Change and Diffusion of Innovations

1. Change and Diffusion of Innovations Levent Cagatay, M.D. ACQUIRE Project/EngenderHealth Adapted from: Jacobstein R., Stanback J., Fostering Change in International Health: The Case of Medical Barriers Jacobstein R., Change Comes with Strings Attached—thinking about change in the context of IUD “revitalization”

2. Why is this an issue? Why does change take so long? Factors affecting diffusion of innovation: what, who and environment Some communication lessons learned So what to do? Presentation overview

3. Policymakers issue new policies Researchers publish new findings Experts devise new guidelines Programs introduce new or expanded services … And few things change WHY? Why is this an issue?

4. Any development intervention requires behavior change Any public health intervention requires behavior change Any medical or clinical intervention requires behavior change Diffusion of innovation means Change

5. Yet we often fail to factor the principles and dynamics of change into our thinking and programming Research paradigm isn’t enough to change behaviors

6. Is central to what we do: development Has predictable phases and dynamics Empirically-based; applies to both “developed” and “developing” countries Can point way to strategic solutions, to better interventions and programming Why is it Important to Understand Diffusion of Innovation?

7. "In health care, invention is hard, but dissemination is harder." "Mastering the generation of good changes is not the same as mastering the use of good changes.” Berwick, JAMA, “Disseminating Innovations in Health Care,” April 16, 2003, Vol 289, no. 15 And …

8. 1497: Scurvy kills 100/160 da Gama sailors 1601: Capt. Lancaster: lemon juice to his sailors, none die; 110/278 (40%) die in other three ships Practice in British Navy does not change 1747: study repeated, proves citrus prevents scurvy 1795: British Navy orders citrus in diet of all sailors; scurvy totally disappears 1865: Citrus mandated on all British marine vessels Total time elapsed to universal naval use: 264 years The Inherently Slow Pace of Human Behavior Change: The Story of Scurvy in British Navy

9. The Slow Pace of Change in Medical Settings: Recent Evidence • Not only “then” (scurvy/264 yrs) • Not only “there” (“developing countries”) • “Now” and “everywhere”: U.S. examples • NSV • C-sections and hysterectomies • Treatment of myocardial infarction (11 yrs)

10. Why Does Change Take So Long?

11. Lack of perceived need for change Lack of provider motivation Ignorance of latest scientific findings of risks and benefits of concept of relative risk Slow Pace of Change in Medical Settings: Some Key Reasons

12. 4. Medical/Clinical Orientation (as contrasted to the Public Health Orientation): Primum non nocere (above all do no harm) Focus on seen not unseen Focus on individual not groups of individuals Curative orientation versus preventive 5. Client and sociocultural factors Slow Pace of Change in Medical Settings: Some Key Reasons (Cont’d)

13. Diffusion of Innovations is the process by which an innovation is communicated through certain channelsover time among the members of a social system.   What is Diffusion of Innovations?

14. I. Perceptions of the innovation (WHAT) ll. Characteristics of the adopters (WHO) lll. Contextual factors, e.g.,: (ENVIRONMENT) Communication Motivation Leadership Management/supervision – support systems Factors Affecting Innovation Diffusion

15. 5 most influential properties of given innovation: I. Perceptions of the Innovation (The “What”) Benefit • perceived Compatibility • perceived Simplicity • perceived “Trialability” • perceived Observability • perceived

16. I. Perceptions of the innovation II. Characteristics of the adopters (WHO) III. Contextual factors, e.g.,: Communication (Job) incentives Leadership Management/supervision Factors Affecting Innovation Diffusion (The “Who”)

17. EarlyAdopters13.5% Laggards16% EarlyMajority34% LateMajority34% Innovators 2.5% -2 SD -1 SD Mean +1 SD Time to Adoption (SDs from Mean) II. Characteristics of Adopters of Innovations (“The Who”)

18. Opinion leaders Locally well-connected socially Cross-pollinators (of ideas) Resources & risk tolerance to try new things Watched by others (thus crucial to dynamics of spread) Often chosen as leaders & representatives Characteristics of Early Adopters

19. I. Perceptions of the innovation II. Characteristics of the adopters III. Contextual factors (ENVIRONMENT) Communication Motivation Leadership Management/supervision – support systems Factors Affecting Innovation Diffusion (The “Environment”)

20. Dynamics of Diffusion Impact Area: Better “understanding” More available IUD services Tipping point Percent Research to Practice Area: IUD “Revitalization” Years

21. 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. Communication Channels: key evidence-based lessons

22. Most individuals do not evaluate an innovation on the basis of scientific studies of its consequences. Most people depend on subjective evaluation of an innovation conveyed to them by “near-peers”—other individuals like themselves, who have previously adopted the innovation. Communication Channels: key evidence-based lessons (cont.)

23. 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: Communication Channels: key evidence-based lessons (cont.)

24. Understand principles, patterns, and dynamics of change—they are: Empirically-based Largely predictable Universal Helpful in pointing to better/more strategic interventions So What (to do): Understand and Harness Change

25. Hence our field’s emphasis on: “Evidence-based” medicine “Data-driven” programs “Best practices” So What (to do): Find Sound Innovations

26. Understand how all parts of the system (institutions, providers, clients, potential clients, communities, decision makers, opinion leaders) “see” the innovation/ planned intervention … and intervene accordingly Remember, perception=reality So What (to do): Walk in the Other Person's Shoes

27. Know, understand, address needs, fears, myths of system actors [a form of empathy] Meet “truth” with appropriate language [science / “street” / program ] - e.g., re IUD: “My patient will get PID” (provider) “Others will outnumber us” (minority client) “IUDs not appropriate for Africa” (program, donor) So What (to do): (cont.) Walk in the Other Person's Shoes

28. Keep messages about a new finding or proposed innovation, simple, accurate, audience-appropriate, memorable, e.g.,: “It’s Chlamydia (and gonorrhea) … not the IUD itself, that causes PID)” It is quality not quantity of the people that counts in terms of power IUDs are safe for HIV+ women So What (to do): Keep Your Message Simple

29. Find, support, nurture champions (Early Adopters / opinion leaders): Individual providers Individual health care institutions Individual users Make Early Adopters’ activity observable So What (to do): Support Champions

30. First things first Many contexts: country, regional, health services, epidemiological, cultural, socioeconomic, etc., … Implies need to use appropriate data for programming Learn from past experience So What (to do): Tailor Effort to Context

31. Program incrementally: Change will likely be slow Change will be incremental Change takes (a lot) of time “There’s no quick fix” So What (to do)?: Be Realistic / Be Patient

32. And Remember: There are 2 Experts in the Room