Exploring Knowledge Broker Influences on Sharing and Use of Evidence for Health Policy and Practice in Low- and Middle-Income Countries PhD Thesis Department of Public Health and Primary Care Ghent University, Belgium Please cite as: Norton, T.C. (2019). Exploring Knowledge Broker Influences on Sharing and Use of Evidence for Health Policy and Practice in Low- and Middle-Income Countries. Thesis submitted in fulfillment of the requirements for the degree of Doctor in Health Sciences. Ghent: Ghent University. Copyright © Theresa Canova Norton 2019 All rights reserved. No part of this publication may be reproduced in any form, by print, photocopying, recording or otherwise, without prior written permission of the author. _______________________________________ Cover Photo: Jhpiego/Kate Holt (South Sudan photo) Exploring Influences on Knowledge Broker Sharing and Use of Evidence for Health Policy and Practice in Low- and Middle-Income Countries Theresa Canova Norton Thesis submitted in fulfillment of the requirements for the degree of Doctor in Health Sciences, Ghent 2019 Promotor: Prof. Dr. Sara Willems, Department of Public Health and Primary Care, Ghent University, Belgium Co-Promotor: Dr. Daniela C. Rodriguez, Johns Hopkins Bloomberg School of Public Health, Department of International Health, Johns Hopkins University, USA Promotors Prof. Dr. Sara Willems, Ghent University, Belgium Dr. Daniela C. Rodriguez, Johns Hopkins University, USA Advisory Committee Prof. Dr. Maureen Dobbins, McMaster University, Canada Dr. Nasreen Jessani, Johns Hopkins University, USA, and Stellenbosch University, South Africa Dr. Devaki Nambiar, The George Institute for Global Health, India Examination Board Prof. Dr. Olivier Degomme, Ghent University, Belgium Prof. Dr. Benedicte Deforche, Ghent University, Belgium Prof. Dr. Rudi Roose, Ghent University, Belgium Prof. Dr. Kristien Michielsen, Ghent University, Belgium Prof. Dr. Koen Vlassenroot, Ghent University, Belgium Dr. Nicola Francesco Dotti, Vrije Universiteit Brussel, Belgium This doctoral thesis has been self-financed. Research on which this thesis was based was made possible in part by the generous support of the American people through the United States Agency for International Development (USAID) under the terms of the Cooperative Agreement AID-OAA-A-14-00028. The contents of this thesis are the responsibility of the author and do not necessarily reflect the views of USAID or the United States Government. The funder did not have a role in the study designs. Table of Contents Acknowledgments ......................................................................................................................................... v Dedication ................................................................................................................................................... vii List of Abbreviations and Definitions ........................................................................................................... ix Preface ........................................................................................................................................................xiii 1 Introduction .......................................................................................................................................... 1 1.1 The Health Burden of Inadequate Use of Evidence in Low- and Middle-Income Countries ........ 3 1.2 Scope and Limitations of Preventable Deaths in Low- and Middle-Income Countries ................ 3 1.3 Intersections of Science, Politics, Environment, and Beliefs in Evidence Use .............................. 5 1.4 Making Evidence Accessible, Understandable, and Useable: Knowledge Translation and Knowledge Brokers ................................................................................................................................... 6 1.4.1 Theories, Models, and Frameworks Relevant to Knowledge Translation ............................ 6 1.4.2 Knowledge Translation ....................................................................................................... 11 1.4.3 Knowledge Brokers ............................................................................................................. 13 1.4.4 Discussions of Knowledge Brokering Effectiveness in the Literature ................................. 19 1.4.5 Calls for Research on Knowledge Brokers........................................................................... 21 2 Research Aims ..................................................................................................................................... 23 3 Methods .............................................................................................................................................. 27 3.1 Methods Overview ...................................................................................................................... 29 3.2 Context of the PhD Project: Global Health Programs ................................................................. 30 3.3 Additional Notes on Methods of the Conference Studies .......................................................... 32 3.4 Ethical Approval .......................................................................................................................... 34 3.5 Overall Scope of the PhD Project (Geographically and Topically) .............................................. 34 3.6 Philosophical Orientation............................................................................................................ 36 4 Publications ......................................................................................................................................... 37 4.1 Paper 1. Enabling Knowledge Exchange to Improve Health Outcomes through a Multi-Partner Global Health Program ............................................................................................................................ 41 4.2 Paper 2. Knowledge Management for Public Health Subspecialties Using Diffusion of Innovations Theory and Information and Communication Technology ................................................. 71 4.3 Paper 3. Exploratory study of the role of knowledge brokers in translating knowledge to action following global maternal and newborn health technical meetings ...................................................... 93 i 4.4 Paper 4. “Maybe we can turn the tide:” An explanatory mixed methods study to understand how knowledge brokers mobilize health evidence in low- and middle-income countries .................. 115 4.5 Paper 5. Applying the Theoretical Domains Framework to understand knowledge broker decisions in selecting evidence for knowledge translation in low- and middle-income countries ...... 143 5 Limitations......................................................................................................................................... 183 5.1 Overview of Limitations ............................................................................................................ 185 5.2 Biases ........................................................................................................................................ 185 5.3 Limited Quantitative Analysis ................................................................................................... 187 5.4 Saturation Issues ....................................................................................................................... 187 5.5 Survey Instrument Limitations .................................................................................................. 188 5.6 Limitations of Researcher Interaction with Participants, Organizations, and Settings ............ 189 5.7 Case Study Limitations .............................................................................................................. 190 5.8 Evaluative Language in Papers .................................................................................................. 191 5.9 Summary of Limitations ............................................................................................................ 192 6 General Discussion and Critical Interpretation ................................................................................. 193 6.1 Main Findings ............................................................................................................................ 195 6.1.1 Study of Knowledge Brokers Versus Knowledge Brokering .............................................. 195 6.1.2 Knowledge Broker Activities that Support Evidence Uptake ............................................ 195 6.1.3 Knowledge Exchange Approaches in a Series of Global Health Programs ....................... 196 6.1.4 Common Attributes and Activities of Knowledge Brokers in the Studies......................... 200 6.1.5 Influences on Knowledge Brokers in Selecting Evidence for Action ................................. 205 6.1.6 Why Evidence Was Not Shared or Used ........................................................................... 210 6.2 Implications of Country Categorization in this PhD Project ...................................................... 212 6.3 Implications of Limitations to Conclusions Based on the Findings ........................................... 213 6.4 Summary of Findings ................................................................................................................. 215 6.5 Further Research Needed ........................................................................................................