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Davies HTO, Powell AE, Nutley SM. Mobilising knowledge to improve UK health care: learning from other countries and other sectors – a multimethod mapping study. Southampton (UK): NIHR Journals Library; 2015 Jun. (Health Services and Delivery Research, No. 3.27.)

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Mobilising knowledge to improve UK health care: learning from other countries and other sectors – a multimethod mapping study.

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Chapter 3Mapping the conceptual literature

Introduction

An early part of the initial desk research for this project involved a ‘review of reviews’ in the area of knowledge mobilisation. Our aim here was to identify and understand the main knowledge mobilisation models, theories and frameworks in health care, education and social care. Further, we also wanted to develop some accounts of the conceptual thinking that lay behind these framings. The search strategy used to uncover and select the relevant reviews is described in Chapter 2, and led to 71 reviews being included. These are listed in Appendix 2.

In reviewing this substantial set of reviews our aims were pragmatic and twofold. Our first was to develop a set of understandings that could be used for analytic purposes in exploring the data gathered in other parts of the study (websites review; depth interviews; web-based survey). This related to RQ 2a, which explores the logic(s) underpinning agency activities:

What models, theories or frameworks have been used explicitly – or can be discerned as implicit underpinning logics – in the development of the knowledge mobilisation strategies reviewed?

The second goal of the review work was to develop a mapping that might have utility to the agencies as they sought to find ways into the complex and growing conceptual literature, something that might be useful to them in developing their knowledge mobilisation strategies. This second goal will receive further development as part of our ongoing collaboration with agencies.

Having uncovered the 71 reviews, we used an inductive, iterative, dialogical process within the research team (and subsequently, with the advice of the advisory board) to distil the key domains (see Chapter 2). As the domains surfaced and were fleshed out (six in total), repeated reading of the reviews was used to provide an account of issues within each of the domains. This chapter provides an integrated account of these domains alongside a visual map.

Understanding the academic literature that links knowledge, knowing and change is a challenging and boundary-less task: relevant literatures sit in a wide range of disciplines (psychology, sociology, organisation studies, political science and more) and ideas appear and reappear within and across these disciplines in sometimes chaotic fashion. In making sense of these conceptualisations it is abundantly clear that debates have not proceeded in a wholly linear, cumulative or convergent manner. While there are some areas of widespread agreement, there are also areas where contestation, problematisation and conflict are evident.

In developing this review we have been guided by a number of framing choices:

  • We have concentrated on that literature which has itself attempted to review the field rather than seeking to collate and synthesise across primary work whether theoretical or empirical (i.e. this is a review of reviews).
  • We have focused on reviews in the three key areas of application of health care, social care and education.
  • We have sought to review work that specifically addresses the creation, collation, communication, implementation and impact of research-based knowledge (albeit that such knowledge is often seen in the context of other forms of knowledge/knowing).
  • We have provided an account that speaks to the action-oriented concerns of the agencies at the heart of this study (i.e. funders, major research producers and intermediaries); that is, we have kept in focus the agencies’ needs to develop practical knowledge mobilisation strategies and portfolios of specific activities.
  • We have sought to lay out the key fault-lines of debate rather than forcing order and convergence where the literature does not readily support this.

Reading across these reviews we first identify a wide range of models, theories and frameworks that have been used to describe and inform knowledge mobilisation. Looking at these models and the empirical work that has been carried out to explore and (occasionally) evaluate them, we can discern a number of insights for the effectiveness of particular approaches. We then read across these models and the wider conceptual literature to create a conceptual map that surfaces key issues, debates and conceptualisations. These are discussed under the six domains that emerged inductively from the set of reviews (see account in Chapter 2). Finally, we note the limited literature that has explored the roles that the public and service users can play in mobilising knowledge.

Models, theories and frameworks, and associated evaluative work

The review papers document a bewildering variety of models, theories and frameworks. Even within individual review papers, 60 or more distinct models are sometimes considered (e.g. Ward et al.;19 Graham et al.1), but the actual set included varied significantly between review papers. From this review of reviews, we extracted the key models that seemed to have potential for use in knowledge mobilisation work in the kinds of agencies that we were considering. Additional checking of this list with our advisory board and other knowledgeable experts in the field reassured us that we were capturing the main models of interest. The set of distinct models and frameworks are listed in Box 1 and are elaborated on further in Table 3. These formed the basis of some of our discussions with agencies (see Chapter 4) and the development of the web-based survey (see Chapter 5).

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BOX 1

Models and frameworks (listed in chronological order of publication) The Institute for Healthcare Improvement (IHI) Model for Improvement (Langley 1996).

TABLE 3

TABLE 3

Synthesis of the main knowledge mobilisation models and frameworks from the review of reviews

Major models, and the testing of these

The models listed are set out in chronological order of publication (see Box 1). They have diverse underpinnings and assumptions, and draw on distinct disciplinary concepts from psychology, sociology, organisation development, implementation science and political science. They vary in the extent to which they draw narrow or more inclusive boundaries around what counts as knowledge, and some differ in their primary areas of application (e.g. being either policy or practice focused).

Many of these models are primarily descriptive of the processes around knowledge creation/flow/application, and they tend not to be explicit about the necessary configurations, actions or resources that will underpin successful knowledge mobilisation. That is, they do not readily provide prescriptions for knowledge mobilisation strategy or operations.80 In addition, with a few notable exceptions, the models have received only limited empirical testing. We briefly discuss here five of the frameworks from Box 1 that have been tested empirically to some degree: the Promoting Action on Research Implementation in Health Services (PARIHS) Framework;52 the Knowledge to Action (KTA) framework;1 the Ottawa Model of Research Use (OMRU);51 the Consolidated Framework for Implementation Research (CFIR)65 and the conceptual framework of the knowledge transfer process developed by Ward et al.19

The PARIHS Framework does draw attention to important components of research use (such as the availability of credible evidence; or the presence of effective facilitation) but again, like other models, it is less specific about how these concerns translate into planned actions. It has, however, been subject to more evaluation than most of the frameworks we considered. A paper by Helfrich et al.81 reviews 24 articles on this framework (six core concept articles from the original PARIHS authors and 18 empirical articles). The authors note that no studies used the framework prospectively to design implementation studies and suggest that this is an important omission in relation to this and other frameworks. The papers reviewed suggested a number of improvements to the framework, for example that the subelements could be specified more clearly. A paper published the following year82 builds on the critical synthesis of the literature81 and suggests revisions and a set of tools that researchers can use to apply the revised framework prospectively and comprehensively.

A later research paper83 provides a rare example of the prospective use of the framework: the framework was prospectively applied to guide decisions about intervention design, data collection and analysis processes in an implementation trial focused on reducing perioperative fasting times. In evaluating this use of the framework, the authors concluded that, although individuals are implicitly included in the three elements of evidence, context and facilitation, the role of individuals needed to be explicitly added to the framework. They noted that the past decade has seen a shift away from a focus on individuals to a greater focus on context and how that affects implementation, but suggest that this risks downplaying the many individual level factors (e.g. beliefs, attitudes, values, motivations, etc.) that can have an impact on the behaviour of individuals and groups/teams. In their study using the framework, they found that the interaction between the three elements of evidence, context and facilitation was influenced by both individual and team behaviour.

The KTA framework developed by Graham et al.1 is one of the few that has been evaluated as a model for planning and evaluating knowledge mobilisation strategies. For example, published studies describe the use of the model for the development and implementation of interprofessional protocols84 for the development of a children’s health participatory action project85 and for the implementation, monitoring and evaluation of a strategy for mentorship in academic medicine.86 However, although these studies pointed to some benefits from using the KTA framework, its theoretical basis (planned action theories) has not been separately evaluated for its adequacy as an explanation of underlying mechanisms, and so the model as a whole – like most others – remains not yet fully substantiated.19

The OMRU has featured in some empirical studies. For example, a comparative case study of technology adoption in hospital settings87 used parts of OMRU (characteristics of innovation, characteristics of potential adopters, characteristics of environment) to guide question and topic selection for interviews and for data coding. The study explored discrepancies between awareness and adoption, highlighting the role of champions, resources, ways of reaching consensus and willingness to take risks, but did not explicitly attempt to validate OMRU. A study the following year85 initially tried to use OMRU in a children’s health participatory action project but found it to be difficult to apply in participatory action research and in a community setting.

Another of the frameworks that has been empirically tested is the CFIR,65 which was tested using a post hoc, deductive analysis of 11 narrative accounts of innovation in health-care services and practice in England.88 The authors suggest that their study may be one of the first evaluations of the framework. They developed a matrix comprising the five domains and 39 constructs of the framework to examine the coherence of the terminology, to compare results across contexts and to identify new theoretical developments. They comment that some concepts (in particular leadership) seem underdeveloped in the framework and that important elements are missing from it, including scale-up, spread and sustainability, and the engagement of patients and members of the public.

Finally, the conceptual framework of the knowledge transfer process developed by Ward et al.19 from 28 different models of the knowledge transfer process was evaluated in use by the authors through a study of a knowledge broker intervention in a large UK mental health service.37 The knowledge broker intervention included three types of knowledge exchange activity: information management; linkage and exchange; and capacity building. Data from the fieldwork were then used to revise the original framework. Revisions to the framework included the following: tighter definitions of each of the five components; noting that all five components occurred on multiple occasions within each team and that at times multiple components were relevant simultaneously; placing greater emphasis on actively exploring the influence of contextual characteristics; and noting that an exclusive focus on one type of knowledge use (e.g. instrumental only and not instrumental and political) seemed to constrain the spread and sustainability of knowledge. A revised diagram of the framework was created illustrating the point that the five components could occur separately or simultaneously and not in any set order and illustrating some of the possible connections between them.

Looking across these empirical studies, we can see that they provide useful accounts of these five models in use. However, none of the models have been comprehensively evaluated, and the majority of the other models in the literature have been subject to even less empirical testing. Indeed, given their descriptive rather than prescriptive orientations, verification and validation may be more realistic prospects than evaluative testing.

The challenges of evaluation

Models apart, what of the evaluative work around specific actions, interventions and mechanism for knowledge mobilisation? One observation that runs deep throughout the literature is that measuring knowledge use89 and assessing what interventions promote that knowledge use are in their infancy.13 There are only a small number of implementation studies of specific knowledge mobilisation mechanisms, and many of these are of poor quality.18 For example, many studies fail to define what they mean by research use or to define outcome measures clearly;13 the validity and reliability of the outcome measures are rarely reported;90 subjective measures of research use are commonly used; and many studies are retrospective, thus risking recall bias and incomplete data. There is, therefore, a lack of practical guidance or robust empirical evidence on many of the likely components of knowledge mobilisation strategies.18,21,91,92

Box 2 lists a number of areas where reviews have established that there is little in the way of an empirical support base; Box 3 draws on the work of the Cochrane Effective Practice and Organisation of Care (EPOC) group to list some types of intervention aimed specifically at professional behaviour change for which there is a growing body of evidence; and Table 24 in Appendix 8 augments these by reading across the major reviews to summarise the key observations made on evaluating knowledge mobilisation work.

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BOX 2

Areas where the evidence base is currently limited Use of systematic reviews in policy-making.

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BOX 3

Interventions aimed at professional behaviour change which EPOC systematic reviews suggest have some effect Printed educational materials.

Despite such evidence gaps, many knowledge mobilisation interventions are promoted even when they have not yet been properly evaluated.10,99 Indeed, the literature often promotes singular techniques relating to linear processes despite the emerging agreement about the limitations of such models in knowledge mobilisation.21 Even where systematic reviews are available that point to discrete interventions aimed at professional behaviour change that do appear to have some effect (see Box 3), the key role played by the interaction between the intervention provider and the context means that it may be difficult to use interventions with confidence in other contexts:100

Externally valid evidence pertaining to the efficacy of specific knowledge exchange strategies is unlikely to be forthcoming . . . the best available . . . advice for someone designing a knowledge exchange intervention will probably be found in empirically sound conceptual frameworks that can be used as field guides to decode the context.

Contandriopoulos et al., p. 46821

Thus, a sound conceptual understanding of the various issues at play – and their dynamic interaction with context – becomes central to the design of effective knowledge mobilisation strategies. In the end, this may be more important than evaluative efforts in the knowledge mobilisation field that seek to isolate the impact of discrete interventions in an attempt to create a menu of ‘proven’ approaches. What may be as important is equipping agencies with the resources that enable them to conduct robust evaluations-in-context of knowledge mobilisation activities that are designed according to the ‘best available’ evidence. Our review of the literature identified some of the key papers and reports that can help agencies to consider how to measure research use and evaluate the impact of their knowledge mobilisation activities, and these are listed and summarised in Table 4.

TABLE 4

TABLE 4

Selected key papers and reports on measuring research use and evaluating impact

In sum, then, despite the lack of focused and cumulative evaluation work (and the difficulties associated with so doing), a collective reading of what the reviews say about the models and about the wider conceptual literature does allow some insights to be gathered which can inform the development of knowledge mobilisation approaches by agencies. These form the basis of the conceptual mapping, to which we now turn.

Six domains of interest

Discussion within the team of the key issues emerging from the reviews, and iterative attempts to group these, led to the emergence of six broad domains (or conceptual groupings). These were:

  1. purpose(s) and goals (implicit or explicit)
  2. knowledge (of all kinds)
  3. connections and configurations (between people; between organisations)
  4. people, roles and positions
  5. actions and resources available and
  6. context of operation (different in kind from the other five domains, but influential and interactive with each of them).

A simple schematic representation of these domains is shown in Figure 1.

FIGURE 1. The conceptual map.

FIGURE 1

The conceptual map.

Each of these six domains is now discussed to mark out the contours of debate covered in the reviews within the purview of that domain. We present these domains as practical ways into a complex and sprawling literature rather than as definitive accounts of the complexities covered. As part of our ongoing work with knowledge mobilisation agencies, we will be considering what tools they would find useful to enable them to explore these domains and to build on these insights in developing their knowledge mobilisation strategies.

Purpose(s) and goals

In developing knowledge mobilisation strategies, a central concern is to what end is the knowledge being mobilised? Agencies of different kinds will have different views on what they are trying to achieve (and how), and such concerns are central in the literature. While clearly closely related to the second domain (knowledge types and sources) and the fifth domain (actions and resources), a consideration of the purpose and goals of a knowledge mobilising agency can be informed by a wide array of literature.

There are multiple definitions of knowledge use in the literature, with no one definition dominating.21 Underneath some of these disputes is a concern to tease out the extent to which research-based information is dominant in the aims of knowledge mobilisation efforts. That is, do we wish to see evidence-based actions, evidence-informed actions or just activities that are evidence-congruent or evidence-aware? The centrality or otherwise of research is a key consideration for agencies, then, and this is an issue picked up further when we consider types of knowledge.

Given a central and somewhat privileged position for research-based knowledge, one common and recurring typology55,90,113 suggests that there are three main types of research use: instrumental, conceptual and symbolic.

  • Instrumental/direct use: applying research findings in specific and direct ways to influence decision choices.
  • Conceptual/indirect use: using research results for changing understanding or attitudes, including introducing new conceptual categories, terminology or theories (sometimes called ‘enlightenment’ uses).114
  • Symbolic/political/persuasive use: using research findings to legitimise and maintain predetermined positions, including the ‘tactical use’ of research, for example justifying inaction while awaiting further study.

These different types of use may be affected by many different factors. For example, direct use is associated with well-defined decision-taking; conceptual use may be longer term and more percolative in style; and symbolic use may be closely associated with political argument and the use of mass media. It is likely, however, that all three will be seen simultaneously in some settings (e.g. in government agencies).

Categorisations such as that above can be further refined by additional analysis within each category. For example, instrumental use may be concerned with decisions that impact on professional processes, individual patient outcomes or aggregate economic outcomes,115 and each of these can become targets or goals of agency activities. An alternative view55 might look for impacts on knowledge-use processes (such as knowledge being seen, discussed and cited), intermediate outcomes (such as key actors’ awareness and attitudes) and decision outcomes (evidence-supported change). Combinations and hybrids of these typologies of use and impact are, of course, possible, and a consideration of these may help to sharpen agencies’ strategic goals.

The categorisations above are related to, and have some overlap with, the influential typology produced earlier by Weiss.114 Although based on seven ‘meanings’ of research use, these models could also be interpreted as types of use in themselves. While Weiss’ typology emerged from empirical work on policy-makers, it has also influenced thinking on research use in practice contexts.15

Weiss argued that there were seven different categories in the way that research-based knowledge was used (adapted and extended from the original):

  • Knowledge driven: where research produces knowledge that might be relevant to public policy decisions. This is closely aligned with the direct and instrumental use noted above (and is central to strategies of research ‘push’) but can also encompass more conceptual uses of research where the knowledge shared is more theoretical or conceptual in nature.
  • Problem-solving: where research is sought out that can provide empirical evidence to help solve contemporary policy problems. This again is most often associated with an instrumental approach (and with notions of research ‘pull’), but can also encompass some conceptual rethinking.
  • Interactive: those engaged in policy or practice seek information from a variety of sources to help make sense of their problems and develop solutions; associated with ‘linkage and exchange’ approaches to knowledge mobilisation; may encompass both direct and indirect uses of research.
  • Political/symbolic: policy-makers and others search for knowledge to help justify their positions, and so research-based information becomes ammunition for whichever side finds it most useful. Intermediary agencies with well-defined value sets may seek to exploit such opportunities.
  • Tactical: where those who could be (and perhaps should be) research users fund or require new research to avoid taking action. Funders and research producers may each see opportunities here for longer-term gains in research-based knowledge.
  • Enlightenment: where research has gradual influence over time in shaping conceptualisations of the issues and framings of the policy agenda. Recognition of these slower percolative processes may lead agencies into planning for the longer term by focusing on social processes.
  • Societal: where policy interest, public concern and professional interests are meshed and stimulated by new research findings. Such a broader view enlarges the scope of agencies to encompass much broader sets of stakeholders.

Other commentators have sought to expose and critique the limited areas of application for research-based knowledge. Drawing on Habermas’ framework of ‘knowledge-constitutive interests’, Murphy and Fafard97 define three types of knowledge use:

  1. instrumental, that is, problem-solving (using research to make decisions)
  2. hermeneutic, that is, explanatory (facilitating greater understanding of the social world)
  3. emancipatory, that is, equity-seeking (critically analysing institutional forces as a means of advancing social justice).

While having overlaps with other categorisations of use, the authors here suggest that most conventional knowledge mobilisation approaches focus on instrumental, problem-solving use. They suggest that social research has, or should have, other goals that are aimed at hermeneutic and emancipatory objectives. Such a reading brings to the fore political considerations whether an agency seeks to work with the grain of existing policy and practice presumptions, or to challenge these from a values-based position.15,29,116

Moving into more practice-based models of research use, Walter et al.60 propose three models. These are described as inductively derived archetypes, and actual practices often combine more than one model:

  • The research-based practitioner model of research use: in this model it is largely the responsibility of the individual practitioner to keep abreast of research and ensure that it is used to inform their practice.
  • The embedded research model of research use: in this model research use is largely achieved by embedding research in the systems and processes of practice (e.g. via standards, policies, procedures and tools).
  • The organisational excellence model of research use: in this model, the key to successful research use largely rests with the leadership, management and organisational arrangements of service delivery organisations and with their promotion of a ‘research minded’ organisational culture.

The models are not seen as prescriptions for action but may be useful at different times and in different service settings.117 Understanding of these archetypes of use may help agencies direct activities supporting the uptake of research in practice.

So, for agencies developing knowledge mobilisation work, it may be important to consider the types of ‘use’ they are aiming to influence and to what end. Such considerations do not stand alone, but are interconnected with the other domains mapped in Figure 1, most especially that concerned with understanding the nature of knowledge and the role played by research within that.

Knowledge

Although at first sight it might seem obvious what knowledge mobilising agencies are seeking to mobilise – that is, research-based knowledge – in fact the reviews we explored reveal considerable complexity and nuance to the nature of that knowledge. Both descriptive and prescriptive models see unpacking what is meant by knowledge as a central concern. For example, one well-known framework55 sets out five questions for research organisations to consider in relation to knowledge mobilisation. The first question in this framework concerns what should be translated, transferred or exchanged: the knowledge of knowledge mobilisation.

There is no clear dominant definition of knowledge in the literature.21 The different philosophical paradigms on which the knowledge mobilisation models draw (explicitly or implicitly) make different assumptions about the nature of knowledge. For example, positivism assumes that knowledge can be uncovered and expressed in generalisable laws, constructivism holds that knowledge is socially constructed and that there are multiple truths, and critical theory analyses the relationship between knowledge and power.

A range of types of knowledge are identified in the literature, and these can be grouped in various ways. For example, types of knowledge can be grouped according to the source: does the knowledge arise from structured data gathering (empirical knowledge), from practical experience (experiential knowledge) or from abstract discourse and debate (theoretical knowledge)? Another grouping in the knowledge mobilisation literature contrasts explicit knowledge (such as can be set down in guidelines) and the tacit knowledge held by individuals and groups.118 Tacit knowledge may be used to inform decisions in the practice setting but may not be susceptible to defining and describing explicitly. Amalgamations of explicit and tacit knowledge in clinical contexts have been referred to as ‘mindlines’.57

One theory of knowledge creation119 holds that there is a close relationship between tacit and explicit knowledge. It suggests that new knowledge is created most rapidly when conversion between different forms of knowledge occurs continually (e.g. from tacit to explicit and from explicit to tacit). Given this, Oborn et al.30 suggest that the negotiation and exchange of tacit knowledge in practice settings has been largely overlooked by knowledge mobilisation researchers so far. A related categorisation, drawing on work by Aristotle, distinguishes between episteme (scientific knowledge), techne (craft knowledge) and phronesis (situation-specific practical wisdom and the ability to apply generic knowledge to the current case).24

In another framing, institutional knowledge is differentiated from individual knowledge, and local knowledge from external knowledge. Such distinctions are made based on whether the knowledge arises from individual or shared experience, and whether the knowledge is created in situ or is imported from elsewhere. A further stream distinguishes between knowledge as data and knowledge as ideas, asserting that data, information and knowledge lie on a continuum and differ in the extent to which human processing and judgement are needed.120 Such literature also considers the extent to which knowledge has been processed, synthesised, ‘recycled’, reinterpreted or adapted; and if the knowledge is specific to a particular issue and context, or whether or not it is more general. Similar notions underpin the ‘knowledge to action’ framework.1 Here, knowledge creation is composed of three phases, each involving a greater degree of processing: knowledge enquiry (first-generation knowledge), knowledge synthesis (second-generation knowledge) and the creation of knowledge tools such as practice guidelines and algorithms (third-generation knowledge).

Methodological categorisations of research-based knowledge also abound.121 This is not just a distinction between quantitative and qualitative findings, but there exist a variety of more-or-less hierarchical distinctions, often with implicit or explicit endorsements as to their validity.122,123 More prosaically, there is debate about whether or not single studies should be disseminated at all, rather than synthesised accumulations across portfolios of work.55,124

Knowledge, or knowing?

But should we even be talking of knowledge as a separate isolatable ‘thing’? If knowledge is seen as socially embedded then separating ‘it’ from its context begins to look problematic. Perhaps, instead, we need to think more of knowledge-in-context – or ‘knowledge-in-practice-in-context’, as Gabbay and le May describe ‘mindlines’.57 Such considerations lead to a series of challenging questions: who is (or should be) involved in setting the research agenda and in deciding what issues warrant the production or collation of research-based knowledge? Who is involved in producing that knowledge and what are the power dynamics around what is defined as knowledge?92,125 Who defines who are the relevant stakeholders and by what processes are they involved? Is such knowledge produced by research ‘experts’? Or is knowledge co-produced by potential users and researchers, and what are the benefits and disadvantages of this? Many of these issues link to those explored in the domains of ‘people and roles’ and ‘context’.

Several authors21,30,56,57 argue strongly from empirical study that research-based knowledge does not occupy a privileged position. Instead, it sits alongside and competes with other forms of existing, structured and contextualised knowledge (e.g. professional knowledge and professional judgement). It follows, then, that there is not a direct correlation between attributes of the knowledge (e.g. the internal validity of the research-based knowledge) and the likelihood of subsequent use.21 For example, professional consensus-based guidelines may be valued more than research-based guidelines, despite having a weaker evidence base. There is, thus, an ecology of knowledge, where research-based knowledge must compete with other ways of knowing for influence.

Taken together then, these observations have a number of implications for knowledge mobilising agencies. First, they suggest that agencies may need to develop mixed portfolios of activities that are heavily shaped by the types of knowledge under consideration. Second, actionable messages for decision-makers may more properly be seen to come from syntheses and systematic reviews rather than from single studies.55,124 This would suggest that research organisations should focus their research mobilisation efforts on bodies of research-based knowledge. Third, agencies may need to consider the difference between information or data and knowledge;126 these may require different kinds of interaction between researchers and users and hence different kinds of knowledge translation training and support. More challengingly, knowledge mobilisation agencies may need to consider how they can support the interaction and integration of different types of knowledge, including perhaps deliberative processes that seek to surface hidden assumptions and tacit knowledge.

Finally, although there may be no absolute correlation between the attributes of research-based knowledge and its subsequent use (as it competes with other forms of knowing in the local context), it is still important to consider the attributes of research that help to make it more conducive to uptake: for example, if the research-based knowledge is perceived by the potential users to be credible, accessible, relevant, based on strong evidence, legitimate and endorsed by respected opinion leaders.93 Tailoring the format and presentation method of knowledge products to the intended users can also make the knowledge that they contain more accessible to potential users.80,127

Connections and configurations

Mobilising knowledge is about making connections. Our agency-based view of activities brings to the fore the need for agencies to connect and communicate in sometimes new and innovative ways. This may mean capitalising on existing networks or building anew. The reviews we uncovered offer insights into what and how such strategies might be developed.

Much of the literature we uncovered discusses the complex institutional, professional and social environment within which knowledge is created, flows (or gets stuck) and is applied. While some of these discussions lay heavy emphasis on ‘context’ as a mediator (which we discuss later in this chapter), there is also more specific consideration of the role of specific networks of interests or the practical configurations of agencies, organisations and relationships. As such connections and configurations are amenable to planned intervention or influence by agencies, it seemed important to tease out literature preoccupations here.

A framework that is increasingly well known (and resonant with other framings) is the ‘three generations’ framework.20 This proposes that there have been three stages or generations of thinking about knowledge to action processes: linear approaches, relationship approaches and systems approaches. The authors set out the characteristics of each of these approaches and suggest conditions under which such approaches might be more or less appropriate. While these approaches are often linked to historical developments, with ideas of progression of thinking from ‘simple’ linear models to ‘complex’ systems thinking, it may be more helpful to think of these as parallel models of the knowledge mobilisation system with contingent application and different strengths and weaknesses.

Linear models of research flow

Linear models of connectivity have dominated the literature, and such thinking can be seen underpinning many of the models and frameworks in use. The research-based practitioner model60 and the embedded research model60 (discussed in the ‘purpose and goals’ domain) are examples of linear models; many other models with ‘rational, linear’ assumptions can be found in the literature.128 Sitting within the linear conception (and, to a lesser extent, within the relational view) is the ‘two communities’ perspective: the idea that there are two separate social worlds of knowledge production and knowledge application, and that there is limited interconnectivity between these. However, more expansive views of knowledge (as discussed earlier; see Knowledge) contribute to a weakening and in some cases a demolition of such neat categorisations.

Despite being very widely used in health care and elsewhere,20,128 linear models have received significant critique: they tend to see ‘knowledge’ as a transferable product; they place much emphasis on individuals and their rational cognitions; and they fail to address notions that knowledge is translated into practice in a social, collective and situated manner.15,30,32 An additional concern is that the evaluative research around knowledge mobilisation has tended to evaluate linear approaches rather than more complex forms,30 providing both symbolic and practical encouragement to organisations to continue to use these approaches.

Relationship models

A shift from linear approaches to more relational approaches has been observed in the health sector and generic management literatures after 2000.16 One of the underlying premises of relationship models is that learning is a social and situated process. Relational models then tend to see knowledge mobilisation as having a political dynamic in which there is negotiation around competing meanings of ‘knowledge’ and ‘evidence’, and around issue framing and problem definitions.

In relationship models, the emphasis is on ‘linkage and exchange’,53 suggesting a greater degree of engagement with potential users than is implied with ‘push’ or ‘pull’ approaches.11 The degree of engagement ranges from dialogue between researchers and practitioners through to collaborative engagement in producing research evidence (co-production) and in working together to implement evidence (e.g. in action research approaches or quality collaboratives).129 A recent study,130 which may be the first to map the work of knowledge brokering organisations, found that the organisations carried out a wide range of brokering functions, including building partnerships, raising awareness, capacity building, implementation support and policy influence. Relational approaches emphasise ongoing, interactive processes of collaboration between research producers and research users around formulation of RQs, production of research evidence and sharing of research findings.18,80 Relationship approaches draw on a range of theories, including principal–agent theory; communities of practice; social capital; organisational learning; sociocultural learning; and resource-dependence.131 Key features of relationship approaches to knowledge mobilisation are an emphasis on accountability, reciprocity and respect for the other party’s knowledge.

A common critique of relationship approaches32 is that many models and approaches fail to fully acknowledge the implications of conflict over what constitutes knowledge, and give insufficient attention to meaning/power negotiations. Ferlie et al.16 suggest that postmodern accounts that emphasise power are a further stage on from relational models. A further concern is that the relationships that are possible will depend on the skill sets and personalities of those involved; many researchers may feel most confident in talking about research findings to their academic peers. Such relationships are also affected by organisational turbulence: if there is high turnover in policy or practice (or academic) settings then it will be more difficult to develop ongoing relationships.132 Some of these issues reappear when we discuss the domain of ‘people, roles and positions’.

Systems thinking

There is no consistent use of the term ‘systems thinking’, encapsulated by Best et al.64 as an approach that ‘recognises that relationships are shaped, embedded and organised through structures that mediate the types of interactions that occur among multiple agents with unique rhythms and dynamics, worldviews, priorities and processes, language, time scales, means of communication and expectations’ (p. 628). There is, however, increasing support for the idea that health systems need to be seen as complex assemblages of interlocking networks that cannot be understood in terms of linear and ‘rational’ relationships but are instead conditional, contextual and relational.133 Reviews suggest that, although the knowledge mobilisation literature is now beginning to embrace systems thinking, practical tools and strategies have yet to emerge.64,133 In addition, reviewers suggest that there are many key aspects of a systems approach to knowledge that have not yet had sufficient attention, including the nature of evidence and knowledge, the role of leadership and the role of networks.20 Exploring this further, Contandriopoulos et al.21 suggest that there are three core aspects of systems that influence knowledge use within that system: polarisation (the extent to which the potential users share similar opinions and preferences); cost-sharing (the distribution between research producers, intermediaries and users of the resource costs associated with knowledge use); and social structures (e.g. formal and informal communication networks).

The evolution of thinking around connections and configurations has highlighted the limitations of ‘two communities’ thinking, suggesting that standard push approaches are unlikely to result in practice or policy change. Agencies that take a relational view, and that work within and through existing networks, or that seek to build new networks, can draw on a wide array of concepts and theories to help shape their actions. In doing so, they will need a nuanced understanding of the role of power, and insights from political science may be of some help here. Although there is increasing support for a systems approach in principle, a lack of practical tools and detailed guidance means that it has been difficult to operationalise these ideas into innovative knowledge mobilisation strategies.

As agencies devise new knowledge mobilisation strategies that capitalise on these insights, we can expect to see them work more within and through networks of interested parties. Sometimes these approaches will capitalise on, and aim to shape, existing networks (e.g. naturally occurring communities of practice); at other times agencies will seek to create and support new networks to further their goals. Fully exploiting the potential of a systems-based view of the world is currently hampered by a lack of operational models and convincing case examples.20,27,134

People, roles and positions

Agencies interested in mobilising knowledge will act through co-ordinating the actions of their own people and through co-opting the skills and resources of others. In part, this is about the configurations and networks created or utilised as previously discussed, but within these we can discern distinct roles that are performed, by agencies and by individuals.

In this project, we have conceived of a threefold role-based typology of knowledge mobilising agencies: funders; research producers; and research intermediaries (of course, some actual agencies take on multiple roles and many exist in hybrid forms). To this we can add various types of ‘audiences’ for research:58 other researchers; members of the public and service users; practitioners; managers; and policy-makers. Several authors (e.g. Contandriopoulos et al.21) point out that none of these are discrete categories and that individuals may belong to more than one group; this fact of multiple identities may constrain or facilitate an individual’s actions around knowledge mobilisation. A further categorisation of ‘insiders’ and ‘outsiders’ (e.g. researchers within government departments or external researchers from universities working with government departments) highlights the potential for individuals’ actions to be determined in part by their status in the social context. For example, studies have shown that internal researchers within government departments have greater access to ministers than do external researchers.135

Moving on from this broad categorisation of audiences or stakeholder groups, Lavis et al.58 suggest two key questions in defining a narrower group of stakeholders in a given situation: who can act on the basis of the research knowledge and who can influence those who can act? These questions helpfully give prominence to the issue of power, which many authors16,32 suggest has been neglected in relation to understanding of knowledge mobilisation.

There has been little empirical work on the actual or potential roles and responsibilities of different knowledge mobilisation actors.11 There is, however, a strong focus in the literature on ‘knowledge brokers’ and other ‘mediator’ roles, and a growing number of empirical studies136140 have investigated these roles. A range of functions has been suggested, including problem definition; research synthesis; facilitating access to research knowledge; developing outputs that are more accessible to users; and developing and brokering networks and other connections.135,141 Linking and mediator roles have been promoted in many organisational settings and are perceived by health organisations to be an important component of the organisational infrastructure to encourage evidence use.142 However, one review21 suggests that the structural position of brokers within organisations may mean that they have most scope to intervene in contexts where there is low polarisation of views (i.e. where actors already share similar views on key issues) and significant user investment in knowledge exchange, and that they may have limited ability to have an impact on the many existing networks that exist outside formal communication channels.

Conceptual uncertainty remains around who should perform knowledge broking and what activities should be encompassed by the role.81,135 For example, it is unclear whether or not and in what ways knowledge broker roles are different from other roles such as opinion leaders, facilitators, champions, change agents or linking agents.143 There are, nonetheless, some different theoretical assumptions behind the use of such terms: opinion leaders are typically seen as long-term ‘insiders’, whereas change agents are typically seen as ‘outsiders’ who have a short-term role in facilitating action around implementation. Knowledge brokers may come from diverse backgrounds, which then suggests roles that link or span different communities.

Many research funding agencies now make stipulations about what their funded researchers have to do in terms of knowledge mobilisation but these requirements are often limited to more traditional activities (e.g. engagement with potential research users, formal reporting and perhaps some ‘translation’ and dissemination). There is rarely any evaluation as to the effectiveness or impact of these requirements.11 Indeed, some caution that researchers may not be the most appropriate people to undertake knowledge mobilising roles133 and that it is unrealistic to expect researchers to develop the broad range of skills required for effective knowledge sharing.126

Leadership (including endorsement of the evidence from expert and peer opinion leaders) is regarded in the literature as important in knowledge mobilisation,93 but the requirements of roles here remain underspecified. Although leadership has been addressed in other literatures, the precise nature of leadership and its defining qualities have not been fully addressed in the knowledge mobilisation literature.20

While roles matter, some authors argue that there has been disproportionate emphasis on individuals and their roles in relation to knowledge mobilisation. They argue that this focus ignores three key issues: that it is unrealistic to expect researchers to develop the broad range of skills required;126 that sustainable knowledge mobilisation requires multilevel systemic changes80 alongside appropriate technological and organisational infrastructures;78 and that greater attention needs to be paid to the organisational systems in which individuals work and which strongly affect what they are able to do.77 Such critiques draw attention to other domains of our conceptual map.

One group that has largely been absent from the knowledge mobilisation literature is the public or service users. While patient and public involvement (PPI) has been strongly encouraged in research, the literature has been largely silent on the potential knowledge mobilisation role of these groups. One exception here is more recent work that has considered the evidence base on patient-direct and patient-mediated knowledge mobilisation interventions.78,144 The gaps, challenges and opportunities of greater involvement of the public, patients, other service users, clients and parents is discussed in a subsequent section, but suffice to say that their role is not widely considered in the knowledge mobilisation literature.

In sum, agencies may find it useful to map their audiences or groups of stakeholders using the broad categories outlined above, differentiating between those who can take action directly (act on the evidence) and those who can influence those who can act, or those who can shape the context within which that action occurs. Moreover, intermediary roles need further elaboration and analysis that takes account of the other domains of the conceptual map (e.g. knowledge types; purpose and goals; existing networks and configurations; and local context). Currently, there is insufficient empirical evidence on the impact of knowledge brokers and other mediating roles, but early findings suggest that they are most likely to have impact when they are working to bring together previously isolated groups and are credible, skilled and well supported.

Actions and resources

To further their goals, agencies need not only to find partners and identify audiences, but also to develop action plans and deploy resources. The actions taken will depend on the underlying model of knowledge mobilisation being used (explicitly or implicitly), and the resource requirements differ for different models of knowledge mobilisation. The wide variety of models uncovered in this review have largely not yet been tested as prescriptions for practice, so it is not clear how suitable they are for planning and evaluating knowledge mobilisation strategies.19 Many models provide a quite general overview of knowledge mobilisation rather than analysing the key features and intended effects of specific knowledge mobilisation interventions.96 They thus leave unaddressed the specific actions required and the resources needed. Indeed, many models seem more descriptive of how change occurs rather than directly addressing the planning of change initiatives.75

Some sets of activities have been identified in the literature that might form the first step in the operationalising of a knowledge mobilisation strategy. For example, Walter et al.145 highlight the key underlying mechanisms that can be used to build research impact: dissemination; interaction; social influence; facilitation; and incentives and reinforcements. In practice, many strategies will involve a judicious mix of these, and selecting the appropriate mix and emphases remains to be addressed.

Taking a holistic view of encouraging research use, one review in social care60 sets out a collection of imperatives, each of which might suggest collections of (resourced) activities that need to be planned. These include ensuring a relevant research base; ensuring access to research; making research comprehensible; drawing out the practice implications of research; developing best practice models (e.g. pilot or demo projects); requiring research-informed practice (e.g. through regulatory influence); and developing a culture that supports research use (multifaceted). Again, these broad categorisations leave much detail that needs to be fleshed out by agencies in their local context and given their resource constraints.

Agencies wishing specifically to advance the field of knowledge mobilisation may draw on the five functional areas outlined by Holmes et al.126 These include advancing the science of knowledge mobilisation; building capacity; managing specific projects; funding knowledge mobilisation activities; and advocating for greater knowledge use. Again, such categorisations may provide a starting point for agency strategy development.

Holmes et al.126 drew on work by Kitson and Bisby to set out nine actions that funding agencies could take to support knowledge mobilisation:

  1. require the involvement of research users throughout the research cycle
  2. support activities to increase the ability of researchers to communicate with users
  3. provide forums for knowledge users and researchers
  4. require a knowledge mobilisation action plan for all funded projects
  5. provide training and support to granting panels for the assessment of knowledge mobilisation plans
  6. include knowledge mobilisation costs as eligible expenditures
  7. fund activities that facilitate easier access to research data by knowledge users
  8. require open-access publishing
  9. fund rapid response programmes to address urgent policy and practice issues.

Agencies could use this list of imperatives to help set priorities for action.126

The narrative synthesis of conceptual frameworks by Wilson et al.146 reviewed 33 knowledge translation frameworks, of which 20 were designed to be used by researchers to guide their dissemination approaches. Twenty-eight of the frameworks reviewed were underpinned (at least in part) by one or more of three theoretical approaches: persuasive communication; diffusion of innovations theory; and social marketing. The authors noted that, although 10 UK funders of health services or public health research made reference to dissemination in their research funding application guides, only one [the Economic and Social Research Council (ESRC)] specifically provided a dissemination framework for use by funding applicants and grant holders. The authors suggested that, as a first step, funding agencies could specifically encourage the adoption of a theoretically informed approach to dissemination activities for their grant holders (e.g. by requiring the use of one of the theoretically informed frameworks). Another narrative review147 reviews 61 dissemination and implementation models and discusses key considerations around model selection and adaptation.

Other reviewers have noted79 that many organisations are increasingly developing practices (such as portals, websites and online interactive spaces) despite the limited evidence in support of such initiatives. Thus, many of the practical actions taken by agencies may have more to do with their face validity, stakeholder acceptability and the availability of local expertise than coherent strategy or supportive literature.11

All of the above suggest that there are actions required by agencies across a number of spheres. This draws attention to the potential for balanced and multifaceted activities. While some reviews suggest that multifaceted approaches are more effective than single interventions,148 some authors suggest that multifaceted approaches may not always be appropriate: there is a risk of a ‘scattergun’ approach, and the effectiveness of multicomponent approaches will depend on the interaction of the different mechanisms within particular contexts.117 One review of strategies used in public health149 found that simple or single strategies were in some cases as effective as complex multicomponent interventions, and suggested that this was because key messages might be diluted or harder to comprehend in complex multiple interventions. Multifaceted approaches are also likely to be more costly than single interventions and consideration needs to be given to how the different components might interact.76

Disaggregating some of the above broad categories, a major review in 2012150 collated 68 specific implementation actions, grouped according to six key implementation processes: planning, educating, financing, restructuring, managing quality and attending to the policy context. The authors differentiated between discrete, multifaceted and blended implementation actions (blended was defined as the use of a number of discrete approaches, addressing multiple levels and barriers, interwoven and packaged as an implementation intervention with a brand or protocol). The review challenged the notion that there are only a limited number of strategic actions available, but as it was a narrative review no attempt was made to assess the methodological quality of sources or the empirical evidence for the actions listed. The resourcing of these strategies was also left unaddressed by this review.

An empirical study of research funding agencies in a range of countries, including Canada and the UK,11 found that many had minimal resources for knowledge mobilisation. Similarly, studies in academic institutions suggest that the majority lack the infrastructure resources to support knowledge use in policy and practice.135 Yet, one of the key lessons from cross-sector review is that knowledge mobilisation requires financial, technical, organisational and emotional resources.93 A widely shared assumption in the literature is that producers, intermediaries and users will invest and cost-share in knowledge mobilisation to the extent that they perceive such investment to be advantageous.21 Yet, how such shared plans can be negotiated, or the basis on which they are founded, are rarely properly explored. One review of knowledge mobilisation approaches found that where there was no viable cost-sharing mechanism or where most of the burden fell on producers or intermediaries, significant research use (with the exception of political uses) was unlikely.21

This account of the actions and resources needed for effective knowledge mobilisation has many implications for agencies. It draws attention to the wide array of actions needed, the breadth and diversity of actions available, the complex and vexed issue of resourcing these, and the need for coherent, interlocking and mutually reinforcing actions within and across agencies. It also draws attention to the significant gap between the articulation of a process of knowledge mobilisation (seen in many of the models, theories and frameworks) and the translation of those accounts into workable, practicable, properly resourced strategies. That is, much of the conceptual background reviewed in this chapter does not readily lend itself to the creation of action plans for agencies. At the heart of these difficulties lies an uncertainty about whose role it is to facilitate knowledge mobilisation. In some senses, effective knowledge mobilisation is a system property, and yet individual actors and agencies have to operate independently and are uncertain in co-ordination. Creating the conditions for shared goals, co-investment and co-ordinated actions remains a major challenge.

Context

Knowledge mobilising agencies are usually alert to the potentially facilitating or (more usually) inhibiting effects of the local environment on their efforts. While some see context as a ‘given’ that simply needs to be taken into account (‘context dictates the realm of the possible’),21 for others it is an active ‘ingredient’ in any successful knowledge mobilisation strategy. As Greenhalgh et al. assert: ‘the multiple (and often unpredictable) interactions that arise in particular contexts and settings are precisely what determine the success or failure of a dissemination initiative’.31

The ‘context is important’ strand in the knowledge mobilisation literature has a long history in organisational research.151 The processual-contextual perspective (e.g. the content, context and process framework)152,153 has informed a number of studies in the change literature in recent decades.154 It is reflected in Pawson and Tilley’s well-known ‘CMO’ (context–mechanism–outcome) configuration in realist evaluation155 and in the PARIHS Framework,52 which was developed in part to address the lack of attention to context in earlier models.72 The importance of context in quality improvement in health care and the key empirical findings from the literature have recently been explored in a publication for the Health Foundation.151

In relation to influencing policy, a recent review156 also emphasises the importance of an analysis of context and refers to two frameworks: the ‘three Is’ of political science (institutions, interests and ideas) and to the framework proposed by Contandriopoulos et al.,21 which considers issues in terms of their polarisation, salience and familiarity. Similar frameworks are available when looking at the uptake of policy interventions. For example, the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework20 emphasises that it is the broader contextual factors that influence adoption, implementation and maintenance and so decision-makers need to balance evidence on effectiveness against these factors.

Analytic approaches to context typically divide it into inner/internal and outer/external, although many authors emphasise that the interaction between these adds to the challenges of assessing and addressing context. Among the aspects of internal context that authors have suggested are relevant to knowledge mobilisation are organisational structures and processes (e.g. the impact of modes of governance on research use, conditions that affect the facilitation and prioritisation of research activity, including incentives and levers, the degree to which service user preferences are accurately known and prioritised); organisational cultures (e.g. the distribution of power between different groups, perspectives on whose responsibility it is to encourage evidence use, current norms and practices, the climate for innovation); and organisational facilities and resources (e.g. time, equipment). In relation to external context, the knowledge mobilisation literature emphasises three key related aspects: the social and political climate/culture; the degree of environmental stability; and the extent of interorganisational communication and norm-setting. In relation to social and political culture, authors have highlighted a range of issues, including the general climate for research production and use (e.g. how those who fund research, universities, researchers and research users support and value knowledge mobilisation efforts) and the influence of policy directives (e.g. the increasing requirement that schools attend to evidence about effective practice as part of continuing professional development leading to an increase in the number of school leaders taking on knowledge broker roles).127

There is broad agreement, therefore,33,75,157 that context is an important (if poorly understood) mediator. It is a feature of many models of barriers to knowledge uptake,100 and analysis of context is one of the five common components shared by the majority of models of the knowledge mobilisation process.19 Indeed, a large proportion of the knowledge mobilisation literature is made up of analyses of ‘barriers and facilitators’.18 For example, there is strong evidence for a wide range of generic barriers to effective research impact, including, for researchers, a lack of resources, a lack of skills and an absence of professional reward for research impact activities and, for research users, competing organisational pressures, an organisational culture that does not value research, a preference for other sources of evidence and a suspicion that research may displace professional skills and experience.145 In a similar vein, the Cochrane EPOC group classifies barriers to change into nine categories (information management, clinical uncertainty, sense of competence, perceptions of liability, patient expectations, standards of practice, financial disincentives, administrative constraints and a miscellaneous category).76

Although identifying and addressing key barriers is recommended in many knowledge mobilisation models as an important consideration when choosing a strategy, many important barriers affecting knowledge use (e.g. difficulties arising from working in multiprofessional teams) are long-standing and complex, and are not actually easily addressed.76 Moreover, this marked emphasis in the literature on understanding barriers and facilitators has been critiqued for leading to a narrow ‘technicist’ understanding of knowledge mobilisation rather than one that is attentive to knowledge mobilisation as an interactive and deeply situated process.37

In contrast, the contextual approach taken by Ward et al.37 proposes that a detailed understanding of local interpersonal interactions, shared experiences and networks may be particularly useful in considering how opportunities for knowledge mobilisation emerge or are constrained within an organisational setting. Thus, they see context as playing a dynamic and interactive role with local actions, not simply existing as a passive and inhibiting backdrop. This perspective emphasises the importance of assessing the existing ‘naturalistic’ knowledge exchange processes that are already occurring (e.g. in relation to other innovations or change programmes), and of building on these when planning formal knowledge mobilisation interventions.

It has also been noted that contexts are multiple rather than singular. Levin’s model of knowledge mobilisation75 refers to three types of contexts for the use of research: the context in which it is produced; the context in which it is used; and all of the mediating processes between these two contexts. Emphasis is thus placed on the multiple dynamics at play within each context. Other authors (e.g. Nicolini et al.158) emphasise the extent to which any one sector (e.g. health care) will have different subsectors within it (e.g. clinical research, health services research, health policy) that may require different approaches to knowledge mobilisation. In that sense, contexts are not just multiple, parallel and perhaps overlapping, but are also nested. Indeed, the ‘complex adaptive systems’ perspective20,27,78 emphasises how the different levels of the system affect each other: interventions at one level are affected by, and affect, factors at other system levels.35

There are differing views about the extent to which and how contextual factors can be managed or even influenced. Many authors (e.g. Greenhalgh et al.31) emphasise that while context is important, it is also unpredictable and not easily controlled. Knowledge mobilisation activities are embedded within a system and changes will be sustained only if attention is paid to the factors that influence that system.64 This rules out simple prescriptions for approaches which will apply in a range of contexts and points to the need to design, tailor, refine and evaluate any knowledge mobilisation approach with reference to the particular setting and alongside those who will be responsible for implementing the changes.31,64 Advocates for an integrated knowledge mobilisation research approach (i.e. collaboration between researchers and knowledge users) emphasise that research knowledge has to be integrated with contextual knowledge (e.g. population data, local expertise, knowledge of the characteristics of the local setting) and that this integration is more likely to happen if the potential users are involved in the research process from the outset.159

For agencies seeking to develop knowledge mobilisation strategies, then, a thoroughgoing and realistic evaluation of context remains central. However, while ‘context’ is a key heading in many models and frameworks of the knowledge mobilisation process, it is variably conceptualised and differentially understood. Moreover, there is divergence of view whether context is a passive (usually inhibitory) backdrop or a potentially modifiable and co-optable ‘resource’ for the knowledge mobilisation effort. What is clear is that it is inadequate to treat context as merely a catch-all term for all that is not modelled: such an approach will disguise vital issues such as goal misalignment, power disparities and political practices. As yet, however, tools to assess and disentangle the role of context in knowledge mobilisation are insufficiently developed.

In developing our conceptual map from the review of reviews we were struck by how little attention was given in the knowledge mobilisation literature to the ultimate recipients of public services: service users, their carers and families. It is to this element that we now turn.

Involving the public and service users in knowledge mobilisation

Although there has been increasing emphasis over the last two decades on the involvement of patients and members of the public in carrying out research rather than their being involved as only research subjects,102,160 the evidence base on the impact of such involvement is currently limited.102,161 Specific consideration of these groups as one of the potential audiences for knowledge mobilisation interventions is not a strong feature of much of the research literature on knowledge mobilisation. This may be unsurprising given that it has been argued that PPI in health research in the UK at least has been relatively ‘invisible’ despite the clear policy driver.162

Public deliberation methods (e.g. citizens’ juries) are increasingly being used in health policy and in health priority setting in the UK, the USA and Canada, but more research is needed to understand and measure their use and impact.163 Some authors (e.g. Oxman et al.164) have made suggestions for interventions to engage the public in evidence-informed policy-making through the mass media, through civil society groups (e.g. patient and carer organisations and statutory organisations) and as consumers, and for measures to enable them to have greater influence in these settings.165 They note, however, that there is little evidence to date about the effects of public engagement in health policy.

In thinking about patients and members of the public as an audience for knowledge mobilisation interventions in the practice field, a recent review144 grouped these interventions into two categories. The first category is patient-direct knowledge translation interventions, which aim to influence patient outcomes directly (by improving patients’ knowledge and potentially thereby improving their health behaviours, their use of health services, etc.). This includes interventions such as mass media campaigns, patient decision aids or self-help groups. The second category is patient-mediated interventions in which the aim is to change the behaviour of health professionals and thereby affect patient outcomes indirectly; interventions in this category include coaching to enable patients to communicate more effectively with health professionals and question cards to prompt patients to ask specific questions during consultations with health professionals. The Cochrane EPOC group defines patient-mediated interventions as those involving the collection by patients of new clinical data (e.g. blood pressure readings) which are given to health professionals. Stacey and Hill144 have expanded this definition in the knowledge mobilisation context to include interventions targeted at patients that aim to improve knowledge use by health professionals; these are mainly interventions directed at improving patient–health professional communication.

Current evidence suggests that patient-direct interventions to improve patients’ health literacy have the most consistent positive effects on patients’ knowledge and to a lesser extent on their experience and use of health services. For example, question prompts and coaching have been shown to increase patients’ knowledge of their condition and their participation in clinical decision-making, while the use of patient decision aids can increase patients’ participation in decision-making, their awareness of the available treatment options and their perception that the subsequent decision about treatment was in accord with their values.144 There is insufficient evidence as yet to show whether or not patient-mediated knowledge mobilisation interventions have an impact on health professionals’ behaviour. The substantive knowledge base used for any of these interventions (e.g. the evidence underpinning a decision aid or question prompts) is clearly critical to their being a mechanism for increasing knowledge use.

A systematic review of PPI in health and social care research166 found that, although the evidence base is limited, it is possible to identify a number of impacts that PPI has had on research and the research process, including on aspects that may contribute to subsequent knowledge use (e.g. the identification and prioritisation of research topics, improving the feasibility of research designs, better recruitment to studies and increased dissemination of results). The authors comment that there has been relatively little theoretical development or conceptualisation in this field and suggest that one of the priorities is to develop a comprehensive theoretical model and instruments that could be used to measure the impact of PPI. They note that there have been positive and negative impacts from PPI and suggest that PPI should be regarded as a complex intervention that requires due account to be taken of ‘what works, for whom, in what circumstances and why’.155 Two HSDR programme-funded studies using a realist evaluation approach to assess the nature, processes and impacts of public involvement in research are currently in progress in the UK (www.nets.nihr.ac.uk/programmes/hsdr; study reference numbers 10/2001/36 and 10/2001/41).

Further progress has been made since that review was carried out. A recent large multiphase study on the impacts of user involvement in health and social care research has reviewed the evidence and conducted new empirical work on the values and impacts associated with public involvement.161 The study has resulted in a framework to assist researchers in developing public involvement plans and assessing the impact of public involvement: the Public Involvement Impact Assessment Framework (PiiAF).102

Our conclusion from the knowledge mobilisation literature is that the potential for involvement of the public and service users is currently underdeveloped in the field. Where attention has been given, this has largely been addressed at engaging the public and service users with the research production process – not with the communication, reinterpretation and actioning of any knowledge so created.

Concluding remarks

Taken together, the six domains of our conceptual map, the elaborations of arguments within each, and – most importantly – the interactions between them provide a dynamic account of knowledge creation, communication and action. Our subsequent empirical work (see Chapters 4 and 5) shows that different agencies are differently focused on the various domains, with varying assumptions and framings. Our suggestion is that more systematic investigation by agencies of all of the domains (and their interactions) may help them to surface assumptions, highlight tensions and create greater coherence.

Copyright © Queen’s Printer and Controller of HMSO 2015. This work was produced by Davies et al. under the terms of a commissioning contract issued by the Secretary of State for Health. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK.

Included under terms of UK Non-commercial Government License.

Bookshelf ID: NBK299408

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