Advertisement

Abstract

With the emergence of patient-centered care, consumers are becoming more effective managers of their care—in other words, “effective consumers.” To support patients to become effective consumers, a number of strategies to translate knowledge to action (KTA) have been used with varying success. The use of a KTA framework can be helpful to researchers and implementers when framing, planning, and evaluating knowledge translation activities and can potentially lead to more successful activities. This article briefly describes the KTA framework and its use by a team based out of the University of Ottawa to translate evidence-based knowledge to consumers. Using the framework, tailored consumer summaries, decision aids, and a scale to measure consumer effectiveness were created in collaboration with consumers. Strategies to translate the products into action then were selected and implemented. Evaluation of the knowledge tools and products indicates that the products are useful to consumers. Current research is in place to monitor the use of these products, and future research is planned to evaluate the effect of using the knowledge on health outcomes. The KTA framework provides a useful and valuable approach to knowledge translation.

With the emergence of patient-centered care, patients are not only starting to participate more actively in their care, they also want to lead it. Although they are experts of their own disease, some patients recognize that they need more information, want to make their own decisions, and want to be able to implement those decisions themselves. Basically, some consumers want to become effective managers of their care—what we have called “effective consumers.”

A team based out of the University of Ottawa has been researching and developing strategies to enable consumers to become effective consumers. One of the principal aims of this research is to put the results of rigorous research into the hands of consumers so they can use it when making important decisions related to their health. Unfortunately, it has been shown, in general, that research often is not being used in decision making and put into practice.1 Fortunately though, with this realization, there has been an increase in interest and research activities to ensure that evidence is applied by health care professionals, policy makers, or any decision maker, including consumers. Despite ongoing debates about what “research into practice” should be called (eg, knowledge translation, transfer, exchange, research utilization, implementation), the concept that research or knowledge has to be put into action is emphasized. Research that is sitting on a shelf cannot possibly save health care dollars, save resources, and—most importantly—save lives. But how do researchers avoid the threat of a dusty shelf and instead put their research evidence into the hands of people who need it and can use it? How can researchers plan for the use of their research? Where to start?

A framework for the process of putting knowledge to action (KTA) has been developed (Figure).1 Graham and colleagues1 provide a map or guide for researchers and implementers to frame and plan how to move the knowledge they have created into action. This framework is relatively new (although based on decades of research and earlier versions) and is being used to organize how the Ottawa Team tackles knowledge translation for consumers. This article describes the steps within the framework that the Ottawa Team took to create knowledge tools and products to empower consumers to participate in and lead their care and the steps taken to facilitate the use of these tools and products by consumers. The Ottawa Team also is currently evaluating and monitoring the use of the tools and strategies and planning additional future research. Each step in the process is drawn from the elements of the KTA cycle shown in the Figure. It will become clear how valuable this framework can be as a guide to researchers when planning their research and how to put it into action.

Figure.

Knowledge-to-action process. Reprinted and modified with permission of the Journal of Continuing Education in the Health Professions from: Graham ID, Logan J, Harrison MB, et al. Lost in knowledge translation: time for a map? J Contin Educ Health Prof. 2006;26(1):13–24.

KTA Framework

The framework divides the entire KTA process into 2 main concepts: knowledge creation and action. Although, the 2 overarching concepts are presented separately in the framework and linearly in our examples, the “phases are fluid and permeable.”1(p18) The knowledge creation phases may influence the action phases and vice versa.

Knowledge creation encompasses the phases of conducting research, pulling together or synthesizing the research, and refining it into a usable format in knowledge tools or products. In our project, knowledge creation was the synthesizing of randomized controlled trial evidence into systematic reviews and creating consumer-friendly summaries and tools based on that evidence.

The KTA cycle involves activities to ensure that the knowledge is used. The phases of this cycle are represented as boxes that make up an outer circle. The action phases, although distinct boxes in the Figure, are not independent of each other and often may occur at the same time or inform each other. In this project, strategies were explored to promote the use of knowledge tools by consumers.

Knowledge Creation: Creating Knowledge Tools and Products for Consumers

Graham and colleagues1 explained that the process of creating knowledge can be represented as a funnel. Research, whether starting out as a scientific study at a molecular level or at a clinical study stage, is distilled and refined as it goes through the funnel to create a more usable form of knowledge, ready to be taken up and used by various stakeholders. Many members of the Ottawa Team contribute to the Cochrane Musculoskeletal Group (CMSG), which specializes in finding, appraising, and synthesizing primary studies into systematic reviews. Researchers, health care professionals, statisticians, and others work together to synthesize research findings from randomized controlled trials that evaluate the effects of interventions for arthritic conditions. The Ottawa Team had this large base of research evidence that was already synthesized (“knowledge synthesis,” Figure), but the knowledge from these reviews was not in a very user-friendly format, especially for consumers. Therefore, the Ottawa Team committed itself to filtering and funneling this synthesized evidence-based information into products and tools for consumers.

Part of knowledge creation at all phases is, as Graham et al1 explained, tailoring knowledge to the potential users. The target in this project was consumers, and it was important to determine which knowledge to refine (“knowledge inquiry,” Figure) and into what format (“tailoring knowledge,” Figure). Therefore, a survey was developed to ask consumers what were their priority issues and concerns for information about arthritis treatment and prevention. Invitations to complete the survey were sent via e-mail to 3 listservs of principal consumer organizations in Canada and internationally: the Arthritis Society of Canada, the Canadian Arthritis Patient Alliance, and the Cochrane Consumer Network. The survey also was publicly available through the CMSG and Arthritis Society of Canada Web sites.

Approximately 110 people responded to the survey. Respondents, although interested in detailed information about drug treatments, wanted more information about complementary and alternative treatments, including physical therapy and exercise and herbal supplements. These results were confirmed during informal discussions with approximately 10 consumer members of the CMSG and through comments received during the peer-review process of producing CMSG protocols and reviews. Using these results, the Ottawa Team determined which evidence was a priority to translate to consumers. This information also fed back into the early stages of knowledge creation, by identifying priority areas to systematically review and important outcomes to include. It also ensured that the findings from the reviews were more relevant to consumers.

The next step was to adapt the knowledge from the systematic reviews into knowledge products that were easy to understand by consumers (create “knowledge tools/products” and “tailoring knowledge,” Figure). To tailor the information, the Ottawa Team reviewed the literature, including published literature and patient information guidelines, to determine the best methods to present research information to consumers.2 Based on this work, one-page summaries of the evidence were created and written in plain language, in which “bottom lines” were highlighted and risks and benefits were presented as event rates (eg, “x” number of people out of 100 had side effects).

Members of the Ottawa Team also lead research activities in the Ottawa Hospital Decision Centre in the Ottawa Health Research Institute.3 Their work and their Cochrane systematic review of 35 randomized controlled trials show that decision aids enhance active consumer participation in decision making.4 Therefore, decision aids based on the evidence from CMSG systematic reviews were created (see example in the Appendix). These knowledge tools are more detailed than the consumer summaries, but provide a step-by-step guide to the decision-making process.5 Consumers are presented with the benefits and harms of interventions as event rates in the text and also graphically. Consumers then are asked to think through how much they value those benefits and harms, whether they need more information, and what role they would like to play in the decision-making process (eg, make decisions on their own, with their physician, or with others).

Although the development and creation of the consumer summaries and decision aids were based on the results of research, the tools and products also were adapted to ongoing feedback and interest by consumers. Workshops with consumers, patient educators, and information producers were run annually at various conferences, including the annual Cochrane Colloquiums and meetings of the Institute of Musculoskeletal Health and Arthritis of the Canadian Institutes of Health Research. The close connection and relationship with consumers helped the Ottawa Team to tailor the tools and were fundamental to promote the use of these products.

Action Cycle: Activities to Promote Action

As described above, the Ottawa Team dedicated resources to create user-friendly knowledge products that summarize and present evidence for consumers. The next step was to enable consumers to use this evidence to effectively participate in and lead their own health care—the action cycle. To facilitate this process, a planned approach was critical. The phases of the action cycle in the Figure represent the steps the team took to ensure our knowledge was put into action.

The first step was clarifying the problem that needed to be addressed (identify problem). Results from semistructured interviews conducted in another project led by this team were used to inform this step.6 Seventy-eight people with musculoskeletal conditions, family members, and physicians were asked about their experiences handling their health situation, the experiences of their family, and of their patients. The intent was to determine what made people effective at managing their care. Analysis of the interviews revealed that people were very aware that they needed and wanted information to be effective, but health care providers often had difficulty translating health care information into their language. They were actively searching for information, primarily about treatments, especially when their own treatments were not working. People also were interested in doing what they could to help themselves. This finding echoed our earlier work with consumers who wanted more information about alternative and complementary treatments that they could implement themselves. Although these results are not surprising, the identification of this problem helped to focus our efforts and confirm that our team had the knowledge products to address the problem (“identify, review, select knowledge,” Figure).

The next step was adapting the knowledge to the local context. In this project, adapting the knowledge meant providing a tool to help consumers to take the general health information and apply it to their own personal experiences and situation. Again, the findings from the semistructured interviews confirmed that, although consumers were searching and reading health information, they were thinking about whether the information applied to them and whether the benefits and harms of treatments were important to them in their own lives. These concepts are key when adapting knowledge to users. In this case, the evidence was adapted, for example, by describing the situations when individuals might need to consider a treatment, by presenting benefits and harms in numbers out of 100 people, and by providing exercises to clarify what benefits and harms are important to the them (as in the decision aids).

Although much of the activity described above focused on developing a tailored product and collaborating with our stakeholders, it was still not guaranteed that these products would reach consumers and be used. The next phase was planning and executing strategies to actively promote awareness and uptake of the products. First, barriers and facilitators to knowledge uptake were identified (“assess barriers to knowledge use,” Figure). The interviews indicated that the Internet was an important source of information, but that physicians were still seen as the gatekeeper to information and services and that cultivating good relationships with health care providers and communicating well with them was important. The literature also describes other barriers and facilitators to implement decision aids for both patients and physicians, including lack of awareness of decision aids, difficult or no access, and limited time of physicians.7

Next was selecting interventions to implement the tools (“select, tailor, implement interventions,” Figure). There are a broad range of interventions to consider. The Cochrane Consumers and Communication Review Group has organized interventions to translate knowledge to consumers into 6 categories8:

  • Interventions directed to the consumer

  • Interventions from the consumer

  • Interventions for communication exchange between providers and consumers

  • Interventions for communication between consumers

  • Interventions for communication to the health care provider from another source

  • Service delivery interventions

Based on the identification of the barriers and supports from the literature and the semistructured interviews, the Ottawa Team focused first on interventions directed to consumers by increasing the awareness of the knowledge products and tools and providing access to them (ie, broad dissemination). We decided to provide our summaries and decision aids on the Internet. Convincing consumer organizations to feature the summaries online and at call centers to increase awareness of the tools was not as challenging as expected, because strong links and relationships with those groups were established early in the knowledge creation phases. The Arthritis Society of Canada9 and Arthritis Victoria in Australia10 are 2 consumer organizations that feature the consumer summaries, and there is interest to post the decision aids on their sites as well.

In the meantime, decision aids are available online in a decision aid database created by colleagues at the Ottawa Health Research Institute.11 This database provides easy and quick access for patients or for physicians to print out decision aids for their patients, thus facilitating their use. Because our work also identified physicians as gatekeepers and communication with physicians as important, the Ottawa Team is currently investigating interventions for communication exchange between providers and consumers. Decision aids have the potential to improve this communication. There are plans to evaluate the effects of using the consumer summaries and decision aids before, during, or after physician appointments in a trial.

At this time, much of our work has focused on knowledge creation and choosing strategies to provide consumers with those tools. The next step is to monitor use of those tools (see “monitor knowledge use” at the top of the KTA framework in the Figure). Graham et al1 described 3 levels of knowledge use: conceptual use (changes in understanding), instrumental use (changes in behavior), and strategic use (use of knowledge for power). The Ottawa Team has focused on conceptual and instrumental use. A basic assessment of the use of consumer summaries by tallying Web site visits to the consumer summaries indicates that more than 6,000 consumers visit the summaries each month on the Arthritis Society of Canada Web site. In addition, a Web survey to evaluate the consumer summaries was posted on 10 (out of 70) high-traffic summaries for 7 months. Approximately 260 consumers completed the survey. Respondents indicated that the summaries increase knowledge and were useful for decision making.

Research into conceptual use and changes in behavior when using decision aids also has been evaluated and reviewed by the Ottawa Team. In general, the Ottawa Team has previously shown that patient decision aids improve knowledge, enhance participation in decision making, and decrease uncertainty and decisional conflict in patients.4 Ongoing research by the Ottawa Team is investigating whether the decision aids created in this project will help consumers make health care decisions with their physicians in a clinical setting. These results should be available soon and will inform the next steps to evaluate and sustain the use of our knowledge products.

Evaluating outcomes and sustaining use are 2 phases of the action cycle that are challenging to carry out and are relatively new fields of research.1 This is true in arthritis research. Most outcomes in arthritis research, including research into interventions to provide patient information and education, measure clinical and symptom outcomes in arthritis, such as pain, function, and range of motion.12 Future research by the Ottawa Team to evaluate the strategies for knowledge translation could use similar outcomes, but these outcomes would not capture our principal goal for creating the knowledge tools and products: to enable consumers to become effective at managing and leading their health care. For this reason, the Ottawa Team is developing and validating a new outcome measure to monitor our knowledge translation strategies. Our research into effective consumers described earlier in this article has led to the creation of an outcome scale measuring the skills and attributes of an effective consumer: the Effective Consumer Scale (EC-17).13 It has been developed within the OMERACT (Outcomes Measures in Rheumatology) process with outcome researchers, health care professionals, and consumers. The EC-17 also has been developed with people who are running self-management programs for people with arthritis. More work is under way to validate this outcome to evaluate our KTA strategies.

Feedback from our current and future research, as well as general research into the presentation and development of patient information, will provide valuable information to change and improve our knowledge products. In addition, the cultural change to a more patient-centered approach may change the barriers and facilitators initially determined in the earlier phase of the cycle. In this way, Graham and colleagues1 explained that the “sustain knowledge use” stage will continually provide feedback into the KTA cycle, and planning and maintaining knowledge translation activities will continue to follow the same process: reassessment of barriers, tailoring products and intervention strategies, monitoring use, evaluating impact and sustaining use, and so on.

Coming Full Circle in the KTA Process

The Ottawa Team consists of a group of researchers with a wide range of expertise who are involved in a variety of projects related to consumers, arthritis, systematic reviews, and decision aids. The CMSG, for example, has traditionally been seen as producers of knowledge, namely systematic reviews. As published, these systematic reviews are not in a user-friendly format ready for use, particularly by consumers. Over the past few years, the Ottawa Team has created knowledge tools and products based on the evidence from systematic reviews, which are specifically for consumers. Recently, there has been an increased focus on promoting and facilitating the uptake of that knowledge. During these activities, the KTA framework has provided our team with a valuable guide to think about the steps necessary to tailor our knowledge tools to consumers and the steps to tailor intervention strategies to ensure knowledge use. The framework has enabled us to organize, investigate, plan, and apply strategies to translate CMSG reviews into action.

As described earlier, the process is fluid and permeable. The steps that the Ottawa Team took in the KTA translation process have not been linear, as presented in this article. We revisited phases of the creation and action cycles many times, and we cut across and even skipped ahead depending on the opportunities. At times, it felt that we were going in circles—a good thing, as it turns out. This KTA approach has been helpful for our team to organize our research efforts and will likely prove to be a useful and valuable guide for others tackling the challenges of creating knowledge and putting it into action.

Appendix.

Appendix.

Sample Decision Sheeta

aThis decision aid is used and reprinted with permission and is publicly available for free at: http://decisionaid.ohri.ca/docs/das/OA_men_65_over.pdf.

Footnotes

  • Dr Tugwell and Dr Wilson provided concept/idea/project design. Dr Tugwell, Ms Santesso, and Dr O'Connor provided writing. Ms Santesso provided data collection and clerical support. Ms Santesso and Dr O'Connor provided project management. Dr O'Connor and Dr Wilson provided consultation (including review of manuscript before submission).

  • Effective Consumer Investigator Group: Peter M Brooks, University of Queensland; S Michelle Driedger, University of Manitoba; Cindy Gallois, PhD, University of Queensland; Peter S Tugwell, MD, Annette M O'Connor, PhD, Janet Wale, George A Wells, Ann Qualman, and Nancy A Santesso, MLIS, University of Ottawa; Andrew J Wilson, PhD, Queensland Health Policy, Planning and Resourcing.

  • This work was presented at the CARE IV International Conference; September 6–8, 2006; Leeds, West Yorkshire, United Kingdom.

    References

    View Abstract