Key Concepts for Knowledge Translation and Implementation
Planning for Knowledge Translation
KT can be haphazard and ineffective or unrealized if it is not planned in advance and integrated into the research plan. The Knowledge Translation Planning Template® (KTPT) is a well-known framework for guiding KT planning that outlines 13 steps in the dissemination planning process (Barwick, 2008, 2013, 2018; available at http://melaniebarwick.com/knowledge-translation-tools/). Similar key components of KT are discussed in at least two other practice-based documents (Jacobsen, Butterill, & Goering, 2003; Reardon, Lavis, & Gibson, 2006).
Planning with the KTPT begins with identifying project partners and main messages to be shared. Main messages can be stated in general terms if the KT planning is prospective and precedes research findings. The intended KU audiences are identified, and the purpose of the communication—the KT goal—is specified for each main message and KU. KT goals capture the KT purpose and include sharing knowledge, building awareness, informing decision-making, facilitating practice or behavior change or policy, commercialization, and informing research. Certain KT goals pertain to diffusion and dissemination aims, whereas others are the purview of IS. Comprehensive and functional KT activities require the identification of at least one KT goal that must align with a particular KU audience, main message, the strategies best suited to achieving the KT goal, and evaluation metrics that can indicate whether or not the goal was achieved. Evaluating whether KT goals were reached can be achieved with indicators of reach, usefulness, use, partnership/collaboration, program or service effectiveness, policy change, knowledge and attitude change, and/or behavior or systems change (Ohkubo, Sullivan, Harlan, Timmons, & Strachan, 2013).
Planning for Implementation
Planning for implementation is complex and requires a good understanding of what is now a rather extensive empirical literature. Researchers produce many evidence-based practices (EBPs) and interventions that can improve outcomes if successfully implemented. Optimal clinical outcomes depend upon their effective (successful) implementation, but implementation is a complex process that is subject to high rates of failure and can take many years to navigate, making it costly and resource intensive.
The Implementation Game© (Barwick, 2019) is a planning and learning tool that supports implementation of evidence-based practices, interventions or innovations using a group simulation activity. The tool guides an implementation team through five evidence-based core components of implementation that have been simplified to make them pragmatically understandable and useful. The tool is applicable to any context, intervention, or discipline.
Knowledge Translation Strategies for Dissemination and Implementation
As discussed in the previous sections, clinical practice consistently lags behind research evidence in health care and other sectors. For instance, widely cited statistics show that patient care is suboptimal: 30% to 40% of the patients do not receive care in accordance with the established research evidence. For 20% to 25% of the patients, the care received is unnecessary or even harmful (Freedman et al., 2011; Knapp, Simon, & Sharma, 2008). Statistics like these highlight an urgent need to bridge the gap between what is known empirically and what is done clinically in practice. As a result, identifying the most effective KT strategies to improve practice is a key priority in North America (Dault, Lomas, & Barer, 2004; Institute of Medicine, 2001), Australia (Tetroe et al., 2008), and the United Kingdom (Smits & Denis, 2014). In line with this priority, a range of methods, activities, and strategies, commonly labelled as KT strategies, have been developed, tested, and implemented across various professional groups and settings.
KT strategies refer to how knowledge translation is executed; that is, the ways in which evidence is communicated to various target audiences and for various KT goals. Most definitions are quite general and describe KT strategies as vehicles to translate evidence without specifying to what end or the exact goal to be achieved (i.e., diffusion, dissemination, and/or implementation of evidence). This reflects definitional imprecision in the field as a whole (as discussed at the beginning of this review) characterized by a lack of standardized terminology for KT, its components, goals, and related activities (McKibbon et al., 2010). Many definitions focus uniquely on KT for practice change. For example:
KT strategies are used in public health to promote evidence-informed decision making. (LaRocca, Yost, Dobbins, Ciliska, & Butt, 2012, p. 2)
KT strategies . . . include a variety of professional, financial, organizational, and regulatory interventions aimed at changing health care professional behaviour (i.e., change decision-making, change treatment, and management) to be aligned with evidence-based recommendations. (Scott et al., 2012, p. 2)
In contrast, Armstrong and colleagues (2013) clearly outline whether the aim of a KT strategy is diffusion, dissemination, implementation, or a combination:
KT is informed by and builds upon conceptual understandings of the translation of research into practice, for which key theories include diffusion, dissemination, and implementation. Diffusion efforts are generally passive, while dissemination is a more active strategy to promote the spread of particular ideas. Implementation refers to systematic efforts to encourage adoption of evidence and knowledge by overcoming barriers. (Armstrong et al., 2013, p. 2)
The literature has not been explicit about the focus of KT strategies research; in Canada, the tendency has been to use this term in reference to practice change or implementation strategies specifically. “A KT intervention is one which facilitates the uptake of research into practice and/or policy and can also be referred to as research utilization. When KT interventions are aimed at the clinician, organization, or health system level, these can also be considered implementation science interventions” (Tricco et al., 2016, p. 2). With the emergence of IS, there is now a greater consensus that KT includes both dissemination and implementation and that strategies to facilitate practice and behavior change are more commonly labelled as implementation strategies (e.g., Mazza et al., 2013; Powell et al., 2015; Proctor, Powell, & McMillen, 2013).
Types of Knowledge Translation Strategies for Dissemination and Implementation
A range of KT strategies have been evaluated for their effectiveness in achieving various KT goals (Grimshaw et al., 2012; Grol & Grimshaw, 2003):
- Printed educational materials—”distribution of published or printed recommendations for clinical care . . . including clinical practice guidelines, journals and monographs.” (Farmer et al., 2011, p. 4)
- Educational meetings—participation of healthcare providers in conferences, lectures, workshops or traineeships (Forsetlund et al., 2009).
- Educational outreach or academic detailing—”use of a trained person . . . who meets with [providers] in their practice settings to give information with the intent of changing the [providers’ practice].” (O’Brien et al., 2008, p. 3)
- Local opinion leaders—use of providers nominated by their colleagues as ‘educationally influential’ (Flodgren et al., 2010).
- Audit and feedback—”any summary of clinical performance of health care over a specified period of time.” (Jamtvedt, Young, Kristoffersen, O’Brien, & Oxman, 2010, p. 2)
- Reminders—”patient or encounter specific information that is provided via a computer console (either visually or audibly) and intended to prompt a health professional to recall information.” (Grimshaw et al., 2012, p. 8)
- Tailored interventions—”strategies to improve professional practice that are planned taking account of prospectively identified barriers to change.” (Baker et al., 2010, p. 2)
More recently, Powell and colleagues reexamined the literature on KT strategies for practice change—herein referenced as implementation strategies—and provided several useful categorizations (Leeman, Birken, Powell, Rohweder & Shea, 2017; Powell et al., 2015, 2018). Powell and colleagues proposed a consolidated compilation of 73 discrete implementation strategies that a wide range of stakeholders validated through a consensus process. While this is not the first taxonomy or classification of implementation strategies, existing classifications appear to be narrow in scope and typically limited to a specific program, intervention, treatment, field of practice, or medical condition (Powell et al., 2015).
This consolidated compilation “advances the field by improving the conceptual clarity, relevance, and comprehensiveness of implementation strategies that can be used in isolation or combination in implementation research and practice” (Powell et al., 2015, p. 1). Specifically, the compilation provides a list of discrete strategies that can be used to develop a multifaceted implementation strategy, can be systematically assessed for feasibility and effectiveness, and can be used as a tool to assess strategies reported in published research. Definitions provided for each strategy ensure consistency in specifying and reporting of strategies in papers.
KT strategy research has been overwhelmingly situated in health, but new KT strategies are emerging that are more amenable to non-health contexts and KT goals, like building awareness and knowledge. For instance, arts-based KT has emerged as a unique way of disseminating knowledge and engaging diverse stakeholders (Parsons & Boydell, 2012) because it can take several forms: visual (e.g., video, photography, painting), performative (e.g., dance), or literary (e.g., poetry, fiction). The use of arts-based KT has the advantage of communicating research findings and best practices by evoking emotional reactions and relying on different ways of representing a certain experience or knowledge. Despite the increasing popularity of arts-based KT, few studies have examined its effectiveness (Parsons & Boydell, 2012). A few studies have demonstrated promising results such as practitioners’ increased awareness and understanding of patient issues (e.g., Colantonio et al., 2008), intention to change clinical practice (Gray, Fitch, Labreque, & Greenberg, 2003), as well as decreased sense of isolation and normalization of illness-related struggles in patients (Mitchell, Jonas-Simpson, & Ivonoffski, 2006). Given that arts-based KT involves diverse stakeholders with fundamentally different backgrounds (scientists, artists, patients, practitioners), the evaluation of arts-based KT is necessarily a complex task that needs to be informed by multiple perspectives to capture a range of outcomes (Parsons & Boydell, 2012).
Advanced social media also is changing how people communicate, share content, interact, and collaborate. Social media has arguably become a valuable platform with tremendous engagement and reach potential for facilitating knowledge sharing and communication (Ahmed, Ahmad, Ahmad, & Zakaria, 2018). Social media tools offer greater opportunities for rapid knowledge flow between people working across different geographical areas and contexts, compared to what can be achieved through traditional search engines or databases (Panahi, Watson, & Partridge 2016).
KT strategies are used either individually (called single, simple, or discrete strategies; e.g., printed educational materials, reminders) or in combination (called multifaceted or multicomponent strategies; e.g., training, consultation, audit, and feedback are combined to form a multifaceted strategy) (Proctor et al., 2013). Early KT research focused heavily on the effectiveness of discrete versus multifaceted strategies (Mazza et al., 2013). Most early studies did not provide any rationale for the component selection in multifaceted strategies or discuss their potential interactions (Grimshaw et al., 2012). Some multifaceted strategies were manualized or branded, such as the Availability, Responsiveness, and Continuity (ARC) organizational implementation strategies (Glisson et al., 2012), the Institute for Healthcare Improvement’s learning collaborative (Institute for Healthcare Improvement, 2003), and the Getting to Outcomes framework (Chinman, Imm, & Wandersman, 2004). Further complicating the nomenclature for KT strategies, the terms used to identify multifaceted strategies and their components have been quite variable. In some cases, multifaceted strategies have been labelled as “implementation strategies” comprised of multiple implementation interventions or as implementation programs that included multiple implementation strategies (Proctor et al., 2013).
Effectiveness of Knowledge Translation Strategies for Implementation
During the last decades, there was keen interest in identifying the most effective KT strategies in order to maximize practice change. Researchers persistently asked, “What works best?” and “what are the most effective KT strategies?” in the search for a prescriptive answer. A definite list of KT strategies that work effectively and offer a limited number of safe options would surely make researchers’ and practitioners’ jobs easier. Reviews of KT strategy effectiveness studies, however, demonstrate limited success in identifying KT strategies that are reliably effective in all contexts. Rather, research has identified KT strategies that are effective for specific areas of practice (e.g., public health, rehabilitation; LaRocca et al., 2012; Menon, Korner-Bitensky, Kastner, McKibbon, & Straus, 2009), clinical areas (e.g., spinal cord injury, child and youth mental health; Barwick et al., 2012; Noonan et al., 2014), or professional groups (e.g., physicians, nurses, allied health professionals; Bero et al., 1998; Grimshaw et al., 2004; Oxman, Thomson, Davis, & Haynes, 1995; Thompson, Estabrooks, Scott-Findlay, Moore, & Wallin, 2007). Table 5 illustrates this point by providing recent examples of KT reviews.
Table 5. Selective Summary of Recent Systematic Reviews of KT Strategies
| Study | KT Strategies/Focus (professional group, clinical area, etc.) | KT Strategies Effectiveness |
|---|---|---|
| Albrecht, Archibald, Snelgrove-Clarke, & Scott (2016) | KT strategies used to support the implementation of research into pediatric practice (e.g., educational materials, meetings and outreach visits, multidisciplinary teams, audit and feedback, reminders). | Three KT strategies were shown to be effective in studies with moderate to strong methodological quality: two single KT strategies (reminders; clinical multi-disciplinary team) and one multiple, educational intervention (educational meeting train the trainer; educational meeting group session lead by trainer; educational outreach visits). |
| Bornbaum et al. (2015) | KT strategy—knowledge brokers; health-related settings. | Knowledge brokers perform a variety of tasks to transfer and exchange information, but inconclusive evidence regarding their effectiveness because only two studies had acceptable methodological rigor. |
| Brouwers et al. (2011) | Nineteen KT strategies (patient education, decision aids, reminders, audit and feedback, local opinion leaders, guidelines to professions allied to medicine, health information technology); cancer control. | Most interventions were rated as promising but needing additional study; difficult to draw conclusions because of uneven methodological quality and limited descriptions of the KT strategies used. |
| Dobbins et al. (2009) | Three KT strategies (access to an online registry of research evidence; tailored messaging; and a knowledge broker) promoting the incorporation of research evidence by public health decision-makers into public health policies and programs promoting healthy body weight in children. | Under certain conditions tailored, targeted messages are more effective than knowledge brokering and access to an online registry of research evidence. In addition to KT strategy selection, greater emphasis must be placed on the identification of organizational factors in order to implement strategies that best meet the needs of individual organizations and fit the context. |
| Gagliardi et al. (2016) | Patient-mediated, single, and multifaceted KT strategies: print materials (brochures, booklets), electronic materials (video, computer program, website), and counselling; health care in cancer and arthritis. | Single interventions involving print material achieved beneficial outcomes, as did more complex interventions. Few eligible studies, and even fewer had acceptable methodological quality. |
| Grudniewicz et al. (2015) | KT strategy: printed educational materials; primary care physicians (knowledge and behaviors); patient outcomes. | Printed educational materials were not effective at improving patient outcomes, knowledge, or behavior of primary care providers. It is recommended for further trials to examine ways to optimize the effectiveness of this strategy and provide detailed information on the design of the materials. Most studies lacked details needed to replicate the intervention. |
| Noonan et al. (2014) | KT interventions (training for clinical staff, computerized reminders, involving organizational leaders) for assisting implementing practice change in the area of the spinal cord injury (SCI) care. | The methodological quality of the studies was mostly poor. There were too few studies and inconsistent results—it is difficult to identify effective KT interventions in SCI care. Interactive KT education for health care providers has a positive effect on patients’ function, but its benefits for other health provider- and patient-related outcomes are inconsistent. Interactive education for patients leads to improvements in knowledge and function. |
| Petkovic et al. (2016) | KT strategy: any type of evidence summary, policy brief, or other products derived from systematic reviews that presented evidence in a summarized form; health policymakers. | Two studies assessed the use of evidence summaries in decision-making and found that they made little to no difference. There also was little or no difference in effect for knowledge, understanding or beliefs (four studies), and perceived usefulness or usability (three studies). Evidence summaries were easier to understand than complete systematic reviews, but their ability to increase the use of systematic review evidence in policymaking is unclear. |
| Scott et al. (2012) | KT strategies; allied health professionals: dietetics, occupational therapy, pharmacy, physiotherapy, speech-language pathology. | Thirty-two studies: A variety of single and multiple KT interventions were identified, with educational meetings being the predominant KT strategy. Generally, the studies were of low methodological quality, and the majority of interventions demonstrated mixed effects on primary outcomes. Only four studies demonstrated statistically significant, positive effects on primary outcomes: multiple, education-only interventions such as educational material and educational meeting/ educational outreach visits; educational materials only. |
| Yost et al. (2015) | KT interventions for promoting evidence-informed decision-making (EIDM) among nurses in tertiary care. Almost all studies included an educational component. | No studies evaluated the impact on knowledge and skills; the focus was on the effectiveness of multifaceted KT strategies for promoting EIDM and improving client outcomes. A meta-analysis of two studies determined that a multifaceted intervention (educational meetings and use of a mentor) did not increase engagement in EIDM. Overall, it is difficult to draw firm conclusions about strategy effectiveness because of study limitations. Qualitative studies highlighted a range of factors (organizational, individual, and interpersonal characteristics of the innovation) with the potential to influence implementation success. |
In addition to studies examining the effectiveness of KT strategies for a specific clinical area or professional group, the Cochrane Effective Practice and Organization of Care (EPOC) group has led several overviews of systematic reviews and conducted many high-quality systematic reviews of professional, organizational, financial, and regulatory interventions (Grimshaw et al., 2012). Overall, these reviews show improvements of various magnitudes in selective outcomes with the use of specific KT strategies (as summarized by Grimshaw et al., 2012). For instance, results for:
- Printed educational materials from 12 randomized trials and 11 nonrandomized studies showed relatively small improvement of care (median absolute improvement of 4.3%, range of -8.9% to +9.6%) on process outcomes such as x-ray requests, prescribing, and smoking cessation activities.
- Educational meetings from 81 randomized trials in which more than 11,000 health professionals indicated (a) median absolute improvement in care of 6% (interquartile range of +1.8% to +15.3%) and (b) larger effects associated with higher attendance rates and more interactive meetings.
- Audit and feedback from 118 randomized trials found a median absolute improvement in care of 5% (interquartile range +3% to +11%).
- Local opinion leaders from 18 randomized trials, 296 hospitals, and 318 primary care physicians showed a median absolute improvement in care of 12% across studies (interquartile range +6% to +14.5%).
- Computerized reminders from 28 randomized trials showed a median absolute improvement in care of 4.2% (interquartile range +0.8% to +18.8%).
KT strategies, then, can facilitate change, but no strategies are universally effective in all contexts (LaRocca et al., 2012). Educational strategies seem to work for improving prescribing behavior and prevention in primary care. Computerized reminders are particularly effective for prevention (vaccination, cancer screening), and financial interventions improve prescribing behaviors (Grol & Grimshaw, 2003). It is very important to emphasize that KT strategy effectiveness requires consideration of the KT goal, the knowledge being shared, the KUs involved, and the mechanisms of change and evaluation.
Common Issues for Implementation Effectiveness Studies
Change requires attention to process, facilitative or hindering factors, and implementation outcomes; consideration of implementation strategy; and empirical evidence. Although KT strategies can lead to improvements in key outcomes, their effectiveness can vary widely, suggesting that contextual factors potentially influence their effectiveness (Armstrong & Kendall, 2010; Dobbins et al., 2009; Grimshaw et al., 2012). The success of the KT strategies thus depends on the extent to which barriers to KT can be overcome throughout the implementation process. To this end, maximizing the success of any KT effort means identifying and addressing modifiable and non-modifiable barriers (Grimshaw et al., 2012).
Implementation is complex and multidimensional, and effectiveness requires an understanding of the mechanisms of change, methods, measures, TMFs, contextual factors, and all their possible interactions (LaRocca et al., 2012). Establishing the effectiveness of implementation approaches requires the use of randomized designs complemented by mixed methods that can provide deeper insight into KT processes, people’s experience with the implementation endeavor, and how implementation strategies may vary with context. Relatedly, several authors have emphasized the importance of theory in the selection of KT strategies, as they serve to articulate an expected path or mechanism toward expected outcomes (Scott et al., 2012). Although important, theory driven KT strategies are rarely reported in the literature: fewer than 10% of the studies on guideline implementation had an explicit theoretical basis for the selection of KT strategies in 2003 (Davis et al., 2003). This has shifted over the years, such that of 63% of process evaluations used alongside trials of implementation interventions cited a theoretical approach. However, only a quarter of these studies were informed by, or applied, or tested a theory (McIntyre, Francis, Gould, & Lorencatto, 2020).
Several methodological and terminological concerns common to the majority of studies of implementation strategy effectiveness hinder our ability to draw firm conclusions about what works best in what context. For instance, as noted in the summary table, many studies evaluating implementation strategies are methodologically weak, making it difficult to both synthesize findings across studies and develop compelling KT practice recommendations (Albrecht et al., 2016). Results synthesis is further complicated by imprecision and variability in the terms used for KT strategies as well as the limited descriptions provided for the KT strategies that were evaluated (Powell et al., 2015; Proctor et al., 2013).
Reporting Standards for Implementation Research
Although implementation strategies are the engine for practice change, their potential has not been fully realized. Implementation strategies “are often inconsistently labelled and poorly described, are rarely justified theoretically, lack operational definitions or manuals to guide their use, and are part of ‘packaged’ approaches whose specific elements are poorly understood” (Proctor et al., 2013, p. 1). Implementation strategies need to be fully and precisely described with sufficient detail to enable measurement and reproducibility of their components (Craig et al., 2008). To address these limitations, Proctor et al. (2013) outline prerequisites for measuring implementation strategies. These include naming the strategy using language that is consistent with existing literature; operationally defining the implementation strategy and its discrete components; specifying the actors who enact the strategy, the actions enacted, and the targets of these actions; the temporality of when strategies are used and their dose; the implementation outcomes affected; and the empirical, theoretical, or pragmatic justification for selecting the implementation strategies.
Several reporting standards have attempted to remedy poor reporting in implementation. The Workgroup for Intervention Development and Evaluation Research (WIDER) Recommendations (Michie, Fixsen, Grimshaw, & Eccles, 2009) call for the provision of detailed descriptions of interventions and implementation strategies in published papers, including change processes and design principles, access to manuals and protocols for the clinical interventions or implementation strategies, and detailed descriptions of active control conditions. The Standards for Quality Improvement Reporting Excellence (SQUIRE; Davidoff, Batalden, Stevens, Ogrinc, & Mooney, 2008) suggest similar accommodations.
More recently, the StaRI (Pinnock et al., 2017a) provided guidelines for transparent and accurate reporting of implementation studies, specifically. Informed by the findings of a systematic review and a consensus-building e-Delphi exercise, an international working group of IS experts discussed and agreed on the StaRI Checklist comprising 27 items. The tool prompts researchers to describe both the implementation strategy (techniques used to promote the implementation of an underused evidence-based intervention) and the effectiveness of the intervention that was being implemented. An accompanying Explanation and Elaboration document (Pinnock et al., 2017b) details each of the items and their rationale and provides examples of good reporting practice. Adoption of StaRI will improve the reporting of implementation studies, potentially facilitating translation of research into practice and improving the health of individuals and populations.
Adopting reporting guidelines would improve research methodology prospectively and address many of the problems that plague implementation research, including inconsistent labelling, poor descriptions, and unclear justification for the use of specific implementation strategies (Proctor et al., 2013). Use of standards would also simplify meta-analysis and replication and render implementation strategies more comparable across studies and contexts by encouraging consistent labelling and description.
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