Disseminating the foundations of knowledge translation and patient engagement science and practice: A quantitative descriptive evaluation of exposure and engagement of the KnowledgeNudge blog and Twitter profile (Preprint)

BACKGROUND
There is a documented need to build capacity for theory- and evidence-informed knowledge translation (KT) and patient engagement (PE) practice in health research. Dissemination of foundational content online coupled with social media promotion may build capacity by increasing awareness, knowledge, and positive attitudes.


OBJECTIVE
This retrospective study sought to (1) describe exposure and engagement of the KnowledgeNudge KT and PE dissemination strategy (online blog and Twitter profile) over 2 years and (2) identify and compare characteristics of individual posts with the most and least exposure and reach.


METHODS
Exposure was assessed by blog site views per month and Twitter profile impressions per month. Engagement was assessed by Twitter profile interactions per month. Descriptive statistics were calculated for 6-month blocks and compared using one-way analysis of variance or Student t test. Individual post exposure was assessed by average post views per week. Individual post reach was assessed by average post reads per week. High- and low-profile blog posts with the highest and lowest 10th percentile for exposure and reach were identified.


RESULTS
A total of 99 posts and 755 tweets were published during the study period. There was a significant increase in exposure (P=.004) and reach (P<.001) during the final 6 months. Seven high-profile and 6 low-profile posts were identified. High-profile posts had a significantly greater average word count than low-profile posts (P=.003). There were no other significant differences between posts.


CONCLUSIONS
The increases in KnowledgeNudge exposure and engagement offer preliminary evidence in support of this dissemination strategy for the practice of KT and PE. Variation in individual post exposure and reach warrants further exploration to tailor content to user needs. Future work will include a prospective evaluation strategy to explore the effect of KnowledgeNudge on awareness, knowledge, attitudes, and behavior.


Foreword
Knowledge translation (KT) is about raising knowledge users' awareness of research findings and facilitating the use of those findings. Only a minority of researchers would call themselves experts in KT, and with KT still an emerging field, there exists a need to build capacity not only in developing research proposals with a KT approach but also in assessing those proposals for scientific merit and potential impact. The Canadian Institutes of Health Research (CIHR) has written this guide as one resource to fill this knowledge gap. We hope this guide will help to strengthen projects that involve a KT approach, while also ensuring that the review of KT within grant proposals is more rigorous and transparent.
The guide is divided into two sections, each tailored to one of CIHR's two forms of KT: integrated knowledge translation (iKT) and end-of-grant KT. Integrated knowledge translation requires that knowledge users (who will be described later in this guide) be members of the research team and participate in many stages of the research process. End-of-grant KT requires applicants to submit a plan for how they will translate their findings when the research is completed. It is worth noting that iKT programs require a dissemination plan, so those involved with iKT proposals should consult both sections. As mentioned, there is a section in the guide specific to each approach. The target audience for this guide is CIHR applicants and reviewers, but the concepts are transferable to a broader audience.
Each section provides: • a description of the category of KT in question; • a brief explanation of the relevant KT factors; • a worksheet with questions pertinent to each factor; and • examples of strong project proposals from each category to assist you in thinking about your KT approach.
The guide is not meant to replace the review criteria or scoring system used for a funding opportunity. Researchers or knowledge users developing a project proposal should use this guide to supplement and strengthen their research and approach to KT. If you are reviewing a proposal with a KT approach, use the guide to help you reach a conclusion about how well the funding opportunity criteria have been met and integrate this conclusion within your final assessment.

Introduction
As is clear from CIHR's mandate, a commitment to excellence applies equally to CIHR's support for research and knowledge translation (KT). As Canada's principal health research funding agency, CIHR plays a fundamental role in bridging the "know-do" gap and ensuring that research findings get into the hands of those who can use them.
KT is of critical importance to health research, as it has become clear that the creation of new knowledge often does not, on its own, lead to widespread implementation or impacts on health. From CIHR's perspective, accountability from the federal and provincial governments, as well as the public, makes it increasingly important to demonstrate the benefits of the investment of taxpayer dollars in health research by moving research into policy, programs and practice.
This guide outlines those elements that contribute to strong KT projects. It is intended to be used both by those developing project proposals and by those who are assessing such proposals for the purposes of funding or partnership.
While KT has been given many different labels, CIHR defines it as "a dynamic and iterative process that includes synthesis, dissemination, exchange and ethically sound application of knowledge to improve the health of Canadians, provide more effective health services and products and strengthen the health care system." This is by no means a simple process and involves a range of "interactions between researchers and knowledge users that may vary in intensity, complexity and level of engagement depending on the nature of the research and the findings as well as the needs of the particular knowledge user." i CIHR has identified two broad categories of KT: integrated KT (iKT) and end-of-grant KT. In iKT, potential knowledge users are engaged throughout the research process. This approach should produce research findings that are more likely to be directly relevant to and used by knowledge users. It should also incorporate a dissemination plan to share the results of the project with other interested knowledge users.
With end-of-grant KT, the researcher develops and implements a plan for making potential knowledge-user audiences aware of the knowledge that is gained during a project. End-of-grant KT can involve more intensive dissemination activities that tailor the message and i More about knowledge translation at CIHR (www.cihr-irsc.gc.ca/e/39033.html)

Knowledge Synthesis
Contextualizing and integrating research studies within the larger body of knowledge on the topic.

Dissemination
Sharing research results by identifying the appropriate audience for the research findings and tailoring the message and medium to the audience.

Knowledge Exchange
Interactions between knowledge users and researchers resulting in mutual learning.

Ethically Sound Application of Knowledge
The iterative process by which knowledge is actually considered, put into practice or used to improve health and the health system. These activities must be consistent with ethical principles and norms, social values and legal and other regulatory frameworks.

Knowledge User
CIHR defines a knowledge user as an individual who is likely to be able to use research results to make informed decisions about health policies, programs and/or practices. A knowledge user's level of engagement in the research process may vary in intensity and complexity depending on the nature of the research and on his/her information needs. A knowledge user can be, but is not limited to, a practitioner, a policy maker, an educator, a decision maker, a health care administrator, a community leader or an individual in a health charity, patient group, private sector organization or media outlet.

Integrated Knowledge Translation (iKT)
iKT is an approach to doing research that applies the principles of knowledge translation to the entire research process. The central premise of iKT is that involving knowledge users as equal partners alongside researchers will lead to research that is more relevant to, and more likely to be useful to, the knowledge users. [1][2][3][4][5][6][7][8][9] Each stage in the research process is an opportunity for significant collaboration with knowledge users, including the development or refinement of the research questions, selection of the methodology, data collection and tools development, selection of outcome measures, interpretation of the findings, crafting of the message and dissemination of the results.
It should be noted that iKT programs also require a dissemination plan (end-of-grant KT), so those submitting or reviewing iKT proposals should consult both sections of this guide. Since knowledge users represent a broader audience group, a well-developed KT plan can increase the benefit and potential impact of the research findings.
iKT has a longstanding tradition in many disciplines but has usually gone by other terms, such as collaborative research, participatory action research, communitybased participatory research, co-production of knowledge or Mode 2 research.
For more information on iKT, please refer to the learning module "A Guide to Researcher and Knowledge-User Collaboration in Health Research" on CIHR's website at www.learning.cihr-irsc.gc.ca/course/view.php?id=3.

Knowledge Translation (KT) Factors for Consideration
Proposals should demonstrate that the project has been shaped by the participating knowledge users and responds to their knowledge needs. In applying for funding, proposals should also outline how the project responds to the objectives of the specific funding

A Note on Merit Review
At CIHR, projects that take an iKT approach must be evaluated using merit review, in which researchers and knowledge users assess both the scientific merit and the potential impact of the project using separate scores.

Research Question
It is essential to clearly describe the intent of the research project, including the objectives and an explanation of the knowledge to be translated. An important objective specific to an iKT project is responding to a problem or knowledge gap identified by knowledge users. This must be clearly articulated.
The research question is meant to be targeted to the knowledge users' context and environment, but the research should be transferable enough that similar audiences will benefit. Other audiences become particularly pertinent when there is the intention to disseminate the research results more broadly.
Working with knowledge users is beneficial for meeting all of these goals.

Research Approach
The methodology selected for the project should clearly address the proposed research question, while the overall study design should be appropriate and sufficiently rigorous. However, the iKT methodology may evolve as the project proceeds and may not be entirely determined at the outset. The primary audience for an iKT project is the knowledge users participating as part of the project team.
There should be strategies for sustaining the meaningful engagement of participating knowledge users throughout the research process. A project has many stages, and each is an opportunity for knowledge exchange between the researchers and the knowledge users. Proposals should specify when, how and for what purpose the researchers and knowledge users will meet.
All feasible opportunities for knowledge exchange should be explored. The proposal should also demonstrate that the researchers and the knowledge users have collaboratively developed the proposal.
A principal goal of all iKT projects is to incorporate the expertise of knowledge users, who will obviously be experts on their own knowledge needs. They can provide insight into the knowledge needs of other knowledge users in their sector. Knowledge users also have expertise on the context of implementation -the realities of the environment in which the research results will be implemented -which researchers may not necessarily be aware of.
Very strong iKT projects will demonstrate an established relationship with the participating knowledge users, one that hopefully precedes and will outlast the project. How the knowledge users will be involved in developing the research question, collecting and analyzing data, interpreting results, crafting the overall message, developing recommendations and identifying audiences for dissemination should be specified in the project proposal. However, it is important to recognize that iKT approaches will require varying levels of engagement with different knowledge users at various times throughout the process and to ensure that the engagement is appropriate for both the project objectives and the availability of the knowledge users.
Proposals should distinguish between the knowledge users participating in the project and other target audiences that will be reached by the dissemination plan. Proposals should also present realistic strategies that integrate knowledge translation into the project. Finally, an end-of-grant KT plan must be included, detailing strategies that are appropriate to the project's goals and target audiences. iv

Feasibility
A number of potential risks can jeopardize the feasibility of an iKT project, and these must be considered. One of the biggest risks is that a knowledge user will change job positions and leave the environment that his/her expertise is linked to. Evidence of an ongoing commitment from the organizations and the knowledge users is ideal. Another risk is the possibility of a dispute between the knowledge users and the researchers. A collaborative agreement outlining such things as access to data, the timing of the release of findings and intellectual property -or some other mechanism for resolving disputes -will protect the project against such a contingency. Financial or in-kind support from the knowledge users' organizations is a good sign of engagement and commitment. With iKT projects, there is a greater expectation that the findings or recommendations will be acted on. The knowledge users should be in a position to influence decisionmaking authority to integrate knowledge into the environment where they practice. Finally, the scope of the research project should be appropriate to the established goals and the resources available. It is important to communicate how the project can be accomplished in the given time frame with the resources described.
For an iKT project, it is expected that a fair amount of detail will be provided about the knowledge users. It is usually a requirement that they submit letters of support as well as CVs. Their role in the project should be clearly stated, and there should be evidence that they have agreed to fulfill their role.
iKT proposals should demonstrate that the knowledge users are the right participants to inform the project and act on the findings and that they understand the roles assigned to them in the project.

Outcomes
In conducting research, iKT is likely to increase the uptake of findings and improve the likelihood that the research will have an impact. [1][2][3][4][5][6][7][8][9] In this regard, an iKT proposal should clearly illustrate how it will potentially have a demonstrable and sustainable impact on practice, programs and/or policy that could ultimately lead to a change in health outcomes.
While the research question may respond to the needs of the knowledge users, project findings can have an even greater impact depending on the extent to which the results are transferable to other contexts. Capturing the outcomes of research can help in validating the original goals of the study and can serve as a basis for further work stemming from the research findings.

Proposals should include an evaluation plan to assess the process of an iKT approach and to learn about barriers and facilitators for collaboration.
These four factors reflect CIHR's merit review criteria used to evaluate grant proposals requiring iKT and provide a useful framework with which to approach any project that involves iKT.
Merit review takes into account the scientific merit as well as the potential impact of the project. Scientific merit generally reflects the rigour and appropriateness of the proposed research methodology and the strength of the research team. Potential impact reflects the relevance or importance of the project to the knowledge users and the likelihood that the project will have a substantive and sustainable impact in the study context.

Integrated Knowledge Translation (iKT) Project Proposal Worksheet
Using CIHR's merit review criteria, this worksheet will guide project teams and reviewers through the key questions associated with each factor within a proposal and will provide bottom-line points for consideration. Despite advances in health care, children who are vulnerable because of their material and social circumstances remain the most likely to suffer the consequences of delayed development and poor health. [10][11][12][13][14] These effects have a long-term, cumulative impact. 15 Lack of access to appropriate health care further compounds these disadvantages and has been identified as an ongoing challenge for children "at risk" in both urban and rural settings. [16][17][18] Looking to CIHR's Partnerships for Health System Improvement (PHSI) program, Dr. Mary Judith Lynam's team proposed to examine an alternative model of community-based health care delivery -the Responsive, Intersectoral-Interdisciplinary, Child-Community, Health, Education and Research (RICHER) model -for children who are vulnerable as a consequence of poverty and exclusion. This innovative proposal involves an interdisciplinary, community-based approach designed to complement existing health services and provide care to those children who are most at risk. The participating practitioners seek to address fragmented care by creating enduring, supportive relationships while also working in partnership with other community organizations. This collaborative relationship building is intended to facilitate access to health services across the continuum of care, from prevention to specialized assessments and treatment, while accommodating natural transitions in service delivery between early childhood, school age and youth or young adulthood.

Research Question
In their proposal, the researchers communicate their aim to work in close partnership with leaders in health services delivery to examine an innovative approach to primary health care (PHC) delivery to a vulnerable population and to involve them in the research process. This aligns well with the objectives of the PHSI grant, to support a collaborative approach to applied health systems and services research that is useful to health system managers and policy makers. The specific research questions to be addressed in the study are outlined in detail. These include examining the perspectives of service providers and at-risk families on the accessibility and responsiveness of existing and proposed models of PHC delivery, exploring the organizational and infrastructure supports needed to sustain a new practice model and identifying appropriate KT strategies to effectively engage knowledge users with the results of the study.

Research Approach
A thorough overview of the study methods is included in the proposal. These methods involve a mixedmethods, collaborative case study approach, with a variety of qualitative and quantitative data collected through interviews and surveys. The project team provides a strong theoretical foundation for the research, drawing upon literature from social pediatrics, child development and health inequities, and supplies ample supporting evidence for this best practice approach to addressing inequities in child health. As the first social pediatrics model of its kind in British Columbia, the proposal highlights the importance the study will have in increasing knowledge about the effectiveness of the model in providing care to at-risk children and their families. It proposes that lessons learned from this study will inform institutional partnerships in other health regions to explore the feasibility of introducing or adapting the model to address health needs of at-risk children in other communities. For this, the researchers outline varied strategies to support ongoing KT activities that will take Guide to Knowledge Translation Planning at CIHR: Integrated and End-of-Grant Approaches

Examples of Integrated Knowledge Translation (iKT)
The following three examples help to illustrate the factors that make a strong proposal for research with an iKT approach.
place in a number of forums in order to foster dialogue among institutional, clinical and community partners as well as potential knowledge users around the province. By providing different forms of engagement through research activities and sharing of emergent insights, the researchers plan to foster a working relationship among formal health services sectors, while also promoting collaboration between the formal sector and community-based resources. The proposal outlines plans for holding annual workshops with provincial health authorities, sponsored by Child Health BC, to discuss emerging insights on access, responsiveness and the organization of care.

Feasibility
The knowledge-user partners involved in the project show a clear commitment to undertaking the study and using the findings to improve practice models, as evidenced by the letters of support that accompany the proposal. Participating knowledge users hold leadership roles in community, provincial and regional health organizations. Given their existing roles in managing and providing health services and care within the study community, they are well situated to inform the project and translate the study findings.

Outcomes
The project team anticipates that the study will produce evidence related to access and responsiveness of community health services, which will inform a new model of delivering PHC to vulnerable pediatric populations. While there are more immediate implications for the delivery of health services within the study location of Vancouver's Downtown Eastside, it is clear that the study findings have strong potential to be transferable to other communities in British Columbia and Canada.

From proposal to reality -where is the project now…
Although data gathering is ongoing, a sufficient amount of qualitative data has been collected to be able to describe key features of the practice approach and to capture the organizational processes that have been developed to implement the clinical practice initiative within the community context. 19 The team also adopted a standardized tool to conduct a survey (in English and Chinese) related to PHC access, responsiveness and continuity of care. The standardized survey results suggest that RICHER does foster better PHC access for a population made vulnerable by social and material circumstances. Respondents were disproportionately poor, had lower education than the provincial average and had a child or children who had an identified developmental delay or chronic health condition. The results also show that the clinical approach reflects quality PHC and that the clinician's interpersonal style of compassion and respectfulness is key to empowering patients to care for their health and the health of their children. These findings suggest why aspects of interpersonal communication are important in achieving outcomes of PHC. [20][21] A unique feature of the project is that it has provided the impetus for bringing together knowledge users from all levels of health systems -consumers, practitioners and leaders within health authorities. The project team regularly participates in presentations, workshops and consultations to wide-ranging audiences. These presentations are used to share Guide to Knowledge Translation Planning at CIHR: Integrated and End-of-Grant Approaches

End-of-Grant KT Plan
The project's principal KT goal is to foster dialogue on issues of accessibility and responsiveness derived from the study data while exploring the feasibility of implementing the proposed model in other communities. As the study unfolds, the project team intends to share emerging lessons through workshops and discussion papers in an effort to engage targeted knowledge users. The strategy requires the involvement of community and knowledgeuser partners within the study location of Vancouver's Downtown Eastside, as well as more broadly within other health regions in British Columbia.
information and research insights on the clinical practice initiative, processes of community engagement, the health challenges of children in the target community and evidence related to effective approaches, while also exploring points of connection with other practice contexts. In addition to this, the team partners each year with a provincial child health policy group and organizes a one-day provincial workshop with decision makers from each of British Columbia's health authorities and policy leaders from related portfolios (e.g. Ministry for Children and Families).

Closing Care Gaps in Cardiovascular Medicine
Every seven minutes in Canada, an individual dies from a heart attack or stroke. 22 Patients who survive a heart attack or stroke are at increased risk for future cardiovascular events and dying from atherosclerosis (hardening of the arteries). 23 Strong evidence from clinical trials suggests that these patients should receive long-term treatment with an anti-platelet drug (such as aspirin), a cholesterol-lowering drug (such as a statin), an ACE inhibitor or angiotensin receptor blocker and a beta blocker. 24 Despite numerous practice guidelines promoting these medications, many affected individuals do not receive these drugs.
Applying for a Knowledge Synthesis grant from CIHR, Dr. Daniel Hackam's team set out to comprehensively review and synthesize the medical literature to determine the most effective strategies for increasing the prescribing of these lifesaving therapies in patients with cardiovascular disease. With the help of its knowledge-user partner, the Canadian Cardiovascular Society (CCS) -in particular, the individuals who sit on the Society's guideline committees -the team plans to disseminate its research results to the cardiovascular community, where it will enter the current guideline creation cycle and enhance ongoing efforts to improve the quality of cardiovascular prevention for Canadians.

Research Question
In the project proposal, CCS clearly identifies a pressing need to bridge the gap between the strong research evidence around effective prevention therapy for atherosclerosis and the actual medical treatment received by most patients with vascular disease. Building on this need, the project team proposes to undertake a synthesis of existing treatment strategies for patients with vascular disease, focusing specifically on those receiving ambulatory care and starting with the concept of non-invasive imaging to improve medical risk reduction. The team intends to use the results of its systematic review to inform practice guidelines for the care of the target patient population.

Research Approach
The methods to be used are well described and appropriate to the research question, following established standards for systematic review, metaanalysis and meta-regression. The proposal further outlines in detail the study selection criteria, search strategy, preliminary outcomes and data synthesis. As a participating knowledge user, CCS is clearly engaged throughout the project, from contributing to the research plan to informing the end-of-grant KT plan.

Feasibility
To successfully undertake the proposed study, the project team includes complementary expertise in systematic reviews, quality of care, cardiovascular disease and pharmacoepidemiology and enlists an appropriate blend of clinical researchers and executive staff from CCS. The proposal identifies the potential limitations of the study but also highlights the involvement of CCS as key to facilitating the interpretation and dissemination of the research results, specifically targeting guideline producers and practitioners at key institutions.

Outcomes
Given the current care gaps identified by the project team, the potential impact of this study is significant.
The team has ensured that its proposal underlines the implications of the synthesis results for clinical care and future research. It also indicates that the data produced from the study will permit clinicians, managers and policy planners to select the most appropriate and promising interventions for improving secondary prevention of atherosclerosis.

From proposal to reality -where is the project now…
In its work to date, the project team has focused its attention on specific strategies that might improve the application of clinical guidelines to current patient care.
As an example, it has systematically reviewed and metaanalyzed whether non-invasive cardiovascular imaging leads to improved cardiovascular clinical care. The results suggest that some process markers do improve in patients randomized to receive non-invasive imaging; while other markers do not. The first publication from the team focuses on primary prevention patients; 25 future publications will analyze and present other modalities that influence closure of care gaps in cardiovascular disease.

Building Tools to Help Patients Manage Rheumatoid Arthritis
For someone with rheumatoid arthritis (RA), the period shortly after diagnosis is often filled with uncertainties and anxiety as the patient searches for information to make treatment decisions. With an aim to improving a patient's ability to participate in shared decision making about a course of treatment, Dr. Linda Li's team is developing a web-based decision aid with the support of a CIHR Knowledge-to-Action grant.
The team proposes to develop and evaluate an Animated, Self-serve, Web-based Research Tool (ANSWER) designed to support people with RA in making decisions about their treatment. ANSWER will combine the best evidence of treatment options, the contextual information about how to make health care decisions and the concept of effective consumers. The project team's proposal highlights the fact that the content, storyline and animation for ANSWER will be developed in collaboration with members from six different disciplines (clinical and health services research, social and information sciences, knowledge translation and graphic design/animation production) as well as knowledge users from the arthritis community, with the final product available for public access at the end of the evaluation.

Research Question
The proposal for this project makes a strong case for the need to bridge the gap between the research evidence around RA care and the actual use of effective treatments. The project team outlines in detail its specific objectives for the development of ANSWER, to provide evidence-based information and decision support for people with RA. Justification for the tool is provided, citing research around the factors that affect the treatment decisions of people who have been recently diagnosed with RA and the effectiveness of interactive decision aids in improving care.

Research Approach
The ANSWER team proposes to develop the program based on rigorous criteria outlined in the International Patient Decision Aid Standards and through a collaboration of health researchers, computer animation experts and trainees and RA patients. The tool will be Guide to Knowledge Translation Planning at CIHR: Integrated and End-of-Grant Approaches

End-of-Grant KT Plan
A strong partnership with CCS strengthens the project's end-of-grant KT plan and increases the likelihood of broad dissemination to the national cardiovascular community. As the producer of a number of major practice guidelines, CCS is well placed to disseminate study findings to panels in the process of updating these guidelines.
piloted and further improved based on feedback from a group of target users. Another strength of the ANSWER project is the active and committed involvement of experts from the six relevant disciplines as well as knowledge-user groups. Collectively, members of this team have contributed from the planning phase of the project through to its completion.

Feasibility
The project team highlights existing relationships with key patient and consumer groups, including the Canadian Arthritis Patient Alliance and The Arthritis Society, that are well positioned to assist in the development of KT activities. Recognizing the potential benefit of the ANSWER program for the management of early RA in primary care, the B.C. Ministry of Health has agreed to provide informal consultation for the tool development and to assist in disseminating the final product in primary care settings in British Columbia.

Outcomes
By developing a user-friendly tool that can be distributed widely on the Internet, the ANSWER team is confident that the final product can reach people who may not be familiar with the use of decision support or who have difficulties in completing the existing paperbased RA decision aids. It is expected that in promoting the practice of shared decision making, ANSWER will ultimately help to improve RA patients' ability to be effective users of health care resources.

From proposal to reality -where is the project now…
In spring 2011, the ANSWER team completed the program development and usability testing with patients and health professionals. 26 The pilot study is currently under way in British Columbia. A total of 51 patients who are newly diagnosed with RA will be recruited to evaluate the effect of the program on the quality of their treatment decisions. Additional funding from the Canadian Initiative for Outcomes in Rheumatology Care will allow the team to expand data collection into Alberta and Ontario.
The ANSWER program was developed in collaboration with four patient/consumers and 15 Masters of Digital Media trainees from the Centre of Digital Media in British Columbia. An achievement of this project is the rich iKT experience that has been provided for these trainees. All of them had expressed an interest in a career of developing health-related online tools and services, but none had worked with people with chronic disease. Through the ANSWER project, the trainees had their first opportunity to work closely with RA patients and to understand their challenges and needs while using web-based tools. This excellent partnership has resulted in a second KT project, which is also being funded by a CIHR Knowledge-to-Action grant.
ANSWER exemplifies how a CIHR-funded KT project can provide unique opportunities for researchers and for those from other innovative disciplines to forge collaborations with knowledge users.
Guide to Knowledge Translation Planning at CIHR: Integrated and End-of-Grant Approaches

End-of-Grant KT Plan
The principal goal of the KT plan is to build awareness of arthritis-related decision aids, such as the ANSWER program, and disseminate key findings from the pilot study to target audiences. The team will engage representatives from patient organizations like The Arthritis Society who will act as spokespersons and participate in refining messages for defined audiences. A strategy is in place to evaluate the impact of proposed KT activities and to help determine the uptake of the ANSWER program among targeted groups.

End-of-Grant Knowledge Translation (KT)
End-of-grant KT covers any activity aimed at diffusing, disseminating or applying the results of a research project, as defined below. Methods appropriate to translating research findings range from simple communication activities (diffusion, dissemination) to more intensive knowledge application efforts, such as workshops, academic detailing and tool development (for more on these strategies, please see Strategies on page 13). Conference presentations and publications in peer-reviewed journals have often been the principal modes of communication to researchers. These forms of KT remain the best approach for research at the early stages of discovery, when the knowledge has more relevance to academics who are contributing to a body of evidence that is not yet appropriate for application. Publishing in open-access journals or repositories has the potential of reaching a much broader audience, thus increasing the likelihood of research uptake by those in the academic community as well as knowledge users and the general public.
When there are potential knowledge-user audiences beyond the research community, end-of-grant KT activities should be more intensive and emphasize nonacademic modes of communication: the language of publications should be adapted to the target audience (e.g. lay language) and can be presented in popular formats, such as websites or creative media (e.g. film, theatre, art). Sharing of knowledge may be done face to face in a meeting/workshop setting by a knowledge broker (an individual specializing in the communication of findings to knowledge users, in their context) or via emerging online technologies (e.g. podcasting, webinars, YouTube). To disseminate more broadly to the general public, media such as television, radio and print may be engaged.
The KT activities chosen should draw on evidence about what media/formats are most effective for that particular group of knowledge users and should be tailored to their individual needs. Even research aimed at scientific audiences and peer reviewers, including early-stage discovery proposals, should have a lay summary at both proposal and final report stages that clearly delineates where the research is expected to lead.
The development of products and services based on research results, including commercialization activities, is also a form of end-of-grant KT.

Appropriateness
For all KT activities, the most important consideration is appropriateness. Each discipline, research project and knowledge-user community is different. When there are limitations on the validity or generalizability of the results, a modest approach is most appropriate. The key to a successful plan is to ensure that there is a match between the expected research findings, the targeted knowledge-user audience and the KT strategies selected.
It may, at times, be appropriate to apply the results of a single study, but the scope and strength of the evidence must be considered when defining the KT activities.
A single study can represent either the culmination of a large body of work ready for application or a nascent area of research where the findings may not yet be generalizable. In the latter case, KT efforts to apply the findings could result in more harm than good. Synthesized evidence is generally more robust and mature, thus it usually constitutes the best knowledge for widespread application.
A good approach to ensure an appropriate KT plan is for the research team to revisit the plan throughout and upon completion of the project and adjust, as necessary, as results evolve.
Guide to Knowledge Translation Planning at CIHR: Integrated and End-of-Grant Approaches

Knowledge Translation (KT) Factors for Consideration
The following five factors should be addressed in endof-grant KT plans. 27 These factors are the same regardless of the domain of research, though how they apply will vary.

Goals
There are two broad goals typical of end-of-grant KT activities: raising awareness and promoting action. Whether goals are modest or ambitious, they must be appropriate to the nature of the research findings and the target audience. Applicants should clearly state and justify their proposed KT goals.

Knowledge-User Audience (outside of project participants)
Applicants should identify the individuals and/or groups that should know about the research findings. A good plan will demonstrate a detailed understanding of its knowledge-user audience. Audiences should be precisely defined with respect to their sector of work and their role in decision making related to the research findings -simply mentioning clinicians, managers, policy makers, etc., is not sufficiently specific to make clear that the audiences selected are appropriate to the identified goals. Applicants should try to understand the current state of the audiences' knowledge, how they tend to use knowledge and the formats in which they prefer to receive their information. For iKT projects, knowledge users participating as members of the research team should be able to assist with this. Depending on the relationship between the research team and its broader knowledge-user audience at the outset of the project, modifications to the end-of-grant KT plan may be required as the plan is being implemented. Because a single project can have several potential audiences, it is acceptable to prioritize, but applicants should provide a rationale for selecting one audience over another. Applicants should clearly identify and justify their target audiences.

Strategies
Applicants should propose methods to reach their identified audiences and deliver on the KT goals that are appropriate to the research results. End-of-grant KT strategies broadly fall into three categories: diffusion, dissemination and application (explained below). The nature of the target audience and the type of evidence will determine which strategies are appropriate.

Diffusion (let it happen) is the communication of
information using delivery mechanisms for which little customization is required to reach target audiences that typically seek out research evidence.

Dissemination (help it happen)
is more tailored, in that the communication vehicle and messaging are adapted to the specific audience and/or context in which the knowledge will be used. It is important to consider both the processes for adapting the evidence and the strategies for its dissemination.
3. Application (make it happen) is more tailored still, as it moves knowledge into use in cases where the strength of the evidence is sufficient. Selected strategies should be well justified in the context of the goals and target audiences and should consider barriers and facilitators to knowledge use. Key messages should be identified.
Applicants should present strategies that support their KT goals and adapt the knowledge to audience needs and context of use.

Factor v Key questions
• Are the KT goals clear, concrete and well justified?

Goals
• Are the KT goals appropriate to the potential research findings and the target knowledge-user audiences?
• Does the plan consider all potentially relevant knowledge-user audiences?
• Are the audiences precisely defined in terms of their sector, roles, responsibilities Audience and decision-making needs/opportunities?
• Does the plan demonstrate an understanding of the proposed target audiences, including their knowledge needs in the research area and their preferences for using knowledge?
• Are key messages clearly identified?
• Are the strategies appropriate to achieve the KT goals?

Strategies
• Does the plan take into consideration the context in which the knowledge is to be used?

Options
KT goals could include: * increase knowledge/awareness * inform future research * inform/change attitudes * inform/change behaviour * inform/change policy * inform/change practice * inform/change technology * other: Target audiences could include: * community-based and not-for-profit organizations * general public * health care professionals/service providers * health system administrators/managers * industry/venture capital group * media (print, TV, etc.) * patients/consumers * policy makers/legislators * private sector * research funders * researchers * other:

Factor Key questions
• If appropriate, is there a plan to adapt the knowledge to each specific audience?

Strategies
• Have mitigating factors been considered that might affect the applicability of the research findings or the effectiveness of the planned KT activities?
• Does the plan consider barriers and facilitators to knowledge use?

Options
Dissemination * patient decision-support aids (e.g. paper or webbased tools that provide information about options and outcomes) • Are all necessary knowledge users involved to achieve the stated goals? • Is there a sufficient description of the Expertise team's ability to execute the proposed strategies?
• Where appropriate, does the team plan to collaborate with members of its target audiences?
• Does the budget allocate adequate Resources financial support to implement the plan?

Options
* identify barriers/supports to the use of findings * tailor messages and interventions to promote use * monitor knowledge use * evaluate outcomes * ensure sustainability * other: Expertise required could include individuals in the following roles:

Examples of End-of-Grant Knowledge Translation (KT)
The following examples illustrate how end-of-grant KT can be applied in practice.

Protein Transport Into and Across Cellular Membranes
Every cell has a membrane that separates its interior from its environment, regulates what moves in and out and maintains the electrical potential of the cell. Embedded within this membrane are a variety of protein molecules that act as channels and pumps to move different molecules into and out of the cell.
For many proteins, there is a good understanding of the machinery that inserts them into membranes. In 2005, however, we knew very little about a class of proteins called tail-anchor proteins. These proteins are involved in a wide range of crucial cellular processes and have been linked to a number of diseases, including diabetes, myotonic dystrophy, ALS (Lou Gehrig's disease), cancer and autoimmune diseases.
Understanding the specific mechanisms related to tailanchor proteins is a key development in furthering this field of study. Dr. David Andrews and his team from McMaster University received a CIHR Operating grant from 2005 to 2010 to explore these proteins. Specifically, one of the team's research questions aimed to determine the molecular machinery by which tailanchor membrane proteins are assembled in the correct subcellular membrane.
The initial grant submission proposal included a KT plan that identified the KT goal of increasing knowledge and awareness of this topic area to inform future research. The team identified the key audience of this research study to be researchers in the fields of genetics and microbiology. To reach this audience, the team's proposed KT strategy included diffusing its research evidence via academic conference presentations and peer-reviewed publications within the fields of biochemistry, cell biology and microbiology. The expertise of the research team clearly identified its ability to communicate with its target audience and publish/present within this field of study. Fees to cover open-access costs and conference registration and travel were included within the grant budget to ensure sufficient resources to implement the KT plan.
Throughout this project, the KT plan was revisited and implemented as initially proposed, since it remained appropriate for these early stages of discovery findings. To achieve its goal of increasing knowledge and awareness among its target audience, the team submitted peer-reviewed publications.

Retention of Locally Trained Physicians
Physician shortages have long been identified as a priority issue in reports released by numerous national bodies. These shortages were highlighted in the National Population Health Survey, which reported that 14% of Canadians did not have a regular physician. 28 The migration of physicians to other parts of Canada contributes to these shortages, and both Saskatchewan and Newfoundland and Labrador have a long history of physician shortages. Historically, these provinces have relied on international medical graduates to address these gaps, particularly in rural and remote communities.
A research team led by Dr. Maria Mathews, associate professor of health policy/health care delivery at Memorial University of Newfoundland, received CIHR funding via the Partnerships for Health System Improvement program to examine this topic area. Specifically, this project aimed to: 1. describe the number and nature of changes in physician practice location over the course of a physician's career; 2. describe the factors related to changing a practice location; and 3. examine the predictors of University of Saskatchewan medical graduates who work in Canada, in Saskatchewan and in rural communities.
The KT goals of this research project included increasing knowledge and awareness of physician relocation patterns and their consequences and informing policy change related to local physician retention. The KT strategy concentrated efforts on audiences in Saskatchewan and Newfoundland and Labrador, such as departments of health, regional health boards, health board associations, medical schools and study participants. To reach these audiences, the team planned to distribute a summary report written in nontechnical language, give presentations (e.g. at meetings of health board medical directors, medical schools, etc.) and conduct one-on-one briefings with provincial health decision makers. The team also intended to utilize the media services available through the participating universities and funding partner organizations to publicize its findings via websites and newsletters. To reach its secondary audience of researchers, the team would present at academic conferences and publish in peer-reviewed journals.
In addition to the expertise within the research team, an advisory panel consisting of decision makers to whom the results of the study would be particularly relevant (e.g. department of health/health and community services, medical associations, licensing boards) was established in each participating province.
These panels were expected to provide feedback on interview questions, help interpret results, craft recommendations and disseminate study findings. This iKT approach can increase the chances of successfully implementing a proposed KT plan. Included within the grant budget were resources to contract a writing consultant to prepare lay summaries of the research findings.
At the conclusion of the research project, the KT plan was revisited and implemented as initially proposed, with some additional components. To achieve its KT goal of informing policy change, the research team provided policy briefs to Health Canada and to provincial health authorities across Canada, rather than just within the participating provinces. The expanded audience included provincial deputy ministers of health. Also, meetings with local physician recruiters were organized. This altered KT strategy was suggested by the advisory panels, whose expertise was crucial throughout the project. The policy briefs provided identical information to each province and were built upon the consultant summaries that were included within the resource allocation of the original grant proposal.

Knowledge Brokering in Pediatric Rehabilitation
When parents first discover that their child has cerebral palsy (CP), a condition that primarily affects motor development,

Resources
No change -plain-language writing consultant -conference registration fees -travel costs communication of findings to knowledge users in their context. The study was to determine the effectiveness and impact this role would have in supporting the evidence-based practice of PTs working with children who have CP.
In developing an end-of-grant KT plan for its grant proposal, the team identified the short-term KT goals of a face-to-face meeting with the KBs to discuss the preliminary results and get their perspective on the knowledge brokering intervention. The longer-term KT goal was targeting the broader community to increase awareness of the KB strategy as a method of supporting the integration of these and other evidence tools into practice. The identified audiences for the preliminary results of this research project were service providers for children with CP and CRO administrators. Russell expected the KT strategy to include a variety of products (e.g. web postings of summary of results, electronic teaching materials), presentations and workshops at relevant clinical conferences (e.g. American Academy for Cerebral Palsy and Developmental Medicine, Canadian Physiotherapy Association) and peer-reviewed publications. With a research team that included clinicians, clinical administrators and academics, the expertise was in place to undertake the proposed activities. The resources detailed in the proposal budget included funds for the development of these electronic materials and conference registration fees.
At the conclusion of this research project, when peerreviewed publications were under way, [29][30][31] Russell and her team identified the need for additional strategies to engage with the participating CROs. Their original KT goals remained the same; however, while undertaking their Operating grant, they recognized that traditional dissemination activities included within their KT strategy (conference presentations, workshops and journal publications) and a broad mass-media strategy (web postings) were not the most effective means of engaging with all their identified audiences. To overcome these barriers, the research team successfully obtained additional resources via a CIHR Dissemination Event grant. The objectives of this grant were to work closely with the KBs to develop and target the dissemination of user-friendly materials describing the findings from the original study and to provide for an interactive exchange between 28 study sites. Appreciating both the hectic schedules of administrators and clinicians and the fact that the study sites were situated across three provinces, the team opted to organize a series of teleconferences with all the participants from the original study, including administrators, KBs and PTs. The focus of the teleconferences was to encourage participating sites to discuss the impact of the KB study and whether and how participants might consider implementing a KB role more broadly, thus combining the expertise of the research team with its identified audiences. Prior to the teleconference meetings, user-friendly research summaries were developed in collaboration with key stakeholders and circulated by the KBs to their own administrators and PTs. 32 In addition, several discussion questions were precirculated to allow dialogue at the individual sites prior to the teleconference, when the participants would be discussing their organizations' ideas and plans with the other CROs and the study team. During the teleconference, suggestions were made for the creation of a one-page summary of study results specifically targeted to the CEOs, 33 the principal decision makers who would ultimately influence the funding of a KB role within rehabilitation organizations. Finally, participants wanted and received a document summarizing the teleconference ideas that they could use for planning, 34 a PowerPoint presentation and a poster to further disseminate the study results within their own organizations. An individual from each CRO was identified for a follow-up interview three months postteleconference to evaluate whether his/her organization was considering implementing a KB role. These followup interviews revealed that a KB model had been implemented in two organizations and that another seven were discussing ways to make it happen.

Knowledge Translation (KT) in the Fight Against the Global Tobacco Epidemic
An estimated one billion people are projected to die in the 21st century as a result of tobacco use. 35 The world's first health treaty, the WHO Framework Convention on Tobacco Control (WHO FCTC), was developed in response to the tobacco epidemic. The WHO FCTC identifies policies that ratifying nations must implement, such as enhanced warning labels, smokefree laws, advertising bans and higher taxes. There were many KT goals for this project, including informing future research and increasing government decision makers' knowledge of tobacco-use prevalence and its consequences as well as their awareness of the current level of effectiveness of their country's tobaccocontrol policies. The research team also had a KT goal to strengthen policy in participating jurisdictions and, ultimately, to change the behaviour of smokers. The initial relevant audiences for these research findings included researchers, policy makers and advocacy groups. In parallel with traditional dissemination efforts like conference presentations and journal publications, the proposed KT strategies included drafting and disseminating plain-language reports, summaries and/or briefing notes of the key findings for government decision makers, with input from knowledge users, including representative policy makers and advocacy groups. The development of these tailored messages, using a broad range of expertise, ensured that the reports, along with policy reports prepared for policy makers on specific policy domains (e.g. warning labels, cessation), were properly contextualized and culturally appropriate and addressed the specific tobacco-control policy needs of each country. These resource-intensive activities were included within the original grant budget because the development and implementation of national tobaccocontrol policies lie within the domain of governments; therefore, it was important to keep policy makers abreast of the current evidence, not only in their country but also in other countries, particularly those that could serve as models of best practice and inspiration for stronger action in tobacco control.
Upon completion of the original grant, the KT plan was reviewed and implemented with minor changes. However, in seeing how well received the research findings were, the research team determined that the results would also be beneficial for the general public and for decision makers in other jurisdictions. The team applied for and received a Knowledge Translation Supplement grant from CIHR, which allowed the ITC Project research team to further its KT goals. To reach this wider audience, including attendees at the World Conference on Tobacco or Health and the general public via the Internet, the research team undertook additional KT strategies with the development of more ITC Project dissemination products. Such products included national reports for low-and middle-income countries and synthesis reports to summarize survey results on the effectiveness of smoke-free policies and the factors associated with successful smoking-cessation programs and policies. Throughout the many years of this initiative and by working with various knowledge users, the research team gained expertise in reporting research findings to non-academic audiences.

KT plan in project proposal Additions to KT plan
Goals Goals -inform future research -influence smokers/public -increase knowledge/awareness -inform/change practice -change behaviour of smokers

Audience
Audience -researchers -general public -tobacco-control policy makers -additional countries/jurisdictions -advocacy groups

Strategies
Strategies Diffusion Dissemination -conference presentations -tailored national reports for participating -peer-reviewed publications countries Dissemination -summary of smoke-free policies -engage champions/opinion leaders -plain-language summaries -summary briefings to stakeholders Application -tailor messages and interventions to promote use (tobacco warning labels)

Expertise
No change -input from representative policy makers and knowledge users -input from representatives from multiple countries -linguistic translation

Resources
Resources -production/printing -Knowledge Translation Supplement grant -workshop/meetings/networking costs -production/printing To view the entire case study, please refer to our Knowledge to Action: An End-of-Grant Knowledge Translation Casebook, see page 26.