Diffusion of Innovations, Mobilization and Empowerment Models and Behavior Change

Epi 246

Margaret Handley, PhD MPHAssistant Professor

Dept. Epidemiology and Biostatistics and Center for Vulnerable Populations,

DGIM-SFGHApril 22, 2010

Outline of Today’s Lecture

I. Discuss the Diffusion of Innovations (DOI) Model and Its Evolution

II. Describe examples that integrate DOI with other theories that we have discussed

III. Discuss Socio-Ecological Models that Focus on Community Mobilizing and Empowerment

IV. Describe examples that integrate community empowerment/mobilization with other theories that we have discussed

Diffusion of Innovations

Overview

“In healthcare, invention is hard, but dissemination is even harder” – D. Berwick

yet,

A recent report indicates that 7 of the 9 causes of death that have significantly declined between 1950 and 2000 (defined as at least a 50% reduction in mortality) clearly required and had diffusion of innovations through triangulated public health & medical care channels

Berwick D. JAMA 2003Rust G et al AJPH, 2010

Diffusion of Innovations & Declines in Mortality

Rust G et al AJPH, 2010

Successful Diffusion of Innovations

Origins - Diffusion of Innovations

Sociologists and others observed a pattern in diffusion processes that combined micro-macro forces

Observed that innovations spread because:

(1) perceptions about innovativeness of the innovation by target audience

(2) the attention/response of influential adopters (3) context could ‘make or break’ adoption

Key Concepts - Diffusion of Innovations

Diffusion: the overall spread of an innovation, the process for which an innovation is communicated over time in a social system

Dissemination: the planned systematic effort designed to make a program or innovation more widely accessible

Innovation: an idea, practice, or object that is perceived to be as new

Social System: inter-related (inds. or groups) that are engaged in joint problem-solving

Rogers 1995

‘Individual’ Stages - Diffusion of Innovations

Knowledge: exposed to the innovation

Persuasion: forms favorable or unfavorable attitude towards the innovation

Decision: Engage in activities, such as trial, that lead to a choice

Implementation: puts the innovation to use

Confirmation: decision-maker seeks reinforcement re decision

Program Stages - Diffusion of Innovations

Adoption: uptake by target audience

Implementation: the active planned efforts to implement an innovation within defined place

Maintenance: ongoing use of innovation over T

Institutionalization: incorporation of program into routines of org. or broader policy/legislation

What matters? - Diffusion of Innovations

1.Relative advantage:Is it better than what was there before?

2.Compatibility: Does the innovation fit with the intended audience?

3.Complexity: Is it easy to use?

4.Trialability:Can the innovation be tried before deciding?

5.Observability: Are the results observable and easy to measure?3.

What matters? - Diffusion of Innovations

6.Communication channels: How does information get spread? Who are the “connectors”?

7.Opinion leaders:Who is talking about the innovation and who is listening? (not the same as early adopters)

8.Like groups: Are there groups that have similar attributes?

9.Norms and roles in social networks: Do these help or hinder the spread?

10.Infrastruture: Are there technologies or other things that cluster with the innovation?

Gladwell, The Tipping Point

Diffusion of Innovations

DOI to Understand Adoption of Food to Treat Under-Nutrition

Thurber M et al, Ecology and Food Nutrition 2009

Can DOI-Based Implementation Accelerate Diffusion?

Or not?

Key Components - Diffusion of Innovations

1. The innovation – perceived attributes of relative advantage

2. The adopter – degree of innovativeness

3. The social system – opinion leaders, pressure to adopt

4. The individual adoption process – tailor to stages of change model for adoption

(knowledge, persuasion, decision, implementation, continuation)

5. The diffusion system - external agents?

Dearing J 2008

A Behavioral Intervention to Improve Obstetric Care

Althabe F et al NEJM 2008Campbell, Belizan, DearingIDS Confrenece 2008

Large randomized trial of hospitals to test a multi-faceted behavioral intervention to increase adoption of guidelines for use of episiotomy and management of third stage of labor in Argentina and Uruguay.

Selection of opinion leaders, interactive training, detailing, reminders, feedback to develop and implement guidelines

Follow-up after end of intervention

A behavioral intervention to improve obstetric care

Althabe F et al NEJM 2008

Belizan et al 2007

Example – Mapping Barriers to Change Processes in Diffusion of Innovations

Examples of Intervention Components Using Diffusion of Innovations

Belizan et al 2009

Intervention Components Using Diffusion of Innovations

Belizan et al 2007

Evaluation Components Using Diffusion of Innovations

Outcomes

Outcomes

Outcomes

Outcomes

Lessons for Dissemination

Adaptation based on local context and culture

intervention components naming and terms used Qualitative methods and observation

Detailed process/implementation evaluation

New Dynamics - Diffusion of Innovations to Dissemination Sciences

1. Importance of Social Networks not Defined by Geography Alone –

How integrated are the social networks related to the proposed innovation?

J Dearing 2008. Shirkey C, Here Comes Everybody, 2009

New Dynamics - Diffusion of Innovations to Dissemination Sciences

2. Non-Centralized Dissemination – Diffusion systems are less centralized- Individuals do not have to react to a strong control over political interest – naturalistic diffusion occurs

Clay Shirkey, Here Comes Everybody, 2009

New Dynamics - Diffusion of Innovations to Dissemination Sciences

3. What goes on in adopting organizations for implementation and adaption is central to success - the ‘moderating’ variables become the focus. Not just opinion leaders- but formal leaders.

If adopters do not feel ownership of the program, how can we ensure its persistence in practice?

‘Guided adaptation’ can help with fidelity

Resources – DOI TOOLS

DOI in Health Care – CHCF 2002 xhttp://www.chcf.org/documents/healthit/DiffusionofInnovation.pdf

AHRQ- Tools for Adopting Innovations

http://www.innovations.ahrq.gov/resources/indexoftools.aspx

Opinion leaders – Cochrane Review

Local opinion leaders: effects on professional practice andhealth care

outcomes (Review) Doumit G, Gattellari M, Grimshaw J, O’Brien MA

II. Developing Empowerment-Focused Interventions – From Community

Organizing to Community Mobilizing, Community Empowerment and Participatory Action Research

Types of Community Interventions

1. A series of activities that needs to be delivered (mostly) to individuals in a community (“package”)

2. A framework for delivery (“system”)

3. A means of galvanizing communities for change (“mobilization”)

NNair et al, PlosMedicine 2010

Definitions of Empowerment

Empowerment: “a process by which people, organizations and communities gain mastery over their affairs” Community empowerment: “a social action process by which individuals, communities, and organizations gain mastery over their lives in the context of changing their social and political environment to improve equity and quality of life”

“The expansion of assets and capabilities of poor people to participate in, negotiate with, influence, control, and hold accountable institutions that affect their lives” (World Bank)

Wallerstein. WHO Regional Office for Europe’s Health Evidence Network 2006http://www.euro.who.int/Document/E88086.pdf

From Building ‘Capacity’ to Community Mobilizing and Empowerment

Conceptual shift from ‘capacity building’ and emphasis on collaboration/advocacy re problems and use of outside technical experts

-- communities can develop insight into and solutions for their own problems (Freire)

-- attempts to remove paternalism w/in health promotion practice/ interventions

The WHO health promotion strategies

describe community action and

empowerment as prerequisites for health N Nair et al, PlosMed 2010

Empowerment influences people’s ability to act through collective participation by strengthening their organizational capacities, challenging power inequities and achieving outcomes on many reciprocal levels in different domains: psychological empowerment/efficacy, household relations, enhanced social capital and cohesion, transformed institutions, greater access to resources, open governance and equitable community conditions.

‘Theory’ of Empowerment & Relation to Health

• Theoretical roots in community psych., health ed. health promotion, liberatory adult ed., comm. organizing, rural and comm. devt, and social work

• Interplay between gaining internal skills and overcoming external structural barriers

• Closely related to community engagement, participatory action, Community Based Participatory Research (CBPR)

‘Theory’ of Empowerment & Relation to Health

• Is socio-ecological, with psychological empowerment being people’s self-efficacy and control in their lives, organizational empowerment the ability of an agency to influence change and community empowerment the ability to change real conditions

• Focuses on power relations and action- intervention strategies (unlike social capital). Power is central with two core aspects based in relationships with others: control over resources (material, human, financial); and control over ideology (values, attitudes, beliefs)

‘Theory’ of Empowerment & Relation to Health

• Is culture, society, and population-specific and therefore requires action within the local context

• Need to define relation with health care system

• Tension as to ethical issues raised:

1. ‘top-down’ approaches can be means to provide support, education and assistance so communities may gain greater autonomy/control

2. ’bottom-up’ may not distribute power equally ? Reflective Equilibrium Community Empowerment ? Community Action Cycle

Complexities–Empowerment Models & Health

Braunack-Mayer and J Louise, 2008

1. Intervention Focus: Community mobilization - women’s groups’ support

(self-efficacy, collective efficacy, DOI, empowerment) Outcome: NNM and depression

2. Intervention Focus: Behavior change – participatory action research informed intervention package Outcome: NNM

(HBM, TPB, SCT, DOI)

3. Intervention Focus: Youth Empowerment Strategies (YES!) Project Outcome: youth capacity, social action work

(SCT, empowerment, CBPR)

Examples of Empowerment/Community Mobilization with Integrated Frameworks

1. Effect of a Participatory Intervention with Women’s Groups on Birth Outcomes and Maternal Depression in Jharkhand and Orissa, India

Tripathy P, et al, Lancet 2010

Large scale cluster randomized trial based on Nepal studies or participatory interventions via women’s groups on reducing neonatal mortality

Cluster randomized trial (36 clusters) >225, 000 people, 3 years, and almost 20,000 births

Participatory intervention-monthly women’s groups

Neonatal mortality, home care practices, health seeking behavior, maternal depression

1. Participatory Learning and Action Cycle

Tripathy P, et al, Lancet 2010

1. Effect of a Participatory Intervention with Women’s Groups on Birth Outcomes cont…

Tripathy P, et al, Lancet 2010

Large reduction in NNM (> 50% in year 3, OR 0,53 (0.41-0.68)

Not associated with health seeking behavior, but possibly with home care practices

Maternal depression declined, ? associated with problem-solving skills and social support

Implications – Addressing ‘critical consciousness’ ; ? more effective than community health workers due to increased reach and increased capacity-building

N Nair, et al, Plos Medicine 2010

Model for Focusing Interventions Related to Community-Based Programs for Newborn Survival

2. Effect of Community-Based Behavior Change Management on Neonatal Mortality, Shivgarh, India

Kumar, et al, Lancet 2008

Large scale cluster randomized trial based on reducing neonatal mortality using behavior change management using participatory methods to deliver the intervention package (co-community developed)

Cluster randomized trial (39 village clusters) >105, 000 people

Trust-Based Intervention- home visits, meetings, initiatives to ‘shift in reasoning’ away from some practices and towards other practices

Neonatal mortality, home care practices, health seeking behavior

2. Effects of Community-Based behavior change management on neonatal mortality in Shivgarh, India

Kumar V, et al, Lancet 2008

Rosato et al Lancet 2006

Community Action Cycle for Community Prioritization of Health Outcomes , Malawi

3. Youth Empowerment Strategies (YES!) West Contra Costa, CA

Wilson N et al Health Prom. Practice 2008

DIAGRAM

HOMEWORK

1.Using the components of the diffusion of innovations develop an outline for a strategy you might use to work on diffusing an innovation related to your work

Describe your rationale for choosing different components to emphasize

2. How might the community mobilization models and empowerment strategies be relevant in your work? Which aspects would you be most interested in developing. Who would you work with to develop a model to form a strategy?