Knowledge translation strategies for sharing evidence-based health information with older adults and their caregivers: Findings from a co-design study

Background By understanding the information seeking behaviors of older adults, we can better develop or iterate effective information technologies, such as the McMaster Optimal Aging Portal, that provide evidence-based health information to the public. This paper reports health-related information seeking and searching behaviours and provides strategies for effective knowledge translation (KT) to increase awareness and use of reliable health information. Methods We conducted a qualitative study with eighteen older adults using a design-thinking approach whereby participants created personas and scenarios describing older adults seeking health information. Scenarios were analyzed using a two-phase inductive qualitative approach, with the personas as context. From the ndings related to pathways of engaging with health information, we identied targeted KT strategies to raise awareness and uptake of evidence-based information resources. Results Twelve women and six men, 60 to 81 years of age, participated. In pairs, they created twelve personas that captured rural and urban, male and female, and immigrant perspectives. Some scenarios described older adults who did not engage directly with technology, but rather accessed information indirectly through other sources or preferred nondigital modes of delivery. Two major themes regarding KT considerations were identied: connecting to information via other people and personal venues (people included healthcare professionals, librarians, and personal networks; personal venues included clinics, libraries, pharmacies, and community gatherings); and health information delivery formats, (e.g., printed and multimedia formats for web-based resources). For each theme, and any identied subthemes, corresponding sets of suggested KT strategies are presented.

This paper reports on a subset of ndings from the rst phase of an overarching three-phase project. The purpose of the three phases were to: 1) use a design-thinking approach to better understand the needs of older adults with respect to health-related information seeking and searching (this paper); 2) summarize user requirements, engage with Portal decision-makers to inform feasibility and viability, and apply phase one ndings to the development of prototypes intended to facilitate the effectiveness of the Portal in promoting evidence uptake by older adults; and 3) conduct a preliminary evaluation of those prototypes.
In the rst phase, we conducted a qualitative study employing the persona-scenario method to co-design a set of generic design speci cations that could be applied to any ICT [21]. This innovative design approach engages users to inform program or resource development in a way that centralizes their perspectives when determining user requirements [22,23,24]. By engaging users in the process, ideas are not limited to those of the research and design teams [25]. Through this study, we gained insight into the ways in which older adults actively seek or passively encounter health information. This paper provides a systematic report of our ndings related to these "pathways of engagement" and suggests targeted KT (implementation) strategies to raise awareness and uptake of evidence-based information resources like the Portal. Knowing where older adults look and who they trust, we have compiled a series of KT strategies supported by previous evidence [26][27][28][29][30][31]. The suggested KT strategies and products can be incorporated into multifaceted KT plans for sharing health information and resources with older adults, including through ICT.

Methods
The methods have been described in detail elsewhere [32]. Brie y, we recruited 18 community-dwelling adults, aged 60 years and older, living in southern Ontario, Canada, who could read and speak in English.
In the persona-scenario approach, participants are asked to create a ctional character (persona), and then develop a narrative story (scenario) featuring their persona, including their thoughts and actions, as their persona addresses requested tasks [24]. Working in pairs, participants were guided to create a ctitious but realistic older adult persona and then create a related scenario in which the persona sought health information related to a personal health concern or health improvement goal. Participants were asked to consider a set of guiding questions to develop their persona and scenario, described in more detail elsewhere [32]. Importantly, they were not guided to consider any speci c ICT source, such as the Portal. Participant pairs created one or two persona-scenarios each, where personas varied in gender, age, comfort with technology, health concerns, available social support, and access to primary care. At the end of the scenario sessions, participants described their personas and their health information-seeking scenarios to the larger group. Towards the closing of the session, the facilitators performed a member check, seeking feedback from participants to a rm the details from the session, by providing a verbal summary of the main messages heard and highlighting similarities and differences across personascenarios created by other participant pairs in the room.
We analyzed the transcripts of persona-scenario summaries according to a two-phase inductive qualitative approach-the rst phase descriptive, and the second phase interpretive. Using NVivo 11 QSR International software, the rst phase involved open coding primarily focused on identifying user requirements to inform the design (e.g., mode, depth of content, presentation elements) of ICT to deliver evidence-based health information to older adults or their caregivers. In this phase, we also identi ed considerations relevant to promoting greater access by this group. In the second analysis phase, user requirements and KT considerations were interpreted and translated into design speci cations (i.e., generic recommendations relevant to the design of any technology for delivering evidence-based health information to older adults).
The design speci cations were grouped into four major categories: 1) content, 2) framing of content, 3) functional speci cations (technical formats and functionalities) [32], and 4) KT strategies. Herein we present the results of the KT category. We employed the Knowledge Translation Planning Template [26] to map actionable KT strategies and information products geared to older adults based on the information seeking behaviours described in the scenarios. The planning template guides knowledge creators through the steps of identifying knowledge users, the main messages to share, and the goals of the KT strategies.

Results
Of the eighteen participants, twelve were women and six were men; ages ranged from 60 to 81 years. The 12 personas that were created captured some rural and urban, male and female, and immigrant perspectives.
Two major themes were developed from the analysis of persona scenario data regarding KT considerations: connecting to information via other people and personal venues (where examples of people include healthcare professionals, librarians, and personal networks; and examples of personal venues include clinics, libraries, pharmacies, and community gatherings); and health information delivery formats (e.g., printed and multimedia formats for web-based resources). For each theme, and any identi ed subthemes, a corresponding set of suggested KT strategies that could include some or all of the following: a) educational outreach/materials, b) information technology decision support, c) interactive small group sessions, d) media campaign/social media, e) champions/opinion leaders, and f) conferences.
Theme 1: Connecting to information via other people and personal venues Subtheme: Trust in health information from healthcare providers The scenarios indicated that older adults rely on their healthcare providers (e.g., family physicians, pharmacists) for information about their health and healthcare. For example, Mabel regularly relies on her physician for information: "Once a week Mabel still visits the doctor to rely on his information. The doctor discusses the information and then asks his nurse to provide a handout." These healthcare providers are trusted sources of information, as illustrated by Frank: You can trust something if it's available in a doctor's o ce, but if you get it elsewhere you can be a bit skeptical, especially if it's online… knowing who the source of the information is and does the information seem reasonable…that it should be aligned with a health care professional.
Given the important roles that healthcare providers play as trusted sources of information, tailored KT strategies to increase awareness of the Portal and similar ICTs among providers are recommended ( Table 1). The goals should be to increase knowledge and use of the ICTs by practitioners to support educating their patients. • Encourage clinicians to push health promotion and health information to patients through targeted emails or using ICT functionality within their health record • Enable push noti cations or messages that contain a website link to access information on applicable health conditions (e.g., facts of the week), and noti cations for their care plans (e.g., appointment times) Champions/opinion leaders • Develop relationships and connections with various health professionals to promote awareness of ICTs, including primary health care practitioners, regional health organizations, home health care and telehealth nurses, optometrists, and pharmacists, traditional healers Subtheme: Librarians and libraries as knowledge hubs Libraries were described as social and knowledge hubs for the personas, "[Alice] often peruses the collection of pamphlets for health-related topics…if, in fact, the library doesn't have that sort of information that would be one channel to get the information out." Several scenarios described roles for librarians as knowledge brokers, including: "she heads to the library and she asks the librarian for help for information" (Edna) and "the usual way she has of getting trusted health information is she goes to a library to access internet, and to read books, access magazines, get help from the librarian…" (Sally). Evaluation metrics to determine the value of the approaches could capture interactions focused on health information seeking between older adult patrons and library staff, usage of the ICTs such as the Portal at libraries, training modules for library staff on how to use and connect older adults to ICT resources, and changes in health-related information provision skills among library staff (Table 2). Family members were common sources of health information and support among the personas: "He tried to use a computer but without much success, so he relies on his daughter for any advice and questions he has about medicine." (Jack). Getting trusted and reliable information to these knowledge users is important. Personas relied on offspring, spouses, and other relatives, as well as friends and caregivers in their communities. Recommended KT strategies include small group sessions facilitated by peers, creating resources for family and other informal caregivers and making them available in primary care o ces, and developing public campaigns to increase awareness of these evidence-based sources of information (Table 3). Other venues that were mentioned included coffee shops, malls, organizations like the Heart and Stoke Foundation of Canada, and local hospital waiting rooms. KT strategies in the community could target community centres as avenues for passive dissemination of brochures or small group education sessions for community service providers and patrons of the centres (Table 4). Similarly, another scenario identi ed multifaceted information seeking approaches which also highlighted the need for consistency in information provided across sources: Alice talked about getting information at her doctor's o ce or at the library and sometimes from her daughter and sometimes on a website, and the need for that to be similar or else that could be confusing. Or her pharmacist as well… her GP is sort of the next person.
These illustrate that there are multiple opportunities to support their knowledge seeking needs.
Theme 2: Health information delivery formats Users of digital sources want recognizable, trusted sources and preferred resources created in multiple formats. Participants described various print formats in which older adults preferred to access health information, which included magazines, pamphlets, and books: June does not look at electronics, but she will look at ads and yers and pamphlets. So, for example, if Shoppers Drug Mart has a yer that says this is good for something, she will often think that that is true and purchase that product. (Pete's wife and caregiver, June).
Another scenario emphasized the value of health information available in printed formats that are "just one page, maybe double-sided, and it has a very concise, summarized information and all that she needs on that one page." (Sally).
Older adults or the people they trusted also consulted online resources: "One of her friends told her about the McMaster Portal to check that out. She also had… another friend [who] told her about the Mayo Clinic website." (Sandra), though they identi ed concerns about trustworthiness. For example, in the case of Pete's wife and caregiver June: …her sister might be able to access electronic information through websites on Google… to be a completely trustable website it should have some kind of government or organization endorsing it…It would also be trustable if it's the physician or pharmacist who gave June's sister or June that information or website.
The various information seeking behaviours and different needs raised by participants suggest that multi-modal KT tools and formats are needed (Table 5). From the scenarios, we see that older adults use the internet to nd health information, are interested in recognizing trusted sources, and prefer resources in multiple formats.

Discussion
Using ndings from a persona-scenario methodology, we have interpreted the narratives of older adult information seeking and searching behaviours and translated them into a set of potential KT strategies to share and promote health information resources to various knowledge users (Table 6). By considering older adults as our knowledge users, deploying strategies informed by the questions of where and from whom and in what formats they are seeking information could increase uptake of health promoting ICTs like the Portal and also other nondigital information resources. A range of approaches have been presented, some directly engaging older adults (e.g., small group education sessions) while others indirectly target older adults through the people or places where older adults seek health information. The Portal exempli es the types of evidence-based health-promoting ICTs that our ndings and recommendations are applicable to, but the elements can be generalized to other health information resources aimed at older adults. As suggested by the literature and based on evidence of e cacy, our recommendations promote reliance on multiple KT activities and strategies, which are more effective than single strategies [26,33]. Small-group education sessions for service providers Knowledge brokers as facilitators for information seeking Knowledge brokers are intermediaries, frequently between researchers and knowledge users such as policy and decision makers; they effectively make connections between people to facilitate the use of evidence [19,[34][35][36]. Key elements of knowledge brokering include creating, acquiring, assessing, adapting, applying, and disseminating knowledge, linkage and networking, and enhancing capacity [34,19]. A strong theme from our ndings is of people in various roles essentially acting as knowledge brokers to support the information seeking behaviours of older adults-people well placed to become champions of evidence-based resources. Our ndings that older adults rely on their physicians, pharmacists, librarians, friends, and family members are consistent with other studies [13]. Many of the people engaged by older adults could be considered informal knowledge brokers, outside the realm of researchers and health system decision-makers, but nonetheless guiding information seekers and users to appropriate sources of knowledge to support their health and wellbeing. An understanding of the context for KT strategies and the stakeholder relationships involved within and across organizations is essential for successful KT [37]. Providing training and informational resources to knowledge brokers, as suggested by several of the KT strategies, would effectively develop their knowledge brokering competencies [38]. For example, by increasing librarian knowledge and access to training and support, information about the Portal could potentially reach more library visitors. Given that patrons seek out the help of a librarian, librarians could con dently guide clients to more reliable sources of information. While ICTs such as the Portal facilitate the acquisition, assessment, and adaptation of sound research evidence, informal brokers are active within their social groupings and could facilitate dissemination, linkages, and capacity building by exchanging informational support and recommendations among peers within their own networks [39]. They frequently take on the role of surrogate seekers, seeking accurate online health information and communicating it to others to in uence healthcare decisions [40].
Receiving information from the identi ed knowledge brokers enhances the potential use of the resource; older adults prefer health information received from people they trust (physicians, pharmacists, family and friends) than from non-human sources (internet or news) [13]. This was echoed in the information seeking behaviours in the scenarios. A strength of the Portal is the reliability of the information and the trustworthiness of the source [41]. This key message should be highlighted in the KT strategies.
There are inequities in access to health information through the internet across socioeconomic and education levels [5,6,42] which were re ected in some of the personas in our study having access to ICTs while others did not. An ongoing survey of health information seeking by older adults in USA (Health Information National Trends Survey [HINTS]) shows that many respondents searched the internet rst, though this was more common among younger adults with higher social economic status and those with higher internet skills [42]. The Portal visitors tend to be older, well-educated, retired women in good health [43]. Providing access and educational supports in community settings, such as libraries and community centres, can support engagement among a broader population of older adults and address inequities in access and health and internet literacy.
KT plan desirability, feasibility, and viability When developing each of the suggested KT strategies and outputs, the elements of desirability, feasibility, and viability were considered together [44]. The most promising KT strategies where those that met all three elements. In contrast, some suggested strategies, like provision of training for library staff, may be very desirable as they are important knowledge brokers, but the implementation of such a strategy may not be feasible or viable to sustain. These considerations need to be balanced to determine the best approaches. Perhaps education modules targeted to those library staff who run seniors programming may be a more feasible and viable approach. Organizations who wish to share health information resources with older adults will need to consider these three elements within the context of community needs and preferences, organizational scope, and available resources when developing their KT plans.

KT plan evaluation
Key to any KT plan, the implementation of any of the suggested strategies and outputs should be evaluated [26]. Though many of the strategies are passive forms of dissemination, some actions such as small group education sessions in community settings led by knowledge brokers are likely to produce greater knowledge gains by participants [45]. We have not included detailed evaluation plans here as the suggested strategies should inform context speci c KT plans. We hope that the identi cation of KT strategies allows organizations to build on this exploratory research, by providing theoretical support for development of multi-faceted programs to increase the reach of evidence-based information products to older adults. Evaluation of such programs would follow.

Strengths and limitations
The study was conceived and designed to generate ndings that were not limited to the Portal or even to reliable online health information products; thus, the results are generalizable to other information resources for older adults, to support their health information seeking behaviours as well as searching for and application of the information. Participants were not limited in describing information seeking behaviours in the context of the Portal or online formats, and the personas had a range of technical con dence, ages, and health conditions, which supports transferability to other older adult populations.
Our study included eighteen older adults, which is a reasonable sample size for qualitative research [46]; though we cannot guarantee that we have reached maximal variation in perspectives, a brief member check was performed at the end of scenario sessions through verbal summaries of cross-cutting issues. Although all participants lived in southern Ontario, the personas represented a range of older adults, capturing some rural and urban, male and female, and immigrant perspectives. Though all participants were English-speaking, one scenario re ected the perspective of a child as the caregiver for an older non-English speaker.

Conclusion
Our ndings underline the importance of people, venues, and formats in the actions of older adults seeking trusted health information. These ndings highlight the need for enhanced KT strategies to meet their needs across personal and professional networks. KT outputs and activities could include educational outreach/materials, decision support tools, small group sessions, publicity campaigns, champions/opinion leaders, and conferences. Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.