1. Public Health and Policy Dissemination Research Research Translation: Lessons from Dissemination and Implementation Research for Interventions Promoting Walking and Walkability August 18, 2016 Ross C. Brownson Washington University in St. Louis

2. Objectives Today, I will provide: – An overview of selected concepts; – Guidance on designs and frameworks; – Critical issues for developing research proposals; and – Funding opportunities and resources to broaden your knowledge.

3. http://greas.ca/publication/pdf/melaniebarwickenglish.pdf The Gap: Scurvy

4. Dickersin, 1987 Koren, 1989 Balas, 1995 Poynard, 1985 Balas & Boren, 2000 variable 0.3 year 6 - 13 years 0.6 year 0.5 year 9.3 years Kumar, 1992 Poyer, 1982 Antman, 1992 “PUBLICATION PATHWAY” Negative results Submission AcceptanceImplementation Reviews, guidelines, textbook Publication Original Research Inconsistent indexing Lack of numbers Bibliographic databases Expert opinion 50% 46% 18% 35% It takes 17 years to turn 14 percent of original research to the benefit of patient care

5. An Evidence-Based PA Intervention Is only so good as how and whether… It is adopted? Practitioners are trained to deliver it? Trained practitioners choose to deliver it? Eligible populations receive it? If we assume 50% threshold for each step… (even w/perfect access/adherence/dosage/maintenance) Impact:.5*.5*.5*.5 = 6% benefit Glasgow RE, Vogt TM, Boles SM. Evaluating the public health impact of health promotion interventions: the RE-AIM framework. Am J Public Health. Sep 1999;89(9):1322

6. Too often, we have assumed… “If you build it…”

7. Definitions Dissemination research is the scientific study of targeted distribution of information and intervention materials to a specific public health or clinical practice audience. The intent is to understand how best to spread and sustain knowledge and the associated evidence-based interventions. Implementation research is the scientific study of the use of strategies to adopt and integrate evidence-based health interventions into clinical and community settings in order to improve patient/population outcomes. From: NIH PAR 16-238: Dissemination and Implementation Research in Health (R01)

8. Key Characteristics of D&I Science Glasgow RE, Chambers D. Developing robust, sustainable, implementation systems using rigorous, rapid and relevant science. Clin Transl Sci. Feb 2012;5(1):48

9. Sample D&I Research Objectives Understand factors influencing the creation, packaging, transmission and reception of valid knowledge on PA promotion Generate new insights and generalizable knowledge regarding implementation processes, barriers, facilitators, and strategies to promote PA Enhance the ability to “scale-up” effective or promising EBPs to promote PA

10. Policy dissemination research

11. The big picture impact: Top 10 public health achievements Examples – Vaccination – Motor-vehicle safety – Safer workplaces – Fluoridation of drinking water – Recognition of tobacco use as a health hazard Each of these advances involved policy Centers for Disease Control and Prevention. Ten great public health achievements-- United States, 1900-1999. MMWR 1999 Apr 2;48(12):241-3

12. How well do research and PA policy connect?

13. Where am I? You’re 30 yards above the ground in a balloon You must be a researcher Yes. How did you know? Because what you told me is absolutely correct but completely useless You must be a policy maker Yes, how did you know? The problem

14. A Few Challenges For the policy maker: 1. Poor timing 2. Lack of relevant data For the researcher: 1. Mismatch of randomized thinking with nonrandom problems 2. Lack of control over the independent variable Brownson et. al. Researchers and policy makers: travelers in parallel universes. Am J Prev Med 2006

15. What is funded…

16. What is distinctive in research design in D&I science? These differences require: 1.Distinct outcomes (implementation vs. effectiveness) 2.Distinctive focus on processes and mechanisms (vs. impacts) 3.Distinctive focus on context (vs. intervention) 4.Pragmatic orientation

17. Hybrid designs, increasingly common Type 1 – Testing intervention effectiveness while gathering limited information on implementation Type 2 – Simultaneous testing of effectiveness and implementation Type 3 – Testing D&I strategy while gathering limited information on effectiveness Curran GM, et al. Effectiveness-implementation hybrid designs: combining elements of clinical effectiveness and implementation research to enhance public health impact. Med Care. Mar 2012;50(3):217

18. Natural experiments Improved causal inference, sometimes – But always subject to selection bias Real world policy/intervention (high relevance) – Diffusion of Complete Streets – Changes in local-level tobacco control policies Sometimes, natural experiments may not exist… – Might be “unnatural” experiments – “Dosage” may change – Or timing may be off

19. Why use D&I Models? Link aims, research designs, measures and analytic strategies Narrow the scope of your research Provide an opportunity to advance theories in the field Source of innovation (e.g., use of models from outside of health)

20. Tabak et al. review Identified 109 models Exclusions – 26 focus on practitioners – 12 not applicable to local level dissemination – 8 end of grant knowledge translation – 2 duplicates Included 61 models Categories: Construct Flexibility, Socio- ecological Framework, D vs. I Tabak RG, Khoong EC, Chambers DA, Brownson RC. Bridging research and practice: models for dissemination and implementation research. Am J Prev Med. Sep 2012;43(3):337

21. Key issues in developing your D&I proposal Are you asking a set of D&I questions? Do D&I grant application aims differ? Keep the “key ingredients” in mind – Is the evidence-based practice well-defined? – Do you use a D&I framework/model? – Do you document your team’s D&I experience? – Are you measuring more than effectiveness endpoints? Also see: Proctor et al. Writing implementation research grant proposals: ten key ingredients. Implementation Science 2012;7:96.

22. Developing core competencies via card sorting Sent out link to 300 identified participants WUNDIR, IRI, TIDIHR listserv & other colleagues Separate link sent out to KT Canada listserv 124 total participants- 40% response rate 43 distinct competencies Country BreakdownExpertise Levels – 86% USA29% Beginners – 7% Canada47% intermediate – 5% Australia24% Advanced – 1% Other – 1% United Kingdom

23. Sample of Results

24. More information on competencies (overall + grant specific) Padek M, Colditz G, Dobbins M, et al. Developing educational competencies for dissemination and implementation research training programs: an exploratory analysis using card sorts. Implement Sci.10:114. Brownson RC, Colditz GA, Dobbins M, et al. Concocting that Magic Elixir: Successful Grant Application Writing in Dissemination and Implementation Research. Clinical and Translational Science. 2015;8(6):710-6

25. The Essence of Specific Aims This is where reviewers decide whether they like your application (or not) Set up the general problem and your specific take on it Sell the Sizzle – What is your unique contribution to new knowledge on an important problem? 2-4 realistic aims – That grandma would understand – That lay out what the project is about – That relate & follow a logical order but still can be accomplished independently – 1-2 lines (Not a paragraph! Not how you will accomplish them, but what you will accomplish) Sell the Steak – How you will accomplish your aims, in broad brush strokes Bring it home – Implications – How the world will be a better place after your project is accomplished

26. What gets you funded?

27. Conferences

28. Websites & Webinars NCI Implementation Science http://cancercontrol.cancer.gov/IS/ UNC Implementation Science Exchange http://impsci.tracs.unc.edu/ Advanced Topics in Implementation Science Series https://cyberseminar.cancercontrolplanet.org/impleme ntationscience

29. http://dissemination- implementation.org/

30. Training Programs NIH Training Institute for D&I Research in Health

31. Training Programs Mentored Training for Dissemination and Implementation Research in Cancer (MT- DIRC) http://mtdirc.org/ Washington University in St. Louis Implementation Research Institute in Mental Health (IRI) http://iristl.org Washington University in St. Louis

32. Textbooks

33. NIH Funding Opportunities Dissemination and Implementation Research in Health – R01 PAR-16-238 R01 PAR-16-238 – R21 PAR-16-236 R21 PAR-16-236 – R03 PAR-16-237 R03 PAR-16-237 Standing study section

35. It won’t always seem fair….

36. With the right preparation, opportunity, and hard work…

37. THANKS to David Chambers, Bridget Gaglio, Christine Hunter, Matt Kreuter, Gila Neta, Maggie Padek, Borsika, Rabin, Kurt Stange!!