Diffusion Theory in Integrative Approaches
Summary and Keywords
Diffusion is the process through which new ideas, technologies, products, or processes are spread through communication among members of a social system via communication channels over time. Diffusion is a specialized form of communication that focuses on disseminating information about new ideas, products, technologies, services, or regulations. It is an especially important form of communication because it promotes social progress in the evaluation and adoption of important new ideas to address social issues. Diffusion helps to reduce uncertainty about how to address difficult issues and provides direction for achieving social goals.
A large body of research has been conducted from many disciplines on the diffusion of innovations since the original publication of Everett M. Rogers’ seminal book The Diffusion of Innovations in 1962, which is now in its fifth edition (2003). In this book, he introduced the Diffusion of Innovations (DOI) model, which describes a general process of adopting new ideas across multiple populations, cultures, and applications. This research has examined innovations in fields such as agriculture, engineering, sales, education, architecture, technology, public policy, and health care, and has been applied to a range of different issues, such as the adoption of new technologies, consumer purchasing behaviors, and public support for political issues and candidates, but has been especially influential in guiding strategic health promotion. The DOI model has contributed to a greater understanding of health behavior change, including adoption of health promotion recommendations. The model has led to a broad scope of practical applications for promoting public health.
Diffusion of Innovations: An Overview
Diffusion is a social (communication) process through which new ideas, technologies, products, or processes spread among the members of a particular social system via specific communication channels over time. Diffusion is a specialized form of communication that focuses on disseminating information about new ideas, products, technologies, services, or regulations. It is an especially important form of communication because it promotes social progress in the evaluation and adoption of important new ideas to address social issues. Diffusion helps to reduce uncertainty about how to address difficult issues and provides direction for achieving social goals.
The diffusion of new ideas and products is an important process in modern society, with the increasingly frequent introduction of new scientific findings, technologies, media, health promotion recommendations, as well as government and organizational regulations. How can we best inform key publics about these innovations and encourage adoption of important new ideas and products? A great deal of research from a variety of academic disciplines has been conducted on the diffusion of innovations over the past five decades. This research has examined innovations in fields such as agriculture, engineering, sales, education, architecture, technology, public policy, and health care. The areas of application for these studies range from the adoption of hybrid seed corn by farmers to applications of modern mathematic formulas by mathematicians, to the purchase of new electric cars by consumers, to the prescription of new medications, to the implementation of new HIV/AIDS prevention strategies.
In 1962, Everett M. Rogers published the first edition of his seminal volume Diffusion of Innovations (now in its fifth edition), where he first introduced the Diffusion of Innovations (DOI) model, often referred to as the Diffusion of Innovations theory, which explains how communication is used to influence the adoption of new ideas, technologies, and processes. The model explains that people’s exposure to information about new ideas, typically through communication across social networks or via different media channels, often has a profound influence on the rate at which they adopt new ideas, products, or behaviors. The model suggests that people are most likely to adopt new ideas, products, or behaviors based upon their favorable evaluations of the ideas as communicated to them by individuals whom they trust and respect. The DOI model has been widely adopted and has generated widespread research and applications.
A recent Google Scholar search indicated that the DOI model was utilized in almost two million research articles and books examining the adoption of new ideas and products in society. The areas of application of innovations that are examined in these publications about diffusion range quite broadly, from the adoption of hybrid seed corn by farmers to applications of modern mathematic formulas by mathematicians, to the purchase of new cars by consumers, to the prescription of medications, to the adoption of HIV/AIDS prevention strategies (Rogers, 2003). The Diffusion of Innovations model has wide applications for examining the ways that many different products, services, ideas, technologies, regulations, and services have been introduced to different audiences and the ways that these audiences have been encouraged to adopt these innovations.
The DOI model has been fruitfully applied to guide programs to promote the adoption of behaviors concerning a range of different issues, but it has been especially influential and important for examining the best ways to promote the adoption of recommended health behaviors, typically through health education efforts and public health promotion campaigns (Haider & Kreps, 2004; Oldenburg & Glanz, 2008). This ground-breaking model has contributed to a greater understanding of how to best facilitate specific recommended health behavior changes, including examination of the variation in rates of adoption of health promotion recommendations (including medication prescriptions, treatment regimens, therapies, and suggested health behavior changes involving diet, exercise, substance use, and health risk avoidance). The DOI model describes a general process, promotion through strategic communication efforts for the adoption of new ideas and activities, that has been shown by numerous research studies to occur in similar ways across multiple populations, cultures, nations, and health application areas (Bertrand, 2004; Buller, Buller, & Kane, 2005; Collins, Harshbarger, Sawyer, & Hamdallah, 2006; Cuijpers, de Graaf, & Bohlmeijer, 2005; Glanz, Steffen, Elliott, & O’Riordan, 2005; Owen, Glanz, Sallis, & Kelder, 2006; Yancey, Ory, & Davis, 2006).
The diffusion of innovation process describes both the planned and spontaneous spread of new ideas, although strategically planned diffusion activities can significantly speed the adoption of health innovations (Rogers, 2003). The communication of messages concerning new ideas, why they are relevant, and how they can be used to improve life, is crucial to the diffusion of innovations. This diffusion process involves the active creation and sharing of relevant information about key innovations among people to promote mutual understanding, demand for the innovations, and strategies for adopting and implementing the innovations. Thus, diffusion is a special type of communication process, in which the messages shared are about new ideas, products, services, regulations, and activities. In addition, diffusion is a type of social change activity, defined as the process by which change occurs in the structure and function of a social system (Rogers, 2003). Social change (including decisions that affect public health) can occur as a result of certain consequences due to the invention, diffusion, and adoption or rejection of new ideas (i.e., innovations).
Rogers (2003) explains that the DOI process involves four main interacting factors:
Innovation. Innovation can be a new idea, a new technology or product, or even a set of new behaviors that a health communicator might want certain groups of people (such as at-risk population members, patients, family caregivers, health care providers, or even health care system administrators) to learn about accept, adopt, and utilize. For example, a health communicator may want to encourage smokers to enroll in a specific new and promising tobacco control smoking cessation program to help them quit the smoking habit and reduce their risks for lung diseases, including cancer. Yet, as we know, smoking is a difficult habit for many smokers to break. It is often an entrenched health habit that involves both physical and psychological forms of addiction. Many smokers may have had difficulties in the past when trying to quit smoking. So the communication strategies needed to help these smokers adopt this innovative smoking cessation program will have to be strategic to attract their attention and motivate them to engage in the desired tobacco control behaviors.
Communication. Channels of communication are the different ways that health communicators can reach intended audience members with information about the innovation they want these audience members to adopt. There are interpersonal communication channels, where individuals interact directly with one another, such as when physicians provide their patients with counseling about health products or behaviors they want them to utilize. There are print channels of communication, such as pamphlets, books, journals, magazines, and newspapers, which can be used to disseminate relevant health information about specific innovations. Increasingly, to communicate health innovations, health promoters are using digital channels, such as web sites, social media sites, and text messaging. There are also a number of entertainment communication channels, such as television, radio, and film that can be used to communicate health innovations. The health communicator needs to determine which communication channels are best for reaching and influencing key audience members, as well as what messages are most likely to influence key audience members to adopt health innovations.
Social Systems. These are the communication networks that different audience members for health innovations utilize and belong to. These social systems include families, work organizations, neighborhood organizations, social groups, and religious organizations. It is important for the health communicator to determine which social systems are most influential for different intended audience members so they can utilize these social networks to communicate, model, and reinforce key health innovations. For example, the family is an important social system for disseminating health information. Parents, especially mothers, are primary providers of health information to other family members. It might be a good idea to enlist key family members to introduce and encourage other family members to adopt health innovations. Family members have many opportunities to interact with and observe whether other family members are faithfully adopting health innovations, such as dietary recommendations, and can provide timely feedback and encouragement to help increase successful adoption of dietary guidelines.
Time. Time refers to how long it is likely to take intended audience members to learn about, accept, try, and adopt different health innovations. Some health innovations may need to be practiced over time to elicit desired health improvements. For example, encouraging specific individuals to engage in regular exercise may demand having these individuals practice these exercise behaviors at regular intervals at specified levels of intensity for a certain length of time on a regular daily, weekly, or monthly basis to improve their health. How long will it take to educate these individuals about the exercise regimen, to encourage them to try the exercise activities, and to institutionalize these new physical activity behaviors as part of their lives? Health communicators often must plan health promotion interventions that will motivate long-term adoption of health behaviors.
Innovations in public health also have five defining characteristics that affect, and help to explain, their differential rate of adoption. These include relative advantage, compatibility, complexity, trialability, and observability.
Relative advantage refers to the evaluations that intended audience members make about the potential rewards and detriments to adopting an innovation. For example, for a smoker, the advantages of adopting a new smoking cessation program might be the ability to reduce their smoking, improve their health, and reduce their chances of getting serious health problems, such as lung cancer. On the other hand, potential detriments might include how difficult it could be for them to reduce their tobacco use, the cravings they might encounter if they reduce their tobacco intake, and the stress and discomfort this will cause them. Health communicators need to help the intended audience member determine that the benefits of adopting the health innovation significantly outweigh the potential detriments.
Compatibility refers how well the innovation fits into the lives of intended audience members. The health communicator must help the intended audience members make positive comparisons between the intended health innovation and other health options available. For example, they can show that the recommended smoking cessations program is less expensive, more effective, and/or easier to accomplish than alternative smoking cessation programs.
Complexity refers to how easy it will be for audience members to adopt the innovation. The health communicator needs to minimize the complexities of adopting the recommended health innovation, for example by providing free access to the innovation, as well as any needed training or support to help intended audience members access and use the innovation.
Trialability refers to providing audience members with first-hand or virtual experience using the innovations. For example, sometimes providing intended audience members with samples of health innovations, trial runs to help them test out the innovation, and/or free initial access to the innovation (trialability) can help encourage health innovation adoption.
Observability refers to showing audience members how relevant others have utilized and benefited from adopting the innovation. For example, providing vivid examples of how others have adopted, utilized, and benefited from the health innovation (observability) can also help promote innovation adoption.
The utility and value of the DOI can be further appreciated in light of the fact that the optimization of these five qualities will allow an innovation to be adopted more rapidly than other innovations that lack them. Thus, health promotion or disease prevention programs can follow these guidelines to be more profitable and productive for a targeted group of people.
The consequences of communication efforts to promote adoption of behavioral health innovations can have significant influences on public health. However, the adoption of public health innovations can be classified as desirable versus undesirable, direct versus indirect, and anticipated versus unanticipated. That is why it is important to develop strategic communication programs to promote adoption of relevant health innovations. Strategic communication efforts that can successfully promote adoption of important health innovations need to move audiences through the five stages of adoption of innovations by developing communication programs that enhance audience awareness, interest, evaluation, trial participation, and adoption.
Awareness or exposure to information about the innovation is an essential stage for the diffusion of innovations. If audience member are not aware of a specific health innovation, they will be unlikely to adopt it.
Interest in the new health idea, product, or activity is also a crucial stage in diffusing health innovations. Communication efforts need to demonstrate the relevance, innovativeness, and utility of new health programs or products for different audiences.
Evaluation of how the innovation can enhance current and future health is also an essential part of diffusion. Communicators need to help audiences recognize the relative advantages and benefits of health innovations to promote adoption.
Trials that test the full use of the innovation are another key part of the adoption process. Providing audience members with opportunities to test the innovation can be very persuasive in encouraging adoption.
Adoption of the innovation is not just trying the health innovation, but involves reinforcement to encourage continuing use and sustainability of the health activity (Rogers, 2003).
The Innovation-Decision process also involves five main steps, as described by Rogers (2003):
1. Knowledge: when an individual learns of the innovation’s existence and gains some understanding of how it functions. The information sought by an individual in this stage typically reduces uncertainty about the cause-effect relationships related to the innovation’s capacity to solve an individual’s problems.
2. Persuasion: occurs when an individual is encouraged by the information provided to form a favorable (or sometimes unfavorable) opinion or attitude toward the innovation.
3. Decision: when an individual forms a favorable or unfavorable attitude toward the innovation based upon the information provided.
4. Implementation: when the individual is encouraged to and actually engages in activities to adopt and utilize the innovation.
5. Confirmation: Knowledge occurs when an individual seeks reinforcement of an innovation-decision that has already been made, but may be reversed if the individual is exposed to conflicting messages about the innovation. At this point, the individual can decide to make full use of an innovation as the best course of action available (i.e., adoption) or choose not to adopt it (i.e., rejection).
Understanding the innovation-decision process is critical to maximizing the scope of diffusion and the rate of adoption of an innovation. Following the aforementioned five phases of this process (knowledge, persuasion, decision, implementation, and confirmation), a public health campaign can be designed optimally in a step-wise framework. According to the DOI model, the first step, the knowledge phase, would focus on the spread of information by means of mass-media channels, as a way to introduce an innovation to a community. The next step, persuasion, would focus on diffusion of the innovation through interpersonal channels of communication that would have more potential to convince late adopters and laggards to adopt the innovation. This phase can also leverage the influential capacities of change agents in a target community. A change agent is an individual who influences clients’ innovation-decisions in a direction deemed desirable by a change agency. An example of a change agent would be a health education specialist from a public health department whose job it is to provide information and recommendations to key groups of people about the best ways to promote their health. Other change agents could be primary care physicians who counsel their patients about following recommended treatments and medications, physical therapists who encourage patients to practice therapeutic exercises and movements, nutritionists who recommend changes in diet, or even family members who encourage loved ones to engage in healthy behaviors. A change agent can approach the health innovation in two ways: Secure the adoption of the new idea, or attempt to slow the diffusion process and prevent adoption of certain innovations with undesirable effects.
Establishing and maintaining a favorable communication relationship between the change agent and the client is vital to the success of any behavioral change program. Communication describes the contact between a change agent and his or her clients. The change agent is responsible for seven roles in the process of introducing an innovation into a client system. These are:
1. Develop clients’ recognition of a perceived need for health behavior changes.
2. Establish an information-exchange relationship with clients where relevant health information can be communicated (health information dissemination).
3. Diagnose potential problems that clients might have in adopting the recommended health innovations.
4. Create an intent in clients to change their specified health behaviors and adopt the health innovations.
5. Translate clients’ intentions to change their health behaviors into actual health actions.
6. Stabilize (sustain and institutionalize) clients’ adoption of specified health behaviors and to prevent discontinuance.
7. Achieve a terminal relationship so additional information and reinforcement can be provided over time if needed.
The DOI model explains that people fall into one of five adopter categories that describe their rate of adoption of a new behavior or belief (Rogers, 2003):
Innovators are the first members of a group to adopt a new innovation. In relation to their peers, they are generally more adventurous, cosmopolite, educated, and can cope with a high degree of uncertainty. They serve as the gatekeeper of an innovation to the population they lead.
2. Early Adopters are also educated, but they are less cosmopolite and less able to deal with uncertainty than innovators.
The Early Majority are those who are likely to adopt an innovation just before the average person. The early majority typically constitutes one third of the members of a system and is likely to deliberate before adopting a new innovation.
The Late Majority are those who adopt new ideas just after the early majority and also comprises one third of the population. They tend to require peer-pressure to adopt new behaviors and are skeptical about new behaviors.
Laggards (sometimes referred to as last adopters) are the final adopters in a system. They tend to be the least educated and cosmopolite. Laggards are also suspicious of innovations and take a great deal of time to adopt a new innovation.
Behavior change processes that are based on the DOI model rest on the idea that one should try to accelerate the filtering of innovations from the innovators to the laggards as quickly and precisely as possible. There are three individual factors that influence the rate at which a new innovation diffuses: adopter characteristics, personality variables, and communication behavior. Each group of adopters possesses certain characteristics that are at least partly responsible for the adopter group to which they belong. These personal characteristics include: level of formal education, socioeconomic status, social status, and upward social mobility. Additional personality traits resulting from the above personal characteristics that would favor earlier adoption of an innovation include greater empathy, ability to cope with uncertainty, rationality, and higher aspirations.
Contributions of the DOI Model
The DOI model has been utilized to address numerous public health issues, including the adoption of HIV/AIDS prevention behaviors (Bertrand, 2004; Collins et al., 2006), skin cancer prevention guidelines (Buller et al., 2005; Escoffery, Glanz, & Elliott, 2007; Glanz et al., 2005), reducing sedentary behavior to promote physical fitness (Owen et al., 2006; Yancey et al., 2006), and heart disease prevention (Scott, Plotnikoff, Karunamuni, Bize, & Rodgers, 2008). An essential link in the promotion of public health is successful communication of consequential messages to enhance the wellness of populations and communities. The significant role that the diffusion of innovations can perform in health promotion efforts cannot be underestimated, especially with the use of mass media channels of communication to influence health awareness, education, decisions, practices, and care.
The DOI model has made significant contributions to the understanding and promotion of behavioral change. For example, DOI research makes it possible for people to improve and customize important innovations to fit their unique cultural needs. Thus, it becomes increasingly important to study how different innovations can affect physical and psychological health. It is equally important to assess why a certain innovation, such as boiling water prior to drinking in countries with unsanitary drinking water, is adopted or rejected.
The field of public health is concerned with promotion and maintenance of the health of a community or population. Thus, disseminating effective messages regarding health education and health behavior is a critical component of most public health programs. The DOI model serves as an invaluable tool to facilitate the spread of health messages within a community. Three types of behavior change relevant to DOI are commencement, cessation, and adoption (i.e., prevention and/or sustained behavior change). These three main types of behavior change can serve as measurable objectives of various public health campaigns.
Commencement describes initiating a new, desirable behavior within the target population. For example, this behavior change includes a broad spectrum of topics, such as promoting exercise as part of a healthy lifestyle, encouraging changes in dietary behaviors to increase nutrition, or encouraging improved health-seeking behavior for low-income pregnant women by providing them with information on accessible clinics and the benefits of prenatal care. In promoting commencement of new health behaviors, it is important to educate intended audiences about the nature of the new behaviors, why they are important, and how to integrate these new behaviors in everyday life.
Cessation refers to ending preexisting and undesirable or risky behavior, such as dangerous health habits. For example, this could include convincing intravenous drug users to end their sharing of contaminated needles with other drug users, or aiding smokers to quit their use of cigarettes. Promoting cessation is often very difficult because many negative health habits are entrenched behaviors that have been practiced over long periods of time, and may involve psychological and, in some cases, physiological addictions. For example, smoking cessation can be very difficult for habitual smokers to accomplish, since they may have both psychological needs to smoke and physiological addictions to nicotine. Helping these addicted smokers to quit is likely to demand intensive communication interventions, reinforcement, and often medications.
Last but not least, diffusion of health innovations efforts typically involve promotion of sustained, long-term adoption of health behaviors. This can include long-term prevention of an undesirable behavior as an important stage in facilitating behavior change, as well as the sustained adoption of new health behaviors. Examples of sustained prevention can range from keeping adolescents from experimenting with substance abuse to advocating condom use to prevent risky sexual behavior that can lead to STDs.
The DOI model can be effectively applied in public health campaigns both to prevent negative health behaviors and to promote long-term adoption of positive health behaviors. For example, classifying the target population of an innovation according to adopter categories could help maximize the efficiency of the diffusion process by enabling the initial focused targeting on innovators. Such a strategy would increase the number of change agents in the innovation-decision process and expand the potential for successful diffusion in the targeted group of people. Furthermore, identifying the strengths and weaknesses of the innovation using the factors that affect the rate of adoption (relative advantage, compatibility, complexity, trialability, and observability) can be extremely advantageous in designing as well as implementing the message campaign. Diffusing an innovation in a way that emphasizes its benefits and downplays the negative consequences can considerably enhance the ultimate efficacy and social acceptance of a public health campaign.
Another aspect of DOI that is particularly useful to public health is the identification of societal norms—that is, the value system and accepted practices of a target community. For example, recognizing the community’s cultural and religious principles that may seem to oppose a health innovation is crucial to the efficacy of the diffusion of an innovation, because such factors inevitably will affect the innovation-decision process. Designers of public health campaigns must identify these potential barriers prior to introducing the innovation into the community. Understanding the reasons behind these established norms may enable the designer to circumvent major impediments to the diffusion process. Thus, emphasizing the benefits of a particular innovation and catering to complementing the societal norms of the community can lead to a greatly improved rate of diffusion and adoption of the innovation.
In the area of public health, the consequences of innovations have significant impacts on the wellness of communities and populations. Consequences are the changes that occur to an individual or to a social system as a result of the adoption or rejection of an innovation. Consequences of public health innovations can be classified as desirable versus undesirable, direct versus indirect, and anticipated versus unanticipated. Invention and diffusion are simply means to an ultimate end: the consequences of adoption of an innovation (Rogers, 2003). Therein lies perhaps one of the most significant applications and values of DOI in the public health arena.
The application of theoretical concepts in public health by agents of change, in the interest of facilitating the spread of favorable attitudes and behaviors throughout a social system, is just one facet of the multifaceted utility and value of the DOI model. One example of the consequences of innovations is the adoption of integrated pest management (IPM) by California tomato farmers (Vänninen, Pereira-Querol, & Engeström, 2015). In this case, the adopters of IPM re-invented the innovation by modifying it to fit their particular situation! Thus, although this was a relatively difficult innovation to adopt, requiring much time and continuous effort, its adoption reflects the tremendous potential that beneficial innovations can hold, especially when they ultimately prove beneficial and are focused and simplified to tangibly help the intended targets of an innovation. When farmers apply lower levels of pesticides to their tomato fields, the health of farm workers improves.
Criticisms of DOI Research
While diffusion research has made many important contributions to the promotion and understanding of human behavior change, its potential has also been limited by shortcomings and biases. For example, DOI makes certain simplifying assumptions about the complex reality it studies. Four main criticisms identified by Rogers (2003) are:
• A pro-innovation bias.
• The individual blame bias.
• Recall problem.
• The issue of equality.
Such biases must be addressed and resolved for the continued success and utilization of the DOI model.
The pro-innovation bias is the implication in diffusion research that a health innovation should be diffused and adopted by all members of a social system, that it should be diffused more rapidly, and that the innovation should be neither re-invented nor rejected. However, not all innovations are equally good. Some suggested innovations are actually bad ideas. In many cases, it may be best for populations to reject innovations that will cause problems. The pro-innovation bias leads diffusion researchers to ignore the study of ignorance about innovations, to underemphasize the rejection or discontinuance of innovations, to overlook re-invention, and to fail to study anti-diffusion programs designed to prevent the diffusion of “bad” innovations (Rogers, 2003).
The individual blame bias is the tendency to blame those who encounter health problems as the cause of their own problems. It is a form of blaming the victim. As a result of who sponsors diffusion research, along with other pro-source factors, one can detect a certain degree of individual-blame, rather than system blame, in diffusion research. Individual-blame is the tendency to hold an individual responsible for his or her problems, rather than the system of which the individual is a part. The individual-blame bias is a type of source bias—a tendency for diffusion research to side with change agencies that promote innovations rather than with the individuals who are potential adopters. This orientation implies that if your shoe doesn’t fit you right, there is something wrong with your foot (Rogers, 2003). The variables used in diffusion models to predict innovativeness are conceptualized so as to indicate the success or failure of the individual within the system rather than as indications of success or failure of the system (Rogers, 2003).
The recall problem refers to the preservation of information accurately over time. Diffusion inquiry differs from most other social science research by the fact that the time variable is not ignored (Rogers, 2003). Diffusion is a process that occurs over time, so there is no way to avoid including time when one studies diffusion. Diffusion research is dependent on recall data from respondents as to their date of adoption of a new idea (Rogers, 2003). Usually, the respondent is asked to look back in time to reconstruct his or her past history of innovation experiences. This hindsight ability is not completely accurate (Rogers, 2003).
The issue of equality involves how the socioeconomic benefits of innovation are distributed within a social system. This is an important issue that has not been given sufficient attention, especially concerning health promotion programs for poor, immigrant, and other under-served populations. Do members of these vulnerable populations benefit from the health innovations implemented? Do they have control over these new health programs and services? On the other hand, are health promotion innovations equally provided to all socioeconomic sectors of the population that are addressing health problems? It is evident that the diffusion of innovations can serve to widen the socioeconomic gap between the higher and the lower status segments of a system, especially, but not limited to, resource-poor settings (Rogers, 2003).
Biases such as the four discussed, the pro-innovation bias, the individual blame bias, the recall problem, and the issue of equality, all must be addressed and resolved for the successful and continued utilization of the DOI model in health promotion. Concerning the pro-innovation bias, before looking at the model itself, acknowledgment and adjustment, if needed, must be considered. Positive and/or negative attitudes towards, in this case, innovations, must be re-oriented towards an objective attitude. Either positive or negative attitudes will affect the implementation and evaluation process of the health innovation. If the focus of the health intervention is “pro-innovation,” then the innovation will be pushed, while problems or challenges that should be acknowledged might be ignored. Rogers (2003) suggested that, instead of gathering evaluation data at the end of the diffusion period, researchers should consider ongoing data collection and evaluation of the diffusion process while it is in course. This should not only provide a constant check on the evaluator/data-gatherer’s attitude, but also enable investigation of less successful, as well as more successful, cases of innovation diffusion. To overcome the individual blame bias, Rogers (2003) suggested refraining from using individuals as the units of analysis for diffusion interventions, therefore removing the possibility of blame on particular individuals. The health promotion specialists should be aware of this tendency to blame the individual and be cautious about accepting definitions of diffusion problems from the change agencies’ perspectives. Increasing awareness of this type of bias is a good way to begin to overcome it.
The recall problem is specifically a concern with the DOI model because, by definition, an innovation diffuses over time. Many persons cannot recall what they had for dinner a few days ago, never mind look back to recall past history in coping with different health issues! The most logical way to overcome this problem is to gather data at various periods during the diffusion process to determine what audience members can recall and to identify any areas of misinformation. Gathering data at several points throughout the process instead of waiting until the process is over will significantly reduce recall bias (Rogers, 2003).
The DOI model holds tremendous promise for influencing adoption of health promoting behaviors, products, technologies, and policies. Yet, the DOI model needs to be implemented with care to avoid encountering different biases and unforeseen problems. It is important to carefully monitor the implementation of diffusion programs and gather relevant data from the intended audiences for health innovations. It is also important to work closely with key audience members to guide the development of appropriate, culturally sensitive, and influential diffusion message strategies, channels, and sources. The careful selection of information sources for introducing health innovations is especially important. Care must be taken to identify and utilize credible information sources who will be admired, trusted, and liked, so they will be paid attention to and will be influential with intended audiences.
Discussion of the Literature
The DOI model has been cited frequently in the academic literature since its introduction in 1962 with the publication of the first edition of The Diffusion of Innovations by Everett M. Rogers. A recent search on Google Scholar identified almost two million citations of The Diffusion of Innovations. Even more remarkable, the DOI model has been adopted by a broad range of academic and professional disciplines, not only the communication and social sciences. Literature concerning the DOI model originates from fields such as engineering, agriculture, public planning, political science, architecture, public health, medicine, nursing, pharmacy, computer science, management, marketing, and even more. This illustrates the broad reach and scope of the DOI model.
The studies conducted that utilize the DOI model are primarily intervention studies that track and evaluate the ways that innovative ideas, products, services, technologies, and policies have been introduced within different social systems. These studies often utilize a case study approach that describes efforts to implement specific interventions with different audiences and in different settings. Meyer (2004) has argued that the majority of diffusion studies have relied on quantitative data, focused on a single innovation, collected data only from adopters, was conducted cross-sectionally (at one point in time), and was conducted after widespread adoption had already taken place. He suggests the need to adopt alternative methodological approaches to broaden and deepen the study of the diffusion of innovations. Recent diffusion studies have followed this advice, employing a variety of research methods, including experimental, survey, textual analytic, and ethnographic methods. The newer diffusion studies also have been using both quantitative and qualitative measures.
Public health and the health professional disciplines, including medicine, nursing, pharmacy, health education, and health communication have probably been the most active areas for application and research concerning the DOI model. The DOI model has been used in numerous published studies to address and improve health outcomes for a variety of challenging health issues, such as cancer, heart disease, HIV/AIDS, chronic diseases, and infectious diseases. Studies have examined issues concerning the adoption of new health care technologies, adherence with medication and treatment recommendations, the adoption of a broad range of recommended health behaviors, and promotion of cessation of many negative health habits, such as smoking, substance abuse, poor nutritional practices, sedentary behavior, and risky sexual behaviors. As the need for innovations in society and the promotion of health continue to increase, we can expect increased use of the DOI model to help evaluate and guide strategic dissemination efforts in a wide range of social settings.
The best sources for information about the Diffusion of Innovations and the DOI model come directly from the large body of research conducted by Everett M. Rogers and his many disciples, most notably Arvind Singhal, Muhiuddin Haider, James Dearing, Thomas Valente, and Douglas Storey (see: Dearing, 2004, 2008, 2009; Haider & Kreps, 2004; Rogers & Storey, 1987; Singhal & Dearing, 2006; Storey & Kaggwa, 2009; Valente, 2006, 2012; Valente, Dyal, Chu, Wipfli, & Fujimoto, 2015). Rogers’ seminal book, The Diffusion of Innovations, originally published in 1962, is currently in its fifth edition (2003). I was able to locate all of these publications concerning the diffusions of innovations online with Google Scholar. Many of them, including the books, are available in full text. In 2004, the Milbank Quarterly published a systematic review of research conducted on diffusion of innovations in service organizations addressing the question, how can we spread and sustain innovations in health service delivery and organizations (Greenhalgh, Robert, Macfarlane,Bate, & Kyriakidou, 2004). While this is a relatively narrow scope of the health applications of the DOI model and is a bit dated now, the systematic review is available open source through the National Library of Medicine. The systematic review concludes that the DOI model is a parsimonious and evidence-based model for examining the diffusion of innovations in health service organizations, there are clear knowledge gaps that need to be addressed in future diffusion research on this topic, and there should be a robust and transferable methodology developed for reviewing other applications of the DOI model (Greenhalgh et al., 2004). However, there are no other published systematic reviews of the diffusion of innovations that are currently available. This is an important direction for future research, evaluating the applications of the DOI model on a wide range of issues in different social settings.
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