Theory discussion ebp

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Open AcceDebate
From theory to practice: improving the impact of health services
research
Kevin Brazil*1, Elizabeth Ozer2, Michelle M Cloutier3, Robert Levine4 and
Daniel Stryer5

Address: 1Department of Clinical Epidemiology and Biostatistics, Faculty of Health Sciences, McMaster University and St. Joseph’s Health System
Research Network, Hamilton, ON, Canada, 2Department of Pediatrics/Adolescent Medicine, University of California, San Francisco, CA, USA,
3Department of Pediatrics, University of Connecticut Health Center and Connecticut. Children’s Medical Center, Hartford, CT, USA,
4Occupational and Preventive Medicine, Meharry Medical College, Nashville, TN, USA and 5Center for Outcomes and Effectiveness Research,
Agency for Healthcare Research and Quality, Rockville, MD, USA

Email: Kevin Brazil* – [email protected]; Elizabeth Ozer – [email protected]; Michelle M Cloutier – [email protected];
Robert Levine – [email protected]; Daniel Stryer – [email protected]

* Corresponding author

Abstract
Background: While significant strides have been made in health research, the incorporation of
research evidence into healthcare decision-making has been marginal. The purpose of this paper is
to provide an overview of how the utility of health services research can be improved through the
use of theory. Integrating theory into health services research can improve research methodology
and encourage stronger collaboration with decision-makers.

Discussion: Recognizing the importance of theory calls for new expectations in the practice of
health services research. These include: the formation of interdisciplinary research teams;
broadening the training for those who will practice health services research; and supportive
organizational conditions that promote collaboration between researchers and decision makers.
Further, funding bodies can provide a significant role in guiding and supporting the use of theory in
the practice of health services research.

Summary: Institutions and researchers should incorporate the use of theory if health services
research is to fulfill its potential for improving the delivery of health care.

Background
While significant strides have been made in medical
research over the past several decades, many research
results considered important by researchers and expert
committees are not being used by health care practition-
ers. While the value of health services research must be
judged by its validity, its utility cannot be taken for
granted. There has been an assumption that when
research information is available it will be accessed,

appraised and then applied [1]. However, knowledge of a
research-based recommendation is by itself insufficient to
ensure its adoption. While the value of research evidence
as a basis for decision making in health care is well estab-
lished, the incorporation of such evidence into decision-
making remains inconsistent [2].

The gap between research evidence and its’ incorporation
into practice has led to an increase in research in how to

Published: 07 January 2005

BMC Health Services Research 2005, 5:1 doi:10.1186/1472-6963-5-1

Received: 20 May 2004
Accepted: 07 January 2005

This article is available from: http://www.biomedcentral.com/1472-6963/5/1

© 2005 Brazil et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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bring new knowledge to bear on everyday health care. Fac-
tors influencing the adoption of research evidence have
been studied extensively [3-5]. Personal attributes, time,
organizational boundaries, geography and educational
background all contribute to decision-makers’ responses
to research evidence [6,7]. An area that has received less
attention is the incorporation of theory in health services
research. The authors of this paper propose a need for a
stronger theoretical base in health services research
wherein health services research would be more informa-
tive and influential, facilitating the adoption of research
results into practise. Integrating theory into health services
research is an important first step. In this paper we first
describe the importance of theory followed by how theory
driven research changes the manner researchers interact
with decision-makers. We conclude on how theory driven
research may influence the training, practice and the fund-
ing of health services research.

Discussion
The importance of theory
In recent years a number of researchers have advocated a
greater role for the use of theory in strengthening the prac-
tice of research [8-12]. However, health services research
has continued to focus primarily on evaluating outcomes
with less attention to the mechanisms by which these out-
comes are produced [10,13,14]. The emphasis on method
at the expense of theory has led to several criticisms. Chen
and Rossi [15] argue that an atheoretical approach to
research is characterized by adherence to a step-by-step
cookbook method for doing outcomes studies. In this sit-
uation they contend that research is reduced to a set of
predetermined steps that are mechanically applied to var-
ious interventions without concern for the theoretical
implications of intervention content, setting, participants
or implementing organizations. The atheoretical
approach tends to result in a simple input/output, or
black box type of study [13]. Such simple evaluations may
provide a gross assessment of whether or not an interven-
tion works under one set of conditions but fail to identify
the reasons why. As such, the conclusions are often less
than satisfying to consumers of research results and not
easily transferable to different settings.

Theory provides a systematic view of a phenomena by
specifying the relations among variables and propositions
with the purpose to explain or predict phenomena that
occurs in the world [16,17]. In health services research
theory can provide a framework to understand the rela-
tionship between program inputs (resources), program
activities (how the program is implemented) and their
outputs or outcomes [11,13]. In addition to identifying
the mechanisms by which programs are effective, theory
may consider program implementation and contextual
factors. While it is important to know the extent to which

an intervention attains intended outcomes, it is also
essential to know what occurred in the implementation of
the intervention. Variation in the implementation of the
intervention may be due to differences among program
providers, target population characteristics, and differ-
ences among sites on how the intervention is delivered.
Theory also offers the opportunity to specify the contex-
tual conditions that will influence the effectiveness of an
intervention. Attitudinal factors at the provider level as
well as structural, cultural factors at the organizational
level have been under appreciated in exploring variations
in health care outcomes [9,18,19]. Understanding the
influence that contextual factors have on program imple-
mentation and outcomes facilitates successful application
of the intervention in alternate settings, therein, address-
ing the generalizabilty of an intervention.

Theory offers many advantages to the health services
researcher. Theory helps to identify the appropriate study
question and target group; clarify methods and measure-
ment issues; provide more detailed and informative
descriptions on characteristics of the intervention and
supportive implementation conditions; uncover unin-
tended effects; assist in analysis and interpretation of
results; and, the successful application of an intervention
to different settings [11,12].

Theory-driven studies are addressing the challenge of both
decision-makers and funding agencies to move beyond
simplistic explanations of significance in health services
research. Decision-makers are seeking explanations about
how an intervention works and whether it will work in a
fashion similar to the intervention that was evaluated
when applied to a different environment [10,12,20].

Despite these potential benefits, there are a number of rea-
sons offered as to why there has been a failure to integrate
theory into research. Ironically, clinical randomized con-
trol trials have discouraged the use of theory in health
services research. Given the genesis of clinical trial meth-
odology, this may derive, in part, from the very origins of
epidemiology, whereby John Snow allegedly ended an
epidemic of cholera by removing the handle from the
Broad Street water pump, even though he had no concept
of what actually caused cholera. By ignoring the need for
theory, Snow was able to overcome the fact that the theo-
ries he would have needed had not yet been elucidated.
Similarly, we know that lung cancer incidence can be
reduced by elimination of cigarette smoking, even though
we do not know exactly how cigarette smoke causes lung
cancer. Experimental trials often determine intervention
effects without considering how the component features
of an intervention work together to bring about study out-
comes [13,15,21]. The more complex the intervention,
the more difficult it is to know what the treatment

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entailed. There is a growing recognition for the need to
establish the theoretical bases of interventions. The
United Kingdom Medical Research Council recently pro-
posed a framework for the development and evaluation of
randomized control trials for complex interventions
where theory is viewed as valuable in assisting hypothesis
development and steering decisions on strategic design
issues [22].

Adopting a theory-driven approach in health services
research is not without its challenges. Given the typical
training of researchers and the uni-disciplinary nature of
the practice the first challenge is the capacity of researchers
to engage in theory driven research. Second, a theory
driven approach requires organizational conditions that
support researchers and decision makers collaborating in
the development and testing of theory. Finally, theory
development and testing is cumulative in nature, encour-
aging researchers to pursue a programmatic approach in
research. This approach has implications on how funding
agencies support health services research. Despite the
potential challenges, a theory based approach offers
promise for a greater understanding on what happens
when interventions work to address social/health prob-
lems.

The importance of collaboration with decision-makers
Collaborative research partnerships between academic
researchers and decision-makers describe a relationship
and process between individuals from different back-
grounds, who together, develop an integrative cooperative
approach to resolve a research problem [23]. It has been
identified as a significant strategy that holds multiple ben-
efits [23-27].

Collaborative practice has also been identified as a key
strategy in facilitating a theory driven approach. Weiss
[28] recommends that the first criterion in selecting a the-
ory to guide the evaluation of a program is to draw the
theory out from those associated from the program,
including designers of the program, program personnel
and relevant clinical staff. The argument is that few pro-
grams are theory driven. Rather, they are typically the
product of the experience and values of those who are
associated with the program. In recent years a number of
techniques have been developed for this purpose. Strate-
gies range from unstructured interviews, to highly struc-
tured iterative interactions between program personnel
and researchers [29-31]. Perspectives of service providers
can be rounded out by a review of the research literature.
In fact, a number of researchers suggest a combination of
these two approaches [10,32].

Viewing program stakeholders as a key source in develop-
ing theory in health services research demands stronger

collaboration between researchers and program decision
makers [9]. In this fashion, collaborative practice becomes
a methodological strategy in health services research.
Lomas [7] has stressed that a first step in encouraging
meaningful partnerships between researchers and deci-
sion-makers is to view linkage and exchange between the
two as a process not as a discrete event. Establishing and
maintaining ongoing links offers a more comprehensive
understanding between the two groups. Researchers
uncover the desired program outcomes, the causal change
of the program intervention and develop a better under-
standing of the contextual factors that influence the varia-
tion on intervention implementation and outcomes.
Similarly, decision-makers will develop a deeper under-
standing of the research process and thus can influence
the development of feasible and sustainable interventions
for practice settings.

The role and impact of the researcher and the research
process in practice settings have received greater attention
in other fields such as program evaluation, nursing,
anthropology and community psychology. For example,
core principles of community psychology practice
include: a) consistency of goals and values between the
researcher and the setting, and b) the notion that interven-
tions should have the potential for being “institutional-
ized” or systematically established within the setting in
such a way that strengthens the natural resources of the
setting [25-27]. Rather than reinventing the wheel, health
services research could benefit from theoretical frame-
works developed within these disciplines.

Implications for the practice of health services research
Recognizing the importance of theory calls for new expec-
tations in the practice of health services research. There are
a number of challenges that must be met in order for these
perspectives to gain acceptance in the health services
research community.

Evolving perspectives on the practice of health services
research require recognition that few disciplines are able
to span the breadth of responsibilities associated with the
research process. To date there has been a tendency for
health services research to be practiced as a uni-discipline
where clinical disciplines tend to practice separately from
the social science disciplines. A priority is to encourage the
formation of research teams that are inter-disciplinary.
Pursuing this agenda will promote the formation of
research teams that may include: business, anthropology,
sociology, psychology, education, engineering, nursing
and medicine. Combined disciplinary skills would, in a
complementary fashion, address the breadth of skills
required in a more complex research environment that
includes the development and testing of theory.

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A second point concerns broadening the training for those
who will practice health services research. By and large,
academic training has focused on methodological issues.
While a focus on research methods has made an impor-
tant contribution to the practice of health services
research, relying on research methods as a core curriculum
has led to limitations in the training of health services
researchers such as inadequate attention to the value of
theory driven research. As health services research expands
its methodological repertoire beyond the classical rand-
omized control trial, researchers face increased ambiguity
in attributing the source of intervention impact. It is in
this circumstance that theory can guide health services
researchers in understanding the causal linkages within an
intervention. Further, students are educated in separate
departments with little planned, formal activity across dis-
ciplines, which discourages co-operative approaches to
research and service [33-35]. Education programs are not
generally structured to facilitate the importance of inter-
disciplinary strategies. Identifying the processes associated
with creating effective linkages between researchers and
decision-makers are also not typically part of training.
Rethinking the current assumptions and practices regard-
ing the training of health services researchers will enable
trainees in health services research to be better prepared
for their evolving responsibilities.

Collaboration between researchers and decision-makers
are contingent upon supportive organizational conditions
for both partners. Researchers have, and most likely will
continue to operate from university-based settings where
incentives for promotion and tenure can act as barriers to
changes in the practice of health services research [7,36].
Most academic institutions award tenure and promote
faculty based upon the frequency and quality of publica-
tions and on obtaining peer review funding [36]. The time
involved in collaborating with decision-makers, joint
planning and implementing research often represents
activities that are not recognized by tenure promotion
committees. As well, these activities may slow the produc-
tion of research results and the generation of publications.
Recognizing these factors requires academic centres to
generate new criteria for evaluating contributions to
knowledge and practice. Decision-making organizations
also play a significant role in ensuring the success of col-
laborative relationships. The clearest indication of institu-
tional support for research is to provide the time and
resources for decision-makers to participate in collabora-
tion activities with researchers.

Funding bodies have the potential to play a significant
role in guiding and integrating these considerations into
health services research. Research sponsors can develop
evaluation criteria that encourage the application of the-
ory. As an example, the Agency for Healthcare Research

and Quality (AHRQ) in the USA funded an initiative
(Translating Research into Practice) to identify sustaina-
ble and reproducible strategies that will: 1) accelerate the
impact of health services research on direct patient care;
and 2) improve the outcomes, quality, effectiveness, effi-
ciency, and/or cost effectiveness of care through partner-
ships between health care organizations and researchers
[37]. Further, research sponsors are beginning to move
away from supporting single shot studies that are con-
ducted in relative independence from one another. This
focus on supporting programmatic research should be
encouraged. Programmatic research offers a cumulative
environment that allows researchers the opportunity to
develop and test the application of theory. In a similar
fashion, collaborative practice is also best practiced in a
programmatic environment. Developing and maintaining
linkages with decision-makers is predicated on develop-
ing and maintaining long-term relations. Embedded
within these linkages are fundamental professional and
personal attributes that include; credibility, familiarity,
mutual understanding and trust [38,39].

Summary
This paper has examined the importance of theory in
health services research. We have argued that by strength-
ening the role of theory encourages collaborative practice
between researchers and decision-makers. It has been
noted that a theory driven approach in health services
research is not without its challenges. However, given the
modest advances towards incorporating research evidence
into healthcare decisions, a theory driven approach is well
worth the effort. The implication of this approach for
health services research is that it has impact on the train-
ing and practice of health services research. Institutions
and researchers should consider this emerging model of
practice if health services research is to fulfill its potential
for improving the delivery of care.

Competing interests
The authors declare that there are no competing interests.
Disclaimer: The opinions expressed are the authors’ and
do not necessarily represent official policy of AHRQ or the
Department of Health and Human Services

Authors’ contributions
KB drafted the manuscript, edited and revised the con-
tents, EO edited and revised the manuscript, KB, EO, MC,
RS, DS all contributed to the conceptual development,
editing and review of the manuscript.

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