Table 1 Knowledge-to-Action framework

Identify problem. Identify, review, select knowledge

Patient self-management training has increasingly become recognized as an important strategy with which to narrow the care gap. Several systematic reviews have examined the impact of diverse self-management interventions and have demonstrated positive effects on knowledge self-reported dietary habits[6], quality of life[3] and glycemic control[4, 6]. Despite the strength of this evidence base, participation in these programs is low. Given the growing prevalence of diabetes worldwide as well as the strong evidence base upon which available guidelines were developed, effectively bridging the knowledge to practice gap in this area has the potential to significantly improve health care outcomes and thus health care delivery and system sustainability.

Adapt knowledge to local context

In July 2008 the Ontario MOHLTC launched the Ontario Diabetes Strategy, to improve prevention and care for Ontarians with chronic diseases, starting with diabetes, through a mix of prevention, access to technology, personal planning and access to specialized resources and health professionals. All Ontarians with diabetes and their health care providers will be supported through a series of inter-related initiatives. As part of this larger initiative, there is an implementation plan for patient self-management tools, as well as a plan for measuring and reporting on improvements in clinical care and outcomes on a web-based patient portal.

Assess barriers to knowledge use

Barriers to knowledge use can occur at several levels, including the health care system, the health care team and organization, the health care profession, the patient and, finally, the guidelines or their education delivery system. Brown described a similar framework, and categorized barriers to diabetes care on three levels: organization, provider, and patient. Barriers at the patient level include acceptance of the diagnosis, education, self-motivation and adaptation to daily living. Poor adherence to guidelines may be a result of patient preferences, expectations or knowledge. Our initiative will focus on barriers at the patient level.

Select, tailor, implement interventions

(a) Selecting the intervention (Phase 1)

Web-based interventions have the potential to bridge the gaps in diabetes care and self-management. Two systematic reviews suggest that web-based media improve knowledge or understanding[9, 10], social support[10], behaviour change[10] and clinical outcomes[10] in a variety of disease states. (b) Tailoring the intervention. The intervention will be refined following feasibility (Phase 2) and usability testing (Phase 3) with patients with diabetes. (c) Implementing the intervention. The refined self-management tool (Phase 4) will be implemented in a pilot study (Phase 5).

Monitor knowledge use

A mixed method study, as described in the main text, will be conducted, consisting of an interrupted time series and individual interviews (Phase 5).

Evaluate outcomes

Sustain knowledge use

Barriers to sustained knowledge use will be addressed in the planning phase of tool development, implementation and dissemination, and further explored upon completion of the pilot study with qualitative methodology (Phase 5).