Bridging the academic and practice/policy gap in public health: perspectives from Scotland and Canada

Abstract This article presents a critical commentary of specific organizational models and practices for bridging ‘the gap’ between public health research and policy and practice. The authors draw on personal experiences of such models in addition to the wider knowledge translation and exchange literature to reflect on their strengths and weaknesses as implemented in Scotland and Canada since the early 1990s.


Background and rationale
The challenge of bringing health research findings to bear on relevant professional practices and public policies in areas such as public health is well documented. 1 Prodigious growth has occurred within the 'knowledge translation and exchange' (KTE) field over the last 2 decades, starting in health services research, 2 moving steadily through 'evidencebased medicine' driven by clinical research 3 and more recently via an analogous thrust in population and public health research. 4 Thus much is known about 'what works' to move research to action in these fields, and considerable implementation of those effective strategies has occurred. Despite this, 'the gap' still remains. In Canada the groundbreaking Naylor et al., 5 report on what happened (and did not, but should have) in the SARS outbreak of 2003, led to the creation of the Public Health Agency of Canada (PHAC) within a year (http://www.phac-aspc.gc.ca/). This report highlighted a lack of coordination among federal and other agencies in developing capacity to use evidence appropriately and a number of research priorities that were disconnected from the needs of public health practice. PHAC was partly created to help overcome this 'gap' by upgrading the research and research-utilization capacity of the public health policy and practice community. More widely, only around half of public health programmes and policies are reported as evidence based in the USA and the UK. 6,7 Certainly, much work has been conducted recently in relation to this particular issue. 8,9 This paper presents a critical commentary of specific organizational models and practices for facilitating collaborative partnerships between research, policy and practice in an effort to bridge the gap, 10  representatives, is also the Director of Public Health Science at NHS-Health Scotland, the nation's major public health policy and programme think-tank).

Factors contributing to the gap
Among the major reports about the public health researchto-action gap, the following underlying factors have been mentioned as contributing to both the origins of the gap, and its perpetuation: • Context and complexity are pertinent factors to consider.
Public health professionals are challenged by scope and scale (the health of populations versus the health of individuals), and the number of actors with whom they need to interact within and outside the health sector to facilitate change. Evidence-based medicine has been able to convince many practitioners, especially in teaching and academic settings, that better patient outcomes, at lower cost, can be achieved by more adherence to what high-quality studies have found. 11 This process has not been as straightforward in public health-partly because of the difficulty of using conclusive RCT study designs to compare different interventions' effectiveness-although significant methodological progress has recently been made in the design and analysis of non-RCT studies of population-level interventions. 12,13 • Despite some improvements, public health continues to be characterized, by formal reviews on both sides of the Atlantic, as 'silo'd' in terms of the relationship between its research arm, based mostly in universities, and its practice and policy arm, based largely in public sector institutions such as Ministries and agencies. In the UK alone, major national reviews since 2001 of the 'public health sector' have criticized the tendency of academically oriented researchers in relevant disciplines to investigate and publish excessively theoretical and impractical studies of little use in policy and practice. [14][15][16][17] The organizational structure of professional public health practice, in many high income countries (HIC), is strikingly removed from academia, unlike clinical research's close ties to practice (at least within academic health science centres). Typically, public health professionals either report to local government (England and Wales since 2014 and before 1974, and much of English Canada and the USA for over a century) OR to a professional hierarchy often situated within a national health service (e.g. the 1974-2014 NHS public health arrangement in England and Wales, still in place in Scotland today, and arguably the entire US national Public Health Service). This separation takes many public health practitioners out of research-oriented settings, often situating them in governmental and other settings where research is only one of many influences on policy. 18 Exacerbating this situation is the completely different reward structure for most academics, based mostly on publications, grants and trainee completions, compared to the more intraorganizational and professional reward system in public health practice and 'policy shops'. • The nature of many public health academic settings is more like the most traditional schools and faculties within higher education-rather unlinked to policy and practice. Again, this is quite unlike academic health science centres' emphasis on 'bench to bedside' translation of clinical research, for better patient care. Thus it is not uncommon for full-time or 'core' faculty in public health-related university departments and Schools in Canada and the UK to have never practised public health professionally; to have no formal ties to such practice (in terms of their current academic job description-as opposed to being actively cross-appointed to the local 'Public Health Department'); and to choose research topics which are typically uninfluenced by local practitioner or policymaker opinion of what would be useful, or meet the needs of local decision-makers. • This separation has been historically aided and abetted by research funding agencies, largely due to the practice of filling peer-review grant panels entirely with academics. Some progress has been made in certain research funder settings to incorporate the views of policy and practice 'users' of research in the prioritization of topics put forward through 'Requests/Calls for Proposals' (e. Organizational models and innovative practices to overcome the gap 1) Centres explicitly charged with bridging the gap (through jointly produced research and knowledge mobilization to action): Examples include: • A national, public sector research funding agency with a strong corporate commitment to knowledge mobilization, such as the 'CIHR Institute of Population and Public Health' (IPPH). 19 As the only public health-oriented CIHR Institute, out of thirteen created in 2000 when CIHR arose out of a major re-organization of the Medical Research Council of Canada, IPPH has for seventeen years been guided by the key principles of bridging the gap, as embodied in two practices: (i) its stakeholder-based approach to identifying priority topics for its many calls for research proposals and (ii) its evaluation of the policy and practice impacts of that research afterwards, including the uptake of research findings by decision-makers. 20 More recently, the second wave of CIHR IPPH leadership has demonstrated that this approach is capable of building, within a decade, an entire applied field of public health research-intervention development, implementation and evaluation-which speaks to decision-makers' need for research findings which can guide policy and practice more directly than has been the case in the past. 21 It should be noted that good co-governance of evidence is fundamental to the success of such centres in meeting their aims and objectives. 27 2) Provision of funding and incentives for meaningful cross-appointments: • No such large-scale programme in Scotland or Canada are known to the authors from the recent period (which is in itself perhaps telling); there are elements of the NIHR Collaborations for Leadership in Applied Health Research and Care (CLAHRCs) across England which have strong cross-appointment features, in that academically appointed researchers are funded to work closely with local public health professionals to analyse practical problems in NHS services (both clinical and public health) and to find and evaluate solutions. 28 3) On-the-job applied research training for public health professionals: • The 'SCPHRP Professional Part-Time PH Fellowship' (2013-17), provided full-time NHS Public Health professionals with SCPHRP faculty mentoring on one research project each, agreed by Directors of Public Health across Scotland as corporate priorities, with the aim of strengthening the methodology of those projects, allowing them to be presented at public health professional/scientific conferences, and (ideally) published in an appropriate peer-reviewed journal. One such project involved a situation analysis exploring the views of health professionals working with women of childbearing age on current and future delivery of preconception care in an NHS board area in Scotland. This work has since influenced NHS board policy and practice (e.g. decision making related to preconception health) in addition to leading to publication in a peer-reviewed journal. 29

4) Provision of honorary appointments for academics within public health bodies and vice-versa
• The Information Services Division (ISD) at NHS Scotland provides health information, health intelligence, statistical services and advice that supports the NHS and Scottish Government in public health matters. ISD operate a small-scale model of tethered academic work through Honorary Consultants arrangements. Similarly, SCPHRP have recently offered Visiting Expert positions within the University of Edinburgh to public health practitioners and decision-makers, with a view to facilitating links between research, policy and practice. These arrangements are typically small-scale, although are beneficial to both academic and non-academic partners.

5) Specific KTE strategies to enhance joint working by public health researchers and research users
• SCPHRP and NHS-Health Scotland have, with other local partner organizations, recently launched a novel  30 It offers public and non-profit organizations a rigorous assessment of the evaluability of any public health programme or policy that is either already implemented or-ideally-being considered for implementation in the future. The methods used are well described in recent publications. 31 This service does require resources from local 'research brokering' organizations, but has the potential 'quid pro quo' that researchers affiliated with those organizations can thereby obtain advance notice of potential opportunities to bid for subsequent evaluation contracts, or write grants for such work. There is therefore the potential for the service to substantially increase the volume of higher-quality evaluations completed in public health policy and practice settings. Table 1 presents our views in relation to the strengths and weaknesses of each approach. Each of the above approaches to 'bridging the gap' between the two public health worldsresearch versus policy and practice-has its strengths and weaknesses. Strikingly, published evaluations that have used strong scientific methods to assess such strengths and weaknesses are more limited, although there is some evidence that may be relevant especially for knowledge brokering. [32][33][34][35] We recommend that those involved in any of the approaches described here to bridging the gap, or other novel approaches, invest in proper evaluation studies to learn precisely where, and why some of them do or do not achieve their potential. Ideally, we suggest that a given approach must be consistently implemented for at least a few years, in order to be able to realistically expect any impact on the gapgiven its longstanding nature, and the many factors (see above) that perpetuate it. This short summary of our personal experiences, in the public health research and professional systems of Scotland and Canada, is intended to provoke further reflection from the Journal's readers on the issue of how best to close the gap. We look forward to hearing those reflections.