tions to local circumstances that are likely to preserve the effectiveness of previous programs in their context.

KNOWLEDGE INTEGRATION

As noted earlier, the new knowledge obtained in following the framework needs to be incorporated into the context of the organization or system where decisions are being made, such as a public health department, a mayor’s office, a health care system, or a school system. Rather than an active step in the framework, knowledge integration is the desired final outcome of the process. Knowledge integration may also generate new questions and feed back into the steps of the framework. The cyclic nature of knowledge generation, use of evidence, integration of relevant evidence into systems, and feedback is thus completed.

The concept of knowledge integration derives from the evolution of thinking about how new knowledge from research is used (Best et al., 2008b). Earlier terms such as “knowledge transfer” and “knowledge uptake” captured the need to move new knowledge generated by research into the hands of users but reflected one-way, linear thinking, with researchers simply producing new knowledge. Experience has suggested that these models do not work (Davis et al., 2003; Grimshaw et al., 2001). Other terms, such as “knowledge translation,” suggest more of a relationship model incorporating the necessary interactions among individuals and the importance of social networks (Canadian Institutes of Health Research, 2008). “Knowledge integration” takes the process of translating evidence to practice a step further, indicating that relationships themselves are shaped by the organizations and systems in which they are embedded and that a system has particular dynamics, priorities, time scales, modes of communication, and expectations (Best et al., 2008a). In a similar manner, the recent emphasis of the National Institutes of Health (NIH) on dissemination and implementation research has encouraged investigators and decision makers to focus their research and programmatic questions on the integration of knowledge within systems (Kerner et al., 2005).

The concept of knowledge integration is closely linked to an appreciation for a study’s generalizability, discussed throughout this report. An understanding of the context in which evidence will be used is clearly part of successful knowledge integration. The challenges of addressing a study’s generalizability, such as recognizing the ecologically complex nature of communities, organizations, and health care systems as opposed to the more tightly (and artificially) controlled conditions of RCTs, have been described (Green and Glasgow, 2006).

Knowledge integration places specific emphasis on systems thinking in health sciences, which has evolved out of scientific inquiry in such fields as mathematics, biology, engineering, ecology, and management science (see Chapter 4). Examples of systems thinking come from the fields of weather forecasting, prevention of pandemics, and tobacco control (Leischow et al., 2008). In the control of obesity, multiple systems or organizations are clearly involved. The management of systems knowledge



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