This protocol describes the TRiaDS (Translation Research in a Dental Setting) programmatic approach to the development of a practical evaluative framework for knowledge translation (KT) research. Improvement in the quality of dental care has been a focus of Scottish Government over successive administrations [1, 2]. One such initiative was the establishment of the Scottish Dental Clinical Effectiveness Programme (SDCEP) in 2004, to develop user-friendly guidance to promote best practice and improve the quality of dental care in Scotland .
A consistent finding in health services research is that the translation of research findings into practice is unpredictable and can be a slow and haphazard process . Studies in medical care in the USA and the Netherlands suggest that 30 to 40% of patients do not receive care according to current scientific evidence, and 20 to 25% of care provided is not needed or potentially harmful [4–6]. A review of quality of care studies from UK primary care concluded that 'in almost all studies the process of care did not reach the standards set out in national guidelines or those set by the researchers themselves' . Evidence about the translation of research findings in dental healthcare identifies similar problems .
It is well documented that the translation of guidelines into clinical practice requires more than the publication of evidence-based clinical guidelines [3–7]. There has been increased interest in the scientific study of methods to promote the systematic uptake of research findings into routine clinical practice over the past fifteen years [8–10]. It has been demonstrated that interventions can be effective, but their effectiveness varies across different clinical problems, contexts, and organisations and this variation is, as yet, largely unexplained . Additionally, there are only limited descriptions of the interventions and contextual data, as well as scant theoretical or conceptual rationale for their choice . There is limited understanding of the impact of, and how best to address, potential barriers and enablers to the translation of research into practice [13, 14].
As recommended by the Clinical Effectiveness Research Agenda Group (CERAG) , KT research must consider the multiple levels at which healthcare is delivered, their interplay, and the impact of context. There is a need for the development of an understanding of the mechanisms of change from both theoretical and empirical perspectives, as well as methodological issues associated with KT research. The challenge for researchers in the KT research field is to develop and evaluate a theory-based approach that moves beyond single evaluation studies to a generalisable framework that incrementally uses data from a series of evaluations to support, in broadly predictable ways, the choice, development, content, delivery, and evaluation of interventions that aim to change professional behaviour. Such a framework should also facilitate the interpretation of behaviour change research results, both in primary studies and in systematic reviews.
While there is an increasing amount of research looking into medical professional behaviour, there is a dearth of examples of translation research in dental settings. One UK study has investigated the effect of audit and feedback and computer-aided learning in primary dental care . Neither intervention was developed using a theoretical framework and neither influenced evidence-based third molar management. Another UK study, the ERUPT trial , examined the effect of a specific fee-for-service and of a general education course (implementing evidence-based practice) on the number of fissure sealants placed. The trial found significantly more fissure sealants were placed by GDPs offered fee-for-service compared to current practice (a general capitation award), but no statistically significant effect of the education intervention. The study contributed to the incentives in healthcare provision debate and led to a policy change with the introduction of a direct fee for this treatment. General dental services are complex small businesses providing a mixture of NHS and private dental care. Although dental practices are subject to regulatory requirements, there is considerable variation in how these are implemented. Therefore, dental practice in Scotland provides the ideal setting for translation research, with generalisable features across other healthcare services, and the opportunity to influence policy is real.
Efforts to improve the quality of care need to occur at, and be coordinated across, multiple levels such as the patient, clinician, team, organisation and policy . Ferlie and Shortell  observed:
'Fuelled by public incidents and growing evidence of deficiencies in care, concern over the quality and outcomes of care has increased in both the United Kingdom and the United States. Both countries have launched a number of initiatives to deal with these issues. These initiatives are unlikely to achieve their objectives without explicit consideration of the multilevel approach to change that includes the individual, group/team, organization, and larger environment/system level. Attention must be given to issues of leadership, culture, team development, and information technology at all levels. A number of contingent factors influence these efforts in both countries, which must each balance a number of tradeoffs between centralization and decentralization in efforts to sustain the impetus for quality improvement over time. The multilevel change framework and associated properties provide a framework for assessing progress along the journey.' (our italics).
Translation research in a dental setting (TRiaDS)
Established in 2008, TRiaDS is a multidisciplinary research collaboration that has been formed to develop a programme of KT research embedded within the SDCEP guidance development process; it has public, academic, policy, service, and professional members.
Adapting the Canadian Institutes of Health Research (CIHR) definition , we define KT as:
'a dynamic and iterative process that includes the synthesis, dissemination, exchange and ethically sound application of knowledge to improve... health..., provide (higher quality), more effective health services and products and strengthen the healthcare system.'
KT aims to bridge the gap between best available evidence and its routine implementation in clinical practice by facilitating exchange between researchers and stakeholders (e.g., healthcare professionals, patients, educators and policy makers) . To do so requires both the understanding of and effecting of change at both micro- (team, healthcare professional and patient) and macro- (environment, policy, and organisation) levels.
As a research collaboration TRiaDS aims to develop and evaluate the implementation of strategies to improve KT into dental practice , and offers the potential to create a research laboratory for the provision and exchange of evidence-based information between the TRiaDS collaboration, dental healthcare professionals, educators, and policy makers on how best to translate service and educational initiatives into practice.
Aim of TRiaDS
The aim of TRiaDS is to improve the quality of the dental healthcare of patients in Scotland by establishing a practical evaluative framework for the translation of guidance through the conduct of a multi-disciplinary programme of translation research embedded within SDCEP.
TRiaDS programme objectives are:
To describe current activities, determinants of behaviour, and the natural history of change in clinical and administrative behaviours in specified areas of dentistry in Scotland.
To review and, as necessary, change the routine collection of data to support the evaluation of practice in relation to areas of specific relevance to SDCEP.
To develop criteria to determine if intervention is required to improve the quality of care.
To develop interventions to generate change in targeted professional behaviour(s), as appropriate.
To evaluate the effectiveness, cost effectiveness, and sustainability of a range of KT interventions using experimental and quasi-experimental study designs.
To investigate and describe the process of professional behaviour change and the process by which change occurs using an appropriate mix of qualitative and quantitative methods.
To synthesise knowledge gained from multiple and sequential behaviour change evaluations using a theoretical framework to build on and improve methodology.
Through the conduct of the programme, inform dental healthcare professionals, patients, educators, and policy makers on how to effectively and cost-effectively translate national recommendations into routine clinical activities.