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Canadian Journal of Psychiatry. Revue Canadienne de Psychiatrie logoLink to Canadian Journal of Psychiatry. Revue Canadienne de Psychiatrie
. 2014 Mar;59(3):160–169. doi: 10.1177/070674371405900308

A Narrative Review of Recent Developments in Knowledge Translation and Implications for Mental Health Care Providers

Elliot M Goldner 1,✉, Emily K Jenkins 2, Benedikt Fischer 3
PMCID: PMC4079124  PMID: 24881165

Abstract

Objective:

Attention to knowledge translation (KT) has increased in the health care field in an effort to improve uptake and implementation of potentially beneficial knowledge. We provide an overview of the current state of KT literature and discuss the relevance of KT for health care professionals working in mental health.

Method:

A systematic search was conducted using MEDLINE, PsycINFO, and CINAHL databases to identify review articles published in journals from 2007 to 2012. We selected articles on the basis of eligibility criteria and then added further articles deemed pertinent to the focus of our paper.

Results:

After removing duplicates, we scanned 214 review articles for relevance and, subsequently, we added 46 articles identified through hand searches of reference lists or from other sources. A total of 61 papers were retained for full review. Qualitative synthesis identified 5 main themes: defining KT and development of KT science; effective KT strategies; factors influencing the effectiveness of KT; KT frameworks and guides; and relevance of KT to health care providers.

Conclusions:

Despite limitations in existing evidence, the concept and practice of KT holds potential value for mental health care providers. Understanding of, and familiarity with, effective approaches to KT holds the potential to enhance providers’ treatment approaches and to promote the use of new knowledge in practice to enhance outcomes.

Keywords: knowledge translation, mental health, knowledge exchange, implementation, health care, dissemination

Within health care, there has been a rapid growth of interest in KT. This growth has been triggered by the realization that clinicians, patients, and decision makers do not pick up many potentially beneficial research findings and discoveries, that is, the new knowledge does not get translated into action or does so only after a lengthy lag time.1–8 Moreover, many promising discoveries and health interventions fail to achieve their maximum potential and (or) reach the people most in need.3,9,10

Researchers are dissatisfied with the prospect of their findings being disregarded and health care providers want to ensure good access to the best quality and most up-to-date findings about specific health care questions—not only for themselves, but for patients, family members, and decision makers.11 In our paper, we review developments in KT and consider the implications for health care practitioners working in mental health.

Methods

Search Strategy

We used a multi-faceted approach to obtain relevant material for review of developments in KT to address the challenges inherent in search strategies that seek to examine publications about KT.12–15 We initiated our search using MEDLINE, PsycINFO, and CINAHL electronic databases, and, given the limitations that have been noted with the use of standard MESH terms to identify articles on KT,15 we instead used 3 of the most widely used KT-relevant terms as identified by Graham et al3: KT, knowledge exchange, and knowledge transfer. We limited our search to reviews and meta-analyses published in the English language between 2007 and 2012. Our decision to limit our search to reviews and meta-analyses was based on our need to reduce the very large volume of publications that address KT to manageable numbers, and the focus of our review, which seeks to provide an up-to-date overview of developments in KT, particularly those relevant to mental health care providers. The search terms and filtering procedures we used are summarized in Figure 1.

Figure 1.

Figure 1

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Search procedures

Clinical Implications

  • Awareness of KT concepts and approaches among mental health treatment providers may enhance the uptake and use of best evidence.

  • Incorporating KT approaches into clinical encounters may enhance quality of care and health outcomes.

  • Contributing to the practice-based research evidence base holds the potential to establish research evidence that is relevant to clinicians and thus benefits patients.

Limitations

  • The systematic search procedure included only review papers and identified only a portion of documents considered to be relevant. The papers that were reviewed should not be considered to be comprehensive.

  • The discussion regarding the applicability of KT concepts to health care providers is not exhaustive but, rather, is meant to illustrate important ways in which these concepts are relevant to clinical practice.

  • Discussion of KT frameworks is limited, however, reference to an appropriate resource for further guidance is provided.

Using an iterative process, we subsequently added papers through hand searching of the citations contained within publications identified through the systematic search process. The results of a recently conducted review of the KT literature were also drawn on to identify publications judged to be relevant to our review.14

Eligibility Criteria and Selection Process

All abstracts identified in the search procedure were reviewed and publications that focused on the application of KT to specific areas of health care practice that were not directly relevant to mental health (such as dermatology, surgery, or oncology) were eliminated. Publications that addressed general and nonspecific issues of KT and those that focused on any aspect of mental health care were retained for full review and were made available to all authors, who also added publications that were considered to be germane to our review, including those that were published before 2007 and those that were identified in reviewing the publications (and references contained within) that had been obtained through the structured search procedures. When including papers that had not been identified in the systematic search procedure, we aimed to identify either seminal papers that were considered to have shaped the evolution of the KT field, papers that held particular relevance to the focused topic of review, or articles that provided valuable information related to the themes that were identified through analysis. This latter component used a snowball search procedure described by Contandriopoulos et al13 in their review of knowledge exchange processes. We did not apply an evidence evaluation process as we surmised that such a process produced a narrow type of analysis, potentially eliminating valuable insights from this type of narrative review.13

Data Abstraction and Synthesis

Qualitative analysis of the publications was undertaken to identify key themes relevant to the topic of our paper. Two of the authors read through selected reviews and produced a coding template to identify and categorize the review data into themes identified within this literature. An iterative process was used throughout the analysis process and, when we considered themes to be inadequately covered by the literature that was obtained, additional efforts were made to identify peer-reviewed papers that could further develop and articulate thematic areas. Summaries of thematic areas were produced by 2 of the authors and then circulated among all 3 authors for review. Our approach to synthesizing the large volume of material was to use an iterative process in which major concepts were first added and then reorganized to diminish the number of thematic areas to a minimum number that retained each of the key areas identified by the reviewing authors. Following qualitative synthesis, the themes were collated and consensus obtained among us to produce the following results.

Results

After removing duplicates, we scanned 214 articles for relevance. An additional 46 articles were added through hand searches of reference lists or identification and agreement by the authors. A total of 61 articles were retained for full review.

The following 5 themes were identified and each is discussed under a separate heading: defining KT and development of KT science; effective KT strategies; factors influencing the effectiveness of KT; KT frameworks and guides; and relevance of KT to health care providers.

Theme 1: Defining KT and Development of KT Science

Despite being described as closing the gap between what we know and what we do,16 it has been difficult to settle on a clear and consistent definition of KT.17 Numerous overlapping terms, such as knowledge transfer, knowledge exchange, knowledge mobilization, research utilization, dissemination, and implementation are used in varying ways by different groups.2,3,5,18,19 The CIHR uses the following definition of KT, now widely adopted in the field of health care:

[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 . . .20, p 1

According to Tetroe:

It [KT] encompasses all steps between the creation of new knowledge and its application to yield beneficial outcomes for society.20, p 2

The concept of KT is thus an umbrella term that includes many activities, such as technology transfer, knowledge management, knowledge use, continuing education, consensus guideline development, and translational research.5 In this definition, KT constitutes a broad concept and various theoretical perspectives have been applied to explain the processes of KT.13,21–23

The KT process often brings knowledge that has been produced through scientific research into contact with knowledge developed through other means.23 Other forms of knowledge can be gained through the experience people have accumulated by living with a certain health problem, through encounters as a close family member or friend of someone with a health problem, through providing treatment as a health care provider to various people with the health problem, or by being involved with cultural, policy, educational, or political processes that address health care issues.13,24–26

Naturally, scientists are keen to apply scientific methods, including systematic observation, data collection, and hypothesis testing, and are often uncomfortable accepting other forms of knowledge unless they have been put through scientific filters. Conversely, nonscientists often feel that their knowledge, often gained through years of experience, should be recognized without the impediment of detailed scientific study.11,27 These conflicting perspectives may cause tensions within the KT process, however, this can be a creative tension; it is often through the interplay among these perspectives that highly valuable knowledge is created and moved into action.4,13,23,25,28

In describing the processes of KT, Lomas29 identifies 3 steps in moving research into action. Diffusion refers to relatively passive and horizontal (that is, among peers) activities, such as publishing findings in journals, presenting papers at academic meetings, or posting information on websites. Despite their limitations as means of effective KT, diffusion activities remain important and form a foundation for the development of more action-oriented KT efforts and opportunities that exist to improve the likelihood that diffused knowledge will reach relevant users. Dissemination delivers messages that are tailored to the target audience and uses effective delivery channels.2,29,30 Such efforts include the development and distribution of materials formatted to match the needs of particular stakeholder groups and may consist of briefings, educational sessions, media communications, and other activities that are designed for specific target audiences. Implementation is described by Lomas29 as the most active process in KT and one that is undertaken primarily at a local level, where barriers to the use of new knowledge can be effectively addressed and overcome. In general, effective implementation requires persistent and multi-faceted efforts that may be directed through various routes and means.2

KT strategies are often divided into those that either push or pull knowledge.24,30 Push strategies involve efforts to enhance the movement of knowledge from those who generate knowledge outward to those who may be able to benefit from its use. It often involves gathering, synthesizing, and funnelling high-quality information, and efforts at distribution and promotion. In health care, push strategies may involve scientific publications, reports, systematic reviews, guidelines, online materials, conference presentations, courses, webinars, educational outreach, prompts, social marketing efforts, financial incentives, and media campaigns. By contrast, pull strategies are those instigated by people seeking to obtain new knowledge,24,30 such as when health care providers, policy makers, or patients seek out the knowledge that is needed to guide their actions. Such efforts can be facilitated by effective search tools that can locate high-quality information, access to knowledge syntheses and databases, training in the identification and application of research findings in decision making, critical appraisal skill development, and creation of rapid response units and government–university liaisons.

Theme 2: Effective KT Strategies

A theme was identified within the published literature that focuses on specific strategies and approaches that have been shown to be effective in KT efforts.8,10,19,31–46 These can be usefully divided into groups of strategies that can be successfully applied with each of the following 3 key stakeholder groups:

  1. health care providers and allied professionals (such as teachers and social service providers);

  2. patients and the general public; and

  3. decision makers (particularly those working in government and health sector decision-making roles).8

Tables 1, 2, and 3 summarize the findings for each of these groups, respectively. Although there is a substantial body of knowledge regarding KT strategies that are effective for the first 2 groups,10,31 there remains a paucity of knowledge regarding effective KT strategies to influence decision makers.8,13,33 In various areas, there remains limited evidence regarding the effectiveness of KT in producing clinically significant outcomes.

Table 1.

Effective KT strategies for influencing health care providers and allied professionals

Strategy Definition Sample evidence
Educational outreach This strategy (also known as academic detailing) refers to personal visits by a trained, credible person to health professionals in their own settings in which evidence-based, tailored information is provided for the purposes of influencing specific practice behaviours. Grimshaw et al8; O’Brien et al34
Audit and feedback Refers to the provision of information to health care providers about their own clinical performance, allowing comparison of their performance with that of their peers. Often, such information is collected through clinical databases and fed back through individualized reports and summaries. Grimshaw et al8; Boaz et al10; Jamtvedt et al35
Use of opinion leaders Opinion leaders are influential members of a community or field of practice whom other health care providers often turn to for advice, opinions, and clinical direction. Grimshaw et al8; Boaz et al10; O’Brien et al34
Reminders and prompts These include various formats (for example, paper reminders in patient charts, computerized decision support, algorithms, or electronic health records) that help clinicians optimize evidence-based protocols and practices at the point of care. Grimshaw et al8; Grol and Grimshaw37
Interactive educational meetings These include courses, workshops, and seminars that are more effective when they use multiple interventions, 2-way communications, printed and graphic materials in person, and locally respected health personnel as educators. Grimshaw et al8; O’Brien et al34; Forsetlund et al38
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Table 2.

Effective KT strategies for influencing patients and the general public

Strategy Definition Sample evidence
Mass media campaigns These are determined efforts used to promote health behaviour through television, radio, Internet, and print or other media. Wakefield et al39; Jepson et al40
Social marketing approaches These strategies aim to improve the welfare of people and society through applying commercial marketing technologies and techniques. For example, social marketing efforts often undertake consumer research to understand consumer values and needs and subsequently use segmentation variables to tailor interventions for use with specific segments of the population. Gordon et al41
Community mobilization Community-wide efforts to address a health or social issue that may bring together local, provincial, and federal governments; professional groups; religious groups; businesses; and individual community members. The process includes mobilizing necessary resources, disseminating information, generating support, and fostering cooperation across public and private sectors in the community to bring about changes in relevant health behaviours. Jepson et al40; Roussos and Fawcett42
Laws and regulations These have been applied by governments to achieve substantial public health achievements, such as tobacco control laws, that have reduced rates of many chronic illnesses and laws addressing the operation of motor vehicles under the influence of alcohol that have reduced accident-related fatalities and injuries. The effectiveness of regulatory and legal tools to address some health-related behaviours, such as substance abuse, is a complex area and must carefully take into account the relative harms that may be created through inappropriate criminalization of people in society. Moulton et al43
Financial incentives and disincentives The use of bonuses or exemptions as inducements (incentives) or excise taxes and pricing burdens (disincentives) to change health-related behaviours, such as reduction of tobacco and alcohol use, among members of the general public. Chaloupka et al44
Self-management Seeks to enhance a person’s ability to manage the symptoms, treatment, physical and psychological consequences, and lifestyle changes associated with a health condition. May be undertaken when people obtain tools, resources, or guidebooks through their own initiative or with the prompting and support of health care providers (that is, supported self-management). Lorig and Holman45
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Table 3.

Effective KT strategies for influencing decision makers

Strategy Definition Sample evidence
Targeted and tailored dissemination of research knowledge to decision makers Efforts to deliver messages to decision makers that are designed to be accessed and used easily, through creating information that uses language and formats that are comfortable, familiar, and comprehensible to the audience. Also involves delivering the information via effective delivery channels. Dobbins et al46
Linkage of researchers and decision makers Creating a means for sustained dialogue between researchers and decision makers. Orton et al33
Capability building of both researchers and decision makers Concerted efforts and programs to increase researchers’ abilities to create and disseminate evidence geared to decision makers’ needs and improve decision makers’ abilities to appraise and interpret research. Orton et al33
Fostering culture of evidence-informed decision making Changing the culture within which decision makers work to increase the value placed on the use of research evidence. Orton et al33
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Theme 3: Factors Influencing the Effectiveness of KT

Numerous factors have been found to influence the effectiveness of KT interventions.2,5,19,30,32,47 KT is more effective when addressing topics that are perceived by knowledge users to be relatively simple and when tools (for example, guidebooks and decision aids) are in place to support the intended behavioural changes.48 Factors associated with better uptake of evidence-based innovations by organizations include larger size, decentralized decision making, greater resourcing, and closer proximity to urban centres, however, these account for a relatively small degree of variance.49 A learning organizational culture promotes absorptive capacity and facilitates the identification, capture, sharing, reorientation, and implementation of evidence-based knowledge.49,50 Organizational characteristics that contribute to good capacity include clear vision and strong leadership, workforce and skills development, ability to access research (library services), fiscal investments, acquisition and development of technological resources, a knowledge management strategy, effective communication, a receptive organizational culture, and a focus on change management.2,30,47,51

Theme 4: KT Frameworks and Guides

KT scholars have developed frameworks and tools to describe and guide the KT process in an effort to minimize the research-practice gap.3,47,52–55 Given the abundance of KT frameworks and methods proposed over the last few decades,53 the National Collaborating Centre for Methods and Tools has established an online registry, cataloguing these frameworks and providing a valuable resource for those interested in incorporating KT approaches into their work.56 Here, we briefly describe 2 KT frameworks that have figured prominently in KT research and practice, and 1 guide that aims to support the practice of KT in mental health care settings.

Among the most prominent KT frameworks is the Knowledge to Action Process devised by Graham et al.3 This framework, which has been adopted by Canada’s federal health research funding agency, the CIHR, consists of 2 components:

  1. knowledge creation (which is conceptualized as the development of scientific evidence), and

  2. action steps.

Although this model presents the KT process as consisting of 2 distinct activities, the authors acknowledge that, in the real world, the process would be much more complex and dynamic with blurring between these 2 concepts, and activities within each of these components occurring simultaneously. At the centre of this model lies the knowledge creation funnel, depicting the different phases of knowledge creation that become more focused and actionable as the funnel narrows. The broadest form of knowledge is described as first-generation knowledge (for example, primary studies), leading to more refined second-generation knowledge (for example, systematic reviews and meta-analyses), which is ultimately distilled into third-generation knowledge (for example, knowledge tools and practice guidelines), which has been developed into user-friendly formats to enhance use. In addition to the knowledge creation component, this model outlines numerous action steps necessary to move knowledge into practice, including: identifying a problem and selecting knowledge or evidence relevant to addressing the issue; adapting knowledge to the local context; assessing barriers to knowledge use; selecting and tailoring interventions to promote knowledge use; monitoring change; evaluating outcomes; and sustaining change.3,5,20

While the KT framework developed by Graham et al3 is primarily focused on supporting and promoting the implementation of scientific research evidence, Kitson et al57 propose that 4 types of knowledge are necessary for effective KT interventions: research evidence, practitioners’ knowledge, patient experience, and knowledge of the local context. This broader conceptualization of knowledge is championed by KT scholars who argue that scientific evidence alone, which is often comprised of data from small, homogenous populations, may not meet the needs of health care practitioners who provide care to diverse client populations.50,58,59 The widely studied and used framework, entitled the PARIHS framework, conceptualizes successful implementation as a function of the interaction of 3 core factors: evidence, context, and facilitation.52 Each of these 3 factors are viewed as lying along a continuum from high to low, with the most effective implementation efforts arising in environments that are high evidence (that is, a strong evidence base that is consistent with practitioners’ values), high context (that is, effective leadership and willingness to change), and high facilitation (that is, support from internal or external change facilitators). Thus this framework provides guidance for practitioners to assess whether their setting is strong or weak in these 3 critical areas, helping identify opportunities to strengthen elements that could impede the knowledge implementation or the utilization process. For example, Owen and Milburn60 describe how the PARIHS framework was applied in the United Kingdom to guide meaningful and sustained improvements in services to women with serious and enduring mental health problems.

The I2I is a step-by-step guide to undertaking KT in health care settings55 developed for the Mental Health Commission of Canada. The I2I encompasses an inclusive view of knowledge and relevant KT stakeholder groups that is particularly resonant in the field of mental health. It highlights the importance of bringing a wide range of participants to the table and promotes a process by which knowledge is jointly identified, created, or applied. The I2I also emphasizes the importance of incorporating various knowledge perspectives. Seven steps are described: identifying the purpose of an intervention; selecting the innovation to be promoted; specifying the actors or stakeholders to engage; identifying agents of change; designing the KT strategy; implementing the intervention or change approach; and evaluating the outcomes (Figure 2). Examples are provided for each stage of the process to support those involved in KT efforts in developing and executing an effective KT strategy.

Figure 2.

Figure 2

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The I2I55 is a practical guide that describes 7 steps to achieving successful KT in health care settings.

Permission to reproduce the figure and the graphic was provided by the Mental Health Commission of Canada.

Theme 5: Relevance of KT to Health Care Providers

In identification of a theme that addresses the relevance of KT to health care providers, 3 subthemes were specified:

  1. KT as applied by health care providers in their clinical activities;8,60

  2. KT activities that seek to influence the behaviour of health care providers3,9,10,31,51,52,57,58; and

  3. KT activities in which health care providers contribute to research, policy, and advocacy.8

As a central component of clinical care is the sharing of knowledge between clinicians and patients, much of clinical practice can be construed to be KT.8 Effective health care provision demands that clinicians use sound means of communicating with patients and their families or caregivers.61 Health care providers must target and tailor key messages and be receptive to knowledge from patients, family members, and caregivers that could influence care and improve outcomes.8 As health care providers are credible and valued sources of knowledge to patients, family members, and caregivers, a health care provider’s capability to assist patients in applying the increasingly sophisticated tools and resources for self-management can optimize patient outcomes.45 Health care providers can play an important role in supporting their patients’ efforts to pull and use valuable knowledge relevant to their own health care needs.

The second subtheme recognizes that health care providers are the targets of many of the KT efforts within health care.3,52,59 The wide range of modalities used to achieve KT, with variable success, includes conferences, workshops, Telehealth, dissemination of practice guidelines and high-quality review sources (such as Cochrane systematic reviews), academic detailing, and financial incentives. A good understanding of KT, including attention to skills in pulling knowledge from high-quality sources can ensure that health practitioners optimize the use of best evidence and improve the quality of care provided to clients. Findings about the effectiveness of various KT approaches can also inform the training and continuing education of health professionals.6,9 For example, courses, workshops, and seminars have been shown to be more effective at transmitting knowledge and promoting changes in clinical practice when they use multiple interventions, 2-way communications, and locally respected health personnel as educators.10,38

The third subtheme addresses circumstances in which KT becomes useful to health care providers who wish to have an influence on research, policy, decision making, and advocacy. The unique and valuable knowledge that is gained through delivering clinical care in real-world settings has the potential to advance research and policy and to bring about beneficial change.24 Although the concept of evidence-based practice is well known, critiques in recent years suggest there is also a need for practice-based evidence, that is, evidence with greater applicability and generalizability to real-world experience that draws on the tacit knowledge and expertise of health care providers and patients.50,52,54,59,62–68

Discussion

In our review of general literature on KT, we identified a series of prominent themes and, here, we address issues that hold specific implications for mental health care providers. As it has been noted that gaps between science and practice are great in the field of mental health,2,27,69 KT strategies may hold particular value.

More so than in other areas of health care, mental health is an area in which detrimental and stigmatizing misinformation is widespread and resistant to modification, both among the general public65 and health care providers.66,67 Moreover, the diverse ethnocultural composition of modern societies bring a multiplicity of cultural and historical beliefs and practices regarding mental health and illness.70 Consequently, effective approaches to KT may be particularly important to facilitate exchange and uptake of high quality knowledge related to mental health. Regarding the effectiveness of KT efforts to foster innovation and improvement in mental health programs, various authors have emphasized the importance of organizational culture and attitudes of health care providers.2,9,69 Within the cultures in which mental health care providers operate, particular value is often placed on tacit knowledge, that is, knowledge that is developed from direct experience and action, highly pragmatic and situation-specific, and often understood and applied subconsciously and thus difficult to articulate or codify.68 Tacit knowledge is often distinguished from explicit knowledge, which follows logic, can be codified, written down, and effectively communicated to others.68 In comparison to many other areas of health care in which explicit scientific knowledge is favoured, tacit knowledge may be of particular importance in the field of mental health. Goering et al50 have described how the successful application of psychotherapies depends prominently on the qualitative and tacit knowledge that is exchanged between clinician and patient.

Conclusions

Developments in both the conceptual understanding and effective practice of KT may be of value to health care providers working in mental health and the definition of KT is broad enough to be relevant to their day-to-day practice. Awareness of effective approaches to KT may help health care providers to optimize their treatment approaches and become adept at locating, using, disseminating, and implementing valuable new knowledge while supporting their patients’ efforts to do so as well. Frameworks, tools, and resources have been developed that may be useful to health care providers in applying effective KT practices.

Acknowledgments

Financial support for conducting this review was provided to Emily Jenkins through a CIHR Canadian Graduate Scholarship Doctoral Award and a Fellowship through Knowledge Translation Canada. Dr Fischer acknowledges research and salary support from a CIHR–Public Health Agency of Canada Applied Public Health Chair.

Abbreviations

CIHR

Canadian Institutes of Health Research

I2I

Innovation to Implementation

KT

knowledge translation

PARIHS

Promoting Action on Research Implementation in Health Services

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