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

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, and probably mis-managed, 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 60
  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
• Later Life Interventions to maintain function
  and independence as long as possible, so as to
  reduce unnecessary or premature disability and
  dependency

31
Scottish Collaboration for Public Health Research
and Policy Next Steps

• Initial survey of Workshop participants reveals
  the great majority are keen to participate in the
  four Working Groups being set up (initial
  meetings in late April)
• Further discussions with key Scottish
  policy-makers around the these topics now
  underway, to achieve engagement of more
  policy/program/practice decision-makers in the
  process, and better assess policy fit
• Antennae up for opportunities to study Scottish
  natural experiments in public health e.g.
  recent changes in local council/SG arrangements
  around social and health care for the elderly?
  Imminent alcohol policy change? Forthcoming
  obesity and overweight initiative?

32
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.