The Knowledge-to-Action Framework

By Leah Crockett

As we’ve discussed in a previous post, there are many theories, models and frameworks used in the field of knowledge translation (KT). Today we’ll highlight one of the most highly cited conceptual frameworks in Canada — the Knowledge-to-Action (KTA) Framework. The KTA Framework is a framework for guiding the process of KT, adopted by the Canadian Institutes of Health Research (CIHR) and other organizations worldwide. Developed by Ian Graham and colleagues [1], the KTA Framework is based on the commonalities of over 30 planned-action theories (which make up the action cycle) with the addition of a knowledge creation component. Notably, the KTA Framework assumes a systems perspective and situates knowledge producers and users within a system of knowledge that is responsive, adaptive, and unpredictable. As such, the process of moving evidence to action is iterative, dynamic, and complex.

The Knowledge-to-Action Framework

The KTA Framework is composed of two distinct, but related components: (i) Knowledge Creation, and (ii) the Action Cycle. As the process of KT is iterative, not only can (i) inform (ii), but components of the action cycle also feed back to inform knowledge creation [2, 3].

Source: Graham et al. (2006) — https://www.ncbi.nlm.nih.gov/pubmed/16557505

Knowledge Creation

The first component of the model is the knowledge creation ‘funnel’, which represents the production and synthesis of knowledge. As knowledge moves through the funnel, it is refined and summarized to be more useful for end-users. This inner component of the model is broken down into 3 phases: (1) knowledge inquiry, (2) knowledge synthesis, and (3) the creation of knowledge tools and products.

Adapted from Graham et al. 2006

Knowledge Inquiry

Referred to as first generation knowledge and vastly out of scale (considering that the body of new, original knowledge in healthcare is enormous — part of the reason we need KT), knowledge inquiry refers to primary studies and represents the majority of research that is conducted. Single studies at this stage are not ready to be translated into practice on a broad scale, but are necessary to inform future research and feed into the larger evidence base.

Knowledge Synthesis

As Kate has described previously, knowledge synthesis (second generation knowledge) involves synthesizing results from individual research studies and interpreting them within the context of global evidence. Knowledge synthesis is essential when considering an initiative’s potential for widespread implementation and collates existing knowledge using rigorous methodologies. Knowledge syntheses take the form of studies that fall into the categories of systematic reviews, scoping reviews, and meta-analyses, just to name a few.

Knowledge Tools and Products

Finally, knowledge tools and products, considered third generation knowledge, are the most refined form of knowledge, based on earlier stages of the funnel. The production of knowledge tools and products uses synthesized knowledge to present evidence in concise and user-friendly formats tailored to meet end-user informational needs. These include things like clinical practice guidelines, decision aids and videos. For an example of how these might be developed, check out our earlier post.

Throughout each of these stages, researchers can take an integrated approach, tailoring their activities (be they developing research questions, messages or dissemination strategies) to that of the end-users. Furthermore, knowledge can inform each phase of the action cycle and the knowledge funnel can ‘rotate’ to feed into different phases.

The Action Cycle

The action cycle includes a range of activities needed for knowledge implementation. The action cycle is iterative and includes the deliberate application of knowledge to cause change in behaviours and/or attitudes. Note that action steps may not be sequential, and one can start at any phase of the cycle. One can also move between the knowledge creation phase and the action cycle, in an iterative fashion.

Adapted from Graham et al. 2006

Identify Problem — Determine the Know/Do Gap — Identify, Review, Select Knowledge

This is typically the recommended starting point for implementation and involves identifying a problem that needs attention. It also involves comparing what is known about a problem and what current practice is — and whether there is a gap that needs to be addressed. Measuring this practice gap can include the use of administrative data, questionnaires, or conducting chart audits, to name a few.

Adapt Knowledge to Local Context

Adapting to local context is a critical step in the process. Knowing your audience and assessing the value, usefulness and appropriateness of the particular knowledge is critical to its uptake and sustained use. For example, in the context of clinical practice guidelines (CPGs), adapting existing national guidelines (which may lack applicability and how organizations need to change to adopt guidelines) to fit local circumstances serves not only to increase the relevance and applicability of guidelines, but also gives end-users a sense of ownership to help promote implementation. However, adaptation of guidelines also runs the risk of deviating from the original evidence base — to address this, a systematic approach to guideline adoption has been developed by a Canadian collaboration called ADAPTE [4].

Assess Barriers/Facilitators to Knowledge Use

There are a number of factors that can hinder or enhance the uptake of knowledge, including issues relating to the knowledge itself, factors relating to those who will be using the knowledge, and the context where the knowledge is to be used. Understanding the barriers to knowledge uptake and implementation strategies, as well as facilitators of change, are critical to effective knowledge translation activities. Assessment of barriers can be done quantitatively and qualitatively using a variety of conceptual models and instruments. In the context of healthcare, the Theoretical Domains Framework (which we break down in another post) is one example of a comprehensive, validated, and integrative model for assessing barriers to change that can be used to inform the development of strategies for changing attitudes and behaviours [5, 6]. For an overview of other determinant frameworks that are useful in this phase, see the determinant frameworks section of Nilsen’s paper [7].

Select, Tailor, Implement Interventions

Once an understanding of the potential barriers and facilitators to adoption has been achieved, the next phase involves planning and carrying out interventions to bring about the intended change. Interventions can be of multiple sorts: educational (passive or active strategies), professional (reminders, audit and feedback), organizational (redesign services), and patient directed (health literacy, patient decision aids) [3]. Selecting an intervention has been described as both an art and a science, and ideally should be based on evidence of its effectiveness [2]. However, because KT interventions are usually tailored to local contexts, and mapped to specific barriers/facilitators, effectiveness in one context does not guarantee success in another. Important considerations for choosing a KT strategy (or strategies) include a clearly defined goal or objective for each strategy, an understanding of how the strategy overcomes one or more barriers to behaviour or attitude change, and the use of theory to inform selection and implementation.

For example, if a strategy has the goal of improving social networking, and the barrier is weak ties between end-users, the social support theory [8] may be used to design an intervention that involves the use of ‘change agents’ to transfer information [2]. CIHR also provides a practical guide to designing a KT intervention for health researchers, with relevant examples of its application. Regardless of the approach, it’s critical to ensure that interventions are tailored to address the specific issue, audience and context to enhance uptake.

Monitor Knowledge Use

Once a KT strategy has been delivered, the use of knowledge should be monitored —which may be instrumental (behaviour), conceptual (attitude/perception), or as a persuasive tool for pushing change(knowledge as ammunition). Monitoring the use of knowledge is critical in understanding how and to what extent the KT strategy has had an impact on outcomes (the next phase in the action cycle). This can be achieved through observation (e.g. administrative databases) and/or active measurement (e.g. questionnaires). Change may occur at more than one level, and for more than one intended end-user, and may require multiple methods of monitoring knowledge use.

Evaluate Outcomes

Evaluating outcomes is an area of KT that requires more attention and involves evaluating whether application of the knowledge is actually impacting the desired outcome — be it patient or practitioner behaviour, health outcomes, or system-level changes. The impact of a strategy should be assessed using explicit, rigorous qualitative and quantitative methods, beginning with formulation of a defined question of interest. Nilsen’s paper provides an overview of evaluation frameworks to guide evaluation of implementation strategies [7].

Sustain Knowledge Use

Unfortunately, an implemented change is not usually self-sustaining and requires ongoing monitoring and effort. Over time, barriers to knowledge use may change from those initially identified, so sustaining knowledge use includes an ongoing feedback loop that cycles back through the action phases. Addressing sustainability also involves planning for both the spread and scaling up of knowledge use, and concerns whether an innovation continues to be used beyond the initial implementation. Key factors present in sustaining knowledge use can include perceived benefits and risks, relevance, leadership, policy integration, resources and politics.

The Importance of Theory-Informed Practice in KT

Why use theory to guide the process of moving evidence into action? The KTA Framework is one of many frameworks, models, and theories that provides KT researchers with a practical yet systematic method of implementation. The benefits of theory-informed KT practice are not limited to providing a deliberate ‘map’ for interventions, but also allow for increased validity and rigor — and more seamless integration of KT-related evidence into the ever-growing body of implementation literature. A strategy informed by theory is also much more likely to be effective in changing behaviours and attitudes. Too many KT strategies use the traditional ISLAGIATT (It Seemed Like A Good Idea At The Time)* approach, and result in uninformed interventions that are often too broad and too ambitious. For example, Eccles et al. looked at 10 behaviour change interventions where explicit use of theory was absent, and mapped these strategies to domains of the Theoretical Domains Framework. Their findings suggested that the more domains that were targeted, the less effective the intervention was [9]. So in terms of doing theory-informed KT, as the saying goes “if you don’t have time to do it right, when will you have time to do it over?”

*ISLAGIATT: Attributed to Dr. Martin P. Eccles

How have you used the KTA Framework in your own work? Share your thoughts in the comments section below, or by tweeting at us at @KnowledgeNudge.

References

1. Graham ID, et al. Lost in knowledge Translation: time for a map? J Contin Educ Health Prof, 2006;26(1):13–24.
2. Straus SE, Tetroe J & Graham ID. Knowledge Translation in Health Care: Moving from Evidence to Practice. 2010, BMJ Books, Wiley-Blackwell.
3. Hartling L. Overview of the Knowledge to Action Cycle. AB Summer Institute, May 3, 2016.
4. Fervers B, et al. Guideline adaptation: an approach to enhance efficiency in guideline development and improve utilisation. BMJ Qual Saf, 2011;20(3):228–36.
5. Cane J, O’Conner D & Mitchie S. Validation of the theoretical domains framework for use in behaviour change and implementation research. Implement Sci, 2012;7:37.
6. Mosavianpour M, et al. Theoretical domains framework to assess barriers to change for planning health care quality interventions: a systematic literature review. J Multidiscip Healthc, 2016;9:303–10.
7. Nilsen P. Making sense of implementation theories, models and frameworks. Implement Sci, 2015;10:53.
8. Hogan BE, Linden W & Najarian B. Social support interventions. Do they work? Psychol Rev, 2002;2:381–440.
9. Little EA, Presseau J & Eccles MP. Understanding effects in reviews of implementation interventions using the Theoretical Domains Framework. Implement Sci, 2015;10:90.

About the Author

Leah Crockett is a doctoral student in the Department of Community Health Sciences at the University of Manitoba.