Knowledge translation in public health: Progress or doing the wrong things righter?
Knowledge translation has evolved from a term in relative obscurity to something that has become commonplace in much of the discussion on health care and public health. At its heart, knowledge translation is:
The Canadian Institutes of Health Research (CIHR) has referred to knowledge translation as “a dynamic and iterative process that includes 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 health care system. The very fact that this term has gained visibility in health research represents a major shift in our priorities. In the past, considerable amounts of money have been spent on clinical research while relatively little attention has been paid to ensuring that the findings of research were captured by its potential beneficiaries. The biomedical and applied research enterprise represents an annual investment of $55 billion US worldwide (Haines, A and Hayes, B., 1998)!”
The reasons for this interest go beyond just money towards population health impact.
It has been estimated that it takes more than 17 years to translate evidence generated from discovery into health care practice (Balas & Boren, 2000) and of that evidence base, only 14 per cent of it is believed to enter day-to-day clinical practice (Westfall, Mold & Fagan, 2007). Some believe that this is an under-estimation and call for considerably more research in the area of dissemination and implementation if evidence-informed practice is to ever be achieved (Trochim, 2010).
This past week the NIH and its Office of Behavioral and Social Science Research held its third conference on the Science of Dissemination and Implementation with a focus on methods and measurement. The conference was a success from my point of view in that it provided a forum for discussion and dialogue on various models, methodologies and challenges, however one issue that wasn’t covered much was related to issues of reliability vs. validity. Our traditional models of research emphasize the former (the degree to which the same activity produces consistent results) at the expense of the latter (whether the findings translate into real differences or changes in the world) and this fundamental tension sits at the cornerstone of knowledge translation. This is best demonstrated in the appalling rates of uptake of most clinical practice guidelines into everyday health care activities [see here for one of many examples]. Russ Glasgow and others have argued that we need to do much more in shaping research that has external validity.
The elephant in the large room was this issue and the more that we continue to ignore it, the more we risk doing what management theorist Russell Ackoff described as “doing the wrong things righter.” That is, we continue to develop evidence in a manner that we hope, if it is just good enough, uses the best methods possible, and boldly proclaims the “truth” people will listen. Yet, the message from this conference was that we don’t even know what people are listening to in the first place, let alone what they do with what they listen to. Are the messages not getting through? Are they getting through, but being mis-understood (or not understood at all)? Or are they being ignored altogether? Or, as I have seen, are they being listened to, but then discarded when they are found to be impractical for their context.
An example of this is web-based tools for collaboration or e-communities of practice. The idea of using tools like Facebook, Twitter, and LinkedIn all sound great in theory, but if your local public health unit won’t allow you to use any of these tools on the job, what good does it do? If you don’t have the bandwidth available in your local community to watch videos online without it chopping up and taking a long time to down how reasonable is it to expect that YouTube will have anything to offer?
These contextual questions are rarely looked at. It was encouraging to hear people like Allan Best and colleagues speak of systems models and the need for more qualitative (i.e., contextually-focused) research , which was well-received, but that was about it. A much wider dialogue about understanding the context in which knowledge is used and translated or not would do much to determine whether we’re making progress or just doing the same wrong things only better.
If you’re in the Toronto area and interested in discussing this topic further, a Lunch-and-Learn event is being held on March 25th from 12-1pm at the Health Sciences Building at the University of Toronto as part of the CoNEKTR series hosted at the Dalla Lana School of Public Health.