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A decade of knowledge translation research—what has changed?
Journal of Clinical Epidemiology 64 (2011) 3e5
KNOWLEDGE TRANSLATION SERIES - GUEST EDITOR, SHARON STRAUS
A decade of knowledge translation researchdwhat has changed? Beverley J. Shea* Community Interventions and Epidemiological Technologies (CIET Canada), Institute of Population Health, University of Ottawa, Ottawa, Ontario, Canada Accepted 2 July 2010
Knowledge translation (KT) is perhaps an overused term. It reportedly has around 90 synonyms and a wide range of definitions [1e4]. The Canadian Institutes of Health Research (CIHR) define KT as ‘‘the exchange, synthesis and ethically sound application of knowledgedwithin a complex system of interactions among researchers and usersdto accelerate the capture of the benefits of research for society through improved health, more effective services and products, and a strengthened health care system’’ [5]. Straus et al. [1] prefer to describe KTas ‘‘the methods for closing the gaps from knowledge to practice.’’ This has an appealing directness. In the United Kingdom, and in other jurisdictions, the investigation of KT is rather prosaically known as ‘‘implementation research’’ [1]. This nicely captures the intent of most KTdto ensure that research findings are implemented appropriately and for the net benefit of patients and the public. KT has been the subject of a great deal of investment in several countries. Research funding agencies, such as the UK National Health Service have created new expectations of researchers, such as the recent trend to require lodgment of publications in digital repositories. This has led to a number of national governments have supported free access to the Cochrane Library. In Canada, the federal government has wavered on the latter; however, the CIHR has provided funding for the Canadian Cochrane Center, supported a number of integrated KT activities (for instance, the partnerships for Health System Improvement competition), provided required specification of end-of-grant KT, and has sponsored a number of policy development forums [6,7]. What have we learned from this major research effort? How has it changed the way we implement research findings? Aside from academic research, what can we learn from examples in civil society? In this issue of the Journal Clinical Epidemiology, five authors provide ‘‘state of the art’’ reviews of the science that underpins the development and application of KT strategies. What insights do our five experts bring to our * Corresponding author. Tel.: þ1-613-233-2740; fax: þ1-613-5625392. E-mail address: [email protected] 0895-4356/$ - see front matter Ó 2011 Elsevier Inc. All rights reserved. doi: 10.1016/j.jclinepi.2010.07.009
understanding of the complex cognitive and behavioral processes involved in KT? What do they say about the optimal approaches for enabling policy makers, practitioners, and the public to use the best evidence? Tricco et al. [8] reviewed the various methods for knowledge synthesis and reported that the skillful summary, contextualization, and interpretation of the results of individual studies help to bridge the gap between research and decision making. Summary data can have a large impact on clinical practice and health policy; therefore, it is important to minimize bias during the review process. Arguably, a biased review could be more misleading than a single biased study. The increasing volume and diversity of the existing literature place increasing demands on systematic review teams. Continuing efforts are essential towards improving the efficiency, validity, and applicability of systematic reviews. AMSTAR: A measurement tool for assessing the quality of systematic reviews, has been developed to meet these criteria and is now being used extensively to quickly assess the quality of systematic reviews by researchers, decision-making bodies, and in teaching [9]. Majumdar [10] notes that investigators increasingly test complex multifaceted interventions but seldom do all of the individual intervention components work. He suggests that we adopt a ‘‘mixed-methods’’ approach of collecting both quantitative and qualitative data to better understand how the different elements of the interventions workdsingly and in combination. Investigators need to provide enough information for others to reproduce their work. Often, such details are missing due to ignorance or lengthy restrictions imposed by journals. For instance, Glasziou et al. [11] found that less than 15% of reports have sufficient information about the intervention itself to allow clinicians or policy makers to implement it. Fortunately, as the authors point out, this is usually remediable. As Straus points out, it is not just about too little evidence and too little translation. We must avoid the ‘‘KT imperative’’: the idea that all knowledge must be translated into action (and by implication that all of this will need to be evaluated). Instead, we must be selective and ensure that there is a mature and valid evidence base before
4
B.J. Shea / Journal of Clinical Epidemiology 64 (2011) 3e5
expending substantial resources on implementation of evidence-based interventions [12]. Majumdar [10] adds to this by pointing out that we have a responsibility to ensure sustainability of our KT initiatives: can such interventions be sustained over a long period of time while competing with and perhaps detracting from other services provided by the health care system? The ‘‘KT imperative’’ should not become a monster that consumes our energy and resources. Gagnon [12] raises the important issue of the need to disseminate research findings to specific audiences and develop a dissemination plan that focuses on the needs of the audience who will be the knowledge users. Gagnon also points out that knowledge brokers, networks, and communities of practice are innovative ways to disseminate and facilitate the application of knowledge. Integrated exchange, involving active collaboration between researchers and knowledge users, built on trust and frequent interactions, holds particular promise. Bhattacharyya et al. [13] highlights the importance of evaluating knowledge interventions by managers and researchers. They argue that managers should routinely incorporate simple evaluation designs into program implementation (something that is usually missing), to assess and increase the impact of their services; Researchers should focus on creating cumulative knowledge through rigorous designs and implementation to explore reason for success and failure. As suggested by Gagnon [12], they believe that combined efforts of managers and researchers will provide a richer knowledge base to move the KT field forward and increase the use of evidence-based implementation strategies to improve the quality of health care provided. The articles in this issue celebrate some successes and point to substantial barriers to improve KT. Appropriately, they have been written in the rather dry and measured language of science. In reviewing the state of this discipline, it is important that we also take a broader look at the interests of the community and not view KT solely as an activity that is ‘‘practiced’’ by scientists, practitioners, and policy makers. If we consider some of the improvements in public health in recent years, the reduction in the incidence of heart attacks stands out as a huge achievement. Rates of heart disease have decreased by one-half in the last 20 years in Canada [14]. Thousands of people are enjoying productive and healthier lives as a result. New treatments have been important but so have preventive strategies, including smoking cessation [15,16]. Between 1985 and 2008, active smoking rates fell from 35% to 18% in Canada [17]. This has been the result of very effective KT. In the case of smoking, a movement for social change erupted, requiring mobilization of a broad range of constituencies, including practitioners, governments, municipalities, media, and advocacy groups. Although it remains a work in progress, it represents KT in action. It was achieved against the entrenched opposition of the tobacco industry and their apologists. There are a number of recent examples demonstrating that such social movements can have an impact on health
and health behavior. Quickly and effortlessly, most Canadians have been persuaded to sneeze into their elbows rather than their hands, to minimize the spread of H1N1. As well, Oprah Winfrey is campaigning vigorously against cell phone use while driving. We are in an age where the term ‘‘KT’’ may refer to actions that engage the entire community, and where the traditional media, the Internet, and Web 2.0 activities (i.e., social networking sites) are the instruments of communication and change. We can now envision a time when terms, such as ‘‘integrated KT’’ and ‘‘communities of practice,’’ while not necessarily being understood by the community, will be embraced by significant proportions of the population. Inevitably, this must include children and their educators. Children can be amazing ambassadors and can also act as very effective agents for change [18]. The touchstone of all KT research is an intent to change behavior so that evidence-based interventions replace intuition and politics in the drive to improve the health of the community. It is vital that we educate children to understand and respect evidence, so they too will become the change agents for a healthier society. References [1] Straus SE, Tetroe J, Graham I. Defining knowledge translation. CMAJ 2009;181:165e8. [2] Kitson A, Phil D, Straus SE. The knowledge-to-action cycle: identifying the gaps. CMAJ 2010;182(2):E73e7. [3] Gagliardi A, Perrier L, Webster F, Leslie K, Bell M, Levinson W, et al. Exploring mentorship as a strategy to build capacity for knowledge translation research and practice: protocol for a qualitative study. Implement Sci 2009;4:55. [4] Straus S, Haynes RB. Managing evidence-based knowledge: the need for reliable, relevant and readable resources. CMAJ 2009;180(9): 942e5. [5] Canadian Institutes of Health Research. Canadian Institutes of Health Research knowledge translation strategy 2004e2009. Available at http:// www.cihr-irsc.gc.ca/e/26574.html#defining. Accessed April 2010. [6] Canadian Institutes of Health Research. About knowledge translation 2009. [7] Canadian Health Services Research Foundation. Summary of the article from research to practice: a knowledge transfer planning guide. Insight and Action 2007;(1). [8] Tricco AC, Tetzlaff JM, Moher D. The art and science of knowledge synthesis. [9] Shea BJ, Grimshaw JM, Wells GA, Boers M, Andersson N, Hamel C, et al. Development of AMSTAR: a measurement tool to assess the methodological quality of systematic reviews. BMC Med Res Methodol 2007;7:10. [10] Majumdar SR. Successful high-quality knowledge translation research: three case studies. [11] Glasziou P, Meats E, Heneghan C, Shepperd S. What is missing from descriptions of treatment in trials and reviews? BMJ 2008;336:1472e4. [12] Gagnon M. Knowledge Dissemination and Exchange. [13] Bhattacharyya OK, Estey EA, Zwarenstein M. Methodologies to evaluate the effectiveness of knowledge translation interventions: a primer for researchers and health care managers. [14] Heart and Stroke Foundation. Available at http://www.heartandstroke. com/site/c.ikIQLcMWJtE/b.3483991/k.34A8/Statistics.htm. Assessed April 2010. [15] Probstfield JL. How cost-effective are new preventive strategies for cardiovascular disease? Am J Cardiol 2003;91:22Ge7G.
B.J. Shea / Journal of Clinical Epidemiology 64 (2011) 3e5 [16] Ranney L, Melvin C, Lux L, McClain E, Lohr KN. Systematic review: smoking cessation intervention strategies for adults and adults in special populations. Ann Intern Med 2006;145:845e56. [17] Available at http://www.hc-sc.gc.ca/hc-ps/tobac-tabac/research-recherche/ stat/ctums-esutc_2009-eng.php.
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[18] Kumar A. Children are powerful agents of change and should be included during the development and implementation of child injury prevention projects at local, national and international levels. Available at http://www.who.int/violence_injury_prevention/child/injury/ world_report/Recommendations_chapter.pdf. Assessed April 2010.
KNOWLEDGE TRANSLATION SERIES - GUEST EDITOR, SHARON STRAUS
A decade of knowledge translation researchdwhat has changed? Beverley J. Shea* Community Interventions and Epidemiological Technologies (CIET Canada), Institute of Population Health, University of Ottawa, Ottawa, Ontario, Canada Accepted 2 July 2010
Knowledge translation (KT) is perhaps an overused term. It reportedly has around 90 synonyms and a wide range of definitions [1e4]. The Canadian Institutes of Health Research (CIHR) define KT as ‘‘the exchange, synthesis and ethically sound application of knowledgedwithin a complex system of interactions among researchers and usersdto accelerate the capture of the benefits of research for society through improved health, more effective services and products, and a strengthened health care system’’ [5]. Straus et al. [1] prefer to describe KTas ‘‘the methods for closing the gaps from knowledge to practice.’’ This has an appealing directness. In the United Kingdom, and in other jurisdictions, the investigation of KT is rather prosaically known as ‘‘implementation research’’ [1]. This nicely captures the intent of most KTdto ensure that research findings are implemented appropriately and for the net benefit of patients and the public. KT has been the subject of a great deal of investment in several countries. Research funding agencies, such as the UK National Health Service have created new expectations of researchers, such as the recent trend to require lodgment of publications in digital repositories. This has led to a number of national governments have supported free access to the Cochrane Library. In Canada, the federal government has wavered on the latter; however, the CIHR has provided funding for the Canadian Cochrane Center, supported a number of integrated KT activities (for instance, the partnerships for Health System Improvement competition), provided required specification of end-of-grant KT, and has sponsored a number of policy development forums [6,7]. What have we learned from this major research effort? How has it changed the way we implement research findings? Aside from academic research, what can we learn from examples in civil society? In this issue of the Journal Clinical Epidemiology, five authors provide ‘‘state of the art’’ reviews of the science that underpins the development and application of KT strategies. What insights do our five experts bring to our * Corresponding author. Tel.: þ1-613-233-2740; fax: þ1-613-5625392. E-mail address: [email protected] 0895-4356/$ - see front matter Ó 2011 Elsevier Inc. All rights reserved. doi: 10.1016/j.jclinepi.2010.07.009
understanding of the complex cognitive and behavioral processes involved in KT? What do they say about the optimal approaches for enabling policy makers, practitioners, and the public to use the best evidence? Tricco et al. [8] reviewed the various methods for knowledge synthesis and reported that the skillful summary, contextualization, and interpretation of the results of individual studies help to bridge the gap between research and decision making. Summary data can have a large impact on clinical practice and health policy; therefore, it is important to minimize bias during the review process. Arguably, a biased review could be more misleading than a single biased study. The increasing volume and diversity of the existing literature place increasing demands on systematic review teams. Continuing efforts are essential towards improving the efficiency, validity, and applicability of systematic reviews. AMSTAR: A measurement tool for assessing the quality of systematic reviews, has been developed to meet these criteria and is now being used extensively to quickly assess the quality of systematic reviews by researchers, decision-making bodies, and in teaching [9]. Majumdar [10] notes that investigators increasingly test complex multifaceted interventions but seldom do all of the individual intervention components work. He suggests that we adopt a ‘‘mixed-methods’’ approach of collecting both quantitative and qualitative data to better understand how the different elements of the interventions workdsingly and in combination. Investigators need to provide enough information for others to reproduce their work. Often, such details are missing due to ignorance or lengthy restrictions imposed by journals. For instance, Glasziou et al. [11] found that less than 15% of reports have sufficient information about the intervention itself to allow clinicians or policy makers to implement it. Fortunately, as the authors point out, this is usually remediable. As Straus points out, it is not just about too little evidence and too little translation. We must avoid the ‘‘KT imperative’’: the idea that all knowledge must be translated into action (and by implication that all of this will need to be evaluated). Instead, we must be selective and ensure that there is a mature and valid evidence base before
4
B.J. Shea / Journal of Clinical Epidemiology 64 (2011) 3e5
expending substantial resources on implementation of evidence-based interventions [12]. Majumdar [10] adds to this by pointing out that we have a responsibility to ensure sustainability of our KT initiatives: can such interventions be sustained over a long period of time while competing with and perhaps detracting from other services provided by the health care system? The ‘‘KT imperative’’ should not become a monster that consumes our energy and resources. Gagnon [12] raises the important issue of the need to disseminate research findings to specific audiences and develop a dissemination plan that focuses on the needs of the audience who will be the knowledge users. Gagnon also points out that knowledge brokers, networks, and communities of practice are innovative ways to disseminate and facilitate the application of knowledge. Integrated exchange, involving active collaboration between researchers and knowledge users, built on trust and frequent interactions, holds particular promise. Bhattacharyya et al. [13] highlights the importance of evaluating knowledge interventions by managers and researchers. They argue that managers should routinely incorporate simple evaluation designs into program implementation (something that is usually missing), to assess and increase the impact of their services; Researchers should focus on creating cumulative knowledge through rigorous designs and implementation to explore reason for success and failure. As suggested by Gagnon [12], they believe that combined efforts of managers and researchers will provide a richer knowledge base to move the KT field forward and increase the use of evidence-based implementation strategies to improve the quality of health care provided. The articles in this issue celebrate some successes and point to substantial barriers to improve KT. Appropriately, they have been written in the rather dry and measured language of science. In reviewing the state of this discipline, it is important that we also take a broader look at the interests of the community and not view KT solely as an activity that is ‘‘practiced’’ by scientists, practitioners, and policy makers. If we consider some of the improvements in public health in recent years, the reduction in the incidence of heart attacks stands out as a huge achievement. Rates of heart disease have decreased by one-half in the last 20 years in Canada [14]. Thousands of people are enjoying productive and healthier lives as a result. New treatments have been important but so have preventive strategies, including smoking cessation [15,16]. Between 1985 and 2008, active smoking rates fell from 35% to 18% in Canada [17]. This has been the result of very effective KT. In the case of smoking, a movement for social change erupted, requiring mobilization of a broad range of constituencies, including practitioners, governments, municipalities, media, and advocacy groups. Although it remains a work in progress, it represents KT in action. It was achieved against the entrenched opposition of the tobacco industry and their apologists. There are a number of recent examples demonstrating that such social movements can have an impact on health
and health behavior. Quickly and effortlessly, most Canadians have been persuaded to sneeze into their elbows rather than their hands, to minimize the spread of H1N1. As well, Oprah Winfrey is campaigning vigorously against cell phone use while driving. We are in an age where the term ‘‘KT’’ may refer to actions that engage the entire community, and where the traditional media, the Internet, and Web 2.0 activities (i.e., social networking sites) are the instruments of communication and change. We can now envision a time when terms, such as ‘‘integrated KT’’ and ‘‘communities of practice,’’ while not necessarily being understood by the community, will be embraced by significant proportions of the population. Inevitably, this must include children and their educators. Children can be amazing ambassadors and can also act as very effective agents for change [18]. The touchstone of all KT research is an intent to change behavior so that evidence-based interventions replace intuition and politics in the drive to improve the health of the community. It is vital that we educate children to understand and respect evidence, so they too will become the change agents for a healthier society. References [1] Straus SE, Tetroe J, Graham I. Defining knowledge translation. CMAJ 2009;181:165e8. [2] Kitson A, Phil D, Straus SE. The knowledge-to-action cycle: identifying the gaps. CMAJ 2010;182(2):E73e7. [3] Gagliardi A, Perrier L, Webster F, Leslie K, Bell M, Levinson W, et al. Exploring mentorship as a strategy to build capacity for knowledge translation research and practice: protocol for a qualitative study. Implement Sci 2009;4:55. [4] Straus S, Haynes RB. Managing evidence-based knowledge: the need for reliable, relevant and readable resources. CMAJ 2009;180(9): 942e5. [5] Canadian Institutes of Health Research. Canadian Institutes of Health Research knowledge translation strategy 2004e2009. Available at http:// www.cihr-irsc.gc.ca/e/26574.html#defining. Accessed April 2010. [6] Canadian Institutes of Health Research. About knowledge translation 2009. [7] Canadian Health Services Research Foundation. Summary of the article from research to practice: a knowledge transfer planning guide. Insight and Action 2007;(1). [8] Tricco AC, Tetzlaff JM, Moher D. The art and science of knowledge synthesis. [9] Shea BJ, Grimshaw JM, Wells GA, Boers M, Andersson N, Hamel C, et al. Development of AMSTAR: a measurement tool to assess the methodological quality of systematic reviews. BMC Med Res Methodol 2007;7:10. [10] Majumdar SR. Successful high-quality knowledge translation research: three case studies. [11] Glasziou P, Meats E, Heneghan C, Shepperd S. What is missing from descriptions of treatment in trials and reviews? BMJ 2008;336:1472e4. [12] Gagnon M. Knowledge Dissemination and Exchange. [13] Bhattacharyya OK, Estey EA, Zwarenstein M. Methodologies to evaluate the effectiveness of knowledge translation interventions: a primer for researchers and health care managers. [14] Heart and Stroke Foundation. Available at http://www.heartandstroke. com/site/c.ikIQLcMWJtE/b.3483991/k.34A8/Statistics.htm. Assessed April 2010. [15] Probstfield JL. How cost-effective are new preventive strategies for cardiovascular disease? Am J Cardiol 2003;91:22Ge7G.
B.J. Shea / Journal of Clinical Epidemiology 64 (2011) 3e5 [16] Ranney L, Melvin C, Lux L, McClain E, Lohr KN. Systematic review: smoking cessation intervention strategies for adults and adults in special populations. Ann Intern Med 2006;145:845e56. [17] Available at http://www.hc-sc.gc.ca/hc-ps/tobac-tabac/research-recherche/ stat/ctums-esutc_2009-eng.php.
5
[18] Kumar A. Children are powerful agents of change and should be included during the development and implementation of child injury prevention projects at local, national and international levels. Available at http://www.who.int/violence_injury_prevention/child/injury/ world_report/Recommendations_chapter.pdf. Assessed April 2010.