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Policy makers, researchers, clinicians, and the public are frustrated that research in the health sciences has not resulted in a greater improvement in patient outcomes. Our experience as clinicians and researchers suggests that this frustration could be reduced if health sciences research were directed by 5 broad principles: (1) the needs of patients and populations determine the research agenda; (2) the research agenda addresses contextual and implementation issues, including the development of delivery and accountability systems; (3) the research agenda determines the research methods rather than methods determines the research agenda; (4) researchers and clinicians collaborate to define the research agenda, allocate resources, and implement findings; and (5) the level of funding for implementation research is commensurate with and proportional to the magnitude of the task. To keep the research agenda focused on the task of improving health and to acknowledge that the effort must be seen as more comprehensive than translating or transferring research into practice (TRIP), we suggest that the task be reframed, using the term optimizing practice through research. [ABSTRACT FROM AUTHOR]

Background: The prevalence of smoking is high in many Aboriginal Canadian communities; rates of 50% are not uncommon. Aboriginal Canadians suffer a severe burden of smoking-related disease. Research in other populations has linked depression and smoking. It is not known whether mental health or affective measures are related to smoking for any of Canada's First Nations, and this study sought to answer this question. Understanding relations between affect and smoking behaviour is requisite to mounting anti-smoking interventions.Methods: Smoking status and psychosocial measures including depression, mastery, affect balance and social support were obtained in a community-based chronic disease survey for a rural Interior Salishan First Nation in British Columbia (Plateau area). Persons surveyed were on-reserve residents (n=187), overweight (body mass index > or = 25 kg/m2), with mean age of 44.1 years (standard deviation 15.0).Results: The prevalence of smoking was 48.1%. Adjusted for age, sex and body mass index, smokers relative to nonsmokers had higher (p<0.010) depression (mean 21.3 [CI 95%, 19.1-23.4] vs. 16.1 [14.1-18.0]) and negative affect (18.6 [14.9-22.3] vs. 11.0 [7.6-14.4]), and lower mastery (36.4 [35.5-37.3] vs. 38.1 [37.2-38.9]). A positive relationship between mastery and social support was greater for nonsmokers (p=0.046).Conclusion: Depression and negative affect are associated with smoking among overweight persons in a rural First Nation in British Columbia. Furthermore, smoking is inversely related to mastery, and this relation varies with social support. Longitudinal study is required to determine whether smoking influences mental health and mastery, or the reverse. [ABSTRACT FROM AUTHOR]

AIM: To use the available literature to identify the causes of suicide among indigenous adolescents. METHOD: The PRECEDE model provided a framework to organize the material and identify the areas where relatively little research had been reported. RESULTS: The epidemiological diagnosis showed that suicide was greater in indigenous than non-indigenous populations and particularly high among adolescent males. Environments of native persons are characterized by remoteness, poverty, cultural displacement, and family disintegration. The educational and organizational diagnosis identified predisposing factors reflecting the social environments previously identified, the enabling factors of televised suicides, and firearm and alcohol availability, in conjunction with an absence of positive expectations. Finally the administrative and policy diagnosis identified a piecemeal, short term perspective, often lacking cultural sensitivity. Although there was more literature from the United States than from Canada, Australia or New Zealand, the pictures emerging were consistent, with problems being identified across continents. Literature was more abundant in relation to the epidemiological, environmental, and educational/ organizational diagnoses than in relation to policy and administration. CONCLUSION: The increased suicide rates among indigenous adolescents were not a product of their native origins, but of the social milieu in which these people generally found themselves. [ABSTRACT FROM AUTHOR]

BACKGROUND: Community-based outreach seeks to move libraries beyond their traditional institutional boundaries to improve both access to and effectiveness of health information. The evaluation of such outreach needs to involve the community in assessing the program's process and outcomes. PURPOSE: Evaluation of community-based library outreach programs benefits from a participatory approach. To explain this premise of the paper, three components of evaluation theory are paired with relevant participatory strategies. CONCEPTS: The first component of evaluation theory is also a standard of program evaluation: use. Evaluation is intended to be useful for stakeholders to make decisions. A useful evaluation is credible, timely, and of adequate scope. Participatory approaches to increase use of evaluation findings include engaging end users early in planning the program itself and in deciding on the outcomes of the evaluation. A second component of evaluation theory seeks to understand what is being evaluated, such as specific aspects of outreach programs. A transparent understanding of the ways outreach achieves intended goals, its activities and linkages, and the context in which it operates precedes any attempt to measure it. Participatory approaches to evaluating outreach include having end users, such as health practitioners in other community-based organizations, identify what components of the outreach program are most important to their work. A third component of evaluation theory is concerned with the process by which value is placed on outreach. What will count as outreach success or failure? Who decides? Participatory approaches to valuing include assuring end-user representation in the formulation of evaluation questions and in the interpretation of evaluation results. CONCLUSIONS: The evaluation of community-based outreach is a complex process that is not made easier by a participatory approach. Nevertheless, a participatory approach is more likely to make the evaluation findings useful, ensure that program knowledge is shared, and make outreach valuing transparent. [ABSTRACT FROM AUTHOR]

Although obesity is increasing to epidemic proportions in many developed countries, some of these same countries are reporting substantial reductions in tobacco use. Unlike tobacco, food and physical activity are essential to life. Yet similar psychological, social, and environmental factors as well as advertising pressures influence the usage patterns of all 3. These similarities suggest that there may be commonalities between factors involved in controlling obesity and tobacco. This review, therefore, seeks to draw lessons from the tobacco experience for the organization of more successful obesity control. Smoking cessation counseling by physicians has been found to be one of the most clinically effective and cost-effective of all disease prevention interventions. When used alone, however, it cannot decrease the cultural acceptability of tobacco and the pressures and cues to smoke. Research and evaluation have shown the key elements of tobacco control to be (1) clinical intervention and management, (2) educational strategies, (3) regulatory efforts, (4) economic approaches, and (5) the combination of all of these into comprehensive programs that address multiple facets of the environment simultaneously. For each element, we present the evidence outlining its importance for tobacco control, discuss its application to date in obesity control, and suggest areas for further research. Viewing all of the elements involved and recognizing their synergistic effects draws researchers and practitioners back from an exclusive concentration on their particular setting to consider how they might seek to influence other settings in which individuals and populations must negotiate desired changes in nutrition and physical activity. Copyright © 2003 American Society for Clinical Nutrition [ABSTRACT FROM AUTHOR]

Background: Current methods for assessing strength of evidence prioritize the contributions of randomized controlled trials (RCTs). The objective of this study was to characterize strength of evidence (SOE) tools in recent use, identify their application to lifestyle interventions for improved longevity, vitality, or successful aging, and to assess implications of the findings., Methods: The search strategy was created in PubMed and modified as needed for four additional databases: Embase, AnthropologyPlus, PsycINFO, and Ageline, supplemented by manual searching. Systematic reviews and meta-analyses of intervention trials or observational studies relevant to lifestyle intervention were included if they used a specified SOE tool. Data was collected for each SOE tool. Conditions necessary for assigning the highest SOE grading and treatment of prospective cohort studies within each SOE rating framework were summarized. The expert panel convened to discuss the implications of findings for assessing evidence in the domain of lifestyle medicine., Results and Conclusions: A total of 15 unique tools were identified. Ten were tools developed and used by governmental agencies or other equivalent professional bodies and were applicable in a variety of settings. Of these 10, four require consistent results from RCTs of high quality to award the highest rating of evidence. Most SOE tools include prospective cohort studies only to note their secondary contribution to overall SOE as compared to RCTs. We developed a new construct, Hierarchies of Evidence Applied to Lifestyle Medicine (HEALM), to illustrate the feasibility of a tool based on the specific contributions of diverse research methods to understanding lifetime effects of health behaviors. Assessment of evidence relevant to lifestyle medicine requires a potential adaptation of SOE approaches when outcomes and/or exposures obviate exclusive or preferential reliance on RCTs. This systematic review was registered with the International Prospective Register of Systematic Reviews, PROSPERO [CRD42018082148].

Background: Community-Based Participatory Research (CBPR) is an approach in which researchers and community stakeholders form equitable partnerships to tackle issues related to community health improvement and knowledge production. Our 2012 realist review of CBPR outcomes reported long-term effects that were touched upon but not fully explained in the retained literature. To further explore such effects, interviews were conducted with academic and community partners of partnerships retained in the review. Realist methodology was used to increase the understanding of what supports partnership synergy in successful long-term CBPR partnerships, and to further document how equitable partnerships can result in numerous benefits including the sustainability of relationships, research and solutions., Methods: Building on our previous realist review of CBPR, we contacted the authors of longitudinal studies of academic-community partnerships retained in the review. Twenty-four participants (community members and researchers) from 11 partnerships were interviewed. Realist logic of analysis was used, involving middle-range theory, context-mechanism-outcome configuration (CMOcs) and the concept of the 'ripple effect'., Results: The analysis supports the central importance of developing and strengthening partnership synergy through trust. The ripple effect concept in conjunction with CMOcs showed that a sense of trust amongst CBPR members was a prominent mechanism leading to partnership sustainability. This in turn resulted in population-level outcomes including: (a) sustaining collaborative efforts toward health improvement; (b) generating spin-off projects; and (c) achieving systemic transformations., Conclusion: These results add to other studies on improving the science of CBPR in partnerships with a high level of power-sharing and co-governance. Our results suggest sustaining CBPR and achieving unanticipated benefits likely depend on trust-related mechanisms and a continuing commitment to power-sharing. These findings have implications for building successful CBPR partnerships to address challenging public health problems and the complex assessment of outcomes.

Part of the Community Health and Preventive Medicine Commons, Health and Medical Administration Commons, Health Policy Commons, Health Services Administration Commons, Health Services Research Commons, and the Public Health Education and Promotion Commons. Many accomplishments of public health have been distributed unevenly among populations. This article reviews the concepts of applying evidence-based practice in public health in the face of the varied cultures and circumstances of practice in these varied populations. Key components of EBPH include: making decisions based on the best available scientific evidence, using data and information systems systematically, applying program planning frameworks, engaging the community and practitioners in decision making, conducting sound evaluation, and disseminating what is learned. The usual application of these principles has overemphasized the scientific evidence as the starting point, whereas this review suggests engaging the community and practitioners as an equally important starting point to assess their needs, assets and circumstances, which can be facilitated with program planning frameworks and use of local assessment and surveillance data.

Objectives: We tested the effectiveness of offering home fecal immunochemical tests (FITs) during influenza vaccination clinics to increase colorectal cancer screening (CRCS)., Methods: In a clinical trial at Kaiser Permanente Northern California influenza clinics in Redwood City, Richmond, South San Francisco, Union City, and Fresno, we randomly assigned influenza clinic dates to intervention (FIT offered) or control (FIT not offered) and compared subsequent CRCS activity., Results: Clinic staff provided FITs to 53.9% (1805/3351) of intervention patients aged 50 to 75 years. In the intent-to-treat analysis, 26.9% (900/3351) and 11.7% (336/2884) of intervention and control patients completed an FIT, respectively, within 90 days of vaccination (P ≤ .001). The adjusted odds ratio for completing FIT in the intervention versus the control arm was 2.75 (95% confidence interval = 2.40, 3.16). In the per protocol analysis, 35.4% (648/1830) of patients given FIT and 13.3% (588/4405) of patients not given FIT completed FIT within 90 days of vaccination (P ≤ .001)., Conclusions: This intervention may increase CRCS among those not reached by other forms of CRCS outreach. Future research should include the extent to which these programs can be disseminated and implemented nationally.

The National Institutes of Health convened a workshop to engage researchers and practitioners in dialogue on research issues viewed as either unique or of particular relevance to rural areas, key content areas needed to inform policy and practice in rural settings, and ways rural contexts may influence study design, implementation, assessment of outcomes, and dissemination. Our purpose was to develop a research agenda to address the disproportionate burden of cardiovascular disease (CVD) and related risk factors among populations living in rural areas. Complementary presentations used theoretical and methodological principles to describe research and practice examples from rural settings. Participants created a comprehensive CVD research agenda that identified themes and challenges, and provided 21 recommendations to guide research, practice, and programs in rural areas.

Background: The science of dissemination and implementation (D&I) is advancing the knowledge base for how best to integrate evidence-based interventions within clinical and community settings and how to recast the nature or conduct of the research itself to make it more relevant and actionable in those settings. While the field is growing, there are only a few training programs for D&I research; this is an important avenue to help build the field's capacity. To improve the United States' capacity for D&I research, the National Institutes of Health and Veterans Health Administration collaborated to develop a five-day training institute for postdoctoral level applicants aspiring to advance this science., Methods: We describe the background, goals, structure, curriculum, application process, trainee evaluation, and future plans for the Training in Dissemination and Implementation Research in Health (TIDIRH)., Results: The TIDIRH used a five-day residential immersion to maximize opportunities for trainees and faculty to interact. The train-the-trainer-like approach was intended to equip participants with materials that they could readily take back to their home institutions to increase interest and further investment in D&I. The TIDIRH curriculum included a balance of structured large group discussions and interactive small group sessions.Thirty-five of 266 applicants for the first annual training institute were accepted from a variety of disciplines, including psychology (12 trainees); medicine (6 trainees); epidemiology (5 trainees); health behavior/health education (4 trainees); and 1 trainee each from education & human development, health policy and management, health services research, public health studies, public policy and social work, with a maximum of two individuals from any one institution. The institute was rated as very helpful by attendees, and by six months after the institute, a follow-up survey (97% return rate) revealed that 72% had initiated a new grant proposal in D&I research; 28% had received funding, and 77% had used skills from TIDIRH to influence their peers from different disciplines about D&I research through building local research networks, organizing formal presentations and symposia, teaching and by leading interdisciplinary teams to conduct D&I research., Conclusions: The initial TIDIRH training was judged successful by trainee evaluation at the conclusion of the week's training and six-month follow-up, and plans are to continue and possibly expand the TIDIRH in coming years. Strengths are seen as the residential format, quality of the faculty and their flexibility in adjusting content to meet trainee needs, and the highlighting of concrete D&I examples by the local host institution, which rotates annually. Lessons learned and plans for future TIDIRH trainings are summarized.

The objective of the study was to determine the extent to which the FLU-FOBT Program, a colorectal cancer screening (CRCS) intervention linking the provision of fecal occult blood tests (FOBT) to the time of annual influenza vaccination, resulted in practice changes in six primary care clinics 1 year after it was introduced in a randomized controlled trial (RCT). We assessed CRCS rate changes for influenza vaccine recipients, administered brief serial clinic staff surveys and interviewed clinic leaders 1 year after the RCT. CRCS rates for influenza vaccination recipients between the ages of 50 and 75 years were 42.5% before the RCT, 54.5% immediately after the RCT and 55.8% 1 year after the RCT (P < 0.001 for difference between baseline and 1 year after RCT). Many FLU-FOBT Program components were maintained in most clinics at 1-year follow-up. Only 63% of clinic staff survey respondents (26 of 41) continued offering FOBT with influenza vaccines, but 85% (35 of 41) continued to provide mailing kits with FOBT. Many patient education materials were maintained and staff satisfaction with the intervention remained high. Clinic leaders acknowledged barriers to maintenance but also observed several beneficial practice changes. Many components of the FLU-FOBT Program were maintained, with beneficial outcomes for participating practices.

Objective: To analyse the models Philip Morris (PM) and British American Tobacco (BAT) used internally to understand tobacco control non-governmental organizations (NGOs) and their relationship to the global tobacco control policy-making process that resulted in the Framework Convention for Tobacco Control (FCTC)., Methods: Analysis of internal tobacco industry documents in the Legacy Tobacco Document Library., Results: PM contracted with Mongoven, Biscoe, and Duchin, Inc. (MBD, a consulting firm specialising in NGO surveillance) as advisors. MBD argued that because NGOs are increasingly linked to epistemic communities, NGOs could insert themselves into the global policy-making process and influence the discourse surrounding the treaty-making process. MBD advised PM to insert itself into the policy-making process, mimicking NGO behaviour. BAT's Consumer and Regulatory Affairs (CORA) department argued that global regulation emerged from the perception (by NGOs and governments) that the industry could not regulate itself, leading to BAT advocating social alignment and self-regulation to minimise the impact of the FCTC. Most efforts to block or redirect the FCTC failed., Conclusions: PM and BAT articulated a global policy-making environment in which NGOs are key, non-state stakeholders, and as a result, internationalised some of their previous national-level strategies. After both companies failed to prevent the FCTC, their strategies began to align. Multinational corporations have continued to successfully employ some of the strategies outlined in this paper at the local and national level while being formally excluded from ongoing FCTC negotiations at the global level.

Context: Participatory research (PR) is the co-construction of research through partnerships between researchers and people affected by and/or responsible for action on the issues under study. Evaluating the benefits of PR is challenging for a number of reasons: the research topics, methods, and study designs are heterogeneous; the extent of collaborative involvement may vary over the duration of a project and from one project to the next; and partnership activities may generate a complex array of both short- and long-term outcomes., Methods: Our review team consisted of a collaboration among researchers and decision makers in public health, research funding, ethics review, and community-engaged scholarship. We identified, selected, and appraised a large-variety sample of primary studies describing PR partnerships, and in each stage, two team members independently reviewed and coded the literature. We used key realist review concepts (middle-range theory, demi-regularity, and context-mechanism-outcome configurations [CMO]) to analyze and synthesize the data, using the PR partnership as the main unit of analysis., Findings: From 7,167 abstracts and 591 full-text papers, we distilled for synthesis a final sample of twenty-three PR partnerships described in 276 publications. The link between process and outcome in these partnerships was best explained using the middle-range theory of partnership synergy, which demonstrates how PR can (1) ensure culturally and logistically appropriate research, (2) enhance recruitment capacity, (3) generate professional capacity and competence in stakeholder groups, (4) result in productive conflicts followed by useful negotiation, (5) increase the quality of outputs and outcomes over time, (6) increase the sustainability of project goals beyond funded time frames and during gaps in external funding, and (7) create system changes and new unanticipated projects and activities. Negative examples illustrated why these outcomes were not a guaranteed product of PR partnerships but were contingent on key aspects of context., Conclusions: We used a realist approach to embrace the heterogeneity and complexity of the PR literature. This theory-driven synthesis identified mechanisms by which PR may add value to the research process. Using the middle-range theory of partnership synergy, our review confirmed findings from previous PR reviews, documented and explained some negative outcomes, and generated new insights into the benefits of PR regarding conflicts and negotiation between stakeholders, program sustainability and advancement, unanticipated project activity, and the generation of systemic change., (© 2012 Milbank Memorial Fund.)

The promise of widespread implementation of efficacious interventions across the cancer continuum into routine practice and policy has yet to be realized. Multilevel influences, such as communities and families surrounding patients or health-care policies and organizations surrounding provider teams, may determine whether effective interventions are successfully implemented. Greater recognition of the importance of these influences in advancing (or hindering) the impact of single-level interventions has motivated the design and testing of multilevel interventions designed to address them. However, implementing research evidence from single- or multilevel interventions into sustainable routine practice and policy presents substantive challenges. Furthermore, relatively few multilevel interventions have been conducted along the cancer care continuum, and fewer still have been implemented, disseminated, or sustained in practice. The purpose of this chapter is, therefore, to illustrate and examine the concepts underlying the implementation and spread of multilevel interventions into routine practice and policy. We accomplish this goal by using a series of cancer and noncancer examples that have been successfully implemented and, in some cases, spread widely. Key concepts across these examples include the importance of phased implementation, recognizing the need for pilot testing, explicit engagement of key stakeholders within and between each intervention level; visible and consistent leadership and organizational support, including financial and human resources; better understanding of the policy context, fiscal climate, and incentives underlying implementation; explication of handoffs from researchers to accountable individuals within and across levels; ample integration of multilevel theories guiding implementation and evaluation; and strategies for long-term monitoring and sustainability.

Type 2 diabetes imposes a large and growing burden on the public's health. This burden, combined with the growing evidence for primary prevention from randomized controlled trials of structured lifestyle programs leads to recommendations to include caloric reduction, increased physical activity and specific assistance to patients in problem solving to achieve modest weight loss as well as pharmacotherapy. These recommendations demand exploration of new ways to implement such primary prevention strategies through more integrated community organization, medical practice and policy. The US experience with control of tobacco use and high blood pressure offers valuable lessons for policy, such as taxation on products, and for practice in a variety of settings, such as coordination of referrals for lifestyle supports. We acknowledge also some notable exceptions to their generalizability. This paper presents possible actions proposed by an expert panel, summarized in Table 1 as recommendations for immediate action, strategic action and research. The collaboration of primary care and public health systems will be required to make many of these recommendations a reality. This paper also provides information on the progress made in recent years by the Division of Diabetes Translation at the US Centers for Disease Control and Prevention (CDC) to implement or facilitate such integration of primary care and public health for primary prevention.

Methods for translating the findings of controlled trials, such as the Diabetes Prevention Program, into real-world community application have not been clearly defined. A standardized research methodology for making and evaluating such a transition is needed. We introduce the multisite translational community trial (mTCT) as the research analog to the multisite randomized controlled trial. The mTCT is adapted to incorporate the principles and practices of community-based participatory research and the increased relevance and generalizability gained from diverse community settings. The mTCT is a tool designed to bridge the gap between what a clinical trial demonstrates can work in principle and what is needed to make it workable and effective in real-world settings. Its utility could be put to the test, in particular with practice-based research networks such as the Prevention Research Centers.

Community interventions are complex social processes that need to move beyond single interventions and outcomes at individual levels of short-term change. A scientific paradigm is emerging that supports collaborative, multilevel, culturally situated community interventions aimed at creating sustainable community-level impact. This paradigm is rooted in a deep history of ecological and collaborative thinking across public health, psychology, anthropology, and other fields of social science. The new paradigm makes a number of primary assertions that affect conceptualization of health issues, intervention design, and intervention evaluation. To elaborate the paradigm and advance the science of community intervention, we offer suggestions for promoting a scientific agenda, developing collaborations among professionals and communities, and examining the culture of science.

Background: Participatory Research (PR) entails the co-governance of research by academic researchers and end-users. End-users are those who are affected by issues under study (e.g., community groups or populations affected by illness), or those positioned to act on the knowledge generated by research (e.g., clinicians, community leaders, health managers, patients, and policy makers). Systematic reviews assessing the generalizable benefits of PR must address: the diversity of research topics, methods, and intervention designs that involve a PR approach; varying degrees of end-user involvement in research co-governance, both within and between projects; and the complexity of outcomes arising from long-term partnerships., Methods: We addressed the above mentioned challenges by adapting realist review methodology to PR assessment, specifically by developing inductively-driven identification, selection, appraisal, and synthesis procedures. This approach allowed us to address the non-uniformity and complexity of the PR literature. Each stage of the review involved two independent reviewers and followed a reproducible, systematic coding and retention procedure. Retained studies were completed participatory health interventions, demonstrated high levels of participation by non-academic stakeholders (i.e., excluding studies in which end-users were not involved in co-governing throughout the stages of research) and contained detailed descriptions of the participatory process and context. Retained sets are being mapped and analyzed using realist review methods., Results: The librarian-guided search string yielded 7,167 citations. A total of 594 citations were retained after the identification process. Eighty-three papers remained after selection. Principle Investigators (PIs) were contacted to solicit all companion papers. Twenty-three sets of papers (23 PR studies), comprising 276 publications, passed appraisal and are being synthesized using realist review methods., Discussion: The systematic and stage-based procedure addressed challenges to PR assessment and generated our robust understanding of complex and heterogeneous PR practices. To date, realist reviews have focussed on evaluations of relatively uniform interventions. In contrast our PR search yielded a wide diversity of partnerships and research topics. We therefore developed tools to achieve conceptual clarity on the PR field, as a beneficial precursor to our theoretically-driven synthesis using realist methods. Findings from the ongoing review will be provided in forthcoming publications.

The usual search for explanations and solutions for the research-practice gap tends to analyze ways to communicate evidence-based practice guidelines to practitioners more efficiently and effectively from the end of a scientific pipeline. This examination of the pipeline looks upstream for ways in which the research itself is rendered increasingly irrelevant to the circumstances of practice by the process of vetting the research before it can qualify for inclusion in systematic reviews and the practice guidelines derived from them. It suggests a 'fallacy of the pipeline' implicit in one-way conceptualizations of translation, dissemination and delivery of research to practitioners. Secondly, it identifies a 'fallacy of the empty vessel' implicit in the assumptions underlying common characterizations of the practitioner as a recipient of evidence-based guidelines. Remedies are proposed that put emphasis on participatory approaches and more practice-based production of the research and more attention to external validity in the peer review, funding, publication and systematic reviews of research in producing evidence-based guidelines.

In public health, the generation, management, and transfer of knowledge all need major improvement. Problems in generating knowledge include an imbalance in research funding, publication bias, unnecessary studies, adherence to fashion, and undue interest in novel and immediate issues. Impaired generation of knowledge, combined with a dated and inadequate process for managing knowledge and an inefficient system for transferring knowledge, mean a distorted body of evidence available for decisionmaking in public health. This article hopes to stimulate discussion by proposing a Global Registry of Anticipated Public Health Studies. This prospective, comprehensive system for tracking research in public health could help enhance collaboration and improve efficiency. Practical problems must be discussed before such a vision can be further developed.

Public health asks of systems science, as it did of sociology 40 years ago, that it help us unravel the complexity of causal forces in our varied populations and the ecologically layered community and societal circumstances of public health practice. We seek a more evidence-based public health practice, but too much of our evidence comes from artificially controlled research that does not fit the realities of practice. What can we learn from our experience with sociology in the past that might guide us in drawing effectively on systems science?

A proposal by Wald and Law (2003) for a single pill containing a statin, three half-dose antihypertensives, aspirin, and folic acid, met with a storm of controversy and seemed to have been relegated as much to the fanciful as to the accolades it might have deserved. The benefits such a Polypill could confer on people age 55+y were to reduce both cardiovascular and stroke events by 80% or more. Considering the daunting and, at best, slow process of changing the same risk factors through health promotion interventions on food policy, dietary and physical activity behaviors, and urban planning to make less prevalent the sedentary lifestyles developed over decades, the argument here is to view the Polypill as a harm reduction strategy that would complement health promotion, as Nicotine Replacement Therapy did for tobacco control, seat belts did for traffic injuries, and needle exchange programs did for secondary complications of injection drug use.

Responding to growing impatience with the limited application of research findings to health practices and policies, both funding bodies and communities are demanding that research show greater sensitivity to communities' perceptions, needs, and unique circumstances. One way to assure this is to employ participatory research-to engage communities at least in formulating research questions and interpreting and applying research findings and possibly also in selecting methods and analyzing data. "Community" should be interpreted broadly as all who will be affected by the research results, including lay residents of a local area, practitioners, service agencies, and policymakers. Participatory research should not be required of every project, but when results are to be used for, in, and by communities, those communities should collaborate not only in applying findings but also in determining the ways in which the findings are produced and interpreted.

A pilot-tested questionnaire was mailed to 325 obstetricians, pediatricians, family practitioners and general practitioners of a British Columbian maternity hospital to measure aspects relating to physicians' attitudes toward breastfeeding counselling. Response rate was 67.3%. The measures of self-efficacy, knowledge and beliefs were added to a regression model containing measures of gender, specialty, years in practice and personal or spousal breastfeeding experience to determine whether additional variance in counselling behaviour could be accounted for. Physicians attempted to convince women to breastfeed if: 1) they believed in the immune properties of breastmilk (OR = 1.23, SE = 0.07) and 2) they were confident in their own breastfeeding counselling (OR = 1.88, SE = 0.36). Likewise, encouraging women to continue breastfeeding in the face of breastfeeding problems was related to confidence in breastfeeding counselling (OR = 1.22, SE = 0.10) and belief in the immune properties of breastmilk (OR = 2.83, SE = 0.45).

Defining health impact assessment as any combination of procedures or methods by which a proposed policy or program may be judged as to the effect(s) it may have on the health of a population, we make recommendations about how to evaluate the health impact of all government-initiated policies. Such health impact cannot be assessed in the absence of a conceptual or organizing framework that provides the requisite guideposts--population health goals and targets. Health impact assessment offers an approach to ensuring that governments' program and policy initiatives align, or are congruent with, the agreed-upon health goals. It suggests that proposed national policies should be supported or resisted on the basis of their probable influence on the health of populations. In the current Canadian national policy framework, however, there are no underpinnings on which to situate such a process. The specification of consensus goals and objectives with measurable targets can provide the requisite guideposts and benchmarks for health impact assessment. Such an undertaking can set the stage and provide the necessary foundation for an effective health impact assessment process.

The question of how to enhance the dissemination of knowledge and the use of innovations related to disease prevention and health promotion was posed to an international group of experts at an invitational research conference held in Vancouver, British Columbia in March 1995. The Canadian Conference on Dissemination Research Strengthening Health Promotion and Disease Prevention was co-sponsored by 15 voluntary organizations, government agencies and industries. It examined advances and gaps in the study of diffusion and adoption of preventive knowledge and practices among health professionals and the public. It was the first national conference of its kind devoted to dissemination research and dissemination of research specifically in health promotion and disease prevention. This paper summarizes the major issues raised in the papers presented at this conference. Policies and strategies for strengthening dissemination research and the dissemination of health promotion knowledge and practices are suggested.

We review the theoretical and research foundations of knowledge dissemination and utilization. We examine first the features that describe the typical pattern of the spread and adoption of ideas in populations. A second level of theory examines the forces that explain and predict the diffusion of health promotion and disease prevention knowledge and innovations in two spheres, the public sphere and te professional sphere. A third level of theory produces models to guide the planning and evaluation of dissemination efforts and advocacy for policies to support the application of knowledge. We trace major research traditions through the literature of various disciplines of professions that have studied diffusion. We then outline some key issues related to knowledge dissemination and utilization in the fields of health promotion and disease prevention.

A thermal ionization mass spectrometric procedure was developed for determination of 240/239 ratios in subpicogram quantities of plutonium (Pu), and was applied to Pu extracted from Lake Ontario sediment. The detection limit was ∼ 4 fg of Pu and the precision of 240/239 ratio measurement was ∼ 7% in the 0.07-0.42 pg range. Results of sediment analyses at various depths showed in all cases 240/239 ratios near the mean global fallout value of 0.176 ± 0.014. The lack of variability of the ratios with depth negated the use of Pu, present in excess in the near-surface samples due to leakage from a nearby reprocessing plant, as a geochronological meter. The 240/239 ratio of the leakage Pu appeared to be very similar to that of fallout Pu.