Health promotion and knowledge translation: two roads to the same destination?

Introduction

This paper emerged out of a series of conversations between two young professionals as they struggled to appreciate and apply what they knew about health promotion (HP) and knowledge translation (KT). Maeve Paterson (MP), a recent graduate with a Master’s in Public Health, has spent the last two years developing an understanding of and appreciation for the various theories and practices of HP. Stephanie Lagosky (SL) also studied HP but found herself increasingly drawn towards KT. After graduating with a Master of Science Degree in Health Professional Education, Stephanie has spent the last 2.5 years working in the KT field at Women’s College Research Institute. Dr Robin Mason, a seasoned professional in research, HP and KT, supervised both Maeve and Stephanie over a summer period and during that time encouraged lively discussion around their academic interests and professional roles.

In the pages that follow we try to convey the essence of our conversations in struggling to understand each other, the historical foundations for some of those struggles, and the compromises we reached in becoming conversant with the emergent and fluid domains of HP and KT.

In the beginning

MP: For many, including myself, understanding what qualifies as a ‘health promotion’ initiative is unclear. This may be attributed to the fact that HP is a constantly evolving field (1) as new approaches to researching social behaviours, addressing health concerns and advocating for the values of equity and healthy public policy are continuously developed. Generally, HP is understood as the process of enabling people to increase control over, and to improve, their health. According to the Ottawa Charter, ‘health promotion is not just the responsibility of the health sector, but goes beyond healthy lifestyles to well-being’ (2). For the diverse professionals working in public health and HP, conceptual vagueness and changing terminologies have been cited as creating critical communication barriers (3).

I was presented with one of these critical ‘communication barriers’ when completing my first practicum at Women’s College Research Institute. I was asked to develop a KT strategy for an online curriculum. At first I was intimidated. I had never heard of ‘knowledge translation’ which, according to the Canadian Institutes of Health Research (4), is 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/products and strengthen the healthcare system. This process is described as taking place within a complex system of interactions between researchers and knowledge users which may vary in 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 (5).

After some preliminary research, I was struck by the ways in which KT tactics, including an emphasis on participant and community feedback, paralleled familiar HP strategies. I wondered what made HP and KT distinct from one another. I asked, ‘How are KT and HP radically different and in what ways are they the same? What are the consequences of creating distinct languages and disciplines to refer to communication procedures in health related fields?’

In looking for answers, I approached SL and we began to discuss and debate these and other questions. From a HP perspective, I argued that KT is not new but a by-product of practices and values already integrated into HP activities.

SL: I was introduced to KT through my undergraduate degree in health sciences. KT was presented as a novel solution to bridging the 17-year lag between research findings and their implementation in practice (6). The action-oriented approach to research immediately appealed to me and I decided to further explore this field. The landmark paper, ‘Lost in knowledge translation: Time for a map?’ (3) has influenced my understanding of the theory behind KT. According to Google Scholar, this seminal paper has been cited over 1500 times. It also forms the basis of the Canadian Institute of Health Research’s KT mandate and it helped shape my master’s thesis on how to monitor knowledge use in parents of children with cerebral palsy. My experience with studying KT in a caregiver/patient population gave me a unique perspective; most people associate KT strategies with policymakers or clinician audiences.

When MP asked me to clarify the difference between KT and HP, my initial response was that the underlying value of KT is that knowledge from research is power, whereas HP’s core belief is that health is a resource for everyday living and a fundamental human right (7). I reflected a bit deeper on their differences. Firstly, KT assumes that using research evidence to inform policy, practice and decision making will improve the health of populations. Secondly, HP uses research evidence and mechanisms like the knowledge-to-action framework described in Graham et al. (3) to improve the health of populations. The differences were not as clear as I had thought. We decided to further explore the literature and speak with more experienced practitioners in the HP and KT communities.

Synonyms and synergies

Exploring the literature was challenging as both HP and KT are beset with definitional and terminological confusion. HP practices can, for example, be found in ‘health improvement’, ‘health education’ and ‘population health’ (8). HP activities are diverse and can include any ‘planned combination of educational, political, environmental, regulatory, or organizational mechanisms that support actions and conditions that are conducive to the health of individuals, groups and communities’ (1).

KT has also been criticized for the multiple titles, terms and vocabulary used to describe its practice. For example, ‘knowledge transfer’, ‘research utilization’, ‘implementation science’, ‘knowledge interaction’ and ‘participatory action research’ are all terms employed to describe processes used to encourage the uptake and utilization of research by the intended target audiences (3,9,10).

Comparing theoretical foundations and end goals

Historically, both HP and KT developed in response to the fact that knowledge does not change behaviour. For example, it is well known that smoking or being sedentary are unhealthy behaviours, yet changing those behaviours has proved difficult. Similarly, advocates know that decision makers may be aware of the latest research findings but they do not readily act upon them, even when those findings are potentially valuable and important to their practice (9).

Health promoters and KT specialists draw upon social behavioural theories to understand how individual intent and subsequent actions are determined, influenced and altered. For example, many HP individual-level interventions are guided by the Health Belief Model. In this framework, the perceived benefits of engaging in an activity (based on supposed risk/severity of a condition) and perceived barriers (self-efficacy and predictive negative consequences of a health action) are weighed and provide the cue to action or inaction (11).

KT processes are often grounded in the two-phase ‘knowledge-to-action cycle’ developed by Graham et al. (3). The knowledge creation phase illustrates the refinement and synthesis of knowledge from first-generation, primary-sourced research-to-knowledge tools or products tailored to knowledge users’ needs (12). The action phase, derived from a review of planned action theories, frameworks and models (3) focuses on supporting planned change (13). Thus, sustainable and intentional change is a core goal of both HP and KT.

Furthermore, HP and KT target similar audiences. HP targets individuals and communities to improve self-determination. The information disseminated is intended to increase choice, empowerment and the ability to make healthy informed decisions. HP initiatives also target decision makers to create healthy public policies, which requires policymakers in all sectors to consider the health consequences of their decisions, including those in non-health-related divisions (2). In KT endeavours, the primary audience is healthcare providers and, similar to HP, policymakers and communities. Then, if successfully translated, the information is adopted into health professional practice and used once again to inform policy decisions.

Stakeholder and end-user participation

Obvious similarities between HP and KT are found in their mutual emphasis on stakeholder engagement and end-user participation. One of the three core HP implementation strategies listed in the 1986 Ottawa Charter includes public participation (14). Engaging end users in HP has been coined using various terms including ‘participatory research’ and ‘community engaged scholarship’ (15).

The contributions of the end users of a program, policy or research findings is also a core value in KT (4). Partnerships are integral in KT and are encouraged among researchers, policymakers, healthcare providers and healthcare users (16). There is growing evidence that successful uptake of knowledge requires more than one-way communication; the interests and needs of those in the field need to be included. Both HP and KT acknowledge that ‘multidirectional information exchange’ (17) among researchers, decision makers and other stakeholders is essential (12).

Strategies and techniques

HP and KT initiatives seem to use similar strategies to share information. A systematic search, conducted by Goldner et al. (9) strengthened our observations. Goldner et al. (9) wanted to identify core KT tactics used in everyday practice. Fifteen techniques used to influence healthcare providers, the general public and decision makers were identified. They included mass media campaigns, community mobilization, laws and regulations, financial incentives and disincentives, educational outreach, reminders and prompts – all are methods used in daily HP practice.

Moreover, additional similarities also became evident. Both HP and KT strategies tailor interventions to local contexts, assess the barriers to knowledge use and evaluate the outcomes of knowledge use while working towards sustainability (3,18). Also, both KT and HP efforts advocate for the support of ‘champions’ or influential leaders to achieve desired outcomes.

The difference: diverging values

We have argued that HP and KT are more alike than different. But there are differences, most notably in the core beliefs or values informing practice. As Carter et al. declared (19), HP professionals are deeply committed to social justice and equity. Self-determination, community capacity building and advocacy are also highly valued (20, 21). These are referenced little, if at all, in the KT literature. The key justification for KT that ‘knowledge is power’ informs KT’s primary purpose, putting research into practice. In so doing, the values of fairness or social integrity are not mentioned. KT, while an essential tool for health promoters, may not share HP’s equity-focused agenda.

Asking participants from the field: Canadian Knowledge Transfer and Exchange Community of Practice (KTE CoP)

Seeking additional clarity, we posed a question to the members of the Canadian Knowledge Transfer and Exchange Community of Practice (KTE CoP) listserv: ‘What is the difference between KT and HP?’ To our surprise, a lively discussion ensued. As we reviewed the many responses, they seemed to fall into one of two positions.

The first acknowledged the considerable overlap between HP and KT. Despite having the same fundamental goals of improving health through informed, evidence-based decision making, the two fields had at some point diverged, largely through the use of different language to describe similar processes. Proponents of this view emphasized the substantive commonalities and integrated nature of the two processes. The second viewpoint, expressed by the majority of respondents, identified HP as a content area and KT as a strategy or approach for sharing that content. In other words, HP is the ‘what’ and KT is the ‘how’.

Conclusion

Health promoters may never have heard of KT and KT specialists may be confused about HP. Yet we have learned that for practitioners these seemingly distinct professions draw upon common strategies and techniques; while not identical, they are complementary. To advance the science of KT and HP, consensus on terms, commonalities and differences is recommended to allow knowledge producers and users to eloquently communicate with each other in order to improve healthcare practices and the health of society at large. As newer practitioners in our designated fields, we hope to continually examine the theories and disciplines that inform our work while building greater understanding across professions instead of perpetuating silos. In this way we hope to better advance our common goal – the improved health of the population.