Introduction
Newer technologies such as smartphones and social media offer innovative opportunities for reaching populations with health promotion interventions [
1]. Evidence shows that these technologies can be effectively and acceptably used for health promotion activities, including provision of health information, delivery of behaviour change interventions, symptom monitoring for self-management of diseases, awareness-raising and advocacy strategies [
1‐
4]. Popular domains of study include tobacco cessation [
1,
5,
6], medication adherence [
7], chronic disease self-management [
1,
5,
7], brief interventions for substance use [
8,
9], symptom monitoring and support for mental health conditions [
10,
11], and education and motivational messaging for sexual health [
12‐
14], physical activity [
15‐
17] and diet [
17‐
19]. We will refer to these types of activities as technology-facilitated prevention interventions throughout this paper.
One of the main benefits of using technology for prevention programmes is its wide reach, offering low-cost opportunities to connect with populations at a large scale and low participant burden due to the high level of integration of mobile phones and social media into people’s daily routines [
20‐
22]. Functional benefits of mobile phones and social media include the potential for real-time monitoring and feedback of participant behaviours and health indicators [
23], complex intervention tailoring [
24], and modes of communication that can be highly interactive, visually appealing and engaging [
20]. A further major benefit is that real-time usage data can be automatically generated within most technology platforms, which can be advantageous for evaluation purposes [
20].
The potential for technology to be used for prevention gains has been the focus of much attention in both the research and practice sectors. Over the past decade, products and campaigns have emerged from the fields of medicine, allied health, health promotion, behavioural science, psychology, marketing, communications and education, each bringing different approaches and theories. While there is growing evidence to support the use of mobile phones and social media for reducing risk behaviours and improving health and wellbeing, there is a clear difference between the interventions developed and tested in research settings and interventions implemented by health promotion practitioners and others in the ‘real world’ [
6,
25].
In the research sector, most of the technology-facilitated prevention work focuses on behaviour change interventions, and most studies are small-scale pilot interventions [
26]. Studies frequently describe the potential for interventions to be scaled up (i.e. expanded under real-world conditions into practice to reach larger populations [
27]), but evidence of larger studies and/or attempts to implement technology-facilitated interventions into community settings are far rarer [
26]. This follows the major trends of intervention studies in general, which are most likely to exist in small, pilot trial form, and often not translated to reach non-research populations [
27,
28]. Other critiques of technology-facilitated prevention research include inadequate description of implementation requirements (including cost and human resourcing), and lack of dissemination in plain language and outside of academic journals [
29]. Some work has been done to update reporting requirements of eHealth and mHealth interventions [
30,
31], but few journals publishing technology-facilitated prevention work require adherence to these criteria.
In the Australian context, health promotion or prevention activities that reach the public are implemented by a range of organisation types. These include government (at a local, state and national level), non-government (such as community health services) and not-for-profit organisations or charities focused on specific health issues (i.e. Diabetes Australia). At a national and state level, investment in prevention has been in flux for the past two decades and, as such, there have been few time-points at which funding has been considered to be relatively stable [
32‐
34]. These organisations conduct a range of activities across the health promotion spectrum, from action focused at the policy and environment level through to initiatives focused at the individual level [
34]. Australia’s health promotion sector has delivered world-leading evidence-based initiatives in particular domains such as tobacco and HIV-related policy and programmes [
35]. However, there are many other areas in which knowledge translation has not occurred effectively, and we have failed to make meaningful progress; a prime example of this is Indigenous health and wellbeing [
34].
There are relatively few Australian publications (in either grey or academic literature) that describe technology-facilitated prevention interventions developed or implemented by health promotion organisations or others working in prevention [
6,
13,
36‐
38]. Evaluations relating to these projects are even more difficult to find [
6,
13]. Content analyses of social networking sites showed that there are health promotion activities, such as information dissemination and social marketing campaigns, occurring on social media, but most were not documented in published literature [
6,
13]. Gold et al. [
13] found that health promotion activities on social media were most likely to be undertaken by not-for-profit organisations and government departments or agencies, with only 10% run by academic institutions. Approximately two-thirds of health promotion social networking sites existed to promote a service or organisation, while just under a third (29%) included a campaign or intervention [
13]. A study from the United States found that 42% of community-based organisations had a social media presence, but they often had short reach, made limited use of the interactivity offered by the media, were unlikely to be updated and maintained over time, and were not evaluated or evaluation results were not disseminated [
39].
Another part of this picture relates to publicly available smartphone applications (apps), which can be created by anyone, including health promotion agencies or departments. In 2016, on the two major mobile platforms (iOS and Android), more than 259,000 mHealth apps were available, up from 100,000 from the previous year [
40]. mHealth apps (including those developed by health promotion agencies) have received criticism relating to lack of theoretical underpinnings, poor quality, promotion of unhealthy behaviours and, most importantly, little or no evidence of effectiveness for their intended purposes [
36,
41‐
43]. A recent study found that there were no publicly available evaluations for any of the 29 apps created by Australian health promotion bodies [
6].
In short, most technology-facilitated interventions produced in research do not end up benefiting non-research populations. Further, most of these interventions that are available outside of research settings are either undocumented or have little or no evidence of benefit [
26]. Despite the problems in the current landscape, there are many advantages to these tools, and many reasons to work with them. The
Lancet Commission on Adolescent Health and Wellbeing highlighted that digital media offer “
outstanding new possibilities for engagement” with youth populations [
44]. Brusse et al. [
6] contended that health promotion practitioners have no option but to engage with technology, given its increasing ubiquity. Others have argued that health promoters need to engage with technology effectively in order to ‘fight fire with fire’, considering the successful and expanding uses of social media and smartphone apps by industries selling harmful products [
4,
45‐
47].
It is important to acknowledge that the gap between research and practice is not unique to the technology-facilitated prevention field. There is a substantial body of evidence to show that the research and practice sectors tend to operate in silos, with barriers including different operating mechanisms, funding requirements, reward systems and priorities [
27,
48‐
50]. However, we and others argue that given the rapid evolution of these technologies, and the large number of organisations and individuals involved as either producers or end-users of technology-facilitated prevention interventions, it is imperative that we specifically investigate translation in the technology field and explore opportunities to enhance collaboration between sectors [
6]. We therefore aimed to explore the following research questions from the perspectives of health promotion experts and researchers working with technology-facilitated prevention:
1.
What are the barriers and facilitators for health promotion practitioners in engaging with technology-facilitated prevention work?
2.
How do researchers working with technology-facilitated prevention see their role in translation?
3.
What are the barriers and facilitators for researchers in engaging with the translation of their technology-facilitated prevention work?
Discussion
Our findings suggest that there are significant barriers to translation of technology-facilitated prevention interventions. Some findings mirror those of other studies of health promotion practice, which found that competing priorities, resource limitations and organisational capacity are important in determining use of evidence in programme planning, engagement in translation and evaluation practice [
49,
54‐
56]. We add to this literature by highlighting barriers more specifically related to technology-facilitated prevention, such as the pace of technological development, and how these clash with the time taken to develop and ready evidence for translation.
Previous studies in the wider prevention sector have found, as we did, that the differing value systems and priorities of research, practice and policy can be barriers to translation of health promotion interventions [
27,
57,
58]. In our study, researchers and health promotion practitioners saw their roles as distinctly separate, and found it difficult to envisage greater collaboration across sectors in their current working context.
Our finding regarding health promotion practitioners’ concerns about equity in technology-facilitated prevention interventions is an important contribution to the discussion, as it highlights a key contention surrounding the populations targeted by each sector. Further discussion of the practical relevance and genuine scalability of the interventions currently being produced in the research field is warranted [
26]. Studies have often shown that there is a digital divide, with those of low socioeconomic status, non-English speaking background, older age and lower health literacy being less likely to engage with health-related content on mobile and internet platforms [
59‐
61]. This divide has important implications for researchers in terms of the technologies that they test and the populations with which they test it.
Although mobile phone access is more ubiquitous across socioeconomic spectrums than internet access [
62], recent research shows that there are still underserved sub-groups such as those with lower educational attainment [
60]. Baum et al. [
63] contend that a ‘vicious cycle’ occurs when information technology access and literacy is assumed in health promotion activities. They argued that the increasing focus on digital delivery of health information and interventions further excludes the marginalised, and urged health promoters to continue to offer strategies in traditional forms [
63]. Though it is likely that technology literacy and use will increase as availability and affordability improve, it is important to consider that newer, more sophisticated technologies will continue to emerge and will not be affordable to all. It is understandable that researchers will want to harness newer technologies and understand their potential uses for improving health, but consideration of access is integral to scalability, relevance and future translation. Future research and evaluations of the use of technology-facilitated prevention interventions in vulnerable populations would also be valuable [
6].
Researchers in our study were predominantly used to a linear, one-way form of translation, with their primary role in the sequence being the simple dissemination of research; this finding is consistent with previous research [
57,
64]. The researchers’ description of translation most closely resembled Rychetnik’s model of translation processes to support evidence-based policy and practice [
65]. In this model, there are five key stages, namely (1) problem definition, (2) solution generation, (3) intervention testing, (4) intervention replication and (5) intervention dissemination. However, this type of linear process (sometimes termed as the ‘pipeline fallacy’ [
66]) has been criticised as slow and ineffective for producing real-world benefits [
35,
67,
68]. Updates to Translation Continuum (‘T’) models demonstrate a more complex route to achieving real world impact [
69]. The T0–T4 model includes five stages, from problem definition (T0) to discoveries (T1), tests of interventions (T2), the production of evidence-based recommendations (T3), to the implementation of interventions into organisations and communities (T4). A key feature of this model is that, between each of these stages are bi-directional arrows, and at each stage, stakeholder engagement and evidence integration occurs. The overall process is also seen to be cyclical, with evidence from programme implementation then informing problem definition. The researchers in our study were predominantly focused on the T1 and T2 stages of translation, with limited engagement or discussion of the other stages. We recommend that researchers consider their work in the context of the larger translational machine, and that they include stakeholder engagement with practitioners and community at the various stages of intervention research.
Researchers could also consider the use of study designs that allow for the simultaneous study of both effectiveness and implementation. The hybrid effectiveness–implementation models described by Wolfenden et al. [
64] are promising in terms of both reducing the time taken for research to be produced and disseminated, and for increasing the relevance of findings for real-world populations. Milat et al. [
27] have previously advocated for a co-production model in which practitioners and researchers are involved from inception to dissemination of research. This model may address many of the barriers to translation raised in our study by pooling skills, resources and knowledge, and enhancing the real-world relevance of the interventions produced. Although there are likely challenges in merging the operations and priorities of research and practice sectors, there is evidence to suggest that research produced under this model is more relevant to end-users and more likely to be integrated into policy and practice [
70].
While research and practice fields continue to operate separately under their respective funding streams, it is hard to see how translation will improve. Our findings support the idea that the relevance of technology-facilitated prevention research could be enhanced through greater consultation with end users such as health promotion practitioners, at the very least. We concur with previous recommendations that researchers should commit to disseminating their work in widely available sources (such as open-access journals) and with transparent accounting of the time, resources and expertise needed to implement their interventions [
29‐
31]. However, it is clear that there needs to be greater incentive for researchers and practitioners to work together, given the resource constraints and perceptions of both technology and research–practice partnerships in each field. Therefore, it is vital to consider improvements to funding schemes in both research and practice to support translation.
Further funding should be invested in translational research that includes research–practice partnerships. Some investments have been made in Australia, but these currently account for a small proportion of research funding. In 2016, approximately 3% of the Australian National Health and Medical Research Council’s competitive grant funding went towards translation-specific funding through the Partnership Grants scheme, the Translation of Research Into Practice Fellowships and the Translational Research Projects for Improved Health Care scheme [
71]. A further issue with the Partnership Grant scheme is the requirement of matched co-funding from partner organisations; this scheme is derived from a traditional model of significant long-term profit opportunities for partners, which may never eventuate for health promotion organisations, meaning that these grants are out of reach.
Challenges to using evidence in health promotion practice and policy have been described, as practitioners and managers seek evidence that is relevant to their context and population, has high external validity, and will meet the needs of managers and funding bodies [
54,
72]. Practitioners may know what high-quality evidence is; however, structural demands influence what they can use in practice. In addition to ongoing emphasis on evidence-based practice, it is important to address these organisational, funding and policy levers from both ends in order to overcome these barriers to translation.
For health promotion practice, increased funding is also required to enable greater investment in formative research, pilot programmes and evaluation. Further documentation and evaluation of technology-facilitated prevention work is essential for building the evidence base for what does work in real-world practice, and with the populations and strategy types prioritised by the health promotion sector. More information on development, implementation and evaluation from these projects would be useful to guide future work, and to ensure that practitioners have a stronger voice in the evolution of this field. The co-production model described above could be beneficial for ensuring that projects are adequately documented and disseminated in places where both researchers and practitioners will find it. Where co-production does not occur, health promotion funding schemes need to allow for evaluation in their budgets, whether this be for research–practice partnerships for evaluation, or to allow practitioners the time and resourcing to undertake it in-house. Contract timeframes should allow flexibility for ethics approval lead times and sufficient evaluation activities at the completion of projects. Efforts have been made to provide specific guidance for evaluating technology-facilitated prevention interventions [
38,
73].