Dissemination

This draft module is currently open for public consultation. You are encouraged to make a submission through the online public consultation portal available at consultations.nhmrc.gov.au. Consultation closes on Wednesday 6 February 2019 at 5:00pm AEDT.

Dissemination

Plan where your guideline goes and the message you send with it.

If you want your guideline to be used you will need to ensure it is accessible. This does not occur automatically and active dissemination of guidelines can be a challenge for developers.

Dissemination can be defined as the targeted distribution of information and materials about an evidence-based intervention to a specific public health or clinical practice audience (AHRQ  2012). Good dissemination is a carefully planned process that involves considering the target audience, the message you want to get across and the communication strategies that will help you achieve this (Wilson, Petticrew et al. 2010). It also involves consumers, whose knowledge and lived experience are critical in the planning stages for dissemination. Well-designed dissemination strategies can improve access to a guideline and lead to improvement in health outcomes (Grimshaw, Thomas et al. 2004; Flodgren, Hall et al. 2016).

Dissemination and implementation of a guideline in practice and policy are often considered in tandem. Developers are responsible for ensuring target audiences are aware of the guideline and can access it. Implementation strategies may then follow and are generally enacted by others to overcome barriers and facilitate practice and policy in line with the guideline’s recommendations.

This module focuses on planning for dissemination and the strategies you can use to inform your target audience about your guideline. Other modules that you might find useful here include Implementability, Implementation, Derivative products, Engaging stakeholders and Consumer involvement.

What to do

1. Plan for dissemination

Planning the best approach to disseminate your guideline will take into account several factors that will have already been considered in the early stages of guideline development (Schipper, Bakker et al. 2016). These include identification of your target audience and key stakeholders who can assist in dissemination, an assessment of their information preferences and a plan to engage end users.

There are many ways to plan for dissemination of your guideline such as those described in the Agency for Healthcare Research and Quality (AHRQ) Dissemination Planning Tool (2005) and the National Institute for Health and Care Excellence (NICE) Guidance on Dissemination.

A dissemination plan or strategy typically contains the following elements:

  • the dissemination objectives
  • the target audience
  • the key messages
  • dissemination options 
  • a list of appropriate materials
  • a stakeholder list with details of who you are going to notify
  • a work plan (e.g. activities, source/channel, timeframe, responsibilities, budget)
  • a plan for evaluating the effectiveness of the dissemination.

It’s a good idea to review information received during any stakeholder consultation process (before or during the guideline development process) to help develop a dissemination strategy. You then need to consider what resources are required for dissemination activities and how you will budget for them—this includes staffing, institutional resources and other tools you might need (see Organisation and budgeting). You may also want to consult communications specialists either within or outside your organisation, especially if the issue is likely to attract media attention. Depending on your resources, you may consider hiring media or communications experts to help you with dissemination activities and a strategy to notify journalists if appropriate. You also need to ensure that you include consumers and other stakeholders in the planning process to make sure that the format and language of dissemination products is appropriate, useful and accessible (see Consumer involvement and Engaging stakeholders). They can also help you identify opportunities for promoting the guideline.

A structured and detailed plan should account for all the dissemination steps outlined in this module. An example of a template that can be used to help prepare a dissemination plan is given in Table 1.

Dissemination planning should consider future plans to communicate to target audiences any updates or changes to the guidelines. It is important that plans are in place to disseminate any updated guideline recommendations to your target audiences.

Table 1: Template for planning dissemination

Domain

Activities

Work plan

Approach

Timeframe

Responsibility

Budget

 

1. Dissemination

objectives

What is the goal or objective of dissemination?

e.g. agenda item at face-to-face meeting of guideline development group

By the end of the scoping process (e.g. 1-2 months)

Project manager

 

 

2. Target audience

Identify your target audience

  • consumers
  • health professionals
  • the general public
  • local health authorities
  • stakeholders

 

 

 

 

 

3. Key messages

What are the main messages you want to share?

 

 

 

 

 

4. Sensitivities

What issues might be contentious for some individuals or organisations?

 

 

 

 

 

5. Dissemination options

Consider options available to you

 

 

 

 

 

6. Appropriate materials

  • What formats will be useful?
  • Is the language appropriate for the intended user?
  • Have copyright and legal issues been addressed?

 

 

 

 

 

7. Evaluation plan

  • Track the online/offline spread
  • Survey target users about their awareness of the guideline
  • Consider the overall effect of dissemination
  • Identify the cost of effective strategies.

 

 

 

 

 

 

Some parts of your dissemination plan (such as budgeting) can be included in your guideline project plan (see Organisation and budgeting). However, the dissemination plan is typically a stand-alone document that accompanies the final guideline. You might like to consider releasing your dissemination plan for public consultation along with your draft guideline. This will allow you to gain feedback from end users about preferred methods of dissemination and help to identify any other channels or opportunities for dissemination that you might have missed.

2. Consider your target audience

It is important to consider who will be affected by your guideline and its recommendations—this is your target audience. Depending on the topic of the guideline, there may be many different groups who will be interested in your guideline or who will want to apply it in different settings. Target audiences for environmental health and public health guidelines can be very different to clinical practice guidelines and often include local, state and federal government agencies. You may have already defined these groups when you scoped your guideline or planned for stakeholder and consumer engagement (see Scoping the guideline, Consumer involvement and Engaging stakeholders) but it is now important to revisit that information to assess their information needs and preferences.

It is important to investigate how these guidelines will be used by the target audience and from where they are likely to access the guideline. Conducting a needs assessment of your target audience will help you tailor your dissemination strategy towards their particular requirements (e.g. Ontario Stroke Guidelines 2006) (Schipper, Bakker et al. 2016). Involving consumers is particularly useful at this stage as they are able to advise on the various pathways and interactions they have had with the health care system when seeking information about this issue and also to know where people might look for this information.

3. Select key messages

Guidelines can contain recommendations and other information that may use technical terms directed at a particular target group. It is good practice to provide lay summaries and other dissemination aids alongside the full guideline for those that aren’t likely to carry out the recommendations, but who’ll have an interest in the guideline. For example, guidelines on water quality aimed at local health authorities and regulators need to have technical key messages for the end user, but also plain language messages for members of the public who may wish to read them or use them in advocacy or promotion activities. These will summarise or focus on key messages that you want to reach your target audience. Different target audiences may be interested in different recommendations so tailor the content of your key messages accordingly. For example, when analysing information preferences of different health professionals for chronic obstructive pulmonary disease (COPD) guidelines, nurses expressed an interest in health promotion and patient education information about early recognition of COPD symptoms, while general practitioners were interested in recommendations for the treatment of depression in COPD patients. (Yawn, Akl et al. 2012). It is important to tailor your key messages from the recommendations so that people can link them back to the evidence. Consumer input at this stage is also useful in identifying what messages matter the most to them and how these messages can be framed in an accessible way.

Messages should be direct, simple, clear, action-oriented, concise and consistent (Wilson et al, 2010). They should also take into account the audience’s needs and abilities with respect to the evidence (WHO 2014). If possible, these messages should be brief—a member of this audience should be able to read (or watch or listen to) their key messages in two minutes or less (see AHRQ Dissemination Planning Tool (2005)).

4. Consider dissemination options

There will be a variety of options available to reach different target audiences (Table 2) (Grimshaw, Eccles et al. 2006; Gagliardi, Marshall et al. 2015; Schipper, Bakker et al. 2016). There is evidence that using a combined dissemination approach is more effective than using a single approach (Grimshaw, Schunemann et al. 2012; Schipper, Bakker et al. 2016). The use of passive dissemination strategies such as leaflet or brochure campaigns has been shown to be ineffective (Grimshaw, Shirran et al. 2001). Instead, use more active strategies such as proactive education campaigns, face-to-face workshops and contact by telephone. Combining traditional options, such as letters and announcements in newsletters or journals, with digital dissemination tools is also an effective approach (Schipper, Bakker et al. 2016).

Table 2: Examples of dissemination options for different audiences

Dissemination options

Reach to target audience

Consumers and the general public

Healthcare Professionals

Other stakeholders (e.g. local government authorities, industry bodies, policymakers)

Official Launch/Release

 

 

 

  Press release

O

O

O

    Web resources release

O

O

O

Marketing

 

 

 

   Mass media campaign

O

O

O

   Social media marketing

O

O

O

   E-mail distribution

O

O

O

   Reminders

 

O

O

Workshop/meetings

 

 

 

   Workshop/Seminar or meeting

O

O

O

   Webinar

O

O

O

Use your networks

 

 

 

   Contact network, opinion leader, champion

O

O

O

Register on guideline databases

 

O

 

Endorsement from related organisations

 

O

O

Journal Publication

 

O

 

 

There are a number of other ways to get your message out to your end users:

  • Identify people or organisations who will help spread the word about your guidelines.
  • Invite your guideline development group members, related organisations and advocacy groups to contribute to dissemination (Gupta, Licskai et al. 2013).
  • Ask the consumer members of your guideline development group if they can help promote the guideline through their networks or by presenting at conferences (see Consumer involvement).
  • Consider advocacy and special interest groups who may have a regular newsletter or social media page to reach their members.
  • Consider posting your guideline on databases that have large followings such as the Australian Clinical Practice Guidelines Portal and the Guideline International Network guidelines database.
  • Consider ways to reach journalists who may be interested in portraying the release of the guidelines and its key messages. Providing consistent and clear key points to journalists helps to prevent misleading media articles on release of your guideline.

Endorsement from professional organisations can be helpful in disseminating and increasing the uptake of guidelines among some user groups. However, you should check the endorsement policy and review processes of your target organisations carefully, together with any associated costs, before submitting your guideline for endorsement.

5. Develop appropriate materials

For healthcare professionals the most common dissemination strategy generally involves distribution of educational materials; however, this might not always be the best option for reaching your target audiences. The different needs of your target audiences will mean that you will have to develop dissemination materials that are appropriate for each audience. You can address this issue by adapting the format, style and output of your guideline to your target audience, ensuring the key contents of the guidelines are maintained and consistent between formats. Involvement of consumers is critical in this process, as their knowledge and experience will help you to prepare dissemination products that will best suit their needs. ‘Questions and Answers’ resources can be particularly helpful, particularly for public health advice and guidelines. Consultation with state and territory health departments can also be very effective in helping to develop these useful and practical resources (e.g. NHMRC’s information materials about water fluoridation and human health in Australia) .

Development of a standardised language that can best explain scientific evidence is an ongoing effort for many organisations (Langendam, Akl et al. 2013) (e.g. Australia Government Writing Guide or NICE rules for clear writing). In general, information can be simplified by using less medical and technical terms or by giving a brief explanation of any terms that you can’t avoid using (Schipper, Bakker et al. 2016). It is essential to use plain language for any dissemination aids—a guideline written in appropriate plain language will make the task of developing dissemination materials that much easier.

Care must be taken to obtain legal advice on potential copyright issues for any proprietary products that might be produced. You might also consider translating any products to multiple languages or assisted technology (using National Accreditation Authority for Translators and Interpreters accredited services) to reach more end users (WHO 2014). This is especially important if your guideline recommendations disproportionately affect sectors of the community that do not use English as their primary language.

6. Consider other ways to improve accessibility

Accessibility can be a barrier to dissemination. End users will need the guideline to be accessible in a way that is clear, concise and in a format or language that will meet their needs. You will also need to consider how end users will actually find and access your guideline when they want to use it. For example, people will be less likely to read your guideline if it is behind a pay wall or only available in print. These accessibility issues can be addressed by providing online or electronic versions of your guideline on websites that are free to users. You can also submit your guidelines to the open access databases mentioned in Section 4.

Digital accessibility is an important factor to consider for any online versions of your guideline. The Australian Government Digital Service Standard provides a set of best practice principles for designing and delivering government services including guidelines produced by government agencies. These principles will also be useful for anyone wanting to provide online versions of their guidelines. There are also guides and tools available to help you make your guideline more searchable, navigable and compliant with government accessibility requirements.

There are several other ways to improve the accessibility of your guideline. For example, when end users search for information within your online guideline they will find large blocks of technical content difficult to read and navigate. Consider providing a “useful links” list of hyperlinks on your guideline’s landing page to direct users to relevant sections within your guideline. You can also consider breaking up the content into smaller, digestible topics through the use of drop-down menus (Robertson, Smith et al. 2014). The use of infographics or iconic indexation instead of plain text can also attract an end user’s interest and improve awareness (Griffon, Kerdelhué et al. 2014; Pereira, Hassler et al. 2014). Using mobile phone applications might also make your guideline more digitally accessible to end users, although you will need to bear in mind that you will need technical support to maintain these platforms (Penders and Mallet 2016). In addition, you may also need to plan and budget for application software development or hiring user experience experts to design your website.

7. Inform your target audience

When you are ready to disseminate your guidelines you can launch them online and you may provide printed materials to your target audiences. Consider holding an official launch event or workshops to help experts, practitioners and other related professionals understand your guidelines (e.g. Australian Clinical Guidelines for Stroke Management 2017, Ontario Stroke Guidelines 2006). As well as providing much needed exposure for your guideline, this is also a good way to acknowledge the work of the guideline development group.

Online formats are variable—it is best to increase accessibility by providing a number of different ways for people to read or download your guideline. For example, as well as having the guideline available on a website you can upload the summary or full version of guidelines as PDF (portable document format) files. You can also use hyperlinks or graphics to help end users recognise and understand the content more easily than with text files (WHO 2014) (e.g. NICE dissemination process). Be aware of any digital accessibility requirements for end users with special needs such as visual or hearing impairments.

The media can also be used to reach stakeholders and promote your guideline. Have a careful strategy in place for dealing with media as there is a risk of disseminating information in a way that might mislead audiences (WHO 2014). Consider hiring media experts or undertake media training to help you with this approach. Make good use of your networks and connections through your guideline development group members, consumer networks and endorsing organisations (e.g. Ontario Stroke guidelines 2006).

If you consider journal publications you may need to make decisions regarding authorship and target journals. You may publish the systematic reviews commissioned for the guideline, but to increase awareness of your guideline the development process and recommendations may also be published in peer-reviewed journals (WHO 2014) (e.g. BMJ rapid recommendation series). In addition, you can upload your guidelines to the guideline databases mentioned in Section 4.

8. Evaluate effectiveness of dissemination

Dissemination requires careful evaluation and feedback from your intended audience to determine if your guideline is reaching your target audience. This can be gathered using formal methods such as surveys and interviews. Information can also be collected using informal methods such as using an ‘impact log’ to accumulate feedback (WHO 2014).

If you are harnessing social media to notify users (e.g. Twitter, Facebook, YouTube) and direct them to your website, it is possible to track usage and traffic sources using Google Analytics. You are also able to access statistical information about your guideline website such as how many people accessed and how long they stayed on the guidelines webpage or were redirected elsewhere. For example, a Canadian diabetes guideline was evaluated after six months from dissemination. The evaluation study found that the website was viewed a total of 190,291 times by users around the world. The average user also spent up to five minutes on the website (Ke, Casey et al. 2014).

It may be useful to maintain a record of where and when you disseminate the guidelines so you can survey the change in awareness and knowledge of your target audience. This will also make it easier to disseminate any future updates to the guideline’s recommendations.

9. Remember that dissemination is an ongoing process

Dissemination doesn’t just stop once you’ve got your guideline into the hands of your target audience—it also extends to any future changes to your guideline. It is equally important to inform people when the guideline is withdrawn from circulation and is no longer current. As the developer, it is your responsibility to disseminate any updates and to let your target audiences know when your guideline has been rescinded. Due to the ongoing nature of this process, it will be critical to set governance procedures in place and ensure that strict version control is adhered to. This will be particularly important as living guidelines become the norm and recommendations are reviewed and updated more frequently.

CASE STUDYThe Kidney Health Australia - Caring for Australasians with Renal Impairment                       
                         (KHA-CARI) guidelines
: dissemination activities summary

  • Publication—summary guidelines in Nephrology
  • Website—posting all summary and complete guidelines 
  • Nephrologists provided with links to electronic version of all guidelines via electronic newsletter
  • Electronic version of the complete guidelines sent to all Australian and New Zealand renal units using USB memory cards
  • Promotion of access to the guidelines through website and news and events (presentation, conferences, publications)
  • E-bulletins, e-mail campaigns, newsletters to consumers (e.g. Kidney Health Australia network, medical institutes)

NHMRC requirements

Guidelines approved by NHMRC must meet all requirements outlined in the Procedures and requirements for meeting the NHMRC standard. The following requirements are specific to the Dissemination module:

  • G.1. A plan for the dissemination of the guideline is submitted as a separate document

from the clinical practice guideline.

  • G.2. Key recommendations that are most likely to lead to improvements in health

outcomes are highlighted for consideration in implementation.

  • G.5. (desirable) Accompanying consumer information is provided.
  • G.6. (desirable) Versions of the plain English summary and consumer information are available in different languages, if appropriate.

NHMRC Standards

The following Standards apply to the Dissemination module:

9. To be accessible guidelines will:

   9.1. Be easy to find

   9.2. Ideally be free of charge to the end user

   9.3. Be clearly structured, easy to navigate and in plain English

   9.4. Be available online.

Useful resources

WHO dissemination toolkit (2014): Module 5. Disseminating the research findings

NICE Guidance Dissemination

NICE Process for dissemination

AHRQ (2005) Dissemination Planning Tool

Cochrane Style manual

Australian Government content guide

Writing for NICE: a guide to help you write more clearly

Australian Government digital service standards

Scottish Intercollegiate Guidelines Networks (SIGN) (2015) - A guideline developer's handbook

University of Queensland dissemination strategy

References

AHRQ (2012). Evidence-based Practice Center Systematic Review Protocol: Communication and Dissemination Strategies To Facilitate the Use of Health and Health Care Evidence. Agency for Healthcare Research and Quality.

Flodgren, G., A. M. Hall, et al. (2016). Tools developed and disseminated by guideline producers to promote the uptake of their guidelines. Cochrane Database Syst Rev(8): CD010669.

Gagliardi, A. R., C. Marshall, et al. (2015). Developing a checklist for guideline implementation planning: review and synthesis of guideline development and implementation advice. Implement Sci 10: 19.

Griffon, N., G. Kerdelhué, et al. (2014). Design and usability study of an iconic user interface to ease information retrieval of medical guidelines. Journal of the American Medical Informatics Association 21(e2): e270-e277.

Grimshaw, J., M. Eccles, et al. (2006). Toward evidence-based quality improvement. Evidence (and its limitations) of the effectiveness of guideline dissemination and implementation strategies 1966-1998. J Gen Intern Med 21 Suppl 2: S14-20.

Grimshaw, J. M., H. J. Schunemann, et al. (2012). Disseminating and implementing guidelines: article 13 in Integrating and coordinating efforts in COPD guideline development. An official ATS/ERS workshop report. Proc Am Thorac Soc 9(5): 298-303.

Grimshaw, J. M., L. Shirran, et al. (2001). Changing provider behavior: an overview of systematic reviews of interventions. Med Care 39(8 Suppl 2): II2-45.

Grimshaw, J. M., R. E. Thomas, et al. (2004). Effectiveness and efficiency of guideline dissemination and implementation strategies. Health Technol Assess 8(6): iii-iv, 1-72.

Gupta, S., C. Licskai, et al. (2013). Introducing the Canadian Thoracic Society framework for guideline dissemination and implementation, with concurrent evaluation. Can Respir J 20(4): 263-264.

Ke, C. H., C. G. Casey, et al. (2014). Disseminating the Canadian Diabetes Association 2013 Clinical Practice Guidelines: Guidelines.diabetes.ca in Action. Canadian Journal of Diabetes 38(5): S72-S73.

Langendam, M. W., E. A. Akl, et al. (2013). Assessing and presenting summaries of evidence in Cochrane Reviews. Systematic Reviews 2(1): 81.

Penders, R. and M. Mallet (2016). Survive On Call - A QI Project to Improve Access to Hospital Clinical Guidelines. BMJ Quality Improvement Reports 5(1): u210274.w214363.

Pereira, S., S. Hassler, et al. (2014). Improving access to clinical practice guidelines with an interactive graphical interface using an iconic language. BMC Med Inform Decis Mak 14(1): 77.

Robertson, I., A. Smith, et al. (2014). Improving accessibility of trust guidelines and protocols at the Great Western Hospital, Swindon. BMJ Quality Improvement Reports 3(1).

Schipper, K., M. Bakker, et al. (2016). "Strategies for disseminating recommendations or guidelines to patients: a systematic review." Implement Sci 11(1): 82.

WHO (2014). WHO dissemination toolkit. Module 5. Disseminating the research findings, World Health Organization

WHO (2014). WHO handbook for guideline development. Ch12. Producing and publishing the guideline, World Health Organisation.

Wilson, P. M., M. Petticrew, et al. (2010). Disseminating research findings: what should researchers do? A systematic scoping review of conceptual frameworks. Implement Sci 5: 91.

Yawn, B. P., E. A. Akl, et al. (2012). Identifying target audiences: who are the guidelines for? : article 1 in Integrating and coordinating efforts in COPD guideline development. An official ATS/ERS workshop report. Proc Am Thorac Soc 9(5): 219-224.

Acknowledgements

NHMRC would like to acknowledge and thank Dr Miyoung Choi (author) and Professor Sally Green from Cochrane Australia (editor) for their contributions to the development of this module.

 

Version 3.0. Last updated 22/11/2018.

Suggested citation: NHMRC. Guidelines for Guidelines: Dissemination. https://nhmrc.gov.au/guidelinesforguidelines/review/dissemination. Last updated 22/11/2018.

ISBN: 978-1-86496-024-2