ARCHIVED - Integrated Strategy on Healthy Living and Chronic Diseases - Knowledge Development and Exchange Functional Component

Key Findings

3.0 Relevance

3.0.1 Continued Need for the KD&E Functional Component

Published literature identifies significant gaps between research, evidence, policy and practice in population and public health.^{Footnote 8} In addition, several influential national reports of relevance to public health and health systems (e.g., Romanow, Naylor, Campbell Commission reports), scientific literature reviews (e.g., Kiefer et al., 2005^{Footnote 9} and project specific needs analyses have identified persistent and problematic issues and gaps related to knowledge development and use with respect to population health generally, and healthy living and chronic disease prevention specifically.^{Footnote 10} Some of these issues and gaps include the need to:

• Develop more congruence between the needs of research users (including policy makers) and the research questions being addressed by investigators;
• Improve linkages between databases of surveillance and research evidence;
• Develop explicit strategies, structures and mechanisms to facilitate knowledge uptake into practice and policy decision-making (e.g., improving access to systematic reviews, decision-maker skills in accessing, appraising, and using evidence);
• Learn from practice (e.g., generating ‘practice-based evidence’)

Internally, the relevance of the KD&E Functional Component is reinforced by its close links to one of the primary activities of the Public Health Agency of Canada, namely to strengthen the links between research, surveillance, policy and programs, and evaluation in public health across Canada. The second objective of PHAC’s Strategic Plan (2007-2012) underscores PHAC’s mandate for supporting knowledge to action: “To ensure actions area supported by integrated information and knowledge function.”^{Footnote 11}

The external stakeholders were of the opinion that there is a need for the KD&E Functional Component and its initiatives, and that it is an important need for public health systems and ultimately the people of Canada. The overwhelming majority of external key informants agreed that Canada needs KD&E initiatives as part of the overall strategy for chronic disease prevention.

“There are tremendous challenges being placed on health systems by chronic disease… effective and informed knowledge development and exchange is critical for finding appropriate solutions to these issues.” External key informant

All internal PHAC key informants are firmly of the view that there is a continued need for the KD&E Functional Component.  It was noted that while currently there are a number of external organizations and P/Ts that are working on various KD&E initiatives specific to their own mandates and issues, all of this work is fairly disconnected and heading in slightly different directions.  For some PHAC key informants, more clarity needs to be brought to the issue of who is doing what in KD&E in public health and how they could better work together for a bigger impact.  Respondents frequently discussed the need for coordination and integration of the activities of the KD&E function internally and externally to increase coherence and alignment so activities are working synergistically towards common priorities.

3.0.2 Overlap and Duplication within and across Functional Components

The interviews with internal PHAC key informants found strong consensus on the need for more clarity around roles and responsibilities with regards to CCDPC Divisions, and some potential for duplication across the ISHLCD.  There was concern about the negative effects of staff changes for the KD&E Functional Component in the National Capital Region (NCR) and the need for direct senior management engagement and staff capacity for effective KD&E.  This was voiced both for the disease-specific KD&E activities and the integrated chronic disease KD&E work.

PHAC key informants also consistently underlined the need for more clarify of what KD&E work is, what it entails, how is it to be addressed by all staff, and what support mechanisms are required to strengthen the work of KD&E.

“I do not see any duplication but some of the work definitely intersects and is not easily separated, especially risk assessment and surveillance activities, sometimes it is the same thing.” Internal key informant

Some PHAC key informants described the ISHLCD as requiring increased integration. It is seen as operating as a number of discrete projects that do not take advantage of the potential for increased coordination or connection to each other.  The need to better communicate and coordinate the many components was raised as an issue where improvements could lead to increased productivity and better progress on the broad objectives. For most internal key informants, so far, the ISHLCD appears to not have succeeded as was envisioned in terms of its coordination and integration efforts.

3.0.3 Overlap and Duplication with External Stakeholders

All PHAC key informants stated there is no duplication of KD&E work with Provinces / Territories (P/T) and Non-Governmental Organizations (NGO).  The respondents discussed how PHAC KD&E initiatives complement the various P/T and NGO work in chronic disease prevention through collaboration and ongoing working relationships with select key stakeholders in the field of public health.  Respondents did report on similarities in work areas.  For example, while, the National Collaborating Centre for Methods and Tools and the Canadian Health Services Research Foundation were noted as also working to contribute to enhanced KD&E climate (i.e., commitment, understanding and resourcing to support KD&E activities), this issue is seen so large that multiple efforts are required by multiple groups to have an impact.

Although the general perception was that there is no overlap or duplication currently, a few areas of potential duplication were noted.  One is with the Canadian Partnerships Against Cancer (CPAC) work in cancer prevention where there is some confusion about roles and inconsistent or infrequent communication about activities with PHAC. Another source of potential duplication is with organizations that develop disease-specific guidelines focused on prevention and the upcoming work of the Canadian Task Force on Preventative Health Care (CTFPHC).  However, it was noted that the CTFPHC will aim to avoid duplicating the work of others since it plans to focus on areas and topics not currently addressed by existing initiatives and, as well, will focus on primary care and community health issues.

3.1 Success/Progress

The external key informants found the interview questions relating to PHAC’s progress on KD&E intended activities to be very complex in large part due to the complexity of KD&E concepts and activities and the infancy of research on effectiveness in this field. The interview evidence available is summarized below and complemented with findings from the project file review.

3.1.1 KD&E System Support and Coordination

About half of the PHAC key informants reported that their activities addressed aspects of KD&E system support and coordination (i.e., joint priority setting, infrastructure development, external coordination).  A third indicated their initiatives have conducted some joint implementation of KD&E activities intended to increase system support (i.e., pan-Canadian and multi-level needs assessments, activities to establish and influence KD&E priorities; joint activity planning with relevant internal and external organizations/networks), and two-thirds said these efforts have contributed to increased KD&E coordination.

“The Demonstration projects focused on system support and coordination and related work that has stemmed from them. Also the shift the resource KD&E in the PHAC Regional Offices in new KD&E positions is major system support.” Internal key informant

In addition, several PHAC key informants noted that given the absence of an overall PHAC Knowledge Translation Strategy or leadership in this area, the KD&E efforts within ISHLCD and CCDPC in particular should be commended for spearheading this work. These individuals suggested that PHAC overall could be providing a better support structure and resources for KD&E and facilitate better linkages to other KD&E activities throughout the Agency and with external partners.

3.1.2 Development of New Knowledge Products

The majority of PHAC key informants reported that of the four activity areas in the KD&E Functional Component, the majority of their activities addressed knowledge development, which focused on the production of reports and syntheses. The analysis of 61 project reports and documents produced the following findings.

Characteristics of Knowledge Products

Current knowledge products stemming from KD&E initiatives are most often produced by Provincial and Territorial governments (38%), followed by universities (23%) and the private sector (21%).  PHAC produces 7% of these products, with the remainder being produced by a mix of other groups.  The rate of creation of knowledge products in 2008 compared to 2007 has doubled (from 16 to 34).  The large majority (92%) of the external projects have received short term funding (one year of PHAC funding).  The analysis found that operating and maintenance budgets are the source of funding for 61% of knowledge products created to date, while grants and contributions funding supported 16% of knowledge products (23% of report funding mechanism were not identified).

Focus of Knowledge Products

Two-thirds (66%) of the reports and documents were focused on the stage of the knowledge cycle known as ‘knowledge creation’, another 18% were for the evaluation of KD&E activities. Only a minority address what works in knowledge exchange, translation, dissemination or adoption/uptake highlighting the potential for intervention research overall and specific to assessing effectiveness of various KD&E approaches.

The reports focused on the following element / program areas within the KD&E Functional Component: Cancer (31%); Best Practices (26%); and Diabetes (43%).

The documents reviewed were classified in terms of the logic model action areas in which the projects produced visible achievements (reports/documents address multiple areas):

Collaborating Organizations

When asked for the names of collaborators/partners and of sponsoring organizations, a count was made of the first named organizations.  Those that were named more than 10% of the time were PHAC (28%) and Consultant firms (21%).  When asked for the names of a second collaborator/partner on a given project, it was found that, 90% of the time, there were no second (collaborating/partnering) named organizations.

3.1.3 Knowledge Exchange and Capacity Building

The external stakeholders were largely in agreement that Canada needs capacity building and knowledge exchange as part of the overall strategy for chronic disease prevention.

PHAC key informants report that consultation with target audiences and key partners to support capacity building and/or knowledge exchange activities should be strengthened.  With respect to ‘knowledge exchange and capacity building’, almost everyone who reported activity in this area said it focussed more on knowledge dissemination (typically one-way) than exchange and capacity building. To date relevant key outputs here include dissemination vehicles and products for knowledge exchange such as websites or web-based applications (e.g., Best Practices Portal) and various communication products such as conference and workshop presentations,as well as capacity building outputs such as tools, workshops, training (e.g., KD&E 101 learning module) and network support both for internal and external capacity building.

“The Best Practices Portal promotion activities and workshops at the Canadian Public Health Association conference are an example of work that increased awareness for applying evidence into practice” External key informant

“We have done some capacity building work through various workshops and information sharing in diabetes KT workshops, best practices workshops, the food security workshop, and cancer risk assessment priority setting workshops.” Internal key informant

Both internal and external respondents strongly endorse a continuing role for PHAC in supporting knowledge exchange and capacity building activities as this is an area with recent and increased focus in PHAC’s KD&E initiatives.

The external stakeholders expressed particular concern that PHAC’s KD&E Functional Component initiatives related to intervention evidence and systems to support pan-Canadian evidence-informed practice (e.g., overall KD&E integrative work, CBPI and Task Force) are not sufficiently ambitious and that it is not adequately funded. Some of the external stakeholder key informants raised the concern that PHAC does not engage in true, full, cooperative collaboration with researchers, scientists, NGOs and other government agencies.

Several internal PHAC key informants also underlined that PHAC could enhance ongoing mechanisms (e.g., consultations, forums, conferences, workshops etc) to receive and action advice and engage in open dialogue with external stakeholders that could improve its policy and program development and their implementation to support KD&E.  The current outreach efforts are seen as requiring attention.

3.1.4 Learning from Practice

PHAC key informants reported activities to support learning from practice were very limited. Some staff members did not fully understand what types of activities could be implemented to address this action area but felt that some evaluation activities and knowledge exchange may contribute to this area. Overall, the area of learning from practice shows the least activity to date.  This was explained, in part, by the relatively early stage of development and implementation of the KD&E initiatives which appear to focus on earlier action areas for KD&E (knowledge development and less so on knowledge exchange and capacity building).  It was noted there is some activity beginning in this area such as the Best Practices Portal’s plans to undertake case studies of practitioners on their use of Portal interventions and an overall KD&E project needs assessment for pan-Canadian evaluation supports and mechanisms for sharing of practice-based learning.

3.1.5 Key Target Groups Identified and Progress on Reach

The intended beneficiaries of the KD&E activities are:

• Policy advisors and makers
• Researchers
• Non-governmental organizations active in public health domains
• Practitioners working in the fields of public health (and for Task Force in primary care) at local and regional levels
• Members of the Public Health Network

Although progress has been made to identify key target groups and reach many of them, the typical view from PHAC key informants is that targets for proportion or level of reach for knowledge products or dissemination efforts were often not set for the identified target audiences.  One person noted that key NGOs have been identified but it is unclear if targets have been set even though there is high demand for it.  Another person stated that it is too early to set targets: “our initial focus is to identify target audiences the next stage will be to set targets.”  Another noted that key targets for reach and quantified estimates of audiences for the CBPI have not been set.

Based on the 61 file review, report and document analysis, practitioners (26%) and researchers at F/P/T levels (23%) are the two most frequently identified target audiences for current knowledge products. The primary target population was not identified for 21% of the reports. In addition, most often (72%), the project/activity was delivered to the target group via an intermediary (i.e., P/T organization, NGOs). From the file reports reviewed to date, 18% have been specifically targeted at high risk populations either directly or indirectly.

3.1.6 Progress Towards Outcomes

Immediate Outcomes

When PHAC key informants were asked for their views regarding progress on immediate outcomes for the various initiatives and program areas of the KD&E Functional Component, half of them presented instances of improved inter-organizational engagement (networking and collaboration). Fewer examples were identified of improved inter-and-intra-sectoral engagement and even less of improved multi-jurisdictional engagement.  Within each of the three engagement categories, while there were examples offered in each, it was difficult for PHAC key informants to assess measured progress on engagement without common indicators.

Half of the external key informants observed moderate or major positive change in engagement and networking with other organizations, sectors or jurisdictions. Most examples focused on inter-organizational engagement.

The project reports offered very little (if any) evidence for improved engagement.  The likely reason is that the aim of the knowledge products was to address knowledge gaps not engagement.  However, they did show a wide range of different research/knowledge creation activities relevant to the broad purposes of KD&E.

Intermediate Outcomes

When the project files and reports were reviewed to see if they provided evidence of progress toward the intermediate outcomes of the KD&E Functional Component, some evidence was found for: a) improved partner's knowledge, awareness, skills and aspirations for improving climate for knowledge development and exchange, b)  identification of gaps in knowledge and capacity; and c) more targeted knowledge translation to address gaps and for enhanced capacity for evidence-informed practice within organizations. The file review did not include evidence relating to: alignment of resources, skills, priorities and activities of research evaluation, policies and programs; increased networking among key stakeholders; or larger inventories or evidence to support practice and policy decisions.

The recent evaluation and needs assessment^{Footnote 12} of the Best Practices Portal produced the following findings for particular intended immediate and intermediate outcomes to be achieved by the KD&E Functional Component.

• Networking

  When asked about the usefulness of the Portal for networking/exchange opportunities between organizations, 52% of individual users survey respondents (n=239) said the Portal is useful as did 54% of representatives surveyed from stakeholder organizations (n=58).  However, opportunities for peer exchange, networking and mentorship were also highlighted, especially the need for facilitated face-to-face sharing of success stories and practice-based evidence, networking related to evaluation and access to mentors/experts, which were noted as unmet needs.

• Awareness

  In the user survey, about 54% of respondents (n=239) had not heard of the Portal and, of the 46% that had, about 25% had never visited it.  In the stakeholder organization survey, about 10% (n=58) reported that no one in their organization had heard of the Portal before the survey, and about 55% stated that only a minority had visited it.  For the stakeholder group, 25% reported that the Portal was known by about half or more of the people in their organization. In both groups, most had heard about the Portal from a colleague or at a conference/presentation. Overall, a substantive percentage of people in both surveys had neither heard of nor visited the Portal.

• Use and usefulness of the Portal according to user survey respondents

  Those who used the Portal (n=85) found it useful.

  • About 60% of user survey respondents reported accessing the Canadian Best Practices Portal routinely when looking for best practice interventions for chronic disease prevention and health promotion.

  • Just over a third of reported favouring the Portal over similar sources of information.

  • Between 15% and 40% reported being very familiar with various aspects of the Portal depending on the feature being queried.

  • About half stated that their needs were fully or partially met most or all the time (the balance less so).

  • About two-thirds had retrieved information from the Portal or a site to which they were referred and, of these, about half of these had retrieved information on interventions.

The present evaluation was also able to compare the views of internal staff and external stakeholders on early progress towards intermediate outcomes (Table 4).  The comparison is limited somewhat by the fact that each set of interviews had slightly different wording and methods obtaining views on progress toward outcomes based on differing key informant roles and involvement.  The external interview respondents were asked if PHAC’s KD&E activities have contributed to early change in each of a list of ten outcome areas.  The internal PHAC interviews asked a similar, albeit not the same, question. Despite this limitation, there clearly is agreement between the two groups on their judgements of progress.

There is agreement that the following outcomes are, relatively speaking, where most progress has been made to date:

• Improved awareness and climate for KD&E
• Increased sharing of information and knowledge with and between external organizations
• Identification of assets and gaps in knowledge and capacity

“We are making progress in bringing external partners and internal staff together to jointly plan activities to support increased understanding and action on KD&E. Some are forums like the one on mental health, some are joint planning sessions like the KD&E network and some are joint conference sessions like we have done with the NCCMT.” Internal key informant

There is agreement that the following outcomes are, in relative terms, where less progress has been made to date:

• Enhanced external KD&E planning, coordination and implementation
• Increased use and adoption of evidence and tools from evidence inventories

Table 4: Perspectives on Progress towards Intermediate Outcomes

External Stakeholders Intermediate Outcomes

Over half (5/9) interviewed indicated that there was moderate or major change on the following 3 of the 10 intended outcomes:

• Improved awareness and climate for KD&E
• Increased sharing of information and knowledge with and between external organizations
• Identification of assets and gaps in knowledge and capacity

One third reported that there was improvement on these outcomes:

• Better internal alignment within PHAC of resources, priorities and activities supporting KD&E
• More targeted knowledge translation and exchange to address gaps
• Enhanced capacity and commitment for evidence-informed policy and practice

Less than one third of the respondents said that progress had been made on:

• Increased use and adoption of evidence and tools from evidence inventories
• Enhanced external KD&E planning, coordination and implementation
• Larger and accessible inventories of evidence to support practice and policy decisions

Internal Stakeholders Intermediate Outcomes

Two-thirds of those interviewed saw progress in:

• Improved partner’s knowledge, awareness, and aspirations for improving climate for KD&E
• Increased sharing of information and knowledge with and between external stakeholders
• Identification of gaps in knowledge capacity and evidence base
• Larger and more relevant inventories of evidence to support practice and policy decisions

Half reported progress in:

• Enhanced capacity and commitment form evidence-informed policy and practice within targeted groups and organizations

One-third reported progress in:

• Better alignment of resources, skills, priorities, and activities of research evaluation, policies and programs
• More targeted knowledge translation and exchange to address gaps

Less than one-third reported progress in:

• Enhanced external KD&E planning, coordination and joint KD&E activities
• Increased use and adoption of evidence and support tools from evidence inventories

3.2 Design and Delivery

3.2.1 Roles and responsibilities supporting KD&E

A continuing role for PHAC in supporting KD&E initiatives was strongly endorsed by all of those interviewed. However, there is a number of gaps in staff and management’s understanding of KD&E and the need for clearer direction or strategic priorities for KD&E and for ISHLCD overall. All of the internal PHAC key informants talked about the need for increased clarity and senior leadership to support joint planning and coordination of KD&E work either within or across disease-strategies.  In addition, internal interview respondents saw a need to clarify KD&E activities and scope in relation to CCDPC activities to all of PHAC’s other overall activities (e.g., surveillance, KT work and support for evidence-informed practice and skill building by other parts of PHAC, etc.).

“There is some confusion about who does what in KD&E in our Centre, current connections within the Centre in general could be strengthened if there was better coordination and clarity of roles. We need to encourage more invitations to joint meetings, more two-way information sharing about what is being done and some quality control.” Internal key informant

More broadly, the internally communication and coordination mechanisms between PHAC divisions in CCDPC, other PHAC Centres and Regional Offices and external communication mechanisms with stakeholders were highlighted by two-thirds of the internal key informants as  a significant challenge to effective KD&E overall.

3.2.2 Key Gaps

The gaps perceived by the external stakeholders are lack of funding appropriate to the mandate related to supporting evidence-informed practice and integrated chronic disease prevention, inadequate consultation with others working on the same issues across Canada, inadequate PHAC internal coordination, and inadequate research on the effectiveness of prevention interventions.

Several of the PHAC key informants underlined that the mechanisms that PHAC uses to receive advice could be improved, which would strengthen its policy and program development overall and their implementation to support KD&E.

The internal PHAC interviews found a third of the respondents stating the need for more intervention research. There are lots of areas where there is a knowledge gap about what types of interventions are effective and this was noted as a key gap that is often not addressed by academic researchers.  One suggestion was for PHAC to facilitate bringing researchers and practitioners together and provide seed funding to support joint intervention research as well as conduct intervention research of national scope and significance.

Another gap that most internal key informants discussed is the need for a larger KD&E support system or coordination in Canada of various players working in KD&E in public health and chronic disease.  Finally, a gap identified by some respondents was in relation to the Demonstration Projects. The funded P/T projects need more personal connection and staff support from NCR to ensure clear and sound implementation.

For the external stakeholders, a stronger, coherent healthy living and chronic disease mandate and plan for PHAC including the role and scope of KD&E activities, along with improved collaboration and communication were seen as key gaps.  All three concerns were consistently expressed.

3.2.3 Key Lessons Learned

The experience to date is that ISHLCD requires:

• need for clarity of mission and leadership
• more dedicated staffing for KD&E related to intervention evidence and exchange and enhanced understanding and skills related to effective knowledge exchange overall
• improved budgetary resource processes
• a requirement to move beyond research and analysis of existing data to a serious focus on what kind of intervention strategy will work and how to share that with field practitioners and policymakers.
• a move to more collaborative activities – collaboration in the sense of shared responsibility and partnership not the more typical assignment of a mandate to a ‘partner’.

The internal interviews revealed many important lessons for the various KD&E initiatives.  Two-thirds of the PHAC key informants underlined the need for dedicated positions with KD&E expertise and for a more meaningful level of financial resources for integrative KD&E activities.  A prominent theme was for everyone linked to the KD&E function to see KD&E as part and parcel of what they do and to contribute to advancing understanding of what works in this area.

“Developing a new area like KD&E is more difficult than implementing an existing public health function. We faced three challenges, KD&E can be seen very broadly and in vague terms, it is so new that there were originally few partners to work with and all using different language to get to common understanding. Good KD&E principles need to be developed in all of the functional components and responsibility for dissemination, exchange and capacity building for each of our knowledge products needs to be shared by all.” Internal key informant

There is a need for there to be a combination of both disease-specific and integrated, chronic disease KD&E activities - to date, the latter had little or no resources allocated with the exception of the Canadian Best Practices Initiative.

More than half of the key informants talked about the need for increased exchange and uptake support activities. For instance, most of the KD&E work in the Functional Component has been research and analysis work (knowledge development) on risks and diseases, with much less focus either on intervention effectiveness research or on how to transform and disseminate that knowledge in forms that stakeholders want and few supports to help them make use of existing knowledge/evidence.

“It is not enough to put something on a website or Portal, you need to help people understand it, frame how to present it, and help people use it is a huge task that involves skills and experience and people support.” External key informant

Many activities that are recognized as knowledge development are not officially part of the KD&E Functional Component (e.g. surveillance), highlighting the need to clarify understanding of various types of KD&E activity.  The potential breadth of KD&E activities is a strength and weakness.

Key informants consistently spoke of the importance of human resources and capacity.  Some raised the need for dedicated KD&E analysts or lead positions in the NCR, and staff with specific KD&E expertise and roles within all divisions.  Respondents also discussed the need to train all staff to have basic understanding of what KD&E is and how their work incorporates or could be strengthened through purposeful use of good KD&E principles.

Grants and contributions (G&C) process-related issues and project funding concerns were raised by two-thirds of the PHAC key informants. G&C money could be used to better advantage to support and implement effective KD&E in the sense of providing better support for rigorous evaluation, and improving mechanisms to facilitate access and sharing of reports from completed G&C projects so everyone could learn from the work that PHAC funds (e.g., publicly accessible database).

The external stakeholders asked that PHAC be focused on a bold vision for their work in chronic disease and healthy living: developing strategy and implementing a large-scale, co-ordinated and effective chronic disease prevention plan throughout Canada. Another key theme that emerged from external key informants was the need for PHAC to reinforce or undertake new collaborative activities.

“Effective dissemination, exchange and translation of knowledge require many partners around the table, collaborating on joint activities ultimately focused on changing risk conditions and behaviours”. External key informant

A key issue is whether PHAC’s KD&E initiatives to support evidence-informed practice (i.e., Observatory of Best Practices, intervention research) are sufficiently ambitious and, from a resource perspective sufficiently funded.  For many, PHAC’s communications and partnership activities are not adequately connected to its KD&E activities.  Additional communication mechanisms such as regular meetings, conferences or workshops for enabling knowledge sharing within the broader KD&E community across Canada would be very useful.

3.2.4 Current Monitoring and Evaluation System

The evaluation identified the need to establish consistent program monitoring processes and to collect common and ongoing program performance tracking data in the KD&E Functional Component initiatives and in relation to KD&E-related activities taking place across ISHLCD.  It was clear during the conduct of the evaluation that a systematic, proactive, approach to evaluation was not in place across all KD&E initiatives and program areas (CBPI is an exception).  Much progress appears to have been made through the course of this formative evaluation as procedures were developed for instituting protocols that would allow for the integration of evaluation findings across KD&E initiatives and activities.

More emphasis is needed on formal evaluations of particular initiatives, continuous communication and use of evaluation results internally and externally as reported by all internal key informants.  All PHAC key informants consistently noted the informal nature of much of their evaluation, and many noted the lack of a common performance measurement system that consistently tracks KD&E activities, outputs and reach.  Formalizing a process for tracking KD&E activities and achievements consistently was suggested by most of the PHAC key informants.

3.2.5 Challenges and Suggestions to Improve the KD&E Functional Component

The external stakeholders saw two issues as fundamental to KD&E efforts to foster improvement in healthy living and reduce chronic disease.  There needs to be sufficient investment for integrative activities to support creation of evidence on what interventions work and how, and then sharing it and supporting use with enough intensity that progress can be made on policy and practice changes.  There needs to be a better balance between disease-specific strategies (i.e., strategies for cancer, cardiovascular disease and diabetes) and an overall chronic disease prevention strategy, based on the view that the roots of many chronic diseases and opportunities for prevention are very similar.

 “To date there isn’t enough focus on integrated chronic disease KD&E activities, and we all know that there is need for both adequately resourced disease specific KD&E activities and integrated chronic disease activities.” Internal key informant

The PHAC key informants highlighted a number of challenges to the KD&E Functional Component activities. These challenges related to staff, resources, and commitment to KD&E, internal priority setting, communication and coordination, and lack of understanding of KD&E.

Resource limitations, both in terms of staff numbers and expertise related to KD&E as well as funding dedicated to joint KD&E activities was a prominent challenge. Human resource limitations are a concern in particular for ERAD which has experienced staff and management turn-over which has impacted workloads and productivity. In addition, one respondent underlined how PHAC currently is a small player in KD&E activity areas in provinces given limited NCR staff resources.

Communication, both internally and externally was identified as an area requiring improvement.  All respondents reported that formal mechanisms need to be reinforced for inter-division communication, planning and priority setting that would allow for more coordinated activities that are complementary across the CCDPC and between CHP and PHAC Regional Offices. It was highlighted that the strategic and consistent processes to feed information and evidence into internal PHAC policy direction and priority setting could also be improved.

Some internal respondents felt that Senior Management commitment and directions for KD&E internally could also be bolstered. Finally, there are some misconceptions about KD&E both at senior management and staff levels and lack of understanding how everyone’s work contributes to KD&E both within the KD&E functional component and overall in the ISHLCD.

Suggestions for improvement included:

• More coordinated priority setting and planning (n=10)
• Clarity in senior management priorities and directions for ISHLCD and KD&E (n=10)
• Strengthen NCR capacity for KD&E- both dedicated positions for KD&E, and overall understanding and skills for KD&E of all staff, also increase KD&E resources for joint projects (n=7)
• Reform the G&C process to better support effective KD&E (n=7)
• More sharing of our reports and syntheses, etc. with external stakeholders via PHAC website, forums, etc. (n=6).
• Host or co-host regular meetings/forums, conferences or workshops for enabling knowledge sharing within the broader KD&E community on what works for supporting evidence-informed decision-making (n=6).
• More consistent participation and contribution of KD&E Functional Component managers and staff towards joint work through the KD&E Internal Network (n=3).

3.3 Unintended Results

Several of internal PHAC key informants reported a positive unintended outcome through their KD&E initiatives.  The Federal role in KD&E was appreciated through the Chronic Disease Prevention Initiative in Manitoba.  In addition, Ontario’s Peel Region recently received funding from the Ontario’s Ministry of Health Promotion and they have approached the PHAC Pre-Diabetes Screening team to partner and use the Pre-Diabetes Screening Tool “CAN-Risk”.