Reflections on the evidence integration triangle and its application to STD/HIV prevention interventions
The evidence integration triangle (EIT) model provides “a simple framework [that depicts] the complex multilevel contextual factors affecting the integration of scientific knowledge into practical applications” (Glasgow, Green, Taylor, & Strange, 2012, p. 647). Glasgow et al. (2012) characterize many current knowledge translation models as overly complex, academic, and/or time-consuming for users of knowledge, and note that their EIT framework is easily applicable and suitable in numerous and diverse contexts (Glasgow et al., 2012, pp. 646-647).
The EIT model employs a three-pronged approach that integrates an intervention program/policy, a participatory implementation process, and practical progress measures as three angles in a triangle. In the centre of this triangle are evidence and stakeholders, signifying the importance of these dual aspects in bringing evidence and policy closer together. The authors further note the significance of taking into account and properly addressing multilevel contexts. Finally, the relationship between the three prongs or angles necessitates feedback at all levels of the process (Glasgow et al., 2012, p. 647).
Perhaps the most crucial component of knowledge translation theories and frameworks is their applicability to and extent of use in real-life contexts. Although, it is understood that theory is by its very nature abstract (St. Lawrence & Fortenberry, 2007, pp. 23-24), the significance of the ability for frameworks to incorporate real-life situations cannot be overlooked. In particular, despite the EIT framework’s intention to offer a simple, uniform, and comprehensive method through which KT strategy can be viewed, as well as its usefulness in considering the factors that may affect and be affected by intervention implementation, some issues arise that also demonstrate certain shortfalls of the model in its entirety. In considering the EIT model, the following complexities are discovered.
Overall, the EIT model seems somewhat overly simplistic and abstract in its overall goal of providing a framework through which to view KT strategy. The triangle appears to have limited practical application in that it is difficult to apply to real-life contexts due to the lack of clear steps and processes. Furthermore, it is lacking an explanation of how each prong can affect and be affected by the other prongs, as well as how the evidence and stakeholders relate to the three prongs individually and as a whole. Most importantly, it doesn’t describe how multilevel context affects the process of the KT strategy (triangle), and how, due to the nature of the context as constantly changing, it doesn’t include sustainability of the intervention as a necessary component.
A variety of interventions have been suggested to prevent the spread of STDs/HIV, with backgrounds from a myriad of disciplines, though St. Lawrence and Fortenberry (2007) posit that such recommendations have fallen short of producing credibility and effectiveness as a method of best practice (St. Lawrence & Fortenberry, 2007). Although the authors describe in detail the different types of behavioural interventions that have been deployed in the fight against STDs/HIV, application of the EIT framework to these interventions evidence significant gaps. For example, the EIT model cannot account for the complexities of the relationships between stakeholder groups, particularly when vulnerable and/or hidden populations are involved, such as those most at risk of acquiring STDs/HIV. Further, the complexities of culture and society are neglected to the extent that the model lacks explanation of how they affect the KT strategy apart from simple including them within the multilevel context feature. Moreover, St. Lawrence and Fortenberry are quick to mention that interventions are lacking in “a thorough statistical evaluation demonstrating their effectiveness” (St. Lawrence & Fortenberry, 2007, p. 24), which may support the idea that certain interventions are more difficult to evaluate effectively than others. As the spread of STDs/HIV pose threats to the health and safety of communities, any intervention that has demonstrated efficacy must also be sustainable. (For more on implementation science in HIV/AIDS research, see resources.)
Essentially, the EIT framework can be useful and is a good start to the process of considering KT strategy, though that is exactly the point: that it is useful for preliminary consideration, but should not be employed without incorporation of other factors within and without the process. Importantly, we must recognize that certain issues in the public health field, such as STD/HIV prevention or illicit drug use, pose complex challenges to the health and safety of communities and cannot always be neatly categorized into a three-pronged approach for knowledge sharing.
Glasgow, R. E., Eckstein, E. T., & ElZarrad, M. K. (2013). Implementation science perspectives and opportunities for HIV/AIDS research: Integrating science, practice, and policy. Journal of Acquired Immune Deficiency Syndromes, 63(S1), S26-S31.
Glasgow, R. E., Green, L. W., Taylor, M. V., & Strange, K. C. (2012). An evidence integration triangle for aligning science with policy and practice. American Journal of Preventive Medicine, 42(6), 646-654.
St. Lawrence, J. S. & Fortenberry, J. S. (2007). Behavioral interventions for STDs: Theoretical models and intervention methods. In S. O. Aral & J. M. Douglas (Eds.), Behavioral interventions for prevention and control of sexually transmitted diseases (pp. 23-59). New York: Springer.