Repositioning Family Planning in West Africa

Repositionnement de la Planification Familiale en Afrique de l’Ouest

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

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”

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 policiesResearchers publish new findingsExperts devise new guidelinesPrograms 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

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

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

• 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

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

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)

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

perceivedperceivedperceived

2. Compatibility

3. Simplicity4. “Trialability”5. 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”)

EarlyAdopters

13.5%

EarlyMajority

34%

LateMajority

34%

Laggards16%

Innovators

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 innovationII. Characteristics of the adoptersIII. Contextual factors (ENVIRONMENT)

• Communication• Motivation• Leadership• Management/supervision – support

systems

Dynamics of DiffusionP

erce

nt

Years

Impact Area:Better

“understanding”More availableIUD servicesTipping

point

Research to PracticeArea:

IUD “Revitalization”

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

Source: JHU/CCP Photoshare