Background

Within the healthcare community there is growing recognition of the difficulty in transferring new evidence-based findings into current clinical practice and public policy.¹ Several countries have undertaken large-scale initiatives to investigate ways to facilitate the effective transfer and wide-scale uptake of evidence-based research findings. For example, within the United States (US), the Agency for Healthcare Research and Quality (AHRQ) is funding a multimillion-dollar research program called Translating Research into Practice (TRIP). The objectives of TRIP are to evaluate different strategies for translating research findings into clinical practice to help accelerate the impact of health services research on direct patient care and to improve the outcomes, quality, effectiveness, efficiency, and/or cost-effectiveness of care through partnerships between healthcare organizations and researchers.²

The National Cancer Institute (NCI) has developed a model³ (Figure 1) displaying a continuum of diffusion and dissemination. It highlights the process from the conduct of the research, diffusion of results, research on diffusion and dissemination itself, through to the application in delivery of care and policy development. The process is not so linear, in reality. Diffusion and dissemination sometimes result in the uptake of non-effective interventions, such as new technologies. The primary research on effectiveness that follows then has implications for dissemination to the general public, practitioners, and policymakers highlighting the need to drop an ineffective intervention. However, this model pictorially indicates the relatively small level of activity and resources devoted to research on diffusion and dissemination (“D&D Res”) in comparison with the other activities that are necessary for the uptake at the practice (delivery) and policy levels. This model can be used with policymakers to identify allocation of resources to different levels along the continuum.

Figure

Figure 1. The Discover-Delivery Continuum [Reprinted with permission from: Kerner J. Designing for dissemination. Presented at “Designing for Dissemination” Conference. Washington, DC: September 19, 2002.].

The theoretical background for research dissemination and diffusion is complex and often contradictory. There are theoretical bases and models for dissemination and diffusion of research generally, and for behavior change of healthcare practitioners and the general public. These major fields of dissemination/diffusion and practitioner/client behavior change are inconsistently integrated into the development of interventions, and the field of cancer control is no exception. This introduction will briefly present some illustrative examples of theories and models of dissemination/diffusion and behavior change, then will present a typology of interventions. Closing the gap from knowledge generation to use in decisionmaking for practice or policy is conceptually and theoretically hampered by diverse terms and inconsistent definitions of terms, including diffusion, dissemination, knowledge transfer or translation or uptake or utilization, adoption, and implementation. A major challenge for those who want to encourage research-informed decisions is to clarify the terms and to continue the conceptual development in order to improve utilization.

Rogers' theory of the Diffusion of Innovations⁴ was developed within the field of agriculture and is targeted to individual audiences, such as the general public, individual practitioners, and individuals within organizations. It has been widely applied to areas outside of agriculture, including health care. Research results can be viewed as the innovation. The theory described five stages of innovation adoption within an individual: knowledge, persuasion, decision, implementation, and confirmation. The individual must be informed of, or discover the new information (innovation), be persuaded to utilize the information for themselves, make the decision to use the innovation, actually implement it, and then evaluate whether it was the right decision. Rogers described the speed of adoption in five types of individuals: innovators, early adopters, middle majority, late adopters, and laggards. In research related to Rogers' model, several factors have been shown to influence adoption of innovations. They include characteristics of individuals to whom the innovation is targeted, of the organization within which they work, of the broader social environment in which the organization exists, and of the innovation itself.⁵

Many researchers are utilizing the definitions provided by Lomas.^{6, 7} He distinguishes the concepts of diffusion, dissemination, and implementation as progressively more active steps in the process of transferring valid and reliable research findings into clinical practice.⁷ Lomas views diffusion as a “passive subset of dissemination in which no special efforts are made to promote the spread of knowledge” (e.g., publication of findings in peer-review journals)⁶. Dissemination is defined as “the spread of knowledge from its source to health care practitioners. It includes any special efforts to ensure that practitioners acquire a working acquaintance with that knowledge”.⁶ Implementation, according to Lomas, implies that the goal of communication is to do more than increase awareness. Implementation involves identifying and overcoming the barriers to the use of knowledge obtained from a tailored message.⁷ In considering a fit with Rogers' work, Lomas has primarily addressed getting the information to Rogers' stage of decision, through the initial stages of knowledge and persuasion. This work has been used to guide research into health care practitioner change and health care system uptake of research.

An example of a model that targets health care system decisions is the RE-AIM framework.⁸ It translates the stages of Diffusion of Innovation theory, with emphasis on implementation and confirmation. The acronym stands for Reach, Effectiveness, Adoption, Implementation, and Maintenance and has been particularly used in assessing the potential of interventions in public health, such as one-on-one counseling, group sessions, telephone calls, mail interventions, and policy.^{8, 9} The framework provides a comprehensive set of criteria for evaluating interventions from individual and system levels and emphasizes external validity (Reach and Adoption) as well as internal validity (Efficacy and Implementation).⁹ Thus it is useful to promote the application of research at the delivery and policy level. It can be used to make decisions between competing programs when resources are restricted.

Many different theories and models of individual behavior change have been proposed, including Behavior Modification and the Health Belief Model.^10–12 These theories have all been proposed to help individuals change their health behaviors and can also be applied to health care practitioners to change their practice; thus they provide useful theoretical backgrounds for the development of both interventions to promote behavior change and as strategies to promote research uptake. These theories form the bases for many interventions for cancer control and for provider behavior change. In addition, the Trans-Theoretical Model of Change^{13, 14} presents an overall cognitive-behavioral change process not derived from any health behavior theory. The individual stage of change is assessed by determining whether the individual has thought about the particular change and has attempted any changes.

Each of the theories and models presented was developed with conceptually different purposes and different levels of audiences in mind. The NCI framework considers the range of activities that needs to occur from obtaining research findings to reaching practitioners and policymakers. Rogers attempted to consider the stages of adoption within individuals. Lomas has considered increasingly more active strategies of knowledge transfer to the end users (practitioners, policymakers and clients). RE-AIM provides a framework for evaluation at the end of Rogers' stage of implementation. Each theory provides some beginning direction for strategy development within the field of diffusion and dissemination and, ultimately uptake, utilization or application, and subsequent evaluation. Behavioral theories, on the other hand, need to be considered at the first stages of intervention development to target behavior change in practitioners or clients. They provide the theoretical development for the intervention to be tested as a first stage in the NCI framework (research), and to motivate individuals to make behavior changes (adoption) that can be studied.

Many interventions have been developed that utilize various behavior theories and models of diffusion and dissemination. Within this evidence report, cancer control interventions are classified according to Rimer's typology¹⁵ as: media campaigns, healthcare provider^a directed, individual (patient) directed, access enhancing, social network, policy-level, or multicomponent (i.e., consist of two or more of the single-component interventions). Refer to Table 1 for further detail and examples of interventions within each of these categories.

Table

Table 1. Classification of cancer control interventions.

Conceptually, many of these models, theories, and typologies do not neatly fit together. Common to all is the underlying premise that behavior change is a complex process influenced by multiple individual, organizational, and environmental factors. All focus more on the “push” to adoption, from researchers to members of the public, practitioners, and policymakers. They do not offer insight as to the direction and effectiveness of “pull” strategies from the clients, practitioners, and policymakers to the researchers. These theories and models are useful in suggesting potential barriers to, or facilitators of, behavior change. However, more work is needed to validate the ability of each of these theories to predict or explain observed changes in behavior. Without such data, it is difficult to determine the absolute utility of these theories or models.¹⁶ This is the state of the field of diffusion and dissemination. This report may make the muddiness more apparent to researchers and policy-level people in the field!

Healthcare Provider Behavior Change

By far, most of the work in this area has focused on assessing the effectiveness of behavioral interventions to change healthcare provider practice. Recently, the Cochrane Effective Practice and Organization of Care (EPOC) group published an update of their extensive overview of systematic reviews of professional behavior change interventions.¹⁷ Forty-one systematic reviews, encompassing a diverse range of targeted behaviors and interventions, met the inclusion criteria. This methodologically rigorous overview concluded that passive approaches, such as publication in peer-review journals or mailing clinical practice guidelines, are generally not effective in promoting behavior change. More active interventions, such as educational outreach, healthcare provider reminders (e.g., computerized prompts), cycles of audit and feedback, and opinion leaders, were found to be effective in certain circumstances. Multicomponent interventions were consistently more likely to result in behavior change than single-component interventions. No intervention, however, was effective under all circumstances.

The complexity of this field of research is highlighted by the EPOC overview¹⁷ and suggests that many interacting factors can influence whether a new research finding is adopted into practice. Potential barriers to behavior change include: incompatibility of the new finding with current practice; expense and time required to incorporate the change; lack of organizational structure; and attitudes, knowledge, and expectations of healthcare providers that are not congruent with the change. In many instances, it will likely be necessary to do a situational analysis to elucidate the barriers and facilitators in each area of characteristics of individuals, organizations, environments, and the innovation itself, which influence a specific behavior change. Tailored dissemination and implementation efforts will be needed to overcome the identified barriers.

Rationale for Commissioning of this Evidence Report

The industrialized world has seen cancer rise from the 8^th leading cause of death in 1900 to the 2^nd leading cause today. Estimates predict it will soon replace cardiovascular disease as the leading cause.¹⁸ Approximately 3 percent of the US population (8 million people) required some form of cancer care in 1999.^{19, 20} The recognition of the complexity of cancer has virtually eliminated the possibility for a single “magic bullet” cure despite impressive biomedical advances, and has highlighted the need for multi-pronged approaches to decrease its incidence and impact.

The field of cancer control attempts to reduce this burden by changing behaviors that have been linked to the development of cancer, such as tobacco use and unhealthy diets. NCI of the US defines cancer control research as “the conduct of basic and applied research in the behavioral, social, and population sciences that independently, or in combination with biomedical approaches, reduces cancer risk, incidence, morbidity, and mortality and improves quality-of-life.”²¹ NCI recently reported its strategy for cancer control research in the 21^st century.²¹ As part of this strategy, NCI adopted the framework of the Advisory Committee on Cancer Control (ACOCC) of the National Cancer Institute of Canada (NCIC).²² This framework consists of five areas: (1) fundamental research (i.e., what do we know?); (2) intervention research (i.e., what works?); (3) application and program delivery (i.e., how to deliver what works?); (4) surveillance research (i.e., where are we at?); and (5) knowledge synthesis (i.e., what's next?). All cancer control research activities can be assigned to one of these five areas. Each area, mediated through the central role of knowledge synthesis and subsequent application and program delivery (i.e., dissemination and implementation), act to reduce cancer burden (Refer to Figure 2).

Figure

Figure 2. Cancer control research. [Adapted, with permission, from:Anonymous. Bridging research to action: a framework and decision-making process for cancer control. Advisory Committee on Cancer Control, National Cancer Institute (more...)

The bulk of cancer control research to date has been focused on developing effective interventions to promote behavior change. Much less work has been done to develop and evaluate methods to disseminate these evidence-based interventions to appropriate target groups (i.e., in the area of application and program delivery). The new NCI cancer control strategy recognizes that to achieve a real impact on the cancer burden in the US, there needs to be wide-scale adoption of the results of cancer control research.²¹

As part of the effort to understand how to achieve this goal of wide-scale adoption, this evidence report was commissioned by AHRQ and its nominating partner organization, NCI's Division of Cancer Control and Population Sciences. The findings of this report will assist NCI in identifying “best practices” for the diffusion and dissemination of evidence-based cancer control interventions to healthcare providers, patients, and the public.

Approaches to Dissemination Research

Different approaches can be made to the same literature. It is possible to look at strategies to change health care practitioner behavior in relation to any evidence-based practice change¹⁷ or to approach dissemination specifically from a topic-specific perspective. The latter approach was taken in this paper as cancer control interventions and strategies to disseminate the effectiveness of these interventions are of specific interest to the commissioners of this report.

However, this approach is hampered by the lack of distinction in the research between interventions to change behavior and strategies to disseminate that information. Furthermore, many studies have combined evaluation of both interventions and strategies within one study. Some activities (e.g., media campaigns, opinion leaders, and peer educators) can be characterized as both cancer control interventions and strategies to disseminate cancer control interventions to target audiences. This can lead to confusion about what is considered a cancer control intervention and what is considered dissemination of cancer control interventions. For the purpose of this evidence report, if an activity was used to provide educational information about the benefits of a desired cancer control behavior, it was classified as a cancer control intervention. If the activity was used to provide information about the availability or benefits of a cancer control intervention, it was classified as a strategy to disseminate a cancer control intervention. For example, if a media campaign provided educational messages about the benefits of smoking cessation and/or the consequences of tobacco use, the campaign would be classified as a cancer control intervention. If the media campaign provided information about the availability of a cancer control intervention, such as the Cancer Information Service (CIS) telephone hotline, the campaign would be considered a strategy to disseminate a cancer control intervention.

Objectives and Scope of this Report

The overall objectives of this evidence report are: (1) to provide an overview of the cancer control interventions that are effective in promoting behavior change; and (2) to identify evidence-based strategies that have been evaluated to disseminate these cancer control interventions.

To maximize the usefulness of this evidence report for our nominating partner organization (NCI) these objectives are addressed for five high priority topics within NCI's current cancer control research goals. Two of the topics are in the area of prevention (adult smoking cessation and adult healthy diet); two are in early detection (mammography and cervical cancer screening); and one is in the area of supportive care (control of cancer pain).

Footnotes

a

For the purpose of this report healthcare providers include: physicians, public health professionals and allied healthcare practitioners.