The magnitude and nature of the work required to translate findings from medical research into valid and effective clinical practice have been grossly underestimated. Frequently, it takes years or even decades for scientific discoveries to reach everyday clinical practice¹. Many discoveries never make it into daily practice^{2, 3}. Numerous barriers limit the movement of evidence-based treatments into clinical practice^{4,5, 6}. Poor adoption of evidence-based recommendations may be the result of the very research enterprise that created the recommendation. Scientific discoveries often use research terms, advanced clinical language, and medical constructs that are not understood by patients and community members⁷. Translation of scientific evidence-based guidelines and recommendations into constructs and language accessible to every-day patients and community members may improve outcomes. If community members don’t fully understand a preventive healthcare recommendation, they will not seek care to receive it. If patients do not fully understand the conceptual framework for a health condition and treatment options, they will not be able to engage in a meaningful conversation with a healthcare provider, successfully choose appropriate treatment options based on their preferences, or maintain adherence to recommended therapy.

Community engagement may be essential to achieving the mission of translating the best evidence into community and clinical practice to improve the health and well-being of the population. Community engagement efforts enhance public trust through long-term relationships with community-based groups⁸. We believe the most appropriate framework for building and sustaining community engagement in the translational research process is community-based participatory research(CBPR), which is defined as: A collaborative process that equitably involves all partners in the research process and recognizes the unique strengths that each brings. CBPR begins with a research topic of importance to the community with the aim of combining knowledge and action for social change to improve community health and eliminate health disparities⁹. More than a decade of experience with CBPR has shown that research can be more relevant, culturally proficient, and effective when conducted through community-academic partnerships^10–13. Rural communities often have a strong sense of civic duty and may be poised to develop robust communities of solution to provide local answers to local health problems¹⁴. Engaging a broad spectrum of community members and health care providers in a locally prioritized health problem can provide the beginning steps for developing a community of solution that fosters stronger, more productive relationships between the community, patients, and their healthcare providers.

The purpose of this manuscript is to describe Boot Camp Translation developed and used in the High Plains Research Network (HPRN) to translate the medical information of evidence-based guidelines and recommendations into common language and constructs accessible to community members and every-day patients.

Housed in the Department of Family Medicine at the University of Colorado Denver Anschutz Medical Campus, the High Plains Research Network (HPRN) is a geographically based practice-based research network covering nearly 30,000 square miles in 16 counties in eastern Colorado (see Figure 1). HPRN consists of collaboration between 16 community hospitals, 55 practices, 120 primary care clinicians, 20 nursing homes, several public health departments, and about 145,000 residents^15–19.The HPRN includes an active Community Advisory Council (C.A.C.) of local farmers, ranchers, school teachers, and others to help guide and ground its research in real patient experience. The creation of the C.A.C. in 2003 required numerous phone calls and one-on-one meetings between the HPRN Director and potential community members. Community members were identified by local physicians, public health professionals, hospital administrators, and discussions with other community members in the region.

The HPRN has been translating evidence based recommendations into high integrity, evidence-based information using community members, patients, and the broad healthcare community for 8 years^20–24. This work has resulted in development of healthcare constructs and language that are readily accessible and understandable to a broad range of rural community members and patients, has prompted increased conversations between patients and healthcare providers, and improved the care provided and received on a host of healthcare issues including colon cancer prevention, asthma management, and hypertension. Boot-Camp Translation identifies patient healthcare priorities, brings together key stakeholders to address health care priority issues, and develops and refines evidence-based care in a manner that acknowledges and respects local culture and individual patient preference.

Boot Camp Translation employs a community-based participatory research approach to develop and test message and dissemination strategies for a variety of healthcare issues in rural and frontier communities. Topics are chosen based on community priorities, C.A.C. member interest, and/or funding opportunities. Local community members know the “problem shed” for their priority health concerns, so they may be in the best position to identify solutions. For instance, community members identified asthma and behavioral health as priority health issues. Colon cancer was not on the priority list; however, after learning about the prevalence of colon cancer in eastern Colorado and learning about funding possibilities from the Centers for Disease Control and Prevention (CDC), the C.A.C. chose this as an opportunity to receive substantial funding to address an important health issue in their community. The C.A.C. considers potential projects presented by researchers from the University and chooses topics based on the community priority list, the potential for funding, and the opportunity to have an impact in their community. For each project, the core C.A.C. is joined by various other key stakeholders in the community: 1–3 local physicians or other health professionals, health department representatives, hospital administrators, patients with the condition of interest, students, and community organization leaders. The C.A.C. has led the development of all aspects of the projects and assisted with analysis, interpretation of results, and dissemination of the findings.^{20, 21, 23, 25}

The High Plains Research Network has completed Boot Camp Translation with our Community Advisory Council on 4 topics identifying “what is the message” and “how to disseminate the message” for: colon cancer prevention, asthma, high blood pressure home monitoring, and the Patient Centered Medial Home. Several other Boot-camps are underway on hypertension, health risk assessments, and behavioral health in primary care.

Boot Camp Translation has translated evidence-based medical care, guidelines, and recommendations into reliable clinical opportunities for communities in rural Colorado to: increase colon cancer testing, improve asthma diagnosis and management, improve high blood pressure care, and improve implementation of the patient-centered medical home. Through the use of this process, communities can successfully determine the content of messaging and how to best disseminate that message to maintain the scientific integrity of the evidence and assure it is locally relevant and culturally appropriate. We include several health care providers in each Boot Camp to assure alignment with local medical standards. By including local primary care in the process, community members are assured of a common language in both the public health and primary care setting. We have found Boot Camp to be an effective method for building stronger partnerships between primary care and public health as both organizations work together on a common topic. Projects have been incorporated into the local primary care practices through continuing education, practice level capacity building, and encouraging patients to access local services for their medical care. For example, in Asthma Toolkits and Community Air, local practices received a new spirometer, on-site training in asthma management, and toolkits to give to patients. The primary care practices derive tangible benefits as well as education and practice support through participation in High Plains Research Network projects.

When a rural community is engaged and activated around a pertinent health issue, the result is a large number of individuals, organizations, healthcare providers, and community leaders become collaborators. By linking primary care, public health, community-based organizations, and schools, Boot Camp Translation is an effective means at developing a community of solution to address local health concerns¹⁴. Our colon cancer prevention program began with a Community Advisory Council of 10 that grew to 15 members. By the end of our program over 230 individuals had participated. Thirty-one community members partnered with 29 clinicians to provide 50 talks to over 900 community members. Palm cards with local photos were placed in 162 locations and over 1450 were taken and another 900 were distributed at talks. 64 unique ads and 45 unique personal stories were printed in 15 local newspapers. This colon cancer “community of solution” developed and deployed a locally relevant answer to an important health concern. Likewise, Community AIR engaged over 700 rural community members and providers in building a community of solution to address the high rate of asthma and associated morbidity. Boot Camp Translation provides a tangible and replicable process for building a community of solution: participants identify quickly with the tasks and outcomes necessary to improve local health.

Boot Camp translation is not a rhetorical process that simply takes guidelines and recommendations and changes a few medical terms. Boot Camp Translation alters the conceptual framework that patients and community members hold for certain medical conditions. We don’t know what we are going to end up with when we start the process. By combining both local and medical expertise, Boot Camp Translation creates local experts who, once educated about a specific health topic, have the capacity and local knowledge to frame the condition in the community milieu. For instance, in our first Boot Camp Translation related to colon cancer, rural male farmers were clearly not compelled by the concept of early detection and diagnosis of colon cancer. However, when the C.A.C. gained a more sophisticated and nuanced understanding of colon polyps leading to colon cancer and realized that removal of polyps early can actually prevent colon cancer, they gravitated to this message for dissemination into the community. Testing to Prevent Colon Cancer was much more compelling to the rural and frontier communities and provided the context for a more accessible conversation between patients and providers. The Asthma Toolkit was a tangible gift from the clinic to the patient that used the common toolkit metaphor. This changed the concept of asthma as an activity-limiting disease to a condition that needed upkeep and maintenance, similar to machines and equipment common in rural Colorado.

Common to every Boot Camp is the message to patients and community members to access their local health care providers. The C.A.C. is clear that while they have learned much about each medical condition, they want community members to go talk to their doctor to get the best care for their individual condition. The C.A.C. provides talking points and relevant language so that community members can have a more thorough and meaningful conversation with their provider. Participation of providers assures that messages align with local medical standards.

Boot Camp Translation requires flexibility and modification. Time-frames are approximate. Sometimes an issue may take several phone calls to complete, while at others times, groups may develop language quickly. Much of this depends on the complexity of the health condition, the evidence-based recommendation, and the cultural context of the specific community. In 4 experiences with Boot Camp Translation, our C.A.C. has worked through a host of topics and ideas. Each time, the final product was both intuitive and a surprise. And each time, the community owned the language and proudly presented it to their community. The engagement of the local community in the process assures local and cultural relevance and increases the chance of uptake and implementation.

Not everyone likes the name Boot Camp for this activity. The term Boot Camp implies a short, intense learning activity, not military or hierarchical hazing. We have found the process to be hard work requiring commitment to complete tasks and activities. We all come through the process stronger and with a much better message. The name itself is not important, and those who wish should call it something else. The process of local community engagement and discovery is the crucial element. It is important to understand that the community members act as the brainstorm interpreters and idea generators, but they do not act as facilitators, note takers or serve in a longitudinal support role. The partnership of the researcher is essential. The community alone may not have the resource or expertise to proceed effectively and produce a scientifically valid message. An academic partner may be necessary to lead and facilitate the conversation and keep the process moving forward.

Boot Camp Translation addresses the core concepts of patient centered care by addressing one of the barriers to advancing the quality of care in the United State. Specifically, the process provides an approach that maintains the scientific integrity of the robust evidence base in healthcare while honoring the local and cultural aspects of community and health. Boot Camp Translation addresses community health priorities, brings together key stakeholders, and develops and refines evidence-based care in a manner that respects local and individual patient preference. Boot Camp Translation may be an effective method for building communities of solution that address the priorities set out by the Patient Center Outcomes Research Institute.