Using the Knowledge to Action Framework in practice: a citation analysis and systematic review

Health professionals across the globe share the challenges of translating the best available evidence into actual health interventions in a timely way to provide the most effective care and service. The Knowledge to Action Framework [1] (‘the KTA Framework’) is a conceptual framework intended to help those concerned with knowledge translation deliver sustainable, evidence-based interventions. Knowledge translation has been defined as a process ‘that includes synthesis, dissemination, exchange and ethically sound application of knowledge to improve…health…provide more effective health services and products and strengthen the health care system’ [2].

Conceptual frameworks are recommended as a way of preparing for the multiple, dynamic and interactive factors that influence the uptake of evidence in practice [3]-[5]. Although the terms conceptual frameworks, theories and models are often used interchangeably, conceptual frameworks are broad and descriptive, whereas theories and models are more specific and amenable to hypothesis testing [6]. Conceptual frameworks provide a frame of reference for organising thinking, a guide for action and interpretation. Potential benefits from applying a conceptual framework include making the process of knowledge translation more systematic, with greater likelihood of changed practice and spread of evidence [4],[6]-[9]. Several conceptual frameworks are pertinent for implementation scientists, including Promoting Action on Research Implementation in Health Services (PARIHS) [5],[10] the Consolidated Framework for Implementation Research (CFIR) [3] as well as the KTA Framework [1].

The Knowledge to Action Framework

The KTA Framework [1] was developed in Canada by Graham and colleagues in the 2000s in response to the confusing multiplicity of terms used to describe the process of moving knowledge into action [1]. They reviewed 31 planned action theories about the process of change. Most of the theories were interdisciplinary or from nursing and were published between 1983 and 2006 [11]. The findings informed their conceptual framework, which was intended to ‘address the need for conceptual clarity in the KTA field and to offer a framework to help elucidate what we believe to be the key elements of the KTA process’ [1] (p. 14).

The KTA Framework comprises two distinct but related components: (i) Knowledge Creation (represented by the funnel) surrounded by (ii) the Action Cycle (Figure 1). Each component involves several phases which overlap and can be iterative; Graham and colleagues [1] describe the phases as ‘dynamic…can influence each other’ (p. 20). Action phases may be carried out sequentially or simultaneously; knowledge phases may impact on the action phases. The Action Cycle outlines a process, representing the activities needed for knowledge to be applied in practice; knowledge is adapted to the local context, and barriers and facilitators to its use are explicitly assessed. Involvement of stakeholders, and tailoring knowledge to the needs of people who are going to use it, is crucial.

The National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care for South Yorkshire (CLAHRC SY) used the KTA Framework to underpin a programme of knowledge translation work undertaken between 2008 and 2013 [12]. As part of this programme, the first author (BF) undertook a knowledge translation project that sought to identify examples of the use of the KTA Framework in practice. No existing systematic review was found on this subject. This review is designed to address this knowledge gap.

This review seeks to answer two questions: ‘Is the KTA Framework being used in practice?’ and ‘If so, how is the KTA Framework being used in practice?’ We were interested in the ‘real-life’ application of this conceptual framework to ‘real-world’ implementation challenges. A secondary concern was theory fidelity [13], which relates to how this conceptual framework was being used in practice, specifically whether the KTA Framework was articulated in a way that was true to the source paper [1].

The KTA Framework [1] is being used in practice with varying degrees of completeness and theory fidelity when the conceptual framework is integrated into the implementation project. It is one of the most frequently cited conceptual frameworks for knowledge translation. A citation search of three databases tracking the source paper ‘Lost in knowledge translation: time for a map?’ identified 1,787 records between 2006 and July 2013. Some indication of the impact of this article can be gained from constructing a ‘normalised citation count’ for comparison purposes. The source paper was cited four times more frequently than the next highest cited article from the same journal published in the same year. It was cited 470 unique times across all databases. However, citation figures do not reflect how this conceptual framework has actually been applied in practice. We initially included 146 studies that reported using the KTA Framework. Closer examination revealed that usage varied considerably, ranging from simple attribution via a reference through to being integral to most aspects of the implementation work. Only ten studies reported and gave supportive examples of incorporating the KTA Framework in an integrated way. All these described the Action Cycle and seven referred to Knowledge Creation, articulating the KTA Framework in a way that was true to the source paper [1].

There was substantial variation in the setting and target audience for each documented change, the methods used to apply the KTA Framework and the terminology employed to report the phases within Knowledge Creation and the Action Cycle. This reflects the spread of the framework across a range of settings, to different health care services and systems and larger scale and smaller projects. The KTA Framework was adapted to different health service settings and resources, indicating a good fit for the diversity of real-world health care. However, the target audiences were primarily patients, the public and the nursing and allied health professions.

Most studies (8/10) were conducted in Canada where the KTA Framework originated. This frequency of use in Canada could be explained by the influence of national Canadian networks and dissemination activities. Perhaps more significantly, the KTA Framework is associated with the Canadian Institutes of Health Research [27]. Estabrooks and colleagues [28] comment that the Canadian research funding organisation had adopted the KTA Framework to guide knowledge translation, deploying specific grant mechanisms ‘to ensure involvement of knowledge users with researchers throughout the research process’ (p. 2). This may explain the varying degrees to which the framework was used.

The KTA Framework was enacted in a variety of ways, from informing to full integration, showing flexibility of use and that it can fit local circumstances and need. Use at a ‘lighter’ level through adapting or combining with other conceptual frameworks could be considered a strength, in that the KTA Framework offers the flexibility to be combined with other frameworks, being responsive to facilitating practitioner preferences and context-specific needs. It is important to note that Graham and colleagues have continued to publish on applications of the framework and the multiple factors to be considered [29]. In addition, this suggests conceptual frameworks do not have to be mutually exclusive.

Each study applied the framework in an idiosyncratic way. None reported using every phase of the KTA Framework. Only four studies detailed Knowledge Creation, yet existing knowledge was utilised in the other studies to identify knowledge-practice gaps, or as part of the Action Cycle. This flexibility was intended, as Graham and colleagues [1] state the framework can ‘…also accommodate different phases being accomplished by different stakeholders and groups (working independently of each other) at different points in time’ (p. 18). Implementation researchers and health professionals can learn from this flexibility. It may be useful for them to consider the extent to which they wish to follow or be guided by a conceptual framework before embarking on a knowledge translation project, especially regarding outcome measures because ‘....the focus of knowledge into action is ultimately to enhance health status’ [1 p. 18]. The Action Cycle was reported in all the integrated examples, illustrating theory fidelity in this specific subset of studies. The prevalence of the Action Cycle may simply reflect the cyclical nature of the change process evident in other common, quality improvement tools such as the ‘Plan, Do, Study, Act’ cycle [30]. Also, this conceptual framework may appeal because of a lack of jargon and a simple diagram depicts the knowledge translation process.

The integrated studies described different ways of integrating the KTA Framework, particularly the Action Cycle. Most studies focused on improving knowledge or awareness, supporting what we know about the preponderance of professional or educational knowledge translation strategies within interventions aiming to promote the uptake of evidence [31]. Nine of the studies reported assessing barriers to change [17]-[19],[21]-[26]. Knowledge-related barriers [32] were the most common, indicating the appropriateness of using educational strategies to address such barriers. Yet the albeit limited, evidence available indicates that bringing information close to the point of decision-making (such as using reminders or decision support tools) is likely to be more effective than using more traditional educational strategies (such as study, teaching or training) to try to address barriers and change practice [31],[33]. Only one study [26] reported using decision support tools as a knowledge translation strategy, although it is possible others did not report all the details of strategies they used to promote the adoption of their interventions. Knowledge translation strategies can include elements such as linkage and exchange, audit and feedback, informatics and patient-mediated and organisational interventions [29]. However, none of these knowledge translation strategies, designed to target different barriers, featured in the included studies, with one exception. Russell and colleagues [25] describe use of a knowledge broker, an example of a ‘linkage and exchange’-type strategy.

The importance of organisational or external factors and the ability to influence them is well recognised [1],[3],[33]-[35]. Authors identified many barriers relating to ‘environmental’ factors [32] such as lack of time and/or resources. Generally, it was difficult to ascertain whether the methods used captured, and indeed subsequently addressed, the full range of barriers. It may be that when people are consulted, they identify those barriers that they feel able to influence, such as knowledge or awareness, rather than organisational barriers, which could be perceived as more problematic or more distant. An exception was the study by Russell and colleagues [25] who reported using a questionnaire to assess a range of potential barriers and facilitators. Molfenter and colleagues [23] describe a strategy to assist clinicians with patient selection which could be interpreted as seeking to influence organisational barriers such as ‘competing priorities’, as well as addressing knowledge-related barriers. Légaré [32] recommends using established taxonomies developed for barriers and facilitators within knowledge translation projects. Our findings support this proposal. We further identified a need to use taxonomies when analysing or evaluating knowledge translation strategies [33],[34]. This study also reinforces the importance of reporting standards [8],[36], such as the new TIDieR checklist [37] to facilitate more explicit reporting of implementation studies and their subsequent inclusion in systematic reviews.

The monitoring, outcomes or sustaining phases of the Action Cycle were less often described, although three noted their plans for doing so [18],[24],[26]. This may reflect a publication bias, between reporting process and outcomes. Claude and colleagues [17] stated that these phases were beyond the scope of their project. Such work may require additional funding for longer term monitoring or strategies to sustain knowledge use over time. It may also be a reflection of the challenges for defining and reporting outcomes for knowledge translation projects. Tugwell and colleagues [26] highlight this particular challenge, commenting that most outcomes in arthritis research are about pain and function. In contrast, they wanted to evaluate the impact of their intervention on people’s ability to understand their choices and make informed decisions about treatment. Consequently, we recommend that the phase ‘select, tailor, implement intervention’ be amended to include ‘define and select outcomes and knowledge use measures’, as a prompt to those using the KTA Framework to specify such outcomes when selecting which knowledge translation strategies to use.

A notable feature of the KTA Framework is the development of knowledge tools or products as part of Knowledge Creation. Most studies created a range of products, either as part of Knowledge Creation [18],[20],[21],[26] or the Action Cycle [21],[23],[24]. Interestingly, a recent evaluation of the Canadian Institutes of Health Research (CIHR) Knowledge Translation Funding Program [38] presented results relating to knowledge translation products, academic outputs and capacity building together, giving the appearance, in our interpretation, that these different dimensions may be regarded as equally important.

Interest in using systematic literature reviews to investigate theories, models and conceptual frameworks has increased in recent years [7],[39]. Yet, this method may prove challenging, often because of limited and imprecise reporting. Davies and colleagues [40] note that less than 6% of 235 studies, albeit published before 1998, explicitly used theories of behaviour or behaviour change. They and we resorted to a simple taxonomy to describe the level and type of usage based on explicit reporting. A coding scheme, with 19 categories for theory use for behaviour change interventions, ranging from mentioned but not demonstrated, right through to theory refinement, has been developed [41]. This scheme may be useful for similar studies examining theory use. However, our review focused primarily on examining how a conceptual framework had been used in practice. Using the framework itself as a device through which to examine how it had been used seemed an appropriate and pragmatic approach for our purposes.

Bartholomew and Mullen [42] suggest that the ‘prevailing wisdom in the field of health-related behaviour change is that well-designed and effective interventions are guided by theory’ (p. S20). Others argue that the effectiveness and generalisability of implementation studies are hindered by weak theoretical underpinnings [40],[43],[44]. Our review, and similar studies [39],[40],[43]-[45], consistently comments on the limited, haphazard use of theory, even though theories can be applied in many different ways [41]. Primary studies, exploring the direct experience and perceptions of different stakeholders in implementation projects, which have been guided by conceptual frameworks, or theories, would add to our understanding of the utility and impact of these tools. A few authors have attempted this, such as McEvoy and colleagues [43] who examined benefits reported by authors using the Normalization Process Theory. A prospective design would strengthen research studies.

Future research could examine the studies which we categorised as using the KTA Framework to a lesser degree, perhaps for conceptual or persuasive reasons rather than instrumentally. It would be interesting to review the conceptual papers we excluded to explore how they were influenced by the framework and informed the development of conceptual frameworks more generally. Exploring the impact of the KTA Framework, and other conceptual frameworks, on patients and the public in terms of health improvement and outcomes would also be worthwhile, as would exploring their involvement in the application of the framework, not just as recipients of services but as key stakeholders in each phase.

This citation analysis and systematic review investigated the practical application of a well-established conceptual framework—the KTA Framework [1]. We found that the framework is being used in practice, to varying degrees of completeness, and with theory fidelity when reported as integral to the implementation effort.

Citation searching for the original reference by Graham and colleagues [1] optimised the sensitivity and specificity of the search strategy. It was cited 470 unique times across the three databases, indicating the bibliometric impact of the source paper. However, we were interested in the real-world application of the KTA Framework as a guide to implementation activities in health care and whether it was used in a way that was true to the framework. The authors’ attribution of use was variable, with most merely referencing the framework or describing how it was used to inform or structure projects. Only 10 of 146 papers reported direct use, with examples demonstrating that the framework was integral to their study. In these studies, the KTA Framework appeared to provide a practical yet flexible guide to getting research findings into practice, allowing it to be applied in idiosyncratic ways. This illustrates the adaptability of the conceptual framework to different health care settings and topics. The KTA could also be used as a literacy device to structure reporting of the framework.

Conventional views support the use of theories, models and conceptual frameworks to underpin the process of change, yet in practice, their application seems more limited [40],[43]-[45]. This may be an artefact of reporting: few studies justify or explain their theoretical stance; even fewer do so using the appropriate constructs or with theory fidelity. This presents an interpretation challenge both for those seeking to learn from such projects and systematic reviewers. Understanding if and how these theoretical tools add value to implementation endeavours and outcomes merits further research.

BF is a researcher at the School of Health and Related Research (ScHARR), University of Sheffield, and also an occupational therapist. AB is Reader in Evidence Based Information Practice at the School of Health and Related Research (ScHARR), University of Sheffield, where he leads on systematic review and evidence synthesis activities. II is an occupational therapist. Between 2009 and 2013, she was a Knowledge Translation Project Lead with the NIHR CLAHRC SY. II provided BF with clinical supervision for her MSc dissertation. KG is a professor of nursing research at the University of Sheffield and Sheffield Teaching Hospitals NHS Foundation Trust where she leads the Translating Knowledge into Action theme of NIHR CLAHRC for Yorkshire and Humber. From 2008 to 2013, she led the Translating Knowledge into Action theme of NIHR CLAHRC SY.