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Knowledge Translation into Policies and Programs: Lessons from 18 Years

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Title: Knowledge Translation into Policies and Programs: Lessons from 18 Years


1
Knowledge Translation into Policies and Programs
Lessons from 18 Years Experience Professor John
Frank Director Scottish Collaboration for Public
Health Research and Policy, Chair, Public Health
Research and Policy, University of Edinburgh
2
Outline
  • Background What is knowledge transfer
  • Transfer to whom? Which knowledge? a suggested
    typology
  • Some observations from the authors Canadian
    experience
  • Provostial Advisor for Population Health,
    University of Toronto, 1994-7
  • Research Director, Institute for Work and Health,
    1991-2008
  • Scientific Director, Canadian Institutes of
    Health Research KT (2000-8) as seen from a PH
    viewpoint
  • Chair, Advisory Council, National Collaborating
    Centres for Public Health -- Public Health Agency
    of Canada (2004-9)
  • Progress Report Scottish Collaboration for
    Public Health Research and Policy (2008-9)
  • Final thoughts

3
Background What is Knowledge Transfer?
  • Virtually every major health research funding
    agency in the Western world has embraced the need
    to foster knowledge transfer
  • The application of research results to policy,
    program and practice settings, via the synthesis
    and translation of findings for use by
    decision-makers in those settings i.e. getting
    knowledge into action.
  • The most sophisticated of these efforts e.g.
    Canadian Health Services Research Foundation
    (founded by Jonathan Lomas a decade ago)
    emphasize several key principles of successful
    KT in the worlds of health services and public
    health as opposed to the world of translational
    (bio)medicine (i.e. bench to bedside)

4
Some Established KT Principles (focussed on HS
and PH Research)
  • Joint researcher and decision-maker planning and
    execution of research, from the start
  • Selection and framing of the research
    question(s), to be addressed, so as to speak to
    decision-maker needs
  • Pro-active intelligence-gathering, throughout the
    project, about probable decision-maker reactions
    to the results, and their changing needs,
    informing strategic updates of project KT
    strategy
  • Passive dissemination of results through
    traditional academic channels (conferences,
    publications) is not enough the media utilized
    must fit the audience
  • KT process must be driven by both research-user
    pull and by targeted, inter-active researcher
    push
  • Timelines can be long James Lind and citrus for
    scurvy
  • Reference Lomas J. Using linkage and exchange to
    move research into policy at a Canadian
    foundation. Health Affairs 2000 19(3)236-240.

5
ASIDE Why did Linds RCT and other scurvy
research take gt 4 decades to influence Navy
policy?
  • In a thoughtful revaluation of Linds work,
    Michael Bartholomew of the Open University points
    out
  • Lind himself waffled for decades on his own
    conclusions, and much of his writing was
    impenetrable
  • Powerful alternative scientific viewpoints had
    strong theoretical reasons to reject the idea of
    a nutritional deficiency
  • Many competing hypotheses had equivalent
    anecdotal support (the evidentiary standard of
    the time)
  • The Royal Navy did not have any precedent for
    science-based decision-making at least in the
    health field
  • Bartholomew, M. James Lind and scurvy a
    revaluation. J Maritime Res 2002, available at
    http//www.jmr.nmm.ac.uk/server/show/conJmrArticle
    .3/viewPage/1

6
General Principles are fine, but
  • Experience shows that best practices in KT vary
    greatly across the primary audience of
    research-users being targeted
  • Some widely recognized types of audiences,
    necessitating different KT approaches, include
  • The general public, including patient populations
    with particular conditions
  • Health professionals in clinical practice
  • Managers of health services -- both clinical and
    public health
  • Higher-level policy-makers (usually public
    sector, but sometimes third sector and private
    sector as well)
  • ERGO TRANSFER TO WHOM? IS A CRITICAL
    CONSIDERATION

7
What (sorts of) knowledge?
  • Some KT audiences have strong preferences for
    certain sorts of knowledge
  • The public often prefer an engaging narrative,
    with compelling examples qualitative research
    has the edge but the costs of far-reach and
    long-impact are very high, as all ad-men know!
  • Clinical professionals prefer pre-digested
    knowledge (e.g. relevant studies have been found,
    critically appraised for quality and crisply
    summarized) and then automatically pushed to
    them preferably by a trusted and arms length
    source in a quickly scan-able format, ideally
    integrated into their work (e.g. in primary care
    screen pop-ups cued by key words in the clients
    reason for the encounter, such as Chief
    Complaint, or Age and Gender for preventive
    measures.)
  • Higher-level program managers and policy-makers
    virtually never make major decisions alone they
    need the use of evidence integrated into their
    organizations normal group processes of decision
    making very concise lay-versions of the facts,
    in order to be read by such busy persons, should
    come in at least 3 sizes 1,3,5 pages.
  • ERGO,WHICH KNOWLEDGE? IS ALSO A CRITICAL
    CONSIDERATION

8
Experience 1 Making Heath Data Maps a
Community-University Research Collaboration
(University of Toronto, 1994-7)
  • Experience with researcher cum research-user
    (i.e. decision-maker) consortia -- for
    planning/designing, executing and using applied
    research of interest to both -- suggests
  • cultural differences between these two worlds
    are significant, and take time to bridge e.g.
    their training, underlying assumptions, language,
    incentives and reward systems at work, competing
    demands, time-scales, etc.
  • Buckeridge DB, Mason R, Robertson A, Frank JW,
    Glazier R, Purdon L, et al. Making health data
    maps a case study of a community/university
    collaboration. Social Science Medicine 2002
    55(7)1189-1206.

9
Lessons from Researcher/User Consortia (contd)
  • The wide range of research questions that are
    relevant in such work, especially if it involves
    new policy or program interventions, often spans
  • environmental scans i.e. who has done what in
    this field?
  • syntheses of available evidence, of many kinds
  • detailed social science studies of new policy or
    program acceptability among key stakeholders
  • novel effectiveness trials to assess both mean
    effects and subgroup effects (re equitability)
  • health economic studies
  • detailed implementation and scalability studies
    and
  • policy-analytic studies on the facilitators and
    barriers to adoption of a new intervention.

10
Lessons from Researcher/User Consortia (contd)
  • The mix of methodological approaches therefore
    necessitated is often very broad, requiring more
    than one universitys/research-centres
    engagement and a trans-disciplinary approach
    (sometimes requiring specialized peer-review, and
    partnered funding by a range of granting agencies
    and other sources.)
  • Trans-disciplinary research is a tender plant,
    requiring fertile soil, and some deeply silod
    universities just arent suitable for such
    experiments!

11
Experience 2 Institute for Work and Health -
Toronto (1991 to 2007)
  • Some fields of applied research have particularly
    untrusting stakeholders, with long histories of
    contended science e.g. occupational health
  • IWH was set up to overcome this distrust, and
    selected an edge of campus, independent-institut
    e model, with several key features
  • Seconded professors from gt1 university, and many
    grad students, all well funded in a welcoming
    setting
  • Multi-partite BoD, with reps from government and
    the university, in addition to labour,
    management, and the insurer (providing the core
    funding 5 million p.a.)
  • Peer-reviewed grants provide complementary
    funding
  • Separate peer-review of all scientific
    activities, initially twice annually, by an
    international Scientific Advisory Committee
    (first Chair Sir Michael Marmot, 1991-1996).

12
KT Lessons from IWH, 1991-2008 (contd)
  • Some topics are too contentious to research in a
    way that all stakeholders will agree on e.g.
    documenting exposure to established toxic
    substances in the workplace needs strong
    regulatory/legislative action FIRST You cant
    do research in a bar-room brawl.
  • Some kinds of research require YEARS of
    trans-disciplinary integration, and new methods
    development, before key tools are ready to tackle
    large empirical projects e.g. learning to use
    workers compensation insurance (administrative)
    data for research on the long-term prognosis of
    low back pain/RSIs.
  • Reference IWH website www.iwh.on.ca

13
KT Lessons from IWH, 1991-2008 (contd)
  • Keeping your reputation for independence and
    integrity intact is the only route to long-term
    survival the edge-of-campus model has many
    advantages in this regard.
  • The full occupational health KT process, from
    doing new research to fully engaging the OSH
    community in its use, takes many years one must
    be patient!
  • Reference IWH website www.iwh.on.ca

14
Experience 3 The KT Journey at the Canadian
Institutes for Health Research, 2000-2008
  • In 2000, the Canadian federal government agreed
    to greatly increase flagging health research
    expenditures IF there was a greater commitment,
    by the funding agency the old MRC (Canada)
    and its grantees, to move research results
    towards application, of all kinds.
  • This led to the formation of the Canadian
    Institutes of Health Research, with 13 separate
    Institutes, each targeting a major field, but
    with only 1 of the budget which has not
    increased in the ensuing eight years.
  • The Institute of Population and Public Health
    found itself as the only national-level funder
    dedicated to that field which was very
    under-developed (no CDC Atlanta, and no Schools
    of Public Health, in the whole country.)
  • The pressure to do something for KT was
    relentless, but the funding was not there to do
    it properly (given competing demands).

15
CIHR- Institute of Population Public Health
Mission Statement
  • The CIHR-IPPH will support
  • research into the complex interactions
    (biological, social, cultural, environmental),
    which determine the health of individuals,
    communities, and global populations and,
  • the application of that knowledge to improve the
    health of both populations and individuals,
    through strategic partnerships with population
    and public health stakeholders, and innovative
    research funding programs.

16
Reflections from CIHRs Institute of Population
and Public Health
  • Before we could address a knowledge translation
    agenda, we had to strengthen the capacity of the
    public health infrastructure to effectively use
    population and public health (PPH) evidence
  • 2003 Future of Public Health Report,
    signalling the fragility of the Canadian public
    health system (before SARS and the Naylor Report)
  • 2005 Major concept paper to guide a knowledge
    synthesis, transfer and exchange in public
    health, which is now informing the six National
    Collaborating Centres for Public Health
  • Created individual and structural incentives to
    meaningfully engage public health policy makers
    and practitioners in research planning and
    governance, in order to foster prompt application
    of knowledge to PPH policy and practice
  • Centres for Research Development
  • Applied Public Health Chairs
  • Reference Kiefer L. et al. Can J Publ Hlth
    2005 May-June I1-I40.

17
Lessons from CIHR, 2000-2008 (contd)
  • Some things at CIHR had to change
  • Previously only universities could administer
    grants and essentially only professors could hold
    them not consortia involving users.
  • Over-reliance on passive, response-mode granting
    best suited to the basic biomedical sciences in
    the lab had held back PPH and HS (and even some
    clinical) research in Canada, due to lack of
    strategic (needs-led) investments, based on
    analysis of infrastructural gaps.

18
Lessons from CIHR, 2000-2008 (contd)
  • Decades of unchanged structures and processes for
    research training had led to a professoriate only
    familiar with the passive, response-mode granting
    model and very protective of it.
  • They were thus unprepared to lead Training
    Programs, Centres and Networks that include KT in
    their mandate (e.g. requiring, for funding
    eligibility, co-governance with a research user
    community) and their institutions likewise.
  • All of this has been started but much of it
    will take a whole generation of researchers to be
    replaced, before it can be completed Thomas
    Kuhns paradigm shift.

19
Canadas National Collaborating Centres for
Public Health (2004-2009)
  • As the lack of resources became evident at CIHR
    to do KT for public health in Canada, fate came
    to the rescue
  • A major SARS outbreak in Toronto, in early 2003,
    led to the formation of Canadas first
    semi-autonomous Public Health Agency (PHAC) and
    the appointment of a Chief Public Health Officer,
    and a sub-Minister for Public Health
  • The Agency soon realized that no one was
    responsible for either KT or professional
    continuing education/ upgrading for any public
    health professionals in Canada there had been
    total neglect, and for years, buck-passing across
    federal/provincial/local governments.
  • The Agency established, by six arms length
    grants, six Centres across Canada to do
    KS(Synthesis)TE (Exchange) for public health
    professionals and decision-makers in six key
    topic areas.
  • Reference Frank JW, Di Ruggiero E, Mowat D,
    Medlar B.
  • Developing knowledge translation capacity in
    public health
  • the role of the National Collaborating Centres.
    Canadian J Public Health
  • 2007July-August1-12

20
Six NCCs across Canada
  • NCC for Environmental Health - British Columbia
    Centre for Disease Control (BCCDC), Vancouver -
    Scientific Lead - Dr. Ray Copes
  • NCC for Aboriginal Health - University of
    Northern British Columbia, Prince George, BC -
    Scientific Lead - Dr. Margo Greenwood
  • NCC for Infectious Diseases - International
    Centre for Infectious Diseases, Winnipeg -
    Scientific Lead - Dr. Margaret Fast
  • NCC for Methods and Tools - McMaster University,
    Hamilton - Scientific Lead - Dr. Donna Ciliska
  • NCC for Healthy Public Policy - Institut national
    de santé publique du Québec (INSPQ), Montréal -
    Scientific Lead - Mr. Francois Benoit
  • NCC for the Determinants of Health - St. Francis
    Xavier University, Antigonish, NS - Scientific
    Lead - Ms. Hope Beanlands

21
The NCCs from Coast to Coast
Prince George, BC
Antigonish, NS
Vancouver, BC
Winnipeg, MB
Montreal, QC
Hamilton ,ON
22
Some Lessons Learned from the NCCs
  • Separation of KSTE units from research
    environments, whilst facilitating their freedom
    to engage with user-communities, comes at a price
    skilled research synthesizers are hard to
    recruit and retain.
  • Some user audiences e.g. aboriginal community
    groups require creative use of novel summaries
    of traditional knowledge.
  • Dedicated public-sector funding is key, distinct
    from research funding per se but long-term
    sustainability likely requires co-funding from
    employers of public health professionals, and
    through professional development fees added to
    their annual association dues/ professional
    college memberships.

23
The Scottish Collaboration for Public Health
Research and Policy Background
  • April 2001 DoH Pattison Report A Research and
    Development Strategy for Public Health
  • Need to involve users in all parts of the
    research process and improve the current
    evidence base, including prioritizing new public
    health research.
  • February 2004 Wanless Report Securing Good
    Health for the Whole Population
  • Recommended strengthening public health
    research highlighted the need for greater
    investment in intervention research and greater
    links between academia and practitioners to
    achieve research on a greater scale.
  • March 2004 Wellcome Trust Frankel Working
    Group Report Public Health Sciences Challenges
    and Opportunities
  • U.K. needs to re-establish public health
    partnerships between universities and the NHSto
    bring together public health science, social
    science, and public health service delivery.
    develop more evidence-based policies.

24
SCPHRP Background (contd)
  • 2006-7 (reported June 2008) UK Clinical Research
    Collaboration (CRC) Public Health Research
    Strategic Planning Group (Chair Prof. Ian
    Diamond)
  • Recommendations included
  • Multidisciplinary and collaborative working
    should be encouraged both within the public
    health research community and between academics,
    practitioners and policy makers.
  • .. need for more research evaluating
    interventions and policies.
  • This Report led to the recent (2008) funding of
    five CRC Centres of Excellence in Public Health,
    based in Belfast, Cambridge, Cardiff, Newcastle,
    and Nottingham, each focused on a specific area
    of PH research (Scientific Advisory Panel chaired
    by Prof. Sally Macintyre.)

25
Founding of the SCPHRP
  • 2006 meetings of Scottish public health research
    and policy/program and practice communities
    examined the best way to strengthen the field
  • Recommended that pump-priming funds from the
    MRC and Chief Scientist Office be used to set up
    a Scottish Collaboration for Public Health
    Research and Policy, to move forward on the above
    recommendations in the Scottish context
  • Mid-2007 International competitive search led to
    hiring of Director, who made several introductory
    visits, taking up the post in July 2008.

26
Mission of the Scottish Collaboration for Public
Health Research Policy
  • To identify key areas of opportunity for
    developing novel public health interventions that
    equitably address major health problems in
    Scotland, and move those forward.
  • To foster collaboration between government,
    researchers and the public health community to
    develop a national programme of intervention
    development, large-scale implementation and
    robust evaluation.
  • Build capacity within the public health community
    for collaborative research of the highest
    quality, with maximum impact on policies,
    programs and practice.

27
The Process
  • SCPHRP will convene a series of consensus
    workshops to prioritise potential interventions
    for development, and to establish a series of
    Working Groups organised around key prevention
    opportunities in the life course
  • Early years
  • Teenage and early adulthood
  • Early to mid-working life
  • Later life
  • Each Working Group will develop a three-year work
    programme designed to support the development and
    piloting of a few promising and novel
    interventions, eventually at the national program
    and policy level.
  • SCPHRP will facilitate the work of the Working
    Groups and provide limited pump-prime funding, as
    well as direct support.
  • Depending on the outcome of these preliminary
    studies, the final outputs from the Working
    Groups should be large-scale intervention-grant
    submissions to U.K. and Intl agencies, by 2012.

28
Aims of Initial SCPHRP Workshop (Edinburgh,
Jan. 27-28, 2009)
  • To initiate four SCPHRP Working Groups
  • Early life
  • Teenage and early adult life
  • Early to mid-working life
  • Later life
  • To identify prioritized opportunities for the
    further development, and robust testing, of
    promising (but unproven) public health program
    and policy interventions that could equitably
    improve Scotlands health, for Working Group
    action

29
Overview of Jan. 27-28 Workshop Results
  • Superb participation over 85 of the 70
    invitees attended, representing diverse fields
    of
  • Public health professional practice, program
    management, and policy-makers the users of
    public health research
  • Researchers from over a dozen different academic
    disciplines, representing over a half-dozen
    universities and independent research units
    across Scotland

30
Partial Summary of Priority Intervention
Categories Selected by SCPHRP Workshop
Life-course Groups
  • Early Life interventions to improve parenting,
    especially for high-risk families, with special
    attention to maternal-infant mental health
    outcomes
  • Teenage and Early Adult Life interventions,
    including high-risk targeting, to facilitate
    social, cultural and family connectedness, and
    mentoring, so that young people make sound
    decisions about health-related behaviours and,
    manage life transitions successfully
  • Early to Mid-Working Life Interventions to
    tackle our obesogenic environment socio-cultural
    and physical work and health interventions
    e.g. to prevent sickness absence
  • Later Life Interventions to maintain function
    and independence as long as possible, so as to
    reduce unnecessary or premature disability and
    dependency

31
Subsequent Working Group Development
  • 58 members of the public health community (43
    research 15 policy/practice) agreed to
    participate in one or more of 4 Working Groups
  • Each WG met for a half day meeting in late April
  • Meeting aims were to
  • Consider the priority areas identified at the
    consensus workshop
  • Confirm that areas identified are still of
    interest and refine further
  • Identify potential contributions of WG members
    relevant to the areas identified.
  • Process of and outcomes from WGs differed, with
    Working Life and Later Life WGs making most
    progress towards agreeing focus of their future
    Work Plans
  • Contributions from policy leads revealed that
    there was a considerable amount of policy driven
    activity relevant to the Early Life and
    Adolescence WGs
  • This underlined the importance of a continuing
    dialogue between policy and research and
    practice
  • to ensure a common understanding among all WG
    members
  • to identify a particular niche for activity of
    WGs

32
Building SCPHRP Capacity
  • 4 SCPHRP Career Development Fellowships (3 years)
  • Remit to support the activities of the WGs
  • Excellent response to job advert
  • 4/6 candidates interviewed offered posts
  • All have accepted one started July 1
  • Other three in post by September 2009
  • SCPHRP Internship for MRC PhD Student (1 year
    placement)
  • 1 candidate accepted placement
  • Specialist Registrar (Public Health) Trainees
    (6mth placement)
  • Agreement in principle for SCPHRP to become
    accredited training placement
  • Opportunities for SCPHRP placements will be
    publicised through Scottish StR network

33
Evaluation of SCPHRP Initial Thoughts
  • SCPHRP represents a bold experiment in capacity
    building in public health leading to the
    development, implementation and evaluation of
    public health interventions
  • AND should be subject to independent evaluation
    (both formative and summative)
  • An initial step will be to develop a preliminary
    logic model in conjunction with key stakeholders,
    which outlines inputs, activities and outcomes of
    the collaboration and sets them within a
    timeframe.
  • The preliminary logic model will provide the
    basis for a commissioning evaluation which will
    be by competitive tender (Autumn 2009).

34
To conclude
  • Research need not always inform current, or
    imminent policies, programs or practices even
    in public health.
  • But much research that aspires to achieve this
    goal could be organized and conducted so as to
    improve the chances of doing so
  • Co-planning and execution of applied public
    health intervention research is a special
    opportunity in this regard, one that deserves a
    fair trial
  • Scotland has particular strengths as a natural
    laboratory for this kind of work.

35
How to Reach Us
  • John Frankjohn.frank_at_hgu.mrc.ac.uk
  • Sally Hawsally.haw_at_hgu.mrc.ac.uk
  • Caroline Reescaroline.rees_at_hgu.mrc.ac.uk
  • Human Genetics Unit Western General Hospital,
    Crewe Rd., Edinburgh EH4 2XU Tel 0131-332-2471,
    ext. 2119
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