Most KT Theories Are Rarely Used
A Scoping Review Summary
By Leah Crockett
I know discussions around theories, models and frameworks don’t make for the most exciting of reads (at least for me). They’re useful tools, for sure. But so are hammers and wrenches — and there’s a large variety of those too. And the word “wrench” takes up a lot less space in an article than “theory, model or framework.” Actually, that’s not a bad idea.
New rule, for the rest of this article, wherever possible:
Wrench = Theory, model or framework
As I was saying, I often get overwhelmed by the number of wrenches available, and how to actually apply them in my practice.
But as we’ve discussed previously, the use of wrenches has an important place in the field of KT. They can help us to systematically plan our KT efforts, identify potential barriers and facilitators, and improve the likelihood of successful implementation, sustainability and scale-up. Additionally, consistent and reported application of wrenches in KT interventions can help grow the evidence base for other researchers.
A 2018 scoping review led by Lisa Strifler of the Li Ka Shing Knowledge Institute in Toronto — the focus of this article — found that although there are a number of different wrenches cited in the KT literature, they are not consistently used.
Scoping It Out
The authors set out to conduct a scoping review (to learn more about scoping reviews, check out Carly’s post To Scope or Not to Scope) to flag which KT wrenches are being used to guide dissemination or implementation of evidence-based interventions related to cancer and other chronic diseases.
They followed established scoping methodology and used an integrated KT approach. They involved knowledge users at all stages, including developing the protocol, searching the literature, screening, abstracting data, and in synthesizing and disseminating the results. Because wrenches are difficult to search for, the authors used an iterative approach called the BeHEMoTh framework [Note: file download] to guide their search. BeHEMoTh, in case you’re curious, is short for: behaviour of interest; health context; exclusions; models or theories.
The researchers only included studies that reported on the use of any type of wrench to guide the dissemination or implementation of a KT intervention. Specifically, they looked for articles that:
- Were aimed at behaviour change at the individual, organization, community or system level, and
- Targeted prevention or management of cancer or other types of chronic diseases (such as mental illness and dementia) in any relevant health or community setting.
The information they extracted about these studies included:
- Study characteristics,
- KT intervention characteristics,
- The evidence-based clinical intervention, and
- Stages of KT practice, categorized using the Knowledge-to-Action framework.
Use Once and Destroy (or Just Discard)?
There were 596 articles published between 2000–2016 that reported using a KT wrench. Almost 70% of studies were published within the last decade, and three quarters were conducted in North America, reflecting the relatively new and rapid growth of the field of KT. Together, these articles reported 159 different wrenches. The majority of wrenches were used only once (60%).
Most interventions targeted patients and the public (84%), followed by healthcare professionals (33%) and organizations (23%). About a third of interventions targeted more than one group. Top intervention settings were the community (36%), followed by clinics (24%), and more than one setting (21%).
Getting back to the topic of wrenches— the authors did a nice job of organizing all 159 wrenches based on the stage of KT that they were used in, the level of behaviour change, the targeted context, whether they were used prospectively or retrospectively, and how often they were used. The top 3 most used were a theory and two models (okay, those references were unavoidable):
- Social Cognitive Theory (168 papers)
- The Transtheoretical Model of Behaviour Change (141 papers)
- The Health Belief Model (67 papers)
Lessons for the Future
As researchers, we are well aware of the dilemma we face when trying to select and apply the most appropriate wrench(es) in our work. The authors note several key implications of their work and challenges that lie ahead:
1. Testing in the Context of KT & Healthcare
There is broad diversity in the wrenches used in KT. Many are borrowed from other disciplines (e.g. education and psychology). On this note, the authors highlight the critical need to test their application beyond their originating field(s) to the KT and healthcare contexts.
2. Better Reporting
Given limited use of many of the wrenches, there is still little known on whether they can actually predict behaviour change in healthcare. Similarly, given that most are infrequently used, we have little evidence base to actually describe their use in practice. Many studies (101 out of 146) cite a wrench but don’t explain how it guided the study in any detail, suggesting a need for better reporting.
3. Consolidation as an Option
Although we know that there are a significant number of wrenches available, this is complicated by the fact that many are modified or informed by existing wrenches. Therefore, the authors argue for the need to consolidate existing wrenches [Editor’s note: a monkey wrench?]. This might allow for more consistent use of fewer wrenches, allowing us to strengthen our evidence base.
4. A Decision Support Tool
Finally, findings from this study point to the need for a decision support tool to help researchers comb their way through the numerous wrenches available, and select one that suits their needs or informs their KT activities. In the meantime, check out our blog on How to Choose a KT Theory, Model, or Framework for a summary of existing recommendations.
Given the authors’ extensive work in summarizing the use of KT wrenches in a variety of stages of KT interventions, contexts, and levels of behaviour change, the summary table provided in the article may be a good starting point to identify a theoretical underpinning relevant to your own work.
Finally, as they note, some areas for future research in this area could include examining how and why researchers choose specific wrenches to guide their work, and also why some (such as the Knowledge-to-Action framework) tend to be cited more frequently.
In the meantime, please let us know if you have any tips or tricks that help guide you in choosing KT wrenches for your work.
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