Document Type


Date of Degree


Primary Advisor

Joseph Bocchino, BA, MBA, EdD


Knowledge translation; Translational knowledge; Implementation science; Policy dissemination; Neural tube defects; Food fortification; Mixed-methods design



Background. Neural tube defects are one of the leading congenital malformations that affect children in Latin America and worldwide, leading to pregnancy terminations, morbidity, mortality, and long-term disability. The most cost-effective and equitable way to prevent them is by implementing public health policies for food fortification with folic acid. However, a lack of knowledge translation strategies partly accounts for the incomplete enactment, enforcement, and scaling-up of mandatory fortification. There is no evidence in the scientific literature of studies attempting to identify the factors contributing to the development and implementation of knowledge translation strategies aiming to influence policymakers’ decisions regarding mandatory food fortification to prevent neural tube defects in Latin American countries.

Objectives. The study's overall purpose was to describe the factors contributing to developing and implementing a knowledge translation strategy, named the NeuroAdvocacy Toolkit, aiming to influence policymakers in Latin American countries regarding mandatory food fortification policies to prevent neural tube defects.

Methods. This study utilized a mixed-method sequential explanatory design with a follow-up explanations variant, which prioritizes the initial quantitative phase and uses the subsequent qualitative phase to explain the quantitative results. The study comprised three phases. First, a document analysis led to determining the status of fortification policies and a needs assessment for regulation change in the 20 Latin American countries, followed by the development of the NeuroAdvocacy Toolkit. The toolkit development was informed by the scientific literature and voices from the target audience regarding preferred mechanisms for knowledge transfer and utilization. Second, a quantitative phase collected survey data from purposefully selected Latin American key opinion leaders through the Measurement Instrument for Determinants of Innovations (MIDI) to identify the barriers and facilitators for implementing the toolkit as an innovative knowledge translation strategy. The surveys were conducted through an online platform in Spanish. And third, a qualitative phase gathered interview data about the perspectives of Latin American key opinion leaders in pediatric neurosurgery (purposefully selected from the survey respondents) on implementing and disseminating the toolkit to policymakers. The interviews were conducted through an online platform in Spanish. This phase concluded by integrating quantitative and qualitative data to gain a deeper understanding of how to address the critical factors.

Results. The document analysis in the study's first phase triangulated different sources of information to identify the status of food fortification policies in Latin America and develop a reliable needs assessment for regulation change. The data gathered allowed categorizing the 20 countries according to the priority to implement regulatory changes to strengthen fortification policies. Four countries are in level 1 priority with an urgent need for regulation change, 14 countries are in level 2 with a high need for regulation change, one country is in level 3 with a medium need, and one is in level 4 with no need for regulatory change. After being introduced to the NeuroAdvocacy Toolkit, 30 key opinion leaders in pediatric neurosurgery from 20 countries responded to the MIDI questionnaire. Their responses allowed identifying 20 facilitators, seven potential facilitators, and two barriers to implementing the Toolkit as a knowledge translation strategy targeting policymakers in the region. Twenty-four interviews with key opinion leaders yielded three themes describing 1) the attitudes toward using the Toolkit, 2) the ideal delivery strategies to policymakers, and 3) how to face potential challenges when bringing policymakers on board during the implementation and dissemination process. Finally, integrating quantitative and qualitative data permitted a deeper understanding of overcoming potential barriers and strategically leveraging facilitating factors when disseminating the Toolkit to the target policymakers. Although the MIDI allowed identifying the main barriers and facilitators for implementing the NeuroAdvocacy Toolkit, the subsequent interviews allowed visualizing alternatives for operationalizing the determinant factors. Key opinion leaders’ behaviors, influenced by subjective norms, social norms, and perceived roles, can spearhead effective data-driven advocacy. Organizational support can enhance the implementation and dissemination of the NeuroAdvocacy Toolkit by consolidating neurosurgical guild unity and promoting alliances with universities, other academic institutions, and other professional societies; also, obtaining support from non-governmental organizations and patients’ associations as critical stakeholders. Gaining support from supranational organizations such as the WHO and PAHO, materialized through a statement or resolution, can accelerate the dissemination process and promote the promulgation, enactment, and enforcement of MFF policies in most of the countries represented in this study.

Conclusions. Most Latin American countries have a compelling need to update, scale up, implement, optimize surveillance, and guarantee the sustainability of mandatory food fortification policies to prevent neural tube defects. The NeuroAdvocacy Toolkit is an innovative knowledge translation strategy enabling key opinion leaders in pediatric neurosurgery to influence policymakers' decisions toward strengthening fortification policies in Latin America. Critical determinant factors can act as barriers or facilitators to implementing and disseminating the Toolkit. Recognizing them is essential to tailor strategies to approach and call policymakers to action, with the ultimate goal of saving thousands of children in Latin America from being born with a devastating but preventable condition and promoting a healthy and fulfilling start to their lives.


©2023 by Kemel A. Ghotme. All rights reserved.

Peer Reviewed


Open Access




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