Translating Knowledge to Practice: The Case for Knowledge Brokering
Margaret Haworth-Brockman, M.Sc.
Public health arose as a field of practice distinct from medicine and nursing in the mid-1800s. The earliest pioneers gathered empirical evidence of what they already perceived to be true: that preventing and treating infectious diseases for the public (or population) as a whole, was beneficial for individuals in a society (1). The first proponents of public health surveillance and prevention established methods to collect and report the data that informed their practice. It appears counter-intuitive, therefore, to find that much of public health practice is not based on empirical evidence or at least, not on current research findings. In fact, studies have consistently found a “failure to translate research into practice and policy” (2) (p. 1), a failure that has been apparent across health care professionals, managers, and policy-makers (3,4). This “know-do gap” as it is called in World Health Organization documents, is a well-recognized problem (5), and, “applying research to guide evidence-based practice is an on-going and significant challenge for public health” (6, p. 1187). There is therefore a “growing concern” among policy makers and researchers “that the fruits of their investment in health research are not reaching the public, policy makers and practitioners with evidence-based practices” (7, p. 151) (see also (8-10).
Knowledge translation has been defined in various ways, as both process and result:
“The use of knowledge in practice and decision-making by the public, patients, health care professionals, managers and policy makers.” (Straus et al. 2011)
“The synthesis, exchange and application of knowledge by relevant stakeholders to accelerate the benefits of global and local innovation in strengthening health systems and improving people’s health.” (World Health Organization, cite Pablos-Mendez)
“Translation moves scientific knowledge from basic discovery to testing for technological efficacy, or from efficacy-tested interventions to testing for effectiveness and acceptability for adoption in practice.” (Green et al.)
The concept of knowledge translation as it is currently used arose in the 1990s (7), and was formalized in the Canadian health sector when the Canadian Institutes for Health Research (CIHR) developed this definition: “knowledge translation is a dynamic and iterative process that includes the synthesis, dissemination, exchange, and ethically-sound application of knowledge to improve the health of Canadians, provide more effective health services and products, and strengthen the healthcare system” (CIHR 2000, as cited in McLean et al. (4)). As the CIHR is the national funding body for health research, this definition was adopted in a deliberate strategy to encourage clinical and other health researchers to consider and convey how their studies would be beneficial and how their results could be adapted to practice settings. Explicitly linking research to practice was deemed essential at the time, and remains so. As the following review of literature will demonstrate, however, this definition does not capture the nuances of the concept, intent, processes or results involved.
Knowledge translation, the deliberate intention to convey research findings for practical application, was understood to be different from, and more than, the long-standing traditions of publishing in peer-review journals and giving presentations at conferences. Much of public health, according to Green et al. rested on a theory that diffusion (the unmanaged, natural spread of information dependent on conversations and other opportunistic meetings) would be sufficient for communication and dissemination of new evidence (7). However, in a review of literature from nursing and other disciplines, Kitson concluded that there is typically a “mismatch between the theories used to explain and influence clinical practice in nursing and the way in which transferring new knowledge into practice is articulated” (11)(p. 217). Or as Greenhalgh and Wiereinge noted, “knowledge obstinately refuses to be driven unproblematically into practice” and this has led to particular difficulties in the fields of “evidence-based management and evidence-based policymaking” (12) (p. 501). Rogers considered this mismatch a cultural gap between researchers and public health policy makers (13, see also (7)).
This document is a narrative review (14) of representative literature concerning current theories and practices in knowledge translation for public health. It draws upon essays and research in public health and other health-related fields, as appropriate, and in particular draws upon summary reviews (e.g. Green et al. (7)). The purpose of this paper is to set some of the context for, and contribute to a 2014 “environmental scan” regarding the future directions, roles and responsibilities of the National Collaborating Centre for Infectious Diseases.
Documents from peer-reviewed and grey literature were retrieved through an on-line search of four databases, CINAHL (EBSCO), Academic Search Complete, Sociological Abstracts and PUBMED, as well as Google Scholar. Search and MESH terms used (depending on the search engine) were “evidence base”, “knowledge translation”, “knowledge exchange”, “knowledge broker” in combination with “health”, “public health” and “infectious disease*”. Publications from the last 10 years were given priority, although some papers retrieved and reviewed were published before 2004. In-paper citations were manually searched to ensure seminal conceptual or discussion papers were not missed. Very few papers (5) were retrieved concerning knowledge translation for infectious disease public health in general.
This review begins with a brief summary of how knowledge and knowledge translation have been described in the selected literature. It is followed by an exploration of some conceptual models that have been proposed and tested. The continuing need for knowledge translators and knowledge translation training are described next and finally, this paper considers opportunities for capacity building and the role of knowledge brokers. Although this paper presents the reviewed literature as if it were a natural progression, it is important for the reader to be aware that within a 10-year period the development of expanding concepts and applications has not been strictly chronological. The world of knowledge translation is messy and complicated.
Mixed Metaphors, Muddled Concepts
What is Knowledge?
In its most simplistic form, knowledge is shorthand for “evidence”, which has been understood to mean empirically-derived results (7,8). Grimshaw et al., for example, proposed that knowledge translation would ideally be based on evidence (results) from randomized-control trials (RCTs) of interventions, and that therefore the basic unit of knowledge translation should be systematic reviews or other syntheses of research findings, specifically of RCTs (2). This view is upheld by a number of authors who agree that the rigour of RCTs ensures that public health interventions are well tested for their efficacy and therefore RCT research forms the basis of evidence-informed decision-making (15). The efficacy of vaccines and vaccine programs are obvious examples where RCTs have provided evidence for infectious diseases public health.
However, other authors challenge this view. In their summary review, Green and his colleagues pointed out that RCTs are a very particular method of research science from which can be derived very specific results for public health interventions, in clearly defined conditions with clearly delineated study parameters (7). On the other hand, RCTs cannot be used to answer other kinds of research questions such as ones concerning public perceptions about an intervention, nor can they account for “geographic spread and diversity of community settings, the role of mass media and social networks, the multiple additional levels at which community or regional interventions must be implemented” (7, p. 153). Other valuable kinds of empirical evidence can also be generated in public health research including survey results, data from qualitative interviews or focus groups, ethnographies, and so on (7). Furthermore, empirically based evidence is just one form of knowledge upon which public health practice is based. In a 2011 study, for example, Kothari et al. found that front-line public health workers draw upon both explicit knowledge and tacit knowledge in their day-to-day practice (16). They define explicit knowledge as often “codified (written) and communicated through language” and use a definition of tacit knowledge from McAdam et al., “knowledge-in-practice developed from direct experience and action; highly pragmatic and situation specific; subconsciously understood and applied; difficult to articulate; usually shared through interactive conversation and shared experience” (cited in (16)). While likely entwined, explicit and tacit knowledge are distinct because of the manner by which they are each acquired and each applied. Similarly, Greenhalgh and Wiereinge encouraged an appreciation of the practical wisdom (phronesis) that underpins clinical judgment as well as what they term “mindlines”, the tacit knowledge that practitioners build over time and share among their peers (12).
It is beyond the scope of this document to dig deeper into the theories and epistemology of knowledge and evidence. It is germane, however, to have noted that the evidence or knowledge on which public health interventions and practice are to be based do not arise solely from the empirical results of controlled studies. This is not to say that such evidence is not important, as will be described in a short discussion of systematic reviews below. The point is to note that “knowledge” in public health does not neatly fit in a box labelled “research evidence” as if they were one and the same.
What is Knowledge Translation?
As noted earlier, the problem of making evidence or knowledge in any of its forms available for practical application is pervasive, and the literature reveals the many ways the problem and its potential solutions are described. Graham and colleagues found 29 terms used in the published literature that refer to some aspect of knowledge translation (17, 18). Not only is there a lexicon of terms invoked but according to the authors, many are used interchangeably, or at least conflated. Some are used as nouns to describe processes, and others, the authors noted, are used as verbs to represent actions or strategies. An entire area of study to describe and evaluate methods and means for knowledge translation (sometimes referred to as implementation research or implementation science has resulted in “competing frameworks and terminology” (6).
Graham et al. found 29 different terms used to describe the process of moving research evidence to practical application:
- Applied health research
- Capacity building
- Competing, cooperation, co-optation
- Getting knowledge into practice
- Knowledge communication
- Knowledge cycle
- Knowledge exchange
- Knowledge management
- Knowledge mobilization
- Knowledge transfer Knowledge translation
- Linkage and exchange
- Popularization of research
- Research into practice
- Research mediation
- Research transfer
- Research translation
- Science communication
- The “third” mission
- Translational research
Knowledge translation was initially implicitly conceptualized as a linear, one-way process: move the knowledge from the producer (researcher) to the user (practitioner). In 2006, Lomas distilled the challenge to five key questions (19):
- What should be transferred?
- To whom should research knowledge be transferred?
- By whom should research knowledge be transferred?
- How should research knowledge be transferred?
- With what effect should research knowledge be transferred?
The five questions illustrate a model wherein knowledge producer assume responsibility to articulate how the knowledge translation will proceed and the desired outcomes. Green et al. described this one-way linear model as a pipeline conveying knowledge evidence from the researcher to the end-user. Among the problems they pointed out were various “leaks” of evidence and other knowledge, lost in the quest for purely empirical results, as well as the fact that there is an average delay of 17 years along the way (7), emphasis added). Even if it were not a leaky pipeline, in the domain of public health interventions this conceptualization also requires a consistency between the circumstances in which the intervention is first tried and the local circumstances in which it is to be applied each time, a premise that Kok et al. pointed out is unrealistic since real-world conditions do not replicate controlled study conditions (20).
As noted, the expression knowledge translation was coined to differentiate the process and results from traditional, passive diffusion and dissemination. However, Fromoso et al. found that although primary data analyses and even secondary analyses of evidence, such as systematic reviews and practice guidelines, should be valid and relevant sources of evidence for public health practitioners, they were typically geared towards other researchers rather than practitioners (21). They found that this kind of knowledge translation was “often not completely intelligible, [did] not explain what it really adds to existing knowledge or which clinical/organizational context to place it in. They concluded that such knowledge transfer was neither accessible nor appealing, and often lacks ‘appeal’ for those who are less informed” (21, p. 950). For example, traditional “lecture-and slide-show” presentations of new knowledge or evidence for practitioners’ continuing education have been shown to be relatively ineffective in changing practice (22). In a review of public health knowledge translation literature, Green et al. found that interventions being translated often did not match with practitioners’ needs, nor with the circumstances in which they worked and in which their clientele lived (7), reflecting the perspective from Kok et al. noted above.
Furthermore, many theories and discussions of knowledge translation were based, if only implicitly, on an assumption that health care systems function mechanistically with inputs leading directly to outputs and desired outcomes. As Kitson pointed out, however, using this paradigm, and therefore studying knowledge translation as if it were strictly linear, conflicts with a more robust and realistic view that understands health care systems as more organic and fluid (11). This becomes more evident when taking into account that the processes and desired outcomes of knowledge translation involve not just researchers and practitioners, but also decision-makers (setting policy for public health), government, funding bodies (including government funding bodies), NGOs and the public at large (23) (7). There are differing political, organizational and social dimensions to knowledge translation among these players, all of which are influenced by differing values and priorities. Lomas and Brown, for example, undertook a study of the results of the Ontario Ministry of Health’s commitment to evidence-informed policy. The participants in their study described policy-making as a balance of political interests, public demand, budgetary constraints as well as the ready availability of the evidence they sought (24, emphasis added). Moreover, policy “windows” or opportunities to translate knowledge to policy, are unpredictable; research that is not considerable valuable at one point may still have considerable value to policy-makers at some later date (25).
An important development in helping to sift through evidence and its application to practice is the greater availability of systematic reviews. As defined by the Cochrane Collaboration Centre, systematic reviews assess the validity of the findings of several or many research studies in combination, particularly with respect to the benefits or harms of health interventions (26). Their value lies in the strict protocols used to find and analyze research evidence related to a specific question; the pre-determined protocols are used to reduce bias. RCTs and meta-analyses of data across studies are the foundations of Cochrane-like systematic reviews, Armstrong et al. (15) and Grimshaw et al. (2), among others, have considered systematic reviews to be an ideal form of knowledge translation in public health. As Dobbins et al. have commented however, while not all randomized control trials may be of sufficient quality to include in a systematic review, not all systematic reviews are of the highest quality either (27). Green et al. have pointed out, also, that the methodological process of systematic reviews necessarily excludes many published papers that could provide important contextual knowledge regarding a particular intervention (7). Welch et al., for example, have critiqued the inability of systematic reviews (or perhaps more correctly, the unwillingness of systematic reviewers) to consider health equity issues, by either ignoring health equity factors or excluding studies which provide context about inequity (28). The weight given to systematic reviews as the “best” form of knowledge translation for public health therefore needs to be critically assessed.
Systematic reviews can provide important information that has been sifted through a precise method of inquiry. They still represent, however, a one-way translation of knowledge from researchers to users (which, according to Green et al., still takes an average of nine years from review to implementation (7)). There has also been greater recognition of the need for knowledge exchange, a two-way, potentially iterative process between researchers and practitioners. Some practitioners may have limited opportunities to learn from and exchange with peers outside of their work-place organization (29), or may see advocating for particular interventions as a conflict, given their vested interests in research results (30). The advantage of creating more conversations rather than lectures is in the opportunities created for practitioners (and this includes policy-makers) to relay what they really need to know to knowledge generators.
Greenhalgh and Wieringa commented that it has been the conceptualization of “translation” that has constrained evidence-based policy-making and applying a wider range of metaphors and models would allow for a more critical and creative examination of the links between knowledge and practice (12). Theories of evidence-based policy making are being re-considered in an attempt to better understand the processes through which knowledge translation occurs, and according to Deas et al., understanding how policy and practice develop has the potential to facilitate effective evidence use (9). Knowledge translation may be better envisaged as a non-linear, iterative, cross-cutting endeavor, a series of processes that involve “not only recent research findings but also the knowledge that is created from the dynamic interaction of people who come together to solve public health problems.” (5, see also (31)). As some authors have noted, the translation of research to policy is more likely to be successful if the issue is articulated in terms of a policy agenda and the evidence is presented in association with a policy solution (9) (32). Their conclusion is that translating surveillance and broader research evidence into policy requires “active management, rather than expecting passive diffusion” (13).
Just as there have been emerging conceptualizations and definitions of knowledge and knowledge translation, there have been a number of models derived to depict the stages and processes of knowledge translation. The Knowledge-to-Action model developed by Graham et al (17) is one example that has been explored by Canadian researchers and policy makers in public health.
In the centre of their model is a funnel through which knowledge is moved in stages from initial inquiry, to synthesis of multiples knowledge sources, to particular “tools” or resources for specific audiences. Attendant, and depicted as encircling this funnel, are stages of problem identification (used either to identify relevant existing knowledge or to inform new knowledge generation), followed by steps used to assess how knowledge is to be adapted and whether the adaptation has been successful. It is interesting to observe that in this depiction there is no explicit link between the processes of adaptation on the outside to knowledge synthesis on the inside, although that was intended.
Other authors have endeavoured to create models describing knowledge translation, as depicted in Table 1.
The variety these models represent illustrates the complexity of knowledge translation, the complexity of the processes involved and the complexity of the systems in which knowledge, researchers, practitioners and the results of knowledge translation must function. If the goal of knowledge translation in public health is indeed effecting change and improving the health of a population, then it is critical to articulate the policy objectives, encompass a broader view of evidence that can be used, and not only assess the evidence for its rigour but also for its generalizability or, at the very least, its adaptability to a particular context and set of circumstances (33).
In their comprehensive review, Green et al., present an entirely different model, one that focuses on the many ways that “use” and “user” can be understood in knowledge translation. Their framework is illustrated here as it applies to surveillance. As the authors noted, “either the need for information can be dominated by contextual subsystems, such as economics or politics, or it can stimulate an information/data partnership among multiple stakeholders… Through a participatory and collective process, decisions can be made about data that would be useful, not just nice to know…” (7, p. 166).
This very brief scan of knowledge translation models illustrates the variety of theories and attempts to classify how knowledge translation “works” and for whom. The obvious conclusion is that this is a dynamic field which many players are thinking about and would like to “get right”. The recently launched journal, Implementation Science, for example, is a newer forum for the on-going discourse on the continued problem of moving knowledge to improve health.
Why Isn’t Everyone Doing Knowledge Translation Well?
In setting up the knowledge translation requirements at the then-new CIHR, the intent was “to promote evidence-based practice and the use of research in practice” (4). Various structures (such as requirements under the CIHR Act itself, and the grant application templates and requirements) were put in place to encourage researchers to consider how their CIHR-funded research would and could be applied to improve the health of Canadians. A 2013 evaluation of the CIHR’s knowledge translation programs, however, found that much remains to be done to a) have researchers consistently undertake knowledge translation and b) teach researchers how to undertake knowledge translation.
Knowledge translation requires a set of skills and resources that may not be immediately apparent and that require time and practice. In a review of the curricula for Public Health programs in Canada, Mishra found that only 14 of 37 university programs provided value statements of KTE (knowledge translation and exchange) activities in the program goals or in the course objectives, and only 10 programs offered KTE training in their curriculum (34). Similarly, Reitmanova noted that medical schools have been slow to provide “medical students and health professionals engaged in research with sufficient opportunities to examine more closely the facilitators and barriers to utilization of research evidence in policymaking and implementation or the effectiveness of their research communication strategies” (35). Newton et al. found statistically significant differences in the perceptions of researchers regarding the importance of knowledge translation activities, with those who were in “applied research” more engaged in knowledge translation than basic researchers (10).
Phillipson, however, has pointed out that if academics are to be “seriously” expected to rethink the ways in which they communicate their findings, “they will need to find strategies for doing so without compromising key aspects of their work.” She noted that knowledge translation in any of its forms requires a shift in thinking from the value of research findings as meritorious in their own right, to “conceptualizing knowledge as a commodity to be packaged for application” (36). This points to a need for skills development programs that focus on analysis of context and process (32).
It is not just academics, however, who must build their skills in knowledge translation. Berta et al. found that the ability to apply knowledge to practice is dependent on the ability of institutions and organizations to facilitate and foster the adaptation of new information (37). Exploring the pathways that “link research to policy makers’ decision-making applications”, Gold found there are many such pathways, none of which is successful in all circumstances. Uptake is more successful, however when findings can be converted into message that are meaningful to policymakers and if they led to ideas that are unambiguous and easy to apply (25). This may not be a new consideration in the realm of knowledge translation but it does emphasize one of the on-going challenges of moving knowledge to action. Lewis contradicts this perspective noting that instead, having to care for individual people makes the “outliers” as important to practitioners as those who fall within a Normal curve of research results. Furthermore, he noted, the sheer enormity of a body of evidence can prevent analyses of what portion is good science and whether it is inherently conflicted (because of funding, for example). In his summary, Lewis wrote: “Indifference to research evidence, then, the inevitable results of the fact that the theorists and producers of that evidence and its hoped-for audiences inhabit different cognitive and empirical worlds. The solution is to recognize the complexities of our epistemological and cognitive make-up, the asymmetries of the estimates of risk and benefit, and the power of and human need for narrative enriched by historical, cultural, political, economic and organizational analysis” (38). His point is to recognize that policy makers are concerned with populations whereas clinicians (or public health practitioners) are necessarily focused on the individuals. The message must match the recipient (see also (39,40)).
The Case for Knowledge Brokers
To restate a point made in the introduction, knowledge translation is messy and complicated, which can also be understood to mean that what is translated, how it is translated, by whom, when and why (questions posed by Lomas (19)) … depends.
Deas et al. and others have concluded that context is of primary importance and that there is no single model of knowledge translation that can be undertaken in all situations (9). It would be more correct to say, in fact, that every situation depends on the players involved and the situations in which they operate. The need for context-specific policy analysis and multiple forms and levels of evidence in health has been argued by scholars of intersectionality (41) for over twenty years (42-46).
As early as 2007, Armstrong et al. speculated that resources developed to apply new evidence to health practice would not truly contribute to change unless those resources were linked to a process of knowledge management (15). Linking knowledge resources, or products, to the process of knowledge translation creates a role for knowledge brokers—agencies or individuals who create opportunities for the multi-level exchange of knowledge (in all its facets), with a goal to integrating evidence in practice.
The creation of the National Collaborating Centres for Public Health in 2004 was to achieve six goals under an overarching mission for the Centres to “…create and foster linkages among researchers, the public health community and other stakeholders…” (47, p. I-1). Paraphrased, the six goals were to:
1) generate knowledge to improve policies and reduce health disparities;
2) produce a better understanding of factors that influence health;
3) produce information about disease and possible measure for prevention and control;
4) contribute to training and mentoring future public health researchers and practitioners;
5) champion best practices in public health; and
6) foster collaboration among public health stakeholders.
Frank et al. noted these goals were ambitious, ranging from knowledge synthesis (secondary research) to training, to knowledge exchange. In their paper, the authors explored the need for knowledge brokering and the role of the NCCs as knowledge brokers (47).
According to Dobbins et al. knowledge brokering was considered an emerging strategy for knowledge translation and exchange by the late 2000s (48). They defined a knowledge broker as an individual or agency that engages with knowledge producers and knowledge end-users in a number of ways: identifying issues with knowledge users that require solutions, bringing producers and users together and determining shared goals as well understandings of respective language, constraints and opportunities (culture) (48).
Conklin et al. (49) summarize the role of knowledge broker in this way: “The knowledge broker adapts to the social and technical affordances of each situation, and fashions a unique and relevant process to create relationships and promote learning and change. The ability to work with teams and to develop relevant models and feasible approaches are critical knowledge broker skills. The knowledge broker is a leader who wields influence rather than power, and who is prepared to adopt whatever roles and approaches are needed to bring about a valuable result.”
Conklin et al. further described knowledge brokers as engaging in a set of relational, technical and analytical activities that help foster the development and operation of communities of practice, or networks. Like knowledge translation itself, the role of the knowledge broker is “difficult to define, emergent, abstract, episodic”, and perhaps not yet fully understood (49). This creates opportunities, however, to remain flexible and responsive, as knowledge brokers can facilitate the exchange of explicit and tacit knowledge among people with similar concerns and interests, to help them work towards solutions in public health. Dobrow et al. described the need to establish policy objectives first in order to then be able to establish the breadth of evidence needed to appropriately answer policy question. They noted that the “interpretation of evidence must acknowledge the varying nature of evidence for different policy objectives, balancing existing emphasis on evidentiary quality with more sophisticated methods for assessing the generalizability of evidence” (33).
Success in public health knowledge translation in Australia, for example, depended on an ability to draw up a number of knowledge translation strategies, collaborations across sectors and disciplines, purposeful relationship-building and an ability to “speak the languages” of media, policy, research and practice (50,51).
Conclusion: Translating Knowledge Brokering for NCCID
Ten years after the NCCs were set up, it is reasonable to re-assess the role of NCCID in knowledge translation for infectious diseases public health. The traditions of knowledge translation, as has been seen earlier in this literature review, are changing as theory and experience have developed. The NCCs collectively and independently have grappled with their particular roles and the best ways to contribute to the continuum of knowledge generation to knowledge uptake.
The role of knowledge broker, as described above, was proposed for NCCID in the 2014 Environmental Scan and Position Paper. Concurrently and since then, NCCID staff have explored the particulars of “what works” to achieve our mandate of providing useable evidence to public health personnel. The results of our inquiries complement the findings of this literature review. That is, NCCID has a role as an interlocutor, facilitating connections between and among individuals and organizations.
As an example, our explorations on effective communities of practice (see Concept Paper, Appendix A) found that, because many community members may be reticent, at least initially, conversations may not proceed easily. In 2015-16, NCCID dedicated time and resources to regularly moderating and encouraging discussions in a community of practice of mathematical modelling researchers and public health decision-makers. Regular communication from the facilitator stimulated new conversations, including some that were quite lengthy, and also encouraged new members to join—more than doubling the membership in four months.
In another example, by staying in touch with the Chief Medical Officers of Health over the past two years, NCCID was able to continue to adapt timely reference materials on emerging infections, most recently concerning the Zika virus outbreaks of 2015-16. Providing medical officers of health and their Chiefs with credible, evidence-based information in formats (web and app based and as podcasts) has been well received (although evaluation follow-up is still to be done).
With these successes in mind, and with clear directions for developing each project in place in the form of the 2016 Communications Strategy, NCCID will continue to serve as knowledge brokers who “connect the connectors”, developing connectors”, developing its role in evidence-informed decision making in infectious disease public health.
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