The impact of knowledge brokering in health sector and the challenges: A review of literature

Abstract

Knowledge brokering is a type of knowledge translation that bridge the researchers and end users. Knowledge brokering assist the interactions between all agents to understand each other’s perspectives and goals to improve health system performance. The failure to deliver how important the research implementation in society may cause significant outcome. A person or organization who perform knowledge brokering is called knowledge broker (KB). Literature review is conducted for the clinical question of how knowledge brokering impact the health sector and the visible challenges. A literature search is performed by systematic search using three major online databases; Cochrane, PubMed, and EBSCO. Hand-searching also yielded one result that fit the objective of this study. The database result search was being screened from the title and abstract which resulted in 14 relevant articles. After reading the full-text articles, four literatures were ruled-in. The study assessed knowledge brokering process using various methods like single framework or model as well as the combination. The challenges include the lack of communication between internal team and end users, leadership skill, engaging end users, knowledge transfer activity, different timeline, and diverse vision. Evaluating and applying knowledge brokering strategies were needed as the practice itself bringing positive outcomes. Knowledge brokering approaches consist of many methods which tailored to the study objective. Challenges that stand out were communication and personal skill, engaging end users, and perspectives difference. The impact of knowledge brokering is challenging to assess. Further studies that evaluate the impacts of knowledge brokering are still needed.

Introduction

Promoting research-based-evidence to be implemented in society as public policy or other forms is needed to improve the health system performance in global health. A way to attain this achievement is through knowledge brokering. The term knowledge brokering refers as a bridge between the researcher and end users like policy makers, doctors, as well as partnerships. After through collaborative process between the involved members, a maximize outcome of health policy was expected. Knowledge brokering is not a common term since the application itself is more common in high-income countries rather than low- and middle-income one. ¹ Back in the early day, brokering practice had took place in informal way for example connecting industries to academic partners. ² However, knowledge brokering is seen as a part of knowledge translation (KT) that makes spreading the knowledge as important action right now. During the knowledge spread, it is easier to develop the new products since it is believed to stimulate innovations. ³

Failure to deliver the importance of research implementation in society might cause significant outcome. The research cardinal findings can make a difference in tackling health issues. Government or policy maker also need expert opinion to bring the best policy in each sector. ⁴ Explaining research result to decision makers and practitioners through passive action has been known as an ineffective measure. ² Therefore, knowledge brokering way to make collaborative links while identifying issues about the solutions followed by picking the relevant research-based-evidence to meet the needs are necessary. ⁴

The person who performs knowledge brokering is called knowledge broker (KB). Broker defined as a person or group who act as middlemen to arrange things such as deal or agreement between two or more groups. Knowledge brokers has been described as “managers” or “capacity builders.” KB consisted of a group or individual that is experienced in this field. ⁵ Brokers play a role assisting the needs between the parties instead of favoring an individual or group. In that way, broker will stay neutral despite the difference of interest that might arise. ² Through this study we sought to see how knowledge brokering work in health sector and the emerging challenge.

Methods

The literature search was performed through PubMed, Cochrane, and EBSCO, and handsearching. Consequently, the selected articles were ruled in after meeting the eligibility criteria. The study selected after looking into detailed frameworks or methods the study used, type of literature, as well as the results. The keywords using MeSH term consisted of “knowledge brokering,” “knowledge translation,” “health sector,” “challenge.”

The inclusion criteria consist of (1) study design including systematic review, meta-analysis, cross-sectional, case study, or literature review; (2) Study scope of knowledge brokering impact in health sector; (3) KB approach with detailed description and written framework or module; (4) Full text available. Meanwhile the exclusion criteria include the literature not available in English. The selected articles getting critically appraised and assess the quality using method from Centre for Evidence-Based Medicine (CEBM), University of Oxford (Figure 1). The literature searched and appraised were done by two of the authors.

Figure 1.

Flowchart diagram of literature search.

Results

Literature search

The literature search through three major databases yielded 36 potential articles. After title and abstract screening, 14 articles were obtained. After duplications removal, a total of 11 articles were present. Throughout full text screening and including the inclusion and exclusion criteria, three articles were obtained for critical appraisal and another one article were added after hand-searching. A total of seven articles were excluded due to one article did not have full-text, five articles did not describe the detailed framework or module, and three articles did not fulfil the study design (Figure 1).

Framework or model used in knowledge brokering

The study by Norton et al. ⁶ used Theoretical Domains Framework (TDF) to assess the knowledge brokering process. Meanwhile Mc Sween-Cadieux et al. ⁷ used Consolidated Framework for Implementation Research and the Ecological Framework. Knowledge to Action (KTA) model and Promoting Action on Research Implementation in Health Services (PARIHS) were used in Newman et al. ⁸ study that occurred with mixed study design of qualitative and quantitative search. A systematic review by Van Eerd et al. ⁹ consisted of nine articles that showed specific knowledge brokering approach and six articles with general KT frameworks. Most of them using linkage and exchange model. More general KT frameworks such as the KTA model as well as PARIHS.

Knowledge brokering in practice

The literature mentioned the objectives of their study. Norton et al. ⁶ use TDF to analyze how would knowledge brokering look like if it is performed in low- and middle income countries (LMIC). Mc Sween-Cadieux et al. ⁷ determined to assess the thing that knowledge brokering practice needed although the study itself was on hold in their last year timeline. Newman et al. ⁸ measured the impact of the knowledge brokering through quantitative method and incorporating insight of it from qualitative method. Meanwhile, Van Eerd et al. ⁹ systematic review was made to consider how knowledge brokering conducted instead of evaluating the effectiveness. The theme of their study was healthy aging with knowledge brokering approaches although it consists of varying knowledge brokering implementation did not only include the same theme (Table 1).

Table 1.

Articles with knowledge brokering outcomes and the challenges.

Articles	Framework or model	Health sector outcomes	Challenges	Conclusion
Norton et al. 6	Theoretical domains framework	Social and professional context as the relevant domains. Meanwhile social influence that were seen in other publications didn’t become relevant in this study.	Overlapping between domain, retrospective use, global health setting complexity, and applicable knowledge.	TDF can enhance the decisions for knowledge brokering with understanding when, where, and for whom it happened especially LMIC in this study.
Sween-Cadieux et al. 7	Consolidated framework for implementation research and the ecological framework	Key recommendations include intervention development, partners engagement, implementation planning, and implementation process.	The project being relocated to central level. Certain shortcoming such as: Inadequate leadership, no shared vision, lack internal communication.	More effort should be performed by researchers and brokers for knowledge brokering strategy especially intervention planning, technical resources, and communications. Implementing frameworks should be used when developing knowledge brokering strategy.
Newman et al. 8	Knowledge to action (KTA) and the promoting action research in health sciences (PARISH)	Implementing factors that influence translation research into practice processes, best way to develop it, and a robust evaluation measure.	Efforts to engage the knowledge users.	Knowledge brokering is expanding but the impact on its targeted knowledge users has yet clearly established. The study recommends to take three-pronged approach in knowledge brokering theory: process models, determinant models, and evaluation models.
Van Eerd et al. 9	Linkage and exchange, KTA, PARISH	Seven out of 15 articles provide specific KB approaches that related to outcomes. Other studies outcomes include measuring KB roles, research uptake or awareness, KT process and practice change.	Goering et al.: different timeline between researchers and decision-makers. Urquhart et al.: maintaining stock holder engagement Hammami et al: few knowledge transfer activities Ward et al: the framework lacking relative importance and applicability.	Knowledge brokering approaches varied greatly depending on the context and stakeholders involved. It emphasis acquiring, adapting, and disseminating knowledge and networking (linkage), especially the linkage and exchange concept.

Theoretical domain framework (TDF) by Norton et al. ⁶ shows that social and professional context as the relevant domains. Implementing frameworks should be used when developing knowledge brokering strategy including intervention development, partners engagement, implementation planning, implementation process, technical resources, and communications. Knowledge brokering is expanding but the impact on its targeted knowledge users has yet clearly established. ⁷ Study from Newman et al. ⁸ recommends taking three-pronged approach in knowledge brokering theory: process models, determinant models, and evaluation models. Knowledge brokering approaches varied greatly depending on the context and stakeholders involved that emphasis acquiring, adapting, and disseminating knowledge and networking (linkage), especially the linkage and exchange concept. ⁹ Knowledge brokers give impacts as a solution for bridging the gap between problem, science, and decision-making. Knowledge brokers spanning the boundaries of study and policy play a central role policy engagement and impact opportunities.

There are several challenges of knowledge brokering. Norton et al. ⁶ shows overlapping between domain, retrospective use, global health setting complexity, and applicable knowledge. The other study mentioned that the project being relocated to central level. ⁷ Certain shortcoming such as: Inadequate leadership, no shared vision, lack internal communication, efforts to engage the knowledge users become other problem of knowledge brokering.^7,8 Different timeline between researchers and decision-makers, problem maintaining stockholder, few knowledge transfer activities and framework lacking relative importance and applicability are other challenges. ⁹

Discussion

The knowledge brokering term plays an important role in knowledge transfer, connecting researchers, clinicians, sponsors, and policymakers. ² The different field of work between users who work in the health sector and clinician or researcher creates a knowledge gap that forms a barrier to understanding the needs and importance of certain knowledge to be prioritized and implemented in the community. ⁷ Therefore, knowledge brokering is important as it is facilitating the interaction between all parties to understand each other’s perspectives and goals as well as their professional culture. It is also defined as a way to influence other’s work, forge new partnerships, and use the research. ¹

Knowledge broker play the role of performing the knowledge brokering process. KB has a role in making research more approachable to other agents. The primary aim of KB itself consists of working as a bridge facilitating both parties and promoting data between the research group and user group while creating the same understanding and culture. ⁸ KB also works to establish and strengthen research-based evidence through collaborative links. The broker can interpret the evidence that are needed from various sources and translate it into action. Other than the previous job descriptions, KB also has the responsibility to provide ongoing support for the upcoming change and strengthen involved member capacities to perform the job. Attractive and tailored tools to distribute the evidence to targeted audiences should be prepared. ⁵ Just like how the medication is prescribed according to clinical signs, tailored knowledge that is applied in the right way will become a powerful weapon to tackle the existing problems.

The skill that KB needed includes a diverse range of soft skills including earning professional data and appraising the evidence, networking and lobbying skill, and commitment to use the data. Tailoring the data and arranging it to become functional as well as fitting the user needs are also KB functions. ¹⁰ Updating their knowledge while building relations is also important that can be achieved through attending an event or joining a conference. Adaptability and detailed reactions toward new evidence is needed considering the constant changing in the research world. ¹¹ While being exposed to many data, filtering and ruling out the one that can cause conflicting interests should be done. Through this situation, KB must know what to do with the conflicting data including planning whom the info will be shared with, where the meeting will take place, and understanding how to process multi-directional view for it to lower the bias and receive a clear view. ⁵

Approach of knowledge brokering

In order to understand more about knowledge brokering, looking up knowledge transfer (KT) theories will be beneficial. There were many models, frameworks, and theories of knowledge brokering. The need to use multiple theories in knowledge brokering might be originated from how the tasks involve many corporates, associations, or research partnerships. The role itself requires diverse knowledge that leads to different knowledge brokering. Most of the time, the research world itself is very dynamic as various needs will arise while the knowledge transferring process did not have a routine practice. Other than KB, developmental evaluation was also performed to collect and analyze the data that lead to considering the better conditions and which were not worth to be carried out anymore. However, the developmental evaluation technique was not clear to be adapted by KB in either Bornbaurn et al. ⁵ or van Eerd et al. ⁹

Knowledge translation (KT) is used into the light by Canadian Institute for Health Research (CIHR) in 2005 and later by the World Health Organization (WHO) in 2005. CIHR defined KT as “the synthesis, exchange, and application of knowledge by relevant stakeholders to accelerate the benefits of global and local innovation in strengthening health systems and improving people’s health.” ¹²

Knowledge to Action (KTA) is a form of KT process that’s practically the most used framework in practice. Knowledge identification, synthesis, and tools or products that were part of knowledge creation were tailored to be analyzed. The tailored data are needed to become objective involving what each party needed as well as staying in the appropriate context. The product of this knowledge tailoring was identifying problems, adapting the knowledge to the local context, determining the gap and reviewing the knowledge, implementing interventions, monitoring the knowledge used, evaluating the outcomes and sustaining it. The action cycle is made to represent the measure that needed to be applied in practice. ¹ The KTA framework itself is useful to figure out the research about, the thing that’s trying to be measured, the impactful part to be applied, and the sustainability in the near future. KTA framework emphasizes social interaction as a significant point of KT. This model also offers the possibility to be combined with other frameworks. ³

There were three frameworks that describe knowledge brokering that being proposed by Oldham and McLean in 1997. The first one is the knowledge system framework that relates to the creation and use of knowledge that’s performed with knowledge brokering activity. It mirrors the role of KB as knowledge manager. Meanwhile, the transactional framework highlighting the interaction between researchers and end users of the knowledge and promote a further link between those two parties. The last one is the social change framework where knowledge brokering is set to level up the access to knowledge by providing knowledge training that can lead to positive social outcomes. KB was seen as capacity builder in this part. ¹³

In knowledge brokering practice, three approaches from Nilsen ¹⁴ might help in assessing what theories are needed at that time. It consists of putting an explanation of translating research into practice, how impactful if it is implemented, and evaluating it. Those three are process models, determinant models, and evaluation models. Process models will describe the KT process while determinant models will describe the influences of KT outcomes. Meanwhile, evaluation models consist of applying classic theory while developing specific theory and identifying what aspect will be evaluated next. ⁸

Linkage and exchange model are seen as a path to linking knowledge through the measurable effort with potential users. This model come from the understanding that adding decision-makers in the process is the best predictor that it will be used and may lead to the successful uptake of the research to become policy and implemented practice. The linkage and exchange model by CHSRF consisted of six items. Research generation is formed and then starting the research synthesis. After that, knowledge translation is performed followed by linkage and exchange which lead to the implementation of research. The last step was evaluating the outcomes and research use. The linkage and exchange process will increase the relevance and appliance of the research. This model emphasized interpersonal activities and excellent communication skills for partnership and collaborations. ¹⁵

Promoting Action on Research Implementation in Health Services (PARIHS) framework is a helpful model to review the application in health care through quality development intervention. There are three elements objective in PARIHS framework, such as evidence, context, and facilitation that associated with the accomplishment of the implementation. ¹⁶

Glegg and Hoens propose The Role Model consisting of five domains in order to maximize the effectiveness of knowledge brokering by eliminating the overlapping role that might have occurred. Those domains are information manager, linking agent, capacity builder, facilitator, and evaluator. This model has the advantage of allowing categorization by role domain without requiring all of it to be present within the specific context. Moreover, other theories can be applied in this model after identifying and setting each domain outcome. ¹

There was not sufficient evidence that showed interaction efficacy between researcher and user in a recent systematic review to influence the implementation of data. Meanwhile, few studies of knowledge brokering use have been observed bringing positive outcomes which came into conclusions that KB possessed more impact than a less developed culture. ³

While making a selection, KB will need to process the evidence through the reflective comparative decisions that consisted of two domains, internal and external factors. This action will lead KB from being biased and distinguishes from having one point of view in disseminating the evidence. The internal factor including KB knowing their characteristic and their action orientation, mental state, and how will they react on the outside world. Knowing the knowledge that KBs possess will result in the action of the next move. Meanwhile, the external influences include the orientation of environmental action, international influences, and knowledge sustainability. Through the internal and external access evaluation, KB will have more quality decision that has been thought with different types of plan. The ability to handle large possibilities while thinking of different scenarios and the best option available that they had to choose was expected. ⁶

Examples of knowledge brokering application in health care setting

Canada is one of the country that brings knowledge brokering into the light. According to Newman et al., the public health sector in Canada is moving to an evidence-informed decision-making system where knowledge brokering has a role in making new approaches in knowledge translation and knowledge brokers connect the researchers and decision makers to make evidence in the health promotion in the last few years as well as the provision of healthcare. As knowledge brokering has been established well in Canada at the moment, the gaps are still there such as the developed theoretical framework comprehension and how to determine evaluative KB practices to be used. In this study, researchers used frameworks, models, and theories they used in the practices as their way to evaluate knowledge brokering interventions by mixing two method design. The quality of engagement between KB and their clients might increment—the knowledge brokering can be more impactful—on the off chance that KB made endeavors to describe, understand, and assess their exercises utilizing hypotheses or models particular to KB. ⁸

KTA application in knowledge brokering showed that this framework was being used with varying degrees of completeness. The framework itself is applicable to be applied in various healthcare topics. However, none of the study was reported using a complete KTA framework, and only four studies detailed knowledge creation. For the action cycle, the integrated studies used different methods in practice. Monitoring activity in KTA framework is sometimes hard to apply considering the need for additional funding as well as time in longer terms. ³

Theoretical domains framework (TDF) was applied to low- and middle-income countries (LMIC) health data to understand KB decision. The application itself was useful in exploring the characteristics of knowledge brokering. A few modifications were made in the TDF domain which was also in accordance with the guidance to focus with the scope of the study. The findings include social and professional context as the relevant domains. Meanwhile, social influences that were seen in other TDF publications did not become relevant in this study. ⁶

Stroke research study using linkage and exchange method of knowledge brokering activity between the researchers and the users. It is involving policymakers and researchers to build integrated stroke care with a new system. Despite some circumstances, KB is affecting more partnership involvement if supported by impressive communication skills and the same apprehension between involved parties. ² Sharples and Sheard stated that the key factor to KB success is matchmaking by providing a third party that can be trusted, adding value between their gaps while enabling relevant evidence and a sensitive setting while maintaining professional status. ¹⁷

The implementation of knowledge brokering practice in West Africa took place in 2012. It was scheduled to be 3 years project for providing the health actors with evidence-based research and transfer knowledge in the research program to potential users of the data. This study used combination of Consolidated Framework for Implementation Research and Ecological Framework. However, the project was suspended in the third year after the difficulty to implement those at the central level. Mc Sween-Cadieux et al. ⁷ analyze the short-coming of this project which are not effective leadership, different vision of intervention orientation, KB role challenges, and lack of clear internal communication. Other causes of this study deployment are decision-making from authority is lacking and the challenge of accessing the central level. Although showing some short-coming, this study also showed several strengths for the first 2 years run which including collaborative development, supporting local partners, as well as training opportunities and support for the broker.

An active relationship with users, tailored evidence, excellent communication practice, the receptiveness of evidence from similar settings, versatility, and action orientation were found to be supporting factors in KB role. The relationship quality between KB and the end users might be increasing and impactful if the effort to apply the activities using specific knowledge brokering theory.^10,11

The challenges amidst knowledge brokering

The degree and nature of challenges affecting KB and the capacity to operate their part while adjusting the country's level of improvement, authoritative settings, assets, and political motivation. Moving the activity in a low-resource country such as Ethiopia may require diverse methodologies for overcoming challenges than in a nation with more assets like India, in expansion to tending to other relevant issues. Decisions to absorb the evidence in LMIC were due to the intersection of four aspects which are science, politics, beliefs, and environment. The change of health care priorities or decisions by politician, the community demand that oppressed decision makers, and the slow progress for approval were also challenges that arise. The hierarchy of traditional knowledge may take part in decision results although it is lesser than the decision maker’s position, experienced knowledge, and local knowledge. ¹¹

Overlapping between domains, retrospective use, global health setting complexity, and applicable knowledge were emerging challenges in TDF applications. Applying the TDF is quiet time-consuming. Also, TDF use in retrospective study is involving knowledge sharing and user behavior instead of specific practice which result in lower score in some TDF domains than in the precedent studies. TDF use in LMIC setting must consider complex contextual aspects which makes the criteria need to be adapted. ⁶

KB can adjust the model, framework, or theory that is most appropriate to the research. If impact evaluation is not asked by the end users, it could mean that the theorization used is limited to describing the research rather than utilizing evaluating aspects in popular frameworks like KTA or PARISH. Concerns about the consistency and evaluation performed in knowledge brokering come into the light in some cases, especially the people’s belief that it does not show the effectiveness in capacity building process. ⁹

Calculating KB impact is challenging due to the unwillingness to claim achievements by some KB. Some of them think that their role is only facilitating or assisting the process and the achievement itself should be earned by the team. ¹⁰ Setting the boundaries is quite a challenge since the job of KB might take turn into different scopes due to stakeholder needs or other dynamic activity.

Conclusion

Knowledge brokering plays an important role in applying research into practice. The knowledge brokering approach consists of many methods which can be tailored to the objective of the study, either using single or combined methods. Challenges along knowledge brokering applications that stands out were communication and personal skill, engaging end users, and perspectives difference. The impact of knowledge brokering is challenging to assess due to non-direct results and the lack of evaluation from knowledge users. Knowledge brokering was found to bring positive outcomes although the user implementation data was not clear. More measures should be performed in the knowledge brokering strategy. Further studies that evaluate the impact of knowledge brokering are still needed.