Effective knowledge mobilisation: creating environments for quick generation, dissemination, and use of evidence
BMJ 2022; 379 doi: https://doi.org/10.1136/bmj-2022-070195 (Published 07 November 2022) Cite this as: BMJ 2022;379:e070195Read our Covid Inquiry series
This article has a correction. Please see:
- Raheelah Ahmad, lead in knowledge mobilisation1 2 3 4,
- Anthony C Gordon, chair in anaesthesia and critical care5 6,
- Paul Aylin, professor of epidemiology and public health1 5,
- Julian Redhead, national clinical director for urgent and emergency care6,
- Alison Holmes, David Price Evans chair in infectious diseases and global health1 8
- 1NIHR Health Protection Research Unit (HPRU) in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
- 2Department of Health Services Research and Management, School of Health and Psychological Sciences, City, University of London, UK
- 3Institute of Business and Health Management, Dow University of Health Sciences, Karachi, Pakistan
- 4The Surveillance and Epidemiology of Drug-resistant Infections Consortium (SEDRIC), Wellcome Trust, UK
- 5Division of Anaesthetics, Pain Medicine and Intensive Care, Imperial College London, London, UK
- 6Imperial College Healthcare NHS Trust, Imperial College London, UK
- 7Department of Primary Care and Public Health, School of Public Health, Imperial College London, UK
- 8Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
- Correspondence to: R Ahmad raheelah.ahmad@city.ac.uk
Key messages
Effective response to the pandemic required real time use of research knowledge
Some existing infrastructures for generating and mobilising research findings accelerated collaborative working during the pandemic, and helped direct research appropriately
Investment is needed in integration of data, particularly for social care
Successful knowledge mobilisation needs to be sustained and expanded to support our recovery from the covid-19 pandemic and respond to further threats
The simplest definition of knowledge mobilisation is the process of optimising the use of knowledge generated from research.1 Connecting academic research with non-academic decision makers, including those involved in public policy and professional practice, is a complex process, but can be facilitated if problems are defined and solutions are tackled collaboratively. Knowledge mobilisation (the process) is focused on producing action that benefits society. It broadly encompasses dissemination, knowledge transfer, and knowledge exchange.23 Effective knowledge mobilisation occurs when research knowledge is perceived as relevant and usable and there is minimal duplication of effort through “unused” research findings.4
The covid-19 pandemic presented a previously unseen level of demand and urgency for research based evidence and for mechanisms to enable use of evidence almost in real time. The United Nations research roadmap for covid-19 recovery5 puts knowledge mobilisation at the top of a list of required investments along with implementation science, rapid learning systems, scaling up data infrastructure, and the science of science.5 It is therefore important that the UK covid inquiry examines how knowledge was mobilised during the pandemic and what can be done to improve use of research evidence in future.
Pandemic mobilisation
From a UK perspective, notable examples of generating usable evidence quickly include the development and trial of the Oxford-AstraZeneca covid-19 vaccine led by the University of Oxford’s Jenner Institute and Oxford Vaccine Group, and well coordinated rapid clinical trials such as the Recovery trial, which helped guide treatment. Existing infrastructure, technology, and expertise at the host centres enabled studies to start much quicker than usual, with joint working with centres across the world and regulatory bodies, open access research protocols, and rapid dissemination of summary results.
Investment in these projects in the face of high uncertainty was justifiable in the context of a pandemic of a novel virus.6 The situation required “intelligent and informed risk taking” and mobilisation of collective action, rather than all the answers.67 Subsequent trials that helped to understand what aspects of immunity contribute to protection also relied on existing infrastructure. For example, the Instinct Covid-19 Household Contacts Study built on the sustained research infrastructure established by the National Institute for Health Research (NIHR) Health Protection Research Unit in Respiratory Infections at Imperial College and wider collaborators.8
These large scale trials also contributed to progress in methods of participant recruitment. Covid trials differed from previous large trials as there was an immediate need for volunteers and the disease was not confined to a specific group. Public participation in research had begun to increase before covid, with the NIHR clinical research network recording a 20% increase in participants from 2017-18 to 2018-19. Additional mechanisms used during the pandemic included mass campaigns, endorsements by the chief medical officers of the four UK nations and NHS medical directors,9 and the NHS vaccine registry allowing any member of the public to volunteer.
Participation is likely to have been encouraged by the increase in accessibility of scientific language and democratisation of knowledge. The R number, modelling, evidence, and data featured in wider public discourse,10 and epidemiologists, infectious disease specialists, and global health experts became household names.
What facilitated knowledge mobilisation?
Below we consider three examples of successful knowledge mobilisation during the pandemic. The lessons from their success can be built on to help deal with routine health system challenges as well as epidemic and pandemic threats.
Integrated care records make studies quicker and easier
Availability of linked data to support patient care and research across health and social care in England remains patchy. The main national database, Clinical Practice Research Datalink, is based on linked primary care records and provides data for around 16% of the UK population, with links to hospital records, the national cancer registry, area level social deprivation information, and national mortality data. However, inferences are limited to specific regions and extracts are not updated in real time.11 This limited its usefulness in research to inform the response to covid-19.
A better system was offered by the whole system integrated care database in northwest London, which was set up before the pandemic to provide comprehensive integrated medical and social care records in near real time (table 1). It covers a population of 2.4 million people and the database can be used for tracking the patient care journey, operational planning, research, and evaluation. Data are de-identified for research, but care organisations, including general practices, are still identifiable, which allows mapping and linkage to healthcare provider variables such as staffing.11
Examples of knowledge mobilisation mechanisms and potential for development
To enable expedited research access at the start of the pandemic this data infrastructure was rapidly expanded to include Imperial College Healthcare NHS Trust inpatient data, from January 2020, in addition to the existing primary and secondary linked data from 2005, and then maintained in de-identified form on a cloud based data analytics platform. The platform is hosted by the NIHR Imperial College Biomedical Research Centre and approved by a Health Research Authority research ethics committee.
A covid-19 data prioritisation review panel was set up, including a patient and public involvement representative. Research protocols were assessed within a week for methodological rigour and, importantly, for relevance to policy and practice. This structure enabled interdisciplinary research teams to quickly pivot to investigate relevant health service management and delivery in surgical care, for example, and to consider important operational and applied research questions, such as the uptake and effectiveness of the vaccination programme.12
The breadth of multidisciplinary, multiprofessional, and cross sectoral projects could not have been conducted when needed without credible and relevant linked data and analysis to inform real time context and population specific problems and decision making across the health and social care sector from studies on mental health to trends in antibiotic prescribing. Near real time feeds were used from local pathology laboratories as well as daily feeds of patient level data from the five northwest London trusts using information such as the NHS England situation report on covid deaths and shielding lists.
This infrastructure is now even more useful for understanding the consequences of covid-19 on population health outcomes and for planning healthcare as the pandemic eases. The challenge will be maintaining it as the system grows and is used more widely beyond covid-19. There is potential for other regions to replicate this infrastructure, particularly the agile methods used for development, access, and permissions. With dedicated resourcing, it has the potential to be a global exemplar of integrated applied research and informed decision making.
Value of adaptive trials
Unlike traditional “A” v “B” randomised controlled trials, participants in randomised, embedded, multifactorial adaptive platform (Remap) trials are randomised to receive one intervention in each of one or more categories of treatment (“domains”). This allows for multiple interventions to be tested simultaneously. Response adaptive randomisation allows information from patients already participating in the study to be used to help guide the treatment of new patients joining the study, weighting randomisation probabilities to the better performing treatments.
The Remap Trial for Community Acquired Pneumonia (Remap-CAP) was set up to evaluate the effect of different interventions on outcome of patients admitted to intensive care with community acquired pneumonia and operates in over 300 sites across 21 countries. In March 2020, the protocol was rapidly adapted to allow timely generation of evidence for treating severe covid-19.13 The specification of pathways enabled the data safety monitoring board to liaise directly with public health authorities as results arose.
The research showed that the interleukin-6 receptor antagonists tocilizumab and sarilumab save lives in people with severe covid-19 and speed up recovery, as do corticosteroids.1415 These results were incorporated into NHS treatment guidelines the day after they became publicly available and formed part of WHO treatment guidelines.16
This infrastructure worked because it had the foundation of a strong international peer network and well established spirit of collaboration and commitment to contributing research evidence for those who urgently need it. If this adaptable method is replicated and scaled up it will enable rapid investigation of responses to future health emergencies.
Potential of technology for mass public participation
The ZOE app was developed for the Predict study to understand how different people respond to food and what determines these variable responses using data self-reported by public participants. The research team rapidly adapted the app as a symptom tracker for covid-19 and launched it in the UK and US before 30 March 2020.
The app collected data from asymptomatic and symptomatic people (table 1) and enabled the ZOE Covid Study, which was highly efficient compared with traditional data collection and epidemiological methods. In the first month 2 450 569 UK and 168 293 US residents reported symptoms through the free smartphone app, and results were published on the study website and in peer reviewed journals.1718
This infrastructure worked because of the unique reach and usability of the technology, coupled with the wider cultural shift in terms of public involvement. The challenge is to expand the reach even further among people who are less confident with smartphone technology, especially in accessing and making sense of the results and feedback.
The app shows the potential of recruiting the public for symptom tracking as part of routine infectious disease surveillance, providing early warning systems. Similar web based systems exist for healthcare professionals and researchers to report and disseminate events related to emerging and re-emerging infectious diseases in humans, animals, and plants (eg, Program for Monitoring Emerging Diseases (ProMED) of the International Society for Infectious Diseases).
Adapting research infrastructure for effective knowledge mobilisation
These examples are a small subset of the many excellent knowledge mobilisation journeys since covid-19. Existing infrastructure such as NIHR biomedical research centres, health protection research units, patient safety translation centres, and notably the clinical research networks, encouraged multidisciplinary working and collaboration. For example, the existence of clinical research networks, which facilitate research on national priorities, contributed to the success of the Recovery trial and helped the UK lead global recruitment in the Remap-CAP trial. Many of these infrastructures also improve commercialisation of ideas by bringing together researchers, practitioners, and managers across clinical and academic disciplines.1920
The Research to Access Pathway for Investigational Drugs for Covid-19 was key to getting new treatments to patients quickly.21 It brought together the NIHR, NHS, National Institute for Health and Care Excellence, and Medicines and Healthcare Products Regulatory Agency to rapidly review results, allowing assessment of preprints as well as peer reviewed publications. Preprint platforms such as bioRxiv and medRxiv allowed rapid global reach of findings, but the sheer volume of research studies available before peer review was difficult for individual readers to evaluate. Editorial boards of journal families (eg, Lancet Group) combined their submission systems given the volume of submissions, saving time for themselves and researchers.
A more permanent shift in early posting of research protocols and results for other less immediate but serious global threats would help reduce duplication of effort, allowing a focus on much needed implementation studies. Such repositories could also help funders when commissioning research; researchers likewise would benefit when refining research plans given the length of time it takes from announcement of funding calls to finally contracting work. Additional resources shared between global interdisciplinary research networks (eg, Global Challenges Research Fund hubs) provided methods for efficient workarounds and for protecting researchers and participants during field work.22
What can we do better?
The experience of knowledge mobilisation during the pandemic suggests some questions that should be considered during the UK public inquiry (box 1). Although contemporary literature rightly emphasises the complexity of uptake of research based knowledge,2324 the pandemic has created an opportunity to pause and reflect on simpler models. The scale of the problem created universal demand for solutions. Infrastructure, track record, and credibility of scientists contributed to enhanced knowledge mobilisation, but there was also a unique opportunity to innovate and for people from outside the systems to help tackle this multifaceted problem.25 Researchers and industry took leadership and were given freedom and autonomy to get on with the work because of the urgency of the problem. We may now need to be more open to the full range of supply push, demand pull, and integrated approaches to routine decision making, so that our systems for generation and use of research knowledge acquire flexibility, memory, and resilience.
Questions for the public inquiry
What were the conditions and infrastructure that allowed NHS and academia to implement successful knowledge mobilisation measures?
How should successful infrastructures, networks, and registries be maintained outside the pandemic?
Are adequate data available on the complete patient pathway across health and social care and was maximum benefit derived from existing platforms?
Where did knowledge fail to be mobilised, and why?
How can pragmatic and adaptive trial methods, particularly for the management of infectious diseases, be more widely applied and supported?
How can trust and strong public commitment best be fostered and harnessed early, to participate and contribute data?
How can we build on the positive cultural change and choreograph informed citizen science to shape and raise questions for research?
The importance of investing in knowledge mobilisation is already recognised. NIHR health protection research units have assigned knowledge mobilisation leads, for example, and the science grants of the Canadian Institute for Health Research Knowledge Mobilization are aimed at achieving equitable health outcomes. But knowledge mobilisation for other global health problems, including the threat of antimicrobial resistance, requires substantial strengthening.2627 Additionally, gaps remain in research in some parts of the system, notably social care. This was exemplified by the harm caused by the failure to assess the risk of discharging patients from acute care to residential and care homes at the start of the pandemic.
The practice of knowledge mobilisation needs to be evidence based28 and to incorporate advances in innovation diffusion and implementation that help embed knowledge mobilisation mechanisms into research and avoid “superficial and wide” or “deep but localised” implementation.24 It is surprising to see the dangers of groupthink listed among the lessons from covid-19 in the report of the House of Commons select committees29; the phenomenon is a well known risk, and mitigation strategies are documented in seminal and contemporary publications in decision science, health management, organisational behaviour, and strategic management.30
We must ensure that the learning from covid-19 will be systematically applied to other global challenges to avoid both duplication of effort and repeatedly missing opportunities. The Recovery trial investigators, for example, are now involved in the NIHR commissioned and funded clinical trial for potential treatments for monkeypox. However, the ZOE study has lost government funding. This seems a missed opportunity for transformational change to increase use of patient generated data, which could have a key role in strengthening research and public involvement and ownership.
We also appreciate that this pandemic has provided a greater awareness of the uncertainty of our knowledge and of the consequences of our actions, both in terms of being “situated in time and of aiming at timeliness.”31 We must ensure that future knowledge mobilisation processes are mindful not to force extreme positions but learn how to communicate the continuum of evidence and be transparent about uncertainty.32
Acknowledgments
We acknowledge Erik Mayer, Kavitha Saravanakumar, and Ben Glampson from the NIHR Imperial Biomedical Research Centre and Nina Zhu from the NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance.
Footnotes
Contributors and sources: AH has worked on the impact of covid-19 on antibiotic use and other infections, the development of case definition of hospital onset covid-19 infections, and real time surveillance of such infections. ACG is the UK chief investigator for the Remap-CAP trial evaluating treatments for covid-19. PA leads research in variations in performance and safety in healthcare delivery at the NIHR Patient Safety Translational Research Centre and on data linkage and surveillance and provides expertise in measurement methods, public health informatics, and advanced statistics at the NIHR North West London Applied Research Collaborative. JR is responsible for helping the NHS to continue to improve urgent care services. He co-leads the NIHR Imperial Patient Safety Translational Research Centre (PSTRC) and is medical director and consultant in emergency medicine at Imperial College Healthcare NHS Trust. RA leads knowledge mobilisation activities at three NIHR Health Protection Research Units at Imperial College London and also at The Surveillance and Epidemiology of Drug-resistant Infections Consortium (SEDRIC) at the Wellcome Trust. Her research includes assessment of macro-level drivers affecting country responses to covid and infection management and prescribing in primary care in England during the pandemic. RA and AH wrote the first draft and all authors contributed to data curation, formal analysis, validation, writing, and review. AH is guarantor.
Patient and public involvement: This analysis was reviewed by Karen Stoddart, public partner at the NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance. A version for non-expert audiences is also in preparation.
Competing interests: We have read and understood BMJ policy on declaration of interests and declare the following. ACG served on the data monitoring committee for a trial run by Respiratory30 with fees paid to Imperial College London. AH has shared a PhD student with the chemical engineering department at Imperial College who is cofunded by Shionogi, a global pharmaceutical company.
Provenance and peer review: Commissioned; externally peer reviewed.
This article is part of a series commissioned, peer reviewed, and edited by The BMJ. The advisory group for the series was chaired by Kara Hanson, and included Martin McKee, although he was not involved in the decision making on the papers that he co-authored. Kamran Abbasi was the lead editor for The BMJ.
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