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Integrated knowledge translation (IKT) in health care: a scoping review

Integrated knowledge translation (IKT) in health care: a scoping review Background: Integrated knowledge translation (IKT) refers to collaboration between researchers and decision-makers. While advocated as an approach for enhancing the relevance and use of research, IKT is challenging and inconsistently applied. This study sought to inform future IKT practice and research by synthesizing studies that empirically evaluated IKT and identifying knowledge gaps. Methods: We performed a scoping review. We searched MEDLINE, EMBASE, and the Cochrane Library from 2005 to 2014 for English language studies that evaluated IKT interventions involving researchers and organizational or policy- level decision-makers. Data were extracted on study characteristics, IKT intervention (theory, content, mode, duration, frequency, personnel, participants, timing from initiation, initiator, source of funding, decision-maker involvement), and enablers, barriers, and outcomes reported by studies. We performed content analysis and reported summary statistics. Results: Thirteen studies were eligible after screening 14,754 titles and reviewing 106 full-text studies. Details about IKT activities were poorly reported, and none were formally based on theory. Studies varied in the number and type of interactions between researchers and decision-makers; meetings were the most common format. All studies reported barriers and facilitators. Studies reported a range of positive and sub-optimal outcomes. Outcomes did not appear to be associated with initiator of the partnership, dedicated funding, partnership maturity, nature of decision-maker involvement, presence or absence of enablers or barriers, or the number of different IKT activities. Conclusions: The IKT strategies that achieve beneficial outcomes remain unknown. We generated a summary of IKT approaches, enablers, barriers, conditions, and outcomes that can serve as the basis for a future review or for planning ongoing primary research. Future research can contribute to three identified knowledge gaps by examining (1) how different IKT strategies influence outcomes, (2) the relationship between the logic or theory underlying IKT interventions and beneficial outcomes, and (3) when and how decision-makers should be involved in the research process. Future IKT initiatives should more systematically plan and document their design and implementation, and evaluations should report the findings with sufficient detail to reveal how IKT was associated with outcomes. Keywords: Integrated knowledge translation, Decision-making, Health system planning, Scoping review Background integrated knowledge translation (IKT) and defined as an It has long been suggested that partnerships between ongoing relationship between researchers and decision- those who produce research and those who use it are makers (clinicians, managers, policy-makers, etc.) for the likely to enhance the relevance of research and facilitate purpose of engaging in a mutually beneficial research its use [1, 2]. A variety of terms have been used to label project or program of research to support decision- this concept, each are subtly unique, and none are making [4]. IKT is viewed as an approach or set of viewed as the over-arching or gold-standard term [3]. In processes that can lead to the generation of knowledge for the health sector in Canada and elsewhere, this co- optimizing health care delivery systems and improving production of knowledge is commonly referred to as health system performance and associated outcomes [5]. Decision-making research in health care settings shows that complex problems require complex solutions involv- * Correspondence: [email protected] 1 ing input from individuals with different expertise and University Health Network, Toronto, Canada Full list of author information is available at the end of the article © 2016 Gagliardi et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Gagliardi et al. Implementation Science (2016) 11:38 Page 2 of 12 perspectives and iterative, generative processes to for- research rather than IKT approaches [15, 16]. Similarly, a mulate, execute, and evaluate solutions [6]. Collabora- recent survey of health policy experts active in 30 tive knowledge generation, as promoted through IKT European countries revealed little use of IKT other than approaches, involves ongoing, dynamic interactions isolated instances of embedded researchers in government among researchers and decision-makers, and repre- research institutes or on advisory committees [17]. Lack sents an ideal means by which to address complex of engagement in IKT may reflect an inability to overcome health care problems [7]. the challenges inherent in coordinating complex, Empirical research in health care settings has demon- protracted initiatives with multiple stakeholders holding strated the concrete benefits of IKT. For example, in- different views and pursuing different interests, or it may person contact with researchers has been repeatedly reflect a lack of incentives for researchers and decision- cited by decision-makers as the most influential factor de- makers to engage in the more protracted and, hence, termining their use of research evidence [8, 9]. Interviews costly processes of knowledge co-generation [18, 19]. with participants of nine researcher-decision-maker part- Reflection on the challenges faced by researcher-decision- nerships funded by the United Kingdom National Health maker partners that investigated primary care networks Service revealed that all achieved improved clinical care resulted in several recommendations to facilitate IKT through a variety of IKT approaches [10]. An exploratory including the following: identify partners with pre- study of a partnership among university administrators established links to ease and expedite interaction; establish and Scottish health authority social workers revealed clear expectations about role, scope, and contribution to several impacts including enhanced dialogue among foster trust and avoid role confusion and misconceptions; partners about priority health issues, and incorporation of put in place mechanisms that initiate and support research results into a training curriculum for social dialogue among partners; and jointly assess progress and workers. As a result, social workers reported the use implement changes as needed [20]. A case study based on of research in formal health authority processes and three health service delivery programs found that IKT ac- enhanced skill and confidence in using research in tivities were dynamic and not linear and highly influenced their practice [11]. by the complex context within which decisions were being IKT appears to improve the uptake of research into made including social and political norms [21]. When IKT policy and practice through a variety of mechanisms. was formally incentivized with considerable funding Collaboration between researchers and decision-makers through national initiatives, the number of interac- may reveal differing perspectives, expectations, and tions and projects increased but the research process values, leading to greater understanding and improved was characterized as largely investigator-driven, and communication, which creates trust and a shared vision there was limited impact on health service delivery that enable more effective and sustained partnership, and outcomes [22, 23]. thereby contributing to the capacity for IKT [12]. On a Clinicians, researchers, and research funders have practical level, decision-makers can inform research emphasized the need to understand how to foster and questions that are relevant to practice or policy; refine achieve IKT in the health sector [24–28]. The purpose research methods and/or data analysis; interpret findings of this study was to characterize the nature of research based on their contextual knowledge; and disseminate or in this area, describe IKT strategies that were empirically implement findings or products [13]. Decision-makers evaluated, reveal whether sufficient research is available benefit from interaction with researchers through a to undertake a systematic review of the effectiveness of broadened reflection on their own activities, enhanced various IKT approaches, and also identify knowledge knowledge and skills, information about other pertinent gaps for future IKT research. research, and new contacts with other researchers or decision-makers [14]. Researchers benefit as they gain Methods a nuanced understanding of the policy or practice Approach environment, develop and pursue research questions Initially, we had intended on a systematic review; that have real-world applicability, and, through on- however, based on our preliminary searches which re- going conversations with decision-makers, interpret vealed a paucity of studies that have actually evaluated results with a deeper understanding of contextual cir- IKT approaches or strategies, we reverted to a scoping re- cumstances which, in turn, enhances the usefulness of view. A scoping review was conducted using approaches the research findings. promoted by Arksey and O’Malley [29] and Levac et al. Despite the emerging evidence of IKT’s positive impact, [30]. This type of review is used to examine the extent, IKT is not yet widely practiced or well understood. Re- range, and nature of research activity for a particular topic. search directors in Canada reported that researchers tend A scoping review generates a profile of the existing litera- to use traditional means of conducting and disseminating ture on that topic and identifies gaps, thus serving as a Gagliardi et al. Implementation Science (2016) 11:38 Page 3 of 12 foundation for future reviews or primary research. Such which we refer to collectively as “approaches” but, in the reviews do not attempt to synthesize quantitative findings absence of a universally accepted taxonomy, may also be or assess the quality of the literature. The five-step referred to as strategies, mechanisms, methods, activities, approach (scoping, searching, screening, data charting, or processes. Decision-makers could take part in one or data analysis) was carried out iteratively as the state of the more of these functions but not solely in dissemination or literature on IKT became clearer. We did not assume a implementation. All studies included in the review theoretical stance or interpretation because that is not explicitly described and evaluated IKT strategies. customary in a scoping review. Given that this review Study comparisons mayhaveevaluated differentIKT ultimately did not identify IKT characteristics that lead to approaches and associated barriers, enablers and im- beneficial outcomes, consultation with experts to validate pacts, either alone or in comparison with typical, or interpret the findings was not carried out [30]. The non-IKT approaches to research, or with other types Preferred Reporting Items for Systematic Reviews and of approaches for promoting collaborative research. Meta-Analyses (PRISMA) criteria guided the conduct and Outcomes included but were not limited to know- reporting of the review [31]. Data were publicly available ledge, attitudes, beliefs, partnership formation (shared so institutional review board approval was not necessary. understanding of issues, common language, etc.), A protocol for this review was not registered. behaviors, and outcomes, while recognizing that one objective of the scoping review was to identify the Scoping the inquiry range of reported impacts. To plan for the full-scale scoping review, a preliminary Eligible study designs included randomized controlled scan of relevant literature was undertaken by searching trials, interrupted time series, observational studies MEDLINE with the MeSH terms “participatory research” (retrospective, prospective, before-after or comparative or “interdisciplinary research” or keywords “knowledge cohorts), surveys, qualitative research, case studies, or exchange” or “integrated knowledge translation.” Search mixed methods research. Studies were not eligible if results were first screened by all investigators to begin to they understand how IKT was operationalized and then discussed by email and a teleconference. This knowledge  concluded that IKT was needed without having was used to establish the research purpose, plan a more described and evaluated it comprehensive search strategy, and generate eligibility  described the planning or development of an IKT criteria based on the PICO (population, intervention, initiative without having evaluated it comparisons, outcomes) framework. Populations refer to  examined issues of authorship among research researchers and organizational or system-level decision- collaborators makers in health care settings including clinician man-  focused on online communities (i.e., interaction or agers, health care managers, and policy-makers involved data collection by social media), translational in academic initiatives (finite or ongoing projects, stud- research (i.e., from wet lab to clinical application), or ies, groups) that used or were based on IKT approaches. collaborations between physicians and industry Partnerships may have been initiated by researchers or  described action research, community-based decision-makers where the goal was evidence-informed interventions, practice-based quality improvement decision- or policy-making, or they could have a dual initiatives (researchers describe conditions in the purpose—to generate knowledge through empirical re- setting within which they are embedded where the search and to resolve practical problems. Non-research overall goal is quality improvement), practice-based partnerships formed solely for quality improvement or research networks (groups of clinicians or institutions to seek input from researchers were not eligible. Studies that jointly deliver patient care), or interorganizational that focused on front-line providers and clinical networks or quality improvement collaboratives that decision-making were excluded, as were those focusing sought to disseminate knowledge to front-line on patients or consumers. Although all are legitimate IKT providers or improve service delivery and partners, they were considered beyond the boundaries of outcomes but do not undertake research the current review. The intervention of interest was  were publications in the form of editorials, opinion IKT, defined as collaboration between researchers and articles, protocols, abstracts, proceedings, or decision-makers in the research process including conceptual analyses establishing the research questions, deciding on the  if the description of the partnership lacked detail methodology, recruiting and/or collecting the data, such that it was unclear if decision-makers interpreting the results, and disseminating the find- participated in research activities ings [32]. In particular, this review examined the IKT  or if research methods used to evaluate the IKT activities that comprised or promoted collaboration, initiative were not provided. Gagliardi et al. Implementation Science (2016) 11:38 Page 4 of 12 Systematic reviews were not eligible but were used to all data from eligible studies were perused to identify identify eligible primary studies. each unique instance of an IKT approach or strategy, enabler, barrier, and outcome. This approach allowed Search strategy and screening process gaps in the IKT literature to be identified. These data A comprehensive literature search was conducted by were added to the IKT approaches or strategies, using several indexed sources. The principal investigator enablers, barriers, and outcomes identified in studies ref- (ARG) and a trained research assistant conducted all erenced in the background of this manuscript and then searches with guidance from a medical librarian. It has compiled in a summary of IKT conditions, influencing been noted by other researchers that the IKT literature factors, and outcomes. This approach made clear what is not consistently indexed [33, 34] so several search was known and not known about IKT interventions. To strategies were tested by the medical librarian to further understand knowledge gaps, we identified poten- optimize the retrieval of a few IKT citations known to tial associations between the characteristics of IKT strat- the investigators (specificity) and, in particular, to egies, contextual factors, and outcomes by categorizing increase the likelihood that all relevant studies would be IKT as used in eligible studies based on type of engage- retrieved (sensitivity). The MEDLINE search strategy is ment (conceptualization or planning, recruitment or shown in Additional file 1 (we used the search shown on data collection, interpretation, and dissemination or line 84). MEDLINE, EMBASE, and the Cochrane Library implementation) [33]; time from initiation; entity that were searched on 1 February 2015 from 2005 to 2014 initiated the partnership; source of funding; and the inclusive. A 10-year time span was likely to capture most reported barriers, enablers, and outcomes. Outcomes relevant literature since IKT is a relatively new were categorized in relation to study objectives as posi- phenomenon in the health care sector. Pairs of investiga- tive (all reported outcomes were positive or improved) tors screened titles and abstracts according to specified or mixed (some reported outcomes were positive/im- eligibility criteria. Rather than resolving selection differ- proved and some were negative/not improved). ences, all those selected by at least one reviewer were retrieved since ultimate judgment about the inclusion Results must often be reserved until the full text is examined. Search results If more than one publication described a single study After duplicate titles were removed, the initial search and each presented the same data, the most recent resulted in 14,754 unique articles. Screening of titles and was included. abstracts excluded 14,648 articles, leaving 106 as poten- tially eligible. Screening of full-text items excluded an Data charting and analysis additional 93 articles: no partnership (57), no evaluation A data charting form was developed and piloted by the (17), ineligible publication type (9), focus on clinical team to collect information on the country in which the quality improvement (6), not health care (3), duplicate research was conducted, study design, underlying theory study (1), leaving 13 that were eligible for inclusion (Fig. 1). used to design the IKT intervention or analyze the find- Charted data appears in Additional file 2 [37–49]. ings, the IKT intervention, enablers and barriers, and any reported outcomes. Based on the Workgroup for Characteristics of eligible studies Intervention Development and Evaluation Research Studies were published between 2005 and 2014. Ten of (WIDER) reporting checklist [35], details about the 13 studies were published in 2013 or 2014 and one each intervention included content (nature and goal of the in 2005, 2006, and 2009. Four studies were conducted in program and/or IKT partnership), mode of delivery Canada, four in the UK, two in the USA, and one each (specific types of IKT activities in which partners were in Lebanon, the Netherlands, and Sweden. Five studies involved), duration and/or frequency (timing of IKT ac- were based on a mixed methods design, five on a case tivities), participants (who was involved in specific IKT study design, and three on qualitative interviews. activities), and personnel (who coordinated or led IKT activities). Time from initiation, the entity that initiated IKT activities used in partnerships the partnership, and source of funding were also noted. No studies explicitly mentioned the use of theory upon All investigators charted data from eligible studies. which the IKT initiative or any of its component strategies Summary statistics were used to describe the number were based. Table 1 summarizes the characteristics of IKT of studies by country, year of publication, and study partnerships in eligible studies. The content or focus of design; whether the IKT initiatives employed single or partnerships varied from specific health topics, for ex- multi-faceted interventions; and whether they were ample, implementation of a depression intervention [38] designed based on theory. Relational analysis was used or studying the impact of environment on breast cancer to summarize study findings [36]. With this technique, [45], to very broad initiatives that conducted applied Gagliardi et al. Implementation Science (2016) 11:38 Page 5 of 12 Fig. 1 PRISMA diagram of eligible studies health services research to ultimately improve population formation, for example, mutual understanding of health [47]. The most common activities or modes of language, work style, needs and constraints, or general interaction were meetings (i.e., team, working group, views about research or the collaborative process. Fewer committee, board) or presentations (i.e., conferences, studies reported measures that reflected the interim or workshops). Five of 13 studies reported the duration and/ longer term impact of IKT. For example, 4 studies or frequency of specific activities [37–39, 46, 47]. While 8 assessed whether research was used for decision-making. of 13 studies mentioned the categories of participants in- volved, 1 of those studies reported the number and/or Characterization of IKT initiatives type of participants involved in specific activities [38]. Table 3 characterizes the IKT partnerships, strategies, While all but 4 of 13 studies mentioned modes of inter- and conditions in eligible studies. Most partnerships action [39, 41, 43, 44], authors provided few specific were initiated by governments that provided dedicated details about when these activities took place and who resources for the initiative (7 of 13 studies). This did not was involved. For example, in one study, authors reported appear to be associated with successful outcomes. Of the that team meetings involving an unspecified number of 7 studies with dedicated funding from government, 2 senior managers and medical directors were held periodic- achieved positive, 4 achieved mixed, and 1 achieved sub- ally over a 3-year period [46]. No studies reported optimal or no impact on measures that were reported. personnel who organized or led the activities. All 8 studies that reported timing of the evaluation with respect to time from initiation of the partnership had Enablers and barriers of IKT existed for a minimum of 2 years; thus, partnership Table 2 lists 9 enablers and 15 barriers of IKT reported maturity did not appear to be associated with outcomes. across studies. All studies reported both barriers and The number of different types of interaction between enablers. researchers and decision-makers did not appear to be associated with outcomes; in the 4 studies that achieved Outcomes of IKT positive impact in all outcomes reported, the number of Table 2 lists the outcomes of IKT that were reported by types of interaction ranged from 1 to 8 (based on data in studies as positive (12) and sub-optimal (7). There was “Mode” column of Table 1). Many studies did not expli- little overlap across studies. For example, the most com- citly report how decision-makers were involved through- monly reported benefit was the development of capacity out the research trajectory. Among those that provided among researchers and decision-makers for engaging in such details, decision-makers were most often involved IKT in 7 studies, and the next most commonly reported in conceptualizing or planning research (10 studies) and benefit was enhanced value for research among in disseminating or implementing the findings (7 studies). decision-makers in 4 studies. Many other benefits and One study reported that decision-makers were involved all sub-optimal outcomes were unique to individual throughout the research process and achieved positive re- studies. Most studies reported measures that reflected sults on all reported outcomes. In contrast, three studies the more immediate impact of IKT on partnership achieved positive results on all reported outcomes when Gagliardi et al. Implementation Science (2016) 11:38 Page 6 of 12 Table 1 Description of IKT initiatives in included studies according to WIDER criteria [35] Study Content (program focus) Mode (IKT approaches/activities) Duration, frequency, timing Participants Personnel El-Jardali 2014 [38] Evidence-based health policy-making Evidence briefs, deliberative NR Researchers, policy-makers, other NR dialogues, priority setting, training stakeholders from many countries sessions, rapid response service, web (NR by activity) portal Eriksson 2014 [39] Health promotion Consultation, meetings, conferences, Varied from monthly Politicians, public clinicians, agency NR annual progress reports, joint to annual meetings representatives, researchers (NR by research, steering group, activity) coordinating committee, working groups Khodyakov 2014 [40] Depression Meetings, working groups, training Biweekly meetings, Researchers, clinicians, social workers, NR sessions, web portal 4 months policy-makers, counselors, clergy (mean 20–25 by event) Kothari 2014 [37] Women’s health Team meetings, priority setting, NR Researchers, partners, trainees from NR applying for research funding, joint many countries (NR by activity) research, web portal Kislov 2014 [41] Applied health research on a range NR Quarterly meetings, NR NR of topics 3 years Hoeijmakers 2013 [42] Public health knowledge sharing Meetings, training sessions, joint NR NR NR research, steering committee, board of governors, public relations Martin 2013 [43] Prevention, early detection, self-care, NR NR NR NR rehabilitation Murnaghan 2013 [44] Youth health, prevention of chronic Meetings, planning sessions, NR Policy-makers, health authority and NR disease presentations; print, web, and media agency representatives, researchers communications (NR per activity) Rycroft-Malone 2013 [45] Applied health research on a range NR NR Board, managers, health authorities, NR of topics committees, researchers (NR per activity) Soper 2013 [46] Applied health research on a range NR NR NR NR of topics Van Olphen 2009 [47] Breast cancer Joint research, meetings, NR NR NR presentations Patten 2006 [48] Priority setting practices Team meetings, joint planning NR Clinicians, managers, researchers NR (NR by activity) Bowen 2005 [49] Health promotion Workshops Three 2-day yearly Health authority personnel, NR events, 5 years researchers (NR by activity) NR not reported Gagliardi et al. Implementation Science (2016) 11:38 Page 7 of 12 Table 2 IKT enablers, barriers, and outcomes Table 2 IKT enablers, barriers, and outcomes (Continued) Measures Reported findings Studies (n) Developed an appreciation for 3 the collaborative process Barriers (9) Differing needs and priorities 5 among participants Enhanced relevance of the 3 research Lack of skill in or understanding 5 of IKT processes Decision-maker involvement 2 sustained through entire process Attitudes about researchers or 4 the value of research Enhanced mutual understanding 2 of language, work style, needs, Goals, roles, and expectations not 3 and constraints clear Number of collaborative projects 2 Lack of incentives to participate 3 undertaken/completed Lack of funding or infrastructure 2 Influenced policy-making 2 for IKT Influenced service delivery 1 Little continuity of involvement 2 due to staff turnover, infrequent Increased diversity of involved 1 attendance partners Participants are busy with 1 Strengthened relationships, trust, 1 multiple responsibilities and goodwill Geographic distant imposes 1 Emergence of community 1 limits on interaction leaders Enablers (15) Multiple and varied opportunities 4 Mixed outcomes (7) Decision-maker involvement 1 for interaction varied across activities Strong leadership commitment, 3 Failure to overcome differences 1 skill, and experience and bridge boundaries Phased approach to develop 3 Collaborations were temporary 1 shared language, achieve early successes Little to no research produced 1 Support from facilitators, 2 Research not used in policy- 1 champions, and boundary making spanners Greater emphasis on research 1 Clear and agreed upon goals, 2 publications than stakeholder roles, and expectations engagement Immersion of researchers in 2 Benefits only beginning to emerge 1 decision-maker setting/co- location decision-makers were involved in only some aspects of Formalized branding, structures, 2 and processes the research process. Establish partnership early in the 1 research process Summary of the IKT conditions, influencing factors, Openness of partners to listen, 1 and outcomes learn, and adapt Figure 2 shows a summary of IKT approaches, enablers, Organizational support for 1 barriers, conditions, and outcomes that were initially decision-makers to meaningfully compiled from background literature and expanded with contribute items that emerged from this study. This summary pre- Dedicated funding 1 sents the enablers, barriers, and conditions that have Shared governance structures 1 been reported to influence the IKT approach and a range Built on preexisting relationship 1 of possible outcomes relevant to IKT partnerships. Given the small number of eligible studies, limited detail about Availability of data to inform 1 activities IKT, and mixed findings, the relationships between en- Periodic external review to assess 1 ablers, barriers, contextual conditions, and outcomes re- progress main unclear. As more IKT studies are reported in the Positive outcomes (12) Capacity developed by 7 literature, the barriers, enablers, and outcomes might be researchers and decision-makers further organized into higher order categories with pro- Decision-makers grew to value 4 posed indicators. In the short term, this framework may research be used by others to prospectively plan IKT projects/ programs and their evaluation. Gagliardi et al. Implementation Science (2016) 11:38 Page 8 of 12 Table 3 Summary of IKT conditions, influencing factors, and outcomes Study Time from Types of Initiator/ Decision-maker involvement Enablers Barriers Outcomes initiation interaction Funding Conceptualize Recruit or Interpret Disseminate or (years) (number) and plan collect data findings implement El-Jardali 2014 [38] 2 to 3 6 WHO +NR + + + + +/− Dedicated Eriksson 2014 [39] NR 8 Government++ + + + + + Dedicated Khodyakov 2014 [40] NR 4 Researcher +NR NR + + + + Research Kislov 2014 [41] 2 NR Government+NR NR + NR + - Dedicated Kothari 2014 [37]2 5 NR + + NR + + + +/− Research Hoeijmakers 2013 [42] 2 6 Government+NR NR NR + + +/− Dedicated Martin 2013 [43] 2 NR Government NR NR NR NR + + +/− Dedicated Murnaghan 2013 [44] NR 6 Government + NR + + + NR + Dedicated Rycroft-Malone 2013 [45] 3 to 4 NR Government NR NR NR NR + + +/− Dedicated Soper 2013 [46] NR NR Government NR NR NR NR + + +/− Dedicated Van Olphen 2009 [47] NR 3 Researcher +NR NR + + + +/− Research Patten 2006 [48] 3 2 Health region+NR + — ++ NR NR Bowen 2005 [49] Over 1NR + NR + NR + + + 5 years Research Outcome refers to beneficial or sub-optimal outcomes as reported by studies: in relation to study objectives + all reported outcomes were positive or improved, +/− mixed outcomes (reported outcomes positive/improved and negative/not improved), NR not reported Discussion such as learning about research, awareness and accept- This scoping review was conducted to describe the ance of research, mutual understanding, development of knowledge base underlying IKT, gleaned from studies trust and goodwill, and an appreciation for the collab- that described and evaluated IKT strategies, and identify orative process are established. Another scoping review gaps to inform future research. Thirteen studies were of stakeholder involvement in rehabilitation research eligible. The most common form of interaction was found that stakeholder preparation was needed to meetings, but they varied in nature, aims, and frequency. understand research and fulfill their role [33]. This took All studies reported both barriers and enablers. While the form of formal and informal training and, in some most studies achieved one or more positive outcomes, studies included in that review, decision-makers were studies reported a wide range of positive and less posi- paid to participate in the training. tive outcomes. Given incomplete and inconsistent To the best of our knowledge, this study is among the reporting of study design, IKT strategies, and outcomes, first to attempt to identify the characteristics of IKT it was not possible to identify relationships between strategies and their potential association with outcomes outcomes and contextual factors related to initiator of using a rigorous approach. Our scoping review is distin- the partnership, dedicated funding, partnership maturity, guished from that of Jagosh et al. who published a realist nature of decision-maker involvement, presence or ab- systematic review on the effectiveness of community- sence of enablers or barriers, or the number of different based participatory research partnerships that included IKT activities employed in a given initiative. A number 276 studies [36]. In participatory, action or community- of studies assessed partnership formation. Given that the based research, the intent is to improve the quality of partnerships evaluated were at least 2 years old, it may service delivery, health equity, or clinical outcomes not be reasonable to evaluate the influence of research where community-identified rather than research-based on decision-making until more immediate outcomes solutions are emphasized, or researchers function as Gagliardi et al. Implementation Science (2016) 11:38 Page 9 of 12 Fig. 2 Summary of IKT approaches, influencing factors, and outcomes consultants. We chose to define IKT as partnerships Applied Health Research and Care (CLAHRC) in the between researchers and organizational or system-level UK [41, 43, 45, 46] and one study evaluating Academic decision-makers including clinician managers, health Collaborative Centres (ACC) for Public Health in the facility managers, and policy-makers for the purpose of Netherlands [42]. Both of these national-level initia- academic research, although those partnerships may have tives involved large-scale investment to foster IKT. enabled improvements in service delivery or clinical out- Since partnerships may develop over time, and add- comes. IKT decision-maker partners are distinct in that itional evaluations may be forthcoming, longitudinal they are specifically selected for their scope of responsibility evaluation of these important initiatives is warranted to and, hence, authoritytoinvokepracticeorpolicychange. identify beneficial outcomes. Another way to interpret This scoping review, which goes beyond anecdotal ac- these findings is that other barriers, enablers, or context- counts, may serve as a springboard to the conduct of future ual conditions may be more important than funding to research that specifically examines researcher-decision- the formation and outcomes of IKT partnerships. Such maker partnerships. insight was not afforded by this study because enablers, Despite suggestions that lack of funding is a deterrent barriers, and outcomes were variable across studies and to practicing or achieving IKT [3, 18, 19], in this study, not consistently recorded or described. In future research, formal IKT partnerships that were specifically initiated longitudinal analytic approaches may be useful to evaluate and funded by governments did not appear to eliminate IKT impact and clarify the relationship between IKT ap- barriers or report better outcomes compared with other proaches and outcomes. A time series design, for example, studies that lacked such infrastructure. This included could be used to systematically track the evolution of part- four studies evaluating Collaborations for Leadership in nership formation and better pin-point the activities or Gagliardi et al. Implementation Science (2016) 11:38 Page 10 of 12 strategies that move the partnership from the formation makers took part in any way in the conduct of the research stage into a more functional and active stage. or interpretation of the findings. Given that the nature of IKT was poorly and inconsistently described, evaluated, decision-maker involvement was largely under-described, and reported in most studies, making it challenging to we cannot say if the involvement of decision-makers identify strong thematic areas. However, three important throughout the course of a research initiative, which is the knowledge gaps were clearly identified. First, some studies purported ideal [3], actually achieves better outcomes. evaluated the IKT initiative but did not describe or detail Other studies of IKT also reported that research remained the IKT activities. Future researchers are encouraged, largely investigator-driven [22, 23], and decision-makers therefore, to capture and report the full extent of IKT ac- were often not directly involved as integral partners [14]. tivities, including the nature or mode of interactive activ- Future research must examine a range of IKT approaches ities (i.e., brainstorming sessions, data interpretation to identify the ideal timing and manner in which decision- sessions, passive dissemination through websites), who is makers must be involved for effective research uptake. involved in which activity, who is leading the activity, and Several issues may limit the interpretation and use of how often activities take place. This cumulative un- these findings. The relatively small number of eligible derstanding will allow a nuanced typology of different studies may have precluded identifying with greater IKT models to emerge. Those who plan and imple- certainty the characteristics and contextual conditions ment and/or evaluate IKT initiatives might employ required to foster and achieve IKT. This may, in part, be the WIDER reporting checklist when they design such due to the fact that studies about IKT are difficult to iden- initiatives or report evaluative findings [34]. The tify. Other researchers have noted that the IKT literature WIDER checklist recommends describing: the interven- is not consistently indexed in databases of published re- tion (approaches, strategies), mode of delivery (intensity, search [33, 34]. Screening of search results was challen- duration, timing), intervention content (knowledge ging due to the large number of search results to assess generated or shared), participants and their role (the and limited detail in the studies by which to ascertain eli- characteristics of those sponsoring, delivering, and receiv- gibility. This means that the resulting summary of IKT ing the intervention), setting, and adherence or fidelity. (Fig. 2) is inclusive of numerous characteristics and condi- The second knowledge gap to emerge was the lack of ex- tions that require further evaluation of their association plicit description of underlying theory or logic upon which with outcomes. Although we searched standard indexed IKT approaches and associated activities were selected and/ sources of published medical literature, the search strategy or evaluated. As the WIDER checklist specifies, details are may not have identified all relevant studies. Study retrieval needed about how the IKT intervention was developed, was limited to journals that are indexed in the three change techniques used in the intervention, and the causal databases that were searched. We did not search the grey processes targeted by the change techniques to achieve par- literature, assuming that most empirical research on IKT ticular outcomes. Therefore, future research could focus on interventions would be found in indexed databases. Many identifying, describing, and testing relevant theory by which studies did not provide a full description of the research to design and/or evaluate IKT initiatives. First, it may be methods used or fully describe the research findings for all useful to conduct an interpretive synthesis of the findings components of a case study or mixed methods research. reported here by analyzing enablers and barriers according Most studies collected qualitative data; however, they were to the context and design of IKT initiatives in the included often not complete or sufficiently detailed to extract clear studies. A scoping review is an appropriate starting point to findings with respect to enablers, barriers, and, in particu- understand the nature of the empirical work in the domain lar, outcomes. Given limited detail about IKT activities, it and to determine if a systematic review is warranted. Thus, was difficult to chart data; however, we employed a rigor- we deliberately maintained a wide focus rather than target- ous methodology that complied with standard approaches ing certain aspects of the IKT process. Our findings suggest for scoping reviews [29, 30], and data were charted inde- that the empirical work in the area is just emerging, and pendently by two investigators for all articles to enhance thus it is premature to embark on a systematic review with reliability. In the absence of a universally accepted atight focus. taxonomy with which to refer to IKT approaches, activ- The third knowledge gap pertains to decision-maker in- ities, processes, etc., it was challenging to describe and volvement. IKT activities most often consisted of meetings summarize how IKT was operationalized in included stud- between researchers and decision-makers. However, the na- ies. Most studies reported one or more positive outcomes ture of those meetings and the level of engagement of which may represent a bias toward reporting favorable decision-makers in research-related decisions or research findings; this is further underscored by the small number activities were not reported. In some cases, decision-makers of eligible studies. Insufficient knowledge emerged from were reported as playing a role in disseminating or imple- this scoping review to enable a full understanding of the menting the results. It was largely not reported if decision- variety of ways to promote IKT partnerships and engage Gagliardi et al. Implementation Science (2016) 11:38 Page 11 of 12 in interactions. Therefore, we are unable to issue clear or Received: 14 December 2015 Accepted: 5 March 2016 justified recommendations in this regard. As more re- search on IKT emerges, this may become possible at some point in the future. Finally, some scholars [30] have sug- References 1. 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Integrated knowledge translation (IKT) in health care: a scoping review

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Springer Journals
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2016 Gagliardi et al.
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1748-5908
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10.1186/s13012-016-0399-1
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Abstract

Background: Integrated knowledge translation (IKT) refers to collaboration between researchers and decision-makers. While advocated as an approach for enhancing the relevance and use of research, IKT is challenging and inconsistently applied. This study sought to inform future IKT practice and research by synthesizing studies that empirically evaluated IKT and identifying knowledge gaps. Methods: We performed a scoping review. We searched MEDLINE, EMBASE, and the Cochrane Library from 2005 to 2014 for English language studies that evaluated IKT interventions involving researchers and organizational or policy- level decision-makers. Data were extracted on study characteristics, IKT intervention (theory, content, mode, duration, frequency, personnel, participants, timing from initiation, initiator, source of funding, decision-maker involvement), and enablers, barriers, and outcomes reported by studies. We performed content analysis and reported summary statistics. Results: Thirteen studies were eligible after screening 14,754 titles and reviewing 106 full-text studies. Details about IKT activities were poorly reported, and none were formally based on theory. Studies varied in the number and type of interactions between researchers and decision-makers; meetings were the most common format. All studies reported barriers and facilitators. Studies reported a range of positive and sub-optimal outcomes. Outcomes did not appear to be associated with initiator of the partnership, dedicated funding, partnership maturity, nature of decision-maker involvement, presence or absence of enablers or barriers, or the number of different IKT activities. Conclusions: The IKT strategies that achieve beneficial outcomes remain unknown. We generated a summary of IKT approaches, enablers, barriers, conditions, and outcomes that can serve as the basis for a future review or for planning ongoing primary research. Future research can contribute to three identified knowledge gaps by examining (1) how different IKT strategies influence outcomes, (2) the relationship between the logic or theory underlying IKT interventions and beneficial outcomes, and (3) when and how decision-makers should be involved in the research process. Future IKT initiatives should more systematically plan and document their design and implementation, and evaluations should report the findings with sufficient detail to reveal how IKT was associated with outcomes. Keywords: Integrated knowledge translation, Decision-making, Health system planning, Scoping review Background integrated knowledge translation (IKT) and defined as an It has long been suggested that partnerships between ongoing relationship between researchers and decision- those who produce research and those who use it are makers (clinicians, managers, policy-makers, etc.) for the likely to enhance the relevance of research and facilitate purpose of engaging in a mutually beneficial research its use [1, 2]. A variety of terms have been used to label project or program of research to support decision- this concept, each are subtly unique, and none are making [4]. IKT is viewed as an approach or set of viewed as the over-arching or gold-standard term [3]. In processes that can lead to the generation of knowledge for the health sector in Canada and elsewhere, this co- optimizing health care delivery systems and improving production of knowledge is commonly referred to as health system performance and associated outcomes [5]. Decision-making research in health care settings shows that complex problems require complex solutions involv- * Correspondence: [email protected] 1 ing input from individuals with different expertise and University Health Network, Toronto, Canada Full list of author information is available at the end of the article © 2016 Gagliardi et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Gagliardi et al. Implementation Science (2016) 11:38 Page 2 of 12 perspectives and iterative, generative processes to for- research rather than IKT approaches [15, 16]. Similarly, a mulate, execute, and evaluate solutions [6]. Collabora- recent survey of health policy experts active in 30 tive knowledge generation, as promoted through IKT European countries revealed little use of IKT other than approaches, involves ongoing, dynamic interactions isolated instances of embedded researchers in government among researchers and decision-makers, and repre- research institutes or on advisory committees [17]. Lack sents an ideal means by which to address complex of engagement in IKT may reflect an inability to overcome health care problems [7]. the challenges inherent in coordinating complex, Empirical research in health care settings has demon- protracted initiatives with multiple stakeholders holding strated the concrete benefits of IKT. For example, in- different views and pursuing different interests, or it may person contact with researchers has been repeatedly reflect a lack of incentives for researchers and decision- cited by decision-makers as the most influential factor de- makers to engage in the more protracted and, hence, termining their use of research evidence [8, 9]. Interviews costly processes of knowledge co-generation [18, 19]. with participants of nine researcher-decision-maker part- Reflection on the challenges faced by researcher-decision- nerships funded by the United Kingdom National Health maker partners that investigated primary care networks Service revealed that all achieved improved clinical care resulted in several recommendations to facilitate IKT through a variety of IKT approaches [10]. An exploratory including the following: identify partners with pre- study of a partnership among university administrators established links to ease and expedite interaction; establish and Scottish health authority social workers revealed clear expectations about role, scope, and contribution to several impacts including enhanced dialogue among foster trust and avoid role confusion and misconceptions; partners about priority health issues, and incorporation of put in place mechanisms that initiate and support research results into a training curriculum for social dialogue among partners; and jointly assess progress and workers. As a result, social workers reported the use implement changes as needed [20]. A case study based on of research in formal health authority processes and three health service delivery programs found that IKT ac- enhanced skill and confidence in using research in tivities were dynamic and not linear and highly influenced their practice [11]. by the complex context within which decisions were being IKT appears to improve the uptake of research into made including social and political norms [21]. When IKT policy and practice through a variety of mechanisms. was formally incentivized with considerable funding Collaboration between researchers and decision-makers through national initiatives, the number of interac- may reveal differing perspectives, expectations, and tions and projects increased but the research process values, leading to greater understanding and improved was characterized as largely investigator-driven, and communication, which creates trust and a shared vision there was limited impact on health service delivery that enable more effective and sustained partnership, and outcomes [22, 23]. thereby contributing to the capacity for IKT [12]. On a Clinicians, researchers, and research funders have practical level, decision-makers can inform research emphasized the need to understand how to foster and questions that are relevant to practice or policy; refine achieve IKT in the health sector [24–28]. The purpose research methods and/or data analysis; interpret findings of this study was to characterize the nature of research based on their contextual knowledge; and disseminate or in this area, describe IKT strategies that were empirically implement findings or products [13]. Decision-makers evaluated, reveal whether sufficient research is available benefit from interaction with researchers through a to undertake a systematic review of the effectiveness of broadened reflection on their own activities, enhanced various IKT approaches, and also identify knowledge knowledge and skills, information about other pertinent gaps for future IKT research. research, and new contacts with other researchers or decision-makers [14]. Researchers benefit as they gain Methods a nuanced understanding of the policy or practice Approach environment, develop and pursue research questions Initially, we had intended on a systematic review; that have real-world applicability, and, through on- however, based on our preliminary searches which re- going conversations with decision-makers, interpret vealed a paucity of studies that have actually evaluated results with a deeper understanding of contextual cir- IKT approaches or strategies, we reverted to a scoping re- cumstances which, in turn, enhances the usefulness of view. A scoping review was conducted using approaches the research findings. promoted by Arksey and O’Malley [29] and Levac et al. Despite the emerging evidence of IKT’s positive impact, [30]. This type of review is used to examine the extent, IKT is not yet widely practiced or well understood. Re- range, and nature of research activity for a particular topic. search directors in Canada reported that researchers tend A scoping review generates a profile of the existing litera- to use traditional means of conducting and disseminating ture on that topic and identifies gaps, thus serving as a Gagliardi et al. Implementation Science (2016) 11:38 Page 3 of 12 foundation for future reviews or primary research. Such which we refer to collectively as “approaches” but, in the reviews do not attempt to synthesize quantitative findings absence of a universally accepted taxonomy, may also be or assess the quality of the literature. The five-step referred to as strategies, mechanisms, methods, activities, approach (scoping, searching, screening, data charting, or processes. Decision-makers could take part in one or data analysis) was carried out iteratively as the state of the more of these functions but not solely in dissemination or literature on IKT became clearer. We did not assume a implementation. All studies included in the review theoretical stance or interpretation because that is not explicitly described and evaluated IKT strategies. customary in a scoping review. Given that this review Study comparisons mayhaveevaluated differentIKT ultimately did not identify IKT characteristics that lead to approaches and associated barriers, enablers and im- beneficial outcomes, consultation with experts to validate pacts, either alone or in comparison with typical, or interpret the findings was not carried out [30]. The non-IKT approaches to research, or with other types Preferred Reporting Items for Systematic Reviews and of approaches for promoting collaborative research. Meta-Analyses (PRISMA) criteria guided the conduct and Outcomes included but were not limited to know- reporting of the review [31]. Data were publicly available ledge, attitudes, beliefs, partnership formation (shared so institutional review board approval was not necessary. understanding of issues, common language, etc.), A protocol for this review was not registered. behaviors, and outcomes, while recognizing that one objective of the scoping review was to identify the Scoping the inquiry range of reported impacts. To plan for the full-scale scoping review, a preliminary Eligible study designs included randomized controlled scan of relevant literature was undertaken by searching trials, interrupted time series, observational studies MEDLINE with the MeSH terms “participatory research” (retrospective, prospective, before-after or comparative or “interdisciplinary research” or keywords “knowledge cohorts), surveys, qualitative research, case studies, or exchange” or “integrated knowledge translation.” Search mixed methods research. Studies were not eligible if results were first screened by all investigators to begin to they understand how IKT was operationalized and then discussed by email and a teleconference. This knowledge  concluded that IKT was needed without having was used to establish the research purpose, plan a more described and evaluated it comprehensive search strategy, and generate eligibility  described the planning or development of an IKT criteria based on the PICO (population, intervention, initiative without having evaluated it comparisons, outcomes) framework. Populations refer to  examined issues of authorship among research researchers and organizational or system-level decision- collaborators makers in health care settings including clinician man-  focused on online communities (i.e., interaction or agers, health care managers, and policy-makers involved data collection by social media), translational in academic initiatives (finite or ongoing projects, stud- research (i.e., from wet lab to clinical application), or ies, groups) that used or were based on IKT approaches. collaborations between physicians and industry Partnerships may have been initiated by researchers or  described action research, community-based decision-makers where the goal was evidence-informed interventions, practice-based quality improvement decision- or policy-making, or they could have a dual initiatives (researchers describe conditions in the purpose—to generate knowledge through empirical re- setting within which they are embedded where the search and to resolve practical problems. Non-research overall goal is quality improvement), practice-based partnerships formed solely for quality improvement or research networks (groups of clinicians or institutions to seek input from researchers were not eligible. Studies that jointly deliver patient care), or interorganizational that focused on front-line providers and clinical networks or quality improvement collaboratives that decision-making were excluded, as were those focusing sought to disseminate knowledge to front-line on patients or consumers. Although all are legitimate IKT providers or improve service delivery and partners, they were considered beyond the boundaries of outcomes but do not undertake research the current review. The intervention of interest was  were publications in the form of editorials, opinion IKT, defined as collaboration between researchers and articles, protocols, abstracts, proceedings, or decision-makers in the research process including conceptual analyses establishing the research questions, deciding on the  if the description of the partnership lacked detail methodology, recruiting and/or collecting the data, such that it was unclear if decision-makers interpreting the results, and disseminating the find- participated in research activities ings [32]. In particular, this review examined the IKT  or if research methods used to evaluate the IKT activities that comprised or promoted collaboration, initiative were not provided. Gagliardi et al. Implementation Science (2016) 11:38 Page 4 of 12 Systematic reviews were not eligible but were used to all data from eligible studies were perused to identify identify eligible primary studies. each unique instance of an IKT approach or strategy, enabler, barrier, and outcome. This approach allowed Search strategy and screening process gaps in the IKT literature to be identified. These data A comprehensive literature search was conducted by were added to the IKT approaches or strategies, using several indexed sources. The principal investigator enablers, barriers, and outcomes identified in studies ref- (ARG) and a trained research assistant conducted all erenced in the background of this manuscript and then searches with guidance from a medical librarian. It has compiled in a summary of IKT conditions, influencing been noted by other researchers that the IKT literature factors, and outcomes. This approach made clear what is not consistently indexed [33, 34] so several search was known and not known about IKT interventions. To strategies were tested by the medical librarian to further understand knowledge gaps, we identified poten- optimize the retrieval of a few IKT citations known to tial associations between the characteristics of IKT strat- the investigators (specificity) and, in particular, to egies, contextual factors, and outcomes by categorizing increase the likelihood that all relevant studies would be IKT as used in eligible studies based on type of engage- retrieved (sensitivity). The MEDLINE search strategy is ment (conceptualization or planning, recruitment or shown in Additional file 1 (we used the search shown on data collection, interpretation, and dissemination or line 84). MEDLINE, EMBASE, and the Cochrane Library implementation) [33]; time from initiation; entity that were searched on 1 February 2015 from 2005 to 2014 initiated the partnership; source of funding; and the inclusive. A 10-year time span was likely to capture most reported barriers, enablers, and outcomes. Outcomes relevant literature since IKT is a relatively new were categorized in relation to study objectives as posi- phenomenon in the health care sector. Pairs of investiga- tive (all reported outcomes were positive or improved) tors screened titles and abstracts according to specified or mixed (some reported outcomes were positive/im- eligibility criteria. Rather than resolving selection differ- proved and some were negative/not improved). ences, all those selected by at least one reviewer were retrieved since ultimate judgment about the inclusion Results must often be reserved until the full text is examined. Search results If more than one publication described a single study After duplicate titles were removed, the initial search and each presented the same data, the most recent resulted in 14,754 unique articles. Screening of titles and was included. abstracts excluded 14,648 articles, leaving 106 as poten- tially eligible. Screening of full-text items excluded an Data charting and analysis additional 93 articles: no partnership (57), no evaluation A data charting form was developed and piloted by the (17), ineligible publication type (9), focus on clinical team to collect information on the country in which the quality improvement (6), not health care (3), duplicate research was conducted, study design, underlying theory study (1), leaving 13 that were eligible for inclusion (Fig. 1). used to design the IKT intervention or analyze the find- Charted data appears in Additional file 2 [37–49]. ings, the IKT intervention, enablers and barriers, and any reported outcomes. Based on the Workgroup for Characteristics of eligible studies Intervention Development and Evaluation Research Studies were published between 2005 and 2014. Ten of (WIDER) reporting checklist [35], details about the 13 studies were published in 2013 or 2014 and one each intervention included content (nature and goal of the in 2005, 2006, and 2009. Four studies were conducted in program and/or IKT partnership), mode of delivery Canada, four in the UK, two in the USA, and one each (specific types of IKT activities in which partners were in Lebanon, the Netherlands, and Sweden. Five studies involved), duration and/or frequency (timing of IKT ac- were based on a mixed methods design, five on a case tivities), participants (who was involved in specific IKT study design, and three on qualitative interviews. activities), and personnel (who coordinated or led IKT activities). Time from initiation, the entity that initiated IKT activities used in partnerships the partnership, and source of funding were also noted. No studies explicitly mentioned the use of theory upon All investigators charted data from eligible studies. which the IKT initiative or any of its component strategies Summary statistics were used to describe the number were based. Table 1 summarizes the characteristics of IKT of studies by country, year of publication, and study partnerships in eligible studies. The content or focus of design; whether the IKT initiatives employed single or partnerships varied from specific health topics, for ex- multi-faceted interventions; and whether they were ample, implementation of a depression intervention [38] designed based on theory. Relational analysis was used or studying the impact of environment on breast cancer to summarize study findings [36]. With this technique, [45], to very broad initiatives that conducted applied Gagliardi et al. Implementation Science (2016) 11:38 Page 5 of 12 Fig. 1 PRISMA diagram of eligible studies health services research to ultimately improve population formation, for example, mutual understanding of health [47]. The most common activities or modes of language, work style, needs and constraints, or general interaction were meetings (i.e., team, working group, views about research or the collaborative process. Fewer committee, board) or presentations (i.e., conferences, studies reported measures that reflected the interim or workshops). Five of 13 studies reported the duration and/ longer term impact of IKT. For example, 4 studies or frequency of specific activities [37–39, 46, 47]. While 8 assessed whether research was used for decision-making. of 13 studies mentioned the categories of participants in- volved, 1 of those studies reported the number and/or Characterization of IKT initiatives type of participants involved in specific activities [38]. Table 3 characterizes the IKT partnerships, strategies, While all but 4 of 13 studies mentioned modes of inter- and conditions in eligible studies. Most partnerships action [39, 41, 43, 44], authors provided few specific were initiated by governments that provided dedicated details about when these activities took place and who resources for the initiative (7 of 13 studies). This did not was involved. For example, in one study, authors reported appear to be associated with successful outcomes. Of the that team meetings involving an unspecified number of 7 studies with dedicated funding from government, 2 senior managers and medical directors were held periodic- achieved positive, 4 achieved mixed, and 1 achieved sub- ally over a 3-year period [46]. No studies reported optimal or no impact on measures that were reported. personnel who organized or led the activities. All 8 studies that reported timing of the evaluation with respect to time from initiation of the partnership had Enablers and barriers of IKT existed for a minimum of 2 years; thus, partnership Table 2 lists 9 enablers and 15 barriers of IKT reported maturity did not appear to be associated with outcomes. across studies. All studies reported both barriers and The number of different types of interaction between enablers. researchers and decision-makers did not appear to be associated with outcomes; in the 4 studies that achieved Outcomes of IKT positive impact in all outcomes reported, the number of Table 2 lists the outcomes of IKT that were reported by types of interaction ranged from 1 to 8 (based on data in studies as positive (12) and sub-optimal (7). There was “Mode” column of Table 1). Many studies did not expli- little overlap across studies. For example, the most com- citly report how decision-makers were involved through- monly reported benefit was the development of capacity out the research trajectory. Among those that provided among researchers and decision-makers for engaging in such details, decision-makers were most often involved IKT in 7 studies, and the next most commonly reported in conceptualizing or planning research (10 studies) and benefit was enhanced value for research among in disseminating or implementing the findings (7 studies). decision-makers in 4 studies. Many other benefits and One study reported that decision-makers were involved all sub-optimal outcomes were unique to individual throughout the research process and achieved positive re- studies. Most studies reported measures that reflected sults on all reported outcomes. In contrast, three studies the more immediate impact of IKT on partnership achieved positive results on all reported outcomes when Gagliardi et al. Implementation Science (2016) 11:38 Page 6 of 12 Table 1 Description of IKT initiatives in included studies according to WIDER criteria [35] Study Content (program focus) Mode (IKT approaches/activities) Duration, frequency, timing Participants Personnel El-Jardali 2014 [38] Evidence-based health policy-making Evidence briefs, deliberative NR Researchers, policy-makers, other NR dialogues, priority setting, training stakeholders from many countries sessions, rapid response service, web (NR by activity) portal Eriksson 2014 [39] Health promotion Consultation, meetings, conferences, Varied from monthly Politicians, public clinicians, agency NR annual progress reports, joint to annual meetings representatives, researchers (NR by research, steering group, activity) coordinating committee, working groups Khodyakov 2014 [40] Depression Meetings, working groups, training Biweekly meetings, Researchers, clinicians, social workers, NR sessions, web portal 4 months policy-makers, counselors, clergy (mean 20–25 by event) Kothari 2014 [37] Women’s health Team meetings, priority setting, NR Researchers, partners, trainees from NR applying for research funding, joint many countries (NR by activity) research, web portal Kislov 2014 [41] Applied health research on a range NR Quarterly meetings, NR NR of topics 3 years Hoeijmakers 2013 [42] Public health knowledge sharing Meetings, training sessions, joint NR NR NR research, steering committee, board of governors, public relations Martin 2013 [43] Prevention, early detection, self-care, NR NR NR NR rehabilitation Murnaghan 2013 [44] Youth health, prevention of chronic Meetings, planning sessions, NR Policy-makers, health authority and NR disease presentations; print, web, and media agency representatives, researchers communications (NR per activity) Rycroft-Malone 2013 [45] Applied health research on a range NR NR Board, managers, health authorities, NR of topics committees, researchers (NR per activity) Soper 2013 [46] Applied health research on a range NR NR NR NR of topics Van Olphen 2009 [47] Breast cancer Joint research, meetings, NR NR NR presentations Patten 2006 [48] Priority setting practices Team meetings, joint planning NR Clinicians, managers, researchers NR (NR by activity) Bowen 2005 [49] Health promotion Workshops Three 2-day yearly Health authority personnel, NR events, 5 years researchers (NR by activity) NR not reported Gagliardi et al. Implementation Science (2016) 11:38 Page 7 of 12 Table 2 IKT enablers, barriers, and outcomes Table 2 IKT enablers, barriers, and outcomes (Continued) Measures Reported findings Studies (n) Developed an appreciation for 3 the collaborative process Barriers (9) Differing needs and priorities 5 among participants Enhanced relevance of the 3 research Lack of skill in or understanding 5 of IKT processes Decision-maker involvement 2 sustained through entire process Attitudes about researchers or 4 the value of research Enhanced mutual understanding 2 of language, work style, needs, Goals, roles, and expectations not 3 and constraints clear Number of collaborative projects 2 Lack of incentives to participate 3 undertaken/completed Lack of funding or infrastructure 2 Influenced policy-making 2 for IKT Influenced service delivery 1 Little continuity of involvement 2 due to staff turnover, infrequent Increased diversity of involved 1 attendance partners Participants are busy with 1 Strengthened relationships, trust, 1 multiple responsibilities and goodwill Geographic distant imposes 1 Emergence of community 1 limits on interaction leaders Enablers (15) Multiple and varied opportunities 4 Mixed outcomes (7) Decision-maker involvement 1 for interaction varied across activities Strong leadership commitment, 3 Failure to overcome differences 1 skill, and experience and bridge boundaries Phased approach to develop 3 Collaborations were temporary 1 shared language, achieve early successes Little to no research produced 1 Support from facilitators, 2 Research not used in policy- 1 champions, and boundary making spanners Greater emphasis on research 1 Clear and agreed upon goals, 2 publications than stakeholder roles, and expectations engagement Immersion of researchers in 2 Benefits only beginning to emerge 1 decision-maker setting/co- location decision-makers were involved in only some aspects of Formalized branding, structures, 2 and processes the research process. Establish partnership early in the 1 research process Summary of the IKT conditions, influencing factors, Openness of partners to listen, 1 and outcomes learn, and adapt Figure 2 shows a summary of IKT approaches, enablers, Organizational support for 1 barriers, conditions, and outcomes that were initially decision-makers to meaningfully compiled from background literature and expanded with contribute items that emerged from this study. This summary pre- Dedicated funding 1 sents the enablers, barriers, and conditions that have Shared governance structures 1 been reported to influence the IKT approach and a range Built on preexisting relationship 1 of possible outcomes relevant to IKT partnerships. Given the small number of eligible studies, limited detail about Availability of data to inform 1 activities IKT, and mixed findings, the relationships between en- Periodic external review to assess 1 ablers, barriers, contextual conditions, and outcomes re- progress main unclear. As more IKT studies are reported in the Positive outcomes (12) Capacity developed by 7 literature, the barriers, enablers, and outcomes might be researchers and decision-makers further organized into higher order categories with pro- Decision-makers grew to value 4 posed indicators. In the short term, this framework may research be used by others to prospectively plan IKT projects/ programs and their evaluation. Gagliardi et al. Implementation Science (2016) 11:38 Page 8 of 12 Table 3 Summary of IKT conditions, influencing factors, and outcomes Study Time from Types of Initiator/ Decision-maker involvement Enablers Barriers Outcomes initiation interaction Funding Conceptualize Recruit or Interpret Disseminate or (years) (number) and plan collect data findings implement El-Jardali 2014 [38] 2 to 3 6 WHO +NR + + + + +/− Dedicated Eriksson 2014 [39] NR 8 Government++ + + + + + Dedicated Khodyakov 2014 [40] NR 4 Researcher +NR NR + + + + Research Kislov 2014 [41] 2 NR Government+NR NR + NR + - Dedicated Kothari 2014 [37]2 5 NR + + NR + + + +/− Research Hoeijmakers 2013 [42] 2 6 Government+NR NR NR + + +/− Dedicated Martin 2013 [43] 2 NR Government NR NR NR NR + + +/− Dedicated Murnaghan 2013 [44] NR 6 Government + NR + + + NR + Dedicated Rycroft-Malone 2013 [45] 3 to 4 NR Government NR NR NR NR + + +/− Dedicated Soper 2013 [46] NR NR Government NR NR NR NR + + +/− Dedicated Van Olphen 2009 [47] NR 3 Researcher +NR NR + + + +/− Research Patten 2006 [48] 3 2 Health region+NR + — ++ NR NR Bowen 2005 [49] Over 1NR + NR + NR + + + 5 years Research Outcome refers to beneficial or sub-optimal outcomes as reported by studies: in relation to study objectives + all reported outcomes were positive or improved, +/− mixed outcomes (reported outcomes positive/improved and negative/not improved), NR not reported Discussion such as learning about research, awareness and accept- This scoping review was conducted to describe the ance of research, mutual understanding, development of knowledge base underlying IKT, gleaned from studies trust and goodwill, and an appreciation for the collab- that described and evaluated IKT strategies, and identify orative process are established. Another scoping review gaps to inform future research. Thirteen studies were of stakeholder involvement in rehabilitation research eligible. The most common form of interaction was found that stakeholder preparation was needed to meetings, but they varied in nature, aims, and frequency. understand research and fulfill their role [33]. This took All studies reported both barriers and enablers. While the form of formal and informal training and, in some most studies achieved one or more positive outcomes, studies included in that review, decision-makers were studies reported a wide range of positive and less posi- paid to participate in the training. tive outcomes. Given incomplete and inconsistent To the best of our knowledge, this study is among the reporting of study design, IKT strategies, and outcomes, first to attempt to identify the characteristics of IKT it was not possible to identify relationships between strategies and their potential association with outcomes outcomes and contextual factors related to initiator of using a rigorous approach. Our scoping review is distin- the partnership, dedicated funding, partnership maturity, guished from that of Jagosh et al. who published a realist nature of decision-maker involvement, presence or ab- systematic review on the effectiveness of community- sence of enablers or barriers, or the number of different based participatory research partnerships that included IKT activities employed in a given initiative. A number 276 studies [36]. In participatory, action or community- of studies assessed partnership formation. Given that the based research, the intent is to improve the quality of partnerships evaluated were at least 2 years old, it may service delivery, health equity, or clinical outcomes not be reasonable to evaluate the influence of research where community-identified rather than research-based on decision-making until more immediate outcomes solutions are emphasized, or researchers function as Gagliardi et al. Implementation Science (2016) 11:38 Page 9 of 12 Fig. 2 Summary of IKT approaches, influencing factors, and outcomes consultants. We chose to define IKT as partnerships Applied Health Research and Care (CLAHRC) in the between researchers and organizational or system-level UK [41, 43, 45, 46] and one study evaluating Academic decision-makers including clinician managers, health Collaborative Centres (ACC) for Public Health in the facility managers, and policy-makers for the purpose of Netherlands [42]. Both of these national-level initia- academic research, although those partnerships may have tives involved large-scale investment to foster IKT. enabled improvements in service delivery or clinical out- Since partnerships may develop over time, and add- comes. IKT decision-maker partners are distinct in that itional evaluations may be forthcoming, longitudinal they are specifically selected for their scope of responsibility evaluation of these important initiatives is warranted to and, hence, authoritytoinvokepracticeorpolicychange. identify beneficial outcomes. Another way to interpret This scoping review, which goes beyond anecdotal ac- these findings is that other barriers, enablers, or context- counts, may serve as a springboard to the conduct of future ual conditions may be more important than funding to research that specifically examines researcher-decision- the formation and outcomes of IKT partnerships. Such maker partnerships. insight was not afforded by this study because enablers, Despite suggestions that lack of funding is a deterrent barriers, and outcomes were variable across studies and to practicing or achieving IKT [3, 18, 19], in this study, not consistently recorded or described. In future research, formal IKT partnerships that were specifically initiated longitudinal analytic approaches may be useful to evaluate and funded by governments did not appear to eliminate IKT impact and clarify the relationship between IKT ap- barriers or report better outcomes compared with other proaches and outcomes. A time series design, for example, studies that lacked such infrastructure. This included could be used to systematically track the evolution of part- four studies evaluating Collaborations for Leadership in nership formation and better pin-point the activities or Gagliardi et al. Implementation Science (2016) 11:38 Page 10 of 12 strategies that move the partnership from the formation makers took part in any way in the conduct of the research stage into a more functional and active stage. or interpretation of the findings. Given that the nature of IKT was poorly and inconsistently described, evaluated, decision-maker involvement was largely under-described, and reported in most studies, making it challenging to we cannot say if the involvement of decision-makers identify strong thematic areas. However, three important throughout the course of a research initiative, which is the knowledge gaps were clearly identified. First, some studies purported ideal [3], actually achieves better outcomes. evaluated the IKT initiative but did not describe or detail Other studies of IKT also reported that research remained the IKT activities. Future researchers are encouraged, largely investigator-driven [22, 23], and decision-makers therefore, to capture and report the full extent of IKT ac- were often not directly involved as integral partners [14]. tivities, including the nature or mode of interactive activ- Future research must examine a range of IKT approaches ities (i.e., brainstorming sessions, data interpretation to identify the ideal timing and manner in which decision- sessions, passive dissemination through websites), who is makers must be involved for effective research uptake. involved in which activity, who is leading the activity, and Several issues may limit the interpretation and use of how often activities take place. This cumulative un- these findings. The relatively small number of eligible derstanding will allow a nuanced typology of different studies may have precluded identifying with greater IKT models to emerge. Those who plan and imple- certainty the characteristics and contextual conditions ment and/or evaluate IKT initiatives might employ required to foster and achieve IKT. This may, in part, be the WIDER reporting checklist when they design such due to the fact that studies about IKT are difficult to iden- initiatives or report evaluative findings [34]. The tify. Other researchers have noted that the IKT literature WIDER checklist recommends describing: the interven- is not consistently indexed in databases of published re- tion (approaches, strategies), mode of delivery (intensity, search [33, 34]. Screening of search results was challen- duration, timing), intervention content (knowledge ging due to the large number of search results to assess generated or shared), participants and their role (the and limited detail in the studies by which to ascertain eli- characteristics of those sponsoring, delivering, and receiv- gibility. This means that the resulting summary of IKT ing the intervention), setting, and adherence or fidelity. (Fig. 2) is inclusive of numerous characteristics and condi- The second knowledge gap to emerge was the lack of ex- tions that require further evaluation of their association plicit description of underlying theory or logic upon which with outcomes. Although we searched standard indexed IKT approaches and associated activities were selected and/ sources of published medical literature, the search strategy or evaluated. As the WIDER checklist specifies, details are may not have identified all relevant studies. Study retrieval needed about how the IKT intervention was developed, was limited to journals that are indexed in the three change techniques used in the intervention, and the causal databases that were searched. We did not search the grey processes targeted by the change techniques to achieve par- literature, assuming that most empirical research on IKT ticular outcomes. Therefore, future research could focus on interventions would be found in indexed databases. Many identifying, describing, and testing relevant theory by which studies did not provide a full description of the research to design and/or evaluate IKT initiatives. First, it may be methods used or fully describe the research findings for all useful to conduct an interpretive synthesis of the findings components of a case study or mixed methods research. reported here by analyzing enablers and barriers according Most studies collected qualitative data; however, they were to the context and design of IKT initiatives in the included often not complete or sufficiently detailed to extract clear studies. A scoping review is an appropriate starting point to findings with respect to enablers, barriers, and, in particu- understand the nature of the empirical work in the domain lar, outcomes. Given limited detail about IKT activities, it and to determine if a systematic review is warranted. Thus, was difficult to chart data; however, we employed a rigor- we deliberately maintained a wide focus rather than target- ous methodology that complied with standard approaches ing certain aspects of the IKT process. Our findings suggest for scoping reviews [29, 30], and data were charted inde- that the empirical work in the area is just emerging, and pendently by two investigators for all articles to enhance thus it is premature to embark on a systematic review with reliability. In the absence of a universally accepted atight focus. taxonomy with which to refer to IKT approaches, activ- The third knowledge gap pertains to decision-maker in- ities, processes, etc., it was challenging to describe and volvement. IKT activities most often consisted of meetings summarize how IKT was operationalized in included stud- between researchers and decision-makers. However, the na- ies. Most studies reported one or more positive outcomes ture of those meetings and the level of engagement of which may represent a bias toward reporting favorable decision-makers in research-related decisions or research findings; this is further underscored by the small number activities were not reported. In some cases, decision-makers of eligible studies. Insufficient knowledge emerged from were reported as playing a role in disseminating or imple- this scoping review to enable a full understanding of the menting the results. It was largely not reported if decision- variety of ways to promote IKT partnerships and engage Gagliardi et al. Implementation Science (2016) 11:38 Page 11 of 12 in interactions. Therefore, we are unable to issue clear or Received: 14 December 2015 Accepted: 5 March 2016 justified recommendations in this regard. As more re- search on IKT emerges, this may become possible at some point in the future. Finally, some scholars [30] have sug- References 1. 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Journal

Implementation Science – Springer Journals

Published: Dec 1, 2015

Keywords: health services research; public health; health informatics; health policy; health administration; health promotion and disease prevention

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