RESEARCH ARTICLE Open AccessIntegrated knowledge translation tostrengthen public policy research: a casestudy from experimental research onincome assistance receipt among peoplewho use drugsJoanna Mendell1 and Lindsey Richardson1,2*AbstractBackground: Solutions to complex public health issues should be informed by scientific evidence, yet there areimportant differences between policy and research processes that make this relationship challenging. Integratedknowledge translation (IKT) is a strategy of sustained stakeholder engagement that intends to address barriers toevidence use. We highlight an example of an IKT project alongside a randomized controlled trial of a public policyintervention that tested different disbursement patterns of income assistance among people who use drugs inVancouver, British Columbia.Methods: A case study design was used where an IKT strategy led by a knowledge broker embedded within theresearch team acts as the case. This case study evaluates the process and effectiveness of the integrated knowledgetranslation project by measuring intermediate outcomes within a Theory of Change created to map pathways toimpact. Content analysis was performed using an evaluation template through document review, post-eventevaluations, and detailed tracking of media, knowledge translation activities and requests for information.Results: A host of knowledge translation products synthesized existing research about the harms of synchronizedincome assistance disbursement and supported stakeholder engagement, facilitating conversation, relationshipbuilding and trust with stakeholders. Engagement improved knowledge of the contextual feasibility for systemchange, and contributed experiential knowledge to study findings. A combination of access to information andstakeholder and media engagement led to increased acknowledgement of the issue by policy makers directlyinvolved in the income assistance system.(Continued on next page)© The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License,which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you giveappropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate ifchanges were made. The images or other third party material in this article are included in the article's Creative Commonslicence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commonslicence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtainpermission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to thedata made available in this article, unless otherwise stated in a credit line to the data.* Correspondence: bccsu-lr@bccsu.ubc.ca1British Columbia Centre on Substance Use, Vancouver, British Columbia,Canada2Department of Sociology, University of British Columbia, Vancouver, BritishColumbia, CanadaMendell and Richardson BMC Public Health          (2021) 21:153 https://doi.org/10.1186/s12889-020-10121-9(Continued from previous page)Conclusions: This project shows how a multipronged approach to IKT addressed barriers to evidence-informedpublic policy and successfully contributed to increased public discourse around income assistance policy reform.Additionally, sustained engagement with diverse stakeholders led to improved contextual knowledge andunderstanding of potential community level impacts that, along with scientific results, improved the evidenceavailable to inform system change. This case study provides insight into the role IKT can play alongside researchaimed at public policy improvements.Trial registration: This IKT project was embedded within the study titled: The impact of Alternative SocialAssistance Disbursement on Drug-Related Harm (TASA), known as Cheque Day Study, registered onClinicalTrials.gov (NCT02457949) May 29, 2015.Keywords: Integrated knowledge translation, Stakeholder engagement, Evidence-informed policyContributions to literature
 Research on knowledge translation predominantlyfocuses on health care and/or behaviouralinterventions. This paper expands this literature byfocusing on the underexplored area of experimentalpublic policy research.
 This paper adds to the literature on how to evaluateIKT and how to overcome the challenges ofevaluating IKT such as data capture fromstakeholders and using policy change to measuresuccess of an IKT project.
 This case study examplifies how experientialknowledge and sustained stakeholder engagementcan improve public policy-oriented research.BackgroundRelying on traditional avenues of disseminating research(i.e. publications and presentations following the end ofa grant) overlooks several issues regarding the use of evi-dence. Such methods have been criticized for encour-aging decision makers to use research withoutacknowledging the barriers decision makers face inimplementing evidence-informed policy making [1]. Astrategy shown to be effective in improving the uptakeof scientific evidence into public policy development ismaintaining ongoing linkages between researchers andstakeholders to improve the evidence that is generatedas well as the readiness of the policy environment forthe uptake of findings [1–4]. Integrated KnowledgeTranslation (IKT) is an approach that prioritizes rela-tionships with stakeholders to co-develop and executeresearch questions [5–8]. In the pursuit of addressingcomplex social issues, IKT has been encouraged as away to amplify research impact [5–8]. Utilizing strategiesconsistent with IKT objectives, knowledge brokers areindividuals that work between stakeholder groups, to in-crease the impact of research evidence [9]. While therole of the knowledge broker will vary between researchcontexts, having a dedicated knowledge broker as part ofa research team is a way to operationalize and formalizeIKT within a research project.While health funders and IKT practitioners promotethe use of IKT strategies to influence healthcare policyand professional practice change [10], there are fewerdescriptions of the planning, implementation andimpacts of IKT processes, especially as they relate toevidence-informed public policy [4]. Additionally,models of stakeholder engagement vary in design and ef-fectiveness depending on the context [11]. To increasethe evidence base of IKT planning and implementationprocesses, we present here a case study of an IKTapproach embedded within an experimental studyinvestigating whether alternative income assistancedisbursement schedules mitigate payment-coincidentdrug-related harm. Conducted alongside a randomizedcontrol trial of a structural intervention, this case studyseeks to describe the planning, implementation and im-pact of IKT embedded within the study from initiationthrough to the release of preliminary study findings.Integrated knowledge translation and addressing barriersto research utilizationIKT is defined by sustained relationships with stake-holders throughout different stages of research with theintention of improving the strength, relevance, and mu-tual benefit of a research project [4, 5, 8, 11–13]. Whilesuch a process can be described by a range of terms (e.g.knowledge exchange, knowledge mobilization), we usedIKT to describe the intentional approach to engagingstakeholders from the beginning to the end of this pro-ject. Additionally, as is done elsewhere [14, 15] we dis-tinguish IKT from community-based participatoryresearch (CBPR), which is similar in its underlying strat-egy to improve research through co-creation of know-ledge with stakeholders, but differs in application. Adistinction is in how CBPR places control over researchwithin the community and/or knowledge users, and hasan embedded commitment to capacity building for com-munity research involvement in addition to the specificMendell and Richardson BMC Public Health          (2021) 21:153 Page 2 of 13goals of the research project [14]. IKT focuses explicitlyon expanding the awareness, reach and uptake of re-search more broadly across sectors [15]. In our researchcontext, where stakeholders spanned several power dif-ferentials from community to government, IKT waschosen as an approach to improve the impact of thisresearch.Reciprocal learning between researchers and stake-holders incorporates a variety of perspectives and experi-ences and introduces different forms of knowledge whendeveloping the research questions and procedures, con-sidering contextual information, and interpreting results[12, 16]. The intention with IKT is that research ques-tions become more relevant and solutions-based, evi-dence is more adaptable to decision maker contexts,there is increased trust of researchers and results amongknowledge users, and knowledge users become moreprepared to use results once they are available [4, 5, 12,16–18]. While the goals of IKT are well understood,there are research and policy processes that makeevidence-informed policy challenging in practice.Among the most problematic barriers to scientific evi-dence being utilized in policy are research not being dir-ectly adaptable to policy contexts or not being availablewhen policy makers need it [19]. The current study out-lines an IKT case study whose strategies sought to ad-dress these barriers, and contributes to the knowledgebase of whether and how such strategies bridge theresearch-policy divide.The research contextThis IKT project was embedded within a randomizedcontrolled trial entitled: The impact of alternative socialassistance disbursement on drug-related harm, knowncolloquially in the research site as the Cheque Day Study[20]. In the study context and other jurisdictions, in-come assistance is commonly distributed once a monthto all recipients on the same day. While income assist-ance critically reduces the harms of poverty [21], the sys-tem of synchronized disbursement has been shown tocontribute to a monthly cycle of escalations of severeharm coinciding with payments for people who use illicitdrugs. This trend has been widely acknowledged in Van-couver, Canada’s Downtown Eastside community, anddemonstrated by many years of observational research inVancouver and across North America [22]. Researchpoints to intensified and riskier drug use followingcheque issue as well as increases in related harm such asfatal and non-fatal overdoses, exposure to violence,emergency department use, police service calls, andtreatment or health care interruption [20, 23–36].Repeated calls for changes in the distribution systemto disrupt this monthly cycle of harm led to the initi-ation of the Cheque Day Study. This field experimentexamined whether changing the timing and frequency ofincome assistance payments would mitigate monthly es-calations of drug use and subsequent drug-relatedharms. Housed within the British Columbia Centre onSubstance Use and described in detail elsewhere [20]briefly, volunteer participants were recipients of incomeassistance living in Vancouver, British Columbia, whoduring screening by the research team reported increasesin drug use around payment days. In partnership with acommunity-located and operated branch of a localCredit Union, the study randomly allocated participantsto continue receiving income assistance on governmentcheque issue days (the study control arm) or one of twointervention arms that differed in either (1) the timing(once a month on a day outside of cheque week) or (2)the timing and frequency of payments (twice a monthon days outside of cheque week). The study tests the im-pacts of changing the income assistance payment sched-ules as a potential strategy to improve the health andwellbeing for people who use drugs and rely on incomeassistance as a source of income.MethodsFollowing ethical approval, the Cheque Day Study beganrecruitment in late 2015. The study had been collectingdata for 5 months when a full-time knowledge brokerjoined the research team to plan and implement an IKTstrategy alongside the Cheque Day Study. The IKT pro-ject took place over 3 years and sought to amplify theimpact the Cheque Day Study would have on mitigatingthe harm around income assistance payments. Theknowledge broker reviewed IKT literature and models,strategically developed an IKT plan, and worked withthe research team (the study’s Principal Investigator[LR], Research Coordinator, and Interviewers) to developKT products, recruit participants, arrange meetings, pre-sentations and exchange events with study stakeholders,and lead consultation for a Community Impact State-ment. This Community Impact Statement summarizedand highlighted stakeholder concerns and anticipatedimpacts of changing the way income assistance is dis-bursed. The knowledge broker kept a detailed impactlog that, along with meeting minutes, IKT and mediatracking, and an evaluation survey following a key know-ledge exchange event (a dedicated Community Forum),acted as the main data for the evaluation of this IKTproject. The impact log tracked each activity, itspurpose, the related IKT objective, the target audienceincluding characteristics of meeting attendees and stake-holders engaged, distribution, participants/reach, ex-pected outcomes, indicators, challenges/lessons learned,feedback received, and reactions from the research team.In keeping with the main purpose of developing The-ories of Change, the knowledge broker developedMendell and Richardson BMC Public Health          (2021) 21:153 Page 3 of 13pathways theorized to produce the desired impact(Fig. 1), explicitly outlining its purpose and strategy. TheTheory of Change also acted as a tool for evaluating theprocess of IKT in a way that did not solely focus on theimpact of a project, but also on intermediate outcomestheorized to help achieve that impact [37, 38]. The The-ory of Change used in this project draws from previouswork mapping how information access and stakeholderengagement can lead to social and political change [39]and incorporates strategic IKT areas from the CanadianInstitutes of Health Research model of KT [40].Working backwards from aspirational high-leveloutcomes, measurable intermediate outcomes and as-sumptions were outlined in the Theory of Change toconceptualize how that impact would be achieved. Threemain areas of IKT strategy were emphasized, drawing onIKT literature that identifies strategies that connectknowledge-based objectives with research processes: 1)Sourcing, synthesizing & co-creating information andmaking it accessible in different formats [5, 8, 39]; 2)Creating partnerships, networks as well as virtual andphysical spaces to bring different stakeholders togetherand solicit local and experiential knowledge [5, 8, 11–13,39]; and 3) Developing knowledge of the contextualfeasibility of changes to income assistance disbursementand how changes might be implemented in a real-worldcontext [12, 16, 41]. The CIHR model of IKT and Know-ledge to Action Cycle [40] was then adapted into astudy-specific model for IKT to highlight opportunitiesfor IKT activities across the research cycle. Activities topropel the underlying strategies of Theory of Changewere identified and added to this IKT model, as werethe corresponding strategies from the Theory of change(S1-S3) (Fig. 2).Data sourcesTo describe this IKT case, data were collectedthrough document review, an evaluation survey fol-lowing the Community Forum (Supplemental Table 1)and a detailed tracking of media, IKT activities andstakeholder requests for information or study results.An impact log was kept detailing each activity, reach(e.g., event attendance, number of KT products dis-seminated) and indicators of impact (e.g. knowledgeusers requesting study findings, policy makers publiclydiscussing the study or its preliminary results).Minutes of meetings with stakeholders were alsoreviewed, as were media stories. Following knowledgeexchange events, we asked participants to share theirexperience through a ‘dotmocracy’ style poster wherepeople were asked to place stickers on a poster to an-swer evaluation questions such as “Were you able toshare your opinion?” or “Did you learn somethingabout the research today?”AnalysisContent analysis was performed by the first author toidentify how IKT activities contributed to each of ourthree IKT strategies and indicators of outcomes outlinedin our Theory of Change. An initial coding template wasdeveloped based on predetermined evaluation questionsdesigned to test how well intermediate outcomes werereached (Table 1).Consistent with developmental evaluation principles,where questions are asked continuously throughout thelifespan of a project in order to improve and adapt pro-cesses in real time [42], coding was ongoing as researchprogressed, with defined check in points at 6 months, 1year, and 2 years. This ongoing approach to evaluationFig. 1 Cheque Day Study theory of changeMendell and Richardson BMC Public Health          (2021) 21:153 Page 4 of 13was chosen to help ensure we were meeting IKT goals,nd knowledge needs of stakeholders in a unique andcomplex context for IKT. Analysis was performedthrough document review of meeting minutes, theKnowledge Broker Impact Log, media stories and theCommunity Forum post-event evaluation survey. Inreviewing each of these data sources at the 6 month, 1year, and 2 year check points, data was input into thecoding template, at which point data were summarizedin an interim evaluation report identifying ‘successes’,‘gaps identified’, ‘priorities moving forward’, and ‘nextsteps’.ResultsEvaluation of IKT activitiesBetween the fall of 2013 and Spring 2019, over 600 indi-viduals were consulted as part of the IKT project. Thisnumber is an approximation as tracking the exactnumber of participants was difficult for some IKT events(e.g. community event-based outreach such as a booth ata Health Fair). A total of 67 organizations were con-sulted with an additional 44 directly contributing tostudy recruitment. KT products included: (1) plainlanguage summaries; (2) infographics and community-tailored research postcards summarizing pre-existingresearch about the harms of synchronized income assist-ance disbursement; (3) briefing notes; (4) technical re-ports; (5) research summary reports as results becameavailable; and (6) the Community Impact Statement. En-gagement with study stakeholders included presentationswith clinical and community service providers, regularcommunication and meetings with policy makers, com-munity events with people in the Downtown Eastside(including a Community Forum hosting 36 individuals),and eight other community engagement events.Additionally, we hosted two forums with first respondersincluding police, firefighters and paramedics. These en-gagement events contributed greatly to our third goal ofdeveloping knowledge about the contextual feasibility ofchanges to the income assistance schedule, and providedFig. 2 Cheque Day Study integrated knowledge translation modelTable 1 Example of evaluation questions in coding templateExamples of evaluation questions and sub questions Indicators, recorded at evaluation checkpoints 6months/1 year/2 yearsQuestion 1 How well is the study exchanging knowledge and soliciting feedback from stakeholders?SubquestionsIs the study effectively creating lines of communication with stakeholders?Does the study team create an environment for reciprocal learning?• # of KT events• # of people indicating they learned something ata KT event• reflection from research teamIs the study effectively synthesizing information about existing harms of chequeday?• # of different KT products produced• Feedback on KT products from stakeholdersQuestion 2 How well is the study developing knowledge of the contextual feasibility of ‘solutions’?SubquestionsWhat information is the study collecting about the wider context that affects/isaffected by a change in income assistance?• # of meetings with stakeholders• # of stakeholder groups contributing knowledgeIs the study considering other sources of knowledge? (i.e. experiential) • inclusion of experiential knowledge in KTproductsMendell and Richardson BMC Public Health          (2021) 21:153 Page 5 of 13the basis for the Community Impact Statement. A sum-mary of all IKT activities is provided in Table 2 and theircontribution to meeting the intermediate outcomes out-lined in the Theory of Change, 1) Information access, 2)Engagement, and 3) Understanding and acknowledge-ment are discussed in detail below.Information accessSourcing, synthesizing, and summarizing existing re-search and making it available to stakeholders was avaluable first step in this project. Most IKT activities re-quired providing background to explain the problemand why the research was being done. Summarizing andsynthesizing this work into stakeholder-appropriate ma-terials facilitated conversation with stakeholders, and insome cases served as a pretext for engaging with stake-holders. This was an important part of improving under-standing and awareness. Additionally, requests werecommonly made from different stakeholders (e.g. atcommunity events) for information about where alterna-tive income assistance schedules had been tried. Know-ing where the gaps in information were was importantto increase understanding and awareness, develop know-ledge of why the study was needed as well as improvetrust and relationships between stakeholders and theresearch team.Stakeholders had access to a variety of KT productsaccessible from the study website with varying levels ofdetail to allow them to choose the level of informationthey wanted or needed. Another strategy was to usevisually engaging media that were informative and pro-viding information alongside something useable. For ex-ample, research summary postcards displayed an originaland picturesque photograph taken in the DowntownEastside neighbourhood that could be used as artworkon one side and included information regarding a pub-lished research study on the back. Feedback from thecommunity about the design of these KT products wasoverwhelmingly positive.EngagementEngagement with stakeholders began before study initi-ation with representatives from provincial and municipalgovernment and health authorities, community organi-zations, service providers and people with lived experi-ence(s). This early engagement informed the studyprotocol and research procedures and served to raiseawareness about the issue and the study. As researchprogressed, the study team maintained lines of commu-nication with these and additional stakeholders throughemail or phone call updates, presentations, meetings orstudy newsletters, with tailored strategies for differentstakeholder groups. For example, email or phone callupdates were the most appropriate for some key stake-holders such as those in policy and/or leadership posi-tions, while for local residents and people with livedexperience(s) presentations, community events, andnewsletters were better suited to community needs.Networking and accessing diverse perspectivesAs stakeholder engagement continued, a number of keypartnerships developed with established coalitions andorganizations that do outreach in the community as partof their organizational mandates. Connecting with theseorganizers in the study context was instrumental in de-veloping a broader network, securing access to a widerrange of organizations and connecting with people thathad not been interested or willing to speak with us priorto being introduced through these organizations.Conversations with harder to reach groups were essen-tial in our efforts to collect contextual information asthey provided different and contrasting perspectives thanthose already supporting the changes being evaluated bythe Cheque Day Study. In addition to refining investiga-tors’ understanding of their reticence for change, thevarying perspectives collected from stakeholders werehighlighted in a Community Impact Statement. ThisCommunity Impact Statement documented diverse per-spectives in a balanced way, intending to profile the im-portance of considering different viewpoints by policymakers when designing policy changes that will differen-tially impact many stakeholders.Access to diverse perspectives ensured that these couldbe included and centered on an ongoing basis, which webelieve reduced community stakeholder perceptions ofbias, this was certainly salient at The CommunityForum. This forum was held at a university-affiliatedorganization in the Downtown Eastside with a centralstorefront location and attended by 36 people who liveand/or work in the neighbourhood, with 25 organiza-tions represented at this forum. Convening of peoplefrom different organizations alongside neighbourhoodresidents provided a forum to hear each other’s con-cerns, exchange ideas, and ask the research team ques-tions. Several people indicated that having the chance todiscuss with other organizations helped them betterunderstand the context and perspectives outside theirown experience. In other community meetings commu-nity members voiced how it felt good that their opinionsseemed to matter. One example is from a resident at alocal single room occupancy hotel, whose feedbackstated: “I am glad to see my insight be valid & validated,Thank you”.Policy engagementAs income assistance is managed through the BC Minis-try of Social Development and Poverty Reduction, andMendell and Richardson BMC Public Health          (2021) 21:153 Page 6 of 13the health impacts of drug-related harm were of coreconcern to the Ministry of Health and Ministry of Men-tal Health and Addictions, provincial policy makers werea priority stakeholder group. Despite interest in reducingthe health harms from substance use from officials inthe Ministry of Health, at study initiation policy makersdirectly involved in income assistance policy identifiedthat changing the schedule of income assistance dis-bursement was not a priority. Consistent with theTheory of Change and its constituent strategies, commu-nication began prior to study initiation and was sus-tained throughout the study with the intention to primethe political environment for the uptake of study results.Initial indicators of successful engagement with policymakers came from media statements by government of-ficials. In March 2018, the Minister of SocialDevelopment and Poverty Reduction said in a mediainterview: “We know there could be unintended conse-quences of making these changes, and we’re very muchinterested in determining what those implications mightbe. That’s why we’re supporting the research that’s beingdone by the BC Centre on Substance [Use]. They’vebeen looking exactly at this cheque day issue, and whatthe impacts are. And I’m hoping that we’re going to seesome results from that in the coming months” [43].Additionally, in April 2019 the Minister of MentalHealth and Addictions provided the following statementin a media interview in response to an opposition polit-ician tabling a private members bill requesting that a re-vision to the income assistance disbursement schedulebe explored: “We will see what [the BC Centre on Sub-stance Use] has to say and we will take action if it meansTable 2 Reach metrics by IKT strategic areaQuantity Description of IKT product or activityA. Synthesis and dissemination14 KT products summarizing existing research on harms coinciding with synchronized income assistance disbursement (e.g. plain languagesummaries, research summary postcards and infographics)2 Graphic recording posters creating during the Community Forum49 Media stories citing research/interviews with study team8 Media stories related to the issue of cheque day1 Study webpage hosting KT products2 KT products summarizing interim results for provincial policy makers (briefing note and technical report)4 KT products summarizing initial results for different audiences (briefing note, technical report, one-page summary of results, and an 8-page summary of initial analyses)7 Presentations of initial results (1 people with lived experience(s), 2 academic, 1 policy makers, 1 community, 1 mixed audience includingresearchers, policy makers, service providers etc., and 1 presentation to Vancouver City Council)B. Networking, relationship building & communication7 Key relationships established prior to study initiation) with representatives from The BC Ministry of Social Development and PovertyReduction, The BC Ministry of Health, Vancouver Coastal Health, City of Vancouver, Vancouver Police Department, Providence Health Care,PHS Community Services Society, VanCity Savings and Credit Union, Vancouver Area Network of Drug Users, and the Western AboriginalHarm Reduction Society22 Presentations/consultations with clinical and community service providers1 Community Forum with 36 individuals representing 25 organizations (community members and community service providers)8 Community engagement events (6 organized by us, 2 we attended)7 Other stakeholder engagement meetings (research groups, community networks)9 Meetings with policy makers2 First responder forums attended by 25 police officers, fire fighters and paramedics600 Individuals involved in knowledge exchange events67 Organizations consulted44 Other organizations involved with recruitment2 Newsletters disseminated to 107 stakeholdersC. Developing knowledge of contextual feasibility1 Provincial survey about experiences with cheque day and potential impacts of changes the system with 39 respondents from 8communities across BC1 Video that shared experiential knowledge in the form of interviews with people affected by Cheque Day1 Community Impact Statement (report summarizing all consultation work)Mendell and Richardson BMC Public Health          (2021) 21:153 Page 7 of 13people making people safer” [44]. Additional discussionswith senior policy and decision makers indicate a highlevel of interest in the results from this research, sug-gesting the importance of early and consistent engage-ment. Outside of provincial ministries, senior officialswithin health authorities have also been engaging withstudy results, indicating their interest in examining po-tential policy reforms.Engagement with Cheque day study resultsAs preliminary results from the scientific study werecomplex, identifying signals for both benefit and in-creased harm from a revised schedule [45, 46], engage-ment in the weeks leading up to preliminary resultsbeing available involved the development of a coordi-nated strategic launch to the scientific community,policy and community stakeholders, and the media toimprove the likelihood that results would be interpretedin a balanced way, avoiding oversimplification or sensa-tionalized reporting. Ahead of the public release of pre-liminary findings, the research team consulted peoplewith lived experience(s) around findings and recommen-dations, provided an embargoed news release and ac-companying media interviews, and communicated withpolicy makers in government, providing a confidentialtechnical report and policy brief. The messaging aroundthe complexity of results and nuanced recommendationswere successfully communicated as evidenced by thenarratives surrounding the release of findings includingmedia stories as well as comments from government of-ficials and community stakeholders.Another indicator of engagement with the researchwas the more than 80 requests for results that havecome from several stakeholder groups, including provin-cial ministries, health authorities, public health organiza-tions, first responders, media, community organizations,service providers, other researchers, and private individ-uals interested in results, including a keynote presenta-tion to policy makers, academics, and first responders atsummit coinciding with the release of results.Understanding and acknowledgementOne of the most significant outcomes of this IKT projectwas the reciprocal learning that study team was able todo with stakeholders (community members, clinical andcommunity service providers, first responders, policymakers at multiple levels of government) and the con-textual knowledge this work was able to provide. Whileat the outset of the project, the main IKT goal was tohelp research results have impact, as we learned more,and witnessed variation in experiences for participants,we realized the potential importance of the IKT in termsof developing a more fulsome understanding of thestudy context, the value of listening to and incorporatingconcerns in the community into the broader studyprocess and anticipating potential impacts of a changeto the income assistance distribution schedule.The community impact statementGiven the range and heterogeneity in concernsexpressed by stakeholders about a change in the incomeassistance disbursement schedule, our IKT goals evolvedto prioritize highlighting experiential knowledge in thecommunity of relevance for policy makers and serviceproviders should reform be considered. This was under-taken through the development of a Community ImpactStatement, a report summarizing perspectives gatheredfrom stakeholders including recipients of income assist-ance, people who use drugs, people who provide supportservices, first responders and policy makers at variouslevels of government. As heard during a communitymeeting, speaking with people who might not want orbe able to participate in the study was an important wayto expand our knowledge about the context, and poten-tial implications of policy reform. One community mem-ber articulated, “Even if the study is voluntary for peoplewho want to make this change, a change may not be vol-untary, so you need to think about who may be affectedby a change and speak to them, whether or not they arewanting to take part in the study”. The Community Im-pact Statement served as an indicator of the reciprocallearning and a centering of diverse viewpoints. It in-creased understanding that the research team drew sig-nificantly on from consultations in their work and was atool to increase understanding and awareness for thoseengaging with results. This Community Impact State-ment was presented alongside scientific results and wasreferred to both by the media and by policy makers.Public acknowledgement of the issueIn the lead up to the release of research findings inspring 2019, policy makers from three provincial minis-tries requested study results. The research team metwith senior policy makers to present initial findings tothose who showed interest in study results. Key indica-tors that income assistance disbursement schedule re-form is being considered in the public domain include aPrivate Member’s Bill being submitted by the oppositiongovernment in the Legislative Assembly of BritishColumbia calling for changes to the income assistanceschedule to be considered [47], and Vancouver CityCouncil passing a motion to support changes at the pro-vincial level [48], during the deliberations for which thePI was invited as a speaker. Political activity in supportof income assistance schedule reform reflects a signifi-cant change in acknowledgement of the issue by thoseresponsible for income assistance policy or in positionsto advocate for policy reform at senior levels ofMendell and Richardson BMC Public Health          (2021) 21:153 Page 8 of 13government. Whether there will be change and howchanges would be implemented are yet to be seen, how-ever these results are indicative of success with the inter-mediate outcomes of engagement, increased awareness,and acknowledgement of the problem.DiscussionSolutions to complex public health issues, like themonthly harm of synchronized income assistance,should be informed by the best possible evidence, butthere are barriers that often prevent the uptake of avail-able evidence. These include, but aren’t limited to, thetiming of research not matching up with windows forpolicy change, research not being directly relevant oradaptable to policy context, the absence of personal con-tact between researchers and policymakers, research evi-dence conflicting with policy or political agendas, andinsufficient evidence from a practical implementationperspective [11, 49]. In the case of the Cheque Daystudy, while multiple studies had previously called for achange to the distribution schedule of income assistance,discussion of that change was largely absent from thepublic sphere, and no scientific evidence had exploredthe practicalities and potential impacts of implementingsuch a change. To supplement the Cheque Day Study,which to our knowledge was the first study to experi-mentally test alternatives to synchronized income assist-ance payments [20], an IKT Theory of Change wasdeveloped aimed at addressing barriers to the use of evi-dence. This Theory of Change tested the hypotheses thatsustained engagement and access to accessible informa-tion would improve understanding and awareness of theresearch-related issues among knowledge users, in turnleading to increased buy-in and strengthened potentialthat research results would support policy or program-matic change. Additionally, it anticipated that meaning-ful engagement with stakeholders would improve thequality, relevance and usability of research evidence byimproving the understanding of the context and poten-tial impacts of a change among researchers.Beyond policy impactThe Cheque Day Study IKT project took on greater im-portance as the study progressed than initially conceptu-alized. In the best-case scenario where a study is able toprovide a clear recommendation for action, IKT intendsto amplify the impact of research evidence throughmechanisms like co-creation of knowledge, priming thepolicy environment for the uptake of findings, and im-proving trust with stakeholders, including policy makersand community members [1, 5, 8, 11–13, 16]. In morecomplex cases, this work can become even more import-ant to add depth of and nuance to stakeholder andpublic understanding. In the current case, considerationof the complexity of results was and continues to beneeded from stakeholders to determine an ethical,evidence-based path for reform. The IKT activitiesundertaken alongside the research critically providedcontextual understanding, legitimacy among stake-holders and insight into the potential impacts of policychange. As such, IKT can expand the scope and reach ofa project, ensuring appropriate impact within and be-yond the original project goals.In the current study context it was important to listento a broad range of stakeholders and revisit and revisethe Theory of Change as more information becameavailable. It was also important to be flexible and adaptplanning where originally conceptualized activitieswould not have effectively achieved high-level impacts asthe project, research environment and policy contextevolved. For example, the Community Impact Statementwas not part of our initial workplan, but as stakeholdersexpressed heterogeneous and often contradictory con-cerns about income assistance system reform, an im-portant part of providing the best possible evidence torelevant stakeholders required the inclusion of this infor-mation. The Community Impact Statement directly re-flects the reciprocal learning that occurred duringconsultation and addressed the intermediate outcomesgoals of understanding the context for implementingchange as well as being able to anticipate community-level impacts from change.Importance of experiential knowledgeIKT research, as with other participatory researchmethods, highlights the value of including other formsof knowledge together with scientific evidence and aca-demic expertise [1, 3]. The importance of experientialknowledge became increasingly evident as this IKT pro-ject progressed. It was important to reflect that studyparticipants had varying experiences of the interventionand people consulted during the IKT engagementprocess anticipated impacts outside of those witnessedin the study population. This also promoted understand-ings that some of the potential impacts would be re-search study-specific: the study changed the schedule foronly a small proportion of those receiving income assist-ance in the community. Stakeholders discussed potentialimpacts of widespread system change if everyone in thecommunity were paid on different days. As participationin the study was voluntary, observations within the studysample may change if such reforms are brought to scale.As such, consulting with people who were not interestedor eligible to participate in the study provided more un-derstanding about what broad change might look like incommunities. This heterogeneity in the community per-spectives, alongside complex research findings supportedMendell and Richardson BMC Public Health          (2021) 21:153 Page 9 of 13recommendations to government that focused on devel-oping the capacity to adapt individual payment sched-ules to recipient needs. The experiential knowledgecollected alongside the study will provide invaluable in-formation regarding next steps in any potential reformprocess.LimitationsA limitation of this case study was the restricted amountof data we were able to collect about IKT activities fromstakeholders. In projects like this, where we are askingfor people’s time to engage with our research and toprovide their expertise, it is often inappropriate to subse-quently ask them to spend time answering questions re-garding their engagement with us, and even less so toask for before-and-after data on either side of an IKT ac-tivity to test changes in awareness or understanding.This was particularly true for two of our key stakeholdergroups, government officials and community membersin the Downtown Eastside of Vancouver, for different,but important reasons. Briefings with policy makers in-volved us requesting time from government officials toengage with us about the research, with the limitedamount of time awarded for these conversations, ourtime was devoted to discussing the substantive issue athand rather than KT processes. In such instances it maynot be appropriate after a meeting for us to ask for feed-back regarding the influence the meeting had, andrequesting additional time in this way could negativelyimpacted future requests for meetings. Additionally, wewanted to be cognisant of the response burden on aheavily researched population in the Downtown Eastsideof Vancouver [47]. We thought carefully about time wewere asking people to invest, and of how to ensure thatthis time was meaningfully contributing to improve-ments in research. It was therefore not part of ourevaluation design to conduct such interviews with stake-holders to track how our IKT work influenced under-standing, awareness, political will, or whether and how itmet stakeholder information needs. In the case of theCommunity Forum it was possible to conduct an evalu-ation survey to elicit some of this information. Anotherstrategy we used to elicit feedback after community en-gagement events was “dotmocracy”, but such attemptshad very low participation, potentially pointing to lowinterest to provide additional self-reflexive feedback inIKT processes in a heavily researched community.Extracting data from stakeholders is particularly challen-ging in a project that prioritized soliciting experientialknowledge from many stakeholder groups to enrich thecontextual information of the research. Instead of havinga small group of deeply involved stakeholders, we had alarge group of stakeholders who engaged in a less con-sistent way.Additionally, this case study relied on evaluating inter-mediate outcomes that the Theory of Change hypothe-sized could influence a policy change rather thandirectly measuring policy change. While evaluating long-term change ideally describes how IKT can amplify re-search impact, this type of intermediate reporting canhelp deepen understanding of the pathways to impactand is an important but often neglected part of the evi-dence base for this type of research activity. Measuringthe impact of IKT through policy change is unrealistic inmany cases, and may miss the wider impact IKT canhave on a research project or public policy area. Kothariand Wathen (2013) discuss, the “positivity bias” whereresearchers assume that findings of a study will contrib-ute to positive change. Due to this bias, researchers andstakeholders alike will go into a project assuming thatchange will be warranted from findings of the study. Inmany cases a single study will not provide the evidencenecessary to elicit such change [1] and it if does, it is dif-ficult to attribute causation to a specific study [50].Therefore, using policy change to measure success ofIKT may unfairly evaluate a project as unsuccessful.Measuring intermediate outcomes may help to describebenefits of IKT independently of policy change. Thechallenges in measuring the impact of IKT may contrib-ute to the lack of reported cases of IKT. We chose to re-port on our project in the absence of (or advance of) anypolicy change to contribute to the evidence base for theimpact of IKT on public policy research, and helpinform other projects implementing similar IKTinterventions.Lastly, this IKT project was led by a dedicated know-ledge broker [JM] who over the course of three-yearsworked full time to plan and execute the activities de-scribed here. Even whilst having a full-time knowledgebroker, this IKT project demanded a substantial amountof time from the study’s PI and Research Coordinator.Having a dedicated position for IKT is not common, andas such, replicating a similar IKT project could be diffi-cult for a research team considering the time commit-ment required to undertake this work.ConclusionThis case report details an IKT project nested within apolicy-relevant experimental study, and outlines howsustained stakeholder engagement impacted the depth ofunderstanding and acknowledgement of the issues sur-rounding synchronized income assistance disbursement.However, a number of factors make it difficult to drawconclusions about the direct pathway between effortsand outcomes from in this project. The difficulty withdata capture from knowledge users and the inappropri-ateness of before-after testing in our context made itchallenging to assign causality to individual knowledgeMendell and Richardson BMC Public Health          (2021) 21:153 Page 10 of 13exchange activities in relation to our stated objectives.However, we are able to conclude that the combinationof activities undertaken alongside the Cheque Day Study,in conjunction with the fact that this study sought to re-solve a salient social and health issue, contributed to anumber of outcomes of importance to reform efforts.For example, the IKT activities in this report raised con-siderable awareness and attention: the provincial govern-ment admitted the current system is flawed [43, 44]; wereceived requests for scientific results from over 80 indi-viduals and organizations including the provincial minis-try that manages the income assistance system; therewas widespread media engagement and coverage; therehas been considerable political activity and public refer-ences to the study by senior elected officials; the studycaptured invaluable experience within the community ina Community Impact Statement that accompanied re-search results and helped craft nuanced recommenda-tions for policy change.The IKT alongside the Cheque Day Study helpedprime the research context for study results to supportthe development of a more public-health promoting in-come assistance disbursement system. We anticipatethat evidence will be used by policy makers and serviceproviders to improve the current system throughchanges within the Ministry of Social Development andPoverty Reduction, programming through communityorganizations to support people around income assist-ance payments, and the possibility to develop innovativeprivate solutions to support public health-promoting in-come assistance disbursement strategies.Our experience with this IKT project supports the ne-cessity for multipronged approaches that address bar-riers to evidence usage in specific research contexts. Assuch, to maximize the policy and community impacts ofresearch requires more than generalized end of projectKT efforts that expect policy makers to simply adoptevidence-based recommendations. Synthesizing andsummarizing related research was important to outlinethe impetus for the study, and helped with stakeholderengagement and relationship building. Building relation-ships and meaningful consultation with stakeholdersadded the value of experiential knowledge, improved thedepth of understanding that the research team was ableto incorporate in their efforts and provided invaluablecontextual knowledge for policy reform recommenda-tions and efforts. Sustained relationships with a widearray of stakeholders, in addition to providing invaluableexperiential knowledge, led to substantial engagementwith results and the issue being discussed in community,among service providers, in the general media as well asin municipal and provincial governments, indicatingengagement, awareness, and acknowledgement of the is-sues associated with synchronized income assistancedisbursement. As demonstrated by this project, IKTpractice has the potential to improve the quality and us-ability of research by including experiential knowledge,influence public acknowledgement of an issue, and amp-lify the impact of public-policy focused research.Supplementary InformationThe online version contains supplementary material available at https://doi.org/10.1186/s12889-020-10121-9.Additional file 1: Supplemental Table 1. Community forumevaluation surveyAbbreviationsIKT: Integrated Knowledge Translation; KT: Knowledge translation; TASA: Theimpact of Alternative Social AssistanceAcknowledgementsWe would like to thank everyone who participated and contributed theirtime and experience to inform this work. Thank you to research staff whohelped with knowledge exchange activities, in particular Allison Laing, theCheque Day Study Research Coordinator who supported the knowledgebroker throughout the project and attended nearly every communitymeeting and event. Additionally, we would like to thank Kevin Hollett,Associate Director of Communications at the BC Centre on Substance Usefor his communication support, particularly around the public release offindings.Authors’ contributionsJM and LR designed and implemented the IKT project described herein. JMdesigned the theory of change and evaluation strategy and collected andanalyzed data. JM took the lead on drafting this manuscript while LRprovided substantial written contributions and guidance in its planning andpreparation. Both authors read and approved the final manuscript.FundingThis work was made possible by dedicated knowledge broker funding fromthe Michael Smith Foundation for Health Research. The Cheque Day Studywas supported by the Canadian Institutes of Health Research (MOP 136827,137068), a PHCRI and VCHRI joint Innovation and Translational Award fundedby the Providence Health Care Research Institute, and a Wall SolutionsInitiative Grant from the Peter Wall Institute. Lindsey Richardson is supportedby a New Investigator Awards from CIHR (MSH 217672) and a Scholar Awardfrom MSFHR. Her research is additionally supported by a CIHR FoundationGrant (FDN-154320). The funders had no role in study design, data collection,analysis, or interpretation, or in writing this manuscript.Availability of data and materialsThe datasets used and analyzed for the current study will be available fromthe corresponding author upon reasonable request.Ethics approval and consent to participateThis IKT project was embedded within the study titled: The impact ofAlternative Social Assistance (TASA), known as Cheque Day Study, registeredon ClinicalTrials.gov (NCT02457949). All participants were required to providewritten informed consent prior to their enrollment in the study. We alsodeclare that this work and its parent study received ethics approval from theUniversity of British Columbia/Providence Health Care Research Ethics Board(H14–02401) and that no additional consent for publication is required.Consent for publicationNot applicable.Competing interestsThe authors declare that they have no competing interests in this section,financial or otherwise.Mendell and Richardson BMC Public Health          (2021) 21:153 Page 11 of 13Received: 28 May 2020 Accepted: 23 December 2020References1. Kothari A, Wathen CN. A critical second look at integrated knowledgetranslation. Health Policy. 2013;109(2):187–91.2. Landry R, Lamari M, Amara N. The extent and determinants of the utilizationof university research in government agencies. Public Adm Rev. 2003;63(2):192–205.3. Wathen CN, MacMillan HL. The role of integrated knowledge translation inintervention research. Prev Sci. 2018;19(3):319–27.4. Gagliardi AR, Berta W, Kothari A, Boyko J, Urquhart R. 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