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McCormack L, Sheridan S, Lewis M, et al. Communication and Dissemination Strategies to Facilitate the Use of Health-Related Evidence. Rockville (MD): Agency for Healthcare Research and Quality (US); 2013 Nov. (Evidence Reports/Technology Assessments, No. 213.)

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Communication and Dissemination Strategies to Facilitate the Use of Health-Related Evidence.

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Introduction

Background

Rationale and Relevance for Conducting the Systematic Review

The Agency for Healthcare Research and Quality (AHRQ) sponsors research to improve the quality, effectiveness, and safety of health care in the United States. Evidence reports and technology assessments generated through AHRQ’s Effective Health Care (EHC) Program provide science-based information about common, relevant health conditions and technologies to serve the needs of patients, clinicians, insurance payers, and other end users. Findings from clinical, health services, and comparative effectiveness studies—especially as assembled for systematic reviews and similar documents—need to be communicated and disseminated effectively to influence optimal and timely practice and health policies.1

Because systematic reviews evaluate multiple studies, they are inherently complex. Nuanced descriptions of benefits, harms, strengths of evidence, and uncertainties often make findings from evidence reports difficult for intended audiences to understand and use in decisionmaking. Evidence reports are typically targeted at scientific researchers in related fields, rather than at the patients or clinicians who ultimately make health related decisions. Clear communication and active dissemination of findings from research reports to all audiences in easy-to-understand formats are critical to increasing awareness, consideration, adoption and use of evidence. Given AHRQ’s mission, a critical goal is to evaluate the effectiveness of techniques to ensure that such findings are correctly understood and placed within the context of existing information on the topic from other sources and of strategies to make evidence report findings widely available. By evaluating the comparative effectiveness of communication techniques and dissemination strategies, this review will inform efforts to make evidence reports that summarize current research both more easily accessible for patients and clinicians and more likely to be used to influence individual decisions, change practice, and inform future research.

Due to the complexities of our topic, we present our work as three separate systematic reviews—one for communication, one for dissemination, and a third for uncertainty—each addressing a separate, but related, Key Question. Combined, these three separate reviews inform how to best translate and disseminate research-based evidence reports.

Terminology and Definitions

Transforming scientific evidence for its use in practice, commonly known as research translation, involves many processes and strategies. Investigators must conduct high-quality studies; and experts must synthesize and summarize these bodies of evidence, often in the form of systematic reviews of comparative effectiveness. Authors of evidence reviews typically presented their findings in complex and technical jargon that must be altered into simpler language and actionable steps that potential end users find easier to understand. Authors or organizations must disseminate such documents to those audiences; and, providers and others must incorporate the information into existing health care processes and systems to improve health. Each step is influenced by factors associated with the evidence itself, as well as others such as the outer context affecting systems, system readiness for innovation, characteristics of potential adopters, and resource needs and availability.2

The terminology for each of these steps overlaps considerably. We focus our review on the comparison of communication and dissemination strategies to translate the evidence base about health and health care, including effective ways to present associated uncertainty. For our review, we define evidence as data that has been assembled, reviewed, and presented by evidence developers and that has been used to make recommendations (see additional details about the definition of evidence in the Methods section).

Table 1 lists six key definitions to help readers understand the scope of our review and the concepts that we will use throughout it.

Table 1. Definitions of concepts relevant for this review.

Table 1

Definitions of concepts relevant for this review.

We deliberately avoid the term “translation” in our review because it has broad and diverse definitions. Rather, we focus on components of translation, specifically communication and dissemination, and on a special issue in communication, that of communicating uncertainty. Adoption and implementation processes to integrate evidence-based practices successfully into health care delivery to improve health outcomes are beyond the scope of this review.

Communication Strategies To Promote the Use of Health Care Evidence

Government agencies and institutions, advocacy groups, media organizations, researchers, and other interested stakeholders can all carry out communication activities. They use various strategies to communicate evidence so that target audiences can understand it better; the strategies are meant to increase the probability that recipients pay attention to the messages conveyed.8,9 People are motivated to process information actively when they perceive it to be personally relevant. This attribute can reflect dimensions such as the number and magnitude of consequences relevant to them and the match of the information to an existing need.10

For purposes of our review, communication strategies fall into the broad area of “health communication” and focus on making evidence interpretable, persuasive, and actionable. The John M. Eisenberg Center for Clinical Decisions and Communications Science translates AHRQ’s comparative effectiveness review information to create a variety of materials ranging from evidence summaries to decision aids and other products. Our review focuses on identifying communication strategies to inform the development of these and other materials for specific audience segments.

Overview of Four Main Communication Strategies

To our knowledge, no overarching framework of communication strategies exists to guide this part of our review. Multiple systematic reviews, however, have explicated key communication strategies that are of interest to the field.1118 They include four core constructs:

  1. Tailoring the message—Communication designed for an individual based on information from the individual.
  2. Targeting the message to audience segments—Communication designed for subgroups based on group membership or characteristics such as age, sex, race, cultural background, language, and other “psychographic” characteristics such as a person’s attitudes about a particular subject matter.
  3. Using narratives—Communication delivered in the form of a story, testimonial, or entertainment education.
  4. Framing the message—Communication that conveys the same messages in alternate ways (e.g., what is gained or lost by taking an action or making a choice).

Table 2 summarizes recent evidence for the effectiveness of the four communication strategies that we examine: tailoring the message, targeting the message to audience segments, using narratives, and framing the message.1118 Other strategies such as using plain language are well established, supported by the literature, and a necessary component of all communication. Thus, they were not included in this review. Multiple systematic reviews have focused on the effectiveness of these included communication strategies relative to not using any strategy, that is, relative to “usual practice.” Thus, these reviews establish the contribution of each strategy compared with not using any communication strategy. By contrast, our focus is on the comparative effectiveness of different strategies.

Table 2. Systematic, meta-analytic, or theoretical reviews supporting various communication strategies.

Table 2

Systematic, meta-analytic, or theoretical reviews supporting various communication strategies.

Tailoring

As with many other communication strategies, the rationale behind creating tailored communication is that it can maximize the relevance of the communication to its intended audience. Rimer and Kreuter (2006)19 argued that tailoring message content to an individual’s informational needs and interests can elicit greater cognitive elaboration (i.e., attending to, thinking about) by increasing its perceived relevance.2022 Tailoring is a multistep and multidimensional process that involves assessing an individual’s characteristics, creating individualized messages, and then delivering these messages.20,21 A typical tailoring study will first collect data from individuals regarding various psychosocial behavioral determinants. It will then use conceptually or empirically based algorithms—usually computer driven—to process each person’s data and generate customized feedback to meet that individual’s unique needs.

Targeting

Targeting (also referred to as audience segmentation) involves developing a single intervention approach for a defined population subgroup that takes into account characteristics that the group shares (e.g., age, sex, race, ethnicity, spoken language).21 Tailored communication is intended to reach a specific individual; by contrast, targeted communication is intended to reach some population subgroup. Once those developing communications have segmented an audience or population in one (or more) ways, they should then design the messages to be maximally effective for that target subgroup (or subgroups). They can accomplish this by manipulating language, visuals, music, or choice of behavior topic. As with tailoring, message targeting is expected to enhance the perceived personal relevance of a message.

Narratives

Narrative messages are defined as “story-like prose pieces that focus on elaborating one example of an event, and they provide appealing detail, characters, and some plot, presented in either the first or third person.”16, p.2080 The characters and the situations in stories serve as models for emulation and learning. Some narratives include personal stories, case histories, anecdotes, and testimonies (e.g., a personal account of an individual’s experience in donating an organ to a sibling). Evidence is mounting for the benefits of narrative health messages in promoting persuasion and behavior change.15,16,23,24

Framing

Appeals aimed at persuading individuals to perform healthy behaviors or avoid risky behaviors can be framed in different ways. Health messages are framed or presented within a specific context to promote or enhance comprehension. For instance, messages might emphasize the positive or negative aspects of a situation, commonly known as gain/loss framing. Gain- and loss-framed messages are factually equivalent. Previous research has found that gain-framed messages are significantly more likely than loss-framed messages to increase the likelihood of positive behavior change (i.e., practicing healthy behaviors).17,18

Interactions Across Techniques and Generic Approaches

Communication techniques do not necessarily occur in isolation. One possible reason that prior literature often reports no or mixed effects from these four strategies25 may be that message features moderate the effects of the strategies. For example, features such as the use of narratives may affect involvement and message relevance and intensify or minimize the effect of message framing on behavioral outcomes.

To date, most research fails to explore potential interactive effects of the strategies. However, because the content of a message typically contains several different features, most messages will likely combine various strategies (e.g., loss-framed narrative or gain-framed statistical evidence). In addition, some techniques can be present in a study because of the nature of the variable itself. For example, with framing, every statement that connects a recommended action to some health outcome can be said to have either a positive or a negative frame. We will consider the potential interplay that may occur when messages contains multiple persuasive techniques by reporting any interaction effects observed in the primary studies.

Finally, several other communication approaches involve applying plain language principles or using theoretically driven messages. These approaches are widespread and can be considered best practices, but we excluded them from this review because they are general approaches used across many different communication techniques.

Dissemination Strategies To Promote the Use of Health Care Evidence

Dissemination is the active and targeted distribution of information or interventions via determined channels using planned strategies to a specific public health or clinical practice audience.4,5,26 Dissemination has been characterized as a necessary but not sufficient antecedent of adoption and implementation. In contrast to diffusion, which is a passive, informal process, dissemination is a formal, planned process with the intent of spreading knowledge and associated evidence-based interventions to stimulate adoption and enhance the integration of the evidence, information, or intervention (or combinations of these) into routine practice.2,47

Dissemination strategies involve “packaging” the evidence, information, or intervention in different ways and using a variety of channels to reach the target audience(s) within or across geographic locations, practice settings, or social networks. Dissemination is often described as a “push/pull effort,” with some strategies directed toward increasing the reach and accessibility of the evidence (i.e., push) and other strategies directed toward increasing the receptivity or readiness of the target audience (i.e., pull). This push/pull description has also been used more generally to describe an approach to closing the overall research-to-practice translation gap.2729

Outside the United States, the phrases “knowledge translation” and more recently “knowledge exchange” are used to reflect iterative cycles of feedback and involvement of the target audience(s) in generating and incorporating evidence into routine practice. Furthermore, the concept of “knowledge brokering” describes the organized way in which the iterative process of knowledge exchange occurs, including dissemination.5,30

Evidence dissemination has several very broad goals relating to evidence and information: (1) to increase their reach to a variety of audiences; (2) to increase people’s motivation to use and apply such information; and (3) to increase people’s ability to actually use and apply evidence. A recent narrative review of dissemination and implementation research models identified 11 dissemination-only models and an additional 16 combined dissemination/implementation models with a predominant focus on dissemination.26 In examining influences that help spread innovations along the continuum between passive diffusion of information and active dissemination, Greenhalgh et al. created an inventory of strategies that aim to influence individual, social, and other adopters in one of three ways: to improve reach by distributing evidence widely; to improve motivation by increasing interest in or acceptability of the evidence; and improve ability by providing additional resources about how to incorporate evidence or how to initiate change based on evidence.2

Other systematic reviews and dissemination research show that active dissemination strategies are more effective than passive strategies.31 For example, in a synthesis of 41 systematic reviews, Grimshaw and colleagues reported that active, multifaceted approaches were most effective for changing provider behavior.32 Educational outreach, academic detailing, and the use of local opinion leaders are the most consistently effective interventions reported. Interventions that are theory-based, that incorporate two or more distinct strategies (i.e., that are multicomponent), or that do both, are consistently more likely to work than single interventions.33,34 Moreover, the Internet, technological platforms for social networking, and Web 2.0 applications all involve active steps, and users can create and interact with information in ways that give classic theories of dissemination a new twist.35

Evaluating strategies for disseminating evidence and information entails specifying interventions and desired outcomes (such as adoption of the disseminated information or intervention at the individual or organizational level). It also requires consideration of two other components: mediators, which are processes through which dissemination occurs, and moderators, which are factors influencing the speed and extent of dissemination.4

Explaining Uncertain Evidence

Uncertainty is inherent in health care and evidence about health care.36 It stems from multiple sources, including imperfect knowledge about scientific evidence, patients’ preferences and circumstances, and how to apply judgment in decisionmaking.3639 Uncertainty may interfere with both patients’ and physicians’ ability to derive appropriate meaning about illness, diagnostic tests, treatments, and prognosis and to use this information in meaningful ways. Further, the experience of uncertainty can create aversive psychological40 responses. For example, the uncertainty in the 2009 U.S. Preventive Services Task Force (USPSTF) breast cancer screening recommendations for women ages 40 to 49 years created significant controversy and left some women more confused than helped.41 Such confusion may sometimes lead end-users to avoid health evidence in an attempt to control anxiety or manage hope.12,13 However, for others it may prompt a variety of more beneficial coping tactics, including collecting additional information, soliciting advice, improving readiness, and preempting negative outcomes.42,43

In the context of evidence translation, uncertainty creates multiple challenges. These include difficulties in (1) determining whether preventive services and treatments should be implemented in clinical practice, (2) determining for whom and in what settings preventive services and treatments should be implemented, and (3) communicating evidence so that end-users can make informed decisions.

To date, the vast majority of work on communicating uncertainty has focused on the narrow realm of stochastic uncertainty: the likelihood or probability of an event occurring. This work has generally focused on alternate presentations of disease risk, side effects, treatment benefits, and treatment harms4448 and has demonstrated that:

  • Qualitative or non-numeric presentations of probability (e.g., “likely,” “certain,” “rare”) are open to individual interpretation.45,48
  • Percentages and “x/1,000” presentations are more understandable than “1 in x” presentations of probability;4850 “x/1,000” presentations are better than percentage presentations for representing conditional probabilities.
  • Using the same denominator in “x/1,000” presentations48,50,51 facilitates understanding.
  • Absolute risk reduction and relative risk reduction are more understandable than number needed to treat presentations.4448
  • Absolute risk reduction tends to be less persuasive than relative risk reduction.4448

Little research has focused on other concepts of uncertainty related to evidence translation. However, published taxonomies of uncertainty identify many domains that might have relevance to uncertainty in evidence translation, including ignorance, bias, lack of consistency of information across sources, imprecision, and doubt about how to apply judgments to determine the balance of benefits and harms for any health service and the applicability of information about that service to individuals (see Table 3).3639,42,5259 Interestingly, published taxonomies use different terminology to identify these domains. For instance, “ambiguity” refers alternately to ignorance, bias, conflicting evidence, imprecision, and variation in linguistic meaning. Thus, to avoid confusion, we avoid broad categorizations of uncertainty (e.g., ambiguity) and instead focus on specific subcomponents of uncertainty as they relate to evidence translation. Uncertainty components of interest to this review are those aligned with the current scheme for grading the strength of evidence for AHRQ’s Evidence-based Practice Center (EPC) program, including risk of bias, consistency, directness, and precision (see Table 4).60 They also include the components related to furnishing recommendations on medical evidence, including the components of net benefit (i.e., whether there is more benefit than harm at a population level or vice versa), the applicability of evidence to individual populations and settings, and the overall strength of recommendations that policymakers provide to guide clinical care.61,62

Table 3. Sources of uncertainty mentioned in existing taxonomies of uncertainty.

Table 3

Sources of uncertainty mentioned in existing taxonomies of uncertainty.

Table 4. Components of medical evidence grading and recommendation development that have potential uncertainty (KQ 3).

Table 4

Components of medical evidence grading and recommendation development that have potential uncertainty (KQ 3).

By optimizing the presentation of uncertainty, evidence creators, synthesizers, and disseminators can enhance awareness of the evidence, discussions around the evidence, and enable people to make the best possible decisions. This review seeks to compare techniques in communicating uncertainty related to evidence translation and assess their comparative effectiveness.

Scope and Key Questions

Scope of the Review

The purpose of this systematic review is to identify communication and dissemination strategies that that increase awareness and use of evidence report findings among patients and consumers, clinicians and other providers, and purchasers and payers to improve health and health care at both the individual and population levels.63 The Institute of Medicine’s list of 100 priority topics highlights the importance of translating and disseminating findings from research evidence.64 Many hope that better communication and dissemination of such research evidence will prompt wider and more effective use of the information.

Coupled with these mandates is the fact that the ad hoc Uncertainty Committee of the EHC Stakeholder Group is interested in promoting effective ways to communicate uncertainty about health and health care evidence to end users. The committee would like to know what approaches to conveying uncertainty increase the likelihood that audiences receiving such information will understand it and be able to factor it into their decisionmaking.

This systematic review has three related components; all focus on promoting informed decisions about health related behaviors and decisions among patients and providers. First, it addresses the comparative effectiveness of communicating evidence in various contents and formats that increase the likelihood that target audiences will both understand and use the information. Second, it examines the comparative effectiveness of a variety of approaches for disseminating evidence from those who develop it to those who are expected to use it. Third, it examines the comparative effectiveness of various ways of communicating uncertainty associated health-related evidence to different target audiences.

In this review, the interventions are communication strategies, dissemination strategies, and methods of explaining uncertainty. The strategies seek to influence health related behaviors and decisions. Due to the complexities of our questions, we present our work as three separate systematic reviews—one for communication, one for dissemination, and a third for uncertainty—each addressing a separate Key Question.

Key Questions

KQ 1

  1. What is the comparative effectiveness of communication strategies to promote the use of health and health care evidence by patients and clinicians?
  2. How does the comparative effectiveness of communication strategies vary by patients and clinicians?

KQ 2

  1. What is the comparative effectiveness of dissemination strategies to promote the use of health and health care evidence for patients and clinicians?
  2. How does the comparative effectiveness of dissemination strategies vary by patients and clinicians?

KQ 3

What is the comparative effectiveness of different ways of explaining uncertain health and health care evidence to patients and clinicians?

Analytic Framework

We present our analytic framework in Figure 1. As noted in the box to the far left, we examined studies that used research-based evidence as the source of information for their communication strategies (KQ 1) and dissemination strategies (KQ 2). For KQ 1 and 2, we specifically defined research-based evidence as evidence that has been assembled, reviewed, and presented by evidence developers and that has been used to make recommendations. For KQ 3, however, we accepted any type of evidence presented given the paucity of overall literature. (See Methods section for more specific inclusion and exclusion criteria for evidence.)

We present our analytic framework in Figure 1. As noted in the box to the far left, we plan to examine studies that use research-based evidence as the source of information for their communication techniques (KQ 1) and dissemination strategies (KQ 2). Strategies and techniques discussed in this review could be beneficial for several audiences. These include (1) the general public; (2) patients; and (3) clinical service providers, including physicians, dentists, nurses, or other professionals who deliver health care. For KQs 1 and 2, we plan to examine how the effectiveness of communication techniques and dissemination strategies varies for different target audiences. Techniques and strategies that work well for one audience may not work as well for another audience. For KQ 3, we will focus on studies that explore ways to explain uncertain evidence. We will include studies that examine intermediate outcomes. These can be awareness of the evidence; knowledge of the evidence; attitudes, feelings, and perceptions toward the evidence; discussions about the evidence; discussions about the evidence; self-efficacy about the evidence; and behavioral intentions to use or apply the evidence. We will also include studies that measure ultimate outcomes. These can be the following: for patients—health-related decisions or behavior, and clinical outcomes; for clinicians—behavior.

Figure 1

Analytic framework for communicating and disseminating strategies and explaining uncertainty.

Strategies and techniques discussed in this review could be beneficial for several audiences. Such audiences include (1) patients and the general public and (2) clinical service providers, including physicians, nurses, midlevel providers, pharmacists, and others who deliver health care; in KQs 1a and 2a, we examine the effect of interventions in aggregate across these populations. Because the effects of interventions can differ for different target populations, we also examined (in KQ 1b and 2b) how the effectiveness of communication and dissemination strategies vary across target audiences, including patients and clinicians. For KQ 3, we focused on studies that explored communication techniques to explain uncertain evidence.

We included studies that examined both intermediate and ultimate (distal) outcomes, as shown in Figure 1. Intermediate outcomes can be awareness of the evidence, knowledge of the evidence, discussions about the evidence, self-efficacy (or one’s confidence) to use the evidence, and behavioral intentions to use or apply the evidence. Ultimate outcomes include the following: for patients—health-related decisions or behaviors and clinical outcomes; for clinicians—behaviors. We expected that most studies focused on intermediate outcomes because they occur sooner and, thus, are more practical to study.

Populations, Interventions, Comparators, Outcomes, Timeframes, and Settings Covered by the Key Questions

Below we describe the populations, interventions, comparators, outcomes, timeframes and settings (PICOTS) for our review (Table 5).

Table 5. Population, intervention, comparators, outcomes, and settings (PICOTS).

Table 5

Population, intervention, comparators, outcomes, and settings (PICOTS).

Organization of This Report

In the next sections, we describe the methods used in this review. We then present three separate results sections for KQ 1, KQ 2, and KQ 3, respectively. We then discuss our conclusions and the implications of our results, limitations of the evidence base and this review, and important research gaps. Appendix A documents our search strategies. Appendix B lists all studies we reviewed at the full-text stage but excluded and the reason for exclusion. Appendix C contains the quality assessments (risk of bias) of the included studies. Appendices D, E and F contain the evidence tables for KQ 1, KQ 2 and KQ 3, respectively.

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