1. If We Want More Evidence-based Practice, We Need More Practice-Based Evidence UCSF Translation-2 Course, April 15, 2008 Lawrence W. Green University of California at San Francisco The Shifting Context for Theory and Evaluation in Translational Research

2. NIH Roadmap Initiative --translating discoveries into health* *Zerhouni E. Science 2003, Oct 3;302(5642):63-72. The roadmap less traveled?** “The Roadmap identifies the most compelling opportunities in three arenas: new pathways to discovery, research teams of the future, and reengineering the clinical research enterprise” (Zerhouni, p. 63).* **Green LW. Am J Prev Med., 2007; 33(2):137-38, after K. Grumbach.

3. The Transdisciplinary Blending of Theoretical Traditions

4. Quality of life Phase 1 Social assessment Health Phase 2 Epidemiological assessment Health education Policy regulation organization Health Promotion Phase 5 Administrative & policy assessment OutputLonger-term health outcome Short-term social impact Short-term impact ProcessInput Long-term social impact Phase 6 Implementation Phase 7 Process evaluation Phase 8 Impact evaluation Phase 9 Outcome evaluation Predisposing Reinforcing Enabling Phase 4 Educational & ecological assessment Behavior Environment Phase 3 Behavioral & environmental assessment *Green & Kreuter, Health Promotion Planning, 2 nd & 3rd eds., Mayfield, 1991, 1999. The Precede-Proceed model as it appeared in the previous two editions of the book* PRECEDE PROCEED

5. PRECEDE-PROCEED Model Predisposing, Predisposing, Reinforcing, & Reinforcing, & Enabling Enabling Constructs in Constructs in Educational/Ecological Educational/Ecological Diagnosis & Diagnosis & Evaluation Evaluation Policy, Regulatory & Organizational Constructs in Educational & Environmental Development Green & Kreuter, Health Program Planning, 4 th ed., NY, London: McGraw-Hill, 2005.

6. Evolution of the Model, Bangladesh Correlates of family planning in Pakistan, 1960s Correlates of family planning in Pakistan, 1960s.. Pakistan Dev. Rev. 6:80 ‑ 104, 1966. Green LW., Krotki KJ. Proximity and other geographical factors in the utilization of family planning clinics in Pakistan. Pakistan Dev. Rev. 6:80 ‑ 104, 1966. Green LW. Validity in family planning surveys: Disavowed knowledge and use of contraceptives in a panel study in Dacca, East Pakistan. Public Opin. Q. 32:504, 1968. Green LW., Krotki KJ. Class and parity biases in family planning programs: The case of Karachi. Soc. Biol.15:235 ‑ 251, 1968. Green LW. East Pakistan: Knowledge and use of contraceptives. Stud. Fam. Planning 1:9 ‑ 14, 1969. Cluster trial of interventions in Dhaka Cluster trial of interventions in Dhaka Green, L.W. Identifying and overcoming barriers to the diffusion of knowledge about family planning. Adv. Fertil. Control 5:21 ‑ 29, 1970. Green, L.W., et al. Field experiment comparing family planning education programs directed at males and females. Int. J. Health Educ. 16:242 ‑ 259, 1973.

7. Evolution: The Hopkins Trials Asthma: the diffusion concept of homophily Asthma: the diffusion concept of homophily Green LW. Toward cost ‑ benefit evaluations of health education: Some concepts, methods and examples. Health Educ. Monogr. 2 (supp.2):34-64, 1974. Green LW. Toward cost ‑ benefit evaluations of health education: Some concepts, methods and examples. Health Educ. Monogr. 2 (supp.2):34-64, 1974. Maiman L, Green LW, Gibson G, Mackenzie EJ. Education for self-treatment by adult asthmatics. J. Am. Med. Assoc. 241:1919-1922, 1979. Maiman L, Green LW, Gibson G, Mackenzie EJ. Education for self-treatment by adult asthmatics. J. Am. Med. Assoc. 241:1919-1922, 1979. Hypertension: the concept of comprehensiveness Hypertension: the concept of comprehensiveness Green LW., Levine DM, Deeds SG. Clinical trials of health education for hypertensive outpatients: Design and baseline data. Prev. Med. 4:417 ‑ 425, 1975. Green LW., Levine DM, Deeds SG. Clinical trials of health education for hypertensive outpatients: Design and baseline data. Prev. Med. 4:417 ‑ 425, 1975. Green, L.W., et al. Development of randomized patient education experiments with urban poor hypertensives. Patient Couns. Health Educ. 1:106 ‑ 111, 1979. Green, L.W., et al. Development of randomized patient education experiments with urban poor hypertensives. Patient Couns. Health Educ. 1:106 ‑ 111, 1979. Levine DM, Green LW, Deeds SG, et al. Health education for hypertension patients. J. Am. Med. Assoc. 241:1700-1703, 1979. Levine DM, Green LW, Deeds SG, et al. Health education for hypertension patients. J. Am. Med. Assoc. 241:1700-1703, 1979. Morisky DE, Levine DM, Green LW, et al. Five ‑ year blood ‑ pressure control and mortality following health education for hypertensive patients. Am J Public Health 73:153 ‑ 162, 1983. Morisky DE, Levine DM, Green LW, et al. Five ‑ year blood ‑ pressure control and mortality following health education for hypertensive patients. Am J Public Health 73:153 ‑ 162, 1983.

8. Quality of life Phase 1 Social assessment Health Educational strategies Policy regulation organization Health Program Phase 4a Phase 5 Implementation Phase 6 Process evaluation Phase 7 Impact & Outcome evaluation Predisposing Reinforcing Enabling Phase 3 Educational & ecological assessment Behavior Environment Phase 4b Phase 2 Epidemiological Assessment Genetics The generic representation of the new version of PRECED-PROCEED, with new elements highlighted.* Administrative & policy assessment Intervention Alignment Green & Kreuter, Health Program Planning, 4 th ed., NY, London: McGraw-Hill, 2005.

9. Social goals & objectives Community engaged? NO Yes Select & apply procedures for community participation (Ch 2, A) Collect/Analyze data, get consensus, set priorities (Chap 2, B ) Are health objectives clear? Go to Chap 3 If Not Yes Are behavioral & environmental causes, objectives clear? Go to part 2 of Chap 3 Yes Are Predisposing, Enabling, and Reinforcing factors clear? If Not Go to Chap 4 Yes Are best practices & resources for program available, & policies in place? If Not Go to Chap 5 If Not Implementation & Evaluation Yes Plan 3 PROCEED PRECEDE Hallmark 1: Both Procedural and Logical

10. PublicationBibliographic databasesSubmissionReviews, guidelines, textbooks Negative results Unknown0.3 year6. 0 - 13.0 years 50% 46% 18% 35% 0.6 year0.5 year9.3 years Dickersin, 1987 Poynard, 1985 Kumar, 1992 Poyer, 1982Antman, 1992 Lack of numbers, Design issues Inconsistent indexing Original researchAcceptanceImplementation “It takes 17 years to turn 14 per cent of original research to the benefit of patient care” * to the benefit of patient care” * Koren, 1989 *Balas, 1995 Where Have All the Data Gone? Longtime Passing… Lack of numbers, Design issues Kumar, 1992 17 yrs

11. R The Pipeline Fallacy of Producing & Vetting Research to Get Evidence-Based Practice* Peer Review Of Grants Publication Priorities & Peer Review Research Synthesis Guidelines for Evidence- Based Practice Academic appointments, promotion, & tenure criteria Funding; patient needs, demands; local practice circumstances; professional discretion; credibility & fit of the evidence. - Evidence-based Medicine movement Practice Priorities for Research Funding *Based on Green, L.W. From research to “best practices” in other settings and populations. Am J Health Behavior 25:165-178, April-May 2001. Full text: www.ajhb.org/25-3.htmwww.ajhb.org/25-3.htm The 17-year odyssey Blame the practitioner or blame dissemination

12. The research indicates that we really should do something with all this research. Diffusion Adoption Quality EBP “Bridging the gap”

13. 5 Ways of Making Research More Relevant for Practice Making research more theory-based Making research more theory-based Setting research & evaluation priorities Setting research & evaluation priorities Making research findings actionable, usable, relevant (to whom?) Making research findings actionable, usable, relevant (to whom?) Disseminating & translating (adapting) research to local circumstances, cultures, and personnel Disseminating & translating (adapting) research to local circumstances, cultures, and personnel Making evidence more practice-based Making evidence more practice-based

14. Filling the Chasm, as Conceived by the U.S. Translation Agency* Practice is We want it to here be here TRIP Implementation Diffusion Adoption Education Innovation *Carolyn Clancy. Agency for Healthcare Research & Quality 2003. Reminiscent of the “Fallacy of the Empty Vessel” from early health education

15. Prototype of Causal Models and Intervention Models X ? INPUTS (educational, organizational economic, etc.) OUTPUTS (behavioral change, health, quality of life, development) Different models interpret the content of “X?” according to different theories (or assumptions) about causation and control (mediating variables). Problem Theory: Causes (X)>->->->->->Effects Action TheoryCausal Theory : Intervention Models: Green & Kreuter, Health Program Planning, 4 th ed., NY, London: McGraw-Hill, 2005.

16. Examples of Causal Theories on Which PRECEDE-PROCEED Model is Based Psychological theories: X includes a behavior, and its antecedents such as attitudes, beliefs, values, perceptions, and other cognitive variables Psychological theories: X includes a behavior, and its antecedents such as attitudes, beliefs, values, perceptions, and other cognitive variables Sociological theories: X includes social norms, networks, diffusion, organizational functioning, and inter- organizational exchange & coalitions. Sociological theories: X includes social norms, networks, diffusion, organizational functioning, and inter- organizational exchange & coalitions. Economic theories: X includes consumer behavior and organizational response to consumer demand; governmental subsidies or incentives, taxes. Economic theories: X includes consumer behavior and organizational response to consumer demand; governmental subsidies or incentives, taxes. Pathophysiological theories: X includes organisms or environmental exposure processes. Pathophysiological theories: X includes organisms or environmental exposure processes.

17. Intervention(s) or Program Cause(s) Outcome Variable(s) Action Theory Program Theory Causal Theory Action Theory and Program Theory Use Causal Theories to Link Intervention and Outcomes *Adapted from Suchman, 1967, pp. 84, 173; Weiss, 1970; Chen, 1990, p. 250; Donaldson, 2001, pp. 473-487; Green & Kreuter, 2005, p. 200. E.g., Fear-arousal communication  Belief in susceptibility  Change portion size Health Belief Model Fear-arousal theory CommunicationProtection-Motivation

18. Intervention or Program Mediator Outcome Variable(s) Moderators Mediating (“X”) and Moderating (Contextual) Variables Moderators Communication Fear Portion size Belief in Severity Age, SESGender, culture Green & Kreuter, Health Program Planning, 4th ed., NY: McGraw-Hill, 2005, p. 204.

19. Level and Stage of Change as a First Consideration Population change defined by diffusion theory Population change defined by diffusion theory early diffusion stages: predisposing factors early diffusion stages: predisposing factors middle diffusion stages: reinforcing factors middle diffusion stages: reinforcing factors late stages of diffusion: enabling factors late stages of diffusion: enabling factors Individual change defined by psycho- logical theory precontemplation to contemplation: predisposing factors preparation & action stages: enabling factors maintenance: rein- forcing factors

21. Tobacco Vending Machine Ordinances 19851986198719881989199019911992* 0 20 40 60 80 100 120 140 160 180 Total Ban Partial Ban Number of Ordinances (Cumulative) Year * Through September 1992. Source: National Institutes of Health, National Cancer Institute (1993). Smoking and Tobacco Control - Monograph 3. Major Local Tobacco Control Ordinates in the U.S. US Dept. of Health and Human Service. Public Health Service, National Institutes of Health. NIH Publ. No. 93-3532.

22. Glasgow’s RE-AIM “Law of halves” e.g., ULTIMATE IMPACT OF MAGIC DIET PILL 50% of Clinics UseAdoption50% 50% of Clinicians PrescribeAdoption25% 50% of Patients Accept MedicationReach12.5% 50% Follow Regimen CorrectlyImplementation6.2% 50% of Those Taking Correctly BenefitEffectiveness3.2% 50% Continue to Benefit After 6 MonthsMaintenance1.6% Dissemination StepConcept % Impacted

23. Quality of life Phase 1 Social assessment Health Educational strategies Policy regulation organization Health Program Phase 4a Intervention Alignment Output Longer-term health outcome Short-term social impact Short-term impact ProcessInput Long-term social impact Phase 5 Implementation Phase 6 Process evaluation Phase 7 Impact and outcome evaluation Predisposing Reinforcing Enabling Phase 3 Educational & ecological assessment Behavior Environment  Precede Evaluation tasks: Specifying measurable objectives and baselines. Phase 4b Administrative & Policy Assessment  Proceed Evaluation Tasks: Monitoring & Continuous Quality Improvement Phase 2 Epidemiological, Behavioral and Environmental Assessment Genetics Evaluation tasks begin at Phase 1, and continue through as many diagnostic, implementation, and follow-up evaluation phases as required.

24. Theory Implied in Phases 3-4 of PRECEDE* Predisposing Knowledge, Attitudes Beliefs Cultural Values Perceptions Reinforcing Reinforcing Health prof’ls, parents, teachers, employers, peers, vendors etc. Enabling Availability of resources Accessibility Skills Behavior and andLifestyle Health Education, Mass Media, Advocacy,Training Environment Policy, Regulation, Organization Organization Ecosystem Phase 3: Educational and Ecological Assessment Phase 4: Intervention Alignment, Administrative And Policy Assessment Genetics and Human Biology Matching and Mapping Interventions with Evidence & Theory Direct Communications Indirect Communi- cations *Green & Kreuter, 2005, p. 149. 1 2 3 4 5 67 8 9 1011 12 13 14 15 16 17

25. Felt needs, Assets, Concerns, Aspirations Setting Priorities Vision Goals Phase 1. Social & Quality-of-Life Assessments & Situation Analysis Phases 2-3. Epidemi- ological, Educational & Ecological Assessments For each goal, assess causes, determinants Asses importance, feasibility of each Set priorities Objec- tives Phase 4. Administrative & Policy Assessment, PROCEED to Action, Formative evaluation Pretest Methods Strategy Tactics Implementation Activate Timelines for Training, Interventions Evaluation…of methods…intermediate objectives…ultimate goals Phase 5 Phase 6  Phase 7Phase 8 Summary of the Narrowing Phasing of PRECEDE-PROCEED For each objective, assess resources, polices Assess theory, evi- dence for change Select methods, Assign roles Green & Kreuter, Health Program Planning, 4 th ed., NY: McGraw-Hill, 2005, p. 65.

26. RFA (PAR) from NIH, 2006 Applications to “ identify, develop, and refine effective and efficient methods, structures, and strategies that test models to disseminate and implement research-tested health behavior change interventions and evidence-based prevention, early detection, diagnostic, treatment, and quality of life improvement services into public health and clinical practice settings.” Applications to “ identify, develop, and refine effective and efficient methods, structures, and strategies that test models to disseminate and implement research-tested health behavior change interventions and evidence-based prevention, early detection, diagnostic, treatment, and quality of life improvement services into public health and clinical practice settings.” Two problems with these framings of the issue: Two problems with these framings of the issue: Are the “research-tested interventions” adequate? Are the “research-tested interventions” adequate? Are they appropriate to other settings, populations? Are they appropriate to other settings, populations? To illustrate the first problem:

27. Canadian Cancer Society RFP for a Review to Answer 4 Questions Are group counseling programs for smoking cessation effective? If so, what is the optimal content of the sessions? What is the optimum number and frequency of sessions that should be offered? What are the characteristics of the most effective facilitators?

28. University of Waterloo Results* A comprehensive literature review of over 40 years of published and unpublished studies A comprehensive literature review of over 40 years of published and unpublished studies Deficiencies in purpose, design and reporting Deficiencies in purpose, design and reporting Research could answer only the first of 4 questions: that group programs for smoking cessation are effective. Research could answer only the first of 4 questions: that group programs for smoking cessation are effective. *Manske SR, Miller S, Moyer C, Phaneuf MR, Cameron RC. Best practice in group- based smoking cessation: Results of a literature review. AJHP 18:409-23, 2004.

29. Evidence-Based Medicine and Patient-Centered Medicine* Information of importance to patient choice that is not even potentially of “evidence-based type.” C A B Area where there is currently good evidence-based information of importance to patients in making choices. Information of importance to patient choice that is potentially of evidence- based type. *In A.L. Cochrane, from T. Hope. Evidence-based patient choice and the doctor-patient relationship. In But Will It Work, Doctor? Kings Fund, London, 1997, 20-24. A “Good evidence” B Potential for “good evidence” C Information of potential importance to patients in making health care choices

30. Evidence-Based Public Health Information of importance to community choice that is not even potentially of “evidence-based type.” C A B Area where there is currently “good evidence-based” information of importance to communities in making choices. Information of importance to community choice that is potentially of “evidence- based” type. A “Good evidence” B Potential for “good evidence” C Information of potential importance to communities in making health choices

31. Issues for Evidence-Based Practice and Translating Research to Practice Making practice more theory-based Making practice more theory-based Setting research priorities Setting research priorities Making research findings actionable, usable, relevant within settings Making research findings actionable, usable, relevant within settings Translating research from outside to local circumstances, cultures, personnel Translating research from outside to local circumstances, cultures, personnel Making evidence more practice-based Making evidence more practice-based

32. Priority-Setting for Health Research* Knowledge Acquisition Knowledge Validation Knowledge Transfer Clinical Investigations Clinical Trials Knowledge Translation CDC NIH Surveillance Community & Statewide Effectiveness Trials Program Evaluation Applied Research & Development Basic Research Demonstration & Education Research Molecular Level Population Level *Green LW, Popovic T, et al. CDC Futures Workgroup on Research. Atlanta, 2004. PBRNs, CQI T1 T2

33. The Internal Validity Drift of Health Sciences Evidence “Lost in Translation” Evidence-based medicine movement taken to scale in general practice & health promotion Evidence-based medicine movement taken to scale in general practice & health promotion The peer review preferences for experimental control and certainty of causation The peer review preferences for experimental control and certainty of causation The publishing preferences for RCTs and positive results The publishing preferences for RCTs and positive results The limitations of print space driving out richer description of interventions, protocols, procedural lessons, subgroup variations The limitations of print space driving out richer description of interventions, protocols, procedural lessons, subgroup variations But a more “natural” type of practice-based evidence has greater influence on multi-level program planning, practice & policy… But a more “natural” type of practice-based evidence has greater influence on multi-level program planning, practice & policy…

34. Change in Per Capita Cigarette Consumption California & Massachusetts vs Other 48 States, 1984-1996 -25 -20 -15 -10 -5 0 5 Percent Reduction Other 48 StatesCaliforniaMassachusetts 1984-19881990-19921992-1996

35. Issues for Evidence-Based Practice and Translating Research to Practice Making practice more theory-based Making practice more theory-based Setting research priorities Setting research priorities Participatory research to make findings actionable, usable, relevant within settings Participatory research to make findings actionable, usable, relevant within settings Translating research from outside to local circumstances, cultures, personnel Translating research from outside to local circumstances, cultures, personnel Making evidence more practice-based Making evidence more practice-based

36. Some Benefits of Participatory Research in Practice-Based Evidence Results are relevant to interests, circumstances, and needs of those who would apply them Results are relevant to interests, circumstances, and needs of those who would apply them Results are more immediately actionable in local situations for people and/or practitioners Results are more immediately actionable in local situations for people and/or practitioners Generalizable findings more credible to people, practitioners and policy makers elsewhere because they were generated in partnership with people like themselves Generalizable findings more credible to people, practitioners and policy makers elsewhere because they were generated in partnership with people like themselves Helps to reframe issues from health behavior of individuals to encompass system and structural issues. Helps to reframe issues from health behavior of individuals to encompass system and structural issues. Green LW, Mercer SL. Am J Public Health Dec. 2001.

37. Definition and Standards of Participatory Research for Health* Systematic investigation… Actively involving people in a co-learning process… For the purpose of action conducive to health** --not just involving people more intensively as subjects of research or evaluation *Green, George, Daniel, et al., Participatory Research… Ottawa: Royal Society of Canada, 1997. www.lgreen.net/guidelines.html

38. The Lenses of Scientists, Health Professionals and Lay People Objective Indicators of Health Subjective Indicators of Health Professional, Scientific Layperson

39. Issues for Evidence-Based Practice and Translating Research to Practice Making practice more theory-based Making practice more theory-based Setting research priorities Setting research priorities Making research findings actionable, usable, relevant: participatory research Making research findings actionable, usable, relevant: participatory research Translating research to local cultures & circumstances: External validity & “fidelity” vs adaptation Translating research to local cultures & circumstances: External validity & “fidelity” vs adaptation Making evidence more practice-based Making evidence more practice-based

40. Building Policy and Practice from Evidence + Theory Not starting with theory and looking for problems on which to test them, but starting with problems and looking for theories to help us solve them* Not starting with theory and looking for problems on which to test them, but starting with problems and looking for theories to help us solve them* Evidence on solutions generalizes to other circumstances, settings, & populations in the form of either replication or theory Evidence on solutions generalizes to other circumstances, settings, & populations in the form of either replication or theory Replication is limited by the infinite number of context-population combinations Replication is limited by the infinite number of context-population combinations "In theory, theory and practice are the same thing. In practice they're not..“ -Jan L.A. van de Snepscheut "In theory, theory and practice are the same thing. In practice they're not..“ -Jan L.A. van de Snepscheut “All models are wrong. Some are useful” --Box “All models are wrong. Some are useful” --Box *Green LW. Public health asks of systems science… Amer J Public Health 96, March 2006.

41. “Fidelity” vs Adaptation* Researchers test an intervention for its efficacy Researchers test an intervention for its efficacy Rigorous test (efficacy) qualifies it for official lists of “evidence-based practices” and guidelines Rigorous test (efficacy) qualifies it for official lists of “evidence-based practices” and guidelines Practitioners try to incorporate it into their programs in other populations, circumstances Practitioners try to incorporate it into their programs in other populations, circumstances Poor fit produces failure of program Poor fit produces failure of program Practitioners are blamed for not implementing with “fidelity” Practitioners are blamed for not implementing with “fidelity” Now buy the producers’ training program Now buy the producers’ training program * Green LW, Glasgow RE, …external validity… Evaluation & the Health Professions, Mar. 2006.

42. Efficacy vs. Effectiveness : Efficacy. The tested impact of an intervention under highly controlled circumstances. Efficacy. The tested impact of an intervention under highly controlled circumstances. Effectiveness. The tested impact of an intervention under more normal circumstances ( relatively less controlled, real-time, “typical” setting, population, and conditions). Effectiveness. The tested impact of an intervention under more normal circumstances ( relatively less controlled, real-time, “typical” setting, population, and conditions). Broad Program Evaluation. The tested impact of a blended set of interventions on larger systems and populations. “Natural Experiments” with minimal control, maximum variability. Broad Program Evaluation. The tested impact of a blended set of interventions on larger systems and populations. “Natural Experiments” with minimal control, maximum variability.

43. The Trade-offs Efficacy. Maximizes internal validity, i.e., the degree to which one can conclude with confidence that the intervention caused the result. Efficacy. Maximizes internal validity, i.e., the degree to which one can conclude with confidence that the intervention caused the result. Effectiveness. Maximizes external validity,* i.e., the degree to which one can generalize from the test to other times, places, or populations. Effectiveness. Maximizes external validity,* i.e., the degree to which one can generalize from the test to other times, places, or populations. Program Evaluation. Maximizes reality testing in particular settings, & with the combination of interventions at multiple levels required for public health effect. Program Evaluation. Maximizes reality testing in particular settings, & with the combination of interventions at multiple levels required for public health effect. * Green LW, Glasgow RE, …external validity… Evaluation & the Health Professions, Mar. 2006.

44. Issues for Evidence-Based Practice and Translating Research to Practice Blending evidence-based practice with theory-based practice Blending evidence-based practice with theory-based practice Setting research priorities Setting research priorities Making research findings actionable, usable, relevant: Participatory Research Making research findings actionable, usable, relevant: Participatory Research Translating research to local circumstances Translating research to local circumstances Making evidence more practice-based: the centrality of evaluation and continuous quality improvement research Making evidence more practice-based: the centrality of evaluation and continuous quality improvement research

45. Intervention or Program Mediator Outcome Variable(s) Moderators Mediating and Moderating Variables Moderators Green & Kreuter, Health Program Planning: An Educational and Ecological Approach. 4th ed. New York: McGraw-Hill, 2005. Green & Glasgow, E&HP, 2006.

46. Aligning Evidence with (and deriving it from) Practice: Matching, Mapping, Pooling and Patching Matching ecological levels of a system or community with evidence of efficacy for interventions at those levels Matching ecological levels of a system or community with evidence of efficacy for interventions at those levels Mapping theory to the causal chain to fill gaps in the evidence for effectiveness of interventions Mapping theory to the causal chain to fill gaps in the evidence for effectiveness of interventions Pooling experience to blend interventions to fill gaps in evidence for the effectiveness of programs in similar situations Pooling experience to blend interventions to fill gaps in evidence for the effectiveness of programs in similar situations Patching pooled interventions with indigenous wisdom and professional judgment about plausible interventions to fill gaps in the program for the specific population Patching pooled interventions with indigenous wisdom and professional judgment about plausible interventions to fill gaps in the program for the specific population *Green & Kreuter, Health Program Planning: An Educational and Ecological Approach. 4th ed. NY: McGraw-Hill, 2005, Chapter 5. Green & Glasgow, 2006.

47. 3 Conceptualizations of the Gap Between Research & Practice Practitioners need to receive the lessons of research and put them into practice. Practitioners need to receive the lessons of research and put them into practice. Research and practice are entirely separate disciplines and each must develop their own answers to their own problems Research and practice are entirely separate disciplines and each must develop their own answers to their own problems Research and practice have complementary perspectives and skills that need to be used together to address the real need, collaborative knowledge production. Research and practice have complementary perspectives and skills that need to be used together to address the real need, collaborative knowledge production. Add to this the need to include the patient’s perspective. Whose perspective prevails? Add to this the need to include the patient’s perspective. Whose perspective prevails? Van De Ven A, Johnson P. Knowledge for theory and practice. Academy of Management Review. 2006;31(4).

48. The Bridge (not the Pipeline) from Research to Practice and Back If we want more evidence-based practice, we need more practice-based evidence. If we want more evidence-based practice, we need more practice-based evidence. The importance of practitioners and policy- makers in shaping the research questions. The importance of practitioners and policy- makers in shaping the research questions. Practitioners and their organizations represent the structural links (and barriers) to addressing the important determinants of health behavior at each level. Engage them, not at passive recipients, but as partners… Practitioners and their organizations represent the structural links (and barriers) to addressing the important determinants of health behavior at each level. Engage them, not at passive recipients, but as partners… *Green, L.W. From research to “best practices” in other settings and populations. Am J Health Behavior 25:165-178, April-May 2001. Full text: www.ajhb.org/25-3.htm.www.ajhb.org/25-3.htm

49. The Vision for Translation 2 A future in which we would not need to ask how to get more evidence-based practice, rather A future in which we would not need to ask how to get more evidence-based practice, rather How to sustain the engagement of students, practitioners, patients and communities in a participatory process of practice-based research and program evaluation? How to sustain the engagement of students, practitioners, patients and communities in a participatory process of practice-based research and program evaluation? How to adapt the “best practices” guidelines through best processes of collecting data to diagnose the biopsychosocial needs of their patients and communities… How to adapt the “best practices” guidelines through best processes of collecting data to diagnose the biopsychosocial needs of their patients and communities…

50. Translation 2 Vision (expanded) How to match the proposed evidence-based interventions to those needs, filling gaps in the evidence-based interventions with the use of theory and mutual consultation, and prospective testing of complementary interventions How to match the proposed evidence-based interventions to those needs, filling gaps in the evidence-based interventions with the use of theory and mutual consultation, and prospective testing of complementary interventions The cumulative, building-block tradition of evidence-based medicine from RCTs would be complemented by a parallel strengthening and support of a tradition of participatory research and evaluation conducted in practice settings. The cumulative, building-block tradition of evidence-based medicine from RCTs would be complemented by a parallel strengthening and support of a tradition of participatory research and evaluation conducted in practice settings.

51. 6 Conclusions (Remedies) Adapt the research funding priorities Adapt the research funding priorities Adapt publication criteria Adapt publication criteria Adapt the criteria for inclusion and weighting of studies into systematic reviews and research syntheses Adapt the criteria for inclusion and weighting of studies into systematic reviews and research syntheses Adapt the derivation and qualification of practice guidelines from the systematic reviews Adapt the derivation and qualification of practice guidelines from the systematic reviews Adapt the academic promotion and tenure criteria and weights given to community- & practice-based research Adapt the academic promotion and tenure criteria and weights given to community- & practice-based research Adapt the research training of students and fellows in methods of practice-based and participatory research Adapt the research training of students and fellows in methods of practice-based and participatory research