A scoping review of frameworks in empirical studies and a review of dissemination frameworks

The goals of this study were threefold. First, we conducted a scoping review of the empirical literature to catalog the dissemination frameworks informing dissemination studies. Second, we compiled the definition of dissemination, and third, we cataloged and defined the constructs from the dissemination frameworks. During our review process, we found that clearly identifying dissemination studies was more complicated than anticipated. Defining the sample of articles to code for this study was a challenge because of the large variability of studies that use the word “dissemination” in the titles but that are actually scale-up or health communication studies.

The high variability in the definition of dissemination poses a challenge for the field because if we do not clearly define what we are doing, we are unable to set boundaries to distinguish dissemination research from other fields. Among the identified frameworks that defined dissemination, the definitions highlighted that dissemination involved the spread of something, whether knowledge, an innovation, or a program. Distinct from diffusion, several definitions described dissemination as an active process, using intentional strategies. Few definitions described the role of determinants, whether dissemination is a process or a discrete event, and what strategies and outcomes may be pertinent. Future work is needed to unify these distinct conceptualizations into a comprehensive definition that dissemination researchers can use.

While it is clear that dissemination differs from diffusion, as the latter has been considered the passive and “haphazard” spread of information [35], the distinction between dissemination and scale-up—as shown in the definitions identified in this study—is less clear. Some articles from our search not included in the review conceptualized dissemination as similar to scale-up. To clarify the distinction between dissemination and scale-up in our review, we used the WHO’s definition of scale-up [36] as “deliberate efforts to increase the impact of successfully tested health innovations to benefit more people and to foster policy and program development on a lasting basis.” In other words, based on these definitions, our team considered scale-up as referencing active efforts to spread evidence-based interventions, whereas diffusion is the passive spread of information. Dissemination, therefore, can be conceptualized as the active and planned spread of information.

Another helpful component in distinguishing dissemination science from other sciences is related to the target audience. Brownson et al. [1] define dissemination as an “active approach of spreading evidence-based information to the target audience via determined channels using planned strategies” (p. 9). Defining the target audience in the context of dissemination is important because it may help distinguish the field from social marketing. Indeed, several studies we excluded involved sharing information with the public (e.g., increasing the awareness of the importance of sunscreen in public swimming pools). Grier and Bryant define social marketing as a “program-planning process that applies commercial marketing concepts and techniques to promote voluntary behavior change ( … ) by groups of individuals, often referred to as the target audience.” [37] The target audience in the context of social marketing, the authors explain, is usually considered consumers but can also be policymakers [37]. To attempt to delineate a distinction between these two fields, dissemination work has traditionally identified professionals (e.g., clinicians, public health practitioners, policymakers) as the target audience of dissemination efforts, whereas the target audience in social marketing is conceptualized as a broader audience. Figure 2 shows how we conceptualize the distinct components of dissemination research from other fields. Based on these distinctions, we propose the following coalesced definition for dissemination research to guide this review: the scientific study of the targeted distribution of information to a specific professional person or group of professionals. Clearly distinguishing dissemination from scale-up as well as health communication will help further advance the dissemination research field.

Fig. 2figure 2

Proposed distinction of definitions between diffusion, scale-up, and dissemination

Our results show that of the empirical papers identified in this review, 51% used a framework to guide their study. This finding mirrors the suboptimal use of frameworks in the field of implementation research [38, 39], with scholars recently putting forth guidance on how to select and use frameworks to enhance their use in implementation research studies [6]. Similarly, we provide a catalog of dissemination frameworks and their constructs identified in dissemination studies. It is necessary to move the dissemination research field forward by embedding frameworks in dissemination-focused studies.

Some empirical papers included in our review used frameworks based on the knowledge translation literature. Knowledge translation, a field most prominent outside the USA, has been defined as “a dynamic and iterative process that includes the synthesis, dissemination, exchange and ethically sound application of knowledge to improve health, provide more effective health services and products, and strengthen the health care system” [40]. As such, it conceptualizes an interactive relationship between the creation and the application of knowledge. In the USA, however, researchers tend to conceptualize dissemination as a concept discrete from implementation and use the acronym “D&I” to identify these two fields.

While one could state that there is a distinct set of outcomes, methods, and frameworks between dissemination and implementation fields, previous scholars have cataloged [4] a continuum, from dissemination only” to “implementation only” frameworks. Consistent with this, our findings show that scholars have adapted implementation frameworks to fit dissemination outcomes (e.g., Klesges’ adaptation of RE-AIM [41]), while other frameworks have both dissemination and implementation components (e.g., integrated Promoting Action on Research Implementation in Health Services [i-PARIHS] [42]). Additionally, behavioral change frameworks (e.g., theory of planned behavior) were cataloged in our study as they were used in included articles. The use of implementation frameworks in studies identified here as dissemination studies highlights at least three potential hypotheses. One possibility is the use of implementation frameworks in dissemination studies is due to the underdevelopment of the field of dissemination, as shown in the challenges that we found in the conceptual definition of dissemination. We hope that, by clearly outlining a definition of dissemination, scholars can start to empirically examine whether there are distinct components between implementation and dissemination outcomes and processes.

The second hypothesis is that we still do not have enough evidence in the dissemination or implementation fields to be dogmatic about the categorization of frameworks as either “dissemination” or “implementation.” Until we have more robust evidence about what is and what is not dissemination (or other continua along which frameworks may be categorized), we caution against holding too firm to characterizations of frameworks [38, 43,44,45] Frameworks evolve as more empirical evidence is gathered [43, 45,46,47,48,49], and they are applied in different settings and contexts. We could hypothesize that it is less important, as of now, to categorize a framework as an implementation or dissemination framework and instead clearly explain why a specific framework was selected and how it is applied in the study.

Selection and application of frameworks in dissemination and implementation research is still a challenge, especially considering scholars may often select frameworks in a haphazard way [6, 50, 51]. While scholars have put forward some guidance to select implementation frameworks [6, 52], the challenge in the dissemination and implementation research fields is likely not only in the selection of the frameworks but perhaps more so in the misuse or misapplication of frameworks, theories, or models. A survey indicated that there is little consensus on the process that scholars use to select frameworks and that scholars select frameworks based on several criteria, including familiarity with the framework [50]. As such, Birken et al. [52] offer other criteria for the selection of frameworks, such as (a) usability (i.e., whether the framework includes relevant constructs and whether the framework provides an explanation of how constructs influence each other), (b) applicability (i.e., how a method, such as an interview, can be used with the framework; whether the framework is generalizable to different contexts), and (c) testability (i.e., whether the framework proposed a testable hypothesis and whether it contributes to an evidence-based or theory development). Moullin et al. [6] suggest that implementation frameworks should be selected based on their (a) purpose, (b), levels of analysis (e.g., provider, organizational, system), (c) degree of inclusion and depth of analysis or operationalization of implementation concepts, and (d) the framework’s orientation (e.g., setting and type of intervention).

More than one framework can be selected in one study, depending on the research question(s). The application of a framework can support a project in the planning stages (e.g., examining the determinants of a context, engaging with stakeholders), during the project (e.g., making explicit the mechanisms of action, tracking and exploring the process of change), and after the project is completed (e.g., use of the framework to report outcomes, to understand what happened and why) [6, 51, 53]. We believe that similar guidance can and should be applied to dissemination frameworks; further empirical work may be needed to help identify how to select and apply dissemination and/or implementation frameworks in dissemination research. The goal of this review is to support the advancement of the dissemination and implementation sciences by identifying constructs and frameworks that scholars can apply in their dissemination studies. Additional file 1: Tables S6-S9 show the frequency of constructs per framework, and readers can see the variability in the frequency of constructs per framework to help in their selection of frameworks.

A third hypothesis is that the processes of dissemination and implementation are interrelated, may occur simultaneously, and perhaps support each other in the uptake of evidence-based interventions. For example, Leppin et al. [54] use the definition of implementation based on the National Institutes of Health: “the adoption and integration of evidence-based health interventions into clinical and community settings for the purposes of improving care delivery and efficiency, patient outcomes, and individual and population health” [55], and implementation research as the study of this process to develop a knowledge base about how interventions can be embedded in practices. In this sense, implementation aims to examine the “how” to normalize interventions in practices, to enhance uptake of these interventions, guidelines, or policies, whereas dissemination examines how to spread the information about these interventions, policies, and practices, intending to support their adoption (see Fig. 1). In other words, using Curran’s [56] simple terms, implementation is about adopting and maintaining “the thing” whereas dissemination is about intentionally spreading information to enable learning about “the thing.” As Leppin et al. argue, these two sciences [54, 57, 58], while separate, could co-occur in the process of supporting the uptake of evidence-based interventions. Future work may entail empirically understanding the role of these frameworks in dissemination research.

This review aimed to advance a critical step in the dissemination literature by defining and categorizing dissemination constructs. Constructs are subjective, socially constructed concepts [59], and therefore their definitions may be bounded by factors including, but not limited to, the researchers’ discipline and background, the research context, and time [60]. This is evident in the constructs’ lack of consistent, clear definitions (see Additional file 1). The inconsistency in the definitions of the constructs is problematic because it impairs measurement development and consequently validity and comparability across studies. The lack of clear definitions of the dissemination constructs may be due to the multidisciplinary nature of the D&I research field in general [61, 62], which is a value of the field. However, not having consistency in terms and definitions makes it difficult to develop generalizable conclusions and synthesize scientific findings regarding dissemination research.

We identified a total of 48 constructs, which we separated into four categories: dissemination processes, determinants, strategies, and outcomes. By providing these categories, we can hope to help advance the field of dissemination research to ensure rigor and consistency. Process constructs are important to guide the critical steps and structure that scholars may need to take when doing dissemination research. Of note is that the processes identified in this study may not be unique to dissemination research but rather to the research process in general. As the field of dissemination research advances, it will be interesting to examine whether there are unique components in these process stages that are unique to the dissemination field. In addition to the process, an examination of dissemination determinants (i.e., barriers and facilitators) is essential in understanding how contextual factors occurring at different levels (e.g., information recipient, organizational setting, policy environment) influence dissemination efforts and impede or improve dissemination success [7]. Understanding the essential determinants will help to guide the selection and design of strategies that can support dissemination efforts. Finally, the constructs in the dissemination outcomes will help examine levels and processes to assess.

The categorization of the constructs was not without challenges. For example, persuasion was coded as a strategy (persuading) and as an outcome (persuasion). Likewise, the construct confirmation could be conceptualized as a stage [16] or as an outcome [19]. The constructs identified in this review provide an initial taxonomy for understanding and assessing dissemination outcomes, but more research and conceptualization are needed to fully describe dissemination processes, determinants, strategies, and outcomes. Given the recent interest in the dissemination literature [22, 63], a future step for the field is examining the precise and coherent definition and operationalization of dissemination constructs, along with the identification or development of measures to assess them.

Limitations

A few limitations to this study should be noted. First, the search was limited to one bibliometric database and from journals publishing D&I in health studies. We limited our search to one database because we aimed to capture articles from Norton et al. [11], and therefore, our search methodology was focused on journals instead of on databases. Future work learning from other fields, and doing a broader search on other databases could provide different perspectives. Second, we did not include terms such as research utilization, research translation, knowledge exchange, knowledge mobilization, or translation science in our search, limiting the scope and potential generalizability of our search. Translation science has been defined as being a different science than dissemination, however. Leppin et al. [54], for example, offer the definition of translation science as the science that aims to identify and advance generalizable principles to expedite research translation, or the “process of turning observations into interventions that improve health” (see Fig. 1). Translation research, therefore, focuses on the determinants to achieve this end. Accordingly, Wilson et al. [7] used other terms in their search, including translation, diffusion of innovation, and knowledge mobilization and found different frameworks in their review. In their paper, Wilson and colleagues [7] provided a different analysis than ours in that they aimed to examine the theoretical underpinning of the frameworks identified by them. Our study is different from theirs in that we offer the definition of disseminating and a compilation of constructs and their definitions. A future study could combine the frameworks identified by our study with the ones identified by Wilson and colleagues and detail the theoretical origins of the frameworks, and the definitions of the constructs to support in the selection of frameworks for dissemination studies. Third, by being stringent in our inclusion criteria, we may have missed important work. Several articles were excluded from our scoping review because they were examining the spread of an evidence-based intervention (scale up) or of the spread of dissemination for the public (health communication). As noted above, however, clearly distinguishing dissemination from scale-up and from health communication will help further advance the dissemination research field and identify its mechanisms of action. Fourth, given the broad literatures in diffusion, dissemination, and social marketing, researchers may disagree with our definitions and how we conceptualized the constructs. Fifth, we did not code qualitative studies because we wanted to have boundaries in this study as it is a scoping study. Future studies could examine the application of frameworks in qualitative work. It is our hope that future research can build from this work to continue to define and test the dissemination constructs.

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