The Action Cycle

Sharon E. Straus, MD, MSc, FRCPC
Eman Leung, PhD

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The action cycle is the process by which knowledge is implemented
The “Action Cycle” represents phases of activities that, according to planned-action theories, are needed for knowledge applications to achieve a deliberately engineered change in groups that vary in size and setting

The 7 Phases of the Action Cycle

Identification of the knowledge-to-action gaps (knowledge needs) is the starting point of knowledge implementation
This process should involve rigorous methods and engage relevant stakeholders
Strategies for needs assessments depend on the
- purpose of the assessment
- the type of data
- available resources
- whether the needs are subjectively or objectively measured
Needs assessments can occur from the perspective of the
- population
- organization
- health care provider
Examples:
- Reducing antibiotic prescription in the community by the prudent use of antibiotics is seen as one way to slow the rise in antibiotic resistance and appears safe
- However, our understanding of HOW best to achieve this is limited

Any knowledge must be adapted to local settings to ensure it is relevant and feasible
For example, although guidelines provide evidence in a more usable form for practitioners and health settings than a plethora of primary studies, the adaptation of the guideline to the context of use is a necessary step
- Customizing a clinical practice guideline for a particular organization may help improve acceptance and adherence
Example:
- In the contemporary West (where absolute rates of complications are lower) the number needed to treat to benefit will rise above a rate at which it might be regarded as worthwhile to treat, and thus the guideline suggests that antibiotic should not be prescribed to healthy adults
- However, in low-income countries where the absolute rate of complications may be much higher, the lower number needed to treat to benefit will mean antibiotics are more likely to be effective
- Hence the previous guideline of prescribing antibiotic will need to be adapted to the low-income community

Methods to access barriers and facilitators to knowledge use include:
- The Delphi procedure (to achieve consensus among a panel of experts)
- Qualitative approaches such as focus groups, interviews, and questionnaires
- Statistical analysis on observational dataset by regressing potential determinants of variation in health care delivery
- Statistical analysis of multiple studies concerning guideline implementation to determine factors that account for the heterogeneity of effects across studies
Examples:
- Lack of awareness
- Current (habitual) practices

Knowledge translation interventions need to be tailored to specific barriers for change, similar to a clinical treatment that is tailored to a diagnosed health problem
Knowledge translation interventions can target different stakeholders:
- Health Care Professionals: e.g. interventions that bring information close to the point of decision making (such as reminders and decision support)
- Patients: e.g. interventions that target health literacy or self-care
- Organizations: e.g. interventions such as quality management, organizational evidence-based practice guidelines
KT interventions should be tailored to the barrier to knowledge use on a theory-driven basis.
- For example,
  - Barriers for change: difficulty in acquiring the information
  - Theory: Cognitive theory on learning
Examples:
- Barrier to knowledge use: Lack of awareness
- Evidence-based intervention: Printed educational material and reminders are not effective in capturing care-providers’ attention in their busy daily routine
  - Interactive educational meetings that invite physicians to actively participate in their learning in an educational setting are effective (Arnold & Straus, 2005)
- Barrier to knowledge use: Prescribing habit
- Evidence-based intervention: Make small changes, DELAY, not abolish antibiotic prescriptions (Arnold & Straus, 2005)

Knowledge use can be:
- Conceptual: to change the levels of knowledge, understanding and attitudes
- Instrumental: to change behavior or practice
- Persuasive: to use knowledge as ammunition in the attainment of power or profit
Knowledge can be translated in a usable form, such as care pathway, and used in making specific decisions
Knowledge use could be monitored by observing the frequency of how often such a decision is made
Example
- Changes in antibiotic prescription practices could be monitored through electronic/sticker tracking

Strategies for evaluating knowledge implementation should use explicit, rigorous methods and should consider both qualitative and quantitative methodologies:
- Examples of qualitative evaluation methodology:
  - interviews, surveys, focus groups
- Examples of quantitative evaluation methodology:
  - Randomised trials, interrupted time series
Because the evaluation of outcome is a lengthy and resource-consuming task, attention is also paid to the resource under which knowledge is being implemented and the activities that bring about knowledge use
Examples:
- Structural measures: Resource available for interactive educational meeting on optimal practice of prescription
- Process measures: Antibiotic prescription
- Outcome measures: Complications, reduced antibiotic-resistant pathogen in local testing hospital

The sustenance of knowledge use refers to the continued implementation of evidence over time
The consideration of sustainability should occur early in the process and include the discussion of:
- Budgetary Resources
- Human Resources
- Health Care System
Example:
- To develop a sustainability action plan for changing the prescription practices of antibiotics, needs to consider the following:
  - How relevant is the issue of antibiotic over-prescription?
  - What is the benefit of implementing strategies that change practice in antibiotic prescription?
  - What are the attitudes of physicians, patients and other relevant stakeholders toward the issue of antibiotic over-prescription?
  - What is the nature of the team/group which can be engaged to facilitate the sustainability of strategies that may lead to optimal prescription practices?
  - Are there champions of change among the senior management?
  - How will the new prescription practice fit with the existing policy?
  - What funding is required, and can cost-effective strategy be used?