Salter, K.J., and Kothari, A. (2014). Using realist evaluation to open the black box of knowledge translation: A state-of-the-art review. Implementation Science, 9:155. doi: 10.1186/s13012-014-0115-y
In knowledge translation, complex interventions may be implemented in the attempt to improve uptake of research-based knowledge in practice. Traditional evaluation efforts that focus on aggregate effectiveness represent an oversimplification of both the environment and the interventions themselves. However, theory-based approaches to evaluation, such as realist evaluation (RE), may be better-suited to examination of complex knowledge translation interventions with a view to understanding what works, for whom, and under what conditions. It is the aim of the present state-of-the-art review to examine current literature with regard to the use of RE in the assessment of knowledge translation interventions implemented within healthcare environments.
Multiple online databases were searched from 1997 through June 2013. Primary studies examining the application or implementation of knowledge translation interventions within healthcare settings and using RE were selected for inclusion. Varying applications of RE across studies were examined in terms of a) reporting of core elements of RE, and b) potential feasibility of this evaluation method.
A total of 14 studies (6 study protocols), published between 2007 and 2013, were identified for inclusion. Projects were initiated in a variety of healthcare settings and represented a range of interventions. While a majority of authors mentioned context (C), mechanism (M) and outcome (O), a minority reported the development of C-M-O configurations or testable hypotheses based on these configurations. Four completed studies reported results that included refinement of proposed C-M-O configurations and offered explanations within the RE framework. In the few studies offering insight regarding challenges associated with the use of RE, difficulties were expressed regarding the definition of both mechanisms and contextual factors. Overall, RE was perceived as time-consuming and resource intensive.
The use of RE in knowledge translation is relatively new; however, theory-building approaches to the examination of complex interventions in this area may be increasing as researchers attempt to identify what works, for whom and under what circumstances. Completion of the RE cycle may be challenging, particularly in the development of C-M-O configurations; however, as researchers approach challenges and explore innovations in its application, rich and detailed accounts may improve feasibility.
MacGregor, J.C.D., Wathen, C.N., Kothari, A., Hundal, P.K., Naimi, A. (2014). Strategies to promote uptake and use of intimate partner violence and child maltreatment knowledge: an integrative review. BMC Public Health, 14:862. doi: 10.1186/1471-2458-14-862.
Intimate partner violence (IPV) and child maltreatment (CM) are major social and public health problems. Knowledge translation (KT) of best available research evidence has been suggested as a strategy to improve the care of those exposed to violence, however research on how best to promote the uptake and use of IPV and CM evidence for policy and practice is limited. Our research asked: 1) What is the extent of IPV/CM-specific KT research? 2) What KT strategies effectively translate IPV/CM knowledge? and 3) What are the barriers and facilitators relevant to translating IPV/CM-specific knowledge?
We conducted an integrative review to summarize and synthesize the available evidence regarding IPV/CM-specific KT research. We employed multiple search methods, including database searches of Embase, CINAHL, ERIC, PsycInfo, Sociological Abstracts, and Medline (through April, 2013). Eligibility and quality assessments for each article were conducted by at least two team members. Included articles were analyzed quantitatively using descriptive statistics and qualitatively using descriptive content analysis.
Of 1230 identified articles, 62 were included in the review, including 5 review articles. KT strategies were generally successful at improving various knowledge/attitude and behavioural/behavioural intention outcomes, but the heterogeneity among KT strategies, recipients, study designs and measured outcomes made it difficult to draw specific conclusions. Four key themes were identified: existing measurement tools and promising/effective KT strategies are underused, KT efforts are rarely linked to health-related outcomes for those exposed to violence, there is a lack of evidence regarding the long-term effectiveness of KT interventions, and authors’ inferences about barriers, facilitators, and effective/ineffective KT strategies are often not supported by data. The emotional and sometimes contested nature of the knowledge appears to be an important barrier unique to IPV/CM KT.
To direct future KT in this area, we present a guiding framework that highlights the need for implementers to use/adapt promising KT strategies that carefully consider contextual factors, including the fact that content in IPV/CM may be more difficult to engage with than other health topics. The framework also provides guidance regarding use of measurement tools and designs to more effectively evaluate and report on KT efforts.
Harris, R.M., Wathen, C.N, and Lynch, R. (2014). Assessing performance in shelters for abused women: Can ‘caring citizenship’ be measured in ‘value for money’ accountability regimes? International Journal of Public Administration, 37:737–746. doi: 10.1080/01900692.2014.903273.
Results are reported from a study of shelters for abused women in Ontario, Canada, suggesting that what clients, managers, and frontline workers value most in shelter services is based on a care perspective in which ongoing relational support is seen as essential to effective service delivery. Presently, government-required metrics used to assess shelter services not only reflect a narrow, justice perspective where “fairness” is defined as equal access to publicly supported services, but reveal a New Public Management emphasis on efficiency in which the focus is more on the “what” than the “how” of practice. Findings are discussed in terms of their implications for the design of accountability systems for evaluating government-contracted social services.
MacGregor, J.C.D. and Wathen, C.N. (2014). 'My health is not a job': A qualitative examination of personal health management and imperatives of the 'new public health'. BMC Public Health, 14:726. doi: 10.1186/1471-2458-14-726.
There is an increasing push in Western healthcare for people to ‘manage’ their health, a key aspect of what has been called the ‘new public health’. It has been argued that this ‘personal health management’ – informal work done to monitor, inform, or influence one’s health – may be a burden, with potential to contribute to poor health outcomes. However, there is little research actually examining perceptions of personal health management and the ‘burden’ of these activities, particularly for generally healthy individuals.
We conducted exploratory qualitative interviews with 30 generally healthy men and women about their perceptions and experiences of personal health management. Questions focused on health behaviours (e.g., information seeking), as well as feelings about these behaviours and perceptions of the time dedicated to health. Audio-recorded interviews were transcribed and analyzed qualitatively using NVivo 10. Where appropriate, quantitative codes were applied and descriptive statistics are reported alongside qualitative findings.
Participants were generally satisfied with the amount of time spent on their health and few perceived personal health management as a burden. Many participants took issue with the concept of ‘work’ being associated with health and stressed the importance of taking personal responsibility for health.
Our findings suggest that generally healthy people have internalised the notion of the ‘new public health’ and accepted the imperative of personal health responsibility. On the one hand, this bodes well for healthy individuals; their positive attitude may lead to better health outcomes, and the manageable amount of time spent suggests personal health management is unlikely to cause negative health consequences associated with stress. On the other hand, our findings may indicate that other factors, such as social determinants of health, are ignored in health promotion efforts and that those who cannot manage their own health may fall further behind. Future research should continue to explore the time people spend ‘working’ for their health, and how they perceive and respond to ‘new public health’ imperatives.
Wathen, C.N., MacGregor, J.C.D., Sibbald, S. L., and MacMillan, H. L.. (2013). Exploring the uptake and framing of research evidence on universal screening for intimate partner violence against women: a knowledge translation case study. Health Research Policy and Systems, 11:13. doi: 10.1186/1478-4505-11-13
Significant emphasis is currently placed on the need to enhance health care decision-making with research-derived evidence. While much has been written on specific strategies to enable these “knowledge-to-action” processes, there is less empirical evidence regarding what happens when knowledge translation (KT) processes do not proceed as planned. The present paper provides a KT case study using the area of health care screening for intimate partner violence (IPV).
A modified citation analysis method was used, beginning with a comprehensive search (August 2009 to October 2012) to capture scholarly and grey literature, and news reports citing a specific randomized controlled trial published in a major medical journal on the effectiveness of screening women, in health care settings, for exposure to IPV. Results of the searches were extracted, coded and analysed using a multi-step mixed qualitative and quantitative content analysis process.
The trial was cited in 147 citations from 112 different sources in journal articles, commentaries, books, and government and news reports. The trial also formed part of the evidence base for several national-level practice guidelines and policy statements. The most common interpretations of the trial were “no benefit of screening”, “no harms of screening”, or both. Variation existed in how these findings were represented, ranging from summaries of the findings, to privileging one outcome over others, and to critical qualifications, especially with regard to methodological rigour of the trial. Of note, interpretations were not always internally consistent, with the same evidence used in sometimes contradictory ways within the same source.
Our findings provide empirical data on the and its potential for multiple, often unanticipated, uses. They have implications for evidence is used and interpreted in policy and practice, particularly in contested knowledge areas.
Sibbald, S.L., Wathen, C.N., Kothari, A., Day, A.M.B. (2013). Knowledge Flow & Exchange in Interdisciplinary Primary Health Care Teams: An Exploratory Study. Journal of the Medical Library Association, 101(2): 128-137. doi: http://dx.doi.org/10.3163/1536-5050.101.2.008
Objective:Improving the process of evidence-based practice in primary health care requires an understanding of information exchange among colleagues. This study explored how clinically oriented research knowledge flows through multidisciplinary primary health care teams (PHCTs) and influences clinical decisions.
Methods: This was an exploratory mixed-methods study with members of six PHCTs in Ontario, Canada. Quantitative data were collected using a questionnaire and analyzed with social network analysis (SNA) using UCINet. Qualitative data were collected using semi-structured interviews and analyzed with content analysis procedures using NVivo8.
Results: It was found that obtaining research knowledge was perceived to be a shared responsibility among team members, whereas its application in patient care was seen as the responsibility of the team leader, usually the senior physician. PHCT members acknowledged the need for resources for information access, synthesis, interpretation, or management.
Conclusion: Information sharing in interdisciplinary teams is a complex and multifaceted process. Specific interventions need to be improved such as formalizing modes of communication, better organizing knowledge-sharing activities, and improving the active use of allied health professionals. Despite movement toward team-based models, senior physicians are often gatekeepers of uptake of new evidence and changes in practice.
Kothari, A., Wathen, C.N. (2013). A critical second look at integrated knowledge translation. Health Policy, 109, 189-191. http://dx.doi.org/10.1016/j.healthpol.2012.11.004.
Wathen, C.N., MacGregor, J.C.D., Hammerton, J., Coben, J.H., Herrman, H., Stewart, D.E., and MacMillan, H.L., for the PreVAiL Research Network (2012). Priorities for research in child maltreatment, intimate partner violence and resilience to violence exposures: Results of an international Delphi consensus development process. BMC Public Health, 12:684. doi:10.1186/1471-2458-12-684.
Kothari, A., Rudman, D., Dobbins, M., Rouse, M., Sibbald*, S. & Edwards, N. The use of tacit and explicit knowledge in public health: a qualitative study. Implementation Science, 7:20, 2012. (top)
Planning a public health initiative is both a science and an art. Public health practitioners work in a complex, often time-constrained environment, where formal research literature can be unavailable or uncertain. Consequently, public health practitioners often draw upon other forms of knowledge.
Through use of one-on-one interviews and focus groups, we aimed to gain a better understanding of how tacit knowledge is used to inform program initiatives in public health. This study was designed as a narrative inquiry, which is based on the assumption that we make sense of the world by telling stories. Four public health units were purposively selected for maximum variation, based on geography and academic affiliation.
Analysis revealed different ways in which tacit knowledge was used to plan the public health program or initiative, including discovering the opportunity, bringing a team together, and working out program details (such as partnering, funding).
The findings of this study demonstrate that tacit knowledge is drawn upon, and embedded within, various stages of the process of program planning in public health. The results will be useful in guiding the development of future knowledge translation strategies for public health organizations and decision makers.
Jack, S.M., Ford-Gilboe, M., Wathen, C.N., Davidov, D.M., McNaughton, D.B., Coben, J., Olds, D.L., MacMillan, H.L. (2012). Development of a nurse home visitation intervention for intimate partner violence. BMC Health Services Research, 12:50. doi:10.1186/1472-6963-12-50. (top)
O'Grady, L., Wathen, C.N., Charnaw-Burger, J., Betel, L., Shachak, A., Luke, R., Hockema, S., Jadad, A. (2012). The use of tags and tag clouds to discern credible content in online health message forums. International Journal of Medical Informatics, 81(1):36-44. (top)
Wathen, C.N., Sibbald, S.L., Jack, S.M., MacMillan, H.L. (2011). Talk, trust and time: A longitudinal case study evaluating knowledge translation and exchange processes in research on violence against women. Implementation Science, 6:102. doi:10.1186/1748-5908-6-102 (designated as Highly Accessed by the journal).
Moodie*, S.T., Kothari, A., Bagatto, M.P., Seewald, R.C., Miller, L.T., and Scollie, S.D. Knowledge translation in audiology: Promoting the clinical application of best evidence. Trends in Amplification, 15(1), 5-22, 2011.(top)
The impetus for evidence-based practice (EBP) has grown out of widespread concern with the quality, effectiveness (including cost-effectiveness), and efficiency of medical care received by the public. Although initially focused on medicine, EBP principles have been adopted by many of the health care professions and are often represented in practice through the development and use of clinical practice guidelines (CPGs). Audiology has been working on incorporating EBP principles into its mandate for professional practice since the mid-1990s. Despite widespread efforts to implement EBP and guidelines into audiology practice, gaps still exist between the best evidence based on research and what is being done in clinical practice. A collaborative dynamic and iterative integrated knowledge translation (KT) framework rather than a researcher-driven hierarchical approach to EBP and the development of CPGs has been shown to reduce the knowledge-to-clinical action gaps. This article provides a brief overview of EBP and CPGs, including a discussion of the barriers to implementing CPGs into clinical practice. It then offers a discussion of how an integrated KT process combined with a community of practice (CoP) might facilitate the development and dissemination of evidence for clinical audiology practice. Finally, a project that uses the knowledge-to-action (KTA) framework for the development of outcome measures in pediatric audiology is introduced.
Kothari, A., McLean, L., Edwards, N., and Hobbs, A. Indicators at the interface: managing policymaker-researcher collaboration. Knowledge Management and Practice, 9(3), 203-214, 2011. (top)
The knowledge transfer literature encourages partnerships between researchers and policymakers for the purposes of policy-relevant knowledge creation. Consequently, research findings are more likely to be used by policymakers during policy development. This paper presents a set of practice-based indicators that can be used to manage the collaborative knowledge creation process or assess the performance of a partnership between researchers and policymakers. Indicators for partnership success were developed from 16 qualitative interviews with health policymakers and researchers involved with eight research transfer partnerships with government. These process and outcomes indicators were refined through a focus group. Resulting qualitative and quantitative indicators were judged to be clear, relevant, credible, and feasible. New findings included the need to have different indicators to evaluate new vs mature partnerships, as well as specific indicators common to researcher-policymaker partnerships in general.
Kothari, A., and Armstrong, R. Community-based knowledge translation: Unexplored opportunities. Implementation Science, 6: 59, 2011. (top)
Knowledge translation is an interactive process of knowledge exchange between health researchers and knowledge users. Given that the health system is broad in scope, it is important to reflect on how definitions and applications of knowledge translation might differ by setting and focus. Community-based organizations and their practitioners share common characteristics related to their setting, the evidence used in this setting, and anticipated outcomes that are not, in our experience, satisfactorily reflected in current knowledge translation approaches, frameworks, or tools.
Community-based organizations face a distinctive set of challenges and concerns related to engaging in the knowledge translation process, suggesting a unique perspective on knowledge translation in these settings. Specifically, community-based organizations tend to value the process of working in collaboration with multi-sector stakeholders in order to achieve an outcome. A feature of such community-based collaborations is the way in which 'evidence' is conceptualized or defined by these partners, which may in turn influence the degree to which generalizable research evidence in particular is relevant and useful when balanced against more contextually-informed knowledge, such as tacit knowledge. Related to the issues of evidence and context is the desire for local information. For knowledge translation researchers, developing processes to assist community-based organizations to adapt research findings to local circumstances may be the most helpful way to advance decision making in this area. A final characteristic shared by community-based organizations is involvement in advocacy activities, a function that has been virtually ignored in traditional knowledge translation approaches.
This commentary is intended to stimulate further discussion in the area of community-based knowledge translation. Knowledge translation, and exchange, between communities, community-based organizations, decision makers, and researchers is likely to be beneficial when ensuring that 'evidence' meets the needs of all end users and that decisions are based on both relevant research and community requirements. Further exploratory work is needed to identify alternative methods for evaluating these strategies when applied within community-based settings.
Conklin, J., Kothari, A., Stolee, P., Chambers, L., Forbes, D., and LeClair, K. Knowledge to action processes in SHRTN Collaborative Communities of Practice: A study protocol. Implementation Science, 6: 12, 2011. (top)
The Seniors Health Research Transfer Network (SHRTN) Collaborative is a network of networks that work together to improve the health and health care of Ontario seniors. The collaborative facilitates knowledge exchange through a library service, knowledge brokers (KBs), local implementation teams, collaborative technology, and, most importantly, Communities of Practice (CoPs) whose members work together to identify innovations, translate evidence, and help implement changes. This project aims to increase our understanding of knowledge-to-action (KTA) processes mobilized through SHRTN CoPs that are working to improve the health of Ontario seniors. For this research, KTA refers to the movement of research and experience-based knowledge between social contexts, and the use of that knowledge to improve practice. We will examine the KTA processes themselves, as well as the role of human agents within those processes. The conceptual framework we have adopted to inform our research is the Promoting Action on Research Implementation in Health Services (PARIHS) framework.
This study will use a multiple case study design (minimum of nine cases over three years) to investigate how SHRTN CoPs work and pursue knowledge exchange in different situations. Each case will yield a unique narrative, framed around the three PARIHS dimensions: evidence, context, and facilitation. Together, the cases will shed light on how SHRTN CoPs approach their knowledge exchange initiatives, and how they respond to challenges and achieve their objectives. Data will be collected using interviews, document analysis, and ethnographic observation.
This research will generate new knowledge about the defining characteristics of CoPs operating in the health system, on leadership roles in CoPs, and on the nature of interaction processes, relationships, and knowledge exchange mechanisms. Our work will yield a better understanding of the factors that contribute to the success or failure of KTA initiatives, and create a better understanding of how local caregiving contexts interact with specific initiatives. Our participatory design will allow stakeholders to influence the practical usefulness of our findings and contribute to improved health services delivery for seniors.
Wathen,C.N., Wyatt, S., Harris, R. (Eds.) (2008). Mediating Health Information: The Go-Betweens in a Changing Socio-Technical Landscape.Basingstoke, Palgrave Macmillan. http://www.palgrave.com/products/title.aspx?PID=285092. (top)
O'Grady, L., Witteman, H., Wathen, C.N. (2008). Supporting experiential learning in collaborative Web-based patient education. BMC Medical Informatics and Decision Making, 8:58. http://www.biomedcentral.com/1472-6947/8/58. doi:10.1186/1472-6947-8-58. (top)
Wathen, C.N., Watson, G., Jack, S.M., Caldwell, S., Lewis, N. (2008). From big to small: A process for developing policy-relevant research summaries.Healthcare Policy, 4(1), 60-69. (top)
Wathen, C.N., Harris, R.M. (2007). “I try to take care of it myself.” How rural women search for health information. Qualitative Health Research,17(5), 639-651. (top)
MacMillan, H.L., Jamieson, E., Wathen, C.N., Boyle, M., Walsh, C., Omura, J., Walker, J., Lodenquai, G. (2007). Development of a policy-relevant child maltreatment strategy. The Milbank Quarterly, 85(2):337-74. (top)