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 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

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 2.Compatibility 3.Simplicity 4.“Trialability” 5.Observability

1.Perceived Benefit of the Innovation Greater the perceived relative advantage, the more rapid its rate of adoption. Subcharacteristics: the perceived: –Degree of economic profitability –Low initial cost –Decrease in discomfort –Increase in social prestige –Savings in time and effort –Immediacy of the reward**

2. Perceived Compatibility of the Innovation Perceived compatibility with values, beliefs, past history & future needs of potential adopters: –Avoid “empty vessel syndrome” –Language used to convey innovation key-- “Language conditions thought” --R.J.

3. Perceived Simplicity of the Innovation Innovation perceived as simple spreads faster than one seen as complex –Hence impulse to adapt [and to simplify] –Local adaptation is nearly universal in successful adaptations: not “spread” but “reinvention”

4. Perceived Trialability of the Innovation Trialability [“pilot testability”] positively related to rate of adoption. Innovations that can be tried on the “installment plan” adopted more quickly than ones that aren’t divisible.

5. Perceived Visibility of the Innovation “Degree to which results of an innovation are visible to potential adopters” The easier to see an innovation, the more likely its adoption

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% Early Majority 34% Late Majority 34% Laggards 16% 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 innovation II. Characteristics of the adopters III. Contextual factors (ENVIRONMENT) Communication Motivation Leadership Management/supervision – support systems

III. Contextual factors (ENVIRONMENT) Environmental and/or system factors may encourage/support or discourage/impede change –Communication patterns –Job incentives –Management / leadership / supervision Organizations/communities/societies vary on this Several styles of leadership-induced spread: –“optional,” “collective,” “authoritative” –No one best; context-specific

Dynamics of Diffusion Percent Years Impact Area: Better “understanding” More available IUD services Tipping point Research to Practice Area: 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