Thirty-two studies met our inclusion criteria (Figure1)[45–76]. Both quantitative (n = 29) and qualitative (n = 3) research designs were represented. Within each profession, the heterogeneity of the study designs, KT interventions, targeted behaviours, and study outcomes precluded combining comparable results. Table 2 summarizes the 32 studies, including important study elements, and is organized by discipline and study design.
KT interventions
The 32 studies included diverse KT interventions. Fifteen studies investigated a single KT intervention (pharmacy n = 5, physiotherapy n = 2, occupational therapy n = 4, dietetics n = 3, speech-language pathology n = 2)[46, 50, 51, 53, 54, 59, 60, 63, 64, 67–69, 71, 75, 76]. Seventeen studies examined multiple KT interventions (pharmacy n = 7, physiotherapy n = 9, occupational therapy n = 2)[45, 47–49, 52, 55–58, 61, 62, 65, 66, 70, 72–74]. Following the EPOC classification scheme, the predominant single KT intervention was educational meetings (n = 11)[46, 51, 53, 54, 59, 63, 64, 69, 71, 75, 76], followed by educational materials (n = 2)[50, 67], educational outreach visits (n = 1)[68], and a financial intervention (n = 1)[60]. The studies employing multiple interventions all contained at least one education-related component. Nine of these studies used education interventions exclusively: educational meeting and educational material (n = 7)[47, 48, 56, 61, 62, 65, 73]; educational outreach visit and educational material (n = 1)[52]; educational meeting, educational outreach visit, and educational material (n = 1)[72]. The remaining eight studies employing multiple interventions represented the following combinations: educational meeting and reminders (n = 2)[57, 70]; educational material and mass media (n = 1)[45]; educational meeting and local opinion leaders (n = 1)[74]; educational meeting, educational material, and reminders (n = 1)[66]; educational meeting, educational outreach visit, and audit and feedback (n = 1)[49]; educational materials, educational outreach visit, and mass media (n = 1)[55]; educational meeting, educational material, and local opinion leaders (n = 1)[58]. Table 3 describes the KT interventions of the studies in greater detail.
KT interventions by profession
When the KT interventions were examined by profession, educational meetings were used most often in dietetics (n = 3; 100% of dietetics studies)[46, 53, 63]; occupational therapy (n = 3; 50% of occupational therapy studies)[59, 75, 76]; pharmacy (n = 3; 25% of pharmacy studies)[51, 54, 69]. Pharmacy studies employed the widest range of interventions, including multiple interventions (n = 7; 58%)[45, 49, 55–58, 62, 65], educational meetings (n = 2; 16%)[54, 69], educational material (n = 1; 8%)[50], and financial intervention (n = 1; 8%)[60]. Two speech-language pathology studies were included in this review; the KT interventions were educational meetings[71] and educational outreach visits[68].
Outcomes
Outcome categories
The studies assessed outcomes at different levels; therefore, we applied the EPOC classification scheme (i.e., professional/process outcomes, patient outcomes, and economic outcomes). Of the 32 included studies, the primary outcomes were professional/process outcomes (n = 25)[46, 47, 49–59, 63–68, 70, 71, 73–76], patient outcomes (n = 4)[48, 60, 62, 72], and economic outcomes (n = 2)[61, 69]. One study identified both professional/process and patient outcomes as primary outcomes (e.g., professional/patient communication and patient education)[45].
Outcomes by profession
The dietetics, occupational therapy, and speech-language pathology studies used only professional/process outcomes to assess KT interventions. The pharmacy and physiotherapy studies identified a wider range of outcomes. The outcomes of the pharmacy studies were: professional/process (n = 8)[49–51, 54–57, 65], patient (n = 2)[60, 62], economic (n = 1)[69], and combination professional/process and patient outcomes (n = 1)[45]. The outcomes of the physiotherapy studies were: professional/process (n = 8) e.g., 48,52,58,64,70,73-76], patient (n = 2)[47, 72], and economic (n = 1)[61].
Outcomes by KT intervention
The studies using educational meetings as the single KT intervention used professional/process outcomes (n = 10)[46, 51, 53, 54, 59, 63, 64, 71, 75, 76] and economic outcomes (n = 1)[69].
Interventions
Intervention effects in quantitative research studies: primary outcomes
Some studies did not clearly identify a primary outcome from a host of outcomes measured. Further, it was typical for an identified primary outcome to be measured in multiple ways. At times, this practice led to mixed results within the main outcome(s). To address this, we looked for consistency (e.g., all positive or all negative effects) within the results. We categorized studies that reported both positive and negative effects for the same outcome as having ‘mixed effect.’ Studies that had all positive or all negative effects for the same outcome were categorized as ‘consistent effect.’ Studies in which the results were not clearly linked to the identified outcome(s) were classified as ‘unclear,’ and studies in which there were no comparative statistics provided or results were not reported for the identified outcome(s) were classified as ‘not done’.
As described in Table2, less than a third of the quantitative studies showed a consistent effect on primary outcome measures (n = 8)[47, 48, 50, 52, 64, 65, 71, 72]. Five studies could not be classified as consistent or mixed effect on primary outcome measures: unclear (n = 2) i.e.,58,70], not done (n = 3)[57, 59, 67].
Studies with mixed effects
The majority of the quantitative studies (n = 16) demonstrated ‘mixed effects’ on primary outcome measures[45, 46, 49, 51, 53–56, 60–63, 66, 69, 74, 75]. The research designs of the studies demonstrating mixed effects were: randomized controlled trial (n = 5)[46, 53, 61, 62, 74], retrospective cohort study (n = 2)[60, 69], non-concurrent cohort study (n = 1)[54], before-after study (n = 6)[45, 49, 55, 56, 66, 75], and cross-sectional study (n = 2)[51, 63].
Studies with consistent effects
Eight studies demonstrated a consistent effects on primary outcomes; however, four studies demonstrated effects that were not statistically significant[48, 64, 71, 72]. The remaining four studies demonstrated a statistically significant, positive effects on primary outcomes[47, 50, 52, 65]. Bekkering et al.[47] conducted a randomized controlled trial that examined a group of physiotherapists (n = 113) attempting to implement clinical guidelines for low back pain by using multiple, education-only interventions (i.e., educational material and educational meeting). The physiotherapists in this study reported a statistically significant increase in adherence to the main recommendations of the guidelines. Bracchi et al.[50] conducted a non-concurrent cohort study that examined a group of pharmacists (n = 261) attempting to change adverse drug reaction reporting procedures by using educational material as a single KT intervention. In this study, the results from the control year were compared to the results from the study year and the study region was compared to a control region during both years. As a result, a statistically significant increase in the number of adverse drug reaction reports and the number of ‘appropriate’ adverse drug reaction reports were reported in the study region. Brown et al.[52] conducted a cross-sectional study that examined a sample of physiotherapists (n = 94) attempting to change fall prevention strategies by using multiple, education-only interventions (i.e., educational outreach visits and educational material). The physiotherapists participating in this study reported a statistically significant increase in the frequency of self-reported fall prevention practice behaviours compared to one year prior to the study intervention. Martin et al.[65] conducted a before-after study that examined a group of pharmacists (n = 25) attempting to change tobacco cessation counseling by using multiple, education-only interventions (i.e., educational meetings and educational material). The pharmacists in this study reported a statistically significant increase in self-efficacy measures and current skill measures for the 5A’s counseling process post-intervention.
Intervention effects in quantitative research studies: secondary outcomes
Secondary outcomes were measured and reported in 12 of 29 quantitative studies[52, 53, 55, 57–61, 64, 71, 72]. The secondary outcomes were: professional/process outcomes (n = 4)[52, 57, 59, 72], patient outcomes (n = 4)[53, 55, 61, 64], economic outcomes (n = 3)[58, 60, 71]. One study measured both professional/process and economic secondary outcomes[72]. Of these studies, one study demonstrated a consistent, statistically significant, positive effect[65], and four demonstrated consistent, statistically non-significant effects on secondary outcome measures[58, 64, 71, 72]. Six studies showed ‘mixed effects’[53, 55, 59–61, 72]. Two studies did not provide comparative statistics and were classified as ‘not done’[52, 57].
Intervention effects by profession
When the intervention effects were examined by profession, two disciplines contained the four quantitative studies that consistently demonstrated consistent, statistically significant, positive effects on primary outcome measures: pharmacy (n = 2)[50, 65] and physiotherapy (n = 2)[47, 52]. The studies with consistent, non-significant effects on primary outcome measures were as follows: physiotherapy (n = 3)[48, 64, 72] and speech-language pathology (n = 1)[71]. All of the dietetics studies (n = 3) demonstrated mixed effects[46, 53, 63]. Mixed effects were also reported for the primary outcome measures in the following professions: pharmacy (n = 9)[45, 49, 51, 54–56, 60, 62, 69]; physiotherapy (n = 3)[61, 74, 75]; occupational therapy (n = 2)[66, 75].
Intervention effects of randomized controlled trials
Ten RCTs were included in this review representing the following professions: physiotherapy (n = 6)[47, 48, 61, 70, 72, 74]; dietetics (n = 2)[46, 53]; pharmacy (n = 1)[62]; speech-language pathology (n = 1)[71]. These studies employed a variety of KT interventions: multiple, education-only (n = 5)[47, 48, 61, 62, 74]; single educational meeting (n = 3)[46, 53, 71]; multiple interventions (i.e., education intervention and another non-education intervention) (n = 2)[70, 72]. Five studies demonstrated mixed effects on primary outcomes[46, 53, 61, 62, 74], four studies demonstrated consistent effects on primary outcomes[47, 48, 71, 72], and the effects of the intervention on the primary outcome in the remaining study was unclear[70]. Of the four studies demonstrating consistent effects on the primary outcomes, three studies demonstrated non-significant effects[47, 71, 72] and the remaining study demonstrated statistically significant, positive effects on the primary outcome[48].
Intervention evaluation in qualitative research studies
The three qualitative studies included in this review represented the following professions: speech-language pathology, physiotherapy, and occupational therapy. Molfentner et al.[68] conducted a qualitative study using the knowledge-to-action (KTA) process model framework to address an identified KTA gap in dysphagia rehabilitation practices for speech-language pathologists (n = 4). This study employed a single KT intervention (e.g. educational outreach visits), and after conducting post-intervention interviews with the study participants, it was determined that ‘the intervention not only enhanced their learning, but also allowed them to offer a greater quantity and variety of services to their patients. Clinicians reported that having hands-on training by a research S-LP was more effective than a lecture on the same topic.’ Schreiber et al.[73] conducted a qualitative, participatory action research study to identify, implement, and evaluate the effectiveness of strategies to incorporate research evidence into clinical decision making in physiotherapy (n = 5). Gathering data through semi-structured interviews, this study reported that multiple, education-only interventions (e.g. educational meetings and educational materials) gave rise to themes that included ‘sustained positive attitudes and beliefs about evidence-based practice, variable implementation of the strategies developed during the initial collaboration phase, variable performance for individual goals; persistent barriers, including a lack of time and a lack of incentives for evidnce-based practice activities; and a desire for user-friendly evidence-based clinical practice guidelines.’ Vachon et al.[76] conducted a qualitative study using grounded theory to describe how rehabilitation professionals use reflective learning to incorporate research evidence into clinical decision making and to identify factors that influenced the reflective learning process. This study employed a single KT intervention (e.g. educational meetings) with a population of occupational therapists (n = 8). Data were collected via meeting videotapes, transcripts, written critical incident descriptions, reflective journals, and the facilitator’s notes and summaries. Through this intervention, ‘the participants developed their ability to use different types of reflective thinking, which brought about perspective changes… however, perspective changes were not achieved at the same pace or the same level by all participants. Some personal and contextual factors were found to influence the participants’ ability to learn reflectively’.
These three studies employed both single and multiple education-related KT interventions targeting an allied health professional’s general management of a problem[68] or evidence-based practices[73, 76]. The behaviour changes in all three studies were evaluated using the professional/process outcomes. While there were some encouraging findings, such as sustained positive attitudes and beliefs[68], ability to use different types of reflective thinking[76], and enhanced learning and services[73], all of the studies acknowledged variable practice changes related to the targeted behaviours.
Published intervention reporting
The quality and detail of the reporting of the KT interventions varied widely between the 32 study reports; therefore, the published intervention descriptions were compared to the WIDER Recommendations to Improve Reporting of the Content of Behaviour Change Interventions[39], which were developed in 2009. While a small number of studies met three of the four criteria, none of the 32 studies satisfied all four of the WIDER Recommendations. However, it is important to note that some authors reported more intervention details than others (Table3). Many of the studies described components of the first recommendation, such as descriptions of intervention recipients, the intervention setting, the mode of delivery, and the intensity and duration of the intervention. Nevertheless, most did not provide a full and detailed description, which would include a description of the characteristics of the individuals delivering the intervention, the adherence/fidelity to delivery protocols, or a detailed description of intervention content. A number of studies provided an outline of the intervention objectives. In relation to the second recommendation, four studies described in detail the clarification of assumed change process and design principles[49, 64, 68, 76]. Several studies included a description of a theoretical framework informing their research, the rationale behind and impetus for the intervention, and the behaviour that the intervention was intended to change; however, most did not describe the development of the intervention, the change techniques used in the intervention, or the causal processes targeted by these change techniques. Only five studies fulfilled the third recommendation of providing access to intervention manuals or protocols within the article or in separate publications[49, 58, 62, 64, 67]. Most studies were exempt from the fourth recommendation because the study designs did not include a control group (n = 17)[45, 49, 52, 54–59, 65–68, 71, 73, 75, 76] or active control conditions (n = 12)[46–48, 50, 51, 53, 60–64]. None of the three studies with active controls satisfied this criteria[70, 72, 74]. Table 3 contains an overview of the WIDER Recommendations[39] in relation to each of the included studies.
Methodological quality
We assessed the 29 quantitative studies and three qualitative studies using separate tools(Additional File 7)[41], six quantitative studies received a moderate rating[48, 54, 55, 62, 74, 75], and 23 studies received a weak rating[45–47, 49–53, 56–61, 63–67, 69–72]. None of the 29 quantitative studies received a strong rating. Additionally, of the four studies that demonstrated consistent, significant positive effects on the primary outcomes illustrating that the KT interventions had effectively changed the identified behaviours, it is important to note that all received a weak rating using this methodological quality assessment tool.
Based on the Quality Assessment Tool for Qualitative Studies[43], with higher values denoting higher study quality, one qualitative study was given a rating of five[76] and the other two studies were rated two[73] and one[68], respectively.
Summary of changes from the study protocol
The following items were changed during the research process; therefore, the study protocol[33] should be adjusted to reflect these changes: the inclusion criteria was clarified according to the EPOC Data Collection Checklist[37] (Addition File2); the data extraction process was modified to include a research design algorithm[38] (Additional File3) to be used in place of the study design component of the EPOC Data Collection Checklist; and the methodological quality assessment tool for qualitative studies that was described in the protocol was replaced with the Quality Assessment Tool for Qualitative Studies[43] (Additional File6).