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Using Integrated Research-Practice Partnerships to Move Evidence-Based Principles Into Practice

Estabrooks, Paul A.1; Harden, Samantha M.2; Almeida, Fabio A.1; Hill, Jennie L.1; Johnson, Sallie Beth3; Porter, Gwenndolyn C.1; Greenawald, Mark H.4

Author Information
Exercise and Sport Sciences Reviews: July 2019 - Volume 47 - Issue 3 - p 176-187
doi: 10.1249/JES.0000000000000194
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Key Points

  • Efficacious physical activity interventions exist but do not reach a high proportion of those who could benefit.
  • Through our program of research, we propose an integrated research-practice partnership process to coproduce intervention strategies that is informed by evidence-based principles and practice values/resources/infrastructure.
  • Our proposed model may lead to interventions that are practical and effective, reach more participants, and are sustained in practice.

INTRODUCTION

The predominant translational paradigm, as it relates to behavioral physical activity interventions, is based on a pipeline model that begins with demonstrating the efficacy of a given intervention when tested under optimal conditions (1,2). This systemic view of translational research embodies a number of deeply held beliefs, rules, and structures that provide a basis for when an intervention is “ready” for testing in typical community or clinical contexts (3). Flay, in a seminal article on the stages of research needed to determine the utility of a health promotion intervention, recommended that research move from (i) development and pilot trials to (ii) efficacy trials to (iii) effectiveness trials that include a large and representative portion of the target population to (iv) implementation effectiveness trials that include typical members from the target population and the typical staff that would ultimately implement an intervention to (v) demonstration projects across large systems.

Thirty years since the publication of Flay’s work, translational research continues to focus on a hierarchy of evidence necessary before an intervention is “ready” for translation. This type of research is described as knowledge translation in Canada (4), scale-up or scalability in Australia (5), or dissemination and implementation research in the United States (6). Indeed, across these and other countries, research-to-practice translation is predicated on the movement of an evidence-based product from science to practice. Yet, across a number of scientific fields, there remains uncertainty as to the level of evidence needed to denote that a particular product is evidence-based (5). Furthermore, the predominant proposition from these perspectives is that providing an evidence-based product with “how to” resources and support — and a focus on fidelity while allowing modest adaptation — will result in improved physical activity for those that receive the intervention (4–6).

When considering the public health potential of integrating physical activity interventions into practice in a timely manner, there are a number of issues that arise with the current translational paradigm. First, practice professionals and decision-makers often do not share the value of a hierarchy of evidence and value multiple types of information, some more than traditional research evidence (7). Second, some practitioners may actively criticize an evidence base as not relevant — in that the evidence was generated in settings that were not representative of the “real world” nor were the study participants representative of the typical population served by practice organizations (8,9). Third, there is limited data demonstrating efficacy is predictive of demonstrating effectiveness when an intervention is implemented with a more diverse population of participants and delivered by a more diverse set of settings or staff. Fourth, and pragmatically, the current translational paradigm suggests that practitioners would or should wait until the best possible evidence is available rather that recommending they act on the best available evidence. This is especially problematic when staff members in clinical, public health, education, or employment systems are faced with addressing current levels of physical inactivity across a broad spectrum of patients, residents, students, or employees.

The predominant focus on implementing evidence-based products with high fidelity as a solution to low levels of physical activity in patient or community populations also can put researchers in a difficult situation when presenting these ideas to practice organizations. Specifically, practice professionals and decision-makers have unique knowledge, skills, and strategies that may not be considered with an evidence-based intervention’s adoption, implementation, or scale-up (10). This can put a researcher at a disadvantage when having to defend (i) why research evidence, and specific forms of research evidence, is necessary and superior to practitioner expertise and (ii) the need to assure fidelity while avoiding adaptation to the local context that is likely necessary to increase the likelihood of broad reach and sustainability (11). Using policy case studies as an example, those that were successfully adopted and implemented were characterized by positive user-testimony, assets-based approaches that leveraged existing resources, short-term evaluation of costs or resources saved at the local level, and evidence of short-term effectiveness for service users, and a potential for high reach (7). Furthermore, when interventions were adopted, they were adapted based on the intended audience, practice professionals, and community organizations that housed the interventions (7).

To address these issues, we developed a systems-based model as a generalizable process to improve the likelihood that a given intervention approach will achieve a local public health impact (12). This process model is based on the following propositions. Our first proposition is twofold in that integration of scientific and community/clinical systems to address questions that are scientifically innovative and have practical implications for stakeholders will (i) result in an increased likelihood of sustained local implementation and (ii) provide replicable evidence of the generalizability of the integration process across systems. Our second proposition is that the development of sustainable program, practice, or policy approaches is best achieved using a vertical and horizontal systems approach (13). Vertical components of our systems-based process model are typically operationalized to include both the staff that interact with the potential recipients of a given intervention and the organizational decision-makers who can approve intervention adoption, implementation, and institutionalization. Horizontal components of a systems-based approach include the engagement of units or sectors across an organization or community that can contribute to promoting physical activity. Our third proposition is that research synthesis that focuses on evidence-based principles (i.e., core mechanisms of change) rather than products (i.e., evidence-based programs) has a higher likelihood of achieving wide adoption and high-quality implementation (12,14). Finally, our fourth proposition is that there is a higher likelihood of scale-up and sustainability when organizational or system governance, values, resources, strategies, and structure are leveraged to ultimately design for dissemination (12).

In this article, our purpose is to define the key elements of our integrated research-practice partnership process model and provide examples from our work in physical activity promotion across projects and partnerships. We used the reach, effectiveness, adoption, implementation, maintenance (RE-AIM) framework (15,16) in project planning with a goal to support partnerships in developing strategies with broad and representative reach, which could effectively change and maintain participant physical activity and be adopted, implemented, and sustained across partnership systems when target metrics were achieved. Similarly, within each partnership, we pragmatically identified RE-AIM dimensions within the evaluation and decision-making phases outlined in the model hereinafter.

The Integrated Research-Practice Partnership Process Model

Similar to other processes including community-based participatory research (CBPR) and educational research-practice partnerships, our process model includes the need for mutual benefit for both the research and practice systems as well as transparency, trust, and sharing of resources to prioritize action across partners (17–19). Distinct from these approaches, our process model allows for varied duration in partnerships from acute, single issue specific partnering to the longer-term partnerships across multiple projects described in CBPR and educational research-practice partnerships (18,19). In addition, our model is explicitly intended to focus on the application of scientific knowledge in practice settings, but is predicated on the use of evidence-based principles, rather than evidence-based products, and the inclusion of vertical and horizontal system representatives as members of a partnership (12). Therefore, in our integrated research-practice partnership process model, we assert that partnerships should be structured to promote a collaborative, multilevel systems approach to the development, testing, and sustained use of evidence-based principles within real-world settings (12).

What is the process?

The Figure provides an updated visual representation of our integrated research-practice partnership process model (12). Central to the figure is the iterative process used to coproduce research-based and practice-relevant evidence. This process was heavily influenced by the innovation decision-making process outlined in Rogers’ Diffusion of Innovations (20). Specifically, coproduction is operationalized by the partnership’s role as the decision-making unit with underlying principles described by Rogers’ five stages — knowledge (exposure to and understanding of and innovation), persuasion (favorable or unfavorable attitude toward innovation is formed), decision (activities that lead to innovation adoption or rejection), implementation (new idea is put to use), and confirmation (seeking reinforcement of decision).

Figure
Figure:
Integrated research-practice partnership process model.

In our process model, there is a continual, overarching emphasis on the collaboration among practice professionals, organizational decision-makers, and scientists. The notion of knowledge — decision-makers exposure to an innovation — occurs early in the integrated research-practice partnership process — typically during the transition from the problem prioritization phase to the strategy selection phase. In our process model, the Rogers’ concept of persuasion is addressed, initially, during the strategy selection stage. This is when the partnership members identify and select the most favorable option from existing evidence-based approaches or sets of evidence-based principles — that is, for ongoing partnership success, initial persuasion that the evidence-based principles may address the problem is needed to then determine potential adaptations. During the strategy adaptation stage, scientists and practice partners engage in a process to ensure fidelity to the underlying evidence-based principles of the intervention and that the decision-makers have and maintain a favorable view of the adapted intervention. As such, the integrated research-practice partnership model is intended to result in a product that leveraged the practice partners’ expertise and developed a sense of local ownership.

Implementation and confirmation components of the innovation decision-making process (20) are operationalized as integration trials and the evaluation, decision-making, and translational solution steps. Determining if a decision is made to sustain and scale-up an intervention, sustain the intervention with further adaptation, or discontinue the intervention and pursue another strategy reflect the final steps within our integrated research-practice partnership approach. We propose that RE-AIM is a useful framework for these final steps and provides metrics that are easily communicated, measured, and addressed in practice settings (21,22). These metrics can provide direction during the decision-making stage for potential intervention adaptations or for specific components to look for in a new intervention.

For example, a target metric could be identified based on the reach of the new intervention with a goal to engage 25 or more people per county as the metric necessary for the partner system to commit to long-term implementation (23). A metric also could be based on effectiveness in that if physical activity is increased significantly by the intervention when compared with a matched-contact control, then the organization will sustain delivery (24). These individual participant level metrics can be balanced by also using metrics related to the feasibility of adoption, implementation, and sustainability from the provider and participant perspective (25). The process concludes an initial test of an intervention with a decision related to if the intervention should be sustained and scaled-up, sustained — but adapted further, or discontinued, and the pursuit of an alternate strategy is necessary. In each case, the alignment of the intervention characteristics and principles is considered concurrently with intervention fit within the organizational system by both researchers and practitioners.

Who is involved in an integrated research-practice partnership?

Concentric circles to the left and right of the figure represent the research and practice domains, respectively. The research domain includes a strong focus on the evidence base, where, and with who, interventions have been tested, and the core elements that reflect the underlying evidence-based principles or mechanisms of intervention action (22). The practice domain includes a hierarchical and horizontal systems-based perspective that focuses on where, how, and by whom new or existing program, policy, or practice are implemented. This also acknowledges the explicit and tacit knowledge related to infrastructure and resources, participant population needs, and organizational values and workflow that are critical to initiating new health promotion strategies (12).

Partnership composition varies based on local context, but consistently uses a team-based approach to develop a collaborative agenda and includes, at a minimum, a practice professional who interacts with the patient or participant population, an organizational administrator with decision-making authority relative to taking action in response to identified priorities, and a scientist with expertise in the potential priority areas (12). In addition, these partnerships frequently engage patient and community representatives from the population intended to benefit from a given intervention. Practice members of the partnership often can expand to include an interprofessional team of organizational administrators, clinic program managers, and front-line program delivery staff. Similarly, research membership on a partnership may expand to include an interdisciplinary team of investigators, data managers, and student research assistants. The number of members and overall composition of teams involved in a partnership depends on the scope of practice, complexity of research design, and available resources (12).

Summary of process and roles

Rogers posited that individuals or organizations move through each stage in a linear fashion but acknowledged that each stage may not be overtly distinguishable by the decision-maker. The initial action within our integrated research-practice partnership process includes identifying a gap in system services that is a high priority for resolution. Once a priority area is identified, the partnership selects an appropriate evidence-based strategy and determines the need for adaptations to ensure that the strategy has relevance and will fit with organizational resources and potential participant preferences. Adapted strategies are then tested within the delivery system to determine if the intervention can be integrated into existing practices. The integration trial design is collaboratively developed with a focus on trial features that will improve scientific confidence in the findings while also providing information necessary for pragmatic decision-making among the practice partners.

Group Dynamics Approaches to Physical Activity Promotion

Approximately 25 yr ago, Carron and Spink (26) published an article examining group dynamics-based strategies to promote physical activity targeting the development of group cohesion. They demonstrated that by actively targeting group processes, structure, and environment within exercise classes, that participants would have increased perceptions of group cohesion and be more likely to attend physical activity sessions over time. This work was replicated by a number of authors using Carron and Spink’s (and other) group dynamics-based approach (27–31). It also provided details on the underlying group dynamics-based principles that were hypothesized to be required to produce a change in physical activity participation. This is similar in concept to Chambers and Norton’s description of intervention core components or mechanisms of action (32). Here, we refer to these core components as evidence-based principles due to the large body of literature that demonstrates that the use of these principles across populations, settings, and different implementation strategies consistently leads to increases in physical activity (31).

We have summarized the evidence-based, group dynamics-based principles for physical activity promotion elsewhere (33). Briefly, the strategies within a group dynamics-based intervention are implemented to develop a sense of distinction for the group (e.g., team name, program t-shirts) (23), facilitate accountability and physical activity intentions using group goal setting and feedback (34), use or foster geographic (e.g., host programs where potential participants already aggregate) or emotional (e.g., recruit teams of friends, coworkers) proximity (24), and facilitate ongoing group interaction through regular communication, cooperative activities, and intergroup competition (35). These evidence-based principles were used consistently across the studies described hereinafter. In addition, the Table provides a description of each study including the key personnel, processes, and outcomes of applying group dynamics-based principles. In each case, the partnership members adhere to the underlying evidence-based principles, but collaborate to adapt the intervention to fit the system or setting, in different contexts — adhering to the underlying evidence-based principles — but working through participatory approaches to develop strategies and translate the work to different settings and systems. Hereinafter, we present the findings of studies completed in chronological order.

TABLE
TABLE:
Summary of key personnel, processes, and outcomes of applying group dynamics–based principles in different settings and systems

St. Mary’s Physical Activity Promotion for Older Adults

In 1999, a partnership was developed among a lead behavioral scientist with expertise in group dynamics and physical activity, a doctoral student, and a research assistant as well as a vertical system component with a nurse manager (i.e., decision-making authority) and physical activity class leader at a local older adult assistance center (St. Mary’s Home Support Services; Table) (36). Together, the partnership identified the need for supervised physical activity programs in rural areas and small towns, such as the community in which St. Mary’s was located. Using the evidence-based group dynamics principles, a 6-wk intervention was offered to older adults at St. Mary’s. Through a small randomized controlled trial (n = 33 participants), the research team was able to establish further evidence in support of applying group dynamics-based principles and strategies to improve physical activity behaviors within this setting and for these participants. Specifically, participants were randomly assigned to either a team-building/group-dynamics condition, a placebo condition, or a control condition. All programs used standard physical activities completed at a moderate intensity that included exercises to improve strength, cardiovascular fitness, and flexibility. The team-building condition was collaboratively developed to introduce strategies focusing on addressing the evidence-based, group-dynamics principles. The placebo condition included having a research assistant attend and cofacilitate standard classes, and the control condition was led only by a class instructor from St. Mary’s. As documented in the Table, the participants in the team-building intervention attended more classes and were more likely to return to the program after a typical summer hiatus. In addition, St. Mary’s Home Support Services practice team was able to sustain a service that did not previously exist in their community (36).

Walk Kansas

Walk Kansas began as a partnership between behavioral scientists with a focus on physical activity promotion, a local health educator who delivered a local fitness program through Kansas State Research and Extension (KSRE), and a statewide specialist from KSRE (23,37,38). This project focused on the horizontal nature of KSRE with coverage across 105 counties and had the vertical nature of the system operationalized in the presence of the local health educator (ultimate implementer) and the statewide specialist (organizational decision-maker). Together, the partnership identified the need for a state-wide physical activity promotion program to address the high prevalence of physical inactivity in adults across the state. The partnership applied evidence-based group dynamics–based principles to promote walking, but due to the lack of expertise of most health educators in delivering a physical activity class and the limitations with scalability, the program was distinct from previous iterations of the intervention. Specifically, health educators recruited self-identified teams of individuals and provided information for the teams to (i) select a team name, (ii) set a group goal to walk the distance across Kansas over 8 wk, (iii) report weekly progress to a team captain, (iv) receive information on progress relative to other teams, and (v) plan for sustained physical activity once the program was completed using weekly newsletters. Group size also was strategically set to increase the likelihood that each team member would meet the recommended guidelines for moderate-intensity physical activity. Team size was limited to six participants so that if each participant walked 2 miles (approximately 30 min), 5 days per week, the team would cover the distance across Kansas during the program period. Inactive and insufficiently active participants significantly increased and maintained physical activity during and 6 months after the program, respectively. The Table includes a complete description of the implementation process and outcomes for Walk Kansas across reach, effectiveness, adoption, and maintenance. Implementation was not assessed, though a follow-up study found that health educators understood the evidence-based principles that were used to create strategies for the intervention and were able to make adaptations to improve efficiency of implementation without violating the underlying principles (38).

Move More

Move More (24) could be considered a hybrid program that included some elements of the St. Mary’s program (e.g., in-person, though less frequent, classes) and of Walk Kansas (e.g., group goals for activities done individually, but reported back to a team). The program and study were collaboratively developed by investigators in the Kaiser Permanente Colorado (KPCO) Clinical Research Unit and providers from KPCO Preventive Medicine and Family Medicine reflecting the horizontal components necessary to identify potential participants and deliver the physical activity program in KPCO (24,39). The partnership included the Chief and Director of Preventive Medicine, the Director of Health Education, a primary care physician, and health educators who would ultimately deliver the program as well as behavioral scientists, a project coordinator, and research assistant. The partnership identified the need for a centralized physical activity program that could be used as a referral outlet for primary care physicians in the region.

The problem prioritization regarded the degree to which a group dynamics-based intervention could be delivered in a system with limited resources and, if so, would the program be sustained in practice? Not only did the program improve physical activity behaviors at 3 months, but also 6 months after the completion of the intervention, Move More! participants maintained, and even increased, minutes of moderate physical activity per week when compared with the enhanced standard of care (print-based materials). This trial provides evidence that group dynamics-based interventions can work in clinical settings as well as the community system in which it was originally tested.

FitEx

Finally, a group of county-based health educators as well as Cooperative Extension leadership (vertical system representation) worked with researchers from the Human Nutrition, Foods, and Exercise Department of Virginia Tech to identify a program that would fit the needs to improve physical activity across the state of Virginia (25,40). Core elements of Walk Kansas were translated to Virginia, but local adaptations were integrated. The Virginia partnership included emphasis on fruit/vegetable consumption to accompany the physical activity component of the intervention. The resultant program was called FitEx. One research interest in this partnership was the degree to which health educators of the system would be more likely to adopt a program developed specifically for Virginia Cooperative Extension when compared with a program developed in more research-intensive settings (i.e., Cooper Institute’s Active Living Every Day). Thirty-six health educators were randomly assigned to either FitEx (n = 18) or Active Living Every Day (n = 18). Only 11% (n = 2) of the health educators assigned to Activity Living Every Day delivered the program, whereas 89% of the health educators assigned to FitEx delivered the program (40). Qualitative inquiry indicated that health educators thought FitEx was easier to deliver and were attracted to the fact that they could adjust the program to fit their county needs (rather than following a set program manual) (25).

FitEx was designed for dissemination to multiple state professionals that could engage in a group dynamics-based approach to physical activity promotion. In addition, other extension systems could adopt the program and develop competition across state lines to further enhance a sense of cohesion within the program (i.e., between individuals on a team, teams against other teams, counties vs other counties, and state vs other states). By 2018, two state systems (Wyoming and Virginia) were delivering FitEx. Future areas of research could apply principles of a participatory approach to unite state-level specialists in identifying program principles that work within their state systems, determining appropriate adaptations for their system, and collaboratively gathering the same effectiveness outcome (Harden SM, Ramalingam NS, Breig SA, Estabrooks PA. Unpublished Data, 2019).

CONCLUSION

We began to use an integrated research-practice partnership approach as a potentially generalizable process to improve the likelihood that a given intervention approach will achieve a local public health impact through the translation of evidence-based physical activity interventions into practice settings (12). We are not the only research group to focus in this area, but the description of this type of approach and examining outcomes that include individual and organizational factors is rare (10,41).

In this article, we provide examples of using this approach with different clinical and community practice partners who serve a broad range of target audiences (older adults, primary care patients). These examples provide preliminary evidence in support of our first proposition — the integration of scientific and community/clinical systems to address questions that are scientifically innovative and have practical implications for stakeholders will result in an increased likelihood of sustained local implementation while providing replicable evidence of the generalizability of the integration process across systems. All four of the interventions demonstrated positive changes in participant physical activity providing generalizable knowledge related to intervention effectiveness. Indeed, the magnitude of effect for each of the trials fell within the range of effect sizes found in a systematic review of other group dynamics–based physical activity interventions (23,24,31,36,40), and each was institutionalized and sustained within the local setting beyond the life of the respective research projects. Our work on Walk Kansas and FitEx also provided support for our third proposition that using evidence-based group dynamics principles (rather than a packaged evidence-based product) resulted in local interventions that were more likely to be broadly adopted in the local extension systems (25,40).

These examples, and our program of research, have yet to provide explicit evidence of our second (the development of sustainable program, practice, or policy approaches is best achieved using a vertical and horizontal systems approach) (13) and fourth (when organizational or system governance, values, resources, strategies, and structure are leveraged to design for dissemination, there is a higher likelihood of scale-up and sustainability) (12) propositions — presenting opportunities for future research varying the composition of partnerships and measuring organizational context factors that could predict scale-up and sustainability. In particular, to date, we have not applied metrics to the approach to identify the underlying principles and process of these partnerships that will increase the likelihood of success. However, the development of metrics to assess process and outcomes in dissemination and implementation science is a current focus of the field (see Society for Implementation Science Collaboration Instrument Review Project https://societyforimplementationresearchcollaboration.org/sirc-instrument-project/). In our current work, we have adapted and developed a number of measures to assess the potential principles by which integrated research-practice partnerships facilitate implementation of evidence-based principles into sustained practice.

Still, as seen in the Table, each program was adapted — using underlying group-dynamics principles rather than any specific evidence-based intervention — based on the needs of the setting in which the program was intended to be delivered, suggesting that alignment with organizational values and resources are important in the adoption decision-making process. This supports the third proposition — that evidence-based principles may have a higher likelihood of achieving wide adoption and high-quality implementation when compared with a packaged evidence-based program. These adaptations often are inevitable when moving evidence-based principles (rather than products) to new populations and settings (42) One area for future research is understanding what adaptations were made, by whom, and why (32). For this reason, we assert that this process model itself can be an implementation strategy (43) to improve the likelihood that the resultant intervention characteristics lead to adoption and implementation and potentially sustainability.

At the core of our approach is practicality. This participatory approach moves away from attempting to “push” evidence-based interventions into practice where proposed changes to clinical or community services often are met with resistance or hesitation due to the uncertainty of the change (44). Second, this process model highlights the nonlinear fashion by which these efforts are usually achieved. Rogers’ also describes the decision to adopt an innovation as a process that includes a set of activities that lead to a choice to either initiate the use of the innovation, or not. Our work suggests that this set of activities can be operationalized as a process to characterize priority areas, the selection of evidence-based principles, and the adaptation of interventions — based on those principles — that provides the best fit within the community or clinical system. This is closely aligned with the construct of reinvention (20) considered as a potential pathway to uptake and sustainability. Our work in a number of settings across varied populations suggests that reinvention or adaptations are inevitable. Use of the integrated research-practice partnership model ensures that the scientific principles and the system level values are continuously considered, over time, to improve patient/participant physical activity behaviors. It is proposed as a distinct stage to highlight the importance of ensuring that the intervention is relevant to, and will fit within, the practice partners’ organizational resources, mission, and service-recipient preferences (20,45).

There also are a number of unanswered questions and potential limitations with this approach. First, we presented partnerships that were primarily associated with single organizations, which simplify processes when compared with approaches that may engage partners from a wide variety of organizations across a community necessitating a larger group of stakeholders with more varied values, resources, and motivation. In some of our work focusing on childhood obesity, we have used this model and successfully engaged multiple community stakeholders with vertical representation across organizations (46). Second, this approach may or may not generalize to policy application for regional or state legislative approaches to create generalizable interventions based on evidence-based principles. This limitation is balanced with the long-term goal of action research — to concurrently move science forward while having an impact in the practice organization or community involved in the research (47). Third, this approach is time intensive for research and practice partners alike. This provides opportunities to examine the potential cost effectiveness of integrated research-practice partnerships across RE-AIM dimensions when compared with the more traditional translation of evidence-based products into practice. Fourth, to date, we have primarily viewed sustainability as a binary outcome that occurs directly after the partnership project is completed — did it continue to be offered or did it not. There is clearly a need to more explicitly focus on sustainability in more depth to examine sustained fidelity to underlying principles. Still, we did demonstrate that the majority of these partnerships led to interventions that were sustained without further research intervention — showing some sustainability promise for the approach.

We conclude by returning to the second proposition regarding the need for vertical and horizontal systems approaches (13). This type of translational research — which leverages systems change — is difficult because of the dynamic characteristics at play. This type of research has traditionally failed due to a tendency toward reductionism that ignores the complexity of an innovation and the implementation system(s). Similar to systems thinking (12,48), we present an approach that respects and leverages characteristics of the system to achieve meaningful change, efficiency, and sustainability. By using a vertical and horizontal systems approach, our process model accounts for the perspectives of individuals involved in program delivery, decision-makers at the delivery site, and the organizational system governing the delivery site. Similarly, while simultaneously focusing on the whole of the health care or public health system, our process model acknowledges the boundaries present in these systems. The definition of boundaries can be especially helpful for researchers to understand who among their practice partners have interests that should be served by research, what information will be most helpful to meet their needs, and to establish a timeline of when those needs will be met throughout the research process.

It is evident that there is value in leveraging expertise and experience from partners within the horizontal and vertical structures of a clinical or community system. We have contributed to the understanding of the generalizability of group-dynamics principles to promote physical activity while our practice partners have valued the development of relevant, effective, and sustainable evidence-based physical activity promotion practices. We also have found that this approach contributed to team science (49) by creating a culture of mutual respect across disciplines. This systems-based integrated research-practice partnership approach serves to direct the purpose of translational research in a manner that will improve efficiency, speed, and public health impact. By drawing on dissemination and implementation evidence and systems-thinking concepts, we have created a generalizable process model for the coproduction of intervention strategies to produce evidence-informed, sustainable solutions to local public health issues.

Acknowledgments

Dr. Estabrooks time was supported in part by the National Institutes of Health (Great Plains IDeA CTR U54GM115458).

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Keywords:

knowledge translation; implementation; scale-up; community-engaged research; physical activity

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