title: A realist review of interventions and strategies to promote evidence-informed healthcare: a focus on change agency.
abstract: BACKGROUND
  Change agency in its various forms is one intervention aimed at improving the effectiveness of the uptake of evidence. Facilitators, knowledge brokers and opinion leaders are examples of change agency strategies used to promote knowledge utilization. This review adopts a realist approach and addresses the following question: What change agency characteristics work, for whom do they work, in what circumstances and why?
  
  
  METHODS
  The literature reviewed spanned the period 1997-2007. Change agency was operationalized as roles that are aimed at effecting successful change in individuals and organizations. A theoretical framework, developed through stakeholder consultation formed the basis for a search for relevant literature. Team members, working in sub groups, independently themed the data and developed chains of inference to form a series of hypotheses regarding change agency and the role of change agency in knowledge use.
  
  
  RESULTS
  24, 478 electronic references were initially returned from search strategies. Preliminary screening of the article titles reduced the list of potentially relevant papers to 196. A review of full document versions of potentially relevant papers resulted in a final list of 52 papers. The findings add to the knowledge of change agency as they raise issues pertaining to how change agents' function, how individual change agent characteristics effect evidence-informed health care, the influence of interaction between the change agent and the setting and the overall effect of change agency on knowledge utilization. Particular issues are raised such as how accessibility of the change agent, their cultural compatibility and their attitude mediate overall effectiveness. Findings also indicate the importance of promoting reflection on practice and role modeling. The findings of this study are limited by the complexity and diversity of the change agency literature, poor indexing of literature and a lack of theory-driven approaches.
  
  
  CONCLUSIONS
  This is the first realist review of change agency. Though effectiveness evidence is weak, change agent roles are evolving, as is the literature, which requires more detailed description of interventions, outcomes measures, the context, intensity, and levels at which interventions are implemented in order to understand how change agent interventions effect evidence-informed health care.
authors.affiliation: Institute of Nursing and Health Research/School of Nursing, University of Ulster, Shore Road, Newtownabbey, BT37 0QB, Antrim, Co, Northern Ireland. bg.mccormack@ulster.ac.uk.
authors.forename: Brendan
authors.initials: B
authors.lastname: McCormack
authors.forename: Joanne
authors.initials: J
authors.lastname: Rycroft-Malone
authors.forename: Kara
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authors.forename: Alison M
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authors.lastname: Hutchinson
authors.forename: Tracey
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authors.lastname: Bucknall
authors.forename: Bridie
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authors.lastname: Kent
authors.forename: Alyce
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authors.lastname: Schultz
authors.forename: Erna
authors.initials: E
authors.lastname: Snelgrove-Clarke
authors.forename: Cheyl
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authors.lastname: Stetler
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authors.lastname: Titler
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authors.lastname: Wallin
authors.forename: Valerie
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authors.lastname: Wilson
mesh_terms: D004059:Diffusion of Innovation; D019317:Evidence-Based Medicine; D006801:Humans; D007857:Leadership; D009936:Organizational Innovation; D011320:Primary Health Care