Empirical Testing

Analyses of DOI Applications Overview 1

Report: examines research on DOI and suggests application of DOI in health care (Berwick 2003).


  • Examine literature of DOI
  • Explore 3 influential factors of the rate of diffusion in an organization
    • Perceptions of the innovation
    • Characteristics of adopters
    • Contextual and managerial factors of organization
  • Provide 7 recommendations on using DOI in health care settings
  • Innovations in health care are disseminated at a slow pace.
    • Time between realization of the use of vitamin C to prevent scurvy and the development of universal British preventative policy - 246 years.
    • Few obstetricians able to reduce cesarean delivery rates from 26% to 15% while others in the same hospital maintained high rates.
    • Although randomized trials have shown that cheap antibiotics reduce first ear infections in children, a study of 12,000 children in the Colorado Medicaid program found that over 30% still used expensive and unnecessary procedures costing over $200,000 per year.
  • In descriptive studies, 3 main clusters influence rate of diffusion of an innovation: perceptions of the innovation, contextual and managerial factors of organization, and characteristics of adopters.
    1. Perceptions of the innovation
      • Predicts 49% to 87% of the variance of the rate of diffusion
      • 5 properties of the innovation are important
        • perceived benefit of change (most powerful and important), Compatibility, complexity of innovation, trailablity and observability
    2. Contextual and managerial factors of organization
      • Successful diffusion depends on how organizations deal with its innovators, early adopters and the relationship between early adopters and early majority than any other group
    3. Characteristics of adopters
      • Innovators, Early Adopters, Early Majority, Late Majority, Laggards
        • In health care, Innovators have invested heavily in a topic or are considered "mavericks"
        • Early adopters are usually representatives of clinical groups or targets of pharmaceutical company detailing
        • Early Majority will readily try innovations that meet their immediate needs over those that are simply interesting
        • Late Majority will adopt innovations when it is standard practice or when it meets guidelines
        • Laggards are physicians who swear by the tried and true
  • Speculative rules for dissemination of innovations in health care
    1. Find sound innovations
      • Formal, deliberate and organized mechanisms must be created to encourage proactive search of innovations through publications, networks, routine search of peer-reviewed journals and attendance at scientific meetings.
    2. Find and support Innovators
      • Novel answers to problem often exist outside of the network. Seniors should identify and encourage innovators to seek these novelties.
    3. Invest in Early Adopters
      • The switch from compliance to support is crucial to effective diffusion. Seniors should invest in the curiosity of a handful early adopters.
    4. Make Early Adopter's Activities Observable
      • Diffusion requires social interaction. Early majority needs to see early adopters to watch them. Similar to the investments by pharmaceutical companies on local one-on-one interactions, seniors need to invest in the social channels that link these groups.
    5. Trust and Enable Reinvention
      • While new innovations are generated outside the system, new processes to support them must be developed within the system. Changes need to be adopted and adapted locally. Reinvention, an act of creativity and courage, is a form of learning.
    6. Invest in Change
      • Through every stage, Innovators to Laggards, adoption takes energy: real time and real money.
    7. Lead by Example
      • Leaders must be prepared for resistance, ridicule and most important, change with themselves.
  • Limitations of DOI and its application to health care
    • Research is descriptive and operational. Lack of empirical and experimental research limits inference and extrapolation.
    • Classification of the five adopter categories are artificial, as they were defined statistically by examining mean adoption time.
    • DOI cannot predict but present "educated guesses"
  • In sum, health care needs leaders that can understand innovation, await its spread, respect its diversity and nurture it.

Analyses of DOI Applications Overview 2

Report: presents an overview, contributions, criticisms, challenges, and future recommendations of DOI and its application in public health (Haider, 2004).

This paper presents:

  • Innovation as a type of social change through which change occurs in the structure and function of a social system
  • Four main characteristics of DOI
    • Innovation, Communication Channels, Social Systems, and Time
  • Defining characteristics of innovation in public health
    • Relative advantage, compatibility, complexity, trialability, and observability
  • Consequences of public health innovations
    • Desirable vs. undesirable, direct vs. indirect, anticipated vs. unanticipated
  • Innovation-Decision Process
    • Knowledge, Persuasion, Decision, Implementation and Confirmation
  • Innovation-decisions Process: The relationship between clients and change agents
    • A change agent, such as a Health Education Officer in a Ministry of Health, influences the clients innovation-decisions in a direction desirable to the change agency.

Seven roles of change agents:

  • Develop need for change
  • Establish an information-exchange relationship
  • Diagnose problems
  • Create an intent to change in the client
  • Translate an intent to action
  • Stabilize adoption and prevent discontinuance
  • Achieve a terminal relationship

Contributions of DOI and its application in public health

  • DOI makes it possible to improve and customize important innovations to fit cultural needs
  • Facilitates the spread of health messages within communities
  • Presents three types of behavior changes (commencement, cessation, adoption) that can serve as measurable objectives of public health campaigns
  • The factors that affect rate of diffusion (relative advantage, compatibility, complexity, trialability, and observability) can be used to identify weakness and strength of innovations and aid in message dvelopment and implementation.
  • Maximizes diffusion efficiency by targeting initial focus to innovators and thereby increases the frequency of change agents
  • Enhances social acceptance and efficacy of innovations by downplaying its negative consequences and underscoring its benefits
  • Enables identification of societal norms e.g., religious principles and cultural norms, as it affects the innovation-decision process
  • Identifies consequences of innovations, changes that occur to an individual or society as a result of the adoption or rejection of an innovation

Criticisms of DOI and its application in public health include

  • Pro-innovation Bias
    • An implication that an innovation SHOULD be adopted and spread by all members of a social system
    • Leads researchers to: 1) ignore study of ignorance about innovations; 2) underemphasize rejection or discontinuance of innovations; 3) overlook re-invention; and 4) fail to study anti-diffusion programs needed to prevent spread of undesirable innovations.
  • Individual Blame Bias
    • Individual blame involves holding individuals, and not the community they are a part of, responsible for their problems. Sponsors of diffusion research and other stakeholders tend to blame individuals rather than the change agencies.
  • Recall Bias
    • As data from DOI is collected retrospectively, DOI depends on adopters' memory of their adoptive date, which can be inaccurate.
  • Issue of Equality
    • While it is evident that DOI widens socio-economic gaps, especially affecting resource-poor settings, data on how socio-economic benefits of innovations has been scarce.
    • Recommendations include assessing and redirecting positive and negative attitudes toward an objective lens of DOI.
  • Challenges of DOI and its application in public health include:
    • speeding up decision-making process
    • identifying appropriate change agents needed to reach different target populations
    • increasing understanding of adopter categories and characteristics
    • making DOI more sustainable
    • building assurance for funding
    • ensuring prospective and not respective assessments of people's response to innovations
    • decreasing diffusion of erroneous, misleading, harmful or undesirable innovations
    • assessing the distribution of the socio-economic benefits of innovations

Recommendations to Decrease Biases

  • Pro-innovation Bias
    • Recommendations include assessing and redirecting positive and negative attitudes toward an objective lens of DOI
    • Outcome evaluation efforts should be coupled with process evaluation activities to accuracy of assessments
  • Individual Blame Bias
    • Individuals should not be the sole units of analysis
  • Recall Bias
    • Information can be gathered at various times during the diffusion process
  • Issue of Equality
    • Questions to be considered to reduce inequality include:
    • What criteria guide the choice of innovations to be diffused:
      • The public welfare? Increased production of good for exports? Maintaining low prices for urban consumers? Increased profits for society's elites?
    • What influence does society's social structure have over individual innovation-decisions?
    • Are the technological innovations being diffused appropriate, well-proven and adequate for the stages of socio-economic development of society?
    • What are the likely consequences of technological innovation to this society? Will the innovation widen or narrow socio-economic gaps?

Analyses of DOI Applications Overview 3

Report: Examines the dominant and current methodological practices in DOI research and offers recommendations (Meyer, 2004).

This paper:

  • Examines the strengths and weaknesses of methodological practice
  • Assesses the contribution of current DOI methodology to the understanding of DOI
  • Presents alternative methodological approaches to DOI research

Current DOI Methodology:

  • Is based on the well-known investigation of hybrid corn in the mid-1900s. The research on hybrid corn "became a template for agricultural research" and then used in "other diffusion traditions."
  • Relies on:
    • Quantitative data
    • Concerning a single innovation
    • From adopters
    • At a single point in time
    • After widespread diffusion of innovation
  • Quantitative data
    • Obtained via paper and pencil questionnaires in survey research
    • Maximizes time and money
    • Is efficient for data collection from a substantial number of individuals
  • Single innovation (vs. innovation cluster)
    • Technology cluster, set of interrelated and complementary innovations, including include adoption of family planning methods is an alternative to single innovations.
    • Data collection, analysis and dissemination is less time-consuming and easier
    • Hard to find complementary innovations with similar cultural contexts
  • Adopter
    • Given that dependent variable is adoption of innovation, information about adopter characteristics and preferred communication channels is usually collected from adopters.
    • Information about inventors, developers and intermediaries are less useful than adopters' characteristics to understand the spread of innovation
  • Single point in time
    • DOI assumes that responses from a snapshot is similar to responses that would be collected at other times
    • Response rates are higher and attrition is lower with cross-sectional data.
  • Post Hoc analysis
    • Preferred data usually later in the in the diffusion process
    • There is more to be learned after diffusion has already occurred

Limitations of Current DOI Methodology:

  • Dominance of current DOI methodology has limited research on other aspects of DOI
  • Less is known about
    • rejection of innovations
    • implementation of innovation
    • negative and unanticipated consequences of adoption
    • causality of variables
    • post-adoption discontinuance

Alternatives to Current DOI Methodology:

  • Longitudinal Panel Studies
    • Pros
      • Can aid in data collection at multiples times during diffusion process
      • Can help researchers maintain large study samples and increase understanding of diffusion process
      • Frequency of data collection can influence extent of recall bias
      • Timing of data collection influences data
    • Cons
      • Demands more energy, time and resources
      • May adversely impact response rates
  • Point-of-adoption study
    • Data is gathered at the time of adoption rather than some other time random to adoption
    • Pros
      • Accurately reflect activities leading up to adoption
      • Enables large samples and control over research variables
    • Cons
      • Post-adoption activities including positive or negative consequences of implementation, re-invention, or cessation are disregarded
      • Researcher must accurately identify precise point of adoption
      • Point of adoption of conceptual, private, and less expensive innovations such as the adoption of the designated driver, are harder to determine
  • Archival Records
    • Written records are objectively used to gather and assess the diffusion process such as time and extent of adoption.
    • Pros
      • It can be used as a validation tool
      • Accurately reflects activities leading up to adoption
    • Cons
      • There aren't written records for many innovations
      • Written information maybe limited in its content and accuracy
      • Written records may be inaccessible to researchers
  • Quasi-experimental Design
    • Pros
      • Enables researchers to establish time ordering a precursor to establishing causality
      • Helps to specify timing, extent and nature of change agent
      • Help determine media channels that are most relevant to diffusion
      • Precise types, content and frames of messages that enhance or restrict adoption can be established
    • Cons
      • Demands more time and resources as adoption can be unpredictable.
      • Variables that may affect outcomes may not be alterable in naturalistic setting where the laboratory allows for more control of such variables.