Fostering Change in Medical Settings: Evidence-based Considerations in the Context of IUD “revitalization”

1. Fostering Change in Medical Settings:Evidence-based Considerations in the Context of IUD “revitalization” Roy Jacobstein, M.D., M.P.H. Clinical Director, ACQUIRE EngenderHealth IUD Standardization Workshop Accra, Ghana June 2006

2. Why Should We Talk About Change?

3. Why Talk About Change? • Any development intervention requires behavior change • Any public health intervention requires behavior change • Any medical or clinical intervention requires behavior change And we’re doing all three!

4. Why Talk of Change? • We are “change agents”: it’s what we do when we “do development” • Scientific / empirical / proven findings across time, place, sector • Can point way to more strategic solutions, better programming

5. But What Too Often Happens? • Policymakers issue new policies • Researchers publish new findings: “rational” model of behavior change implicit in science / medicine: new “knowledge” will = new behavior • Experts devise new guidelines • Programs introduce new or expanded services … And nothing much changes

6. Why? Because we fail to factor the provenprinciples and dynamics of change into our thinking and our programming.

7. Who Here Has A Cell Phone? Consider: Why Has The Cell Phone Spread So Fastin Your Country?

8. Consider: Why Hasn’t VCT (Voluntary Counseling and Testing for HIV)Been More Widely Accepted?

9. Consider: Why Has Modern Contraception, Especially IUD, Spread So Slowly?

10. A Useful Theory of Change: The Diffusion of Innovations

11. The Diffusion of Innovations Has four elements, present in every behavior change (i.e., program) effort: • “an innovation • communicated through channels • over time • among members of a social system.” Source: Rogers, Everett, The Diffusion of Innovations, 1995

12. The Three Main “Clusters of Influence” in Innovation Diffusion • What: Perceptions of the innovation • Who: Characteristics of the adopters • How: Contextual factors, e.g.,: • Communication • Leadership • Management/supervision • Policies and guidelines

13. Dynamics of Diffusion:The Tipping Point Tipping point Percent Years

14. Dynamics of Diffusion: The Tipping Point Impact Area: Better “understanding” Widely available IUD services Tipping point Percent Research to Practice Area: IUD “Revitalization” Years

15. I. Perceptions of the Innovation (“the what”) The five most influential properties of a given innovation are its: Benefit • perceived • perceived Compatibility Simplicity • perceived “Trialability” • perceived • perceived 5. Observability Taken together: account for 49-87% of variance in rate and/or extent of change

17. Perceived Benefit of the Innovation: • Single most important variable influencing rate and extent of adoption of new behavior • “What’s in it for me?”   • “Perceived” = eye of beholder / ”changee” (NOT the change agent) • Implies there are many “truths” • Implies we need more “empathy”

18. Perceived Benefit of the Innovation(cont.) • Greater the perceived relative advantage, the more rapid the rate of adoption/change • Subcharacteristics of this are theperceived: • Degree of economic profitability • Low initial cost • Decrease in discomfort • Increase in social prestige • Savings in time and effort • Immediacy of the reward**

19. 2. Perceived Compatibility of the Innovation: • Compatibility with values, beliefs, norms, past history &/or future needs of potential adopters (individuals and organizations), in context of their social systems • Potential changes perceived as more compatible are more likely to diffuse

20. Potential Adopters are NOT Empty Vessels

21. 2. Perceived Compatibility of the Innovation (cont.) • Avoid “empty vessel syndrome” • Language conveying innovation is key • “Copper-T” in Korea • “No-va T” in Latin America • Local analogues to FP Methods • Beliefs around menstruation

22. 3. Perceived Simplicity of the Innovation: • Innovations perceived as “simple” spread faster than “complex” ones • Hence impulse to adapt [and almost always also to simplify] • Local adaptation nearly universalin successful adaptations: not “spread” or “replication” or “scale-up” but “reinvention”

23. 4. Perceived Trialability of the Innovation: • Trialability (“pilot testability”) is positively related to the rate of adoption of a new behavior. • Innovations that can be tried on the “installment plan” are adopted more quickly than ones that are not divisible. • More important in early stages

24. 5. Perceived Observability of the Innovation: • “Degree to which results of an innovation are visible to potential adopters” • The easier to see an innovation, the more likely its adoption • Applicable to “pilots” • Preventive innovations less observable • FP by its nature generally less “visible”

25. II. Characteristics of the Adoptersof Innovations (“who”) EarlyAdopters13.5% Laggards16% EarlyMajority34% LateMajority34% Innovators 2.5% -2 SD -1 SD Mean +1 SD Time to Adoption (SDs from Mean)

26. Characteristics of Early Adopters Programmatically key because: • Opinion leaders • Locally well-connected socially • Cross-pollinators (of ideas) • Resources & risk tolerance to try the new • Watched by others (thus crucial to dynamics of spread) • Often chosen as leaders & representatives

27. Other Considerations about “the Who” • Innovators “need not apply” (“we” already “have” the innovation) • Later adopters more likely to discontinue • Innovativeness-Needs Paradox: Individuals or units who most need benefits of new idea (the less educated, the less wealthy, etc.) are generally last to adopt it • Thus, ironically, many innovations meant to improve things widen gaps (not inevitable but needs attention)

28. The Three Main “Clusters of Influence” in Innovation Diffusion: “how” Perceptions of the innovation II. Characteristics of the adopters III. Contextual factors • Leadership • Policy/advocacy • Management/supervision • (Job) incentives • Communication

29. Evidence-based Lessons About Successful Communication of Innovation

30. Key Evidence-based Lessons about Communication • Mass media communication channels are more effective in creating knowledge of innovations. • Interpersonal communication channels are more effective in forming and changing attitudes toward an innovation, and thus in influencing decisions to adopt or reject an innovation.

31. Key Evidence-based Lessons about Communication (cont.) • Most individuals do not evaluate an innovation on the basis of scientific studies of its consequences. • Most depend on subjective evaluation of an innovation conveyed to them by “near-peers”—other individuals like themselves, who have already adopted the innovation. (client-potential client; provider-provider)

32. Key Evidence-based Lessons about Communication (cont.) • More effective communication occurs when two or more individuals are homophilous. • Heart of the diffusion process consists of modeling and imitation by potential adopters of behavior of previous adopters closely “networked” to them.

33. Do You Think Change Is Difficult and Slow in Medical Settings? If So, Why?

34. The Slow Pace of Change in Medical Settings: Evidence • “Then”: scurvy/British navy/264 yrs (1497-1865) • “There”: common in “developing countries” • “Here” and “now”: U.S. examples • C-sections and hysterectomies • Myocardial infarcts: 11 yrs for 51% of American MDs to adopt correct rx as standard of care • NSV: 1972: devised; 1980s: proven better/main approach in programs; 2003: WHO still calling it a new method; 2004: majority of V in U.S.

35. Why the Slow Pace of Change in Medical Settings?: Some Reasons • Tend to be conservative, hierarchical • Lack of perceived need for change (“What’s worked for me is working”) • Ignorance of: • latest scientific findings • risks / benefits of methods (e.g., IUD) • concept of relative risk (FP side effects vs. risk of pregnancy, and maternal morbidity /mortality

36. Slow Pace of Change in Medical Settings: Some Reasons (cont.) • Lack of provider motivation (e.g., lack of perceived benefit to ↑ services; org. of work) • Medical/Clinical vs. Epid/ Public Health Orientation • Primum non nocere (fear of iatrogenic disease) Great fear of “harm of doing” vs. little awareness or concern of “harm of not-doing” • Focus on individual, not population • Curative versus preventive orientation • Prevention and PH have lower priority & status

37. What to Do? Some Approaches and Solutions Suggested by Change Theory

38. Understand How Actors “See” the Change (e.g., IUD) You Want to Introduce • If perception = reality: • understand how a proposed change is “seen” by all the various actors in the system (client, provider, policymaker, program manager, donor) • Understand their “truths” about the benefits and/or aversiveness of the proposed change, and intervene accordingly • Address their reward systems, needs, fears, myths • “We must walk in their shoes … or else we will fail”

39. Change Considerations: Address Their “Truths” — not (y)ours • Meet their given “truth” with appropriate and • effective communication messages:, e.g. • “My patient will get PID” (provider) • “More IUDs = More work” (provider) • “The IUD will migrate to my head” (client) • “IUD is not appropriate for Africa” (policymakers, program managers, donors)

40. Change considerations: Tailor Messages About “Truth” • Keep messages simple and memorable: e.g., for messages to providers: • It’s Chlamydia, and GC — not the IUD itself that causes PID (and the risk is much, much lower than you think) • Risk of IUD causing infertility is very very small • IUDs safe and a good choice for HIV+ women • Greater IUD use will mean less work for you

41. Change Considerations: Find and Support Early Adopters • Identify, invest in, support/nurture Early Adopters (individual providers and individual org. units) • As respected opinion leaders, • Can act as change agents/champions • We need to know who potential ones are • Make Early Adopters’ activity observable • Social channels important • Local networks important • Promote face-to-face interactions

42. Change Considerations: Pilots, Demonstrations, “Positive Deviants” • Pilot/demonstration/replication needs to be planned for up-front • Pilots need to reflect program realities (WHO, contraceptive introduction, 1997) • Identify, replicate, adapt good initial efforts • “Rollout” or “Scale-up” IS diffusion • Need to / good opportunity to / include policy- makers, decision-makers, future implementers, & convert them to “champions”

43. Change Considerations: Learn from Past Mistakes • “Research fallacy” (rational paradigm of science): “Build it and they will come” — not! • “Training fallacy”: You have a performance problem? —“Training is the answer” — is it? • Services fallacy: “We need to get services everywhere, now” — is that realistic? feasible? • A “pilot activity” – is not (necessarily) a pilot: ask first “Who’s interested? How are they involved?” • Something not called a “pilot” may still be one – e.g., many of our “IUD project activities” are pilots

44. Change Considerations: Remember… there are two experts in the room