Dissemination and Implementation Research in Health

Translating Science to Practice 2nd Edition

Visit the link below to download the full version of this book:

https://medipdf.com/product/dissemination-and-implementation-research-in-health-
translating-science-to-practice-2nd-edition/

Click Download Now

■ We dedicate this book to our spouses: Carol Brownson, Pat Cox, and
Frank Proctor. We are grateful for their loving support and good humor
This page intentionally left blank
■ FOREWORD

I write this having just marked my tenth year at the National Institute of Mental
Health, the balance of that time spent on efforts to grow the field of dissemination
and implementation research. With great enthusiasm, I consider this comprehen-
sive volume that reflects that progress the field has made and the significant chal-
lenges that lie ahead. It has been a privilege to see the development of the theories,
frameworks, and empirical data captured by the authors. We can see a dramatic shift
from an era in which dissemination and implementation processes were considered
to be beyond science to the current state, in which diverse scientists, practitioners,
and policymakers are actively pursuing knowledge on how to accrue the most public
health benefit from our scientific discoveries.
From my perspective, the origins of dissemination and implementation research
lie in a number of key developments in the last century: Archibald Cochrane’s
efforts, highlighted by his landmark monograph Effectiveness and Efficiency,1 to
derive empirical support for health care treatments and the subsequent development
of the Cochrane Collaboration, which systematized the process for considering evi-
dence sufficient enough to warrant widespread use of health interventions; Andrew
Oxman and colleagues’ 1995 paper, “No Magic Bullets to Change,”2 which system-
atically assessed a large number of studies targeting clinical behavior change, fi nd-
ing better results with active (not passive) strategies, and discussing the necessity of
a comprehensive approach to maximize the likelihood of change; David Sackett’s
1996 paper heralding the arrival of modern “Evidence-Based Medicine,” where
clinical practice could be optimized by the “judicious use of evidence” in concert
with medical acumen. 3 Around the same time, public health and other related disci-
plines were formalizing tenets of evidence-based practice and policy.4 The popular-
ization of Everett Rogers’s Diff usion of Innovations theory, 5 which originated from
his own experience as a farmer and then as an investigator of the spread of agricul-
tural innovations, was another important development and one from which health
researchers learned a great deal about spread of evidence-based interventions.
Each was an important stepping-stone toward the significant advancement of
the field. Quite relevant to me in draft ing the fi rst NIMH program announcement
on Dissemination and Implementation Research (2002)6 was the work of Jonathan
Lomas, whose 1993 paper sought to clarify concepts of Diff usion, Dissemination,
and Implementation as related to transferring knowledge into health care practice.7
Th is framework described the different levels of intensity through which the goals
could be achieved, and continues to be the source for NIH’s working defi nitions for
the field.
In contemplating the growth of dissemination and implementation research,
I fi nd myself returning to a basic theory of behavior change quite present in D&I
discussions—the Transtheoretical Model of Change. 8 Prochaska and DiClemente’s

vii
viii ■ for ewor d

model provides a helpful heuristic for me to frame the dramatic shift s in thinking.
Certainly not everyone has traversed the stages from precontemplation to mainte-
nance (perhaps to termination), but I fi nd that an increasing contingent of health
researchers have not only progressed but also become agents of change themselves.

Precontemplation (pre-1990s):

For many years, there was no field of dissemination and implementation research.
The linear model from research to practice of most treatment or preventive interven-
tions proceeded from intervention development to efficacy studies (less frequently
to effectiveness studies) and then to the literature, destined to be a paperweight or
reliant on a microfi lm projector to be further disseminated. The biomedical research
community seemed to assume that the journals that they published in were fully
digested by clinicians, and thus the work to get science to the masses was accom-
plished. Few considered that publication was not the golden path to full integration
of interventions within health systems.

Contemplation (1990s–2000):

The 1990s saw a significant rise in a discussion of dissemination and implemen-

tation as conferences, commentaries, special issues, and federal and independent
reports underscored the ineffectiveness of the publication as a tool to change clini-
cal practice. The rise of evidence-based medicine and evidence-based public health,
fi rst in the UK and then elsewhere, popularized the notion that scientific fi ndings
should be more comprehensively implemented within typical practice, fi lling the
gulf (or “Quality Chasm” as the IOM depicted).9 The Agency for Health Care Policy
Research (later AHRQ ) began to fund a series of evidence-based practice centers
around the country to improve the “translation of research to practice,” and articles
appeared by the truckload, identifying many facilitators and barriers to the diff u-
sion of innovations. There was recognition that the path from research to practice
was a messy and frequently futile one, but litt le organized inquiry into the “how” and
“why” existed. In short, the field was heavy on contemplation and light on action.
For many of us, the culmination of this period was the Balas and Boren (2000) arti-
cle in the Yearbook of Medical Informatics, which quantified this path from research
to practice at 17 years after which some 14% of fi ndings fi ltered into clinical use.10

Preparation (2000–2003)

By the end of the last century, we had reached the dawn of a new stage in our field.
Well recognized were the diverse and multiple barriers and facilitators to dissem-
inate research fi ndings and implement effective interventions. The next step was
figuring out what to do about it. These next few years saw more organized calls
for research, from federal agencies, foundations, and states. Many researchers still
remained hesitant to jump fully into the fray, but an increasing number of study
ideas began to emerge. We saw an influx of reports, chronicling multiple demonstra-
tion projects targeting the uptake of effective interventions, but frequently focusing
 Foreword ■ ix

more on “what happened” and less on “how do get something good to happen.” The
dissemination and implementation strategies were crafted with experience and
expertise behind them but rarely tested in a way to bring knowledge about how to
do better.

Action (2003–Present)

Recently, we have seen a true explosion in the quantity and quality of dissemination
and implementation research in health. Attendance at the annual NIH conferences
has quadrupled, and the rigor and ambitiousness of ongoing studies has signifi-
cantly advanced. Many conceptual frameworks have been developed and are being
tested, measures of key constructs (e.g., organizational readiness, fidelity, reach,
culture and climate, clinician acceptability of innovations) have been validated,
and we are seeing more comparative effectiveness studies of active strategies to
disseminate health information and implement evidence-based interventions. We
are in a golden age for dissemination and implementation research, helped through
capacity building of multiple research centers and networks, and with comprehen-
sive texts that summarize much of the learning of the last generation. Action is
upon us.

Maintenance (The Future):

So with this book as a tool, and perhaps a divining rod, we look ahead to a bright
future. The capacity of the field has grown, but while progress has been made, we
have not yet reached a status in which perceived value of this science is ubiqui-
tous and unchallenged. Scientifically, we have yet to progress to a long-term view
of dissemination and implementation. The next generation of studies to get us
there will address the sustainable integration of interventions within dynamic
health care delivery systems and the implementation of evidence-based systems
of care rather than the individual intervention. We will rely on improved qual-
ity and specificity of methods and measures, and more available data to look at
the ultimate impact of dissemination and implementation efforts on popula-
tion health. Our science will embrace the increased globalization of health care
research and encompass the application of dissemination and implementation
across the world.
Reflecting this exciting journey, this book brings together much of what is cur-
rently known about dissemination and implementation, priming readers with all
levels of familiarity and expertise. Within our field, necessary expertise typically
transcends the bounds of any individual; this book orients us to what we know, and
what we don’t. With this volume as a marker of progress to this point, it is even more
exciting to gaze ahead and see what the next decade will bring.

— David Chambers, D.Phil.

Associate Director, Dissemination and Implementation Research
National Institute of Mental Health
National Institutes of Health
x ■ for ewor d

REFERENCES

1. Cochrane AL. Effectiveness and efficiency. Random reflections of health services (new
edition). London: RSM Publishing, 1999.
2. Oxman AD, Thomson MA, Davis DA, Haynes RB. No magic bullets: a systematic
review of 102 trials of interventions to improve professional practice. CMAJ. Nov 15
1995;153(10):1423–1431.
3. Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence based
medicine: what it is and what it isn’t. BMJ. January 13 1996;312(7023):71–2. PMID
8555924.
4. Satterfield JM, Spring B, Brownson RC, et al. Toward a transdisciplinary model of
evidence-based practice. Milbank Q. Jun 2009;87(2):368–390.
5. Rogers, Everett M. Diff usion of innovations. 5th edition. New York: Free Press, 2003.
6. NIMH. PA-02–131: Dissemination and Implementation Research in Mental Health.
Accessed at htt p://grants.nih.gov/grants/guide/pa-fi les/PA-02–131.html on July 30,
2011.
7. Lomas, J. Diff usion, dissemination, and implementation: who should do what? Ann N
Y Acad Sci. 1993;703: 226–237.
8. Prochaska, JO, DiClemente, CC. The transtheoretical approach: crossing traditional
boundaries of therapy. Homewood, IL: Dow Jones-Irwin; 1984. ISBN 087094438X.
9. Institute of Medicine. Crossing the quality chasm: a new health system for the 21st cen-
tury. Washington, DC: National Academy Press, 2001.
10. Balas EA, Boren SA. Managing clinical knowledge for health care improvement. In:
Bemmel J, McCray AT, eds. Yearbook of medical informatics. Stuttgart: Schatt auer;
2000:65–70.
■ PREFACE

Decades of support by governmental and private sources has produced a remarkable

foundation of knowledge in all disciplines related to public health, mental health, and
health care. The discovery of new knowledge should not occur in large measure to
satisfy the curiosity of scientists; rather, the goal must be to improve the human con-
dition (lower morbidity and mortality, enhance quality of life). Yet the gap between
care that could be, were health care informed by scientific knowledge, and the care
that is in routine practice has been characterized as a “chasm” by the Institute of
Medicine. The lack of ability to apply research fi ndings has sometimes been equated
to a leaky or broken pipeline between discovery and application.
To understand and begin to fi ll these leaks, an exciting new science is emerging.
It goes by numerous titles, including: translational research, knowledge translation,
knowledge exchange, technology transfer, and dissemination and implementation
(D&I) research. Although the terminology can be cumbersome and changing exist-
ing practices complex, the underlying rationale is simple: too often, discovery of
new knowledge begets more discovery (the next study) with litt le attention on how
to apply research advances in real-world public health, social service, and health
care sett ings. The early efforts in D&I research focused on ways to increase the use
of evidence-based guidelines among practitioners. The subsequent research has
shown that in efforts to disseminate practice guidelines using passive methods (e.g.,
publication of consensus statements, mass mailings), adoption has been relatively
low, resulting in only small changes in the uptake of a new evidence-based practice.
A return on investment of the billions spent on basic and clinical research requires
a marked increase in translational research, including the development of its tools,
and analytic approaches. These efforts have been receiving much greater attention
in mainline medical and public health journals. There also is a small set of jour-
nals dedicated to D&I research, notably Implementation Science (begun in 2006)
and Translational Behavioral Medicine (begun in 2011). Similarly, federal agencies
and foundations are beginning to support D&I research more fully. For example,
recent funding announcements from the National Institutes of Health (NIH) show
the higher priority being placed on translational research. While NIH is placing
renewed emphasis on T1 research from bench to bedside (fi rst in human studies
as defi ned by Collins in July 2011), we place emphasis on methods and research
opportunities for moving from scientific discovery of efficacy to population-wide
benefits.
There are tangible examples where the D&I gap has been shortened. Th is may
be best illustrated over the 20th century in the United States where life expectancy
rose from 49 years in 1900 to 77 years in 2000. In large part, this increasing longev-
ity was due to the application of discoveries on a population level (e.g., vaccinations,
cleaner air and water). Yet for every victory, there is a parallel example of progress yet

xi
xii ■ pr eface

to be realized. For example, effective treatment for tuberculosis has been available
since the 1950s, yet globally, tuberculosis still accounts for 2 million annual deaths
with 2 billion people infected. In many ways, the chapters in this book draw on suc-
cesses (e.g., what works in tobacco control) and remaining challenges (e.g., how to
address translational research challenges in populations with health disparities).
What needs to happen to shorten the translational research gap?
• First, priorities need to shift . Of the U.S. annual health expenditures, only
about 0.1% is spent on health services research (where D&I research is nested).
Th is shift in priorities requires political will and a need for social change.
• Second, capacity for fi nding and implementing evidence-based practice needs
to improve among numerous practitioner audiences. For example, most indi-
viduals working in public health practice have no formal training in a public
health discipline—which suggests the need for more and better on-the-job
training.
• Th ird, the science of D&I research needs further development. The range of
research needs is vast and covered extensively in this volume.
• Fourth, capacity for conducting D&I research needs to be advanced through
training. Th is training can occur in government agencies, academic insti-
tutions, and nongovernmental organizations (such as the World Health
Organization).
• And fi nally, to build this science and capacity, institutional support and incen-
tives are needed. For example, academic institutions need to shift priorities
for faculty to reward time spent in conducting D&I research.
We have organized the book in a format that covers the major concepts for D&I
researchers and practitioners. It draws on the talents of some of the top D&I scholars
in the world—crossing many disciplines, health topics, and intervention sett ings.
Our book has four sections. The fi rst section provides a rationale for the book, high-
lights core issues needing attention, and begins to develop the terminology for D&I
research. In the second section, we highlight the historical development of D&I
research and describe several key analytic tools and approaches. Some of the tools
are well developed with a rich literature (e.g., economic evaluation, participatory
approaches) and others are relatively new, developing fields (e.g., comparative effec-
tiveness, systems thinking). Th is section also emphasizes the need to better plan
interventions for dissemination and think creatively about how lessons from busi-
ness and marketing can be applied to health. The third section is devoted to design
and analysis of D&I studies. It covers core principles of study design, measurement
and outcomes, and evaluation. In addition, this section highlights the concepts of
fidelity and external validity, which are fundamental to D&I science. The fi nal sec-
tion of the book focuses on sett ings and populations. Since D&I research occurs in
places where people live their lives (communities, schools) or receive care (health
care, social service agencies), we devote chapters to specific sett ings. Th is section
also recognizes the importance of policy influences on health, the need for cultural
adaptation, and the science of addressing health disparities. Our book concludes
with a short chapter on emerging issues and future research directions.
 Preface ■ xiii

The target audience for this text is broad and includes researchers and practi-
tioners across many different disciplines, including epidemiology, biostatistics,
behavioral science, medicine, social work, psychology, and anthropology. It seeks to
inform practitioners in health promotion, public health, health services, and health
systems. We anticipate this book will be useful in academic institutions, state and
local health agencies, federal agencies, and health care organizations. Although the
book is intended primarily for a North American audience, there are authors and
examples drawn from various parts of the world, and we believe that much of the
information covered will be applicable in both developed and developing countries.
The challenges of moving research to practice and policy appear to be universal,
so future progress calls for collaborative partnership and cross-country research.
Our book documents that in a time of increasing pressure on scientific and
public resources, researchers must continue to meet the implied obligation to the
public that the billions of dollars invested in basic science will yield specific and
tangible benefits to their health. Taxpayers have paid for many new discoveries,
yet these are not being translated into better patient care, public policy, and public
health programs. We believe that applying the principles in this volume will begin
to bridge the chasm between discovery and practice.

R. C. B.
G. A. C.
E. K. P.
This page intentionally left blank
■ ACKNOWLEDGMENTS

We are grateful to numerous individuals who contributed to the development of

this book.
We particularly wish to thank the outstanding team of authors who contributed
chapters. Their exceptional knowledge and dedication is reflected in the chapters,
providing an up-to-date snapshot of dissemination and implementation science.
Four reviewers provided valuable comments that allowed us to revise and improve
the manuscript. We also appreciate the assistance from Lauren Carothers, Linda
Dix, Katie Duggan, Nora Geary, Wes Gibbert, and Nosa Osazuwa-Peters.
Development of this book was supported by the following awards: (1) UL1
RR024992, Clinical and Translational Science Award (CTSA) program of the
National Center for Research Resources; (2) Cooperative Agreement Number
U48/DP001903 from the Centers for Disease Control and Prevention, Prevention
Research Centers Program; (3) Grant Number 1R01CA124404–01 from the
National Cancer Institute at the National Institutes of Health, (4) P30 MH 068579,
Advanced Centers for Interventions and Services Research; (5) R25 MH080916,
National Institute of Mental Health; (6) a grant to Graham Colditz to Build
Prevention and Control Research at Siteman Cancer Center from Barnes-Jewish
Hospital Foundation, St Louis; and (7) the American Cancer Society Clinical
Research Professorship CRP-03–194-07-CCE.
We acknowledge the leadership of Washington University’s George Warren
Brown School of Social Work, Institute for Public Health, Alvin J. Siteman Cancer
Center, Institute for Clinical and Translational Science, and Department of Surgery
(Division of Public Health Sciences) for fostering an environment in which trans-
disciplinary and translational science are valued and encouraged. Finally, we are
indebted to Maura Roessner and Nicholas Liu, Oxford University Press, who pro-
vided valuable advice throughout the production of this edition.

xv
This page intentionally left blank
■ CONTENTS

Contributors xi

SECTION ONE ■ Background

1 The promise and challenges of dissemination and implementation

research 3
graham a. colditz
2 Developing the terminology for dissemination and implementation
research 23
borsika a. rabin, ross c. brownson

SECTION TWO ■ Theory and Approaches

3 Historical roots of dissemination and implementation science 55

james w. dearing, kerk f. kee
4 Comparative effectiveness research to accelerate translation:
Recommendations for an emerging field of science 72
russell e. glasgow, john f. steiner
5 The role of economic evaluation in dissemination
and implementation research 94
ramesh raghavan
6 Designing for dissemination of environmental and policy
initiatives and programs for high-risk groups 114
neville owen, ana goode, brianna fjeldsoe,
takemi sugiyama, elizabeth eakin
7 The role of organizational processes in dissemination
and implementation research 128
gregory a. aarons, jonathan d. horowitz,
lauren r. dlugosz, mark g. ehrhart
8 Viewing dissemination and implementation research
through a network lens 154
douglas a. luke
9 Systems thinking in dissemination and implementation research 175
bev j. holmes, diane t. finegood, barbara l. riley, allan best
10 Participatory approaches for study design and analysis
in dissemination and implementation research 192
meredith minkler, alicia l. salvatore
11 Enhancing dissemination through marketing and
distribution systems: A vision for public health 213
matthew w. kreuter, christopher m. casey,jay m. bernhardt
xvii