Transcript Document

Change and
Diffusion of Innovations
Repositioning
Family Planning
in West Africa
Repositionnement
de la Planification
Familiale en
Afrique de l’Ouest
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”
Sponsored by: U.S. Agency for International Development (USAID), World Health Organization (WHO),
Action for West Africa Region Project - Reproductive Health (AWARE-RH), Advance Africa, the POLICY Project
Presentation overview
• 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?
Why is this an issue?
Policymakers issue new policies
Researchers publish new findings
Experts devise new guidelines
Programs introduce new or expanded
services …
And few things change
WHY?
Diffusion of innovation
means Change
• Any development intervention requires
behavior change
• Any public health intervention requires
behavior change
• Any medical or clinical intervention
requires behavior change
Research paradigm isn’t enough
to change behaviors
Yet we often fail to factor the
principles and dynamics of change
into our thinking and programming
Why is it Important to Understand
Diffusion of Innovation?
• 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
And …
"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
The Inherently Slow Pace of
Human Behavior Change:
The Story of Scurvy in British Navy
• 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 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)
Why Does Change Take So Long?
Slow Pace of Change in Medical
Settings: Some Key Reasons
1. Lack of perceived need for change
2. Lack of provider motivation
3. Ignorance
– of latest scientific findings
– of risks and benefits
– of concept of relative risk
Slow Pace of Change in Medical
Settings: Some Key Reasons (Cont’d)
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
What is Diffusion of
Innovations?
Diffusion of Innovations is the
process by which an innovation is
communicated through certain
channels over time among the
members of a social system.
Factors Affecting Innovation
Diffusion
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
I. Perceptions of the Innovation
(The “What”)
5 most influential properties of given innovation:
perceived
1. Benefit
perceived
perceived
perceived
perceived
2.
3.
4.
5.
Compatibility
Simplicity
“Trialability”
Observability
Factors Affecting Innovation
Diffusion (The “Who”)
I.
Perceptions of the innovation
II. Characteristics of the adopters (WHO)
III. Contextual factors, e.g.,:
•
Communication
•
(Job) incentives
•
Leadership
•
Management/supervision
II. Characteristics of Adopters
of Innovations (“The Who”)
Early
Adopters
13.5%
Innovators
Laggards
16%
Early
Majority
34%
Late
Majority
34%
2.5%
-2 SD
-1 SD
Mean
+1 SD
Time to Adoption (SDs from Mean)
Characteristics of Early Adopters
• 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
Factors Affecting Innovation
Diffusion (The “Environment”)
I. Perceptions of the innovation
II. Characteristics of the adopters
III. Contextual factors (ENVIRONMENT)
•
•
•
•
Communication
Motivation
Leadership
Management/supervision – support
systems
Dynamics of Diffusion
100
90
Percent
80
Tipping
point
70
60
50
40
30
20
10
Research to Practice
Area:
IUD “Revitalization”
0
Years
Impact Area:
Better
“understanding”
More available
IUD services
Communication Channels:
key evidence-based lessons
1. Mass media communication channels
are more effective in creating knowledge
of innovations.
2. 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 (cont.)
3. Most individuals do not evaluate an
innovation on the basis of scientific
studies of its consequences.
4. 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.)
5. More effective communication occurs
when two or more individuals are
homophilous.
6. Heart of the diffusion process consists of
modeling and imitation by potential
adopters of behavior of previous
adopters closely “networked” to them:
So What (to do):
Understand and Harness Change
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):
Find Sound Innovations
Hence our field’s emphasis on:
• “Evidence-based” medicine
• “Data-driven” programs
• “Best practices”
So What (to do):
Walk in the Other Person's Shoes
• 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): (cont.)
Walk in the Other Person's Shoes
• 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):
Keep Your Message Simple
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):
Support Champions
•
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):
Tailor Effort to Context
• 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)?:
Be Realistic / Be Patient
Program incrementally:
• Change will likely be slow
• Change will be incremental
• Change takes (a lot) of time
“There’s no quick fix”
And Remember:
There are 2 Experts in the Room