Thomas R Prohaska, Karen E Peters, Jan S Warren. Handbook of Social Studies in Health and Medicine. Editor: Gary L Albrecht, Ray Fitzpatrick, Susan C Scrimshaw. Sage Publications, 2000.
The general public is continually being informed of research findings that indicate harmful or beneficial effects of health behaviors such as smoking, exposure to the sun, and physical activity. There are also numerous published reports of health promotion programs that demonstrate success at fostering positive behavior change in the population. However, the translation of scientifically tested research findings to community-based health promotion programs is often slow, fragmented, and subject to speculation by the practitioner community. Similarly, the ‘lessons learned’ from practitioners who develop and administer health behavior intervention programs for the benefit of their communities are slow to influence subsequent health behavior research. Why is there an apparent gulf between health behavior research and community-based practice? This chapter examines the transition from research to practice in the field of behavioral health promotion to identify and discuss sources that impede the timely and accurate communication of health behavior research findings into useful information for health practitioners. We focus on the process of behavioral health research and on the practice of health promotion in community settings in order to determine what factors contribute to the less than optimal exchange of ideas between research and practice. Finally, we make suggestions for bridging gaps between the practice and research communities.
During the past 20 years there has been significant growth in our understanding of health behaviors, behavioral health risk factors, and the impact of health promotion activities through epidemiological and behavioral health research. This research effort has resulted in the development of health education and health promotion programs with documented efficacy and effectiveness (Flay 1986; see also the Combined Health Information Database, CHID, at http://chid.nih.gov—USDHHS 1998a). However, even with the proliferation of empirically tested health behavior research interventions, relatively few of these research programs or their components are adapted to widespread community-based health promotion programs (Glanz et al. 1997; Iverson and Kolbe 1983). Similarly, there are numerous health behavior interventions and programs located throughout the United States which receive considerable attention and dissemination, but which demonstrate minimal effects on health and health behavior change once the program is fully evaluated (e.g., DARE (Drug Abuse Resistance Education) Hansen and McNeal 1998). This situation has led to an increased recognition that a gap exists in the transition between health behavior research and community-based health promotion practice (Altman 1995; Morrissey et al. 1997; Orlandi et al. 1990).
The increasing need to address complex social problems such as violence, drug abuse, and sexually transmitted diseases makes the issue of reciprocal translation between health behavior research and community-based practice timely and significant. This chapter examines the transition between health behavior research and community-based programs to identify factors contributing to the gap between health behavior science and health education/health promotion practice. Recommendations are offered on how to bridge this gap in order to facilitate reciprocal information transfer and interaction between health behavior researchers and practitioners, to disseminate and incorporate behavioral research findings into effective community-based health promotion programs, and to promote the usefulness of community-experience-based ‘lessons learned’ for informing the future agenda in behavioral health research.
Gaps in the Transition from Research to Practice
The gap in our ability to incorporate research findings on health-risk behavior into health promotion interventions and community-based health promotion practice consists of at least three factors: (1) the timeframes involved in the transition between the development of innovations based on research and the application of these innovations into practice; (2) the loss of theory and content between research and practice; (3) the lack of utility of research methods and findings in their application or in practice.
The time between the publication of research findings demonstrating the value of a government or foundation-sponsored behavioral health research project and its subsequent adoption into community health promotion practice can be a matter of years, or it may never happen. Delays can be lengthy even for effectiveness trials which have already tested treatments, procedures, and interventions under real-world conditions (Morrissey et al. 1997; Portnoy et al. 1989). Another type of delay results from the dynamic nature of the circumstances and events that shape health-risk behavior in community populations and the researcher’s ability to incorporate these changes into research designs. While practitioners are likely to recognize and respond to these situations early in the course of program implementation, the time interval may be greater for researchers due to the often inflexible nature of research protocols. The consequences of these time delays are research findings and innovations that are not very useful to the practice community.
The gap in the use of theory between health behavior researchers and health promotion and health education practitioners appears to be the difference between explicit and implicit use of theory (Hochbaum and Lorig 1992). While the explicit use of theory to guide research questions and program interventions is fundamental to the academic research process, the explicit use of theory is not central in the development of community-based programs. Burdine and McLeroy (1992) interviewed practitioners concerning the use of theory in health promotion programs. They found that while practitioners may not be explicitly using social science theory to direct the development of health education interventions, theory is involved in a ‘common sense’ understanding of how an intervention should work and what the outcomes should be. One reason for the gap in the application of theory in practice settings is the perceived limitation of theory to applied situations.
The third gap between behavioral research and practice pertains to a lack of utility of research-based health promotion intervention components when applied to community-based health promotion programs. Practitioners report that specific intervention components used in health promotion research are often not applicable to the real-world settings of community-based health promotion interventions (Burdine and McLeroy 1992). For example, researchers are often able to justify extensive and costly participant assessments and program evaluations that are not typically possible for community practitioners. Given the priorities of most community-based health promotion programs, the perceived utility of these research components are questionable. Weiss and Bucuvalas (1980) note that decision makers and practitioners apply a ‘utility test’ in screening social behavioral research for new ideas or application. Research utility is based on two distinct components, application and innovation. Practitioners evaluate application utility in terms of how well it can provide explicit and practical direction on matters they can address. Practitioners also evaluate the utility of behavioral research based on its ability to provide insight for new directions and new goals. Practitioners often screen research for guidance in determining alternatives to current intervention practices and program revisions.
Next, we examine the process of conducting health behavior research in contrast to the activities associated with the development of community-based health promotion programs. The different nature of these processes contributes to an understanding of why gaps occur, resulting in the lack of reciprocal transfer of information between health behavior research and community practice.
Health Behavior Research Issues
A considerable proportion of the health behavior research that is generated is conducted by academic research faculties in college and university settings. Health behavior researchers come from a variety of disciplines, including communication, psychology, sociology, gerontology, medicine, public health, education, nursing, and anthropology. They have advanced graduate degrees and are trained to look at health behavior from the perspective of their own disciplinary perspectives. This plethora of approaches can cause confusion, as findings are not always presented in a single coherent framework.
Regardless of the perspective taken, the majority of health behavior research typically focuses on addressing one or more of four interrelated questions (Prohaska and Clark 1997).
- What is the incidence and prevalence of specific health behaviors in populations?
- What are the health consequences of specific health behaviors on the health and well-being of individuals and populations?
- What are the antecedents and mechanisms (e.g., cultural, psychosocial, environmental) controlling the initiation, maintenance, and termination of specific health behaviors?
- Can we intervene in these health-risk behaviors, and if so, under what conditions and settings does this work best?
Behavioral scientists have identified many of the most critical health-risk behaviors, their incidence and prevalence rates, and their health consequences in various populations (for example, see USDHHS 1991, 1996). Researchers in the behavioral sciences assume that the individual has some volitional control over these behaviors, and that the adoption or cessation of behavior is a product of subjective perceptions and rational decision making. There is also recognition that health-risk factors have multiple environmental and contextual determinants. Researchers in the field of health practices have developed a number of cognitive/rational decision-based models of behavior, as well as macro, environmental, and system factors associated with these behaviors in various populations.
Among the more widely utilized theoretical models guiding behavior risk reduction interventions are the health belief model (Janz and Becker 1984; Rosenstock 1974; Rosenstock et al. 1988), Bandura’s social cognitive theory (Bandura 1977, 1989; Strecher et al. 1986), the theory of planned behavior (Ajzen 1985), the PRECEDE model (Green and Kreuter 1991; Green et al. 1980), the transtheoretical model of behavior change (Prochaska and DiClemente 1992; Prochaska et al. 1992) and ecological perspectives (Flay and Petraitis 1994; McLeroy et al. 1988). It is this literature and research that guide researchers’ decisions for determining health-risk behavior interventions, targeting specific populations, and assessing components of the health promotion intervention. These models focus on the inter-relationship of the individual’s knowledge, perceptions, attitudes, and beliefs as well as his or her interpersonal, organizational, and community environments on behavior change. In addition, the role of public policy is also examined in association with health-risk behavior.
The use of theory by behavioral scientists is fundamental to the research process. Theories facilitate our understanding of the array of causal antecedents to behavior and help determine a parsimonious group of variables contributing to behavior change. A goal of health behavior research is to test how well a particular theory (or components of multiple theories), operationalized into an intervention strategy, applies to different health behaviors (e.g., is the health belief model predictive in determining a woman’s likelihood of undergoing mammogram screening, joining a smoking cessation program, or starting an exercise class).
Health behavior researchers are encouraged to focus on innovation rather than replication of program interventions. At least two forces, research funding and priorities in research publication, drive this. Academic researchers are encouraged to obtain funding for their research from federal research grants and awards from private foundations. These funding sources typically specify research objectives and criteria that stress experimental control, employment of novel concepts, approaches, and methods and aims that are original and innovative. This funding rarely includes resources for program dissemination or program continuation beyond the grant period (examples of notable exceptions include the Centers for Disease Control and Prevention, the W.K. Kellogg Foundation, and the Robert Wood Johnson Foundation). Published health promotion research in scientific journals share these same values for originality, statistical significance, and innovation. It is unusual for journals to devote space to the reporting of nonsignificant results, or the replication of programs to different age groups, cultures, and settings.
Practitioners’ Program Implementation Issues
The process used by practitioners in community-based environments can be evaluated on two levels: direct service, practice organizations that deliver health education/health promotion programs, and the field practitioners who direct program implementation such as health educators, program directors, and program evaluated. Practice organizations such as state and local health departments, hospitals and community clinics, social service agencies, not-for-profit organizations, churches, schools, and housing groups have diverse organizational mandates, constituencies, reimbursement mechanisms, material and economic resources, environments, and populations to serve that drive their program development.
Within organizations, health intervention programs may be initiated for a variety of reasons. One reason is to maintain certification as a provider or to meet federal block grant requirements (e.g., local health departments). Other reasons are to improve health status in the surrounding community (local hospitals), to provide a social activity (churches, senior centers), to improve quality of life (nursing homes), to reduce health-care costs (hospitals, clinics, and health maintenance organizations (HMOs)), or to improve relations with the community and generate goodwill. Many organizations implement health intervention programs in partnerships involving multiple community organizations, funders, and networks. For example, Prohaska (1998) noted a trend in health promotion programs for older adults in which there are increasing numbers of community partnerships, such as mall-walking exercise programs sponsored by hospitals and shopping malls. In addition, once practitioner organizations have institutionalized a community health promotion program, it becomes difficult to discontinue or revise it, particularly if it is popular.
Individual field practitioners work within these organizations to implement health education and health promotion programs. The educational training and background of community practitioners varies considerably, ranging from individuals who have little formal training on how to design or implement health promotion programs to persons with graduate degrees in disciplines related to health education and the behavioral sciences. Recent efforts by the National Commission for Health Education Credentialing Inc. to launch a voluntary credentialing system for health education specialists will contribute to assuring quality and standards in the delivery of health education services by practitioners (Wolle et al. 1998).
There is information describing the process by which practitioners choose, adapt, and implement health education/health promotion programs. Morrissey et al. (1997) noted that practitioners use past experience, published research, and other related sources of information when considering implementing health promotion programs. In addition, several practice-based or applied journals such as Health Education Quarterly and the Journal of Health Promotion regularly publish study results with an emphasis on implementation. Also, computerized databases (e.g., the Computerized Health Information Database, CHID and the Computer Retrieval of Information on Scientific Projects, CRISP, USDHHS 1998b) are continually updated with new health promotion intervention information and health behavior research studies. Research can be helpful in determining the significance of a health problem, targeting at-risk populations, and helping to set health-risk behavior priorities. For example, recommendations provided by the USDHHS (1991) are based on research that has mapped the incidence and prevalence of health-risk behavior in various demographic groups, and has set target objectives for reducing health-risk factors. State and local health departments have mandates to try to meet the objectives issued by their federal funding agencies, and other practitioner organizations use these objectives to determine health promotion program priorities. For example, practitioners within a health department may be asked to implement a health education program for blood pressure control in a targeted area or for a specific population as part of a federal block grant. The concerns of the stakeholders and the priorities of the agency or network in which the practitioner performs his or her activities often determine other types of programs and target populations.
While practitioners may have mandates on what risk factor they address and who they target, they generally have greater latitude on ‘how’ they address the risk factor. In this regard, it would be expected that research addressing the mechanisms influencing health behavior change and studies documenting the success of interventions on health behavior would be of primary interest to practitioners (research questions 3 and 4). Health educators use research findings in these two content areas to help design intervention programs as well as to provide references for expected success. Ideally, this body of research would be reviewed for pertinent literature and findings, and then be incorporated into the system and the constraints under which the practitioner implements the community-based health promotion programs.
On occasion, practitioners and researchers may collaborate to implement a research intervention as a community-based program through program dissemination. However, even with researcher-practitioner collaboration, there are barriers that make this process problematic and contribute to difficulty in the transition between research and practice.
Sources for the Lack of Transition between Research and Practice
Diffusion theory, or diffusion and dissemination of innovations, has been used to understand the barriers in transitioning from health behavior research innovation to widespread behavior change (Green et al. 1987; Oldenburg et al. 1997; Rogers 1983). Program dissemination involves the transfer of experimental programs from research environments to community organizations and practitioners who will adapt, implement, and maintain these programs (Manfredi and Warnecke, forthcoming). Application of diffusion theory requires an understanding of the resource innovation attributes (i.e., the research characteristics), the characteristics of the innovation adopter (i.e., the practitioner), and the process by which the transition from research to practice has been implemented (Orlandi et al. 1990). The diffusion process generally involves four phases: awareness, interest, trial, and adoption (Dignan et al. 1994) and can be viewed at two levels or transition points. At one level, diffusion of innovation can be viewed as the transition from the researcher to the practitioner, while at another level, it involves diffusion from the practitioner to widespread use in the community. Our focus is on the diffusion of innovation in research to the practitioner.
Iverson and Kolbe (1983), identified features of successful diffusion of innovation that are applicable to the transition from research to practice. These include compatibility, flexibility, reversibility, relative advantage, complexity, cost-efficiency, and risk. Applying these qualities in successful diffusion, Iverson and Kolbe (1983) and Orlandi et al. (1990) noted that practitioners of community-based health education programs are more likely to adopt innovations in research when they are consistent with the practitioner’s (and organization’s) value system, have sufficient flexibility to be applied to current circumstances, can be reversed, have advantages over existing programs and innovations, are not overly complex, demonstrate cost efficiency, and do not include significant risk. Unfortunately, these attributes are rarely included in published research. This is often left to the practitioner to determine.
A number of recent articles have focused on possible causes for the difficulty in the transition between health promotion science and health promotion practice. Freudenberg et al. (1995) focused on the lack of interaction between academic researchers and practitioners, and stressed the need for closer collaboration between the two. Others (Morrissey et al. 1997) identified sources for the gap between prevention practice and prevention research, including different theoretical orientations and training, funding procedures, resource constraints, systems-level barriers, and community readiness. In a special issue of Health Education Quarterly, D’Onofrio (1992) and others (Burdine and McLeroy 1992; Hochbaum et al. 1992; van Ryn and Heaney 1992) focused on differences in the use of theory in health education research and practice. They concluded that a variety of factors, such as the lack of appropriate teaching of theory to practitioners and differences in explicit and implicit use of theory by researchers and practitioners, have contributed to difficulties in the translation of research and practice.
We believe that the causes for the gap in transition can be categorized into the three previously mentioned areas: the time delay in the transition between research and practice, the loss of theory and content between theory and practice, and the gap in utility between research interventions and community-based programs. Within these three areas we identify six specific reasons for the difficulties found in the transition between research and practice: (1) delay in the research process and transition of research; (2) limitations in the communication of research findings; (3) use of theory; (4) the unidirectional nature of the transition; (5) constraints inherent in program application; (6) different measures of outcomes and success.
Delays in the Research Process
There is a considerable time lag between when funds targeted toward specific areas of research are made available, the development and submission of a proposed research project, the implementation of the research project, and the communication of research results through the publication review process, including the time between acceptance and actual publication. This is most likely a minimum of 3 years. This delay can make even the most ‘cutting-edge’ behavioral research obsolete in the face of the rapidly changing health behavior issues in the community. Our practical understanding of many health behavior issues changes far more rapidly than the speed with which we can communicate this knowledge, at least through the traditional research publication process. For example, the nature of high-risk behaviors, such as the spread of HIV and other sexually transmitted diseases, the dynamic picture of populations at risk, the factors for risk, and the perceptions held by individuals at risk, all change rapidly. The concerns and problems faced by practitioners who deal with the behavioral risk factors associated with HIV and AIDS frequently outpace the rate of publications on the topic. National and regional topic presentations are often more timely, but may also be subjected to the same delaying process.
Another source of delay is the time between publication and presentation of findings and the awareness, translation, and application of the findings by the practitioner. Even if the initial research has successfully moved from a controlled efficacy trial to an effectiveness trial to a program impact evaluation, delays can occur in terms of the program becoming ‘common knowledge’ and being perceived as applicable in the context confronted by the practitioner (Flay 1986). Delays can also occur between the time research-based health promotion programs have been adapted and implemented by some practitioners and in the wider dissemination of the program to other agencies, regions, or countries. There appear to be few timely and effective mechanisms in the United States to facilitate the widespread distribution and implementation of successful health education programs. However, some progress has been made through the use of the Internet (e.g., CHID and CRISP), in some peer-reviewed journals that are beginning to feature ‘practice’-oriented sections (e.g., Health Education and Behavior Practice Notes, American Journal of Public Health Notes from the Field), and in the community-based practice field, with its recognition of model programs through award programs.
Critical time is also lost between the point at which field practitioners identify problems with health promotion programs based on research and when the researcher becomes aware of these problems. Changes in the communities where these programs are implemented bring new and important challenges to the practitioner that may not be communicated to the researcher on a timely basis. These challenges may have important implications for revisions in subsequent research that may not even be conducted by the original researcher or author. Finally, emerging health-risk behavior such as the use of new illegal substances are more likely to be observed by community practitioners long before health behavior researchers and funding agencies discover the problem.
Limitations in the Communication of Research Findings
Probably one of the most fundamental reasons for the difficulty in the transition between research and practice is due to the communication process and channels used by the academic research community. Research is often a required activity in most academic settings, and the primary mechanism for communicating research findings is through peer-reviewed journal articles. Peer-reviewed research articles, based on accepted empirical methods, are considered a quality standard for academic research. Manuscript reviews are subjected to criteria such as documentation of significant findings, extensive use of theory to guide intervention components, and sufficient experimental control to eliminate or minimize alternative explanations or confounds for the findings observed. Researchers review this published literature with the intention of building on their own research. In short, much of the research communication process is directed and evaluated by researchers for other researchers. While there are practitioner-oriented journals where health behavior researchers contribute, these are the exception rather than the rule.
The emphasis in health behavior research publications is on quantitative methods and the presentation of statistically significant differences between study groups participating in the health promotion intervention. While the reporting and usage of rigorous statistical methods may be important to theory development (a primary concern of behavioral science researchers), it is less relevant to practitioners. Practitioners require more information on differences that are meaningful, and on the actual implementation process for the intervention. The focus on quantitative data does not always provide sufficient background on the nuts and bolts of how the intervention was implemented and what roadblocks were encountered. More qualitative and observational data could provide the practitioner with relevant facts about the actual implementation issues involved with the intervention, such as recruitment problems, program adherence issues, language or literacy issues in administering measurement instruments, participant beliefs about the intervention or about research in general, and how these barriers were overcome. Qualitative methods, which can be applied with sufficient academic rigor, can provide additional insights into intervention participants’ reactions to the program, its materials, the setting, the health educator who conducted the program, and other variables that might not fit into a strictly quantitative evaluation design. Qualitative data of a more descriptive nature may yield the attributes that practitioners need for successful adoption and, ultimately, diffusion. For example, the use of an ethnographic focus group approach with nonparticipants of exercise health promotion programs helped identify factors contributing to attrition during program recruitment and provided useful information for tailoring exercise recruitment strategies (Prohaska and Walcott-McQuigg 1996).
Hand-in-hand with what and how researchers publish is the problem with the research findings that never make it into the communication pipeline. Health behavior research journals rarely publish research that fails to replicate previous intervention successes. Failure to find statistical significance between theoretical constructs and changes in health risk behavior does not get communicated. McGuire (1984) noted that often the researcher will criticize or explain away the insignificance by determining that the design of the intervention was wrong, not that the theory did not work. This problem of nonreplication takes on added importance when interventions targeting a specific community or at-risk population fail to duplicate successful results found with other populations. However, this is important information that may imply that there are theoretical constructs missing that are important to consider for populations other than the original study group. This may result in the unfortunate situation in which considerable time and effort is lost implementing weak or ineffective programs.
While the academic publication process and criteria have been used in health behavior research to increase academic rigor and set standards, it can obscure salient information needed by practitioners. Researchers typically caution the reader on the generalizability of the experimental intervention with respect to populations not included in the study sample and its unknown applicability in other settings. However, it is just this type of information that is critical to the practitioner’s decision to adapt and implement the program to their particular circumstances. Also, practitioners, because of their varied background, may lack the critical analysis skills needed when reading published research to discern what is a viable health education/health promotion intervention program which can be adapted for the circumstances within their target community.
Use of Theory
A substantial amount of health behavior research focuses on theory development in order to understand the mechanisms controlling behavior. There are at least four general content areas in health behavior change that require some understanding of theory:
- the mechanisms controlling the behavior (e.g., perceptions of self-efficacy, social support);
- differences between populations (age groups, gender, cultures, and income and education levels);
- the target behavior (e.g., moving from one stage of change to another, exercise versus physical activity, getting a baseline mammogram versus getting annual mammograms);
- the context and environment in which the behavior is performed (e.g., environmental cues, exercise programs conducted at health clubs, at home, in community centers, and group settings versus self-directed).
Discussion of theory in health education research tends to focus on the first of these content areas. That is, a considerable amount of effort has been devoted to the development and refinement of cognitively based theoretical models of behavior change typically examining the psychosocial perspectives of the individual. If practitioners had more exposure to theory relevant to populations, target behaviors, and contextual and environmental influences, it may provide insight on how to tailor the health promotion research to fit their program needs.
Research and theory incorporating an ecological model provides a contextual basis for understanding human behavior within the individual’s environment and life circumstances. The ecological approach addresses the need for a deeper understanding of the interaction between individuals, their families, communities, and the environment, so that there is a clearer understanding of how health can be achieved and maintained over time. As a result, multiple types of interventions are required to address the complex issues facing at-risk communities. Using this approach, there is an explicit recognition of the multiple levels of influence that interrelate to impact on the health behavior of individuals and groups including the community, the environment, and public policy (Bronfenbrenner 1979; Garbarino and Abramowitz 1992; McLeroy et al. 1988; Syme 1992). The ecological approach may be more in line with the ‘experience’-based understanding that practitioners, who often work and live in the community, bring to an identified problem (Bartholomew et al. 1998).
Researchers often test an individual health behavior theory’s generalizability by applying it to a broad array of behaviors to determine its predictive ability. When specific theories in health education interventions are tested, they report significant contributions of theoretical components in predicting behavior change, although only a small to moderate amount of the variance in the behavior may be explained. Subsequent cycles of research build on the previous theoretical application in an effort to explain a greater proportion of the variance through successive refinements of the theory.
In essence, theory drives research but theory guides practice. Part of the utility of a theory to a practitioner is its commonsense application to intended program activities. If a particular theory is compatible with the practitioner’s personal experience or makes intuitive sense (i.e., has face validity), then the program components will more likely be incorporated. Too often, practitioners and researchers alike develop a tendency to use a favorite theoretical model of behavior. While this can limit both groups, practitioners with this perspective can severely limit program development by focusing just on research with their favorite theoretical model. A related problem is the perception by practitioners (and encouraged by researchers) that theories cannot be combined, or that theory must be used in its entirety. This can also severely limit the effectiveness of the practitioner in making full use of the research literature.
Unidirectional Nature of the Transition
Ideally, research and practice should exert a powerful influence on one another, but the reality is that all too often there is an assumed oneway flow from research to practice. However, practitioners have critical information and observations that need to be integrated into the next cycles of research. Unfortunately, there are few resources available for practitioners to communicate their findings back to the research community. Resource constraints often do not allow for program evaluation, and practitioners have neither the time nor the budget to produce manuscripts for publication. The result is that the research community, which operates under its own rigid standards, views program outcomes and ‘lessons learned’ that do make it into the publication pipeline as suspect.
The relationship between research and its application should move in both directions. Currently, theory and research is perceived as being owned by academics, but we need to demystify theory and theory development so that they become more widely understood and used by practitioners (D’Onofrio 1992). Knowledge of theoretical perspectives and the ability to apply theory to the population, context, and settings encountered during program implementation should be just another skill in the practitioner’s toolbox. In turn, practitioners have significant contributions to make in terms of expanding theory to encompass real-world situations. The application of theory in a particular setting and to specific target populations may uncover additional variables or constructs that need to be incorporated as we look at various cultures within these populations. Individuals sharing a cultural identity hold their own values and priorities in relationship to health, health behavior, and health care. For example, the fatalistic outlook (fatalismo) reported among Latinos has been associated with perceptions of cancer as being incurable, thereby making the use of cancer screening tests unlikely (Perez-Stable et al. 1992). Religious practices, nationality, language, income, gender relations, level of acculturation, and place of residence will all influence behavior and should, in turn, influence theory development. It is not that the researcher is not also aware of these influences, but that the practitioner’s hands-on experience with these populations can be a valuable resource for further theory development. In short, practitioners can provide important insights into the realities of applying the health promotion program that would benefit the research process. This is similar to the concept of principles of practice (Freudenberg et al. 1995). They suggest that practitioners have an understanding of the community and the complex environments in which health promotion programs are implemented. This would help researchers better comprehend the context of their own research.
Practitioners’ understanding of the community stem from the fact that they are frequently more integrated than researchers into the communities they serve. This occurs in two ways. First, practitioners often come from the communities they serve. For example, it would be expected that Latino health educators and practitioners be from the Latino community and that they live and work in Latin neighborhoods. Practitioners working with the disabled may themselves be disabled, or they may have grown up with a disabled sibling or other relative. In essence, practitioners live and breathe the community because they are part of the community.
Second, practitioners operate in community settings, and they are skilled at community liaison building, a skill that would be a benefit to academic researchers. Community-based health promotion programs are delivered in settings based on partnerships with major stakeholders. There are prerequisites to program implementation in the community that involve building acceptance and trust with community partners and program participants. Academic researchers experience a high level of distrust by the community, especially from disadvantaged populations. These concerns include perceptions from community participants of being exploited by university researchers (Livingston 1994). Seasoned practitioners are acutely aware of community sensitivities and the need for them to build long-term relationships with the community.
Constraints Inherent in Program Application
Health behavior researchers have a higher degree of control over factors that may confound research study findings and the ultimate success of the study than do community-based practitioners. As part of the research activity, university researchers can often provide incentives to study participants, provide transportation to the intervention site, and offer timely feedback and follow-up. Practitioners have fewer resources available and more partners with which to negotiate. This lack of control in community health promotion programs by practitioners is best summarized by Hochbaum et al.
They [practitioners] cannot often choose a problem, a situation, or a population that happens to fit their interest and allow them to use and test some of their preferred strategies or methods. They are usually expected to assail assigned problems in a given situation and population under conditions over which they have very little control…. While academicians generally have a relatively wide range of freedom in designing and conducting their work once it is approved and funded, practitioners do not enjoy such independence. They work constantly with administrators, colleagues and superiors, community leaders, and others whose support or resistance they cannot disregard without paying a price. (Hochbaum et al. 1992: 303)
Given the constraints under which practitioners design and implement health promotion interventions, it is rare that a program developed by researchers will be implemented into the community without revisions.
A health education practitioner frequently cannot incorporate an intervention in its entirety into her community-based program. Rather, a practitioner is looking at the research for a few good jewels to take with her to apply to a specific situation. An obvious problem with this approach is that isolated program components taken from larger intervention strategies may not work the same when applied in a different program context. When practitioners do find a program that can be adopted ‘as is,’ they may find that it has limited relevance to the environment in which it will be implemented.
Different Measures of Outcomes and Success
Health organizations and community practitioners have articulated specific criteria for determining successful health behavior program interventions and indicators of success. For example, the American Public Health Association (APHA), in collaboration with the Center for Health Promotion and Education of the Center for Disease Control (APHA 1987), has recommended five criteria for the development of health behavior programs. These are listed below.
- A health promotion program should address one or more risk factors that are carefully defined, measurable, modifiable, and prevalent among the members of a chosen target group; factors that constitute a threat to the health status and the quality of life of target group members.
- A health promotion program should reflect a consideration of the special characteristics, needs, and preferences of its target group(s).
- Health promotion programs should include interventions that clearly and effectively reduce a targeted risk factor and are appropriate for a particular setting.
- A health promotion program should identify and implement interventions that make optimum use of available resources.
- From the outset, a health promotion program should be organized, planned, and implemented in such a way that its operation and effects can be evaluated.
The majority of researchers have adopted these criteria when designing and implementing health education promotion interventions. In particular, more research is being targeted to previously neglected at-risk groups. However, with regard to the fourth criteria, the resources available to university researchers often exceed those of the average practitioner, and practitioners are the ones who will ultimately be using the program.
From the practitioner viewpoint, these criteria are consistent with the understanding of what constitutes a successful community-based program. Morrissey et al. (1997) conducted a pilot survey of community health program practitioners (center directors) on the most important characteristics of successful community-based programs. The program characteristics given the highest priorities were: the comprehensiveness of the program in addressing individual, family, and environmental influences (e.g., the desire to design interventions using an ecological approach); a full understanding of the complexity of the target problem (based on research and past experience); sufficient intensity, duration, and dosage of the intervention; a focus on specific target groups and risk factors; appropriateness of the program to fit the needs of the community and the culture of the target group. However, these stated goals and criteria can be in conflict with the realities faced by practitioners as they proceed to design and implement community-based programs.
Even though there may be general agreement between researchers and practitioners on what goes into a successful health education/health promotion program, these two groups frequently have different process and outcome measures. Research projects measure outcomes such as participants’ change in behavior, change in attitudes about the behavior, as well as the participants’ health status. They also measure process variables such as recruitment rates, retention rates, consistency of participation, and program enjoyment. For practitioners, outcomes are often set by the regulatory agencies and organizations funding the programs and the community partners contributing to the program. Reporting to regulatory agencies can result in outcome and success indicators based on fiscal reporting (e.g., number of unduplicated persons served; number of units of service (time) provided on the intervention) rather than health status or behavior. Practitioners are also faced with pressures to write program objectives that exceed the capacity of the program’s impact while having limited access to data relevant to meaningful outcomes (Institute of Medicine 1988). In addition, limited funds may restrict or eliminate program evaluation activity making it difficult accurately to gauge a program’s success or failure. While researchers and practitioners have the same goals—improving the populations’ health status—they often measure their progress toward the goal in different ways.
Professional organizations and research groups have provided recommendations that are pertinent to solving many of the gaps between behavior research and practice presented in this chapter (Institute of Medicine 1988; Morrissey, et al. 1997; Orlandi et al. 1990). Recent literature on this issue has identified three possible approaches to bridging the gap between research and practice: improving technology transfer, conducting participatory research, and promoting practice-centered prevention. As outlined by Morrissey et al. (1997), the first approach emphasizes education, training, and dissemination through standard academic channels such as journal publications, conferences, and reports. They note that this approach assumes that the gap is the result of a lack of information dissemination between researchers and practitioners. In terms of the flow of information from researchers to practitioners, we have argued that it is not just a lack of information dissemination that is the problem, but also how the information is organized and presented for consumption by practitioners, as well as the speed with which this information is made available to the practitioner. Therefore, the first recommendations focus on the need for researchers to be more responsive to the information needs of the practitioner. This can be accomplished by:
- teaching researchers how to write for both the practitioner and the public consumer;
- increasing publications in journals and magazines read by practitioners and writing articles specific to practitioner needs and concerns;
- providing opportunities for direct communication and interaction between researchers and practitioners;
- utilizing the Internet and related technologies for more timely information dissemination;
- providing incentives in the academic setting to encourage publication and packaging of materials that can be adopted off-the-shelf by practitioners and the public.
Considerable progress has been made with many of these recommendations. The ‘Practice Notes’ section in the journal Health Education and Behavior is an example of a health behavior research journal reaching out and targeting information directly to practitioners. The section focuses on practice notes and innovative programs as well as practice-related issues and solutions. The use of the Internet for more timely dissemination of innovations has also been established. For example, the Health Resources and Services Administration’s Bureau of Primary Care established ‘Models that Work,’ a biannual award that recognizes innovative community health programs. These programs are publicized in a practitioner journal and are made available on the Internet. Since its inception in 1994 fifteen of the award-winning programs have been replicated (Broughton 1998).
While progress is evident in this area, the above recommendations do not address the reciprocal information flow, that is, the information flow from practitioners to researchers.
This can be addressed by:
- encouraging practitioners to communicate important changes observed in their communities, and how health-risk behaviors are expressed that have a bearing on research activities (e.g., practitioners quickly picked up on the dangerous nature of crack cocaine, which was slow to make it into the research pipeline);
- having practitioners provide ‘lessons learned’ on effective collaboration with community gatekeepers and community liaison building;
- empowering practitioners to become proactive in asking for the types of research and information they need to be effective in the community.
These recommendations could be addressed by providing opportunities for practitioners to collaborate with academic researchers in the education and training of future community health promotion practitioners (Institute of Medicine 1988). By having practitioners and researchers combine talents and skills in the classroom, students will benefit from timely real-world experiences and will facilitate reciprocal dialogues between practitioners and researchers.
The second approach to bridging the gap focuses on strategies that facilitate participatory research and close collaboration between health behavior researchers and community-based health education/health promotion practitioners. An example of such a strategy is offered by Orlandi et al. (1990), who recommend a linkage approach to diffusion of innovation by developing cooperative exchanges and interaction between the resource system (researcher) and the user system (practitioner). As an approach to scientific inquiry, participatory research integrates three major elements: research, education, and action. A participatory research model also includes the partnering of academic, practitioner, and community representatives who jointly engage in identifying the problem and formulating the solution by selecting the types of activities to address the target issue, analyzing or interpreting the results of the intervention (understanding the effect of the activities), applying the results, and disseminating the results. ‘Different actors, each with their own knowledge, techniques and experiences, work together in dialectical process, through which new forms of knowledge are produced’ (Cornwall and Jewkes 1995: 1671). While participatory research can advance science through new knowledge and understanding about a social world, it also produces a practical knowledge that can be directly applied to improve the well-being of participants or those whom they represent. The underlying assumption is that in an academic-practitioner-community research partnership, members of a given community are crucial to analyzing and prioritizing their situations, and are necessary partners in designing appropriate solutions. Most importantly, their interpretation of the meaning of the results can contribute to further iterations of the intervention and the research, resulting in a timely flow of information from the practitioner (and community) to the researcher.
Linking researchers and practitioners in participatory research also provides an opportunity to observe theory development in action. It is an opportunity for the practitioner to demystify theory (D’Onofrio 1992) and for researchers to appreciate the contributions of practitioners in terms of expanding theory to encompass real-world situations.
Community participatory research, while conceptually appealing, does have its own set of problems. A fundamental question with participatory research relationships is what are the specific roles and responsibilities of each member (researcher, practitioner, and community representative), and what processes and activities within the partnership facilitate dissemination of innovative research? Participatory research requires a significant amount of flexibility and compromise among all the parties. Researchers usually already have a defined problem that they wish to address in the community. Participants may have an entirely different assessment of priorities and view the researcher’s problem as significantly less important. Changing the target of the entire intervention is a major issue, and one that may not be feasible given the constraints imposed by research funding. Also, inclusion of community participants in the design, implementation, data collection, and data analysis will often expand the project time-line because of the need for additional training, accommodation of work schedules, skills, and personalities, as well as the inclusion of another group in the research process. However, the resulting partnership between researchers, practitioners, and the community has the potential for establishing a long-term relationship with the ability to facilitate knowledge acquisition/transfer by all parties. Community participants and community groups also have insight into issues such as effective recruitment strategies, and cultural and regional relevance that are not always known to practitioners. In this scenario, the community participants have project ownership which motivates their ability to recruit participants and to adopt the program once the research has ended. Involving participants and key community groups in community-based health promotion research and program implementation is also compatible with the PRECEDE model (Green and Kreuter 1991) and recommendations by APHA (1987) for effective health promotion programs in that it makes optimum use of available resources.
The participatory research approach has distinct advantages, and should be encouraged by:
- inviting community groups and practitioners to participate in grant proposals, and in responses to requests for proposals (RFPs), and in helping to set agendas and incorporate more real-world issues into intervention recruitment and design;
- choosing community-based settings for interventions even though academic facilities may be more convenient;
- encouraging practitioners and community representatives to participate in problem solving during research and program implementation and to respond to the interpretation of program findings.
The third approach to bridging the gap involves adopting the practice-centered approach, which involves using continuous quality improvement processes in order to improve the effectiveness of community-based prevention programs (Morrissey et al. 1997). In this approach, program evaluators play a key role in bridging the gap between research and practice by providing technical assistance to practitioners, encouraging practitioners to make effective use of behavioral science literature, and facilitating reciprocal transfer of information. This approach has considerable utility in that it recognizes the inherent constraints in program application, takes into account the lack of resources hampering practitioners, and has the potential for correcting the unidirectional nature of information transfer discussed earlier. It also focuses on the need for more and better evaluation of community-based programs. However, this approach of using an intermediary evaluator does not address the benefits of direct practitioner-researcher interaction. Researchers would profit from timely information on changes in the community and direct information on the utility of specific health promotion programs. Practitioners would benefit from education and training on how to abstract information from the research to improve their programs. While evaluators can facilitate practitioner-researcher interactions, direct interactions between the practitioner and the researcher can reinforce the practice-centered prevention approach. Direct interactions be accomplished by:
- bringing practitioners and researchers together in the classroom to promote reciprocal information exchange and jointly to teach future health practitioners;
- providing training for researchers on how to develop community liaisons and maintain long-term relationships with community partners;
- providing collaborative research opportunities to promote mutual learning experience;
- encouraging joint researcher-practitioner publications that reflect both sound research and relevant health promotion practices.
In a more practical vein, Bartholomew et al. (1998) developed a practice-centered approach based on a framework that helps health education practitioners incorporate academic research into their program planning process. ‘Intervention mapping’ provides practitioners with specific tasks and ways of analyzing research literature in order to integrate relevant theories and interventions into their schema. Intervention mapping has five steps: (1) create a matrix of proximal program objectives; (2) select theory-based intervention methods and practical strategies; (3) design and organize a program; (4) specify adoption and implementation plans; (5) generate program evaluation plans. While the process of intervention mapping can involve researcher practitioner collaboration, this approach provides sufficient guidelines for individual practitioners to search the literature and determine the utility of the research findings for program development.
All three approaches outlined above move us a step closer to bridging the gap between research and community-based practice. However, no one approach or recommendation offered here is sufficient to close the apparent gulf between health behavior research and community-based practice. The transition from research to practice and from practice to research will continue to be an on-going learning process. Both the behavioral science researcher and the health promotion practitioner have a pivotal interest in the development of timely, useful, and reciprocal information transfer systems that include continuous feedback loops between research and practice. A number of recommendations, useful suggestions, and techniques have been offered for researchers and practitioners, each with its own inherent strengths and weaknesses. For example, a collaborative process among the researcher, the practitioner, and the community is contingent upon the goodwill and initiative of all individuals involved. Fortunately, the research and practice communities, along with funding agencies, are recognizing the impetus to encourage collaborative activities. Researchers are frequently asked to serve as consultants on community-based health promotion projects. Practitioners are in demand to serve in advisory capacities on sponsored research projects. These activities provide the practitioner and the researcher with opportunities to gain first-hand knowledge and experience of each others’ field. In addition, we have noted that increasingly there exist other activities that promote collegial interaction among professionals in the research and practice fields.
Syme (1992) noted that health education/health promotion research and programs will continue to play a major role in addressing the health needs of society due to the constant influx of successive cohorts who have not been exposed to the health promotion message, the constant evolution of health-risk behavior that impacts on the health of society, and the changing social structure that influences health-risk behavior. To work toward a foundation and structure that facilitates interaction between health behavior research and practice is in the best interests of all of us. We strongly encourage researchers to broaden their academic perspective and to take the lead in working with community-based practitioners and their organizations, thus widening the impact of health behavior research. Similarly, we urge practitioners to take a more active role in integrating research concepts into their field practice, and then communicating their field experiences to influence the research agenda in the behavioral sciences related to health education/health promotion. Direct involvement in collaborative partnerships and a mutual exchange of information can only improve the fields of health behavior research and health promotion practice, and ultimately the nation’s health.