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The Maritime SPOR SUPPORT Unit Bridge Process: An Integrated Knowledge Translation Approach to Address Priority Health Issues in Nova Scotia

Background:

The Maritime SPOR SUPPORT Unit (MSSU) was established in 2013 as part of the Canadian Institute for Health Research (CIHR) Strategy for Patient Oriented Research (SPOR). The MSSU aims to support patient-oriented health research that is applicable to policy/practice by engaging healthcare decision-makers, healthcare professionals and Patient Partners from across the three Maritime provinces.

In 2018, the Nova Scotia (NS) Site of the MSSU established the “Bridge process” to foster collaborative research teams between researchers and knowledge-users and to produce research that addresses priority-health issues in NS. The Bridge process takes an integrated knowledge translation (iKT) approach by engaging knowledge-users across all stages of the research process.

Method:

The Bridge process includes four main stages:

Stage 1: Identify priority health topics: The MSSU collaborates with the two provincial health authorities (Nova Scotia Health and the IWK Health) and the NS Department of Health and Wellness to identify priority health topics. The topics are then focused into questions, defined and prioritized. The approach to solicit priority health topics was guided by the Contextualized Health Research Synthesis Program, developed by the Newfoundland and Labrador Centre for Applied Health Research.

Stage 2: Engage stakeholders to refine priority health topics:  Researchers, healthcare decision-makers, healthcare professionals and Patient Partners with interest and expertise in priority topic areas attend a half-day event to discuss and further refine the topics into research questions, through facilitated group discussions.

Stage 3:  Facilitate groups to undertake priority projects: Research questions aligning with priority health topics are identified for further exploration, based on the needs of decision-makers and expertise brought by researchers and Patient Partners. The MSSU supports the development of research projects around the priority research questions.

Stage 4: Priority project application and support: If a project is identified, collaborative research teams can apply for MSSU Priority Project Support, thereby providing access to in-kind project management, coordination and research supports.

Results:

The full Bridge process has been implemented four times since June 2018. In total, 304 participants have attended the events including representatives from government (n = 33), health authorities (n = 103), patient/community (n = 36), research/university (n = 116) and other organizations (n = 16).  Twenty-five priority topics have been discussed at the events and eight collaborative research teams have received MSSU Priority Project Support. Projects successful in receiving MSSU Priority Project Support include research projects on e-mental health, primary healthcare, osteoarthritis, and pharmacist prescribing.

The event provides other beneficial opportunities for stakeholders to network and build relationships. Based on our event evaluation survey, an average of 88% of participants across the four events reported they “Strongly Agreed/Agreed” that they have engaged with researchers, healthcare providers, decision-makers, and/or patients/citizens they would not have otherwise met.

Conclusion:

The Bridge process has served as a promising model for building collaborations across stakeholder groups and integrating the use of evidence into policy/practice. Next stages include adapting this process to be effective through a virtual platform due to COVID-19 restrictions and evaluating the impact of priority projects on informing policy/practice.

 

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Indigenous Knowledge Translation in Action: Learning from Traditional and Community Wisdoms

Background:

There is increasing awareness and respect of Indigenous ways of knowing in research. The research world is all about generating and applying knowledge to increase understanding, solve problems or enhance best practices. There is however a long-standing complexity between generating knowledge and applying that knowledge in timely and effective ways. Knowledge Translation (KT) is active in that middle space between knowledge and action, helping to move evidence into practice in the most efficient and effective ways possible. We share Indigenous KT philosophies and strategies.

Methods:

The knowledge being shared, has been gathered over fifteen years of working with various Indigenous groups nationally and internationally through a combination of observation, interaction and participatory engagement within Indigenous contexts. More recently being community-based participatory health and healthcare research with First Nations and Metis peoples in Manitoba.

Results:

Indigenous KT is a process that begins with establishing relevance, valuing particular knowledge sharing and experiencing processes, aiming for predetermined significance, applying meaningful knowledge gathering tools and organically applying evidence to resolve immediate or ongoing issues.

Conclusions:

Indigenous knowledge systems have inbuilt KT philosophies and strategies to facilitate quick and practical use of relevant information and knowledge to support community-based health and social well-being. Understanding Indigenous KT that is, how these philosophies and strategies are deployed in gathering and applying knowledge could increase success in data leverage, health promotion and social advancement.

 

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Adapting a National Glycemic Index Education Platform for Nova Scotian Patients and Clinicians Treating Gestational Diabetes Mellitus Using Distance Education Strategies

Background:

Dietary interventions traditionally focus on medically relevant primary outcomes (e.g., blood glucose), often failing to recognize complexity of nutrition-education and the impact of the educator on knowledge-transfer. Current Diabetes Canada Clinical Practice Guidelines (2018) recommend low glycemic index (GI) food and drink for glycemic control. These recommendations are based upon decades of high-quality evidence supporting GI-utility in type 1, type 2 and gestational diabetes (GD). Nevertheless, evidence suggests that nutrition educators are not including GI-education in practice. Since 2007, efforts have been made to explore these findings, addressing feedback from stakeholders, and applying an integrative approach to dissemination. This has resulted in development and dissemination of several education materials (with Diabetes Canada and Dietitians of Canada). The majority of Canadian data available on GI-utility is based on Ontario-based patients attending in-person appointments led by seasoned Dietitians/ Diabetes Educators. Clinicians, trainees, and patients at the IWK Health Centre, Nova Scotia, are interested in (local) effectiveness of these materials. Their patients, blended treatment for GD (in-person and online), provide an opportunity to evaluate previously developed GI intervention(s), in an Atlantic Canadian context. This talk will provide an overview of the work done since 2007, providing insight into contemporary integrative GI-KT efforts.

Methods:

Design: Randomized control trial (RCT-NCT04272840). 60 participants, receiving standard care education for GD, will be randomly allocated to a control or intervention group (low GI). The intervention (and associated evaluation) was developed using a four-step pedagogical model, called Kirkpatrick Model. Outcomes include: 1) satisfaction, 2) knowledge uptake, 3) behaviour change (primary outcome) and 4) glycemic control and was the basis of the glycemic index questionnaire (GIQ©). The GIQ, three-day diet record, and self-monitored blood glucose are collected from participants pre- and post- intervention (repeated measures). Prior to collection of these data, feedback has been collected from Dietitians providing standard care (mixed-form questionnaire) and integrated into the intervention. Currently, feedback from recent East Asian immigrant patients (mixed form questionnaire) are also being collected; a growing patient population at IWK.

Results:

Dietitians (n = 4) were satisfied with the intervention and reported learning novel information and counseling approaches when reviewing the resources. The RCT was active for three months before pandemic shutdown (March 2020). Reactivation occurred January 2021. To date, 19 letters of information and 2 consents have been signed. We predict, the intervention will satisfy GD participants, increase their GI-knowledge, and support a statistically and clinically significant decrease in diet-GI within and between groups.

Conclusions:

Adaptation of materials for Atlantic Canadians represents a necessary step in the knowledge-to-action cycle for GI-KT.

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Initiating a Science of Storytelling: A Framework for Using Stories in Knowledge Translation Interventions

Background:

Stories are ubiquitous, have been used for communication and entertainment for thousands of years, engage us by evoking emotion, and can compel us to think or behave differently. Using story-based methods in knowledge translation interventions capitalizes on our affinity for stories by presenting evidence-based health information in context-rich, accessible, entertaining and memorable ways. Indeed, recent systematic reviews have found that changing health-promoting behaviours using stories appears to be a promising option for knowledge translation (KT); however, there is little guidance to help determine how and when to use storytelling as a KT intervention. In response, we aimed to build a framework for using stories as KT interventions to assist researchers and practitioners in thoughtful planning and evaluation.

Methods:

We conducted a broad search of the literature, within parameters determined by the team, to identify studies that used storytelling as KT interventions across various disciplines (health research, education, policy development, anthropology, organizational development, technology research, and media studies). We extracted purposes, theories, models, mechanisms and outcomes from the articles and mapped the theoretical and practical considerations pulled from the literature onto the Medical Research Council guidance for complex interventions. This mapping exercise uncovered common considerations for storytelling in KT interventions, and thus comprised the basis of our storytelling framework development. Methodological experts helped refine and revise the drafted framework based on their expertise using stories in KT activities and interventions. These team members helped to assess and deepen the completeness, accuracy, nuance, and usability of the storytelling framework.

Results:

Storytelling is an attractive KT method but is a complex approach that, to be high quality and successful, requires thoughtful planning and full consideration of multiple intervention components. We designed our framework to make explicit the considerations required to identify when storytelling might be appropriate for the intervention goals and audience, and subsequently, how to build and test the storytelling intervention. In turn, the framework can help guide decisions around whether storytelling is appropriate and/or feasible in a given set of circumstances.

Conclusions:

We built this framework through a complex intervention lens to: 1) help people consider the appropriateness of stories for their intervention goals; and 2) rigorously plan and evaluate their storytelling interventions. Providing such a framework creates the opportunity to embed theory when using storytelling as a complex KT intervention. In this presentation we will walk through the framework components with storytelling examples.

 

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Parent perspectives on a knowledge translation resource for pediatric vaccination pain management

Background:

Pain associated with vaccination is a significant barrier to parents’ adherence to their child’s vaccination schedule. Despite decades’ worth of research on best practices for managing children’s vaccination pain, including clinical practice guidelines, there is both a lack of knowledge and poor uptake of evidence by parents and health care providers (HCPs) to manage children’s vaccination pain. Given parents’ low awareness and uptake of this information, KT interventions are needed to address this gap. A two-page KT resource, based on a vaccination pain management clinical practice guideline, was developed in collaboration with Immunize Canada. The purpose of the resource was to share evidence-based vaccination pain management strategies directly with parents in an accessible way via a national parenting magazine. The aim of this study was to evaluate parents’ perspectives on the acceptability, utility, and design of the resource to help guide future parent-directed KT interventions and resources.

Methods:

Using a qualitative descriptive approach, parents (of children 0-17 years of age) who had participated in a larger study, focused on parents’ use of a KT resource for vaccination pain management, took part in this study. Parents reviewed an electronic copy of the KT resource prior to their child’s upcoming vaccination. At follow up, approximately 6 months later, all children had been vaccinated and semi-structured interviews were conducted with parents to gain an in-depth understanding of their impressions of the resource. Interviews were recorded, transcribed, and analyzed with Braun and Clarke’s reflexive thematic analysis using an inductive approach.

Results:

A total of 20 parents (95% mothers) participated. Parents were generally positive in their evaluation of the KT resource and also identified areas for improvement. Parents’ perspectives were captured by 3 main themes, within which they identified both strengths and limitations: (1) The relevance of content in the resource (e.g., the applicability and practicality of the pain management information provided); (2) The layout and design of the resource (e.g., the visual organization and presentation of the information); and (3) The format of information delivery (e.g., parents’ preferred ways of accessing the resource and the timing of access to the information, relative to the child’s upcoming vaccination).

Conclusions:

Parents generally found this resource to be acceptable and useful in terms of the content, layout, and delivery of the information. However, parents also identified areas for improvement in the resource, such as the timing of access to the information and physical availability of the resource. These results improve our understanding of aspects that are important to include, or account for, in parent-directed KT resources to promote ease of understanding and use. Future research should consider the impact of this type of resource on parents’ use of vaccination pain management strategies and children’s related vaccination pain outcomes and vaccination compliance.

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How is routinely-collected health data used to investigate the impact of automatic cognitive processes on healthcare professional behaviour? A scoping review

Background:

KT interventions often focus on healthcare professionals’ deliberative, analytical thinking as a route to achieving practice change, e.g. educational meetings that provide instruction but leave attendees to integrate the lessons into practice. Such deliberative mechanisms are clearly an important element of practice change. However, human behaviour is guided by two cognitive systems: one involving deliberative processes, the other involving automatic processes (e.g. habits, cognitive heuristics). Automatic processes are under-considered in theoretical frameworks commonly used to explore barriers to change. These processes can be difficult to study, since they are not easily observed or self-reported on. Routinely-collected health data can provide a new window into these processes. Such data provide a means to explore processes that are common across all human decision makers and may have substantial impact on real-world clinical behaviour, through investigation across large samples. We are conducting a scoping review to map the ways in which routine data has been used to investigate the impact of automatic processes on clinical practice.

Methods:

We ran electronic searches in MEDLINE, EMBASE, CINAHL, and PsycINFO. Records are being screened by two independent reviewers. Data will be extracted from included articles relating to clinical contexts (setting, provider and patient group, clinical behaviours investigated), methods used (data sources, steps in analysis procedure), automatic processes investigated, outcomes, and study results. We will compile a detailed descriptive and narrative summary of included studies, informed by qualitative content analysis techniques.

Results:

The searches identified 17,696 unique records. Title/abstract screening is nearing completion. Relevant studies identified so far investigated the availability heuristic (the tendency to assess the likelihood of an event based on the ease with which previous occurrences come to mind), e.g., using billing data to show that physicians were less likely to appropriately prescribe warfarin after another patient had a major adverse bleeding event associated with warfarin (a rare but salient and easily remembered event). Others have investigated the impact of decision fatigue (depletion of abilities to engage in reflective thinking over time, which leads to reliance on automatic processes), e.g., using electronic health record data to show that the likelihood of family physicians prescribing opioids increased as the workday progressed, consistent with cognitive fatigue limiting capacity to make effortful decisions around reducing opioid therapy. Finally, studies have focused on the representativeness heuristic (the tendency to classify an event into a category based on how typical it is of the category), e.g., a study of triage decisions found that despite transfer to a trauma centre being appropriate for all patients studied, patients judged as not typically representative were less likely to be transferred.

Conclusions:

This scoping review will demonstrate ways in which routine data has been used to test hypotheses related to automatic decision-making processes by healthcare professionals, which will support the generation of new hypotheses and help guide the prioritization of next steps for future research. Further work may ultimately support the development of novel or adapted KT interventions to target these processes as routes to improving quality of care.

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Using behavioural theory and shared decision-making to understand clinical trial recruitment: Interviews with recruiters

Background:

Clinical trial recruitment is a continuing challenge for medical researchers. Previous efforts to improve study recruitment have rarely been informed by theories of human decision making and behaviour change. We investigate the trial recruitment strategies reported by study recruiters, guided by two influential frameworks: shared decision-making (SDM) and the Theoretical Domains Framework (TDF).

Methods:

We interviewed nine study recruiters from a multi-site, open-label pilot study assessing the feasibility of a large-scale randomized trial. Recruiters were primarily nurses or masters-level research assistants with a range of 3 to 30 years of experience. The semi-structured interviews included icebreaker questions, questions about the typical recruitment encounter, questions concerning the main components of SDM (e.g. verifying understanding, directive vs. non-directive style), and questions investigating the barriers to and drivers of recruitment, based on the TDF. We used directed content analysis to code quotations into TDF domains, followed by inductive thematic analysis to code quotations into sub-themes within domains and overarching themes across TDF domains. Responses to questions related to SDM were aggregated according to level of endorsement, and informed the thematic analysis.

Results:

The inductive analysis revealed 28 subthemes across 11 domains. The subthemes were organized into six overarching themes: coordinating between people, providing guidance to recruiters about challenges, providing resources to recruiters, optimizing study flow, guiding the recruitment decision, and emphasizing the benefits to participation. The SDM analysis revealed recruiters were able to view recruitment interactions as successful even when enrollment did not proceed, and most recruiters took a non-directive (i.e. providing patients with balanced information on available options) or mixed approach over a directive approach (i.e. focus on enrolling patient in study). Most of the core SDM constructs were frequently endorsed.

Conclusions:

Identified subthemes can be linked to TDF domains for which effective behaviour change interventions are known, yielding interventions that can be evaluated as to whether they improve recruitment. Despite having no formal training in shared decision making, study recruiters reported practices consistent with many elements of SDM. The development of SDM training materials specific to trial recruitment could improve the informed decision-making process for patients.

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Leveraging Technology to build a Comprehensive Infrastructure to Support the Implementation of Evidence-Based Practices in Health Care Systems

Background:
Despite considerable investments in health research in Ontario, a significant gap remains between evidence and health care policy and practice, costing millions to the health care system, and to the wellbeing of Ontarians. Translating research evidence into programmatic change has proved challenging on many levels, including structural, organizational, and temporal.  Learning health systems have been posed as a possible solution however, the evidence around how to effectively promote and facilitate this process is still relatively limited.

Methods:
The Nicotine Dependence Services at CAMH has leveraged technology to create a learning health system based on Dr. Friedman’s three components: afferent, efferent and scale and the Interactive Systems Framework for Dissemination and Implementation.  Specifically it has:
1. Created synthesis of scientific knowledge such as:
a. Built and evaluated computerize clinical decision support system that guides practitioners into proving evidence based interventions by following clinical guidelines.
b. Built a platform that allows for collaborative care to be provided
2. Built capacity in the system by:
a. Having an online program in evidence-based tobacco dependence treatment that is useful across disciplines and diverse health service settings
b. Creating a virtual collaborative care model where information and education can be shared with healthcare providers, clients and their families
3. Delivered our interventions by:
a. Sharing a portal that our partners working in primary care sites and addiction agencies across Ontario can use to provide smoking cessation treatment directly to Ontario smokers in their communities.
b. Creating a web-based virtual platform to support a virtual collaborative care model that allowed health coaches to provide treatment recommendations to youth with early psychosis to address smoking, physical activity and nutrition to decrease their cardiometabolic risk factors.

Results:
Over 4,980 practitioners from 6 provinces, over 15 disciplines, and 812 organizations have been trained in tobacco cessation since the projects initiation in 2006. One hundred and sixty-one Family Health Teams (FHTs) (87%); 56 Community Health Centers (CHCs) (76%); 68 Addiction Agencies (34%); and 32 Public Health Units (PHUs) (100%) have partnered with the NDS and have implemented care pathways for smokers in their practice.
In addition we have tested the feasibility of engaging patients and healthcare providers to use a virtual collaborative care model which allows us to reach people who otherwise would not have access to specialists and treatment resources.

Conclusion:
In this workshop we will share our experience building a learning health system that:
1. Builds on a comprehensive knowledge translation framework (ISF)
2. Leverages technology (CDSS, virtual platform)
3. Ensures that data is collected, analyzed (afferent phase) and that analysis are shared back into the system, solutions to change practices are tested (efferent phase), and promising results are scaled up
This system has been successful in treating over 253,000 smokers, as well as testing the feasibility of a virtual care team for a population that has been described as hard to reach and treat.

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A Patient Decision Aid for Mild Asthma: Navigating a New Asthma Treatment Paradigm

Background:

Daily inhaled corticosteroids (ICS) have been the standard of care for asthma for decades but remain underused in real-world practice, partly due to steroid aversion and suboptimal communication between patients and providers. Recently, four seminal trials have led to a major change in the asthma treatment paradigm, showing that as-needed ICS-formoterol carries a similar benefit to daily ICS therapy for reduction of severe asthma exacerbations. While as-needed ICS-formoterol is additionally associated with >80% reduced cumulative ICS exposure (vs. daily ICS), it also comes with a cost of increased day-to-day asthma symptoms. Given these pros and cons that directly impact the patient, it has become even more critical to gauge patient preferences in choosing the best treatment for mild asthma.

Objective:

We aimed to design a patient decision aid (DA) to help asthma patients and their primary care providers to discuss first-line mild asthma medication options in order to mutually agree upon an evidence- and preference-based decision regarding asthma therapy.

Methods:

Following the International Patient Decision Aid Standards, we assembled a steering committee comprising of clinical, knowledge translation, and DA experts, and primary care and patient representatives to determine the index decision targeted by the DA and which options and outcomes to present in the DA (the latter based on a literature review). We then worked with a graphic designer to format a paper-based prototype of the DA (based on the Ottawa Personal Decision Guide). To optimize DA content and format, we plan to embark upon a rapid-cycle design process. This process entails: (1) DA acceptability, usability, and content testing in sequential rounds, each comprised of one focus group with 3 to 5 asthma patients and 1 interview with a primary care physician; (2) qualitative analysis of focus group and interview findings after each round; (3) corresponding modifications to the DA; and (4) re-testing of the modified DA in the next round. This process continues until no new critical acceptability-, usability-, and content-related issues emerge (i.e. stopping criteria reached). A final summative qualitative content analysis will be performed to determine overall user preferences.

Results:

The paper-based DA was designed for patients having asthma symptoms 2 or more times per month, with the following index decision: “Which asthma medication should you take to best manage your asthma?” Medication options included: (a) as-needed rescue medication only (given observational studies showing that this is what many patients do, despite recommendations for ICS); (b) as-needed ICS-formoterol combination; and (c) daily ICS + as-needed rescue medication. Clinical outcomes included: weeks with well-controlled asthma, rate of severe exacerbations, lung function, airway inflammation, and cumulative ICS exposure. The rapid-cycle design process is currently underway; results will be presented at the meeting.

Conclusion:

We are co-designing a user-centered DA prototype to assist patients and primary care providers in sharing decisions about medications for mild asthma. Next, we will embed this DA into the Electronic Asthma Management System (eAMS) in order to address known barriers to shared decision-making and DA uptake, and then evaluate its real-world uptake and impact.

 

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Aligning implementation science with practice by co-designing an evaluation tool

Background:

The Alberta SPOR SUPPORT Unit Knowledge Translation Platform (AbSPORU KT Platform) works with health science researchers and practitioners to incorporate implementation science principles into research and quality improvement initiatives taking place in Alberta’s health care system. Incorporating implementation evaluation metrics into evaluation plans are of particular interest to those seeking implementation support because of the recognized importance of capturing successful implementation, as well as ways to improve ongoing implementation efforts.

A commonly used framework to evaluate health innovations in Alberta is The Alberta Quality Matrix for Health (AQMH) developed by the Health Quality Council of Alberta. The matrix includes six dimensions of health service quality adapted to the Alberta health care context: acceptability, accessibility, appropriateness, effectiveness, efficiency, and safety. Several of these dimensions overlap with Proctor et al.’s recommended taxonomy of implementation outcomes: acceptability, adoption, appropriateness, feasibility, fidelity, implementation cost, penetration, and sustainability.

To help bridge these approaches, the KT Platform has brought together a team of intended users, content experts, and health system partners to co-design a user-friendly tool to help people incorporate implementation outcomes, such as those recommended by Proctor et al., into evaluations based on the six dimensions of health service quality captured in the AQMH.

 

Methods:

To create this tool, our team followed the Successive Approximation Model from the field of instructional design, which outlines an iterative, participatory design and development process that focuses on end users’ experiences, engagement, and motivation. All stages of this co-design process were shaped by and carried out in collaboration with team members as the project unfolded:

  • Set the Stage – Determine end users’ needs, gaps, and collect relevant background information.
  • Savvy Start Feedback Loops – Using the information gathered in Set the Stage, bring together the co-design team to identify the problem, other potential users, their contexts, brainstorm solutions, carry out rapid prototyping and feedback loops, and select one prototype for further development.
  • Prototype Development and Testing – Build the selected prototype in an iterative manner based on ongoing user testing and feedback.
  • Evaluate – Carry out an ongoing evaluation to ensure both the co-design process and final product meet team members’ and end users’ expectations.

 

Results:

The co-design activities outlined here have enabled our team to develop a web-based, interactive evaluation tool prototype that helps users incorporate implementation outcomes into AQMH-based evaluations. To date, 16 individuals have participated in usability and feedback surveys. This feedback has been used to make continuous improvements to the prototype. Interviews are now underway with a subset of usability participants to better understand the relevance of the tool to their projects and how they might incorporate the tool into their day-to-day work. Additionally, the ongoing evaluation will enable the KT Platform to learn about effective co-design and development processes for producing tools like this one, with the goal of informing future projects.

 

Conclusions:

The development of this tool will enable our Platform to address a need identified by health science researchers and practitioners seeking implementation evaluation support.

Poster