). This decrease returned to values similar to baseline 3 months (MΔ = 0.009) after the program was completed. Implementation fidelity was high and implementation fidelity did not differ between community or research delivery agents.

CONCLUSION

The process to help organizations identify and select evidence-based programs appropriate for their community led to consensus on a single EBP. While iChoose was successful in initiating changes in BMI z-scores, could be implemented in a low resource community with fidelity, it was insufficient to lead to sustained child BMI z-scores. In response to these data, maintenance of program effects and delivery are the current focus of the CBPR team.

"Fat is really a four-letter word": Exploring weight-related communication best practices in children with and without disabilities and their caregivers

BACKGROUND

Health care professionals play a critical role in preventing and managing childhood obesity, but the American Academy of Pediatrics recently stressed the importance of using sensitive and nonstigmatizing language when discussing weight with children and families. Although barriers to weight-related discussions are well known, there are few evidence-based recommendations around communication best practices. Disability populations in particular have previously been excluded from work in this area. The objectives were to present the findings of a recent scoping review to children with and without disabilities and their caregivers for their reactions; and to explore the experiences and perceptions of the children and their caregivers regarding weight-related communication best practices.

METHODS

Focus group and individual interviews were conducted with 7-18-year olds with and without disabilities and their caregivers. The interview guide was created using findings from a recent scoping review of weight-related communication best practices. Inductive thematic analysis was employed.

RESULTS

Eighteen children (9 boys; 7 children with disabilities) and 21 caregivers (17 mothers, 1 step-father, 3 other caregivers) participated in 8 focus group and 7 individual interviews. Preferred communication strategies were similar across those with and without disabilities, although caregivers of children with autism spectrum disorder endorsed more concrete approaches. Discussions emphasizing growth and health were preferred over weight and size. Strengths-based, solution-focused approaches for weight conversations were endorsed, although had not been widely experienced.

CONCLUSION

Perceptions of weight-related communication were similar across stakeholder groups, regardless of children's disability or weight status. Participants generally agreed with the scoping review recommendations, suggesting that they apply broadly across different settings and populations; however, tailoring them to specific circumstances is critical. Empirical evaluations are still required to examine the influence of weight-related communication on clinically important outcomes, including behaviour change and family engagement in care.

It's hard to play ball: A qualitative study of knowledge exchange and silo effects in public health

BACKGROUND

Partnerships in public health form an important component of commissioning and implementing services, in England and internationally. In this research, we examine the views of staff involved in a City-wide health improvement programme which ran from 2009 to 2013 in England. We examine the practicalities of partnership work in community settings, and we describe some of barriers faced when implementing a large, multi-organisation health improvement programme.

METHODS

Qualitative, semi-structured interviews were performed. Purposive sampling was used to identify potential participants in the programme: programme board of directors, programme and project managers and intervention managers. Interviews were conducted one-to-one. We conducted a thematic analysis using the 'one sheet of paper' technique. This involved analysing data deductively, moving from initial to axial coding, developing categories and then identifying emerging themes.

RESULTS

Fifteen interviews were completed. Three themes were identified. The first theme reflects how poor communication approaches hindered the ability of partnerships to deliver their aims and objectives in a range of ways and for a range of reasons. Our second theme reflects how a lack of appropriate knowledge exchange hindered decision-making, affected trust and contributed to protectionist approaches to working. This lack of shared, and communicated, understanding of what type of knowledge is most appropriate and in which circumstance made meaningful knowledge exchange challenging for decision-making and partnership-working in the City-wide health improvement programme. Theme three demonstrates how perceptions about silos in partnership-working could be problematic, but silos themselves were at times beneficial to partnerships. This revealed a mismatch between rhetoric and a realistic understanding of what components of the programme were functional and which were more hindrance than help.

DISCUSSION

There were high expectations placed on the concept of what partnership work was, or how it should be done. We found our themes to be interdependent, and reflective of the 'dynamic fluid process' discussed within the knowledge mobilisation literature. We contend that reframing normal and embedded processes of silos and silo-working already in use might ease resistance to some knowledge exchange processes and contribute to better long-term functioning of public health partnerships.

Classification schemes for knowledge translation interventions: a practical resource for researchers

BACKGROUND

As implementation science advances, the number of interventions to promote the translation of evidence into healthcare, health systems, or health policy is growing. Accordingly, classification schemes for these knowledge translation (KT) interventions have emerged. A recent scoping review identified 51 classification schemes of KT interventions to integrate evidence into healthcare practice; however, the review did not evaluate the quality of the classification schemes or provide detailed information to assist researchers in selecting a scheme for their context and purpose. This study aimed to further examine and assess the quality of these classification schemes of KT interventions, and provide information to aid researchers when selecting a classification scheme.

METHODS

We abstracted the following information from each of the original 51 classification scheme articles: authors' objectives; purpose of the scheme and field of application; socioecologic level (individual, organizational, community, system); adaptability (broad versus specific); target group (patients, providers, policy-makers), intent (policy, education, practice), and purpose (dissemination versus implementation). Two reviewers independently evaluated the methodological quality of the development of each classification scheme using an adapted version of the AGREE II tool. Based on these assessments, two independent reviewers reached consensus about whether to recommend each scheme for researcher use, or not.

RESULTS

Of the 51 original classification schemes, we excluded seven that were not specific classification schemes, not accessible or duplicates. Of the remaining 44 classification schemes, nine were not recommended. Of the 35 recommended classification schemes, ten focused on behaviour change and six focused on population health. Many schemes (n = 29) addressed practice considerations. Fewer schemes addressed educational or policy objectives. Twenty-five classification schemes had broad applicability, six were specific, and four had elements of both. Twenty-three schemes targeted health providers, nine targeted both patients and providers and one targeted policy-makers. Most classification schemes were intended for implementation rather than dissemination.

CONCLUSIONS

Thirty-five classification schemes of KT interventions were developed and reported with sufficient rigour to be recommended for use by researchers interested in KT in healthcare. Our additional categorization and quality analysis will aid in selecting suitable classification schemes for research initiatives in the field of implementation science.

Strengths-Based Nursing: A Process for Implementing a Philosophy Into Practice

Strengths-Based Nursing (SBN) is both a philosophy and value-driven approach that can guide clinicians, educators, manager/leaders, and researchers. SBN is rooted in principles of person/family centered care, empowerment, relational care, and innate health and healing. SBN is family nursing yet not all family nursing models are strengths-based. The challenge is how to translate a philosophy to change practice. In this article, we describe a process of implementation that has organically evolved of a multi-layered and multi-pronged approach that involves patients and families, clinicians, educators, leaders, managers, and researchers as well as key stakeholders including union leaders, opinion leaders, and policy makers from both nursing and other disciplines. There are two phases to the implementation process, namely, Phase 1: pre-commitment/pre-adoption and Phase 2: adoption. Each phase consists of distinct steps with accompanying strategies. These phases occur both sequentially and concurrently. Facilitating factors that enable the implementation process include values which align, readiness to accept SBN, curiosity-courage-commitment on the part of early adopters, a critical mass of early adopters, and making SBN approach both relevant and context specific.

The inter-play between facilitation and context in the promoting action on research implementation in health services framework: A qualitative exploratory implementation study embedded in a cluster randomized controlled trial to reduce restraint in nursing homes

AIM

To explore the inter-play between external facilitation and nursing home contexts relative to intervention outcomes.

BACKGROUND

The Promoting Action on Research Implementation in Health Services framework is frequently used to theoretically inform implementation and research in nursing and recent reviews indicate high face validity for health services. However, the inter-play and relationship between framework sub-elements of evidence, context and facilitation and the prospective utility in non-English speaking contexts warrant further illumination.

DESIGN

In an overarching single-blind cluster-randomized controlled trial, we applied participatory action research and ethnography from August 2011-June 2015 to evaluate a standardized education intervention to reduce restraint and agitation in nursing home residents living with dementia. The trial results are published elsewhere.

METHODS

Prospectively informed by the PARIHS framework, a research team and eight facilitators participating in dual roles as action researchers designed, implemented, and evaluated the intervention. How contextual factors influenced the facilitation processes were explored in focus group interviews (1), reflection notes (84) written by the facilitators' after each education session, ethnographic field studies (6 homes), and co-analysis workshops (5). Directed content analysis was used to analyse data.

RESULTS

Clinical leaders taking roles of internal facilitator influenced the success of implementation, while complex and fluctuating context elements determined whether restraint use was reduced- or not. The PARIHS framework was found to be relevant in a non-English nursing home setting, albeit some elements merit further conceptualization.

CONCLUSIONS

Our findings confirm the prospective utility of the PARIHS framework for implementation in a non-English context, particularly the notion of implementation processes as dynamic and multifaceted.

Research utilisation and knowledge mobilisation in the commissioning and joint planning of public health interventions to reduce alcohol-related harms: a qualitative case design using a cocreation approach

Background

Considerable resources are spent on research to establish what works to improve the nation’s health. If the findings from this research are used, better health outcomes can follow, but we know that these findings are not always used. In public health, evidence of what works may not ‘fit’ everywhere, making it difficult to know what to do locally. Research suggests that evidence use is a social and dynamic process, not a simple application of research findings. It is unclear whether it is easier to get evidence used via a legal contracting process or within unified organisational arrangements with shared responsibilities.

Objective

To work in cocreation with research participants to investigate how research is utilised and knowledge mobilised in the commissioning and planning of public health services to reduce alcohol-related harms.

Design, setting and participants

Two in-depth, largely qualitative, cross-comparison case studies were undertaken to compare real-time research utilisation in commissioning across a purchaser–provider split (England) and in joint planning under unified organisational arrangements (Scotland) to reduce alcohol-related harms. Using an overarching realist approach and working in cocreation, case study partners (stakeholders in the process) picked the topic and helped to interpret the findings. In Scotland, the topic picked was licensing; in England, it was reducing maternal alcohol consumption.

Methods

Sixty-nine interviews, two focus groups, 14 observations of decision-making meetings, two local feedback workshops (n = 23 andn = 15) and one national workshop (n = 10) were undertaken. A questionnaire (n = 73) using a Behaviourally Anchored Rating Scale was issued to test the transferability of the 10 main findings. Given the small numbers, care must be taken in interpreting the findings.

Findings

Not all practitioners have the time, skills or interest to work in cocreation, but when there was collaboration, much was learned. Evidence included professional and tacit knowledge, and anecdotes, as well as findings from rigorous research designs. It was difficult to identify evidence in use and decisions were sometimes progressed in informal ways and in places we did not get to see. There are few formal evidence entry points. Evidence (prevalence and trends in public health issues) enters the process and is embedded in strategic documents to set priorities, but local data were collected in both sites to provide actionable messages (sometimes replicating the evidence base).

Conclusions

Two mid-range theories explain the findings. If evidence hassaliency(relates to ‘here and now’ as opposed to ‘there and then’) andimmediacy(short, presented verbally or visually and with emotional appeal) it is more likely to be used in both settings. A second mid-range theory explains how differing tensions pull and compete as feasible and acceptable local solutions are pursued across stakeholders. Answering what works depends on answering for whom and where simultaneously to find workable (if temporary) ‘blends’. Gaining this agreement across stakeholders appeared more difficult across the purchaser–provider split, because opportunities to interact were curtailed; however, more research is needed.

Funding

This study was funded by the Health Services and Delivery Research programme of the National Institute for Health Research.

Using a Historical Lens to Envision the Next Generation of Genomic Translation Research

BACKGROUND

The past 20 years have witnessed successive and exponential advances in genomic discovery and technology, with a broad scientific imperative pushing for continual advancements. The most consistent critique of these advances is that they have vastly outpaced translation of new knowledge into improvements in public health and medicine.

METHODS

We employ a historical and epistemological analysis to characterize how prevailing scientific meta-narratives have shaped the pace and priorities of research applying genomics to health promotion. We use four 'pivotal events' - the genetic characterization of Down syndrome, the launch of the Human Genome Research Project, the discovery of BRCA1, and the emergence of direct-to- consumer genetic testing - to illustrate how these scientific meta-narratives have inhibited genomic translation research.

RESULTS

The notion that discovery should precede translation research has over-focused translation research on the latest genetic testing platform. The idea that genetic-related research has an exceptional potential for public harm has encouraged research on worst case scenarios. The perceived competition between genetics and social determinants of health has discouraged a unified research agenda to move genomic translation forward.

CONCLUSION

We make a case for creating new scientific meta-narratives in which discovery and translation research agendas are envisioned as an interdependent enterprise.

Synthesizing Marketing, Community Engagement, and Systems Science Approaches for Advancing Translational Research

The adoption and implementation of evidence-based interventions (EBIs) are the goals of translational research; however, potential end-users' perceptions of an EBI value have contributed to low rates of adoption. In this article, we describe our application of emerging dissemination and implementation science theoretical perspectives, community engagement, and systems science principles to develop a novel EBI dissemination approach. Using consumer-driven, graphics-rich simulation, the approach demonstrates predicted implementation effects on health and employment outcomes for socioeconomically disadvantaged women at the local level and is designed to increase adoption interest of county program managers accountable for improving these outcomes in their communities.

Mobilising knowledge to improve UK health care: learning from other countries and other sectors – a multimethod mapping study

Background

The past two decades have seen rich conceptual development and a wide variety of practical initiatives around research use or ‘knowledge mobilisation’, but so far there has been little systematic effort to map, conceptualise and learn from these initiatives, or to investigate the degree to which they are underpinned by contemporary thinking as set out in the literature. This gap is particularly apparent when looking at knowledge mobilisation at the ‘macro’ level, that is the strategies and activities of major research funders, major research producers and key research ‘intermediaries’.

Aims and objectives

The study had three key objectives with associated research questions: to map the knowledge mobilisation landscape in health care (in the UK and internationally) and in social care and education within the UK; to understand the models, theories and frameworks that underpin the approaches to knowledge mobilisation; and to learn from the success or otherwise of the strategies and approaches in use.

Methods

The study was multimethod and multiphased, with considerable interactivity between the different strands. Data were collected through a review of 71 published reviews on knowledge mobilisation; website review of the knowledge mobilisation activities of 186 agencies; in-depth interviews (n = 52) with key individuals in agencies; a web survey (response rate 57%;n = 106); and two stakeholder workshops (at months 6 and 16).

Findings

We identified a wide range of models, theories and frameworks used to describe knowledge mobilisation and created a conceptual map that highlights six domains of thinking and debate in the literature. The interview and survey data showed three broad, overlapping roles undertaken by agencies: developing and sharing research-based products; emphasising brokering; and focusing on implementation. The knowledge mobilisation approaches in use had been shaped by many factors but there was only limited use of the models, theories and frameworks from the literature. Participants saw formal evaluation of knowledge mobilisation activities as important but highly challenging. Rich formative experience was described but formal evaluation was relatively rare. Few agencies involved service users or members of the public in knowledge mobilisation activities. Working inductively from the study data we derived eight key archetypes or ‘bundles of knowledge mobilisation activities’ that could be used by agencies to explore their knowledge mobilisation activities, future strategies and stakeholder perspectives.

Conclusions

Knowledge mobilisation could be enhanced by providing support to enable cross-sector and interagency learning, reflection on the conceptual basis of approaches and increased evaluation of knowledge mobilisation activities. Further research is needed to evaluate approaches to assessing research use and impact, on systems approaches to knowledge mobilisation, on sustaining and scaling-up approaches, and on applying a wider range of literatures to knowledge mobilisation. Further research would also be useful on the knowledge mobilisation archetypes and how they can work in complementary ways.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

A systematic review of implementation frameworks of innovations in healthcare and resulting generic implementation framework

BACKGROUND

Implementation science and knowledge translation have developed across multiple disciplines with the common aim of bringing innovations to practice. Numerous implementation frameworks, models, and theories have been developed to target a diverse array of innovations. As such, it is plausible that not all frameworks include the full range of concepts now thought to be involved in implementation. Users face the decision of selecting a single or combining multiple implementation frameworks. To aid this decision, the aim of this review was to assess the comprehensiveness of existing frameworks.

METHODS

A systematic search was undertaken in PubMed to identify implementation frameworks of innovations in healthcare published from 2004 to May 2013. Additionally, titles and abstracts from Implementation Science journal and references from identified papers were reviewed. The orientation, type, and presence of stages and domains, along with the degree of inclusion and depth of analysis of factors, strategies, and evaluations of implementation of included frameworks were analysed.

RESULTS

Frameworks were assessed individually and grouped according to their targeted innovation. Frameworks for particular innovations had similar settings, end-users, and 'type' (descriptive, prescriptive, explanatory, or predictive). On the whole, frameworks were descriptive and explanatory more often than prescriptive and predictive. A small number of the reviewed frameworks covered an implementation concept(s) in detail, however, overall, there was limited degree and depth of analysis of implementation concepts. The core implementation concepts across the frameworks were collated to form a Generic Implementation Framework, which includes the process of implementation (often portrayed as a series of stages and/or steps), the innovation to be implemented, the context in which the implementation is to occur (divided into a range of domains), and influencing factors, strategies, and evaluations.

CONCLUSIONS

The selection of implementation framework(s) should be based not solely on the healthcare innovation to be implemented, but include other aspects of the framework's orientation, e.g., the setting and end-user, as well as the degree of inclusion and depth of analysis of the implementation concepts. The resulting generic structure provides researchers, policy-makers, health administrators, and practitioners a base that can be used as guidance for their implementation efforts.

A scoping review of classification schemes of interventions to promote and integrate evidence into practice in healthcare

BACKGROUND

Many models and frameworks are currently used to classify or describe knowledge translation interventions to promote and integrate evidence into practice in healthcare.

METHODS

We performed a scoping review of intervention classifications in public health, clinical medicine, nursing, policy, behaviour science, improvement science and psychology research published to May 2013 by searching MEDLINE, PsycINFO, CINAHL and the grey literature. We used five stages to map the literature: identifying the research question; identifying relevant literature; study selection; charting the data; collating, summarizing, and reporting results.

RESULTS

We identified 51 diverse classification schemes, including 23 taxonomies, 15 frameworks, 8 intervention lists, 3 models and 2 other formats. Most documents were public health based, 55% included a literature or document review, and 33% were theory based.

CONCLUSIONS

This scoping review provides an overview of schemes used to classify interventions which can be used for evaluation, comparison and validation of existing and emerging models. The collated taxonomies can guide authors in describing interventions; adequate descriptions of interventions will advance the science of knowledge translation in healthcare.

Towards a common terminology: a simplified framework of interventions to promote and integrate evidence into health practices, systems, and policies

BACKGROUND

A wide range of diverse and inconsistent terminology exists in the field of knowledge translation. This limits the conduct of evidence syntheses, impedes communication and collaboration, and undermines knowledge translation of research findings in diverse settings. Improving uniformity of terminology could help address these challenges. In 2012, we convened an international working group to explore the idea of developing a common terminology and an overarching framework for knowledge translation interventions.

FINDINGS

Methods included identifying and summarizing existing frameworks, mapping together a subset of those frameworks, and convening a multi-disciplinary group to begin working toward consensus. The group considered four potential approaches to creating a simplified framework: melding existing taxonomies, creating a framework of intervention mechanisms rather than intervention strategies, using a consensus process to expand one of the existing models/frameworks used by the group, or developing a new consensus framework.

CONCLUSIONS

The work group elected to draft a new, simplified consensus framework of interventions to promote and integrate evidence into health practices, systems and policies. The framework will include four key components: strategies and techniques (active ingredients), how they function (causal mechanisms), how they are delivered (mode of delivery), and what they aim to change (intended targets). The draft framework needs to be further developed by feedback and consultation with the research community and tested for usefulness through application and evaluation.

Using organizational network analysis to plan cancer screening programs for vulnerable populations

OBJECTIVES

We examined relationships among organizations in a cancer screening network to inform the development of interventions to improve cancer screening for South Asians living in the Peel region of Ontario.

METHODS

From April to July 2012, we surveyed decision-makers, program managers, and program staff in 22 organizations in the South Asian cancer screening network in the Peel region. We used a network analytic approach to evaluate density (range = 0%-100%, number of ties among organizations in the network expressed as a percentage of all possible ties), centralization (range = 0-1, the extent of variability in centrality), and node characteristics for the communication, collaboration, and referral networks.

RESULTS

Density was similar across communication (15%), collaboration (17%), and referral (19%) networks. Centralization was greater in the collaboration network (0.30) than the communication network (0.24), and degree centralization was greater in the inbound (0.42) than the outbound (0.37) referral network. Diverse organizations were central to the networks.

CONCLUSIONS

Certain organizations were unexpectedly important to the South Asian cancer screening network. Program planning was informed by identifying opportunities to strengthen linkages between key organizations and to leverage existing ties.

Implementation science approaches for integrating eHealth research into practice and policy

PURPOSE

To summarize key issues in the eHealth field from an implementation science perspective and to highlight illustrative processes, examples and key directions to help more rapidly integrate research, policy and practice.

METHODS

We present background on implementation science models and emerging principles; discuss implications for eHealth research; provide examples of practical designs, measures and exemplar studies that address key implementation science issues; and make recommendations for ways to more rapidly develop and test eHealth interventions as well as future research, policy and practice.

RESULTS

The pace of eHealth research has generally not kept up with technological advances, and many of our designs, methods and funding mechanisms are incapable of providing the types of rapid and relevant information needed. Although there has been substantial eHealth research conducted with positive short-term results, several key implementation and dissemination issues such as representativeness, cost, unintended consequences, impact on health inequities, and sustainability have not been addressed or reported. Examples of studies in several of these areas are summarized to demonstrate this is possible.

CONCLUSIONS

eHealth research that is intended to translate into policy and practice should be more contextual, report more on setting factors, employ more responsive and pragmatic designs and report results more transparently on issues important to potential adopting patients, clinicians and organizational decision makers. We outline an alternative development and assessment model, summarize implementation science findings that can help focus attention, and call for different types of more rapid and relevant research and funding mechanisms.

Disparities in cancer care: perspectives from the front line

OBJECTIVE

The purpose of this qualitative study was to investigate how frontline healthcare professionals witness and understand disparity in cancer care.

METHOD

Six healthcare providers from a range of care settings, none with < 15 years of frontline experience, engaged with researchers in an iterative process of identifying and reflecting on equity and disparity in cancer care. This knowledge exchange began with formal interviews. Thematic analysis of the interviews form the basis of this article.

RESULTS

Participants drew attention to health systems issues, the meaning and experience of discontinuities in care for patients at personal and community levels, and the significance of social supports. Other concerns raised by participants were typical of the literature on healthcare disparities.

SIGNIFICANCE OF RESULTS

Providers at the front lines of care offer a rich source of insight into the operation of disparities, pointing to mechanisms rarely identified in traditional quantitative studies. They are also well positioned to advocate for more equitable care at the local level.

Vocational rehabilitation: facilitating evidence based practice through participatory action research

BACKGROUND

Improving vocational rehabilitation in line with the current evidence base is an area of considerable interest. Aims To describe the strategies used by a multidisciplinary team in the initial stages of a participatory action research (PAR) approach to improving a vocational rehabilitation service.

METHOD

A literature review and PAR process were completed. One hundred and fifteen participants engaged in multifaceted data collection and analysis, building consensus around key principles for a new vocational rehabilitation service.

RESULTS

A synthesis of our literature review and PAR process was developed into a set of principles for practice which we plan to implement across the service.

CONCLUSIONS

We have developed methodologies in interdisciplinary collaborations spanning statutory and non-statutory services. We have developed a set of principles for practice and detailed plans for implementation are being drawn up to inform provision in the future.

Transforming epidemiology for 21st century medicine and public health

In 2012, the National Cancer Institute (NCI) engaged the scientific community to provide a vision for cancer epidemiology in the 21st century. Eight overarching thematic recommendations, with proposed corresponding actions for consideration by funding agencies, professional societies, and the research community emerged from the collective intellectual discourse. The themes are (i) extending the reach of epidemiology beyond discovery and etiologic research to include multilevel analysis, intervention evaluation, implementation, and outcomes research; (ii) transforming the practice of epidemiology by moving toward more access and sharing of protocols, data, metadata, and specimens to foster collaboration, to ensure reproducibility and replication, and accelerate translation; (iii) expanding cohort studies to collect exposure, clinical, and other information across the life course and examining multiple health-related endpoints; (iv) developing and validating reliable methods and technologies to quantify exposures and outcomes on a massive scale, and to assess concomitantly the role of multiple factors in complex diseases; (v) integrating "big data" science into the practice of epidemiology; (vi) expanding knowledge integration to drive research, policy, and practice; (vii) transforming training of 21st century epidemiologists to address interdisciplinary and translational research; and (viii) optimizing the use of resources and infrastructure for epidemiologic studies. These recommendations can transform cancer epidemiology and the field of epidemiology, in general, by enhancing transparency, interdisciplinary collaboration, and strategic applications of new technologies. They should lay a strong scientific foundation for accelerated translation of scientific discoveries into individual and population health benefits.

Evaluating a knowledge exchange intervention in cancer survivorship care: a workshop to foster implementation of Online Support Groups

PURPOSE

The purpose of the research described here is to assess the overall effectiveness of the workshop format as a Knowledge Exchange (KE) strategy in (1) disseminating scientific evidence, clinical experience, and systems information related to professionally led Online Support Groups (OSG) for cancer survivors and (2) facilitating the implementation of this intervention by a select group of end users--decision makers and clinical leads in psychosocial supportive care.

METHODS

The KE-Decision Support (KE-DS) Model, operationalizing the Health Technology Approach, guided the development of pre- and postworkshop questionnaires, and a follow-up questionnaire administered 5 months after the workshop. Questionnaire results were categorized according to participants' responses to these elements: methods of engagement, evidence (scientific, experiential, systems) and the delivery of this evidence, and external factors at the institutional level, such as administrative support, budgetary issues, etc., that influence decision-maker abilities and strategies.

RESULTS

Traditional KE strategies such as peer-reviewed journal articles are optimal for disseminating scientific evidence, while face-to-face interactions, such as in a workshop, are best used to disseminate systems-level implementation information, such as fiscal implications, budgetary requirements, and policy relevance, which is not found in journal articles or conferences. An apparent shift in workplace culture signifies the availability of institutional support for high-level staff to engage in KE.

CONCLUSIONS

As a KE strategy with identified end users, the workshop format is effective in facilitating the implementation of this intervention in participants' institutions.

Introduction--Knowledge translation and urban health equity: advancing the agenda

In 2011, an interdisciplinary symposium was organized in Toronto, Canada to investigate prevailing models of health policy change in the knowledge translation literature and to assess the applicability of these models for equity-focused urban health research. The papers resulting from the symposium have been published together, in the Journal of Urban Health, along with this introductory essay. This essay describes how the different papers grapple in different ways with how to understand and to bridge the gaps between urban health research and action. The breadth of perspectives reflected in the papers (e.g., social epidemiology, public health, political science, sociology, critical labor studies, and educational psychology) shed much light on core tensions in the relationship between KT and health equity. The first tension is whether the content of evidence or the context of decision making is the strong determinate of research impact in relation to health equity policy. The second tension is whether relationships between health equity researchers and decision makers are best viewed in terms of collaboration or of conflict. The third concerns the role that power plays in evidence-based policy making, when the issues at stake are not only empirical but also normative.

Are we producing the right kind of actionable evidence for the social determinants of health?

Globally, health and social inequities are growing and are created, actively maintained, and aggravated by existing policies and practices. The call for evidence-based policy making to address this injustice seems a promising strategy to facilitate a reversal of existing strategies and the design of new effective programming. Acting on evidence to address inequities requires congruence between identifying the major drivers of disparities and the study of their causes and solutions. Yet, current research on inequities tends to focus on documenting disparities among individuals or subpopulations with little focus on identifying the macro-social causes of adverse population health. Moreover, the research base falls far short of a focus on the solutions to the complex multilevel drivers of disparities. This paper focuses upon recommendations to refocus and improve the public health research evidence generated to inform and create strong evidence-based recommendations for improving population health.

State-of-the-art and future directions in multilevel interventions across the cancer control continuum

We conducted literature searches and analyses to describe the current state of multilevel intervention (MLI) research and to identify opportunities to advance cancer control and prevention. We found single-level studies that considered other contextually important levels, and multilevel health-care systems research and community-wide studies. This literature is characterized by limited reporting of theoretical, contextual, temporal, and implementation factors. Most MLIs focus on prevention and screening, rather than diagnosis, treatment, or survivorship. Opportunities relate to 1) dynamic, adaptive emergent interventions and research designs that evolve over time by attending to contextual factors and interactions across levels; 2) analyses that include simulation modeling, or multimethod approaches that integrate quantitative and qualitative methods; and 3) translation and intervention approaches that locally reinvent MLIs in different contexts. MLIs have great potential to reduce cancer burden by using theory and integrating quantitative, qualitative, participatory, and transdisciplinary methods that continually seek alignment across intervention levels, pay attention to context, and adapt over time.

Conceptual challenges in the translation of research into practice: it's not just a matter of "communication"

This paper identifies key barriers to the translation of science into practice and policy and makes recommendations for addressing them. It focuses on the challenges of translation within the field of tobacco control, but we argue that the insights are widely generalisable. Actor-Network Theory is used to frame an analysis, supplemented by focussed discussions with international tobacco control practitioners (service delivery and advocacy) and researchers. The central challenge to translation is that researchers and practitioners have different "practical ontologies". Researchers use findings from specific contexts to generalise to universal principles, while practitioners try to use these generalisations to inform their work in what are typically a somewhat different set of specific contexts. Neglecting the need to translate back from the general to the particular means research syntheses are not framed to meet practitioners' needs. Traditional knowledge broking roles need to be extended to better align the needs of researchers and practitioners. This may be facilitated by more creative use of "social computing" to enable real-time input into research syntheses from all interested parties, including input to the questions that research addresses. To do this systematically requires that we construct "generalisation gradients" to help practitioners apply general research conclusions to their particular situation and researchers to identify the relevance of their work. Disadvantaged communities in particular need help, since there is typically less research directly applicable to their contexts; thus, they need to generalise more.

A thematic analysis of theoretical models for translational science in nursing: mapping the field

The quantity and diversity of conceptual models in translational science may complicate rather than advance the use of theory. This paper offers a comparative thematic analysis of the models available to inform knowledge development, transfer, and utilization. Literature searches identified 47 models for knowledge translation. Four thematic areas emerged: (1) evidence-based practice and knowledge transformation processes, (2) strategic change to promote adoption of new knowledge, (3) knowledge exchange and synthesis for application and inquiry, and (4) designing and interpreting dissemination research. This analysis distinguishes the contributions made by leaders and researchers at each phase in the process of discovery, development, and service delivery. It also informs the selection of models to guide activities in knowledge translation. A flexible theoretical stance is essential to simultaneously develop new knowledge and accelerate the translation of that knowledge into practice behaviors and programs of care that support optimal patient outcomes.

The Genome-based Knowledge Management in Cycles model: a complex adaptive systems framework for implementation of genomic applications

The main mission of the Genomic Applications in Practice and Prevention Network™ is to advance collaborative efforts involving partners from across the public health sector to realize the promise of genomics in healthcare and disease prevention. We introduce a new framework that supports the Genomic Applications in Practice and Prevention Network mission and leverages the characteristics of the complex adaptive systems approach. We call this framework the Genome-based Knowledge Management in Cycles model (G-KNOMIC). G-KNOMIC proposes that the collaborative work of multidisciplinary teams utilizing genome-based applications will enhance translating evidence-based genomic findings by creating ongoing knowledge management cycles. Each cycle consists of knowledge synthesis, knowledge evaluation, knowledge implementation and knowledge utilization. Our framework acknowledges that all the elements in the knowledge translation process are interconnected and continuously changing. It also recognizes the importance of feedback loops, and the ability of teams to self-organize within a dynamic system. We demonstrate how this framework can be used to improve the adoption of genomic technologies into practice using two case studies of genomic uptake.

Getting evidence into policy: The need for deliberative strategies?

Getting evidence into policy is notoriously difficult. In this empirical case study we used document analysis and key informant interviews to explore the Australian federal government's policy to implement a national bowel cancer screening programme, and the role of evidence in this policy. Our analysis revealed a range of institutional limitations at three levels of national government: within the health department, between government departments, and across the whole of government. These limitations were amplified by the pressures of the 2004 Australian federal election campaign. Traditional knowledge utilisation approaches, which rely principally on voluntarist strategies and focus on the individual, rather than the institutional level, are often insufficient to ensure evidence-based implementation. We propose three alternative models, based on deliberative strategies which have been shown to work in other settings: review of the evidence by a select group of experts whose independence is enshrined in legislation and whose imprimatur is required before policy can proceed; use of an advisory group of experts who consult widely with stakeholders and publish their review findings; or public discussion of the evidence by the media and community groups who act as more direct conduits to the decision-makers than researchers. Such deliberative models could help overcome the limitations on the use of evidence by embedding public review of evidence as the first step in the institutional decision-making processes.

Designing health innovation networks using complexity science and systems thinking: the CoNEKTR model

RATIONALE, AIMS AND OBJECTIVES

Complex problems require strategies to engage diverse perspectives in a focused, flexible manner, yet few options exist that fit with the current health care and public health system constraints. The Complex Network Electronic Knowledge Translation Research model (CoNEKTR) brings together complexity science, design thinking, social learning theories, systems thinking and eHealth technologies together to support a sustained engagement strategy for social innovation support and enhancing knowledge integration.

METHODS

The CoNEKTR model adapts elements of other face-to-face social organizing methods and combines it with social media and electronic networking tools to create a strategy for idea generation, refinement and social action. Drawing on complexity science, a series of networking and dialogue-enhancing activities are employed to bring diverse groups together, facilitate dialogue and create networks of networks.

RESULTS

Ten steps and five core processes informed by complexity science have been developed through this model. Concepts such as emergence, attractors and feedback play an important role in facilitating networking among participants in the model.

CONCLUSIONS

Using a constrained, focused approach informed by complexity science and using information technology, the CoNEKTR model holds promise as a means to enhance system capacity for knowledge generation, learning and action while working within the limitations faced by busy health professionals.

Invited commentary: The epicenter of translational science

Epidemiology is at the center of translational science. Uniquely among biomedical disciplines, the methods and perspective of epidemiology span research from discovery to effective interventions and ultimately to their dissemination and implementation. However, shorthand designations for various phases of translational science, such as "T1, T2, T3, and T4," may be proliferating past the level of their usefulness. It is worthwhile to reflect on the actual nature of the science undertaken by epidemiologists along the continuum of discovery to application. The new challenge for epidemiology is the integration of knowledge and effective interventions into various societal settings working with allied disciplines not necessarily in the biomedical domain to ensure that these interventions have their intended effects on individual and public health.

An actor-network theory analysis of policy innovation for smoke-free places: understanding change in complex systems

Complex, transnational issues like the tobacco epidemic are major challenges that defy analysis and management by conventional methods, as are other public health issues, such as those associated with global food distribution and climate change. We examined the evolution of indoor smoke-free regulations, a tobacco control policy innovation, and identified the key attributes of those jurisdictions that successfully pursued this innovation and those that to date have not. In doing so, we employed the actor-network theory, a comprehensive framework for the analysis of fundamental system change. Through our analysis, we identified approaches to help overcome some systemic barriers to the solution of the tobacco problem and comment on other complex transnational problems.

Future health applications of genomics: priorities for communication, behavioral, and social sciences research

Despite the quickening momentum of genomic discovery, the communication, behavioral, and social sciences research needed for translating this discovery into public health applications has lagged behind. The National Human Genome Research Institute held a 2-day workshop in October 2008 convening an interdisciplinary group of scientists to recommend forward-looking priorities for translational research. This research agenda would be designed to redress the top three risk factors (tobacco use, poor diet, and physical inactivity) that contribute to the four major chronic diseases (heart disease, type 2 diabetes, lung disease, and many cancers) and account for half of all deaths worldwide. Three priority research areas were identified: (1) improving the public's genetic literacy in order to enhance consumer skills; (2) gauging whether genomic information improves risk communication and adoption of healthier behaviors more than current approaches; and (3) exploring whether genomic discovery in concert with emerging technologies can elucidate new behavioral intervention targets. Important crosscutting themes also were identified, including the need to: (1) anticipate directions of genomic discovery; (2) take an agnostic scientific perspective in framing research questions asking whether genomic discovery adds value to other health promotion efforts; and (3) consider multiple levels of influence and systems that contribute to important public health problems. The priorities and themes offer a framework for a variety of stakeholders, including those who develop priorities for research funding, interdisciplinary teams engaged in genomics research, and policymakers grappling with how to use the products born of genomics research to address public health challenges.

Building knowledge integration systems for evidence-informed decisions

PURPOSE

This paper aims to describe methods and models designed to build a comprehensive, integrative framework to guide the research to policy and practice cycle in health care.

DESIGN/METHODOLOGY/APPROACH

Current models of science are summarised, identifying specific challenges they create for knowledge to action (KTA). Alternative models for KTA are outlined to illustrate how researchers and decision makers can work together to fit the KTA model to specific problems and contexts. The Canadian experience with the evolving paradigm shift is described, along with recent initiatives to develop platforms and tools that support the new thinking. Recent projects to develop and refine methods for embedded research are described. The paper concludes with a summary of lessons learned and recommendations that will move the KTA field towards an integrated science.

FINDINGS

Conceptual models for KTA are advancing, benefiting from advances in team science, development of logic models that address the realities of complex adaptive systems, and new methods to more rapidly deliver knowledge syntheses more useful to decision and policy makers.

PRACTICAL IMPLICATIONS

KTA is more likely when co-produced by researchers, practitioners, and policy makers. Closer collaboration requires shifts in thinking about the ways we work, capacity development, and greater learning from practice.

ORIGINALITY/VALUE

More powerful ways of thinking about the complexities of knowledge to action are provided, along with examples of tools and priorities drawn from systems thinking.

Diffusion theory and knowledge dissemination, utilization, and integration in public health

Legislators and their scientific beneficiaries express growing concerns that the fruits of their investment in health research are not reaching the public, policy makers, and practitioners with evidence-based practices. Practitioners and the public lament the lack of relevance and fit of evidence that reaches them and barriers to their implementation of it. Much has been written about this gap in medicine, much less in public health. We review the concepts that have guided or misguided public health in their attempts to bridge science and practice through dissemination and implementation. Beginning with diffusion theory, which inspired much of public health's work on dissemination, we compare diffusion, dissemination, and implementation with related notions that have served other fields in bridging science and practice. Finally, we suggest ways to blend diffusion with other theory and evidence in guiding a more decentralized approach to dissemination and implementation in public health, including changes in the ways we produce the science itself.

Online cancer communication: meeting the literacy, cultural and linguistic needs of diverse audiences

OBJECTIVE

This article provides an analysis of issues and empirical evidence related to literacy, cultural, and linguistic factors in online health and cancer communication, and recommendations to improve cancer communication for diverse audiences.

METHODS

We examined English-language online literature and selected books and policy documents related to literacy, cultural, and linguistic factors in health and cancer communication.

RESULTS

Studies about literacy, cultural, and linguistic factors in online cancer communication for diverse audiences are limited, but have increased during the past 15 years. Empirical evidence and theoretical guidance describe the critical importance of these factors, significant unmet needs among low-literate, multicultural and non-English-speaking populations, and strategies to improve communication.

CONCLUSION

Overall, online cancer communication has not met the literacy, cultural, and linguistic needs of diverse populations. The literature offers valuable recommendations about enhancing research, practice, and policy for better cancer communication.

PRACTICE IMPLICATIONS

Practitioners should understand the strengths and weaknesses of online cancer communication for vulnerable groups, guide patients to better Websites, and supplement that information with oral and tailored communication.