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Translating Social Work Research for Social Justice: Focusing Translational Research on Equity Rather than the Market Stephen Edward McMillin
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School of Social Work, Saint Louis University , St. Louis , Missouri , USA Published online: 09 Jan 2014.
To cite this article: Stephen Edward McMillin (2014) Translating Social Work Research for Social Justice: Focusing Translational Research on Equity Rather than the Market, Journal of Evidence-Based Social Work, 11:1-2, 148-156, DOI: 10.1080/15433714.2013.845029 To link to this article: http://dx.doi.org/10.1080/15433714.2013.845029
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Journal of Evidence-Based Social Work, 11:148–156, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 1543-3714 print/1543-3722 online DOI: 10.1080/15433714.2013.845029
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Translating Social Work Research for Social Justice: Focusing Translational Research on Equity Rather than the Market Stephen Edward McMillin School of Social Work, Saint Louis University, St. Louis, Missouri, USA
Management of the dissemination of effective interventions in social work is often uncertain, and even when attention is paid to diffusing effective, innovative interventions, the focus is often disproportionately on a marketplace orientation of increasing the market share of branded, manualized interventions and social service treatment products. Public health frameworks of dissemination can improve knowledge translation in social interventions by focusing dissemination efforts on achieving equity and increasing the availability of effective interventions to all those who can benefit from them rather than simply focusing on commercial processes. This article identifies three equity-focused translation frameworks that can aid the dissemination of effective social interventions at the macro-, meso-, and micro-levels. Implications for policy and practice are discussed. Keywords: Evidence-based practice, translational research, social justice, equity, market
To the extent that empirically well-supported interventions are not treatment-as-usual or the standard-of-care, in social welfare as well as in public health and medicine, disparities and inequities in health and wellbeing will persist. Translation of effective health and social services has generally relied on the marketplace and a diffusion of innovational products approach that fails to take into account the social injustice aspect of these disparities. As social services become more fragmented, U.S. social work can benefit from borrowing public health translational research frameworks and approaches that return to notions of the common good or the public health and wellbeing. Health disparities have already become a better-understood concept thanks to public health efforts and translational research in medicine and prevention. New dilemmas arise for social work in this context. Substantial disparity and inequality may be “under the radar” to the point that the slow or non-existent dissemination of effective social services and programs is not even identified as a problem. There is often a structured lack of access to empirically well-supported social care that simply goes unnoticed. While there has been an increasingly recognized need for translational research focused on “translating” research findings and best practices out of the laboratory and into daily life and encouraging and evaluating the uptake of best practices, this view of translation tends to use a business approach. The emphasis has often been on the successful diffusion of innovational products, convincing more and more social service providers to purchase and adopt Earlier drafts of this work were presented at the annual meetings of the American Public Health Association and the Society for the Study of Social Problems. Address correspondence to Stephen Edward McMillin, School of Social Work, Saint Louis University, Tegeler Hall, 3550 Lindell Boulevard, St. Louis, MO 63103, USA. E-mail: [email protected]
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specific, manualized treatments, rather than on an incremental approach that emphasizes reducing health disparities caused by lack of access to evidence-based social work services. Entrepreneurial expansion has been the rule of the day in U.S. social work in terms of dissemination evidencebased programs and services. Entrepreneurial expansion alone will not be enough to translate and spread evidence-based social work practices that are ready for dissemination. An important question at hand is how to measure or score successful dissemination. In a diffusion of innovations approach, the implicit grade of success or evaluation of dissemination is a positive one, starting at zero and seeing how far market forces can extend market share and product uptake—every extension is seen as a positive advance, even if many people who could benefit from an intervention are never exposed to it. A disparities approach implies a different, negative, starting point and score—beginning at a state of negative dissemination, when no one benefits from the intervention, and becoming smaller over time until ideally reaching zero, indicating no one who could benefit from the innovative intervention is left out. The count is of who is left out and who continues to be left out, not simply of who is brought in to the intervention’s benefits through successful expansion of market share. Sometimes seeing the glass as half empty rather than half full can be more helpful in terms of extending utilization of well supported interventions to reach the most people. This article will examine in detail four problems in the dissemination of effective social work interventions that have motivated new attention to models of translation that are as effective as the interventions themselves. Then, three potential practice changes that help ameliorate these problems are discussed conceptually, and three models of translation and dissemination that operate at macro-, meso-, and micro-levels are examined as to their potential to be applied to knowledge translation in social welfare. Implications for practice and policy in making these changes are discussed.
PROBLEMS IN TRANSLATING EFFECTIVE SOCIAL SERVICES Although numerous problems plague the dissemination of social interventions, four problems are particularly important for translational research in the social sciences to address: 1) Even established social interventions often have unproven or uncertain effectiveness; social workers even with the best of intentions can and do harm people in the name of helping (Gambrill, 2001, 2006). Moreover, students in professional education programs, such as Master of Social Work (MSW) programs, are not commonly taught the profession’s history or track record of harm, and typically this does not even come to light unless a journalist writes an exposé of a specific case (Gambrill, 2007). 2) Knowledge of interventions that are empirically supported as effective face uncertain utilization, diffusion, implementation, transfer, and translation; that is, social interventions that are effective in the laboratory or research setting need to be translated into the everyday life of practice, but often few or no efforts are made in this regard. These different terms are conceptually linked yet mean somewhat different things (Ottoson, 2009), and it is helpful to define them individually: a. Knowledge utilization for health and social welfare today often refers to how research synthesis such as systematic reviews and meta-analyses are drawn upon (or not) to inform practice (Blake & Ottoson, 2009, p. 23). b. Diffusion refers to how an intervention spreads to new sites and users; interventions diffuse or are taken up selectively and in varied ways, while dissemination refers to a more carefully plotted plan for diffusion when intervention fidelity is particularly important (Ashley, 2009, p. 41). Dissemination is an intentional strategy and successful
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dissemination often depends on using user-friendly “triage strategies” that help a program achieve a certain level of “critical mass” (Backer, 2000, p. 365) rather than merely blanket efforts at dissemination that easily become unfocused (Backer & Norman, 2000). c. Implementation refers to the process of how a policy decision to execute a change process becomes reality, across many actors including both champions and saboteurs (DeGroff & Cargo, 2009, p. 47). Implementation is a set of specific, identified activities that can be identified by an external observer or evaluator (Fixsen, Naoom, Blase, Friedman, & Wallace, 2005, p. 5). d. Transfer occurs on a larger scale than implementation of an intervention at a solitary site and can refer to an intervention moving across several sites or even across disciplines (Oliver, 2009, p. 61). e. Finally, translation is ultimately a communication process in which stakeholders participate in an iterative feedback loop, their experiences and concerns rendering the intervention usable in daily practice and precipitating the next round of questions and research projects that will develop the body of knowledge about the intervention and help all concerned understand the intervention’s long- and short-term effects (Davison, 2009, p. 75). 3) Management practices and attitudes regarding education and evaluation can negatively or neglectfully impact the sustainability of empirically supported interventions and practice. Translation and its aspects and components do not happen on their own; they require diligent management efforts, and any lack of diligent effort and supervision is in itself a social service management decision that will effect whether and how translation takes place. 4) Even when social service management pays attention to questions of diffusion and dissemination, it tends to be one-sided attention rooted in market assumptions that may not be valid. The perspective and operating assumptions behind translation need to be acknowledged and carefully examined. This is the primary motivating problem addressed in the remainder of this article. However, other interrelated problems lead up to the over-emphasis on market assumptions and also merit discussion, as changing practice to better support translation will be a complex endeavor. ARGUMENTS FOR CHANGING PRACTICE TO SUPPORT TRANSLATION This article makes three arguments. First, it echoes the common criticism that many interventions to solve social problems are not strongly supported empirically and that empirically supported interventions are not adequately translated in a thorough or timely way to those who can most benefit from them. However, this article also argues that calls for evidence-based practice and rapid dissemination of empirically supported social interventions are commonly motivated by cost-benefit analysis and market-based concerns rather than by maximizing access to sometimes expensive interventions among disadvantaged and marginalized populations. Finally, this article argues that to correct the market-imperative that motivates so much emphasis on evidence-based practice and rapid diffusion of innovations, translational research frameworks in the social sciences must explicitly and consistently emphasize modalities that increase accessibility and availability of expensive interventions to all those who can benefit from them rather than simply bowing to market conditions that limit or slow dissemination. Argument 1: Overcome Bad Practices and Bad Translation of Good Practices Before we can focus on translating good practices and interventions, it is necessary to identify and eliminate bad and harmful practices in social welfare and social services. In many respects,
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this is the bad-tasting medicine for social work that must be ingested before any real change in the profession is possible. Gambrill (1999) pointed out how historically social work in the United States has been an authority-based profession deeply rooted in tradition. While there has often been an assertion that the profession should recognize diverse forms of knowledge and different ways of knowing, Gambrill (1999) noted that this emphasis on diversity has not resulted in a reduction of biased thinking and logical fallacies; often it simply increases relativism that ignores political and economic conditions and permits more propaganda to inflate claims about what interventions can do. Research makes a contribution even when it simply unearths uncertainties and points out what remains unknown; relativism that denies the power of research to make a contribution simply masks knowledge and empowers the status quo. Technology has also introduced a paradigm shift in expectations that public and social services must respond to. As Gambrill (2006) suggested, “Saying there is nothing new about a paradigm shift is one way to continue business as usual (e.g., authoritarian practices such as ignoring important uncertainties regarding decisions that must be made)” (p. 339). Denying the paradigm shift quality of how empirically informed practice is different from the status quo is often seen in assertions that practitioners or agencies have “always” integrated research findings into practice, when in fact only the expansion of the internet and other technologies made the research easily available for integration. For example, while physicians regularly use handheld digital devices to remind them of important assessment questions, social workers who frequently must ask more questions and conduct broader assessments rarely do so. In 2007, Gambrill noted this with alarm, recommending “user-friendly palm pilots to guide decision-making and minimize cognitive biases” (p. 558); reading this years later, the first thought that comes to mind is whether or not “there’s an app for that,” and that developing this good practice might be scaled up simply by teaching workers to use their smartphones and tablet computers in assessment. As technology changes and becomes more available, the tool chest of ways to detect and decrease bad practices becomes larger. Argument 2: Adequately Defining and Focusing Translation Efforts A wide variety of research questions can be asked in translational research, and there is no standardized conceptualization for these questions because of struggles to define knowledge translation consistently (Davison, 2009). While translation is often envisioned as the end phase of research, there is increasing recognition that translational research questions need to be considered throughout the research process and “in all aspects of research” (Davison, 2009, p. 77) if benefits to stakeholders are to be maximized. To this end, a particular framework of translational research is helpful to be very clear about operating assumptions. Many theories of knowledge translation are considerably oriented toward a diffusion of innovational products in which market supply and demand will abet translation. For many knowledge products, this framework of knowledge translation is likely adequate. However, for many empirically supported social interventions, the outcomes of interventions are public goods rather than private goods that are easily malleable by or directly responsive to economic supply and demand. Moreover, market forces may directly work against knowledge translation for many social interventions, reinforcing or exacerbating existing inequities. Rogers’ (2003) diffusion of innovations framework suggests that the uptake or reception of new products or services moves through segmented stages that can rely a great deal on processes of adoption. After being exposed or gaining some knowledge of the innovation (Stage 1), the person or agency becomes persuaded to find out more about the innovation (Stage 2), makes a decision to accept or reject the innovation (Stage 3), tries out the innovation in different settings if it has been accepted (Stage 4), and then adopts the innovation for regular use (Stage 5). Rogers also suggested that patterns of adoption could be predicted based on adopter characteristics; early adopters are more likely to be younger, highly educated, and closer to science and technology, while laggards are more likely to be older, resistant to change, of lower social status, and hewing closely
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to tradition. Rogers noted that for organizations, adoption of innovations are often “authorityinnovation” decisions in which a few hierarchical leaders may be making decisions on behalf of the organization. In these cases the innovation may lack sustainability if the innovation’s champion leaves the organization (p. 429). When compared to Gambrill’s (1999) description of U.S. social work as rooted in authority-based practice, it is easy to predict that social workers are relatively more likely to be laggards rather than early adopters, and when the typically high rates of turnover in social work (Kim & Lee, 2009; Mor Barak, Travis, Pyun, & Xie, 2009) are examined, the sustainability of many social interventions is also suspect. However, the diffusions of innovations model faces several challenges in informing translational research for social services. Rogers (2003) envisioned an “S-curve” pattern of adoption, with relatively few early adopters and somewhat more but still relatively few laggards at the other end of the adoption spectrum. This adoption pattern seems premised on a static innovation that is not adapted and re-adapted as it is implemented, when in fact rapid change and technological advancement can modulate the pace of adoption relatively quickly and transform a previously marginal innovation into a “must-have.” Likewise, interesting and attractive innovations that cannot overcome institutional barriers can fail to take off, so that an “S-curve” of adoption fails to curve and simply peters out. Moreover, social service organizations face common barriers to translation that a simple diffusion of innovations approach cannot capture. Despite the ubiquity of the term helping professions, too often practitioners see their roles as “custodial” (Corrigan, Steiner, McCracken, Blaser, & Barr, 2001, p. 1599) rather than assistive, so that workers take over and dispose of a case rather than assist clients to move toward their own goals and outcomes. This reflects the tendency toward bureaucratic “people-processing” in complex social service organizations even when the intention is to achieve “people-changing” or individual improvement (Hasenfeld, 1972, 1992). Moreover, Corrigan and colleagues (2001) suggested that despite having certain educational credentials, practitioners might lack meaningful competencies to achieve the goals of the intervention; many are trained in therapies that are not empirically well supported, while some may actively be taught that outcome measurement is incompatible with care-giving. Social workers are among the most common professions to provide psychotherapy and clinical services, yet nationwide are among the least likely to graduate from programs that require training in empirically supported treatments (Weissman et al., 2006), and some professional associations in clinical social work demand theoretical allegiances that are inconsistent with many empirically supported treatments (Thyer, 2007). Argument 3: Keeping Translation Efforts Equity-Focused for Social Justice Knowledge translation in service fields refers to how intervention knowledge has been exchanged, synthesized, and applied (Davison, 2009, p. 75) in a given field. Translational research examines how typical clients in typical settings receive the intervention under review as delivered by typical staff, or seeks to determine whether a particular intervention works with a specific type of client, setting, staff, or other conditions (Glasgow, 2009). To the extent that empirically well-supported or evidence-based interventions are not treatment-as-usual or the standard-of-care, disparities and inequities in treatment will persist. For social welfare and social services there is a special need for translational research “to speed the introduction of promising, evidence-based practices into usual-care settings” (Brekke, Ell, & Palinkas, 2007, p. 124) given a lag time for innovative social interventions that can average a generation or more (Brekke et al.). Moreover, the accessibility of social interventions is often much below identified need in a given population or community, and translational research seeks to gain a sense of the state or degree of translation of a given intervention across the field of need or eligibility for it. Brekke and colleagues (2007) pointed to empirically well-supported psycho-social interventions reaching less than 10%
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of one targeted, eligible population diagnosed with schizophrenia, with only 30% receiving any intervention at all irrespective of the level of empirical support for it. This demonstrates the importance of translational research in highlighting “service sectors in need” (Brekke et al., 2007, p. 124) to which additional intervention resources can be targeted. As social service agencies experience more pressure to be accountable for outcomes, they are increasingly turning toward theory-driven decision-making strategies and management systems (Briggs & McBeath, 2009; Briggs & McMillin, 2012). In short, while evidence-based practice has largely been framed as something most immediately affecting the activities of direct service workers, there is a growing push to see evidence-based management on the part of social service administrators as well as evidence-based practice in the delivery of direct services. Moreover, the growth of hybrid approaches and the expansion of disciplines, such as public health and public administration, as well as specialties, such non-profit business administration and health care administration, have led to a new consideration of evidence-based management (Kovner & Rundall, 2006) as especially suitable for services that combine social, health, and public dimensions, as so much social work does. One difficulty in adapting translational research frameworks for social interventions is taking adequate account of the amount of conflict and contestation that can be present in social and public services. Empirically oriented social work is frequently misunderstood conceptually (Gibbs & Gambrill, 2002), on the level of direct practice (Regehr, Stern, & Shlonsky, 2007) and also in macro-level program development (Thyer, 2008). Within social service agencies, the streetlevel bureaucracy (Lipsky, 1980) and service rationing of individual social service workers can radically change how interventions, however empirically supported, are actually delivered. With this is mind, translational research frameworks for social interventions must also take into account conflict factors in how evidence-based interventions are perceived. RECOMMENDATIONS: THREE POSSIBLE MODELS FOR TRANSLATION Given these three dilemmas, the uncertain newness of translational research for social welfare, the translation difficulties unique to the non-profit world of social services, and a need to focus broadly on inequity rather than merely cost effectiveness, focusing on specific frameworks for translation efforts is helpful. Many of these frameworks have an interdisciplinary quality, either beginning in disciplines outside of social work proper, or being developed across several disciplines and finding relevance in several as well. Model 1: A Global, Macro-Model of Dissemination The Joanna Briggs Institute at the University of Adelaide, South Australia, an international academic collaboration focused on best practice in nursing and allied health care, models the translation of evidence-based healthcare as a cyclical process with four principal components (Pearson, Wiechula, Court, & Lockwood, 2005) arising out of and cycling back into global health. The first component, evidence generation, consists of current research on interventions as to whether they are feasible, appropriate, meaningful, and effective, combined with the current discourse on interventions and practitioner experience. The second, evidence synthesis, consists of systematic review of a given intervention, supported by theory and utilizing appropriate methods, including meta-analysis for quantitative data where possible. The third, evidence transfer, looks at the translation of knowledge confirmed via evidence synthesis through education, information delivery, and organizational systematization. The fourth, evidence utilization, examines how practice changes as a result of knowledge transfer and how practice change is evaluated and embedded in organizational contexts.
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The Briggs model suggests that knowledge is transferred through information that is transmitted through training and systematized. These components of knowledge translation are analogous to the concepts of evidence-based practice as verb or noun (Proctor, 2007); the information or best practice can be seen as an evidence-based practice noun or product, while the training and systematization of best practices can be seen as an ongoing evidence-based practice verb. Systematization and ongoing practice lead to the next component of the Briggs model, how evidence is utilized, embedded into practice, and evaluated. Model 2: Measuring Equity-Effectiveness in a Specific Dissemination and Context Tugwell, Robinson, Grimshaw, and Santesso (2006) proposed an equity-oriented framework that provides “a systematic method for decision-makers to ensure the application of evidence-based knowledge in disadvantaged populations” (p. 643). This method of translational research begins with looking at the results of an intervention’s systematic review or meta-analysis but also examines what market-based, institutional, socio-economic, and behavioral factors can be identified as barriers to extending the intervention. Tugwell and colleagues also calculated point estimates of equity-effectiveness based not only on the effectiveness of the empirically supported intervention, but also on how well knowledge of the intervention has been translated past the identified barriers. This method complements the quantitative analysis in research synthesis; heuristically, it can be thought of as a statistical correction of the meta-analytic effect size, based on the estimated effect the intervention is likely to have in the real world. This type of translational research for social interventions is profoundly interdisciplinary, basically applying a public health method to a social welfare problem. Model 3: Measuring Dissemination at the Micro-Level Finally, a model of translation explicitly designed for local use by individual agencies and organizations in the Reach, Efficacy, Adoption, Implementation, and Maintenance (RE-AIM) framework. The RE-AIM framework (Glasgow, 2009) focuses specifically on translating research to practice by checking both internal and external validity and using a standardized way of measuring key factors. This framework offers a very simple, easy-to-understand summary of knowledge translation for a given intervention, such that it could be described as high on reach, low on efficacy, medium on implementation, and also allows translation domains to be examined to see how they might be related to one another. The RE-AIM framework aligns well with an equity-effectiveness framework because RE-AIM does not separate cost-benefit or cost-effectiveness measures, but rather recognizes that costs and benefits may vary across different translation domains. In larger samples, actual measures of reach, efficacy, adoption, implementation, and maintenance can be taken at both individual and setting/agency levels. In qualitative translational research, participants can be interviewed to ascertain their perceptions of reach, efficacy, implementation, adoption, and maintenance, at both individual and setting/agency levels. Given that this level of analysis for knowledge translation has not yet been broadly attempted in social welfare, this framework seeks to gain stakeholder insight in how participants conceptualize translation right now.
DISCUSSION AND IMPLICATIONS FOR PRACTICE While translational research in social work must challenge the inequities and disparities produced by the market, it must also take into account market and business factors and methods that influence
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knowledge translation. Specific domains of knowledge diffusion in social care include social marketing and social entrepreneurship. Social marketing refers to the use of the tools of the market tools to attain non-market ends, such as the adoption and implementation of social interventions that cost money up front and produce no profit. Social entrepreneurship has no commonly agreed definition; Germak and Singh (2010) suggested that the core of social entrepreneurship “comprises innovative ideas for social change executed utilizing sound business strategies and skills” (p. 81). Conversely, while social entrepreneurship has been highlighted as a way to advance the diffusion of innovations, other scholars have pointed out that institutional entrepreneurship, which seeks to understand how diffused practices become embedded in and through institutions to become the new status quo, may more accurately describe the diffusion of innovations in non-profit and non-market contexts (Hardy & McGuire, 2008; Garrow, 2009). Changing institutional patterns so that effective social services are recognized as the standard-of-care and become common enough to become treatment-as-usual is a more natural goal for many translational efforts than simply increasing the sales of treatment manuals. Translational research that focuses on dissemination examines and evaluates “the conditions that impede or facilitate widespread use of the intervention promoting a health status or behavior change process” (Sussman, Valente, Rohrbach, Skara, & Pentz, 2006, p. 11). Sussman et al. attempted to see how empirically supported interventions become institutionalized or do not, and whether the intervention under study has had a public health impact and is cost-effective. The limited attention paid to this research is likely responsible for both the too-slow dissemination of empirically supported interventions as well as the too-rapid adoption of trendy interventions that ultimately prove disappointing or ineffective (Kerner, Rimer, & Emmons, 2005). More research is needed to help rectify the lack of translational research in social interventions and to promote the adoption of translation frameworks that put equity at their center. Transparency and social justice, not cost savings and profit, are the public goods that are of primary interest.
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Translating Social Work Research for Social Justice: Focusing Translational Research on Equity Rather than the Market Stephen Edward McMillin
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To cite this article: Stephen Edward McMillin (2014) Translating Social Work Research for Social Justice: Focusing Translational Research on Equity Rather than the Market, Journal of Evidence-Based Social Work, 11:1-2, 148-156, DOI: 10.1080/15433714.2013.845029 To link to this article: http://dx.doi.org/10.1080/15433714.2013.845029
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Journal of Evidence-Based Social Work, 11:148–156, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 1543-3714 print/1543-3722 online DOI: 10.1080/15433714.2013.845029
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Translating Social Work Research for Social Justice: Focusing Translational Research on Equity Rather than the Market Stephen Edward McMillin School of Social Work, Saint Louis University, St. Louis, Missouri, USA
Management of the dissemination of effective interventions in social work is often uncertain, and even when attention is paid to diffusing effective, innovative interventions, the focus is often disproportionately on a marketplace orientation of increasing the market share of branded, manualized interventions and social service treatment products. Public health frameworks of dissemination can improve knowledge translation in social interventions by focusing dissemination efforts on achieving equity and increasing the availability of effective interventions to all those who can benefit from them rather than simply focusing on commercial processes. This article identifies three equity-focused translation frameworks that can aid the dissemination of effective social interventions at the macro-, meso-, and micro-levels. Implications for policy and practice are discussed. Keywords: Evidence-based practice, translational research, social justice, equity, market
To the extent that empirically well-supported interventions are not treatment-as-usual or the standard-of-care, in social welfare as well as in public health and medicine, disparities and inequities in health and wellbeing will persist. Translation of effective health and social services has generally relied on the marketplace and a diffusion of innovational products approach that fails to take into account the social injustice aspect of these disparities. As social services become more fragmented, U.S. social work can benefit from borrowing public health translational research frameworks and approaches that return to notions of the common good or the public health and wellbeing. Health disparities have already become a better-understood concept thanks to public health efforts and translational research in medicine and prevention. New dilemmas arise for social work in this context. Substantial disparity and inequality may be “under the radar” to the point that the slow or non-existent dissemination of effective social services and programs is not even identified as a problem. There is often a structured lack of access to empirically well-supported social care that simply goes unnoticed. While there has been an increasingly recognized need for translational research focused on “translating” research findings and best practices out of the laboratory and into daily life and encouraging and evaluating the uptake of best practices, this view of translation tends to use a business approach. The emphasis has often been on the successful diffusion of innovational products, convincing more and more social service providers to purchase and adopt Earlier drafts of this work were presented at the annual meetings of the American Public Health Association and the Society for the Study of Social Problems. Address correspondence to Stephen Edward McMillin, School of Social Work, Saint Louis University, Tegeler Hall, 3550 Lindell Boulevard, St. Louis, MO 63103, USA. E-mail: [email protected]
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specific, manualized treatments, rather than on an incremental approach that emphasizes reducing health disparities caused by lack of access to evidence-based social work services. Entrepreneurial expansion has been the rule of the day in U.S. social work in terms of dissemination evidencebased programs and services. Entrepreneurial expansion alone will not be enough to translate and spread evidence-based social work practices that are ready for dissemination. An important question at hand is how to measure or score successful dissemination. In a diffusion of innovations approach, the implicit grade of success or evaluation of dissemination is a positive one, starting at zero and seeing how far market forces can extend market share and product uptake—every extension is seen as a positive advance, even if many people who could benefit from an intervention are never exposed to it. A disparities approach implies a different, negative, starting point and score—beginning at a state of negative dissemination, when no one benefits from the intervention, and becoming smaller over time until ideally reaching zero, indicating no one who could benefit from the innovative intervention is left out. The count is of who is left out and who continues to be left out, not simply of who is brought in to the intervention’s benefits through successful expansion of market share. Sometimes seeing the glass as half empty rather than half full can be more helpful in terms of extending utilization of well supported interventions to reach the most people. This article will examine in detail four problems in the dissemination of effective social work interventions that have motivated new attention to models of translation that are as effective as the interventions themselves. Then, three potential practice changes that help ameliorate these problems are discussed conceptually, and three models of translation and dissemination that operate at macro-, meso-, and micro-levels are examined as to their potential to be applied to knowledge translation in social welfare. Implications for practice and policy in making these changes are discussed.
PROBLEMS IN TRANSLATING EFFECTIVE SOCIAL SERVICES Although numerous problems plague the dissemination of social interventions, four problems are particularly important for translational research in the social sciences to address: 1) Even established social interventions often have unproven or uncertain effectiveness; social workers even with the best of intentions can and do harm people in the name of helping (Gambrill, 2001, 2006). Moreover, students in professional education programs, such as Master of Social Work (MSW) programs, are not commonly taught the profession’s history or track record of harm, and typically this does not even come to light unless a journalist writes an exposé of a specific case (Gambrill, 2007). 2) Knowledge of interventions that are empirically supported as effective face uncertain utilization, diffusion, implementation, transfer, and translation; that is, social interventions that are effective in the laboratory or research setting need to be translated into the everyday life of practice, but often few or no efforts are made in this regard. These different terms are conceptually linked yet mean somewhat different things (Ottoson, 2009), and it is helpful to define them individually: a. Knowledge utilization for health and social welfare today often refers to how research synthesis such as systematic reviews and meta-analyses are drawn upon (or not) to inform practice (Blake & Ottoson, 2009, p. 23). b. Diffusion refers to how an intervention spreads to new sites and users; interventions diffuse or are taken up selectively and in varied ways, while dissemination refers to a more carefully plotted plan for diffusion when intervention fidelity is particularly important (Ashley, 2009, p. 41). Dissemination is an intentional strategy and successful
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dissemination often depends on using user-friendly “triage strategies” that help a program achieve a certain level of “critical mass” (Backer, 2000, p. 365) rather than merely blanket efforts at dissemination that easily become unfocused (Backer & Norman, 2000). c. Implementation refers to the process of how a policy decision to execute a change process becomes reality, across many actors including both champions and saboteurs (DeGroff & Cargo, 2009, p. 47). Implementation is a set of specific, identified activities that can be identified by an external observer or evaluator (Fixsen, Naoom, Blase, Friedman, & Wallace, 2005, p. 5). d. Transfer occurs on a larger scale than implementation of an intervention at a solitary site and can refer to an intervention moving across several sites or even across disciplines (Oliver, 2009, p. 61). e. Finally, translation is ultimately a communication process in which stakeholders participate in an iterative feedback loop, their experiences and concerns rendering the intervention usable in daily practice and precipitating the next round of questions and research projects that will develop the body of knowledge about the intervention and help all concerned understand the intervention’s long- and short-term effects (Davison, 2009, p. 75). 3) Management practices and attitudes regarding education and evaluation can negatively or neglectfully impact the sustainability of empirically supported interventions and practice. Translation and its aspects and components do not happen on their own; they require diligent management efforts, and any lack of diligent effort and supervision is in itself a social service management decision that will effect whether and how translation takes place. 4) Even when social service management pays attention to questions of diffusion and dissemination, it tends to be one-sided attention rooted in market assumptions that may not be valid. The perspective and operating assumptions behind translation need to be acknowledged and carefully examined. This is the primary motivating problem addressed in the remainder of this article. However, other interrelated problems lead up to the over-emphasis on market assumptions and also merit discussion, as changing practice to better support translation will be a complex endeavor. ARGUMENTS FOR CHANGING PRACTICE TO SUPPORT TRANSLATION This article makes three arguments. First, it echoes the common criticism that many interventions to solve social problems are not strongly supported empirically and that empirically supported interventions are not adequately translated in a thorough or timely way to those who can most benefit from them. However, this article also argues that calls for evidence-based practice and rapid dissemination of empirically supported social interventions are commonly motivated by cost-benefit analysis and market-based concerns rather than by maximizing access to sometimes expensive interventions among disadvantaged and marginalized populations. Finally, this article argues that to correct the market-imperative that motivates so much emphasis on evidence-based practice and rapid diffusion of innovations, translational research frameworks in the social sciences must explicitly and consistently emphasize modalities that increase accessibility and availability of expensive interventions to all those who can benefit from them rather than simply bowing to market conditions that limit or slow dissemination. Argument 1: Overcome Bad Practices and Bad Translation of Good Practices Before we can focus on translating good practices and interventions, it is necessary to identify and eliminate bad and harmful practices in social welfare and social services. In many respects,
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this is the bad-tasting medicine for social work that must be ingested before any real change in the profession is possible. Gambrill (1999) pointed out how historically social work in the United States has been an authority-based profession deeply rooted in tradition. While there has often been an assertion that the profession should recognize diverse forms of knowledge and different ways of knowing, Gambrill (1999) noted that this emphasis on diversity has not resulted in a reduction of biased thinking and logical fallacies; often it simply increases relativism that ignores political and economic conditions and permits more propaganda to inflate claims about what interventions can do. Research makes a contribution even when it simply unearths uncertainties and points out what remains unknown; relativism that denies the power of research to make a contribution simply masks knowledge and empowers the status quo. Technology has also introduced a paradigm shift in expectations that public and social services must respond to. As Gambrill (2006) suggested, “Saying there is nothing new about a paradigm shift is one way to continue business as usual (e.g., authoritarian practices such as ignoring important uncertainties regarding decisions that must be made)” (p. 339). Denying the paradigm shift quality of how empirically informed practice is different from the status quo is often seen in assertions that practitioners or agencies have “always” integrated research findings into practice, when in fact only the expansion of the internet and other technologies made the research easily available for integration. For example, while physicians regularly use handheld digital devices to remind them of important assessment questions, social workers who frequently must ask more questions and conduct broader assessments rarely do so. In 2007, Gambrill noted this with alarm, recommending “user-friendly palm pilots to guide decision-making and minimize cognitive biases” (p. 558); reading this years later, the first thought that comes to mind is whether or not “there’s an app for that,” and that developing this good practice might be scaled up simply by teaching workers to use their smartphones and tablet computers in assessment. As technology changes and becomes more available, the tool chest of ways to detect and decrease bad practices becomes larger. Argument 2: Adequately Defining and Focusing Translation Efforts A wide variety of research questions can be asked in translational research, and there is no standardized conceptualization for these questions because of struggles to define knowledge translation consistently (Davison, 2009). While translation is often envisioned as the end phase of research, there is increasing recognition that translational research questions need to be considered throughout the research process and “in all aspects of research” (Davison, 2009, p. 77) if benefits to stakeholders are to be maximized. To this end, a particular framework of translational research is helpful to be very clear about operating assumptions. Many theories of knowledge translation are considerably oriented toward a diffusion of innovational products in which market supply and demand will abet translation. For many knowledge products, this framework of knowledge translation is likely adequate. However, for many empirically supported social interventions, the outcomes of interventions are public goods rather than private goods that are easily malleable by or directly responsive to economic supply and demand. Moreover, market forces may directly work against knowledge translation for many social interventions, reinforcing or exacerbating existing inequities. Rogers’ (2003) diffusion of innovations framework suggests that the uptake or reception of new products or services moves through segmented stages that can rely a great deal on processes of adoption. After being exposed or gaining some knowledge of the innovation (Stage 1), the person or agency becomes persuaded to find out more about the innovation (Stage 2), makes a decision to accept or reject the innovation (Stage 3), tries out the innovation in different settings if it has been accepted (Stage 4), and then adopts the innovation for regular use (Stage 5). Rogers also suggested that patterns of adoption could be predicted based on adopter characteristics; early adopters are more likely to be younger, highly educated, and closer to science and technology, while laggards are more likely to be older, resistant to change, of lower social status, and hewing closely
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to tradition. Rogers noted that for organizations, adoption of innovations are often “authorityinnovation” decisions in which a few hierarchical leaders may be making decisions on behalf of the organization. In these cases the innovation may lack sustainability if the innovation’s champion leaves the organization (p. 429). When compared to Gambrill’s (1999) description of U.S. social work as rooted in authority-based practice, it is easy to predict that social workers are relatively more likely to be laggards rather than early adopters, and when the typically high rates of turnover in social work (Kim & Lee, 2009; Mor Barak, Travis, Pyun, & Xie, 2009) are examined, the sustainability of many social interventions is also suspect. However, the diffusions of innovations model faces several challenges in informing translational research for social services. Rogers (2003) envisioned an “S-curve” pattern of adoption, with relatively few early adopters and somewhat more but still relatively few laggards at the other end of the adoption spectrum. This adoption pattern seems premised on a static innovation that is not adapted and re-adapted as it is implemented, when in fact rapid change and technological advancement can modulate the pace of adoption relatively quickly and transform a previously marginal innovation into a “must-have.” Likewise, interesting and attractive innovations that cannot overcome institutional barriers can fail to take off, so that an “S-curve” of adoption fails to curve and simply peters out. Moreover, social service organizations face common barriers to translation that a simple diffusion of innovations approach cannot capture. Despite the ubiquity of the term helping professions, too often practitioners see their roles as “custodial” (Corrigan, Steiner, McCracken, Blaser, & Barr, 2001, p. 1599) rather than assistive, so that workers take over and dispose of a case rather than assist clients to move toward their own goals and outcomes. This reflects the tendency toward bureaucratic “people-processing” in complex social service organizations even when the intention is to achieve “people-changing” or individual improvement (Hasenfeld, 1972, 1992). Moreover, Corrigan and colleagues (2001) suggested that despite having certain educational credentials, practitioners might lack meaningful competencies to achieve the goals of the intervention; many are trained in therapies that are not empirically well supported, while some may actively be taught that outcome measurement is incompatible with care-giving. Social workers are among the most common professions to provide psychotherapy and clinical services, yet nationwide are among the least likely to graduate from programs that require training in empirically supported treatments (Weissman et al., 2006), and some professional associations in clinical social work demand theoretical allegiances that are inconsistent with many empirically supported treatments (Thyer, 2007). Argument 3: Keeping Translation Efforts Equity-Focused for Social Justice Knowledge translation in service fields refers to how intervention knowledge has been exchanged, synthesized, and applied (Davison, 2009, p. 75) in a given field. Translational research examines how typical clients in typical settings receive the intervention under review as delivered by typical staff, or seeks to determine whether a particular intervention works with a specific type of client, setting, staff, or other conditions (Glasgow, 2009). To the extent that empirically well-supported or evidence-based interventions are not treatment-as-usual or the standard-of-care, disparities and inequities in treatment will persist. For social welfare and social services there is a special need for translational research “to speed the introduction of promising, evidence-based practices into usual-care settings” (Brekke, Ell, & Palinkas, 2007, p. 124) given a lag time for innovative social interventions that can average a generation or more (Brekke et al.). Moreover, the accessibility of social interventions is often much below identified need in a given population or community, and translational research seeks to gain a sense of the state or degree of translation of a given intervention across the field of need or eligibility for it. Brekke and colleagues (2007) pointed to empirically well-supported psycho-social interventions reaching less than 10%
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of one targeted, eligible population diagnosed with schizophrenia, with only 30% receiving any intervention at all irrespective of the level of empirical support for it. This demonstrates the importance of translational research in highlighting “service sectors in need” (Brekke et al., 2007, p. 124) to which additional intervention resources can be targeted. As social service agencies experience more pressure to be accountable for outcomes, they are increasingly turning toward theory-driven decision-making strategies and management systems (Briggs & McBeath, 2009; Briggs & McMillin, 2012). In short, while evidence-based practice has largely been framed as something most immediately affecting the activities of direct service workers, there is a growing push to see evidence-based management on the part of social service administrators as well as evidence-based practice in the delivery of direct services. Moreover, the growth of hybrid approaches and the expansion of disciplines, such as public health and public administration, as well as specialties, such non-profit business administration and health care administration, have led to a new consideration of evidence-based management (Kovner & Rundall, 2006) as especially suitable for services that combine social, health, and public dimensions, as so much social work does. One difficulty in adapting translational research frameworks for social interventions is taking adequate account of the amount of conflict and contestation that can be present in social and public services. Empirically oriented social work is frequently misunderstood conceptually (Gibbs & Gambrill, 2002), on the level of direct practice (Regehr, Stern, & Shlonsky, 2007) and also in macro-level program development (Thyer, 2008). Within social service agencies, the streetlevel bureaucracy (Lipsky, 1980) and service rationing of individual social service workers can radically change how interventions, however empirically supported, are actually delivered. With this is mind, translational research frameworks for social interventions must also take into account conflict factors in how evidence-based interventions are perceived. RECOMMENDATIONS: THREE POSSIBLE MODELS FOR TRANSLATION Given these three dilemmas, the uncertain newness of translational research for social welfare, the translation difficulties unique to the non-profit world of social services, and a need to focus broadly on inequity rather than merely cost effectiveness, focusing on specific frameworks for translation efforts is helpful. Many of these frameworks have an interdisciplinary quality, either beginning in disciplines outside of social work proper, or being developed across several disciplines and finding relevance in several as well. Model 1: A Global, Macro-Model of Dissemination The Joanna Briggs Institute at the University of Adelaide, South Australia, an international academic collaboration focused on best practice in nursing and allied health care, models the translation of evidence-based healthcare as a cyclical process with four principal components (Pearson, Wiechula, Court, & Lockwood, 2005) arising out of and cycling back into global health. The first component, evidence generation, consists of current research on interventions as to whether they are feasible, appropriate, meaningful, and effective, combined with the current discourse on interventions and practitioner experience. The second, evidence synthesis, consists of systematic review of a given intervention, supported by theory and utilizing appropriate methods, including meta-analysis for quantitative data where possible. The third, evidence transfer, looks at the translation of knowledge confirmed via evidence synthesis through education, information delivery, and organizational systematization. The fourth, evidence utilization, examines how practice changes as a result of knowledge transfer and how practice change is evaluated and embedded in organizational contexts.
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The Briggs model suggests that knowledge is transferred through information that is transmitted through training and systematized. These components of knowledge translation are analogous to the concepts of evidence-based practice as verb or noun (Proctor, 2007); the information or best practice can be seen as an evidence-based practice noun or product, while the training and systematization of best practices can be seen as an ongoing evidence-based practice verb. Systematization and ongoing practice lead to the next component of the Briggs model, how evidence is utilized, embedded into practice, and evaluated. Model 2: Measuring Equity-Effectiveness in a Specific Dissemination and Context Tugwell, Robinson, Grimshaw, and Santesso (2006) proposed an equity-oriented framework that provides “a systematic method for decision-makers to ensure the application of evidence-based knowledge in disadvantaged populations” (p. 643). This method of translational research begins with looking at the results of an intervention’s systematic review or meta-analysis but also examines what market-based, institutional, socio-economic, and behavioral factors can be identified as barriers to extending the intervention. Tugwell and colleagues also calculated point estimates of equity-effectiveness based not only on the effectiveness of the empirically supported intervention, but also on how well knowledge of the intervention has been translated past the identified barriers. This method complements the quantitative analysis in research synthesis; heuristically, it can be thought of as a statistical correction of the meta-analytic effect size, based on the estimated effect the intervention is likely to have in the real world. This type of translational research for social interventions is profoundly interdisciplinary, basically applying a public health method to a social welfare problem. Model 3: Measuring Dissemination at the Micro-Level Finally, a model of translation explicitly designed for local use by individual agencies and organizations in the Reach, Efficacy, Adoption, Implementation, and Maintenance (RE-AIM) framework. The RE-AIM framework (Glasgow, 2009) focuses specifically on translating research to practice by checking both internal and external validity and using a standardized way of measuring key factors. This framework offers a very simple, easy-to-understand summary of knowledge translation for a given intervention, such that it could be described as high on reach, low on efficacy, medium on implementation, and also allows translation domains to be examined to see how they might be related to one another. The RE-AIM framework aligns well with an equity-effectiveness framework because RE-AIM does not separate cost-benefit or cost-effectiveness measures, but rather recognizes that costs and benefits may vary across different translation domains. In larger samples, actual measures of reach, efficacy, adoption, implementation, and maintenance can be taken at both individual and setting/agency levels. In qualitative translational research, participants can be interviewed to ascertain their perceptions of reach, efficacy, implementation, adoption, and maintenance, at both individual and setting/agency levels. Given that this level of analysis for knowledge translation has not yet been broadly attempted in social welfare, this framework seeks to gain stakeholder insight in how participants conceptualize translation right now.
DISCUSSION AND IMPLICATIONS FOR PRACTICE While translational research in social work must challenge the inequities and disparities produced by the market, it must also take into account market and business factors and methods that influence
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knowledge translation. Specific domains of knowledge diffusion in social care include social marketing and social entrepreneurship. Social marketing refers to the use of the tools of the market tools to attain non-market ends, such as the adoption and implementation of social interventions that cost money up front and produce no profit. Social entrepreneurship has no commonly agreed definition; Germak and Singh (2010) suggested that the core of social entrepreneurship “comprises innovative ideas for social change executed utilizing sound business strategies and skills” (p. 81). Conversely, while social entrepreneurship has been highlighted as a way to advance the diffusion of innovations, other scholars have pointed out that institutional entrepreneurship, which seeks to understand how diffused practices become embedded in and through institutions to become the new status quo, may more accurately describe the diffusion of innovations in non-profit and non-market contexts (Hardy & McGuire, 2008; Garrow, 2009). Changing institutional patterns so that effective social services are recognized as the standard-of-care and become common enough to become treatment-as-usual is a more natural goal for many translational efforts than simply increasing the sales of treatment manuals. Translational research that focuses on dissemination examines and evaluates “the conditions that impede or facilitate widespread use of the intervention promoting a health status or behavior change process” (Sussman, Valente, Rohrbach, Skara, & Pentz, 2006, p. 11). Sussman et al. attempted to see how empirically supported interventions become institutionalized or do not, and whether the intervention under study has had a public health impact and is cost-effective. The limited attention paid to this research is likely responsible for both the too-slow dissemination of empirically supported interventions as well as the too-rapid adoption of trendy interventions that ultimately prove disappointing or ineffective (Kerner, Rimer, & Emmons, 2005). More research is needed to help rectify the lack of translational research in social interventions and to promote the adoption of translation frameworks that put equity at their center. Transparency and social justice, not cost savings and profit, are the public goods that are of primary interest.
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