468 REVUE CANADIENNE DE SANTÉ PUBLIQUEVOLUME 94, NO. 6
Generation with Knowledge
Diffusion and Utilization
A Case Study Analysis of the Consortium for Applied
Research and Evaluation in Mental Health
Evelyn Vingilis, PhD, CPsych1
Kathleen Hartford, RN, PhD2
Ted Schrecker, MA3
Beth Mitchell, PhD, CPsych4
Barbara Lent, MD, CCFP, FCFP5
Joan Bishop, MD, FRCP6
Objective: Knowledge diffusion and utilization (KDU) have become a key focus in the
health research community because of the limited success to date of research findings to
inform health policies, programs and services. Yet, evidence indicates that successful KDU
is often predicated on the early involvement of potential knowledge users in the
conceptualization and conduct of the research and on the development of a “partnership
culture”. This study describes the integration of KDU theory with practice via a case study
analysis of the Consortium for Applied Research and Evaluation in Mental Health
Methods: This qualitative study, using a single-case design, included a number of data
sources: proposals, meeting minutes, presentations, publications, reports and curricula
vitae of CAREMH members.
Results: CAREMH has adopted the following operational strategies to increase KDU
capacity: 1) viewing research as a means and not as an end; 2) bringing the university and
researcher to the community; 3) using participatory research methods; 4) embracing trans-
disciplinary research and interactions; and 5) using connectors. Examples of the iterative
process between researchers and potential knowledge users in their contribution to
knowledge generation, diffusion and utilization are provided.
Conclusions: This case study supports the importance of early and ongoing involvement of
relevant potential knowledge users in research to enhance its utilization potential. It also
highlights the need for re-thinking research funding approaches.
become a high priority for the health
research community. The recent inter-
national review of the Canadian Health
Services Research Foundation recom-
mended that “knowledge transfer work
that has already begun...should become the
highest priority”.1Similarly, numerous
newsletters, conferences and workshops in
Canada and abroad have been dedicated to
KDU.2-9The simple reason for the current
interest in KDU is that despite a wealth of
health-related, policy- and practice-
relevant research, the transfer of health and
medical research into practice is often
slow, if it occurs at all.8,10-12
One major barrier to KDU is that
researchers and potential knowledge users
operate in different social systems, which
limits knowledge transfer.13-15If they con-
nect at all, it is after an issue has become a
policy agenda item.11This is a less than
opportune time to inform policy.11Yet as
Lomas writes, “The clearest message from
evaluation of successful research utilization
is that early and ongoing involvement of
relevant decision makers in the conceptual-
ization and conduct of a study is the best
predictor of its utilization.”11If research is
treated as an end-point product rather
than as a process, potential knowledge
users are not given the opportunity to
inform the topics to be researched or the
approaches to be adopted.11The challenge
thus becomes: how to involve potential
knowledge users into a research program
and engage in KDU before studies have
been conducted and completed? This qual-
itative study, using a single-case design,16,17
of the Consortium for Applied Research
and Evaluation in Mental Health
(CAREMH) provides an example of the
integration of KDU theory with practice.
nowledge diffusion and utilization
(KDU), also called knowledge
transfer, uptake or translation, has
The context of this study was to examine
the strategies and outcomes of integrating
knowledge generation with KDU, based
on KDU theories, during the first three
years of CAREMH. Two data sources were
used: direct observation and documenta-
tion,17which included all CAREMH grant
proposals, meeting minutes, quarterly
reports, presentations, publications and
members’ curricula vitae. Member check-
La traduction du résumé se trouve à la fin de l’article.
1. Population & Community Health Unit, Family Medicine, The University of Western Ontario,
2. Lawson Health Research Institute, London ON; Faculty of Health Sciences, The University of
3. Saskatchewan Population Health and Evaluation Unit, University of Saskatchewan, Saskatoon, SK
4. Mental Health Care Program, London Health Sciences Centre; Departments of Psychology,
Podiatries and Psychiatry, The University of Western Ontario
5. Department of Family Medicine, The University of Western Ontario, Victoria Family Medical
6. Riverview Hospital, Port Coquitlam, BC
Correspondence and reprint requests: Dr. Evelyn Vingilis, Population & Community Health Unit,
Family Medicine, The University of Western Ontario, 100 Collip Circle, Suite 245, London, ON,
Tel: 519-858-5063, Fax: 519-858-5029, E-mail: firstname.lastname@example.org
Funded by the Donner Canadian Foundation
CAREMH does not take specific policy positions. Accordingly, all views, positions and conclusions
expressed in this article should be understood to be solely those of the authors.
NOVEMBER – DECEMBER 2003CANADIAN JOURNAL OF PUBLIC HEALTH 469
INTEGRATING KNOWLEDGE GENERATION WITH KDU
ing was used to enhance the validity of the
In 1999, a team of eight investigators
received funding to paint a comprehensive
picture of psychiatric de-institutionaliza-
tion using southwestern Ontario, where
two Provincial Psychiatric Hospitals were
then slated for closure, as a “natural labora-
tory”. Using a public health approach, this
research program integrated systems and
individual outcomes data to provide an
understanding of the prevalence and needs
of mental illness, factors related to appro-
priate service provision, methods for sys-
tem improvement and diffusion of find-
The initial proposal was developed in
response to frustration expressed by local
professionals who felt a disconnection
between government reform policies and
their daily experiences with the mental
health system. The research plan was to
gather data before the psychiatric hospitals
were closed, so that the data could inform
mental health reform.
To ensure this research would both tap
the relevant community issues, and be use-
ful to and used by the potential knowledge
users, this research group built into the
original research proposal a series of three
colloquia of potential knowledge users, and
established an “open-door policy” that
brought to meetings other interested
researchers and potential knowledge users.
This broadening of the original research
group led to the formation of CAREMH.
Further, a list-serve directory and news-
letters were developed for CAREMH as a
knowledge transfer vehicle for relevant
research findings, news and policy issues.
Knowledge diffusion and utilization
Recent research examining KDU methods
and processes generated a model where a
key element was the development of a
“partnership culture”. This culture is to be
established at the beginning rather than at
the end of the research, so researchers and
potential knowledge users develop a part-
nership of trust, respect, ownership and
common ground, as the fundamental first
step to successful KDU.19Using this model
and previous experience in KDU,19-22
CAREMH engaged in a number of opera-
Viewing Research as “Means” and Not
A major challenge to KDU is that the
research enterprise is more concerned with
creating knowledge than whether it actual-
ly gets used.10,23Moreover, public access to
research findings is rarely addressed.24-26
For CAREMH, the conduct of high
quality research is not an end in itself.
Rather it is the means to enhance the well-
being of persons with serious mental ill-
ness. This philosophy shapes CAREMH’s
research approach and methodology, as
investigator-driven questions are moderat-
ed by questions from the potential knowl-
edge user community. The first collo-
quium set the stage for researchers to listen
to potential knowledge users about mental
health reform issues. The researchers’ agen-
da was to identify health care service gaps
and needs. However, the issues identified
by potential knowledge users were much
more fundamental. A major concern was
the loss of a “home” for many with mental
illness.27,28Participants emphasized that
poverty could make it difficult to access
safe and affordable housing and needed
tion, clients also faced the need to navigate
complex and sometimes contradictory, fed-
eral, provincial and local bureaucratic sys-
tems.27,28These and other findings were
presented to a regional task force drawing
up plans for mental health service restruc-
turing. The task force flagged their impor-
tance, and the issues were referred to a sub-
committee to be addressed.29
Despite research not being an end in
itself, CAREMH members secured fund-
ing for 11 additional spin-off projects.
Public and academic dissemination has
included hospital, community and task
force presentations, two op-ed articles,30,31
press releases, a TV information talk show,
plus numerous international conference
presentations and eight academic publica-
Bringing the University and
Researcher to the Community
Potential knowledge users who do not pri-
marily conduct research were encouraged
to join CAREMH. Many had specific
questions of direct relevance to local men-
tal health reform. Mentoring by
CAREMH researchers and the use of
research grant money to pay for a research
assistant were key to knowledge generation
For example, policy planning for de-
institutionalization is predicated on the
assumption that family physicians will
address the health needs of people with
serious mental illness and direct them to
appropriate individuals or agencies in the
social services system. This policy piqued
the interest of two CAREMH members (a
family physician and a psychiatrist).
Through a key informant study, they and
colleagues determined that family physi-
cians were comfortable with the idea of
caring for people with mental illness but at
times felt overwhelmed by the complexities
of their needs or unsupported by their psy-
chiatrist colleagues.32Because of other
changes in the health care system, they felt
unable to take on the extra load – findings
of importance to the regional implementa-
tion task force.
Another community-university project
identified that many with mental illness
were presenting at emergency departments
(ED) with non-medical problems. In
response, the local hospital implemented a
double triage with referral of non-medical
problems to an on-site mental health crisis
worker empowered to deal with legal,
financial or housing issues.40Additionally,
based on a needs assessment, a pro bono
legal clinic for psychiatric in-patients (the
first in Canada) was established in partner-
ship with The University of Western
Ontario’s Faculty of Law. These demon-
strations are being evaluated with support
from the Change Foundation.
Using a Participatory Research
The purpose of participatory research is “to
empower participants by increasing their
research skills, and producing information
that will enhance their capacity to
strengthen and improve their programs
and take collective action on key issues
affecting them.”41For example, a key
CAREMH academic question was to iden-
tify the prevalence of mental illness and
needs in various settings, including home-
less shelters. Local homeless shelters want-
ed to assess the needs of their clients in
order to reassess their resources.
INTEGRATING KNOWLEDGE GENERATION WITH KDU
470 REVUE CANADIENNE DE SANTÉ PUBLIQUEVOLUME 94, NO. 6
CAREMH researchers guided shelter staff
with instrument identification, the ethics
proposal, the conduct, analysis and inter-
pretation of the research. This collabora-
tion not only provided the shelters with
the planning information they needed, but
also provided CAREMH with important
data to complement their hospital, out-
patient and corrections data sets.42
Embracing Trans-disciplinary Research
A key predictor of KDU is “homophily”:
the degree to which individuals who inter-
act share similar attributes, knowledge and
beliefs.14Vingilis and Lindsay19found that
successful KDU was predicated on
researchers and potential knowledge users
from different disciplines working closely
together. Time was required to build
mutual respect and shared knowledge, thus
creating greater homophily and potential
CAREMH includes individuals from the
disciplines of business, correctional ser-
vices, economics, education, epidemiology,
family medicine, law, nursing, political sci-
ence, police science, psychiatry, psycholo-
gy, social work and sociology working as
researchers, health care practitioners, policy
analysts, administrators and managers, in
district health councils, acute care and psy-
chiatric hospitals, private practice, social
services, housing, police and correctional
services. In addition, consumers and their
families are part of the larger network.
The worlds of researchers and potential
knowledge users are social systems defined
and identified by their own sets of rules,
values, languages and communication pat-
terns.13,19Knowledge gaps occur when
there is a lack of shared values, common
perceptions, and inter-system communica-
tion patterns. KDU models imply that the
gap can be bridged if persons, groups or
resources are interposed between the two
systems.5,11,13,14,19,25,43,44The role of these
intermediaries or “connectors” is to assist
potential knowledge users in identifying
knowledge needs and to assist researchers
in translating, influencing and initiating
knowledge diffusion.13Connectors can
have roles of conveyor, consultant, trainer,
leader, innovator, defender, knowledge
builder, practitioner and user.13They con-
centrate on creating awareness of new
knowledge, and on the persuasion-decision
steps for KDU.
CAREMH members fulfill the role as
connectors with non-CAREMH potential
knowledge users regionally and inter-
nationally. For example, in 2000 a partner-
ship called the London Mental Health
Alliance with the support of the Ontario
Ministry of Health and Long-Term Care
and the local District Health Council,
which includes conventional health care
facilities, community-based services and
providers, consumers and families, was
formed to identify and address system
issues and to ensure quality mental health
care on an ongoing basis.45Some
CAREMH members belong to the
Alliance and act in various connector
capacities, bridging the knowledge gap
between CAREMH and non-CAREMH
potential knowledge users.
CAREMH puts into practice the findings
of KDU research that early and ongoing
involvement of potential knowledge users
in the conceptualization and conduct of
research is important for knowledge uti-
lization.5,46CAREMH was able to imple-
ment KDU operational strategies because
they received a large research program
grant. Yet a serious challenge for integrat-
ing KDU with knowledge generation
research is funding. As Lomas emphasizes,
“Grant funding agencies, particularly tradi-
tional biomedical and clinical ones, have
inadvertently perpetuated the inappropri-
ate idea that single studies are worthy units
of transfer and dissemination. This is
because of their major focus on funding
project- based assessments rather than
issue-based programs of research and/or
relevant summaries and syntheses.”11
Moreover, because KDU by its very nature
is non-linear, participatory and evolving,
the research designs of programs including
KDU cannot be specified with the exacti-
tude required by traditional funding agen-
cies.19Few such agencies support programs
of research that include resources to
involve potential knowledge users in defin-
ing and answering policy- and practice-
relevant questions. The availability of a
research assistant for CAREMH, in addi-
tion to the mentoring offered by senior
CAREMH researchers, has been indispens-
able in this respect. The effort and time
required for submission and review of
grant proposals by traditional funding
agencies is a barrier to the development of
issue-based, research programs that
embrace and encourage the type of part-
nership needed between researchers and
potential knowledge users to facilitate
KDU and subsequent evidence-based poli-
cies. Clearly as research agencies, govern-
ments and other potential knowledge users
promote KDU as a critical component of
the research enterprise, greater creativity
and flexibility will need to be built into the
funding and support of applied health
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Objectif : La diffusion et l’utilisation des connaissances sont devenues des orientations clés pour les
chercheurs médicaux, car jusqu’à maintenant, les politiques, programmes et services de santé ne
s’inspirent pas beaucoup des résultats de recherche. Certains indices portent cependant à croire
qu’une diffusion et une utilisation efficaces des connaissances dépendent souvent de la
participation précoce des utilisateurs éventuels des connaissances à la conceptualisation et à la
conduite de la recherche, ainsi que de l’avènement d’une « culture de partenariat ». Notre étude
décrit l’intégration, dans la pratique, de la théorie de la diffusion et de l’utilisation des
connaissances, par le biais de l’analyse d’une étude de cas du CAREMH (un consortium pour la
recherche appliquée et l’évaluation en santé mentale).
Méthode : Étude qualitative fondée sur un cas et faisant appel à plusieurs sources (les propositions,
procès-verbaux, présentations, publications, rapports et curriculum vitæ des membres du
Résultats : Le CAREMH a adopté les stratégies opérationnelles suivantes pour accroître sa capacité
de diffusion et d’utilisation des connaissances : 1) considérer la recherche comme un moyen plutôt
qu’une fin; 2) amener l’université et le chercheur dans la collectivité; 3) utiliser des méthodes de
recherche participatives; 4) profiter de la recherche et des interactions transdisciplinaires; et
5) utiliser des « connecteurs ». L’étude donne des exemples du processus itératif entre les
chercheurs et les utilisateurs éventuels des connaissances pour que ces derniers contribuent à la
création, à la diffusion et à l’utilisation de savoirs.
Conclusions : L’étude de cas confirme l’importance, pour la recherche, de la participation précoce
et continue des utilisateurs éventuels des connaissances, ceci pour améliorer l’utilisation des
résultats. Elle souligne également le besoin de repenser les méthodes de financement de la