How should we assess knowledge translation in research organizations; designing a knowledge translation self-assessment tool for research institutes (SATORI)

Background The knowledge translation self-assessment tool for research institutes (SATORI) was designed to assess the status of knowledge translation in research institutes. The objective was, to identify the weaknesses and strengths of knowledge translation in research centres and faculties associated with Tehran University of Medical Sciences (TUMS). Methods The tool, consisting of 50 statements in four main domains, was used in 20 TUMS-affiliated research centres and departments after its reliability was established. It was completed in a group discussion by the members of the research council, researchers and research users' representatives from each centre and/or department. Results The mean score obtained in the four domains of 'The question of research', 'Knowledge production', 'Knowledge transfer' and 'Promoting the use of evidence' were 2.26, 2.92, 2 and 1.89 (out of 5) respectively. Nine out of 12 interventional priorities with the lowest quartile score were related to knowledge transfer resources and strategies, whereas eight of them were in the highest quartile and related to 'The question of research' and 'Knowledge production'. Conclusions The self-assessment tool identifies the gaps in capacity and infrastructure of knowledge translation support within research organizations. Assessment of research institutes using SATORI pointed out that strengthening knowledge translation through provision of financial support for knowledge translation activities, creating supportive and facilitating infrastructures, and facilitating interactions between researchers and target audiences to exchange questions and research findings are among the priorities of research centres and/or departments.


Background
Knowledge translation, considered as both strategies and processes, has received worldwide attention in the application of health research for decision making in many universities in recent years [1,2]. Some universities and organizations see the process as a priority [3]. The necessity for the optimal utilization of research has become even more prominent in low-and middleincome countries which suffer resource shortage [4]. Knowledge translation, on the other hand, is a complex, non-linear, ongoing and dynamic process which cannot be achieved easily [4].
Knowledge translation theories have developed considerably in recent decades, and various models have been put forward to explain them [5,6]. Even though some think there is basically no need for such theories [5,7] many researchers believe a model-based framework, adopted at different levels ranging from individual to group to organizational behaviour, is required to design and implement effective and assessable interventions for turning research results into decision making [8,9]. [5]. Various knowledge translation models have been designed in different fields of study (i.e., social sciences, nursing, and health services) and for a variety of organizations, each one of which emphasizes one aspect of knowledge translation. However, there is no extensive model which can be used in all situations. Basically, such a model cannot exist, because Knowledge translation strategies must be attuned to the groups' and organizations' needs and structures [7]. Only a few models have been designed for examining the performance of research organizations (e.g., universities) [5,6,10]. Therefore, the knowledge translation model was designed at Tehran University of Medical Sciences (TUMS) as a framework to identify knowledge translation capacities and weaknesses in the university and to suggest appropriate and necessary interventions, a detailed report of which has already been published elsewhere [11].
Since one way of applying models is to design and develop appropriate tools on the basis of an available model, a tool was designed to assess knowledge translation in research institutes using the 'Knowledge Translation Model of Tehran University of Medical Sciences' [12]. Such a move can not only transform a theoretic model into applicable knowledge but also helps identify strengths and weaknesses of knowledge translation in universities, as knowledge-producing organizations, and subsequently promote the utilization of knowledge in the country.
In Iran Knowledge translation has two aspects. Firstly, the Iranian healthcare system, is an integrated structure formed following the integration of the Ministry of Health into medical education in 1985 [13]. The system has potentially prepared the ground for health knowledge translation [14]. Secondly, the production of science has followed a rapid pace in recent years, pointing out the fact that the translation of this rapidlygrowing knowledge needs special attention [14] [15].
Apart from designing a self-assessment tool for knowledge translation activities in research-producing institutes, TUMS research centres and faculties, this pilot study uses the tool to assess the weaknesses and strengths of knowledge translation in the university.

Tool Development
The TUMS model provided a framework for the development of a self-assessment tool for knowledge translation [11]. All the determinant factors of knowledge translation in the model were summarized in homogenous domains, and a preliminary draft was prepared.
To ensure internal validity, five experts were asked to give their impression on each statement by 'thinking aloud', and necessary changes were subsequently made if the items did not convey the meanings we had in mind. Then, the tool was discussed for the sequence of questions and content validity among 23 researchers from five universities around the country and final modifications were implemented on the basis of their feedback.
The finalized version of the tool consists of 50 statements in four main domains (Additional file 1 and 2). Each item covers at least one of the determinant factors of knowledge translation, needing to be evaluated.
The four main domains and their sub-domains are as follows: 1-The question of research: Do we identify decision makers' research needs and convert them into research questions? This covers two sub-domains of resources (four statements) and strategies (eight statements) 2-Knowledge production: Do we produce useful evidence for decision making? (nine statements) 3-Knowledge transfer: Do we have appropriate means for disseminating the organization's research results to their target audiences? This covers two sub-domains of resources (nine statements) and strategies (16 statements) 4-Promoting the use of evidence: Do we help decision makers utilize research results better? (four statements) By 'resources' we mean all the financial, equipment, legal and human resources that have been provided by the organization for knowledge translation activities. And by 'strategies' we mean all the steps taken in the concerned domains.
The tool permits the self-assessment of the organization through group discussions and consensus by its members, rather than by survey method. To assess an institute, the research authorities and its selected researchers should complete the tool. It would be preferred if other stakeholders of the researches carried out in the organization also participate in the meeting. First, the participants list the organization's research target audiences. Then, they review each statement and rate each item on a Likert scale upon discussion, exchange of ideas and overall consensus.
Each statement will assess at least one of the aspects influencing knowledge translation. And each item will secure a score that would cover a range of five options, ranging from 'the situation is good and needs no intervention' to 'the situation is quite unfavourable and/or there is a dire need for intervention'.
The results of the assessment will not be considered as the overall score obtained by the organization regarding knowledge translation activities. Instead, they will be used to identify the strengths and weaknesses of the organization for future interventions. This is why the tool is considered as a guide and not a questionnaire for cross-sectional study purposes.

Reliability Assessment
To study the reliability of the tool using intra class correlation, 21 researchers in three research centres answered the self-assessment tool twice, at two-week intervals.
Internal consistency with Cronbach's alpha was estimated by having 45 researchers from five research centres (24 persons in addition to the first 21 researchers) complete the tool. Items having lower reliability were then revised.

TUMS Pilot Testing
TUMS is the oldest and largest centre for health sciences in Iran, consisting of seven faculties, over 1,250 faculty members, 47 research centres and 16 teaching hospitals. Also, it holds the greatest share of medical publications in Iran [15].
Among the 47 TUMS research centres and departments, 12 research centres and eight departments were chosen to participate. One department was chosen from each faculty; in the medical faculty, a clinical and a basic science department were selected. Selection criteria included (a) Holding regular research council meetings (b) Willingness to participate in the study.
The selected research groups and centres were invited to participate in the study, and were asked to introduce one of their research council members as a focal point as a contact person. The three-hour briefing session was held to familiarize the focal points with the tool, and as a drill they completed it on their own.
The questionnaire was thereafter completed by the members of the research council and the researchers from different centres and departments. An average of six individuals participated in these sessions. In order to assure the quality of the study, the focal points were asked to arrange the research council meeting in each centre and inform the research team of its time so they would be available to answer possible questions regarding the tool.
The research team answered the questions on phone in order to avoid any possible information bias caused by their presence in the meeting.

Data analysis
To assess each statement and domain, the mean score of each statement was calculated. The option 'the situation is quite unfavourable and/or there is a dire need for intervention' scored 1 and 'the situation is good and needs no intervention' scored 5 points. The statements which obtained the highest and lowest score were identified. To determine the lowest and highest scores, the quartiles were used.
To observe ethical considerations, the participants were told that writing down their names or the name of their centre was not necessary. The research was approved by the Ethical Board Committee of TUMS.

Tool reliability
In addition to the domains, the intra-class correlation coefficient (ICC) was calculated for each of the statements. The three domains of 'the question of research, knowledge production and knowledge transfer' had an ICC and Cronbach's alpha higher than 0.70, whereas the figure was lower than 0.70 for 'promoting the use of evidence' (Table 1). A low Cronbach's alpha was likely considering the small number of questions and the nature of the statements in the fourth domain. A small ICC, however, showed the low reliability of the statements in the very domain. Considering the importance of these statements, they were kept in the tool in spite of their low reliability. For better clarification of the statements, we specified them with an asterisk in the guide, and asked the focal points to give further explanations to the participants.

Assessment of research centres and departments
All the selected centres (12 research centres and eight departments) completed and delivered the self-assessment questionnaire.
The mean score of each statement was calculated for the centres and departments. The minimum and maximum mean scores obtained in various statements were 1.15 and 3.95 respectively. Tables 2, 3, 4 and 5 represent the mean scores and standard deviations of each of the statements in the four domains. The statements which gained the highest and lowest scores respectively have been specified in these tables.
The statements which obtained the lowest scores represented issues that were believed to be in a poorer condition and needed interventions. The contrary was true for the statements which obtained the highest scores. The items with a mean score lower than 1.6 (the first quartile) included setting research priorities with research users, financial resources, infrastructures, researchers' intellectual rights, researchers' need assessment and evaluation of their knowledge translation activities, direct communication with media and research users and follow-up of research utilization.
The following statements reflect weaknesses in the university due to their low scores (less than 1 st quartile): determining research priorities through meetings with stakeholders (statement 8 from 1 st domain), considering budgets in proposals and securing funds for knowledge translation (statement 9 from 2 nd domain and statement 4 from 3 rd domain), communication between researchers and research target audiences and follow-up of utilization of research results (statements 21, 22 and ↓ The statements which obtained the lowest scores. ↑ The statements which obtained the highest scores. *Each of the twenty centres and departments that participated in the study agreed upon a single score which was used in calculating the mean score. Table 3 The mean score and standard deviation for each statement in 'knowledge production'    Statements which obtained the lowest scores pertained to knowledge transfer strategies (5 statements), knowledge transfer resources (4 statements), strategies for developing research questions (1 statement), knowledge production (1 statement) and promoting the use of evidence (1 statement). On the other hand, statements which obtained the highest scores (greater than the third quartile) respectively, were, from knowledge production (6 statements) strategies for developing research questions (2 statements), knowledge transfer resources (2 statements) and strategies (1 statement), and promoting the use of evidence (1 statement).
The mean domain score was also calculated. Knowledge production obtained the highest score with a mean score of 2.92 ± 0.83, whereas promoting the use of evidence obtained the lowest (1.89 ± 0.55). The mean score of the research question domain was 2.26 ± 0.50, and the knowledge transfer domain obtained a mean score as low as 2.00 ± 0.59.

Discussion
The SATORI tool (SATORI: a Japanese Buddhist term for enlightenment, literally meaning 'understanding') provides a way to operationalize the TUMS knowledge translation model. This tool consists of 50 statements about requisites, resources and strategies for facilitating knowledge translation in research institutes. Use of the tool enables research managers and researchers to identify strengths and weaknesses of knowledge translation within their institution and to subsequently develop interventions that could improve their organization's KT infrastructure and capacity.
This tool was developed to assess knowledge translation activities from the "push side" perspective, meaning activities which are undertaken by researchers or research organizations to transfer research results to target audiences.
Research managers and researchers can identify the strengths and weaknesses of their organization regarding knowledge translation upon using this 50-statement tool, and work toward identifying solutions for the improvement of the organization's infrastructure and capacity. Actually, this tool is a complement to the "Is research working for you?" which is a self-assessment tool and discussion guide designed by the Canadian Health System Research Foundation (CHSRF) to examine "pull side" activities; activities performed by health services management and policy organizations to benefit from research evidences [16][17][18][19].
In many countries, evaluation of research outputs in academic units is used as a method of allocating funds, it is also used as a management tool to monitor the performed activities [20]. Nonetheless, methodologies for assessing the KT capacity of research organizations are still in their infancy and until the execution of this study the authors had not come across a tool that could evaluate the capacities of research organizations (university, faculty, public and private research centres and groups), nor the obstacles faced in knowledge translation. To our knowledge, existing questionnaires for assessing knowledge translation activities are completed by health researchers individually [21,22]. A framework has, however, been proposed by Lavis to evaluate 'linking research to action' measures from 'Push, Pull, and Exchange' aspects at national levels [19]. A questionnaire has also been designed by Tugwell et al to assess the capacity of low and middle-income countries for performing equity-oriented research at national levels [23]. Other studies conducted in this regard have mostly qualitatively assessed the quality of knowledge translation at organizational levels [4].
The comparison of organizational strengths and weaknesses, based on the scores gained through this questionnaire can help officials define intervention priorities. Prioritization, however, could not be done solely by comparing the statements' raw scores, since all these statements have equal weights but different significance and generalization values. For example, sending a reminder regarding the research results to decision makers is a simple process in need of few resources. Although the establishment of an organizational unit for improving knowledge translation is a costly strategy; it may be beneficial for developing strategies to promote KT, such as designing a guideline for publishing the results, and the development of regulations to support the intellectual rights of the researchers. The following steps can help prioritize KTE interventions: (1) preparing a list of the statements which have obtained low scores on the selfassessment test, (2) formulating intervention options, and (3) assessing the organizational context and different aspects such as feasibility, cost and chance of success for each intervention.
The pilot study conducted across 20 TUMS centres and departments showed that while conducting research and producing knowledge are performed with appropriate quality and timeliness in the university, there are significant weaknesses in the interactions between researchers and their research target audiences (both in selecting research priorities and transferring the results), securing the financial resources and following supportive regulations for knowledge translation activities. The comparison of the mean scores obtained in different domains confirmed that research capacity and knowledge production is acceptable but there are certain weaknesses in the aptitude of the last two domains of knowledge transfer and promoting the use of evidence.
In view of the weaknesses identified in our study, the main interventions needed for TUMS include: 1) Facilitating knowledge translation activities through provision of financial resources required for these activities; 2) Facilitating knowledge translation activities through creating supportive and facilitating infrastructures for these activities; 3) Facilitating interactions between researchers and target audiences to exchange questions and research findings.
The challenges faced by TUMS in knowledge translation issues are somewhat similar to those faced by other countries [24][25][26]. Though many investors in developed countries financially support knowledge translation activities [27], and have established certain structures and regulations to strengthen knowledge translation, the interaction between researchers and target audiences is still a major concern. Most of the interventions proposed to strengthen knowledge translation, even in developed countries, focus on facilitating and enhancing the interaction between researchers and research users [28][29][30].
The aim of this study was to develop a tool to identify the obstacles (weaknesses) in knowledge translation in TUMS-affiliated faculties and research centres. It seems the knowledge translation-related issues are somewhat similar in research organizations located in developed and developing countries. As a result, the standardizedversion of the tool can be used in other research organizations.
The SATORI has some particular aspects. First of all, this tool has been prepared on the basis of the "Knowledge Translation Model at Tehran University of Medical Sciences" on the grounds of domestic studies and a comprehensive literature review on knowledge translation barriers. And in addition to being used in Iran's academic environment, we believe it could be applied to other countries' research organization settings as well. This tool covers the most important activities, necessary resources and facilitating strategies for knowledge translation at the organizational level, and similar to its Canadian counterpart, this tool can also be used for re-evaluation of the organization's promotion in knowledge translation [17]. In addition, discussion and dialogue is possible concerning each statement of the tool that could lead to identification of intervention(s) regarding weaknesses of the organization. Finally, different perspectives could be elaborated upon and considered during the prioritization of interventions, since the discussion group consists of a variety of different stakeholders including members of research councils, research managers, researchers and research users.

Conclusions
In addition to identifying the weaknesses in the KT capacities of research centres and organizations, the tool can help develop interventional priorities to solve these barriers and difficulties. It seems that strengthening knowledge translation in TUMS will take place through the provision of financial support for knowledge translation activities, creating supportive and facilitating infrastructures, and facilitating interactions between researchers and target audiences.