Preventive Medicine 49 (2009) 313–315
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Preventive Medicine
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Bridging the gap: Translating research into policy and practice
Ross C. Brownson a,b,⁎, Ellen Jones c
a Prevention Research Center in St. Louis, George Warren Brown School of Social, Washington University in St. Louis, 660 S. Euclid, Campus Box 8109, St. Louis, MO 63110, USAb Alvin J. Siteman Cancer Center, Work, Department of Surgery Washington, University School of Medicine, Washington University in St. Louis, 660 S. Euclid, Campus Box 8109,St. Louis, MO 63110, USAc National Association of Chronic Disease Directors, Atlanta, GA and School of Health Related Professions, University of Mississippi Medical Center, Jackson, MS, USA
⁎ Corresponding author. Fax: +1 314 362 9665.E-mail address: [email protected] (R.C. Browns
0091-7435/$ – see front matter © 2009 Elsevier Inc. Aldoi:10.1016/j.ypmed.2009.06.008
a b s t r a c t
a r t i c l e i n f oAvailable online 22 June 2009
Keywords:DisseminationEvidencePhysical activityPolicyPublic health
Effective physical activity interventions do not achieve their full potential if they are not applied beyond theiroriginal testing in research studies. Potentially effective interventions can be adopted in community settingsthrough the efforts of numerous agencies, organizations, and individuals. This paper highlights the importantroles of public health practitioners and policy makers, who differ in their decision-making processes. To enhancethe uptake of evidence-based interventions, several steps are needed to: build the science by moving upstream,increase the understanding of practice-based evidence, move beyond the “what” to the “how,” re-frame thedissemination challenges, place greater emphasis on workforce development, and make research more accessible
for policy audiences. The most effective strategies to bridge the gap between research and practice, will have aton).
l rights reserved.
their heart, effective academic-practice-policy maker partnerships.© 2009 Elsevier Inc. All rights reserved.
It is often necessary to make a decision on the basis of informationsufficient for action but insufficient to satisfy the intellect. —
Immanuel Kant
Effective physical activity interventions do not achieve their fullpotential if they are not applied beyond their original testing inresearch trials. For example, even partial implementation of the publichealth recommendation for moderate physical activity would likelyresult in thousands of preventable deaths each year in the UnitedStates (Powell and Blair, 1994). Evidence-based interventions promot-ing physical activity are cost-effective and represent a good value(Roux et al., 2008). Therefore, more efforts are needed to system-atically disseminate effective approaches in “real world” conditions(both practice and policy settings). In a recent national survey of statechronic disease practitioners, an estimated 58% of chronic diseaseprograms were described as evidence-based (Dreisinger et al., 2008).This compares closely with a recent study of clinical preventiveservices in which 55% of patients received the medical care that isrecommended in the literature (McGlynn et al., 2003).
Two converging bodies of scientific knowledge hold promise forbridging the gap between discovery of new research findings andapplication in public health settings. First, the concept of evidence-based public health is growing in prominence due in part to a largerbody of intervention research on what works to improve populationhealth (e.g., the Community Guide recommendations on promoting
physical activity) (Brownson et al., 2009). Evidence-based decision-making in public health follows the following principles: 1) makingdecisions using the best available peer-reviewed evidence (bothquantitative and qualitative research), 2) using data and informationsystems systematically, 3) applying program-planning frameworks(that often have a foundation in behavioral science theory), 4)engaging the community in assessment and decision-making, 5)conducting sound evaluation, and 6) disseminating what is learned tokey stakeholders and decisionmakers (Brownson et al., 2009). Second,effective methods of dissemination and implementation (D&I) areneeded to put evidence to work in “real world” settings. While in itsinfancy, there is increased attention and growing literature on D&Iresearch. This type of research elucidates the processes and factors thatlead to widespread use of an evidence-based intervention by aparticular population or within a certain setting (e.g., worksite,school). This D&I research has identified a number of importantfactors to enhance the uptake of evidence-based interventions in bothpractice (e.g., a state health department) and policy (e.g., a statelegislature) settings. For example, if an intervention is too complex andresource intensive, it may be difficult for a small agency to implement.
It is noteworthy that the decision to adopt, accept, and utilize aneffective intervention is not an instantaneous act, but more often aprocess that occurs in stages (Rogers, 2003). In practice settings,effective dissemination of an evidence-based program often calls fortime-efficient approaches, ongoing training, and a high organizationalvalue on research-informed practice (Dobbins et al., 2001). Inaddition, practitioners often seek: a strong connection to communityneeds, realistic and economically-feasible intervention options, andleadership capacity to translate research to policy.
Table 1Differences in decision-making among public health practitioners and policy makers.
Characteristic Executive branch, public health administrator Legislative branch, elected official Legislative branch, staff member
Time in position Longer Shorter ShorterAccountability Governor, board of health, agency head Constituents by whom they are elected,
political partyElected legislator, committee chair
Personal connection to constituents Moderate High High to moderateKnowledge span Deeper knowledge on health issues Less depth, wider breadth Less depth, wider breadthDecision making based on externalfactorsa (aside from research)
Low to moderate High High
Time spent on a particular issue Longer Shortest ShorterType of evidence relied upon Science, empirical studies, experience from
the field, personal experienceScience, media, “real world” stories,constituents, lobbyists, party priorities
Science, the media, “real world” stories,constituents, lobbyists, party priorities
a External factors commonly include habit, stereotypes, and cultural norms.
314 R.C. Brownson, E. Jones / Preventive Medicine 49 (2009) 313–315
The potential by setting
There are several important settings for D&I of physical activityinterventions. Potentially effective interventions can be adopted incommunity settings through the efforts of numerous agencies,organizations, and individuals. Here, we highlight the importantroles of public health practitioners and policy makers, whom differ intheir decision-making processes (Table 1). Many of these differencescan be considered contextual factors (Rabin et al., 2006), that shouldbe kept in mind when attempting to translate science to practiceor policy.
Public health agencies (the executive branch of government)
State and territorial health departments are important convenersfor promoting physical activity interventions. Their role is crucialbecause of their ability to assess public health problems, developappropriate programs or policies, and assure that the programs andpolicies are effectively delivered and implemented. There is limitedinformation on D&I of physical activity interventions among healthdepartments. Recently, data on use of evidence-based physical activityrecommendations were collected from state and local health depart-ments (two years after publication of the Community Guide). At thestate level, several key factors were associated with the adoption ofevidence-based interventions, including the presence of state fundingfor physical activity, whether the respondent participated in moderatephysical activity, presence of adequate staffing, and presence of asupportive state legislature (Brownson et al., 2007b). In these data,only 30% of local health respondents were aware of the CommunityGuide and even fewer (11%) believed the leadership of their agencywas aware of the Community Guide (Brownson et al., 2007a). Themost important factors related to decision-making at the local levelwere the availability of adequate resources and the presence ofestablished community coalitions.
Policy-making bodies (the legislative branch of government)
We focus on the state-level policy given the constitutional doctrineof reserved powers, where the fifty states retain enormous authorityto protect the public's health. The states shoulder their broad publichealth responsibilities through work carried out by state and localagencies (e.g., state health departments). At the state level, a statelegislature can promote policies that are supported by scientificevidence. For example the Community Guide has identified severaltypes of policy interventions that are effective in promoting physicalactivity (e.g., enhanced access to places for physical activity, urbanplanning and policy) (Heath et al., 2006). State level policy is reflectedin funding priorities where chronic disease programs often receivedisproportionately low funding in relation to health and economicburden of diseases such as heart disease, cancer, stroke, and diabetes(Brownson and Bright, 2004).
The path ahead
Drawing on experience in clinical and community practice, severallessons about D&I of evidence-based interventions to promotephysical activity should be considered.
Build the science by moving upstream
Too much of our research in physical activity has focused ondownstream, individual-level interventions. Upstream approaches(e.g., macro-level policy change) hold great potential (McKinlay,1998) yet are often not well evaluated and are under-utilized.
Increase understanding of practice-based evidence
More evidence needs to come from settings and organizations thatreflect public health practice and policy. For example, efforts such asthe Steps to a HealthierUS Initiative, YMCA Activate America, andfaith-based interventions demonstrate that using existing leadershipdevelopment approaches can enhance the use of evidence forpromoting physical activity (Cyzman et al., 2009; WK KelloggFoundation, 2002).
Move beyond the “what” to the “how.”
The “how” in D&I research often relates to context for theintervention—i.e., What factors need to be taken into account whenan internally-valid program or policy is implemented in a differentsetting or with a different population? If the adaptation processchanges the original intervention to such an extent that the originalefficacy data may no longer apply, then the programmay be viewed asa new intervention under very different contextual conditions.Feasibility research can help to inform the adaptation and expansionof research to practice (Bowen et al., 2009).
Re-frame the D&I challenges
Research on D&I has now taught us several important lessons:1) D&I does not occur spontaneously, 2) passive approaches to D&Iare largely ineffective, and 3) single-source prevention messagesare generally less effective than comprehensive approaches. Giventhe lack of a marketing and distribution system for D&I evidence-based public health programs, we need to build system infra-structure and responsibility for D&I in public health (Kreuter andBernhardt, in press).
Place greater emphasis on workforce development
The majority of the public health workforce has no formaltraining in a public health discipline (e.g., epidemiology, healtheducation). Therefore, without a greater commitment to workforce
315R.C. Brownson, E. Jones / Preventive Medicine 49 (2009) 313–315
training and leadership development, it is unlikely that goals fortranslation of research to practice can be attained. A model programin this area is the course for practitioners: Physical Activity andPublic Health (Franks et al., 2005). In addition, policy-relatedskills are not prominent in competency frameworks for workforcedevelopment.
Make research more accessible for policy audiences
Evidence becomesmore relevant to policymakers when it involvesa local example and when the effects are framed in terms of its directimpact on one's local community, family, or constituents (Jones et al.,2006). In the policy arena, decision makers indicate that relevance tocurrent debates is a critical factor in determining which research willbe used and which proposals will be considered. Research oncontextual issues and the importance of narrative communication isbeginning to present data in the form of story that helps to personalizean issue.
Conclusion
To ensure that scientific discoveries on reducing the burden ofphysical inactivity are realized, key actions are needed. For example,these are several immediate steps that researchers can take:
• Design research trials for dissemination by involving end users ofpotentially effective interventions early on, to propose and testapproaches that can be “scaled up” at the appropriate time(Caburnay et al., 2001);
• Seek out partnerships with practice agencies (e.g., state and localhealth departments) with the goal of adding evaluation andmeasurement expertise to existing programs. This can be espe-cially useful for a variety of state-level programs supported by theCenters for Disease Control and Prevention or tobacco settlementfunds;
• Put more emphasis on D&I research at the federal level. Forexample, new funding announcements support translationalresearch from the National Cancer Institute, the National Instituteof Mental Health, and the Centers for Disease Control andPrevention (Colditz et al., 2008);
• Identify and advocate for faculty incentives that support D&Iresearch (e.g., promotion standards calling for D&I research) andthe creative packaging of research findings for various audiences(e.g., turning promising research findings into policy briefs); and
• Develop and implement training programs to reach the vast array ofpractitioners whom have no formal training in public health, withspecial emphasis on tested, effective training models (Dreisingeret al., 2008; Franks et al., 2005).
In taking these steps, researchers will better recognize the practicalapplication of their scientific findings. The most effective strategies tobridge the gap between research and practice, will have at their heart,effective academic-practice-policy maker partnerships. Withoutgreater attention to the issues briefly described in this article, addingto the evidence-based alone will do little to address the current jointepidemics of physical inactivity and obesity.
Conflict of interest statementThe authors declare that there are no conflicts of interest.
Acknowledgments
This work was supported by the Centers for Disease Control andPrevention contract U48/DP000060 (Prevention Research CentersProgram).
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