The Canadian Institutes of Health Research (CIHR), founded in 2000, is Canada's federal health research funding agency that has, as its mandate, not only to support scientific excellence through the creation of new knowledge, but its translation into improved health and improved health services and products. Given our mandate, the following definition of knowledge translation (KT) was developed after careful consideration of each of the component constructs:

Knowledge translation 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 and products and strengthen the health-care system.1

In breaking down the definition into its components, it is apparent how our operationalisation of the KT process charts the way for achieving, understanding and measuring the impact of health research. We have argued elsewhere that 'the knowledge translation process is about identifying solutions to clinical, health services and population health problems and facilitating their widespread application'.2

The process of KT is dynamic, it is constantly changing, or generated on-demand. It is not a 'state' or simple end-product. It is often characterised by continuous and productive activity. Furthermore, it is iterative - a concept that refers to the process for arriving at a progressively 'better' or desired result by constant intervention, monitoring and improvement. The objective is to increasingly fine-tune the KT process/mechanisms to suit the needs and context of a specific situation. Knowledge synthesis is one important way to ensure that the knowledge to be transferred is both reliable and valid. Synthesis in this context means the contextualisation and integration of research findings of individual research studies within the larger body of knowledge on the topic. A synthesis must be reproducible, minimise bias and be transparent in its methods, using quantitative and/or qualitative methods. Synthesis is a family of methodologies and could take the form of a systematic review; follow the methods developed by the Cochrane Collaboration or the Joanne Briggs Institute; result from a consensus conference or expert panel and may synthesise qualitative or quantitative results. Realist syntheses, narrative syntheses, meta-analyses, meta-syntheses and practice guidelines are all forms of synthesis. The implication is that some thought should be given to what knowledge should be translated and the strength and quality of the evidence supporting it. Dissemination involves identifying the appropriate audience and tailoring the message and medium to the audience. Dissemination activities can include summary/briefings to stakeholders, educational sessions with patients, public, practitioners and/or policy makers, engaging knowledge users in developing and executing dissemination/implementation plan, tools creation and media engagement. Exchange refers to the interaction between the knowledge user and the researcher resulting in mutual learning. It encompasses the concept of collaborative or participatory, action-oriented research where researchers and knowledge users work together as partners to conduct research to solve problems of mutual interest (called integrated KT at CIHR, also known as co-production of knowledge or Mode 2 knowledge production3). KT activities must be consistent with ethically sound principles and norms, social values as well as legal and other regulatory frameworks. Also, even in cases where there is strong evidence of benefit, the strategies used to implement the findings should themselves be ethical. For example, the use of unduly coercive strategies to bring about behaviour change may be effective but they are unlikely to be considered acceptable. There are also opportunity costs associated with KT that need to be taken into account and decisions regarding the trade-offs of cost versus benefit are ethical decisions that may vary from setting to setting. Although the process of engaging in KT is important, we must be careful to avoid the 'KT imperative' - to disseminate and implement all research findings at any cost - and instead ensure the judicious translation of research into practice and policy.4Application refers to the iterative process by which knowledge is actually considered, put into practice or used to improve health and the health system. It is important to note the use of the word 'knowledge' rather than 'evidence' or 'research'. CIHR has been careful in its messaging that knowledge is a broader concept than research or evidence, and takes into account the tacit or implicit knowledge held by researchers, practitioners and patients, as well as the more explicit procedural knowledge such as clinical and organisational expertise. Application also encompasses conceptual, instrumental and symbolic knowledge use.5 We advocate that application (or implementation) is best achieved through the use of a conceptual framework. Use of a conceptual framework6 can both guide implementation and facilitate the interpretation and understanding of implementation (including quality improvement) efforts. In other words, use of a conceptual framework can provide both a forward-looking map/protocol for the study and a backward-looking means of analysis of relative success or failure of the adoption of the innovation. The knowledge to action process7 is an example of a conceptual framework that could be applied in the manner described. Based on a synthesis of 31 planned action theories, it addresses the key implementation phases. The model has two components: knowledge creation phases comprised of knowledge production, knowledge synthesis and knowledge tools and the action cycle, which is composed of the following phases: identify the problem, adapt knowledge, assess barriers, select, tailor and implement interventions to increase uptake, monitor knowledge use, evaluate outcomes and sustain knowledge use. In reality the process is complex, dynamic and the boundaries between knowledge production and the action cycle and their ideal phases are fluid and permeable. The action phases may occur sequentially or simultaneously and the knowledge phases can inform each action phase. The action cycle phases are dynamic, can influence each other and can be influenced by the knowledge creation phases. As each action phase can be influenced by the phases that precede it, there may also be feedback between the phases. It is important to also emphasise that both local and external knowledge creation/research can be integral to each action phase.

As indicated in the description of the knowledge to action cycle, evaluation and monitoring should be key aspects of the knowledge process. As such, the judicious translation of knowledge into practice is implied in the CIHR definition. This means that the intensity of interactions between researchers and research users will vary as a result. This intensity would depend on factors such as the potential importance/impact of using the findings; the strength of the evidence supporting the findings (synthesis); the target audience(s); what is known about effective strategies to reach the audience(s); what is practical and feasible to do under the circumstances and considerations of who else should be involved in KT efforts. In fact, the second part of the CIHR definition of KT states:

This process takes place within a complex system of interactions between researchers and knowledge users which 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.

This refers to the human factor, the 'linkage and exchange' component that is critical to KT. The process of KT requires facilitation, to use Kitson et al.'s terminology, or some form of what others call, knowledge brokering.8,9 KT does not just happen by itself, or we would all be out of business - it requires careful planning, implementation and monitoring with people who are engaged in and committed to change. Similarly, KT always takes place within a context and an organisational culture - these concepts form an overlay to the knowledge to action cycle and form the foundation of our definition of KT. The context and culture can have a huge impact on the success of any organisational changes, or implementation of any innovations.

At CIHR, we have coined the term integrated KT (iKT) to describe a way of doing research that meaningfully engages potential knowledge users in the research process, including determining the research question. It is about collaborative, action-oriented, participatory research and involves two-way interactions between researchers and knowledge users. Through this engagement, the knowledge users are more likely to be predisposed to apply the results when they become available, hence increasing the chances of real impact. This way of doing research can be even more powerful when combined with a conceptual framework to guide the application or implementation of research.

As argued earlier, use of a conceptual framework can provide a means of organisation for thinking, for observation and for interpreting what is seen. A framework can provide a systematic structure and a rationale for activities. Implementation guided by a conceptual framework has the added value of contributing to the science of KT, which involves studying the determinants of knowledge use and effective methods of promoting the uptake of knowledge. Through the application of a conceptual framework, implementation researchers can test the framework's contribution to the uptake of the evidence-based innovation. In conclusion, KT is about making users aware of knowledge and facilitating their use of it to improve health and health-care systems; it is about closing the gap between what we know and what we do (reducing the know-do gap) and in its most intense form, is about moving knowledge into action. Through KT and through furthering KT science, researchers and knowledge users can work together to increase the impact of not only their work but the work of scientists more focused on the creation, rather than the application of knowledge.

Knowledge Translation Portfolio, Canadian Institutes of Health Research, Ottawa, Ontario, Canada

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