Dissemination and Implementation Research: A 'Critical, but Still Emerging Area of Science' |
By Angela Sharpe, Deputy Director for Health Policy, Consortium of Social Science Associations (COSSA)
Note: MPSA is a governing member of COSSA, which monitors all federal agencies that provide support for social and behavioral research and advocates for a non-politicized research agenda. This article appeared in the September 2007 issue of COSSA Washington UPDATE. For more information about COSSA, visit their website at http://www.cossa.org/.
On September 10 -11, the National Institutes of Health (NIH), led by the Office of Behavioral and Social Sciences Research (OBSSR) held a sold-out conference on Building the Science of Dissemination and Implementation in the Service of Public Health. Welcoming the more than 700 registrants and those watching via NIH Videocast, OBSSR Director David Abrams explained that the conference is the result of “a growing synergy between an existing trans-NIH Funding Opportunity Announcement (FOA) in support of dissemination and implementation research (Dissemination and Implementation Research in Health) and the implementation of a new strategic prospectus of OBSSR.
According to Abrams, the prospectus identifies increasing the “science of implementation” as a key avenue for moving behavioral and social science forward. It specifically calls for research to understand the factors promoting or impeding the adoption, adaptation, implementation, and maintenance of evidence-based practices by health providers, insurers, policy makers, and the public. Accordingly, the FOA seeks to test models that will sustain evidence-based health behavior change, preventive, diagnostic, treatment, and quality-of-life improvement services into public health and clinical practice settings.
Abrams expressed his excitement at seeing the “critical mass” coming together in this area. “Behavior and behavior change have to be central to making a key impact . . . It bridges biology and the environment. We have to embrace behavior change at every level.” He explained that OBSSR is a trans-NIH entity with the responsibility to promote that “germ of support” designed to encourage the 27 NIH institutes and centers to collaborate and participate in basic science that leads to population change at a meaningful level of impact.
He cited the decline in smoking in one generation as an example of such a change in population behavior. Similarly, the incidence of AIDS over the past 15- 20 years has been cut in half as a result of changes in behavior and risk taking, he added. “If we use the rules of behavior, we can change behavior large scale,” he said. We are not going a good job of putting what we know in practice and policy with respect to what we could do to change population health behaviors in large numbers, especially for the chronic diseases, according to Abrams. The persistent problems we have struggled with for decades, including health disparities and tobacco, and the new and emerging challenges, such as the well-known obesity epidemic and its associated downstream consequences, are why this is a critical time for the new initiative, he argued.
While primarily supported by the OBSSR, the conference was also partially supported by the National Cancer Institute, the National Institute on Alcohol Abuse and Alcoholism, the National Institute of Child Health and Human Development, the National Institute on Drug Abuse, and the National Institute of Mental Health. Abrams noted that there are also entities outside of the NIH that are interested in the area of research. Conference supporters viewed it as “an initial effort to pool the momentum, insights, and efforts around issues of dissemination and implementation research across a broad range of NIH institutes.” It is hoped that the event will be the first in a series of research conferences devoted to this “critical, but still emerging, area of science.”
Definition of Dissemination and Implementation (D & I) Research. Conference planners defined dissemination and implementation as:
Dissemination is defined by conference conveners as the targeted distribution of information and intervention materials to a specific public health or clinical practice audience. The intent is to spread knowledge and the associated evidenced-based interventions. Research on dissemination addresses how information about health promotion and care interventions are created, packaged, transmitted, and interpreted among a variety of important stakeholder groups.
Implementation is defined as the use of strategies to adopt and integrate evidence-based health interventions and change practice patterns within specific settings. Research on implementation addresses the level to which health interventions can fit within real-world public health and clinical service systems.
The committee emphasized that the distinction is made “because interventions developed in the context of efficacy and effectiveness trials are rarely transferable without adaptations to specific settings.” Accordingly, “research is needed to examine the process of transferring interventions into local settings, settings that may be similar to but also somewhat different from the ones in which the intervention was developed and tested.”
The goals of the conference were four fold:
1. To explicate the state of the theory, methods, and practice of dissemination and implementation research;
2. To highlight where increased conceptual, empirical, and methodological development is still needed, thus identifying challenges for the field;
3. To foster dissemination and implementation science with the ultimate goal of improving public health through the availability, adoption, adaptation, and sustained maintenance of efficacious approaches that improve the quality of health and human services; and
4. To recruit additional researchers and develop a diverse community of scientists, thus fostering the interdisciplinary collaborations necessary to pursue such complex and multidimensional dissemination and implementation research.
Improving the Scientific Basis of Health Care Research D & I. The meeting’s keynote speaker, Jeremy M. Grimshaw, University of Ottawa, noted that D & I is a new field and congratulated the NIH for sending a “clear signal to researchers” in the U.S. but also more globally. Grimshaw expressed his hope that the agency will be able to sustain these efforts over time.
Grimshaw began his remarks by calling attention to a 2006 Washington Post op-ed by Steve Wolfe, entitled “All Breakthrough, No Follow Through,”which stressed that without equal emphasis on dissemination and implementation research, we are wasting our resources on discovery research. According to Grimshaw, we have reached the breakthrough point. We have made such advances in discovery research that we now need to move into an era where we give as much focus to dissemination and implementation research for the benefits of patients. He contended that it is his belief that the U.S. has, in fact, reached that point where much of its “investment in biomedical and health research is wasted because of dissemination and implementation failures.” One of the most consistent findings of health services research, explained Grimshaw, is that the health care system and health care professionals fail to deliver the quality of care they aspire to” deliver. He cited emerging knowledge surrounding the ineffective delivery of care for diabetes as an example.
He referenced Richard Grol, a psychologist in the Netherlands and a leader in D & I research, who insists that “evidence-based medicine should be complemented by evidence-based implementation.” According to Grimshaw, we should be trying to build and use a robust evidence base to make sure we do not waste our resources. He also noted that in most health care settings approaches adopted to change clinical practice were more often based on beliefs of the actors in the room rather than on scientific evidence. Lots of people are sure that they know how to change behavior and improve quality and very few of them refer back to evidence to support the change, he asserted. He explained that there are many different issues under the umbrella of D & I research:
- Knowledge synthesis;
- Research into the evolution and critical discourse around research evidence;
- Research into knowledge retrieval, evaluation and knowledge management infrastructure;
- Development of methods to assess barriers and facilitators to D&I;
- Development of the methods for optimizing D&I strategies;
- Evaluation of the effect and efficiency of D&I strategies;
- Development of D&I theory; and
- Development of D&I research methods.
Grimshaw also summarized the current available evidence and highlighted what he thinks are the key methodological and conceptual weaknesses within that evidence base. He maintained that randomized controlled trials will provide the best evidence of effectiveness of the dissemination interventions. He closed by stressing that there is a substantial evidence base out there that we should learn from if we want to move the field forward.
To accommodate the overwhelming interest the conference the conference planners decided to videocast which is now available for viewing on the NIH website at http://videocast.nih.gov/PastEvents.asp?c=998. For more information on possible funding opportunities see: “Dissemination and Implementation Research in Health,” PAR-07-086, PAR-06-520, and PAR-06-521; http://grants.nih.gov/grants/guide/pa-files/PAR-07-086.html; http://grants.nih.gov/grants/guide/pa-files/PAR-06-520.html; http://grants.nih.gov/grants/guide/pa-files/PAR- 06-521.html