As qualitative research becomes increasingly recognized and valued, it is imperative that it is conducted in a rigorous and methodical manner to yield meaningful and useful results. To be accepted ...

https://journals.sagepub.com/doi/pdf/10.1177/1609406917733847

Thematic Analysis: Striving to Meet the Trustworthiness Criteria

Scoping studies are an increasingly popular approach to reviewing health research evidence. In 2005, Arksey and O'Malley published the first methodological framework for conducting scoping studies. While this framework provides an excellent foundation for scoping study methodology, further clarifying and enhancing this framework will help support the consistency with which authors undertake and report scoping studies and may encourage researchers and clinicians to engage in this process. We build upon our experiences conducting three scoping studies using the Arksey and O'Malley methodology to propose recommendations that clarify and enhance each stage of the framework. Recommendations include: clarifying and linking the purpose and research question (stage one); balancing feasibility with breadth and comprehensiveness of the scoping process (stage two); using an iterative team approach to selecting studies (stage three) and extracting data (stage four); incorporating a numerical summary and qualitative thematic analysis, reporting results, and considering the implications of study findings to policy, practice, or research (stage five); and incorporating consultation with stakeholders as a required knowledge translation component of scoping study methodology (stage six). Lastly, we propose additional considerations for scoping study methodology in order to support the advancement, application and relevance of scoping studies in health research. Specific recommendations to clarify and enhance this methodology are outlined for each stage of the Arksey and O'Malley framework. Continued debate and development about scoping study methodology will help to maximize the usefulness and rigor of scoping study findings within healthcare research and practice.

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Scoping studies: advancing the methodology

Lincoln, Yvonna, and Egon Guba, "Postpositivism and the Naturalist Paradigm," pp. 14-46 in Yvonna Lincoln and Egon Guba, Naturalistic Inquiry . Beverly Hills, CA: Sage, 1985.*

An unresolved issue in the field of implementation research is how to conceptualize and evaluate successful implementation. This paper advances the concept of “implementation outcomes” distinct from service system and clinical treatment outcomes. This paper proposes a heuristic, working “taxonomy” of eight conceptually distinct implementation outcomes—acceptability, adoption, appropriateness, feasibility, fidelity, implementation cost, penetration, and sustainability—along with their nominal definitions. We propose a two-pronged agenda for research on implementation outcomes. Conceptualizing and measuring implementation outcomes will advance understanding of implementation processes, enhance efficiency in implementation research, and pave the way for studies of the comparative effectiveness of implementation strategies.

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Outcomes for Implementation Research: Conceptual Distinctions, Measurement Challenges, and Research Agenda

Doing Qualitative Research

The Canadian Institutes of Health Research (CIHR) is the major federal agency responsible for funding health research in Canada. It aims to excel in the creation of new health knowledge and to translate that knowledge from the research setting into real-world applications. The results are improved health for Canadians, more effective health services and products, and a strengthened Canadian health-care system. It was created under an act of parliament that came into force on June 7, 2000.

Knowledge Translation at the Canadian Institutes of Health Research: A Primer

“We have in hand most of the information we need to facilitate a new golden age of medicine. And what we don’t have in hand we can get fairly readily by wise investment in targeted research and intervention.” This “dangerous idea” (Ewald, 2007) was put forward by Paul Ewald, an evolutionary biologist. His idea has merit and is consistent with the way we, at the Canadian Institutes of Health Research, think about knowledge translation, which is our term for closing the gap between what we know from research and what we do.

From our perspective, knowledge translation (KT) is about making users aware of knowledge or innovations and facilitating their use of it to improve health and health care systems. It is about closing the gap between what we know and what we do (reducing the know-do gap) and about moving knowledge into action. There are other terms in use to describe this concept, many of which are not operationally defined (Tetroe et al., 2008; Graham I.D. et al., 2006) but, at the CIHR, we have developed the following working definition: “Knowledge translation is a dynamic and iterative process that includes synthesis, dissemination, exchange and ethically sound application of knowledge to improve the health of Canadians, provide more effective health services and products and strengthen the health care system. This process takes place within a complex system of interactions between researchers and knowledge users which may vary in intensity, complexity and level of engagement depending on the nature of the research and the findings as well as the needs of the particular knowledge user.” An examination of the meaning of the specific concepts in this definition allows a more in-depth understanding of what we mean by KT.

Synthesis in this context means the contextualization and integration of research findings of individual research studies within the larger body of knowledge on the topic. A synthesis must be reproducible and transparent in its methods, using quantitative and/or qualitative methods. It could take the form of a systematic review; follow the methods developed by the Cochrane or Campbell Collaborations, or other methods; and may synthesize qualitative or quantitative findings. Meta-analyses, realist reviews, narrative syntheses, meta-syntheses and practice guidelines are all forms of synthesis. Dissemination involves identifying the appropriate audience, and tailoring the message and medium to the audience. Dissemination activities can include such things as summary/briefings to stakeholders, educational sessions with patients, practitioners and/or policy makers, engaging knowledge users in developing and executing dissemination/implementation plan, tools creation, and media engagement. The exchange of knowledge refers to the interaction between the knowledge user and the researcher resulting in mutual learning through the process of planning, producing, disseminating, and applying existing or new knowledge. Ethically sound knowledge translation activities are those that are consistent with ethical principles and norms, social values as well as legal and other regulatory frameworks- while keeping in mind that principles, values and laws can compete among and between each other at any given point in time. The term application is used to refer to the iterative process by which knowledge is put into practice or policy and has been illustrated in the action cycle of the knowledge to action process (see Figure 1) Implicit in the CIHR definition is the notion that evaluation and monitoring of KT initiatives, processes, and activities are key components of KT.



Figure 1

The Knowledge to Action Process



Given the complexity of behavior change and the multiple factors that can influence it in positive and negative ways, there is growing recognition that application efforts could and should be guided by conceptual models or frameworks (McDonald et al., 2004; The Improved Clinical Effectiveness through Behavioural Research Group (ICEBeRG), 2006). The usefulness of conceptual models comes from the organization they provide for thinking, for observation, and for interpreting what is seen. They provide a systematic structure and a rationale for activities and have the basic purpose of focusing, ruling some things in as relevant and ruling others out due to their lesser importance. The Knowledge to Action Process, which guides our understanding of KT, was derived from a concept analysis of 31 planned action theories and models (Graham & Tetroe, 2009; Graham & Tetroe, 2007).

In CIHR’s view, knowledge translation can be divided into three broad categories; KT Science -studying the determinants of knowledge use and effective methods of promoting the uptake of knowledge, end of grant KT – initiatives undertaken once the grant/research has been completed and integrated KT (iKT) - initiatives woven into the research process. End of grant KT refers to the standard KT activities of most researchers: KT to their peers such as conference presentations and publications in peer-reviewed journals. But CIHR also encourages end of grant dissemination activities that tailor the message and medium to a specific audience, such as summary briefings to stakeholders; educational sessions with patients, practitioners and/or policy makers; media engagement and the use of knowledge brokers to get the findings to relevant audiences. Integrated KT at CIHR represents a different approach and involves collaboration between researchers and research users in the research process including the shaping of the research questions, deciding the methodology, involvement in the data collection and tools development, interpreting the findings and helping disseminating the research results. Research users could be other investigators from difference disciplines, teams or countries but more often are policy makers, decision makers, research funders, industry, clinicians or the public. This category of KT is similar to participatory research (Macaulay et al., 1999), or Gibbons’ Mode 2 knowledge production (Gibbons et al., 1994) in that it includes “a wider, more heterogeneous set of practitioners, collaborating on a problem defined in a specific and localized context”(Gibbons et al 1994, page 3). It is not our view that every researcher should be involved in integrated KT. For many researchers, disseminating research findings to the appropriate audience (this includes other researchers) is usually sufficient. In cases where more intense knowledge translation is warranted to roll out research findings proven to be effective, this can take place at the end of the grant or in a more integrated fashion – depending on the circumstances. The intensity of knowledge translation would depend on factors such as the potential importance/impact of using the findings; the strength of the evidence supporting the findings (synthesis); the target audience(s); what is known about effective strategies to reach the audience(s); what is practical and feasible to do under the circumstances and considerations of who else should be involved in KT efforts.

What does all this have to do with Paul Ewald’s quote? “We have in hand most of the information we need to facilitate a new golden age of medicine.” In line with the views of Paul Ewald, we need syntheses to determine what we already know (or should know). Tens of thousands of medical research articles are published every year. Through synthesis and systematic reviews, we can sift the wheat from the chaff to determine areas requiring clear action based on strong evidence. For example, Choripta et al. (Chorpita et al., 2007) pointed out the need for the widespread promotion and implementation of treatments with a strong evidence base, in both scientific and applied research in psychology and psychiatry. To facilitate this, they developed a distillation and matching model to provide a means for clinicians to identify evidence-based treatments. Similarly, Thomas (Thomas, 2006), demonstrated the value of searching the Cochrane Library’s Database of Systematic Reviews as a source of synthesized evidence on treating conduct disorder. Finally, Fergusson et al (Fergusson et al., 2005) conducted a systematic review, which documented an association between suicide attempts and the use of SSRIs, which would have not been known without combining the results of many studies. Their cumulative meta analysis further reinforced concern with the potential trend towards harm with this class of drugs.

“….And what we don’t have in hand we can get fairly readily by wise investment in targeted research and intervention.” When research gaps are identified through synthesis, the appropriate people need to be involved from the beginning in order to conduct applied, collaborative, interdisciplinary research – in other words – iKT. Today’s health problems are complex and interdisciplinary and require mixed methods to solve them. Furthermore, research users need to be involved in setting the research agenda and defining the research questions to ensure relevance and greater likelihood of uptake of the findings when they become available. With their input, relevant research can be fostered and encouraged through appropriate targeted funding.

But even if relevant research is being funded and conducted, once the results are in, they are not “one size fits all.” This is equally true of clinical practice guidelines, systematic reviews and quality improvement initiatives. Users need to adapt and take ownership of knowledge for local use. In health care, use of research is not only influenced by the evidence itself, but by existing resources, patient preferences, and clinical expertise (DiCensco & Cullum, 1998; Cullum et al., 2007). The knowledge to action cycle (Graham I.D. et al., 2006) demonstrates how adaptation can be incorporated into the implementation process.

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Getting Evidence into Policy and Practice: Perspective of a Health Research Funder

In the knowledge-to-action cycle, after the intervention related to knowledge translation has been implemented, uptake of knowledge should be monitored. [1][1] This step is necessary to determine how and to what extent the knowledge is used by the decision-makers. [1][1] How we measure uptake of

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Monitoring use of knowledge and evaluating outcomes.

It is widely accepted that research can lead to improved health outcomes. However, translating research into meaningful impacts in peoples’ lives requires actions that stretch well beyond those traditionally associated with knowledge creation. The research reported in this manuscript provides an international review of health research funders’ efforts to encourage this process of research uptake, application and scaling, often referred to as knowledge translation. We conducted web-site review, document review and key informant interviews to investigate knowledge translation at 26 research funding agencies. The sample comprises the regions of Australia, Europe and North America, and a diverse range of funder types, including biomedical, clinical, multi-health domain, philanthropic, public and private organisations. The data builds on a 2008 study by the authors with the same international sample, which permitted longitudinal trend analysis. Knowledge translation is an objective of growing significance for funders across each region studied. However, there is no clear international consensus or standard on how funders might support knowledge translation. We found that approaches and mechanisms vary across region and funder type. Strategically tailored funding opportunities (grants) are the most prevalent modality of support. The most common funder-driven strategy for knowledge translation within these grants is the linking of researchers to research users. Funders could not to provide empirical evidence to support the majority of the knowledge translation activities they encourage or undertake. Knowledge translation at a research funder relies on context. Accordingly, we suggest that the diversity of approaches uncovered in our research is fitting. We argue that evaluation of funding agency efforts to promote and/or support knowledge translation should be prioritised and actioned. It is paradoxical that funders’ efforts to get evidence into practice are not themselves evidence based.

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Translating research into action: an international study of the role of research funders.

Decision aids are evidence based tools that assist patients in making informed values-based choices and supplement the patient-clinician interaction. While there is evidence to show that decision aids improve key indicators of patients' decision quality, relatively little is known about physicians' acceptance of decision aids or factors that influence their decision to use them. The purpose of this study was to describe physicians' perceptions of three decision aids, their expressed intent to use them, and their subsequent use of them. We conducted a cross-sectional survey of random samples of Canadian respirologists, family physicians, and geriatricians. Three decision aids representing a range of health decisions were evaluated. The survey elicited physicians' opinions on the characteristics of the decision aid and their willingness to use it. Physicians who indicated a strong likelihood of using the decision aid were contacted three months later regarding their actual use of the decision aid. Of the 580 eligible physicians, 47% (n = 270) returned completed questionnaires. More than 85% of the respondents felt the decision aid was well developed and that it presented the essential information for decision making in an understandable, balanced, and unbiased manner. A majority of respondents (>80%) also felt that the decision aid would guide patients in a logical way, preparing them to participate in decision making and to reach a decision. Fewer physicians (<60%) felt the decision aid would improve the quality of patient visits or be easily implemented into practice and very few (27%) felt that the decision aid would save time. Physicians' intentions to use the decision aid were related to their comfort with offering it to patients, the decision aid topic, and the perceived ease of implementing it into practice. While 54% of the surveyed physicians indicated they would use the decision aid, less than a third followed through with this intention. Despite strong support for the format, content, and quality of patient decision aids, and physicians' stated intentions to adopt them into clinical practice, most did not use them within three months of completing the survey. There is a wide gap between intention and behaviour. Further research is required to study the determinants of this intention-behaviour gap and to develop interventions aimed at barriers to physicians' use of decision aids.

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Jacqueline Tetroe

Papers

Knowledge Translation at the Canadian Institutes of Health Research: A Primer

Getting Evidence into Policy and Practice: Perspective of a Health Research Funder

Monitoring use of knowledge and evaluating outcomes.

Translating research into action: an international study of the role of research funders.

Physicians' intentions and use of three patient decision aids